Surgical therapy for periodontitis: Periodontal curettage Flaps
Plan :
Introduction
1. Objectives
2. Reminders: Healthy periodontium / The periodontal pocket / Loss of clinical attachment
3. Definition of periodontal curettage
4. Principles of curettage
5. Indications for periodontal curettage
6. Open curettage technique
7. closed curettage
8. Results after periodontal curettage
9. Periodontal curettage with ultrasonic devices
10. Laser periodontal curettage
11. The Shreds
11.1 Definition
11.2 Objectives of flap interventions
11.3 Classification of flaps
11.4 Indications for flap procedures
11.5 Contraindications to flap procedures
11.6 General principles of flap procedures
11.8 Different types of sanitation flaps
11.8.1 Widman flap (original technique)
11.8.2 Modified Widman flap
11.8.3 Full-thickness apically positioned flap
11.8.4 Papilla preservation flap
Conclusion
Bibliographic references
Introduction: Periodontitis is an inflammatory disease, characterized by the presence of periodontal pockets, the treatment of which often requires the use of surgical techniques (sanitation flaps).
1. Objectives:
. Reduce the depth of the periodontal pocket
. Learn the surgical principles of pocket surgery and mucogingival surgery
2. Reminders: Healthy periodontium: is defined as a stable state over time of all 4 periodontal tissues (gingiva, cementum, alveolar bone and periodontal ligament) which adhere and/or attach to the entire surface of the dental root. The most coronal part of this attachment is at the cementoenamel junction.
Clinically, healthy gingiva is firmly attached to underlying structures, has a pale pink, pitted “orange peel” appearance and does not bleed when brushing, chewing, spontaneously and/or when probing with a force of approximately 50 g.
Periodontal pocket / Clinical attachment loss:
It is the pathological increase in the depth of the sulcus which results either from the apical migration of the epithelial attachment, or from the increase in the volume of the gingiva, or both.
Pathogenesis of periodontal pocket formation: The transformation of a healthy gingival sulcus into a periodontal pocket sulcus involves the following steps:
• Plaque accumulation and resulting gingival inflammation destroy the dentogingival connective tissue fibers just below the junctional epithelium (JE) at the base of the pocket.
• This allows viable EJ cells to migrate apically along the root surface to collagen-depleted areas to maintain continuity with the tooth surface.
• This apical migration, combined with the concomitant coronal separation of JE cells from the tooth surface at the base of the sulcus (due to increased neutrophil infiltration between JE cells and the resulting loss of tissue cohesion), leads to a pathologic deepening of the gingival sulcus called a “pocket.” The separated JE cells at the coronal end may be part of the pocket epithelium at the base of the sulcus.
The clinical attachment level: represents the distance separating the enamel-cement junction from the bottom of the pocket, the difference between the two measurements being the gingival recession (it is therefore the addition of the probing depth and the recession height, which is the main marker of periodontitis).
3. Definition of periodontal curettage: Periodontal curettage: (open curettage, flap curettage): it is a technique by which the elimination of the pocket epithelium is done under direct vision, obtained after the detachment of a flap.
Closed curettage: This is the technique by which the pocket epithelium and the infiltrated connective tissue are removed without removing a flap, i.e. without direct vision of the root surfaces.
Surgical therapy for periodontitis: Periodontal curettage Flaps
4. Principles of curettage: The use of curettage is based on the following reasoning:
Removal of the pocket epithelium and inflamed connective tissue results in the formation of a new connective and/or epithelial attachment at the tooth surface.
Tissue contraction following curettage contributes to reducing pocket depth
5. Indications for periodontal curettage:
. Inflamed and edematous tissue.
. Open curettage (Deep periodontal pockets (≥5mm)
. Preparation for more complex periodontal surgery, in order to assess the tissue reaction and the patient’s ability to control the bacterial biofilm.
. In case of periodontal abscess, curettage accelerates healing.
. It presents the extension of the surfacing if there is significant granulation tissue.
. Can be performed as part of attempts at reattachment in moderately deep intraosseous pockets located in accessible areas.
. Curettage may be performed on follow-up visits as a maintenance treatment method for areas of recurring inflammation.
6. Open curettage technique:
. Asepsis then local anesthesia;
. Internal incision to separate the healthy connective tissue on one side and the inflammatory tissue on the other.
the epithelium that lines the pockets
. The gum is receding.
. Removal of remaining granulation tissue and epithelium
. The root surfaces are carefully debrided.
. The flap is replaced in its initial position.
. Interproximal stitches.
7. closed curettage:
Indications:
. Supra-bony periodontal pocket less than 5 mm
. Periodontal abscess
Contraindications:
. Infrabony pockets;
. Pockets greater than 5mm
. Furcation injuries.
Benefits :
. Simple and easy technique, not very traumatic
. Less bleeding
. Limited instrumentation
Surgical technique: Curettage is done quadrant by quadrant.
. Asepsis then local anesthesia
. Descaling above and below the gum line;
. Root planing
. Curettage of the soft wall
. Removal of the junctional epithelium and underlying connective tissue.
. Polishing of dental surfaces
. Cleaning the operating field
Disadvantages: When treatment is done without eye control, some root surfaces escape treatment completely and others are only partially cleared of tartar and plaque.
8. Results after periodontal curettage : After open or closed curettage, we will assist:
. A decrease in pocket depth
. Has a reduction in inflammation, decreasing edema, bleeding and tooth mobility
. To the formation of a long junctional epithelium
9. Periodontal curettage with ultrasonic devices: Ultrasonic vibrations interrupt tissue continuity, remove epithelium, cut collagen bundles, and alter the morphological characteristics of fibroblast nuclei. Ultrasound is effective in debriding the epithelium of periodontal pockets. This results in a narrow band of necrotic tissue (microcautery) that denudes the inner wall of the pocket.
10. Laser Periodontal Curettage: The goals of laser curettage are epithelial removal, as with the previous methods, and in addition, bacterial reduction as well. A short-term study reported that Nd:YAG laser treatment did not produce a statistically significant bacterial reduction.
Surgical therapy for periodontitis: Periodontal curettage Flaps
11. The Shreds:
11.1 Definition: A flap is a fragment of gingiva and/or mucosa, of variable shape, surgically separated from the underlying tissues to provide visibility and access to the bone and root surfaces.
11.2 Objectives of flap interventions:
. Accessibility of instruments to the root surface.
. Surgical removal of periodontal pockets
. Regeneration of the periodontal system destroyed by periodontal disease.
. Resolution of mucogingival problems.
11.3 Classification of flaps: According to the indication: we distinguish:
- Sanitation flaps: (pocket surgery)
- Cover flaps: (mucogingival surgery)
Periodontal flap procedures can be classified: based on bone exposure after flap reflection, flap repositioning, or based on papilla management.
Depending on the repositioning of the flap after surgery: we distinguish:
- Simple flap: the flap is returned to its pre-surgical position at the end of the procedure
- Repositioned flap: replaced in a new position at the end of the procedure.
The flap can be moved in three directions: apical, coronal or lateral.
Full-thickness and partial-thickness flaps can be displaced. Palatal flaps cannot be displaced due to the absence of a mucogingival junction and mobile elastic tissue.
According to flap thickness: based on bone exposure after flap reflection :
• Mucoperiosteal flap : or full thickness flap, consisting of the superficial epithelium, connective tissue and periosteum of the underlying bone. Also called mucoperiosteal flap, this is the most commonly performed flap in dentistry. The incision must cross the periosteum to the bone. It consists of detaching the entire gum covering the alveolar bone while keeping the periosteum attached to the connective tissue of the latter.
Full-thickness detachment is more difficult to perform in an area that has received bone grafting. The bone should not be left exposed at the end of the procedure. Coverage by the flap must be complete. This complete exposure and access to the underlying bone is indicated when resective or regenerative bone surgery is being considered.
Technique:
. Ensure that the incision path has been made up to bone contact. The incision can be intrasulcular or internally beveled.
. Begin the elevation by inserting a stripper into the corner of an incision path.
. While maintaining bone contact, advance the detacher, from close to close, under the flap by crawling movements. The movement requires a certain force which must be controlled by good support points.
The mucoperiosteal flap gradually peels off, exposing the bone surface.
• Mucosal flap : or partial thickness consists of epithelium and a thin layer of underlying connective tissue. Bone is not exposed.
Technique:
. The incision stops before the periosteum. Begin the partial thickness dissection at the level of a coronal angle delimited by the incisions made. The incision is either intrasulcular or internally beveled
. As soon as possible, hold the angle of the flap thus created with a claw forceps and curve it so as to visualize the dissection site.
. Progress in the apical direction by making incisions from near to near. The blade must be parallel to the bone surface or even slightly convergent.
The main interest of this flap is to create a vascularized connective bed. This bed can be:
. the recipient site of a displaced graft or flap;
. left raw which results in secondary intention healing but protects the underlying bone.
• Double-thickness flap: Has a full-thickness portion and a second partial-thickness apical portion. A double-thickness flap is a flap with a full-thickness portion comprising epithelium, connective tissue, and periosteum and a second partial-thickness apical portion comprising only connective tissue and epithelium.
. Depending on the papilla arrangement : in regenerative therapy and in aesthetic cases, the papillary preservation technique, which retains the entire papilla, is preferred. This requires an adequate width of interdental space to allow the intact papilla to be detached with either a vestibular or lingual-palatal side of the flap.
11.4 Indications for flap procedures:
- Pockets greater than 5 m
- coronary elongation
- Correction of recessions
- Treatment of interradicular lesions
- Implant placement
- Root hemisection or root amputation.
- guided tissue regeneration/guided bone regeneration
11.5 Contraindications to flap procedures:
. Patient with poor oral hygiene
. Cardiovascular diseases with HIGH risk of infective endocarditis
. Patients on anticoagulant treatment.
. Hematological disorders (leukemia, agranulocytosis).
. Cervicofacial radiotherapy.
. Any unstable chronic disease
11.6 General principles of flap procedures:
Incisions:
. Make the incisions with a clean line.
. Analyze the anatomical obstacles to avoid.
. Delineate a flap large enough to access the site.
. Be careful to limit trauma to the taste buds.
. Manipulate the scalpel with a tridigital grip
Types of incision: The shape of the incision depends on the type of lesion, the purpose of the procedure and the desired result:
. Internal bevel incision: When gingival eviction is desired, this incision allows the elimination of a gingival collar including the epithelial and connective tissue attachments. The blades used are blades no. 15, 15C, 11 or 12 for the least accessible sectors.
Technique:
. Incise the attached gingiva with a scalpel at an angle of between 10 and 45° from coronal to apical relative to the long axis of the tooth.
. Look for bony contact with the top of the bony crest.
. Follow a line parallel to the gingival scallop.
. External bevel incision:
. Apico-coronary incision, oriented at 45° apically to the long axis of the tooth up to dental contact
. Angular incision trace to allow removal of the free gingiva and the junctional epithelium.
. Intrasulcular Incision: This is the most commonly used incision in dental and periodontal surgery. Its principle is tissue economy. In fact, this type of incision tends to preserve the entirety of the gingival tissue. The blades used are blades no. 15, 15C and 12 for delicate access areas.
Technique:
- Insert the scalpel into the sulcus of the tooth along an axis almost parallel to the long axis of the tooth.
- The inner face of the blade must be in direct contact with the dental organ and its tip must be located at the emergence of the desmodont.
- Follow the gingival scallop of the teeth to be treated while keeping the blade in the sulcus.
- On several teeth, move from one sulcus to the other, incising the papillae directly above the dental contact points so as to respect the integrity of the papillae as much as possible.
. Discharging incisions: The discharging incision is an incision that starts at the tip of the intrasulcular or internal bevel incision. It is directed from coronal to apical and extends beyond the mucogingival junction line. This vertical or slightly oblique incision is made with a #15 or #15C blade.
Relieving incisions increase flap laxity, facilitate its manipulation, and provide better access to the surgical site.
Details on coronal positioning of discharges: A poorly located coronal discharge incision can lead to defects during healing:
- An incision starting in the center of a papilla can result in papillary retraction and the appearance of interdental “black holes.”
- An incision starting directly above the neck of a tooth can cause a recession to appear.
To avoid these problems, the rule of thirds must be respected: the start of the relieving incision must be made halfway between the top of the dental papilla and the most apical part of the free vestibular gingiva of the tooth. The relieving incision is then made vertically up to beyond the mucogingival junction line.
. Flap design:
. The two discharge incisions should be either parallel or, preferably, divergent.
The length of the flap should not exceed twice its width.
. Respect the axis of gingival vascularization
11.7 Instrumentations:
. Anesthesia equipment
. Scalpel blades
. Blade holder
. Stripper
. Periodontal curettes
. Needle holder
. Dissecting forceps
. Suture scissors
. Suture thread
. Periodontal dressing
. Sutures: Suturing is usually the last phase of surgery. It is nonetheless a fundamental act for the smooth running of the postoperative period. During surgical periodontal treatments, sutures are the guarantors of healing. Each stitch to be performed must be carefully considered and performed. Mastery of these sutures is therefore essential in periodontal surgery.
Principles to be respected:
. Before any suturing, ensure passive repositioning of the flap so as not to transmit tension forces at the stitches. Excessive tension would promote tears of the sutured edges.
. Evaluate the position to give to the point to fix the flap in the desired position.
. Begin the sutures at a coronal angle of the flap in the attached gingiva.
. Always pass the wire from the most mobile bank to the most fixed bank.
. Before any passage of the needle into a mobile flap, it must be immobilized with dissecting forceps placed in the immediate vicinity of the area to be sutured.
. Maintain a space of at least 2 mm between the edge of the flap and the point of needle penetration.
In periodontology, the preferred execution of the nodes is done in the following order:
· Two turns in the positive (counterclockwise) direction of the thread around the needle holder to flatten the fabrics.
· One turn in the negative direction (clockwise) to block the first knot.
· One turn in the positive direction to secure the blockage.
Surgical therapy for periodontitis: Periodontal curettage Flaps
11.8 Different types of sanitation flaps:
11.8.1 Widman flap (original technique): In 1918, Leonard Widman published one of the first pocket removal procedures. The author proposed a technique that allowed for the removal of the pocket epithelium as well as the inflamed connective tissue to allow for better plaque control.
The advantages of this technique over gingivectomy are:
. Less postoperative discomfort (first-intention healing)
. Access to the bone surface.
Technique:
. First, releasing incisions are made to demarcate the surgical site.
. The two discharging incisions are connected by another incision that follows the marginal gingival line and separates the pocket epithelium and the inflamed connective tissue from the rest of the gingiva.
The flap is peeled off at full thickness up to at least 2-3 mm from the bone crest.
The tissue around the neck of the tooth is removed with a curette, and the root surface is carefully scaled and polished.
. Bone plastic surgery is recommended to restore the bone to a physiological morphology.
. After careful debridement of the teeth in the operated area, the vestibular and lingual flaps are reapplied to the alveolar bone and held in this position by interproximal sutures.
11.8.2 Modified Widman flap (MWF): Described by Ramfjord and Nissle in 1974, the modified Widman flap (MWF) is the reference technique for the surgical treatment of periodontitis.
Principle: Raise a full-thickness flap of 2 to 3 mm in order to have a direct view of the root and bone surface to be treated.
. Indications:
- Treatment of periodontitis responding insufficiently to non-surgical treatment.
- Presence of periodontal pockets more than 5 mm deep.
- Premolar-molar sectors only.
- Furcation lesions and root anatomy making access difficult by non-surgical treatment.
- Depending on the anatomopathological situation of the teeth and periodontium, the technique can be combined with the use of large fully mobilized flaps (resective methods) and special procedures: distal wedge, root resection or hemisection, periodontal sanitation associated with bone filling or guided tissue regeneration, etc.
Contraindications:
. The absence or extreme thinness of the attached gingiva can make the technique difficult because it does not allow an internal bevel incision. In such a situation, an intrasulcular incision may have to be used.
. Planned bone surgery procedures (extended osteoplasty, possibly ostectomies) in the case of very deep bone lesions with irregular bone resorption at the vestibular and lingual/palatal level and if apical repositioning of the flap is planned.
Surgical therapy for periodontitis: Periodontal curettage Flaps
Surgical technique:
- Asepsis
- Local anesthesia
- 1st internal bevel incision: 1mm from the gingival margin
- 2nd intrasulcular incision: of all teeth to be treated
Using a fine elevator inserted into the first incision, begin elevation of the full-thickness buccal and palatal/lingual flaps. Relieving incisions are generally not used.
- 3rd horizontal incision: in order to detach the internal wall of the pocket so as to detach the gingival collar (pocket epithelium and granulation tissue).
- Excision of the inflamed tissue collar using a periodontal curette
- Full thickness flap detachment
- Periodontal debridement
- Washing and cleaning the surgical site with physiological serum
- Repositioning the flap and performing the stitches.
Benefits :
. Visibility of the site to be treated, facilitating treatment and control.
. First intention healing.
. Few crestal resorptions.
. Moderate postoperative pain.
Inconvenience :
. Technique contraindicated in the aesthetic sector in the absence of attached gum.
11.8.3 Full-thickness apically positioned flap: The apically positioned flap (APF) has also been referred to as apical repositioning flap, apically repositioned flap, and apically displaced flap.
This full-thickness flap positioned at the alveolar crest eliminates the periodontal pocket while preserving the keratinized gingiva.
Technique:
According to Friedman (1962) this technique should be implemented as follows:
. A scalloped, internal bevel incision is made using a scalpel equipped with a Bard-Parker blade (#12 or #15). The distance between the incision line and the vestibular/lingual gingival margin depends on the depth of the pockets and the thickness and height of the gingival band.
. At each end of the primary incision path, a vertical releasing incision is made that extends into the alveolar mucosa, this allows apical displacement of the flap.
A full-thickness flap including the gingiva and alveolar mucosa is retracted using a detacher.
. The collar of marginal tissues which includes the pocket epithelium and granulation tissue is removed using curettes.
The root surfaces are carefully scaled and surfaced.
The bony crest is remodeled in order to restore the alveolar process to a physiological morphology but at a more apical level.
Bone remodeling is performed using burs and/or bone chisels.
. The vestibular/lingual flap is placed at the level of the remodeled bony crest and maintained in this position.
. This technique does not always provide adequate coverage of the exposed alveolar bone at the interproximal spaces, hence the need for a periodontal dressing. The dressing protects the exposed bone and maintains the soft tissues at the bone crest.
Benefits :
- Eliminates periodontal pockets.
- Preserves and may increase the height of attached gingiva.
- If optimal coverage of the alveolar bone by soft tissue is achieved, postsurgical bone loss will be minimal.
- Establishes a gingival morphology allowing effective hygiene.
Disadvantages:
- Sacrifice of periodontal tissues by bone resection.
- Exposure of root surfaces can cause aesthetic problems, root hypersensitivity and may increase the risk of root caries.
- Not suitable for the treatment of deep periodontal pockets.
11.8.4 Papilla preservation flap: In order to preserve the interdental soft tissues for maximum soft tissue coverage after surgical intervention involving the treatment of proximal bony defects, authors have proposed a surgical approach called papilla preservation technique. This surgical design completely preserves the interdental soft tissues and was therefore mainly indicated for surgical treatment of anterior dental areas or posterior areas when regenerative techniques are used in the treatment of intrabony defects.
Principle: Preserve the dental papillae intact by elevating them entirely in the full-thickness flap.
Objectives: To raise a sanitation flap to treat deep pockets while limiting the aesthetic impact of the treatment.
Minimize surgically induced papilla recessions and losses.
Indication: Presence of periodontal pockets of more than 5 mm in the maxillary anterior sector requiring open surfacing.
. Technique:
It consists of accessing an inter-proximal defect by intrasulcular incisions at the level of the vestibular and proximal faces of the teeth without cutting the interdental papillae.
. Subsequently, an intrasulcular incision is made along the lingual/palatal surface of the teeth.
. Followed by a semilunar incision through each interdental area from the linear angles of the teeth.
. After carefully freeing the interdental papilla from the underlying hard tissues, the detached interdental tissue is pushed through the embrasure with a sharp instrument from the palatal to the buccal side and full-thickness flaps are elevated.
. After complete debridement of the root surfaces and bone defects , the flaps are repositioned and sutured using mattress stitches.
Conclusion: There are multiple flap intervention techniques. The choice of a technique is based on compliance with the indications and the goal to be achieved by the intervention.
Surgical therapy for periodontitis: Periodontal curettage Flaps
Bibliographic references:
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[2]. BORGHETTI.A, Monnet-Corti.V. Periodontal plastic surgery. JPIO. Edition Cdp. 2nd edition.2008
[3]. CARRANZA F, NEWMAN M, TAKEI H. Clinical periodontology. 9th edition. W. B. Saunders Company. 2002.
[4]. Cortellini.P, Tonetti.M; Clinical concepts for regenerative therapy in intrabony defects. Periodontol 2000. 2015
[5]. LINDHE J., Manual of clinical periodontology. Editions CdP, Paris, 1986.
[6]. LINDHE J., Clinical Periodontology and Implant Dentistry. Fifth editions, Blackwell Munksgaard, 2008.
[7]. Lindhe.I: Lindhe’s Clinical Periodontology and implant Dentistry. Volume Seventh Edition. Wilew.B. 2022.
[8]. Louise.F, Cucchi.J, Deruelle-Fouque.C, Liebart.MF, Surgical treatments of periodontal pockets, EMC 23-445-G-10 (2004)
[9]. Newman.MG Newman and Carranza’s Essentials of Clinical Periodontology. Elsevier. 2022.
[10]. RATEISCHAK KH & EM, WOLF HF, Atlas of dental medicine Periodontology. Flammarion Edition, 1993.
[11]. SATO N., Clinical Atlas of Periodontal Surgery. Editions Quintessence, 2002
[12]. VIGOUROUX F., Practical guide to periodontal surgery. Editions Elsevier Masson, 2011; 47-87.
[13]. WOLF HF, RATEISCHAK KH & EM, Periodontology, 3rd edition. Masson, 2003.
Surgical therapy for periodontitis: Periodontal curettage Flaps
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.