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Periodontal Flap Surgery


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Periodontal Flap Surgery

  1. 1. Flap SurgeryPresenter: R2 鄭瑋之 Instructor: Dr. 陳娟娟 2012/11/14
  2. 2. Purpose1. To gain access to deeper periodontal structures with direct vision.2. Relocation of the frenulum3. Maintenance of the attached tissue4. Pocket elimination and regeneration
  3. 3. Indications• Pockets > 5mm persisting after phase I therapy• Bony pockets and interdental craters• Bony lesions in the furcations• Need for surgical crown lengthening• When to open up a flap? complicated morphology like: – Deep and narrow pocket – Difficult to achieve the correct angle
  4. 4. Contraindications• Shallow, supraalveolar pockets – subgingival scaling/rootplaning• Esthetically sensitive areas• Fibrous thickened gingiva – gingivectomy  more favorable morphology
  5. 5. Comparison of open vs. closed
  6. 6. Instruments
  7. 7. Instruments Small elevators for mobilization of the mucoperiosteal flap
  8. 8. Instruments
  9. 9. Principles of Flap Design• Local flap 1.outlined by a surgical incision 2.carries its own blood supply 3.allows surgical access to underlying tissues 4.can be replaced in the original position 5.can be maintained with sutures and is expected to heal  Used in oral surgical, periodontic, and endodontic procedures to gain access.
  10. 10. Principles of Flap Design• Complications A. Flap necrosis B. Flap Dehiscence C. Flap Tearing D. Injury to Local Structures
  11. 11. Principles of Flap Design A. Flap necrosis1. Base > Free margin • to preserve an adequate blood supply • unless a major artery is present in the base2. Width of Base > Length of Flap*2 • less critical in oral cavity, but length < width • a long, straight incision with adequate flap reflection heals more rapidly than a short, torn incision.3. An axial blood supply in the base4. Hold the flap with a retractor resting on intact bone to prevent tension.
  12. 12. Principles of Flap Design B. Flap Dehiscence1. The incisions must be made over intact bone2. If the pathologic condition has eroded the buccocortical plate, the incision must be at least 6 or 8 mm away from it.3. The incision is 6 to 8 mm away from the bony defect created by surgery.4. Gently handle the flaps edges5. Do not place the flap under tension6. Do not cross bony prominences, ex: canine eminence
  13. 13. Principles of Flap Design B. Flap Dehiscence
  14. 14. Principles of Flap Design C. Flap Tearing• Envelope flaps – an incision around the necks of several teeth. – extends 2 teeth anterior and 1 tooth posterior.If not provide sufficient access…• Vertical (oblique) releasing incisions: – extends 1 tooth anterior and 1 tooth posterior. – started at the line angle of a tooth. – carried obliquely apically into the unattached gingiva. – If cross the papilla  localized periodontal problems
  15. 15. Principles of Flap Design D. Injury to Local Structures• Mandible: lingual n. & mental n.
  16. 16. Principles of Flap Design D. Injury to Local Structures• Maxilla: greater palatine a. & nasopalatine n./a.
  17. 17. Basic Incisions• Can be sulcular, crestal, or inverse bevel
  18. 18. Basic Incisions Full thickness(mucoperiosteal) a: sulcularDepending on b: crestalthe amount ofattached tissuepresent
  19. 19. Basic Incisions Split/partial thickness (mucosal)In areas of thinbony plates andfor mucogingivalprocedures
  20. 20. Basic Incisions 2. inversebeveled Modified flap incision to the crest (mucoperiosteal) of bone.Requires adequate 1. gingivectomyattached Incision forkeratinized gingiva pocket reductionOn the palate,enlarged tissue, orwith limited access
  21. 21. Comparison of full- vs. partial-
  22. 22. Types of Mucoperiosteal Flaps1. Envelope/sulcular incision2. Envelope with one releasing incision (three- corner flap)3. Envelope with two releasing incisions (four- corner flap) Full-thickness Full-thickness mucoperiosteal flap mucoperiosteal flap
  23. 23. Types of Mucoperiosteal Flaps 1. Envelope/Sulcular flap 2 teeth anterior 1 tooth posterior
  24. 24. Types of Mucoperiosteal Flaps2. Three-corner flap 1 tooth anterior 1 tooth posterior Greater access in an apical direction, especially in the posterior aspect of the mouth
  25. 25. Types of Mucoperiosteal Flaps3. Four-corner flap 1 tooth anterior 1 tooth posterior rarely indicated
  26. 26. Common Periodontal Flap
  27. 27. 1. Inverse bevel incision 0.5~2mm, extending to the alveolar crest. Thins gingival tissue and permits compete closure of the interdental osseous defects postoperatively.
  28. 28. 2. Flap reflection. Full thickness mucoperiosteal flap is reflected to permits visualization.
  29. 29. 3. Crevicular incision between the hard tooth and the diseased pocket epi., to the depth of the junctional epi.
  30. 30. 4. Horizontal incision carried along the alveolar crest
  31. 31. 5. Root planing with direct vision
  32. 32. 6. Complete coverage of interdental defects
  33. 33. 1. Sulcularly, crestally, or full-thickness flap labially positioned inverse beveled incision to bone2. Flap completed, reflected off bone3. Flap is apically positioned and sutured
  34. 34. A: The internal bevelled,scalloped incision is usedfor pocket eliminationthrough apicalrepositioning of the flap.B: The flappositioned apically forpocket elimination.
  35. 35. 1. Crestal incision with blade, partial-thickness flap parallel to long axis of tooth2. Flap raised by sharp dissection, periosteum retained over bone3. Flap is apically positioned at or below alveolar crest
  36. 36. 1. No alveolar mucosa is present on the palate to permit apical positioning.2. Pocket elimination by palatal flap that just covers the contours of the bone to eliminate osseous defects.3. Requires skill and experience.
  37. 37. Osteoplasty Osseous grooving, peprmits better adaption of flaps to facilitate plaque removal alter healing
  38. 38. Osteoplasty
  39. 39. Osteoplasty
  40. 40. Suturing for Flap Surgery
  41. 41. Simple Loop Modification of Interrupted
  42. 42. Figure 8 Modification of Interrupted
  43. 43. Vertical mattress suture
  44. 44. Horizontal mattress suture
  45. 45. Single Interrupted Sling
  46. 46. Reference1. Contemporary Oral and Maxillofacial Surgery, 4th Edition, Larry J Peterson, DDS, MS, Edward Ellis, III, DDS, MS, James R Hupp, DMD, MD, JD, FACS and Myron R Tucker, DDS2. Petersons principles of oral and maxillofacial surgery, Michael Miloro,G. E. Ghali,Peter Larsen,Peter Waite3. An atlas of minor oral surgery: principles and practice, David A. McGowan4. Manual of minor oral surgery for the general dentist, Karl R. Koerner5. Critical Decisions in Periodontology, 4th Edition, WALTER B. HALL, BA, DDS, MSD6. Color Atlas of Periodontology, Klaus H. & Edith M. Rateitschak7. Atlas of Cosmetic and Reconstructive Periodontal Surgery 3rd edition, EDWARD S. COHEN, DMD
  47. 47. Thanks for your attention!