SURGICAL THERAPY OF PERIODONTITIS FLAPS

SURGICAL THERAPY OF PERIODONTITIS FLAPS

DIFFERENT INTERVENTIONS

1. WIDMAN FLAP (ORIGINAL TECHNIQUE)

This is one of the first techniques described, WIDMAN described a mucoperiosteal flap model whose aim was to eliminate the pocket epithelium as well as the inflamed connective tissue, thus facilitating the achievement of optimal cleaning of the root surfaces. The advantages of this technique compared to gingivectomy are:

Less postoperative discomfort (first-intention healing);
Access to the bone surface.

Technical

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.

Fig.1 Discharging incisions are made to demarcate the surgical site.

The flap is peeled off at full thickness up to at least 2-3 mm from the bony 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.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Fig. 2 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 tissue around the neck of the tooth is removed with a curette, and the root surface is carefully scaled and polished.

Fig. 3 Bone plastic surgery is recommended to restore the bone to a physiological morphology.

Disadvantage of this technique

root denudation.

Benefits

Less discomfort for the patient;
Possibility of remodeling of bone defects.

2. NEUMANN FLAP (1920)

In 1920 Neumann invented a technique to improve the original form of the Widman flap, in which he used two basic incisions “the intrasulcular incision and the releasing incision.”

Technical

An intrasulcular incision is made.
A flap is removed in full thickness.
Discharging incisions to demarcate the surgical site.
The inner wall of the flap is curetted to remove pocket epithelium and granulation tissue.
Surface the roots with an ultrasonic or manual instrument.
Polish the tooth surfaces and, if possible, the root surfaces.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

His technique provides optimal adaptation of the flap around the teeth even in the interproximal regions. However, its major drawback was the reduction of flap irrigation due to the releasing incisions.

For this reason Kirkland in 1931 modified Neumann’s technique, the modification consists in eliminating the discharge incisions which gives it other more important advantages:

Focus on aesthetics “indication at the level of aesthetic sectors”
The flap becomes less invasive “a single intrasulcular incision”
It potentiates bone regeneration in infra-bony defects.

3. MODIFIED WIDMAN FLAP

This access flap is named after the first person to describe it in 1918. Modifications were made to this technique by Ramfjord and Nissle in 1974. The modified Widman flap is the gold standard technique for the surgical treatment of periodontitis.

Principle

Elevate 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.

Goals

Remediate diseased periodontium by visually and mechanically accessing areas that are difficult to access when implementing closed-air root planing.
Promote control when performing surfacing.
Reduce the depth of periodontal pockets.
Recreate a physiological attachment system.
Create an anatomy that facilitates plaque control.

Indications

Treatment of periodontitis responding insufficiently to non-surgical treatment.
Presence of periodontal pockets more than 0.5 mm deep.
Premolar-molar sectors only.
Furcation lesions and root anatomy making access difficult by non-surgical treatment.
Root resection or hemisection.
Periodontal sanitation associated with bone filling or guided tissue regeneration.

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 gums.

Surgical technique:

Asepsis.
Local anesthesia.
Incision: Three incisions are made in the modified Widman flap technique.

1st incision: this is an internal beveled scallop along ^the long axis of the tooth (0.5-1mm from the gingival margin) depending on the area operated on and the inflammatory state of the tissues, the incision must reach the bony crest.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Flap detachment.

2nd incision : located in the SGD around each tooth to the bottom of the pockets ^.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

3rd incision: Horizontal and perpendicular to the long axis of the teeth, it is located ^a little above the alveolar crest.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Excision of the collar of infiltrated tissue.
Root preparation: this important phase allows the removal of all deposits present on the root.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Flap repositioning: The flaps are thinned and adjusted to the alveolar bone.
Sutures “interdental sutures”.
Application of surgical dressing.

4. AESTHETIC ACCESS FLAP: LEA

This technique was born from the observation of systematic aesthetic damage after surgical periodontal sanitation in the anterior sectors.
Indeed, surgical access by Widman flap induces the loss of interdental papillae and thereby accentuates the appearance of “long teeth”.
Also called the “palatal access flap”, the aesthetic access flap replaces the Widman flap for the maxillary incisor-canine block.

Principle

Preserve the dental papillae intact by elevating them completely within the full-thickness flap.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Goals

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.

Advantage

Reduces the aesthetic impact of surgical treatment.
Inconvenience
Operative difficulties during the passage of the papillae into the vestibular region.

Technical

Make the intrasulcular incisions of the teeth to be treated with a No. 15 blade. With a No. 12 blade, extend the lines into the interdental sulcus of each tooth and continue into the sulcus of the palatal surfaces up to one third of the crown.
Join the intrasulcular incisions at the palate level with arcuate incisions.
Begin the full thickness detachment with a thin detacher on the vestibular side of each tooth.
Detach at the level of the palatal semilunar incisions and advance the detacher interpapillarily.
Pass the papillae thus released into the vestibular region, pushing them with a plugger through the embrasures.
Complete the vestibular detachment.
Remove granulation tissue with a CK6.
Surface, polish the roots and fill bone defects if necessary.
Return the papillae to their initial position by passing them back through the embrasures.
Suture each semilunar incision at the palatal level with O-shaped stitches.

5. APICALLY POSITIONED FULL THICKNESS FLAP

The apically positioned flap has been proposed to preserve the volume of attached gingiva during sanitation surgery.

Nabers (1954) was one of the first authors to describe a technique allowing the preservation of a strip of attached gingiva after surgery.

In 1962, Friedman pointed out that at the end of the procedure the entire soft tissue complex (gingiva and alveolar mucosa) rather than the gingiva alone was displaced in an apical direction.

Therefore, instead of excising the amount of gingiva that would be excess after osseous surgery, the entire mucogingival complex was preserved and moved to the apical position.

Technical

An internal bevel incision is made.
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 a curette.
The root surfaces are carefully scaled and surfaced.
The bony crest is remodeled in order to restore the physiological morphology of the alveolar process.
The 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 bone, hence the need for a dressing.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

7. APICALLY POSITIONED PARTIAL THICKNESS FLAP (LPAEP)

It is a technique which consists of moving an entire flap containing a certain volume of keratinized gingiva in an apical direction.

Principle

Partial thickness passage provides sufficient laxity to allow its movement and immobilization by periosteal stitches.

Indications

Arrangement of crestal, peri-implant and prosthetic keratinized tissue volume.
Coronary lengthening.
Surgical release for orthodontic purposes of an impacted tooth.
Surgical treatment of peri-implantitis.

Disadvantages

Painful second intention healing postoperatively.
Not feasible in the total absence of attached gum.

CORONARY LENGTHENING

Crown lengthening is one of the most commonly used periodontal surgeries because it involves the most commonly practiced disciplines of dentistry: restorative dentistry and prosthetics.

Goals

Recreate sufficient space in the apical position of a dental restoration to allow the reformation of the biological space.
Reduce or eliminate a gummy smile.
Harmonize the gingival contour line and eliminate asymmetries in the alignment of the necks.
Increase clinical crown height.
Increase the inter-arch space and therefore the available prosthetic height.

Principle

Elevation of a full-thickness flap to access the bone surface to be resected, then passage to partial thickness to allow its mobilization.
Bone resection must allow a space of 3 mm to be left between the limit of the restoration to be carried out and the bone crest to recreate the biological space.

These 3 mm correspond to the pre-prosthetic surgical space in which the epithelial attachment and the connective tissue attachment must be recreated while allowing 1 mm of safety between the restoration and the coronal part of the attachment system.

A dental reconstruction should never encroach on biological space.

Indications

Dental caries or deep coronal fracture preventing atraumatic restoration of the biological space.
Anterior asymmetry of the neck line, hindering aesthetics.
Gummy smile hinders aesthetics.
External cervical root resorption.

Benefits

Simplicity of implementation,
A single surgical site,
Predictable result,
Moderately painful post-operative period,

Technical

After anesthesia and precise measurements with the periodontal probe of the work to be carried out, make an intrasulcular or internal bevel incision on the bony crest of the gum of the tooth to be treated.
Make the releasing incisions beyond the mucogingival junction line while respecting the rule of thirds to protect the papillae and avoid any recession.
Peel off the full thickness of the flap up to a third in order to visualize the bone surface.
In the case of an internal bevel, cut the base of the residual collar in order to detach it.
Remove the gum collar.
Incise the periosteum horizontally and dissect in partial thickness in an apical direction beyond the mucogingival junction line.
After visualizing and measuring the bone volume to be resected, remove it with a sterile round bur under irrigation.
Smooth the bone surface using a hand bone chisel.
Once the bone plastic is performed, reposition the flap apically to the initial situation so as to completely cover the bone.
Suture with O-shaped stitches at the discharges. The half thickness creates an immobile mucoperiosteal bed fixed to the bone and allowing the stitches to be anchored.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Surgical care

Pre-operative care

Prescription of antibacterials:

These are most often antiseptics in the form of mouthwashes (Chlorhexidine is the reference).

Oral antibiotic therapy may be prescribed in addition to mechanical debridement.

It can be used in the treatment of aggressive periodontitis or severe periodontitis, particularly in the presence of pus.

When prescribed, it must be targeted as well as possible, reasoned and its administration must be concomitant with mechanical treatment.

Precautions in case of risk of bleeding

B. Post-operative care

Level 1 analgesics
Antiseptics : Mouthwash,
The post-surgical toothbrush should only be used in the operated area, and do not use any brushes in this area until the wires are removed.
Brushing with a normal brush + toothpaste + brushes in other areas.

C. Post-operative advice

Ice pack for post-op edema for 20 min. Problem if edema is associated with pain. Advise patient to return if pain and edema present.
Warn the patient that he may have a hematoma.
Favor a bland diet: non-aggressive texture, cold or lukewarm, no spices, no citrus fruits, no vinaigrette.
No head-shaking sports or swimming for at least 8 days.

7. Healing after surgery

Wound healing is the result of a coordinated succession of events, involving the migration, proliferation, and phenotypic expression of a large number of cell types.

It allows the deposition and remodeling of an extracellular matrix specific to the damaged tissue, and is classically divided into 3 stages :

inflammation , closely linked to the hemostasis process , allows the wound to be cleansed and results in the formation of a specific matrix which will support the proliferation phase,
proliferation , characterized by the formation of granulation tissue that gradually replaces the fibrin clot. It is accompanied by re-epithelialization of the wound,
consolidation corresponds to a remodeling which continues for several months, allowing a functional adaptation of the tissue.

Conclusion

The elimination of the periodontal pocket has become safer and more accessible by flap procedures, but the guarantee of their success still remains accompanied by perfect plaque control .

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.

SURGICAL THERAPY OF PERIODONTITIS FLAPSSURGICAL THERAPY OF PERIODONTITIS FLAPS

DIFFERENT INTERVENTIONS

1. WIDMAN FLAP (ORIGINAL TECHNIQUE)

Less postoperative discomfort (first-intention healing);
Access to the bone surface.

Technical

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.

Fig.1 Discharging incisions are made to demarcate the surgical site.

The flap is peeled off at full thickness up to at least 2-3 mm from the bony 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.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Fig. 3 Bone plastic surgery is recommended to restore the bone to a physiological morphology.

Disadvantage of this technique

root denudation.

Benefits

Less discomfort for the patient;
Possibility of remodeling of bone defects.

2. NEUMANN FLAP (1920)

In 1920 Neumann invented a technique to improve the original form of the Widman flap, in which he used two basic incisions “the intrasulcular incision and the releasing incision.”

Technical

An intrasulcular incision is made.
A flap is removed in full thickness.
Discharging incisions to demarcate the surgical site.
The inner wall of the flap is curetted to remove pocket epithelium and granulation tissue.
Surface the roots with an ultrasonic or manual instrument.
Polish the tooth surfaces and, if possible, the root surfaces.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

For this reason Kirkland in 1931 modified Neumann’s technique, the modification consists in eliminating the discharge incisions which gives it other more important advantages:

Focus on aesthetics “indication at the level of aesthetic sectors”
The flap becomes less invasive “a single intrasulcular incision”
It potentiates bone regeneration in infra-bony defects.

3. MODIFIED WIDMAN FLAP

Principle

Elevate 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.

Goals

Remediate diseased periodontium by visually and mechanically accessing areas that are difficult to access when implementing closed-air root planing.
Promote control when performing surfacing.
Reduce the depth of periodontal pockets.
Recreate a physiological attachment system.
Create an anatomy that facilitates plaque control.

Indications

Treatment of periodontitis responding insufficiently to non-surgical treatment.
Presence of periodontal pockets more than 0.5 mm deep.
Premolar-molar sectors only.
Furcation lesions and root anatomy making access difficult by non-surgical treatment.
Root resection or hemisection.
Periodontal sanitation associated with bone filling or guided tissue regeneration.

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 gums.

Surgical technique:

Asepsis.
Local anesthesia.
Incision: Three incisions are made in the modified Widman flap technique.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Flap detachment.

2nd incision : located in the SGD around each tooth to the bottom of the pockets ^.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

3rd incision: Horizontal and perpendicular to the long axis of the teeth, it is located ^a little above the alveolar crest.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Excision of the collar of infiltrated tissue.
Root preparation: this important phase allows the removal of all deposits present on the root.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Flap repositioning: The flaps are thinned and adjusted to the alveolar bone.
Sutures “interdental sutures”.
Application of surgical dressing.

4. AESTHETIC ACCESS FLAP: LEA

This technique was born from the observation of systematic aesthetic damage after surgical periodontal sanitation in the anterior sectors.
Indeed, surgical access by Widman flap induces the loss of interdental papillae and thereby accentuates the appearance of “long teeth”.
Also called the “palatal access flap”, the aesthetic access flap replaces the Widman flap for the maxillary incisor-canine block.

Principle

Preserve the dental papillae intact by elevating them completely within the full-thickness flap.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Goals

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.

Advantage

Reduces the aesthetic impact of surgical treatment.
Inconvenience
Operative difficulties during the passage of the papillae into the vestibular region.

Technical

Make the intrasulcular incisions of the teeth to be treated with a No. 15 blade. With a No. 12 blade, extend the lines into the interdental sulcus of each tooth and continue into the sulcus of the palatal surfaces up to one third of the crown.
Join the intrasulcular incisions at the palate level with arcuate incisions.
Begin the full thickness detachment with a thin detacher on the vestibular side of each tooth.
Detach at the level of the palatal semilunar incisions and advance the detacher interpapillarily.
Pass the papillae thus released into the vestibular region, pushing them with a plugger through the embrasures.
Complete the vestibular detachment.
Remove granulation tissue with a CK6.
Surface, polish the roots and fill bone defects if necessary.
Return the papillae to their initial position by passing them back through the embrasures.
Suture each semilunar incision at the palatal level with O-shaped stitches.

5. APICALLY POSITIONED FULL THICKNESS FLAP

The apically positioned flap has been proposed to preserve the volume of attached gingiva during sanitation surgery.

Nabers (1954) was one of the first authors to describe a technique allowing the preservation of a strip of attached gingiva after surgery.

In 1962, Friedman pointed out that at the end of the procedure the entire soft tissue complex (gingiva and alveolar mucosa) rather than the gingiva alone was displaced in an apical direction.

Therefore, instead of excising the amount of gingiva that would be excess after osseous surgery, the entire mucogingival complex was preserved and moved to the apical position.

Technical

An internal bevel incision is made.
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 a curette.
The root surfaces are carefully scaled and surfaced.
The bony crest is remodeled in order to restore the physiological morphology of the alveolar process.
The 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 bone, hence the need for a dressing.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

7. APICALLY POSITIONED PARTIAL THICKNESS FLAP (LPAEP)

It is a technique which consists of moving an entire flap containing a certain volume of keratinized gingiva in an apical direction.

Principle

Partial thickness passage provides sufficient laxity to allow its movement and immobilization by periosteal stitches.

Indications

Arrangement of crestal, peri-implant and prosthetic keratinized tissue volume.
Coronary lengthening.
Surgical release for orthodontic purposes of an impacted tooth.
Surgical treatment of peri-implantitis.

Disadvantages

Painful second intention healing postoperatively.
Not feasible in the total absence of attached gum.

CORONARY LENGTHENING

Crown lengthening is one of the most commonly used periodontal surgeries because it involves the most commonly practiced disciplines of dentistry: restorative dentistry and prosthetics.

Goals

Recreate sufficient space in the apical position of a dental restoration to allow the reformation of the biological space.
Reduce or eliminate a gummy smile.
Harmonize the gingival contour line and eliminate asymmetries in the alignment of the necks.
Increase clinical crown height.
Increase the inter-arch space and therefore the available prosthetic height.

Principle

Elevation of a full-thickness flap to access the bone surface to be resected, then passage to partial thickness to allow its mobilization.
Bone resection must allow a space of 3 mm to be left between the limit of the restoration to be carried out and the bone crest to recreate the biological space.

A dental reconstruction should never encroach on biological space.

Indications

Dental caries or deep coronal fracture preventing atraumatic restoration of the biological space.
Anterior asymmetry of the neck line, hindering aesthetics.
Gummy smile hinders aesthetics.
External cervical root resorption.

Benefits

Simplicity of implementation,
A single surgical site,
Predictable result,
Moderately painful post-operative period,

Technical

After anesthesia and precise measurements with the periodontal probe of the work to be carried out, make an intrasulcular or internal bevel incision on the bony crest of the gum of the tooth to be treated.
Make the releasing incisions beyond the mucogingival junction line while respecting the rule of thirds to protect the papillae and avoid any recession.
Peel off the full thickness of the flap up to a third in order to visualize the bone surface.
In the case of an internal bevel, cut the base of the residual collar in order to detach it.
Remove the gum collar.
Incise the periosteum horizontally and dissect in partial thickness in an apical direction beyond the mucogingival junction line.
After visualizing and measuring the bone volume to be resected, remove it with a sterile round bur under irrigation.
Smooth the bone surface using a hand bone chisel.
Once the bone plastic is performed, reposition the flap apically to the initial situation so as to completely cover the bone.
Suture with O-shaped stitches at the discharges. The half thickness creates an immobile mucoperiosteal bed fixed to the bone and allowing the stitches to be anchored.

SURGICAL THERAPY OF PERIODONTITIS FLAPS

Surgical care

Pre-operative care

Prescription of antibacterials:

These are most often antiseptics in the form of mouthwashes (Chlorhexidine is the reference).

Oral antibiotic therapy may be prescribed in addition to mechanical debridement.

It can be used in the treatment of aggressive periodontitis or severe periodontitis, particularly in the presence of pus.

When prescribed, it must be targeted as well as possible, reasoned and its administration must be concomitant with mechanical treatment.

Precautions in case of risk of bleeding

B. Post-operative care

Level 1 analgesics
Antiseptics : Mouthwash,
The post-surgical toothbrush should only be used in the operated area, and do not use any brushes in this area until the wires are removed.
Brushing with a normal brush + toothpaste + brushes in other areas.

C. Post-operative advice

Ice pack for post-op edema for 20 min. Problem if edema is associated with pain. Advise patient to return if pain and edema present.
Warn the patient that he may have a hematoma.
Favor a bland diet: non-aggressive texture, cold or lukewarm, no spices, no citrus fruits, no vinaigrette.
No head-shaking sports or swimming for at least 8 days.

7. Healing after surgery

Wound healing is the result of a coordinated succession of events, involving the migration, proliferation, and phenotypic expression of a large number of cell types.

It allows the deposition and remodeling of an extracellular matrix specific to the damaged tissue, and is classically divided into 3 stages :

inflammation , closely linked to the hemostasis process , allows the wound to be cleansed and results in the formation of a specific matrix which will support the proliferation phase,
proliferation , characterized by the formation of granulation tissue that gradually replaces the fibrin clot. It is accompanied by re-epithelialization of the wound,
consolidation corresponds to a remodeling which continues for several months, allowing a functional adaptation of the tissue.

Conclusion

The elimination of the periodontal pocket has become safer and more accessible by flap procedures, but the guarantee of their success still remains accompanied by perfect plaque control .

SURGICAL THERAPY OF PERIODONTITIS FLAPS

SURGICAL THERAPY OF PERIODONTITIS FLAPS

SURGICAL THERAPY OF PERIODONTITIS FLAPSSURGICAL THERAPY OF PERIODONTITIS FLAPS

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