Slide 1

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 displacement is possibleNo split thickness flap is possibleIf thick may complicate healingThinning of the flap can be done holding it with mosquito hemostat or Adsons forceps and .

THE PAPILLA PRESERVATION FLAP In order to preserve the interdental soft tissues for maximum soft tissue coverage following surgical intervention involving treatment of proximal osseous defects.Takei et al. (1985) proposed a surgical approach called papilla preservation technique. Later, Cortellini et al. (1995, 1999) described modifications of the flap design to be used in combination with regenerative procedures. i.e. modified papilla preservation flap (MPPF) and simplified papilla preservation flap (SPPF).For esthetic reasons, the papilla preservation technique is often utilized in the surgical treatment of anterior tooth regions. Technique :

THE PALATAL FLAP The surgical approach to the palatal area differs from that for other areas because of the character of the palatal tissue and the anatomy of the area. The palatal tissue is all attached, keratinized tissue and has none of the elastic properties associated with other gingival tissue. Therefore the palatal tissue cannot be apically displaced, nor can a partial (split) thickness flap be accomplished. The initial incision for the palatal flap should be such that when the flap is sutured, it is precisely adapted at the root-bone junction. The palatal tissue may be thin or thick, it may or may not have osseous defects, and the palatal vault may be high or low. These anatomic variations may require changes in the location, angle, and design of the incision. If the tissue is thick, a horizontal gingivectomy incision may be made, followed by an internal bevel incision that starts at the edge of this incision and ends on the lateral surface of the underlying bone. The placement of the internal bevel incision must be done in such a way that the flap fits around the tooth without exposing the bone. Flaps should be thin to adapt to the underlying osseous tissue and provide a thin, knifelike gingival margin. A sharp, thin papilla positioned properly around the interdental areas at the tooth-bone junction is essential to prevent recurrence of soft tissue pockets. The edge of the flap should be thinner than the base; therefore the blade should be angled toward the lateral surface of the palatal bone. The dissected inner connective tissue is removed with a hemostat. As with any flap, the triangular papilla portion should be thin enough to fit snugly against the bone and into the interdental area. The principles for the use of vertical releasing incisions are similar to those for using other incisions. Care must be exercised so that the length of the incision is minimal to avoid the numerous vessels located in the palate. DISTAL WEDGE PROCEDURES OR DISTAL MOLAR SURGERY In many cases the treatment of periodontal pockets on the distal surface of distal molars is complicated by the presence of bulbous tissues over the tuberosity or by a prominent retromolar pad. The most direct approach to pocket elimination in such cases in the maxilla is the gingivectomy procedure. The incision is started on the distal surface of the tuberosity and carried of forward to the base of the pocket of the distal surface of the molar. However, when only limited amounts of keratinized tissue are present, or none at all, or if a distal angular bony defect has been diagnosed, the bulbous tissue should be reduced in size rather than being removed in toto. This may be accomplished by the distal wedge procedure (Robinson 1966). This technique facilitates access to the osseous defect and makes it possible to preserve sufficient amounts of gingiva and mucosa to achieve soft tissue coverage.

POST OPERATIVE INSTRUCTIONSPatient should be given analgesics and antibiotics and told to start the tablets before the effect of anesthesia wears off and continue the tablets for the require duration of time. Aspirin should be avoided as it causes bleeding.Patient should be instructed that he should not consume any food for few hours after the placement of periodontal pack (until it hardens) to prevent it from dislodgment. In case the pack gets dislodge, the patient should immediately consult his periodontist.For the first 24 hours, patient should avoid hot liquids and should have only semisolid or minced foods and should chew from the non operated site.Citrus fruits, fruit juices, alcoholic beverages and highly spiced foods should be avoided.Patient should not smoke.Patient should be asked to take adequate bed rest and avoid speaking.Patient should be advised not to brush on the operated area and use chlorhexidine mouthwash.Patient should not try to remove the periodontal dressing himself.In case of bleeding he should immediately contact the periodontist and avoid spitting.To ease any postoperative swelling, patient should apply cold pack.THE FIRST POSTOPERATIVE WEEKThe periodontal pack is removed after 1 week. The area is irrigated with a sterile saline solution and sutures are removed. Properly performed periodontal surgery does not present any postoperative complications.After a flap operation, the areas corresponding to the incisions are epithelialized but may bleed when touched. They should not be disturbed and pockets should not be probed. The lingual and facial mucosa may be covered with a grayish yellow or white granular layer of food debris that has spread under the pack. This is removed with moist cotton. The root surfaces may be sensitive to a probe or to a thermal change and the teeth may be stained.HEALING AFTER FLAP SURGERY: (Carranza and Newman)Immediately after suturing (0 to 24 hours):Connection established between the flap and the tooth / bone surface via blood clot.Blood clot consists of a fibrin reticulum with many PMN leucocytes, erythrocytes, and debris from injured cells and capillaries at the edge of the wound (Caffesse et al 1968).Bacteria and an exudates or transudate as a result of tissue injury are also present.One to three days after surgery: Space between the flap and the tooth or bone is thinner and epithelial cells migrate 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.One week after surgery:Epithelial attachment to the root is established by means of hemidesmosomes and a basal lamina.The blood clot is replaced by a granulation tissue derived from a gingival connective tissue, the bone marrow and the periodontal ligament. Two weeks after surgery: Collagen fibers begin 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.Clinical aspect may appear almost normal.One month after surgery: A fully epithelialized gingival crevice with a well defined epithelial attachment is present.There is a beginning of functional arrangement of the supracrestal fibers.HEALING AFTER FULL THICKNESS FLAP SURGERY Superficial bone necrosis at one to three days.Osteoclastic resorption follows and reaches a peak at four to six days declining thereafter (Staffileno et al 1962).The resultant bone loss is about 1 mm (Cafesse et al 1968, Wilderman 1970).Greater bone loss if the bone is thin (Wilderman 1964, 1970).Other Flap Designs for Periodontal Plastic SurgeriesThe coronally repositioned periodontal flap, has been reported by many different people in the literature. Kalmi (1949), first described a type of coronal repositioned flap that was performed after a gingivoplasty of the attached gingiva. Bernimoulin et al. (1975), reported on the clinical evaluation of a two-step Coronally repositioned periodontal flap. Semilunar coronally repositioned flap" (Tarnow 1986) A trapezoidal flap design yielding high predictability was presented by Allen & Miller (1989).Harold E. Grupe and Richard F. Warren (1956) introduced contiguous soft tissue autografts to the literature under the term "lateral sliding flap". Variations of the laterally positioned pedicle graft include the double papilla graft (Cohen and Ross 1968) and the oblique rotated graft (Pennel et al 1965).

Flaps for Subepithelial Connective Tissue GraftBruno modified coronally advanced technique by eliminating the vertical incisions and introducing sulcular incisions on adjacent teeth.

Raetzke suggested an envelope technique for isolated root coverage.The sulcular epithelium of the affected tooth is removed. A partial thickness envelope is created in the tissues surrounding the recession. A graft twice the width of the area of recession is placed into the envelope, completely covering the exposed root.

Nelson, in his technique elevated Full thickness pedicle flaps on either side of the defective area with care not to jeopardize the interdental papilla or periodontal coverage of adjacent teeth.

Allen presented the supraperiosteal envelope for use in multiple adjacent areas of recession. (Tunnel technique).Blanes and Allen combined a tunnel with lateral pedicle flaps to treat adjacent areas of recession. Double split thickness lateral pedicle flaps are elevated at the level of the CEJ at the proximal extent of the recession and extended apically 10-12 mm. A tunnel is created under the tissue remaining between the two pedicle flaps. The graft is placed through the tunnel and sutured in place. The pedicle flaps are then sutured to the tunnel.

ReferencesClinical periodontology and Implant dentistry Jan Lindhe 5th ednClinical Periodontology; Carranza 10th ednOutline of Periodontics. Manson and Eley;4th ednNevins Periodontal therapyPeriodontal surgery A clinical Atlas SatoPeriodontics Genco, Rose, Mealey Atlas of cosmetic and reconstructive periodontal surgery Cohen 2nd edn Conclusion The success of flap operations depend on multiple clinical considerations such as anatomy, correct flap positioning, adaptation and maintenance, and prevention of bacterial plaque accumulation.Loose sutures or muscular activity may create spaces filled with a large clot that could be temporarily detrimental to reattachment.Digital pressure applied to the flap for several minutes immediately after surgery is one means of obtaining good adaptation postoperatively of soft to hard tissues and avoiding space (pseudocyst) between the wound surfaces.

GOOD AFTERNOONPALATAL FLAPSDr.Jyothi S.G.

Introduction

The palate, unlike other areas, is composed mainly of dense collagenous connective tissue. This fact precludes the palatal tissue from being positioned apically, laterally, or coronally. Therefore, surgical techniques are required that allow the tissue to be thinned and apically positioned at the same time.

Historical Review

The palatal flap procedure historically involved reflecting a full-thickness flap to gain access to the underlying bone and remove necrotic and granulomatous tissue. Ochsenbein and Bohannan (1963, 1964) described a palatal approach for osseous surgery (A) Full-Thickness Flap, (B) Partial-Thickness Palatal Flap. (C) Modified Partial-Thickness Flap, The objective and result of all three are the same a thin, even-flowing gingival architecture that closely approximates the underlying bone. Ochsenbein and Bohannan, in comparing the palatal and buccal approaches to osseous surgery, noted the following advantages, disadvantages, and indications of the palatal approach.Advantages of Palatal Approach1.Esthetics2.Easier access for osseous surgery3.Wider palatal embrasure space4.A naturally cleansing area5.Less resorption because of thicker bone

Disadvantages of Buccal Approach1. Esthetics2.Closeroot proximity3.Possible involvement of the buccal furcation4. Thin plate of bone overlying the maxillary molars where dehiscences and fenestrations may be present.

Indications1.Areas that require osseous surgery2. Pocket elimination3.Reduction of enlarged and bulbous tissue Contraindicationswhen a broad, shallow palate does not permit a partial-thickness flap to be raised without possible damage to the palatal artery.

Diagnostic ProbingBefore beginning the operation, but after adequate administration of anesthetic, periodontal probing bone sounding for the underlying osseous topography is indicated (Easley, 1967). This is especially important on the palate, where frequently the tissue is enlarged and bulbous with underlying heavy bony ledges and exostoses. These exostoses frequently occur in second and third molar areas.

Sounding permits one to discriminate between dense fibrotic tissue and enlarged tissue resulting from the osseous irregularities. Furthermore, because palatal tissue cannot be repositioned, failure to access the underlying topography adequately often results in a flap that is either too long or too short.

Note that, even though the tissue appears to be the same in all instances and the results may be the same, the incisions vary according to the underlying osseous topography.

Full thickness palatal flap

PARTIAL-THICKNESS PALATAL FLAPThis technique was developed by Staffileno (1969) to overcome some of the problems of extensive gingival resection and to facilitate treatment of palatal osseous defects, which until then was approached cautiously.

Advantages: Minimal trauma Rapid healing Ease of palatal tissue manipulation Establishment of favorable gingival contours Presurgical Phase: the operator sounds for the underlying osseous topography. This is very important because the flap cannot be repositioned after the initial incision. A short flap will result in bone exposure and long flap will have to be trimmed, which is difficult and leaves thick marginal tissue. The thicker the tissue, the more exaggerated the scalloping of the incision. For this reason, the exact thickness of the tissue must be determined at the start. Underlying osseous irregularities and osseous resection techniques must also be anticipated.

Surgical Phase:

The primary incision is made with a No. 15 (usually) or No. 12 (if access is limited) scalpel blade. It is usually begun at the margin of the last tooth in the tuberosity area as an extension of the distal wedge procedure. It is continued forward, using a scalloped, inverse beveled, partial-thickness incision to create a thin partial-thickness flap.

The blade of the scalpel should always be kept on the vertical height of the alveolus. This prevents unnecessary involvement or cutting of the palatal artery. Once the initial part of the primary incision has been completed, the tissue may be retracted with rat-tail pliers for completion of the incision. Upon completion, the scalpel blade is directed toward the bone to score it at the base of the flap. This separates the periosteum in this area and permits easy removal of the secondary flap from bone. Without this scoring, it is more difficult to remove the secondary inner flap and generally results in a torn, ragged periosteal tissue with many tags. A secondary sulcular incision is now completed both facially and interproximally, using a No. 15 or No. 12 scalpel blade down to the crest of the bone. This incision frees the coronal aspects of the inner or secondary flap, permitting removal. Ochsenbein chisels (Nos. 1 and 2) are now used from both the occlusal and apical extensions of the flap to completely free and remove the secondary inner flap. If the periosteum has not previously been scored, this procedure will be more difficult and leave a torn, ragged periosteum. A Friedman rongeur may also be used to remove the secondary inner flap.

It is important to note that the inner 20 flap of connective tissue that has been removed can now be trimmed and used for a free connective-tissue autograft (Edel, 1974) or as part of a subepithelial connective-tissue graft (Langer and Colagna, 1980 Langer and Langer, 1985).

MODIFIED PARTIAL-THICKNESS PALATAL FLAP: Ochsenbein 1958, and Ochsenbein and Bohannan in 1963 described this technique, but it was not until 1965 that it became popularized by Prichard. It has also become known as the ledge-and-wedge technique. This is a two-stage procedure main disadvantage- the fact that healing interdentally is by secondary intention. This fact precludes the use of this procedure with such procedures as the Modified Widman flap, E.N.A.P., osseous grafting, and any others that require primary closure. This procedure also requires a certain degree of technical skill or the palatal artery can be damaged easily Presurgical Phase:

With the patient under adequate anesthesia, sounding is carried out to determine the underlying osseous topography, pocket depth, and thickness of the tissue. This stage is not as critical as it is in the single-stage procedure because the first-stage gingivectomy incision will allow visualization of tissue thickness. Surgical Phase:Stage I: Gingivectomy Stage II: Partial-Thickness Flap

It is necessary to mark the base of the pockets with pocket markers. A periodontal probe may be used to estimate pocket depth. A periodontal knife is used to resect the tissue above the crest of bone. Unlike the basic gingivectomy technique, no bevel is placed. A tissue ledge is established to allow visualization of tissue thickness and permit easier placement of the primary palatal incision. Sometimes it may not be desirable to make the gingivectomy incision down to the base of the pocket, especially on thicker tissue. When such tissue is thinned and falls back against the bone, it will be short of the bony crest. This can result in excessive bone exposure and postoperative discomfort. Stage II: Partial-Thickness Flap: Similar to the partial-thickness palatal flap.

Common MistakesThe short flap: This generally is the result of too deep a primary incision, gingivectomy to the crest of bone of a thick tissue, or use of a beveled gingivectomy. This results in delayed healing and increased patient discomfort. Poor marginal flap adaptation caused by incomplete thinning of the tissue: The margin of the flap stands away from the tooth when the flap is replaced. This can be corrected either by additional thinning of the inner flap surface close to the base of the original incision or by more osteoplasty. Incision beyond the vertical height of the alveolus, bringing the scalpel blade in the close proximity to the palatal artery: Cutting the palatal artery can be especially dangerous.Extension beveling or thinning of tissue on a low, broad palate invites damages to the palatal artery. Tissue placement high onto the teeth results in poor adaptation and recurrent pocket formation. This can be corrected by proper trimming at the time of flap placement prior to suturing; DISTAL WEDGE: The 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 in the case of the retromolar area, a fatty, glandular, mucosal - type tissue. Historically, while periodontal surgical techniques were being developed for all other areas, development in this one area remained stagnant, and gingivectomy was the treatment of choice. This problem was first addressed by Robinson in 1963 and later by Kramer and Schwartz (1964) 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. The main limitation is only of access or anatomy (e.g., ascending ramus or external oblique ridge). Wedge Design : Triangular Square, parallel, or H-design Linear or pedicle PALATAL APPROACH TO IMPLANT PLACEMENTTo avoid the difficult healing with vestibular incisions and at the same time provide adequate implant coverage, especially when augmentation procedures are required, Langer and Langer (1990) recommended a palatal approach. Advantages: The use of overlapping flaps prevents flap opening and implant exposure. Facilitates healing and reduces postoperative trauma.

SPLIT PALATAL FLAP: A SURGICAL APPROACH FOR PRIMARY SOFT TISSUE HEALING IN RIDGE AUGMENTATION PROCEDURES Localized ridge deformities of varying severity usually occur after tooth loss as a result of advanced periodontal disease, root fracture, extensive root caries, and / or periapical pathology. Ridge deformity could also be the result of trauma or traumatic tooth extraction in which the labial plate is fractured, destroying the 4-walled socket in which blood clots form and are protected.

CONCLUSION

Various modifications of palatal flap designs help in managing special situations like treatment of osseous defects, implant coverage, closure of oroantral fistula, ridge augmentation etc.Thus, designing the palatal flaps benefit a lot to the periodontal plastic surgeries.

THANK YOUThe Periodontal Flap SurgeryPresented byDr. Neeta BhavsarTypes of Sutures

SUTURING The purpose of suturing is to maintain the flap in the desired position until healing has progressed to the point where sutures are no longer needed.

Suture materials The resorbable sutures have gained popularity since they enhance patient comfort and eliminate suture removal appointments. The monofilament type of suture alleviates the "wicking effect" of braided sutures that may allow bacteria from the oral cavity to be drawn through the suture to the deeper areas of the wound. classification of the sutures available today: The nonresorbable, braided silk suture was the most commonly used in the past due to its ease of use and low cost. The expanded polytetrafluoroethylene synthetic monofilament is an excellent nonresorbable suture widely used today. The most commonly used resorbable sutures are the natural, plain gut and the chromic gut. Both are monofilaments and are processed from purified collagen of either sheep or cattle intestines. The chromic suture is a plain gut suture processed with chromic salts to make it resistant to enzymatic resorption, thereby increasing the resorption time. The synthetic resorbable sutures are also often used.

Suturing Technique1 Interdental LigationDirect or loop sutureFigure Eight suture2 Sling Ligation3 Horizontal mattress suture4 Cjontinuous, Independent Sling suture5 Anchor Suture6 Closed Anchor SutureSuturing Technique The needle is held with the needle holder and should enter the tissues at right angles and no less than 2 to 3 mm from the incision. The needle is then carried through the tissue, following the needle's curvature. The knot should not be placed over the incision.

The periodontal flap is closed either with independent sutures or with continuous, independent sling sutures. The latter method eliminates the pulling of the buccal and lingual or palatal flaps together and instead, uses the teeth as an anchor for the flaps. There is less tendency for the flaps to buckle, and the forces on the flaps are better distributed.Sutures of any kind placed in the interdental papillae should enter and exit the tissue at a point located below the imaginary line that forms the base of the triangle of the interdental papilla

The location of sutures for closure of a palatal flap depend on the extent of flap elevation that has been performed. The flap is divided in four quadrants as depicted in Fig. If the elevation of the flap is slight or moderate, the sutures can be placed in the quadrant closest to the teeth. If the flap elevation is substantial, the sutures should be placed in the central quadrants of the palate. One may or may not use periodontal dressings. When the flaps are not apically displaced, it is not necessary to use dressings other than for patient comfort.

Placement of suture in the interdental space below the base of an imaginary triangle in the papilla

LigationInterdental Ligation.

Two types of interdental ligation can be used: 1. the director loop suture (Fig) and 2. the figure-eight suture (Fig).

A simple loop suture is used to approximate the buccal and lingual flaps. A, The needle penetrates the outer surface of the first flap. B, The undersurface of the opposite flap is engaged, and the suture is brought back to the initial side (C), where the knot is tied (D).

1 the director loop suture The direct suture permits a better closure of the interdental papilla and should be performed when bone grafts are used or when close apposition of the scalloped incision is required.2 the figure-eight suture In the figureeight suture, there is thread between the two flaps. This suture is therefore used when the flaps are not in close apposition because of apical flap position or nonscalloped incisions. It is simpler to perform than the direct ligation.

An interrupted figure-eight suture is used to approximate the buccal and lingual flaps.The needle penetrates the outer surface of the first flap (A) and the outer surface of the opposite flap (B).The suture is brought back to the first flap (C), and the knot is tied (D).

Sling Ligation. The sling ligation can be used for a flap on one surface of a tooth that involves two interdental spaces (Fig.)

A single, interrupted sling suture is used to adapt the flap around the tooth.A, The needle engages the outer surface of the flap and encircles the tooth (B).C, The outer surface of the same flap of the adjacent interdental area is engaged.D, the suture is returned to the initial site and the knot tied.

Horizontal Mattress Suture. This suture is often used for the interproximal areas of diastmata or for wide interdental spaces to properly adapt the interproximal papilla against the none. Two sutures are often necessary. The horizontal mattress suture can be incorporated with continuous, independent sling sutures as shown in figure

The penetration of the needle is performed in such a way that the mesial and distal edges of the papilla lie snugly against the bone. The needle enters the outer surface of the gingiva and crosses the undersurface of the gingiva horizontally. The mattress sutures should not be close together at the midpoint of the base of the papilla. The needle reappears on the outer surface at the other base of the papilla and continues around the tooth with the sling sutures.

A, Continuous, independent sling suture using a horizontal mattress suture around diastemata or wide interdental areas (B and C).This mattress suture is utilized on both the buccal (D) and the lingual (E and F) surfaces. Continuation of suture on lingual surfaces (G to 1) and completed suture (J).

Anchor Suture. The closing of a flap mesial or distal to a tooth, as in the mesial or distal wedge procedures, is best accomplished by the anchor suture. This suture closes the facial and lingual flaps and adapts them tightly against the tooth. The needle is placed at the line angle area of the facial or lingual flap adjacent to the tooth, anchored around the tooth, passed beneath the opposite flap, and tied. The anchor suture can be repeated for each area that requires it (Fig). A to D, Distal wedge suture.This suture is also used to close flaps that are mesial or distal to a lone-standing tooth

Closed Anchor Suture. Another technique to close a flap located in an edentulous area mesial or distal to a tooth consists of tying a direct suture that closes the proximal flap, carrying one of the threads around the tooth to anchor the tissue against the tooth, and then tying the two threads (Fig.).

closed anchor suture, another technique to suture distal wedges.

Periosteal Suture. This type of suture is used to hold in place apically displaced partial thickness flaps. There are two types of periosteal sutures: 1 the holding suture and The holding suture is a horizontal mattress suture placed at the base of the displaced flap to secure it into the new position. 2 the closing suture. Closing sutures are used to secure the flap edges to the periosteum. Both types of periosteal sutures are shown in Fig.

Periosteal sutures for an apically displaced flap.Holding sutures, shown at the bottom, are done first, followed by the closing sutures, shown at the coronal edge of the flap.

HEALING AFTER FLAP SURGERY Immediately after suturing (0 to 24 hours), a connection between the flap and the tooth or bone surface is established by a blood clot, which consists of a fibrin reticulum with many polymorphonuclear leukocytes, erythrocytes, debris of injured cells, and capillaries at the edge of the wound. A bacteria and an exudate or transudate also result from tissue injury. One to 3 days after flap surgery, the space between the flap and the tooth or bone is thinner, and epithelial cells migrate 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.

One week after surgery, an epithelial attachment to the root has been established by means of hemidesmosomes and a basal lamina. The blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow, and the periodontal ligament. Two weeks after surgery, collagen fibers begin 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. One month after surgery, a fully epithelialized gingival crevice with a well-defined epithelial attachment is present. There is a beginning functional arrangement of the supracrestal fibers.

Full-thickness flaps, which denude the bone, result in a superficial bone necrosis at 1 to 3 days; osteoclastic resorption follows and reaches a peak at 4 to 6 days, declining thereafter. This results in a loss of bone of about 1 mm", the bone loss is greater if the bone is thin.

LEFT, ARROW POINTING DOWNWARD DEPICTS PENETRATION OF A PROBE IN AN UNTREATED PERIODONTAL POCKET.THE PROBE TIP GOES PAST THE JUNCTIONAL EPITHELIUM AND THE INFLAMED TISSUE AND IS STOPPED BY THE FIRST INTACT, ATTACHED COLLAGEN FIBERS.RIGHT: AFTER THOROUGH SCALING AND ROOT PLANING, THE LOCATION OF THE BOTTOM OF THE POCKET HAS NOT CHANGED, BUT THE PROBE PENETRATES TO ONLY ABOUT ONE THIRD THE LENGTH OF THE JUNCTIONAL EPITHELIUM. THE REDUCTION IN PROBING DEPTH MAY NOT REFLECT A CHANGE IN ATTACHMENT LEVEL

A: PERIODONTAL POCKET PREOPERATIVELYB:PERIODONTAL POCKET IMMEDIATELY AFTER SCALING, ROOT PLANING, AND CURETTAGEC: NEW ATTACHMENT. THE ARROW INDICATES THE MOST APICAL PART OF THE JUNCTIONAL EPITHELIUM. NOTE REGENERATION OF BONE AND PERIODONTAL LIGAMENTD: HEALING BY LONG JUNCTIONAL EPITHELIUM. AGAIN THE ARROW INDICATES THE MOST APICAL PART OF JUNCTIONAL EPITHELIUM.NOTE THE BONE IS NEW BUT THE PERIODONTAL LIGAMENT IS NOT

Flap surgery- Concepts and rationale Morrison (1980) studied 90 patients with advanced periodontitis over a period of 4 weeks.

Baderstein (1984)a probing depth reduction of 0.5 mm, 1.0 1.5 mm 2.5 5.0 mm respectively.

Pocket depth

Mean initial probing depth

Mean final probing depth

1-3mm2.29 mm2.13 mm4-6mm4.56 mm3.59 mm>7mm7.56 mm5.35 mmClaffey (2000) in his review reported the following attachment levels after N.S.T

Pocket depthA.H. gains1-3.5 mm-0.5 mm (att loss)4-6.5 mm0-1 mm >7 mm1-2 mmProbing depth indicated by blue lines before and after N.S.T Recession = green line

Advantages-

Good access to root and bone surfaceGood post-op adaptation of tissues to tooth surface

Disadvantages-

Heals by long junctional epithelium and not by new attachmentPresence of residual probing depths in the presence of infrabony defects

Rationale Removal of the pocket lining allows more access to the periodontal ligament cells to populate in the region and give rise to new attachmentAccess to root surface is increased with less morbidity

Undisplaced flap internal bevel gingivectomy Differs from the modified widman flap in that the soft tissue pocket wall is removed with the initial incision Ind- adequate amount of attached gingiva even after elimination of the pocket wall eg diffuse gingival enlargements, palatal flap

Dead space formation is reduced as flap margin over the alveolar crest

To avoid creation of a mucogingival problem- adequate attached gingiva should remain after the removal of poket wall

Internal bevel for an undisplaced flap Apically positioned flapNaber (1954)- repositioning of attached gingiva

Ariaudo and Tyrelli (1957)- two vertical incisionsFriedman (1962)- apically repositioned flap

Either full thickness or split thickness

Indications-Pockets extending beyond mucogingival lineNarrow zone of keratinized gingivaCrown lengthening procedure for restorative and prosthodontic purposes

Contraindications-Esthetically critical areasTeeth with severe attachment lossDeep infrabony pockets pts with high caries rate/ severe hypersensitivity

Friedman and Levin Classification

Class I: Wide and sufficient keratinized gingiva width (4-6 mm)Full thickness flap is reflected which covers the marginal bone and 1-2 mm coronally

Class II: Sufficient keratinized gingiva width

Full or partial thickness flap at the level of the alveolar crest

Class III- Insufficient gingival kertinized width

full or partial thickness flapmore augmentation of attached gingiva

Advantages-

Eliminates periodontal pocketPreserves keratinized gingivaEstablishes good gingival morphologyProvides necessary biologic width for restorative procedures

Disadvantages-

Results in root exposureMay lead to clinical attachment lossOutcome depends on healing Special anatomic situationsPalatal pocketsDistal pockets

1. Palatal pocketsAttached keratinized epitheliumNo elastic fibresNeurovascular bundlesProcedures GingivectomyLedge wedge procedureBeveled flapUndisplaced flapLedge wedge procedure

Horizontal incision

Internal bevel incision

Third incisionBevelled flap ( Friedman)

Palatal flapOchsenbein and Bohannan in 1963, 196

3 designs- Full thichness flapModified partial thickness Partial thickness flap

Advantages of palatal approach-EstheticsLess resorption because of thicker boneWider palatal embrassure space

Full thickness flapModified partial thickness Partial thickness flap

Partial thickness flap

Indications-Areas that require osseous surgeryPocket reductionReduction in enlarged bulbous tissue

Contraindications-Broad shallow palate- damage to palatal vesselsDistal wedge procedureRobinson (1966)

1. Presence of bulbous tissues over the tuberosity

2. A prominent retromolar pad in the mandible

3 .Inadequate attached gingiva

4. Abruptly ascending tuberosity

5. A close ascending ramus of the mandibleFactors AccessibilityAmount of keratinized gingivaPocket depthAvailable distance from distal aspect of tooth to end of tuberosity & retromolar padAnatomical considerations- lingual nerve- Internal oblique ridge- Muscle attachment

Distal wedge- triangular design

Distal wedge- square, parallel or H design

Linear or pedicle design

Advantages Access for treatment of distal furcation and underlying osseous irregularitiesMaintenance of attached gingivaInverted periostel graftInverted periosteal flap

Double split flap-Thalmair (2009)

Osseous surgery for pocket eliminationSchluger (1949), Goldman (1950), Friedman (1955)

Gingival contour is dependent on the underlying bony contour and the elimination of the soft tissue pockets has to be combined with osseous recontouring.

Osteoplasty Ostectomy Osteoplasty Friedman in 1955

Reshaping of alveolar bone to achieve a more physiological form without removal of tooth supporting bone

Ostectomy Removal of tooth supporting bone to reshape the deformities.

Indications-Elimination of interdental cratersCorrection of one walled defectsOther angular defcts not amneable to regenerationSelection of a surgical techniqueSuprabony, fibrous pocket with sufficient attached gingiva- Gingivectomy

Infrabony pocket, furcation inv, osseous deformities, muco-gingival problems- Flap surgery

Location Amount of attached gingivaNeed for osseous recontouring

Healing of flapsCaffesse et al. (1968)- reverse bevel flapHistological examination- 2hrs,13hrs and 1, 2, 3, 5, 9, 14, 21, 35 & 72 days

2hrs- Narrow zone of necrosis covered by clotFew PMNsAlveolar process show empty lacunae

13 hrs-Usual arrangement of cementoblasts missing on root surface- 0.5mm from flap1 day-Thick band of PMNsEpi cells not started to migrate

2 days-Epi cells started to migrate & cover 0.1- 0.2 mm of inner surface of CTAngioblasts & fibroblasts seenInterproximal bone shows necrosis

3 days-Epi makes contact with tooth surfaceInflammatory reaction is less severeCT grows betw flap and boneFormation starts from PDL, marrow space & margins

5 days-Partial establishment of contactGranulation tissue is present over PDL & alv crestOsteoclasts at crest originate form marrow space7 days-Epi attachment to enamelFlap adheres by granulation tissueOsteoclastic activity

9 days-Gingival crevice epitheliazedNew epi attachment formedSevere osteoclastic activity

14 days-Alternative osteoclastic & osteoblastic activityNew periosteumImmature collagen seen21 days-Fully epi gingival crevice & Well defined epi attachmentFunctional arrangement of supracrestal fibresPeriosteum- not fully matured

35 days-Osteoblastic activity at crest

72 days-Well defined epi attachmentKeratinization of gingivaPeriosteum appears normalLayers of newly formed bone on alveolar crest

Ramfjord et al. (1968)

Partial thickness flaps-Repair of epi & CT is sameReaction of alveolar boneOsteoclastic activity starts at 4th day- 2 weeks

Full thickness-Resorption begins at 7-14 days- several weeks

Long term studies comparing surgical and non- surgical therapiesStudy Method Observations & conclusions Michigan studies

1. Ramfjord et al. (1968) 32 pts- mod- sev pditisSubgingival curettage pocket elimination ( APF with osseous reduction / gingivectomy)Short term observation (1-3 years)-

Curettage- slight gain

Pocket elimination tech- loss in attachmentLong term observation (4-7 yrs)-No sig diffMore pocket reduction with surgicalGothenburg studyLindhe et al. (1982)Gothenburg study VI

2 yrs post-op-

15 ptsMore PD reduction with surgicalRP or RP & MWF Critical probing depthSplit mouth designFor RP- 2.9mmFor flaps 4.2mmMinnesota StudyAhlstrom et al. (1983)SRP alone vs FlapsNo sig pocket depth reduction6 yrs follow upAttachment gain greater in flap procedures for deeper pocketsAarhus Study:Isidor and Korning (1986) compared the effect of root planing and modified widman flap to apically positioned flap during 5 year of follow up. They obtained similar results for both the treatment.

Washington Study:Oslen et al (1985) compared apically positioned flap without osseous recontoring to a.p.f. with osseous recontouring in a 5 year follow up study.They concluded that the osseous recontouring was more effective in reducing pockets and controlling the inflammation than flap surgery.

Tucson studies Becker et al. (1988)RP, MWF APF with osseous reductionMin diff betw 3 procedures1 yr observationNebraska studiesKaldahl et al. (1988)82 ptsReduction in PD- all2 yrs- split mouth designSc, RP, MWF, MWF with osseous reductionPocket- MWF with red> MWF> RP> Sc

Gain in CAL-MWF & RP- greatest gainAll- except scalingInterpretation of longitudinal studiesNon-surgical therapy is the corner stone of periodontal therapy in all types of pocket depths.

surgical techniques have produced greater pocket depth reductionno difference on long term evaluation.

S.R.P. will always be performed first on any patient suffering from moderate periodontal pockets.

Shallow pockets should not treated by surgical therapy as it may result in C.A.L.

Moderate/Advanced pockets can be treated by tailor made surgical techniques to suit the patients condition.

proper regular maintenance is paramount for success of therapy.

Failures of flap surgeryDivided into 1)Pretherapeutic causes2)Therapeutic causes3)Posttherapeutic causes

Pre- therapeutic causes1) Incorrect patient selection

2) Improper diagnosisSystemic conditionType of periodontitisInvolvement of hopeless toothoral hygiene assessment

3) Inappropriate dental restorations

4)Morphology of tooth surfaces- Failure to eliminate abberations like resorptive lacunae , enamel pearls and grooves which act as a guide plane for a bacterial penetration of deeper periodontal tissues

5)Habits - mouth breathing ,- bruxism - thumb sucking- smoking6)Occlusal trauma

Therapeutic causes1. Improper selection of surgical technique-

width of attached gingiva height of remaining bonepocket depth mobility co-operation of the patient patients systemic back ground.decreased width of attached gingiva- internal bevel incision will further decrease the width of attached gingiva leading to mucogingival problems.

Surgical technique which does not allow proper adaptation of interdental tissue will lead to food and plaque accumulation in the interproximal area and therapy leads to recurrence of periodontal disease.

Improper asepsis of the surgical field and patient, improper sterilization of the instruments.

2. Improper flap design: A properly designed flap will anatomically fall into its correct position on its bony base following surgery.

If a mucoperiosteal flap is not designed correctly it may

Rise too high coronally- redundant tissue with subsequent repocketing Fall far short of the osseous margin- resorption or sequestra formationInadequately cover the bone graft- minimizing the opportunity for ideal healing.

Inadequate thinning of the full thickness flap (palatal flap), results in an excessively thick bulky gingival margin -gingivoplasty

It may also encourage the overzeolous tightening of the sutures, thereby endangering the blood supply and enhancing the possibility of sloughing of flap and post operative pain

3. Incomplete debridement

4. Improper suturing

Post therapeutic causes1. Unsupervised healing-- Post-operative care

2. Inadequate restorations post surgically-- failure to replace missing teeth- correct overhanging restorations- correct carious lesionsConclusion Pocket elimination is considered to be one of the main goals of periodontal therapy.

Clinical studies comparing non- surgical and surgical therapy for the treatment of shallow to moderate pockets showed similar long term results.However, in cases of deep pockets, surgical therapy showed better results.Whatever maybe the choice of treatment modality, it is the detailed thoroughness of root debridement and patients standards of oral hygiene , which determine the long term maintenance of the periodontium.Thank you

Thank you!Surgical Technique For Undisplaced FlapINCISIONStep 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.Step 2: The initial, internal bevel incision is made after the scalloping of the bleeding marks on the gingiva . The incision is usually carried to a point apical to the alveolar crest, depending on the thickness of the tissueStep 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.

ELEVATION OF FLAPStep 4: The flap is reflected with a periosteal elevator (blunt dissection) from the internal bevel incision. Usually there is no need for vertical incisions because the flap is not displaced apically.Step 5: The interdental incision is made with an interdental knife, separating the connective tissue from the bone.Step 6: The triangular wedge of tissue created by the three incisions is removed with a curette.

ROOT PLANING AND REMOVAL OF GRANULATION TISSUEStep 7: The area is debrided, removing all tissue tags and granulation tissue using sharp curettes.Step 8: After the necessary scaling and root planing, the flap edge should rest on the root-bone junction. If this is not the case, due to improper location of the initial incision or to the unexpected need for osseous surgery, the edge of the flap is rescalloped and trimmed to allow the flap edge to end at the root-bone junction.

SUTURINGStep 9: A continuous sling suture is used to secure the facial and the lingual or palatal flaps. This type of suture, using the tooth as an anchor, is advantageous to position and hold the flap edges at the root-bone junction. The area is covered with a periodontal pack.

POST-OPERATIVE

ARMAMENTARIUMIncision and excision (periodontal knives)Deflection and readaptation of mucosal flaps (periosteal elevators)Removal of adherent fibrous and granulomatous tissue (tissue scissors, cumin scaler)Scaling and root planing (scalers and curettes)Removal of bone tissue (bone rongeurs, chisels and files)Root sectioning (burs)Suturing (sutures and needle holders, suture scissors)Application of wound dressing (plastic instruments)Newer instrumentslasers, cryosurgery, electosurgery

Classification of periodontal pocket managementI. Nonsurgical pocket therapy: -supra/ subgingival debridement with oral hygiene instructions. - chemotherapeutics. - lasers.II. Pocket elimination procedures: - gingivectomy - apically positioned flap - flap osseous surgeryClassification of periodontal pocket managementPocket reduction procedures: - Access flap. - Modified Widman flap. - Excisional New Attachment procedure. - Replaced flap.

UNDISPLACED FLAPmost commonly performed type of periodontal surgery. it may be considered an internal bevel gingivectomy The undisplaced flap and the gingivectomy are the two techniques that surgically remove the pocket wall

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.Step 2: The initial, internal bevel incision is made after the scalloping of the bleeding marks on the gingiva.Step 3: The second or crevicular incision is made from the bottom of the pocket to the bone Step 4: The flap is reflected with a periosteal elevator from the first incision. Step5: The interdental incision is made with an interdental knife, separating the connective tissue from the bone.Step 6: The triangular wedge of tissue created by the three incisions is removed with a curette.

Step 7: The area is debrided, removing all tissue tags and granulation tissue using sharp curettes.

Step 8: A continuous sling suture is used to secure the facial and the lingual or palatal flaps.

Gingival Pockets 1) Character of the pocket wall - Edematous or Fibrotic2) Pocket accessibility.

Slight Periodontitis A conservative approach and adequate oral hygiene generally sufficient. Recurrence in previously treated sites - surgical approach.

Moderate to Severe Periodontitis in the Anterior Sector -Scaling and root planing - Technique of choice. - Papilla preservation flap - First choice when a surgical approach is needed. - Teeth too close interproximally - Sulcular incision flap - next choice. - Esthetics is not the primary consideration - Modified Widman flap. - In some infrequent cases - Apically displaced flap with bone contouring.214Moderate to Severe Periodontitis in the Posterior Area

Purpose of surgery in the posterior area is either enhanced accessibility or the need for definitive pocket reduction requiring osseous surgery. Accessibility can be obtained by either the undisplaced or apically displaced flap.Osseous defects amenable to regeneration - the papilla preservation flap - Technique of choice because it better protects the interproximal areas where defects are frequently present. Second and third choices are the sulcular flap and the modified Widman flap, maintaining as much of the papilla as possible.Osseous defects with no possibility of reconstruction - Technique of choice - Flap with osseous contouring.215