Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
POCKET ELIMINATION
Guided By:-
Dr. Prashant Bhusari
Prof. & Guide
Index
• Introduction.
• Definitions of Flap.
• Indications of Flap.
• Contraindications of Flap.
• Instruments used in flap surgery.
• Treatment decisions for soft & hard tissue pockets in flap surgery.
• Suturing techniques.
• Periodontal dressing.
• The concept that not only inflamed soft tissue but also
“infected and necrotic bone” had to be eliminated called
for the development of surgical techniques by which the
alveolar bone could be exposed and resected (flap
procedures).
• A Periodontal flap is defined as, “a section of the
gingiva and or oral mucosa, surgically elevated
from the underlying tissues to provide visibility of the
bone and root surface. (Carranza 1996)
periodontal pockets.
2. Neumann flap.
3. Undisplaced flap.
4. Kirkland flap.
7. Palatal flap
Flap for reconstructive and regenerative
surgery :
1. Pocket Elimination
2. Width of Attached gingiva increase.
Management of the papilla
Conventional Flap :- Interdental papilla is split beneath
the contact point of the two approximating teeth to
allow reflection of buccal & lingual flap.
used :-
1. interdental space is too narrow.
2. when the flap is to be displaced.
Envelop flap Quicker to heal and are Limit access to the bony
associated with less post tissues
operative pain and bleeding
• Rotational flap
• Advancement flap
• Cardiovascular Diseases :
• Blood Disorders :
• Smoking :
Although smoking negatively affects wound healing (Siana et
al 1989), it may not be considered a contraindication for
surgical periodontal treatment. The clinician should be
aware, however, that less resolution of probing pocket depth
and smaller improvements in clinical attachment may be
observed in smokes than in non-smokers. (Preber &
Bergstorm 1990)
General Surgical Considerations
• Procedural selection should be based on the following :
1. Simplicity
2. Predictability
3. Efficiency
4. Underlying osseous topography
5. Anatomic and physical limitations (e.g. small mouth,
gagging, mental foramen)
• Surgical burs.
• Irrigating syringe.
Premedication for Surgery :
• It should be given when indicated and may include the
administration of antibiotics to patients with valvular heart
disease or other conditions requiring antibiotics. Accoridng to
ADA in such cases 2 gm of amoxicillin should be started 1
hour before surgery to provide adequate levels and minimize
bacterial resistance.
a. Depth
c. Configuration
8. Esthetic considerations.
• Horizontal incisions
1. Internal bevel
a. Scalloping
b. Linear
2. Crevicular
3. Interdental
• Vertical Incisions
Horizontal Incision
• Internal Bevel incision or reverse bevel or inverse bevel incision:-
It starts at a distance from the gingival margin & is aimed at the bone
crest. The portion of the gingiva that is left around the tooth contains
the epithelium of the pocket lining and the adjacent granulomatous
tissue.
• It is the incision from which the flap will be reflected to expose the
underlying bone and root.
Instruments :-
Surgical scalpel blade No. #11 or #15
• Crevicular or sulcuar incision (second incision) :
This starts form the base of the pocket to the crest of the bone.
This, along with the first incision, forms a V-shaped wedge
ending at or near the crest of the bone; this wedge of tissue
contains most of the inflamed and granulomatous areas that
constitute the lateral wall of the pocket, as well as the junctional
epithelium and the connective tissue fibers that still persist
between the bottom of the pocket and the crest of the bone.
• Indicatios :-
Instruments :-
• The incision is made not only around the facial & lingual
radicular area but also interdentally, connecting the facial &
lingual segments, to free the gingiva completely around the
tooth.
Orbans Knife
Incisions Description Indications Instruments
Vertical or Releasing Perpendicular to 1. To increase access. Scalpel blades no. 11
gingival margin at the 2. To allow apical or or 15
line angles of teeth coronal positioning of
flap
Cutback Small incision made at Pedicle flap that are Scalpel bladed no. 11
the apical aspect of a laterally positioned or 15
releasing incision &
directed towards the
base of the flap
Periosteal releasing Incision at the base of To release flap tension Scalpel blade no. 15
the flap severing the allowing coronal
underlying periosteum advancement of the
flap
Original widman flap
• Advantages :
• Root exposure.
• Post operative pain and edema.
• Superficial resorption of exposed bone.
• Bony exposure in interproximal areas.
Technique for original widman flap
• Sectional releasing incisions were first made to
demarcate the area scheduled for surgery.
Advantage of original widman flap over
gingivectomy procedure
• The margin of the flap was then trimmed & scalloped with the
scissors to reach exactly the bone margin and sutured using
straight & curved needle & silk thread.
Difference between Original widman &
Neumann Flap
Original widman Flap Neumann Flap
No Lingual / palatal Both buccal & lingual flap Only buccal flap should
pocket should be reflected be reflected
• Soft tissue pocket wall is removed with the initial incision; thus it
enough attached gingiva will remain after removal of the pocket wall. –so pocket
Internal bevel incision is made after the scalloping of the bleeding marks on the
gingiva.
Stage II :- The initial, internal bevel incision is made after the scalloping of the
bleeding marks on the gingiva.
The incision is usually carried to a point apical to the alveolar crest, depending on the
thickness of the tissue.
The thicker the tissue, the more apical is the ending point of the incision.
Stage III :- The second or crevicular incision is made from the bottom of the pocket to
detach the connective tissue from the bone.
Stage IV :- flap is reflected with a periosteal elevator (blunt dissection) from the
internal bevel incision. Usually there is no need for vertical incisions because the
flap is not displaced apically.
Stage V :- The interdental incision is made with an interdental knife, separating
the connective tissue from the bone.
A continuous sling suture is used to secure the facial and the lingual or palatal
flaps. This type of suture, using the tooth as an anchor, is advantageous to
position and hold the flap edges at the root-bone junction.
Advantages :
Disadvantage :
1. Poor esthetics
2. Root exposure –sensitivity and caries
Modified Flap Operation
• Deep Pockets.
• Intrabony Pockets.
If pockets are deeper than 3 mm-incision is placed ½ -1mm away from the
gingival margin to ensure removal of all crevicular epithelium .
Second incision i.e crevicular incision is made around the neck of the tooth
from bottom of the crevice to the alveolar crest.
Third incision –made in the horizontal direction to separate the soft tissue
collar of root surface s from the bone
Following proper debridement and curettage of angular bone defects,
the flaps are carefully adjusted to cover the alveolar bone and sutured
Advantage of Modified Widman Flap
• Access & visualization of the root surfaces.
gingiva.
Contraindications :
Disadvantage :
5. Rapid healing.