Flap in Periodontal Pocket Treatment PDF

, NEAR EAST UNİVERSİTY FACULTY OF DEPARTMENT OF PERIODONTOLOGY FLAP İN PERİODONTAL POCKET TREATMENT Learning Outcomes 1- Will be able to enumerate the indications for flap operation in periodontal pocket treatment. 2- Will be able to list types of flaps and incisi...

, NEAR EAST UNİVERSİTY FACULTY OF DEPARTMENT OF PERIODONTOLOGY FLAP İN PERİODONTAL POCKET TREATMENT Learning Outcomes 1- Will be able to enumerate the indications for flap operation in periodontal pocket treatment. 2- Will be able to list types of flaps and incisions. 3- Will be able to define repositioned and unrepositioned flap techniques based on their indications. 4- Will be able to list flap techniques used in regenerative therapy. 5- Will be able to List suture techniques used in periodontal surgery. 6- Will be able to list postoperative recommendations for surgical aftercare. Periodontal laps are used in surgical periodontal therapy to accomplish the following: 1. Access for root instrumentation 2. Gingival resection 3. Osseous resection 4. Periodontal regeneration To fulill these purposes, ive different lap techniques are used: the modiied Widman lap, the undisplaced lap, the apically displaced lap, the papilla preservation lap, and the distal terminal molar lap. The modiied Widman lap facilitates root instrumentation. It does not attempt to reduce the pocket depth, but it does eliminate the pocket lining. The objectives of the undisplaced and apically displaced laps include root surface access and the reduction of probing depth. The choice of which procedure to use depends on two important anatomic landmarks: the transgingival probing depth and the location of the mucogingival junction. These landmarks establish the presence and width of the attached gingiva, which are the basis for the decision he papilla preservation lap is used when possible in regenerative and aesthetic cases to minimize recession and loss of interdental papillae. The distal terminal molar lap is used for treating pockets and osseous defects on the distal surface of the terminal maxillary and mandibular molars. Modified Widman Flap The original Widman lap used two vertical releasing incisions connected by a submarginal scalloped internal bevel incision to demarcate the area of surgery. A full-thickness lap was relected and the marginal collar of tissue was removed to provide access for root instrumentation and osseous recontouring. In 1974, Ramfjord and Nissle published the “modiied Widman lap”, which used only horizontal incisions. This technique offers the possibility of establishing an intimate postoperative adaptation of healthy collagenous connective tissue to tooth surface and it provides access for adequate instrumentation of the root surfaces and immediate closure of the area. The step-by-step technique for the modiied Widman lap is as follows: Step 1: The irst incision parallel to the long-axis of the tooth is a scalloped internal bevel incision to the alveolar crest starting 0.5 to 1 mm away from the gingival margin.The papillae are dissected and thinned to have a thickness similar to that of the remaining laps. Step 2: Full-thickness laps are relected 2 to 3 mm away from the alveolar crest. Step 3: The second, crevicular incision is made in the gingival crevice to detach the attachment apparatus from the root. Step 4: The interdental tissue and the gingival collar are detached from the bone with a third incision. Step 5: The gingival collar and granulation tissue are removed with curettes. The root surfaces are scaled and planed Residual periodontal ibers attached to the tooth surface should not be disturbed. Step 6: Bone architecture is not corrected unless it prevents intimate lap adaptation. Every effort is made to adapt the facial and lingual interdental tissue in such a way that no interdental bone remains exposed at the time of suturing. The laps may be thinned to allow for close adaptation of the gingiva around the entire circumference of the tooth. Step 7: The laps are stabilized with sutures and covered with a surgical dressing. Ramfjord26 performed an extensive longitudinal study that compared the modiied Widman procedure with the curettage technique and the pocket elimination (gingivectomy and osseous surgery) methods. Patients were assigned randomly to one of the techniques, and results were analyzed yearly for up to 7 years after therapy. The researchers reported similar results for each of the three methods tested. Pocket depth was initially similar for all methods, but it was maintained at shallower levels with the modiied Widman lap; the attachment level remained higher with the modiied Widman lap. Undisplaced Flap Currently, the undisplaced lap may be the most frequently performed type of periodontal surgery. For the undisplaced lap, the submarginal scalloped internal bevel incision is initiated at a distance from the tooth that is roughly one-half to two-thirds the interdental transgingival probing depth. This incision can be accomplished only if suficient attached gingiva remains apical to the incision. Therefore, the two anatomic landmarks, the transgingival interdental probing depth and the mucogingival junction, must be considered to evaluate the amount of attached gingiva that will remain after surgery. The internal bevel incision should be scalloped to create surgical papillae, which are essential to covering the interdental bone. If the tissue is too thick, the lap margin should be thinned with the initial incision. Proper placement of the lap margin at the alveolar crest during closure is important to prevent either recurrence of the pocket or exposure of bone. The step-by- step technique for the undisplaced lap is as follows: Step 1: The periodontal probe is inserted into the gingival crevice and penetrates the junctional epithelium and connective tissue down to bone. Step 2: The mucogingival junction is assessed to determine the amount of keratinized tissue. Step 3: The initial placement of the submarginal scalloped internal bevel incision is based on the transgingival interdental probing depth and the mucogingival junction. The incision is made parallel to the long axis of the tooth and directed down to the alveolar bone. The angulation of the incision may be altered depending on the thickness of the gingiva, as well as the initial placement of the submarginal scalloped incision, to produce a thin lap margin. The thicker the tissue, the more apically the incision will end. A short mesial vertical incision may be employed to allow lap release on the palate or to avoid extension of the horizontal incision into the aesthetic area. Step 4: Full-thickness laps are relected 1 mm apical to the mucogingival junction. Step 5: The crevicular is made in the gingival crevice to detach the attachment apparatus from the root. Step 6: The gingival collar and granulation tissue are removed with curettes. The root surfaces are scaled and planed. Step 7: Osseous recontouring is performed to eliminate defects and reestablish positive architecture. Step 8: The laps are coapted on the alveolar crest with the lap margin well adapted to the roots. The laps may be trimmed and rescalloped if necessary. Step 9: The laps are stabilized with sutures and covered with a surgical dressing. Apically Displaced Flap The apically displaced lap is selected for cases that present with a minimal amount (