```markdown INTRODUCTION TO PERIODONTAL SURGERY Amelia Hemmati ```  Presented by Amelia Hemmati A circular photo showing a person in blue gloves holding dental instruments, including a mirror and probes, against a background of a dental office with equipment. # Key References <img src="https://i.imgur.com/9JZQzQl.png" alt="LINDHE'S Seventh Edition Clinical Periodontology and Implant Dentistry Volume 1"> <img src="https://i.imgur.com/7XZJzQl.png" alt="NEWMAN AND CARRANZA'S Clinical Periodontology and Implantology 14th Edition"> <img src="https://i.imgur.com/8JZQzQl.png" alt="Periodontology at a Glance"> Images are from these references or from my own patients unless otherwise stated    #### Primary Textbooks and Resources - **Lindhe's Clinical Periodontology and Implant Dentistry**, Seventh Edition, Volume 1 - **Newman and Carranza's Clinical Periodontology and Implantology**, 14th Edition - **Periodontology at a Glance** #### Image Credits All images contained within this presentation are sourced from the references listed above or are clinical photographs of my own patients, unless otherwise specified. Cover of 'Lindhe's Clinical Periodontology and Implant Dentistry, Seventh Edition, Volume 1', featuring a purple design with two inset images of dental structures. Cover of 'Newman and Carranza's Clinical Periodontology and Implantology, 14th Edition', showing a blue background with images of teeth and dental implants. Cover of 'Periodontology at a Glance', displaying a 3D rendering of a dental implant in the jaw with a glowing effect. ```markdown Contents - Definition - Objectives - Indications - Contraindications - Steps of Periodontal Therapy - Classification of Periodontal Surgical Procedures - Basic Surgical Principles - Biological Basis of Periodontal Surgery - Complications - Patient Communication and Consent - Evidence-Based Perspective ```  #### Core Topics in Periodontal Surgery - Definition - Objectives - Indications - Contraindications - Steps of Periodontal Therapy - Classification of Periodontal Surgical Procedures - Basic Surgical Principles - Biological Basis of Periodontal Surgery - Complications - Patient Communication and Consent - Evidence-Based Perspective A colorful illustration of a bookshelf filled with various books, positioned on the right side of the page. The bookshelf contains books of different sizes and colors, arranged on two shelves with some books stacked on top. This figure appears to be decorative, complementing the contents list on the left side of the page. # Definition of Periodontal Surgery Periodontal surgery refers to surgical procedures performed to: - Arrest progression of periodontal disease - Access root surfaces for debridement - Reduce or eliminate periodontal pockets - Regenerate lost periodontal tissues - Improve aesthetics and function It is typically indicated after completion of non-surgical periodontal therapy when residual pathology persists. <img src="https://i.imgur.com/8XJzQvK.png" alt="Illustration of teeth with periodontal pockets being cleaned by a dental instrument"/>  Periodontal surgery refers to surgical procedures performed to: - Arrest progression of periodontal disease - Access root surfaces for debridement - Reduce or eliminate periodontal pockets - Regenerate lost periodontal tissues - Improve aesthetics and function It is typically indicated after completion of non-surgical periodontal therapy when residual pathology persists. An illustration showing two teeth with periodontal pockets, where a dental instrument is cleaning the root surfaces. The image visually represents the concept of periodontal surgery, emphasizing the removal of plaque and calculus from below the gum line to treat periodontal disease. # Objectives of Periodontal Surgery ## Primary Objectives - Eliminate or reduce periodontal pockets - Establish a maintainable periodontal environment - Arrest disease progression ## Secondary Objectives - Regenerate lost attachment apparatus - Improve aesthetics - Facilitate restorative/prosthodontic treatment - Correct mucogingival defects <img src="https://i.imgur.com/5QvXZjL.png" alt="Figure 22.2 (a) A periodontal lesion before treatment. (b) Early healing of a periodontal pocket. (c) Further healing of a periodontal pocket." />  #### Primary Objectives - Eliminate or reduce periodontal pockets - Establish a maintainable periodontal environment - Arrest disease progression #### Secondary Objectives - Regenerate lost attachment apparatus - Improve aesthetics - Facilitate restorative/prosthodontic treatment - Correct mucogingival defects A triptych diagram illustrating the progression of a periodontal lesion before treatment, early healing, and further healing. It shows histological changes including loss of attachment, inflammatory infiltrate, and bone loss in the initial state, followed by reduction in neutrophils, decreased inflammation, and healing processes in subsequent stages. # Indications for Periodontal Surgery - Residual pockets ≥5–6 mm with bleeding on probing after NSPT - Infrabony (vertical) defects - Class II furcation defects - Mucogingival defects (recession, lack of attached gingiva) - Altered passive eruption - Crown lengthening for restorative purposes - Periodontal abscess not responding to non-surgical care - Root surface irregularities (e.g., palatoradicular groove) Figure 27.1 Anatomy of bone defects.    - Residual pockets ≥5–6 mm with bleeding on probing after NSPT - Infrabony (vertical) defects - Class II furcation defects - Mucogingival defects (recession, lack of attached gingiva) - Altered passive eruption - Crown lengthening for restorative purposes - Periodontal abscess not responding to non-surgical care - Root surface irregularities (e.g., palatoradicular groove) #### Anatomy of Bone Defects - Vertical and horizontal bone loss patterns - Infrabony architecture A diagram illustrating the anatomy of bone defects, showing three types: three-walled, two-walled, and one-walled defects, with corresponding tooth and bone structures. A clinical photograph showing a surgical view of teeth with periodontal defects, highlighting inflamed tissue and bone structure, likely used to demonstrate surgical indications. A series of diagrams depicting a surgical instrument interacting with bone defects, illustrating the process of accessing and treating infrabony defects. ```markdown # Contraindications ## Absolute - Uncontrolled systemic disease (e.g., uncontrolled diabetes) - Poor plaque control - Non-compliant patient ## Relative - Heavy smoking - Pregnancy (elective surgery deferred) - Poor restorative prognosis - Psychological limitations ```     #### Absolute Contraindications - Uncontrolled systemic disease (e.g., uncontrolled diabetes) - Poor plaque control - Non-compliant patient #### Relative Contraindications - Heavy smoking - Pregnancy (elective surgery deferred) - Poor restorative prognosis - Psychological limitations A cartoon illustration of a tooth with cavities, showing a sad expression with red cheeks and downturned eyes, symbolizing poor dental health related to contraindications. An illustration of a blood glucose meter with a red screen and test strips, representing uncontrolled systemic disease like diabetes, which is listed as an absolute contraindication. A stylized illustration of a pregnancy test with a positive result, indicating pregnancy, which is listed as a relative contraindication for elective surgery. An illustration of a cigarette with smoke, symbolizing heavy smoking, which is listed as a relative contraindication for the procedure. # Periodontal Therapy - Steps ## Journal Information **Journal of Clinical Periodontology** **EFP** *Official scientific journal of the European Federation of Periodontology and its member national societies* **Volume 47, Issue S22** **Special Issue: Treatment of Stage I-III Periodontitis. The EFP S3 Level Clinical Practice Guideline** **Pages: 1-391** **July 2020** **Issue Edited by:** David Herrera Gonzalez, Mariano Sanz, Maurizio Tonetti ## Periodontal Therapy Steps | Step | Action | | :--- | :--- | | **Step 0** | **PREREQUISITE TO THERAPY** - Educate, classification, diagnosis, risk assess, care plan | | **Step 1** | **RISK** - Risk factor control, OHI, adjuncts for G1, PMPR, supra-gingival scaling | | **Step 2** | **INTERVENE** - Sub-gingival biofilm & calculus removal ± adjuncts | | **Step 3** | **CHECK** - Non-responder sites; Re-RSD/surgery | | **Step 4** | **EXIT** - Plan longer-term care (above) | | **Supportive care/rehabilitation** | **E** | --- *Note: The flowchart is presented as a staircase with each step labeled. The letters P, R, I, C, E at the top of each step correspond to the actions listed below.*   The EFP S3 Level Clinical Practice Guideline outlines a structured approach to therapy: 1. **Step 0: Prerequisite to Therapy** - Education, classification, diagnosis, risk assessment, and care planning. 2. **Step 1: Risk Factor Control** - Oral hygiene instruction (OHI), adjuncts for gingivitis, professional mechanical plaque removal (PMPR), and supra-gingival scaling. 3. **Step 2: Intervention** - Sub-gingival biofilm and calculus removal with or without adjuncts. 4. **Step 3: Evaluation of Non-Responders** - Re-evaluation of sites; consideration for repeated instrumentation or surgery. 5. **Step 4: Long-term Care** - Supportive periodontal care and rehabilitation planning. A staircase-style flowchart illustrating the steps of periodontal therapy, labeled as Step 0 through Step 4, with an additional 'Supportive care/rehabilitation' step. Each step is color-coded and includes a brief description of the actions involved, such as 'PREREQUISITE TO THERAPY' and 'INTERVENE - Sub-gingival biofilm & calculus removal ± adjuncts'. The diagram visually represents the progression of treatment for periodontitis. A photograph of a group of people, likely professionals or researchers, standing together in a formal setting. The image is part of a journal cover for the 'Journal of Clinical Periodontology', and the group appears to be associated with the European Federation of Periodontology (EFP), as indicated by the logo and text. ```markdown EFP Clinical Guideline Treatment of stage I-III periodontitis The EFP S3-level clinical practice guideline STEP 3 Aim: Treating those sites non-responding adequately to the second step of therapy with the purpose of getting access to deep pocket sites, or aiming at regenerating or resecting those lesions, that add complexity in the management of periodontitis (infraibony and furcation lesions). If periodontal pockets > 4 mm with bleeding on probing and/or deep pockets [≥ 6 mm] are still present at re-evaluation, different options for step 3 can be considered: - Repeated subgingival instrumentation with or without adjunctive therapies. - Access flap periodontal surgery. - Resective periodontal surgery. - Regenerative periodontal surgery. Re-evaluation after step 2 Endpoints: - No periodontal pockets ≥ 5 mm with bleeding on probing. - No deep pockets [≥ 6 mm]. If these endpoints are achieved, the patient should join a SPC program. General aspects of step 3 Recommended interventions Recommended Suggested Surgery should be performed by dentists with additional specific training or by specialists. As a minimum requirement, repeated subgingival instrumentation, with or without access flap of the area, in the context of high-quality step 1 and 2 treatment, and a frequent program of supportive periodontal care including subgingival instrumentation, are recommended. In presence of moderately deep residual pockets (4-5 mm), non-surgical subgingival instrumentation should be repeated. ```   #### Aim of Step 3 Treating sites not responding adequately to the second step of therapy to gain access to deep pocket sites, or aiming at regenerating or resecting lesions that add complexity (infrabony and furcation lesions). #### Clinical Indications If periodontal pockets > 4 mm with bleeding on probing and/or deep pockets (≥ 6 mm) are still present at re-evaluation, options include: - Repeated subgingival instrumentation with or without adjunctive therapies - Access flap periodontal surgery - Resective periodontal surgery - Regenerative periodontal surgery #### Endpoints of Success - No periodontal pockets ≥ 5 mm with bleeding on probing - No deep pockets (≥ 6 mm) #### Recommended Interventions - Surgery should be performed by dentists with additional specific training or by specialists. - In the presence of moderately deep residual pockets (4-5 mm), non-surgical subgingival instrumentation should be repeated. A diagram illustrating recommended and suggested interventions for Step 3 of periodontitis treatment, showing three circular icons with illustrations of a dentist, a dental instrument, and a tooth with a probe, each labeled with their respective recommendations or suggestions. A figure showing the re-evaluation criteria after Step 2, with a circular icon containing a checklist and text outlining the endpoints for successful treatment, including no periodontal pockets ≥ 5 mm with bleeding on probing and no deep pockets ≥ 6 mm. # Classification of Periodontal Surgical Procedures ## Resective Surgery - Pocket reduction surgery - Osseous resective surgery - Apically positioned flap <img src="data:image/png;base64,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      #### Pocket Reduction Techniques - Pocket reduction surgery - Osseous resective surgery - Apically positioned flap A diagram illustrating the apically repositioned flap procedure, showing a vertical releasing incision and a reverse bevel incision to separate inflamed tissue from the tooth. The diagram depicts the surgical instrument and the repositioning of the flap. A diagram showing the apically repositioned flap technique, where a mucoperiosteal flap is raised and the tissue collar around the teeth, including the pocket epithelium and inflamed connective tissue, is removed with a curette. The image highlights the surgical instruments and the repositioned flap. A diagram depicting a surgical procedure involving the use of a dental instrument on the gingiva, with a highlighted area indicating inflamed tissue. The diagram illustrates the application of the instrument to the gingival tissue adjacent to the teeth. A diagram showing the apically repositioned flap procedure, where the flaps are repositioned in an apical direction to the level of the recontoured alveolar bone crest and retained in this position by sutures. The image illustrates the surgical technique and the placement of sutures. A diagram illustrating the apically repositioned flap procedure, showing the repositioning of the flaps in an apical direction to the level of the recontoured alveolar bone crest and their retention by sutures. The image highlights the surgical technique and the placement of sutures. # Classification of Periodontal Surgical Procedures ## Resective Surgery - Root resection - Hemisection - Furcation tunnelling Images from Nibali, Diagnosis and Treatment of Furcation‐Involved Teeth, 2018. <figure> <img src="https://i.imgur.com/9Xz9ZzL.png" alt="Figure 9.4 Different approaches for tunnelling surgery needed according to the amount of keratinized gingiva (KG). In a case of an adequate amount of KG (a), scalloped incisions can be performed to expose the furcation area for self-performed cleaning (b). In a case of a reduced amount of KG (c), an apically repositioned flap is performed in order to preserve the KG while still exposing the furcation area for self-performed cleaning (d)."> <figcaption>Figure 9.4 Different approaches for tunnelling surgery needed according to the amount of keratinized gingiva (KG). In a case of an adequate amount of KG (a), scalloped incisions can be performed to expose the furcation area for self-performed cleaning (b). In a case of a reduced amount of KG (c), an apically repositioned flap is performed in order to preserve the KG while still exposing the furcation area for self-performed cleaning (d).</figcaption> </figure>      #### Furcation Management - Root resection - Hemisection - Furcation tunnelling #### Tunnelling Approaches - **Adequate Keratinized Gingiva (KG):** Scalloped incisions can be performed to expose the furcation area for self-performed cleaning. - **Reduced Keratinized Gingiva (KG):** An apically repositioned flap is performed to preserve KG while exposing the furcation area. A diagram illustrating different approaches for tunnelling surgery based on the amount of keratinized gingiva (KG). It shows two scenarios: (a) and (b) depict scalloped incisions for adequate KG, while (c) and (d) show an apically repositioned flap for reduced KG, preserving the gingiva while exposing the furcation area. A clinical photograph showing a tooth with a furcation involvement, highlighting the exposed area for periodontal treatment. A radiographic image displaying a tooth with furcation involvement, providing a diagnostic view of the internal structure. A close-up clinical photograph of a tooth with a furcation area exposed, illustrating the surgical site for self-performed cleaning. A clinical photograph showing a tooth with a furcation involvement and a restoration, demonstrating the post-treatment condition. # Classification of Periodontal Surgical Procedures ## Regenerative Surgery - Guided tissue regeneration (GTR) - Bone grafting - Enamel matrix derivative - Biologics (e.g., growth factors) --- Figure 26.4 Procedure for use of Emdogain®. - After gaining surgical access to the site the cleaned root surfaces are conditioned with an EDTA (ethylene diamine tetra acetate) gel to remove the smear layer - The Emdogain® gel is syringed directly onto the washed roots and the flap replaced --- Figure 26.1 Guided tissue regeneration. - Epithelium of replaced flap - Membrane preventing epithelium and connective tissue from contacting root surface - Cell migration - Periodontal ligament --- <img src="https://i.imgur.com/9sLZvqS.png" alt="Guided tissue regeneration: membrane placement." /> --- <img src="https://i.imgur.com/7hZzXJz.png" alt="Diagram illustrating the components of guided tissue regeneration, including the epithelium of the replaced flap, the membrane preventing epithelium and connective tissue from contacting the root surface, cell migration, and the periodontal ligament." />    #### Regenerative Modalities - Guided tissue regeneration (GTR) - Bone grafting - Enamel matrix derivative (Emdogain®) - Biologics (e.g., growth factors) #### Enamel Matrix Derivative Procedure 1. Surgical access to the site. 2. Root surface conditioning with EDTA gel to remove the smear layer. 3. Syringing Emdogain® gel directly onto washed roots. 4. Flap replacement. #### Guided Tissue Regeneration (GTR) Components - Epithelium of replaced flap. - Membrane placement to prevent epithelium and connective tissue from contacting the root surface. - Promotion of cell migration from the periodontal ligament. Figure 26.4 illustrates the procedure for using Emdogain®, showing a syringe applying gel to cleaned root surfaces after surgical access, with the flap replaced afterward. Figure 26.1 depicts guided tissue regeneration, showing a membrane placed over a furcation defect to prevent epithelial and connective tissue from contacting the root surface, allowing for cell migration and periodontal ligament regeneration. This diagram illustrates guided tissue regeneration, highlighting the epithelium of the replaced flap, the membrane preventing epithelial and connective tissue from contacting the root surface, cell migration, and the periodontal ligament. # Classification of Periodontal Surgical Procedures Access Flap Surgery - Open flap debridement (left) - Modified Widman flap (right) ---    #### Techniques - **Open Flap Debridement:** Direct visualization and access for root surface cleaning. - **Modified Widman Flap:** Facilitates instrumentation while minimizing tissue loss to maintain aesthetics. A diagram illustrating the steps of access flap surgery, including open flap debridement and modified Widman flap procedures, with labeled illustrations showing surgical instruments and tissue manipulation. A series of diagrams depicting the modified Widman flap procedure, showing the elevation of flaps, incisions, and tissue separation, with detailed illustrations of the surgical technique. A diagram illustrating the final steps of the modified Widman flap procedure, showing the repositioning and suturing of flaps to cover the alveolar bone and achieve complete coverage of interdental bone. # Classification of Periodontal Surgical Procedures ## Mucogingival/Plastic Surgery - Coronally advanced flap - Connective tissue graft - Free gingival graft - Tunnel technique --- Figure 32.4 Free grafts: free epithelialised gingival graft. At the recipient site the epithelium and outer part of the connective tissue are removed by split dissection around and below the recession defect. The graft is taken from the remote donor site and sutured securely at the recipient site. --- Figure 32.6 Free grafts: subepithelial connective tissue graft. A free graft is taken from the palate, removing underlying connective tissue with only a thin epithelial border. The tissue is sutured at the prepared recipient site. The graft is then covered by a flap (commonly a coronally advanced flap) so that the graft gains its nutrition from the underlying periosteum and deep connective tissue and the overlying flap. --- <img src="https://i.imgur.com/8XQ8v8p.jpg" alt="Clinical image of periodontal surgical site with gingival recession and surgical instrument in use." />    #### Surgical Techniques - Coronally advanced flap - Connective tissue graft - Free gingival graft - Tunnel technique #### Grafting Procedures - **Free Epithelialised Gingival Graft:** Epithelium and outer connective tissue are removed from the recipient site via split dissection. The graft is harvested from a donor site and sutured. - **Subepithelial Connective Tissue Graft:** Connective tissue is harvested from the palate with a thin epithelial border. It is sutured at the recipient site and covered by a flap (typically coronally advanced) for nutrition. Clinical image showing a periodontal surgical site with gingival recession and a surgical instrument in use, illustrating the application of a periodontal procedure. Diagram illustrating Figure 32.4, showing a free epithelialised gingival graft where the epithelium and outer connective tissue are removed at the recipient site, and the graft is sutured securely. Diagram illustrating Figure 32.6, showing a subepithelial connective tissue graft where a free graft is taken from the palate with a thin epithelial border and sutured at the recipient site, covered by a flap. # Classification of Periodontal Surgical Procedures ## Crown Lengthening Surgery - Aesthetic crown lengthening for altered passive eruption (APE) Fig 2 Representative case illustrating the esthetic crown lengthening surgical procedure (case 6). (a) Pretreatment view of the maxillary anterior teeth. (b) Gingival margin measurement using a specific tip. (c) Gingival demarcation on midbuccal aspect. (d) External bevel incision following the CEJ anatomy. (e) Gingival margin removal with a periodontal curette. (f) Gingival contour finalization using a Goldman Fox microscale and pliers. (g) Full-thickness flap elevation. (h) Ostectomy and osteoplasty using carbide steel burs. (i) Ostectomy and osteoplasty, final aspect. (j) Single interrupted sutures. (k) Labial frenectomy. (l) Immediate postoperative, final aspect. Aroni et al, The International Journal of Esthetic Dentistry, Volume 14, Number 4, 2019  #### Aesthetic Crown Lengthening Indicated for Altered Passive Eruption (APE). The procedure involves: 1. Gingival margin measurement and demarcation. 2. External bevel incision following CEJ anatomy. 3. Gingival margin removal and contour finalization. 4. Full-thickness flap elevation. 5. Ostectomy and osteoplasty using burs to establish proper supracrestal tissue attachment. 6. Suturing and ancillary procedures (e.g., labial frenectomy). A series of 12 labeled photographs illustrating the steps of a crown lengthening surgical procedure for altered passive eruption (APE), showing pretreatment views, gingival margin measurement, incision, tissue removal, flap elevation, osteoplasty, suturing, and final postoperative results. # Classification of Periodontal Surgical Procedures Crown Lengthening Surgery - Surgical exposure for restorative margin placement <img src="https://i.imgur.com/1234567.png" alt="Classification of Periodontal Surgical Procedures: Crown Lengthening Surgery - Surgical exposure for restorative margin placement. Images from Shah J, Webb L, McColl E, Daldry M, Bhagi S, Witton R. Supracrestal tissue attachment: an update. Dental Update, 2024, 50:1, 707-709." /> Images from Shah J, Webb L, McColl E, Daldry M, Bhagi S, Witton R. Supracrestal tissue attachment: an update. Dental Update, 2024, 50:1, 707-709.    #### Functional Crown Lengthening - Surgical exposure for restorative margin placement. - Management of supracrestal tissue attachment (formerly biological width) to ensure restorative margins do not compromise periodontal health. A diagram illustrating the biological width and tissue components involved in crown lengthening surgery, showing measurements for junctional epithelium, connective tissue, and sulcus depth, with data from Gargiulo et al (1961). A diagram depicting the process of crown lengthening, showing a tooth before and after surgical resection, with labels for apically repositioned flap, supracrestal tissue attachment (STA), and increased crown length. A clinical photo showing a surgical procedure in progress, with a dental instrument exposing the gingival tissue around a tooth, illustrating the surgical exposure for restorative margin placement. # Basic Surgical Principles Patient Selection * Stable systemic health * Good plaque control (<20% plaque score ideally)   #### Patient Selection Criteria - Stable systemic health. - High level of plaque control (ideally <20% plaque score). A stylized illustration of a stethoscope with a heart symbol, representing stable systemic health as part of patient selection criteria for basic surgical principles. An illustration of a tooth being brushed with a toothbrush, symbolizing good plaque control, which is a key factor in patient selection for surgical procedures. # Basic Surgical Principles ## Surgical Asepsis - Sterile instruments - Proper draping - Chlorhexidine rinse pre-operatively <img src="https://i.imgur.com/8XzJzQv.png" alt="Surgical Instruments">  #### Aseptic Protocols - Use of sterile instruments. - Proper patient and surgical field draping. - Pre-operative chlorhexidine rinse to reduce microbial load. A photo displaying various sterile surgical instruments arranged on a green surface, including forceps, scalpels, scissors, and other tools, corresponding to the topic of surgical asepsis discussed in the text. # Basic Surgical Principles ## Flap Design Principles - Preserve blood supply - Ensure adequate access - Allow tension-free closure - Respect papillary integrity <img src="https://i.imgur.com/8XzK9zL.png" alt="Three diagrams illustrating flap design principles in dental surgery. Fig. 1 shows a sulcular incision for exodontia. Fig. 2 shows a flap wider at its base to ensure adequate blood supply. Fig. 3 shows a vertical releasing incision for access to the apical region, considering blood supply." /> Image by Reznick, J.B. Principles of Flap Designs and Closure, 2016.  #### Flap Design Principles - **Blood Supply:** Flaps should be wider at the base to ensure adequate vascularity. - **Access:** Ensure sufficient visibility of the underlying bone and root surfaces. - **Closure:** Design allows for tension-free suturing. - **Papillary Integrity:** Respect the interdental papilla to prevent recession and aesthetic defects. #### Incision Types - Sulcular/Crevicular incisions. - Vertical releasing incisions for apical access. Three diagrams illustrating flap design principles in dental surgery. Fig. 1 shows a sulcular incision for exodontia. Fig. 2 shows a flap wider at its base to ensure adequate blood supply. Fig. 3 shows a vertical releasing incision for access to the apical region, considering blood supply. # Basic Surgical Principles ## Incisions - Internal bevel incision - Crevicular incision - Vertical releasing incisions (when required) <img src="https://i.imgur.com/7zXJz9L.png" alt="FIG. 60.15 The three incisions necessary for flap surgery. (A) First (internal bevel) incision; (B) second (crevicular) incision; and (C) third (interdental) incision." />  #### Surgical Incision Sequence 1. **Internal Bevel Incision:** The initial incision to remove the pocket lining and conserve gingiva. 2. **Crevicular Incision:** Performed from the base of the pocket to the bone crest to release the tissue. 3. **Interdental Incision:** Used to separate the collar of tissue from the interproximal areas. A diagram illustrating the three incisions necessary for flap surgery, labeled as (A) first (internal bevel) incision, (B) second (crevicular) incision, and (C) third (interdental) incision, with corresponding numbered arrows indicating the incision points on dental structures. [^1]: Original PDF page 1: [[L1 Introduction to Periodontal Surgery.pdf#page=1|L1 Introduction to Periodontal Surgery, p.1]] [^2]: Original PDF page 2: [[L1 Introduction to Periodontal Surgery.pdf#page=2|L1 Introduction to Periodontal Surgery, p.2]] [^3]: Original PDF page 3: [[L1 Introduction to Periodontal Surgery.pdf#page=3|L1 Introduction to Periodontal Surgery, p.3]] [^4]: Original PDF page 4: [[L1 Introduction to Periodontal Surgery.pdf#page=4|L1 Introduction to Periodontal Surgery, p.4]] [^5]: Original PDF page 5: [[L1 Introduction to Periodontal Surgery.pdf#page=5|L1 Introduction to Periodontal Surgery, p.5]] [^6]: Original PDF page 6: [[L1 Introduction to Periodontal Surgery.pdf#page=6|L1 Introduction to Periodontal Surgery, p.6]] [^7]: Original PDF page 7: [[L1 Introduction to Periodontal Surgery.pdf#page=7|L1 Introduction to Periodontal Surgery, p.7]] [^8]: Original PDF page 8: [[L1 Introduction to Periodontal Surgery.pdf#page=8|L1 Introduction to Periodontal Surgery, p.8]] [^9]: Original PDF page 9: [[L1 Introduction to Periodontal Surgery.pdf#page=9|L1 Introduction to Periodontal Surgery, p.9]] [^10]: Original PDF page 10: [[L1 Introduction to Periodontal Surgery.pdf#page=10|L1 Introduction to Periodontal Surgery, p.10]] [^11]: Original PDF page 11: [[L1 Introduction to Periodontal Surgery.pdf#page=11|L1 Introduction to Periodontal Surgery, p.11]] [^12]: Original PDF page 12: [[L1 Introduction to Periodontal Surgery.pdf#page=12|L1 Introduction to Periodontal Surgery, p.12]] [^13]: Original PDF page 13: [[L1 Introduction to Periodontal Surgery.pdf#page=13|L1 Introduction to Periodontal Surgery, p.13]] [^14]: Original PDF page 14: [[L1 Introduction to Periodontal Surgery.pdf#page=14|L1 Introduction to Periodontal Surgery, p.14]] [^15]: Original PDF page 15: [[L1 Introduction to Periodontal Surgery.pdf#page=15|L1 Introduction to Periodontal Surgery, p.15]] [^16]: Original PDF page 16: [[L1 Introduction to Periodontal Surgery.pdf#page=16|L1 Introduction to Periodontal Surgery, p.16]] [^17]: Original PDF page 17: [[L1 Introduction to Periodontal Surgery.pdf#page=17|L1 Introduction to Periodontal Surgery, p.17]] [^18]: Original PDF page 18: [[L1 Introduction to Periodontal Surgery.pdf#page=18|L1 Introduction to Periodontal Surgery, p.18]] [^19]: Original PDF page 19: [[L1 Introduction to Periodontal Surgery.pdf#page=19|L1 Introduction to Periodontal Surgery, p.19]] [^20]: Original PDF page 20: [[L1 Introduction to Periodontal Surgery.pdf#page=20|L1 Introduction to Periodontal Surgery, p.20]]