THE PERIODONTAL FLAP

INTRODUCTION DEFINITION CLASSIFICATION OF FLAPS DESIGN OF FLAPS INCISIONS (HORIZONTAL AND VERTICAL) ELEVATION OF THE FLAP

THE VARIOUS FLAP TECNIQUE FOR POCKET THERAPY GENERAL INDICATIONS FOR FLAPS TREATMENT DECISIONS FOR SOFT AND HARD TISSUE POCKETS SUTURING PERIODONTAL DRESSINGS

INTRODUCTION

DEFINITION A PERIODONTAL FLAP IS A SECTION OF THE GINGIVA AND/OR MUCOSA SURGICALLY SEPARATED FROM THE UNDERLYING TISSUES TO PROVIDE VISIBILTY OF AND ACCESS TO THE BONE AND ROOT SURFACE

CLASSIFICATION OF FLAPS 1)BASED ON BONE EXPOSURE AFTER FLAP REFLECTION FULL THICKNESS(MUCOPERIOSTEAL)FLAPS PARTIAL THICKNESS(MUCOSAL) FLAPS

Full Thickness Flap

Partial Thickness Flap

INDICATIONS OF PARTIAL THICKNESS FLAP WHEN THE FLAP IS TO BE PLACED APICALLY CRESTAL BONE MARGIN IS THIN. WHEN DEHISCENCES OR FENESTRATIONS ARE PRESENT

CLASSIFICATION OF FLAPS 2)BASED ON PLACEMENT OF FLAP AFTER SURGERY NON-DISPLACED FLAPS DISPLACED FLAPS

CLASSIFICATION OF FLAPS 3)BASED ON MANAGEMENT OF PAPILLA CONVENTIONAL FLAPS PAPILLA PRESERVATION FLAPS

DESIGN OF THE FLAPS DICTATED BY:- SURGICAL JUGDEMENT OF THE OPERATOR OBJECTIVES OF THE OPERATION DEGREE OF ACCESS TO THE UNDERLYING BONE AND ROOT SURFACES NECESSARY FINAL POSITION OF THE FLAP

INCISIONS HORIZONTAL INCISIONS THE INTERNAL BEVEL/REVERSE BEVEL/INTIAL INCISION

Primary Incision

MOST BASIC INCISION FOR MOST OF THE PERIODONTAL FLAP PROCEDURES IT ACHIEVES 3 IMPORTANT OBJECTIVES:- 1)REMOVES THE POCKET LINING 2)CONSERVES THE RELATIVELY UNINVOLVED OUTER SURFACE OF THE GINGIVA 3)IT PRODUCES A SHARP THIN FLAP MARGIN FOR ADAPTATION TO THE TOOTH-BONE JUNCTION

INDICATIONS OF PRIMARY INCISION SUFFICIENT BAND OF ATTACHED GINGIVA TO CORRECT BONE MORPHOLOGY THICK GINGIVA DEEP PERIODONTAL POCKETS AND BONE DEFECT TO LENTHEN CLINICAL CROWN

HORIZONTAL INCISIONS 2) THE CREVICULAR/SULCULAR/SECOND INCISION

THIS INCISION ALONG WITH THE INTERNAL BEVEL INCISION, FORMS A V-SHAPED WEDGE ENDING AT OR NEAR THE CREST OF THE BONE. THIS WEDGE OF TISSUE CONTAINS INFLAMMED OR GRANULOMATOUS AREAS OF LATERAL WALL OF THE POCKET,AS WELL AS THE JUNCTIONAL EPITHELIUM & THE CONNECTIVE TISSUE FIBRES THAT STILL PERSIST BETWEEN THE BOTTOM OF THE POCKET & THE CREST OF THE BONE.

THE PERIOSTEAL ELEVATOR IS INSERTED IN TO THE INTITIAL INTERNAL BEVEL INCISION, AND THE FLAP IS SEPERATED FROM THE BONE, WITH THIS ACCESS, THE THIRD INCISION IS MADE.

HORIZONTAL INCISIONS 3)THE THIRD/INTERDENTAL INCISION

VERTICAL INCISIONS INCISIONS ARE MADE AT THE LINE ANGLES OF A TOOTH EITHER TO INCLUDE THE PAPILLA OR EXCLUDE THESE INCISIONS MUST REACH BEYOND THE MUCOGINGIVAL LINE

ELEVATION OF THE FLAP ELEVATION OF FLAP IS DONE WITH A PERIOSTEAL ELEVATOR TO OBTAIN A FULL THICKNESS FLAP ELEVATION OF FLAP IS DONE WITH A BARD-PARKER KNIFE TO OBTAIN A SPLIT THICKNESS FLAP

THE FLAP TECHNIQUE FOR POCKET THERAPY FLAPS USED FOR POCKET THERAPY ACCOMPLISH THE FOLLOWING:- INCREASED ACCESSIBILITY TO THE ROOT DEPOSITS. ELIMINATE OR REDUCE THE POCKET DEPTH. EXPOSE THE AREA TO PERFORM REGENERATIVE METHODS.

FLAP PROCEDURES THE ORIGINAL WIDMAN FLAP (1918)

THE NEUMANN FLAP(1920,1926) AN INTRACREVICULAR INCISION WAS MADE THROUGH THE BASE OF THE POCKETS, AND THE ENTIRE GINGIVA(& PART OF THE ALVEOLAR MUCOSA) WAS ELEVATED IN A MUCOPERIOSTEAL FLAP.

THE MODIFIED FLAP OPERATION(THE KIRKLAND FLAP,1931) IT IS A SURGICAL PROCEDURE TO BE USED IN THE TREATMENT OF “PERIODONTAL PUS POCKETS”, ITS BASICALLY AN ACCESS FLAP FOR PROPER ROOT DEBRIDEMENT.

THE INTRACREVICULAR INCISION

THE GINGIVA IS RETRACTED TO EXPOSE THE DISEASED ROOT SURFACE

MECHANICAL DEBRIDEMENT

IN CONTRAST TO THE PREVIOUS TWO FLAPS THIS FLAP DID NOT INCLUDE:- EXTENSIVE SACRIFICE OF NON INFLAMED TISSUES. APICAL DISPLACEMENT OF THE GINGIVAL MARGIN. ANOTHER ADVANTAGE OF THIS FLAP WAS THE POTENTIAL FOR BONE REGENERATION IN INRABONY DEFECTS WHICH OCCURRED FREQUENTLY ACCORDING TO KIRKLAND(1931)

THE MAIN OBJECTIVES OF FLAP PROCEDURES SO FAR WERE TO:- FACILITATE DEBRIDEMENT OF THE ROOT SURFACES AS WELL AS THE REMOVAL OF THE POCKET EPITHELIUM & THE INFLAMED CONNECTIVE TISSUE. ELIMINATE THE DEEPENED POCKETS(THE ORIGINAL WIDMAN FLAP& THE NEUMANN FLAP) CAUSE A MINIMAL AMOUNT OF TRAUMA TO THE PERIODONTAL TISSUES & DISCOMFORT TO THE PATIENT.

IN 1950’s& 1960’s NEW SURGICAL TECHNIQUES FOR REMOVAL OF SOFT & HARD TISSUE POCKETS WERE DESCRIBED. IMPORTANCE OF MAINTAINING AN ADEQUATE ZONE OF ATTCHED GINGIVA WERE EMPHASIZED. NABERS(1954)-DESCRIBED TECHNIQUE FOR PRESERVATION OF GINGIVA FOLLOWING SURGERY,DENOTED AS “REPOSITIONING OF ATTACHED GINGIVA” LATER MODIFIED BY ARIAUDO & TYRRELL(1957)

THE APICALLY REPOSITIONED FLAP(FRIEDMAN,1962)

THE APICALLY REPOSITIONED FLAP FOLLOWING A VERTICAL INCISION A REVERSE BEVEL INCISION MADE

THE APICALLY REPOSITIONED FLAP A MUCOPERIOSTEAL FLAP RASED AND TISSUE COLLAR AROUND THE TEETH IS REMOVED WITH A CURETTE

THE APICALLY REPOSITIONED FLAP OSSEOUS SURGERY IS PERFORMED WITH ROTATING BUR

THE APICALLY REPOSITIONED FLAP RECAPTURE THE PHYSIOLOGIC CONTOUR OF THE ALVEOLAR BONE

THE APICALLY REPOSITIONED FLAP FLAPS REPOSITIONED IN AN APICAL DIRECTION

THE APICALLY REPOSITIONED FLAP PERIODONTAL DRESSING PLACED

THE BEVELED FLAP INTRACREVICULAR INCISION

BEVELED FLAP MUCOPERIOSTEAL FLAP IS RAISED

BEVELED FLAP SCALING,ROOT PLANING AND OSSOEUS RECONTOURING DONE

BEVELED FLAP PALATAL FLAP REPLACED AND A SECONDARY SCALLOPED REVERSE BEVELED INCISION IS MADE TO ADJUST FLAP TO THE REMAINING ALVEOLAR BONE

BEVELED FLAP SHORTENED AND THINNED FLAP IS REPLACED OVER ALVEOLAR BONE IN CLOSE CONTACT WITH THE ROOT SURFACE

ADVANTAGES OF APICALLY POSITIONED FLAP MINIMUM POCKET DEPTH POST OPERATIVELY IF OPTIMAL SOFT TISSUE COVERAGE OF THE ALVEOLAR BONE IS OBTAINED, THE POST SURGICAL BONE LOSS IS MINIMAL. POSTOPERATIVE POSITION OF THE GINGIVAL MARGIN MAY BE CONTROLLED AND THE ENTIRE MUCOGINGIVAL COMPLEX MAY BE MAINTAINED.

DISADVANTAGES SACRIFICE OF PERIODONTAL TISSUES BY BONE RESECTION. SUBSEQUENT EXPOSURE OF ROOT SURFACES.(WHICH CAUSES ESTHETIC AND ROOT HYPERSENSITIVITY PROBLEMS)

IN 1965,MORRIS REVIVED THE TECHNIQUE DESCRIBED IN EARLY LITERATURE, AND CALLED IT UNREPOSITIONED MUCOPERIOSTEAL FLAP. RAMFJORD & NISSLE(1974) DESCRIBED THE MODIFIED WIDMAN FLAP TECHNIQUE, WHICH IS ALSO RECOGNISED AS THE “OPEN CURETTAGE TECHNIQUE” IT OFFERS THE POSSIBILITY OF OBTAINING AN INTIMATE POSTOPERATIVE ADAPTATION OF HEALTHY COLLAGENOUS CONNECTIVE TISSUE TO THE TOOTH SURFACES,ALSO PROVIDES ACCESS FOR PROPER ROOT INSTRUMENTATION & IMMEDIATE CLOSURE OF THE AREA.

THE MODIFIED WIDMAN FLAP TECHNIQUE(RAMFJORD & NISSLE,1974)

MODIFIED WIDMAN FLAP INITIAL INCISION IS PLACED 0.5-1mm FROM GINGIVAL MARGIN AND PARALLEL TO LONG AXIS OF TOOTH

MODIFIED WIDMAN FLAP FOLLOWING ELEVATION OF THE FLAP,SECONDARY INCISION IS MADE

MODIFIED WIDMAN FLAP THIRD INCISION IS MADE PERPENDICULAR TO ROOT SURFACE

MODIFIED WIDMAN FLAP DEBRIDEMENT AND CURETTAGE OF ANGULAR BONE DEFECTS,FLAPS REPLACED AND SUTURED

ADVANTAGES:- POSSIBILITY OF OBTAINING A CLOSE ADAPTATION OF THE SOFT TISSUES TO THE ROOT SURFACES. MINIMUM OF TRAUMA TO WHICH THE ALVEOLAR BONE AND THE SOFT CONNECTIVE TISSUES ARE EXPOSED. LESS EXPOSURE OF ROOT SURFACES, WHICH FORM AN ESTHETIC POINT OF VIEW IS AN ADVANTAGE IN TREATMENT OF ANTERIOR SEGMENTS OF DENTITION.

TO PRESERVE THE INTERDENTAL SOFT TISSSUES FOR MAXIMUM SOFT TISSUE COVERAGE FOLLOWING SURGICAL INTERVENTION INVOLVING TREATMENT OF PROXIMAL OSSEOUS DEFECTS,TAKEI et al.,1985 PROPOSED PAPILLA PRESERVATION TECHNIQUE. THIS TECHNIQUE OFTEN USED IN SURGICAL TREATMENT OF ANTERIOR TOOTH REGIONS FOR ESTHETIC REASONS.

PAPILLA PRESERVATION FLAP INTRASULCULAR INCISIONS MADE AT FACIAL AND PROXIMAL ASPECTS

PAPILLA PRESERVATION FLAP AN INTRASULCULAR INCISION ON LINGUAL/PALATAL ASPECT OF TEETH WITH SEMILUNAR INCISION ACROSS INTERDENTAL AREA

PAPILLA PRESERVATION FLAP A CURETTE OR INTERDENTAL KNIFE IS USED TO FREE THE INTERDENTAL PAPILLA FROM UNDERLYING HARD TISSUE

PAPILLA PRESERVATION FLAP DETACHED INTERDENTAL TISSUE IS PUSHED THROUGH THE EMBRASSURE WITH BLUNT INSTRUMENT TO BE INCLUDED IN FACIAL FLAP

PAPILLA PRESERVATION FLAP FLAP REPLACED, SUTURES PLACED ON THE PALATAL ASPECT OF INTERDENTAL AREA

THE UNDISPLACED FLAP

PALATAL FLAP

CONVENTIONAL FLAP FOR REGENERATIVE SURGERY

DISTAL WEDGE PROCEDURE SIMPLE GINGIVECTOMY INCISION TO ELIMINATE A SOFT TISSUE POCKET BEHIND MAXILLARY MOLAR

DISTAL WEDGE PROCEDURE BUCCAL AND LINGUAL INCISION,TRIANGULARWEDGE SHAPED TISSUE REMOVED

DISTAL WEDGE PROCEDURE FLAPS REDUCED IN THICKNESS,TRIMMED & SHORTENED& SUTURED

MODIFIED DISTAL WEDGE PROCEDURE

MODIFIED DISTAL WEDGE PROCEDURE

MODIFIED DISTAL WEDGE PROCEDURE

MODIFIED DISTAL WEDGE PROCEDURE

MODIFIED INCISION TECNIQUES IN DISTAL WEDGE PROCEDURE

GENERAL INDICATIONS OF FLAPS FLAP OPERATIONS CAN BE USED IN ALL CASES WHERE TREATMENT OF PERIODONTAL DISEASE IS INDICATED. FLAP PROCEDURES ARE PARTICULARLY USEFUL AT SITES WHERE POCKETS EXTEND BEYOND MUCOGINGIVAL BORDER AND/OR WHERE TREATMENT OF BONY LESIONS AND FURCATION INVOLVEMENT IS REQUIRED.

ADVANTAGES OF FLAP OPERATIONS:- EXISTING GINGIVA IS PRESERVED. MARGINAL ALVEOLAR BONE IS EXPOSED WHEREBY THE MORPHOLOGY OF BONY DEFECTS CAN BE IDENTIFIED AND PROPER TREATMENT RENDERED. FURCATION AREAS ARE EXPOSED, THE DEGREE OF INVOLVEMENT & THE “TOOTH-BONE” RELATIONSHIP CAN BE IDENTIFIED .

THE FLAP CAN BE REPOSITIONED AT ITS ORIGINAL LEVEL OR SHIFTED APICALLY, THEREBY MAKING IT POSSIBLE TO ADJUST GINGIVAL MARGINS TO THE LOCAL CONDITIONS. THE FLAP PROCEDURE PRESERVES THE ORAL EPITHELIUM & OFTEN MAKES THE USE OF SURGICAL DRESSING SUPERFLUOUS. PREOPERATIVE PERIOD IS LESS UNPLEASANT FOR PATIENT WHEN COMPARED TO GINGIVECTOMY.

TREATMENT DECISIONS FOR SOFT AND HARD TISSUE POCKETS

SOFT TISSUE POCKETS DEPENDING ON THE SURGICAL TECHNIQUE USED, THE SOFT TISSUE FLAP SOULD BE EITHER APICALLY POSITIONED AT THE LEVEL OF THE BONE CREST(ORIGINAL WIDMAN FLAP,NEUMAN FLAP& APICALLY POSITIONED FLAP) OR MAINTAINED IN A CORONAL POSITION(KIRKLAND FLAP,MODIFIED WIDMAN FLAP& PAPILLA PRESERVATION FLAP) IN THE ANTERIOR TOOTH REGION AESTHETICS IS IMPORTANT CONSIDERATION,SO MAINTAIN PRESURGICAL SOFT TISSUE HEIGHT

LONG TERM CLINICAL RESULTS HAVE SHOWN THAT MAJOR DIFFERENCES IN THE FINAL POSITION OF SOFT TISSUE MARGIN ARE NOT EVIDENT BETWEEN SURGICAL PROCEDURES INVOLVING CORONAL & APICAL POSITIONING OF FLAP MARGIN. REPORTED DIFFERENCES IN FINAL POSITIONING OF GINGIVAL MARGIN IS ATTRIBUTED TO OSSEOUS RECONTOURING. GOAL SHOULD BE TO ACHIEVE COMPLETE SOFT TISSUE COVERAGE OF ALVEOLAR BONE.

HARD TISSUE POCKETS OPT FOR CONVERSION OF AN INTRABONY DEFECT IN TO SUPRABONY DEFECT,WHICH IS THEN ELIMINATED BY AN APICAL REPOSITIONING OF THE SOFT TISSUE. FACTORS CONSIDERED IN TREATMENT DECISION ARE ESTHETICS TOOTH/TOOTH SITE INVOLVED DEFECT MORPHOLOGY AMOUNT OF REMAINING PERIODONTIUM

THE VARIOUS TREATMENT OPTIONS AVAILABLE FOR HARD TISSUE POCKETS ARE ELIMINATION OF THE OSSEOUS DEFECT BY RESECTION OF BONE. MAINTENANCE OF THE AREA WITH OUT OSSEOUS RESECTION COMPROMISING THE AMOUNT OF BONE REMOVAL AND ACCEPTING THAT A CERTAIN POCKET DEPTH WILL REMAIN. AN ATTEMPT TO IMPROVE HEALING THROUGH THE USE OF A REGENERATIVE PROCEDURE EXTRACTION OF THE INVOLVED TOOTH IF THE BONY DEFECT CONSIDERED TOO ADVANCED.

INTERRUPTED INTERDENTAL SUTURES

MODIFIED INTERRUPTED INTERDENTAL SUTURES

MODIFIED MATTRESS SUTURE

SUSPENSORY SUTURE

CONTINUOUS SUTURE

PERIODONTAL DRESSING

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