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Hisham AlShorman
Eman Dylawani
20 10 2016
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The Periodontal Flap
This script include summery for chapter #57 from the book + the dr. notes in the lecture.
What is a FLAP ?
basically we mean the soft tissue, we need to have an access to the bone just to get that access we
release a flap which is section of the soft tissue that is left away from under laying bone , so it is
surgically separate from the under laying tissues in most of cases the reason for that is to reshape
or to add bone or to place an implant, to see things under soft tissue or for soft tissue augmentation
as well.
CLASSIFICATION OF FLAPS
~ Periodontal flaps can be classified based on the following:
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In case of bone graft , we put bone & we want to suture the flap back , the bulk of the bone
prevent us from putting the flap back in its original position , so we need to stretch it more, to do
that we make periosteal incision to slice the periosteum just to enable the soft tissue to stretch a
little bit.
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 however, are usually not clinically significant.
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Both full thickness and partial thickness flaps can be displaced, but to do so, the attached
gingiva has to be totally separated from the underlying bone, thereby enabling the
unattached portion of the gingiva to be moveable. However, palatal flaps cannot be
displaced owing to the absence of unattached gingiva.
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crevicular interdental incisions to sever the connective tissue attachment and a horizontal
incision at the base of the papilla leaving it connected to one of the flap.
INCISIONS
1. Horizontal Incisions
> Directed along the margin of the gingiva in a mesial or a distal direction.
> types of horizontal incisions have been recommended(1,2,3)
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positioned, becomes attached gingiva.
3) It produces a sharp, thin flap margin for adaptation to the bone-tooth junction.
> This incision has also been termed reverse bevel incision, because its bevel is
in reverse direction from that of the gingivectomy incision.
> #15C or #15 surgical scalpel is used.
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c. The interdental incision (third incision):
Is performed after the flap is elevated, after a periosteal elevator is inserted
into the initial internal bevel incision, and the flap is separated from the
bone, With this access, the surgeon is able to make the third or interdental
incision to separate the collar of gingiva that is left around the tooth.
So this incision is made not only around the facial and lingual radicular
area but also interdentally, connecting the facial and lingual segments, to
completely free the gingiva around the tooth.
These three incisions allow the removal of the gingiva around the tooth (i.e., the pocket
epithelium and the adjacent granulomatous tissue), and the remaining connective tissue in the
osseous lesion should be carefully curetted out so that the entire root and the bone surface
adjacent to the teeth can be observed.
Flaps can be reflected using only the horizontal incision if sufficient access can be obtained by
this means and if apical, lateral, or coronal displacement of the flap is not anticipated. If vertical
incisions are not made, the flap is called an envelope flap.
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> Vertical incision can be used on one or both ends of the horizontal incision,
depending on the design and purpose of the flap.
> Vertical incisions at both ends are necessary if the flap is to be apically
displaced.
> Vertical incisions must extend beyond the mucogingival line, reaching the
alveolar mucosa, to allow for the release of the flap to be displaced.
> Vertical incisions in the lingual and palatal areas are avoided.
> Facial vertical incisions should not be made in the center of an interdental
papilla or over the radicular surface of a tooth. Incisions should be made at
the line angles of a tooth either to include the papilla in the flap or to avoid it
completely.
>>why do we avoid placing the vertical incision at the
mid of the root ?
If we place the vertical incision on the mid of the root
there is increase the likelihood for recession.
> The vertical incision should also be designed so as to avoid short flaps
(mesiodistal) with long, apically directed horizontal incisions because these
could jeopardize the blood supply to the flap
A combination of full and partial thickness flaps can often be indicated to obtain the
advantages of both. The flap is started as a full thickness procedure, and then partial
thickness flap is made at the apical portion. In this way the coronal portion of the bone,
which may be subject to osseous remodeling, is exposed while the remaining bone remains
protected by its periosteum.
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ELEVATION OF THE FLAP
SUTURING TECHNIQUE
> The purpose of suturing is to maintain the flap in the desired position where it
should remain without tension until healing has progressed to the point where
sutures are no longer needed.
There are many types of sutures, suture needles, and materials. Suture materials may
be either:
1. Nonresorbable:
- The most common nonresorbable is silk & nylon.
2. or resorbable:
- They enhance patient comfort and eliminate suture removal appointments.
- Vicryl (polyglactin 910) suture : is an absorbable,synthetic suture.
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And they may be further categorized as
1. braided
2. or monofilaments.
alleviates the "wicking
effect" of braided
sutures that may allow
bacteria from the oral
cavity to be drawn
through the suture to the
deeper areas of the
wound.
The bigger the number the smaller the size )4-0 size is smaller than 3-0 size).
The curvature of the needle can be 1/2 circle or some thing else and in dentistry we always prefer
3/8 circle curvature of the needle for better access , 1/2 circle would be too much curved this is
good for GI or skin suture .
You have to know cutting or non-cutting needles , in non-cutting the cross section is circle it only
cut at the tip , they used for GI difficult surgery's they do not use in oral tissue , because the tissue
in the mouth very fragile we do not want to put pressure , so we use cutting needle which cut from
3 sides, the cross section of it is triangle like a scaler.
Reverse cutting is the most commonly used in perio; because when u start suturing u push the
needle u will not harm the tissue because the sharp edge of the needle is down word.
Smaller the suture (diameter) the less likelihood the inflammation ,silk type can cause
inflammation which is a not desirable thing to happen afterwards.
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Non-absorbable
Suturing Technique
The needle is held with the needle holder and should enter the tissues at
right angles (90 degree) and no less than 2 to 3 mm from the incision,
needle is held around the middle for better access and to avoid bending.
The needle is then carried through the tissue, following the needle's
curvature (so you enter at 90 then after penetration follow the curvature).
The knot should not be placed over the incision, should be in either side of
incision..
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Sutures of any kind placed in the
interdental papillae should enter and exit
the tissue at a point located below the
imaginary line that forms the base of the
triangle of the interdental papilla.
______________________________________________________________
Ligation:
1. Interdental Ligation.
Two types of interdental ligation can be used:
a. The direct or loop suture:
Is basically join the two pieces of
the flap in one loop, which permits
a better closure of the interdental
papilla .
b. The figure-eight suture:
The needle penetrates the outer surface of
the first flap and the outer surface of the
opposite flap. The suture is brought back
to the first flap, and the knot is tied.
Types of Sutures
Horizontal Mattress Suture:
Is inserting the needle in 2 points rather than one point
in the two sides of the flap. So we have 2 point on buccal
flap & 2 point on the lingual flap.
If our direction vertically we call it vertical Mattress,
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or if double stitch that is made perpendicular
we call it vertical Mattress if made parallel we call it
(horizontal mattress).
Mattress mean : 2 point in the tissue.
Often used for the interproximal areas of diastemata
or for wide interdental spaces .
*suture can be made continuous which give more strength to the suture.
Full-thickness flaps, which denude the bone, result in a superficial bone necrosis at 1 to 3 days;
This results in a loss of bone of about 1 mm, the bone loss is greater if the bone is thin .
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Loss of bone occurs in the initial healing stages both in radicular bone and in interdental bone areas:
interdental areas, which have cancellous bone, the subsequent repair stage results in total restitution
without any loss of bone.
whereas in radicular bone, particularly if thin and unsupported by cancellous bone, bone repair results in
loss of marginal bone.
Osteoplasty (thinning of the buccal bone) using diamond burs, included as part of the surgical technique,
results in areas of bone necrosis with reduction in bone height, which is later remodeled by new bone
formation. Therefore, the final shape of the crest is determined more by osseous remodeling than by
surgical reshaping.
The end ..
Eman Dylawani
A lot of thanks to Sara Al-Ajrashi
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