Perio Sheet #4 By Abdull Hameed Mahmood

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Perio Sheet #4 By Abdull Hameed Mahmood

Post by Sura on 19/10/2012, 9:37 pm

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Re: Perio Sheet #4 By Abdull Hameed Mahmood

Post by Shadi Jarrar on 12/11/2012, 9:14 pm

Flap technique for pocket therapy
In the last lecture, we took new modalities in treatment of periodontal pocket which are flaps . we knew types of flaps , objectives , goals , type of incisions

· We have three types of incisions of flaps :

1- inversed bevel or internal incision

2- sulcular , gingival or cravicular incision

3- Inter dental incision

· We have to use two of these three incision in any flap we do

· We have to decide earlier which type of incision we use , according to type of flap we use .

· We took in the last lecture types of incisions used in regenerative techniques ( something missing in structure we want to replace it , for example, we replace the bone architecture that lost due to long standing chronic inflammatory process that is associated with connective tissue attachment and gingival attachment )

· Types of regenerative techniques are :

1- Papillary preservation flap

2- Conventional flap



· We use only one type of incision in these regenerative techniques which is sulcular , gingival or cravicular incision ( incision through sulcus )

· Flap classification :

1- full – thickness flap (reflection of flap with all soft tissue including muco-periosteum completely )

2- split- thickness flap , partial thickness flap , ( include only the epithelium and a layer of underlying connective tissue , muco-periosteum remains covered by a layer of connective tissue )

3- displaced flap

4- Papillary preservation flap

5- Conventional flap



· Steps for flap technique:

· Any flap technique of these five mentioned above must follow the following steps :

· Incision (the three above) > elevation of the flap > suturing of the flap ( we have to decide which type of suture and which type of suturing technique(before doing the incision) according to design of flap )

· then , after suturing the flap , its your option to put a layer called periodontal dressing to gives more stability to surface of tissues or not

· back to our subject , flaps in pocket therapy , we have many types :

1- modified Wodman flap

2- un-displaced flap

3- apically displaced flap + papillary displaced flap



· uses of flaps in pocket therapy:

Ø increased accessibility to root deposits : some types of flaps give us accessibility and other types doesn’t give

Ø eliminate or reduce pocket depth by resection of pocket wall

Ø expose the area to perform regenerative methods

· what is the difference between the first point ( accessibility ) and the second (reduce or eliminate pocket depth) ??. in other words , if I do accessibility and removing of deposits , is it enough to eliminate pocket depth??

· Yes , in the first point (accessibility) we do flap to only access the area without doing reduction or elimination the pocket depth but because meticulous debridement of the root surface until CEJ plus using curettage to remove infected pocket wall , this results in healing that ends in shrinkage of pocket depth ( pocket therapy by healing and shrinkage )

· In the second point ( elimination) , we do mechanical and chemical detoxification on the root surface and ,by the end, we place the flap apically to original marginal of the gingival ( pocket therapy by reduce or eliminate the pocket depth)

· In the third point ( regenerative method ) , if I do regenerative methods , does they result in elimination of pocket depth ???

· In the first two points , we do conditioning or repairing of existing tissues , but in the regenerative techniques , we do replacement of missing tissues (bone ) , so , if the bone lost and we just do accessibility , scalling and root planning , nothing will happen , because the tissues will not adhere again to the bone which is lost so , in regenerative technique ( we should use either or, in combination with , bone material as artificial substance to replace a lost architecture of the alveolar bone and then we use guided tissue membranes to promote the periodontal ligament attachment ) , so this regenerative technique is very specific technique ( in case of sufficient amount of bone loss certainly associated with connective tissue loss)









Flaps for pocket therapy
flaps for regenerative technique
Modified Wodmen flap : only for pocket therapy not for regenerative .
Papillary preservation flap : only for regenerative technique




Un-displaced flap : only for pocket therapy
Conventional flap : : only for regenerative technique


Apically displaced flap(repositioned flap) : only for pocket therapy



· The difference between papillary reservation flap and conventional flap :

· In conventional flap : when we have teeth very close to each other( crowding) , we have to do full- thickness flap ,because we have bone architectural lost, through using only cravicular,sulcular or gingival incision and we split the interdental papillae into two sites , labial and ligual/palatal

· In papillary preservation flap : when we have spacing between teeth so, no need to split the papillae , so if we can circumscribe with blade as on part instead of splitting it , we cut it from underneath and shifted to other side.





· Modified Wodmen flap:



· The most common flap technique in periodontology

· The easiest , the best and time saving and income for dentists

· Used for :

· 1- calculus removal (meticulous debridement) ,

· 2- granulation tissue removal ( because the root cementum and the lining of the pocket become infected as the result of increased pocket depth above 5 mm so, migration of junctional epithelium will happen )

If we remove at 100% calculus deposits and soft enamel and cementum , no re- attachment will occur because still we have infected pocket lining or wall toward the tooth surface , so we have to use curettage to remove the granulation tissue so, re-attachment will result now

· so, modified wodman technique is used for accessibility because we do debridement + granulation tissue removal

· as we said befor , modified wodman technique will result in re- attachment not new attachment .. why ? because as a result of accessibility , healing( re-attachment) will result in the same connective tissue that is already presented but in regenerative technique ( lost bone tissue architecture + connective tiuue attachment ) new-attachment will result because we have induced the attachment

· the end result of modified Wodmen technique is shrinkage ( recession ) that results in healing hence pocket depth reduction and doesn’t result in displacement apically or other directions

· finally , we do flap closure through interrupted suturing technique

· Modified Widmen technique is the first incision or initial incision which is inversed bevel incision….

· Steps of modified widman technique :

· 1- The initial incision(internal bevel) starts ,through using the blade, apically to gingival crest , not in the sulcus , ( from 0.5 mm to Max. of 2.0mm) and no more than 2mm

· 2- then we push the knife downward until it touches at the vicinity of the crest of the bone

· 3- then we should follow the scalloping of gingival margin because the gingival margin anatomically follow the contour of CEJ so , if we don’t do that , the healing will not follow the biological rules or width ( that composes of sulcus , 1mm connective tissue attachment , and 1mm junctional epithelium )

Why there is differences in the distant from the gingival margin to the point of starting incision (0.5 to 2 mm)??

Because as we said before , the main purpose of modified Widmen technique is to get healing by removing the infected pocket lining so ,the amount of incision is the width of infected pocket lining(contains granulation tissue) …so, the modified widman technique doesn’t remove the pocket wall … as a result , the goal of inversed bevel incision is removal of pocket lining also , the distant(0.5 to 2mm) depends on the remaining attached gingival(Dr asked does we measure the attached gingival horizontally or vertically… and how much is it ??

· The width of attached tissue is critical, because the more there is available provides a greater sense of protection against the aforementioned insults to the tissue. Using the mucogingival junction as the boundary demarcating the apical border of the attached gingiva, a periodontal probe in inserted into the gingival sulcus to measure how much of the keratinized gingiva coronal to the mucogingival junction is in fact attached to the underlying bone. The depth of the gingival sulcus, determined by the depth to which the probe enters the sulcus, is not attached to the underlying bone, and is subtracted from the total height of the keratinized tissue.

· Thus, if the entire height of the keratinized gingiva, from the free gingival margin to the mucogingival junction is 8 mm, and the probing depth on the tooth at that location is 2 mm, the effective width of attached gingiva is 6 mm…… from Wikipedia)



· 4- after that , we use muco- periosteual elevator to pushing the gingival away but the collar remains un-detached

· 5- then, we start removing the collar through using second cravicular incision(the first one , is the internal bevel that result in collar remains un-attached) to detach the collar

· 6- the third incision is used to detach the interdental papilla through using blade no.12 or urban knife through doing horizontal incision labial and lingual/palatal

Now , the flap is completely released : craviculary , 1-2mm far away from gingival margin and interdental margin

· 7- after removal of pocket lining , we use the curate to do proper debridement of the root and no need to do curettage because we remove the whole infected pocket lining that contains the granulation tissue

· 8-then , we do direct root planning to remove any remaining debris

· 9- return the flap to original position without any displacement >> the we get healing

· 10- finally , we do direct interrupted suturing why ?? to insure complete coverage of interdental bone spaces , otherwise , bone resorption will result … so we have four steps :

· Inistial (internal bevel)incision > second(cravicular)incision> third incision(horizontal incision)>suturing and we get healing within one week that cause shrinkage, hence we lost the pocket

· Note : part of root surface will remain exposed because the benefit and priority of removing the pocket lining is more that the risk of expose the root

· Purposes of modified widman flap:

1- Exposing the root surfaces for meticulous instrumentation

2- For removal of pocket lining but it deos not intend to remove the pocket wall and deose not attempt to reduce pocket depth but it reduces it by healing



· The indication of modified widman flap : when the other methods fail to removing the infected pocket lining …









· Un-displaced flap:

· the cut starts far away apically from gingival crest and ends to a point apical to crest of the bone (alveolar crest) but in modified widman flap it ends at alveolar crest .

· we remove ,in this flap ,we remove the pocket lining plus pocket wall then we return the flap to its original position







· Apically displaced flap

· The same as modified widman flap but the difference between them :

· In modified widman flap : we cut the flap but without deflection and without removal of muco-periosteum line

· In apically displaced flap : we cut the flap then we deflect and reflect the flap

· So, in this flap we remove the pocket lining and we keep the pocket wall







· Muco-periostual flap without vertical incision :

· It is repositioned flap or displaced flap , does not return to its original position, but it is full-thickness flap or it could be partial –thickness flap



Note : before doing initial incision , we have to improve the oral hygiene status of the patient to improve the result of treatment

Dr. said that you have to read from the book about the rest two flaps ( papillary preservation , conventional )

I found them from the article given by the doctor :

· Papillary preservation flap :

· Step 1 : a crevicular incision is made around each tooth with no incisions across interdental papilla

· Step 2 : the preserved papilla can be incorporated in to the facial or lingual/palatal flap , although it is most often integrated into facial flap . in these cases , the lingual or palatal incision consists of semilunar incision across interdental papilla . the incision dips apically from the line angles of the tooth so that the papillary incision is at least 5mm from the crest of papilla

· Step 3 : an Orban knife is then introduced into this incision to sever half to two-thirds the base of interdental papilla . the papilla is then dissected from the lingual or palatal aspect and elevated intact with facial flap

· Step 4 : the flap is reflected without thinning the tissue .





· Conventional flap

· Step 1 : using blade no. 12 , incise the tissue at the bottom of the pocket to the crest of the bone , splitting the papilla below the contact point every effort should be made to retain as much tissue as possible to protect area subsequently

· Step 2 : reflect the flap , maintain it as thick as possible , not attempting to thin it as it done for respective surgery . the maintenance of a thick flap is necessary to prevent exposure of graft or membrane resulting in necrosis of flap margin



The End …..

GOOD LUCK



DONE BY : ABDULLHAMEED MAHMOUD

LECTURE NO.: 4

DATE OF LECTURE : 10/10/2012
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Shadi Jarrar
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