2. PURPOSE
1. To gain access to deeper periodontal structures
with direct vision.
2. Relocation of the frenulum.
3. Maintenance of the attached tissue.
4. Pocket elimination and regeneration.
3. INDICATIONS
• Pockets > 5mm persisting after phase 1 therapy.
• Bony pockets and interdental craters.
• Bony lesions in the furcation .
• Need for surgical crown lengthening .
• When to open up a flap ? Complicated morphology
like :
• Deep and narrow pockets
• Difficult to achieve the correct angle
8. 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.
9. PROCEDURE:
STEP 1: The initial incision is “INTERNAL BEVEL INCISION “ to the
alveolar crest , 0.5-1mm away from the gingival margin along the
gingival scalloped margin .
10. STEP 2: The gingiva is reflected with a periosteal elevator .
11. STEP 3: Crevicular incision is made from the bottom of the
pocket to the bone , encircling the triangular wedges of tissue
containing the pocket lining .
12. STEP 4 : After the reflection of the flap , third incision is
made in the interdental spaces coronal to the bone with
curette or with interproximal knife to remove the gingival
collar .
13. STEP 5: Tissue tag and granulation tissue are removed with a
curette . Scaling and root planing done.
14. STEP 6: Complete coverage of the interdental defect is done
and sling shot suturing is done.
17. INDICATIONS
• In cases with optimal width of attached gingiva.
• To eliminate true pockets .
18. PROCEDURE :
STEP 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.
PREOPERATIVE VIEW
19. STEP 2: Internal bevel incision in the facial and palatal aspects .
21. STEP 4 : Interdental incision is made .
STEP 5:Triangular wedge of tissue is removed with curette.
STEP 6: All tissue tags and granulation tissue are removed.
22. STEP 7: After scaling and root planing the flap edge should rest
on the root bone junction .
STEP 8: Flaps have been placed in their original site and
sutured .
28. Procedure :
STEP 1 : An internal bevel incision is made, it should be more
than 1 mm from the crest of the gingiva and directed to the crest
of gingiva .
29. STEP 2: Crevicular incision are made, followed by initial elevation of the flap ; then
interdental incision are performed and the wedge of tissue containing the pocket wall
is removed .
30. STEP 3 :Vertical incision are made extending beyond the mucogingival
junction
•If the objective is full thickness flap , it is elevated by blunt
dissection with periosteal elevator .
•If a spilt thickness flap is required , it is elevated by using sharp
dissection with a Bard –Parker knife to split it , leaving a layer of
connective tissue , including the periosteum , on the Bone .
31. STEP 4 :After removal of granulation tissue , scaling and root
planing , the flap is displaced apically .
32. STEP 5 : If a full thickness flap was performed , a sling suture
around the tooth prevents the flap from sliding more apically
and maintains periodontal dressing in position.
•Dressing and sutures are to be removed after one week .
38. INDICATION :
• Where esthetics is of concern .
•Where bone regeneration techniques are attempted.
39. PROCEDURE :
STEP 1: A crevicular incision is made around each tooth with no
incisions across the interdental papilla .
40. STEP 2: The preserved papilla can be incorporated into the
facial or lingual / palatal flap (mostly integrated in facial
flap).
41. STEP 3: An orban knife is then introduced into this incision
to sever half to two –third the base of the interdental
papilla . The papilla is then dissected from the lingual
/palatal aspect and elevated intact with the facial flap.
42. STEP 4: The flap is reflected without thinning the tissue.
46. INDICATIONS :
•When the interdental areas are too narrow to permit preservation
of flap .
•When there is a need of displacing of flaps .
47. PROCEDURE :
•STEP 1 : Using #12 blade incise the tissue at the bottom of the pocket to the
crest of the bone , splitting the papilla beneath the contact point of the two
approximating teeth to allow for reflection of buccal and lingual flap.
STEP 2 : Reflect the flap without thinning as this is necessary to prevent exposure of
graft or membrane due to necrosis of flap margin.
51. INCISION DESIGNS :
•Incision design for surgical
procedure distal to mandibular
second molar .
•Incision must follow the areas of
greatest attached gingiva and
underlying bone .
52. PROCEDURE :
STEP 1: Distal pocket eradication procedure where the incision is
distal to the molar .