PERIODONTALFLAPS

DRJEBIN,MDS.,D.ICOI

DEF:
Aperiodontalflapisasectionofgingivaand/ormucosasurgicallyseparatedfromthe
underlyingtissuestoprovidevisibilityandaccesstotheboneandrootsurface.

INDICATIONS:
Irregularbonycontours
Deepcraters
Pocketsonteethinwhichacompleteremovalofrootirritantsisnotclinicallypossible
GradeIIorIIIfurcationinvolvement
Rootresection/hemisection
Intrabonypocketsondistalareasoflastmolars
Persistentinflammationinareaswithmoderatetodeeppockets.
CONTRAINDICATIONS:
Uncontrolledmedicalconditionssuchas
unstableangina
uncontrolleddiabetes
uncontrolledhypertension
myocardialinfarction/strokewithin6months
Poorplaquecontrol
Highcariesrate
Unrealisticpatientexpectationsordesires

CLASSIFICATIONOFFLAPS
Classifiedbasedon:

Boneexposureafterflapreflection
Fullthickness(mucoperiosteal)
Partialthickness(mucosal)

Placementoftheflapaftersurgery
Nondisplacedflaps
Displacedflaps

Managementofthepapilla
Conventionalflaps
Papillapreservationflaps

BASEDONBONEEXPOSUREAFTERREFLECTION

FULLTHICKNESSFLAP
Periosteumisreflectedtoexposetheunderlyingbone.
Indicatedinresectiveosseoussurgery.

Contraindications :
Areawheretreatmentforosseousdefectwithmucogingivalproblemisnotrequired.
Thinperiodontaltissuewithprobableosseousdehiscenceandosseousfenestration.
Areawherealveolarboneisthin.

PARTIALTHICKNESSFLAP

Splitthicknessflap.
Periosteumcoversthebone.
Indicatedwhentheflaphastobepositionedapically.
Whentheoperatordoesnotdesiretoexposethebone.

BASEDONFLAPPLACEMENTAFTERSURGERY

Nondisplacedflaps:
Whentheflapisreturnedandsuturedinitsoriginalposition.

Displacedflaps:
Whentheflapisplacedapically,coronallyorlaterallytotheiroriginalposition

DESIGNOFTHEFLAP

Splitthepapilla(conventionalflap)or
Preserveit(papillapreservationflap).

BASEDONMANAGEMENTOFTHEPAPILLA
CONVENTIONALFLAP

The interdental papilla is split beneath the contact point of the two approximating teeth to
allow reflection of buccal and lingual flaps.

Theconventionalflapisusedwhen
Theinterdentalspacesaretoonarrow
Whentheflapistobedisplaced.

Conventionalflapsincludethe
TheModifiedWidmanflap,
Theundisplacedflap,
Theapicallydisplacedflap,and
Theflapforregenerativeprocedures.

PAPILLAPRESERVATIONFLAP

The papilla preservation flap incorporates the entire papilla in one of the flaps

Twobasicflapdesigns,thosewithandthosewithoutverticalreleasingincisions:
EnvelopeFlap: Aflapthatisreleasedinalinearfashionatthegingivalmarginbuthasno
verticalreleasingincision(s).
PedicleFlap: Iftwoverticalreleasingincisionsareincludedintheflapdesign.
TriangularFlap: Ifoneverticalreleasingincisionisincludedintheflapdesign.

Envelope Flap

Pedicle Flap

Triangular Flap

Themajorbloodsupplytoaflapisatitsbaseandtravelsinanapicaltocoronal
direction.
Recommendedflaplength(height)tobaseratioshouldbenogreaterthan2:1

INCISIONS

Horizontalincisions.

Verticalincisions.

HORIZONTALINCISIONS
Horizontalincisionsaredirectedalongthemarginofthegingivainamesialoradistal
direction.
Twotypesofhorizontalincisionshavebeenrecommended:
A)Theinternalbevelincision,whichstartsatadistancefromthegingivalmarginandis
aimedatthebonecrest,and
B)Thecrevicularincision,whichstartsatthebottomofthepocketandisdirectedtothe
bonemargin.
C)Inaddition,theinterdentalincision isperformedaftertheflapiselevated.

INTERNALBEVELINCISION

1st incision
1 incision
Reverse bevel incision
11 or 15 surgical scalpel
used
Starts at a distance from the
gingival margin aiming at the
bone crest.

Removespocketlining.

Producesasharpthinflap
margin.

Startsfromadesignatedareaon
thegingivaandisdirectedtoan
areaatornearthecrestofthe
bone.

V ari ousl oc ati onsand

angles of internal bevel

incision

CREVICULAR INCISION

Also known as second

incision
Made from the base of
the pocket to the crest
of the bone
This incision, together
with the initial reverse
bevel incision, forms
a V-shaped wedge
ending at or near the
crest of bone

PROCEDURE:
1) Beak-shaped #12D blade is used
2) Periosteal elevator inserted into the initial internal bevel incision
3) Flap separated from the bone

INTERDENTAL INCISION

Also known as third incision

To separate the collar of
gingiva that is left around the
tooth
Incision made facially
lingually & interdentally
connecting the 2 segments.
Orbans knife is used

VERTICAL INCISIONS

Can be used on one or both ends of the horizontal incision

Must extend beyond the mucogingival line, reaching the alveolar mucosa, to allow
for the release of the flap to be displaced
Vertical incisions in the lingual and palatal areas are avoided

This incision should be made at the line angles to prevent splitting of a

papilla or incising directly over a radicular surface.

ELEVATION OF THE FLAP

Blunt dissection with periosteal elevator

For reflection of full thickness flap

Sharp dissection with surgical scalpel (#11 or #15)

For reflection of partial thickness flap

AflapthatincludesonlygingivaltissueisreferredtoasaGINGIVALFLAP.

Aflapthatextendsbeyondthemucogingivaljunctiontoincludealveolarmucosa,is
aMUCOGINGIVALFLAP.

FLAPRETRACTION

Retractionshouldbepassivewithoutanytension.

Forceshouldnotbenecessarytokeeptheflapretracted.

Theedgeoftheretractoralwaysbekeptonbone.

Continuousflapretractionforlongperiodsisalsoisnotadvised.Suchapracticewill
desiccatethesofttissueandbonecausingadelayinwoundhealing.

Whentheflapisretracted,thesurgicalassistantshouldfrequentlyirrigatethesurgicalfield
withsterilesaline,tokeepthetissuesmoistened,toreducecontamination,andtoimprove
visibility.

OPENFLAPDEBRIDEMENT

provideaccesstorootsurfacesandmarginalalveolarbone.

FLAPPOSITIONING
surgicalflapsmayberepositioned,apicallypositioned,coronallypositionedor
laterallypositioned

Anapicallypositionedflapisonethatisapicallydisplacedfromitsoriginalposition
tothelevelofthealveolarcrestorabout1mmcoronaltothecrest.

Thecoronallypositionedflapisadvancedcoronaltoitsoriginalposition.

FLAPTECHNIQESFORPOCKETTHERAPY

Increaseaccessibilitytorootdeposits
Eliminateorreducepocketdepthbyresectionofthepocketwall
Exposetheareatoperformregenerativemethods

FLAPTECHNIQUES

Themodifiedwidmanflap
Theundisplacedflap
Thepalatalflap
Theapicallydisplacedflap
Flapsforregenerativesurgery
Thepapillapreservationflap
Conventionalflapforregenerativesurgery
Distalmolarsurgery

THEORIGINALWIDMANFLAP

ByLeonardWidman (1918)
Widmandescribedamucoperiostealflapdesignedtoremovethepocketepitheliumand
theinflamedconnectivetissue,therebyfacilitatingoptimalcleaningoftherootsurfaces.
ADVANTAGES:

Lessdiscomfortforthepatient,sincehealingoccurredbyprimaryintention.
Itwaspossibletoreestablishapropercontourofthealveolarboneinsiteswithangular
bonydefects.

STEP 1

STEP 2

STEP 3

STEP 4

THEMODIFIEDWIDMANFLAP

RamfjordandNissle (1974) ThemodifiedWidmanflap.

Themaingoalsoftheprocedureincludeoptimummechanicalsubgingivalroot
planingwithdirectvision.

INDICATIONS:
Especiallyeffectivewithpocketdepthsof57mm.
CONTRAINDICATIONS:
Lackoforverythinandnarrowattachedgingivacanrenderthetechniquedifficult,because
anarrowbandofattachedgingivadoesnotpermittheinitialscallopedincision(internal
gingivectomy)..
osseoussurgicalprocedure

ADVANTAGES:

Rootcleaningwithdirectvision.
Tissuefriendly.
Healingbyprimaryintention.
Minimalcrestalboneresorption.
Lackofpostoperativediscomfort.
STEP 1

STEP 2

STEP 3

STEP 5

STEP 4

STEP 6

THEUNDISPLACEDFLAP

Currently,itisthemostcommonly performedtypeofperiodontalsurgery.

ItdiffersfromthemodifiedWidmanflapinthatthesofttissuepocketwallisremovedwith
theinitialincision;thusitmaybeconsideredaninternalbevelgingivectomy.

Pre-operative Facial & Lingual Views

Internal Bevel Incisions Facial & Palatal Aspects

Flap Elevated Showing Osseous Defects

Osseous surgery has been performed

Flaps Placed In Their Original Site And Sutured

Post Operative Results

PARTIALTHICKNESSPALATALFLAPSURGERY

DevelopedbyStaffileno andimprovedbyCornetal.
eliminationofperiodontalpocketswherethickpalataltissuesoccur.

ADVANTAGES:
Flapthicknessmaybeadjusted.
Palatalflapmaybeadaptedtotheproperposition.
Betterpostoperativegingivalmorphologyispossiblewithathinflapdesign.
Treatmentsmaybecombined(osseousresectionandwedgeprocedure).
Rapidhealing.
Easymanagementofpalataltissue.
Minimaldamagetopalataltissue.

Outline of primary incision

Primary incision

Thin primary flap preparation.

. Secondary incision

Secondary flap removal

Suture

THEAPICALLYDISPLACEDFLAP

Itcanbeusedforbothpocketeradicationaswellaswideningthezoneofattachedgingiva.
Itcanbeafullthickness(mucoperiosteal)orasplitthickness(mucosal)flap.

ADVANTAGES:
Eliminatesperiodontalpocket.
Preservesattachedgingivaandincreasesitswidth.
Establishesgingivalmorphologyfacilitatinggoodhygiene.
Ensureshealthyrootsurfacenecessaryforthebiologicwidthonalveolarmarginand
lengthenedclinicalcrown.

DISADVANTAGES:

Maycauseestheticproblemsduetorootexposure.
Maycauseattachmentlossduetosurgery.
Maycausehypersensitivity.
Mayincreasetheriskofrootcaries.
Unsuitablefortreatmentofdeepperiodontalpockets.
Possibilityofexposureoffurcationsandroots,whichcomplicatespostoperative
supragingivalplaquecontrol.
CONTRAINDICATIONS:
Periodontalpocketsinsevereperiodontaldisease.
Periodontalpocketsinareaswhereestheticsiscritical.
Deepintrabonydefects.
Patientathighriskforcaries.
Severehypersensitivity.
Toothwithmarkedmobilityandsevereattachmentloss.
Toothwithextremelyunfavourableclinicalcrown/Rootratio.

Facial And Lingual Preoperative Views

Facial And Lingual Flaps Elevated

After Debridement Of The Areas

Sutures In Place

Healing After 1 Week

Preoperative

Healing After 2 Months

Postoperative

BEFORE OSSEOUS RESECTION

PRE-TREATMENT

AFTER OSSEOUS RESECTION

FLAP APICALLY POSITIONED AND SUTURED

POST-TREATMENT

FLAPSFORREGENERATIVESURGERY

Twoflapdesignsareavailableforregenerativesurgery:
Thepapillapreservationflap &
Theconventionalflapwithonlycrevicularincisions.

AdequateinterdentalspaceInterdentalspaceisverynarrow
PapillapreservationflapConventionalflapwithonlycrevicularincisions

THEPAPILLAPRESERVATIONFLAP

Entirepapillaisincorporatedintooneoftheflaps.

INDICATIONS:
Whereestheticsisofconcern.
Whereboneregenerationtechniquesareattempted.

CONVENTIONALFLAPFORREGENERATIVESURGERY
Intheconventionalflapoperation,theincisionsforthefacialandthelingualorpalatal
flapreachthetipoftheinterdentalpapilla,therebysplittingthepapillaintoafacialhalf
andalingualorpalatalhalf.

INDICATIONS:
Whentheinterdentalareasaretoonarrowtopermitthepreservationofflap.
Whenthereisaneedfordisplasingflaps.

DISTALMOLARSURGERY

Treatmentofperiodontalpocketsonthedistalsurfaceofterminalmolarsisoften
complicatedbythepresenceofbulbousfibroustissueoverthemaxillarytuberosityor
prominentretromolarpadsinthemandible.
OperationsforthispurposeweredescribedbyRobinson andBraden

Impaction Of A Third Molar

Distal To A Second Molar

Little Or No Bone Distal

To The Second Molar.

Often Leads To A Vertical

Osseous Defect Distal To
The Second Molar.

A typical incision design for a surgical procedure distal to the

maxillary second molar.

Incisiondesignsfor
surgicalproceduresdistal
tothemandibularsecond
molar.

Theincisionshouldfollow
theareasofgreatest
attachedgingivaand
underlyingbone.

TRIANGULARDISTALWEDGE:

Triangularwedgeincisionsareplacedcreatingtheapexofthetriangleclosetothehamularnotch
andthebaseofthetrianglenexttothedistalsurfaceoftheterminaltooth.

LINEARDISTALWEDGE:

Thelineardistalwedgeincorporatestwoparallelincisionsoverthecrestofthetuberositythatextend
fromtheproximalsurfaceoftheterminalmolartothehamularnotcharea.
Thedistancebetweenthetwolinearincisionsisdeterminedbythethicknessofthetissues

DISTAL POCKET ERADICATION PROCEDURE WITH

THE INCISION DISTAL TO THE MOLAR

SCALLOPED INCISION AROUND THE REMAINING TEETH

FLAP REFLECTED AND THINNED AROUND THE DISTAL INCISION

FLAP IN POSITION BEFORE SUTURING. IT SHOULD BE CLOSELY APPROXIMATED

FLAP SUTURED BOTH DISTALLY AND OVER THE REMAINING SURGICAL AREA

HEALINGAFTERFLAPSURGERY

Immediatelyaftersuturing(0to24hours), establishedbyabloodclot,whichconsistsofa
fibrinreticulumwithmanypolymorphonuclearleukocytes,erythrocytes,debrisofinjured
cells,andcapillariesattheedgeofthewound.

Oneto3daysafterflapsurgery, thespacebetweentheflapandthetoothorboneis
thinner,andepithelialcellsmigrateovertheborderoftheflap

Oneweekaftersurgery Thebloodclotisreplacedbygranulationtissuederivedfromthe
gingivalconnectivetissue,thebonemarrow,andtheperiodontalligament.

Twoweeksaftersurgery, collagenfibersbegintoappearparalleltothetooth
surface.Unionoftheflaptothetoothisstillweak,owingtothepresenceof
immaturecollagenfibers,althoughtheclinicalaspectmaybealmostnormal.

Onemonthaftersurgery, afullyepithelializedgingivalcrevicewithawelldefined
epithelialattachmentispresent.Thereisabeginningfunctionalarrangementof
thesupracrestalfibers.

THANKU