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The basic clinical steps followed during this flap procedure are as follows. Residual periodontal fibers attached to the tooth surface should not be disturbed. As described in, Image showing primay and secondary incisions used in ledge and wedge technique. Inferior alveolar nerve block C. PSA 14- A patient comes with . 34. (1995, 1999) 29, 30 described . Contents available in the book .. For flap placement after surgery, flaps are classified as either (1) nondisplaced flaps, when the flap is returned and sutured in its original position, or (2) displaced flaps, which are placed apically, coronally, or laterally to their original position. Tooth with extremely unfavorable clinical crown/root ratio. This will allow the clinician to retain the maximum amount of gingival tissue, including the papilla, which is essential for graft or membrane coverage. That portion of the gingiva left around the tooth contains the epithelium of the pocket lining and the adjacent granulomatous tissue. 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. A periosteal elevator is inserted into the initial internal bevel incision, and the flap is separated from the bone. The internal bevel incision should be scalloped into the interdental area to preserve the interdental papilla (see Figure 59-2). Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Increase accessibility to root deposits for scaling and root planing, 2. After administration of local anesthesia, bone sounding is done to assess the thickness of gingiva and underlying osseous topography. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. Step 2:The gingiva is reflected with a periosteal elevator (Figure 59-3, D). The triangular wedge of the tissue, hence formed is removed. Laparoscopic technique for secondary vaginoplasty in male to female transsexuals using a modified . In a full-thickness flap, all of the soft tissue, including the periosteum, is reflected to expose the underlying bone. Short anatomic crowns in the anterior region. Step 2:The initial or internal bevel incision is made (Figure 59-4) after scalloping the bleeding marks on the gingiva (Figure 59-5). Contents available in the book . After the removal of the secondary flap, scaling and root planing is done and the flap is adapted to its position. The most apical end of the internal bevel incision is exposed and visible. 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. Irrespective of performing any of the above stated surgical procedures, periodontal wound healing always begins with a blood clot in the space maintained by the closed flap after suturing 36. 1. The narrow width of attached gingiva which may further reduce post-operatively. The three incisions necessary for flap surgery. The entire surgical procedure should be planned in every detail before the procedure is initiated. Thus, an incision should not be made too close to the tooth, because it will not eliminate the pocket wall, and it may result in the re-creation of the soft-tissue pocket. Henry H. Takei, Fermin A. Carranza and Jonathan H. Do. . This type of incision, starting just below the bleeding points, removes the pocket wall completely. As described in History of surgical periodontal pocket therapy and osseous resective surgeries the palatal approach for . The first documented report of papilla preservation procedure was by. . These meniscus tears are displaced into the tibia or femoral recesses and can be often difficult to diagnose intraoperatively. The periodontal flap is one of the most frequently employed procedures, particularly for moderate and deep pockets in posterior areas (see, Increase accessibility to root deposits for scaling and root planing, Eliminate or reduce pocket depth via resection of the pocket wall, Gain access for osseous resective surgery, if necessary, Expose the area for the performance of regenerative methods, Technique for Access and Pocket Depth Reduction or Elimination, All three flap techniques that were just discussed involve the use of the basic incisions described in. To perform this technique without creating a mucogingival problem it should be determined that enough attached gingiva will remain after after removal of pocket wall. Step 6:Bone architecture is not corrected unless it prevents good tissue adaptation to the necks of the teeth. Eliminate or reduce pocket depth via resection of the pocket wall, 3. The techniques that are used to achieve reconstructive and regenerative objectives are the papilla preservation flap8 and the conventional flap, which involve only crevicular or pocket incisions. Placing periodontal depressing is optional. Contents available in the book .. The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. Evian et al. A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissue to provide visibility and access to the bone and root surfaces, Periodontal flap surgeries are also done for the establishment of. The book is usually delivered within one week anywhere in India and within three weeks anywhere throughout the world. The main advantages of this procedure are the preservation of maximum healthy tissue and minimum post-operative discomfort to the patient. The undisplaced (unrepositioned) flap improves accessibility for instrumentation, but it also removes the pocket wall, thereby reducing or eliminating the pocket. a. Non-displaced flap. 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. The proper placement of the flap margin at the toothbone junction during closure is important to prevent either recurrence of the pocket or the exposure of bone. Incisions used in papilla preservation flap using primary and secondary incisions. Suturing techniques. 1972 Mar;43(3):141-4. By doing this, the periosteum is cut and it becomes easy to remove the secondary flap from the bone. 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. Contents available in the book .. The design of the flap is dictated by the surgical judgment of the operator, and it may depend on the objectives of the procedure. A crescent-shaped incision is sometimes used during the crown lengthening procedure. Tooth with marked mobility and severe attachment loss. In the present discussion, we discussed various flap procedures that are used to achieve these goals. Re-inspection of the operated area is done to check for any deposits on the root surfaces, remaining granulation tissue or tissue tags which are removed, if detected. This procedure cannot be done on the palatal aspect as it has attached gingiva which cannot be displaced apically. The periodontal pockets on the distal aspects of last molars, both in maxillary and the mandibular arches present a unique situation for which specific surgical designs have been advocated. 6. However, to do so, the attached gingiva must be totally separated from the underlying bone, thereby enabling the unattached portion of the gingiva to be movable. Methods Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting , were included for this prospective cohort . 2. The incision is made not only around the facial and lingual radicular area but also interdentally, where it connects the facial and lingual segments to free the gingiva completely around the tooth (Figure 57-9; see Figure 57-5). With this access, the surgeon is able to make the. Normal interincisal opening is approximately 35-45mm, with mild, Periobasics A Textbook of Periodontics and Implantology, Text Book of Basic Sciences for MDS Students, History of surgical periodontal pocket therapy and osseous resective surgeries. Following is the description of step by step procedure followed while doing a modified Widman flap surgery. Flap reflection till alveolar mucosa to mobilize the flap causes more post-operative pain and discomfort. A small periosteal elevator or Molt 2/4 curette can be used for this purpose. (adsbygoogle = window.adsbygoogle || []).push({}); The external bevel incision is typically used in gingivectomy procedures. The reasons for placing vertical incisions at line angles of the teeth are. The granulation tissue is highly vascularized, so it bleeds profusely. Conventional surgical approaches include the coronal flap, direct cutaneous incision, and endoscopic techniques. Several techniques can be used for the treatment of periodontal pockets. Undisplaced flap and apically repositioned flap. Figure 2:The graph represents the distribution of various Fundamental principles in periodontal plastic surgery and mucosal augmentationa narrative review. It does not attempt to reduce the pocket depth, but it does eliminate the pocket lining. Following is the description of these flaps. It is caused by trauma or spasm to the muscles of mastication. It is contraindicated in areas where the width of attached gingiva would be reduced to < 3 mm. This is especially important because, on the palatal aspect, osseous deformities such as heavy bone ledges and exostoses are commonly seen. The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. Contents available in the book .. The partial-thickness flap may be necessary when the crestal bone margin is thin and exposed with an apically placed flap or when dehiscences or fenestrations are present. After the flap has been elevated, a wedge of tissue remains on the teeth and is attached by the base of the papillae. Coronally displaced flap Connective tissue autograft Free gingival graft Laterally positioned flap Apically displaced flap 5. The clearly visible root surfaces and osseous defects are then debrided with the help of hand (curettes) and ultrasonic (ultrasonic scalers) instruments. Crown lengthening procedures to expose restoration margins. A. Contents available in the book .. Periodontal Flap Surgery Wendy Jeng 117.4k views 035. periodontal flap Dr.Jaffar Raza BDS 7.5k views 17.occlusal schemes anatomic and semiamatomic occlusion www.ffofr.org - Foundation for Oral Facial Rehabilitiation 1.1k views Suturing techniques involved in dental surgery Hasanain Alani Contents available in the book .. The interdental incision is then made to severe the inter-dental fiber attachment. 12 or no. Contents available in the book .. In case of periodontitis with active pockets 5-6 mm deep or greater, that do not respond satisfactorily to the initial therapy. Square, parallel, or H design. Tooth with marked mobility and severe attachment loss. The researchers reported similar results for each of the three methods tested. 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. Contents available in the book .. Contents available in the book .. 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. Contents available in the book . 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. Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. The bone remains covered by a layer of connective tissue that includes the periosteum. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. Although some details may be modified during the actual performance of the procedure, detailed planning allows for a better clinical result. In other words, we can say that. 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. This type of flap is also called the split-thickness flap. Mitral facies or malar flush There is a tapping apex beat which is undisplaced. After removing the wedge of the tissue the margins of the flap are undermined with the help of scalpel blades, In this technique, two incisions are made with the help of no. Along with removing the tissue above the alveolar crest, this incision also reveals the thickness of the soft tissue. The conventional flap is used (1) when the interdental spaces are too narrow, thereby precluding the possibility of preserving the papilla, and (2) when the flap is to be displaced. Table 1: showing thickness of gingiva in maxillary tooth region . Therefore, these flaps accomplish the double objective of eliminating the pocket and increasing the width of the attached gingiva. Two types of horizontal incisions have been recommended: the internal bevel incision. Incisions used in papilla preservation flap using primary, secondary and tertiary incisions. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. Maintaining primary closure after guided bone regeneration procedures: Introduction of a new flap design and preliminary results. The thicker the tissue is, the more apical the ending point of the incision (see Figure 59-4). The area is then debrided for all the granulation tissue present and scaling and root planing of the root surfaces are carried out. Periodontal flaps involve the use of horizontal (mesialdistal) and vertical (occlusalapical) incisions. As soon the granulation tissue is removed, the clear bone margins and root surfaces are visible. To fulfill these purposes, several flap techniques are available and in current use. Palatal flaps cannot be displaced because of the absence of unattached gingiva. There is no need to determine where the bottom of the pocket is in relation to the incision for the apically displaced flap as one would for the undisplaced flap. The incisions made should be reverse bevel to achieve thinning of tissue so that an adequate final approximation of the flaps can be achieved. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window). 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. Fugazzotto PA. To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). 6. Locations of the internal bevel incisions for the different types of flaps. 7. ), Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 59: The Flap Technique for Pocket Therapy, Several techniques can be used for the treatment of periodontal pockets. During the initial phase of healing, inflammatory cells are attracted by platelet and complement derived mediators and aggregate around the blood clot. Contents available in the book . Click this link to watch video of the surgery: Modified Widman Flap surgery. Conventional flaps include the. The crevicular incision is then placed from the bottom of the pocket till the alveolar crest. The apically displaced flap technique is selected for cases that present a minimal amount of keratinized, attached gingiva. Areas where greater probing depth reduction is required. The antibiotics should be started before the surg-ical procedure so that appropriate antibiotic levels are there in blood at the time of surgery to prevent spread of infection. See video of the surgery at: Modified flap operation. Step 3:A crevicular incision is made from the bottom of the pocket to the bone in such a way that it circumscribes the triangular wedge of tissue that contains the pocket lining. In this flap procedure, all the soft tissue, including the periosteum is reflected to expose the underlying bone. Contents available in the book .. These landmarks establish the presence and width of the attached gingiva, which is the basis for the decision. Click this link to watch video of the surgery: Areas where greater probing depth reduction is required. A periodontal flap is a section of gingiva, mucosa, or both that is surgically separated from the underlying tissues to provide for the visibility of and access to the bone and root surface. 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. This approach was described by Staffileno (1969) 23. Clinical crown lengthening in multiple teeth. Ramfjord and Nissle 8 in 1974, modified the original Widman flap procedure . 12 or no. In addition, the interdental incision is performed after the flap is elevated to remove the interdental tissue. Trismus is the inability to open the mouth. Laterally displaced flap. Contents available in the book .. 1. After this, partial elevation of the flap is done with the help of a small periosteal elevator. During crown lengthening, the shape of the para-marginal incision depends on the desired crown length. The modified Widman flap is indicated in cases of perio-dontitis with pocket depths of 5-7 mm. In the present discussion, we shall study in detail, the current concepts and advances in various periodontal flap surgeries.