FLAP SURGERY CONCEPTSRATIONALE OF POCKET ELIMINATION

• The ultimate goal of periodontal therapy has been aimed to restore the health and function of the periodontium.

• To achieve this goal, many non surgical and surgical techniques have been proposed to treat a variety of periodontal conditions, most commonly – the periodontal pocket

PERIODONTAL POCKET

Periodontal pocket is defined as ‘ a pathologically deepened gingival sulcus’

The etiologic factor for pocket formation is plaque.

Vicious cycle continues without pocket therapy

POCKET THERAPY EFFECTSACTIVE POCKET:

Underlying bone is lost

• After Phase I therapy the inflammatory changes in the pocket wall subside, rendering the pocket inactive and reducing its depth

• The extent of this reduction depends on the depth before treatment and the degree to which the depth reduces, is the result of the edematous and inflammatory component of the pocket wall.

INACTIVE POCKET:

• Inactive pockets can sometimes heal with a long junctional epithelium

• Unstable condition, chances of recurrence

• Inactive pockets maintained by:

Frequent scaling and root planing

Transforming pocket into healthy sulcus

Bottom of healthy sulcuseither coronal to the bottom of the pocket- re

attachmentat the bottom of the pocket- no gain of attachment

TREATMENT OUTCOME

• PERIODONTAL REGENERATION is defined histologically as regeneration of the tooth’s supporting tissues, including alveolar bone, periodontal ligament, and cementum over a previously diseased root surface.

• NEW ATTACHMENT - embedding of new periodontal ligament fibers into new cementum and the attachment of the gingival epithelium to a tooth surface previously denuded by disease. (GPT 2001)

• RE ATTACHMENT – the attachment of the gingiva or the periodontal ligament to the areas of the tooth from which they have been removed in the course of treatment (or during preparation of teeth for restorations)

• EPITHELIAL ADAPTATION – the close apposition of the gingival epithelium (long junctional epithelium) to the tooth surface with no gain in height of gingival fiber attachment.

Possible results of pocket therapy. An active pocket can become inactive and heal by means of a long junctional epithelium. Surgical pocket therapy can result in a healthy sulcus, with or without gain of attachment. Improved gingival attachment promotes restoration of bone height, with re-formation of periodontal ligament fibers and layers of cementum.

TREATMENT MODALITIES FOR POCKET ELIMINATION

Most common method.

Rationale: The wall of the pocket consists of soft tissue and may also include bone in the case of intrabony pockets.

It can be removed by the following:

• Retraction or shrinkage: Scaling and root-planing procedures resolve the inflammatory process gingiva shrinks pocket depth reduction.

• Surgical removal - gingivectomy technique /undisplaced flap.

• Apical displacement with an apically displaced flap.

accomplished by tooth extraction or by partial tooth extraction

(hemisection or root resection).

Gingival curettage

Excisional new attachment procedure (ENAP)

Flap for debridement (Modified Widman flap)

Gingivectomy

Apically positioned flap, often in conjunction with bone resection

Root resection or amputation

1 Characteristics of the pocket: depth, relation to bone, and configuration.

2 Accessibility to instrumentation, including presence of furcation involvements.

3 Existence of mucogingival problems.

4 Response to Phase I therapy.

5 Patient cooperation, including ability to perform effective oral hygiene. Smokers

must be willing to stop their habit.

Criteria for Method Selection

6 Age and general health of the patient.

7 Overall diagnosis of the case: various types of gingival

enlargement and types of periodontitis (e.g., chronic marginal

periodontitis, localized aggressive periodontitis, generalized

aggressive periodontitis).

8 Esthetic considerations.

9 Previous periodontal treatments.

NON SURGICAL THERAPY- SCALING AND ROOT PLANING

• Supra and subgingival debridement results in mechanical disruption of plaque biofilm

• modality for periodontal treatment

Attributed to:

1) Exposure of cementum, root dentin and pocket epithelium for novel colonization

2) Species thriving in diseased pocket find new habitat less hospitable

3) Decrease in pocket depth as a result of resolution of inflammation, decreased edema, and a readaptation of apical junctional epithelium

• Healing following non surgical therapy is almost complete at 3 months, however limited healing continues for 9 or more months.

• Measurements are made at baseline and again at 3 months as a method of evaluation and effectiveness of therapy( LINDHE)

STUDY INITIAL PROBING DEPTH RESULTS AFTER SRP

Cobb et al. (1996)Meta- analysis

1-3mm 4-6mm˃7mm

-0.34mm(attachment loss)+0.55mm ( gain)+1.29mm (gain)

Claffey et al. (2000)˂3.5mm4- 6.5 mm˃7mm

-0.5mm attachment loss0-1mm attachment gain1-2 mm attachment gain

The effectiveness of periodontal therapy is predicated on success in completely eliminating calculus, plaque, and diseased cementum from the tooth surface.

LIMITATIONS OF NON SURGICAL THERAPY

The presence of irregularities on the root surface

As the pocket becomes deeper, the surface to be scaled increases, more irregularities appear on the root surface, and accessibility is impaired

The presence of furcations will also create insurmountable problems for scaling the root surface

• First surgical technique used in periodontal therapy were described as means of gaining access to diseased root surfaces

Access accomplished without excision of soft tissue pocket by

Open view operations

Diseased gingiva excised by gingivectomy procedures

Concept – not only soft and inflamed tissue but also infected and necrotic bone had to be eliminated

Required alveolar bone exposure- FLAP PROCEDURES

• Increase accessibility to root surfaces, making it possible to remove all irritants

• Reduce or eliminate pocket depth ,making it possible for the patient to maintain root surface free of plaque

• Reshape hard and soft tissues to attain harmonious topography.

Criteria for selection of surgical technique: based on clinical findings1) Soft tissue pocket wall

2) Tooth surface3) Underlying bone4) Attached gingiva

• Pocket elimination procedures not involving underlying osseous structures:

Gingival curettage

ENAP

Gingivectomy

CURETTAGE

• Defined as ‘ removal of pocket epithelium and underlying connective tissue’. (Genco ,1976)

• Subgingival curettage: Pocket epithelium and connective tissue are removed down to the crest of alveolar bone.

CONTRAINDICATIONSINDICATIONS

Can be done as a part of new attachment attempts in intrabony pockets

As a part of non-definitive therapy prior to other regenerative procedures

In medically compromised patients where other extensive flap surgeries are not indicated

As a part of maintenance therapy

Acute infections

Fibrous pockets

Pockets beyond MGJ

Furcation involvements

1989 World Workshop in Clinical Periodontics concluded that curettage had ‘no justifiable application during active therapy for chronic adult periodontitis’

Curettage is a procedure which provides historic interest in the evolution of periodontal therapy but has no current clinical relevance in the treatment of chronic periodontitis

• (AAP Academy Report 2002)

EXCISIONAL NEW ATTACHMENT PROCEDURE (ENAP)ENAP is the surgical procedure of which an internal bevel incision is made to remove the epithelial lining of the crevice and the junctional epithelium, allowing root preparation

Definitive subgingival curettage

Developed by the U.S Naval Dental Corps based on studies by Yukna (1976), Yukna and Fedi (1976)

Gain new attachmentDecrease probing depth

Access root surfaceMaintenance of esthetics

PROCEDURE

• Internal bevel incision from marginal gingiva to a point below the bottom of the pocket- to cut inner portion of soft tissue wall

• Remove excised tissue with a curette, root planing on exposed root preserving all CT fibers that are attached to root

• Approximate wound edges, bone recontouring if necessary

Author Studies Result

Yukna et al,1976 Excisional new attachment procedure was used to treat 75 suprabony pockets on 32 teeth in 9 patients

One-year postoperative -mean pocket reduction from 4.7 mm to 2.0 mm, of which 2.1 mm (77%) was new attachment and 0.6 mm was recession.

Yukna and Williams Jr,1980 Patients treated with the Excisional New Attachment Procedure were evaluated 5 years or more following the procedure

An overall mean net gain in clinical attachment of 1.5 mm was found at 5 years after treatment, and probeable depths approached 3.0 mm

LASER ASSISTED EXCISIONAL NEW ATTACHMENT PROCEDURE ( LANAP)

• Patterned after the Excisional New Attachment Procedure (ENAP), LANAP is designed to remove diseased and necrotic tissue selectively from within the periodontal sulcus

• The first pass with the laser (referred to as laser troughing) is accomplished by using the short duration pulse.

• Laser troughing affects sulcular debridement and de-epithelialization.

• Executed by moving the fiber continuously, beginning at the gingival crest and working back and forth systematically, stepping down to the base of the pocket.

• Following laser troughing, SRP is accomplished first by using a piezo-electric scaler

• Followed by small curettes and root files for removing root surface accretions. Aggressive root planing is minimized.

• A second pass, using the PerioLase with the 635-μ/sec “long pulse,” finishes debriding the pocket, completes removal of epithelial tissue, provides hemostasis, and creates a soft clot.

• The primary goal of LANAP is debridement to remove pocket epithelium and underlying infected tissue within the periodontal pocket completely and to remove calcified plaque and calculus adherent to the root surface

Clinical steps of LANAP, beginning with charting probe depths (A). The primary endpoint of LANAP is debridement of inflamed and infected connective tissue within the periodontal sulcus (B) Removal of calcified plaque and calculus adherent to the root surface (C). In addition, the bacteriocidal effects of the FR pulsed Nd:YAG laser plus intraoperative use of topical antibiotics are designed for the reduction of microbioticpathogens (antisepsis) within the periodontal sulcus and surrounding tissues.A second pass with the 635 μ/sec “long pulse” laser finishes debriding the pocket (D).

Gingival tissue is compressed against the root surface to close the pocket and aid with formation and stabilization of a fibrin clot (E). Oral hygiene is stressed and continued periodontal maintenance is scheduled. No probing is performed for at least six months.

GINGIVECTOMY

The excision of the soft tissue wall of a pathogenic periodontal pocket

- coined ‘gingivectomy’

- modified the Robicsek technique, proposed a scalloped incision

described the current gingivectomyprocedure

CONTRAINDICATIONS

Firm, fibrotic suprabony pockets ˃ 5mm, persisting after SRP

Gingival enlargements-pseudopockets

Suprabony abscesses

Presence of alveolar ledges, irregular margins

Infrabony pockets

Pockets extending beyond the MGJ

Anterior aesthetic areas

INDICATIONS

• Pocket marking

• Gingivectomy incision

• Knives- No. 12/15 blade, Blake knife, Kirkland, Orban,

• Goldman-Fox

• External bevel incision- at 45°, apical to base of pocket, continuous, scalloped

• Secondary incisions done with orbans knife.

• Tissue removal- Curette/scaler

• Root scaling and planing

• Periodontal dressing

Pocket marking

Gingivectomyincision

Tissue removal-curette /scaler Residual pocket

depth is assessed

LIMITATIONS

• Open wound, healing by secondary intention

• Zone of attached gingiva may be reduced/ eliminated

• Alveolar defects not revealed, if present

• Exposure of root -root sensitivity

FLAP SURGERY

• Periodontal flap is defined as ‘ the section of gingiva and/or mucosa surgically elevated from the underlying tissues to provide visibility and access to the bone and root surfaces’

GLICKMAN

RATIONALE

To enable visual instrumentation of root

surfaces

To re-establish the healthy, clinical status of periodontium

with long term maintenance

To restore the periodontal apparatus when attachment

loss has occurred

• Pocket elimination or reduction

• Preservation of adequate zone of attached gingiva

• To permit access to underlying bone for treatment of osseous defects

SPECIAL INDICATIONS

HISTORICAL BACKGROUNDNeumann (1911) 1st introduced mucoperiosteal flap- ‘Neumann flap’

Cieszynski (1911) Reverse bevel incision

Leonard Widman (1918) Modified the Neumann flap

Kirkland (1931) Modified flap procedure

Nabers (1954) Introduced ‘repositioning of attached gingiva’

Ariaudo and Tyrrell (1962) Modified Nabers procedure

Friedman (1962) Apically positioned flap

Morris (1965) ‘Unrepositioned mucoperiosteal flap’

Ramfjord and Nissle (1974) ‘Modified Widman flap’

•Mucoperiosteal flapFULL THICKNESS FLAP

•Split thickness; mucosalPARTIAL

THICKNESS FLAP

UNDISPLACED (NON-DISPLACED; UNREPOSITIONED)

• Eg: Modified Widman, undisplaced flap

DISPLACED (REPOSITIONED)

• Eg : Coronally positioned

• Laterally positioned

• Apically positioned

BASED ON THE MANAGEMENT OF PAPILLA

CONVENTIONAL FLAPS: modified widman flap, undisplaced flap, apically displaced flap, flap for reconstructive procedures

• Papilla is split at center under contact point and included in both buccaland palatal/lingual flaps

PAPILLA PRESERVATION FLAP

• Papilla is included in one of the flaps by semicircular incision

• According to the main purpose of the procedure

Pocket elimination flap

Reattachment flap surgery

Mucogingival repair.

• Widman flap, The undisplaced (unrepositioned) flapThe apically displaced flap.

COMPARISON BETWEEN FULL THICKNESS AND PARTIAL THICKNESS

Full thickness Partial thickness

Healing Primary intention Secondary intention

Bone defect treatment possible difficult

Blood supply to flaps sufficient decrease

Elimination/ reduction of periodontal pocket

possible possible

Bleeding less much

Postoperative discomfort less much

Possibility of flap penetration

less much

Fixation of flaps Firm fixation with periosteal sutures

HORIZONTAL INCISIONS

VERTICAL INCISIONS

HORIZONTAL INCISIONS

Directed along the margin of the gingiva in a mesial or a distal direction.

Two types of horizontal incisions have been recommended:

A) starts at a distance from the gingival margin and is aimed at the bone crest.

B) starts at the bottom of the pocket and is directed to the bone margin.

C) performed after the flap is elevated

INTERNAL BEVEL INCISION

• First incision/ Reverse bevel incision

• Basic incision

Placement of internal bevel incision- depends

on the objective of treatment

• Removal of pocket lining : close to the gingival margin (0.5-1mm) -Modified Widman flap

• Removal of pocket lining and preservation of the keratinized gingiva : close to gingival margin- Apically displaced flap

• Removal of pocket lining and minimizing dead space formation : apical to bottom of pocket -Undisplaced flap

• PRIMARY INCISION DEPENDS ON:

Width of attached gingiva

Type of surgery

Esthetics

Osseous reconstruction ,If required

Depth of pockets

Clinical crown lengthening, if required

CREVICULAR INCISION

• Second incision

• Starts from base of pocket and is directed to alveolar crest

• Along with the first incision it produces a V shaped wedge of tissue

• Third incision

• Directed horizontally from the internal bevel incision to remove the wedge shaped tissue

• Given when flaps have to be displaced

• Directed perpendicularly to gingival margins at the line angles of teeth

• THEY SHOULD NOT BE PLACED :

Pronounced concavities

Prominent bony ledges

Exostoses

Should not cross root prominences

Should not split interdental papilla

• Best to include papilla with the flap to enhance blood supply and facilitate suturing

CORRECT INCISION

INCORRECT INCISION

• Internal/ undermining incisions extending from gingival margin towards base of flap to decrease bulk of connective tissue on the underside of flap

• Indicated in Palatal flaps, Distal wedge, Internal bevel gingivectomy, Bulky papillae

Incisions at base of flap severing underlying periosteum

INDICATED

to release flap tension allowing for coronal/ lateral placement,

to provide primary closure over barrier membranes in GTR and GBR procedures

Full thickness mucoperiosteal flap aimed at removing:

Pocket epithelium and the inflamed connective tissue

ADVANTAGES

Facilitates optimal cleaning of root surfaces

Less discomfort for the patient, healing occurs by primary intention

Re establish a proper contour of the alveolar bone in sites with angular bony defects

Two releasing incisions, scalloped reverse bevel incision connecting two

releasing incisionsCollar of inflamed gingival tissue is

removed after flap elevation

Bone recontouring suturing

• Intracrevicular incision through the base of the gingival pocket

• Entire gingiva (and part of the alveolar mucosa) was elevated in a mucoperiosteal flap

• Sectional releasing incisions

• Flap elevation, the inside of the flap curetted to remove the pocket epithelium and the granulation tissue

• The root surfaces were subsequently carefully “cleaned”

• Any irregularities of the alveolar bone corrected to give the bone crest a horizontal outline

• Flaps trimmed to allow both an optimal adaptation to the teeth and a proper coverage of the alveolar bone on both the buccal/lingual (palatal) and the interproximal sites

• Flap replaced at crest of alveolar bone

• Modified flap operation- to be used in the treatment of “ Periodontal pus pockets”.

• Incisions made intracrevicularly through the bottom of the pocket

• Retraction of the gingiva- debridement

• Elimination of the pocket epithelium and granulation tissue from the inner surface of the flaps

Intracrevicular incision Gingiva is retracted to expose the diseased root surface

Exposed root surfaces are subjected to mechanical debridement

Suturing

DIFFERENCE FROM NEUMANN AND ORIGINAL WIDMAN FLAP

• Pocket elimination procedure using internal bevel incision. Also called as INTERNAL BEVEL GINGIVECTOMY

• Pocket wall is eliminated with first incision

• Elimination of ‘dead space’ as the flap margin is place over bone crest postoperatively

• However, sufficient attached gingiva is a pre-requisite

• Usually used for pocket elimination of palatal pockets

The incision is made at the level of the pocket to discard the tissue coronal to the pocket if there is sufficient remaining attached gingiva.

Nabers(1954) –one vertical

incision-‘repositioning of attached gingiva’

Ariaudo and Tyrrell (1957) –

two vertical incisions

Friedman (1962) – coined the term

‘apically repositioned flap’

Apical displacement of entire mucogingival unit to eliminate the pockets while retaining the attached gingiva. To maintain keratinized gingiva

Surgical access for osseous surgery, treatment of infrabony pockets and root planing.

OBJECTIVES

USED FOR

The apically displaced flap technique can be used for(1) pocket eradication and/or

(2) widening the zone of attached gingiva.(3)crown lengthening procedures for cosmetic enhancement and

restorative treatment

Indicated in

• Mandibular buccal and lingual surfaces

• Maxillary buccal surfaces

It can be raised as

• Full thickness flap

• Partial thickness flap

Reduction of probing depth,

Preserving or increasing the presurgical zone of gingiva,

Facilitation of healing, accessibility to bone, roots, furcations, subgingivalcaries, and other anatomical aberrations,

Controlling the tissue placement,

Usefulness in conjunction with other treatment modalities.

Sacrifice of crestal alveolar process and supporting bone

Extensive exposure of root surfaces.

Vertical releasing incision, the reverse bevel incision is made through the gingiva and

periosteum to separate the inflamed tissue adjacent to the tooth

Mucoperiosteal flap is raised and the tissue collar remaining around the teeth, including the pocket epithelium and the

inflamed connective tissue is removed with a curette

Osseous surgery is performed with a rotating bur

Recapture the physiologic contour of the bone

Repositioned in an apical direction to level of the recontoured bone crest and retained by sutures

FRIEDMAN AND LEVIN CLASSIFICATION ,1962

Class I: More than adequate keratinized gingiva width

Labial or buccal incision 1-3mm from crest of gingiva.

Flap apically positioned to cover 1-2mm of cementum

Class II: Adequate keratinized gingiva

Crestal incision used.

Flap apically positioned to the crest of the bone

Class III- Insufficient gingival keratinized width

Sulcular incision

Flap is positioned 1-2mm below crest of bone to increase width of keratinized gingiva.

• Ramfjord and Nissle in 1974 coined the term modified Widman flap

• Procedure was employed by Morris in 1965 and was termed the unrepositioned mucoperiosteal flap.

• Morris in 1965 has described this flap as “the simple mucoperiosteal flap, combined with the inverted beveled incision and osseous resection.”

• Conservative flap design of which includes a reverse bevel incision from the marginal gingiva to the alveolar crest, the intrasulcular incision to the bottom of the pocket, and the horizontal incision from the alveolar crest to the bottom of the pocket.

• It is used whenever reattachment with minimal gingival recession is desired.

• Moderately deep pockets

• Moderate furcation involvement, and

Patient with a high caries rate and root sensitivity problem.

Initial incision is placed:0.5-1mm from the gingival margin

Parallel to long axis of tooth

Elevation of the flaps,Intracrevicular incision is made to alveolar bone

crestTo separate the collar tissue from root surface

Third incision is made:Perpendicular to root surface and

As close to possible to the bone crest thereby separating the tissue collar from alveolar

bone

Flaps are carefully adjusted to cover the alveolar bone and sutured

Complete coverage of the interdental bone as well as close adaptation of the flaps to the tooth surfaces should

be accomplished

Advantages:

• Possibility of obtaining close adaptation of soft tissues to root surfaces

• Less exposure of root surfaces – esthetic advantage in the anterior segments ( Ramfjord and Nissle,1974)

• SRP at base of deep pockets can be done with direct vision

• Complete removal of pocket epithelium

• Primary intention healing

• Esthetically superior to gingivectomy/ APF

Original Widman flap Modified Widman flap

Pocket elimination procedure Pocket reduction procedure

Apical displacement of flap No apical displacement

Osseous recontouring can be done Not designed for osseous contouring

• Ramfjord and Nissle performed an extensive longitudinal study comparing the Widman procedure, as modified by them, with the curettage technique and the pocket elimination methods that include bone contouring when needed.

• The patients were assigned randomly to one of the techniques, and results were analyzed yearly up to 7 years after therapy.

• Similar results with the three methods tested.

• Pocket depth was initially similar for all methods but was maintained at shallower levels with the Widman flap;

• The attachment level remained higher with the Widman flap.

• Pocket lining was removed with the help of a diode laser

• The laser setting used for this procedure was 4 W in continuous mode.

• Crevicular incision was given with a bard parker # 15 blade directed toward the alveolar crest. Full thickness mucoperiosteal flap was raised buccally and lingually. The granulation tissue was removed from the defects by manual debridement

• Reduction in probing depth was from 11 mm to 6 mm

• Radiographs revealed increased bone fill

• To preserve the interdental soft tissues for maximum soft tissue coverage involving treatment of proximal osseous defects

• Cortellini et al. (1995, 1999) – modifications of the flap design to be used in combination with regenerative procedures.

• For aesthetic reasons, it is often utilized in the surgical treatment of anterior tooth regions

Sulcular incision Semilunar incision- dip 5mm apically from line angles

Papilla elevated in facial flap

suturing

• Access to the interdental defect consists of a horizontal incision buccal keratinized gingiva at the base of the papilla

• Connected with mesio-distal buccal intrasulcular incisions for elevation of full-thickness buccal flap

• Residual interdental tissues are dissected from neighboring teeth and the underlying bone and elevated towards the palatal aspect

• Elevation of full thickness palatal flap, including the interdental papilla, interdental defect exposure

• Debridement of the defect

• Buccal flap is mobilized with vertical and periosteal incisions, when needed

Difficult application in narrow interdental spaces and in posterior areas

Suturing technique not appropriate for use with non supportive barriers

Modified papilla preservation is used in wide interdental spaces (>2mm ) especially in anterior dentition.

Sulcular incisions and buccal flap elevation

Palatal flap reflection

Oblique incision in papilla begins at the gingival margin line angle, blade parallel to the long axis of

the tooth and reaches the midpoint of the distal surfaceof adjacent tooth below the contact point

• Palatal flaps historically involved reflecting full thickness flap to remove necrotic and granulomatous tissue.

Advantages of palatal approach-EstheticsEasier access for osseous surgeryLess resorption because of thicker boneWider palatal embrasure spaceA natural cleansing area.

Oschenbein and Bohannan(1963,1964) described a palatal approach for osseous surgery

Indications-

• Areas that require osseous surgery

• Pocket reduction

• Reduction in enlarged bulbous tissue

Contraindications-

• Broad shallow palate- damage to palatal vessels

• Full thickness

• Partial thickness

• Modified partial thickness

• Beveled flap

• Undisplaced flap

PARTIAL THICKNESS PALATAL FLAP

• Developed by Staffileno et al (1969)

To facilitate treatment of palatal osseous defectsTo overcome problems of extensive gingival recession

Minimal traumaRapid healing

Ease of palatal tissue manipulationEstablishment of favorable gingival contours

MODIFIED PARTIAL THICKNESS PALATAL FLAP

• Oshenbein(1958) ,Oshenbein and Bohannan(1963) described the technique

• Popularized by Prichard( 1965)

• Also known as

• Stage I : Gingivectomy

But no bevel

tissue ledge is created

• Stage II : Partial thickness flap

• Primary partial thickness thinning incision

• Secondary incision - inner flap removal

BEVELED FLAP- MODIFICATION OF THE APF

Primary incision is made intracrevicularly

Scaling, root planing and osseous recontouring

Shortened and thinned flap replaced over the alveolar bone

Secondary, scalloped reverse bevel incision is made to adjust to the height of the remaining alveolar bone

• Treatment of periodontal pockets on the distal surface of distal molars is complicated by the presence of bulbous tissues over the tuberosity (maxillary) or by a prominent retromolar pad (mandibular)

Factors to be considered for distal-molar surgery

• Pocket depth

• Amount of keratinized gingiva

• Accessibility

• Available distance from distal aspect of tooth to the end of tuberosity/ retromolar pad

• Anatomic considerations : Lingual nerve, Internal oblique ridge, Muscle attachments

DISTAL WEDGE PROCEDURE ( ROBINSON,1966)

INDICATIONS

• When only limited amounts of keratinized gingiva is present

• Presence of distal angular bony defect

Facilitates access to osseous defectPreserves sufficient amounts of gingiva and mucosa to

achieve soft tissue coverage

Buccal and lingual vertical incisions through the retromolar

pad to form a triangle behind mandibular molar

Triangular shaped wedge of tissue is dissected from the

underlying bone and removed

Flaps are reduced in thickness by undermining incisions

Suturing

FOR MANDIBULAR MOLARS

Incisions are governed by location of keratinized gingiva

Incisions :

• Triangular wedge

• Square, parallel or H design

• Linear or pedicle

FOR MAXILLARY MOLARS

Simpler compared to mandibular as more fibrous and attached tissue is generally present

Incisions may be

• Triangular wedge

• Linear wedge

ADVANTAGES OF DISTAL WEDGE

• Maintenance of attached tissue

• Access for treatment of both the distal furcations and underlying osseous irregularities

• Closure by a mature thin tissue which is especially important in retromolar area

• Greater access and opening when done in conjunction with other flap procedures

• Principles outline by Schluger(1949) and Goldman( 1950)

• “Gingival contour is dependent on the underlying bony contour and the elimination of the soft tissue pockets has to be combined with osseous recontouring”.

• To maintain

Shallow pockets

Optimal gingival contour after surgery

OSTEOPLASTY- FRIEDMAN (1955)

• Reshaping of alveolar bone to achieve a more physiological form without removal of tooth supporting bone

Indications

• Buccal/ lingual bony

• ledges

• Intrabony defect-buccal/lingual,

• tilted molars

• Interproximal defects

• Furcation involvement

OSTECTOMY

Removal of tooth supporting bone to reshape the deformities.

INDICATIONS :

• Elimination of interdental craters

• Correction of one walled defects

• Other angular defects not amenable to regeneration

• Horizontal alveolar bone loss with irregular marginal contours

a connection between the flap and the tooth or bone surface is established by a blood clot,

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.

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

collagen fibers begin to appear parallel to the tooth surface.

a fully epithelialized gingival crevice with a well-defined epithelial attachment is present.

Beginning functional arrangement of the supracrestal fibers

• 1 to 3 days- Full-thickness flaps, result in a superficial bone necrosis.

• 4 to 6 days- Osteoclastic resorption follows .Loss of bone of about 1 mm and the bone loss is greater if the bone is thin.

• If Osseous remodeling does not include excessive thinning of the radicular bone. Bone repair reaches its peak at 3 to 4 weeks.

LONG TERM STUDIES COMPARING SURGICAL AND NON- SURGICAL

THERAPIES

MICHIGAN STUDIES

Ramfjord et al. (1968)

32 patients with moderate-severe periodontitis

all patients 1st received nonsurgical therapy and then divided into

Group 1: subgingival curettage

Group II: pocket elimination (gingivectomy, APF with osseous resection)

Short term observations (1-3 yrs)

• Group 1: slight gain in CAL

• Group II : loss of attachment following pocket elimination procedures

Long term evaluation (4-7 yrs)

• No significant differences between the 2 groups

• Surgical technique – reduction in PD was greater and better sustained

Knowles et al. (1979)

78 patients evaluated over 1-8 yrs

Effect of subgingival curettage, Modified Widman flap and pocket elimination

procedure

Results:

All techniques reduced PD with subgingival curettage being the least effective

Moderate pockets (4-6 mm)- similar CA gain

Advanced pockets (7-10mm)- Modified Widman produced greatest gain in CA,

followed by curettage and pocket elimination

GOTHENBURG STUDIES

Lindhe et al. (1982)

15 patients, split mouth study

SRP alone vs. SRP + Modified Widman

Results at 2 yrs demonstrated that surgical therapy results in greater probing depth reduction than nonsurgical therapy

CRITICAL PROBING DEPTH

Root planing : 2.9 mm

Flap : 4.2 mm

MINNESOTA STUDY

Pihlstrom et al. (1985)

SRP alone vs. flap in 6 ½ yr follow up

No significant difference in probing depth reduction and gingival

inflammation

Although attachment gain seemed to be greater with flap procedures

for deeper pockets.

AARHUS STUDY

Isidor and Korning (1986)

Root planing and Modified Widman flap to apically positioned flap during 5

year of follow up

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.

osseous recontouring was more effective in reducing pockets and

controlling the inflammation than flap surgery

TUCSON STUDIES

Becker et al. (1988)

Root planing, Modified Widman flap, apically positioned flap with osseous

surgery

1 yr observation period – minimal differences in probing depth reductions and

attachment gain between the 3 procedures

NEBRASKA STUDIES

Kaldahl et al. (1988)

82 patients, split mouth design study for 2 yrs

SRP vs. Modified Widman flap vs. Modified Widman flap with osseous resection

All resulted in decrease in PD

Greatest with flap with osseous resection, followed by Modified Widman flap and

SRP

INTERPRETATION OF LONGITUDINAL STUDIES

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

Thus, SRP will always be performed first for any patient with periodontitis

• Clinical probing depth and clinical attachment levels evaluated.

• Modified widman flap gave better results for gain in clinical attachment ,while all three modalities significantly reduced probing depth.

( Becker et al,2001)

• Effect of root planing alone and with a modified widman flap

• Assessment of resultant level of attachment and in relation to initial pocket depth

• SRP- loss of attachment in pocket shallower than 2.9mm

• Gain of attachment in deeper pockets

Modified widman flap- loss of attachment in pockets shallower than 4.2mm

Gain of attachment in deeper pockets

Loss of attachment implies true loss of connective tissue

Gain- could be false

Failures of flap surgery

• Pre therapeutic causes

• Therapeutic causes

• Post therapeutic causes

PRE THERAPEUTIC CAUSES

1) Incorrect patient selection

2) Improper diagnosis

Systemic condition

Type of periodontitis

Involvement of hopeless tooth

Oral hygiene assessment

3) Inappropriate dental restorations

4)Morphology of tooth surfaces

Failure to eliminate aberrations like enamel pearls and grooves which act as a “guide plane” for a bacterial penetration of deeper periodontal tissues

5)Habits

mouth breathing

bruxism

thumb sucking

Smoking

6)Occlusal trauma

THERAPEUTIC CAUSES

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

• decreased width of attached gingiva- internal bevel incision will further decrease the width of attached gingiva leading to mucogingival problems

• 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

Improper flap design:

• A properly designed flap will anatomically fall into its correct position on its bony base following surgery

• If a mucoperiosteal flap is not designed correctly it may

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

• It may also encourage the overzealous tightening of the sutures, thereby endangering the blood supply and enhancing the possibility of sloughing of flap and post operative pain

Incomplete debridement

Improper suturing

• Improper incision: the rationale of any periodontal flap surgery is to gain access to underlying root and bone surfaces.

• If incisions are not made upto the bone/root surface and a mucosal flap is elevated which hinders in gaining proper access to the underlying root surfaces, It can cause increased amount of bone resorption.

• Therefore while giving incision the blade should hit the bone in order to elevate a full thickness flap.

• REFLECTION OF THE FLAP: elevation of the periodontal flap should be such that only around 1 mm of marginal bone is exposed.

Over reflection - bone resorption,

Under reflection - limited access to the underlying root/bone surface.

• DEBRIDEMENT OF THE ROOT SURFACES AND THE BONE: complete debridement with removal of plaque and calculus from the root surface

• SUTURING of the separated flaps should be done to closely adapt the flap to the tooth margins.

Failure to properly place the sutures gaping of the wound and hence recurrence of the disease

POST THERAPEUTIC CAUSES

Unsupervised healing :

• Post-operative care

Inadequate restorations post surgically :

• failure to replace missing teeth

• correct overhanging restorations

• correct carious lesions

FAILURES ASSOCIATED WITH PALATAL FLAPS

The flap may be too short. This results in delayed healing & increased patient discomfort.

Poor marginal flap adaptation caused by incomplete thinning of the tissue.

Damage to the palatal artery- Incision beyond the vertical height of the alveolus, bringing the scalpel blade close to the palatal artery

Extension beveling or thinning of tissue on a low, broad palate.

Tissue placement to high onto the teeth results in poor flap adaptation & recurrent pocket formation.

Selection of technique???

• Suprabony, fibrous pocket with sufficient attached gingiva-Gingivectomy

• Infrabony pocket, osseous deformities, furcation involvement, muco-gingival problems- Flap surgery

• Location

Amount of attached gingiva

Need for osseous recontouring

• Pocket wall can be

Edematous & soft

Fibrotic

• Edematous pockets shrink after elimination of local factors. Therefore scaling & root planing and curettage is the preferred treatment.

• Fibrotic pockets do not subside predictably after S.R.P. Hence preferred method is gingivectomy

Therapy for pockets with horizontal bone loss

• N.S.T

• Surgical therapy if required

Therapy for pockets with vertical bone loss

• N.S.T

• Surgical therapy to eliminate the bone defect by resection or regeneration

• Scaling and root planing is the technique of choice

• PAPILLA PRESERVATION FLAP- improved accessibility for root surfaces

regenerative surgery of osseous defects

• Results in less recession and reduced soft tissue crater formation interproximally

• SULCULAR INCISION FLAP- teeth too close interproximally

• MODIFIED WIDMAN FLAP- esthetics not the primary consideration

• APICALLY DISPLACED FLAP with bone recontouring

• Osseous surgery required for enhanced accessibility or the need of definitive pocket elimination

• Accessibility- undisplaced flap/ apically displaced flap

• Osseous defects amenable to reconstruction- papilla preservation flap

sulcular flap

modified widman flap

• Osseous defects with no possibility of reconstruction- flap with osseous recontouring

Excisional surgeries

Resectivesurgery

Regenerative procedures

• Tissue attachment procedures , although not capable of generating predictable new attachment, are effective in controlling the progression of chronic periodontitis.

• The patient and the dentist have an option between flap debridement procedures and other debridement approaches to control disease progression.

• Choice must be made upon a multitude of factors including clinical expertise, systemic and local etiologic factors, time and economic factors.

Among the tissue attachment procedures, FLAP DEBRIDEMENT SURGERY remains an important part of

periodontal therapy.