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Periodontal Flaps

Hisham AlShorman
Eman Dylawani
20 – 10 – 2016

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> It takes more times more meticulous but the end result is having more blood perfusion to the area. > All the soft tissue. can u put bone in partial thickness ? no u have to expose the original bone . > Also called the split thickness flap. or when dehiscences or fenestrations are present. Full thickness (mucoperiosteal). which is better a full thickness or a partial thickness flap ? It Depends on indications. CLASSIFICATION OF FLAPS ~ Periodontal flaps can be classified based on the following: 1. Based on Bone exposure after flap reflection. to see things under soft tissue or for soft tissue augmentation as well. so we go for full thickness in case if we need to expose bone. > Includes only the epithelium and a layer of the underlying connective tissue. is reflected to expose the underlying bone. > Indicated when the flap is to be positioned apically or we does not desire to expose bone & may be necessary in cases in which the crestal bone margin is thin and is exposed. so it is surgically separate from the under laying tissues in most of cases the reason for that is to reshape or to add bone or to place an implant. including the periosteum. 1 . a. > much easier than partial thickness flap. > Indicated when resective osseous surgery is contemplate & if we need to get an access to the bone. notes in the lecture. What is a FLAP ? basically we mean the soft tissue. some times we do implant. if u want to displace the gingiva to make it stretchable u have to had partial thickness because the periosteum is very tuff connective tissue can't be stretched so if u want to remove the gingiva "repositioned flap" u better do partial thickness . Partial thickness (mucosal). The Periodontal Flap This script include summery for chapter #57 from the book + the dr. > When we do implant & when remove a root we use full thickness flap b. we need to have an access to the bone just to get that access we release a flap which is section of the soft tissue that is left away from under laying bone .

Displaced flaps: that are placed apically. we put bone & we want to suture the flap back . When bone is stripped of its periosteum. and this loss is prevented when the periosteum is left on the bone however. For example: if you originally had recession and you want to cover this recession this mean . a. Nondisplaced flaps: when the flap is returned and sutured in its original position. Based on placement of the flap after surgery. so we need to stretch it more. the bulk of the bone prevent us from putting the flap back in its original position . coronally. Full thickness Partial thickness 2. you should put the flap up which called " coronally repositioned or displaced flap" 2 . b. a loss of marginal bone occurs. are usually not clinically significant. or laterally to their original position. In case of bone graft . to do that we make periosteal incision to slice the periosteum just to enable the soft tissue to stretch a little bit.

> Conventional flaps include the modified Widman flap. but to do so. extraction of impacted canine when we need surgical exposure. b. palatal flaps cannot be displaced owing to the absence of unattached gingiva. Modified Widman flap Widman: described a mucoperiosteal flap designed to remove the pocket epithelium and the inflamed connective tissue & granulation tissue . thereby enabling the unattached portion of the gingiva to be moveable. Based on Management of the papilla. Used In case of apexictomy to reach the apex of the root . Semilunar Flap A curved incision over the tooth root. without removing thick part of the gingiva. the attached gingiva has to be totally separated from the underlying bone. Papilla preservation flap (preserve the papilla) > The papilla preservation flap incorporates the entire papilla in one of the flaps by means of 3 . the undisplaced flap. Therefore they accomplish the double objective of eliminating the pocket and increasing the width of the attached gingiva.sinus lifting. Conventional flap (split the papilla) > The interdental papilla is split beneath the contact point of the two approximating teeth. However.  3. Both full thickness and partial thickness flaps can be displaced. the apically displaced flap and the flap for regenerative procedures. Two basic flap designs are used: a. > We can use it also to do crown lengthening. and when 2) the flap is to be displaced. The flap is displaced coronally. > Used when 1) the interdental spaces are too narrow. thereby precluding the possibility of preserving the papilla. and facilitating optimal cleaning of the root surfaces. It is not part of our periodontal incision.  Apically displaced flaps : > Have the important advantage of preserving the outer portion of the pocket wall and transforming it into attached gingiva.

> The entire surgical procedure should be planned in every detail before the intervention is begun. > internal bevel incision accomplishes three important objectives: 1) It removes the pocket lining. > types of horizontal incisions have been recommended(1°. > Which starts at a distance from the gingival margin and is aimed at the bone crest.3°) a.crevicular interdental incisions to sever the connective tissue attachment and a horizontal incision at the base of the papilla leaving it connected to one of the flap. which. Conventional flap Papilla preservation flap DESIGN OF THE FLAP > The degree of access to the underlying bone and root surfaces necessary and the final position of the flap must be considered in designing the flap. 2) It conserves the relatively uninvolved outer surface of the gingiva. > It is the initial incision in the reflection of a periodontal flap.2°. Horizontal Incisions > Directed along the margin of the gingiva in a mesial or a distal direction. detailed planning allows for a better clinical result. INCISIONS 1. if apically 4 . > Preservation of good blood supply to the flap is an important consideration. The internal bevel incision (first incision): > most commonly use in perio.

3) It produces a sharp.  The beak-shaped #12D blade is usually used for this incision. forms a V- shaped wedge ending at or near the crest of bone.  This incision. The starting point on the gingiva is determined by whether the flap is apically displaced or not displaced. as well as the junctional epithelium and the connective tissue fibers that still persist between the bottom of the pocket and the crest of the bone. b. > #15C or #15 surgical scalpel is used. together with the initial reverse bevel incision. because its bevel is in reverse direction from that of the gingivectomy incision. The incision is carried around the entire tooth. The crevicular incision (second incision):  which starts at the bottom of the pocket and is directed to the crest of the bone (is inserting the blade within the sulcus). The internal bevel (first) incision can be made at varying locations and angles according to the different anatomic and pocket situations. This wedge of tissue contains most of the inflamed and granulomatous areas that constitute the lateral wall of the pocket. becomes attached gingiva. 5 . thin flap margin for adaptation to the bone-tooth junction.positioned. > This incision has also been termed reverse bevel incision.

e. 6 . and the remaining connective tissue in the osseous lesion should be carefully curetted out so that the entire root and the bone surface adjacent to the teeth can be observed. the surgeon is able to make the third or interdental incision to separate the collar of gingiva that is left around the tooth. the pocket epithelium and the adjacent granulomatous tissue). 2. lateral. after a periosteal elevator is inserted into the initial internal bevel incision. If vertical incisions are not made. if I feel my access is not enough and I need this vertical incision some times I would extend my horizontal incision to more teeth just to avoid vertical (releasing) incision. Vertical Incisions or oblique releasing incisions: > in perio. the flap is called an envelope flap.  So this incision is made not only around the facial and lingual radicular area but also interdentally. connecting the facial and lingual segments. or coronal displacement of the flap is not anticipated. The interdental incision (third incision):  Is performed after the flap is elevated. we not encourage releasing incision because it is difficult to reposition to return it back to its original place . With this access. c. to completely free the gingiva around the tooth. These three incisions allow the removal of the gingiva around the tooth (i.. Flaps can be reflected using only the horizontal incision if sufficient access can be obtained by this means and if apical. and the flap is separated from the bone.

In this way the coronal portion of the bone. >>why do we avoid placing the vertical incision at the mid of the root ? If we place the vertical incision on the mid of the root there is increase the likelihood for recession. and then partial thickness flap is made at the apical portion. > Vertical incisions in the lingual and palatal areas are avoided. to allow for the release of the flap to be displaced. 7 . >>Why do we avoid placing the vertical incision at the mid of the papilla ? imagine that if u section the papilla like this it will be very difficult to suture it . > Vertical incisions must extend beyond the mucogingival line. > Vertical incision can be used on one or both ends of the horizontal incision. is exposed while the remaining bone remains protected by its periosteum. **so the best case is to incise lateral to papilla and away from the mid of the root** > The vertical incision should also be designed so as to avoid short flaps (mesiodistal) with long. which may be subject to osseous remodeling. apically directed horizontal incisions because these could jeopardize the blood supply to the flap A combination of full and partial thickness flaps can often be indicated to obtain the advantages of both. depending on the design and purpose of the flap. so our route always incise the papilla in one piece. reaching the alveolar mucosa. > Facial vertical incisions should not be made in the center of an interdental papilla or over the radicular surface of a tooth. Incisions should be made at the line angles of a tooth either to include the papilla in the flap or to avoid it completely. The flap is started as a full thickness procedure. > Vertical incisions at both ends are necessary if the flap is to be apically displaced.

or resorbable: . suture needles.They enhance patient comfort and eliminate suture removal appointments. and materials.The most common nonresorbable is silk & nylon.  There are many types of sutures.Vicryl (polyglactin 910) suture : is an absorbable. ELEVATION OF THE FLAP In full thickness flap. distally. SUTURING TECHNIQUE > The purpose of suturing is to maintain the flap in the desired position where it should remain without tension until healing has progressed to the point where sutures are no longer needed. . A periosteal elevator is used to separate the Sharp dissection is necessary to reflect mucoperiosteum from the bone by moving a partial thickness flap. 2. desired reflection is accomplished. the reflection is accomplished by blunt dissection.synthetic suture. Suture materials may be either: 1. A surgical it mesially. 8 . Nonresorbable: . and apically until the scalpel (#11 or #15) is used.

 The curvature of the needle can be 1/2 circle or some thing else and in dentistry we always prefer 3/8 circle curvature of the needle for better access . the cross section of it is triangle like a scaler. alleviates the "wicking effect" of braided sutures that may allow bacteria from the oral cavity to be drawn through the suture to the deeper areas of the wound. 9 . so we use cutting needle which cut from 3 sides. because the tissue in the mouth very fragile we do not want to put pressure . they used for GI difficult surgery's they do not use in oral tissue .  Reverse cutting is the most commonly used in perio. braided 2. or monofilaments.  Smaller the suture (diameter) the less likelihood the inflammation .silk type can cause inflammation which is a not desirable thing to happen afterwards. When u buy your suture there is information that u need to know:  The bigger the number the smaller the size )4-0 size is smaller than 3-0 size). in non-cutting the cross section is circle it only cut at the tip . And they may be further categorized as 1.  You have to know cutting or non-cutting needles . 1/2 circle would be too much curved this is good for GI or skin suture . because when u start suturing u push the needle u will not harm the tissue because the sharp edge of the needle is down word.

. 10 .  The needle is then carried through the tissue. Suturing Technique  The needle is held with the needle holder and should enter the tissues at right angles (90 degree) and no less than 2 to 3 mm from the incision.  The knot should not be placed over the incision. needle is held around the middle for better access and to avoid bending. should be in either side of incision. Non-absorbable This triangle mean that the cross section of this needle is triangle and if the tip of the triangle is up this is for regular cutting if it is down revers cutting . following the needle's curvature (so you enter at 90° then after penetration follow the curvature).

If our direction vertically we call it vertical Mattress. 11 . Sutures of any kind placed in the interdental papillae should enter and exit the tissue at a point located below the imaginary line that forms the base of the triangle of the interdental papilla. and the knot is tied. b. ______________________________________________________________ Ligation: 1. So we have 2 point on buccal flap & 2 point on the lingual flap.  Types of Sutures Horizontal Mattress Suture: Is inserting the needle in 2 points rather than one point in the two sides of the flap. which permits a better closure of the interdental papilla . The figure-eight suture: The needle penetrates the outer surface of the first flap and the outer surface of the opposite flap. The direct or loop suture: Is basically join the two pieces of the flap in one loop. Interdental Ligation. Two types of interdental ligation can be used: a. The suture is brought back to the first flap.

Collagen fibers begin to appear parallel to the tooth surface. usually contacting the tooth at this time. *suture can be made continuous which give more strength to the suture. > The blood clot is replaced by granulation tissue. although the clinical aspect may be almost normal. When the flap is closely adapted to the alveolar process. A fully epithelialized gingival crevice with a well-defined epithelial attachment is present. there is only a minimal inflammatory response . A connection between the flap and the tooth or bone surface is established by a blood clot.  Two weeks after surgery. HEALING AFTER FLAP SURGER  Immediately after suturing (0 to 24 hours).  One week after surgery. Often used for the interproximal areas of diastemata or for wide interdental spaces .  One month after surgery. This results in a loss of bone of about 1 mm.' Union of the flap to the tooth is still weak. owing to the presence of immature collagen fibers. Mattress mean : 2 point in the tissue. or if double stitch that is made perpendicular we call it vertical Mattress if made parallel we call it (horizontal mattress). There is a beginning functional arrangement of the supracrestal fibers. result in a superficial bone necrosis at 1 to 3 days. the bone loss is greater if the bone is thin . 12 . and epithelial cells migrate over the border of the flap. Full-thickness flaps. The space between the flap and the tooth or bone is thinner. which denude the bone.  One to 3 days after flap surgery. > An epithelial attachment to the root has been established.

included as part of the surgical technique. results in areas of bone necrosis with reduction in bone height. particularly if thin and unsupported by cancellous bone. The end . which have cancellous bone. Therefore. Eman Dylawani A lot of thanks to Sara Al-Ajrashi 13 . Osteoplasty (thinning of the buccal bone) using diamond burs. which is later remodeled by new bone formation. the final shape of the crest is determined more by osseous remodeling than by surgical reshaping. Loss of bone occurs in the initial healing stages both in radicular bone and in interdental bone areas: interdental areas.. whereas in radicular bone. bone repair results in loss of marginal bone. the subsequent repair stage results in total restitution without any loss of bone.