Resective Periodontal Surgery: Flap Design Overview (PDF)

Resective Periodontal Surgery II The Periodontal “Flap” General Principles & Designs January 22, 2025 K. Wolfram, DDS, MS  Periodontal Flaps ◼Definition ◼Surgical elevation of gingiva and / or mucosa from the underlying tissue...

Resective Periodontal Surgery II The Periodontal “Flap” General Principles & Designs January 22, 2025 K. Wolfram, DDS, MS  Periodontal Flaps ◼Definition ◼Surgical elevation of gingiva and / or mucosa from the underlying tissue  Surgical Flap ◼ Uses in Dentistry ◼ Endodontics ◼ Apicoectomies ◼ Oral Surgery ◼ Surgical extractions etc. ◼ Prosthodontics ◼ Implants ◼ Periodontics ◼ Gain access to subgingival areas  Periodontal Flap Applications ◼ Access to… ◼ Deep pockets & Root surfaces ◼ Subgingival calculus ◼ Bone defects ◼ Bone grafts ◼ Root concavities ◼ Mucogingival Deformities ◼ Reconstruct KT  Periodontal Flap ◼ Facilitates excision of diseased pocket lining Colonized by pathogens Saturated with inflammatory mediators ◼ Reduces periodontal pockets depths ◼ Preserves keratinized tissue ◼ Protects the surgical site ◼ Good wound-closure  Main Categories ◼ Full Thickness Flap ◼ Partial Thickness Flap ◼ Undisplaced Flap ◼ Displaced Flaps Design of Flaps Type of Incision Flap-Thickness Mode of Replacement  Flap Design By…. Incision  Periodontal Flaps Most common Incisions ◼ External Bevel ◼ Internal Bevel ◼ Reversed bevel…inversed bevel ◼ Intra-sulcular ◼ Sulcular…crevicular ◼ Horizontal ◼ Scalloped ◼ Linear ◼ Vertical ◼ Cutback ◼ Releases a displaced flap for repositioning  Incisions External Bevel Internal Bevel Intra-sulcular Conventional General/Perio Surgery Periodontal Surgery Gingivectomy External Bevel Incision Gingivectomy Supra-bony pocket Gingival hyperplasia Rateitschak,et al Internal Bevel Incision Rateitschak,et al Intrasulcular Incision Int.BI  Horizontal Incisions ◼Parallel to occlusal plane ◼Scalloped ◼ Follows contour gingival margin ◼ Facial component ◼ Lingual component ◼Linear Scalloped Incision Linear Incision  Vertical Incision ◼ Confines the surgical site…laterally ◼ “Releasing” incision ◼ Facilitates better reflection ◼ Placed at the line-angle ◼ Must extend past MGJ on facial MGJ  Vertical Incision >90 - Limits the surgical site Minimizes bone exposure… where not needed - Slightly wider base Horizontal & Vertical (Releasing) Incisions *  “Do NOT’s” Vertical Incisions ◼ Don’t bisect interdental papillae ◼ Sloughs papillae ◼ Don’t use on “Direct” facial site ◼ Recession ◼ Don’t place over osseous graft site ◼ Exposes the graft Rateitschak,et al  Flap Design By.. Flap Thickness Full Thickness Flap Partial Thickness Flap  Flap Design Flap Thickness The depth & angle of the incision determines flap thickness “Full” thickness or “Partial” thickness flap Full Thickness Flap Includes periosteum (Mucosa + Periosteum) “Mucoperiosteal flap” - Separated from bone with.. blunt B reflection with periosteal elevator - Fully exposes bone >  Full Thickness Flap Mucosa + Periosteum (Mucoperiosteal flap) Partial Thickness Flap ◼ ◼ Does NOT include periosteum ◼ - “Splits” tissue thickness “Split Thickness Flap” - Formed by Sharp dissection With BP-Blade Mucosal Flap  Partial Thickness Flap ◼ Often starts at the MGJ… ◼ To retain maximum keratinized tissue  Partial Thickness Flap ◼ Protects bone ◼ Covered by periosteum ◼ Deepens vestibule ◼ Suitable for soft tissue grafts ◼ Provides vascular bed  Summary Full Thickness Partial Thickness Mucosal flap After internal bevel incision Splits mucosa with a sharp blade Reflects with periosteal elevator Reflects the Mucosal flap  Flap Design By.. Flap Replacement Undisplaced vs Displaced  Periodontal Flaps Methods of Flap Replacement ◼ Undisplaced Flap ◼ Replaced to original position… at the time of wound closure ◼ Displaced Flap ◼ Moved to another site… at the time of wound closure Undisplaced Flaps Flap stays in original site  Undisplaced Flap ◼ Following incision & reflection (Not beyond MGJ) ◼ Root planning ◼ Replaced to the original position MGJ  Undisplaced Flap ◼ Gives direct access to root & alveolar crest ◼ Site of Incision… ◼ Dictated by pocket depth ◼ Width of KT (Keratinized Tissue) dependent ◼ Reduces pocket depth ◼ Full thickness flap reflect ◼ Flap replaced to original site  Undisplaced Flap 1. Following reflection & root planing 2. Osseous contouring 3. Suture Undisplaced Flap Most common periodontal flap procedure Extensive bony contouring Flap replaced to cover recontoured crest  Displaced Flap Flap is moved to another site  Displaced Flaps ◼ Displaced Flap ◼ Flap moved to another site… at the time of wound closure ◼ Two different Uses / Types: 1. Pocket reduction Apical displaced flap 2. Correction of mucogingival defects Coronal displaced flap Lateral displaced Others Displaced Flap #1 Apical Displaced Flap  Apical Displaced Flap Treats Periodontitis ◼ Direct access to root & alveolar crest ◼ Full Thickness flap ◼ Significant “supportive bone” reduction & contouring ◼ Initial incision not necessarily dictated by PPD ◼ ~1mm from gingival margin ◼ Maintain maximum KT ◼ Flap is shifted (displaced) apically to Displacement accommodate newly re-shaped bone level… Past the MGJ  Apical Displaced Flap ◼ Deep apical reflection of flap ◼ Past MGJ ◼ Associated with significant osseous resection ◼ Flap is repositioned at new tooth-bone interface  Apical Displaced Flap Predictable Pocket Reduction Minimizes loss of keratinized gingiva As compared to Undisplaced flap Displaced Flap #2 Pedicle Flap Flap converts to a graft  Pedicle Flap/Graft Uses ◼To cover exposed root surfaces ◼Recession ◼Reconstruct keratinized tissue ◼Flap converts to a graft once displaced  Pedicle Flap ◼ Donor site ◼ Same tooth ◼ Site adjacent to Receptor-site ◼ Not a “FREE” graft ◼ Remains attached to donor site ◼ Retains its blood supply  Pedicle Flap ◼ Good tissue blending ◼ Color ◼ Texture ◼ Site selection has to be a good match ◼ Adjacent or same tooth ◼ Techniques ◼ Lateral displaced flap (Lateral “Sliding”) ◼ Coronal displaced flap ◼ Double papillae flap ◼ Semilunar incision with coronal repositioning  Lateral Displaced Flap Adjacent Donor Site ◼ Adjacent site provides graft * ◼ Base remains attached ◼ Blood supply not disrupted Cutback incision * Coronal displaced Flap Same Tooth Donor Site Split-thickness flap Vertical incisions beyond MGJ Clinical Examples Pedicle Flaps Lateral Displaced Flap Prepare the Receptor Site Donor site Receptor site  Lateral Displaced Flap Flap..Cutback Incision & Rotate Cutback incision Lateral Displaced Flap Pre & Post  Lateral Displaced Flap Abutment Tooth * Cutback incision Lateral Displaced Flap  Double Papillae Flap Split Thickness Problems: Recession Shallow vestibule Frenum Lack of KT Double Papillae Flap Pre & Post 10 wks PO  Displaced Flaps Summary: Two Main Categories Apical displaced Flap (Full Thickness) Tx: Periodontitis Pocket Reduction Pedicle Flap (Full or Partial) Lateral displaced etc. Tx: Mucogingival Deformities Root Coverage Rateitschak,et al  Overall Summary Soft Tissue Grafts ◼ Pedicle Graft/Flap, Ex: Coronally & lateral displaced etc ◼ Donor Site: Same or adjacent tooth ◼ Base: Stays attached ◼ Esthetic ◼ Free Gingival Graft (1) ◼ Donor site: Palate ◼ Free: Fully removed ◼ Outside: Epithelium Undersite: CT ◼ Least esthetic ◼ Connective Tissue Graft (2) ◼ Donor site: Palate ◼ Free: Fully removed ◼ Both sides CT ◼ Esthetic  Distal Wedge Soft Tissue Resection 55  Distal Wedge ◼ Objective ◼ Pocket reduction ◼ Gain access to improve SRP ◼ Location ◼ Distal of molars ◼ Last tooth in arch ◼ Mostly maxillary ◼ Mesial * * ◼ If edentulous space ◼ If lone-standing teeth ◼ Mesial & / or distal  Distal Wedge ◼ Maxillae ◼ Better success in maxillae ◼ More attached gingiva ◼ More favorable anatomy of tuberosity * * ◼ Mandible ◼ High recurrence of ppd in mandible ◼ Less attached gingiva in retromolar area ◼ More mobile mucosa Distal Wedge Two Approaches Distal Wedge Distal Wedge Case Case: Pre-op Distal molar extraction sites *  Distal Wedge Clinical Sequence  Distal Wedge Clinical Sequence Distal Wedge Wolf,et.al Esthetic Zone Flaps & Esthetic Zones Esthetic Consequences Apical Displaced Flap Open Embrasure Spaces Elongated Clinical Crowns  Minor Flap “Collateral” Unfavorable Side Effects  Facial / Lingual Flap Avoid Interdental Flaps in Esthetic Zone ◼BLL Loss of Interdental Papillae Black Triangle Alternate Options 1. “Papillae Preservation Flap” 2. Palatal Flap Only Provide Papillae Preservation Option to preserve Papillae Papillae Preservation Flap  Papilla Preservation Flap Pre-op & Initial Incision Design 9mm ppd Palatal Facial Papilla Preservation Flap FULL Papillae pushed/pulled thru to facial Root planned Manage bone defect  Papilla Preservation Flap Post- op Buccal flap repositioned Pushed-back thru embrasure space Minimal “Black Triangle” After healing Option to Preserve Papillae Palatal Flap (Only)  Palatal Flap ONLY Preservation of Papilla ◼LLL 10mm ppd Maxillary incisor region Deep palatal bone defect Palatal internal bevel incision Reflection of palatal flap Palatal intra-sulcular incision Palatal Horizontal incision Remove soft tissue >  Palatal Flap ONLY Palatal collar removed Bone defect exposed Root planned Osseous graft placed No reflection of facial papillae Palatal Flap ONLY Sling suture Palatal Flap ONLY Post-op Facial papillae retained Minimized formation of black triangle  Palatal Flap Posterior Region ◼ Unique due to dense tissue covering hard palate ◼ Attached keratinized tissue ◼ No mucogingival junction ◼ Palatal flap is NOT apically displaceable ◼ “Undisplaced“ flap ◼ Pocket reduction achieved ◼ Osseous contouring ◼ Soft tissue excision (crestal scalloping) ◼ Thinning the thickness of palatal flap > ◼ CT-side  Palatal Flap Thinning Thickness of Palatal Tissue  “Modified Widman Flap” The Fundamental Flap Design Model for Flap Procedures  “Modified” Widman Flap Many Design Changes ◼ Objectives ◼ Primarily to gain access & visibility for SRP “Open Debridement” ◼ No deliberate attempt to gain pocket reduction ◼ Minimal exposure of alveolar bone ◼ Minimal reflection of papillae ◼ Not beyond MGJ ◼ Minor contouring of bone permitted ◼ Undisplaced Flap  Modified Widman Flap Provides basic pattern for full thickness flaps MGJ MGJ Procedural Sequence MODIFIED WIDMAN FLAP  Modified Widman Flap Primary (first) Incision Step ◼Dd Facial & Lingual incisions: -Internal bevel -Full thickness Modified Widman Flap 2nd Step: Flap Reflection!! Not beyond the MGJ MGJ  Modified Widman Flap Intra-sulcular Incision ◼ Cuts supra-crestal fibers still attached to cementum Modified Widman Flap Horizontal Incision Cuts supra-crestal fibers still attached to alveolar crest Remove the diseased tissue-collar Modified Widman Flap Root Planing Remove residual calculus Remove remaining tissue tags Modified Widman Flap Simple Interrupted Sutures - Sutured - Strive for full interdental coverage  Healing of Modified Widman Flap LJE LJE Repopulation of root: (Same as SRP) Result: 1 Cells from gingival epithelium Formation of LJE 2 Fibroblasts from gingival CT 3 Fibroblasts from PDL Slight Reattachment 4 Osteoblasts Rateitschak,et al  Modified Widman Flap Summary: Sequence Conservative reflection after first incision Minimizes bone exposure MGJ 2 1 4 3 1. Internal bevel incision 5 2. Reflect flap 3. Intra-sulcular incision 4. Horizontal incision 5. Root plane 6. Suture Rateitschak,et al Previous Lab. Procedure Playdough  MWF Lab. Exercise Palatal & Facial Internal Bevel Incisions Distal Wedge Distal Wedge  Lab. Exercise Primary Incisions completed with D.W. Reflect the Flap Intrasulcular followed by Horizontal Incision Remove Redundant Tissue Palatal & Facial Remove Redundant Tissue Distal Wedge Flap thinned…Calculus removed Modified Widman Flap Completed & Sutured  Auxillary Lab Pick-up Cassette ◼ First Lab. Groups IDP: Wednesday, Feb.12 ◼ Two groups 12:30 & 2:30pm ◼ 5-Question Quiz on both Videos ◼ Check contents of Cassette: Sign-in & sign-out ◼ Bring computer ◼ Bring typodont ◼ Mount typodont on rod (No head) ◼ Use video as guide ◼ First procedure: Gingivectomy ◼ Mark Bleeding Points as discussed on video ◼ Max. R or L ◼ Second procedure ◼ MWF: Start with Internal Bevel Incision