(Courtesy Dr. Silvia Oreamuno, San Jose, Costa Rica. 19. After debridement, flaps are closely adapted around the teeth in close approximation, allowing healing by primary intention. 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. Connective tissue grafting harvesting techniques as well as free gingival graft. These landmarks establish the presence and width of the attached gingiva, which is the basis for the decision. Contents available in the book . Areas where greater probing depth reduction is required. 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). A full-thickness flap is then elevated to expose 1-2 mm of the marginal bone. After the removal of the secondary flap, scaling and root planing is done and the flap is adapted to its position. Sulcular incision is now made around the tooth to facilitate flap elevation. The first step, Trismus is the inability to open the mouth. Tooth with extremely unfavorable clinical crown/root ratio. 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. Following is the description of these flaps. Pockets around the teeth in which a complete removal of root irritants is not clinically possible without gaining complete access to the root surfaces. After the area to be operated is irrigated with an anti-microbial solution, local anesthesia is applied and the area is isolated after profound anesthesia has been achieved. Papilla Preservation Flaps :it incorporates the entire papilla in one of the flap by means of crevicular interdental incison to sever the connective tissue attachment & a horizontal incision at the base . Background: Three-dimensional (3D) printing technology is increasingly commercially viable for pre-surgical planning, intraoperative templating, jig creation and customised implant manufacture. It does not attempt to reduce the pocket depth, but it does eliminate the pocket lining. 1. 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). - Undisplaced flap - Apicaliy displaced flap - All of the above - Modified Widman flap. Henry H. Takei, Fermin A. Carranza and Jonathan H. Do. Enter the email address you signed up with and we'll email you a reset link. May cause hypersensitivity. It is indicated when the flap has to be positioned apically and when the exposure of the bone is not required. This is mainly because of the reason that all the lateral blood supply to. 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. 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. After these three incisions are made correctly, a triangular wedge of the tissue is obtained containing the inflamed connective . Once the interdental papilla is mobile, a blunt instrument is used to carefully push the interdental papilla through the embrasure. If the surgeon contemplates osseous surgery, the first incision should be placed in such a way to compensate for the removal of the bone tissue so that the flap can be placed at the toothbone junction. After one week, the sutures are removed and the area is irrigated with normal saline solution. As the flap is to be placed in an apical position, vertical incisions are made extending beyond the mucogingival junction. In the upcoming chapters, we shall read about various regenerative procedures which are aimed at achieving regeneration of lost periodontal structures. Contents available in the book .. The area to be operated is then isolated with the help of gauge. With the migration of these cells in the healing area, the process of re-establishment of the dentogingival unit progresses. 3. If the dressing has to be placed, a dry foil is first placed over the flap before covering it with the dressing so that the displacement of the pack under the flap is prevented. Genon and Bender in 1984 27 also reported a similar technique indicated for esthetic purpose. The area is re-inspected for any remaining granulation tissue, tissue tags or deposits on the root surfaces. Triangular This website is a small attempt to create an easy approach to understand periodontology for the students who are facing difficulties during the graduation and the post-graduation courses in our field. Contents available in the book . Expose the area for the performance of regenerative methods. News & Perspective Drugs & Diseases CME & Education To facilitate the close approximation of the flap, judicious osteoplasty, if required, is performed. The apically displaced flap is . Areas which do not have an esthetic concern. In Figure 2, the frequency of the types of flap surgical techniques followed were analyzed. 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. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. The internal bevel incision should be scalloped into the interdental area to preserve the interdental papilla (see Figure 59-2). After administrating local anesthesia, profound anesthesia is achieved in the area to be operated. 3. The beak-shaped no. According to flap reflection or tissue content: Access flap for guided tissue regeneration. If detected, they are removed. Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5-15% of all maxillofacial fractures. The periodontal dressing is not required if the flap has been adapted adequately to cover the interdental area. The following steps outline the undisplaced flap technique. The undisplaced flap and gingivectomy are the two techniques that surgically removed the pocket wall. A. 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. Severe hypersensitivity. 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). For the undisplaced flap, the internal bevel incision is initiated at or near a point just coronal to where the bottom of the pocket is projected on the outer surface of the gingiva (see Figure 59-1). Although some details may be modified during the actual performance of the procedure, detailed planning allows for a better clinical result. 1. a. When bone is stripped of its periosteum, a loss of marginal bone occurs, and this loss is prevented when the periosteum is left on the bone.4 Although this is usually not clinically significant,7 the differences may be significant in some cases (Figure 57-2). These techniques are described in detail in Chapter 59. The square . b. Papilla preservation flap. The design of the flap is dictated by the surgical judgment of the operator, and it may depend on the objectives of the procedure. The secondary. Areas which do not have an esthetic concern. Sulcular incision is now made around the tooth to facilitate flap elevation. 5. 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. Any excess blood is expressed and an intimate adaptation of the flap to the teeth and the alveolus is ensured. Contents available in the book . This is mainly because of the reason that all the lateral blood supply to . The researchers reported similar results for each of the three methods tested. The narrow width of attached gingiva which may further reduce post-operatively. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. Undisplaced flap, 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. Step 2: The mucogingival junction is assessed to determine the amount of keratinized tissue. Position of the knife to perform the internal bevel incision. Then, it is decided that how much tissue has to be removed so that the appropriate thickness of the gingiva is achieved at the end of the procedure. The soft tissue is then retracted with tissue forceps and the scoring incision is given to separate the periosteum from the bone. Eliminate or reduce pocket depth via resection of the pocket wall, 3. Suturing is then done using a continuous sling suture. Ahmad Syaify, Sp.Perio (K) Spesialis Konsultan Bedah Perio & Estetik. Preservation of good blood supply to the flap is another important consideration. 1 and 2), the secondary inner flap is removed. This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. Minor osseous recontouring may be done and the flap is then adapted into the interdental areas. As already stated, depending on the thickness of the gingiva, any of the following approaches can be used. That portion of the gingiva left around the tooth contains the epithelium of the pocket lining and the adjacent granulomatous tissue. This is especially important because, on the palatal aspect, osseous deformities such as heavy bone ledges and exostoses are commonly seen. Local anesthesia is administered to achieve profound anes-thesia in the area to be operated. The flap technique best suited for grafting purposes is the papilla preservation flap because it provides complete coverage of the interdental area after suturing. The area is anesthetized and bone sounding is done to evaluate the osseous topography, pocket depth, and thickness of the gingiva. 5. All the pocket epithelium and granulation tissue from the inner surfaces of the flaps is then eliminated using sharp curved scissors or Castroviejo scissors. 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. Technique-The technique that weusehas been reported previously (Zucman and Maurer 1965). 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. b. Split-thickness flap. Contents available in the book .. This incision has also been termed the first incision, because it is the initial incision for the reflection of a periodontal flap; it has also been called the reverse bevel incision, because its bevel is in reverse direction from that of the gingivectomy incision. In this technique no. Contents available in the book .. in adults. The Orban knife is usually used for this incision. Step 1:The pockets are measured with the periodontal probe, and a bleeding point is produced on the outer surface of the gingiva to mark the pocket bottom. A periosteal elevator is inserted into the initial internal bevel incision, and the flap is separated from the bone. 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. Therefore, these flaps accomplish the double objective of eliminating the pocket and increasing the width of the attached gingiva. The interdental incision is then made to severe the inter-dental fiber attachment. Contents available in the book .. Contents available in the book .. An interdental (third) incision along the horizontal lines seen in the interdental spaces will sever these connections. The distance of the incision from the gingival margin (thickness of the incision) varies according to the pocket depth, the thickness of the gingiva, width of the attached gingiva, shape and contour of gingival margins and whether or not the operative area is in the esthetic zone. Step 7:Continuous, independent sling sutures are placed in both the facial and palatal areas (Figure 59-3, I and J) and covered with a periodontal surgical pack. Several techniques such as gingivectomy, undisplaced flap with or without osseous surgery, apically repositioned 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. It protects the interdental papilla adjacent to the surgical site. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. The crevicular incision is then placed from the bottom of the pocket till the alveolar crest. The area is then re-inspected for any remaining granulation tissue, tissue tags and deposits on root surfaces. 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). For this reason, the internal bevel incision should be made as close to the tooth as possible (i.e., 0.5mm to 1.0mm) (see Figure 59-1). A vertical incision may be given unilaterally (at one end of the flap) or bilaterally (on both ends of the flap). At last periodontal dressing may be applied to cover the operated area. As already stated, this technique is utilized when thicker gingiva is present. 4. Contents available in the book . 15 scalpel blade, parallel to each other beginning at the distal end of the edentulous area, continued to the tooth. The first step . This incision, together with the initial reverse bevel incision, forms a V-shaped wedge that ends at or near the crest of bone. The area is then irrigated with an antimicrobial solution. There is a loud S1 The murmur is a mid-diastolic rumbling heard best at . . Conventional surgical approaches include the coronal flap, direct cutaneous incision, and endoscopic techniques. Contents available in the book .. B. Persistent inflammation in areas with moderate to deep pockets. The secondary flap removed, can be used as an autogenous connective tissue graft. 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). However, there are important variations in the way these incisions are performed for the different types of flaps (Figures 59-1 and 59-2). With the help of Ochsenbein chisels (no. 15 scalpel blade is used to make a triangular incision distal to the molar on retromolar pad area or the maxillary tuberosity. In other words, we can say that. To perform this technique without creating a mucogingival problem, the clinician should determine that enough attached gingiva will remain after removal of the pocket wall. Step 3: The second, or crevicular, incision is made from the bottom of the pocket to the bone to detach the connective tissue from the bone. Contents available in the book .. Contents available in the book .. 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. 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). Give local anaesthetic for 2 weeks and recall C. Recall for follow up after 6 weeks D. 13- Which is the technique that will anesthetize both hard and soft tissues of the lower posterior teeth region in one injection A. Gow gates***** B. 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. Chlorhexidine rinse 0.2% bid . After it is removed there is minimum bleeding from the flaps as well as the exposed bone. The buccal and the lingual/palatal flaps are then elevated to expose the diseased root surfaces and the marginal bone. The blade is introduced into the sulcus or pocket and is inserted as far as possible into the interdental space around the tooth, keeping it close to the crown. Laterally displaced flap. Normal interincisal opening is approximately 35-45mm, with mild . Along with removing the tissue above the alveolar crest, this incision also reveals the thickness of the soft tissue. Chlorhexidine rinse 0.2% bid was prescribed for 2 weeks, along with analgesics and the patient was given appropriate . b. The modified Widman flap. These meniscus tears are displaced into the tibia or femoral recesses and can be often difficult to diagnose intraoperatively. The periosteum left on the bone may also be used for suturing the flap when it is displaced apically. Contents available in the book . To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). Periodontal pockets in severe periodontal disease. Figure 2:The graph represents the distribution of various Mitral facies or malar flush There is a tapping apex beat which is undisplaced. Incisions used in papilla preservation flap using primary, secondary and tertiary incisions. The margins of the flap are then placed at the root bone junction. Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. This flap procedure utilizes two incisions referred to as primary and secondary incisions which contain tissue which has to be removed. To preserve the present attached gingiva or even to establish an adequate strip of it, where it is narrow or absent. Contents available in the book .. The triangular wedge technique is used in cases where the adequate zone of attached gingiva is present and in cases of short or small tuberosity. In areas with deep periodontal pockets and bone defects. One of the most common complication after periodontal flap surgery is post-operative bleeding. This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. 1. Step 5:Tissue tags and granulation tissue are removed with a curette. Clinical crown lengthening in multiple teeth. 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. Ramfjord and Nissle 8 in 1974, modified the original Widman flap procedure . The surgical approaches that split the papilla cause shrinkage and decrease in the height of the interdental papilla leading to the exposure of interproximal embrasures. This is also known as Ledge-and-wedge technique. 1. Henry H. Takei, Fermin A. Carranza and Kitetsu Shin. 15c or No. Platelets rich fibrin (PRF) preparation and application in the . Endodontic Topics. 15 scalpel blade, parallel to each other beginning at the distal end of the edentulous area, continued to the tooth. The area is then irrigated with an antimicrobial solution. 4. In case where the soft tissue is quite thick, this incision. The area to be operated is irrigated with an antimicrobial solution and isolated. The distance of the incision from the gingival margin (thickness of the incision) varies according to the pocket depth, the thickness of the gingiva, width of the attached gingiva, shape and contour of gingival margins and whether or not the operative area is in the esthetic zone. 1. the.undisplaced flap and the gingivectomy. Periodontal pockets in severe periodontal disease. Several techniques can be used for the treatment of periodontal pockets. 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. Tooth with extremely unfavorable clinical crown/root ratio. The flap was repositioned and sutured [Figure 6]. Contents available in the book .. 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. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD. This is a commonly used incision during periodontal flap surgeries. A Technique to Obtain Primary Intention Healing in Pocket Elimination Adjacent to an Edentulous Area Article Jan 1964 G. Kramer M. Schwarz View Mucogingival Surgery: The Apically Repositioned. If extensive osseous recontouring is planned, an exaggerated incision is given. It allows the vertical incision to be sutured without stretching the flap over the cervical convexity of the tooth. The partial-thickness flap includes only the epithelium and a layer of the underlying connective tissue. Contents available in the book .. Step 6:Bone architecture is not corrected unless it prevents good tissue adaptation to the necks of the teeth. Contents available in the book .. This technique offers the possibility ol establishing an intimate postoperative adaptation ol healthy collagenous connective tissue to tooth surlaces " and provides access for adequate instrumentation ol the root surtaces and immediate closure ol the area the following is an outline of this technique: With the conventional flap, the interdental papilla is split beneath the contact point of the two approximating teeth to allow for the reflection of the buccal and lingual flaps. Contents available in the book .. Incisions can be divided into two types: the horizontal and vertical incisions, Basic incisions used in periodontal surgeries, This internal bevel incision is placed at a distance from the gingival margin, directed towards the alveolar crest. They are also useful for treating moderate to deep periodontal pockets in the posterior regions. In areas with shallow periodontal pocket depth. Flap adaptation is then done with the help of moistened gauze and any excess blood is expressed. The flap design may also be dictated by the aesthetic concerns of the area of surgery. This is also known as. According to flap reflection or tissue content: C. According to flap placement after surgery: Diagram showing full-thickness and partial-thickness flap. Depending on the purpose, it can be a full . This flap procedure allows complete access to the root surfaces allowing their mechanical debridement and decontamination under direct vision. The key point to be remembered here is, more the thickness of the gingiva more scalloped is the incision. preservation flap ) papila interdental tidak terpotong karena tercakup ke salah satu flep (gambar 2C). Modified Widman flap and apically repositioned flap.