different types of flaps used in periodontal surgeries

1. NIKHIL C PANICKER
4TH YEAR PART I

2. 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.

3.  Irregular bony contours
 Pockets on teeth in which a complete removal
of root irritants is not clinically possible
 Grade II or III furcation involvement
 Intrabony pockets on distal areas of last
molars
 Persistent inflammation in areas with
moderate to deep pockets

4.  Uncontrolled medical conditions
-unstable angina
-uncontrolled diabetes
-uncontrolled hypertension
-MI/stroke within 4 months
 Poor plaque control
 High caries rate

5.  Classified based on
1.Bone exposure after flap reflection
2.Placement of flap after surgery
3.Management of the papilla

6. 
BONE EXPOSURE
AFTER FLAP
REFLECTION
PLACEMENT OF
FLAP AFTER
SURGERY
MANAGEMENT
OF THE PAPILLA
• Full thickness flap
• Partial thickness
flap
• Non displaced flaps
• Displaced flaps
• Conventional flap
• Papilla
preservation flaps

7. a) Full thickness flaps (mucoperiosteal) :- All the
soft tissues ,including the periosteum is reflected
to expose underlying bone.
-indicated when resective osseous
surgery is contemplated.
b)Partial thickness flap (mucosal) :- Includes only
the epithelium and a layer of underlying
connective tissue. Bone remains covered by a
layer of connective tissue ,including periosteum
-indicated when flap is to be positioned
apically/operator doesn’t want to expose bone

8. a) Non displaced flaps :- When the flap is
displaced and returned and sutured in its
original position.
b)Displaced flaps:- Placed apically, coronally, or
laterally to their original position.

9. a)Conventional flaps:- Interdental papilla is split
beneath the contact point of the two
approximating teeth to allow reflection of the
buccal and lingual flaps.
INCISION IS USUALLY SCALLOPED
Used when-1)interdental spaces too narrow
2) when the flap is to be displaced.
-includes MODIFIED WIDMAN FLAP,UNDISPLACED
FLAP, APICALLY DISPLACED FLAP, FLAP FOR
RECONSTRUCTIVE PROCEDURES.

10. b) Papilla preservation flap :- incorporates the
entire papilla in one of the flaps by means of
crevicular interdental incisions to sever
connective tissue attachment and a horizontal
incision at the base of the papilla,leaving it
connected to one of the flaps.

11.  Dictated by the surgical judgement of the
operator
 Factors to be kept in mind-
1.Degree of access to the underlying bone
and root surfaces.
2.Final position of the flap
3.Preservation of good blood supply to the flap

12. Two basic flap designs are used:
1.Conventional flap
2.Papilla preservation flap
Conventional flaps Papilla preservation flaps
• The incisions for the facial, and the
lingual or the palatal flap reach the
vicinity, there by splitting the papilla
into facial half and a lingual or
palatal half
• Papilla is preserved

13.  There are basically two types of periodontal
flap incisions-
Incisions
Horizontal incisions Vertical incisions
1.Internal bevel
incision
2.Crevicular incision
3.Interdental incision
1.Oblique releasing
incision

14.  Directed along the margins of the gingiva in a
mesial or a distal direction.
 Types of horizontal incisions are
1. INTERNAL BEVEL INCISION
-flap is reflected to expose the underlying bone
and root.
-also termed as the first incision-initial incision
In flap reflection
-reverse bevel incision-since bevel is in reverse
direction
#15C or #15
blades are used

15. 2.Crevicular incisions
Made from the base of pocket to the
crest of bone
-the incision together with the initial
reverse bevel incision forms a V- shaped
wedge ending at or near the crest of
bone

16. 3.Interdental incision
Incision is made to separate the collar
of gingiva that is left around the tooth
Incision is made not only around the
facial and lingual radicular area but
also interdentally connecting the facial
and lingual segments to the free
gingival completely around the tooth
Orban knife is used

17.  Can be used on one or both ends of the
horizontal incision, depending on purpose and
design of flap.
 Vertical incision must extend beyond the
mucogingival line,reaching the alveolar mucosa
 Avoided in lingual or palatal areas
 In facial areas it should not be made in the centre
of 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.

18. S.No Type of flap Reflection
accomplished by
Instrument used
1) Full thickness flap
or mucoperiosteal
flap
Blunt disection Periosteal elevator
2) Partial thickness
flap or mucosal flap
Sharp dissection Surgical scalpel
(#15)

19.  The purpose of suturing is to maintain the
flap in the desired position until healing has
progressed to the point where sutures are no
longer needed.
Non absorbable Absorbable Synthetic
• Silk, braided
• Nylon, monofilament (ethilion)
• EPTfe, monofilament (Gore-
tex)
• Polyester, braided (ethibond)
• Surgical gut
• Plain gut;
monofilament(30
days)
• Chronic gut;
monofilament (45-
60 days)
• Polyglycolic, braided (16-
20 days)
(vicryl;ethicon)(dexon;Dav
is & Geck)
• Polyglecaprone,
monofilament (90-120
days
• Polyglyconate,
monofilament

20.  Entry of needle in to tissues – right angles, not less than 2-3 mm
from incision.
 Needle is then carried through the tissue, following the needles
curvature
 Knot should not be placed over the incision
 The flap is closed either with independent sutures or with
continuous, independent sling sutures
 Sutures of any type in the interdental papillae should be placed at
a point located below the imaginary line that forms the base of
the triangle of interdental papilla
 In closure of palatal flap location of sutures depends on extent of
flap elevation- flap is divided in 4 quadrant, if flap elevation is slight
or moderate- sutures can be placed in closest quadrant to the
teeth, if flap elevation is substantial- sutures should be placed in
central quadrants of palate

21.  Interdental ligation- 1)direct loop suture
2)figure-eight suture
 Sling ligation- can be used for a flap on one
surface of a tooth that involves two
interdental spaces

22.  Horizontal mattress suture
 Continuous, independent sling suture
 Anchor suture
 Closed anchor suture
 Periosteal suture
two types- 1)the holding suture
2)the closing suture