flap procedures

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Anja Ainamo 1992 in his 18 year follow up study after Apically Repositioned flap surgery on the location of the Mucogingival junction on 17 patients , 13 arrived for recall approximately 18 years later 1 subject had died, 1 had lost all his teeth, 2 had moved out of the area, 3 presented with poor oral hygiene and showed progression of diseaseDISTAL WEDGE OPERATIONS Probing depths in excess of normal often occur distal to the terminal tooth as a result of the adjacent tissue covering a portion of the crown.The presence of impacted third molar,or the soft tissue result of previous surgical removal of third molar frequently contributes to the severity of the probing depth found distal to the maxillary second molars.The existence of such problems is an indication for surgical soft tissue reduction.

DISTAL WEDGEThe retromolar area of the mandible and the tuberosity area of the maxilla offer unique problems for the clinician.They generally have enlarged tissue, unusual underlying osseous topography and fatty glandular (retromolar area) mucosal-type tissue.Historically, while periodontal surgical techniques were being developed for other areas, gingivectomy was the treatment of choice in this area.

DISTAL WEDGEThis problem was first addressed by Robinson in 1963 and later by Kramer and Schwartz(1964).But it was Robinsons classic article on the Distal Wedge Operation(1966) that outlined the indications and treatment procedures still used today.Distal Wedge Operation overcame the shortcomings of gingivectomy which did not allow treatment of irregular osseous deformities or access to maxillary distal furcation area. Advantages Maintenance of attached tissue.access for treatment of both the distal furcation and underlying osseous irregularities.Closure by a mature thin tissue, which is especially important in the retromolar area.Greater opening and access when done in conjunction with other flap procedures Limitations Access to the surgical site.Anatomical limitations- eg; ascending ramus or external oblique ridge.Wedge designsTriangular square, parallel or H-design.Linear or pedicle Size, shape, thickness, and access of the tuberosity or retromolar area determine treatment procedures.Wedge designTriangular wedge requires an adequate zone of keratinized tissue and can be used in a very short or small tuberosity.Square, parallel or H-design allows conservation of keratinized tissue and maximum closure.Also provides greater access to underlying topography and distal furcation.Indicated where tuberosity is longer.

Tuberosity Reductions Tuberosity reduction procedures are commonly combined with buccal and palatal flap reflection, to gain access to the teeth and underlying bone for both debridement and osseous surgery procedures Inverse bevel triangular distal wedge (Mohawk procedure)Inverse bevel linear distal wedge procedure.Tuberosity pedicle flap (trapdoor) procedure.

Inverse Bevel Triangular Distal Wedge (Mohawk procedure)

This procedure is usually integrated with buccal and palatal inverse access incisions and flap reflection.The probe is used to sound through the mucogingival complex to bone,both horizontally and vertically to map the thickness of overlying tissue and the under lying bone configuration. ProcedureThe location of the initial incision is dependant on the magnitude and thickness of the gingiva present,the presence and severity of the bone defects and the therapists estimation of where the final tissue position will be.ProcedureAn initial palatal tracing incision is placed approximately 1mm in depth from the most mesial involvement,distally to the hamular notch.A bleeding line is established for further dissection before flap reflection.The initial tracing incision is extended apically to the bone thinning the flaps as it is made.

Mohawk procedureProcedureThe tuberosity tissue and collar of marginal tissue are removed using Ochsenbein #2 chisel. After removal of this soft tissue osseous resective surgery is completed and the distal bony defect is eliminated.The thinned flaps and tuberosity region are closed primarily and sutured Inverse Bevel Linear Distal Wedge ProcedureInverse bevel linear distal wedge procedure is similar to triangular distal wedge but the distal incision is made perpendicular to the parallel linear incisions extending past the MGJ buccally to end in mucosa.Palatally the distal incision is extended as far as the palatal tissue will be thinned.The thinned flaps and tuberosity region are closed primarily and sutured

Advantages This technique is of greater use in edentulous areas between existing teeth.It is particularly useful when the tuberosity has short anterior posterior dimension.

Tuberosity pedicle flap (trapdoor) procedure.

The trapdoor procedure was designed to manage maxillary tuberosity region in the presence of pockets depths.A straight incision is made from the distopalatal line angle of the terminal molar to the most posterior extant of the tuberosity.Two incisions are then made perpendicular to the initial incision.The first courses buccally through the distal pocket region and into the buccal gingiva and mucosa.

Procedure The second extends from the most distal aspect of the straight line incision out into the buccal mucosa.By undermining and thinning the tuberosity, pedicle flap tissue through split thickness dissection from the palatal to the buccal the pedicle flap is elevated and reflected buccally

Trap procedureProcedureInternal bevel incisions are then extended from the distal of the terminal tooth anteriorly.After root debridement and osseous treatment, the flaps are closed primarily and sutured. Advantages Excellent access to bone deformities.

Complete coverage of the tuberosity when properly executed and sutured.Retromolar Pad ReductionsIt is similar to maxillary tuberosity procedures however due to unique anatomical structures like anatomic concavity on the lingual aspect created by lateral flare of the ascending ramus,incisions must always be placed over bone.Retromolar Inverse Bevel Triangular Distal WedgeInitial incisions extend from the base of the triangle,at the distal aspect of the terminal molar posterior to the apex,which is skewed some what towards the buccal to maintain contact with the underlying bone.

Retromolar Inverse Bevel Linear Wedge ProcedureThe lingual incision must be kept in contact with bone and must not be placed so far lingually as to risk trauma to the lingual nerveThe distal perpendicular incision carries great risk to the lingual anatomic region hence most clinicians prefer either triangular or trap door approaches.

Retromolar modified pedicle flap procedure (Braden Modifications)In 1969 Braden suggested a modification that simplifies the procedure and is particularly useful where the pad is fibrous in nature.Here the retromolar tissue remains either the component of either the buccal or the lingual flap.Braden buccal retro molar flap reflectionInitial facial scalloped inverse bevel incision is carried around the distal aspect of the tooth to the distolingual line angle where it meets the scalloped lingual incision A secondary incision then extends from the disto lingual line angle distally but parallel and slightly buccal to the lingual border of the retromolar triangle,to the distal of the retromolar pad.

Braden buccal modificationBraden lingual modificationHealing after flap surgeryImmediately after suturing (0 to 24 hours),a connection between the flap and the tooth or the bone surface is established by a blood clot which consists of fibrin reticulum with many polymorpho- nuclear leucocytes,erythrocytes ,debris of injured cells,and capillaries at the edge of the wound.A bacteria and an exudates or transudate also results from tissue injury.

Healing after flap surgeryOne to three days- after flap surgery the space between the flap and the tooth and bone are thinner and epithelial cells migrate over the over the border of the flap usually contacting the tooth at this time.when the flap is closely adapted to the alveolar process there is only a minimal inflammatory response.Healing after flap surgery One week after surgery -An epithelial attachment to the root is established by means of hemidesmosomes and a basal lamina.The blood clot is replaced by granulation tissue derived from the CT,The bone marrow and the PDL Two weeks after surgery- collagen fibers bigen to appear parallel to the tooth surface.Union of the flap to the tooth is still weak,owing to the presence of immature collagen fibers although the clinical aspect may be almost normal Healing after flap surgeryOne month after surgery A fully epithelialised gingival crevice with a well defined epithelial attachment is present there is a beginning functional arrangement of the supracrestal fibers

Modified Widman flapDuring the healing phase bone resorption takes place together with bone regeneration width ways .A long junctional epithelium is inter posed between the regenerated tissue and the root surface.During tissue maturation (6-12months ) moderate apical migration of the gingival margin occurs.

Apically positioned flapBone reshaping is performed and the flap is positioned at the crest The bone continues to be reabsorbed and there is attachment loss During tissue maturation (6-12 months) a certain amount of regeneration of the bone and coronal attachment apparatus occurs.

ConclusionsLongitudinal studies have shown (1st European Workshop on Periodontology-1993) that the various surgical methods are equally effective in decreasing pocket depth and controlling the progression of chronic adult periodontitis.

THANK YOU FLAP TECHNIQUESPALATAL FLAPSurgical approach differsAll attached, keratinized and no elastic properties.No apical or coronal displaceme