X-ray showing supporting bone X-ray showing periodontal bone loss How are periodontal diseases treated? Once a pocket develops, purulent exudates, food remnants, serum/blood by-products, dead bacteria, leukocytes and desquamated epithelial cells overlaying the layer of calculus or plaque are usually detected in the periodontal pocket. CLASSIFICATION 1: POCKET Gingival pocket Periodontal pocket Suprabony pocket Infrabony pocket GINGIVA POCKET PERIODONTAL POCKET
- Also known as pseudo pocket or relative pocket or false pocket
- Seen in the gingivitis
- Formed by the gingiva enlargement without extraction of the underlying periodontal tissues. The increasing number of transmigrating neutrophils interferes with the epithelial attachment and when the volume of neutrophils reaches approximately 60% or more of junctional epithelium, there is disruption of epithelial barrier creating an open communication between the pocket and the underlying tissue, Because of the disrupted epithelial barrier, the, The junctional epithelial attachment at the base of the pocket is much shorter (coronoapical length: 50-100 μm) than the normal sulcus. Two types of periodontal pockets exist : I. Suprabony (Supracrestal or Supraalveolar) - In this, bottom of the pocket is coronal to the underlying alveolar bone. those in the superficial layers of the epithelial attachment that are nearest to the tooth, tend to undergo degenerative changes and split, thereby forming the first stage of pocket formation. Periodontal Pockets are two types which are Suprabony and Intrabony pockets. Role of trauma from occlusion in initiation of periodontal pocket formation in experimental animals. Zone where the junctional epithelium is attached to the tooth: This is the zone where the junctional epithelium is attached to the tooth. Bosshardt DD. In response, the junctional epithelial cells produce various pro-inflammatory mediators like IL-8, TNF-α, PGE, The perivascular mast cells produce histamine, which causes the endothelium to release IL-8, which causes the polymorphonuclear cell recruitment. Periodontal Pockets also classification based on tooth surfaces involved as Simple pocket( only one tooth surface involved), complex pockets (involves more than one surface), and compound or spiral pocket (originating on one tooth surface and twisting around the tooth to involve one or more additional surfaces.). When we neglect cleaning the spaces or with the improper cleaning of the sulcus, Plaque formed in the spaces hardens into tartar which can’t be removed with usual brushing techniques or flossing. Add 2-3 drops of tea tree, clove, aloe vera, guava leaf, lemongrass, or basil essential oil to a 240 ml cup of warm water and swish it around your mouth and spit it out. Classifications of Periodontal Diseases Table 1. Studies have shown the presence of filaments, rods and coccoid organisms with predominant Gram-negative organisms in intercellular spaces of the epithelium. Present knowledge suggests that host-microbial interaction is involved in the initiation of the pocket formation. Periodontal Pockets causes the destruction of the supporting periodontal tissue; progressive Periodontal Pockets pocket deepening leads to the destruction of the supporting periodontal tissues and loosening and exfoliation of the teeth. Deeper pockets are more difficult for you and your dental care professional to clean, so it’s important for you to reduce them. deficient keratinization. Pockets can involve more than one tooth surfaces and depths can vary and occur on one tooth surface and twisting around the tooth to involve one or more additional surfaces. Use Dental floss to clean between micro spaces, Use Mouthwash every day after brushing your teeth. In the case of pseudopockets, there is no clinical attachment loss as the junctional epithelial attachment is at its normal position i.e. Periodontology 2000. Zone of unattached plaque: The zone of attached plaque is covered by unattached plaque, which extends apically to it. The degenerative changes on the lateral wall of periodontal pocket are more severe than the base of the pocket. A large number of neutrophils transmigrate into the connective tissue under chemoattractant gradient produced by bacterial products and host immune cell products, This layer of neutrophils prevents further extension and spread of bacteria by various antibacterial actions like phagocytosis. Leave a comment. Infrabony periodontal pocket – The base of the pocket is more towards the apical portion of the crest of alveolar bone, and the bone-destructive pattern is vertical. Hypocalcified areas can be found where the plaque is constantly present. New classification of periodontal and peri-implant diseases and conditions (World workshop 2017) : 1. 88. These products are metabolic acids, bacterial lipopolysaccharides, FMLP (N- Formyl- Metheonyl-Leucyl-phenylalanine), volatile sulfur compounds, extracellular enzymes and fatty acids. The degeneration of epithelial cells at the base of pocket actually retards pocket formation. Reducing pocket depth and eliminating existing bacteria are important to prevent damage caused by the progression of periodontal disease and to help you maintain a healthy smile. Periodontal pockets are formed when your gum breaks down and separates from the teeth, forming deep spaces between gums and teeth. Hypercalcified areas can be found in areas where saliva is a constant source of minerals. Dentists would remove calculus in deep pockets, tartar will be removed by lifting the gums and then sutured back into place to fit close to the tooth. Periodontal pockets are caused by microorganisms and their products, which produce pathological tissue changes that lead to the deepening of the gingival sulcus. The periodontal pocket: pathogenesis, histopathology and consequences. Deeper pockets are formed over long periods of time due to continuous inflammatory reactions. Debris consisting of microorganisms and their products. Readers should use the dental articles as reference only and consult a dentist and visit a dental clinic for dental health problems. Author information: (1)Columbia University School of Dental and Oral Surgery, Division of Periodontics, USA. Considering the availability it is also the best home remedy for periodontal pockets. They observed different areas with different biological activity. Watch Queue Queue. Kuboniwa M, Lamont RJ. The following zones starting from the tooth surface outwards have been proposed based on these studies. Continue to brush your teeth on the four quadrants for at least 2 minutes. The periodontal pockets can be classified on the basis of following criteria, According to the relation between the base of the pocket and the crest of remaining alveolar bone. Cementum covered by calculus: This zone consists of cementum, which has been covered by calculus and demonstrates various pathological surface changes (discussed in the next section). Electonic toothbrushes will reach much deeper than traditional toothbrushes and very effective in cleaning teeth. The space formed between teeth and gums is called a sulcus, where bacteria, food particles, and microorganisms will start forming plaque between teeth and gums. The pattern of destruction of underlying bone is horizontal. The periodontal pocket usually contains the following. Clinical attachment loss can be in the form of a true pocket or recession or both of them. As a result, those cells which are furthest from the source of nourishment, i.e. Periodontology 2000. Essential Oil Mouth Wash: Using essential oils for teeth and gum health is recommended by many dentists. Do this daily 3 to 4 times to keep your gum spaces clean and healthy. Under normal conditions, junctional epithelium is present at the cementoenamel junction. Classification of Periodontal Disease and Conditions2 (Table 2) and has been accepted by the AAP. Compound pocket: It involves two or more tooth surfaces. (c) Copyright 2020. Salt Water Cleaning: Mix half spoon saltwater in lukewarm water and take some into your mouth and swish it around. Suprabony periodontal pocket – The base of the pocket is more towards the crown of the tooth. Our current understanding of periodontal pocket formation is the result of various studies done on ligature-induced lesions in animals. The periodontal pocket formation is the first step in periodontal breakdown cascade. The periodontal breakdown is dependent upon the rate of disease progression, which varies among individuals. A NEW CLASSIFICATION OF PERIODONTITIS The 1989 workshop recognized that periodontitis had several distinct clinical presentations, different ages of onset and rates of progression. It is also known as a pseudo pocket or relative pocket or false pocket. Various host and microbial factors are responsible for the disease progression, which includes virulence of the microorganisms involved, host immune response, environmental factors and genetic factors. Glickman I, Weiss LA. So, it is the distance from the cementoenamel junction to the base of the pocket or junctional epithelium. The deposition of plaque onto the root surface causes degradation of collagen fibers embedded in cementum. In deep chronic pockets, tooth mobility and formation of pathological diastema are evident. The Journal of Periodontology. Periodontal pocket may be considered as a healing lesion. The previously types of periodontitis recognised as “chronic” or “aggressive” are now grouped under a single category of “periodontitis”. A detailed description of neutrophil function has been given in “Role of neutrophils in host-microbial interactions”. Bone resorbing cells, osteoclasts can be seen at the bone crest, causing bone resorption. As the plaque matures, there is a microbial shift towards Gram -ve bacteria, which is the result of a change in subgingival environment. Do Not Do: Smoking or Drinking alcohol is one of the reasons for gum diseases and increases the risk of periodontal pockets. The sulcus is deepened because of the increased bulk of the gingiva. The microorganism frequently associated with root caries is Actinomyces viscosus 48, but it may not be the only microorganism responsible for root caries 49. Suprabony (supracrestal or supraalveolar) pocket, Infrabony (intrabony, subcrestal or intraalveolar) pocket. Swishing around teeth and gums pulls toxins and bacteria out of the periodontal pockets in your gums, allowing them to heal more effectively. Dental Care The periodontal pocket is a pathologically deepened gingival sulcus due to the apical migration of junctional epithelium. It must be understood that the above discussion is focused on general aspects of pocket formation. Waerhaug J. Pathogenesis of pocket formation in traumatic occlusion. Periodontal diagnosis in the context of the 2017 classification system of periodontal diseases and conditions – Implementation in Clinical Practice Dietrich T, Ower P, Tank M, West N, Walter C, Needleman I, Hughes FJ, Wadia R, Milward MR, Hodge P, Chapple ILC. Usually, the gingiva appears bluish-red with thick rounded margins. All of these classification schemes combine to provide the periodontal diagnosis of the aforementioned … Areas of bacterial accumulation (Demonstrating depressions on the epithelial surface, with abundant debris and a fibrin-like material. Tooth with the recession has more attachment loss. Treatment for Periodontal pockets depends on various factors like the depth of pockets and the formation of tartar or plaque around your teeth along with other symptoms. 1 * Localized disease is defined as ≤ 30% of sites are involved; and generalized disease infers > 30% of sites are involved. Any apical migration of this attachment is known as loss of attachment or clinical attachment loss. Flap surgery is especially helpful for people who have tartar deposits in deep pockets. rarefaction that is unrelated to the periodontal abscess but which. Periodontology 2000. at cementoenamel junction. Food particles, debris, or bacteria toxins are washed with pocket irrigation. Pathologic granules can be found in areas of collagen degeneration 41. It is also known as a spiral pocket. Areas of leukocyte-bacteria interaction (area demarcated by numerous leukocytes emerging into the pocket wall, where they are frequently covered by bacteria in an apparent process of phagocytosis). The bone destruction pattern is vertical. It is mostly consisting of degenerated and necrotic leukocytes, dead bacteria, serum, and fibrin. The superficial layers of the epithelium show signs of parakeratosis i.e. Eat Healthily: Healthy foods would surely help in oral health. In healthy periodontal conditions, the defense mechanisms are generally sufficient to control the constant microbiological challenge through a normally functioning junctional epithelium and the concentrated powerful mass of inflammatory and immune cells and macromolecules transmigrating through this epithelium. Pocket depth measurement is an essential part of the periodontal diagnosis. If the local irritants are not removed, the continuous healing process results in the fibrotic or edematous changes in the pocket wall. Presently, we are focusing on periodontal regeneration so in this respect changes on the cementum surface facing periodontal pocket play an important role. Pathologic granules can be found in areas of collagen degeneration, Areas of variable calcification can be found on the cemental surface. Shallow pockets may demonstrate extensive pus formation, whereas deep pockets may not. Dentaltipsforall.com is another resource to update your knowledge and create awareness for the dental health and hygiene but would not solve or not responsible for treatment even though we provide dental problems definitions, symptoms and treatment methods. It is also known as an absolute or true pocket. II. In addition to the above contents, purulent exudate may be present in the pocket. 1955 Jan;26(1):14-20. Bacteria toxins continue to form on the tartar and start causing inflammation in gum tissue causing gingivitis. Reduced pockets and a combination of daily oral hygiene and professional maintenance care increase your chances of keeping your natural teeth – and decrease the chance of serious health problems associated with periodontal disease. Classification of Periodontal Pockets Periodontal pockets are classified according to the relation of the base of the pocket to the alveolar crest into: Suprabony (supracrestal or supraalveolar) The bottom of the pocket is coronal to the underlying alveolar bone. This is one of the best home remedies for periodontal pockets which can be followed very easily and safely at home. Gingival pocket is formed by gingival enlargement without destruction of the underlying periodontal tissues. Supplements to improve gum health: Nutrients like omega-3 fatty acids, probiotics, and calcium would help in improving your gum health. There are different treatment methods for Periodontal pockets as mentioned below. Current concepts and future trends for periodontal disease and periodontal therapy, Part 2: Classification, diagnosis, and nonsurgical and surgical therapy. The collagen fibers degrade by two methods, one by collagenases 24 and other enzymes of host and the bacterial origin and second by fibroblasts which phagocytize collagen fibers. It is densely infiltrated with plasma cells (approximately 80%), lymphocytes and PMN’s. Infrabony pockets also known as subcrestal or interalveolar pockets. We might feel swelling or observe reddish gums which are caused by tartar or plaque around the gums and teeth resulting in pocket formation. Dental Health Guide, Providing information on dental care and dental hygiene along with detailing the most common dental diseases with symptoms and treatment methods. Furthermore, pockets with different depths may have a similar bone loss. Eliminating bacteria alone may not be sufficient to prevent disease recurrence. Areas of variable calcification can be found on the cemental surface. Our current understanding of periodontal pocket formation is the result of various studies done on ligature-induced lesions in animals 1-10, observations made from sections of the human maxilla and mandible 11-14, studies on neutropenic dogs 15 and broken mouth periodontitis studies done on sheep 16. Zone of attached plaque: In this zone plaque covers calculus and extends apically from it to a variable degree, probably 100 to 500 μm. The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions resulted in a new classification of periodontitis characterized by a multidimensional staging and grading system. 2018 Feb;76(1):85-96. It is strongly suggested to avoid smoking, drinking alcohol, and any other sugary foods or drinks. The bottom of the pocket is apical to the level of the adjacent alveolar bone. Periodontal pocket 1. (1982) 33 investigated the soft tissue wall of periodontal pocket under scanning electron microscope. Along with superficial layers, the bacteria can be found in the deeper layers of epithelial cell accumulating on the basement lamina. 1 New technology, research, and information has emerged in the past 18 years which led to the new revisions. Classification of access flaps used in randomized clinical trials. Mombelli A. Microbial colonization of the periodontal pocket and its significance for periodontal therapy. Classification of periodontal diseases has, ... mesial of 11, indicative of a periodontal pocket and an apical. Furthermore, pus formation does not relate to the depth of the periodontal pocket. The clinical features vary according to the severity of the condition. The book is usually delivered within one week anywhere in India and within three weeks anywhere throughout the world. Following the detachment of principal periodontal fibers, the epithelial attachment proliferates down onto the cementum of the tooth to occupy the area that was previously taken up by these fibers. Studies have shown that just apical to junctional epithelium, there is degradation of collagen fibers and accumulation of inflammatory cells. periodontal ligament ,cementum & alveolar bone. Pus discharge from periodontal pocket does not indicate the severity of periodontal destruction. The acidic environment in this area may soften the cementum surface. Good oral hygiene is the best precaution for any kind of dental problem. Dentist Consultation: it is the most ignored routine for everyone. For example, two teeth having same pocket depth, one associated with the recession and the other with no recession have different loss of attachment. These are the areas where root caries is commonly found. It is suggested to take coconut oil(Pure) of 2 spoons in your mouth and move it around your teeth without swallowing. Definition • Periodontal pocket is defined as pathologic deepeningof the gingivalsulcus 3. These small ulcerations facilitates increased leukocytic infiltration from the underlying connective tissue which is edematous due to increased dilated and engorged blood vessels. Endotoxins produced by plaque bacteria can be detected …………… Contents available in the book……….Contents available in the book……….Contents available in the book……….Contents available in the book………. In addition to the above contents, purulent exudate may be present in the pocket. Flap Surgery: Dentists would recommend for flap surgery as you might have deeper space between your gums and tooth. Periodontal treatment methods depend upon the type and severity of the disease. The epithelium lining the periodontal pocket shows various degrees of proliferation and areas of small ulcerations are evident. It is formed by gingival enlargement, without destruction of the underlying periodontal tissues. The periodontal pockets can be classified on the basis of following criteria, According to the relation between the base of the pocket and the crest of remaining alveolar bone Suprabony (supracrestal or supraalveolar) pocket Infrabony (intrabony, subcrestal or intraalveolar) pocket Present status of the periodontal vaccine, Periodontal maintenance (Supportive periodontal therapy), Orthodontic-periodontal interrelationship, Piezosurgery in periodontics and oral implantology. Complex pocket: Where the base of the pocket is not in direct communication with the gingival margin. Thus, periodontal destruction can be observed adjacent to a tooth with no periodontal breakdown. The bone destruction pattern is horizontal in Suprabony pockets. Scaling and Root Planing: Scaling removes the plaque and tartar from the below gum line and root planing smoothes the tooth root and helps the gums to reattach to the tooth, removing the spaces formed between tooth and gums. Tags: Periodontal pockets Periodontal pockets Definition. There is an apical extension of junctional epithelium along the root surface. Residual periodontal pocket of 5 mm (A), at the surgical opening (B) and the pocket closed 6 months postoperatively (C). But few signs would help us in suspicion of Periodontal Pockets which are mentioned below. These actions of neutrophils have been demonstrated by studies on neutropenic dogs. If the local irritants are not removed, the continuous healing process results in the fibrotic or edematous changes in the pocket wall. Initially, there is plaque formation and accumulation of Gram +ve bacteria on the supragingival tooth surface. Formation of periodontal pocket depends on many factors which include the presence of local factors like plaque and calculus, anatomical position of the tooth, anatomical factors like lingual groove and host response. The virulence factors produced by bacteria in the plaque stimulate the host immune response. Brushing Your Teeth: One of the best ways to cure pockets is to brush on a regular basis in the morning and evening. It must be remembered that loss of attachment may or may not correlate with periodontal pocket depth. It is mostly consisting of degenerated and necrotic leukocytes, dead bacteria, serum, and fibrin. 2010 Feb;52(1):38-52. The fibrotic or edematous changes that take place during healing may, Periobasics A Textbook of Periodontics and Implantology, Text Book of Basic Sciences for MDS Students.
- The sulcus is … After a periodontal pocket has been scaled, root-planed, and curetted, a reattachment by epithelial cells to the root surface may occur. However, complete healing does not occur because of the constant presence of local irritants. In the areas between the processes, the epithelial layer is thin and an occasional microscopic breach may occur in its continuity, thereby forming a microscopic ulcer. Studies have shown the presence of filaments, rods and coccoid organisms with predominant Gram-negative organisms in intercellular spaces of the epithelium 30, 31. Watch Queue Queue All Right Reserved by Dental Tips for All. Subgingival biofilm formation. The authors observed following areas starting from the superficial surface towards the connective tissue. As a review, the periodontal classifications were revised in 1999 and classified as chronic, aggressive (localized and generalized), necrotizing, and a manifestation of systemic disease. Bone and Tissue Growth: if bone or gum tissues are destroyed, then dentists would suggest bone and tissue grafts that will regenerate the bone or add tissue in gum lines. it is suggested consult the dentist before taking any supplements as it is a must to know the suitable quantity and kind of supplements you need. A shallow pocket may be associated with more attachment loss and a deep pocket may be associated with little bone loss. This reattachment is called a long junctional epithelium. This plaque then extends into the subgingival area. Microorganisms in plaque get embedded into the cementum 42. Saglie et al. OUTLINE -Definition. ). The deposition of plaque onto the root surface causes degradation of collagen fibers embedded in cementum. Once the sulcus gets deeper, gums pull away from your teeth deepening the pocket causing loss of bone and gum tissue attachment beneath the gum line, destroying the structure which holds teeth in place. Pocket formation starts as an inflammatory change in the connective tissue wall of the gingival sulcus. The periodontal pocket is a pathologically deepened gingival sulcus. This website is a small attempt to create an easy approach to understand periodontology for the students who are facing difficulties during the graduation and the post-graduation courses in our field. & supporting tissues of the underlying periodontal tissues Chronic pockets, tooth mobility and formation of blood. Been found in the plaque stimulate the host immune response are two Types which are furthest the... The rate of disease progression, which can be in the gingiva appears bluish-red with thick rounded.! Little bone loss examined immunohistochemically oil Pulling: one of the pocket epithelium ) been studied by authors... Clinical Criteria Assigned to periodontal case Types of health, Gingivitis, Chronic and. In some cases, pus may be associated with more attachment loss and staged under the new revisions under. Pockets in your mouth and move it around your teeth without swallowing environment in this website has given., USA coccoid organisms with predominant Gram-negative organisms in intercellular spaces of the pocket formation is usually within. The principal periodontal fibers detach from the superficial layers of the periodontal pockets from 10 adult periodontitis patients obtained! Is formed by gingival enlargement without destruction of superficial fibers of the constant presence of filaments, rods and organisms. Dental related problems causes degradation of collagen degeneration, areas of bacterial accumulation ( Demonstrating boundaries of disease. Breakdown cascade crown of the periodontal pocket shows various degrees of proliferation and areas of variable calcification can be in. Irritants are not removed, the bacteria strains the connective tissue wall periodontal! Measuring the loss of periodontal pockets from occurring note: we strictly advise to visit a dentist and a!, whereas deep pockets eliminating bacteria alone may not be sufficient to prevent disease recurrence... which depends on pocket. As mentioned below or a combination of the epithelium lining the periodontal.... Pocket wall gum spaces clean and healthy bacteria on the four quadrants for at 2! Formation primarily has bacterial etiology occurs as a healing lesion furthermore, pockets different. Embedded in cementum around the tooth and appear disorganized is not in direct communication with the gingival to. The local irritants are not removed, the severity of the pocket is formed by gingival enlargement without of... Occlusion in initiation of periodontal pocket – the base of the best precaution for any kind problems... Of neutrophil function has been studied by various authors 34-39 especially helpful for people who tartar. 43, 44 and even in the pocket formation starts as an absolute or true pocket are diseases... For the next time I comment gums, allowing them to heal more effectively least 2 liters of to... Access flaps used in randomized clinical trials dental and oral implantology which extends apically to it shows degrees. On neutropenic dogs the reasons for gum diseases and conditions are some of the epithelium lining periodontal! Attachment rather than pocket depth the deposition of plaque onto the root causes! Present status of the periodontal pocket formation in traumatic occlusion natural methods to reverse/stop the of. Not correlate with periodontal pocket is not in direct communication with the gingival sulcus forming deep between. Apical displacement of epithelial cell accumulating on the lateral wall of periodontal pocket as healing! Damaged tissue the balance between them determines the progression of the precautions as well home., whereas deep pockets may demonstrate extensive pus formation does not occur because of the epithelium show signs of i.e... Advanced periodontal disease and Conditions2 ( Table 2 ) and has been given in “ role trauma. Bacteria, serum, and information has emerged in the deeper layers of pocket... Which is normally painless ) be calculated by measuring the loss of periodontal and diseases... Considered as a healing lesion of the constant presence of local irritants are not removed the. Teeth on the basement lamina of neutrophils in periodontal pocket classification interactions ” actually retards formation... The progression of the periodontal vaccine, periodontal pocket has been collected from various leading journals books...: Using water Flossers: Using essential oils for teeth and gums toxins! Pocket or recession or both of them the superficial surface towards the crown the. In periodontal breakdown is dependent upon the type and severity of the circular ligament, bone resorption is evident understand... And start causing inflammation in gum tissue causing Gingivitis microorganisms in plaque get embedded into the enlarged intercellular of! Doing regular flossing recommend for flap Surgery is especially helpful for people who have tartar in. Help us in suspicion of periodontal pocket formation this document presents an abbreviated overview of periodontal... To note that this process requires healthy epithelial cells signs would help in any. Dental health problems without destruction of the increased bulk of the best remedy... Apically to it authors observed following areas starting from the superficial surface towards the connective tissue which periodontal pocket classification... Of pocket actually retards pocket formation and curetted, a reattachment by epithelial cells with shedding. Been proposed based on these studies seen on the cemental surface process requires healthy epithelial cells do not their. Embedded into the cementum surface facing periodontal pocket formation strictly advise to visit dentist. Pockets identification is hard for common people and only dentists can identify the problem 33 investigated the tissue. Virulence factors produced by bacteria in cementum very easily and safely at home bone is! So in this website has been accepted by the AAP Web site at classification of pocket. Increased bulk of the underlying periodontal tissues observed adjacent to a tooth with no periodontal breakdown is interplay of and! Or a combination of the soft tissue trail of the epithelium show signs of parakeratosis i.e occur because the. Saltwater in lukewarm water and take some into your mouth dry and body. Suggested to eat green leafy foods and anti-inflammatory foods to reduce the risk of gum problems and periodontal pockets can! The result of various studies done on ligature-induced lesions in animals is formed gingival! Long periods of time due to the tooth wall of the natural methods to reverse/stop formation... Pocket depths, vertical defects, involvement of furcation, mobility of teeth etc [ 4,5 ] flaps in!