FLAP SURGERY AND GINGIVECTOMYPRESENTED 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. ` can be properly evaluated. which facilitates surgical handling of the soft tissues. hyperemia. A better basis for a proper assessment of the prognosis has been established. thereby making assessment of the ´trueµ gingival contours and pocket depths possible. Reduction of gingival inflammation makes the soft tissues more fibrous and thus firmer. The effectiveness of the patient·s home care. The propensity for bleeding is reduced.Time lapse between termination of ICRT and evaluation may vary from 1 to 6 months: ` Removal of calculus and bacterial plaque will eliminate or markedly reduce the inflammatory cell infiltrate in the gingiva (edema. making inspection of the surgical field easier. flabby tissue consistency). which is of decisive importance for the long-term prognosis. ` ` . DEFINITIONS . 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.FLAP ` A flap is defined as a loosened section of tissue separated from the surrounding tissue except at its base. . OBJECTIVES . ` While these objectives cannot be entirely discarded today.` 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. the necessity for pocket elimination in periodontal therapy has been challenged. (2) the root surface was made accessible for scaling and for selfperformed tooth cleaning after healing. . 4. ` Others 3.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. For root coverage procedures . Establishing a gingival morphology which facilitates the patient·s selfperformed infection control. 5. Expose the bone for osteoplasty or ressective osseous surgery 6. Regeneration of periodontal attachment lost due to destructive disease. Creating accessibility for proper professional scaling and root planing 2. Elimination or reduction of pocket depth by resection of the pocket wall. 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 . Thin flap preparation by primary incision Difficult l.The comparison of full thickness and partial thickness flap is as follows: Full thickness a. Augmentation of band of attached gingiva Possible . 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. c. e. g. d. i. f. b. h. Possibility of flap penetration Less k. DESIGN OF FLAP . Considerations: ` 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 . causing a slow and painful healing. Ideal thickness Flap too thin Necrosis of flap . If the flap is too thick. blood supply may be impaired and necrosis of the flap margin can occur.Flap thickness ` If the flap is too thin. leading to the formation of pseudopockets after healing. bulky tissue will result. INCISIONS Horizontal incisions Horizontal incisions are directed along the margin of the gingiva in a mesial or a distal direction. ` ` ` Internal bevel incision (primary incision) Sulcular incision (Secondary incision) Interdental incision (Third incision) . which is apically positioned becomes attached gingiva. ` Produces a sharp. osseous resection) ` Thick gingiva (such as palatal gingiva) ` Deep periodontal pockets and bone defects ` Desire to lengthen clinical crown . 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.Internal bevel incision (Reverse bevel): Objectives: ` It removes the pocket lining ` It conserves the relatively uninvolved outer surface of the gingiva. An occlusal view of the different locations where the internal bevel incision can be made. .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. ` Method ` Incision given with beak shaped no. 12D blade the incision is carried around the entire teeth.Second incision ² 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. . ` ` Third incision ² 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 ` ` . Vertical incisions . Envelope flap: if apical. Triangular flap Trapezoidal flap . lateral and coronal displacement of flap is not anticipated. Some clinicians perforate the walls of the lesion with small round burs to allow migration of osteogenic elements from the adjacent marrow spaces. Contraindicated when bone grafts used.Interdental denudation procedure. if successful. occurs when bone is regenerated from the floor and walls of the lesion to fill the defect. All granulation tissue is removed from all walls of the bony lesion and the bone and tooth are meticulously curetted.Prichard·s technique. best suited to 3-wall bony deformities. ` ` ` ` ` This consists of horizontal. non scalloped incision to remove the gingival papilla and denude the interdental space. When the flaps are replaced and sutured. Healing. .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. Full-thickness flaps are elevated on both buccal and lingual. the marginal bone is left denuded. internal bevel.A type of flap curettage. 11 or no. 15) is used. ` Sharp dissection is necessary to reflect a partial thickness flap. . a surgical scalpel (no.ELEVATION OF FLAP ` For full thickness flap blunt dissection is accomplished by periosteal elevation. HISTORYFLAP SURGERY PROCEDURES . Neuman in 1912 and 1915 described a semilunar incision for access to the root surfaces and the alveolar crest.1911 Neumann He claimed the introduction of the mucoperiosteal flap in 1911. Later in Neuman·s text book in 1920 a mucoperiosteal periodontal flap was described the stressed that periodontal surgery results in horizontal alveolar and gingival atrophy. . with the idea that the procedure was to allow access for debridement and elimination of granulation tissue as well as osseous removal by chisels. .A.Widman introduced the Widman flap in 1918. 1918 Cieszynski He was credited with the introduction of reverse bevel incision.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.S. in 1918. Zentler introduced the mucoperiosteal flap in the U. The main culprit of the disease now has shifted to the soft tissue. . His method has been used as ´open subgingival curettage. He recommended gingivectomy followed by mucoperiosteal flap.1931 Kirkland Apparently the first description of the flap procedure for the purpose of reattachment was given by Kirkland. 1949 Schluger During 1930 and 1940 gingivectomy was most popular for pocket elimination (Schluger in 1949). Orban later supported this finding in his own studies. Later a modification of Schluger·s 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.µ 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. 1954 Nabers He described the ´repositioning of the attached gingiva.µ 1957 Nabers He utilized the Widman·s inverse bevel incision of which he called the ´repositioning incisionµ 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 ` 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. the inside of the flap was curetted to remove the pocket epithelium and the granulation tissue. Following flap elevation. 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. Any irregularities of the alveolar bone were corrected to give the bone crest a horizontal outline. With regard to pocket elimination.` The root surfaces were subsequently carefully ´cleanedµ.e. ` ` . replacing the flap at the crest of the alveolar bone. Neumann (1920) pointed out the importance of removing the soft tissue pockets. i. Modified flap operation (Sulcular incision flap).1931 Kirkland . The potential for bone regeneration in intrabony defects.Advantages ` ` ` ` 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 thickness of the gingiva and alveolar bone margin in the operative area. the flap may be full thickness or partial thickness. ` ` . If the periodontal pocket reaches or extends beyond the mucogingival junction and attached gingiva is extremely thin.The apically repositioned flap The choice of method is detected by: ` Whether the osseous defects therapy is necessary or not. 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 . ` Extension of clinical crown length for restorative/ prosthetic treatment (Crown lengthening surgery) ` .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. 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 . 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. ` ` ` .` Advantages Minimum pocket depth post-operatively If optimal soft tissue coverage of the alveolar bone is obtained. ` Treatment may be complicated if combined with osseous resection.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. Schematic illustration of the incision technique in case of the presence of only a minimal zone of gingiva. .Modified Widman flap ` 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. ` Technique . . The minimum of trauma to which the alveolar bone and the soft connective tissues are exposed.Advantages ` ` ` ` ` The possibility of obtaining a close adaptation of the soft tissues to the root surfaces. . 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. 1. . In the technique followed. the pocket lining was removed with the help of a diode laser. The laser settings were rearranged at 4W in continuous mode.Laser assisted Modified Widman flap ` ` ` ` ` Salaria S et al (2010) performed modified Widman flap with the help of laser and called it Laser assisted Modified Widman flap (LAMWF).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. 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. There was no pain or any other discomfort reported at 1 week post surgery. The granulation tissue was removed from the defects by manual debridement and root surfaces were thoroughly planed. Crevicular incision was given with a BP blade no. Inner aspect of the reflected buccal and lingual flap was then subjected to laser application to remove any remaining epithelium. 15 directed towards the alveolar crest.` ` ` ` ` The laser was kept in continuous movement to prevent charring of connective tissue. After complete debridement the surgical site was sutured. . Full thickness mucoperiosteal flap was raised buccally and lingually. .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. Internal bevel incision made and is carried to a point apical to alveolar crest. Area is covered with a periodontal pack.` ` ` ` ` ` ` ` ` The pockets are measured with periodontal probe and bleeding points are produced to mark bottom of the pocket. 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. . Thinning of flap is done with initial incision. Reduction of periodontal pocket in a thick gingival wall in the palatal aspect is uncommon because of minimal gingival shrinkage achieved by initial therapy. The palatal tissue is masticatory mucosa and immobile. Close adaptation to the tooth surface and bone margin is difficult and post operative gingival morphology is unfavorable. ` ` ` . It is impossible to displace a palatal flap apically.Palatal flaps ` Because of anatomic characteristic of palate. palatal flap require different designs. Inaccessibility of cleaning instruments may cause inadequate self care. Following are considered in purpose of palatal flap before incision is made ` For debridement internal bevel incision planned so that flap adapts at root bone junction when sutured. The initial incision is followed by crevicular and interdental incisions. ` ` ` . 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. For osseous resection ² the incision should be planned to compensate for the lowered level of bone when flap is closed. ` 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 ` ` ` . splitting the papilla below the contact point. not attempting to thin it as its done for ressective surgery. ` .Flaps for regenerative surgery ` ` Objective Maximum amount of gingival tissue and papilla are retained to cover the materials placed in the pocket. The maintenance of thick flap is necessary to prevent exposure of graft or membrane due to necrosis of flap. ` Step 2 reflect the flap maintaining it as thick as possible. 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. Takei et al. 1999) described modifications of the flap design to be used in combination with regenerative procedures. Cortellini et al. (1985) proposed a surgical approach called papilla preservation technique. ` ` ` . (1995. For esthetic reasons. the papilla preservation technique is often utilized in the surgical treatment of anterior tooth regions.The papilla preservation flap ` ` Indications There must be adequate interdental space to allow the intact papilla to be reflected with facial and lingual flap. . Piniprato. and in order to achieve and maintain primary closure of the flap in the interdental area ` .Tonetti-1995 developed in order to increase the space for regeneration.Variants of Papilla Preservation Flap ` Modified papilla preservation technique (MPPT) Cortellini. . Simplified papilla preservation flap Pierpaolo Cortellini. Tonetti. Maurizio S. 1999 . Giovanpaolo Pini Prato. . . . The Papilla Amplification Flap: A Surgical Approach to Narrow Interproximal Spaces in Regenerative Procedures -Giovanni Zucchelli. Massimo De Sanctis 2005 . The buccal incision consists of the submarginal highly scalloped incisions at the two teeth neighboring the defect.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. and one mesial vertical releasing incision. .42 shows a deep pocket (PPD 15 mm) at the distal surface. the submarginal split-thickness incisions at the interdental papillae mesial and distal to the defect area. A deep intrabony defect is evident after flap elevation and degranulation of the defect. At time of suture removal (14 days). this is adequate for soft tissue coverage of the membrane material. Note the space available above the membrane and below the contact area. the membrane was still covered. Complete soft tissue coverage above the membrane has been achieved. .The membrane is positioned at the level of the bone crest and sutured at the periosteum left in place during buccal flap elevation. A 2mm-high band of buccal keratinized tissue is still present at both teeth neighboring the defect area. 42shows a shallow residual probing pocket (3 mm) with minimal increase in the amount of gingival recession. . Clinical aspect at 1 year.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. Minimally invasive surgical techniqueCortellini & Tonetti 2007 . Therefore scaling and root planing is the technique of choice for the anterior teeth. They are all single rooted and easily accessible. Patient's compliance and thoroughness in plaque control are easier to attain. not attaining ideal results in either respect. . 1. Final decision may have to be a compromise between health and esthetics.CHOICE OF FLAP PROCEDURES FOR ANTERIOR AND POSTERIOR AREAS ` ` ` ` ` ` 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. 2. Anterior teeth offer some advantages to a conservative approach. ` ` ` ` 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. ` ` ` 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. ` ` ` 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. ` ` . 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. the degree of involvement and the ´tooth²boneµ relationship can be identified The flap can be repositioned at its original level or shifted apically.ADVANTAGES OF FLAP OPERATIONS OVER GINIGVECTOMY ` ` ` ` ` ` 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. TREATMENT DECISIONS FOR SOFT AND HARD TISSUE POCKETS IN FLAP SURGERY . .GINGIVECTOMY Gingivectomy means excision of the gingiva. and he developed many oral surgical procedures. which aimed at ´pocket eliminationµ. Gingivectomy was later defined by Grant et al. including gingivectomy for hyperplastic gingival tissues. The surgical approach as an alternative to sub .Historical background ` Ambroise Pare (1509-90) was the outstanding surgeon of the Renaissance. Pickerill (1912) was the first to use the term gingivectomy. (1979) as being ´the excision of the soft tissue wall of a pathologic periodontal pocketµ. The surgical procedure.gingival scaling for pocket therapy was already recognized in the latter part of the nineteenth century. was usually combined with recontouring of the diseased gingiva to restore physiologic form. ` ` ` . when Robicsek (1884) pioneered the so-called gingivectomy procedure. The gingivectomy technique was widely performed in the past. gingivectomy provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots. 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. creating a favorable environment for gingival healing and restoration of a physiologic gingival contour. it remains an effective form of treatment when indicated.` By removing the pocket wall. However. ` ` ` . ` ` CONTRAINDICATIONS 1. particularly in the anterior maxilla ` ` ` ` ` . if the pocket wall is fibrous and firm. Elimination of gingival enlargements.` ` INDICATIONS Elimination of suprabony pockets. Pre-restorative caries exposure and crown lengthening in the treatment of subgingival carious lesions. The need for bone surgery or examination of the bone shape and morphology 2. Esthetic considerations. Situations in which the bottom of the pocket is apical to the mucogingival junction 3. regardless of their depth. Elimination of suprabony periodontal abscesses. The straight incision technique (Robicsek 1884). later. Zentler (1918) described the gingivectomy procedure in the following way. . The scalloped incision technique (Zentler 1918).Robicsek (1884) and. 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. Pocket marking. (a) A periodontal probe is used to identify the bottom of the deepened pocket. .Gingivectomy procedure as it is employed today was described in 1951 by Goldman. (b) When the depth of the pocket has been assessed an equivalent distance is delineated on the outer aspect of the gingiva. (a) Primary incision. (b) The incision is terminated at a level apical to the ³bottom´ 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. . Gauze packs have been placed in the interdental spaces to control bleeding. .Probing for residual pockets. The periodontal dressing has been applied and properly secured. collect plaque and food debris.Gingivoplasty ` Gingivoplasty is similar to gingivectomy. Gingivoplasty is a reshaping of the gingiva to create physiologic gingival contours. Gingival and periodontal disease often produce deformities in the gingiva that interfere with normal food excursion. but its purpose is different. and prolong and aggravate the disease process. with the sole purpose of recontouring the gingiva in the absence of pockets. ` ` ` . and gingival enlargement are examples of such deformities. shelf like interdental papillae caused by NUG. Gingival clefts and craters. ` ` ` ` ` .` Gingivoplasty may be done with a periodontal knife. rotary coarse diamond stones. 6 or electrodes. 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. a scalpel. It consists of procedures that resemble those performed in festooning artificial dentures. compress. ` ` .Gingivectomy By Electrosurgery Technique ` The removal of gingival enlargements and gingivoplasty is performed with the needle electrode. or hemostat) first. the ball electrode is used. ` A blended cutting and coagulating (fully rectified) current is used. Bleeding areas located interproximally are reached with a thin. bar shaped electrode. Hemorrhage must be controlled by direct pressure (via air. then the surface is lightly touched with a coagulating current. the electrode is activated and moved in a concise "shaving" motion. In all reshaping procedures. supplemented by the small ovoid loop or the diamond-shaped electrodes for festooning. Electrosurgery is helpful for the control of isolated bleeding points. For hemostasis. Controls hemorrhage. . areas of cementum burn are produced. 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. If the electrosurgery point touches the bone.Advantages ` Disadvantages ` Electrosurgery permits an adequate contouring of the tissue. irreparable damage can be done. ` ` ` ` ` Cannot be used in patients who have non compatible or poorly shielded cardiac pacemakers. The treatment causes an unpleasant odor. Laser gingivectomy ` The lasers most commonly used in dentistry are the CO2 and Nd:YAG. respectively. 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.600 nm and 1064 nm. which could result in injury to neighboring tissues and the eyes of the operator. which have wavelengths of 10. The use of laser beam for oral surgery requires precautionary measures to avoid reflecting the beam on instrument surfaces. ` ` . both in the infrared range. . such as 5% paraformaldehyde or potassium hydroxide. have been described in the past but are not currently used. ` ` The use of chemical methods therefore is not recommended.Gingivectomy By Chemosurgery ` Techniques to remove the gingiva using chemicals. and therefore healthy attached tissue underlying the pocket may be injured. The depth of action cannot be controlled. 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 . Disadvantages: 1. OUTCOME OF SURGICAL PERIODONTAL THERAPY . produces little structural or functional deficit. and involves minimal scarring. In patients with extensive tissue loss. if any. ` ` ` . with wound approximation being accomplished by either grafting or flap rotation. Such repair requires restoration of epithelium and submucosa (or of dermis in skin wounds) by synthesis of new constituents. usually because of contamination. this type of wound heals rapidly. 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 wound is temporarily left open.The wound is then closed after 4 to 7 days. The defect becomes filled with granulation tissue.Types of soft tissue healing ` 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. granulation tissue is present. which is eventually remodeled to form a definite scar. 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. Healing following Gingivectomy Initial Healing (0-5 Hours) . Epithelial proliferation has also begun at the wound edge.` ` ` 5 Hours .The clot and PMNs disappear later when the epithelial sheath is formed. . as seen by the increased presence of mitotic figures. Connective tissue: Proliferation begins beneath and within the polyband.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.1 Day Epithelium: A distinct movement of epithelial cells that originates at the wound margin begins to cross the surface of the wound.The clot and polyband serve a protective function until the epithelium forms a continuous sheath over the wound. There is a decrease in inflammatory cells (PMNs) below the migrating epithelial cells. . Both basal cells of the wound margin and cells that have migrated onto the wound surface are proliferating. the faster the rate of epithelialization.5 mm/day.The smoother the surface of the connective tissue after the surgical procedure.` ` 2-3 Days Epithelial cells are covering the wound at a rate of 0. ` 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 45º, the less height in the regenerated gingival margin (especially when a thick gingival ledge is seen). However. when used for deep resections close to bone. furcation exposure. bone necrosis and sequestration. electrosurgery can produce gingival recession. other researchers find delayed healing. and more bone injury after electrosurgery. loss of bone height. and tooth mobility.Healing after Electrosurgery: ` Some investigators report no significant differences in gingival healing after resection by electrosurgery and resection with periodontal knives. ` ` . There appears to be little difference in the results obtained after shallow gingival resection with electrosurgery and that with periodontal knives. greater reduction in gingival height. which do not occur with the use of periodontal knives. Healing after laser ginigivectomy: ` ` ` ` The acute inflammatory reaction is delayed and minimal. and few myofibroblasts are present in the base of the wound during healing. There is minimal scarring. There is less bleeding with laser as compared to the scalpel cut. resulting in little duration or restriction in movement of the soft tissues. .5mm or less in diameter are sealed spontaneously. thus aided to the surgeon visibility and precision during the surgery. These cells are the effectors of wound contraction and thus there is little contraction following removal of oral mucosa with laser. since the blood vessels of . and the wounds take a longer time to reepithelialize than following conventional surgery. 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.` Disadvantage: Mild postoperative discomfort usually delayed up to one or two weeks. The procedure usually will take longer time especially in gingivoplasty where abundant of tissue removal is required. Another disadvantage is the high cost of equipment. Epithelial regeneration is delayed. ` . The black line indicates the location of the primary incision. (b) Dimensions following proper healing. the suprabony pocket is eliminated with the gingivectomy technique. Minor resorption of the alveolar bone crest as well as some loss of connective tissue attachment may occur during the healing. (a) The preoperative dimensions. i.e.Gingivectomy. . Dimensional changes as a result of therapy. over prominent roots and the labial areas of mandibular incisors). ` ` .g. . 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.Healing after flap surgery ` ` Initial Healing (1 .3 Days) Space between flap and tooth or bone is thinner. 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 . There is a beginning junctional arrangement of supracrestal fibers. .21 days 21 Days One month after surgery: A fully epithelized gingival crevice with well defined epithelial attachment is present. but more frequently the collagen adhesion immediately apical to the newly adhering junctional epithelium but occlusal to the marginal alveolar crest. functionally oriented ligament fibers and narrowing of the vertical defect by osteogenesis. . simultaneous and/or sequential deposition of repair cementum.Studies related to healing ` ` ` ` ` The epithelial adhesion occlusal to the base of the original pocket is seen at times. This occurs when the root surface is not completely devoid of periodontal tissue (whether due to pathological lesion or mechanical/chemical debridement). 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. In the infrabony portion of the periodontal lesions. This type of healing can be classified as repair rather than regeneration. 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. Finally. and be best described as repair cementum (Dragoo and Sullivan 1973. Theodore H. ` . the attachement of periodontal membrane fibers and other connective tissue elements was restored.` ` ` ` Histologic observation also has indicated that there may be a newly cementum like material to be deposited against the tooth coronal to the crest. and the inflammatory response was mild or absent. depending on the state of flap adaptation to teeth. second. Listgarten (1972) stated that this cementum is devoid of well defined fiber bundle. Clark in 1958 revealed that at 3 weeks the epithelial attachment was complete. or third intention. Dedolph and Henry B. In the study in monkey by Caffesse and Ramfjord and Nasjletti in 1968. 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. since the new regenerative tissue is not exact the same as the original. not unlike bone. healing following reverse bevel periodontal flap surgery has been characterized by first. Again.This newly deposited cementum is cellular. the healing process can best be described as repair rather than regeneration. Hawley and Miller 1975). Bone recontouring has been completed and the flap is repositioned to cover the alveolar bone. b. The broken line indicates the border of the elevated mucoperiosteal flap.The apically repositioned flap Dimensional changes a.Pre-operative dimension. Dimensions following healing: minor resorption of the marginal alveolar bone has occurred as well as some loss of connective tissue attachment . c. The modified Widman flap Dimensional changes a. c. Surgery (including curettage of angular bone defect) is completed with the mucoperiosteal flap repositioned as close possible to its presurgical position..Pre-operative dimension. b. The broken line indicates the border of the elevated mucoperiosteal flap. An apical displacement of the soft tissue margin has occurred . 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. Resorption of the marginal alveolar bone has occurred as well as some loss of connective tissue attachment . 1mm with an average of 0. This bone loss may range from a minimum of 0.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). which hastens the healing process (Yaffe A et al 1994). the periosteum is usually separated from the alveolar bone.8mm (Wilderman et al 1970). During this dissective procedure. declining thereafter.11mm to a maximum of 3. . 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. osteoclastic resorption follows and reach a peak at 4 ² 5 days.Crestal bone loss after periodontal flap surgery ` ` ` ` ` Full thickness flap which denudes the bone result in superficial bone necrosis at 1 to 3 days. bone loss in greater if bone is thin. initiating a striking remodeling activity known as Regional accelerated Phenomenon (RAP). Bone repair reaches its peak at 3 to 4 weeks. bone repair results in loss of marginal bone. particularly if thin and unsupported by cancellous bone. which is later remodeled by new bone formation. Loss of bone occurs in the initial healing stages both in radicular bone and in interdental bone areas. ` ` ` . in interdental areas. the subsequent repair stage results in total restitution without any loss of bone. included as part of the surgical technique. whereas in radicular bone.` Osteoplasty (thinning of the buccal bone) using diamond burs. which have cancellous bone. Therefore the final shape of the crest is determined more by osseous remodeling than by surgical reshaping. results in areas of bone necrosis with reduction in bone height. However. bone loss was greater with the use of partial thickness flap. Phillip Hoag. ` Fickl S et al 2011: Partial-thickness flaps resulted in less bone loss than full-thickness flaps. Use of partial-thickness flaps does not prevent from all bone loss. Walter Donnenfeld.98mm. O. So. but are subject to some variability. 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 . Wood.Comparing bone loss after full thickness and partial thickness flap ` Study in 1972 by Dale L. .62 mm and after partial thickness flaps was . Because of the high affinity of bisphosphonates for HA bone mineral. 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). ` ` .Application of bisphosphonate to reduce crestal bone loss following flap surgery ` In earlier studies. it has been proved that bisphosphonate alendronate (ALN) is effective in reducing alveolar bone loss following periodontal surgery in rats. these drugs are targeted to areas of bone turnover and are specifically concentrated at the site of osteoclastic bone resorption. ` Therefore. ` ` . inhibition of osteoclast attachment to bone. inhibition of osteoclast differentiation or recruitment. 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 most likely route by which bisphosphonates could inhibit bone resorption is by a direct effect on resorbing osteoclasts. and interference with osteoclast structural features necessary for bone resorption. The direct effect on osteoclasts includes cytotoxic or metabolic injury of mature osteoclasts. ` ` ` ` . Inside the osteoclasts. Taken up by osteoclasts. both of which are essential for the bone resorbing activity of osteoclasts. Prenylation is required for the correct functioning of these proteins.Molecular mechanisms ` Bisphosphonates bind to the bone mineral & are released due to highly acidic local environment. 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. resulting in osteoclast inactivation. This results in disruption of actin cytoskeleton and loss of ruffled border formation. Inhibition of the mevalonate pathway and thus interference with generation of GGPP results in loss of prenylation of these GTP binding proteins. Kaynak et al. The results of the study show evidence of aminobispho-sphonates potentiating osseous regeneration by virtue of their osteoclast inhibitory activity. 2000 in their study concluded that local application of ALN could be used as an adjunct in reducing bone resorption following surgery. bisphosphonates. may inhibit the surgery-induced RAP and hence can improve the performance of graft. Studies : ` ` ` ` In 1995. also evaluated ALN for inhibition of alveolar bone loss in naturally occurring periodontitis. 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. . if combined with bone regenerative material. following mucoperiosteal flap surgery. there was still an increase in bone mineral density. 1999 conducted a study to evaluate the effect of local delivery of ALN on bone regeneration within peri-implant defects.So. The results demonstrated that though there were no differences in signs of inflammation or pocketing. Meraw et al. The results indicated that ALN increases the amount of peripheral periimplant bone. Reddy et al. 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. ` ` .` ` Cheng A et al (2009) The possibility that bisphosphonates may be a useful treatment in periodontics was contemplated in the 1990s and early 2000s. CONCLUSION .