PERIODONTAL FLAP SURGERY

Presented by:ANEET KAURMDS 2nd year

INTRODUCTION: The ultimate aim of periodontal therapy is to

establish a healthy dentition with sound attachment apparatus resulting in proper form, function and esthetics.

Periodontal therapy comprises of initial non- surgical debridement followed by a re- evaluation, at which stage the need for further treatment, usually surgical in nature is established.

DEFINITIONS: Periodontal flap is defined as a section of gingiva

and/or mucosa surgically separated from the underlying tissues to provide visibility of and access to the bone and root surface. (Carranza 10th edition).

Flap is defined as the separation of a section of tissue from the surrounding tissue except at its base. (Glossary of periodontal terms).

A flap is defined as a mass of tissue, usually including skin, only partially removed from one part of the body so that it retains its own blood supply during transfer to another site. (Dorland’s medical dictionary)

HISTORY OF FLAP:

Periodontal surgical techniques used in the nineteenth century were essentially gingivectomies with straight line incisions followed by an aggressive curettage to remove the crestal bone & thorough scaling of the root surface.

HISTORYCarl

Parstch 19th cntry Parstch

incision

Neumann 1912

Leonard Widman in

1918

A. Cyszeinsk

y

G.V. Black

Olin Kirkland in

1931

PIER

RE

FAU

CH

AR

D

Pierre Fauchard, who has been called “ the father of modern dentistry” 1723, said that “little or no care as to the cleanliness of the teeth is ordinalrily the cause of all the maladies that destroy them”- one of the earliest expression recorded in history of the importance of oral hygiene.

He described a procedure in 1742 and designed specific instrumentation to remove the excessive gingival tissue.

RIGGS

John W. Riggs (1811-1885). (From Hoffman-Axthelm W: History of dentistry, Chicago, 1981,uintessence.)

Riggs(1810-1885) known as “the father of periodontology” credited the cause of periodontal disease to the calculary deposits over the teeth and advocated their removal followed by curettage of the alveolar process. John W. Riggs (1811-1885).

(From Hoffman-Axthelm W: History of dentistry, Chicago, 1981,Quintessence.)

Advent of flap :

Carl Partsh developed a technique in nineteenth century, for the surgical treatment of periapical lesions and cysts.( performed under cocaine local anesthesia)

The procedure involved a curved incision with convexity toward the crown of the teeth, called the Partsch incision. After separating the tissues and elevating the flap, a cyst could be removed and the flap was returned to its original position.

After 1907, Partsch recommended that the flap be sutured.

Most of the progress in periodontal surgery in this period came from germany and other central European countries, and is associated with three names: Robert Neumann, Leonard Widmann and A. Cieszinski.

The newmann flap:

Robert Neumann , born in 1882;advocated “the radical surgical treatment of pyorrhoea”.

He introduced mucoperiosteal flap in 1912.

In a famous article titled “Robert Neumann: a pioneer in periodontal surgery”, the contributions of Neumann to the development of periodontal surgery was acknowledged.

Widman flap : In 1918, Leonard Widman introduced Widman

flap. He described his technic in his article “The operative treatment of pyorrhoea alveolaris”.

The reverse bevel incision was introduced by A. Ciezynski.

Arthur Zentler of USA in 1918 were first to describe the mucoperiosteal flap operation.

He allowed access for debridement and elimination of granulation tissue as well as osseous removal by chisels.

Kirkland Flap/conventional flap; 1931.

Kirkland described a procedure to be used in the treatment of “ periodontal pus pockets”

The procedure was called the modified flap operation or a vest pocket edition of the radical flap operation and was basically an access flap for root debridement.

Kronfeld, 1935 In 1935, Kronfeld performed autopsy studies of

bone and found that bone is not necrotic and inflamed but destroyed by an inflammatory process. .

Orban conducted similar studies.

Dr. Carranza in 1939 proposed in his doctoral thesis “ the surgical treatment of periodontitis” which involved pocket elimination surgery by raising the flap.

Naber, 1954 In 1954, Naber described “repositioning of

attached gingiva”. He placed flap apically for the first time and utilized one vertical releasing incision mesial to the area of deepest periodontal pocket.

In 1957 , Ariaudo and Tyrell, modified Nabers technique by giving two vertical incisions and resembled Widmans technic, except that it was positioned apically.

In 1962, Friedman proposed the term “apically repositioned flap”. Today, the word “reposition” is replaced by the term “position”. So, now it is called “apically positioned flap”.

1963, 1964- Ochsenbein and Bohannan described the palatal flap approach as an alterative to buccal approach.

In 1985, Takei et al. proposed a surgical approach called papilla preservation technique.

According to CARRANZA (10TH EDITION), periodontal surgery is classified into:

Pocket ReductionSurgery:

Resective (gingivectomy, apically displaced flap and undisplaced flap with or without osseous resection.

Regenerative( flaps with grafts, membranes)

Correction of anatomic/morphologic defects:

Plastic Surgery techniques to widen attached gingiva.

Esthetic surgical techniques(root coverage)

Preprosthetic considerations Placement of dental implants.

The INDICATIONS for surgical therapy ??

Unaccesible areas like root concavities, furcation areas etc,

Deep periodontal pockets:- Waerhaug stated that pocket depth greater than 5mm demonstrated only an 11% efficacy in removal of plaque and calculus.

Osseous defects:- the morphology of osseous defects can limit the effectiveness of nonsurgical therapy.eg: narrow intrabony defects.

-Esthetic considerations-Implant surgeries-patient co-operation-systemic health of the patient

CONTRAINDICATIONS:

a. Patient non co-operation: Since, optimal post-operative infection control is

decisive for the success of periodontal treatment ( Axelsson & Lindhe,1981), a patient who fails to co-operate during the cause related phase of therapy should not be exposed to surgical treatment.

B. Systemic conditions: Cardiovascular disease: arterial hypertension: patient’s consent should

be taken and local anesthesia with low adrenaline or without adrenaline (as it has ionotropic effect on heart muscles) must be used.

Angina pectoris: premedication with sedatives and L.A, low in adrenaline is recommended.

Myocardial Infarction: MI patients should not be subjected within 6 months following hospitalization and thereafter only in co-operation with the physician of the patient.

Anticoagulant treatment: The range within which scaling & surgical procedures can be safely performed is one and half to two times the average normal prothrombin time (12-14 sec). (Lindhe 5th edition)

Aspirin and other NSAID drugs should not be used for post-operative pain control.

Rheumatic Endocarditis, Congenital heart lesions and heart/vascular implants involve risk of transient bacteremia that follows manipulation of infected periodontal pockets.

ADA- recommeded antibiotic prophylaxis and antiseptic mouthrinsing 0.2% chlorhexidine prior to surgery .

AHA (1997), 2 grams of amoxicillin administerated orally 1 hour before the treatment, if allergic to penicillin, clindamycin (600 mg) orally 1 hour before treatment is recommended.

Organ Transplantation: Prophylactic antibiotics are recommended in

transplant patients taking immunosuppressive drugs.

Blood Disorders:patients suffering from acute leukemias, agranulocytosis, and lymphogranulomatosis must not be subjected to periodontal surgery.

Diabetes: well controlled diabetics(Hb A1c6-8%) may be subjected to periodontal surgery provided precautions are taken taken. (Seymour and Heasman,1992).

Neurologic disorders:multiple sclerosis and Parkinson’s disease in severe cases,make ambulatory periodontal surgery impossible.

Epilepsy : drugs used to treat epilepsy may cause gingival enlargements. These patients may without special restrictions be subjected to periodontal surgery.

Classification of flaps: Based on bone exposure after flap reflection

(by Carranza, 1979):

Full thickness Partial thickness Combination flap flap flap

Based on flap placement after surgery (by Carranza in 1990):

Repositioned or positioned orUndisplaced flaps displaced flapsEg: conventional flaps Based on management of papilla:

Conventional papilla preservation flap flap.

Based on Presence/Absence of releasing incisions

Flap with flap without releasing incision releasing incision(relaxed flaps) (envelope flaps)

According to the main purpose of the procedure (by Ramfjord in 1979)

Pocket elimination flap Reattachment flap surgery Mucogingival repair

Flaps are also classified by the anatomic type of mucosa.

Gingival Flap: Includes only the gingival tissue. Mucogingival flap: extends beyond the

mucogingival junction to include the alveolar mucosa.

Objectives of flap surgery :

1. Access to roots and alveolar bone • enhance visibility • increase scaling and root planing effectiveness • less tissue trauma2. Modification of osseous defect • establish physiologic architecture of hard tissues

through regeneration or resection • augment alveolar ridge defects3. Repair or regeneration of the periodontium

4. Pocket reduction • enhance maintenance by patient and therapist • improve long-term stability5. Provide acceptable soft tissue contours • enhance plaque control and maintenance • improve esthetics

Principles of flap design: According to Hupp (1933) the following

principles should be followed: Prevention of flap necrosis: 1.) The apex of the flap should never be wider

than the base.

2.) Flap should either run parallel to each other or preferably converge from the base of the flap to its apex.

3. Flap length to base ratio should be no greater than 2:1

The major blood supply to a flap was found to exist at its base and travels in an apical to coronal direction. So,It was also determined that the greater the ratio of flap length to flap base, the greater the vascular compromise at the flap margins.

Whenever possible, an axial blood supply should be included in the base of the flap.

The base of the flap should not be excessively twisted or stretched (as either of these will compromise the supplying vessels).

2. Prevention of flap tearing

The access of the flap should be enough to avoid tearing.

If an envelope flap does not provide sufficient access, another incision should be made.

Vertical (oblique) releasing incisions should be placed one full tooth anterior to the area of any anticipated bone removal.

The incision should be started at the line angle of the tooth & carried obliquely apically into the unattached gingiva.

Surgical considerations: Procedural selection should be based on the

following: a. Simplicity b. Predictability c. Efficiency d. Mucogingival considerations e. Underlying osseous topography f. Anatomic and physical limitations g. Age and systemic factors

All incisions should be clear, smooth, and denifite.

All flaps should be designed for maximum use and retention of keratinized gingiva.

The flap design should allow for adequate access and visibility.

Involvement of adjacent non involved areas should be avoided.

The flap design should prevent unnecessary bone exposure, with resultant possible loss and dehiscence or fenestration formation.

Where possible, primary intention procedures are preferred to those of secondary intention.

The base of a flap should be as wide for adequate vascularity.

Tissue tags should be removed to allow for rapid healing and prevent regrowth of granulation tissue.

Adequate flap stabilization is necessary to prevent displacement, unnecessary bleeding, hematoma formation, bone exposure, and possible infection.

INCISIONS:

Principles governing incision placement:

According LASKIN (1980), they are-: The incision should not be made over the operative

site but in the adjacent, undisturbed areas so that the flap will be supported by normal tissue & the potential for rapid revascularization is preserved.

The incision should be placed so that major nerves are not transected unless necessary.

An adequate blood supply should be maintained by incising parallel to the major vessels, minimizing the number of side cuts, & having the base of the flap as wider than the apex.

Incisions should not be made in areas of thinned mucosa like that found over an exostosis because the blood supply is reduced, suturing is difficult & rate of dehiscence is very high.

When developing flaps around teeth, the incisions should be made in the gingival crevice.

It is also important to maintain the integrity of the interdental papillae.

If access is inadequate, the surgeon may extend the length of the incision or make a releasing incision. The releasing incision is usually made at about at an angle of 450 from the direction of the parent incision.

If the flap is to include both mucosa & the periosteum, the incision should be made directly to the bone with one cut & it should be elevated in one piece without tearing the periosteum.

After the necessary surgery, the clotted blood should be removed from beneath the flap to lessen the possibility of infection & permit tissue fluid to penetrate more readily.

Seven main incision types are commonly used in periodontal surgery:  

1. THE EXTERNAL BEVEL OR GINGIVECTOMY INCISION :

It is contained in the gingiva and coronally directed with the surgical objectives of pocket elimination, access to roots, and improved gingival contours.

Indications: to treat gingival enlargement and to perform esthetic crown lengthening when access to the underlying bone is not required.

It is sometimes used in conjunction with flap surgery when there is need to thin the tissues externally before flap reflection.

An example would be a case of severe gingival enlargement with lobulated gingiva and highly irregular gingival margins.

Recontouring gingiva with an irregular surface morphology is difficult if attempted using an internal thinning technique on the underside of the flap.

The dotted line represents the external bevel incision, and the shaded area corresponds to thetissue to be excised.

2. TYPES OF HORIZONTAL INCISIONS:

A) The internal bevel incision, which starts at a distance from the gingival margin and is aimed at the bone crest.

B) The crevicular incision, which starts at the bottom of the pocket and is directed to the bone margin.

C) interdental incision is performed after the flap is elevated.

This incision has been termed as the first incision because it is the initial incision in the reflection of the flap &

the reverse bevel incision, because its bevel is in reverse direction from the gingivectomy incision.

the # 11 or #15 surgical scalpel is used most commonly.

Objectives of internal bevel incision: It removes the pocket lining and the area of the

tissue invaded by microorganisms (Bacterial invasion can occur up to a distance of 400 microns- Nisengard and Bascons, 1987. In an SEM study bacteria have been observed to penetrate even the subepithelial connective tissue in periodontitis- Saglie, 1982.

Therefore the chief advantage of this incision is that it eliminates the part of the gingival margin which has been penetrated by pathogens.

It conserves the relatively less involved outer surface of the gingiva.

It produces a sharp, thin flap margin for adaptation to the bone tooth junction.

Indications: Primary incision of the flap surgery if there is a

sufficient band of attached gingiva. Desire to correct bone morphology (osteoplasty,

osseous resection) Thick gingiva (such as palatal gingiva) Deep periodontal pockets and bone defect Desire to lengthen clinical crown

INCISION DESIGN:

The placement of the primary incision is determined by the following factors:

l. Band of attached gingiva.2. Method of periodontal surgery.3. periodontal pocket depth.4. Whether osteoplasty and ostectomy are necessary5. Esthetics6. Whether restorative treatment is necessary after periodontal surgery7. Clinical crown length needed for abutment

A scalloped incision design is incorporated in the flap when this incision is used.

The shape of this scallop is dictated by the anatomy of the tooth and underlying root form.

variations in the type of internal bevel incision for the different types of flaps.

Modified Widman flap does not intend to remove the pocket wall, but eliminates the pocket lining. Therefore the internal bevel incision starts close, no more than 1 to 2 mm apically to the gingival margin and follows the normal scalloping of the gingival margin.

For apically displaced flap, the pocket wall is to be preserved to be positioned apically while its lining is removed. So, the internal bevel incision is to be made as close to the tooth as possible 0.5 to 1mm.

For an undisplaced flap, the internal bevel incision is initiated at or near a point just coronal to the projection of the bottom of the pocket on the outer surface of the gingiva.

INT

ER

NA

L BE

VE

L INC

ISION

Locations of the internal bevel incisions for the different types of flaps. 

Diagram showing the location of two different areas where the internal bevel incision is made inan undisplaced flap.

The incision is made at the level of the pocket . 

Studies in favour of the benefits of removal of pocket epithelium by internal bevel incision:

Morris 1949 stated that the

removal of pocket

epithelium is necessary for

new connective tissue

attachment.

Stone 1966 postulated that any residual epithelium on the wound edge

could serve as a “seed area” and result in rapid

proliferation of the junctional

epithelium along the root surface.

Yukna 1976 successfully removed all epithelium

with internal bevel incison as described

by ENAP .

Caffesse et al 1968 observed that all pocket epithelium was

removed with the reverse bevel

incision as described in the

Modified Widman Flap

procedure.

Carranza has stated that placement of the scalloped internal bevel incison 1mm subcrestally will remove most of the

granulation tissue contained in the lateral wall of pocket.

STUDIES AGAINST the Benefit of REVERSE BEVEL INCISION:

Bowen et al, observed residual

epithelium with the

internal bevel incision in

ENAP used by Yukna in

1976.

Fischer et al 1982 also

established the inability of the reverse bevel

incision in Modified

Widman Flap Procedure to remove all

pocket epithelium.

Litch et al 1984 stated that

neither crestal nor subcrestal internal bevel

incisions consistently

eliminated all pocket

epithelium.

A SULCULAR, OR CREVICULAR, INCISION

It is selected if preservation of all the existing keratinized tissue is desirable.

The scalpel blade is inserted into the gingival crevice, aligned parallel to the long axis of the tooth, and angled toward the alveolar crest. Interproximally, the incision is extended into the embrasure space to include as much papilla as possible.

INDICATIONS : Narrow band of attached gingiva Thin gingiva and alveolar process Shallow periodontal pocket Desire to lessen post operative gingival recession

for esthetic reasons in the maxillary anterior region

As a secondary incision of usual flap surgery Bone graft or GTR: desire to preserve as much

periodontal tissue (especially interdental papilla) as possible to completely cover grafted bone and membrane by flaps.

Its purpose is to facilitate the removal of the inflammatory granulation tissue surrounding the cervical area and the secondary flap of soft tissue walls of the periodontal pocket (after reflecting the primary flap).

A no. 12 blade, is recommended.

After the first two incisions have been placed, periosteal elevator is inserted into the initial internal bevel incision, and the flap is separated from the bone. With this access the interdental incision is placed to separate the collar of gingiva(around facial,lingual & interdental areas that is left around the tooth.

Orban Knife is used

VERTICAL RELEASING INCISIONS

They are normally perpendicular to the gingival margin and placed at the line angles of the teeth.

ADVANTAGES: increase access to alveolar bone, decrease tension on retracted flaps, allow apical and coronal positioning of flaps,

Vertical incisions in the lingual and palatal areas are avoided.

Facial vertical incision should always be placed at the line angles of the teeth and never over the height of contour of the root. This accomplishes two things:

i) It protects the interdental papilla adjacent to the surgical site.

ii) It allows the vertical incision to be sutured without having to stretch the flap over the cervical convexity of the tooth.

As a rule, when trying to decide on what side of the interproximal space to place the releasing incision, it is best to include the papilla with the flap to enhance the blood supply to the flap and to allow for ease of suturing.

Suture vertical incisions before horizontal portion of flap.

Cutback Incisions:

Vertical incisions may be used to move the flap laterally (as in pedicle flap.)

In this situation vertical incision is made at an acute angle to the horizontal incision, in the direction toward which flap is moved, placing the base of the pedicle at the recipient site. This is termed as cutback incision.

care must be taken not to extend cutback incisions more than 2 to 3 mm to minimize disruption of the remaining blood supply to the flap.

THINNING INCISIONS It reduces the bulk of connective tissue from the

underside of the flap and are used to reduce the thickness of flaps before reflection.

Such incisions are used as part of distal wedge procedures and to thin bulky papillae.

Thinning incisions are performed either in conjunction with flap reflection (i.e., reflecting the flap as it is thinned) or after completing flap reflection.

Distal wedge incisions Triangular: These are placed creating the apex

of the triangle close to the hamular notch and the base of the triangle next to the distal surface of the terminal tooth.

The thinning or undermining incisions are accomplished before full reflection of tissue and are extended 2 to 3 mm apical to the crestal aspect of the tuberosity.

Incision designs for surgical procedures distal to the mandibular second molar.

The incisionshould follow the areas of greatest attached gingiva and underlying bone. 

The linear distal wedge incorporates two parallel incisions over the crest of the tuberosity that extend from the proximal surface of the terminal molar to the hamular notch area.

The distance between the two linear incisions is determined by the thickness of the tissues, with wider separation of the incisions in thicker tissue.

PERIOSTEAL RELEASING INCISIONS

These are used when coronal or lateral advancement of a flap onto the root or crown of the tooth is indicated.

This incision, which severs the underlying periosteum at the base of full-thickness flaps, allows tension-free coronal positioning of the flap to cover exposed root surfaces and to provide primary closure over barrier membranes used in guided tissue and guided bone regeneration procedures.

Method: The periosteum on the underside of the flap is

scored with a scalpel blade to increase flap mobility, allowing passive coronal advancement of the flap.

FLAP PREPARATION: Once the initial incisions have been made, the

body of the flap is reflected one of the 3 ways:

Full thickness Partial combination Thickness flap

Full-thickness flaps are prepared by making an incision through the mucosal layers and the periosteum until the bone is felt. A periosteal elevator is then used to gently separate the periosteum along with the superficial mucosal layers from the bone.

The partial-thickness flap is technically more challenging than a full-thickness flap and should not be attempted in areas where the gingiva is thin (1-2 mm).

It is also contraindicated in posterior areas of the mandible where the vestibule is shallow and access is difficult.

When performing a partial thickness flap, the tip of the surgical blade is used to split the connective tissue layer into two parts: one, which is left covering the periosteum, and the other, which becomes part of the tissue flap.

FLAP RETRACTION If the flap has been properly designed and

reflected adequately, retraction should be passive without any tension.

It is also critically important that the edge of the retractor always be kept on bone. Trapping the flap between the retractor and bone can cause tissue ischemia and lead to postoperative flap necrosis.

Continuous flap retraction for long periods also is not advised. Such a practice will desiccate the soft tissue and bone causing a delay in wound healing.

When the flap is retracted, the surgical assistant should frequently irrigate the surgical field with sterile saline, to keep the tissues moistened, to reduce contamination, and to improve visibility.

ELEVATION OF THE FLAPBlunt dissection with periosteal elevator

For reflection of full thickness flap

Sharp dissection with surgical scalpel (#11 or #15)

For reflection of partial thickness flap

OPEN FLAP DEBRIDEMENT

The rationale for this basic surgical approach is the same as all flap surgery: to provide access to root surfaces and marginal alveolar bone. Direct visualization of these structures will increase the effectiveness of scaling and root planing and allow debridement of granulomatous tissue from osseous defects.

 REMOVAL OF GRANULATION TISSUE:

Granulation tissue consists of angioblastic and fibroblastic components which proliferate in response to the bacterial challenge from plaque, areas of chronic inflammation and pieces of dislodged calculus and bacterial colonies.

This may perpetuate the pathologic features of the tissue and hinder healing.

This granulation tissue lined by epithelium is construed as a barrier to the attachment of new fibers in the area.

2 schools of thought??

The concept of complete removal of this granulation tissue dominated the therapeutic procedures.

But lately it has been shown that when root is planed and all bacterial plaque has been removed, the major source of bacteria disappears and the pathologic changes resolve with no need to eliminate the inflamed granulation tissue.

The existing granulation tissue is slowly resorbed: the bacteria present in the absence of replenishment of their numbers by the pocket plaque, are destroyed by defence mechanisms of the host and this granulation tissue , in an environment free of plaque and calculus, matures into connective tissue.

The current concept however, is still the complete removal of granulation tissue during flap surgery for technical rather than biological reasons( Newman et al., 2007)

Granulation tissue is a source of bleeding during the surgery and may obstruct proper visualization of calculus deposits and root as well bone defect morphology. Therefore, its removal is important during surgery. However, complete elimination of the nidus of infection is more important than the removal of granulation tissue

REMOVAL OF TRANSEPTAL FIBERS DURING SURGERY:

Transseptal fibers should be removed completely during the surgery: Transseptal fibers regenerate soon after they are destroyed by the

disease process & they lie just coronal to the alveolar bone. So, there removal is essential to see the exact topography of bone defects.

These fibers extend in an angular course over the surface of osseous defects in infrabony pockets occupying space between the wall of defect on one side and root on the other. The removal of these fibers permits the flow of blood, undifferentiated mesenchymal cells from pdl and osteogenic cells into the osseous defect thus favouring new attachment.

When inflamed these fibers undergo degeneration and are partly or completely replaced by granulation tissue. So, granulation tissue may get entagled with these fibers which necessitate their removal.

FLAP POSITIONING Once the debridement treatment has been

completed, surgical flaps may be repositioned, apically positioned, coronally positioned, or laterally positioned.

The final flap location is usually determined by the goal(s) of therapy and the specific periodontal surgical technique performed.

DETAILED DESCRIPTION OF

VARIOUS FLAP PROCEDURES:

Full thickness flap: In 1979, Carranza classified flap as Full thickness- In this, all the soft tissue along

with the periosteum is reflected to expose the underlying bone.

Advantages: They offer improved visibility of the alveolar

bone. They are generally associated with less

bleeding and post operative pain.

Based on bone exposure (Carranza, 1979)

Full thickness flap

It is the most common type of flap used when access to the bone is indicated for resective or regenerative procedures.

The full-thickness flap can be used to reduce or eliminate periodontal pockets, but there must be a sufficient band of attached gingiva and sufficient alveolar crest width to achieve this

Contraindications:Area where treatment for osseous defect with mucogingival problem is not required.Thin periodontal tissue with probable osseous dehiscence and osseous fenestration.Area where alveolar bone is thin.

Partial/Split thickness:In this only the epithelium and a layer of the underlying connective tissue are included. The bone remains covered by a layer of connective tissue, including the periosteum.

Indications: when the flap is to be positioned apically

or when the operator does not want to expose the bone.

Indicated on buccal surfaces. Palatal and lingual surfaces , with their wide zones of attached gingiva and thick alveolar bone do not require split thickness flaps.

 

Contraindications: The partial-thickness flap should not be

attempted in areas where the gingiva is thin (1mm).

It is also contraindicated in posterior areas of the mandible where the vestibule is shallow and access is difficult.

ADVANTAGES: The partial-thickness flap is favorable in

augmentation of attached gingiva with thin bone (done by positioning the flap apically or laterally)

DISADVANTAGE: The biggest problem of a partial-thickness flap is

with the thickness of the remaining periosteum-connective tissue bed on the bone. If it is less than 0.5-1 mm, the remaining periosteum-connective tissue may become necrotic.

Comparison:FULL THICKNESS PARTIAL

THICKNESS

Healing

Primary healing

Secondary healing

Technical difficulty

Relatively easy

Difficult

Bone defect

treatment

Possible Difficult

Blood supply to

flaps

Sufficient Decrease

Elimination of

periodontal pocket

Possible Possible

FULL THICKNESS PARTIAL THICKNESS

Bleeding Less More

Postoperative

swelling

Less

more

Postoperative pain

and discomfort

Use with

mucogingival

surgery

Less

Impossible

Much

Possible

Combination flap: A useful variation of these two flaps is the combination or

“ Split-full-split” flap. First, a crevicular incision is made lateral to the

periodontal pocket and down to the crest of the alveolar bone (Split).

periodontal elevator is used to bluntly dissect the flap down to the approximate level of the mucogingival junction (full).

scalpel is again used to split the alveolar mucosa apically

beyond the mucogingival junction (split).

This type of flap design exposes alveolar bone, which can then be recontoured or augmented,while it maintain periosteum in the apical part of the surgical site for the protection and to aid in suturing and flap reattachment.

 The original Widman Flap:

One of the first detailed descriptions of the use of a flap procedure for pocket elimination was published in 1916 by Leonard Widman.

Widman described a mucoperiosteal flap design aimed at removing the pocket epithelium and the inflamed connective tissue, thereby facilitating optimal cleaning of the root surfaces.

Two releasing incisionsdemarcate the area scheduled for surgical therapy. A scalloped reverse bevel incision is made in the gingivalmargin to connect the two releasing incisions.

The collar of inflamedgingival tissue is removed following the elevation of a mucoperiosteal flap.

By bone recontouring, a"physiologic" contour of the alveolar bone may bereestablished.

The coronal ends of the buccal and lingual flaps are placed at the alveolar bone crest and secured in this position by interdentally placed sutures

Advantages of ‘original widman flap” procedures were:

Less discomfort for the patient, since healing was by primary intention and

It was possible to re-establish a proper contour of the alveolar bone in sites with angular bony defects.

THE NEUMANN FLAP: Neumann in 1912 suggested the use of a flap

procedure which was:Technique:

The first incisions are vertical incisions made in long axis of the tooth, generally in sextants without bisecting the papilla.

An intracrevicular incision was made through the base of the gingival pockets, and the entire gingiva was elevated in a mucoperiosteal flap to gain a clear view of the field being operated.

Following flap elevation, the inside of the flap was curetted to remove the pocket epithelium and granulation tissue.

The root surfaces were subsequently carefully “cleaned:. Any irregularities of the alveolar bone were corrected to give the bone crest as far as possible the “normal shape nature intended for it”.

The flaps were trimmed to allow both an optimal adaptation to the teeth and a proper coverage of the bone at the alveolar crest margin.

Differences between Neumann flap and Widman Flap:

NEWMANN FLAP WIDMAN FLAP

Neumann advocated flap elevation only in the areas of pocket and said that where no lingual or palatal pockets existed, only a buccal or labial flap should be used

Widman advocated treatment with both buccal and lingual flaps in all cases of periodontitis.

Neumann advocated elevation of flap in sextants

Widman said that surgical field should not extend beyond 2 or 3 teeth except in the region of the lower anteriors where he operated from cuspid to cuspid.

NEWMANN FLAP WIDMAN FLAP

Neumann used sulcular incisions

Widman used reverse bevel incision for pocket elimination.

Neumann advocated vertical releasing incisions at the line angles of the teeth.

Widman placed them at centre of the tooth surfaces to have a clear view of interproximal area.

Neumann always recommended provisional splinting prior to surgery

Widman felt that it interfered with his surgical approach and only stabilized teeth post operatively.

The Modified flap or Kirkland flap:

In a publication from 1931 Kirkland described surgical procedure to be used in the treatment of “periodontal pus pockets”.

The procedure was called as the modified flap operation, and is basically an access flap for proper root debridement.

Modified flap operation (the Kirkland flap) - Intracrevicular incision.

The gingiva is retracted to expose the “diseased” root surface.

The exposed root surfaces are subjected to mechanical debridement.

The flaps are replaced to their original position and sutured.

The advantages are:

Less extensive procedure, thus preserving the non inflamed tissues from unnecessary trauma.

Less postoperative pain and swelling. No apical displacement of the gingival margins. More esthetic results postoperatively. More chances of bone regeneration.

MODIFIED WIDMAN FLAP:

Ramfjord and Nissle (1974) described the Modified Widman technique, which is also recognized as OPEN FLAP CURETTAGE TECHNIQUE. While the original Widman Flap technique included both apical displacement of the flaps and osseous reontouring to obtain proper pocket elimination, the modified Widman flap technique is not intended to meet these objectives.

116

Step 1: The initial incision is an internal bevel incision to the alveolar crest starting 0.5 to 1 mm away from the gingival margin

Step 2: The gingiva is reflected with a periosteal elevator .

Step 3: A crevicular incision is made from the bottom of the pocket to the bone,

117

Step 4: third incision is made in the interdental spaces coronal to the bone with a curette or an interproximal knife, and the gingival collar is removed .

Step 5:Tissue tags and granulation tissue are removed with a curette.

Step 6: adapt the facial and lingual interproximal tissue adjacent to each other in such a way that no interproximal bone remains exposed at the time of suturing . Interrupted direct sutures are placed .

Differences between Modified Widman and Original Widman flaps:

MODIFIED WIDMAN FLAP ORIGINAL WIDMAN FLAP

Main aim is access for root debridement with pocket reduction

Main aim is pocket elimination.

Flaps are elevated to a much lesser extent Flaps are elevated to a larger extent.

The crevicular and third incision is also a modification allowing removal of the collar of tissues around teethFlaps are placed at alveolar crest margins

Less postoperative pain and swelling

Flaps are placed apically

More post operative pain and swellling

ADVANTAGES of Modified Widman flap as compared to other procedures:

Intimate post operative adaptation of healthy collagenous tissue to all tooth surfaces leading to new attachment.

The minimum of trauma to which alveolar bone and soft connective

tissues are exposed.

Less exposure of the root surfaces, this form an esthetic point of view & is advantageous in the treatment of anterior segments of the dentition.Less exposure of the root surfaces

also means potentially less root sensitivity and fewer caries. It

facilitates oral hygiene.

DISADVANTAGES:Unfavourable proximal architecture

immediately following surgery. However, it has been shown that if

meticulous oral hygiene is maintained, the proximal tissues will

regenerate.

Pockets are not completely eliminated.

Cannot be used for regenerative purposes.

UNDISPLACED FLAP It differs from the modified Widman flap in that

the soft tissue pocket wall is removed with the initial incision; thus it may be considered an “internal bevel gingivectomy.”The undisplaced flap and the gingivectomy are the two techniques that surgically remove the pocket wall.

Advantage : It can be used to increase the width of

keratinized gingival

UN

DISPL

AC

ED

FLA

P

Undisplaced flap. A and B, Preoperative facial and palatal views. C and D, Internal bevel incisionsin the facial and palatal aspects. Note the deeper scalloping palatally for the replaced flap. E and F, Flap elevated showing osseous defects. G and H, Osseous surgery has been performed. I and J,Flaps have been placed in their original site and sutured. K and L, Postoperative results.

THE PALATAL FLAP: The surgical approach to the palatal area differs

from that for other areas because of the character of the palatal tissue and the anatomy of the area.

The palatal tissue is all attached, keratinized tissue and has none of the elastic properties associated with other gingival tissues.Therefore the palatal tissue cannot be apically displaced, and a partial-thickness (split-thickness) flap cannot be accomplished.

Two methods for eliminating a palatal pocket. One incision is an internal bevelincision made at the area of the apical extent of the pocket.

The other procedure uses agingivectomy incision, which is followed by an internal bevel incision.

primary incision is made intracrevicularly through the bottom of the periodontal pocket

The palatal flap is replaced andOsseous recontouring is performed in the surgical area. A secondary, scalloped, reverse bevel incision is made to adjust the length of the flap to the height of the remaining alveolar bone.

The shortened and thinned flapis replaced over the alveolar bone and in close contact with the root surfaces.

APICALLY REPOSITIONED FLAP: In 1950s and 1960s new surgical techniques for

the removal of soft tissue were described.The importance of maintaining an adequate zone of attached gingival after surgery was emphasized.

Apically positioned flap surgery, in which flaps are reflected with an internal bevel incision and sutured apical to pre-operative position.

Norberg (1926) first advocated this technique for mucogingival problems in periodontal disease. Nabers (1954) described this technique for the preservation of the gingiva following surgery.

Apically repositioned flap:

Following a vertical releasing incision, the reverse bevel incision is madethrough the gingiva and the periosteum to separate theinflamed tissue adjacent to the tooth from the flap.

A mucoperiostealflap is raised and the tissue collar remaining aroundthe teeth, including the pocket epithelium and the inflamedconnective tissue, is removed with a currette.

Osseous surgery is performed with the use of a rotating bur

The flaps are repositionedin an apical direction to the level of the recontouredalveolar bone crest and retained in this positionby sutures.

A periodontal dressingis placed over the surgical area to ensure that theflaps remain in the correct position during healing.

INDICATIONS:

i. To eliminate periodontal pockets.ii. To increase the width of attached gingiva.iii. To lengthen the clinical crown for prosthetic treatment.iv. To improve gingiva and alveolar bone morphology.

CONTRAINDICATIONS:Periodontal pockets in severe periodontal disease.Periodontal pockets in areas where esthetics is critical.

Deep intrabony defects.

Patient at high risk for caries.

Severe hypersensitivity.

Tooth with marked mobility and severe attachment loss.Tooth with extremely unfavourable clinical crown/root ratio.

ADVANTAGES:Minimum pocket depth

postoperatively.

If optimal soft tissue coverage of the alveolar bone is obtained, the

postsurgical bone loss is minimum.

Preserves attached gingiva and increase its width.

Establishes gingival morphology facilitating good hygiene.

Ensures healthy root surface necessary for the biologic width on alveolar margin

and lengthened clinical crown.

DISADVANTAGES:

May cause esthetic problems due to root exposure.

May cause attachment loss due to surgery.

May cause hypersensitivity.

May increase risk of root caries.

Unsuitable for treatment of deep periodontal pockets.

Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control.

APICALLY POSITIONED PARTIAL THICKNESS FLAP: 

Here a partial thickness flap is raised, displaced apically and a periosteal suture placed. This technique increases the width of the attached gingival on the exposed periosteum connective tissue.

Factors in determining the position of the apically postioned flap: Width and thickness of gingiva. Thickness of marginal alveolar bone. Amount of periodontal pocket to be eliminated. Clinical crown length required for restorative/prosthetic treatment

and esthetics. Length of root trunk.

Conditions necessary for partial thickness, apically positioned flap surgery:

partial thickness flap must be of adequate thickness (1-1.5 mm) where there is adequate blood supply.

Absence of thick alveolar bone margin, marginal alveolar bone defect, bony protuberance or exostoses, which require extensive osseous resection.

Sufficient oral vestibule depth.

Adequate alveolar bone covering the root.

Little attached gingiva on gingival margin preoperatively.

No shallow deep intrabony defect.

ADVANTAGES: Ability to fix flap to optimal position with periosteal suture.

Periosteal pocket eliminated and width of the attached gingiva increased with one treatment.

Thin marginal alveolar bone can be protected by periosteum- connective tissue site.

Easily combined with other forms of mucogingival surgery.

Clinical crown length extended while biologic width gained.

Treatment may be complicated if combined with osseous resection.

INDICATIONS:

Increase of the attached gingiva in an area with narrow attached gingival and sufficient

oral vestibule depth.

Avoid exposing areas where the alveolar bone is thin because of the protruding tooth and where there is likelihood of osseous dehiscence or

osseous fenestration.

Elimination of a periodontal pocket that extends beyond

the mucogingival junction with narrow attached gingival.

Extension of clinical crown length for restorative/prosthetic treatment (crown lengthening

surgery).

CONTRAINDICATIONS:Thin gingiva.

Lack of keratinized gingiva at gingival margin.

Narrow oral vestibule.

Extremely thin alveolar process.

Extensive osseous surgery required.

Deep intra bony defect requiring bone regeneration or restoration.

FLAPS FOR RECONSTRUCTIVE SURGERY

Two flap designs are available for

reconstructive surgery:

Papilla preservation flap

Conventional flap with only crevicular incisions

i.) PAPILLA PRESERVATION FLAP: Proposed by Takei et al (1985) later, Cortellini et

al (1995,1999) described modifications of flap design to be used in combination with regenerative procedures.

For esthetic reasons, the papilla preservation technique is often utilized in the surgical treatment of anterior tooth regions.

(a) An intrasulcular incision is made along the lingual/palatal aspect of the teeth with a semi-lunar incision made across each interdental area. (b) A curette or interproximal knife is used to carefully free the interdental papilla from the underlying hard tissue. (c-d) The detached interdental tissue is pushed through the embrasure with a blunt instrument to be included in the facial flap.

The flap is replaced and sutures are placed on the palatal aspect of the interdental areas.

II. CONVENTIONAL FLAP FOR REGENERATIVE SURGERY:

Step 1: Using a #12 blade, incise the tissue at the bottom of the pocket and to the crest of the bone, splitting the papilla below the contact point. Every effort should be made to retain as much tissue as possible to protect the area subsequently.

Step 2: Reflect the flap, maintaining it as thick as possible, not attempting to thin it as is done for resective surgery. The maintenance of a thick flap is necessary to prevent exposure of the graft or the membrane resulting from necrosis of the flap margins.

III. DISTAL MOLAR SURGERY  The gingivectomy incision is the most direct

approach in treating distal pockets that have adequate attached gingiva and no osseous lesions. However, the flap approach is less traumatic postsurgically, because it produces a primary closure incision.

In addition, it results in attached gingiva and provides access for examination and, if needed, correction of the osseous defect.

Procedures for this purpose were described by Robinson and Braden and modified by several other investigators.

 Objectives of wedge procedure:1. Eliminate periodontal pockets.2.Maintain and preserve attached gingiva.3.Make area accessible to the instruments.4.Lengthen clinical crown.5.Create easily clearable gingival – alveolar form.

Factors that determine the flap design of a wedge: Size and shape. Thickness of soft tissue. Difficulty of access. Band of attached gingival of the abutment teeth. Depth of periodontal pocket and degree of

osseous depth on the edentulous side of abutment.

Clinical crown length required as an abutment for restorative/ prosthetic treatment.

Maxillary Molars. Usually simpler than mandibular molars because

of the following reasons: The tuberosity presents a greater amount of

fibrous attached gingiva than does the area of retromolar pad.

The anatomy of tuberosity extending distally is more adaptable to pocket elimination than is that of mandibular molar.

A, Removal of a pocket distal to the maxillary second molar may be difficult if there isminimal attached gingiva. If the bone ascends acutely apically, the removal of this bone may make the procedure easier.

B, Long distal tuberosity with abundant attached gingiva is an ideal anatomic situation for distal pocket eradication.

B. MANDIBULAR MOLARS: Differences from the treatment in the maxillary

tuberosity region due to to the following reasons: The retromolar pad area does not usually present as

much fibrous attached gingiva. The keratinized gingiva, if present may not be found

directly to the molar. The greatest amount may be distolingual or

distofacial and may be over the bony crest. The ascending ramus of the mandible may also create

a short horizontal area distal to the terminal molar. The shorter this area, the more difficult it is to treat any deep distal lesion around the terminal molar.

A, Pocket eradication distal to a mandibular second molar with minimal attached gingiva and aclose ascending ramus is anatomically difficult.

B, For surgical procedures distal to amandibular second molar, abundant attached gingiva and distal space are ideal.

Modified distal wedge procedureBuccal and palatal flaps are elevated (a) and the rectangular wedge is released from the tooth and underlying bone by sharp dissection and removed (b).

Modified distal wedge procedure. Following bone recontouring and root debridement, the flaps aretrimmed and shortened to avoid overlapping wound margins and sutured (a). A close soft tissue adaptationshould be accomplished to the distal surface of the molar. The remaining fibrous tissue pad distal to the buccolingual incision line is "leveled" by the use of a gingivectomy incision .

SUTURING: A surgical suture is one that approximates the adjacent

cut surfaces or compresses blood vessels to stop bleeding.  Goals of suturing Provide an adequate tension of wound closure

without dead space but loose enough to obviate ischaemia and necrosis.

Maintain hemostasis. Permit primary intention healing. Provide support for tissue margins until they have

healed and support is no longer needed.

Reduce post – operative pain. Prevent bone exposure resulting in delayed

healing and unnecessary resorption. Permit proper flap position.

SUTURING NEEDLE: The needle consists of 3 parts Needle point Body (grasping area) Eye / Swaged end

SUTU

RING

NEED

LES:

Depending on the presence or absence of eye

  Eyed/Traumatic –Has an eye .(tying the

suture to the eye is not recommended , as it increases the bulk of suture material drawn through the tissues).

Eyeless (swaged)/atraumatic – swaged needles do not require threading and permit a single strand of suture material to be drawn through tissues. Inserted into the hollow end during manufacture& the metal iscompressed around it.This doesn’t cause injury to the tissues compared to eyed needle ‐Atraumatic needles

Depending on the shape of the body: Round oval rectangular trapezoid side

flattened.

Depending on the shape of the point;

Depending on the curvature:

Depending upon cutting surface: Conventional cutting: cutting edges along the

inner curvature of the needle. Reverse cutting needle: doesn’t have any cutting

edge along its inner curvature & has flat internal surface.

This needle will cut less tissue in its path through that issue, and thus its use will present needless tissue damage and wound enlargement.

In periodontal surgeries-always use Reverse cutting needles.

This prevents the suture material from tearing through the papillae or surgical flap edges , referred to as “cut-out”, which most commonly happens while using conventional cutting needles

Depending on material-steel, carbon steel.

Qualities of an ideal suture material

The following qualities of the ideal suture materialare compiled from Postlethwait (1971),Varmaand colleagues (1974), and Ethicon (1985):1. Pliability, for ease of handling2. Knot security3. Sterilizability4. Appropriate elasticity5. Nonreactivity6. Adequate tensile strength for wound healing7. Chemical biodegradability as opposed to foreign body breakdown

Suture materials for periodontal flaps: 

Non absorbable  Silk : braided(It consists of many thinner filaments , twisted

together to form a string of desired diameter.) Monofilament suture is advantageous over the Braided suture as, the Braided suture does have the “ wicking effect ” . ” i.e, it pulls the bacteria & fluid into the wound site .

Nylon : monofilament(ethilon)

EPTFE : monofilament(Gore-tex) (used in with implants, bone grafts, guided tissue regeneration, or guided bone regeneration)

  Polyester : braided (Ethibond)

Absorbable  Plain gut : monofilament (30 days)  Chromic gut : monofilament (45-60 days.) 

Synthetic  Polyglycolic : braided (16-20 days) (Vicryl) ( Dexon)

Polyglecaprone : Monofilament (90-120 days) (monocryl)

Polyglyconate : monofilament (Maxon)

Principles of suturing (Laskin): The needle holder should

grasp the needle at approximately 3/4th of the distance from the needle point.

The needle should enter the tissue perpendicular to the surface .

Sutures should be located 2-3mm below the imaginary line that forms the base of the triangle of the interdental papillae.

The suture should be placed at an equal distance [ 2‐3 mm ] on both sides of the incision .

Suture should be always inserted through the more mobile & from thinner flap first.

The suture should be tied so the tissue is merely approximated & not blanched.

The knot shouldn’t be placed on the incision line to avoid wicking effect.

Sutures should be placed 3-4 mm apart. The closeness of sutures depend upon the underlying tension across the suture line. Closer spaced sutures are indicated in areas of underlying muscular activity such as tongue or in other areas of increased tension.

Suturing:

Indications of interrupted sutures:

Vertical incision Tuberosity and retromolar areas. Bone regeneration procedures with or without GTR Widman flaps , open flap curettage, unrepositioned flaps,

or apically positioned flaps where maximum interproximal coverage is required.

Edentulous areas. Partial or split thickness flaps. Osseointegrated implants. 

Simple loop suture: Most commonly used

suture because of its simplicity.

Suture forms a simple circular loop uniting the two edges of the surgical incision.

This suture permits a better closure of the interdental papilla and should be performed when bone grafts are used.

FIGURE – 8 SUTURE

As the name tells, this suture forms a loop with a figure of eight, with the criss‐cross limbs of eight placed between the two flap edges.

Interrupted vertical mattress:

The vertical mattress (nonperiosteal) suture is recommended for use with bone regeneration procedures because it permits maximum tissue closure while avoiding suture contact with the implant material, thus preventing wicking.

Laurell modification Laurell modified

mattress suture (1993)for coronal flap positioning and primary flap coverage is a technique which, although capable of being employed for all regenerative techniques, is used predominantly when standard interproximal incisions are used.

Modified flap suturing technique This technique (Cortellini et al

1995) was introduced for achieving maximum interproximal coverage and primary closure over intrabony defect is treated by GTR.

It requires the initial incision be made at the buccal line angles in the area of the interproximal defect. It is a papillary preservation technique. The suturing permits coronal positioning, flap stabilization, and primary interproximal closure.

Intrapapillary sutures:This technique is recommendedfor use only with modified Widmanflaps and regeneration procedures in which there is adequate thickness of the papillary tissue.

Sling Ligation. (interrupted sling suture)

The sling suture is primarily used for a flap that has been raised on only one side of a tooth, involving only one or two adjacent papillae.

It is most often used in coronally and laterally positioned flaps. The technique involves use of one of the interrupted sutures, which is either anchored about the adjacent or slung around the tooth to hold both papillae.

Interrupted sling suture around single tooth

sling suture around adjacent tooth:

CON

TINO

US SU

TURES:

When multiple teeth are involved, this is preferred.

Advantages: Can include as many teeth as required. Minimizes the need for multiple knots. Simplicity. The teeth are used to anchor the flap. Permits precise flap placement. Avoids the need for periosteal sutures. Allows independent placement and tension of

buccal and lingual/palatal flaps.

disadvantages The main disadvantage of continuous sutures is

that if the suture breaks, the flap may become loose or the suture may come untied from multiple teeth.

Horizontal Mattress Suture.

Indication:1.This suture is often used for the interproximal

areas of diastema 2.for wide interdental spaces to properly adapt the

interproximal papilla against the bone.

When greater papillary control and stability and more precise placement are required or to prevent flap movement, vertical or horizontal mattress sutures are used. This is most often the case on the palate, where additional tension is often required, or when the papillary tissue is thin and friable.

Locking. The continuous locking suture is indicated

primarily for long edentulous areas, tuberosities, or retromolar areas. It has the advantage of avoiding the multiple

knots of interrupted sutures. If the suture is broken, however, it may

completely untie.

Continuous locking sutureused primarily for edentulous areas.

Continuous Independent Sling Suture.  

Indication: This is used when there is both a facial and a

lingual flap involving many teeth.

This type of suturing is used for the maxillary arch because the palatal gingiva is attached and fibrous, whereas the facial tissue is thinner and mobile.

Anchor Suture. The closing of a flap mesial or distal to a tooth,

as in the mesial or distal wedge procedures, is best accomplished by the anchor suture.

This suture closes the facial and lingual flaps and adapts them tightly against the tooth. The needle is placed at the line angle area of the facial or lingual flap adjacent to the tooth, anchored around the tooth, passed beneath the opposite flap, and tied.

A to D, Distal wedge suture. This suture is also used to close flaps that are mesial or distal to alone-standing tooth. 

Closed Anchor Suture.

Another technique to close a flap located in an edentulous area mesial or distal to a tooth consists of tying a direct suture that closes them proximal flap, carrying one of the threads around the tooth to anchor the tissue against the tooth, and then tying the two threads.

The closed anchor suture, another technique to suture distal wedges.  

Periosteal sutures: This type of suture is used to hold in place

apically displaced partial thickness flaps. There are two types of periosteal sutures: the holding suture and the closing suture. The holding suture is a horizontal mattress suture

placed at the base of the displaced flap to secure it into the new position.

Closing sutures are used to secure the flap edges to the periosteum.

Periosteal suturing :

1.Penetration : the needle point is positioned perpendicular to the tissue surface and underlying bone. It is the inserted completely through the tissue until bone is engaged.

2.Rotation : the body is now rotated about the needle point in the direction opposite to that in which the needle is intended to travel. The needle point is held lightly against the bone so as not to damage or dull the needle point.

Glide: The needle point is now permitted to glide against the bone for only a short distance. Care must be taken not to lift or damage the periosteum.

Rotation: As the needle glides against the bone, it is rotated about the body, following its circumferenced outline. In this way, the needle will not be pushed through the tissue.

5.Exit : the final stage of gliding and rotation is needle exit.it is made to exit the tissue through gentle application of pressure from above allowing the tip to pierce the tissue.

Periosteal sutures for an apically displaced flap. Holding sutures, shown at the bottom, are done first, followed by the closing sutures, shown at the coronal edge of the flap. 

Sutured Knot Components The knot may be tied in 2

techniques INSTRUMENT TIE :Using

needle holder ONE‐HANDED & TWO‐

HANDED TIE: Using fingers

As periodontal surgeries instrument tie is the most appropriate & extensively used technique.

Principles of Knot tying….Ethicon 1985

1.Knot must be firm ….no slippage.2.Knot should not be placed on incision

lines ..avoid wicking.3.Avoid excessive tension…..crimping of suture.5. Knot ends must be 2‐3mm.6. An added throw does not increase the

strength of the knot.7. Final tension or final throw should be as

nearly horizontal as possible.

Principles of suture removal….Ethicon

1. The area should be swabbed with hydrogen peroxide for removal of encrusted necrotic debris, blood, and serum from about the

sutures.2. A sharp suture scissors should be used

to cut the loops of individual or continuous sutures about the teeth.

A cotton pliers is now used to remove the sutures. The location of the knots should be noted so that they can be removed first. This will prevent unnecessary entrapment under the flap.

Sutures should be removed in 7 to 10 days to prevent epithelialization or wicking about the suture. (Cohen)

Types of Knots:

Square surgeons slip or granny knot knot knot

Square knot:

This knot appears squarish before tightening the knot.

Technique: It is formed by tying 2

ties. The first one in one

direction & the second tie by throwing the suture in opposite direction

ADVANTAGES

Quick and simple useful when surgeon is using silk suture

which has good frictional resistance to loosening

DISADVANTAGES When the flaps are not lying passively against

the bone, the square knot cannot be used because the tension of the flaps will pull them apart.

Surgeon’s knot:

It is the most commonly used knot as it reduces slippage of the first tie, while the 2nd tie is placed.

Technique: It is formed by tying 2 ties. The first tie is formed by

2 throws in one direction & the 2nd tie in opposite direction.

Granny’s knot:

Technique: It involves a first tie in

one direction followed by a second tie in the same direction as first.

Later a third tie is made to hold the knot permanently.

Advantages:

Once it is tightened to the desired

extent, it can be locked into place by another over hand

knot, made in opposite direction

of first two.

This ability to be tightened makes the slip knot extremely

useful in many surgical situations example it can be

used to stretch flaps to achieve primary healing over a surgical

site.

SUTURE REMOVAL› As a rule Intra oral sutures are removed 5‐7

days after the suturing.Complications following Suturing The knot slips gives rise to 90% of the

complications following suturing, leading to dehiscence of wound.

If the non‐resorbable sutures like silk, are left in place for longer duration the lead to abcess formation. Here termed as “ Stich Abcess ”

In case of braided sutures,because of the“wicking‐effect”there can be spread of infection all along the suture line.

If the suture material is left in‐situ for longer periods than 3 weeks, the epithelial cells migrate down the suture pathway leading to Epithelial inclusion cysts“ & Railroad track ” scar

Periodontal dressing: Defined as surgical dressings, after periodontal

surgery, applied to the necks of teeth and adjacent tissue to cover and protect the surgical wound.

Forms a physical barrier and is placed in the surgical site to protect the healing tissues from the forces of mastication.

History: Introduced in

1923 by Dr. A.W. Ward. In the form of “wonderpack”

1942 Box & Ham used ZnO Eugenol

dressing to perform chemical curettage in treatment of NUG

1943- Orban used ZnO Eugenol &

Paraformaldehyde to perform

gingivectomy by chemosurgery.

1947- Bernier & Kaplan for

wound protections.

1962- Blanquie-control

postoperative bleeding-splint

loose teeth-desensitize cementum

1964 Gold-splint teeth, as it was cement dressing that

set hard.

1964- Weinreb & Shapiro- ZnO Eugenol

impregnated cords into periodontal

pockets, but found less effective than

gingivectomy

1969- Baer et al stated that primary purpose of a dressing –patient

comfort, protect wound from further

injury during healing-hold flap in position

Classification of dressings:

Eugenol containing without eugenol

I. Zinc oxide eugenol dressings: Powder & liquid form (Kirkland pack) Setting occurs as a result of chemical interaction

between zinc oxide & eugenol form zinc eugenolate. Paste form: two separate tubes- base & accelerator**ward’s Wonder pack

II. Non Eugenol packs:

Coepak• Supplied as 2 pastes- base&

accelerator or as an auto – mixing system conatined within a syringe.

• Base: Metallic (zinc oxide),oil for plasticity,gum for cohesiveness & lorothidiol(fungicide).

• Catalyst: liquid coconut fatty acid thickened with resin &chlorothymol(bacteriostatic agent).

periocare – available in form of paste-gel &setting occurs by chemical reaction.

Perio putty- contains methyl & propyl parabens for effective bactricidal & fungicidal properties& benzocaine as topical anesthetic.

Peripac – this is a pre mixed dressing.when this material is exposed to air or moisture, it sets by loss of organic solvent.

Vocopac- contains 90 gm base & 90 gm catalyst. Adheres excellently to teeth & promote healing.

Tissue conditioners/methacrylic gel dressing. Methacrylic gels exhibit clase adaptation, constant flow for 3 days and excellent compatibilty with wound site.

Collagen dressing: it is a collagen sponge. Eg: Collacote –type I collagen derived from bovine Achilles tendon.Completely resorbable dressing that is used to cover & protect palatal graft sites.

Cyanoacrylates: with the spray, an application of cyanoacrylate can be completed in 0.3sec. The material adheres easily to the outer surface of tissue & results in instant hemostasis.

Visible light cure periodontal dressing- BARRICAID

Available in syringe for direct application or dispensing on a mixing pad, and placed intraorally.

Curing of material is then accomplished with a visible light curing unit .

Ingredients:

Polyether urethane dimethacrylate resin, silanated silica,visible right (VLC)photo initiator & accelerator stabilizer.

ADVANTAGES:

Offers a translucent pink colour on setting which is esthetically pleasing.

Limitations:

Not the choice of dressing to be used in situations where the flap has to be apically retained ,due to its soft state before curing.

Contain polymerisable monomers which may cause skin sensitization.(allergic contact dermatitis)

Whether to give periodontal dressing or not ?

In favour

ward in 1923

advocated the use of wonder pack to

avoid pain, infection,

root sensitivity.

bernier and

kaplan in 1947,

reported that

dressing facilitates healing process.

Linghorne in 1949, studied

different periodontal dressings to determine

their bacteriostatic

properties and found it

to be an effective

bacteriostatic agent.

Loe and Slilness 1957, reported that dressing provided

more favorable environment for

healing.

Blanquie 1962 stated that porpose of dressing is to control post operative discomfort, act as a splint

for losse teeth, allow tissue healing under

aseptic conditions,prevent re establishment of

periodontal pocket and desenitize denuded

cementum.

Against :

waerhaug 1955 , Baer et al 1969 pointed out that

application of periodontal

dressing did not influence the final

outcome of healing.

Jones and Cassingham 1979 in their study

concluded that dressings caused more pain and

discomfort to the patients without serving any useful

purpose in flap surgery.

Allen &Caffesse

1983 pointed out that

periodontal packs did not

improve healing and its

use is a matter of personal choice.

Some studies have shown that

dressings promote bacterial

colonisation and compromise patient’s oral hygiene.well adapted flaps

serve as a barrier to bacteria & thus provide

better protection than dressings.

POST OPERATIVE INSTRUCTIONS:

For the 1st 3 hours, hot foods should be avoided. Semisolid diet is preferable and should be chewed from non

operated side. Citrus fruits, fruit juices and highly spiced foods and

alcoholic beverages should be avoided as they will cause irritation and pain of the wound.

Food supplements or vitamins are prescribed if needed, but not mandatory.

Mouthwash rinsing ( chlorhexidine 0.12%) twice a day is prescribed following toothbrushing. It refreshes the mouth and decrease plaque formation in the oral cavity which is usually increased postoperatively because of the compromised toothbrushing of the patient.

DAY 1 Analgesics,cold packs, avoidance of wound disturbance

After day 1 Pain , swelling, bleeding should diminish or disappear.Chemical plaque control recommended.

After 5 – 10 days: Remove dressing and sutures,Professionally de – plaque supragingivally.

After 4 – 6 weeks: Weekly or biweekly recall for de-plaquing & oral hygiene instructions.

The dento gingival junction should not be probed or instrumented for 6 to 8 weeks following surgery.

HEALING AFTER FLAP SURGERY: Immediately after suturing (0 to 24 hours) a

connection between the flap and the tooth or bone surface is established by a blood clot (which consists of a fibrin reticular with many PMNs, RBCs, debris of injured cells, and capillaries at the edge of the wound. There are also bacteria and an exudates or transudate as a result of tissue injury.)

1 to 3 days after flap surgery the space between the flap and the tooth or bone is thinner and epithelial cells migrate over the border of the flap.

One week after surgery ,epithelial attachment to the root has been established by means of hemidesmosomes and a basal lamina. The blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow and periodontal ligament.

Two weeks after surgery , collagen fibers begin to appear parallel to the tooth surface. Union of the flap to the tooth is still weak, owing to the presence of immature collagen fibers, although the clinical aspect may be almost normal.

One month after surgery , a fully epithelialized gingival crevice with a well defined epithelial attachment is present. There is a beginning of functional arrangement of the supra crestal fibers.

Full thickness flaps, which denude the bone, result in a superficial bone necrosis at 1 to 3 days; osteoclastic resorpion follows and reaches a peak at 4 to 6 days, declining thereafter. This results in a bone loss of about 1 mm; the bone loss is greater if the bone is thin.

Bone repair reaches its peak at 3 to 4 weeks. Loss of bone occurs in the initial healing stages

both in radicular and in interdental bone areas. However, in interdental areas, which have cancellous bone, the subsequent repair results in total restitution without any loss of bone, bone repair results in loss of marginal bone.

Studies related to healing:

VASCULAR HEALING Cutright (JP,1969) : Proliferation of blood vessels in

gingival wounds  Day 1 : withdrawal and blockage of cut ends of the vessels at

wound margin.

Day 2 : new sprouts, club – shaped stubs at bottom of wound.   Day 3 : Short capillary loops forming , arising from the cut

surfaces of existing vessels which anastomose. No regeneration at the edges of the wound.

Day 5 : Increased capillary loops with dilation of one limb. Corners of the wound show revascularization.

Day 7 : General contour of gingival re established, floor and edges show completion of capillary loops.

Day 9 : Capillary loops almost reach height of normal loops, density less than normal.

Day 11 : Further restoration of normal pattern and size, density stil not equal to normal gingival.

Soft tissue healing: Kon ( JP, 1969) :

0 hour : Thin blood clot over exposed bone and CT.

2 days : increased flap vascularization / vasodilation. Rete pegs flat.

6 – 7 days : increased inflammatory reaction, flap still prone to separation, bloot clot replaced by immature CT.

7 days : Osteoclastic activity reaches peak at day 7.

12 days : Flap is reattached to bone and tooth, osteoblastic activity predominates at day 12.

  23 – 31 : Bone reformed at crest and buccal

septum, organized CT.

55 – 85 : Periodontal tissues reconstructed ,DGJ renewed, buccal plate is rebuilt.

 DIETERY FACTORS affecting healing after flap : 

Vogel et al. (1984):   Zinc : stabilizes membranes and decreases lysosomal

enzyme and histamine release.

Vitamin C : May alter PMN function, needed for collagen synthesis ( cross link process).

Iron : Collagen metabolism, may alter macrophage function and PMN

Protein : epithelial barrier

Folic acid : epithelial barrier. Collagen metabolism

REFRENCES: Carranza 10th edition Lindhe 5th edition Cohen Atlas of periodontal surgery( Sato) Laskin’s book of surgery.

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