Mucogingival Surgery: The Apically Repositioned Flap

Abstract

T HERE is no aspect of periodontal surgery that is in as great a state of confusion and flux as is that of mucogingival surgery. Since its inception a multiplicity of operations have been devised, modified and remodified; all with an eye to achieving maximum results with a minimum amount of trauma to the patient. The objectives of mucogingival surgery have been delineated clearly but the means of realizing these objectives have not been systematically devised. At this writing there remains the task of selecting the most effective of the techniques, standardizing them and laying down clear indications for their use.There are two basic approaches to mucogingival surgery when gingiva exists preoperatively. The surgeon either may retain this gingiva, alter it and utilize it by repositioning it apically; or he may remove it and depend on the healing process to create a new zone of gingiva. The terminology used in this paper for the first type of operation is the apically repositioned flap (previously called "Repositioning of the Attached Gingiva") ; for the second it is the apically displaced flap (originally known as the "pushback"). Modifications and variations of the displaced flap have been devised and each is designed to accomplish a specific purpose. However, they all have one principle in common: the excision and discarding of the existing gingiva and the dependency on a large granulating wound to obtain new gingiva. Historically, the apically displaced flap procedures ("pushback" and "pouch") were very important advances in the development of mucogingival surgery. 1 They provided the surgeon with the means of achieving objectives of treatment that pre-Associate Professor of Periodontology and Oral Pathology, School of Dentistry, University of Southern California. viously could not be attained. However, they are crude surgical procedures in which large areas of bone are left exposed postsurgically, often resulting in a great amount of postoperative pain, prolonged healing time, massive wounds that heal by second intention with all of the attendant problems such as exuberant granulation tissue and occasionally sequestration of bone, particularly in the mandibular posterior region. With the advent of more refined surgical procedures, the displaced flap operations, in the main, are obsolete and should be discarded.The term "Apically Repositioned Flap" as used in this paper is preferred to "Repositioning of the Attached Gingiva." The reason for this lies in the fact that more than the gingiva is repositioned. The entire complex of gingiva, alveolar mucosa and all of the structures and tissues within the flap are repositioned apically, as is the mucogingival junction. In addition, if a frenum is present, it will be repositioned apically or collapse entirely and a shallow vestibule will be deepened because the fornix too will be apical to its previous position. Such a vestibular deepening is precise and stable; it does not become shallower during the healing process as is the case with the several variations of the a...

Reconstruction of A Deformed, Partially Edentulous Ridge with A Free Gingival Onlay Graft- A Case Report

“…A certain amount of keratinized tissue has been considered necessary for maintaining periodontal health [3,4] .It was also concluded that for the maintenance of gingival health 2mm of keratinized gingiva is adequate [5] .Since an adequate amount of keratinized tissue is yet to be decided, the resolution to increase the width of keratinized gingiva still depends upon the preference of clinician. Historically, the methods to augment keratinized tissue included-1) an apically positioned flap (APF), 2) an APF in conjunction with autogenous tissue and, 3) an APF in conjunction with allogenic tissue [6][7][8] . Autogenous soft tissue grafting procedures have also been proposed to surgically correct localized alveolar deficiencies, as a preparation and development of the site during pre-prosthetic surgeries, and as ridge preservation procedures [9][10][11] .…”

Interdisciplinary Collaboration Between Orthodontics and Periodontics

“…13.12). The apically positioned flap (Friedman 1962) is a mucoperiosteal internal bevelled flap, positioned at the (1)…”

Novel approach of retension of maxillary molars with grade III furcation involvement with the use of glass ionomer cement

“…Long term studies of advanced furcation involvement have demonstrated poor survival rates. [1] Many treatment modalities are available to treat the furcation like scaling and root planing (non-surgical approach), [1] osteoplasty/ostectomy, odontoplasty, [2] surgery to increase the access to furcation area, [3] root resection/root amputation, [4] bicuspidization (to remove furcation), tunnel procedure, [5] guided tissue regeneration and a combination of graft materials and membranes. [6] Glickman [1] classified furcation invasion into four classes.…”