This incision causes extensive loss of tissue and is indicated only in cases of gingival overgrowth. Pronounced gingival overgrowth, which is handled more efficiently by means of gingivectomy / gingivoplasty. The area to be operated is then isolated with the help of gauge. A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissue to provide visibility and access to the bone and root surfaces 1. Diagram showing the location of two different areas where the internal bevel incision is made in an undisplaced flap. Scaling, root planing and osseous recontouring (if required) are carried out. Contents available in the book .. Contents available in the book . Irrespective of performing any of the above stated surgical procedures, periodontal wound healing always begins with a blood clot in the space maintained by the closed flap after suturing 36. In 1973, App 25 reported a similar technique and termed it as Intact Papilla Flap which retained the interdental gingiva in the buccal flap. This incision is indicated in the following situations. The conventional flap is used (1) when the interdental spaces are too narrow, thereby precluding the possibility of preserving the papilla, and (2) when the flap is to be displaced. Inferior alveolar nerve block C. PSA 14- A patient comes with . The base of the flap should be wider than the flap margin so that the blood supply to the flap is not jeopardized. A full-thickness flap is elevated with the help of a periosteal elevator whereas partial-thickness flap is elevated using sharp dissection with a Bard-Parker knife. Areas which do not have an esthetic concern. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. Incisions used in papilla preservation flap using primary and secondary incisions. Scalloping required for the different types of flaps (see, The apically displaced flap technique is selected for cases that present a minimal amount of keratinized, attached gingiva. The granulation tissue is highly vascularized, so it bleeds profusely. During the initial phase of healing, inflammatory cells are attracted by platelet and complement derived mediators and aggregate around the blood clot. Tooth with marked mobility and severe attachment loss. After this, the second incision or the sulcular incision is made from the bottom of the pocket to the crest of the alveolar bone. The undisplaced flap is therefore considered an internal bevel gingivectomy. During crown lengthening, the shape of the para-marginal incision depends on the desired crown length. The periosteum left on the bone may also be used for suturing the flap when it is displaced apically. 3. The challenging nature of scaphoid fracture and nonunion surgery make it an obvious target. Apically-displaced Flap 3. More is the thickness of the gingiva, farther is the incision placed to include more tissue which needs to be removed. C. According to flap placement after surgery: Signs and symptoms may include continuous flow, oozing or expectoration of blood or copious pink saliva. According to management of papilla: This incision can be accomplished only if sufficient attached gingiva remains apical to the incision. Contents available in the book .. UNDISPLACEDFLAP |Also known as internal bevel gingivectomy |Differs from the modified widman flap inthat pocket wall is removed with the initial incision TECHNIQUE |Pockets are measured with a pocket marker & a bleeding point is created THE INITIAL INTERNAL BEVEL INCISION IS CARRIED APICAL TO THE CREST OF BONE CONTD. Flap design for a sulcular incision flap. This is a modification of the partial thickness palatal flap procedure in which gingivectomy is done prior to the placement of primary and the secondary incision. The three different categories of flap techniques used in periodontal flap surgery are as follows: (1) the modified Widman flap; (2) the undisplaced flap; and (3) the apically displaced flap. The main causes for the bleeding include intrinsic trauma to the operated site, even after repeated instructions patients tend to play with the area of surgery with their tongue and dislodge the blood clot, tongue may also cause suction of blood by creating small negative pressures that cause secondary bleeding, presence of foreign bodies, infection, salivary enzymes may lyse the blood clot before it gets organized and slippage of suture. The area is anesthetized and bone sounding is done to evaluate the osseous topography, pocket depth, and thickness of the gingiva. Following is the description of marginal and para-marginal internal bevel incisions. Chlorhexidine rinse 0.2% bid . Flaps in which the interdental papilla is split beneath the contact of two approximating teeth, allowing the reflection of buccal and lingual flaps, are described as the conventional flaps. Modified Widman flap and apically repositioned flap. Areas with sufficient band of attached gingiva. In this technique, two incisions are made with the help of no. The primary incision or the internal bevel incision is then made with the help of No. This flap procedure causes the greatest probing depth reduction. Takei et al. 3. The internal bevel incision is basic to most periodontal flap procedures. Step 2:The initial or internal bevel incision is made (Figure 59-4) after scalloping the bleeding marks on the gingiva (Figure 59-5). This flap procedure may be regarded as internal bevel gingivectomy because the first incision or the internal bevel incision given during this procedure is placed at the level of pocket depth (Figure 62.1), thus including all the soft tissue containing and supporting periodontal pocket. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. ), Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 59: The Flap Technique for Pocket Therapy, Several techniques can be used for the treatment of periodontal pockets. Suturing is then done using a continuous sling suture. Contents available in the book . The incision is carried around the entire tooth. Osseous surgical procedures with very deep osseous defects and irregular bone loss, facially and lingually/ palatally. Contents available in the book .. It enhances the potential for effective periodontal maintenance and preservation of attachment levels. The most apical end of the internal bevel incision is exposed and visible. Need to visually examine the area, to make a definite diagnosis. The granulation tissue and the pocket lining may be then separated from the inner surface of the reflected flap with the help of surgical scissors and a scalpel. 6. 1. During this whole procedure, the placement of the primary incision is very important because if improperly given it may become short, leaving exposed bone or may become longer requiring further trimming which is difficult. With the conventional flap, the interdental papilla is split beneath the contact point of the two approximating teeth to allow for the reflection of the buccal and lingual flaps. In areas with deep periodontal pockets and bone defects. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. As described in, Image showing primay and secondary incisions used in ledge and wedge technique. This incision, together with the initial reverse bevel incision, forms a V-shaped wedge that ends at or near the crest of bone. A crevicular incision is made from the bottom of the pocket to the bone in such a way that it circumscribes the triangular wedge of tissue that contains the pocket lining. B. Contents available in the book .. The cell surface components or adhesive molecules of bacteria that interact with a variety of host componentsand responsible for recognizing and binding to specific host cell receptors A. Cadherins B. Adhesins C. Cohesins D. Fimbriae Answer: B 2. The apically displaced flap is . Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. A vertical incision may be given unilaterally (at one end of the flap) or bilaterally (on both ends of the flap). In 1965, Morris4 revived a technique described early during the twentieth century in the periodontal literature; he called it the unrepositioned mucoperiosteal flap. Essentially, the same procedure was presented in 1974 by Ramfjord and Nissle,6 who called it the modified Widman flap (Figure 59-3). Laterally displaced flap. Contents available in the book .. Full-thickness or partial thickness flap may be elevated depending on the objectives of the surgery. Areas where post-operative maintenance can be most effectively done by doing this procedure. It conserves the relatively uninvolved outer surface of the gingiva. May cause esthetic problems due to root exposure. A technique using a mixture of bone dust and blood is called as a. bone blend technique b. bone swaging technique Placing periodontal depressing is optional. After the area to be operated is irrigated with an anti-microbial solution, local anesthesia is applied and the area is isolated after profound anesthesia has been achieved. Laparoscopic technique for secondary vaginoplasty in male to female transsexuals using a modified . Contents available in the book .. Then, it is decided that how much tissue has to be removed so that the appropriate thickness of the gingiva is achieved at the end of the procedure. In this technique no. Methods Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting , were included for this prospective cohort . This incision, together will the para-marginal internal bevel incision, forms a V-shaped wedge ending at or near the crest of bone, containing most of the inflamed and . A full-thickness flap is then elevated to expose 1-2 mm of the marginal bone. Contents available in the book .. The periodontal pockets on the distal aspects of last molars, both in maxillary and the mandibular arches present a unique situation for which specific surgical designs have been advocated. Fibrous enlargement is most common in areas of maxillary and mandibular . Contents available in the book .. The modified Widman flap facilitates instrumentation for root therapy. 12 or no. 2011 Sep;25(1):4-15. Coronally displaced flap Connective tissue autograft Free gingival graft Laterally positioned flap Apically displaced flap 5. Access flap for guided tissue regeneration. This incision is made 1mm to 2mm from the teeth. The initial or the first incision is the internal bevel incision given not more than 1 mm from the crest of the gingiva and directed to the crest of the bone. The area is then irrigated with an antimicrobial solution. The area is then irrigated with normal saline and flaps are adapted back in position. After debridement, flaps are closely adapted around the teeth in close approximation, allowing healing by primary intention. 4. Fugazzotto PA. Contents available in the book . The flap procedures on the palatal aspect require a different approach as compared to other areas because the palatal tissue is composed of a dense collagenous fiber network and there is no movable mucosa on the palatal aspect. Because the alveolar bone is partially exposed, there is minimum post-operative pain and swelling. It is discarded after the crevicular (second) and interdental (third) incisions are performed (Figure 57-5). Therefore, these flaps accomplish the double objective of eliminating the pocket and increasing the width of the attached gingiva. The area is then irrigated with an antimicrobial solution. Fundamental principles in periodontal plastic surgery and mucosal augmentationa narrative review. The incision is usually scalloped to maintain gingival morphology and to retain as much papilla as possible. This type of flap is also called the split-thickness flap. If the dressing has to be placed, a dry foil is first placed over the flap before covering it with the dressing so that the displacement of the pack under the flap is prevented. Ramfjord SP, Nissle RR. Within the first few days, monocytes and macrophages start populating the area 37. In this technique no. 1. Alveolar crest reduction following full and partial thickness flaps. The proper placement of the flap margin at the toothbone junction during closure is important to prevent either recurrence of the pocket or the exposure of bone. Contents available in the book .. Posterior spinal fusion for adolescent idiopathic scoliosis using a convex pedicle screw technique; . Contents available in the book .. Which of the following mucogingival surgical techniques is indicated in areas of narrow gingival recession adjacent to a wide band of attached gingiva that can be used as a donor site? free gingival autograft double papilla flap modified Widman flap laterally displaced (positioned . Pockets around the teeth in which a complete removal of root irritants is not clinically possible without gaining complete access to the root surfaces. It is contraindicated in the areas where treatment for an osseous defect with the mucogingival problem is not required, in areas with thin periodontal tissue with probable osseous dehiscence or osseous fenestration and in areas where the alveolar bone is thin. Palatal flaps cannot be displaced because of the absence of unattached gingiva. 15c, 11 or 12d. Areas which do not have an esthetic concern. After this, the second or the sulcular incision is made from the bottom of the pocket till the crest of the alveolar bone. A. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Local anesthesia is administered to achieve profound anes-thesia in the area to be operated. The internal bevel incision should be scalloped into the interdental area to preserve the interdental papilla (see Figure 59-2). This is especially important in maxillary and mandibular anterior areas which have a prime esthetic concern. The full-thickness mucoperiosteal flap procedure is the same as that described for the buccal and lingual aspects. Log In or, (Courtesy Dr. Kitetsu Shin, Saitama, Japan. Contraindications of periodontal flap surgery. The square . Contents available in the book . This incision is made on the buccal aspect of the tooth till the desired level, sparing the interdental gingiva. According to flap reflection or tissue content: It is most commonly caused due to infection and sloughing of blood vessels. The undisplaced (unrepositioned) flap improves accessibility for instrumentation, but it also removes the pocket wall, thereby reducing or eliminating the pocket. It must be noted that if there is no significant bleeding and flaps are closely adapted, periodontal dressing is not required. The necessary degree of access to the underlying bone and root surfaces and the final position of the flap must be considered when designing the flap. Suturing techniques. The entire surgical procedure should be planned in every detail before the procedure is initiated. Contents available in the book .. The secondary incision is given from the depth of the periodontal pocket till the alveolar crest. Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. To facilitate the close approximation of the flap, judicious osteoplasty, if required, is performed. They are also useful for treating moderate to deep periodontal pockets in the posterior regions. 6. This increase in the width of the attached gingiva is based on the apical shift of the mucogingival junction, which may include the apical displacement of the muscle attachments. Flap for regenerative procedures. 6. Henry H. Takei, Fermin A. Carranza and Jonathan H. Do. The main advantages of this procedure are maximum conservation of the keratinized tissue, maximum closure of the flaps and greater access to the underlying bony topography and the distal furcation. What is a periodontal flap? Periodontal flaps can be classified on the basis of the following: For bone exposure after reflection, the flaps are classified as either full-thickness (mucoperiosteal) or partial-thickness (mucosal) flaps (Figure 57-1). The flap design may also be dictated by the aesthetic concerns of the area of surgery. Two types of horizontal incisions have been recommended: the internal bevel incision. It reduces mouth opening, is commonly associated with pain and causes difficulty in mastication. These, Historically, gingivectomy was the treatment of choice for these areas until 1966, when Robinson 32 addressed this problem and gave a separate surgical procedure for these areas which he termed, The triangular wedge technique is used in cases where the adequate zone of attached gingiva is present and in cases of short or small tuberosity. Interrupted or continuous sling sutures are then placed to secure the flaps in their place. Contents available in the book .. Re-inspection of the operated area is done to check for any deposits on the root surfaces, remaining granulation tissue or tissue tags which are removed, if detected. The reasons for placing vertical incisions at line angles of the teeth are. Deep intrabony defects. The blood clot provides a framework for the proliferation and migration of cells from surrounding tissues including gingiva, periodontal ligament (PDL), cementum, and alveolar bone 38. The process of healing progresses through various phases of . Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. The distance of the primary incision from the gingival margin depends on the thickness of the gingiva. While doing laterally displaced flap for root coverage, the vertical incision is made at an acute angle to the horizontal incision, in the direction toward which the flap will move, placing the base of the pedicle at the recipient site. 2. The esthetic and functional demands of maxillofacial reconstruction have driven the evolution of an array of options. However, there are important variations in the way these incisions are performed for the different types of flaps (Figures 59-1 and 59-2). It is most commonly caused due to infection and sloughing of blood vessels. The pockets are then measured and bleeding points are produced with the help of a periodontal probe on the outer surface of the gingiva, indicating the bottom of the pocket. This suturing causes the apical positioning of the facial papilla, thus creating open gingival embrasures (black holes). After the primary incision, tissue can now be retracted with the help of rat-tail pliers. Otherwise, the periodontal dressing may be placed. Contents available in the book .. This type of incision, starting just below the bleeding points, removes the pocket wall completely. This technique offers the possibility ol establishing an intimate postoperative adaptation ol healthy collagenous connective tissue to tooth surlaces " and provides access for adequate instrumentation ol the root surtaces and immediate closure ol the area the following is an outline of this technique: 74. A Technique to Obtain Primary Intention Healing in Pocket Elimination Adjacent to an Edentulous Area Article Jan 1964 G. Kramer M. Schwarz View Mucogingival Surgery: The Apically Repositioned. (adsbygoogle = window.adsbygoogle || []).push({}); The external bevel incision is typically used in gingivectomy procedures. A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissue to provide visibility and access to the bone and root surfaces, Periodontal flap surgeries are also done for the establishment of. The triangular wedge of the tissue made by the above three incisions is then removed with the help of curettes. The beak-shaped no. The most abundant cells during the initial healing phase are the neutrophils. The first step, Trismus is the inability to open the mouth. 11 or 15c blade. The distance of the incision from the gingival margin (thickness of the incision) varies according to the pocket depth, the thickness of the gingiva, width of the attached gingiva, shape and contour of gingival margins and whether or not the operative area is in the esthetic zone. 7. The incision is made . One incision is now placed perpendicular to these parallel incisions at their distal end. See video of the surgery at: Modified flap operation. The present systematic review analysed the clinical outcomes of resective surgery versus access flap procedures in subjects with periodontitis stages II-III (previously termed moderate to advanced periodontitis), in order to support the development of evidence-based guidelines for periodontal therapy. Step 2:The gingiva is reflected with a periosteal elevator (Figure 59-3, D). These are indicated in cases where interdental spaces are too narrow and when the flap needs to be displaced. 30 Q . A crescent-shaped incision is sometimes used during the crown lengthening procedure. In areas with a narrow width of attached gingiva. The objectives for the other two flap proceduresthe undisplaced flap and the apically displaced flapinclude root surface access and the reduction or elimination of the pocket depth. Contents available in the book .. The periodontal flap is one of the most frequently employed procedures, particularly for moderate and deep pockets in posterior areas (see, Increase accessibility to root deposits for scaling and root planing, Eliminate or reduce pocket depth via resection of the pocket wall, Gain access for osseous resective surgery, if necessary, Expose the area for the performance of regenerative methods, Technique for Access and Pocket Depth Reduction or Elimination, All three flap techniques that were just discussed involve the use of the basic incisions described in. All three flap techniques that were just discussed involve the use of the basic incisions described in Chapter 57: the internal bevel incision, the crevicular incision, and the interdental incision. The horizontal incisions are used to separate the gingiva from the root surfaces of teeth. Also, complicated or prolonged surgical procedures that require full-thickness mucoperiosteal flaps with resultant edema can lead to trismus. As already stated, depending on the thickness of the gingiva, any of the following approaches can be used. Trismus is the inability to open the mouth. With some variants, the apically displaced flap technique can be used for (1) pocket eradication and/or (2) widening the zone of attached gingiva. 2. The incision is made at the level of the pocket to discard the tissue coronal to the pocket if there is sufficient remaining attached gingiva. Gain access for osseous resective surgery, if necessary, 4. These meniscus tears are displaced into the tibia or femoral recesses and can be often difficult to diagnose intraoperatively. 1. If a full-thickness flap has been elevated, the sutures are placed along the mesial and the distal vertical incision lines to. The periodontal dressing is not required if the flap has been adapted adequately to cover the interdental area. This is termed. Swelling hinders routine working life of patient usually during the first 3 days after surgery 41. Following shapes of the distal wedge have been proposed which are, 1. The basic clinical steps followed during this flap procedure are as follows. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. the.undisplaced flap and the gingivectomy. The flap was repositioned and sutured [Figure 6]. Contents available in the book .. FLAP Flap yaitu suatu lembaran jaringan mukosa yang terdiri dari jaringan gingiva, mukosa alveolar, dan atau jaringan periosteum yang dilepaskan/ dissection dari permukaan tulang alveolar. The periodontal flap is one of the most frequently employed procedures, particularly for moderate and deep pockets in posterior areas (see Chapter 57). This technique offers the possibility of establishing an intimate postoperative adaptation of healthy collagenous connective tissue to tooth surfaces,2,3,5,6 and it provides access for adequate instrumentation of the root surfaces and immediate closure of the area. The no. It does not attempt to reduce the pocket depth, but it does eliminate the pocket lining. Increase accessibility to root deposits for scaling and root planing, 2. The first, second and third incisions are placed in the same way as in case of modified Widman flap and the wedge of the infected tissue is removed. 4. After administration of local anesthesia, bone sounding is done to assess the thickness of gingiva and underlying osseous topography. Contents available in the book .. 15 or 15C surgical blade is used most often to make this incision. By doing this, the periosteum is cut and it becomes easy to remove the secondary flap from the bone. For the management of the papilla, flaps can be conventional or papilla preservation flaps. A new technique for arthroscopic meniscectomy using a traction suture, , 2015-02, ()KCI . One of the most common complication after periodontal flap surgery is post-operative bleeding. An electronic search without time or language restrictions was . To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). DESCRIPTION. It is contraindicated in areas where the width of attached gingiva would be reduced to < 3 mm. 5. . The clearly visible root surfaces and osseous defects are then debrided with the help of hand (curettes) and ultrasonic (ultrasonic scalers) instruments. Care should be taken to insert the blade in such a way that the papilla is left with a thickness similar to that of the remaining facial flap. There is a loud S1 The murmur is a mid-diastolic rumbling heard best at . With the help of Ochsenbein chisels (no. Undisplaced flaps are one of the most common periodontal surgeries for correcting anatomical factors that predispose patients to predisposing periodontal disease, and makes it possible to improve aesthetics by eliminating obstacle of wearing a denture. This incision, together will the para-marginal internal bevel incision, forms a V-shaped wedge ending at or near the crest of bone, containing most of the inflamed and, The base of the flap should be wider than the flap margin so that the blood supply to the flap is not jeopardized. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. 7. The partial-thickness flap may be necessary when the crestal bone margin is thin and exposed with an apically placed flap or when dehiscences or fenestrations are present.