A periodontal flap is a section of gingiva and/mucosa that is surgically separated from the underlying tissue to provide visibility and the access to the bone and the root surface. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement. In this PowerPoint presentation, the periodontal flap is described under the headings: indication, contraindications, classification of flaps, flap design, horizontal and vertical incisions and various flap technique such as modified widman flap, undisplaced flap, palatal flap, apically displaced flap, papilla preservation flap and distal molar surgery for maxillary and mandibular molars. It also contains healing after flap surgery.

1. Name- Chhaya Dev
Roll No- 106
BDS 4th year

2. A periodontal flap is a section of gingiva and/or
mucosa that is surgically separated from the
underlying tissues to provide visibility and
access to the bone and root surface. The flap
also allows the gingiva to be displaced to a
different location in patients with mucogingival
involvement.

3. Presence of persistent moderate to deep pockets [more than
5 mm]
Presence of osseous defects
Presence of inflammation at the base of sulcus as seen by
bleeding on probing
Furcation involvement
To regenerate periodontal tissues by the use or bone grafts,
membranes, etc.
Gingival overgrowth and asymmetry
Periodontal pockets adjacent to distal molars
Other dental procedures such as crown lengthening,
apicectomy,

4. When optimal results can be obtained by nonsurgical
periodontal therapy.
Unprepared. soft and edematous gingival tissues
Medically compromised patients where surgery is a risk
proposition.
Patients presenting consistently with poor oral hygiene
Teeth with hopeless prognosis
When surgery is likely to result in extreme esthetic
disfigurement.

5. Periodontal flaps are classified on the basis of the following
criteria:
1. Bone exposure after flap reflection
2. Placement of the flap after surgery
3. Management of the interdental papilla

6. I.For bone exposure after reflection,
the flaps are classified as:
1. Full-thickness (mucoperiosteal)- all of the soft tissue,
including periosteum, is reflected to expose the
underlying bone
2. Partial-thickness (mucosal) flaps- includes only the
epithelial and a layer of the underlying connective
tissue. The bone remains covered by a layer of
connective tissue that includes the periosteum. This
type of flap is also called the split-thickness flap.

8. II.For flap placement after
surgery, flaps are classified as:
1. Nondisplaced flaps- when the flap is returned and
sutured in its original position
2. Displaced flaps- which are placed apically, coronally or
laterally to their original position

9. III. For management of the papilla, flaps
can be classified as:
1. Conventional Flap- The interdental papilla is split
beneath the contact point of the two teeth
2. Papilla preservation flap- incorporates the entire
papilla in one of the flap

10. The design of the flap is dictated by the surgical judgment
of the operator and it may depend on the objectives of the
procedure.
The necessary degree of access to the underlying bone
and root surfaces and the final position of the flap must be
considered when designing the flap.
The flap design may also be dictated by the esthetic
concerns of the area of surgery.
Preservation of good blood supply to the flap is another
important consideration

11. The entire surgical procedure should be planned in every
detail before the procedure is initiated.
The surgical plan should include the type of flap, the
exact location and type of incisions, the management of the
underlying bone, and the final closure of the flap and
sutures.

12. Periodontal flap involve the use of
horizontal (mesio-distal) and vertical
(occlusal-apical) incisions.

13. Horizontal incisions are directed along the margins of the
gingiva in a mesial or distal direction.
Two types of horizontal incisions have been recommended:
1. Internal bevel incision- starts at a distance from the
gingival margins and which is aimed at the bone crest
2. Crevicular incision- starts at the bottom of the pocket and
which is directed to the bone margin

14. Internal bevel incision is the incision from which the flap
is reflect to expose the underlying bone and root.
The internal bevel accomplishes three important objective
(1) it removes the lining
(2) it conserves the relatively uninvolved outer surface of the
gingiva which, if apically positioned, becomes attached
gingiva
(3) it produces a sharp, thin flap margin for adaptation to the
bone-tooth junction
This incision has also been termed the first incision because
it is the initial incision for the reflection of a periodontal
flap
It has also been called the inverse or reverse bevel incision,
because its bevel is 1n reverse direction from that of the
gingivectomy incision

15. The crevicular incision is also called the second incision, is
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 that ends at or near the crest of bone
This wedge of tissue contains most of the inflamed and
granulomatous areas that constitute the lateral wall of the
pocket
The incision is carried around the entire tooth.
A periosteal elevator is inserted into the initial internal bevel
incision and the flap is separated front 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 third
incision, which is also known as interdental incision.

17. Vertical or oblique releasing incision is necessary if the flap
is to be apically or coronally displaced.
Vertical incision should be avoided in:
1. Lingual and palatal areas
2. Interdental papilla or over radicular surface of tooth

18. MODIFIED WIDMAN FLAP:
Presented in 1965 by Morris and in 1974 by Ramfjord and
Nissle.
Step 1: An initial, internal bevel incision 0.5 to I mm away
from the gingival margin, directed to the alveolar crest.
Step 2: Gingiva is reflected with a periosteal elevator
Step 3: A crevicular incision is made.
Step 4: After the flap is reflected, third incision is made in
the interdental spaces with Orban's knife and the gingival
collar is removed.
Step 5: Tissue tags and granulation tissue are removed with a
curette. The root surfaces are examined and scaled.
Step 6: Flap is placed back.
Step 7:Continuous suturing done.

20. Step 1: The pockets are measured with the periodontal probe and a
bleeding point is produced on the outer surface of the gingiva to
mark the base of the pocket.
Step 2: The initial, internal bevel incision is made following the
scalloping bleeding points made on the gingiva.
Step 3: The second or crevicular incision is made from the bottom
of the pocket to the bone.
Step 4: The flap is then reflected with a periosteal elevator.
Step 5: Interdental incision is made with an Orban's interdental
knife.
Step 6: Triangular wedge of tissue is removed with a curette.
Step 7: The area is debrided, removing tissue tags and granulation
tissue with sharp curettes.
Step 8 The roots are scaled.
Step 9: The flaps are sutured together with continuous sling suture
or interrupted sutures.

22. The surgical approach is different here because of the
nature of the palatal tissue which is attached, keratinized
tissue and has no elastic properties associated with other
gingival tissues, hence no displacement and no partial
thickness flaps.
Usual internal bevel incision, followed by crevicular and
interdental incisions
Before flap is reflected to the final position for scaling and
management of osseous defect, its thickness should be
reduced to adapt to the underlying osseous tissue and
provide a thin, knife like gingival margin
Too thick flap may have a propensity to separate from tooth
which may delay and complicate healing.

24. Step I : Internal bevel incision is made, 1 mm from the crest
of the gingiva and directed towards the crest of the bone.
Step 2 : Crevicular incisions are made followed by initial
elevation of flap and then interdental incision is performed,
the wedge of tissue containing the pocket wall is removed.
Step 3: Vertical releasing incisions are made extending
beyond the mucogingival junction and flap is elevated with a
periosteal elevator
Step 4: Remove all the granulation tissue, root planing is
done and flap is positioned apically at the tooth bone
junction.
Step 5: Flaps are sutured together.

25. Step 1: Crevicular incision is made around each tooth. No
incisions through the interdental papilla.
Step 2: Papilla is usually incorporated facially, hence a
semilunar incision across the interdental papilla in the
palatal or lingual surface is made, which is at least 5 mm
from the crest of the papilla
Step 3: The papilla is dissected from the lingual or palatal
aspect using Orban knife and elevated intact with the facial
flap.

27. FOR
MAXILLARY
MOLARS
FOR
MANDIBULAR
MOLARS

28. Technique for maxillary molars : Two parallel incisions
at the distal surface of terminal tooth are made. The deeper
the pocket, the greater will be the distance between the two
parallel incisions. Followed by this a transversal incision is
made so that a long rectangular piece of tissue is removed.
These incisions can be placed using No. 12 blade. After flap
reflection and curetting the bone surface, the flaps are
sutured together.

29. Technique for mandibular molars: Two parallel
incisions at the retromolar pad area are made. The incisions
should follow the areas of greatest attached gingiva and
underlying bone. After the reflection of the flap and removal
of tissue, osseous surgery may be performed (if necessary)
and flaps are sutured

30. Immediately after suturing (0 to 24 hours), connection
between the flap and the tooth or bone surface is established
by the blood clot.
One to three days after flap surgery—space between the
flap and the tooth or the bone is thinner and epithelial cells
migrate over the border of the flap
One week after flap surgery—an epithelial attachment to
the root has been established by means of hemidesmosomes
and a basal lamina. The blood clot is replaced by granulation
tissue

31. Two weeks after surgery- collagen fibers begin to appear
parallel to tooth surface
One month after surgery—a fully epithelialized gingival
crevice with a well-defined epithelial attachment is present.