If the incisions have been made correctly, the flap will be at the crest of the bone with the scalloped papillae positioned interproximally, thus permitting its primary closure. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. After the patient has been thoroughly evaluated and pre-pared with non-surgical periodontal therapy, quadrant or area to be operated is selected. Expose the area for the performance of regenerative methods. Log In or, (Courtesy Dr. Kitetsu Shin, Saitama, Japan. . A. Disain flep ini memberikan estetis pasca bedah yang lebih baik, dan memberikan perlindungan yang lebih baik terhadap tulang interdental, hal mana penting sekali dalam tehnik bedah yang mengharapkan terjadinya regenerasi jaringan periodontium. 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. 1. Root planing is done followed by osseous surgery if needed. 3. The first documented report of papilla preservation procedure was by Kromer 24 in 1956, which was designed to retain osseous implants. in adults. 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. The antibiotics should be started before the surg-ical procedure so that appropriate antibiotic levels are there in blood at the time of surgery to prevent spread of infection. To preserve the present attached gingiva or even to establish an adequate strip of it, where it is narrow or absent. Several techniques such as gingivectomy, undisplaced flap with or without osseous surgery, apically repositioned flap . 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. Depending on the purpose, it can be a full . The incision is carried around the entire tooth. The beak-shaped no. The clearly visible root surfaces and osseous defects are then debrided with the help of hand (curettes) and ultrasonic (ultrasonic scalers) instruments. Contents available in the book .. Burkhardt R, Lang NP. These techniques are described in detail in. 2006 Aug;77(8):1452-7. 12 or no. Following is the description of marginal and para-marginal internal bevel incisions. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. 7. preservation flap ) papila interdental tidak terpotong karena tercakup ke salah satu flep (gambar 2C). 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). - Charter's method - Bass method - Still man method - Both a and b correct . Another important objective of periodontal flap surgery is to regenerate the lost periodontal apparatus. Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. 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%). Contents available in the book .. 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 distal wedge operation. The no. Pocket depth was initially similar for all methods, but it was maintained at shallower levels with the Widman flap; the attachment level remained higher with the Widman flap. This flap procedure allows complete access to the root surfaces allowing their mechanical debridement and decontamination under direct vision. Deep intrabony defects. 7. Contents available in the book .. Contents available in the book .. Trismus is the inability to open the mouth. The initial or internal bevel incision is made (. 16: 199-203 . The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. The first incision or the internal bevel incision is then made from the bleeding points directed at an apical level to the alveolar crest. The area is then re-inspected for any remaining granulation tissue, tissue tags and deposits on root surfaces. Need to visually examine the area, to make a definite diagnosis. 1. Technique-The technique that weusehas been reported previously (Zucman and Maurer 1965). The surgical approaches that split the papilla cause shrinkage and decrease in the height of the interdental papilla leading to the exposure of interproximal embrasures. Vertical incisions increase flap mobility, thus facilitating better access to the operative area. Flap reflection till alveolar mucosa to mobilize the flap causes more post-operative pain and discomfort. If detected, they are removed. As soon the granulation tissue is removed, the clear bone margins and root surfaces are visible. 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. After administration of local anesthesia, bone sounding is done to assess the thickness of gingiva and underlying osseous topography. 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. In the upcoming chapters, we shall read about various regenerative procedures which are aimed at achieving regeneration of lost periodontal structures. 3. Contents available in the book . The flap was repositioned and sutured and . Contents available in the book .. The periodontal flap surgeries have been practiced for more than one hundred years now, since their introduction in the early 1900s. Step 1:The pockets are measured with the periodontal probe, and a bleeding point is produced on the outer surface of the gingiva to mark the pocket bottom. A new technique for arthroscopic meniscectomy using a traction suture, , 2015-02, ()KCI . This incision, together with the initial reverse bevel incision, forms a V-shaped wedge that ends at or near the crest of bone. This incision can be accomplished only if sufficient attached gingiva remains apical to the incision. After healing, the resultant architecture of the area should enhance the ease and effectiveness of self-performed oral hygiene measures by the patient. Long-term outcome of undisplaced fatigue fractures of the femoral neck in young male adults; Contents available in the book .. The coronally directed incision is designated as external bevel incision whereas the apically directed incisions are the internal bevel and sulcular incision. The flap design may also be dictated by the aesthetic concerns of the area of surgery. 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. The incision is usually carried to a point apical to the alveolar crest, depending on the thickness of the tissue. 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. This preview shows page 166 - 168 out of 197 pages.. View full document. This is essentially an excisional procedure of the gingiva. 4. The horizontal incisions are used to separate the gingiva from the root surfaces of teeth. With this access, the surgeon is able to make the third incision, which is also known as the interdental incision, to separate the collar of gingiva that is left around the tooth. Contents available in the book .. The internal bevel incision should be scalloped into the interdental area to preserve the interdental papilla (see Figure 59-2). As described in History of surgical periodontal pocket therapy and osseous resective surgeries the palatal approach for . Trombelli L, Farina R. Flap designs for periodontal healing. The area is then debrided for all the granulation tissue present and scaling and root planing of the root surfaces are carried out. 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. a. Non-displaced flap. In this technique no. After this, partial elevation of the flap is done with the help of a small periosteal elevator. (2010) Factor V Leiden Mutation and Thrombotic Occlusion of Microsurgical Anastomosis After Free TRAM Flap. Table 1: showing thickness of gingiva in maxillary tooth region . Step 6:Bone architecture is not corrected unless it prevents good tissue adaptation to the necks of the teeth. Then sharp periodontal curettes are used to remove the granulomatous tissue and tissue tags. Contents available in the book . The researchers reported similar results for each of the three methods tested. The starting point on the gingiva is determined by whether the flap is apically displaced or not displaced (Figure 57-7). May cause esthetic problems due to root exposure. Locations of the internal bevel incisions for the different types of flaps. Incisions can be divided into two types: the horizontal and vertical incisions, Basic incisions used in periodontal surgeries, This internal bevel incision is placed at a distance from the gingival margin, directed towards the alveolar crest. News & Perspective Drugs & Diseases CME & Education The incision is made not only around the facial and lingual radicular area but also interdentally, where it connects the facial and lingual segments to free the gingiva completely around the tooth (Figure 57-9; see Figure 57-5). What are the steps involved in the Apically Displaced flap technique? The information presented in this website has been collected from various leading journals, books and websites. To improve esthetics as well as treat periodontal disease the method of choice remains is undisplaced flap surgery [12, 13]. Periodontal pockets in areas where esthetics is critical. The primary objective of the flap surgeries is to gain access to the root surfaces and bone defects so that the deposits on the root surfaces can be eliminated and the granulation tissue can be removed. Swelling hinders routine working life of patient usually during the first 3 days after surgery 41. Contents available in the book .. However, there are important variations in the way these incisions are performed for the different types of flaps (Figures 59-1 and 59-2). The internal bevel incision in an undisplaced flap procedure is started at the same point where an external bevel incision is started in agingivectomyprocedure. To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). Bone architecture is not corrected unless it prevents good tissue adaptation to the necks of the teeth. Journal of clinical periodontology. If extensive osseous recontouring is planned, an exaggerated incision is given. The incision is then carried out till the line angle of the tooth blending it into the gingival crevice. With some variants, the apically displaced flap technique can be used for (1) pocket eradication and/or (2) widening the zone of attached gingiva. The design of the flap is dictated by the surgical judgment of the operator, and it may depend on the objectives of the procedure. 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 incision is made . It differs from the modified Widman llap in that the soft tissue pocket wall is removed with the initial incision; thus it may be considered an internal bevel glngivectomy. Areas where greater probing depth reduction is required. The modified Widman flap is indicated in cases of perio-dontitis with pocket depths of 5-7 mm. 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. Furthermore, the access to the bone defects facilitates the execution of various regenerative procedures. HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva.It can cover teeth in various degrees, and can lead to aesthetic disfigurement. 2. In the present discussion, we discussed various flap procedures that are used to achieve these goals. The aim of this study was to test the null hypothesis of no difference in the implant failure rates, postoperative infection, and marginal bone loss for patients being rehabilitated by dental implants being inserted by a flapless surgical procedure versus the open flap technique, against the alternative hypothesis of a difference. Frenectomy-frenal relocation-vestibuloplasty. It is better to graft an infrabony defect than not grafting. The first documented report of papilla preservation procedure was by. 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. 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. After the flap has been elevated, a wedge of tissue remains on the teeth and is attached by the base of the papillae. Pronounced gingival overgrowth, which is handled more efficiently by means of gingivectomy / gingivoplasty. (adsbygoogle = window.adsbygoogle || []).push({}); The external bevel incision is typically used in gingivectomy procedures. 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. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. The internal bevel incision is basic to most periodontal flap procedures. This will allow the clinician to retain the maximum amount of gingival tissue, including the papilla, which is essential for graft or membrane coverage. Later on Cortellini et al. Clinical crown lengthening in multiple teeth. Incisions used in papilla preservation flap using primary, secondary and tertiary incisions. The area is re-inspected for any remaining granulation tissue, tissue tags or deposits on the root surfaces. Depending on how the interdental papilla is managed, flaps can either split the papilla (conventional flap) or preserve it (papilla preservation flap). This complete exposure of and access to the underlying bone is indicated when resective osseous surgery is contemplated. Osseous surgical procedures with very deep osseous defects and irregular bone loss, facially and lingually/ palatally. What is a periodontal flap? It is discarded after the crevicular (second) and interdental (third) incisions are performed (Figure 57-5). Apically displaced flap, and Flap design for a sulcular incision flap. Tooth with extremely unfavorable clinical crown/root ratio. Position of the knife to perform the crevicular (second) incision. 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 (. 1 and 2), the secondary inner flap is removed. The most apical end of the internal bevel incision is exposed and visible. 74. Contents available in the book .. (Courtesy Dr. Silvia Oreamuno, San Jose, Costa Rica. It must be noted that if there is no significant bleeding and flaps are closely adapted, periodontal dressing is not required. The interdental incision is then made to severe the inter-dental fiber attachment. 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. Contents available in the book .. 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. Vertical relaxing incisions are usually not needed. The buccal and palatal/lingual flaps are reflected with the help of a periosteal elevator. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. 3) The insertion of the guide-wire presents Contents available in the book .. 12 blade on both the buccal and the lingual/palatal aspects continuing it interdentally extending it in the mesial and distal direction. Contents available in the book .. 1. Intrabony pockets on distal areas of last molars. Contents available in the book . . It differs from the modified Widman flap in that the soft-tissue pocket wall is removed with the initial incision; thus, it may be considered an internal bevel gingivectomy. The undisplaced flap and the gingivectomy are the two techniques that surgically remove the pocket wall. Laterally displaced flap. The square, 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. Step 3: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. The secondary incision is given from the depth of the periodontal pocket till the alveolar crest. No incision is made through the interdental papillae. After it is removed there is minimum bleeding from the flaps as well as the exposed bone. 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. There is a loud S1 The murmur is a mid-diastolic rumbling heard best at . A vertical incision may be given unilaterally (at one end of the flap) or bilaterally (on both ends of the flap). These . The following statements can be made regarding periodontal regeneration procedures. One of the most common complication after periodontal flap surgery is post-operative bleeding. 15 scalpel blade, parallel to each other beginning at the distal end of the edentulous area, continued to the tooth. Periodontal flap surgeries are also done for the establishment of . It can be used in combination with other procedures such as osseous resection, regenerative procedures, hemisection procedure and procedures involving wedge excision. Flap design for a conventional or traditional flap technique. Several techniques can be used for the treatment of periodontal pockets. Unsuitable for treatment of deep periodontal pockets. Step 2: The mucogingival junction is assessed to determine the amount of keratinized tissue. Chlorhexidine rinse 0.2% bid . The primary goal of this flap procedure is not necessarily pocket elimination, but healing (by regeneration or by the formation of a long junctional epithelium) of the periodontal pocket with minimum tissue loss. 2. In case of periodontitis with active pockets 5-6 mm deep or greater, that do not respond satisfactorily to the initial therapy. Contents available in the book .. Placement of the vertical incisions is absolutely essential in cases where the flap has to be re-positioned coronally (coronally displaced flap) or apically (apically displaced flap) from its original position. This type of incision, starting just below the bleeding points, removes the pocket wall completely. This approach was described by Staffileno (1969) 23. . Areas which do not have an esthetic concern. Contents available in the book .. It allows the vertical incision to be sutured without stretching the flap over the cervical convexity of the tooth. Rough handling of the tissue and long duration of the surgery commonly result in post-operative swelling. For the management of the papilla, flaps can be conventional or papilla preservation flaps. This is also known as. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. Evian et al. It is also known as a partial-thickness flap. When the flap is returned and sutured in its original position. This flap procedure causes the greatest probing depth reduction. Periodontal flaps involve the use of horizontal (mesialdistal) and vertical (occlusalapical) incisions. Once the interdental papilla is mobile, a blunt instrument is used to carefully push the interdental papilla through the embrasure. 2. 30 Q . The area to be operated is irrigated with an antimicrobial solution and isolated. The vertical incisions are made from the center of palatal/lingual surfaces of teeth extending palatally/lingually. Background: Three-dimensional (3D) printing technology is increasingly commercially viable for pre-surgical planning, intraoperative templating, jig creation and customised implant manufacture. The incision is made around the entire circumference of the tooth using blade No. 1. APICALLY REPOSITIONED FLAP/ PERIODONTAL FLAP SURGICAL TECHNIQUE/ DR. ANKITA KOTECHA 17,228 views Jul 30, 2020 This video is about APICALLY REPOSITIONED FLAP .more Dislike Share dental studies.