CHAPTER 57 & 59: PERIODONTAL FLAP

classification of flaps

bone exposure after flap exposure

placement of the flap after surgery

management of the papilla

objectives of flaps in general

gain access for osseous resective surgery, if necessary

expose the area for the performance of regenerative methods

eliminate or reduce pocket depth via resection of the pocket wall

increase accessibility to root deposits for scaling and root planing

flaps under bone exposure after flap exposure

full-thickness flap

partial / split thickness flap

flaps under placement of the flap after surgery

nondisplaced flap

displaced / repositioned flap

management of the papilla

conventional flap

papilla preservation flap

full thickness flap

indicated when resective osseous surgery is indicated

all the soft tissue including the periosteum is reflected to expose the underlying bone

partial / split thickness flap

bone remains covered by a layer of connective tissue

includes only the epithelium & a layer of the underlying bone

indicated when flap is to be repositioned apically or when the operator does not want to expose bone

conventional flap

used when the flap is to be replaced

used when the interdental spaces are too narrow

the interdental papilla is split beneath the contact point of the 2 approximating teeth to allow reflection of buccal & lingual flaps

papilla preservation flap

incorporates the entire papilla in one of the flaps by means of crevicular interdental incisions to sever the connective tissue & a horizontal incision at the base of the papilla, leaving it connected to one of the flaps

nondisplaced flap

flap is returned & sutured in its original position

displaced flap / repositioned flap

flap which is placed coronally, laterally or apically to their original position

examples of displaced flap / repositioned flap

coronally positioned flap

laterally positioned flap

apically positioned flap

coronally positioned flap

for single or multiple-tooth recession defects

a split-thickness flap that is advanced coronally to gain root coverage

laterally positioned flap

aka: double papilla technique

a pedicle graft

better color matching & less damage

for small single-tooth recession defects

apically positioned flap

crown lengthening

reduces pocket depth

exposes impacted tooth

modified widman flap

no vertical incision needed

bleeding points is not marked

no ability to treat osseous defects

incisional procedure of the gingiva

only removes pocket lining, not pocket depth

facilitates root debridement to remove pocket lining

shallow to moderate pocket depth with base of pocket coronal to mucogingival junction

objectives of modified widman flap

to remove pocket lining

to achieve primary closure

to preserve an adequate zone of keratinized tissue

to gain access to underlying bone and root surfaces

indications of modified widman flap

no need for osseous recontouring

access to subgingival calculus and root surfaces for thorough debridement

preservation of soft tissue while ensuring adequate access for instrumentation

areas with aesthetic concerns where gingival recession needs to be minimized

maintenance therapy for periodontitis when more aggressive surgery is not required

moderate to deep periodontal pockets (5-7 mm) that do not respond to non-surgical therapy

contraindications of modified widman flap

where there is little or no attached gingiva

when there are large bony thickenings or exostoses to be removed

when there is pronounced gingival enlargements or overgrowth

does not permit initial scalloped incision (internal gingivectomy) due to narrow band of attached gingiva

extensive bone surgery such as osteoplasty or ostectomy, particularly if there are deep bone defects and uneven bone loss in the facial and oral regions.

instruments used in MWF

no. 11 — 3rd incision

no. 12 — 2nd incision

no. 15 — 1st incision

no. 9 MOLT — periosteal elevator

orban knife

procedure for MWF

1st incision: internal bevel incision 0.5-1mm away from gingival margin towards alveolar bone parallel to tooth's long axis

2nd incision: crevicular incision from pocket bottom to bone, circumscribing pocket lining

3rd incision: interdental spaces coronal to bone with curette or interproximal knife

removal of gingival collar and tissue tags and granulation tissue

checking and scaling root surfaces

bone architecture not corrected unless it prevents tissue adaptation

placement of continuous, independent sling sutures in facial and palatal areas

undisplaced flap

aka: internal bevel gingivectomy

marks bleeding points

cannot treat osseous defects

no need for a vertical incision

excisional procedure of the gingiva

flap margin should be at root-bone junction

most frequently performed type of periodontal surgery

internal bevel incision should eliminate the pocket wall

initiated at or near a point just coronal to the bottom of the pocket

involves eliminating or removing the pocket wall of the gingiva

improves instrumentation accessibility but also removes the pocket wall

2 anatomical landmarks to consider in undisplaced flap

BP — bottom of pocket / depth of the pocket

MGJ — location of mucogingival junction

— the cut foes below the crest of bone

— these landmarks establish the presence and width of the attached gingiva.

indications of undisplaced flap

there is enough keratinized attached gingiva

there is a need to gain access for osseous resective surgery

for deep periodontal pockets where there is a need to remove pocket wall to reduce or eliminate the pocket

contraindications of undisplaced flap

significant bone loss

deep intrabony defects

insufficient attached gingiva

shallow pockets (less than 5mm)

procedure for undisplaced flap

measure pockets with periodontal probe

mark pocket bottom with bleeding point

make initial or internal bevel incision

make second or crevicular incision from pocket bottom to bone

reflect flap with periosteal elevator

make third or interdental incision with interdental knife

remove triangular wedge of tissue with curette

debride area, remove tissue tags and granulation tissue

scale and root plane, ensure flap edge rests on root-bone junction

secure facial and lingual/palatal flaps with a continuous sling suture

advantages of MWF

less impact on esthetics

direct access and visibility

minimal inflammation or bleeding

conservative because it does not remove bone

facilitates the formation of long junctional epithelium

disadvantages of MWF

technique-sensitive

unfavorable interproximal architecture

regeneration is the exception, not the rule

requires meticulous oral hygiene maintenance to regenerate loss of tissues

apically displaced flap

“workhorse” of periodontal therapy

provides accessibility and eliminates pocket

preserves or increases width of attached gingiva

incisional procedure to eliminate moderate to deep pockets

moderate to deep pockets with base of pocket apical to the mucogingival junction

Nabers (1954)

introduced the apically displaced flap

Ariaudo and Tyrell (1957)

modified the apically displaced flap

objectives of apically displaced flap

provides root surface access

eliminate pocket depth without decreasing the amount of existing keratinized tissue

indications of apically displaced flap

crown lengthening

minimal amount of gingiva

moderate to deep periodontal pockets

contraindications of apically displaced flap

mx & mn anterior region

px at risk for root caries

px with systemic impairment

procedure of apically displaced flap

internal bevel incision directed to bone crest, following gingiva scalloping

crevicular incisions around tooth

initial elevation of flap, followed by interdental incisions

removal of tissue containing pocket wall

removal of granulation tissue, scaling, root planing, and osseous surgery

apical displacement of flap

full-thickness flap secured with sling suture

partial-thickness flap secured with direct loop or anchor suture

dry foil placed before periodontal dressing

full-thickness flap: blunt dissection with periosteal elevator

split-thickness flap: sharp dissection with Bard-Parker knife

distal molar surgery / distal wedge

intended for treatment of periodontal pockets on the distal surface of terminal molars

done by making two parallel incisions beginning at the distal portion of the tooth & extending to the mucogingival junction

procedure is often complicated by presence of bulbous fibrous tissue over maxillary tuberosity or prominent retromolar pads

incision for maxilla

parallel

incision for mandible

triangle

Ramfjord and Nissle (1974)

founded the modified widman flap technique

horizontal incisions

are directed along the margins of the gingiva in a mesial or a distal direction

internal bevel incision

1st incision

it removes the pocket lining (MWF)

it removes the pocket wall (undisplaced flap)

if apically positioned, becomes the attached gingiva

it conserves the relatively uninvolved outer surface of the gingiva

it produces a sharp, thin flap margin for adaptation to the bone-tooth junction

crevicular incision

2nd incision

made at the gingival sulcus

made from the base of the pocket to the crest of the bone

together with the initial reverse bevel incision forms a V-wedge ending at or near the crest of bone

interdental incision

3rd incision

last incision done to separate the collar of gingiva that is left around the tooth