PERIODONTAL

FLAPS
Dr Sadia Tabassum

Asst Prof

Optv Dent

JMDC
DEFINITION
A periodontal flap is a section of gingiva and/or
mucosa surgically separated from the underlying
tissues to provide visibility and access to the bone
and root surface
INDICATIONS
•Irregular bony contours
•Deep craters
•Pockets on teeth in which a complete removal of root
irritants is not clinically possible
•Grade II or III furcation involvement
•Root resection / hemisection
•Intrabony pockets on distal areas of last molars
•Persistent inflammation in areas with moderate to deep
pockets.
CONTRAINDICATIONS
• Uncontrolled medical conditions such as
‐unstable angina
‐uncontrolled diabetes
‐uncontrolled hypertension
‐myocardial infarction / stroke within 6 months
•Poor plaque control
•High caries rate
•Unrealistic patient expectations or desires
CLASSIFICATION OF FLAPS
Bone exposure after flap reflection
•Full thickness (mucoperiosteal)
•Partial thickness (mucosal)

Placement of the flap after surgery

•Non displaced flaps
•Displaced flaps

Management of the papilla

•Conventional flaps
•Papilla preservation flaps
BASED ON BONE EXPOSURE AFTER REFLECTION

FULL THICKNESS FLAP

• Periosteum is reflected to expose the underlying bone
• All the soft tissue including periosteum is reflected
• Indicated in resective osseous surgery
PARTIAL THICKNESS FLAP

SPLIT THICKNESS FLAP

• Periosteum covers the bone
• Indicated when the flap has to be positioned apically
• When the operator does not desire to expose the bone
A) internal bevel incision to reflect full thickness flap.
B) internal bevel incision to reflect a partial thickness
flap.
BASED ON FLAP PLACEMENT AFTER
SURGERY

Non displaced flaps:

• When the flap is returned and sutured in its original
position.

Displaced flaps:
• When the flap is placed apically, coronally or laterally
to their original position
• Both full-thickness and partial-thickness flaps can be
displaced, but to do so, the attached gingiva must be
totally separated from the underlying bone, thereby
enabling the unattached portion of the gingiva to be
movable.

• Palatal flaps cannot be displaced because of the

absence of unattached gingiva.
DESIGN OF THE FLAP

•Split the papilla (conventional flap)

•Preserve it (papilla preservation flap)
CONVENTIONAL FLAP

• Interdental papilla is split beneath the contact point of

the two approximating teeth to allow reflection of buccal
and lingual flaps.

• Scalloped incision to maintain gingival morphology and

retain as much papilla as possible.
CONVENTIONAL FLAP
• Indications-
1) When the interdental spaces are too narrow,
thereby precluding the possibility of preserving the
papilla.
2) When the flap is to be displaced.
• Examples- modified Widman flap, the apically
displaced flap, & the flap for reconstructive procedures.
1) Conventional flap
• The incisions for the facial, and the lingual or palatal
flap reach the tip of the interdental papilla or its
vicinity, thereby splitting the papilla into facial half and
a lingual or palatal half.

Flap design for

conventional flap
technique.
2) Papilla preservation flap
• Entire papilla is incorporated into one of the flaps by
means of 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 flaps.
Indications
• When there are open interdental spaces
• When esthetics is of concern
• When bone regeneration techniques are attempted.
2) Papilla preservation flap
2) Papilla preservation flap
INCISIONS
Two types of periodontal flap incisions-

Horizontal Vertical
incisions incisions

1)Internal 1) Oblique
bevel releasing
incision incision
2)Crevicula
r incision
3)Interdent
al incision
HORIZONTAL INCISIONS
• Horizontal incisions are directed along the margin of
the gingiva in a mesial or a distal direction.

• Types of horizontal incisions recommended are-

1) Internal bevel incision

• It is the incision from which the flap is reflected to

expose the underlying bone and root.
Objectives of internal bevel incision
are -
1. It removes the pocket lining
2. Conserves the relatively uninvolved outer surface of the
gingiva, which when apically positioned, becomes
attached gingiva.
3. Produces a sharp, thin flap margin for adaptation to the
bone tooth junction.
• This incision is also termed as the first incision because
it is the initial incision in the reflection of a periodontal
flap.

• Also termed as reverse bevel incision because its bevel

is in reverse direction from that of the gingivectomy
incision.
• Blade used for making this incision - #15C or #15
surgical blade.

Position of the knife in performing internal bevel incision.

• The internal bevel incision starts from a designated

area on the gingiva and is directed to an area at or
near the crest of the bone.
2) Crevicular incision

• It is made from the base of the pocket to the crest of

the bone.

• The incision together with the initial reverse bevel

incision forms a V- shaped wedge ending at or near the
crest of bone.

• This wedge of tissue contains most of the inflamed &

granulomatous areas & the connective tissue fibers
that still persist between the bottom of the pocket &
the crest of the bone.
Position of knife in performing crevicular incision.
3) Interdental incision
• A periosteal elevator is inserted into the initial
internal bevel incision, & the flap is separated from
the bone .

• The most apical end of the internal bevel incision is

exposed and visible. With this access, the surgeon is
able to make the interdental incision.

• This incision is made to separate the collar of the

gingiva that is left around the tooth.

• Knife used for this incision- Orban knife.

• The incision is made not only around the facial & the
lingual radicular area but also interdentally, connecting
the facial and the lingual segments to free the gingiva
completely around the tooth.

Three incisions necessary for flap surgery. A) internal bevel incision

B) crevicular incision C) interdental incision.
VERTICAL INCISIONS

• Vertical or oblique releasing incisions can be used on one

or both ends of the horizontal incision, depending on the
purpose & design of the flap.

• Vertical incisions at both the ends are necessary if the flap

is to be apically displaced.

• Vertical incision must extend beyond the mucogingival

line, reaching the alveolar mucosa, to allow for the release
of the flap to be displaced.
• Vertical incisions are avoided in the lingual or palatal
areas.

• Facial vertical incisions should not be made in the centre

of an interdental papilla or over the radicular surface of a
tooth.

The incision should be made at the line angles.

• Incisions should be made at the line angles of a tooth
either to include the papilla in the flap or to avoid it
completely.

• Vertical incisions should also be designed to avoid short

flaps with long, apically directed incisions because this
could jeopardize the blood supply of the flap.
MODIFIED WIDMAN FLAP
• Exposure of the interproximal bone and elimination of
infrabony defects by osseous recontouring is not carried
out (No surgical pocket elimination and apical
displacement of the flap)
• Incase of esthetic considerations, intracrevicular incisions
starting at the free gingival margins are used to minimize
postsurgical gingival shrinkage.
• Vertical releasing incisions are usually not used
INDICATIONS
• Effective with pocket depths of 5-7 mm
• Where esthetics is of primary concern
• When root surface debridement is required

CONTRAINDICATIONS
• Lack of or very thin and narrow attached gingiva can render
the technique difficult, because a narrow band of attached
gingiva does not permit the initial scalloped incision
(internal gingivectomy).
 • Root cleaning done with
direct vision.
• Healing by primary intention.
ADVANTAGES: • Minimal crestal bone
resorption.
• Lack of post operative
discomfort.
PROCEDURE:
• Internal bevel incision should be made
to the alveolar crest starting
0.5 to 1 mm away from the gingival margin.

• 1- Modified widman flap

• 2- Undisplaced flap
• 3- Apically displaced flap
INTERNAL BEVEL INCISION IN FACIAL
AND PALATAL ASPECTS
• 2) Flap is elevated

• 3) Crevicular incision is
• made from the bottom of
• the pocket to bone
• 4) Interdental incision sectioning
• the base of the papilla

• 5) Tissue tags and granulation

• tissue are removed.
• 6) Scaling and root planing of
exposed root surfaces
7) Suturing done and covered with
tetracycline ointment and with a
periodontal surgical pack
THE UNDISPLACED FLAP
• Most commonly performed type of periodontal
surgery.

• It differs from the modified Widman flap in that the

soft tissue pocket wall is removed with the initial
incision; thus it considered an internal bevel
gingivectomy.
PROCEDURE
• 1) The pockets are measured with periodontal probe
and a bleeding point is produced on the outer surface
of gingiva to mark the pocket bottom

PRE OPERATIVE VIEWS

• 2) Internal bevel incision in the facial and palatal aspects
• 3) Crevicular incision is made and Flap is elevated
• 4) Interdental incision is made
• 5) Triangular wedge of tissues is removed with curette
• 6) All tissue tags and granulation tissue are removed
7)After the scaling and root planing the flap edge should
rest on the root bone junction.
8)Flaps have been placed in their original site and
Sutured.
POST OPERATIVE
RESULTS
 THE APICALLY DISPLACED FLAP

• It can be used for both pocket eradication as well as

widening the zone of attached gingiva.

• It can be a full thickness (mucoperiosteal) or a split

thickness (mucosal) flap.
DISADVANTAGES:
• May cause esthetic problems due to root exposure.

• May cause attachment loss due to surgery.

• May cause hypersensitivity.

• May increase the risk of root caries.

• Unsuitable for treatment of deep periodontal pockets.

• Possibility of exposure of furcations and roots, which

complicates post operative supragingival plaque control.
CONTRAINDICATIONS:
• Periodontal pockets in severe periodontal disease.
• Periodontal pockets in areas where esthetics is critical.
• Deep intrabony defects.
• Patient at high risk for caries.
• Severe hypersensitivity.
• Tooth with marked mobility and severe attachment loss.
• Tooth with extremely unfavorable clinical crown / Root
ratio.
PROCEDURE FOR APICALLY DISPLACED FLAP
1. An internal bevel incision is made, it should be no more than 1mm
from the crest of the gingiva and directed to the crest of bone.

• 2. Crevicular incisions are made, followed by initial elevation of

the flap; then interdental incision and the wedge of tissue
containing pocket wall is removed
3. VERTICAL INCISIONS ARE MADE EXTENDING
BEYOND THE MUCOGINGIVAL JUNCTION.
Full thickness flap elevated Split –thickness flap
by blunt dissection with elevated using sharp
periosteal elevator dissection with a bard-
parker knife
4. AFTER DEBRIDEMENT OF THE
AREAS

5. SUTURES IN PLACE
PRE TREATMENT-

POST TREATMENT
CROWN LENGTHENING BY APICALLY DISPLACED F
PRE-TREATMENT BEFORE OSSEOUS RESECTION

FLAP APICALLY POSITIONED AND POST-TREATMENT

SUTURED
CROWN LENGTHENING BY APICALLY DISPLACED
FLAP PRE-TREATMENT Incision

Before debridement After debridement

Sutures in place
Pre treatment Post treatment
FLAPS FOR REGENERATIVE SURGERY
Two flap designs are available for regenerative surgery:
1. The papilla preservation flap &
2. The conventional flap with only crevicular incisions.
THE PAPILLA PRESERVATION
FLAP
.Entire papilla is incorporated into one of the flaps

INDICATIONS:
•Where esthetics is of concern.
•Where bone regeneration techniques are attempted
CONVENTIONAL FLAP FOR REGENERATIVE
SURGERY
• In the conventional flap, the incisions for the facial and the
lingual or palatal flap reach the tip of the interdental papilla,
thereby splitting the papilla into a facial half and a lingual or
palatal half.
CONVENTIONAL FLAP FOR REGENERATIVE
SURGERY
INDICATIONS:
• When the interdental areas are too narrow to permit the
preservation of papilla
• When there is a need for displacing flaps.
• The interdental papilla is split beneath the contact point of the
two approximating teeth to allow for reflection of buccal and
lingual flaps
PERIODONTAL PACKS

• Periodontal dressing or periodontal packs is a productive

materials applied over the wound created by periodontal
surgical procedure
• Minimize postoperative infection and hemorrhage
• Facilitates healing
ZINC –OXIDE EUGENOL PACKS

• Zno eugenol packs packs based on reaction of ZnO &

eugenol include –wondr pak
• The addition of accelerators such as Zinc acetate gives the
dressing a better working time.
• It is supplied as a liquid and a powder that are mixed prior
to use.
• Eugenol may produce allergic reaction (reddening of area
and burning pain
NON EUGENOL PACKS

• Reaction between metallic oxide and fatty acid is basis

for coe-Pak
• Supplied in two tubes
• One tube contains oxides of various metals (Mainly
zinc oxide) and lorothidol (a fungicide) and second
tube contains non ionized carboxylic acids and
chlorothymol (bacteriostatic agents)
RETENTION OF PACKS

• Mechanically by interlocking in interdental spaces and

joining the facial and lingual portion of the pack
 ANTIBACTERIAL PROPERTIES

• Improved healing and patient comfort – incorporating

antibiotics
• Bacitracin, oxytetracycline , neomycin
nitrofurazone(hypersensitivity)
PREPARATION AND APPLICATION OF
PERIODONTAL DRESSING

• Equal length of the

two paste placed
on a paper pad

• Mixed with a wooden

tongue depressor for 2-
3 minutes until paste
loses its tackiness
PREPARATION AND APPLICATION OF
PERIODONTAL DRESSING

• Paste is placed in a paper cup of water at room

temperature
• With lubricated fingers rolled into cylinders and placed
on the surgical wound
• Strip of pack is hooked
around last molar and
pressed into place
anteriorly
• Lingual pack is joined to
facial strip at the distal
surface of last molar
and fitted into place
anteriorly
• Gentle pressure on the
facial and lingual
surfaces join the pack
interproximally
• Continuous pack cover the edentulous space
INSTRUCTIONS FOR PATIENTS AFTER
SURGERY

• 1. The pack should remain in place until it is removed

in the office at the next appointment
• 2. For the first three hours after the operation avoid
hot foods to permit the pack to harden
• 3. Do not smoke
• 4. Do not brush over the pack
REMOVAL OF PERIODONTAL PACK

• After 1 week
• Inserting a surgical hoe along the margin and exert
gentle lateral pressure
• Pieces of pack- removed with scalers
• Entire area rinsed with peroxide to remove superficial
debris
• Epithelialized but bleed readily when touched
• Pockets should not be probed
HEALING AFTER FLAP SURGERY
• Immediately after suturing (0 to 24 hours) a blood clot
forms consists of a fibrin reticulum with many
polymorphonuclear leukocytes, erythrocytes, debris of
injured cells, and capillaries at the edge of the wound.
• One to 3 days after flap surgery, the space between the
flap and the tooth or bone is thinner, and epithelial cells
migrate over the border of the flap
• One week after surgery the blood clot is replaced by
granulation tissue
HEALING AFTER FLAP SURGERY

• Two weeks after surgery, 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.