Periodontal flap surgeries: current concepts

The periodontal flap surgeries have been practiced for more than one hundred years now since their introduction in early 1900’s. There have been a lot of modifications and improvisations in various periodontal surgical techniques during this period. A detailed description of the historical aspect of various flap surgeries has been given in the previous chapter.  In the present discussion, we shall study in detail, the current concepts and advances in various periodontal flap surgeries.

What is a periodontal flap?

A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissue to provide visibility and access to the bone and root surfaces 1. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement.

Objectives of periodontal flap surgeries

The main objective of periodontal flap surgical procedures is to allow access for the cleaning of the roots of teeth and the removal of the periodontal pocket lining, as well as to treat the irregularities of the alveolar bone, so that when gingiva is repositioned around the teeth, it will allow for the reduction of pockets, infections, and inflammation. After healing, the resultant architecture of the area should enhance the ease and effectiveness of self-performed oral hygiene measures by the patient. The reduction of bacterial load and inflammation minimizes further loss of tooth-supporting structures and thus aid in the better prognosis of teeth, provided, the patient stays on a strict maintenance schedule. Another important objective of periodontal flap surgery is to regenerate the lost periodontal apparatus.

Periodontal flap surgeries are also done for the preparation of periodontal environment suitable for restorative and prosthodontic treatment. Periodontal surgery serves as the therapy prior to prosthodontic treatment. Finally, periodontal flap surgeries are also done to improve the esthetics by recontouring the soft and hard tissue in the esthetic zone.

Indications of periodontal flap surgery:

  • In case of periodontitis with active pockets 5-6 mm deep or greater, that do not respond satisfactorily to the initial therapy
  • Intra-bony pockets
  • Irregular bony contours
  • Deep craters
  • Pockets around the teeth in which a complete removal of root irritants is not clinically possible without gaining complete access to the root surfaces
  • For………………………..

123

Contraindications of periodontal flap surgery:

  • Uncontrolled medical conditions such as,
  1. Unstable angina
  2. Uncontrolled diabetes
  3. Uncontrolled hypertension
  • Myocardial infarction / stroke within 6 months
  • Poor plaque control
  • Pronounced gingival overgrowth, which is handled more efficiently by means of gingivectomy / gingivoplasty
  • Unrealistic patient expectations or desires

Incisions for periodontal surgeries

Before we go into the detail of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy (Figure 58.1). Incisions can be divided into two types: the horizontal and vertical incisions 2.

Figure 58.1Commonly used incisions in periodontal surgeries

Basic incisions used in periodontal surgeries

Horizontal incisions:

The horizontal incisions are used to separate the gingiva from the root surfaces of teeth. These incisions are made in a horizontal direction and may be coronally or apically directed. The coronally directed incision is designated as external bevel incision whereas the apically directed incisions are the internal bevel and sulcular incision.

External bevel incision:

The external bevel incision is typically used in gingivectomy procedures. This incision causes extensive loss of tissue and is indicated only in cases of gingival overgrowth.

Internal bevel incisions:

The internal bevel incisions are typically used in periodontal flap surgeries. The internal bevel incision is also known as reverse bevel incision because its bevel is in the reverse direction from that of the gingivectomy incision. The internal bevel incision may be a marginal incision (from the top of gingival margin) or para-marginal incision (at a distance from the gingival margin). Following is the description of marginal and para-marginal internal bevel incisions and sulcular incision,

Marginal incision:

This incision is made from the crest of the gingival margin till the crest of alveolar bone. Practically, it is very difficult to put this incision because firstly, it is very difficult to keep the cutting edge of the blade at the gingival margin and secondly, the blade easily slips down into the pocket because of its close proximity to the tooth surface. This incision is not indicated unless the margin of the gingiva is quite thick.

Para-marginal incision:

This internal bevel incision is placed at a distance from the gingival margin, directed towards the alveolar crest. This is commonly used incision during periodontal flap surgeries. The distance of the incision from the gingival margin (thickness of the incision)…………….

123

This incision is always accompanied by a sulcular incision which results in the formation of a collar of gingival tissue which contains the periodontal pocket lining. During crown lengthening, the shape of the para-marginal incision depends on the desired crown length. In non-esthetic areas with moderate to deep pockets and for crown lengthening, this incision is indicated. It is contraindicated in areas where the width of attached gingiva would be reduced to < 3mm. The para-marginal internal bevel incision accomplishes three important objectives.

  • It removes the pocket lining.
  • It conserves the relatively uninvolved outer surface of the gingiva.
  • It produces a sharp, thin flap margin for adaptation to the bone tooth junction.

This incision is indicated in the following situations,

  • Areas with sufficient band of attached gingiva.
  • For the correction of bone morphology (osteoplasty, osseous resection).
  • In areas with deep periodontal pockets and bone defects.
  • In cases of crown lengthening.

A crescent-shaped incision is sometimes used during the crown lengthening procedure. This incision is made on the buccal aspect of the tooth till the desired level, sparing the interdental gingiva.

Sulcular/ crevicular incision:

This incision is given through the gingival sulcus. The blade is introduced into the sulcus or pocket and is inserted as far as possible into the interdental space around the tooth, keeping it close to the crown. The blade is pushed into the sulcus till resistance is felt from the crestal bone crest. With this incision, the gingiva containing pocket lining is separated from the tooth surface. The granulation tissue and the pocket lining may be then separated from the inner surface of the reflected flap with the help of surgical scissors and a scalpel. This incision is indicated in the following situations,

  • For access flap
  • Access flap for guided tissue regeneration
  • In areas with narrow width of attached gingiva
  • In areas with thin gingiva and alveolar process
  • In areas with shallow periodontal pocket depth
  • In esthetic zone

This incision, together will the para-marginal internal bevel incision, forms a V-shaped wedge ending at or near the crest of bone, containing most of the inflamed and granulomatous tissue that constitutes the lateral wall of the pocket, as well as the junctional epithelium and connective tissue fibers that still persist between the bottom of the pocket and the crest of the bone. The incision is carried around the entire tooth. The beak-shaped # 12 D-blade is usually used for this incision.

Vertical incisions:

Vertical incisions increase flap mobility, thus facilitating better access to the operative area. A vertical incision may be given unilaterally (at one end of the flap) or bilaterally (on both ends of the flap). Placement of the vertical incisions is absolutely…………………

123

Periobasics: A Text Book of Periodontics and Implantology
For India Users:
Buy Now
For International Users:


The vertical incision should always be placed at the line angles of teeth and never (except rare instances, such as a double papilla flap) over the height of contour of the root. The reasons for placing vertical incisions at line angles of the teeth are,

  • It protects the interdental papilla adjacent to the surgical site.
  • It allows the vertical incision to be sutured without stretching the flap over the cervical convexity of the tooth.

The vertical incision should be made in such a way that interdental papilla is completely preserved. Under no circumstances, the incision should be made in the middle of the papilla. An intact papilla should be either excluded or included in the flap.

While doing laterally displaced flap for root coverage, the vertical incision is made at an acute angle to the horizontal incision, in the direction toward which the flap will move, placing the base of the pedicle at the recipient site. This is termed cutback incision.

Classification of periodontal flaps

Periodontal flaps can be classified on the basis of,

A. According to flap reflection or tissue content:
a. Full-thickness flap.
b. Split-thickness flap.
B. According to management of papilla:
a. Conventional flap.
b. Papilla preservation flap.
C. According to flap placement after surgery:
a. Non-displaced flap.
b. Displaced flap:
• Apical displaced flap.
• Coronal displaced flap.
• Lateral displaced flap.

Following is the description of these flaps,

Full thickness flap:

In this flap procedure, all the soft tissue, including the periosteum are reflected to expose the underlying bone (Figure 58.2). It is also known as the mucoperiosteal (mucosal tissue + periosteum) flap. It is indicated where complete access to the bone is required, for example, in case of osseous resective surgeries. It is contraindicated in the areas where treatment for an osseous defect with the mucogingival problem is not required, in areas with thin periodontal tissue with probable osseous dehiscence or osseous fenestration and in areas where the alveolar bone is thin.

Figure 58.2Diagram showing full and partial thickness flap

Full thickness and partial thickness flap

Split thickness flap:

It is also known as a partial thickness flap. In this flap only epithelium and the underlying connective tissue are reflected, leaving the periosteum intact (Figure 58.2). It is indicated when the flap has to be positioned apically and when the exposure of the bone is not required.

Conventional flaps:

Flaps in which the interdental papilla is split beneath the contact of two approximating teeth, allowing the reflection of buccal and lingual flaps, are described as the conventional flap. These are indicated is cases where interdental spaces are too narrow and when the flap needs to be displaced. Conventional flaps include the

  • Modified Widman flap,
  • Modified flap operation,
  • Undisplaced flap,
  • Apically displaced flap,
  • Flap for regenerative procedures.

Papilla preservation flaps:

In these flaps, the entire papilla is incorporated into one of the flaps. The surgical approaches that split the papilla cause shrinkage and decrease in the height of the interdental papilla leading to exposure of the interproximal embrasures. This drawback of conventional flap techniques led to the development of this flap technique which intended to spare the papilla instead of splitting it.

Non-displaced flaps:

When the flap is returned and sutured in its original position.

Displaced flaps:

When the flap is placed apically, coronally or laterally to its original position.

 In the following discussion, we shall study in detail, the surgical techniques that are followed in various flap procedures.

Modified Widman flap

As already discussed in, “History of surgical periodontal pocket therapy and osseous resective surgeries” the original Widman flap was presented to the Scandinavian Dental Association in 1916 by Widman which was later published in 1918. Ramfjord and Nissle 3 in 1974, modified the original Widman flap procedure and coined the term “modified Widman flap”. This flap procedure may also be called as the “access flap operation” because the goal of the flap reflection is, primarily, to provide improved visual access to the periodontally involved tissues.

The primary goal of this flap procedure is………………

123

Periobasics: A Text Book of Periodontics and Implantology
For India Users:
Buy Now
For International Users:


Indications:

  • The modified Widman flap is indicated in cases of periodontitis with pocket depths of 5-7 mm.
  • It can be used in combination with other procedures such as osseous resection, regenerative procedures, hemisection procedure and procedures involving wedge excision.

Contraindications:

  • The presence of thin gingiva which does not allow placement of adequate initial internal bevel incision.
  • The narrow width of attached gingiva which may further reduce post-operatively.
  • Osseous surgical procedures with very deep osseous defects and irregular bone loss, facially and lingually/palatally.

Clinical procedure:

The modified Widman flap procedure involves placement of three incisions: the initial internal bevel/ reverse bevel incision (first incision), the sulcular/crevicular incision (second incision) and the horizontal/interdental incision (third incision). After these three incisions are made correctly, a triangular wedge of the tissue (as shown in the diagram) is obtained containing the inflamed connective tissue and the pocket lining. This infected and inflamed tissue is then removed, leaving behind the healthy tissue. Knife-edge margins of the gingiva are achieved with this procedure.

Following is the description of step by step procedure followed during doing a Modified Widman flap surgery (Figure 58.3 a-g),

Figure 58.3 The modified Widman flap procedure. 

Modified Widman Flap

  • After the patient has been thoroughly evaluated and prepared with non-surgical periodontal therapy, quadrant or area to be operated is selected.
  • Local anesthesia is administered to achieve profound anesthesia in the area to be operated.
  • The area is then irrigated with an antimicrobial solution.
  • The area to be operated is then isolated with the help of gauge.
  • The primary incision or the internal bevel incision is then made with the help of……………………….

123

123

  • At last periodontal dressing may be applied to cover the operated area. It must be noted that if there is no significant bleeding and flaps are closely adapted, periodontal dressing is not required. The operated area will be cleaner without dressing and will heal faster.
  • After one week, the sutures are removed and the area is irrigated with normal saline solution.

See video of the surgery at: https://periobasics.com/modified-widman-flap.html or https://www.youtube.com/watch?v=wKvBUZvksRM

Un-displaced flap

This flap procedure may be regarded as internal bevel gingivectomy because the first incision or the internal bevel incision given during this procedure is placed at the level of pocket depth (Figure 58.1), thus including all the soft tissue containing and supporting periodontal pocket.

Indications:

  1. Areas where greater probing depth reduction is required.
  2. Enough width of attached gingiva.
  3. Areas which do not have an esthetic concern.

Contraindications:

  1. Areas of esthetic concern.
  2. Deep intrabony defects.
  3. Less width of attached gingiva.
  4. Severe hypersensitivity.

Clinical technique:

  • After the area to be operated is irrigated with an anti-microbial solution, local anesthesia is applied and the area is isolated after profound anesthesia has been achieved.
  • The pockets are then measured and bleeding points are produced with the help of a periodontal probe on the outer surface of gingiva indicating the bottom of the pocket.
  • The first incision or the internal bevel incision is then made from the bleeding points directed at an apical level to the alveolar crest. The thickness of the gingiva determines how far apical to the alveolar crest the incision reaches. Thicker the gingiva more apical the incision reaches as compared to the thin gingiva. One important point to note here is that the thinning of the gingiva should be done with the initial incision because once the flap has been elevated; it is difficult to manage especially if the thinning of the flap is to be done.
  • After this, the second or the sulcular incision is made from the…………….

123123

Apically displaced flap

Apically displaced flap can be done with or without osseous resection. For treatment of periodontal pockets with minimal osseous defects, a procedure without or minimal osseous resection is done, whereas in case of moderate osseous defects and crown lengthening procedures, osseous resection is done with the flap procedure. This procedure cannot be done on the palatal aspect as it has attached gingiva which cannot be displaced apically.

This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. The apically displaced flap is considered as a pocket elimination procedure because the margins of the flap are re-positioned in an apical position (slightly coronal to the alveolar crest) as compared to its original position, thus eliminating the pocket.

Indications:

  1. Areas where greater probing depth reduction is required.
  2. Areas which do not have esthetic concern.
  3. Areas where post-operative maintenance can be most effectively done by doing this procedure.
  4. Short anatomic crowns in the anterior region.
  5. Clinical crown lengthening in multiple teeth.
  6. To preserve the present attached gingiva or even to establish an adequate strip of it, where it is narrow or absent

Contraindications:

  1. Periodontal pockets in severe periodontal disease.
  2. Periodontal pockets in areas where esthetics is critical.
  3. Deep intrabony defects.
  4. Patients at high risk for caries.
  5. Severe hypersensitivity.
  6. Tooth with marked mobility and severe attachment loss.
  7. Tooth with extremely unfavorable clinical crown/root ratio.

Advantages:

  1. This flap procedure causes greatest probing depth reduction.
  2. It enhances the potential for effective periodontal maintenance and preservation of attachment levels.

Disadvantages:

  1. May cause esthetic problems due to root exposure.
  2. Flap reflection till alveolar mucosa to mobilize the flap causes more post-operative pain and discomfort.
  3. May cause attachment loss due to surgery.
  4. May cause hypersensitivity.
  5. May increase the risk of root caries.
  6. Unsuitable for treatment of deep periodontal pockets.
  7. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control.

Clinical technique:

The basic clinical steps followed during this flap procedure are as follows (Figure 58.4 a-e),

Figure 58.4Images of an apically displaced flap 

Apically displaced flap

  • After the area to be operated has been irrigated with an antimicrobial solution and isolated, the local anesthetic agent is delivered to achieve profound anesthesia.
  • The incisions given are the same as in case of modified Widman flap procedure. The initial or the first incision is the internal bevel incision given not more than 1 mm from the crest of the gingiva and directed to the crest of the bone. The scalloping of the incision may not be accentuated as the flap has to be apically displaced and is not adapted interdentally.
  • After this, partial elevation of the flap is done with the help of a small periosteal elevator.
  • The crevicular incision is then placed from the bottom of the pocket till the alveolar crest. The interdental incision is then given to remove the wedge of tissue that contains the pocket wall.
  • As the flap is to be placed in an apical position, vertical incisions are made extending……………..

123

123

Palatal flap procedures

The flap procedures on the palatal aspect require a different approach as compared to other areas because the palatal tissue is composed of a dense collagenous fiber network and there is no movable mucosa on the palatal aspect. As described in chapter 57, “History of surgical periodontal pocket therapy and osseous resective surgeries” the palatal approach for osseous surgery was introduced by Ochsenbein and Bohannan 4 in 1963. There are three types of flap designs which can be applied to the palatal aspect. A full thickness flap is used in cases where the palatal gingiva is relatively thin. The modified partial-thickness flap or ledge-and-wedge flap is used for a thicker palatal tissue. A partial-thickness primary flap is used for a thicker palatal tissue.

Clinical technique:

After administration of local anesthesia, bone sounding is done to assess the thickness of gingiva and underlying osseous topography. This is especially important because on the palatal aspect osseous deformities such as heavy bone ledges and exostoses are commonly seen. Once the bone sounding has been done and the thickness of the gingiva has been established, the design of the flap is decided. The key point to be remembered here is, more the thickness of the gingiva more scalloped is the incision. If extensive osseous recontouring is planned, an exaggerated incision is given. As already stated, depending on the thickness of the gingiva, any of the following approaches can be used,

Full thickness flap:

The full thickness mucoperiosteal flap procedure is the same as that described for the buccal and lingual aspects. The first, second and third incisions are placed in the same way as in case of modified Widman flap and the wedge of the infected tissue is removed. Minor osseous recontouring may be done and the flap is then adapted into the interdental areas. Sutures are placed to secure the flaps in their position.

Partial-thickness palatal flap:

This approach was described by Staffileno (1969) 5. As already stated, this technique is utilized when thicker gingiva is present. This flap procedure utilizes two incisions referred to as primary and secondary incisions which contain tissue which has to be removed (Figure 58.5). After the administration of local anesthesia, bone sounding is performed to identify the exact thickness of the gingiva. Then, it is decided that how much tissue has to be removed so that the appropriate thickness of the gingiva is achieved at the end of the procedure.

Figure 58.5 Lines demonstrating the primary and secondary incisions used in case of ‘ledge and wedge technique’

ledge and wedge technique

  • The primary incision is placed with the help of 15c blade, but in case of limited access, blade 12 D can be used. The distance of the primary incision from the gingival margin depends on the thickness of the gingiva. More is the thickness of the gingiva, farther is the incision placed to include more tissue which needs to be removed. The blade should be kept on the vertical height of the alveolus so that palatal artery is not injured. The incision is usually started at the disto-palatal line angle of the last molar and continued forward using a scalloped, inverse-beveled, partial-thickness incision to create a thin partial-thickness flap.
  • After the primary incision, tissue can now be retracted with the help of a rat-tail pliers. Now, after the completion of partial thickness flap, the scalpel blade is directed from the base of this incision towards the bone to give a scoring incision. By doing this, the periosteum is cut and it becomes easy to remove the secondary flap from the bone. The secondary sulcular incision is them made from the depth of the sulcus/pocket till the crest of the alveolar bone. In this way, the secondary flap is now free from both sides for removal. Ochsenbein chisels (nos. 1 and 2) are then used to free this tissue from the bone and the secondary flap is removed.
  • During this whole procedure, the placement of the primary incision is very important because………………..

123

Modified partial-thickness palatal flap:

This is a modification of the partial thickness palatal flap procedure in which gingivectomy is done prior to the placement of primary and the secondary incision. This is also known as “Ledge-and-wedge technique”. Following are the steps followed during this procedure,

  • The area is anesthetized and bone sounding is done to evaluate the osseous topography, pocket depth, and thickness of the gingiva.
  • Once bone sounding has been done, a gingivectomy incision without bevel is given using a periodontal knife to remove the tissue above alveolar crest. Along with removing the tissue above the alveolar crest, this incision also reveals the thickness of the soft tissue. In case where the soft tissue is quite thick, this incision should not be given till the base of pocket because after removal of the secondary flap the soft tissue margins may become short to cover the bone, thus leaving uncovered bone and post-operative discomfort to the patient. A scalloping incision has been recommended so that better interproximal primary closure can be achieved.
  • After the gingivectomy incision, primary and the secondary incisions are placed in the same way as described in the partial thickness flap procedure.
  • The primary incision is placed at the outer margin of the gingivectomy incision starting at the disto-palatal line angle of the last molar and continued forward. The soft tissue is then retracted with tissue forceps and the scoring incision is given to separate the periosteum from the bone.
  • The secondary incision is given from the depth of the periodontal pocket till the alveolar crest.
  • With the help of Ochsenbein chisels (nos. 1 and 2), the secondary inner flap is removed.
  • Scaling, root planing and osseous recontouring (if required) are carried out.
  • The flap is sutured with interrupted or continuous sling sutures.

The main disadvantage of this procedure is that healing in the interdental areas takes place by secondary intention. So, this procedure cannot be employed when modified Widman flap, excisional new attachment procedure and regenerative procedures such as osseous grafting are done because these procedures require primary closure.

Papilla preservation flap

Periodontal flap surgery with conventional incision commonly results in gingival recession and loss of interdental papillae after treatment. This is especially important in maxillary and mandibular anterior areas which have a prime esthetic concern. To overcome the problem of recession, papilla preservation flap design is used in these areas.

The first documented report of papilla preservation procedure was by Kromer 6 in 1956, which was designed to retain osseous implants. In 1973, App 7 reported a similar technique and termed it as ‘Intact Papilla Flap’ which retained the interdental gingiva in the buccal flap. This procedure was aimed to provide maximum protection to osseous and transplant recipient sites. Evian et al. (1985) 8 modified this procedure to preserve anterior esthetics after flap surgery. Genon and Bender 9 in 1984 also reported a similar technique indicated for esthetic purpose. Takei et al. 10  in 1985 introduced a detailed description of the surgical approach reported earlier by Genon and named the technique as “Papilla Preservation Flap”. Later on Cortellini et al. (1995, 1999) 11, 12 described modifications of the flap design to be used in combination with regenerative procedures. This procedure is indicated only in cases where embrasures are wide enough to permit passage of the interproximal tissue.

Clinical procedure:

  • The area to be operated is irrigated with an antimicrobial solution and isolated. The local anesthetic agent is delivered to achieve profound anesthesia.
  • An intrasulcular incision is given all around the teeth to be involved in the surgical procedure. No incision being made through the interdental papillae.
  • There are two types of incisions that can be used to include interdental papillae in the facial flap:

One technique includes semilunar incisions which are made across each interdental papilla that dip apically from the line angles of the tooth so that the papillary incision line is at least 5 mm from the gingival margin, allowing the interdental tissues to be dissected from the lingual or palatal aspect so that it can be elevated (Figure 58.6 a).

Figure 58.6 a, b The incisions techniques used in papilla preservation flap for inclusion of papillae in buccal flap. 1°, 2°and 3°indicate the incisions lines used in these designs

Papilla preservation flap

In another technique, vertical incisions and a horizontal incision are placed. The vertical incisions are made from the center of palatal/lingual surfaces of teeth extending palatally/lingually. The vertical incisions are extended far enough apically so that they are at least 3 mm apical to the margin of the interproximal bony defect and 5 mm from the gingival margin. These vertical incisions are now joined with a horizontal incision as shown in the (Figure 58.6 b).

  • The interdental papilla is then freed from the underlying bone and is completely mobilized.
  • Once the interdental papilla is mobile, a blunt instrument is used to carefully push the interdental papilla through the embrasure (Figure 58.7).
  • After pushing the papillae buccally, both the flap and the papilla are reflected off the bone with a periosteal elevator.
  • The granulation tissue is removed from the area and scaling and root planing is done.
  • The area is then re-inspected for any remaining granulation tissue, tissue tags and deposits on root surfaces. If detected, they are removed.
  • The papillae are then carefully pushed back through the interdental embrasures to palatal or lingual aspect.
  • Papillae are then sutured with interrupted or horizontal mattress sutures.
  • The patient is recalled after one week for suture removal.

 

Figure 58.7  The papilla preservation flap

Papilla preservation flap

Modified flap operation

It was described by Kirkland in 1931. It is basically an access flap for the debridement of the root surfaces. The main advantages of this procedure are the preservation of maximum healthy tissue and minimum post-operative discomfort to the patient.

Figure 58.7  Modified flap operation

Modified flap operation

Clinical procedure:

  • After administrating local anesthesia a profound anesthesia is achieved in the area to be operated. The area is then irrigated with an antimicrobial solution.
  • The intrasulcular incision is given using No. 15c or No. 12 blade on both the buccal and the lingual/palatal aspects continuing it interdentally extending it in the mesial and distal direction.
  • The buccal and the lingual/palatal flaps are then…………………..

123

Periobasics: A Text Book of Periodontics and Implantology
For India Users:
Buy Now
For International Users:


See video of the surgery at: https://periobasics.com/modified-flap-operation.html or https://www.youtube.com/watch?v=F64eufg4rPM

Distal molar surgery

The periodontal pockets on the distal aspects of last molars, both in maxillary and the mandibular arches present a unique situation for which specific surgical designs have been advocated. These areas generally have enlarged tissue with variable underlying osseous topography. The surgical procedure in this area for the treatment of deepened periodontal pocket presents difficulties to the clinicians.

Figure  58.9  The  distal  molar  surgery

Distal molar surgery

Historically, gingivectomy was the treatment of choice for these areas until 1966, when Robinson 13 addressed this problem and gave a separate surgical procedure for these areas which he termed “distal wedge operation”. Following shapes of the distal wedge have been proposed which are,

  1. Triangular
  2. Square, parallel, or H design

Triangular wedge:

The triangular wedge technique is used in cases where the adequate zone of attached gingiva is present and in cases of short or small tuberosity. In this technique no. 12 or no. 15 scalpel blade is used to make a triangular incision distal to the molar on retromolar pad area or the maxillary tuberosity. The triangular wedge of the tissue, hence formed is removed. After removing the wedge of the tissue the margins of the flap are undermined with the help of scalpel blades to allow proper adaptation to the underlying bone. If required, corrective osseous resection is done and all the granulation tissue and tissue tags are removed from the area. Scaling and root planing of the root surface are done. The flaps are then approximated and sutured with the help of interrupted sutures.

Square, Parallel, or H Design:

In this technique, two incisions are made with the help of no. 12 or no. 15 scalpel blade, parallel to each other beginning at the distal end of the edentulous area, continued to the tooth (Figure 58.9 a-l).  The incisions made should be reverse bevel to achieve thinning of tissue so that an adequate final approximation of the flaps can be achieved. One incision is now placed perpendicular to these parallel incisions at their distal end. Sulcular incision is now made around the tooth to facilitate flap elevation. The buccal and palatal/lingual flaps are reflected with the help of a periosteal elevator. The square wedge of the tissue is now removed with the help of Kirkland or Orban knife down to the bone. Required osseous correction is done and scaling and root planing of the root surfaces are completed. The flaps are then approximated and sutured with the help of interrupted sutures.

The main advantages of this procedure are maximum conservation of the keratinized tissue, maximum closure of the flaps and greater access to the underlying bony topography and the distal furcation.

Conclusion

The primary objective of the flap surgeries is to gain access to the root surfaces and bone defects so that the deposits on the root surfaces can be eliminated and the granulation tissue can be removed. Furthermore, the access to the bone defects facilitates the execution of various regenerative procedures. In the present discussion, we discussed various flap procedures that are used to achieve these goals. In the following chapters, we shall read about various regenerative procedures which are aimed at achieving regeneration of the lost periodontal structures.

Periobasics: A Text Book of Periodontics and Implantology
For India Users:
Buy Now
For International Users:


References:

References available in the hard copy of the website

Periobasics: A textbook of periodontics and implantology

Leave a Reply

You must be logged in to post a comment.