THE PERIODONTAL FLAP

OUTLINE

 DEFINITION
 CLASSIFICATION OF FLAPS
 DESIGN OF THE FLAP
 INCISIONS
 Horizontal Incisions
 Vertical Incisions
 ELEVATION OF THE FLAP
 SUTURING TECHNIQUES
 Technique
 Ligation
 Types of Sutures
 HEALING AFTER FLAP SURGERY
 Definition

 A periodontal flap is a section of gingiva and /

or mucosa surgically elevated from the
underlying tissues to provide visibility of and
access to the bone and root surface
 Indications / Objectives

 Gain access for root debridement

 Reduction or elimination of pocket depth, so that
patient can maintain the root surfaces free of
plaque
 Reshaping soft and hard tissues to attain a
harmonious topography (physiologic architecture)
 Regeneration of alveolar bone, periodontal
ligament and cementum
CLASSIFICATION OF FLAPS
 According to the thickness of the flap/ Bone
exposure after flap reflection
 Full thickness / mucoperiosteal flap
 Partial thickness / mucosal flap / split thickness flap
 According to the placement of flap after surgery
 Nondisplaced flap
 Displaced flaps – Coronal, Apical, Lateral
 According to design of the flap / management of the
papilla
 Conventional flaps –E.g. Modified Widman flap,
undisplaced flap, apically displaced flap
 Papilla preservation flaps
Comparison between full – thickness
and partial – thickness flaps
Incisions
 For Conventional flap
 Horizontal Incisions-
 Internal bevel incision (First incision, reverse bevel
incision)
 Crevicular incision (Second incision)
 Interdental incision
 Vertical Incision
 Oblique releasing incision

 For Papilla Preservation flap

 Crevicular incision with no incisions across the
interdental papilla
Indications for the Internal Bevel Incision

 Sufficient band of attached gingiva

 Desire to correct bone morphology (osteoplasty,

osseous resection)

 Thick gingiva (palatal gingiva)

 Deep periodontal pockets and bone defect

 Desire to lengthen clinical crown

Indications for the Sulcular Incision

 Narrow band of attached gingiva

 Thin gingiva and alveolar process
 Shallow periodontal pocket
 Desire to lessen postoperative gingival recession for
esthetic reasons in the maxillary anterior region
 As a secondary incision of usual flap surgery
 Bone graft or GTR: desire to preserve as much
periodontal tissue (especially interdental papilla) as
possible to completely cover grafted bone and
membrane by flaps
Flap Elevation

Can be done either by:

 Blunt dissection ( full thickness or mucoperiosteal
flap)
OR

 Sharp dissection ( partial thickness or mucosal

flap)
Suturing
Goals of suturing
 Maintains haemostasis

 Permits healing by primary intention

 Reduces post operative pain

 Permits proper flap position

 Prevents bone exposure resulting in delayed healing

and unnecessary resorption
 Interrupted suture
 Direct or loop suture
 Figure eight
 Horizontal mattress
 Vertical mattress
 Distal wedge or Anchor suture
 Periosteal suturing

 Continuous suture
 Papillary sling
 Horizontal mattress
 Vertical mattress
Sutures for Periodontal Flaps
 HEALING AFTER FLAP SURGERY
 Immediately after suturing (0 to 24 hours)
 A blood clot consisting of a fibrin reticulum with many
polymorphonuclear leukocytes, erythrocytes, debris of
injured cells, and capillaries at the edge of the wound is seen.
An exudate or transudate also result from tissue injury.
 One to 3 days after flap surgery
 The epithelial cells migrate over the border of the flap,
usually contacting the tooth at this time.
 One week after surgery
 The epithelial attachment to the root is established by
means of hemidesmosomes and a basal lamina. The blood
clot is replaced by granulation tissue derived from the
gingival connective tissue, the bone marrow, and the
periodontal ligament.
 Two weeks after surgery
 The collagen fibers begin to appear parallel to the
tooth surface. Union of the flap to the tooth is still
weak, owing to the presence of immature collagen
fibers, although the clinical aspect may be almost
normal.
 One month after surgery
 A fully epithelialized gingival crevice with a well-
defined epithelial attachment is present. There is a
beginning functional arrangement of the
supracrestal fibers.