Flap surgeries
I. Definition:
The periodontal flap is a portion of gum and/or mucosa that has been detached
Surgically remove underlying tissues to provide the visibility and direct access needed for treatment.
The flap may involve the epithelium, the chorion, and the periosteum
II. Classification:
1- The full thickness flap (mucoperiosteal)
⮲ Reclination of all soft tissue including the periosteum
⮲ Exposure of underlying bone
⮲ Accessibility if bone surgery is considered
The full thickness flap is retracted by blunt dissection using an elevator to separate the mucoperiosteum from the bone
2- Partial thickness flap (mucosal):
⮲Includes the epithelium and a layer of underlying connective tissue
⮲The bone remains covered by a layer of connective tissue and the periosteum
⮲ Indicates when the practitioner does not wish to expose the bone
⮲In mucogingival surgery
⮲When repositioned apically
The partial thickness flap is retracted using a surgical scalpel (no. 15 or 11)
3- The non-repositioned flap: placed in its pre-surgical position
Apically
4- The repositioned flap:
III- Objectives:
☞Accessibility of instruments to root surfaces
☞ Elimination of inflammation
☞Assessment of the degree of bone lysis
☞Creation of an oral environment allowing effective plaque control
☞ Elimination of periodontal pockets
☞ Highlighting bone defects in order to adopt the best treatment (filling, ROG, etc.)
IV- Advantages:
☞ The pocket epithelium is completely removed through the internal bevel incision
☞Direct vision allows surfacing and curettage to the bottom of the pocket
☞ At the end of the procedure the flap can be repositioned
☞There are no open wounds after the procedure.
Flap surgeries
V- Indications and Contraindications:
1- Indications:
☞ Insufficient accessibility to root surfaces
🡽 of the depth of pockets
🡽 of the surface area of the teeth
🡽Presence of root fissures, concavities, furcation
☞Active pockets more than 4 mm deep that do not respond sufficiently to initial treatment
☞Pockets whose bottom is beyond the mucogingival line
☞Infrabony pockets
☞Expose the furcations in order to treat them properly (hemisection to allow
Easy access of surgical and hygiene instruments to the inter-radicular space)
☞Significant thickening of the bony edge
☞Tooth extraction with treatment of adjacent periodontal structures.
2- Contraindications
Absolute:
– Lack of motivation and cooperation from the patient
– Presence of a serious general defect or life-threatening risk:
🢖Heart disease at major risk
🢖Acute leukemia
🢖Severe anemia
🢖Agranulocytosis and lymphogranulomatosis
🢖Multiple sclerosis
🢖 Parkinson’s disease
🢖Irradiated; HIV
Relatives:
– HTA
– Angina pectoris
– Patient on anticoagulant
– Diabetes
VI- General principles of flap interventions :
1- Thickness:
✓ Full thickness flap
The incisions are frank and seek bone contact
✓ Partial thickness flap: The incisions are very light.
VII- The different flap techniques
1- Modified Widman flap:
The disadvantage of this technique is that it causes post-operative gingival recessions and the loss of interdental areas.
2- ENAP (excisional new attachment procedure):
It is a technique which consists precisely of a periodontal curettage carried out with the scalpel blade.
Indication :
☞Suprabony periodontal pocket not exceeding the mucogingival line
☞Upper incisor-canine region because it limits recessions
Protocol:
3- Flap moves apically:
It is a technique used to eliminate the periodontal pocket
The incision is internally beveled, it is moved apically relative to its initial position
The location of the displaced flap depends on:
– thickness of the marginal edge in the area to be treated
– height of attached gum
– the length of the clinical crown required for a prosthetic abutment.
Indication:
– Reduce the periodontal pocket
– Increase the height of the attached gum
– Lengthen the clinical crown
– Furcation damage
Contraindication:
– Thin gums
– Aesthetic sector
– Deep intraosseous defects
– Patient at high risk of caries
– Severe hypersensitivity
– Tooth mobility and significant loss of attachment
– Unfavorable coronary-radicular report
4- Palatal access flap: (aesthetic access flap)
It constitutes another variant of LWM taking into account aesthetics and preserving the papillae on the vestibular side: Indicated in case of diastema
5- Laterally displaced flap:
The oldest technique, also called pedicled grafting, consisted of using a partial thickness flap dissected from a neighboring tooth showing sufficient height of attached gingiva, in order to transpose it to the site affected by recession. The limitations of the procedure relate to both the recipient site (width and height) and the donor site (quality of the tissue).
-Objective:
– This technique allows to cover a localized recession
– increase the height of keratinized tissue using a pedicled flap from a site adjacent to the recession. The gingiva is displaced (rotational movement) and sutured to the area to be treated.
Flap surgeries
-Indication:
The donor site:
⮲Has significant gingival thickness and height to allow partial thickness dissection.
⮲ Absence of bone lysis
⮲Edentulous areas or teeth in a lingual position are good donor sites, as thick gingival tissue is most often available there.
⮲Increase the height of the keratinized tissue using a pedicled flap from a site adjacent to the recession
– Technique
-The receiving bed must be wide, twice the size of the area to be covered
. The epithelial tissue is removed and a periosteal bed is prepared beyond the mucogingival junction line.
– The lateral incision is made at a bevel to allow good coaptation with the displaced flap, and first-intention healing at the recipient site.
-At the donor site, two vertical releasing incisions are made. The flap is then dissected in partial thickness, while maintaining sufficient thickness to avoid secondary recession at this level during healing. Once the flap is released, two incisions complete the releases at the level of the mucosa. They are made in the direction of movement, in order to allow rotation of the flap without excessive muscle tension.
– The graft is sutured at the recipient site and at the periosteum at the donor site.
– Placement of a surgical dressing at the operating area (donor site and recipient site).
Benefits
☞The laterally displaced flap is relatively easy and quick to perform.
☞Tissue integration after healing is good.
☞There is only one operating area, the donor site and the recipient site being located in contact with each other.
☞The flap is vascularized by its apical base, which promotes optimal healing and limits morbidity.
-Inconvenience:
This technique often only allows the treatment of a single recession, and requires the presence of a significant amount of tissue near the lesion.
This often limits the indications to situations of dental malpositions.
-Benefits:
– Good aesthetic integration giving good clinical results.
6- bipapillary flap:
Technique described by Nelson in 1987, it is associated or not with the use of a connective graft.
-Objective:
– Allow the recovery of a single recession, with a single surgical site.
-Indications:
In Miller classes I and II with the presence of large papillae on either side of the recession.
-Disadvantages:
– Careful technique. The suture of the two papillae is delicate and has a weak point at its base (risk of necrosis).
– The indication of the technique is limited, because it requires the presence of large and thick papillae on either side of the recession.
7- Coronally displaced flap
It is a pedicled flap described by Patur ett Glickman in 1958.
-Objective:
– Used alone, it aims to cover the root of class I recessions.
– It cannot allow the increase in gingival height or the thickening of tissues.
– In periodontal regeneration, it allows the protection and closure of the surgical site (covering of the membrane or protection of the root covered with protein derived from the enamel matrix).
-Indications :
At the level of simple or multiple recessions of Miler class I.
-De-epithelialization of the papillae to a height corresponding to the size of the recession.
– Two vertical discharge incisions.
– A horizontal incision located at the limit of the de-epithelialized zone of the papillae, and associated with an intrasulcular tracing at the level of the recession.
– Flap detachment. The latter must be able to completely cover the recession without constraints. To do this, the releasing incisions are extended into the alveolar mucosa, and a partial thickness dissection limits muscle traction on the flap.
– Once positioned without constraints, the coronally pulled flap is sutured at the level of the de-epithelialized papillae and on the sides.
– Benefits :
Simple technique, single surgical site, with satisfactory aesthetic integration.
-Disadvantages:
Does not thicken or increase the height of the gum. The two vertical discharge incisions may be visible after healing in the maxillary anterior sectors
8-Semilunar flap:
This technique was described by Tarnow in 1986. It is a variant of the coronally displaced flap.
-Goals:
Root coverage of narrow recessions.
-Indications:
– Miller Class I recessions, single or multiple.
– relatively thick keratinized tissue, apical to the recession to be treated.
-Technical:
– Intrasulcular incision completed by an incision
Arcuate at the mucogingival line.
– From the intrasulcular incision, a blade is used to perform a half-thickness dissection
Up to the semilunar incision.
– A pedicled and vascularized flap is thus released not by its apical part but by its lateral edges, which represents the second specificity of this technique.
The flap is pulled coronally and applied to the recession, then protected by a dressing.
-Benefits:
– Simple and rapid technique to perform, which can be used for moderate class I recessions, single or multiple, mainly in the maxillary anterior sector.
-Disadvantages:
– Possibility of scar bands in the alveolar mucosa, at the site of the semilunar incision.
– Requires thick fabrics.
Flap surgeries
9 -Post-operative advice
⮩ Do not eat hot, spicy foods
⮩ Semi-liquid diet for the first few days
⮩Do not take hot baths
⮩Do not remove the bandage
⮩ Avoid brushing at the operated site
⮩Ensure hygiene in the rest of the regions
⮩ Avoid sports activities
⮩Prescription:
– ATB
– painkiller.
Flap surgeries
IVX- Healing:
Epithelialization occurs from the epithelial cells of the tissue covering the edges of the wound.
The keratinized marginal gingiva, repositioned apically on a periosteal bed, also transforms into attached gingiva in the apically displaced flap; healing occurs by first intention.
During the initial phase of healing, resorption of varying intensity almost always occurs.
During the phase of tissue regeneration and maturation a new donto-gingival limit is formed by coronal migration of the TC
A long junctional epithelium is always observed interposed between the bone tissue and the root surface.
Flap surgeries
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.