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had lost all his teeth, 2 had moved out of the area, 3
presented with poor oral hygiene and showed
progression of disease
Probing depths in excess of normal often occur distal to the terminal tooth as a result of the adjacent tissue covering a portion of the crown.
The
presence of impacted third molar,or the soft tissue result of previous surgical removal of third molar frequently contributes to the severity of the probing depth found distal to the maxillary second molars.
The
DISTAL WEDGE
The retromolar area of the mandible and the tuberosity area of the maxilla offer unique problems for the clinician. They generally have enlarged tissue, unusual underlying osseous topography and fatty glandular (retromolar area) mucosaltype tissue. Historically, while periodontal surgical techniques were being developed for other areas, gingivectomy was the treatment of choice in this area.
DISTAL WEDGE
This problem was first addressed by Robinson in 1963 and later by Kramer and Schwartz(1964). But it was Robinsons classic article on the Distal Wedge Operation(1966) that outlined the indications and treatment procedures still used today. Distal Wedge Operation overcame the shortcomings of gingivectomy which did not allow treatment of irregular osseous deformities or access to maxillary distal furcation area.
Advantages
Maintenance of attached tissue. access for treatment of both the distal furcation and underlying osseous irregularities. Closure by a mature thin tissue, which is especially important in the retromolar area. Greater opening and access when done in conjunction with other flap procedures
Limitations
Access to the surgical site. Anatomical limitations- eg; ascending ramus or external oblique ridge.
Wedge designs
Triangular square, parallel or H-design. Linear or pedicle Size, shape, thickness, and access of the tuberosity or retromolar area determine treatment procedures.
Wedge design
Triangular wedge requires an adequate zone of keratinized tissue and can be used in a very short or small tuberosity. Square, parallel or H-design allows conservation of keratinized tissue and maximum closure. Also provides greater access to underlying topography and distal furcation. Indicated where tuberosity is longer.
Tuberosity Reductions
Tuberosity reduction procedures are commonly combined with buccal and palatal flap reflection, to gain access to the teeth and underlying bone for both debridement and osseous surgery procedures Inverse bevel triangular distal wedge (Mohawk procedure) Inverse bevel linear distal wedge procedure. Tuberosity pedicle flap (trapdoor) procedure.
This procedure is usually integrated with buccal and palatal inverse access incisions and flap reflection. The probe is used to sound through the mucogingival complex to bone,both horizontally and vertically to map the thickness of overlying tissue and the under lying bone configuration.
Procedure
The location of the initial incision is dependant on the magnitude and thickness of the gingiva present,the presence and severity of the bone defects and the therapists estimation of where the final tissue position will be.
Procedure
An initial palatal tracing incision is placed approximately 1mm in depth from the most mesial involvement,distally to the hamular notch. A bleeding line is established for further dissection before flap reflection. The initial tracing incision is extended apically to the bone thinning the flaps as it is made.
Mohawk procedure
Procedure
The tuberosity tissue and collar of marginal tissue are removed using Ochsenbein #2 chisel. After removal of this soft tissue osseous resective surgery is completed and the distal bony defect is eliminated. The thinned flaps and tuberosity region are closed primarily and sutured
Inverse bevel linear distal wedge procedure is similar to triangular distal wedge but the distal incision is made perpendicular to the parallel linear incisions extending past the MGJ buccally to end in mucosa. Palatally the distal incision is extended as far as the palatal tissue will be thinned. The thinned flaps and tuberosity region are closed primarily and sutured
Advantages
This technique is of greater use in edentulous areas between existing teeth. It is particularly useful when the tuberosity has short anterior posterior dimension.
The trapdoor procedure was designed to manage maxillary tuberosity region in the presence of pockets depths. A straight incision is made from the distopalatal line angle of the terminal molar to the most posterior extant of the tuberosity. Two incisions are then made perpendicular to the initial incision.The first courses buccally through the distal pocket region and into the buccal gingiva and mucosa.
Procedure
The second extends from the most distal aspect of the straight line incision out into the buccal mucosa. By undermining and thinning the tuberosity, pedicle flap tissue through split thickness dissection from the palatal to the buccal the pedicle flap is elevated and reflected buccally
Trap procedure
Procedure
Internal bevel incisions are then extended from the distal of the terminal tooth anteriorly. After root debridement and osseous treatment, the flaps are closed primarily and sutured.
Advantages
It is similar to maxillary tuberosity procedures however due to unique anatomical structures like anatomic concavity on the lingual aspect created by lateral flare of the ascending ramus,incisions must always be placed over bone.
Initial incisions extend from the base of the triangle,at the distal aspect of the terminal molar posterior to the apex,which is skewed some what towards the buccal to maintain contact with the underlying bone.
The lingual incision must be kept in contact with bone and must not be placed so far lingually as to risk trauma to the lingual nerve The distal perpendicular incision carries great risk to the lingual anatomic region hence most clinicians prefer either triangular or trap door approaches.
In 1969 Braden suggested a modification that simplifies the procedure and is particularly useful where the pad is fibrous in nature. Here the retromolar tissue remains either the component of either the buccal or the lingual flap.
Initial facial scalloped inverse bevel incision is carried around the distal aspect of the tooth to the distolingual line angle where it meets the scalloped lingual incision A secondary incision then extends from the disto lingual line angle distally but parallel and slightly buccal to the lingual border of the retromolar triangle,to the distal of the retromolar pad.
Immediately after suturing (0 to 24 hours),a connection between the flap and the tooth or the bone surface is established by a blood clot which consists of fibrin reticulum with many polymorphonuclear leucocytes,erythrocytes ,debris of injured cells,and capillaries at the edge of the wound. A bacteria and an exudates or transudate also results from tissue injury.
One to three days- after flap surgery the space between the flap and the tooth and bone are thinner and epithelial cells migrate over the over the border of the flap usually contacting the tooth at this time. when the flap is closely adapted to the alveolar process there is only a minimal inflammatory response.
One week after surgery -An epithelial attachment to the root is established by means of hemidesmosomes and a basal lamina.The blood clot is replaced by granulation tissue derived from the CT,The bone marrow and the PDL Two weeks after surgery- collagen fibers bigen to appear parallel to the tooth surface.Union of the flap to the tooth is still weak,owing to the presence of immature collagen fibers although the clinical aspect may be almost normal
One month after surgery A fully epithelialised gingival crevice with a well defined epithelial attachment is present there is a beginning functional arrangement of the supracrestal fibers
During the healing phase bone resorption takes place together with bone regeneration width ways .A long junctional epithelium is inter posed between the regenerated tissue and the root surface. During tissue maturation (6-12months ) moderate apical migration of the gingival margin occurs.
Conclusions
Longitudinal studies have shown (1st European Workshop on Periodontology1993) that the various surgical methods are equally effective in decreasing pocket depth and controlling the progression of chronic adult periodontitis.
FLAP TECHNIQUES
PALATAL FLAP
Surgical approach differs All attached, keratinized and no elastic properties. No apical or coronal displacement is possible
In order to preserve the interdental soft tissues for maximum soft tissue coverage following surgical intervention involving treatment of proximal osseous defects. Takei et al. (1985) proposed a surgical approach called papilla preservation technique. Later, Cortellini et al. (1995, 1999) described modifications of the flap design to be used in combination with regenerative procedures. i.e. modified papilla preservation flap (MPPF) and simplified papilla preservation flap (SPPF). For esthetic reasons, the papilla preservation technique is often utilized in the surgical treatment of anterior tooth regions. Technique :
The surgical approach to the palatal area differs from that for other areas because of the character of the palatal tissue and the anatomy of the area. The palatal tissue is all attached, keratinized tissue and has none of the elastic properties associated with other gingival tissue. Therefore the palatal tissue cannot be apically displaced, nor can a partial (split) thickness flap be accomplished. The initial incision for the palatal flap should be such that when the flap is sutured, it is precisely
The palatal tissue may be thin or thick, it may or may not have osseous defects, and the palatal vault may be high or low. These anatomic variations may require changes in the location, angle, and design of the incision. If the tissue is thick, a horizontal gingivectomy incision may be made, followed by an internal bevel incision that starts at the edge of this incision and ends on the lateral surface of the underlying bone. The placement of the internal bevel incision must be done in such a way that the flap fits around the tooth without exposing the bone. Flaps should be thin to adapt to the underlying
A sharp, thin papilla positioned properly around the interdental areas at the tooth-bone junction is essential to prevent recurrence of soft tissue pockets. The edge of the flap should be thinner than the base; therefore the blade should be angled toward the lateral surface of the palatal bone. The dissected inner connective tissue is removed with a hemostat. As with any flap, the triangular papilla portion should be thin enough to fit snugly against the bone and into the interdental area. The principles for the use of vertical releasing incisions are similar to those for using other
DISTAL WEDGE PROCEDURES OR DISTAL MOLAR SURGERY In many cases the treatment of periodontal pockets on the distal surface of distal molars is complicated by the presence of bulbous tissues over the tuberosity or by a prominent retromolar pad. The most direct approach to pocket elimination in such cases in the maxilla is the gingivectomy procedure. The incision is started on the distal surface of the tuberosity and carried of forward to the base of the pocket of the distal surface of the molar. However, when only limited amounts of keratinized tissue are present, or none at all, or if a distal angular bony defect has been diagnosed, the bulbous tissue should be reduced in size rather than being removed in toto. This may be accomplished by the distal wedge procedure (Robinson 1966). This technique facilitates access
Citrus fruits, fruit juices, alcoholic beverages and highly spiced foods should be avoided. Patient should not smoke. Patient should be asked to take adequate bed rest and avoid speaking. Patient should be advised not to brush on the operated area and use chlorhexidine mouthwash. Patient should not try to remove the periodontal dressing himself. In case of bleeding he should immediately contact the periodontist and avoid spitting. To ease any postoperative swelling, patient should apply cold pack.
THE FIRST POSTOPERATIVE WEEK The periodontal pack is removed after 1 week. The area is irrigated with a sterile saline solution and sutures are removed. Properly performed periodontal surgery does not present any postoperative complications.
After a flap operation, the areas corresponding to the incisions are epithelialized but may bleed when touched. They should not be disturbed and pockets should not be probed. The lingual and facial mucosa may be covered with a grayish yellow or white granular layer of food debris that has spread under the pack. This is
HEALING AFTER FLAP SURGERY: (Carranza and Newman) Immediately after suturing (0 to 24 hours): Connection established between the flap and the tooth / bone surface via blood clot. Blood clot consists of a fibrin reticulum with many PMN leucocytes, erythrocytes, and debris from injured cells and capillaries at the edge of the wound (Caffesse et al 1968). Bacteria and an exudates or transudate as a result of tissue injury are also present. One to three days after surgery: Space between the flap and the tooth or bone is thinner and epithelial cells migrate over the border of the flap usually contacting the tooth at this time. When the flap is closely adapted to the alveolar process, there is only a minimal inflammatory response.
One week after surgery: Epithelial attachment to the root is established by means of hemidesmosomes and a basal lamina. The blood clot is replaced by a granulation tissue derived from a gingival connective tissue, the bone marrow and the periodontal ligament. Two weeks after surgery: Collagen fibers begin to appear parallel to the tooth surface. Union of the flap to the tooth is still weak owing to the presence of immature collagen fibers. Clinical aspect may appear almost normal. One month after surgery: A fully epithelialized gingival crevice with a well defined epithelial attachment is present. There is a beginning of functional arrangement of
days.
Osteoclastic resorption follows and reaches a peak at four to six days declining thereafter (Staffileno et al 1962).
The coronally repositioned periodontal flap, has been reported by many different people in the literature. Kalmi (1949), first described a type of coronal repositioned flap that was performed after
Bernimoulin et al. (1975), reported on the clinical evaluation of a two-step Coronally repositioned periodontal flap. Semilunar coronally repositioned flap" (Tarnow
1986)
Harold
E. Grupe and Richard F. Warren (1956) introduced contiguous soft tissue autografts to the literature under the term "lateral sliding flap".
Variations
of the laterally positioned pedicle graft include the double papilla graft (Cohen and Ross 1968) and the oblique rotated graft (Pennel et al
modified
coronally advanced
technique by eliminating
the vertical incisions and introducing sulcular incisions on adjacent
Raetzke
sulcular epithelium of the affected tooth is removed. A partial thickness envelope is created in the tissues surrounding the recession. A graft twice the width of the area of recession is placed into
Nelson,
in his
technique elevated
Allen
presented the supraperiosteal envelope for use in multiple adjacent areas of recession. (Tunnel technique). Blanes and Allen combined a tunnel with lateral pedicle flaps to treat adjacent areas of recession. Double split thickness lateral pedicle flaps are elevated at the level of the CEJ at the proximal extent of the recession and extended apically 10-12 mm. A tunnel is created under the tissue remaining
References
Clinical periodontology and Implant dentistry Jan Lindhe 5th edn Clinical Periodontology; Carranza 10th edn Outline of Periodontics. Manson and Eley;4th edn
Conclusion The success of flap operations depend on multiple clinical considerations such as anatomy, correct flap positioning, adaptation and maintenance, and prevention of bacterial plaque accumulation. Loose sutures or muscular activity may create spaces filled with a large clot that could be temporarily detrimental to reattachment. Digital pressure applied to the flap for several minutes immediately after
GOOD AFTERNOON
PALATAL FLAPS
Dr.Jyothi S.G.
Introduction
The palate, unlike other areas, is composed mainly of dense collagenous connective tissue. This fact precludes the palatal tissue from being positioned apically, laterally, or coronally. Therefore, surgical techniques are required that allow the tissue to be thinned and apically positioned at the same time.
Historical Review
The palatal flap procedure historically involved reflecting a full-thickness flap to gain access to the underlying bone and remove necrotic and granulomatous tissue. Ochsenbein and Bohannan (1963, 1964) described a palatal approach for osseous surgery (A) Full-Thickness Flap, (B) Partial-Thickness Palatal Flap. (C) Modified Partial-Thickness Flap,
The objective and result of all three are the same a thin, even-flowing gingival architecture that closely approximates the underlying bone. Ochsenbein and Bohannan, in comparing the palatal and buccal approaches to osseous surgery, noted the following advantages, disadvantages, and indications of the palatal approach.
1.Esthetics 2.Easier access for osseous surgery 3.Wider palatal embrasure space 4.A naturally cleansing area 5.Less resorption because of thicker bone
1. Esthetics 2.Closeroot proximity 3.Possible involvement of the buccal furcation 4. Thin plate of bone overlying the maxillary molars where dehiscences and fenestrations may be present.
Indications
1.Areas that require osseous surgery 2. Pocket elimination 3.Reduction of enlarged and bulbous tissue
Contraindications
when a broad, shallow palate does not permit a partial-thickness flap to be raised without possible damage to the palatal artery.
Diagnostic Probing
Before beginning the operation, but after adequate administration of anesthetic, periodontal probing bone sounding for the underlying osseous topography is indicated (Easley, 1967). This is especially important on the palate, where frequently the tissue is enlarged and bulbous with underlying heavy bony ledges and exostoses. These exostoses frequently occur in second and third molar areas.
Sounding permits one to discriminate between dense fibrotic tissue and enlarged tissue resulting from the osseous irregularities. Furthermore, because palatal tissue cannot be repositioned, failure to access the underlying topography adequately often results in a flap that is either too long or too short.
Note that, even though the tissue appears to be the same in all instances and the results may be the same, the incisions vary according to the underlying osseous topography.
This technique was developed by Staffileno (1969) to overcome some of the problems of extensive gingival resection and to facilitate treatment of palatal osseous defects, which until then was approached cautiously.
Advantages: Minimal trauma Rapid healing Ease of palatal tissue manipulation Establishment of favorable gingival contours
Presurgical Phase: the operator sounds for the underlying osseous topography. This is very important because the flap cannot be repositioned after the initial incision. A short flap will result in bone exposure and long flap will have to be trimmed, which is difficult and leaves thick marginal tissue.
The thicker the tissue, the more exaggerated the scalloping of the incision. For this reason, the exact thickness of the tissue must be determined at the start. Underlying osseous irregularities and osseous resection techniques must also be anticipated.
Surgical Phase:
The primary incision is made with a No. 15 (usually) or No. 12 (if access is limited) scalpel blade. It is usually begun at the margin of the last tooth in the tuberosity area as an extension of the distal wedge procedure. It is continued forward, using a scalloped, inverse beveled, partial-thickness incision to create a thin partial-thickness flap.
The blade of the scalpel should always be kept on the vertical height of the alveolus. This prevents unnecessary involvement or cutting of the palatal artery. Once the initial part of the primary incision has been completed, the tissue may be retracted with rat-tail pliers for completion of the incision. Upon completion, the scalpel blade is directed toward the bone to score it at the base of the flap.
This separates the periosteum in this area and permits easy removal of the secondary flap from bone. Without this scoring, it is more difficult to remove the secondary inner flap and generally results in a torn, ragged periosteal tissue with many tags.
A secondary sulcular incision is now completed both facially and interproximally, using a No. 15 or No. 12 scalpel blade down to the crest of the bone. This incision frees the coronal aspects of the inner or secondary flap, permitting removal.
Ochsenbein chisels (Nos. 1 and 2) are now used from both the occlusal and apical extensions of the flap to completely free and remove the secondary inner flap. If the periosteum has not previously been scored, this procedure will be more difficult and leave a torn, ragged periosteum. A Friedman rongeur may also be used to remove the secondary inner flap.
It is important to note that the inner 20 flap of connective tissue that has been removed can now be trimmed and used for a free connective-tissue autograft (Edel, 1974) or as part of a subepithelial connective-tissue graft (Langer and Colagna, 1980 Langer and Langer, 1985).
Ochsenbein 1958, and Ochsenbein and Bohannan in 1963 described this technique, but it was not until 1965 that it became popularized by Prichard. It has also become known as the ledgeand-wedge technique.
This is a two-stage procedure main disadvantage- the fact that healing interdentally is by secondary intention. This fact precludes the use of this procedure with such procedures as the Modified Widman flap, E.N.A.P., osseous grafting, and any others that require primary closure. This procedure also requires a certain degree of technical skill or the palatal artery can be damaged easily
Presurgical Phase:
With the patient under adequate anesthesia, sounding is carried out to determine the underlying osseous topography, pocket depth, and thickness of the tissue. This stage is not as critical as it is in the single-stage procedure because the firststage gingivectomy incision will allow visualization of tissue thickness.
Surgical Phase:
It is necessary to mark the base of the pockets with pocket markers. A periodontal probe may be used to estimate pocket depth. A periodontal knife is used to resect the tissue above the crest of bone. Unlike the basic gingivectomy technique, no bevel is placed. A tissue ledge is established to allow visualization of tissue thickness and permit easier placement of the primary palatal incision.
Sometimes it may not be desirable to make the gingivectomy incision down to the base of the pocket, especially on thicker tissue. When such tissue is thinned and falls back against the bone, it will be short of the bony crest. This can result in excessive bone exposure and postoperative discomfort.
Flap:
Common Mistakes
The short flap: This generally is the result of too deep a primary incision, gingivectomy to the crest of bone of a thick tissue, or use of a beveled gingivectomy. This results in delayed healing and increased patient discomfort. Poor marginal flap adaptation caused by incomplete thinning of the tissue: The margin of the flap stands away from the tooth when the flap is replaced. This can be corrected either by additional thinning of the inner flap surface close to the base of the original incision or by more osteoplasty.
Incision beyond the vertical height of the alveolus, bringing the scalpel blade in the close proximity to the palatal artery: Cutting the palatal artery can be especially dangerous. Extension beveling or thinning of tissue on a low, broad palate invites damages to the palatal artery. Tissue placement high onto the teeth results in poor adaptation and recurrent pocket formation. This can be corrected by proper trimming at the time of flap placement prior to suturing;
DISTAL WEDGE:
The retromolar area of the mandible and the tuberosity area of the maxilla offer unique problems for the clinician. They generally have enlarged tissue, unusual underlying osseous topography, and in the case of the retromolar area, a fatty, glandular, mucosal type tissue. Historically, while periodontal surgical techniques were being developed for all other areas, development in this one area remained stagnant, and gingivectomy was the treatment of choice. This problem was first addressed by Robinson in 1963 and later by Kramer and Schwartz (1964)
Advantages:
Maintenance of attached tissue Access for treatment of both the distal furcation and underlying osseous irregularities. Closure by a mature thin tissue, which is especially important in the retromolar area. Greater opening and access when done in conjunction with other flap procedures. The main limitation is only of access or anatomy (e.g., ascending ramus or external oblique ridge).
Wedge Design :
Triangular Square, parallel, or H-design Linear or pedicle
To avoid the difficult healing with vestibular incisions and at the same time provide adequate implant coverage, especially when augmentation procedures are required, Langer and Langer (1990) recommended a palatal approach.
1. 2.
Advantages:
The use of overlapping flaps prevents flap opening and implant exposure. Facilitates healing and reduces postoperative trauma.
SPLIT PALATAL FLAP: A SURGICAL APPROACH FOR PRIMARY SOFT TISSUE HEALING IN RIDGE AUGMENTATION PROCEDURES
Localized ridge deformities of varying severity usually occur after tooth loss as a result of advanced periodontal disease, root fracture, extensive root caries, and / or periapical pathology. Ridge deformity could also be the result of trauma or traumatic tooth extraction in which the labial plate is fractured, destroying the 4-walled socket in which blood clots form and are protected.
CONCLUSION
Various modifications of palatal flap designs help in managing special situations like treatment of osseous defects, implant coverage, closure of oroantral fistula, ridge augmentation etc. Thus, designing the palatal flaps benefit a lot to the periodontal plastic surgeries.
THANK YOU
Types of Sutures
SUTURING The purpose of suturing is to maintain the flap in the desired position until healing has progressed to the point where sutures are no longer needed.
Suture materials
The resorbable sutures have gained popularity since they enhance patient comfort and eliminate suture removal appointments. The monofilament type of suture alleviates the "wicking effect" of braided sutures that may allow bacteria from the oral cavity to be drawn through the suture to the deeper areas of the wound. classification of the sutures available today: The nonresorbable, braided silk suture was the most commonly used in the past due to its ease of use and low cost. The expanded polytetrafluoroethylene synthetic monofilament is an excellent nonresorbable suture widely used today. The most commonly used resorbable sutures are the natural, plain gut and the chromic gut. Both are monofilaments and are processed from purified collagen of either sheep or cattle intestines. The chromic suture is a plain gut suture processed with chromic salts to make it resistant to enzymatic resorption, thereby increasing the resorption time. The synthetic resorbable sutures are also often used.
Suturing Technique
1 Interdental Ligation a. Direct or loop suture b. Figure Eight suture 2 Sling Ligation 3 Horizontal mattress suture 4 Cjontinuous, Independent Sling suture 5 Anchor Suture 6 Closed Anchor Suture
Suturing Technique
The needle is held with the needle holder and should enter the tissues at right angles and no less than 2 to 3 mm from the incision. The needle is then carried through the tissue, following the needle's curvature. The knot should not be placed over the incision.
The periodontal flap is closed either with independent sutures or with continuous, independent sling sutures. The latter method eliminates the pulling of the buccal and lingual or palatal flaps together and instead, uses the teeth as an anchor for the flaps. There is less tendency for the flaps to buckle, and the forces on the flaps are better distributed. Sutures of any kind placed in the interdental papillae should enter and exit the tissue at a point located below the imaginary line that forms the base of the triangle of the interdental papilla
Fig. If the elevation of the flap is slight or moderate, the sutures can be placed in the quadrant closest to the teeth. If the flap elevation is substantial, the sutures should be placed in the central quadrants of the palate. One may or may not use periodontal dressings. When the flaps are not apically displaced, it is not necessary to use dressings other than for patient comfort.
The location of sutures for closure of a palatal flap depend on the extent of flap elevation that has been performed. The flap is divided in four quadrants as depicted in
Placement of suture in the interdental space below the base of an imaginary triangle in the papilla
Ligation
Interdental Ligation.
Two types of interdental ligation can be used: 1. the director loop suture (Fig) and 2. the figure-eight suture (Fig).
first flap. B, The undersurface of the opposite flap is engaged, and the suture is brought back to the initial side (C), where the knot is tied (D).
1 the director loop suture The direct suture permits a better closure of the interdental papilla and should be performed when bone grafts are used or when close apposition of the scalloped incision is required. 2 the figure-eight suture In the figureeight suture, there is thread between the two flaps. This suture is therefore used when the flaps are not in close apposition because of apical flap position or nonscalloped incisions. It is simpler to perform than the direct ligation.
and the outer surface of the opposite flap (B). The suture is brought back to the first flap (C), and the knot is tied (D).
Sling Ligation.
The sling ligation can be used for a flap on one surface of a tooth that involves two interdental spaces (Fig.)
C, The outer surface of the same flap of the adjacent interdental area is engaged. D, the suture is returned to the initial site and the knot tied.
This suture is often used for the interproximal areas of diastmata or for wide interdental spaces to properly adapt the interproximal papilla against the none. Two sutures are often necessary. The horizontal mattress suture can be incorporated with continuous, independent sling sutures as shown in figure
The penetration of the needle is performed in such a way that the mesial and distal edges of the papilla lie snugly against the bone. The needle enters the outer surface of the gingiva and crosses the undersurface of the gingiva horizontally. The mattress sutures should not be close together at the midpoint of the base of the papilla. The needle reappears on the outer surface at the other base of the papilla and continues around the tooth with the sling sutures.
around diastemata or wide interdental areas (B and C). This mattress suture is utilized on both the buccal (D) and the lingual (E and F) surfaces. Continuation of suture on lingual surfaces (G to 1) and completed suture (J).
Anchor Suture. The closing of a flap mesial or distal to a tooth, as in the mesial or distal wedge procedures, is best accomplished by the anchor suture. This suture closes the facial and lingual flaps and adapts them tightly against the tooth. The needle is placed at the line angle area of the facial or lingual flap adjacent to the tooth, anchored around the tooth, passed beneath the opposite flap, and tied. The anchor suture can be repeated for each area that requires it (Fig).
A to D, Distal wedge suture. This suture is also used to close flaps that are mesial or distal to a lone-standing tooth
Closed Anchor Suture. Another technique to close a flap located in an edentulous area mesial or distal to a tooth consists of tying a direct suture that closes the proximal flap, carrying one of the threads around the tooth to anchor the tissue against the tooth, and then tying the two threads (Fig.).
Periosteal Suture.
This type of suture is used to hold in place apically displaced partial thickness flaps. There are two types of periosteal sutures:
1 the holding suture and The holding suture is a horizontal mattress suture placed at the base of the displaced flap to secure it into the new position. 2 the closing suture. Closing sutures are used to secure the flap edges to the periosteum. Both types of periosteal sutures are shown in Fig.
Periosteal sutures for an apically displaced flap. Holding sutures, shown at the bottom, are done first, followed by the closing sutures, shown at the coronal edge of the flap.
Immediately after suturing (0 to 24 hours), a connection between the flap and the tooth or bone surface is established by a blood clot, which consists of a fibrin reticulum with many polymorphonuclear leukocytes, erythrocytes, debris of injured cells, and capillaries at the edge of the wound. A bacteria and an exudate or transudate also result from tissue injury. One to 3 days after flap surgery, the space between the flap and the tooth or bone is thinner, and epithelial cells migrate over the border of the flap, usually contacting the tooth at this time. When the flap is closely adapted to the alveolar process, there is only a minimal inflammatory response.
One week after surgery, an epithelial attachment to the root has been established by means of hemidesmosomes and a basal lamina. The blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow, and the periodontal ligament. Two weeks after surgery, collagen fibers begin to appear parallel to the tooth surface. Union of the flap to the tooth is still weak, owing to the presence of immature collagen fibers, although the clinical aspect may be almost normal. One month after surgery, a fully epithelialized gingival crevice with a well-defined epithelial attachment is present. There is a beginning functional arrangement
Full-thickness flaps, which denude the bone, result in a superficial bone necrosis at 1 to 3 days; osteoclastic resorption follows and reaches a peak at 4 to 6 days, declining thereafter. This results in a loss of bone of about 1 mm", the bone loss is greater if the bone is thin.
LEFT, ARROW POINTING DOWNWARD DEPICTS PENETRATION OF A PROBE IN AN UNTREATED PERIODONTAL POCKET. THE PROBE TIP GOES PAST THE JUNCTIONAL EPITHELIUM AND THE INFLAMED TISSUE AND IS STOPPED BY THE FIRST INTACT, ATTACHED COLLAGEN FIBERS. RIGHT: AFTER THOROUGH SCALING AND ROOT PLANING, THE LOCATION OF THE BOTTOM OF THE POCKET HAS NOT CHANGED, BUT THE PROBE PENETRATES TO ONLY ABOUT ONE THIRD THE LENGTH OF THE JUNCTIONAL EPITHELIUM. THE REDUCTION IN PROBING DEPTH MAY NOT REFLECT A CHANGE IN ATTACHMENT LEVEL
A: PERIODONTAL POCKET PREOPERATIVELY B:PERIODONTAL POCKET IMMEDIATELY AFTER SCALING, ROOT PLANING, AND CURETTAGE
C: NEW ATTACHMENT. THE ARROW INDICATES THE MOST APICAL PART OF THE JUNCTIONAL EPITHELIUM. NOTE REGENERATION OF BONE AND PERIODONTAL LIGAMENT
D: HEALING BY LONG JUNCTIONAL EPITHELIUM. AGAIN THE ARROW INDICATES THE MOST APICAL PART OF JUNCTIONAL EPITHELIUM. NOTE THE BONE IS NEW BUT THE PERIODONTAL LIGAMENT IS NOT
Morrison (1980) studied 90 patients with advanced periodontitis over a period of 4 weeks.
Pocket depth Mean initial probing depth 2.29 mm 4.56 mm 7.56 mm Mean final probing depth 2.13 mm 3.59 mm 5.35 mm
Baderstein (1984) a probing depth reduction of 0.5 mm, 1.0 1.5 mm 2.5 5.0 mm respectively.
Claffey (2000) in his review reported the following attachment levels after N.S.T
Pocket depth 1-3.5 mm 4-6.5 mm >7 mm A.H. gains -0.5 mm (att loss) 0-1 mm 1-2 mm
Probing depth indicated by blue lines before and after N.S.T Recession = green line
Advantages
Good access to root and bone surface Good post-op adaptation of tissues to tooth surface
Disadvantages
Heals by long junctional epithelium and not by new attachment Presence of residual probing depths in the presence of infrabony defects
Rationale
Removal of the pocket lining allows more access to the periodontal ligament cells to populate in the region and give rise to new attachment
Undisplaced flap
internal bevel gingivectomy Differs from the modified widman flap in that the soft tissue pocket wall is removed with the initial incision
Dead space formation is reduced as flap margin over the alveolar crest To avoid creation of a mucogingival problemadequate attached gingiva should remain after the removal of poket wall
Naber (1954)repositioning of attached gingiva Ariaudo and Tyrelli (1957)- two vertical incisions Friedman (1962)- apically repositioned flap
Indications Pockets extending beyond mucogingival line Narrow zone of keratinized gingiva Crown lengthening procedure for restorative and prosthodontic purposes
Contraindications Esthetically critical areas Teeth with severe attachment loss Deep infrabony pockets pts with high caries rate/ severe hypersensitivity
Full thickness flap is reflected which covers the marginal bone and 1-2 mm coronally
Advantages
Eliminates periodontal pocket Preserves keratinized gingiva Establishes good gingival morphology Provides necessary biologic width for restorative procedures
Disadvantages
Results in root exposure May lead to clinical attachment loss Outcome depends on healing
1. Palatal pockets
Procedures
Beveled flap
Undisplaced flap
Palatal flap
Indications Areas that require osseous surgery Pocket reduction Reduction in enlarged bulbous tissue Contraindications Broad shallow palate- damage to palatal vessels
Robinson (1966)
1. Presence of bulbous tissues over the tuberosity 2. A prominent retromolar pad in the mandible 3 .Inadequate attached gingiva 4. Abruptly ascending tuberosity 5. A close ascending ramus of the mandible
Factors Accessibility
Amount of keratinized gingiva Pocket depth Available distance from distal aspect of tooth to end of tuberosity
Anatomical considerations
Advantages
Gingival contour is dependent on the underlying bony contour and the elimination of the soft tissue pockets has to be combined with osseous recontouring.
Osteoplasty
Friedman in 1955 Reshaping of alveolar bone to achieve a more physiological form without removal of tooth supporting bone
Ostectomy
Indications Elimination of interdental craters Correction of one walled defects Other angular defcts not amneable to regeneration
Suprabony, fibrous pocket with sufficient attached gingiva- Gingivectomy Infrabony pocket, furcation inv, osseous deformities, muco-gingival problems- Flap surgery
Healing of flaps
Caffesse et al. (1968)- reverse bevel flap Histological examination- 2hrs,13hrs and 1, 2, 3, 5, 9, 14, 21, 35 & 72 days
2hrsNarrow zone of necrosis covered by clot Few PMNs Alveolar process show empty lacunae 13 hrsUsual arrangement of cementoblasts missing on root surface0.5mm from flap
2 days-
3 daysEpi makes contact with tooth surface Inflammatory reaction is less severe CT grows betw flap and bone Formation starts from PDL, marrow space & margins
5 daysPartial establishment of contact Granulation tissue is present over PDL & alv crest Osteoclasts at crest originate form marrow space
21 daysFully epi gingival crevice & Well defined epi attachment Functional arrangement of supracrestal fibres Periosteum- not fully matured
35 daysOsteoblastic activity at crest
72 daysWell defined epi attachment Keratinization of gingiva Periosteum appears normal Layers of newly formed bone on alveolar crest
Gothenburg study
Gothenburg study VI 2 yrs post-op15 pts RP or RP & MWF Split mouth design More PD reduction with surgical Critical probing depth For RP- 2.9mm For flaps 4.2mm
Minnesota Study Ahlstrom et al. (1983) SRP alone vs Flaps 6 yrs follow up No sig pocket depth reduction Attachment gain greater in flap procedures for deeper pockets
Aarhus Study: Isidor and Korning (1986) compared the effect of root planing and modified widman flap to apically positioned flap during 5 year of follow up. They obtained similar results for both the treatment.
Washington Study: Oslen et al (1985) compared apically positioned flap without osseous recontoring to a.p.f. with osseous recontouring in a 5 year follow up study. They concluded that the osseous recontouring was more effective in reducing pockets and controlling the inflammation than flap surgery.
Tucson studies Becker et al. (1988) RP, MWF APF with osseous reduction Min diff betw 3 procedures
1 yr observation
Nebraska studies Kaldahl et al. (1988) 82 pts 2 yrs- split mouth design Sc, RP, MWF, MWF with osseous reduction Reduction in PD- all PocketMWF with red> MWF> RP> Sc Gain in CALMWF & RP- greatest gain All- except scaling
Non-surgical therapy is the corner stone of periodontal therapy in all types of pocket depths.
surgical techniques have produced greater pocket depth reduction no difference on long term evaluation.
S.R.P. will always be performed first on any patient suffering from moderate periodontal pockets. Shallow pockets should not treated by surgical therapy as it may result in C.A.L. Moderate/Advanced pockets can be treated by tailor made surgical techniques to suit the patients condition.
proper regular maintenance is paramount for success of therapy.
Divided into
1)Pretherapeutic causes
2)Therapeutic causes
3)Posttherapeutic causes
Type of periodontitis
Involvement of hopeless tooth oral hygiene assessment
5)Habits
- mouth breathing ,
- bruxism - thumb sucking - smoking
6)Occlusal trauma
Therapeutic causes
1. Improper selection of surgical technique
width of attached gingiva height of remaining bone pocket depth mobility co-operation of the patient patients systemic back ground.
Surgical technique which does not allow proper adaptation of interdental tissue will lead to food and plaque accumulation in the interproximal area and therapy leads to recurrence of periodontal disease.
Improper asepsis of the surgical field and patient, improper sterilization of the instruments.
Rise too high coronally- redundant tissue with subsequent repocketing Fall far short of the osseous margin- resorption or sequestra formation Inadequately cover the bone graft- minimizing the opportunity for ideal healing.
Inadequate thinning of the full thickness flap (palatal flap), results in an excessively thick bulky gingival margin -gingivoplasty
3. Incomplete debridement
4. Improper suturing
1. Unsupervised healing-
- Post-operative care
- failure to replace missing teeth - correct overhanging restorations - correct carious lesions
Conclusion
Clinical studies comparing non- surgical and surgical therapy for the treatment of shallow to moderate pockets showed similar long term results.
Whatever maybe the choice of treatment modality, it is the detailed thoroughness of root debridement and
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SUTURING
Step 9: A continuous sling suture is used to secure the facial and the lingual or palatal flaps. This type of suture, using the tooth as an anchor, is advantageous to position and hold the flap edges at the root-bone junction. The area is covered with a periodontal pack.
POST-OPERATIVE
ARMAMENTARIUM
Incision and excision (periodontal knives) Deflection and readaptation of mucosal flaps (periosteal elevators)
Removal of adherent fibrous and granulomatous tissue (tissue scissors, cumin scaler)
I. Nonsurgical pocket therapy: -supra/ subgingival debridement with oral hygiene instructions. - chemotherapeutics. - lasers. II. Pocket elimination procedures: - gingivectomy - apically positioned flap - flap osseous surgery
Pocket reduction procedures: - Access flap. - Modified Widman flap. - Excisional New Attachment procedure. - Replaced flap.
UNDISPLACED FLAP
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.
Step 4: The flap is reflected with a periosteal elevator from the first incision.
Step 6: The triangular wedge of tissue created by the three incisions is removed with a curette.
Step 7: The area is debrided, removing all tissue tags and granulation tissue using sharp curettes.
Step 8: A continuous sling suture is used to secure the facial and the lingual or palatal flaps.
Gingival Pockets 1) Character of the pocket wall - Edematous or Fibrotic 2) Pocket accessibility. Slight Periodontitis A conservative approach and adequate oral hygiene generally sufficient. Recurrence in previously treated sites - surgical approach. Moderate to Severe Periodontitis in the Anterior Sector -Scaling and root planing - Technique of choice. - Papilla preservation flap - First choice when a surgical approach is needed. - Teeth too close interproximally - Sulcular incision flap - next choice. - Esthetics is not the primary consideration - Modified Widman flap. - In some infrequent cases - Apically displaced flap with bone contouring.
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Purpose of surgery in the posterior area is either enhanced accessibility or the need for definitive pocket reduction requiring osseous surgery. Accessibility can be obtained by either the undisplaced or apically displaced flap. Osseous defects amenable to regeneration - the papilla preservation flap - Technique of choice because it better protects the interproximal areas where defects are frequently present. Second and third choices are the sulcular flap and the modified Widman flap, maintaining as much of the papilla as possible. Osseous defects with no possibility of reconstruction - Technique of choice - Flap with osseous contouring.
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