Ch02: Surgical Basics

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Surgical Basics
Basic Incisions
Peridontal disease is multifaceted in the nature,
scope, and types of problems created (eg,
mucogingival problems, osseous deformities,
gingival enlargement); therefore, many types of
treatment exist (Figure 2-1). There is no one way
to approach a single problem or procedure. Training, ability, philosophy, and objectives ultimately
determine final treatment selection. The following is a list of basic surgical incisions.
1.
2.
3.
4.
5.
Curettage: The removal of the inner epithelial lining, epithelial attachment, and underlying inflamed connective tissue on the inner
aspect of the pocket. This is a closed surgical
procedure (Figure 2-2A).
Gingivectomy: The excisional removal of tissue for treatment of suprabony pockets. This
procedure is indicated where bone loss is
horizontal and there is an adequate zone of
attached keratinized gingiva (Figure 2-2B).
Full-thickness (mucoperiosteal) flap: A flap
designed to gain access and visibility for
osseous surgery, relocation of the frenulum,
maintenance of the attached tissue, and
pocket elimination and regeneration procedures. The incision can be sulcular, crestal, or
inverse bevel, depending on the amount of
attached tissue present (Figure 2-2C).
Partial- or split-thickness (mucosal) flap: A
flap designed to retain and maintain the
periosteal covering over the bone. A sharp or
supraperiosteal dissection technique parallel
to the bone is used in this procedure. It is indicated mostly in areas of thin bony plates and
for mucogingival procedures (Figure 2-2D).
Modified full-thickness (mucoperiosteal) flap:
A flap for which a first-stage gingivectomy
incision is used for pocket reduction or elimination, followed by a secondary inversebeveled incision to the crest of bone. This technique requires an adequate zone of attached
keratinized gingiva and is used primarily on
the palate, on enlarged tissue, or in areas in
which limited access may prevent a primary
inverse-beveled incision (Figure 2-2E).
Tables 2-1 and 2-2 compare the various
treatment procedures. These should be used only
as a general guide in deciding which technique to
use. Table 2-3 is a comparative analysis of the various surgical techniques.
Classification of Surgical Procedures
Correction of Soft Tissue Pockets
Closed Procedures.
1. Curettage
2. Excisional new attachment procedure (ENAP)
and modified ENAP
3. Modified Widman flap
4. Apically positioned (repositioned) flap
a. Full thickness
b. Partial/full thickness
c. Partial thickness (supraperiosteal)
5. Palatal flap
a. Full thickness
b. Partial thickness
6. Distal wedge procedure
a. Tuberosity
b. Retromolar area
Open Procedures.
1. Gingivectomy
2. Gingivoplasty
Surgery for Correction of Osseous
Deformities and Osseous Enhancement
Procedures
Closed Procedures.
1. Full- or partial-thickness flap
a. Apically positioned flap
b. Unpositioned flap
c. Modified flap
d. Modified Widman flap
2. Distal wedge procedure
3. Palatal flap
Open Procedures.
1. Gingivectomy
a. Rotary abrasives
b. Interproximal denudation
c. Intrabony pocket procedure
2. Prichard procedure for osseous fill
Guided Tissue Regeneration (GTR).
Guided Bone Regeneration (GBR).
Correction of Mucogingival Problems
Preservation of Existing Attached Gingiva.
1. Apically positioned (repositioned) flap
a. Full thickness
b. Partial thickness
2. Frenectomy or frenotomy
3. Modified Widman flap
Increasing Dimension of
Exisiting Attached Gingiva.
1. Mucosal stripping
2. Periosteal separation
3. Laterally positioned flap (pedicle)
a. Full thickness
b. Partial thickness
c. Periosteally stimulated
d. Partial/full thickness
4. Papillary flaps
a. Double papillae
b. Rotated papillae
c. Horizontal papillae
5. Edlan-Mejchar, subperiosteal vestibular
extension operation, or double lateral bridging flap
6. Free soft tissue autografts
a. Partial thickness
b. Full thickness
7. Connective tissue autograft
8. Subepithelial connective tissue graft
Procedures Commonly Used
for Root Coverage
Pedicle Flaps (Full or Partial Thickness).
1. Laterally positioned flaps
2. Double-papillae flaps
3. Coronally positioned flaps
4. Periosteally stimulated flaps
5. Semilunar flap
6. Rotated or transpositional pedicle flap
Free Soft Tissue Autografts.
1. Full thickness
2. Partial thickness
Subepithelial Connective Tissue Graft.
Acellular Dermal Matrix Grafts.
Guided Tissue Regeneration.
1. Nonresorbable
2. Resorbable
Procedure Commonly Used
for Ridge Augmentation
Connective Tissue Graft.
1. Pouch procedure
2. Connective tissue graft/coronally positioned
flap
3. Pediculated connective tissue graft
4. Onlay interpositional graft
5. Interpositional graft
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10 Basics
Historical review
Radical gingivectomy flap procedure
1862 - 1884
S.Robicsek
Unrepositioned flap
Cizezinky 1914
Bentler
1916
Coronally
repositioned flap
Norberg
1926
Semiflap
Kirkland
1931
All bone healthy
(Not necrotic)
Kronfeld
1935
Apically displaced flap
Neuman
1912
Widman
1916
Repositioned flap
Zemsky
1926
Modified flap
Kirkland
1936
Treatment of
pre-maxilla
Ingle
1952
Preprosthetic
vestibular
deepening
Mucogingival surgery
Goldman
1953
Friedman
1957
Kazanjian
1936
Gingival replacement
Pushback
1953
Pouch
1953
Development of
physiologic contours
Goldman 1950
Lateral sliding
flap
Grupe 1956
Use of two
vertical incisions
1957
From edentulous
ridge
1964
The apically
repositioned flap
1962
Double lat.
reposit. flap
1963
Grupe
modification
1966
Classification
of flaps
1964
Oblique rotated
Flap
1965
Contiguous lat.
sliding flap
1967
Unrepositioned
flap
1965
Horizontal sliding
papillary flap
1967
For furcation
involvement
1968
The distal wedge
1963, 1964,
1966
Double papillae
flap
1968
Periostealstimulated flap
1968
Curtain
procedure
1969
Rotated lat.
sliding flap
1969
Gingival fiber
retention
1972
Periosteal
separation
1961, 1962
Obwegeser
1956
Double flap
1963
Fixed long labial
mucosal flap
1963
Use of oblique
incision
1957
Split thickness
lat. flap
1964
Apical repositioned split-flap
1960
Elden - Mejchar
1963
Free gingival graft
1966
S.V.E.
1976
Double lat.
bridging fap
1985
Lip switch
1991
Cosmetic root
coverage
Ridge
augmentation
Classification
1968, 1985
Classification
1983
Coronally positioned flap
1976, 1986
Roll technique
1979
Free gingival grafts
1982, 1985
Onlay grafting
1979, 1983
Subepithelial C.T. graft
1985, 1986
Subepithelial C.T. graft
1979, 1982
Envelope flap
1985
Pouch procedure
1980, 1981
E.N.A.P.
1976
Semilunar flap
1986
Modified or improved tech.
1985
Modified E.N.A.P.
1977
Guided tissue regeneration
G-TAM 1991, 1992
Socket preservation
1989
Semilunar flap
1986
Open flap
curettage
1976
Transpositional
flap
1990
Papillary
preservation technique
1988
GTR for ? 1983
ADM
1996
Interpositional graft 1996
FIGURE 2-1. Historical review.
Osteopathy and
osteotomy
Friedman 1955
Classification of
intrabony defects
1958
Palatal approach
for osseous surgery
1963, 1964
Autogenous
bone chips
1964
Demineralized freeze
dried allografic bone
(DFDAB) 1965, 1968
Bone swaging
1965
Palatal ledge and
wedge technique
1958, 1965
Split-thickness
palatal flap
1969
Illac crest
bone implants
1968
Bone from
extraction sites
1969
Osseous
coagulum
1970
Tuberosity
grafts
1971
Modified Widman
flap
1974
Guided tissue regeneration
G-TAM 1988
Papillary
reconstruction 1996
Treatment of
intrabony defect
Goldman 1949
Repositioning of
attached gingiva
Nabers 1954
Mucosal stripping
and frenectomy
1954
Stewart
1954
Rationale for
osseous surgery
Schluger 1949
Bone
blending
1972
Guided tissue
regeneration
1985, 1988, 1991
Palatal modification
for implant placement
1990
Pediculated flap
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Surgical Basics
A
FIGURE 2-2. Outline of basic incisions. A, Curettage
incision and removal of an inflamed inner pocket
wall. B, Gingivectomy incision and subsequent
removal of excised tissue (note that the incision is
above the mucogingival junction [mgj]). C, Sulcular
(a) and crestal (b) incisions for full-thickness
mucoperiosteal flaps. D, Partial-thickness incisions
for partial-thickness flaps. E, Modified flap incisions
for ledge-and-wedge techniques.
B
C
D
E
11
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12 Basics
Surgical Considerations
Table 2-1 Comparison of Open (Gingivectomy) versus Closed (Flap) Procedures
Open
(Gingivectomy)
Closed (Partial- or
Full-Thickness Flaps)
Secondary intention
Fast
No
Low
Yes
Inadequate
Inadequate
No
Primary intention
Slower
Possible
High
Minimum
Good
Good
Yes
Variables
Healing
Time requirement for completion of procedure
Reattachment
Degree of difficulty
Bleeding postoperatively
Visibility for osseous surgery
Ability to treat irregularities and defects
Preservation of keratinized gingiva
hemorrhagic disorders) should be under
adequate control. Medications should be
carefully noted, and medical consultations
and preoperative laboratory work should be
performed where indicated. It is important
to note that the medical history consists of
a review of drug abuse, transfusion, and
alternative lifestyles in attempting to determine the risk of acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV). This should be
combined with a thorough oral examination
(eg, ulcers, candidiasis, hairy leukoplakia).
Procedures Commonly Used for Socket
Preservation
1.
2.
3.
4.
Basic procedure
a. Socket filler
b. Connective tissue graft
Socket seal
CollaPlug (Sulzer Medica, Carlsbad, California)
Prosthetic support
Procedures Commonly Used
for Papillary Reconstruction
1.
2.
Connective tissue grafts
Bone graft/connective tissue graft
Contraindications for Periodontal
Surgery (Lindhe, 2003)
1.
2.
3.
4.
5.
6.
7.
Patient cooperation
Cardiovascular disease
a. Uncontrolled hypertension
b. Angina pecton’s
c. Myocardial infarction
d. Anticoagulant therapy
e. Rheumatic endocarditis, congenital heart
lesions, and heart vascular implants
Organ transplants
Blood disorders
Hormonal disorders
a. Uncontrolled diabetes
b. Adrenal dysfunction
Hematologic disorders
a. Multiple sclerosis and Parkinson’s disease
b. Epilepsy
Smoking—more a limiting factor than a
contraindication
Note: No periodontal surgery should be undertaken
on a medically compromised patient without a recent
physical evaluation and clearance by a physician.
General Surgical Considerations
Presurgical Considerations
1.
A complete medical history should be taken
and any underlying systemic disorders or
problems (ie, hypertension, diabetes, or
Note: The best protection against AIDS and
hepatitis is a proper barrier technique and
sterilization at all times.
2.
3.
4.
Blood pressure should be recorded.
Surgical therapy should be considered only
after adequate control, scaling, root planing,
and all necessary restorative, prosthetic,
endodontic, orthodontic, and occlusal stabilization and splinting procedures have been
completed and the case has been reevaluated. Without proper plaque control, there is no
need for surgery.
A surgical consent form should be completed in all cases, and periodontal documentation (including tissue quality, pocket depths,
radiographs, and models) is a must.
1.
Procedural selection should be based on the
following:
a. Simplicity
b. Predictability
c. Efficiency
d. Mucogingival considerations
e. Underlying osseous topography
f. Anatomic and physical limitations (eg,
small mouth, gagging, mental foramen)
g. Age and systemic factors (eg, cardiac
arrhythmias and murmurs, diabetes, history of radiation treatment, hypothyroidism, hyperthyroidism)
2. All incisions should be clear, smooth, and
denifite. Indecision usually results in an
uneven, ragged incision, which requires more
healing time.
3. All flaps should be designed for maximum
use and retention of keratinized gingival tissue so as to maintain a functional zone of
attached keratinized gingiva and prevent
needless secondary procedures.
4. The flap design should allow for adequate
access and visibility.
5. Involvement of adjacent noninvolved areas
should be avoided.
6. The flap design should prevent unnecessary
bone exposure, with resultant possible loss
and dehiscence or fenestration formation.
7. Where possible, primary intention procedures
are preferred to those of secondary intention.
8. The base of a flap should be as wide as
the coronal aspect to allow for adequate
vascularity.
9. Tissue tags should be removed to allow for
rapid healing and prevent regrowth of granulation tissue.
10. Adequate flap stabilization is necessary to
prevent displacement, unnecessary bleeding,
hematoma formation, bone exposure, and
possible infection.
Table 2-2 Comparison of Full- and Partial-Thickness Flaps
Variables
Full Thickness
(Mucoperiosteal)
Partial Thickness
(Mucosal)
Healing
Degree of difficulty
Pocket elimination
Osseous surgery, resective or inductive
Periosteal retention
Relocation of frenum
Widen zone of keratinized gingiva
Increase in attached keratinized gingiva
Combine with other mucogingival procedures
Suture variability
Presence of a thin periodontium—dehiscence or fenestration
Bleeding and tissue trauma
Primary intention
Moderate
Yes
Yes
No
Yes
No
Yes
No
Low
No
Limited
Secondary intention
High
Yes
No
Yes
Yes
Yes
Yes
Yes
High
Yes
Greater
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Surgical Basics
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Table 2-3 Comparative Analysis of Five Gingival Surgical Procedures
I
II
III
Curettage
Scaling and root planing for
removal of calculus,
plaque, cementum
Curettage of inner inflamed
wall of pocket
ENAP
Mark pocket with probe
Scallop internal beveled
incision to base of pocket
Remove incised epithelium
and granulation tissue
Root plane
Position flap and suture to
presurgical level
Modified Widman flap
Primary incision 0.5–1 mm
from margin to crest
of bone
Reflect flap 2–3 mm off bone
2° sucular releasing incision
Horizontal 3° incision above
crest of bone
Remove epithelium and
granulation tissue
Scale and root plane
Reposition flap and suture
with interrupted sutures
Apically positioned
full-thickness flap
Sulcularly, crestally, or
labially positioned inverse
beveled incision to bone
Flap completed, reflected
off bone
Flap is apically positioned
and sutured
Apically positioned
partial-thickness flap
Crestal incision with blade
parallel to long axis
of tooth
Flap raised by sharp
dissection
Periosteum retained
over bone
Flap is apically positioned
at or below alveolar crest
Adapted from Kinoshita S, Wen RC. Color atlas of periodontics. St. Louis: Mosby-Year Book; 1985.
ENAP = excisional new attachment procedure.
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