Severe hypersensitivity. The three incisions necessary for flap surgery. 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 periodontal flap surgeries have been practiced for more than one hundred years now, since their introduction in the early 1900s. It is an access flap for the debridement of the root surfaces. This will allow the clinician to retain the maximum amount of gingival tissue, including the papilla, which is essential for graft or membrane coverage. A technique using a mixture of bone dust and blood is called as a. bone blend technique b. bone swaging technique The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. 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. Palatal flaps cannot be displaced because of the absence of unattached gingiva. Endodontic Topics. The entire surgical procedure should be planned in every detail before the procedure is initiated. Ramfjord and Nissle6 performed an extensive longitudinal study that compared the Widman procedure (as modified by them) with the curettage technique and the pocket elimination methods, which include bone contouring when needed. 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 . These are indicated in cases where interdental spaces are too narrow and when the flap needs to be displaced. Contents available in the book . One technique includes semilunar incisions which are . The triangular wedge of the tissue, hence formed is removed. 15 scalpel blade, parallel to each other beginning at the distal end of the edentulous area, continued to the tooth. 4. Step 2: The initial, or internal bevel, incision is made. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. Pronounced gingival overgrowth, which is handled more efficiently by means of gingivectomy / gingivoplasty. The Orban knife is usually used for this incision. 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. An intact papilla should be either excluded or included in the flap. Click this link to watch video of the surgery: Modified Widman Flap surgery. 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. Posterior spinal fusion for adolescent idiopathic scoliosis using a convex pedicle screw technique; . Locations of the internal bevel incisions for the different types of flaps. Hereditary gingival fibromatosis (HGF), also known as idiopathic gingival hyperplasia, is a rare condition of gingival overgrowth. See Page 1 This is termed. The modified Widman flap. After these three incisions are made correctly, a triangular wedge of the tissue is obtained containing the inflamed connective. Genon and Bender in 1984 27 also reported a similar technique indicated for esthetic purpose. The gingival margin is removed, and the flap is reflected to gain access for root therapy. 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. Kirkland flap method was the most commonly followed (60.47%), then it was modified widman flap (29.65%), undisplaced flap (6.39%) and distal wedge which was the lowest (3.48%). Patients at high risk for caries. Contraindications of periodontal flap surgery. The first step, Trismus is the inability to open the mouth. Contents available in the book .. After the administration of local anesthesia, bone sounding is performed to identify the exact thickness of the gingiva. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. The incisions made should be reverse bevel to achieve thinning of tissue so that an adequate final approximation of the flaps can be achieved. As discussed in, Periodontal treatment of medically compromised patients, antibiotic prophylaxis is must in patients with medical conditions such as rheumatic heart disease. Intrabony pockets on distal areas of last molars. The internal beveled incision for the modified Widman flap closely follows the scalloped outline of the dentition to minimize the loss of the attached keratinized gingiva. Flap adaptation is then done with the help of moistened gauze and any excess blood is expressed. May cause hypersensitivity. The periosteum left on the bone may also be used for suturing the flap when it is displaced apically. With this access, the surgeon is able to make the. Contents available in the book .. The interdental incision is then made to severe the inter-dental fiber attachment. Inferior alveolar nerve block C. PSA 14- A patient comes with . Contents available in the book .. Apically displaced flap, and 7. The aim of this review is to determine the use of 3D printed technologies in the treatment of scaphoid fractures. When bone is stripped of its periosteum, a loss of marginal bone occurs, and this loss is prevented when the periosteum is left on the bone. The area is then re-inspected for any remaining granulation tissue, tissue tags and deposits on root surfaces. Suturing is then performed to stabilize the flaps in their position. The triangular wedge of the tissue, hence formed is removed. Contents available in the book . Contents available in the book .. This flap procedure utilizes two incisions referred to as primary and secondary incisions which contain tissue which has to be removed. However, there are important variations in the way these incisions are performed for the different types of flaps (Figures 59-1 and 59-2). techniques revealed that 67.52% undergone kirkland flap, 20.51% undergone modified widman flap, 5.21% had papilla preservation flap, 2.25% had undisplaced flap, 1.55% had apically displaced flap and very less undergone distal wedge procedure which depicts that most commonly used flap technique was kirkland flap among other techniques. Residual periodontal fibers attached to the tooth surface should not be disturbed. The palatal flap offers a technically simple and predictable option for intraoral reconstruction. The undisplaced flap and gingivectomy are the two techniques that surgically removed the pocket wall. Unrealistic patient expectations or desires. The incision is made around the entire circumference of the tooth using blade No. Contents available in the book .. This drawback of conventional flap techniques led to the development of this flap technique which intended to spare the papilla instead of splitting it. Contents available in the book .. Because the alveolar bone is partially exposed, there is minimum post-operative pain and swelling. The beak-shaped no. Local anesthesia is administered to achieve profound anes-thesia in the area to be operated. Contents available in the book .. Preservation of good blood supply to the flap is another important consideration. The original intent of the surgery was to access the root surface for scaling and root planing. The margins of the flap are then placed at the root bone junction. The patient is then recalled for suture removal after one week. - Charter's method - Bass method - Still man method - Both a and b correct . . The clearly visible root surfaces and osseous defects are then debrided with the help of hand (curettes) and ultrasonic (ultrasonic scalers) instruments. The beak-shaped no. In case, where osseous recontouring is done the flap margins may be re-scalloped and trimmed to adapt to the root bone junction. 5. The area is then irrigated with an antimicrobial solution. It enhances the potential for effective periodontal maintenance and preservation of attachment levels. a. In this technique no. Step 2:The gingiva is reflected with a periosteal elevator (Figure 59-3, D). This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. Tooth with extremely unfavorable clinical crown/root ratio. 2)Wenow employ aK#{252}ntscher-type nailslightly bent forward inits upper part, allowing easier removal when indicated. 1. May cause esthetic problems due to root exposure. Contents available in the book . Contents available in the book .. Pockets around the teeth in which a complete removal of root irritants is not clinically possible without gaining complete access to the root surfaces. Position of the knife to perform the internal bevel incision. 12 or no. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. The process of healing progresses through various phases of . The flap design may also be dictated by the aesthetic concerns of the area of surgery. Following shapes of the distal wedge have been proposed which are, 1. drg. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. The flap was repositioned and sutured and . FLAP PERIODONTAL. The bleeding is frequently associated with pain. A detailed description of the historical aspect of various flap surgeries has been given in the previous chapter. When the flap is returned and sutured in its original position. The main advantages of this procedure are the preservation of maximum healthy tissue and minimum post-operative discomfort to the patient. Scalloping follows the gingival margin. Contents available in the book .. This will allow better coverage of the bone at both the radicular and interdental areas. This complete exposure of and access to the underlying bone is indicated when resective osseous surgery is contemplated. Areas with sufficient band of attached gingiva. After this, the second or the sulcular incision is made from the bottom of the pocket till the crest of the alveolar bone. Evian et al. Tooth with extremely unfavorable clinical crown/root ratio. 3. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. After this, partial elevation of the flap is done with the help of a small periosteal elevator. After one week, the sutures are removed and the area is irrigated with normal saline solution. Henry H. Takei, Fermin A. Carranza and Kitetsu Shin. ), 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. However, to do so, the attached gingiva must be totally separated from the underlying bone, thereby enabling the unattached portion of the gingiva to be movable. The vertical incision should always be placed at the line angles of the teeth and never (except rare instances, such as a double papilla flap) over the height of contour of the root. They are also useful for treating moderate to deep periodontal pockets in the posterior regions. Because the pocket wall is not displaced apically, the initial incision should eliminate the pocket wall. 3. The operated area will be cleaner without dressing and will heal faster. The primary incision or the internal bevel incision is then made with the help of No. It is indicated where complete access to the bone is required, for example, in the case of osseous resective surgeries. The apically displaced flap provides accessibility and eliminates the pocket, but it does the latter by apically positioning the soft-tissue wall of the pocket.2 Therefore, it preserves or increases the width of the attached gingiva by transforming the previously unattached keratinized pocket wall into attached tissue. . 6. Fundamental principles in periodontal plastic surgery and mucosal augmentationa narrative review. A full-thickness flap is then elevated to expose 1-2 mm of the marginal bone. Conventional flap. The periodontal dressing is not required if the flap has been adapted adequately to cover the interdental area. Contents available in the book .. Every effort is made to adapt the facial and lingual interproximal tissue adjacent to each other in such a way that no interproximal bone remains exposed at the time of suturing. Contents available in the book .. Contents available in the book . In this flap procedure, all the soft tissue, including the periosteum is reflected to expose the underlying bone. Contents available in the book .. That portion of the gingiva left around the tooth contains the epithelium of the pocket lining and the adjacent granulomatous tissue. After the flap is reflected, a third incision is made in the interdental spaces coronal to the bone with a curette or an interproximal knife, and the gingival collar is removed (, Tissue tags and granulation tissue are removed with a curette. (1985) 26 modified this procedure to preserve anterior esthetics after flap surgery. After healing, the resultant architecture of the area should enhance the ease and effectiveness of self-performed oral hygiene measures by the patient. Contents available in the book .. Contents available in the book .. The horizontal or interdental incision is then made using a small knife (Orban 1 or 2), severing the supracrestal gingival fibers. Within the first few days, monocytes and macrophages start populating the area, Post-operative complications after periodontal flap surgery, Hemorrhage occurring after 7-14 days is secondary to trauma or surgery. This is essentially an excisional procedure of the gingiva. . The root surfaces are checked and then scaled and planed, if needed (Figure 59-3, G and H). Areas where greater probing depth reduction is required. Now, after the completion of the partial-thickness flap, the scalpel blade is directed from the base of this incision towards the bone to give a scoring incision. The meniscus comma sign has been described for displaced flap tears of the meniscus. The following steps outline the undisplaced flap technique: Step 1: The pockets are measured with the periodontal probe. The incision is made . 2. In this technique, two incisions are made with the help of no. 5. Contents available in the book .. May cause attachment loss due to surgery. Both full-thickness and partial-thickness flaps can also be displaced. Contents available in the book .. This flap procedure causes the greatest probing depth reduction. Journal of periodontology. The esthetic and functional demands of maxillofacial reconstruction have driven the evolution of an array of options. This incision is indicated in the following situations. The following steps outline the undisplaced flap technique. Areas which do not have an esthetic concern. In non-esthetic areas with moderate to deep pockets and for crown lengthening, this incision is indicated. 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. Contents available in the book .. The thicker the tissue is, the more apical the ending point of the incision (see Figure 59-4). 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. To facilitate the close approximation of the flap, judicious osteoplasty, if required, is performed. THE UNDISPLACED FLAP TECHNIQUE Step 1: Measure pockets by periodontal probe,and a bleeding point is produced on the outer surface of the gingiva by pocket marker. Tooth with marked mobility and severe attachment loss. 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. Modified flap operation, C. According to flap placement after surgery: 1- initial internal bevel incision 2- crevicular incisions 3- initial elevation of the flap 4- vertical incisions extending beyond the mucogingival junction 5- SRP performed 6- flap is apically positioned 7- place periodontal dressing to ensure the flap remains apically displaced The vertical incision must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow for the release of the flap to be displaced. Apically displaced flap can be done with or without osseous resection. Areas where post-operative maintenance can be most effectively done by doing this procedure. 11 or 15c blade. Contents available in the book .. Step 2: The initial, internal bevel incision is made after the scalloping of the bleeding marks on the gingiva. The following statements can be made regarding periodontal regeneration procedures. The location of the primary incision is based on the thickness of the gingiva, width of attached gingiva, the contour of the gingival margins, surgical objectives, and esthetic considerations. The researchers reported similar results for each of the three methods tested. In a full-thickness flap, all of the soft tissue, including the periosteum, is reflected to expose the underlying bone. The crevicular incision, which is also called the second incision, is made from the base of the pocket to the crest of the bone (Figure 57-8). These meniscus tears are displaced into the tibia or femoral recesses and can be often difficult to diagnose intraoperatively. Vertical relaxing incisions are usually not needed. Contents available in the book . The book is usually delivered within one week anywhere in India and within three weeks anywhere throughout the world. Minor osseous recontouring may be done and the flap is then adapted into the interdental areas. In this technique no. Later on Cortellini et al. Periodontal maintenance (Supportive periodontal therapy), Orthodontic-periodontal interrelationship, Piezosurgery in periodontics and oral implantology. 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. Depending on how the interdental papilla is managed, flaps can either split the papilla (conventional flap) or preserve it (papilla preservation flap). 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. The use of continuous suturing in suture materials tearing through the flap edges and both plastic surgery (1) and periodontal surgery subsequent retraction of the flaps to less desirable has many advantages. It is indicated when the flap has to be positioned apically and when the exposure of the bone is not required. The flaps may be thinned to allow for close adaptation of the gingiva around the entire circumference of the tooth and to each other interproximally. It is caused by trauma or spasm to the muscles of mastication. Need to visually examine the area, to make a definite diagnosis. Another important objective of periodontal flap surgery is to regenerate the lost periodontal apparatus. The flaps are then apically positioned to just cover the alveolar crest. Step 1:The initial incision is an internal bevel incision to the alveolar crest starting 0.5mm to 1mm away from the gingival margin (Figure 59-3, C). 1. 4. 1. Sutures are removed after one week and the area is irrigated with normal saline. It is also known as the mucoperiosteal (mucosal tissue + periosteum) flap. Triangular (adsbygoogle = window.adsbygoogle || []).push({}); The external bevel incision is typically used in gingivectomy procedures. Sutures are placed to secure the flaps in their position. Areas which do not have an esthetic concern. The classic treatment till today in developing countries is removal of excess gingival growth by scalpel but one should remember about the periodontal treatment which should be done before commencing the surgical part of . ), For the conventional flap procedure, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla or its vicinity, thereby splitting the papilla into a facial half and a lingual or palatal half (Figures 57-3 and. 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. See video of the surgery at: Modified flap operation. 2. B. Contents available in the book .. 7. 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. Every effort is made to adapt the facial and lingual interproximal tissue adjacent to each other in such a way that no interproximal bone remains exposed at the time of suturing. 7. Access flap for guided tissue regeneration. Contents available in the book .. 30 Q . The modified Widman flap procedure involves placement of three incisions: the initial internal bevel/ reverse bevel incision (first incision), the sulcular/crevicular incision (second incision) and the horizontal/interdental incision (third incision). Swelling is another common complication after flap surgery. The para-marginal internal bevel incision accomplishes three important objectives. Modified Widman flap and apically repositioned flap. 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 incision is then carried out till the line angle of the tooth blending it into the gingival crevice. A crescent-shaped incision is sometimes used during the crown lengthening procedure. 5. Contents available in the book . This is especially important in maxillary and mandibular anterior areas which have a prime esthetic concern. This wedge of tissue contains most of the inflamed and granulomatous areas that constitute the lateral wall of the pocket as well as the junctional epithelium and the connective tissue fibers that still persist between the bottom of the pocket and the crest of the bone. Refer to oral surgeon for biopsy ***** B. Alveolar crest reduction following full and partial thickness flaps. 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. This incision, together with the initial reverse bevel incision, forms a V-shaped wedge that ends at or near the crest of bone. In areas with shallow periodontal pocket depth. Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5-15% of all maxillofacial fractures. Otherwise, the periodontal dressing may be placed. In case of generalized chronic periodontitis with localized gingival overgrow th,undisplaced flap with internal bevel incision has given better results esthetically and structurally .Thus with th is approach there is improvement in periodontal health along with good esthetics. The main objective of periodontal flap surgical procedures is to allow access for the cleaning of the roots of teeth and the removal of the periodontal pocket lining, as well as to treat the irregularities of the alveolar bone, so that when gingiva is repositioned around the teeth, it will allow for the reduction of pockets, infections, and inflammation. As described in, Image showing primay and secondary incisions used in ledge and wedge technique. For the conventional flap procedure, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla or its vicinity, thereby splitting the papilla into a facial half and a lingual or palatal half (Figures 57-3 and 57-4). This type of incision, starting just below the bleeding points, removes the pocket wall completely. The following outline of this technique: 2. 16: 199-203 . The thickness of the gingiva. These incisions are made in a horizontal direction and may be coronally or apically directed. May cause attachment loss due to surgery. 1. If extensive osseous recontouring is planned, an exaggerated incision is given. The internal bevel incision starts from a designated area on the gingiva, and it is then directed to an area at or near the crest of the bone (. 2. To perform this technique without creating a mucogingival problem, the clinician should determine that enough attached gingiva will remain after removal of the pocket wall. Rough handling of the tissue and long duration of the surgery commonly result in post-operative swelling. 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 is a commonly used incision during periodontal flap surgeries. Contents available in the book .. Areas where post-operative maintenance can be most effectively done by doing this procedure. 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. One incision is now placed perpendicular to these parallel incisions at their distal end. Maintaining primary closure after guided bone regeneration procedures: Introduction of a new flap design and preliminary results. Unsuitable for treatment of deep periodontal pockets. 3) The insertion of the guide-wire presents Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. Root planing is done followed by osseous surgery if needed. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. For this reason, the internal bevel incision should be made as close to the tooth as possible (i.e., 0.5mm to 1.0mm) (see Figure 59-1). A periodontal flap is a section of gingiva, mucosa, or both that is surgically separated from the underlying tissues to provide for the visibility of and access to the bone and root surface. 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. 2014 Apr;41:S98-107. The patient is recalled after one week for suture removal. 4. Periodontal Flap Surgery Wendy Jeng 117.4k views 035. periodontal flap Dr.Jaffar Raza BDS 7.5k views 17.occlusal schemes anatomic and semiamatomic occlusion www.ffofr.org - Foundation for Oral Facial Rehabilitiation 1.1k views Suturing techniques involved in dental surgery Hasanain Alani Contents available in the book . Click this link to watch video of the surgery: Areas where greater probing depth reduction is required. The factors that are associated with post-operative swelling include the type of the incision, its extension, tissue manipulation during the surgery and the duration of surgery. Conventional flaps include: The modified Widman flap, The undisplaced flap, The apically displaced flap, The flap for regenerative procedures. In these flaps, the entire papilla is incorporated into one of the flaps. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Full-thickness or partial thickness flap may be elevated depending on the objectives of the surgery. Flaps are used for pocket therapy to accomplish the following: 1. Ramfjord SP, Nissle RR. Position of the knife to perform the crevicular (second) incision. Along with removing the tissue above the alveolar crest, this incision also reveals the thickness of the soft tissue. Contents available in the book . Periodontal flaps involve the use of horizontal (mesialdistal) and vertical (occlusalapical) incisions. In areas with thin gingiva and alveolar process. Platelets rich fibrin (PRF) preparation and application in the .
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