Periodontal flap design for access on osseous surgery

1. PERIODONTAL FLAP
DESIGN FOR ACCESS ON
OSSEOUS SURGERY

2. CONTENTS
• INTRODUCTION
• RATIONALE
• CLASSIFICATION
• INCISIONS
• FLAP DESIGN -NEWMANS FLAP
-WIDMANS FLAP
-KIRKLAND FLAP
-APICALLY DISPLACED FLAP
-MODIFIED WIDMANS FLAP
-UNDISPLACED FLAP
-PALATAL FLAP
-PAPILLA PRESERVATION FLAP
-DISTAL WEDGE
• CONCLUSION

3. INTRODUCTION
• A periodontal flap is a section of gingiva, mucosa, or both that is surgically separated
from the underlying tissues to provide for the visibility of and access to the bone and root
surface. (Carranza’s Clinical Periodontology).
• Is a loosened section of tissue separated from the surrounding tissues except at its base
(Glossary of Periodontal Terms, 4 th Edition).

4. 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

5. Classification of Flaps
Periodontal flaps can be classified on the basis of the
following:
• Bone exposure after flap reflection
• Placement of the flap after surgery
• Management of the papilla

6. • For bone exposure after reflection, the flaps are classified as either
FULL-THICKNESS (MUCOPERIOSTEAL)
 all of the soft tissue, including the
periosteum, is reflected to expose
the underlying bone.
 This complete exposure of and
access to the underlying bone is
indicated when resective osseous
surgery is contemplated.

7. • The PARTIAL-THICKNESS FLAP includes only the epithelium 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.
• The partial-thickness flap is indicated when the flap is to be positioned apically or when
the operator does not want to expose bone

9. • For flap placement after surgery, flaps are classified as either
• (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.

10. • Management of papilla
• CONVENTIONAL FLAP- the interdental papilla is split beneath the contact point of the two
approximating teeth to allow for the reflection of the buccal and lingual flaps. The
incision is usually scalloped to maintain gingival morphology and to retain as much papilla
as possible.
• The conventional flap is used
(1) when the interdental spaces are too narrow, thereby precluding the possibility of
preserving the papilla, and
(2) when the flap is to be displaced.
• Conventional flaps include the modified Widman flap, the undisplaced flap, the
apically displaced flap, and the flap for reconstructive procedure .

11. • The papilla preservation flap incorporates the entire papilla in one of the flaps by
means of crevicular interdental incisions to sever the connective tissue attachment as
well as a horizontal incision at the base of the papilla to leave it connected to one of the
flaps.

12. INCISIONS

13. INCISIONS
• Periodontal flaps involve the use of horizontal (mesial –distal) and vertical (occlusal–
apical) incisions.
• Horizontal Incisions: along the margin of the gingiva
Coronally directed
or external bevel
Apically directed
* Internal bevel
* Sulcular/ intra
crevicular
* Interdental
incision

14. • The internal bevel incision is basic to most periodontal flap procedures. It is the incision
from which the flap is reflected to expose the underlying bone and root.
• The internal bevel incision accomplishes three important objectives:
(1) it removes the pocket lining
(2) it conserves the relatively uninvolved outer surface of the gingiva, which, if apically
positioned, becomes attached gingiva; and
(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 reverse bevel incision, because its
bevel is in reverse direction from that of the gingivectomy incision.
The no. 15 or 15C surgical blade is used most often to make this incision

15. • The crevicular incision, which 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 as well as the junctional epithelium and the
connective tissue fibers

16. • The Interdental Incision: separates the collar of gingiva around the tooth.
• The Orban knife is usually used for this incision.
• The incision is made not only around the facial and lingual radicular area but also
interdentally, where it connects the facial and lingual segments to free the gingiva
completely around the tooth

17. • These three incisions allow for the removal of the gingiva around the tooth (i.e., the
pocket epithelium and the adjacent granulomatous tissue).
• A curette or a large scaler (U15/30) can be used for this purpose. After the removal of
the large pieces of tissue, the remaining connective tissue in the osseous lesion should be
carefully curetted and removed so that the entire root and the bone surface adjacent to
the teeth can be observed.
• Flaps can be reflected with the use of only the horizontal incision if sufficient access can
be obtained in this way and if apical, lateral, or coronal displacement of the flap is not
anticipated.
• If vertical incisions are not made, the flap is called an ENVELOPE FLAP.

18. Vertical Incisions
• Vertical or oblique releasing incisions can be used on one or both ends of the horizontal
incision, depending on the design and purpose of the flap.
• Vertical incisions at both ends are necessary if the flap is to be apically displaced.
Vertical incisions must extend beyond the mucogingival line to reach the alveolar mucosa;
this allows for the release of the flap to be displaced.
• In general, vertical incisions in the lingual and palatal areas are avoided.
• 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 vertical incision should also be designed to avoid short flaps (mesiodistal) with long,
apically directed incisions, because this could jeopardize the blood supply to the flap

19. 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

20. FACTORS AFFECTING FLAP DESIGN
• Necessary access to the underlying bone and root surfaces
• Final position of the flap
• Preservation of good blood supply to the flap

21. INDICATIONS
• 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

22. FLAP DESIGN

23. NEUMAN FLAP (1911)
• Neuman(1920) claimed the introduction of the mucoperiosteal flap in 1911.
• The procedure involved an INTRASULCULAR INCISION AND TWO RELEASING INCISIONS
ON THE BOTH SIDES OF defect area, involving up to 6 teeth.
• The flaps were raised up to the mucobuccal fold on buccal and lingual aspect.
• Approximately 2mm of gingival margin and bone was removed in the area of deep pockets
and sutured back to original position.
• Neumann described his technique as the radical treatment of alveolar pyorrhea.

24. WIDMANS FLAP
• Widman in 1916 presented a modification of Neuman's flap to Scandinavin dental
association, which was published in 1918.
Two releasing incisions demarcate the area
scheduled for surgical therapy. A scalloped
reverse bevel incision is made in the gingival
margin to connect the two releasing incisions
The collar of inflamed gingival tissue is
removed following the elevation of a
mucoperiosteal flap.

25. By bone recontouring, a “physiologic”
contour of the alveolar bone may be
re‐established
Original Widman flap. The
coronal ends of the
buccal and lingual flaps are
placed at the alveolar bone
crest and secured in this position
by interdentally
placed sutures.

26. 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

27. MODIFIED FLAP OPERATION
• Kirkland in 1931 published a flap procedure which he called the modified flap operation.
• 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

28. THE APICALLY REPOSITIONED FLAP
• NABERS in 1954 ,introduced apically repositioned flap. The procedure was named as
REPOSITIONING OF THE ATTACHED GINGIVA.
• He described procedure with only one vertical releasing incision, which was placed
mesially to the area of the deepest pocket.
• After the flap elevation, teeth were thoroughly scaled, all granulomatous tissue was
removed ,the flap was curetted and the gingival margins were trimmed upto the depth of
at least 2mm.
• Now, the flap was positioned apically to the crest of the bone and sutured loosely.
• In 1957, NABERS, modified the procedure by adding inverse bevel instead of trimming of
gingival margins. It was done to achieve thin and knife edge gingival margins. He called
this incision the REPSITIONING INCISION.

29. • ARIAUDO AND TYRELL(1957) in the same year, modified Naber's technique by using 2
vertical releasing incisions.
• It provided greater flexibility and easy manipulation of the flap.
• FRIEDMAN (1962) , explained surgical technique and coined the term apically
repositioned flap.
• Presently, the term reposition is not used as it means, placing the flap into original
position ,instead term position or displaced is used.

30. • APICALLY DISPLACED FLAP:- Depending on the purpose, the apically displaced flap can be
a full-thickness (mucoperiosteal) flap or a split-thickness (mucosal) flap.
• Incision Placement:- Proper placement of the initial or primary inverse-beveled incision
is critical when the amount of keratinized gingiva is limited. Friedman (1964a) classified
incision placement based on the amount of keratinized attached tissue present.
• Class I: keratinized gingiva is more than adequate; use of a labial or buccal incision
placed 1 to 3 mm from the crest of the gingiva; the flap is apically positioned to cover 1
to 2 mm of cementum

31. • Class II: keratinized gingiva is adequate; use of crestal incision; the flap is apically
positioned to the crest of bone.
• Class III: keratinized gingiva inadequate; Use of sulcular incision; the flap is apically
positioned 1 to 2 mm below the crest of bone to increase the zone of keratinized gingiva

32. Full-thickness apically positioned mucoperiosteal flap
Indications.
• 1. Pockets that extend beyond the mucogingival junction
• 2. Areas of minimal keratinized gingiva
• 3. Inductive or resective osseous surgery required
• 4. Enhance cleansibility
• 5. Facilitate restorative procedures
• 6. Unesthetic or asymmetric gingival topography

33.  Primary scalloped,
inverse-beveled
incision made down
to the crest of bone.
This primary incision
thins the tissue.
 Vertical incisions are
used to outline the
flap.
 The papilla is
dissected to create a
partial-thickness flap
and thus remove the
thick triangular
wedge of
interproximal tissue

34. A secondary sulcular incision down to the crest of bone frees the inner flap of tissue.
, Scalers are used to remove the inner flap of tissue.

35. The flap is raised with a periosteal elevator. , Osseous resective measures are
implemented. , The flap is apically positioned to the crest of bone and sutured.
Final healing is shown

37. Modified Apically Positioned
Full-Thickness Flap
• The modified flap procedure uses no vertical incisions. Although generally indicated for
the posterior area as an extension of the distal wedge operation, the modified flap may
be used anywhere.
A, Deep pockets probed at or below the mucogingival junction (mgj). B, A scalloped, inverse-
beveled incision with no vertical incisions continued from the distal wedge. Maximum
conservation of keratinized gingiva is attempted. C, For proper reflection, the flap is undermined
at its most anterior extension. This permits adequate draping without the use of vertical incisions

38. D, The flap is reflected, and the secondary flap is removed. E, Scaling and
osseous surgery are carried out. F, The flap is apically positioned and sutured

40. Apically Positioned Partial-Thickness Flap
• The technique for partial-thickness flaps uses a sharp dissection parallel to the bone,
leaving a periosteal covering in an attempt to protect the underlying bone, eliminate
pockets, reduce post operative pain, and shorten healing time ( Ariaudo and Tyrell, 1960;
Hileman 1960).
• Indications.
1. Areas of thin periodontium or prominent roots in which dehiscences or fenestrations may
be present
2. A need to increase the zone of keratinized gingiva

41. Advantages.
1. Eliminate pockets
2. Protect underlying bone (ie, donor site of pedicle flap)
3. Can be combined with other mucogingival procedures to increase the zone of keratinized
gingiva
4. Permit periosteal suturing for flap stabilization and exact positioning.
Disadvantages.
1. Cannot be used for osseous surgery without resulting in a ragged, torn periosteum
2. High degree of difficulty to perform
3. Secondary intention healing

42. Initial vertical incision and horizontal incisions are made. Incisions are not made down
to bone. The flap is dissected from an apico-occlusal direction as tension is applied to
the flap with tissue pliers

43. A horizontal incision is made just above the crest of bone to permit removal of the inner
flap. Scalers and curets are now used to remove the inner flap and residual granulation
tissue. Periosteal sutures permit exact flap placement at or below the crest of bone. A
more apical placement is used if necessary to increase the zone of attached gingiva

44. Modified Widman Flap
• In 1965, Morris revived a technique described early during the twentieth century in the
periodontal literature; he called it the “unrepositioned mucoperiosteal flap.” Essentially,
the same procedure was presented in 1974 by Ramfjord and Nissle, who called it the
“modified Widman flap” .
• Indications:
1.Moderate-deep periodontal pockets
2.In sufficient attached gingiva
3.Patients with sensitivity
4.Reattachment with minimal gingival recession is desired

45. • Advantages 1. Minimal bone removal 2. Immediate close postsurgical contact of healthy
collagenous tissue with the tooth surface 3. Maximum conservation of periodontal tissue
4. Esthetic desirability 5. Facilitation of oral hygiene 6. Less root exposure with less
sensitivity 7. Less mechanical trauma than closed curettage.
• Disadvantages 1. Technically demanding and exacting 2. Requires a high degree of
technical skill 3. Interproximal flaps require exact placement 4. Immediate unfavorable
interproximal contours when dressings are first removed.

46. Primary incisions made
down to bone. The flap is reflected to
expose only 2 to 3 mm of bone.
A secondary sulcular incision
is made to release the inner flap. ,
Facial view showing reflection of the
flap and secondary incision. A sharp
periodontal knife is used to sever the
remaining collar of tissue above the
crest of bone and loosen the tissue
interproximally

47. Scalers are used
to remove the inner flap.
Intrabony defects are
scaled and curetted if present.
, Osteoplasty is performed to
remove bone ledges that
inhibit flap placement. The
flaps are sutured tightly,
without taking a deep bite of
the tissue.

48. Courtesy of Giovanni Castellucci,
Boston, MA.

49. • Ramfjord and Nissle (1977) performed an extensive longitudinal study that compared the
Widman procedure (as modified by them) with the curettage technique and the pocket
elimination methods, which include bone contouring when needed.
• The patients were assigned randomly to one of the techniques, and results were analyzed
yearly for up to 7 years after therapy. The researchers reported similar results for each of
the three methods tested.
• Pocket depth was initially similar for all methods, but it was maintained at shallower
levels with the Widman flap; the attachment level remained higher with the Widman flap .

50. Undisplaced Flap
• Currently, the undisplaced flap may be the most frequently 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 may be considered an “ internal bevel gingivectomy.”
• The undisplaced flap and the gingivectomy are the two techniques that surgically remove
the pocket wall.
• To perform this technique without creating a mucogingival problem, the clinician should
determine that enough attached gingiva will remain after removal of the pocket wall

51. (Courtesy Dr. Paulo Camargo, University of California,
Los Angeles.)

52. PALATAL FLAP PROCEDURES
• The palate, unlike other areas, is composed mainly of dense collagenous tissue. This fact
precludes the palatal tissue from being positioned apically, laterally, or coronally.
Therefore, surgical techniques are required that allow the tissue to be thinned and
apically positioned at the same time.
• The palatal flap procedure historically involved reflecting a full -thickness flap to gain
access to the underlying bone and remove necrotic and granulomatous tissue.
• It was not until Ochsenbein and Bohannan (1963, 1964) described a palatal approach for
osseous surgery that precise palatal surgical techniques were described and developed.

53. Full-thickness palatal flap
used predominantly on thin
palatal tissue.
Modified partial-
thickness ledge-
and-wedge flap for
thicker palatal
tissue
Partial-thickness primary
flap for thicker palatal
tissue

54. • Advantages of the Palatal Approach
1. Esthetics
2. Easier access for osseous surgery
3. Wider palatal embrasure space
4. A natural cleansing area
5. Less resorption because of thicker bone
Disadvantages of the Buccal Approach
1. Close root proximity
2. Possible involvement of the buccal furcation
3. Thin plate of bone overlying the maxillary molars where dehiscences and fenestrations may be
present

55. • Indications
1. Areas that require osseous surgery
2. Pocket elimination
3. Reduction in enlarged and bulbous tissue
Contraindications The palatal approach procedure is contraindicated when a broad, shallow
palate does not permit a partial-thickness flap to be raised without possible damage to the
palatal artery.

56. Partial-thickness palatal flap
Primary partial-thickness palatal flap.
A, Outline of primary initial scalloped
incisions on the palate. A', Cross-
sectional view of primary thinning
incision. B, Primary scalloped incision
is begun. B', Cross-sectional view
shows that in thick palatal tissue it is
not always possible to go straight
down to the bone. C and C', Tissue
pliers may be used to reflect the
palatal flap as the incision is carried
down to the bone, severing the
periosteum at the base. Note: The
primary incision is used to thin and
shorten the flap at the same time.

57. A secondary, sulcular incision is now
made to free the inner flap prior to
removal. D', The sulcular incision is made
to the crest of bone. E and E',
Ochsenbein chisels are used to loosen
and lift the inner flap for removal and
bone exposure. F and F', The thinned and
shortened flap is positioned over the
bone and sutured interproximally

59. Modified Partial-Thickness Palatal Flap
• Ochsenbein in 1958 and Ochsenbein and Bohannan in 1963 described this technique, but
it was not until 1965 that it became popularized by Prichard. It has also become known
as the ledge and-wedge technique.
• This is a two-stage procedure that is technically easier than the single -step partial-
thickness palatal flap.
• It has as its main disadvantage the fact that healing interdentally is by secondary
intention.

60. Modified partial-thickness or ledge-and-
wedge palatal flap. A, Outline of initial
gingivectomy incision. A', Cross-sectional
view showing a nonbeveled initial
gingivectomy incision above the bone. B
and B', The initial gingivectomy incision is
carried out using periodontal knives. C
and C', Removal of the excised tissue and
creation of a flat tissue ledge.

61. The primary incision is
carried down to the bone,
making sure that the
periosteum is severed at the
base of the inner flap. The
secondary incision is a
sulcular incision made down
to the crest of bone. E and
E', Ochsenbein chisels are
used to remove the
secondary inner flap and
expose bone. F and F', The
flaps are sutured apically and
the interproximal areas are
permitted to granulate in by
secondary intention

63. PAPILLA PRESERVATION FLAP
• The flap procedure usually causes interdental soft tissue recession. To preserve the
interdental soft tissues and for maximum soft tissue coverage following surgical
intervention a new technique PAPILLA PRESERVATION FLAP TECHNIQUE was introduced
by TAKEI et.al(1985).
Indications 1. Embrasures wide enough to permit passage of the interproximal tissue.
Advantages 1. Esthetically pleasing 2. Primary coverage of implant material 3. Prevention
of postoperative tissue craters
Disadvantages 1. Technically difficult 2. Time consuming
Contraindication 1. Narrow embrasures

64. A, Palatal view with
incisions outlined. B,
Completion of palatal
incisions. C, A periosteal
elevator is used to reflect
individual papillary flaps. D,
A blunt instrument used to
push tissue buccally,
exposing underlying
osseous deformities and
subgingival root deposits.
E, Defects debrided, root
scaled, and root planed. F,
Flaps sutured palatally.
Suturing should avoid
papillary compression,
which may result in loss of
interproximal tissue height.

66. 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
Oblique incision Intrasulcular incision Horizontal incision

67. Distal Wedge Procedure:
• The retromolar area of the mandible and the tuberosity of the maxilla offer unique
problems for the clinician.
• These generally have enlarged tissue, unusual underlying osseous topography, and, in
the case of the retromolar area, a fatty, glandular, mucosa -type tissue.
• Historically, while periodontal surgical techniques were being developed for all other
areas, development in this one area remained stagnant, and gingivectomy was the
treatment of choice.
• This problem was first addressed by Robinson in 1963 and later by Kramer and Schwartz
(1964), but it was Robinson’s classic article on the distal wedge operation (1966) that
outlined the indications and treatment procedures still used today.

68. • Advantages
1. Maintenance of attached tissue
2. Access for treatment of both the distal furcation and underlying osseous irregularities
3. Closure by a mature thin tissue, which is especially important in the retromolar area
4. Greater opening and access when done in conjunction with other flap procedures.
The main limitation is only one of access or anatomy (eg, ascending ramus or external oblique
ridge).
WEDGE DESIGNS
1. Triangular
2. Square, parallel, or H design
3. Linear or pedicle

69. Distal wedge—
triangular design. A,
Outline of triangular
incision distal to the
molar. outline of two
small releasing incisions
(a, b), which can be
used if needed. B,
Cross-sectional view
showing wedge removal
and thick tissue. C,
Undermining incisions
are used to thin the
tissue. D, Reflection of
flaps for osseous
correction. E and F,
Cross-sectional and
occlusal views of
sutured tissue

70. Distal-wedge—square, parallel, or
H design. A, Occlusal view with
incisions outlined. two parallel
incisions over tuberosity joined
by distal releasing incision (a, b).
B, Cross-sectional view shows
proper blade angulation in
making initial incisions. C and D,
Flaps reflected and tissue being
removed from tuberosity using a
periodontal knife. E, Bone
exposed for correction of osseous
irregularities. F, Final suture

72. COMPARISON OF DIFFERENT SURGICAL PROCEDURES

73. • Rosling et. Al (1976) conducted a 2 year clinical trial where they compared apically
positioned flap, apically positioned flap with osseous surgery and Widman flap ,Widman
flap with osseous surgery for their healing and pocket depth reduction. Results showed
that all the procedures were effective in reducing the pocket depth to various levels.
• Becker et.al(1988) in a longitudinal study compared SRP , apically positioned flap with
osseous surgery and modified Widman procedures for pocket depth reduction.A split
mouth design was used . After one year, the surgery resulted in greater pocket depth
reduction was seen in other groups compared SRP group. Surgery also resulted in
significantly greater clinical attachment gain.Results showed that surgical procedures
were more effective in pocket depth reduction compared to SRP.

74. CONCLUSION
• The entire surgical procedure should be planned in every detail before the intervention.
This include type of flap, exact location, type of incisions, management of underlying
bone and final closure of flap and suture.
• Proper understanding and knowledge of different incisions and flaps results in better
treatment results with greater patient satisfaction.

75. REFERENCES
• Atlas of Cosmetic and Reconstructive-Periodontal-Surgery-3RD EDITION -EDWARD S.
COHEN.
• NEWMAN AND CARRANZAS CLINICAL PERIODONTOLOGY -13TH EDITION
• PERIOBASICS- NITHIN SAROACH
• Lindhes Clinical_Periodontology_and_Implantology-4th edition

76. THANK YOU