Surgical treatments for periodontal diseases: flaps
Introduction :
- The indication of flap surgery for the treatment of periodontal diseases is to improve the clinical results of the initial treatment.
- Root surface treatment is more effective under direct vision than blindly.
General
1-Incisions : making the incisions is the first act performed, after anesthesia, to delimit the flap.
It is the fine section of soft tissue using sharp instruments.
The careful choice of incision paths determines the smooth running of the surgery and the sutures.
Principles:
-make the incisions with a clean line
-analyze the anatomical obstacles to avoid
-delimit a flap large enough to access the site. An undersized flap is difficult to correct.
– respect the axis of gingival vascularization as often as possible to prevent the risk of flap necrosis
-control the penetration of the blade. Most often, when delimiting the flap, bone or dental contact is sought
Avoiding taste bud trauma
-manipulate the scalpel with a tri-digital grip (pen) and ensure that you have fixed support points with the ring finger and little finger.
Different types of incisions
1-External bevel incision: apicocoronary: the incision path is angled to allow the removal of the free gingiva and the junctional epithelium. It is done using a blade no. 15, 15C, 11 or 12. The main indication is GBI.
Surgical treatments for periodontal diseases: flaps
2-internal bevel incision: when no gingival eviction is sought, this incision allows the elimination of a gingival collar including the epithelial attachments and
Conjunctiva. This technique does not leave a raw area. The blades used are blades no. 15, 15C, 11 or 12.
3-Intrasulcular incision: this is the most used in periodontal surgery. Its principle is tissue economy, this type of incision tends to preserve the entirety of the gingival tissue.
The blades used are blades no. 15, 15C and 12. Indicated in all flap techniques not requiring gingival eviction.
4-Discharging incision: it is an incision that starts at the end of the intrasulcular or internal bevel incision. It is directed from coronal to apical and exceeds the mucogingival junction line. It is vertical or slightly oblique. It is made with a blade no. 15 or 15C.
Indication:
-access to the apical part of a site
-flap requiring apical, coronal or lateral repositioning.
5- periosteal incision: consists of incising the periosteal membrane over the entire width of the flap raised in total thickness.
Indication
Transition of the flap from full thickness to partial thickness
-significantly increase the laxity of the flap to facilitate its apical, coronal or lateral repositioning.
2-Sutures : performing sutures is generally the last phase of surgery. It is a fundamental act for the smooth post-operative progress. During surgical periodontal therapies, sutures are the guarantors of healing. Each point to be performed must be thought out and performed carefully.
In periodontology, the preferred execution of the nodes is done in the following order:
- two turns in the positive direction (anti-clockwise) of the thread around the needle holder to flatten the fabrics
- one turn in the negative (clockwise) direction to block the first knot
- one turn in the positive direction to secure the lock
The shreds
1-Definition : A periodontal flap is a portion of gum and/or mucosa that has been surgically detached from the underlying tissues, in order to provide the visibility and direct access that are necessary for treatment.
There are two basic types of flaps:
-the simple flap (non-repositioned flap) which is replaced in its pre-surgical position at the end of the operation
-the repositioned flap which is replaced in a new position at the end of the intervention.
Flaps can also be sutured apically (apicalized flap) or coronally (coronal flap) to their initial position. The terms “apically/coronally displaced” flaps or “apically/coronally positioned” flaps are also used.
2-Objectives:
-root surface treatment
-surgical elimination of periodontal pockets
-surgical reduction of periodontal pockets
-treatment of infrabony lesions
-treatment of inter-radicular lesions
3-Classification of flaps
– Full thickness or mucoperiosteal flap : it consists of detaching the entire gum covering the alveolar bone while keeping the periosteum fixed to the latter’s connective tissue.
Indications :
-all procedures requiring visualization of bone tissue
-for certain procedures requiring maximum gum thickness to cover a recession.
Technique :
1-ensure that the incision path has been made up to bone contact. The incision can be intrasulcular or internally beveled
2-start the elevation by inserting a stripper into the corner of an incision path
3-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
4-the flap gradually peels off, exposing the bone surface.
-Partial thickness flap :
Indications :
-all mucogingival surgery techniques requiring a vascularized recipient site
-technique leaving a raw connective tissue exposure area to avoid exposing the underlying bone
-technique requiring flap displacement
-technique requiring periosteal stitches
Technical:
1-begin partial thickness dissection at the level of a coronal angle delimited by the incisions made. The incision is either intrasulcular or internally beveled.
2-As soon as possible, hold the angle of the flap thus created with a claw clamp and curve it so as to visualize the dissection site.
3-progress in the apical direction by making incisions from close to close. The blade must be parallel to the bone surface or slightly convergent.
-Double thickness flap : this is a flap with a full thickness part comprising epithelium, connective tissue and periosteum and a second partial thickness apical part comprising connective tissue and epithelium.
Directions:
-flap requiring a certain laxity in order to promote their passive repositioning.
-displaced flaps requiring on the one hand the protection of the exposed surface by connective tissue and on the other hand a sufficient thickness of tissue for coverage. (flap positioned laterally)
Technical:
1-if the full thickness flap is already elevated, keep the flap curved and make a periosteal incision in the thickness of the latter. Then dissect step by step to continue the elevation.
2-if the flap has started in partial thickness, incise the periosteum directly above the flap, looking for bone contact with the blade and continue the elevation with the detacher. Make sure to never lose bone contact with the detacher.
4-The different types of flap
1-Widman flap
-In 1918, Leonard Widman published one of the first detailed descriptions of the use of flap reclination for pocket removal.
Advantage:
-postoperative comfort (first-intention healing)
-possibility of restoring a suitable bone contour at sites with angular bone defects
Technical:
-make relieving incisions to demarcate the surgical site
-connect the two releasing incisions with a gingival incision that follows the contour of the gingival margin and separates the pocket epithelium and inflamed connective tissue from the non-inflamed gingiva.
-retract a mucoperiosteal flap to expose at least 2 to 3 mm of marginal alveolar bone
-remove the collar of inflamed tissue surrounding the neck of the teeth using a curette
-carefully descale exposed root surfaces
-perform bone remodeling to give the underlying alveolar bone an ideal anatomical morphology
-reapply both vestibular and lingual flaps to the alveolar bone and maintain them with interproximal sutures.
2-Newmann flap 1920:
Technical:
-make an intrasulcular incision
– take off a full thickness flap
-curet the internal surface of the flap in order to eliminate the pocket epithelium and the granulation tissue
-clean the root surfaces carefully
-correct irregularities of the alveolar bone
3-Modified WIDMAN flap : This flap is named after the first person to describe it in 1918. Modifications were made to this technique by Ramfjord and Nissle in 1974. It 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.
Goals:
-cleanse the pathological periodontium by visually and mechanically accessing areas that are difficult to access when implementing closed-air surfacing
– promote control when performing surfacing
-reduce the depth of periodontal pockets
-recreate a physiological attachment system
-create an anatomy that facilitates the control of dental plaque.
Directions:
-treatment of periodontitis responding insufficiently to non-surgical treatment
-presence of periodontal pocket more than 5 mm deep
-premolar sectors only
-furcation lesion and root anatomy making access difficult by non-surgical treatment
– root resection or hemisection
Periodontal sanitation associated with filling or guided tissue regeneration.
Advantage :
-visibility of the site to be treated, facilitating treatment and control
-first intention healing
-little crestal resorption
-moderate post-operative pain
Inconvenience:
-technique contraindicated in the anterior sector in the absence of attached gum
Technical:
-perform anesthesia by para-apical infiltration, supplemented by palatal anesthesia
-three incisions are made: internal bevel, intrasulcular and horizontal
– make an internal bevel cut up to bone contact, following the contour of the scallop of each tooth to be treated
– finish this incision with a dental contact at the level of the mesial or distal third of the tooth bordering the site
-make the intrasulcular incision of all the teeth to be treated
-using a thin stripper inserted into the first incision, begin raising the flap in full thickness
-detach at least enough to visualize the alveolar edge. As soon as it is visible over the extent of the flap, stop the detachment
-make the third horizontal incision so as to detach the gum collar
-remove the latter using a CK6 type sickle instrument
-remove granulation tissue present in periodontal pockets with a Gracey curette
-surface the roots with an ultrasonic or manual instrument
– polish the dental surfaces and, if possible, the root surfaces
-irrigate the pockets with physiological serum and an antiseptic solution
-if bone retouching is necessary, carry it out at a minimum
-reposition the flap. The scalloped shape created by the first incision allows complete coverage of the bone surfaces
-suture the flap with interdental O-stitches, vertical mattress stitches or suspended stitches
4-access aesthetic flap:
Surgical access by Widman flap induces the loss of interdental papillae and thereby accentuates the appearance of “long teeth”. The aesthetic damage in the anterior sector gave rise to the aesthetic access flap also called palatal access flap which replaces the Widman flap for the canine incisor block.
Principle:
Maintain intact dental papillae by elevating them completely within the full-thickness flap
Goals:
Raise a sanitation flap to treat deep pockets while limiting the aesthetic impact of the treatment and minimizing recessions and loss of papillae induced by the surgical procedure.
Directions:
-presence of periodontal pockets of more than 5 mm in the maxillary anterior sector requiring open resurfacing
Advantage :
Reduces the aesthetic impact of surgical treatment
Disadvantage : operative difficulty when passing the papillae vestibularly
Technical:
-make intrasulcular incisions of the teeth to be treated with a No. 15 blade, extend the lines into the interdental sulcus of each tooth and continue into the sulcus of the palatal surfaces up to a third of the crown with a No. 12 blade
-join the intrasulcular incisions at the level of the palate by arcuate incisions
-start the full thickness detachment with a thin detacher on the vestibular side of each tooth
-detach at the level of the palatal semi-lunar incisions and advance the detacher interdentally
-pass the papillae thus released into the vestibular, pushing them with a rammer through the embrasures
-finish the vestibular detachment
-remove granulation tissue with a CK6
-surface, polish the roots and fill bone defects if necessary
-replace the papillae in their initial position by passing them back through the embrasures
-suture each semilunar incision at the palatal level with O stitches
Surgical treatments for periodontal diseases: flaps
Surgical treatments for periodontal diseases: flaps
5-Apically positioned flap:
The apically positioned flap has been proposed to preserve the volume of attached gingiva during sanitation surgery.
Apical displacement finds its main indications in prosthetic tissue development in implantology and in coronal lengthening.
The apically positioned flap with the aim of increasing the height of the pre-prosthetic attached gingiva is made in partial thickness only and is called an apically repositioned partial thickness flap (LEPRA)
This technique is used less and less and the epithelial connective tissue graft seems better adapted.
Principle: move the entire flap containing a certain volume of keratinized gingiva in the apical direction. The partial thickness passage allows sufficient laxity to be obtained to allow its movement and immobilization by periosteal sutures.
Surgical treatments for periodontal diseases: flaps
Objective :
-Maintain or increase the height of attached gingiva after apical repositioning of a flap
Directions:
-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
Pre-prosthetic LEPRA technique :
– anesthetize and realize the importance of the movement to be carried out
-make an internal bevel incision following the gingival scallop of the area to be treated. This incision is made in the coronal attached gingiva and a strip of attached gingiva must be present in the flap
-if the flap is of small extent, make two releasing incisions going beyond the mucogingival junction line
-start the partial thickness dissection at one of the angles of the flap
-continue this dissection apically so as to free the
flap completely and obtain sufficient laxity of it.
-position the flap apically passively in the desired position
– perform periosteal stitches in the attached gingiva of the flap in order to immobilize it.
6-Full thickness apically displaced flap
Principles:
-preserve the existing keratinized tissue by moving it to a more apical position and immobilizing it with a suture to the periosteum left in place.
-have access to the bone through a full-thickness flap, to perform the necessary bone resection.
Technical:
-The tracing begins with an intrasulcular incision up to bone contact, in order to preserve all the keratinized tissue.
– vertical discharging incisions distal and mesial to the flap penetrating deep into the alveolar mucosa to allow movement of the flap without creases
– mucoperiosteal detachment (using a detacher) exposes the bone over a few millimeters, generally up to the mucogingival line
-The height of this detachment depends on the extent of the bone correction to be carried out.
-the root surfaces are carefully scaled and surfaced
-the bony crest is remodeled in order to restore a physiological morphology to the alveolar process
-the flap is placed at the level of the remodeled bony crest and maintained in this position.
-if an internal bevel incision is made (instead of the intrasulcular incision) for different reasons (tissue to be thinned, large height of keratinized tissue) the flap is considered to be partial thickness.
7-Coronal lengthening : it is one of the most used periodontal surgeries because it concerns the most practiced disciplines of dentistry: restorative dentistry and prosthetics.
Principles:
– 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 performed 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 leaving 1 mm of safety between the restoration and the coronal part of the attachment system.
-a dental reconstruction must never encroach on biological space.
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
Indications : dental caries or deep coronal fracture not allowing atraumatic restoration of the biological space
-anterior asymmetry of the neck line hindering aesthetics
-gummy smile hindering aesthetics
-external cervical root resorption
Advantage:
-simplicity of implementation
-a single surgical site
-predictable result
-moderately painful post-operative period
Disadvantages:
-not feasible if the tooth is not functional
-requires a clinical root/crown ratio greater than 1, once the procedure has been performed
-contraindicated if there is furcation damage or a short root trunk
-difficult to implement in the posterior sector
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
Surgical treatments for periodontal diseases: flaps
-make the discharge incisions going beyond the mucogingival junction line while respecting the rule of thirds to protect the papillae and avoid any recession
– peel off the full thickness up to a third of the flap in order to visualize the bone surface
Surgical treatments for periodontal diseases: flaps
-in the case of an internal bevel, incise the base of the residual collar in order to detach it
-remove the gum collar
Surgical treatments for periodontal diseases: flaps
– horizontally incise the periosteum and dissect in partial thickness in an apical direction beyond the mucogingival junction line
-after having visualized and measured the bone volume to be resected, eliminate it with a sterile round burr under irrigation
-regulate the bone surfaces using a manual bone chisel
-once the bone plasty is performed, reposition the flap apically to the initial situation so as to completely cover the bone.
-suture with O stitches at the level of the discharges. The half thickness creates an immobile muccoperiosteal bed fixed to the bone and allowing the anchoring of the stitches. These stitches thus allow the immobilization of the flap in the desired position.
Surgical treatments for periodontal diseases: flaps
5-Periodontal dressing : periodontal dressings are used mainly for:
-protect the wound
-obtain and maintain a close adaptation of the mucosal flaps to the underlying bone (especially when a flap has been moved to the apical position)
-patient comfort
6-Post-operative advice and care:
-possible taking of analgesics-anti-inflammatories upon waking from anesthesia
-chlorhexidine mouthwash (10ml of pure solution twice a day for one week)
– basic brushing for the operated area
-the sutures are removed after one week, with the usual plaque control then gradually resumed.
Conclusion : flap creation can meet one or more objectives depending on the initial clinical situation. Many flap surgery techniques have been described to meet these objectives.
Bibliography:
-Bercy. Tenenbaum periodontology from diagnosis to practice
-Francois Vigouroux practical guide to surgery Elsevier Masson
-Glickman Irving
-Jan Lindhe Textbook of Clinical Periodontology
CDP Edition
-Philippe Bouchard periodontology implant dentistry volume 2-surgical therapeutics Lavoisier Medicine sciences
Good oral hygiene Regular scaling at the dentist Dental implant placement Dental x-rays Teeth whitening A visit to the dentist The dentist uses local anesthesia to minimize pain