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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). Sulcular incision is now made around the tooth to facilitate flap elevation. The modified Widman flap has been described for exposing the root surfaces for meticulous instrumentation and for the removal of the pocket lining.6 Again, it is not intended to eliminate or reduce pocket depth, except for the reduction that occurs during healing as a result of tissue shrinkage. Conflicting data surround the advisability of uncovering the bone when this is not actually needed. This is also known as Ledge-and-wedge technique. Long-term outcome of undisplaced fatigue fractures of the femoral neck in young male adults; 3. Contents available in the book .. Log In or, (Courtesy Dr. Kitetsu Shin, Saitama, Japan. Evian et al. An intact papilla should be either excluded or included in the flap. The initial or internal bevel incision is made (. Square, parallel, or H design. To perform this technique without creating a mucogingival problem it should be determined that enough attached gingiva will remain after after removal of pocket wall. Another important objective of periodontal flap surgery is to regenerate the lost periodontal apparatus. Apically-displaced Flap During the initial phase of healing, inflammatory cells are attracted by platelet and complement derived mediators and aggregate around the blood clot. HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva.It can cover teeth in various degrees, and can lead to aesthetic disfigurement. According to flap reflection or tissue content: C. According to flap placement after surgery: Diagram showing full-thickness and partial-thickness flap. The vertical incisions are made from the center of palatal/lingual surfaces of teeth extending palatally/lingually. The incisions given are the same as in case of modified Widman flap procedure. A new technique for arthroscopic meniscectomy using a traction suture, , 2015-02, ()KCI . The distance of the incision from the gingival margin (thickness of the incision) varies according to the pocket depth, the thickness of the gingiva, width of the attached gingiva, shape and contour of gingival margins and whether or not the operative area is in the esthetic zone. Step 7:Continuous, independent sling sutures are placed in both the facial and palatal areas (Figure 59-3, I and J) and covered with a periodontal surgical pack. FLAP Flap yaitu suatu lembaran jaringan mukosa yang terdiri dari jaringan gingiva, mukosa alveolar, dan atau jaringan periosteum yang dilepaskan/ dissection dari permukaan tulang alveolar. 5. Although some details may be modified during the actual performance of the procedure, detailed planning allows for a better clinical result. 15c, 11 or 12d. Contents available in the book .. Minor osteoplasty may be carried out if osseous irregulari-ties are observed. 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. Following is the description of these flaps. 3. Bone architecture is not corrected unless it prevents good tissue adaptation to the necks of the teeth. Flaps are used for pocket therapy to accomplish the following: 1. Once the bone sounding has been done and the thickness of the gingiva has been established, the design of the flap is decided. Re-inspection of the operated area is done to check for any deposits on the root surfaces, remaining granulation tissue or tissue tags which are removed, if detected. - Charter's method - Bass method - Still man method - Both a and b correct . In this flap procedure, no ostectomy is performed; however, minor osetoplasty may be done to modify the undesired bony architecture. To perform this technique without creating a mucogingival problem, the clinician should determine that enough attached gingiva will remain after removal of the pocket wall. The buccal and palatal/lingual flaps are reflected with the help of a periosteal elevator. This incision is indicated in the following situations. The granulation tissue is highly vascularized, so it bleeds profusely. After the primary incision, tissue can now be retracted with the help of rat-tail pliers. In these flaps, the entire papilla is incorporated into one of the flaps. In the present discussion, we discussed various flap procedures that are used to achieve these goals. Severe hypersensitivity. 15 scalpel blade, parallel to each other beginning at the distal end of the edentulous area, continued to the tooth. The no. 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. Its final position is not determined by the placement of the first incision. 2. UNDISPLACEDFLAP |Also known as internal bevel gingivectomy |Differs from the modified widman flap inthat pocket wall is removed with the initial incision TECHNIQUE |Pockets are measured with a pocket marker & a bleeding point is created THE INITIAL INTERNAL BEVEL INCISION IS CARRIED APICAL TO THE CREST OF BONE CONTD. The book is usually delivered within one week anywhere in India and within three weeks anywhere throughout the world. In this technique no. The margins of the flap are then placed at the root bone junction. This flap procedure is indicated in areas that do not have esthetic concerns and areas where a greater reduction in pocket depth is desired. After the administration of local anesthesia, bone sounding is performed to identify the exact thickness of the gingiva. The undisplaced (unrepositioned) flap improves accessibility for instrumentation, but it also removes the pocket wall, thereby reducing or eliminating the pocket. The incision is made not only around the facial and lingual radicular area but also interdentally, where it connects the facial and lingual segments to free the gingiva completely around the tooth (Figure 57-9; see Figure 57-5). Expose the area for the performance of regenerative methods. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. 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 not indicated unless the margin of the gingiva is quite thick. Tooth with marked mobility and severe attachment loss. Contents available in the book .. This is mainly because of the reason that all the lateral blood supply to. The patient is recalled after one week for suture removal. According to flap reflection or tissue content: Step 2: The mucogingival junction is assessed to determine the amount of keratinized tissue. ious techniques such as gingivectomy, undisplaced flap with/without bone surgery, apical resected flap with/without bone resection, and forced eruption with/without fiberotomy have been proposed for crown lengthening procedures.2-4 Selecting the technique depends on various factors like esthetics, crown-to-root ratio, root morphology, furcation The Orban knife is usually used for this incision. It allows the vertical incision to be sutured without stretching the flap over the cervical convexity of the tooth. The distance of the incision from the gingival margin (thickness of the incision) varies according to the pocket depth, the thickness of the gingiva, width of the attached gingiva, shape and contour of gingival margins and whether or not the operative area is in the esthetic zone. As described in, Image showing primay and secondary incisions used in ledge and wedge technique. Every effort is made to 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. 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. Every effort is made to 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. Contents available in the book . The blood clot provides a framework for the proliferation and migration of cells from surrounding tissues including gingiva, periodontal ligament (PDL), cementum, and alveolar bone 38. 12 blade on both the buccal and the lingual/palatal aspects continuing it interdentally extending it in the mesial and distal direction. 6. Contents available in the book . Contraindications of periodontal flap surgery. 3. 1. drg. This flap procedure causes the greatest probing depth reduction. 12D blade is usually used for this incision. It is most commonly caused due to infection and sloughing of blood vessels. Platelets rich fibrin (PRF) preparation and application in the . It conserves the relatively uninvolved outer surface of the gingiva. Contents available in the book .. . This type of flap is also called the split-thickness flap. Periodontal pockets in severe periodontal disease. Step 2:The initial or internal bevel incision is made (Figure 59-4) after scalloping the bleeding marks on the gingiva (Figure 59-5). Apically displaced flap. May cause attachment loss due to surgery. Apically displaced flaps have the important advantage of preserving the outer portion of the pocket wall and transforming it into attached gingiva. The basic clinical steps followed during this flap procedure are as follows. The vertical incision must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow for the release of the flap to be displaced. . Genon and Bender in 1984 27 also reported a similar technique indicated for esthetic purpose. The incisions made should be reverse bevel to achieve thinning of tissue so that an adequate final approximation of the flaps can be achieved. The flap was repositioned and sutured and . Contents available in the book .. Horizontal incisions are directed along the margin of the gingiva in a mesial or distal direction. The periodontal flap is one of the most frequently employed procedures, particularly for moderate and deep pockets in posterior areas (see, Increase accessibility to root deposits for scaling and root planing, Eliminate or reduce pocket depth via resection of the pocket wall, Gain access for osseous resective surgery, if necessary, Expose the area for the performance of regenerative methods, Technique for Access and Pocket Depth Reduction or Elimination, All three flap techniques that were just discussed involve the use of the basic incisions described in. It is an access flap for the debridement of the root surfaces. Also, complicated or prolonged surgical procedures that require full-thickness mucoperiosteal flaps with resultant edema can lead to trismus. The choice of which procedure to use depends on two important anatomic landmarks: the pocket depth and the location of the mucogingival junction. 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. After it is removed there is minimum bleeding from the flaps as well as the exposed bone. Contents available in the book . Chlorhexidine rinse 0.2% bid . Step 5:Tissue tags and granulation tissue are removed with a curette. 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. (The use of this technique in palatal areas is considered in the discussion that follows this list. 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. 2. Disain flep ini memberikan estetis pasca bedah yang lebih baik, dan memberikan perlindungan yang lebih baik terhadap tulang interdental, hal mana penting sekali dalam tehnik bedah yang mengharapkan terjadinya regenerasi jaringan periodontium. It is indicated where complete access to the bone is required, for example, in the case of osseous resective surgeries. Both full-thickness and partial-thickness flaps can also be displaced. This incision can be accomplished only if sufficient attached gingiva remains apical to the incision. This approach was described by Staffileno (1969) 23. Contents available in the book .. Later on Cortellini et al. The internal bevel incision starts from a designated area on the gingiva, and it is then directed to an area at or near the crest of the bone (Figure 57-6). A small periosteal elevator or Molt 2/4 curette can be used for this purpose. techniques revealed that 67.52% undergone kirkland flap, 20.51% undergone modified widman flap, 5.21% had papilla preservation flap, 2.25% had undisplaced flap, 1.55% had apically displaced flap and very less undergone distal wedge procedure which depicts that most commonly used flap technique was kirkland flap among other techniques. The following steps outline the undisplaced flap technique. Contents available in the book .. Before we go into the details of the periodontal flap surgeries, let us discuss the incisions used in surgical periodontal therapy. Contents available in the book .. The area is anesthetized and bone sounding is done to evaluate the osseous topography, pocket depth, and thickness of the gingiva. Continuous, independent sling sutures are placed in both the facial and palatal areas (. Suturing techniques. More is the thickness of the gingiva, farther is the incision placed to include more tissue which needs to be removed. The narrow width of attached gingiva which may further reduce post-operatively. If the tissue is too thick, the flap margin should be thinned with the initial incision. The distance of the primary incision from the gingival margin depends on the thickness of the gingiva. Historically, gingivectomy was the treatment of choice for these areas until 1966, when Robinson 32 addressed this problem and gave a separate surgical procedure for these areas which he termed distal wedge operation. These techniques are described in detail in. Rough handling of the tissue and long duration of the surgery commonly result in post-operative swelling. Because the alveolar bone is partially exposed, there is minimum post-operative pain and swelling. In another technique, vertical incisions and a horizontal incision are placed. Tooth with extremely unfavorable clinical crown/root ratio. If the dressing has to be placed, a dry foil is first placed over the flap before covering it with the dressing so that the displacement of the pack under the flap is prevented. May cause esthetic problems due to root exposure. 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. 1. The scalloping of the incision may not be accentuated as the flap has to be apically displaced and is not adapted interdentally. The conventional flap is used (1) when the interdental spaces are too narrow, thereby precluding the possibility of preserving the papilla, and (2) when the flap is to be displaced. Click this link to watch video of the surgery: Modified Widman Flap surgery. Eliminate or reduce pocket depth via resection of the pocket wall, 3. The most abundant cells during the initial healing phase are the neutrophils. The incision is carried around the entire tooth. 15 scalpel blade is used to make a triangular incision distal to the molar on retromolar pad area or the maxillary tuberosity. Undisplaced flap Palatal Flap The surgical approach is different here because of the nature of the palatal tissue which is attached, keratinized tissue and has no elastic properties associated with other gingival tissues, hence no displacement and no partial thickness flaps. The periodontal dressing is not required if the flap has been adapted adequately to cover the interdental area. The internal beveled incision for the modified Widman flap closely follows the scalloped outline of the dentition to minimize the loss of the attached keratinized gingiva. After administration of local anesthesia, bone sounding is done to assess the thickness of gingiva and underlying osseous topography. Root planing is done followed by osseous surgery if needed. Chlorhexidine rinse 0.2% bid was prescribed for 2 weeks, along with analgesics and the patient was given appropriate . The triangular wedge of the tissue, hence formed is removed. 2) by pushing the instrument in the interdental area and twisting it to remove the infected granulomatous tissue. Possibility of exposure of furcations and roots, which complicates postoperative supragingival plaque control. This complete exposure of and access to the underlying bone is indicated when resective osseous surgery is contemplated. See video of the surgery at: Modified flap operation. No incision is made through the interdental papillae. Once bone sounding has been done, a gingivectomy incision without bevel is given using a periodontal knife to remove the tissue above the alveolar crest. Contents available in the book .. Hereditary gingival fibromatosis (HGF), also known as idiopathic gingival hyperplasia, is a rare condition of gingival overgrowth. 15 or 15C surgical blade is used most often to make this incision. These vertical incisions are now joined with a horizontal incision as shown in the following figure. When bone is stripped of its periosteum, a loss of marginal bone occurs, and this loss is prevented when the periosteum is left on the bone. The bleeding is frequently associated with pain. Contents available in the book . Local anesthesia is administered to achieve profound anes-thesia in the area to be operated. Areas where greater probing depth reduction is required. Periodontal Flap Surgery Wendy Jeng 117.4k views 035. periodontal flap Dr.Jaffar Raza BDS 7.5k views 17.occlusal schemes anatomic and semiamatomic occlusion www.ffofr.org - Foundation for Oral Facial Rehabilitiation 1.1k views Suturing techniques involved in dental surgery Hasanain Alani The internal bevel incision is basic to most periodontal flap procedures. Then sharp periodontal curettes are used to remove the granulomatous tissue and tissue tags. May cause hypersensitivity. There is a loud S1 The murmur is a mid-diastolic rumbling heard best at . Contents available in the book .. The coronally directed incision is designated as external bevel incision whereas the apically directed incisions are the internal bevel and sulcular incision. Contents available in the book . Several techniques such as gingivectomy, undisplaced flap with or without osseous surgery, apically repositioned flap with or without resective osseous surgery, and orthodontic forced eruption with or without fibrotomy have been proposed for clinical crown lengthening. Contents available in the book .. After debridement, flaps are closely adapted around the teeth in close approximation, allowing healing by primary intention. Conventional flaps include the modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for reconstructive procedures. The interdental incision is then given to remove the wedge of tissue that contains the pocket wall. FLAP PERIODONTAL. Takei et al. Journal of periodontology. Contents available in the book . Incisions can be divided into two types: the horizontal and vertical incisions, Basic incisions used in periodontal surgeries, This internal bevel incision is placed at a distance from the gingival margin, directed towards the alveolar crest. Contents available in the book .. The papillae are then carefully pushed back through the interdental embrasures to palatal or lingual aspect. Irrespective of performing any of the above stated surgical procedures, periodontal wound healing always begins with a blood clot in the space maintained by the closed flap after suturing 36. Flap reflection till alveolar mucosa to mobilize the flap causes more post-operative pain and discomfort. Assign a 'primary' menu craigslist hattiesburg ms community ; cottonwood financial administrative services, llc The bone remains covered by a layer of connective tissue that includes the periosteum. preservation flap ) papila interdental tidak terpotong karena tercakup ke salah satu flep (gambar 2C). Position of the knife to perform the internal bevel incision. Unsuitable for treatment of deep periodontal pockets. The area to be operated is then isolated with the help of gauge. 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. Periodontal therapy, flap, periodontal flap, full thickness flap, partial thickness flap, nondisplaced flap, displaced flap, conventional flaps, papilla preservation . The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. 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, Periodontal flap surgeries are also done for the establishment of. The main causes for the bleeding include intrinsic trauma to the operated site, even after repeated instructions patients tend to play with the area of surgery with their tongue and dislodge the blood clot, tongue may also cause suction of blood by creating small negative pressures that cause secondary bleeding, presence of foreign bodies, infection, salivary enzymes may lyse the blood clot before it gets organized and slippage of suture. The periodontal flap surgeries have been practiced for more than one hundred years now, since their introduction in the early 1900s. Triangular Ramfjord and Nissle6 performed an extensive longitudinal study that compared the Widman procedure (as modified by them) with the curettage technique and the pocket elimination methods, which include bone contouring when needed. Tooth movement and implant esthetics. The internal bevel incision should be scalloped into the interdental area to preserve the interdental papilla (see Figure 59-2). 2. Coronally displaced flap. 1. The square, Irrespective of performing any of the above stated surgical procedures, periodontal wound healing always begins with a blood clot in the space maintained by the closed flap after suturing 36. Figure 2:The graph represents the distribution of various These landmarks establish the presence and width of the attached gingiva, which is the basis for the decision. Incisions can be divided into two types: the horizontal and vertical incisions 7. Access flap for guided tissue regeneration. ), Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 59: The Flap Technique for Pocket Therapy, Several techniques can be used for the treatment of periodontal pockets. The secondary incision is given from the depth of the periodontal pocket till the alveolar crest. Contents available in the book .. In 1973, App 25 reported a similar technique and termed it as Intact Papilla Flap which retained the interdental gingiva in the buccal flap. Modified flap operation, References are available in the hard-copy of the website. Contents available in the book .. The flap was repositioned and sutured [Figure 6]. This incision is made on the buccal aspect of the tooth till the desired level, sparing the interdental gingiva. May increase the risk of root caries. News & Perspective Drugs & Diseases CME & Education Thus, an incision should not be made too close to the tooth, because it will not eliminate the pocket wall, and it may result in the re-creation of the soft-tissue pocket. This technique offers the possibility of establishing an intimate postoperative adaptation of healthy collagenous connective tissue to tooth surfaces,2,3,5,6 and it provides access for adequate instrumentation of the root surfaces and immediate closure of the area.

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