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FLAP SURGERY AND GINGIVECTOMY

PRESENTED BY: SONIA SACHDEVA

Periodontal surgery comprises initial treatment, in which the original cause of periodontal disease is eliminated, and definitive surgery in which an environment conducive to long-term health and maintenance is achieved. The decision concerning what type of periodontal surgery should be performed and how many sites should be included is usually made after the effect of initial cause-related measures has been evaluated.

Time lapse between termination of ICRT and evaluation may vary from 1 to 6 months:
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Removal of calculus and bacterial plaque will eliminate or markedly reduce the inflammatory cell infiltrate in the gingiva (edema, hyperemia, flabby tissue consistency), thereby making assessment of the true gingival contours and pocket depths possible. Reduction of gingival inflammation makes the soft tissues more fibrous and thus firmer, which facilitates surgical handling of the soft tissues. The propensity for bleeding is reduced, making inspection of the surgical field easier. A better basis for a proper assessment of the prognosis has been established. The effectiveness of the patients home care, which is of decisive importance for the long-term prognosis, can be properly evaluated.

DEFINITIONS

FLAP ` A flap is defined as a loosened section of tissue separated from the surrounding tissue except at its base. PERIODONTAL FLAP ` A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissues to provide visibility of and access to the bone and root surface.

OBJECTIVES

Traditionally, pocket elimination has been the main objective of periodontal therapy. The removal of the pocket by surgical means served two purposes:

(1) Elimination of pocket, which established an environment conducive to progression of periodontal disease. (2) the root surface was made accessible for scaling and for selfperformed tooth cleaning after healing.
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While these objectives cannot be entirely discarded today, the necessity for pocket elimination in periodontal therapy has been challenged.

Main objective of periodontal surgery is to contribute to the longterm preservation of the periodontium by facilitating plaque removal and infection control, and periodontal surgery can serve this purpose by: 1. Creating accessibility for proper professional scaling and root planing 2. Establishing a gingival morphology which facilitates the patients selfperformed infection control.
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Others 3. Regeneration of periodontal attachment lost due to destructive disease. 4. Elimination or reduction of pocket depth by resection of the pocket wall. 5. Expose the bone for osteoplasty or ressective osseous surgery 6. For root coverage procedures

CLASSIFICATION OF FLAPS

Bone exposure after flap reflection (Carranza 1979) Placement of the flap after surgery (Carranza 1990) Management of papilla Main purpose of the procedure (Ramfjord 1979)

Full thickness Partial thickness Undisplaced Displaced Apically displaced Coronally displaced Laterally displaced Conventional flap Papilla preservation flap Pocket elimination flap Reattachment flap surgery Mucogingival repair

Periodontal flap classification based on

The comparison of full thickness and partial thickness flap is as follows:


Full thickness
a. b. c. d. e. f. g. h. i. Healing Technical difficulty Bone defect treatment Elimination /reduction of periodontal pocket Use with mucogingival surgery Bleeding Post operative swelling Post operative pain and discomfort Fixation of flaps Primary healing Relatively easy Possible Possible Possible Less Less Less Less

Partial thickness
Secondary healing Difficult Difficult Possible Possible Much Severe Much Firm fixation with periosteal suture Much Easy Difficult

j. Possibility of flap penetration Less k. Thin flap preparation by primary incision Difficult l. Augmentation of band of attached gingiva Possible

DESIGN OF FLAP

Considerations:
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The degree of access to the underlying bone and root surface necessary The final position of the flap Width of attached gingiva Preservation of good blood supply to the flap is very important

1. Conventional flap With internal bevel incision

Sulcular incision flap

2. Papilla Preservation flap

Flap thickness
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If the flap is too thin, blood supply may be impaired and necrosis of the flap margin can occur, causing a slow and painful healing. If the flap is too thick, bulky tissue will result, leading to the formation of pseudopockets after healing.

Ideal thickness

Flap too thin

Necrosis of flap

INCISIONS
Horizontal incisions Horizontal incisions are directed along the margin of the gingiva in a mesial or a distal direction.
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Internal bevel incision (primary incision) Sulcular incision (Secondary incision) Interdental incision (Third incision)

Internal bevel incision (Reverse bevel): Objectives: ` It removes the pocket lining ` It conserves the relatively uninvolved outer surface of the gingiva, which is apically positioned becomes attached gingiva. ` Produces a sharp, thin flap margin for adaptation to bone tooth junction Indications for internal bevel incision ` Primary incision of flap surgery if there is a sufficient band of attached gingiva ` Desire to correct bone morphology (osteoplasty, osseous resection) ` Thick gingiva (such as palatal gingiva) ` Deep periodontal pockets and bone defects ` Desire to lengthen clinical crown

The internal bevel (first) incision can be made at varying locations and angles according to the different anatomic and pocket situations using blade no. 11 or 15.

An occlusal view of the different locations where the internal bevel incision can be made.

Second incision crevicular incision Indications ` Narrow band of attached gingiva ` Thin gingiva and alveolar mucosa ` Shallow periodontal pocket ` Desire to lessen postoperative gingival recession for esthetic reasons in the maxillary anterior region. ` As a second incision for flap surgery ` Bone graft or GTR: desire to preserve as much periodontal tissue (interdental papilla) as possible to completely cover grafted bone and membrane by flaps.
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Method ` Incision given with beak shaped no. 12D blade the incision is carried around the entire teeth.

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Third incision interdental incision This is made along the alveolar crest and alveolar septum from the buccal to the lingual side. This separates cervical secondary flap from the alveolar crest and interdental bone after reflecting the buccal and lingual flaps. Method The orban interdental knife is recommended

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Vertical incisions

Envelope flap: if apical, lateral and coronal displacement of flap is not anticipated.

Triangular flap

Trapezoidal flap

Interdental denudation procedure- Prichards technique- A type of flap curettage, best suited to 3-wall bony deformities.
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This consists of horizontal, internal bevel, non scalloped incision to remove the gingival papilla and denude the interdental space. Full-thickness flaps are elevated on both buccal and lingual. All granulation tissue is removed from all walls of the bony lesion and the bone and tooth are meticulously curetted. Some clinicians perforate the walls of the lesion with small round burs to allow migration of osteogenic elements from the adjacent marrow spaces. When the flaps are replaced and sutured, the marginal bone is left denuded.The rationale is that it may take longer for the surface epithelium to migrate into the defect thus providing time for coronal regeneration to take place. Contraindicated when bone grafts used. Healing, if successful, occurs when bone is regenerated from the floor and walls of the lesion to fill the defect.

ELEVATION OF FLAP

For full thickness flap blunt dissection is accomplished by periosteal elevation.

Sharp dissection is necessary to reflect a partial thickness flap, a surgical scalpel (no. 11 or no. 15) is used.

HISTORYFLAP SURGERY PROCEDURES

1911 Neumann
He claimed the introduction of the mucoperiosteal flap in 1911. Neuman in 1912 and 1915 described a semilunar incision for access to the root surfaces and the alveolar crest. Later in Neumans text book in 1920 a mucoperiosteal periodontal flap was described the stressed that periodontal surgery results in horizontal alveolar and gingival atrophy.

1916 Widman

Appears to be first to describe flap surgery for pocket elimination although Cieszynskin in a discussion in 1914 referred to periodontal flap for pocket reduction.Widman introduced the Widman flap in 1918.

1918 Cieszynski He was credited with the introduction of reverse bevel incision. Zentler introduced the mucoperiosteal flap in the U.S.A. in 1918, with the idea that the procedure was to allow access for debridement and elimination of granulation tissue as well as osseous removal by chisels.

1931 Kirkland

Apparently the first description of the flap procedure for the purpose of reattachment was given by Kirkland. His method has been used as open subgingival curettage.

1935 Kronfeld Flap surgery became popular after 1935, when Kronfeld in his autopsy Orban study of which he stated that the bone adjacent to the periodontal pockets was neither necrotic nor infected but rather destroyed by an inflammatory process. Orban later supported this finding in his own studies. The main culprit of the disease now has shifted to the soft tissue. 1949 Schluger During 1930 and 1940 gingivectomy was most popular for pocket elimination (Schluger in 1949). He recommended gingivectomy followed by mucoperiosteal flap. Later a modification of Schlugers approach:They were pushback and pouch operation with extensive exposure by alveolar process and mucobuccal fold extension following surgical remodeling of bone for pocket elimination. 1954 Nabers He described the repositioning of the attached gingiva. 1957 Nabers He utilized the Widmans inverse bevel incision of which he called the repositioning incision which includes the internal incision from the gingival margin to the alveolar crest.

DIFFERENT TYPES OF FLAP TECHNIQUES

Basic incisions for flap designs

The original Widman flap

The Neumann flap


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An intracrevicular incision was made through the base of the gingival pockets and the entire gingiva (and part of the alveolar mucosa) was elevated in a mucoperiosteal flap. Sectional releasing incisions were made to demarcate the area of surgery. Following flap elevation, the inside of the flap was curetted to remove the pocket epithelium and the granulation tissue.

The root surfaces were subsequently carefully cleaned. Any irregularities of the alveolar bone were corrected to give the bone crest a horizontal outline. The flaps were then trimmed to allow both an optimal adaptation to the teeth and a proper coverage of the alveolar bone on both the buccal/lingual (palatal) and the interproximal sites. With regard to pocket elimination, Neumann (1920) pointed out the importance of removing the soft tissue pockets, i.e. replacing the flap at the crest of the alveolar bone.

Modified flap operation (Sulcular incision flap)- 1931 Kirkland

Advantages
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There is not extensive sacrifice of non inflamed tissues Apical displacement of gingival margin is not done Since root surfaces were not markedly exposed the method could be esthetic, hence used in anterior regions of dentition. The potential for bone regeneration in intrabony defects.

The apically repositioned flap


The choice of method is detected by:
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Whether the osseous defects therapy is necessary or not. The thickness of the gingiva and alveolar bone margin in the operative area. If the periodontal pocket reaches or extends beyond the mucogingival junction and attached gingiva is extremely thin, the flap may be full thickness or partial thickness.

Full thickness ARP

Indications ` Pocket eradication ` Widening the zone of attached gingiva ` crown lengthening procedures for cosmetic enhancement and restorative treatment Contraindications ` Compromised esthetic and anatomical preclusion

The split thickness ARP: Indications ` Increase of the attached gingiva an area with narrow attached gingiva and sufficient oral vestibule depth with no extensive treatments for bone necessary ` Avoid exposing areas where the alveolar bone is thin because of protruding tooth ` where there is likelihood of osseous dehiscence or osseous fenestration ` Elimination of the periodontal pocket that extends beyond the mucogingival junction with narrow attached gingiva. ` Extension of clinical crown length for restorative/ prosthetic treatment (Crown lengthening surgery)
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Contraindications ` Thin gingiva ` Lack of keratinized gingiva at gingival margin ` Narrow oral vestibule ` Extremely thin alveolar process ` Extensive osseous surgery required ` Deep intrabony defect requiring bone regeneration or restoration

Technique

Beveled flap

Advantages Minimum pocket depth post-operatively If optimal soft tissue coverage of the alveolar bone is obtained, the post-surgical bone loss is minimal The post-operative position of the gingival margin may be controlled and the entire muco-gingival complex may be maintained.

Disadvantages: ` The sacrifice of periodontal tissues by bone resection and the subsequent exposure of root surfaces. ` Technically demanding ` Danger of penetrating flap during incision ` Necrosis may result because of severe damage to blood vessels ` Difficulty in manipulating the suture ` Post operative swelling ` Delayed healing because of secondary intention. ` Treatment may be complicated if combined with osseous resection.

Modified Widman flap


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Ramfjord and Nissle in 1974 coined the term modified Widman flap though the procedure was employed by Morris in 1965 and was termed the unrepositioned mucoperiosteal flap

Internal beveled gingivectomy. Schematic illustration of the incision technique in case of the presence of only a minimal zone of gingiva.

Technique

Advantages
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The possibility of obtaining a close adaptation of the soft tissues to the root surfaces. The minimum of trauma to which the alveolar bone and the soft connective tissues are exposed. Access for adequate instrumentation of root surfaces and immediate closure of the area Minimum trauma to which the alveolar bone and soft connective tissue are exposed Less exposure of the root surfaces which from an esthetic point of view is an advantage in the treatment of anterior segments of dentition.

Laser assisted Modified Widman flap


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Salaria S et al (2010) performed modified Widman flap with the help of laser and called it Laser assisted Modified Widman flap (LAMWF). In the technique followed, the pocket lining was removed with the help of a diode laser. The fiberoptic tip of the laser was directed parallel to the root surface and was moved laterally and apically along the lateral pocket wall eventually reaching close to base of pocket. The laser settings were rearranged at 4W in continuous mode. 1.5W in continuous mode and applied in the sulcus for atleast 1 min to achieve laser bacterial reduction in the pocket as well as the connective tissue.

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The laser was kept in continuous movement to prevent charring of connective tissue. Crevicular incision was given with a BP blade no. 15 directed towards the alveolar crest. Full thickness mucoperiosteal flap was raised buccally and lingually. The granulation tissue was removed from the defects by manual debridement and root surfaces were thoroughly planed. Inner aspect of the reflected buccal and lingual flap was then subjected to laser application to remove any remaining epithelium. After complete debridement the surgical site was sutured. There was no pain or any other discomfort reported at 1 week post surgery.

The undisplaced flap

Diagram showing the location of different areas where the internal bevel incision is made in an undisplaced flap. The incision is made at the level of the pocket to discard the tissue coronal to it if there is sufficient remaining attached gingiva.

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The pockets are measured with periodontal probe and bleeding points are produced to mark bottom of the pocket. Internal bevel incision made and is carried to a point apical to alveolar crest. Thinning of flap is done with initial incision. Crevicular incision is made Flap is reflected with a periosteal elevator (blunt dissection) from internal bevel incision Interdental incision is made with interdental knife Triangular wedge is removed with curette Area is debrided and all tissue tags and granulation tissue is removed After scaling and root planing the flap edge should rest on the root bone junction A continuous sling suture is used to secure the facial and lingual flap to hold the flap edges at root bone junction. Area is covered with a periodontal pack.

Palatal flaps
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Because of anatomic characteristic of palate, palatal flap require different designs. The palatal tissue is masticatory mucosa and immobile. It is impossible to displace a palatal flap apically. Close adaptation to the tooth surface and bone margin is difficult and post operative gingival morphology is unfavorable. Reduction of periodontal pocket in a thick gingival wall in the palatal aspect is uncommon because of minimal gingival shrinkage achieved by initial therapy. Inaccessibility of cleaning instruments may cause inadequate self care.

Following are considered in purpose of palatal flap before incision is made


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For debridement internal bevel incision planned so that flap adapts at root bone junction when sutured. For osseous resection the incision should be planned to compensate for the lowered level of bone when flap is closed. The initial incision varies with anatomic situation the internal bevel incision should be done in such a way that flap fits around tooth without exposing bone. The initial incision is followed by crevicular and interdental incisions.

If tissue is thick horizontal gingivectomy incision made followed by internal bevel incision Thick palatal should be thinned before reflection to adapt to the underlying osseous tissue and provide a thin knife edge margin. The use of vertical incisions care must be taken to avoid the numerous vessels located in palate. Ability to fix flap to optimal position by periosteal suture

Flaps for regenerative surgery


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Objective Maximum amount of gingival tissue and papilla are retained to cover the materials placed in the pocket.

Conventional flap for regenerative surgery Technique ` Step 1 using no. 12 blade incise the tissue at the bottom of the pocket and to the crest of bone, splitting the papilla below the contact point. ` Step 2 reflect the flap maintaining it as thick as possible, not attempting to thin it as its done for ressective surgery. The maintenance of thick flap is necessary to prevent exposure of graft or membrane due to necrosis of flap.
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The papilla preservation flap


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Indications There must be adequate interdental space to allow the intact papilla to be reflected with facial and lingual flap. Takei et al. (1985) proposed a surgical approach called papilla preservation technique. Cortellini et al. (1995, 1999) described modifications of the flap design to be used in combination with regenerative procedures. For esthetic reasons, the papilla preservation technique is often utilized in the surgical treatment of anterior tooth regions.

Variants of Papilla Preservation Flap


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Modified papilla preservation technique (MPPT) Cortellini, Piniprato,Tonetti-1995 developed in order to increase the space for regeneration, and in order to achieve and maintain primary closure of the flap in the interdental area

Simplified papilla preservation flap


Pierpaolo Cortellini, Giovanpaolo Pini Prato, Maurizio S. Tonetti, 1999

The Papilla Amplification Flap: A Surgical Approach to Narrow Interproximal Spaces in Regenerative Procedures -Giovanni Zucchelli, Massimo De Sanctis 2005

42 shows a deep pocket (PPD 15 mm) at the distal surface.The interdental space between 42 & 43 is very narrow as the result of rotation of 42. A high band of keratinized tissue is present at the buccal aspect of both teeth.

The buccal incision consists of the submarginal highly scalloped incisions at the two teeth neighboring the defect, the submarginal split-thickness incisions at the interdental papillae mesial and distal to the defect area, and one mesial vertical releasing incision.

A deep intrabony defect is evident after flap elevation and degranulation of the defect.

The membrane is positioned at the level of the bone crest and sutured at the periosteum left in place during buccal flap elevation. Note the space available above the membrane and below the contact area; this is adequate for soft tissue coverage of the membrane material.

Complete soft tissue coverage above the membrane has been achieved. At time of suture removal (14 days), the membrane was still covered.

At time of membrane removal (6 weeks), newly formed tissue completely fills the space available below the membrane. Note the good maturation of the regenerated tissue and the absence of clinical signs of inflammation.

Clinical aspect at 1 year. 42shows a shallow residual probing pocket (3 mm) with minimal increase in the amount of gingival recession. A 2mm-high band of buccal keratinized tissue is still present at both teeth neighboring the defect area.

Minimally invasive surgical techniqueCortellini & Tonetti 2007

CHOICE OF FLAP PROCEDURES FOR ANTERIOR AND POSTERIOR AREAS


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Anterior Sector: Techniques that induce the least amount of visual root exposure should be considered first. But nonelimination of the pocket may place the tooth in jeopardy. Final decision may have to be a compromise between health and esthetics, not attaining ideal results in either respect. Anterior teeth offer some advantages to a conservative approach. 1. They are all single rooted and easily accessible; 2. Patient's compliance and thoroughness in plaque control are easier to attain. Therefore scaling and root planing is the technique of choice for the anterior teeth.

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If surgery required for improved accessibility for root planing or regenerative surgery of osseous defects, papilla preservation flap can be used for both purposes and also offers a better postoperative result with less recession and reduced soft tissue crater formation interproximally. When the teeth are too close interproximally, it may not be feasible, and sulcular incision flap offers good esthetic results and is the next choice. When esthetics are not the primary consideration, Modified Widman flap can be chosen. In some infrequent cases, bone contouring may be needed despite the resultant root exposure. The technique of choice is the apically displaced flap with bone contouring.

Posterior Area.
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Treatment for premolars and molars usually poses no esthetic problem but frequently involves difficult accessibility. Bone defects are more frequent and root morphologic features, particularly in relation to furcations, may offer unsurmountable problems for instrumentation in a close field. Therefore surgery is frequently indicated in this region. Accessibility can be obtained by either the undisplaced or apically displaced flap. Most cases of moderate to severe periodontitis have developed osseous defects that require some degree of osseous remodeling or regenerative procedures.

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When osseous defects amenable to regeneration are present, the papilla preservation flap is the technique of choice because it better protects the interproximal areas where defects are frequently present. Second and third choices are the sulcular flap and the modified Widman flap, maintaining as much of the papilla as possible. When osseous defects with no possibility of reconstruction, such as interdental craters, are present, the technique of choice is the flap with osseous contouring.

ADVANTAGES OF FLAP OPERATIONS OVER GINIGVECTOMY


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Existing gingiva is preserved The marginal alveolar bone is exposed whereby the morphology of bony defects can be identified and the proper treatment rendered Furcation areas are exposed; the degree of involvement and the toothbone relationship can be identified The flap can be repositioned at its original level or shifted apically, thereby making it possible to adjust the gingival margin to the local conditions The flap procedure preserves the oral epithelium and often makes the use of surgical dressing superfluous The post-operative period is usually less unpleasant to the patient when compared to gingivectomy.

TREATMENT DECISIONS FOR SOFT AND HARD TISSUE POCKETS IN FLAP SURGERY

GINGIVECTOMY
Gingivectomy means excision of the gingiva.

Historical background
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Ambroise Pare (1509-90) was the outstanding surgeon of the Renaissance, and he developed many oral surgical procedures, including gingivectomy for hyperplastic gingival tissues. The surgical approach as an alternative to sub - gingival scaling for pocket therapy was already recognized in the latter part of the nineteenth century, when Robicsek (1884) pioneered the so-called gingivectomy procedure. Pickerill (1912) was the first to use the term gingivectomy. Gingivectomy was later defined by Grant et al. (1979) as being the excision of the soft tissue wall of a pathologic periodontal pocket. The surgical procedure, which aimed at pocket elimination, was usually combined with recontouring of the diseased gingiva to restore physiologic form.

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By removing the pocket wall, gingivectomy provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots, creating a favorable environment for gingival healing and restoration of a physiologic gingival contour. The gingivectomy technique was widely performed in the past. Improved understanding of healing mechanisms and the development of more sophisticated flap methods have relegated the gingivectomy to a lesser role in the current repertoire of available techniques. However, it remains an effective form of treatment when indicated.

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INDICATIONS Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous and firm. Elimination of gingival enlargements. Elimination of suprabony periodontal abscesses. Pre-restorative caries exposure and crown lengthening in the treatment of subgingival carious lesions.

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CONTRAINDICATIONS 1. The need for bone surgery or examination of the bone shape and morphology 2. Situations in which the bottom of the pocket is apical to the mucogingival junction 3. Esthetic considerations, particularly in the anterior maxilla

Robicsek (1884) and, later, Zentler (1918) described the gingivectomy procedure in the following way.

The straight incision technique (Robicsek 1884).

The scalloped incision technique (Zentler 1918).

Gingivectomy procedure as it is employed today was described in 1951 by Goldman.

Pocket marking. (a) A periodontal probe is used to identify the bottom of the deepened pocket. (b) When the depth of the pocket has been assessed an equivalent distance is delineated on the outer aspect of the gingiva. The tip of the probe is then turned horizontally and used to produce a bleeding point at the level of the bottom of the probeable pocket.

(a) Primary incision. (b) The incision is terminated at a level apical to the bottom of the pocket and is angulated to give the cut surface a distinct bevel.

The secondary incision through the interdental area is performed with the use of a Waerhaug knife.

The detached gingiva is removed with a scaler.

Probing for residual pockets. Gauze packs have been placed in the interdental spaces to control bleeding.

The periodontal dressing has been applied and properly secured.

Gingivoplasty
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Gingivoplasty is similar to gingivectomy, but its purpose is different. Gingivoplasty is a reshaping of the gingiva to create physiologic gingival contours, with the sole purpose of recontouring the gingiva in the absence of pockets. Gingival and periodontal disease often produce deformities in the gingiva that interfere with normal food excursion, collect plaque and food debris, and prolong and aggravate the disease process. Gingival clefts and craters, shelf like interdental papillae caused by NUG, and gingival enlargement are examples of such deformities.

Gingivoplasty may be done with a periodontal knife, a scalpel, rotary coarse diamond stones, 6 or electrodes. It consists of procedures that resemble those performed in festooning artificial dentures; namely, tapering the gingival margin creating a scalloped marginal outline thinning the attached gingiva creating vertical interdental grooves and shaping the interdental papillae to provide sluiceways for the passage of food.

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Gingivectomy By Electrosurgery
Technique ` The removal of gingival enlargements and gingivoplasty is performed with the needle electrode, supplemented by the small ovoid loop or the diamond-shaped electrodes for festooning.
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A blended cutting and coagulating (fully rectified) current is used. In all reshaping procedures, the electrode is activated and moved in a concise "shaving" motion. For hemostasis, the ball electrode is used. Hemorrhage must be controlled by direct pressure (via air, compress, or hemostat) first; then the surface is lightly touched with a coagulating current. Electrosurgery is helpful for the control of isolated bleeding points. Bleeding areas located interproximally are reached with a thin, bar shaped electrode.

Advantages
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Disadvantages
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Electrosurgery permits an adequate contouring of the tissue. Controls hemorrhage.

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Cannot be used in patients who have non compatible or poorly shielded cardiac pacemakers. The treatment causes an unpleasant odor. If the electrosurgery point touches the bone, irreparable damage can be done; The heat generated by injudicious use can cause tissue damage and loss of periodontal support when the electrode is used close to bone. When the electrode touches the root, areas of cementum burn are produced.

Laser gingivectomy
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The lasers most commonly used in dentistry are the CO2 and Nd:YAG, which have wavelengths of 10,600 nm and 1064 nm, respectively, both in the infrared range. The CO2 laser beam has been used for the excision of gingival growths, although healing is delayed when compared with healing after conventional scalpel gingivectomy. The use of laser beam for oral surgery requires precautionary measures to avoid reflecting the beam on instrument surfaces, which could result in injury to neighboring tissues and the eyes of the operator.

Gingivectomy By Chemosurgery
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Techniques to remove the gingiva using chemicals, such as 5% paraformaldehyde or potassium hydroxide, have been described in the past but are not currently used.

Disadvantages: 1. The depth of action cannot be controlled, and therefore healthy attached tissue underlying the pocket may be injured. 2. Gingival remodeling cannot be accomplished effectively. 3. Epithelialization and reformation of the junctional epithelium and reestablishment of the alveolar crest fiber system are slower in chemically treated gingival wounds than in those produced by a scalpel .
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The use of chemical methods therefore is not recommended.

OUTCOME OF SURGICAL PERIODONTAL THERAPY

Types of soft tissue healing


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Primary wound healing (Healing by primary intention): occurs in incised wounds when minimal tissue loss has occurred and the wound edges are brought into contact by sutures. Because little, if any, granulation tissue is present, this type of wound heals rapidly, produces little structural or functional deficit, and involves minimal scarring. Secondary wound healing (Healing by secondary intention): seen where the wound edges are widely separated either as a part of intentional surgical procedures or as a consequence of tissue loss or destruction. The defect becomes filled with granulation tissue, which is eventually remodeled to form a definite scar. Such repair requires restoration of epithelium and submucosa (or of dermis in skin wounds) by synthesis of new constituents. In patients with extensive tissue loss, secondary wound healing may result in significant functional or cosmetic problems with excessive scar formation. Third intention wound healing (Delayed primary closure): in healing by third intention, the wound is temporarily left open, usually because of contamination.The wound is then closed after 4 to 7 days, with wound approximation being accomplished by either grafting or flap rotation.

Healing following Gingivectomy


Initial Healing (0-5 Hours)

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5 Hours - 1 Day Epithelium: A distinct movement of epithelial cells that originates at the wound margin begins to cross the surface of the wound.This migration is from the spinous layer and occurs by cells wedging themselves between the surface coagulum and the underlying viable connective tissue of the wound. Epithelial proliferation has also begun at the wound edge, as seen by the increased presence of mitotic figures. Connective tissue: Proliferation begins beneath and within the polyband.The clot and polyband serve a protective function until the epithelium forms a continuous sheath over the wound.The clot and PMNs disappear later when the epithelial sheath is formed.

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2-3 Days Epithelial cells are covering the wound at a rate of 0.5 mm/day.The smoother the surface of the connective tissue after the surgical procedure, the faster the rate of epithelialization. Both basal cells of the wound margin and cells that have migrated onto the wound surface are proliferating.There is a decrease in inflammatory cells (PMNs) below the migrating epithelial cells.

0-4 days

4-7 days

10-28 Days

Clinical Implications of Excisional Surgery Healing


If a long bevel is made (exposing a greater wound surface), then the healing will take longer because the epithelial cells have further to migrate. The more accurate the bevel is to 45, the less height in the regenerated gingival margin (especially when a thick gingival ledge is seen).

Healing after Electrosurgery:


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Some investigators report no significant differences in gingival healing after resection by electrosurgery and resection with periodontal knives; other researchers find delayed healing, greater reduction in gingival height, and more bone injury after electrosurgery. There appears to be little difference in the results obtained after shallow gingival resection with electrosurgery and that with periodontal knives. However, when used for deep resections close to bone, electrosurgery can produce gingival recession, bone necrosis and sequestration, loss of bone height, furcation exposure, and tooth mobility, which do not occur with the use of periodontal knives.

Healing after laser ginigivectomy:


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The acute inflammatory reaction is delayed and minimal, and few myofibroblasts are present in the base of the wound during healing. These cells are the effectors of wound contraction and thus there is little contraction following removal of oral mucosa with laser. There is minimal scarring, resulting in little duration or restriction in movement of the soft tissues. There is less bleeding with laser as compared to the scalpel cut, since the blood vessels of .5mm or less in diameter are sealed spontaneously, thus aided to the surgeon visibility and precision during the surgery.

Disadvantage: Mild postoperative discomfort usually delayed up to one or two weeks. Epithelial regeneration is delayed, and the wounds take a longer time to reepithelialize than following conventional surgery. Another disadvantage is the high cost of equipment. This delayed of wound healing is thought to be the result of the lack of wound contraction and thus failure of the area to reduce in size. The procedure usually will take longer time especially in gingivoplasty where abundant of tissue removal is required.

Gingivectomy. Dimensional changes as a result of therapy. (a) The preoperative dimensions. The black line indicates the location of the primary incision, i.e. the suprabony pocket is eliminated with the gingivectomy technique. (b) Dimensions following proper healing. Minor resorption of the alveolar bone crest as well as some loss of connective tissue attachment may occur during the healing.

Healing after flap surgery


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Initial Healing (1 - 3 Days) Space between flap and tooth or bone is thinner, epithelial cells migrate over the border of the flap. Irreversible bone resorption is greatest in areas where alveolar bone is thin and is comprised of two plates of compact bone fused together (e.g. - over prominent roots and the labial areas of mandibular incisors). Less irreversible destruction of bone occurs where cancellous or supporting bone exists between the outer cortical plate and alveolar bone proper because the marrow spaces and vascular sites act as a reservoir for healing.

0-4 days

4-10 days

10-21 days

21 days
21 Days

One month after surgery: A fully epithelized gingival crevice with well defined epithelial attachment is present. There is a beginning junctional arrangement of supracrestal fibers.

Studies related to healing


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The epithelial adhesion occlusal to the base of the original pocket is seen at times, but more frequently the collagen adhesion immediately apical to the newly adhering junctional epithelium but occlusal to the marginal alveolar crest. In the infrabony portion of the periodontal lesions, simultaneous and/or sequential deposition of repair cementum, functionally oriented ligament fibers and narrowing of the vertical defect by osteogenesis. It is possible that supracrestal healing following flap surgery is a connective tissue adherence over a limited space immediately apical to the junctional epithelial adherence. Another pattern of healing in connective tissue is the splicing of fiber ends from the tooth surface with new fibers from the healing flap wound edge. This occurs when the root surface is not completely devoid of periodontal tissue (whether due to pathological lesion or mechanical/chemical debridement). This type of healing can be classified as repair rather than regeneration.

Histologic observation also has indicated that there may be a newly cementum like material to be deposited against the tooth coronal to the crest.This newly deposited cementum is cellular, not unlike bone, and be best described as repair cementum (Dragoo and Sullivan 1973, Hawley and Miller 1975). Listgarten (1972) stated that this cementum is devoid of well defined fiber bundle. Again, since the new regenerative tissue is not exact the same as the original, the healing process can best be described as repair rather than regeneration. Theodore H. Dedolph and Henry B. Clark in 1958 revealed that at 3 weeks the epithelial attachment was complete, the attachement of periodontal membrane fibers and other connective tissue elements was restored, and the inflammatory response was mild or absent. In the study in monkey by Caffesse and Ramfjord and Nasjletti in 1968, healing following reverse bevel periodontal flap surgery has been characterized by first, second, or third intention, depending on the state of flap adaptation to teeth. Finally, the transient lowering of the attachment level and bone resorption at the alveolar crest 3 to 4 weeks following flap surgery tend to heal back to the presurgical level within 10 weeks after the surgery.

The apically repositioned flap

Dimensional changes a.Pre-operative dimension. The broken line indicates the border of the elevated mucoperiosteal flap. b. Bone recontouring has been completed and the flap is repositioned to cover the alveolar bone. c. Dimensions following healing: minor resorption of the marginal alveolar bone has occurred as well as some loss of connective tissue attachment

The modified Widman flap

Dimensional changes a.Pre-operative dimension. The broken line indicates the border of the elevated mucoperiosteal flap. b. Surgery (including curettage of angular bone defect) is completed with the mucoperiosteal flap repositioned as close possible to its presurgical position.. c. Dimensions following healing: osseous repair as well as some crestal bone resorption expected during healing with establishment of a long junctional epithelium interposed between regenerated bone tissue and the root surface. An apical displacement of the soft tissue margin has occurred . Resorption of the marginal alveolar bone has occurred as well as some loss of connective tissue attachment

Crestal bone loss after periodontal flap surgery


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Full thickness flap which denudes the bone result in superficial bone necrosis at 1 to 3 days, osteoclastic resorption follows and reach a peak at 4 5 days, declining thereafter. During this dissective procedure, the periosteum is usually separated from the alveolar bone, initiating a striking remodeling activity known as Regional accelerated Phenomenon (RAP), which hastens the healing process (Yaffe A et al 1994). The phenomenon is a transient burst of localized remodeling activity following surgical wounding of cortical bone. This results in a loss of bone about 1mm, bone loss in greater if bone is thin.Various reports state that periodontal flap surgery results in varying amounts of alveolar crest loss (Wood DL et al 1972) and interdental bone loss (Bragger U et al 1988). This bone loss may range from a minimum of 0.11mm to a maximum of 3.1mm with an average of 0.8mm (Wilderman et al 1970).

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. Bone repair reaches its peak at 3 to 4 weeks. Loss of bone occurs in the initial healing stages both in radicular bone and in interdental bone areas. However, in 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.

Comparing bone loss after full thickness and partial thickness flap
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Study in 1972 by Dale L. Wood, Phillip Hoag, O. Walter Donnenfeld, and Leon Rosenfeld reveals of the loss of crestal radicular bone after both the full thickness and the partial thickness flap. The mean bone loss for the full thickness flap was .62 mm and after partial thickness flaps was .98mm. So, bone loss was greater with the use of partial thickness flap.

Fickl S et al 2011: Partial-thickness flaps resulted in less bone loss than full-thickness flaps, but are subject to some variability. Use of partial-thickness flaps does not prevent from all bone loss.

Application of bisphosphonate to reduce crestal bone loss following flap surgery


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In earlier studies, it has been proved that bisphosphonate alendronate (ALN) is effective in reducing alveolar bone loss following periodontal surgery in rats. Topical application of sponge soaked in 10 l of ALN solution at the time of surgery demonstrated marked reduction of bone resorption while maintaining the alveolar crest height (Yaffe A et al 1997). Aminobisphosphonate given intravenously significantly reduced alveolar bone resorption after mucoperiosteal flap surgery (Yaffe A et al 1995). Because of the high affinity of bisphosphonates for HA bone mineral, these drugs are targeted to areas of bone turnover and are specifically concentrated at the site of osteoclastic bone resorption.

Therefore, the most likely route by which bisphosphonates could inhibit bone resorption is by a direct effect on resorbing osteoclasts, though the fine mechanism/mechanisms by which bisphosphonates act on bone are not very clear. There may be an indirect effect on secretion of osteoclast activating factor by osteoblasts. The direct effect on osteoclasts includes cytotoxic or metabolic injury of mature osteoclasts, inhibition of osteoclast attachment to bone, inhibition of osteoclast differentiation or recruitment, and interference with osteoclast structural features necessary for bone resorption.

Molecular mechanisms
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Bisphosphonates bind to the bone mineral & are released due to highly acidic local environment. Taken up by osteoclasts. Inside the osteoclasts, they inhibit the enzyme(s) of the mevalonate pathway responsible for the production of cholesterol and isoprenoid lipids which are important substrates for the post-translational lipid modification (prenylation) of small GTPases. Prenylation is required for the correct functioning of these proteins. Inhibition of the mevalonate pathway and thus interference with generation of GGPP results in loss of prenylation of these GTP binding proteins. This results in disruption of actin cytoskeleton and loss of ruffled border formation, both of which are essential for the bone resorbing activity of osteoclasts, resulting in osteoclast inactivation.

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So, bisphosphonates, if combined with bone regenerative material, may inhibit the surgery-induced RAP and hence can improve the performance of graft. Studies :
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In 1995, Reddy et al. also evaluated ALN for inhibition of alveolar bone loss in naturally occurring periodontitis. The results demonstrated that though there were no differences in signs of inflammation or pocketing, there was still an increase in bone mineral density. Meraw et al. 1999 conducted a study to evaluate the effect of local delivery of ALN on bone regeneration within peri-implant defects. The results indicated that ALN increases the amount of peripheral periimplant bone. Kaynak et al. 2000 in their study concluded that local application of ALN could be used as an adjunct in reducing bone resorption following surgery. Jyoti Gupta et al (2011) evaluated the relative efficacy of the alloplast used alone and in conjunction with an osteoclast inhibitor (topically delivered bisphosphonate) in the treatment of human periodontal infrabony defects. The results of the study show evidence of aminobispho-sphonates potentiating osseous regeneration by virtue of their osteoclast inhibitory activity, following mucoperiosteal flap surgery.

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Cheng A et al (2009) The possibility that bisphosphonates may be a useful treatment in periodontics was contemplated in the 1990s and early 2000s. It was considered that bisphosphonate use may prevent bone loss around teeth and implants and possibly stimulate new bone formation. These studies all ceased once osteonecrosis of the jaws ONJ was described in the literature.

CONCLUSION