General Principles of Surgical Techniques for Periodontal Regeneration
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OBJECTIVES OF THE SURGICAL PHASE1- Improvement of the prognosis of teeth and their replacements.2- Improvement of esthetics. The surgical phase consists of techniquesperformed for pocket therapy and for thecorrection of related morphologic problems,namely mucogingival defects.
Surgical techniques allow :1- Increase accessibility to the root surface, making it possible to remove all irritants.2- Reduce or eliminate pocket depth.3- Reshape soft and hard tissues to attain a harmonious topography.
Indications for periodontal surgery1- Areas with irregular bony contours, deep craters, and other defects usually require a surgical approach.2- Pockets on teeth in which a complete removal of root irritants is not considered clinically possible may call for surgery.3- In cases of furcation involvement of Grade II or III, a surgical approach ensures the removal of irritants; any necessary root resection or hemisection also requires surgical intervention.
4- Intrabony pockets on distal areas of last molars, frequently complicated by mucogingival problems, are usually unresponsive to nonsurgical methods.5- Persistent inflammation in areas with moderate to deep pockets may require a surgical approach.
Classification of Flaps:1- Bone exposure after flap reflection.2- Placement of the flap after surgery.3- Management of the papilla.Based on bone exposure after reflection:** Full thickness (mucoperiosteal) is indicated when resective osseous surgery is contemplated.** Partial thickness (split thickness flap) is indicated when the flap is to be positioned apically or when the operator does not desire to expose bone.
Diagram of the internal bevel incision (first incision) to reflect a full thickness and the split thickness flap.
Based on flap placement after surgery, flaps are classified):** Nondisplaced flaps, when theflap is returned and sutured in its original position; or 2) displaced flas that are placed apically, coronally, or laterally.Based on management of the papilla:** Flaps can be conventional or papilla preservation flaps.The conventional flap is used:(1) The interdental spaces are too narrow.(2) When the flap is to be displaced.
Conventional flaps include the modifiedwidman and the flap, the undisplaced flap,the apically displaced flap, and the flap forregenerative procedure procedures.Design of the Flap: The design of the flap is dictated by thesurgical judgement of the operator andmay depend on the objectives of theoperation.
Vertical incisions:Vertical or oblique releasing incisions canbe used on one or both ends of thehorizontal incision, depending on thedesign and purpose of the flap.
Elevation of the Flap:1- Full thickness flap. The reflection is accomplished by bluntdissection.2- Partial thickness flap. The reflection is accomplished by sharpdissection.
A, Diagram of the internal bevel incision (first incision) to reflect a tull thickness(mucoperiosteal) flap. Note that the incision ends on the bone to allow for the reflection of theentire flap. B, Diagram of the internal bevel incision to reflect a partial thickness flap. Note thatthe incision ends on the root surface to preserve the periosteum on the bone.
Ligation:Interdental Ligation:1- The director loop suture.2- Figure-eight suture.
Sling Ligation: A single, interrupted sling suture is used to adapt the flap arount the tooth.
Continuous Independent Sling Suture. The continuous, independent sling suture is used to adapt the buccal and lingual flapswithout tying the buccal flap to the lingual flap. The teeth are used to suspend each flap againstthe bone. It is important to anchor the suture on the two teeth at the beginning and end of theflap so that the suture will not pull the buccal flap to the lingual flap.
Anchor SutureDistal wedge suture. This suture is also used to closeflaps that are mesial or distal to a lone-standing tooth.
Periosteal SutureThis type of suture is used to hold in place apically displaced partial thickness flaps.
FLAPS FOR POCKET FLAPS FOR THERAPY REGENERATIVE SURGERY1- The modified widman 1- The papilla flap. preservation flap.2- The undisplaced flap 2- Conventional flap for the palatal flap. regenerative3- The apically displaced surgery. flap.
FLAPS FOR POCKET THERAPYFlaps are used for pocket therapy to accomplish the following:1- Increase accessibility to root deposits.2- Eliminate or reduce pocket depth by resection of the pocket wall.3- Expose the area to perform regenerative methods.
The modified widman flap.1- Facilitates instrumentation.2- Removal of the pocket lining.3- Not eliminate or reduce pocket depth.
The undisplaced (Unrepositioned) flaps.1- Improving accessibility for instrumentation.2- Removes the pocket wall.3- Reducing or eliminating the pocket. Diagram showing the location of different areas where the internal bevel incision is made in an undisplaced flap.
The apically displaced flap:1- Improving accessibility.2- Removes the pocket wall.3- It increases the width of the attached gingiva by transforming the previously unattached keratinized pocket wall into attached tissue.
FLAPS FOR REGENERATIVE SURGERY1- The papilla preservation flap.2- Conventional flap for regenerative surgery. The flap using only crevicular or pocket incisions, to retain the maximum amount of gingival tissue, including the papilla, for graft or membrane coverage.