Contents available in the book .. Trismus is the inability to open the mouth. The no. According to flap reflection or tissue content: C. According to flap placement after surgery: Diagram showing full-thickness and partial-thickness flap. The internal bevel incision starts from a designated area on the gingiva, and it is then directed to an area at or near the crest of the bone (Figure 57-6). Unsuitable for treatment of deep periodontal pockets. Suturing is then done using a continuous sling suture. Within the first few days, monocytes and macrophages start populating the area 37. After debridement, flaps are closely adapted around the teeth in close approximation, allowing healing by primary intention. With the help of Ochsenbein chisels (no. 2014 Apr;41:S98-107. This incision is indicated in the following situations. The following steps outline the modified Widman flap technique. For the conventional flap procedure, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla or its vicinity, thereby splitting the papilla into a facial half and a lingual or palatal half (Figures 57-3 and 57-4). This type of flap is also called the split-thickness flap. At last periodontal dressing may be applied to cover the operated area. In the present discussion, we discussed various flap procedures that are used to achieve these goals. The most abundant cells during the initial healing phase are the neutrophils. Ramfjord and Nissle6 performed an extensive longitudinal study that compared the Widman procedure (as modified by them) with the curettage technique and the pocket elimination methods, which include bone contouring when needed. After the area to be operated has been irrigated with an antimicrobial solution and isolated, the local anesthetic agent is delivered to achieve profound anesthesia. As discussed in, Periodontal treatment of medically compromised patients, antibiotic prophylaxis is must in patients with medical conditions such as rheumatic heart disease. Enter the email address you signed up with and we'll email you a reset link. Placing periodontal depressing is optional. The local anesthetic agent is delivered to achieve profound anesthesia. Pronounced gingival overgrowth, which is handled more efficiently by means of gingivectomy / gingivoplasty. the.undisplaced flap and the gingivectomy. Journal of periodontology. b. Step 4:After the flap is reflected, a third incision is made in the interdental spaces coronal to the bone with a curette or an interproximal knife, and the gingival collar is removed (Figure 59-3, E and F). Square, parallel, or H design. The area is anesthetized and bone sounding is done to evaluate the osseous topography, pocket depth, and thickness of the gingiva. Disain flep ini memberikan estetis pasca bedah yang lebih baik, dan memberikan perlindungan yang lebih baik terhadap tulang interdental, hal mana penting sekali dalam tehnik bedah yang mengharapkan terjadinya regenerasi jaringan periodontium. The first documented report of papilla preservation procedure was by Kromer 24 in 1956, which was designed to retain osseous implants. Contents available in the book .. The incision is usually scalloped to maintain gingival morphology and to retain as much papilla as possible. ious techniques such as gingivectomy, undisplaced flap with/without bone surgery, apical resected flap with/without bone resection, and forced eruption with/without fiberotomy have been proposed for crown lengthening procedures.2-4 Selecting the technique depends on various factors like esthetics, crown-to-root ratio, root morphology, furcation Contents available in the book . It must be noted that if there is no significant bleeding and flaps are closely adapted, periodontal dressing is not required. What are the steps involved in the Apically Displaced flap technique? The root surfaces are checked and then scaled and planed, if needed (. The flaps may be thinned to allow for close adaptation of the gingiva around the entire circumference of the tooth and to each other interproximally. Contents available in the book .. It is contraindicated in areas where the width of attached gingiva would be reduced to < 3 mm. Within the first few days, monocytes and macrophages start populating the area, Post-operative complications after periodontal flap surgery, Hemorrhage occurring after 7-14 days is secondary to trauma or surgery. That portion of the gingiva left around the tooth contains the epithelium of the pocket lining and the adjacent granulomatous tissue. 2. The clinical outcomes of early internal fixation for undisplaced . The flap design may also be dictated by the aesthetic concerns of the area of surgery. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. Contents available in the book . Another important objective of periodontal flap surgery is to regenerate the lost periodontal apparatus. The internal bevel incision should be scalloped into the interdental area to preserve the interdental papilla (see Figure 59-2). As the flap is to be placed in an apical position, vertical incisions are made extending beyond the mucogingival junction. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Preservation of good blood supply to the flap is another important consideration. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. Every effort is made to adapt the facial and lingual interproximal tissue adjacent to each other in such a way that no interproximal bone remains exposed at the time of suturing. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. Ramfjord SP, Nissle RR. The internal bevel incision may be a marginal incision (from the top of gingival margin) or para-marginal incision (at a distance from the gingival margin). Clinical crown lengthening in multiple teeth. Minor osteoplasty may be carried out if osseous irregulari-ties are observed. Coronally displaced flap Connective tissue autograft Free gingival graft Laterally positioned flap Apically displaced flap 5. 12D blade is usually used for this incision. Long-term outcome of undisplaced fatigue fractures of the femoral neck in young male adults; Therefore, these flaps accomplish the double objective of eliminating the pocket and increasing the width of the attached gingiva. This incision is always accompanied by a sulcular incision which results in the formation of a collar of gingival tissue which contains the periodontal pocket lining. Flaps are used for pocket therapy to accomplish the following: 1. We describe the technique of diagnosis and treatment of a large displaced lateral meniscus flap tear, presenting as a meniscus comma sign. 7. After administrating local anesthesia, profound anesthesia is achieved in the area to be operated. Periodontal pockets in severe periodontal disease. The vertical incision should be made in such a way that interdental papilla is completely preserved. Contents available in the book . Conflicting data surround the advisability of uncovering the bone when this is not actually needed. Contents available in the book .. 61: Periodontal Regeneration and Reconstructive Surgery, 63: Periodontal Plastic and Esthetic Surgery, 59: The Flap Technique for Pocket Therapy, 55: General Principles of Periodontal Surgery, 31: Radiographic Aids in the Diagnosis of Periodontal Disease. 61: Periodontal Regeneration and Reconstructive Surgery, 63: Periodontal Plastic and Esthetic Surgery, 55: General Principles of Periodontal Surgery, 30: Significance of Clinical and Biologic Information. Periodontal flaps can be classified as follows. May cause attachment loss due to surgery. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. The incision is carried around the entire tooth. The flap technique best suited for grafting purposes is the papilla preservation flap because it provides complete coverage of the interdental area after suturing. An intact papilla should be either excluded or included in the flap. After the removal of the secondary flap, scaling and root planing is done and the flap is adapted to its position. 3. Flap design for a conventional or traditional flap technique. This approach was described by Staffileno (1969) 23. It allows the vertical incision to be sutured without stretching the flap over the cervical convexity of the tooth. Crown lengthening procedures to expose restoration margins. It is an access flap for the debridement of the root surfaces. A detailed description of the historical aspect of various flap surgeries has been given in the previous chapter. After the patient has been thoroughly evaluated and pre-pared with non-surgical periodontal therapy, quadrant or area to be operated is selected. The flaps are then apically positioned to just cover the alveolar crest. 12 blade on both the buccal and the lingual/palatal aspects continuing it interdentally extending it in the mesial and distal direction. Fundamental principles in periodontal plastic surgery and mucosal augmentationa narrative review. There are two types of incisions that can be used to include interdental papillae in the facial flap: One technique includes semilunar incisions which are. The primary incision is placed at the outer margin of the gingivectomy incision starting at the disto-palatal line angle of the last molar and continued forward. Contents available in the book .. ), For the conventional flap procedure, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla or its vicinity, thereby splitting the papilla into a facial half and a lingual or palatal half (Figures 57-3 and. While doing laterally displaced flap for root coverage, the vertical incision is made at an acute angle to the horizontal incision, in the direction toward which the flap will move, placing the base of the pedicle at the recipient site. Undisplaced flap Palatal Flap The surgical approach is different here because of the nature of the palatal tissue which is attached, keratinized tissue and has no elastic properties associated with other gingival tissues, hence no displacement and no partial thickness flaps. 2. This flap procedure causes the greatest probing depth reduction. It differs from the modified Widman flap in that the soft-tissue pocket wall is removed with the initial incision; thus, it may be considered an internal bevel gingivectomy. The undisplaced flap and the gingivectomy are the two techniques that surgically remove the pocket wall. After this, partial elevation of the flap is done with the help of a small periosteal elevator. Areas which do not have an esthetic concern. The apically displaced flap provides accessibility and eliminates the pocket, but it does the latter by apically positioning the soft-tissue wall of the pocket.2 Therefore, it preserves or increases the width of the attached gingiva by transforming the previously unattached keratinized pocket wall into attached tissue. Areas where post-operative maintenance can be most effectively done by doing this procedure. The three incisions necessary for flap surgery. After thorough debridement, the area is then inspected for any remaining deposits on the root surfaces, granulation tissue or tissue tags. Contents available in the book .. Contents available in the book .. The soft tissue is then retracted with tissue forceps and the scoring incision is given to separate the periosteum from the bone. Areas where greater probing depth reduction is required. The secondary incision is given from the depth of the periodontal pocket till the alveolar crest. Contents available in the book . Apically displaced flaps have the important advantage of preserving the outer portion of the pocket wall and transforming it into attached gingiva. Step 5:Tissue tags and granulation tissue are removed with a curette. Along with removing the tissue above the alveolar crest, this incision also reveals the thickness of the soft tissue. The para-marginal internal bevel incision accomplishes three important objectives. After these three incisions are made correctly, a triangular wedge of the tissue is obtained containing the inflamed connective. It can be used in combination with other procedures such as osseous resection, regenerative procedures, hemisection procedure and procedures involving wedge excision. These . In this flap procedure, all the soft tissue, including the periosteum is reflected to expose the underlying bone. Unrealistic patient expectations or desires. 1. In other words, we can say that. This incision, together will the para-marginal internal bevel incision, forms a V-shaped wedge ending at or near the crest of bone, containing most of the inflamed and, The base of the flap should be wider than the flap margin so that the blood supply to the flap is not jeopardized. The incision is made around the entire circumference of the tooth using blade No. After suturing, the flap is adapted around the neck of the teeth with the help of moistened gauze. Areas which do not have an esthetic concern. Several techniques such as gingivectomy, undisplaced flap with or without osseous surgery, apically repositioned flap with or without resective osseous surgery, and orthodontic forced eruption with or without fibrotomy have been proposed for clinical crown lengthening. This wedge of tissue contains most of the inflamed and granulomatous areas that constitute the lateral wall of the pocket as well as the junctional epithelium and the connective tissue fibers that still persist between the bottom of the pocket and the crest of the bone. The following statements can be made regarding periodontal regeneration procedures. The flap procedures on the palatal aspect require a different approach as compared to other areas because the palatal tissue is composed of a dense collagenous fiber network and there is no movable mucosa on the palatal aspect. Periodontal pockets in areas where esthetics is critical. To preserve the present attached gingiva or even to establish an adequate strip of it, where it is narrow or absent. The flap is sutured with interrupted or continuous sling sutures. Contents available in the book .. Furthermore, the access to the bone defects facilitates the execution of various regenerative procedures. The primary goal of this flap procedure is not necessarily pocket elimination, but healing (by regeneration or by the formation of a long junctional epithelium) of the periodontal pocket with minimum tissue loss. The periodontal flap surgeries have been practiced for more than one hundred years now, since their introduction in the early 1900s. In the upcoming chapters, we shall read about various regenerative procedures which are aimed at achieving regeneration of lost periodontal structures. Root planing is done followed by osseous surgery if needed. The vertical incisions are made from the center of palatal/lingual surfaces of teeth extending palatally/lingually. Step 2: The initial, internal bevel incision is made after the scalloping of the bleeding marks on the gingiva. (2010) Factor V Leiden Mutation and Thrombotic Occlusion of Microsurgical Anastomosis After Free TRAM Flap. With some variants, the apically displaced flap technique can be used for (1) pocket eradication and/or (2) widening the zone of attached gingiva. Contents available in the book .. The flap is placed at the toothbone junction by apically displacing the flap. This incision is placed through the gingival sulcus. The undisplaced flap is therefore considered an internal bevel gingivectomy. Contents available in the book .. 4. Although some details may be modified during the actual performance of the procedure, detailed planning allows for a better clinical result. The flap was repositioned and sutured and . The initial or the first incision is the internal bevel incision given not more than 1 mm from the crest of the gingiva and directed to the crest of the bone. Chlorhexidine rinse 0.2% bid . 6. Undisplaced (replaced) flap This type of periodontal flap Apically positions pocket wall and preserves keratinized gingiva by apically positioning Apically displaced (positioned) flap This type of incision is used for what type of flap? Unsuitable for treatment of deep periodontal pockets. The following steps outline the undisplaced flap technique. As already stated, depending on the thickness of the gingiva, any of the following approaches can be used. This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. After these three incisions are made correctly, a triangular wedge of the tissue is obtained containing the inflamed connective . With our innovative curriculum and cutting-edge training methods, we are committed to delivering the highest quality of dental education and expertise to our students. This incision is not indicated unless the margin of the gingiva is quite thick. This is a modification of the partial thickness palatal flap procedure in which gingivectomy is done prior to the placement of primary and the secondary incision. Areas which do not have an esthetic concern. Conventional surgical approaches include the coronal flap, direct cutaneous incision, and endoscopic techniques. The first step . Also, complicated or prolonged surgical procedures that require full-thickness mucoperiosteal flaps with resultant edema can lead to trismus. The patient is then recalled for suture removal after one week. After this, the second or the sulcular incision is made from the bottom of the pocket till the crest of the alveolar bone. During this whole procedure, the placement of the primary incision is very important because if improperly given it may become short, leaving exposed bone or may become longer requiring further trimming which is difficult. It protects the interdental papilla adjacent to the surgical site. The modified Widman flap. Different suture techniques Course Duration : 8,9,10,15,16,17 Mar Early registration fees before15/2: 5500 L.E . Contents available in the book .. A. This is mainly because of the reason that all the lateral blood supply to . To improve esthetics as well as treat periodontal disease the method of choice remains is undisplaced flap surgery [12, 13]. This should include the type of flap, the exact location and type of incisions, the management of the underlying bone, and the final closure of the flap and sutures. By doing this, the periosteum is cut and it becomes easy to remove the secondary flap from the bone. One of the most common complication after periodontal flap surgery is post-operative bleeding. Care should be taken to insert the blade in such a way that the papilla is left with a thickness similar to that of the remaining facial flap. Most commonly done suturing is the interrupted suturing. The basic clinical steps followed during this flap procedure are as follows. It is indicated when the flap has to be positioned apically and when the exposure of the bone is not required. The process of healing progresses through various phases of . The apically displaced flap is. One incision is now placed perpendicular to these parallel incisions at their distal end. Both full-thickness and partial-thickness flaps can also be displaced. May cause attachment loss due to surgery. Contents available in the book .. 7. The modified Widman flap procedure involves placement of three incisions: the initial internal bevel/ reverse bevel incision (first incision), the sulcular/crevicular incision (second incision) and the horizontal/interdental incision (third incision). The granulation tissue is removed from the area and scaling and root planing is done. With this access, the surgeon is able to make the third incision, which is also known as the interdental incision, to separate the collar of gingiva that is left around the tooth. Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. Periodontal flap surgeries are also done for the establishment of . The triangular wedge of the tissue, hence formed is removed. Tooth with extremely unfavorable clinical crown/root ratio. A periosteal elevator is inserted into the initial internal bevel incision, and the flap is separated from the bone. Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. There is a loud S1 The murmur is a mid-diastolic rumbling heard best at . As soon the granulation tissue is removed, the clear bone margins and root surfaces are visible. Position of the knife to perform the crevicular (second) incision. After administration of local anesthesia, bone sounding is done to assess the thickness of gingiva and underlying osseous topography. The vertical incision should always be placed at the line angles of the teeth and never (except rare instances, such as a double papilla flap) over the height of contour of the root. (The use of this technique in palatal areas is considered in the discussion that follows this list. The incision is carried around the entire tooth. Ramfjord and Nissle 8 in 1974, modified the original Widman flap procedure . 4. HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva.It can cover teeth in various degrees, and can lead to aesthetic disfigurement. The margins of the flap are then placed at the root bone junction. Itisnecessary toemphasise thefollowing points: I)Reaming ofthemedullary cavity wasnever employed. 5. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. Osseous surgical procedures with very deep osseous defects and irregular bone loss, facially and lingually/ palatally. Contents available in the book . The primary objective of the flap surgeries is to gain access to the root surfaces and bone defects so that the deposits on the root surfaces can be eliminated and the granulation tissue can be removed. The main advantages of this procedure are maximum conservation of the keratinized tissue, maximum closure of the flaps and greater access to the underlying bony topography and the distal furcation. Position of the knife to perform the internal bevel incision. 6. Flap adaptation is then done with the help of moistened gauze and any excess blood is expressed. Technique-The technique that weusehas been reported previously (Zucman and Maurer 1965). If a full-thickness flap has been elevated, the sutures are placed along the mesial and the distal vertical incision lines to. In 1973, App 25 reported a similar technique and termed it as Intact Papilla Flap which retained the interdental gingiva in the buccal flap. The cell surface components or adhesive molecules of bacteria that interact with a variety of host componentsand responsible for recognizing and binding to specific host cell receptors A. Cadherins B. Adhesins C. Cohesins D. Fimbriae Answer: B 2. This is also known as Ledge-and-wedge technique. Coronally displaced flap. After this, the second incision or the sulcular incision is made from the bottom of the pocket to the crest of the alveolar bone. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. Click this link to watch video of the surgery: Areas where greater probing depth reduction is required.

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