the flap technique for pocket therapy

8/18/2019 The Flap Technique for Pocket Therapy

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The Flap Technique for

Pocket Therapy


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Flaps are used for pocket therapy to accomplish thefollowing:

1. Increase accessibility to root depositsfor scaling and root planing.

2. Eliminate or reduce pocket depth byresection of the pocket wall.

3. Gain access for osseous resectiesurgery if it is necessary.

!. E"pose the area to performregeneratie methods.


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MODIFIED WIDMAN FLAP

• #his techni$ue o%ers the possibilityof establishing an intimatepostoperatie adaptation of healthycollagenous connectie tissue totooth surfaces and proides accessfor ade$uate instrumentation of the

root surfaces and immediate closureof the area.


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• Step 1: The initial incision is an internalbevel incision to the aleolar creststarting &.' to 1 mm away from the

gingial margin (Figure ')*3+ C).Scalloping follows the gingival margin.,are should be taken to insert the bladein such a way that the papilla is left witha thickness similar to that of theremaining facial -ap. ertical rela"ingincisions are usually not needed.


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• Step 2: The gingiva is reected witha periosteal elevator (Figure ')*3+ ).

• Step !: " crevicular incision is #adefro# the botto# of the pocket to thebone+ circumscribing the triangularwedge of tissue containing thepocket lining.


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• Step $: "fter the ap is reected% a thirdincision is #ade in theinterdental spacescoronal to the bone with a curette or an

interpro"imal knife and the gingialcollar is remoed (Figure ')*3+ & and F).

•

Step ': Tissue tags and granulationtissue are re#oved with a curette. #heroot surfaces are checked+ then scaledand planed if needed (Figure ')*3+ and

). *esidual periodontal /bers attached


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• Step +: ,one architecture is notcorrected% e-cept if it prevents goodtissue adaptation to the necks of the

teeth. Eery e%ort is made to adaptthe facial and lingual interpro"imaltissue ad0acent to each other in such

a way that no interpro"imal boneremains e"posed at the time ofsuturing. #he -aps may be thinned to

allow for close adaptation of the


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• Step : Continuous% independentsling sutures are placed in both thefacial and palatal (Figure ')*3+ / and

0) and covered with a periodontalsurgical pack.


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UNDISPLAED FLAP

• ,urrently+ the undisplaced -ap maybe the most fre$uently performedtype of periodontal surgery. It di%ers

from the modi/ed idman -ap inthat the soft tissue pocket wall isremoed with the initial incision thus

it may be considered an internalbeel gingiectomy.4


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UNDISPLAED FLAP

• Step 1: The pocets are #easuredwith the periodontal probe% and ableeding point is produced on the

outer surface of the gingia to markthe pocket bottom.


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UNDISPLAED FLAP

• Step 2: The initial% or internal bevel%incision is #ade (Figure ')*!5 afterscalloping the bleeding marks on the

gingia (Figure ')*'5. #he incision isusually carried to a point apical to thealeolar crest+ depending on the thicknessof the tissue. #he thicker the tissue is the

more apical the ending point of theincision (see Figure ')*!5. In addition+thinning of the -ap should be done withthe initial incision because it is easier to

accomplish at this time than later+ with a


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UNDISPLAED FLAP

• Step !: The second% or crevicular%incision is #ade fro# the bottom ofthe pocket to the bone to detach the

connectie tissue from the bone.

• Step $: The ap is reected with a periosteal elevator (blunt dissection5

from the internal beel incision.7sually there is no need for erticalincisions because the -ap is not

displaced apically.


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UNDISPLAED FLAP

• Step ': The third% or interdental%incision is #ade with an interdentalknife+ separating the connectie

tissue from the bone.

• Step +: The triangular wedge oftissue created b the three incisions

is remoed with a curette.• Step : The area is debrided%

re#oving all tissue tags and

granulation tissue using sharp


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UNDISPLAED FLAP

• Step 3: "fter the necessar scalingand root planing% the ap edgeshould rest on the root*bone 0unction.

If this is not the case+ because ofimproper location of the initialincision or the une"pected need for

osseous surgery+ the edge of the -apis scalloped again and trimmed toallow the -ap edge to end at the

root*bone 0unction.


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UNDISPLAED FLAP

• Step 4: " continuous sling suture isused to secure the facial and thelingual or palatal -aps. #his type of

suture+ using the tooth as an anchor+is adantageous to position and holdthe -ap edges at the root*bone

0unction. #he area is coered with aperiodontal pack.


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APIALL! DISPLAEDFLAP

• ith some ariants+ the apically displaced-ap techni$ue can be used for (15 pocketeradication and8or (25 widening the 9one

of attached gingia. epending on thepurpose+ it can be a fullthickness(mucoperiosteal5 or a split*thickness(mucosal5 -ap. #he split*thickness -ap

re$uires more precision and time+ as wellas a gingial tissue thick enough to split+but it can be more accuratel positionedand sutured in an apical position using a

periosteal suturing techni$ue.


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• Step 1: "n internal bevel incision is #ade(Figure '454). To presere as much of thekeratini9ed and attached gingia as

possible+ it should be no more than about1 mm from the crest of the gingia anddirected to the crest of the bone (seeFigure ')*15. #he incision is made after the

e"isting scalloping+ and there is no need tomark the bottom of the pocket in thee"ternal gingial surface because theincision is unrelated to pocket depth. It is

also not necessary to accentuate the


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• Step 2: Crevicular incisions are#ade% followed b initial elevation ofthe -ap then interdental incisions

are performed+ and the wedge oftissue that contains the pocket wall isremoed.


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• Step !: 6ertical incisions are #adee-tending beond the #ucogingival

0unction. If the ob0ectie is a full*

thickness -ap+ it is eleated by bluntdissection with a periosteal eleator.If a split*thickness -ap is re$uired+ it

is eleated using sharp dissectionwith a ;ard*


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• Step $: "fter re#oval of allgranulation tissue% scaling and rootplaning+ and osseous surgery if

needed+ the -ap is displaced apically.It is important that the erticalincisions an therefore the -ap

eleation+ reach past themucogingial 0unction to proideade$uate mobility to the -ap for its

apical displacement.


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• Step ': /f a full5thicness ap was perfor#ed% a sling suture around the toothpreents the -ap from sliding to a position

more apical than that desired+ and theperiodontal dressing can aoid itsmoement in a coronal direction. =partialthickness -ap is sutured to the

periosteum using a direct loop suture or acombination of loop and anchor suture. =dry foil is placed oer the -ap beforecoering it with the dressing to preent

the introduction of pack under the -ap.


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• =fter 1 week+ dressings and suturesare remoed. #he area is usuallyrepacked for another week+ after

which the patient is instructed to usechlorhe"idine mouth rinse or to applychlorhe"idine topically with cotton*

tipped applicators for another 2 or 3weeks.


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FLAPS FO" "EONST"UTI#ESU"$E"!

a% Papilla Pre&er'ation Flap

#he techni$ue for employing apapilla preseration -ap (Figures ')*1& and ')*115 is as follows:

•. Step 1: " crevicular incision is #adearound each tooth with no incisions

across the interdental papilla.


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• Step 2: The preserved papilla can beincorporated into the facial orlingual8palatal -ap+ although it is

most often integrated into the facial-ap. In these cases+ the lingual orpalatal incision consists of a

semilunar incision across theinterdental papilla in its palatal orlingual aspect this incision

dipsapically from the line angles of


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• Step !: "n 7rban nife is thenintroduced into this incision to seerhalf to two*thirds the base of the

interdental papilla. #he papilla isthen dissected from the lingual orpalatal aspect and eleated intact

with the facial -ap.

• Step $: The ap is reected without

thinning the tissue.


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(%on'entional Flap

#he techni$ue for employing aconentional -ap for reconstructiesurgery is as follows:

•. Step 1: 8sing a 912 blade% incise thetissue at the botto# of the pocket

and to the crest of the bone+ splittingthe papilla below the contact point.Eery e%ort should be made to retain

as much tissue as possible to protect


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• Step 2: *eect the ap% #aintainingit as thic as possible% not attemptingto thin it as is done for resectie

surgery. #he maintenance of a thick-ap is necessary to preent e"posureof the graft or the membrane

resulting from necrosis of the -apmargins.


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a% Ma)illary Molar&

#he treatment of distal pockets on thema"illary arch is usually simpler thanthe treatment of a similar lesion on themandibular arch because thetuberosity presents a greater amount

of /brous attached gingia than doesthe area of the retromolar pad.


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a% Ma)illary Molar&

In addition+ the anatomy of thetuberosity e"tending distally is moreadaptable to pocket elimination than isthat of the mandibular molar arch+where the tissue e"tends coronally.

>oweer+ the lack of a broad area ofattached gingia and the abruptlyascending tuberosity sometimes

complicate therapy (Figure ')*135.


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a% Ma)illary Molar&

#he following considerations determinethe location of the incision for distalmolar surgery: accessibility+ amount ofattached gingia+ pocket depth+ andaailable distance from the distal

aspect of the tooth to the end of thetuberosity or retromolar pad.


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a% Man*i(ular Molar&

Incisions for the mandibular arch di%erfrom those used for the tuberositybecause of di%erences in the anatomyand histologic features of the areas.

#he retromolar pad area does not

usually present as much /brousattached gingia. #he keratini9edgingia+ if present+ may not be found

directly distal to the molar.


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#he greatest amount may bedistolingual or distofacial and may notbe oer the bony crest. #he ascendingramus of the mandible may also createa short+ hori9ontal area distal to the

terminal molar (Figure ')*1?5. #heshorter this area+ the more di6cult it isto treat any deep distal lesion around

the terminal molar.


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#he two incisions distal to the molarshould follow the area with thegreatest amount of attached gingia(Figure ')*1@5. #herefore the incisionscould be directed distolingually or

distofacially+ depending on which areahas more attached gingia.


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;efore the -ap is completely re-ected+it is thinned with a A1' blade. Itiseasier to thin the -ap before it iscompletely free and mobile =fter there-ection of the -ap and the remoal

of the redundant /brous tissue+ anynecessary osseous surgery isperformed. #he -aps are appro"imated

similarl to those in the ma illar

the flap technique for pocket therapy

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