The document discusses flap surgery procedures in periodontal treatment. It defines a flap as a section of tissue separated from surrounding tissues except at its base. The history and rationale of flap surgery is described. Key aspects covered include classifications of flaps, factors affecting flap design, types of incisions, properties of an ideal flap, indications and contraindications for flap surgery, and descriptions of various flap designs like the Widman flap and papilla preservation flap. Post-operative healing and potential complications are also mentioned.

1. 57
Good
morning

2. FLAP SURGERY
PRESENTER:
SHASHWATI PAUL
II YR PG
DEPT. OF PERIODONTOLOGY

3. CONTENTS
 INTRODUCTION
 DEFINITION
 HISTORY
 RATIONALE
 CLASSIFICATION OF FLAPS
 FACTORS AFFECTING FLAP DESIGN
 INCISIONS
 PROPERTIES OF IDEAL FLAP
 PRE-OPERATIVE CHECK LIST
 INDICATIONS
 CONTRAINDICATIONS
 FLAP DESIGNS
 CLOSURE OF FLAPS
 HEALING AFTER FLAP SURGERY
 COMPLICATIONS
 CONCLUSION
 REFERENCES

4. INTRODUCTION
The surgical phase of periodontal therapy has the following
objectives
 Improvement of prognosis of teeth
 Improvement of esthetics
It consists of techniques for pocket therapy and for the
correction of osseous and mucogingival defects.

5. DEFINITION
 Is a loosened section of tissue separated from the surrounding tissues
except at its base
Glossary of Periodontal Terms, 4th Edition
 Is a section of the gingiva and/or mucosa surgically separated from
the underlying tissues to provide visibility of and access to the bone
and the root surface
Carranza’s Clinical Periodontology, 10th Edition

6. HISTORY
n
.Robicsek
1884
Neuman 1911
Widman 1916
Kronfeld
1935
Nabers
1954
Apically repositioned
flap 1962
Modified
Widman 1974
Papillary
preservation 1985

7. RATIONALE
 Means of gaining access to diseased root surfaces
 For pocket elimination / reduction
 To eliminate the infected and necrotic alveolar bone
 To maintain the mucogingival complex
 Possibility of regeneration of periodontal tissues

8. CLASSIFICATION OF FLAPS

9. I ) Purpose of Surgery: (Ramfjord 1979)
 Pocket elimination
 Re-attachment flap surgery
 Mucogingival repair

10. II) Bone exposure after flap reflection: (Carranza)
 Full thickness (mucoperiosteal flap)
 Partial thickness (mucosal flap)

11. MUCOPERIOSTEAL V/S MUCOSAL FLAPS
Full Thickness Flap Partial Thickness Flap
Healing Primary Intention Secondary Intention
Bone defect treatment Possible Difficult
Blood supply to flap Sufficient Decreased
Pocket elimination/
reduction
Possible Possible
Bleeding Less More
Post operative swelling Less Severe
Post operative pain and
discomfort
Less More
(Periodontal Surgery: A Clinical Atlas by Sato)

12. III) Flap placement after surgery: (Carranza)
 Non displaced flap
 Displaced flap
Coronally displaced flap
Apically displaced flap
Laterally/ Horizontally displaced flap

13. IV) Management of papilla: (Carranza)
 Conventional flap
 Papilla preservation flap

14. FACTORS AFFECTING FLAP DESIGN
 Necessary access to the underlying bone and root surfaces
 Final posision of the flap
 Preservation of good blood supply to the flap

15. TWO BASIC FLAP DESIGNS ARE:
 Conventional flap
 Papilla preservation flap

16. INCISIONS
HORIZONTAL INCISIONS
 Internal bevel incision/ first incision
 Crevicular incision/ second incision
 Interdental incision/ third incision
VERTICAL INCISION

17.  Horizontal Incisions: along the margin of the gingiva
Coronally directed or Apically directed
Externel bevel
* Internal bevel
* Sulcular/ intra crevicular
* Interdental incision

18.  Internal bevel Incision: first/ primary/ reverse bevel incision
From a designated area on the gingiva to an area at or near the
crest of bone #11 0r #15 surgical scalpel

19. Objectives
 Removes the pocket lining
 Preserves the uninvolved outer surface of gingiva
 Produces a sharp, thin margin for adaptation at bone-tooth
junction
Indications:
-Presence of moderate/deep periodontal pocket
-Desire to correct bone morphology
Pre-requisite: Sufficient Keratinized tissue

20.  Crevicular Incision: second/ sulcular incision from base of pocket to
crest of bone
V-shaped wedge: inflammed and granulomatous areas of lateral pocket
wall JE and connective tissue fibres

21. Indications:
 Periodontal pocket elimination/ reduction
 As a secondary incision for flap surgery
 to lessen post operative gingival
recession in anterior maxillary regions
Decisive Criteria:
 Narrow band of keratinized tissue
 Thin gingival biotype

22. Internal Bevel Incision
Crevicular Incision

23.  The Interdental Incision: separates the collar of gingiva
around the tooth
Orban’s interdental knife

25.  Vertical Incisions: Must extend beyond the mucogingival line
reaching the alveolar mucosa when displacement of flap is desired
 At line angles of the tooth – to include/exclude the papilla from flap
 Never over height of contour or root
 Avoid short (mesio-distal) flaps

26. Incisions Description Indication
External Bevel Coronally Directed Gingivectomy, crown
lengthening,
Gingivoplasty
Internal Bevel Apically directed, placed at the crest
of the gingival margin or stepped
back from the margin 0.5 to 2.0 mm
Excisional new
attachment procedure,
modified Widman flap,
flap and curettage,
crown lengthening
Sulcular Apically directed, placed in the
gingival crevice and directed toward
the alveolar crest
When preservation of
gingiva. is critical, as in
esthetic areas or areas
of minimal keratinized
tissue, guided tissue
regeneration (GTR)
procedures

27. Incisions Description Indication
Releasing Perpendicular to the gingival
margin at line angles of teeth
To increase access, to
allow apical or
coronal positioning of
flap
Thinning Internal or undermining incision
extending from gingival margin
toward the base of the flap to
decrease the bulk of connective
tissue on the underside of the flap
Palatal flaps, distal
wedge procedures,
internal bevel
gingivectomy, bulky
papillae
Periosteal Incision at the base of the flap
severing the underlying
periosteum
To release flap tension
allowing coronal
advancement of the
flap

28. PROPERTIES OF IDEAL FLAP
Ideal Flap/ Section of a soft tissue:
 Is outlined by a surgical incision
 Carries its own blood supply
 Allows surgical access to underlying tissues
 Can be placed in the original position
 Can be maintained with sutures in a particular desired position
 And is expected to heal

29.  Sharp incisions heal rapidly
 Flap extension- 2 teeth anterior and 1 tooth posterior to area of surgery
 Incisions- over intact bone/ 6-8mm away from diseased bone.
( Peterson)

30. PRE OPERATIVE CHECKLIST
 Review case history and Phase I therapy
 Informed Consent
 Cessation of medication: Anti coagulants 48hours prior to procedure
 To quit or stop smoking for minimum of 3-4 weeks after the procedure.
 Daily dose of particular medication/ meal taken
 Patient records
 Emergency equipment/ medication
 Tests: Hb%, Clotting time 6-10mins, Bleeding time 1-6mins
 Appropriate infection control

31.  To gain access for root debridement
 Bone regeneration in infrabony defects
 Pockets on teeth in which a complete removal of root irritants is not
possible by non surgical therapy
 Areas with irregular bone contours or defects which need to be corrected
 Infrabony pockets distal to first molars
 In grade II and grade III furcations
 Persistent inflammation in moderate to deep pockets

32.  Lack of patient motivation or compliance
 Acute oral infections which may spread
 Systemic conditions / Medically compromised patients. Eg. Uncontrolled
diabetes mellitus

33. FLAP DESIGNS

34. THE NEUMANN FLAP: 1911
Intracrevicular incision
 full thickness flap reflected
Sectional releasing incisions made
 Inside of flap curetted
 Root surfaces “cleaned”
 Irregular alveolar bone corrected
 Flaps trimmed
 Replacing flap at crest of alveolar bone
( Periodontal Surgery: Resection to Regeneration, Richard Young,
2003)

35. THE ORIGINAL WIDMAN FLAP: 1918
Gingival incision follows outline of
gingival margin
2 vertical release incisions
Physiologic contour of alveolar bone re-
established

36. Aimed at:
 Elimination of pocket epithelium
 Accessibility to root surfaces
 Bone Recontouring
Sufficient ATTACHED GINGIVA is a pre-requisite.
Advantages:
 Soft tissue margin at alveolar bone crest- no pockets remained
 Less discomfort- faster healing
 Recontour bone
Disadvantage:
 Exposure of root surfaces
 vertical incisions

37. Sutured to original position
Intracrevicular incision Expose diseased roots
THE MODIFIED FLAP OPERATION: KIRKLAND 1931
Roots debrided- defects corrected

38. The Modified Flap Operation: Kirkland 1931
 Did not include extensive sacrifice of non inflammed tissue
 No apical displacement of gingival margin
 Indicated in anterior aesthetic areas
 Potential for bone regeneration in intrabony defects

39. THE MODIFIED WIDMAN FLAP: Ramfjord and Nissle 1974
*1st incision: 0.5-1mm away
from gingival margin.
*Accentuated initial incision : 1-
2mm from mid palatal surface of
tooth
* Bone architecture not
corrected
*No inter proximal bone
exposure
*Interrupted inter proximal
sutures

40. Indications:
1.Moderate-deep periodontal
pockets
2.In sufficient attached gingiva
3.Patients with sensitivity
4.Reattachment with minimal
gingival recession is desired

41. ADVANTAGES:
 Access and visualization of root surfaces
 Good adaptation of healthy connective tissue to root
surfaces
 Better aesthetics
 Less potential root hypersensitivity
 Preservation of gingival width
DISADVANTAGES:
 Residual probing depths in presence of infra bony pockets

42. * Use of vertical incisions
*Reverse bevel incision: 1-2mm
from gingival margin
Bone exposure: 2-3mm
Minimal bone re-contouring
recommended
Flap positioned at the new alveolar
crest margin
* No vertical release incisions
* 1st incision -0.5-1mm from
gingival margin
Bone exposure- 1.5-2mm
Bone architecture not corrected
Flap repositioned
The Original Widman Flap The Modified Widman Flap

43. THE UNDISPLACED FLAP:
 ‘Internal bevel gingivectomy’- surgically removes the pocket wall
Sufficient keratinized tissue a pre-requisite, to avoid mucogingival
problem

44. The Undisplaced Flap:
Pockets measured- Bleeding points produced
Internal bevel incision- thinning of flap done
Crevicular incision- full thickness flap reflected
Interdental incision- triangular tissue wedge removed
Edge of flap re-scalloped/ trimmed to rest on ‘root-bone’ junction
Continuous sling suture

45. THE PALATAL FLAP:
 Initial incision varies with anatomic situation- internal bevel incision
 Thick tissue- horizontal gingivectomy incision
 Scalloping narrower apically than line angle areas
 Blade angled towards lateral surface of palatal bone while thinning
flap
 Thin, knife-like gingival margin and sharp, thin gingival papilla

46. The Palatal Flap:
* Thickness of palatal tissue
* Purpose of palatal flap

47. THE APICALLY REPOSITIONED FLAP: FRIEDMAN
1962
Indications:
Pocket reduction
Increasing the zone of attached gingiva
Disadvantages:
Unaesthetic results- root exposure
Hypersensitivity
Incision is unrelated to pocket depth
Not necessary to accentuate scallop interdentally

48. The Apically Displaced
Flap:
Classification of
primary incision and
displaced flap positions
(Periodontal
Surgery: A Clinical Atlas
by Sato)

49. THE BEVELED FLAP :FRIEDMAN
 Modification of apically repositioned flap
 For treatment of periodontal pockets on the palatal aspect of teeth.
 First, a conventional mucoperiosteal flap
 Debridement and osseous recontouring performed.
 The palatal flap prepared with a secondary scalloped and beveled
incision
 Secured with interproximal sutures.

50. PAPILLA PRESERVATION FLAP: TAKEI ET AL, 1985
In Conventional flap:
incise from bottom of pocket to crest of bone- splitting papilla below
contact point
In reconstructive surgery
Maximum amount of gingiva and papilla are retained to cover the
materials placed in the pocket
 Intra crevicular incision
 Semilunar incision across interdental area
 Wide osseous defect lingually/palatally- semilunar incision on facial
aspect

51.  Preserved papilla can be incorporated into the facial or
lingual/palatal flap.
 The lingual or palatal incision should be semilunar incision
across the interdental papilla. This incision dips apically
from the line angle of the tooth so that the papillary incision
is at least 5 mm from the crest of the papilla.

52.  4. An orban knife is introduced into this incision to sever half to two-thirds
the base of the interdental papilla.
 5. The papilla is then dissected from the lingual or palatal aspect and
elevated intact with the facial flap.
 6. The flap is elevated without thinning the tissue.

53. Palatal semilunar incision
Crevicular incision
Papilla reflected
sutures

54. 5mm

55. SIMPLIFIED PAPILLA PRESERVATION TECHNIQUE
 Cortellini et al. in 1999
 For narrow interdental spaces (< 2mm).
 An oblique incision across the defect-associated papilla, starting from the
buccal line angle of the involved tooth to reach the mid-interdental part of
the papilla at the adjacent tooth below the contact point.
 The papilla is cut into two equal parts

56. Oblique incision
Intrasulcular incisions
Horizontal inc at base
sutures

57. DISTAL WEDGE PROCEDURE: ROBINSON (1966) AND
BRADEN (1969)
 Treatment of periodontal pockets on the distal surface of terminal
molars is complicated by the presence of bulbous fibrous tissue over
the maxillary tuberosity or prominent retromolar pads in the mandible.
 Deep vertical defects may often present in conjunction with redundant
fibrous tissue.
 These osseous lesions may result from incomplete repair after the
extraction of impacted third molars

58.  Location of incision:
1)Amount of attached gingiva
2)Available distance from distal aspect of molar
to end of retromolar pad/ tuberosity
3) Pocket depth
 Simple gingivectomy incision can be used for soft tissue
pocket and adjacent fibrous tissue.

59. MODIFIED DISTAL WEDGE PROCEDURE
 In case of a deep periodontal pocket combined with angular
bone defect at distal aspect of a maxillary molar.
 Two parallel reverse bevel incisions.
 Rectangular wedge tissue is removed.
 Root debridement, recontouring bone, flaps trimmed and
sutured.

62. CLOSURE OF FLAPS
OBJECTIVES
 Supporting and strengthening the wounds until healing increases their
tensile strength.
 Minimizing the risk of infection and control of bleeding.
 Continuous Sling Suture
 Interrupted suture
 Mattress Sutures
 Periosteal Sutures
 Anchor sutures

63. HEALING AFTER FLAP SURGERY
Flap-tooth by
blood clot
24 hours
Space reduced.
Epithelial cells
migrate
1-3 days
Epithelial
attachment to root
by
hemidesmosomes
1 week
Collagen fibres
arranged
parallely
2 weeks
Fully
epithelialized
gingival crevice
1 month

64. COMPLICATIONS
 Periodontal surgery can produce profuse bleeding,especially
during initial incisions and flap reflection.
 Excessive haemorrhaging after initial incisions and flap
reflection may be caused by venules,arterioles and vessels.
 Anatomic variation- inadvertent laceration
 Root exposure post flap surgery- hypersensitivity
 Liver clot/ currant jelly clot – repeated delayed organisation
of blood coagulum.
 Sensitivity to percussion
 Prolnged exposure or dryness of bone

65. Correction of Soft Tissue Pockets
Closed Procedures.
1. Modified Widman flap
2. Apically positioned (repositioned) flap a. Full thickness b. Partial thickness
(supraperiosteal)
3. Distal wedge procedure
Open Procedures. Gingivectomy
Surgery for Correction of Osseous Deformities and Osseous Enhancement
Procedures
Closed Procedures.
1. Full- or partial-thickness flap
a. Undisplaced flap b. Modified flap c. Modified Widman flap
2. Modified Distal wedge procedure
3. Conventional flap/ papilla preservation flaps

66. Correction of Mucogingival Problems
Preservation of Existing Attached Gingiva. 1. Apically
positioned (repositioned) flap a. Full thickness b. Partial
thickness 2. Conventional flap
Increasing Dimension of Exisiting Attached Gingiva.
1. Laterally positioned flap (pedicle) a. Full thickness b.
Partial thickness
2. 2. Papillary flaps a. Double papillae b. Rotated papillae
3. 3. Free soft tissue autografts a. Partial thickness b. Full
thickness
4. 4. Connective tissue autograft
5. 5. Subepithelial connective tissue graft

67. Procedures Commonly Used for Root Coverage
Pedicle Flaps (Full or Partial Thickness).
1. Laterally positioned flaps
2. Double-papillae flaps
3 Coronally positioned flaps
4. Semilunar flap
Free Soft Tissue Autografts.

68. CONCLUSION
Proper understanding and knowledge of different incisions and
flaps results in better treatment results with greater patient
satisfaction.

69. REFERENCES
 CARRANZA 10TH EDITION
 LINDHE 4TH EDITION
 PERIODONTAL SURGERY BY SATO
 COHEN