Periodontal flaps

PERIODONTAL FLAPS
DR P MIKITHA
II MDS
DEPT OF PERIODONTOLOGY
AECS MAARUTI COLLEGE OF DENTAL SCIENCES

Contents
• Introduction
• Definition
• Historical background
• Objectives of flap surgery
• Indications and contraindications
• Advantages and disadvantages
• Principle of flap design
• Classification of flap
• Properties of ideal flap
• Types of incisions
• Different flap techniques
• Healing after flap surgery
• Factors affecting the outcome of
flap surgery
• Conclusion
• references

INTRODUCTION
• The ultimate aim of periodontal therapy is to establish a healthy dentition
with sound attachment appartus resulting in proper frrm, function and
esthetics.
• To achieve this goal many non-surgical and surgical techniques have been
proposed to treat a variety of periodontal conditions most commonly the
periodontal pocket.
• Periodontal therapy comprises of initial non-surgical debridement followed
by a re-evaluation at which stage the need for further treatment, usually
surgical in nature is established.

DEFINITIONS
• Periodontal flap is defined as a section of gingiva and/or mucosa surgically
separated from the underlying tissues to provide visibility of and access to
the bone and root surface. -(Carranza 10th edition).
• Flap is defined as the separation of a section of tissue from the surrounding
tissue except at its base, -(Glossary of periodontal terms)
• A flap is defined as a mass of tissue, usually including skin, only partially
removed from one part of the body so that it retains its own blood supply
during transfer to another site. –(Dorland’s medical dictionary).
Takei H, Carranza FA, Shin K. the flap technique for pocket therapy In: carranza’s clinical periodontolgy, Elsevier, 12, 2012; 593- 603.

Carl Partch- 19th century -1907 Partch incison
Robert Neumann- 1912 1st introduced mucoperiosteal flap –”Neumann
flap”
Leonard Widman – 1918 Modified the Neumann flap – “Widmann flap”
Cieszynski- 1918 Reverse bevel incision
Kirkland – 1931 Modified flap procedure
Carranza – 1939 Surgical treatment of periodontitis
Nabers – 1954 Introduced “repositioning of attached gingiva”
Ariaudo and Tyrrell – 1957 Modified Nabers procedure
Friedman- 1962 Apically positioned flap
Oschenbein and Bohannan – 1964 Palatal flap
Morris – 1965 Unrepositioned mucoperiosteal flap
Ramjford and Nissle – 1974 Modified Widmann flap
Takei et al- 1985 Pappila preservation flap
Trombelli et al – 2007 Single flap approach (SFA)
Bianchi and Bassetti - 2009 Whales technique

Objectives of flap surgery
MAIN OBJECTIVE of periodontal
surgery is to contribute to the long-
term preservation of the
periodontium by facilitating plaque
removal and plaque control.
-Jan Lindhe
To enable visual
instrumentation of root
surfaces
To re-establish the healthy,
clinical status of
periodontium with long term
maintenance
To restore the periodontal
apparatus when attachment
loss has occurred
Cohen SE. fundamental of surgical therapy. In: Atlas of cosmetic and reconstructive periodontal surgery, BC Decker Inc, 3, 2007; 56-72.

1. Access to roots and alveolar bone
2. Modification of osseous defects:
• estabilish physiologic architecture of hard tissues through regeneration or
resection
• Augment alveolar ridge defects
3. Repair or regeneration of the periodontium
4. Pocket reduction:
• Enhance maintenance by patient and therapist
• Improves long term stability
5. Provide acceptable soft tissue contours
• Enhances plaque control measures
• Improve esthetics

indications
• Irregular bony contours
• Deep craters
• Pockets on teeth in which a complete removal of root irritants is not clinically
possible
• Grade II or III furcation involvemnet
• Root resection/ hemisection
• Intrabony pockets on distal areas of last molars

• Persistent inflammation in aresas with moderate to deep pockets
• Unaccesible areas like root concavities, furctaion areas, etc
• Deep periodontal pockets: Waerhaug stated that pocket depth greater tha
5mm demonstrated onlu an 11% efficacy in removal of plaque and
calculus.
• Osseous defect: morphology of osseous defects can limit the effectiveness
of non-surgical therapy

contraindications
A. Patient non co-operation
B. Poor plaque control
C. High caries rate
D. Systemic conditions:
Cardiovascular diseases:
 Arterial HTN: patients consent should be taken and LA with adrenaline or
without adrenaline must be used
 Angina pectoris: premedication with sedatives and LA, low in adrenaline is
recommended.

 Myocardial infarction
 Anticoagulant treatment: the range in which SRP and surgical procedures
can be safely performed is one and half to 2 times the avarage normal
prothrombin time (12-14 sec)
 Aspirin and other NSAID drugs should not be used for post-op pain control
 Rheumatic endicarditis, congenital heart lesions and heart/vascukakr
implants involve risk of transient bacteremia that follows manipulation of
infection periodontal pockets,
 ADA- recommended antibiotic prophylaxis and antiseptic mouthrinsing
0.2% CHX prior to surgery

Organ transplantation:
 Prophylactic antibiotics are recommended in transplant patient taking
immunosuppressive drugs
Blood disorders:
 Patients suffering from acute leukemia, agranulocytosis and
lymphogranulomatosis must not be subjected to periodontal surgery
 Diabetes
Neurological disorders:
 Multiple sclerosis and parkinsons disease make periodontal surgery impossible
Epilepsy
 Drugs used to treat epilepsy may cause gingival enlargements. Theese patients
may withspecial restrictions be subjected to periodontal surgery.

advantages
• Pocket epithelium is removed by the
inverse bevel incision
• The inter dental bone or infrabony
defects can be covered by the flaps
• No open wound persists
postoperatively
• Rapid healing.
• Less post operative discomfort and
fewer complications.
• Less post operative gingival
recession, therefore esthetic
• Less dentin exposure.
• Short surgical time
• Direct healing
disadvantages
• When flaps are repositioned
apically, the cervical areas of the
teeth are often exposed, long and
sensitive, due also to shrinkage of
the tissues.
• Possibility of deep periodontal
pockets remaining after surgery.
• Possibility of formation of post-
operative gingival craters in
proximal surface areas (especially
in molars).
• New attachment is unpredictable.
• Less regeneration achieved
compared to other regenerative
procedures.

Principles of flap design
• According to HUPP 1933 following principles should be followed:
Prevention of flap necrosis:
 The apex of flap should never be wider than the base
 Flap should either run parallel to each other or preferably converge from the
base of the flap to its apex
 Flap length to base ratio should be no greater than 2:1
 The major blood supply to a flap was found to exist at its base and travels in an
apical to coronal direction. So, it was also determined that the greater the ratio
of flap length to flap base, the greater the vascular compromise at the flap
margins.

 Whenever possible axial blood supply should be included in the base of the
flap
 The base of the flap should not be excessively twisted or stretched (as either of
these will compromise the supplying vessels)
• Prevention of flap tearing:
 The access of the flap should be enough to avoid tearing
 If an envelope flap doesn’t provide sufficient access, another incision should be
made

 Vertical releasing incisions should be placed one full tooth anterior to the
area of any anticipated bone removal
 The incision should be started at the line angle of the tooth and carried
obliquely apically into the unattached gingiva.

Properties of ideal flap
Ideal flap/section of soft tissue:
• Is outlined by a surgical incision
• Carries its own blood supply
• Allows surgical access to the underlying tissues
• Can be placed in the original position
• Can be maintained with sutures in a particular desired position
• Expected to heal
• Sharp incisions heal rapidly
• Flap extension- 2 teeth anterior and 1 tooth posterior to the area of surgery
• Incisions- over intact bone/ 6-8mm away from the diseased bone (Peterson)

Types of incision
Principles governing incision placement
According to LASKIN 1980:
• The incision should not be made over the operative site but in the adjacent, undisturbed areas
so that the flap will be supported by normal tissue and the potential for rapid
revascularization is preserved
• The incision should be placed do that major nerves are not transected unless necessary
• An adequate blood supply should be maintained by incising parallel to the major vessels
• Incisions should not be made in areas of thinned mucosa like that found over an exostosis
because the blood supply is reduced, suturing is difficult and rate of dehiscence is very high.

• When developing flaps around teeth, incisions should be made in gingival
crevice.
• Important to maintain the integrity of the interdental papillae.
• If access is inadequate, the surgeon may extend the length of the incision or
make a releasing incision. The releasing incision is usually made at about an
angle of 45 degrees from the direction of the parent incision
• If the flap is to include both mucosa and the periosteum the incision should be
made directly to the bone with one cut and it should be elevated in one piece
without tearing the periosteum
• After the necessary surgery, the clotted blood should be removed from beneath
the flap to lessen the possibility of infection and permits tissue fluid to penetrate
more readily.

Seven main incision types are commonly used in
periodontal surgery
• External bevel or gingivectomy incision
• Horizontal incision:
a. internal bevel incision
b. Crevicular incision/ sulcular incision
c. Interdental incision
• Vertical/ oblique releasing incision
• Cutback incisions
• Thinning incisions
• Distal wedge incisions
• Periosteal releasing incisions

THE EXTERNAL BEVEL OR GINGIVECTOMY
INCISIONS
• It is contained in the gingiva and coronally
directed with the surgical objectives of pocket
elimination, access to roots and improved
gingival contours.
• Indications:
1. To treat gingival enlargement and to perform
esthetic crow lengthening
2. Used in conjunction with flap surgery when
there is need to thin the tissues externally
before flap reflection. Eg: severe gingival
enlargement with lobulated gingiva and highly
irregular gingival margins

Typesof horizontalincisons
a. The internal bevel incision- starts at a
distance from the gngival margin and is
aimed at the bone crest.
b. The crevicular incision- starts at the bottom
of the pocket and is directed to the bone
margins
c. The interdental incision- performed after the
flap is elevated

Internalbevelincision • First incision- it is initial incision in the reflection of
the flap
• Reverse bevel incision- its bevel is in reverse direct
from the gingivectomy imcison
• #11 or #15 surgical scalpel is used mostly
Objectives of internal bevel incision:
1. Removes pocket lining and areas of tissue invaded by
microorganisms.
2. Chief advantage- eliminates the part of the gingival
margin which has been penetrated by the pathogens
3. Conserves the relatively less involved outter surface
of gingiva
4. Produces sharp, thin flap margin for adaptation to the
bone tooth junction

Indications:
• Primary incision of the flap surgery if there is sufficient band of attavhed
gingiva
• Desire to correct bone morphology
• Thick gingiva
• Deep periodontal pockets and bone defect
• Desire to lengthen clinical crown
Incision design:
The placement of primary incision is determined by the following factors:
1. Band of attached gingiva
2. Method of periodontal surgery
3. Periodontal pocket depth

4. Whether osteoplasty and ostectomy are
necessary
5. Esthetics
6. Whether restorative treatment is necessary
after periodontal surgery
7. Clinical crown length needed for abutment

Variations in the type of
internal bevel incision for
different types of flaps:
 Modified widmann flap doesn’t intend to
remove the pocket wall, but eliminates pocket
lining. Starts close, no more than 1-2mm
apically to the gingival margin and follows the
normal scalloping of the gingival margin.
 Apically displaced flap, pocket wall is to be
preserved; so, incision is to be made as close to
the tooth as possible 0.5- 1mm
 Undisplaced flap, incision is initiated at or near
a point just coronal to the projection of the
bottom of the pocket on the outer surface of
gingiva

Studies in favor of the benefits of removal of pocket
epithelium by internal bevel incision
Morris
1949
•Removal of pocket epithelium is necessary for new CT attachment
Stone
1966
•Any residual epithelium on the wound edge could serve as a seed area and result in rapid proliferation of the JE along the root
surface
Yukna
1976
•Successfully removed all epithelium with internal bevel incision as described by ENAP
Caffesse
at al
1968
•Observed that all pocket epithelium was removed with the reverse bevel incision as described in the modified widman flap
procedure
carranza
•Stated that placement of the scalloped internal bevel incision 1mm subcrestally will remove most of the granulation tissue
contained in the lateral wall of pocket

Sulcularor crevicularincision
• It is selected if preservation of all existing keratinized tissue is desirable
• Scalpel blade is inserted into the gingival crevice, aligned parallel to the
long axis of the tooth, and angled towards the alveolar crest. Interproximally
the incision is extended into the embrasure space to include as much papilla
as possible

Indications
• Narrow band of attached gingica
• Thin gingiva and alveolar process
• Shallow periodontal pocket
• Esthetic reason
• As a secondary incison of usual flap surgery
• Bone graft or GTR
• Facilitate the removal of inflammatory granulation tissue surrounding the
cervical area and the secondary flap of soft tissue walls of the periodontal
pocket

Interdentalincison • After first 2 incisions have been placed,
periosteal elevator is inserted into the initial
internal bevel incision, and the flap is
separated from the bone. With this access the
interdental incision is placed to separate the
collar of gingiva (around facial, lingual and
interdental areas that is left around the tooth)
• Orban knife is used

Verticalreleasingincisions
• They are normally perpendicular to the
gingival margins and placed at the line angles
of the tooth
Advantages:
• Increase access
• Decrease tension on retracted flap
• Allow apical and coronal positioning of flaps
• Vertical incisions in the lingual and palatal
areas are avoided
• Facial vertical incision shouls always be placed
at the line angles of the teeth and never over
the height of contour of the root

• As a rule, when trying to decide on what side of the interproximal space to
place the releasing incision, it is best to include papilla with the flap to
enhance the blood supply to the flap and to allow for ease of suturing
• Suture vertical incisions before horizontal portion of flap

Cutbackincisions
• Vertical incisions may be used to move the flap
lateraaly as in pedicle flap
• Vertical incision is made at an acute angle to
the horizontal incision, in the direction toward
which flap is moved, placing the base of the
pedicle at the recipient site. This is termed as
cutback incision.
• Care must be taken not to extended cutback
incisions more than 2-3mm to minimize
disruption of the remaining blood supply to the
flap.
Indicated to prevent tension in tissues during
healing, and to prevent the displacement of
laterally displaced flap

Thinningincisions
• Reduces the bulk of CT from the underside
of the flap and are used to reduce the
thickness of flaps before reflection
• Such incisions are used as a part of distal
wedge procedures and to thin the bulky
papillae.

Distalwedgeincisions
• Triangular: placed creating the apex of the
triangel close to the hammular notch and the
base of the triangle next to the distal surface
of terminal tooth.
• The thinning or undermining incisions are
accomplished before full reflection of tissue
and are extended 2-3mm apical to the crestal
aspect of tuberosiy

• The linear distal wedge- 2 parallel incisions
over the crest of the tuberosity that extend
from the proximal surface of the terminal
molar to hammular notch area.
• The distance between 2 incisions is
determined by the thickness of the tissues,
with wider separation of the incisions in
thicker tissues.

Periostealreleasingincisions
• Used when coronal or lateral advamcement of a
flap onto the root or crown of the tooth is
indicated.
• The periosteum on the underside of the flap is
scored with a scalpel blade to increase flap
mobility allowing passive coronal advancement
of the flap.
• This incision which severs the underlying
periosteum at the base of full-thickness flap,
allows tension free coronal positioning of the flap
to cover exposed root surfaces and to provide
primary closure over barrier membranes used in
GTR and GBR procedures.

Incisions Description Indication
External bevel Coronally directed Gingivectomy, crown
lengthening, gingivoplasty
Internal bevel Apically directed placed at crest of
the gingival margin or stepped back
from the margin 0.5-2mm
ENAP, Modified widman
flap, falp and curettage, crow
lengthening
Sulcular / crevicular Apically directed placed in gingival
crevice and directed towards the
alveolar crest
When preservation of
gingiva is critical, esthetic
areas, GTR procedures
Releasing Perpendicular to the gingical margin
at the line angles of teeth
Increase access, to allow
apical or coronal positioning
of flap
Thinning Internal or undermining incison
extemding from gingival margin
towards the base of flap to decrease
the bulk of CT underside of the flap
Palatal flaps, distal wedge
procedures, internal bevel
gingivectomy, bulky
paipillae
periosteal Incisions at the base of flap severing
the underlying periosteum
To release flap tension
allowing coronal
advancement of flap

Classification of flaps
• Based on bone exposure after flap reflection (carranza 1979)
• Based on flap placement after surgery (carranza 1990)
• Based on management of papillae
• Based o presence/ absence of releasing incisions
• Based on the main purpose of procedure (Ramfjord 1979)
• Based on the anatomic type of mucosa

• Mucoperiosteal or full thickness flap
• Partial thickness or mucosal flap
• Combination flap
Based on bone exposure
after flap reflection
• Non displaced flap
• Displaced flap/ positioned flap:
• apical displaced flap
• Coronal displaced flap
• Lateral displaced flap
Based on placement of
flap after surgery
• Conventional flap
• Pappila preservation flap
Based on management
of papillae
Based on presence /
absence of releasing
incisions
•Flap with releasing incisions
•Flaps without releasing incision

• Pocket elimination flap
• Reattachment flap surgery
• Mucogingival repair
Acc. To main purpose of
the procedure (Ramfjord
1979)
• Gingival flap
• Mucogingival flap: extends beyond
the mucogingival junction to include
alveolar mucosa
Based on the anatomic
type of mucosa

FullthicknessFlap
• In this flap all the soft tissue along with the
periosteum is reflected to expose the
underlying bone.
Advantages:
 Improved visibility
 Associated with less bleeding and post-op pain
 Most common type of flap used when access to
the bone is indicated for resective or
regenerative procedure
 Can be used to reduce or eliminate periodontal
pockets, but there must be a sufficient band of
attached gingiva and sufficient alveolar crest
width to achieve this

Contraindications:
• Thin periodontal tissues with probable osseous dehiscence and osseous
fenestration
• Area where alveolar bone Is thin

Partial/splitthicknessflap
• In this only the epithelium and a layer of the
underlying CT are included. The bone remains
covered by a layer of CT, including the
periosteum.
Indications:
• When the flap is to be positioned apically or
when the operator doesn’t want to expose the
bone.
• Indicated on buccal surfaces. Palatal and
lingual surfaces with their wide zones of
attached gingiva and thick alveolar bone do not
require split thickness flap

Contraindications:
• Thin areas of gingiva
• Posterior areas of the mandible
Advantages:
• Favorable in augmentation of attached gingiva with thin bone (done by
positioning flap apically or laterally)
Disadvantages:
• The biggest problem- thickness of remaining periosteum-connective tissue
bed on bone.
• If it is less than 0.5-1mm the remaining periosteum-connective tissue may
become necrotic.

ComparisonbETwEEnfull thicknessand partial thickness

Combination flap
• A useful variation of these 2 flaps is the combination or split-full-split flap.
• 1st a crevicular incision is made lateral to the periodontal pocket and down
to the crest of ther alveolar bone (split)
• 2nd periodontal elevator is used to bluntly dissect the flap down to the
approximate level of the mucogingival junction (full)
• 3rd scalpel is again used to split the alveolar mucosa apically beyond the
mucogingival junction (split)

The original widman flap
• One of the first detailed descriptions of the use of a flap procedure for
pocket elimination was published in 1918 by Leonard Widman.
• Widman described a mucoperiosteal flap design aimed at removing the
pocket epithelium and the inflamed connective tissue, thereby facilitating
optimal cleaning of the root surfaces.

Advantages
• Less discomfort for the oatient
since healing was by primary
intention
• Re-establish a proper contour of
the alveolar bone in sites with
angular bony defects
Disadvantages
• Exposure of root surfaces
• Vertical incisions

PROCEDURE
• 2 releasing incisions demarcate the area
scheduled for surgical therapy. A scalloped
reverse bevel incision is made in the gingival
margin to connect the 2 releasing incisions.
• The collar of inflamed gingival tissue is
removed following the elevation of a
mucoperiosteal flap
• By bone recontouring a physiologic contour of
the alveolar bone may be reestablished
• The coronall ends of the buccal and lingual
flaps are placed at the alveolar bone crest and
secured in this position by interdentally placed
sutures.

The Neumann Flap
• Neumann (1920, 26) suggested the use of a flaps procedure which in some
respects was different from the originally described by Widman.
Technique
• An intracrevicular incision was made through the base of the gingival
pockets, and the entire gingiva (and a part of the alveolar mucosa) was
elevated in a mucoperiosteal flap.
• Sectional releasing incisions well made to demarcate the area of surgery.
• Following flap elevation, the inside of the flap was curetted to remove the
pocket epithelium and the granulation tissue.

• The root surfaces were subsequently carefully “cleaned”. Any
irregularities of the alveolar bone were corrected to give the bone crest a
horizontal outline.
• The flaps were trimmed to allow both an optimal adaptation to the teeth
and a proper coverage.

Vertical incisonsi
Exposed root surfaces
subjected to mechanical
debridement
Suturing
Intra crevicular incision
Retracted gingiva to
expose the diseased
root surface

The modified flap or Kirkland Flap
• In a publication from 1931 Kirkland described a surgical procedure to be used in
the treatment of “Periodontal Pus Pockets”. The procedure was called the
modified flap operation, and is basically an access flap for proper root
debridement.
Advantages:
• Less extensive procedure
• Less postop pain and swelling
• More esthetic results
• No apical displacement of the gingival margins
• More chances of bone regeneration

Technique:
• Intracrevicular incision
• The gingiva is retracted to expose the
diseased root surfaces
• Exposed root surfaces are subjected to
mechanical debridement
• Flaps are replced to their original position
and sutured.

Modified widman flap
• Ramfjord and Nissle 1974 and it’s a open flap curettage technique
• Original widman flap= apical displacement+ osseous recontouring
• Modified widman flap= doesn’t meet above objectives
Indications :
• Whenever reattachment with minimal gingival recession is desired
• Especially effective with pocket depths of 5-7mm
• Moderate furcation involvement
• Patient with a high caries rate and root senstivity problem

Contraindications :
• Very thin and narrow attached gingiva
• Osseous surgical procedures with very deep osseous defects and irregular
bone loss.
Advantages :
• Tissue friendly
• Reparative with healing byb primary intention
• Minimal crestal bone resorption
• Lack of post-op discomfort
Disadvantages:
• Unfavourable proximal architecture immediately following surgery
• Pockets are not completely eliminated
• Cant be used for regenerative purposes

PRINCIPLES
1. Initial incision- continuous, scalloping, paramarginal (intragingival)
incisions; no vertical releasing incision
2. 2nd incision- sulcular incision
3. 3rd incision- horizontal incision, also interdentally; removal of the
delineated tissue and all granulation tissue
4. Root cleaning and planing with direct vision
5. Flap adaptation complete coverage interdentally

1. Initial incision is an internal bevel incision to the alveolar crest starting
0.5-1mm away from the gingival margin
2. Gingiva is reflected
3. Crevicular incision is made from the bottom of the pocket to the bone
4. 3rd incision is mae in interdental spaces coronal to the bone with a curette or
an interproximal kife, and gingival collar is removed
5. Tissue tags and granulation tissue are removed
6. Adapt the facial and lingual interproximal tissue adjacent to each other in
such a way that no interproximal bone remains exposed at the time of
suturing. Interrupted direct sutures are placed

Differencesbetween modified and original widman flap

Laser assisted MWF
• Current alterations to the Modified Widman Flap include the use of diode laser
to aid in the removal of the epithelial lining of pockets and improve clinical
outcomes of flap surgery.
• Treatment protocols include the steps of incision and reflection of modified
widman flap
• In addition, the application of an 810- nm diode laser to all surfaces of the flap,
the exposed bone, and the tooth surface takes place
• While this study included only a small sample size over a rela tively short
follow-up period, they show promising results in decreasing postopera tive pain
while improving clinical measurements of probing depth and attachment level

Post op PD CAL at
baseline
Post debridement in
modified widman
flap A. using laser
b. alone

Removal of pocket lining using diode laser
- Sanjeev et al 2010

Apically repositioned flap
• In 1950s and 1960s new surgical techniques for the removal of soft tissue were
described
• Importance of maintaining an adequate zone of attached gingiva after surgery was
emphasized
• Apically positioned flap surgery, in which flaps are reflected with an internal bevel
incision and sutured apical to pre-op position
• Norberg (1926)- advocated this technique for mucogingival problems in periodontal
disease
• Nabers(1954)- described this technique for the preservation of the gingiva following
surgery

ADVANTAGES
• Minimum pocket depth post
operatively.
• If optimal soft tissue coverage of the
alveolar bone is obtained, the post
surgical bone loss is minimal.
• Preserves attached gingiva and
increases its width.
• Establishes gingival morphology
facilitating good hygiene
• Ensures healthy root surface necessary
for the biologic width on alveolar
margin and lengthened clinical crown.
DISADVANTAGES
• May cause esthetic problems due to
root exposure
• May cause attachment loss due to
surgery.
• May cause hypersensitivity
• May increase risk of root caries.
• Unsuitable for treatment of deep
periodontal pockets.
• Possibility of exposure of furcations
and roots, which complicates post
operative supragingival plaque
control.

INDICATIONS
• To eliminate periodontal pockets.
• To increase the width of attached
gingiva.
• To lengthen the clinical crown for
prosthetic treatment.
• To improve gingival and gingival
alveolar bone morphology.
CONTRAINDICATIONS
• Periodontal pockets in severe
periodontal disease.
• Periodontal pockets in areas where
esthetics is critical
• Deep intrabony defects
• Patient at high risk for caries.
• Severe hypersensitivity.
• Tooth with marked mobility and
severe attachment loss
• Tooth with extremely unfavorable
clinical crown / root ratio.

TECHNIQUE
• Following a vertical releasing incision the
reverse bevel incision is made through the
gingiva and the periosteum to separate the
inflamed tissue adjacent to the tooth from
the flap
• A mucoperiosteal flap is raised and the tissue
collar remaining around the teeth including
the pocket epithelium and inflamed CT is
removed with curette
• Osseous surgery is performed with the use of
a rotating bur

• The flaps are repositioned in an apical direction to the level of the
recontoured alveolar bone crest and retained in this position by sutures
• A periodontal dressing is placed over the surgical area to ensure that the
flaps remain in the correct position during healing.

Pappila preservation flap
• Proposed by Takei et al 1985, cortellini et al 1995, 1999; described
modifications of flap design to be used in combination with the
regenerative procedures
• For esthetic reasons, papillae preservation technique is often utilized in the
surgical treatment of anterior tooth regions
2 types:
Modified papilla preservation (cortellini et al 1995)
Simplified papilla preservation (cortellini et al 1999)

TECHNIQUE
a. An intrasulcular incision is made along the
lingual/palatal aspects of the teeth with a
semi-lunar incision made across each
interdental area
b. Curette or interproximal knife is used to
carefully free the interdental papilla from
the underlying hard tissue
C-d. the detached interdental tissue is pushed
through the embrasure with a blunt
instrument to be included in the facial flap
e. The flap is replaced and sutures are placed on
the palatal aspect of the interdental areas.

Modified papilla preservation (Cortellini et al 1995)
• Access to the interdental defects consists of a horizontal incision buccal
keratinized gingiva at the base of the papilla
• Connected with mesio-distal buccal intrasulcular incisions for elevation of
full-thickness buccal flap
• Residual interdental tissues are dissected from neighboring teeth and the
underlying bone and elevated towards the palatal aspect
• Elevation of full thickness palatal flap, including the interdental papilla,
interdental defect exposure

Simplified papillapreservation (Cortellini et al 1999)
• To overcome the technical problems encountered with MPPT:
• Difficult application in narrow interdental spaces and In posterior areas
• Suturing technique not appropriate for use with non supportive barriers
• Modified papilla preservation is used in wide interdental spaces(>2mm)
especially in anterior dentition.

Distal molar surgery
• Described by Robinson and Braden and modified by several other
investigators.
Objectives of wedge procedure:
• Eliminate periodontal pockets
• Maintain and preserve the attached gingiva
• Make area accessible to instruments
• Lengthen clinical crown
• Create easily clearable gingival- alveolar form

Maxillary molars:
Usually simpler than mandibular molars because:
• Tuberosity presents a greater amount of fibrous attached gingiva
• Anatomy of tuberosity extending distally is more adaptable to pocket
elimination than is that of mandibular molars

Mandibular molars:
Differences from the treatment in the maxillary tuberosity region due to:
• Retromolar pad area doent usually present as much fibrous attached gingiva
• Keratinized gingiva if present may not be directly to the molar
• The greatest amount may be distolingual or distofacial and may be over the
bony crest
• The ascending ramus of the mandible may also create a short horizontal
area distal to the terminal molar.

Modified distal wedge procedure
• Buccal and palatal flaps are elevated
a. Rectandular wedge is released from the tooth and underlying bone by
sharp dissection and removed.
b. Following bone recontouring and root debridement, the flaps are trimmed
and shortened to avoid overlappoing wound margins and sutured.
c. A close soft tisuue adaption should be accomplished to the distal surface
of the molar. The remaining fibrous tissue pad distal to the buccolingual
incision line is leveled by the use of gingivectomy incision

The palatal flap
• The surgical approach to the palatal area differs from that for the other areas
because of the character of the palatal tissue and the anatomy of the area.
• The palatal tissue is all attached, keratinized tissue and has none of the elastic
properties associated with other other gingival tissues. Therefore the palatal
tissues cant be apically displaced and a partial- thickness flap cant be
accomplished
2 methods for eliminating palatal flap:
• One incision is an internal bevel
• The other procedure uses a gingivectomy incision, which is followed by internal
bevel incision

Procedure:
• Primary incison is made intracrevicularly through the bottom of the
periodontal pocket
• The palatal flap is replaced and osseous recontouring is performed in the
surgucal area
• A secondary, scalloped reverse bevel incision is made to adjust the length
of the flap to the height of the remianing alveolar bone
• The shortened and thinned flap is replaced over the alveolar bone and in
close contact with root surfaces

The single flap approach (SFA)
• SFA is a simplified, minimally invasive surgical approach to access intra-osseous
periodontal defect. – Trombelli et al 2007
Advantages:
• Facilitate flap repositioning and suturing; flap can easily be stabilized to the
undetached papilla, thus optimizing wound closure for primary intention healing.
• By limiting surgical trauma on the vascular supply of the interproximal
supracrestal soft tissues due to a limited flap elevation, a faster wound-healing
process, particular;y at the level of the incision line
• Wound stabilization and preservation of an intact interdental papilla may laso
minimize the post-surgery shrinkage of gingival tissues and therefore limit the
esthetic improvement of the patient.
Trombelli L, Farina R et al. single flap approach with buccal access in periodontal reconstructive procedures. J Periodntol 2009; 80 (2): 353-60.

Trombelli L, Farina R et al. single flap approach with buccal access in periodontal reconstructive procedures. J Periodntol 2009; 80 (2): 353-60.

Buccal SFA and rh-pdgf-bband b-tcp
• When combined with rhPDGF-BB and b-TCP, the SFA ma result in similar
clinical outcomes, better quality of early wound healing and lower pain and
consumption of analegsics during the first post-op days compared to the
DFA . -Schincaglia GP, 2015
Trombelli L, Simonelli A et al. Single-flap approach for surgical debridement of deep intraosseous defects: A randomized controlled trial. J Periodontol. 2012; 83: 27-35.

CTG+SFA
• The adjunctive use of a CTG in the regenerative treatment of intraosseous
defects associated with buccal bone dehiscence accessed by buccal SFA
may support the stability of the gingival profile. –Leonardo Trombelli 2016
Trombelli L, Farina R et al. single flap approach with and without GTR and a hydroxyapatite biomaterial in the management of intraosseous periodontal defects. J Periodontal. 2010; 81: 1256-
1263.

Whales technique
• Bianchi and Bassetti (2009) described a new surgical technique- the
whale’s tail technique, which was designed for the treatment of wide
intrabony defects in the esthetic zone.
• This technique involves the elevation of large flap from the buccal to the
palatal side to facilitate access and visualization of the intrabony defects
and was created especially to perform regeneration while maintaining
interdental tissue over grafting materials
Vijay DM, Deepika P C, Sharma H M. Whale's tail technique. J Int Clin Dent Res Organ 2019; 11: 110-3.

advantages
• Good access to defect
area
• Handling of
interdental papilla is
easier and more
convienient
indications
• Surgical treatment of
anterior teeth with
diastema present
• Therapies aimed at
regeneration of
periodontal defects
such as bone grafts,
membrane or both
Contraindication
• High frenal
attachments
• recession
• Diastema <2mm

Healingafter flap surgery
Homlay W, Greenwell H. Periodontal surgery. J Periodontol 2000, 2001, 25: 89-105.

Factors affecting the outcome of flap surgery
• Pre therapeutic causes
• Therapeutic causes
• Post therapeutic cases
1. pre-threapeutic causes:
 Incorrect patient selection
 Improper diagnosis
 Inappropriate dental restorations
 Morphology of root surfaces
 Habits
 Occlusal trauma

2. Therapeutic causes:
 Improper selection of surgical technique:
 Width of attached gingiva
 Height of remaining bone
 Pocket depth
 Mobility
 Co-operation of patient
 Patient systemic background
 Improper asepsis of surgical field and patient, improper sterilization of the
imstruments

• Improper flap design:
 A properly designed flap will anatomically fall into correct position on its
bony base following surgery
 If a mucoperiosteal flap is not designed correctly it may
 Rise too high coronally- redundant tissue with subsequent repocketing
 Fall for short of the osseous margin- resorption or sequestra formation
 Inadequately cover the bone graft- minimizes the opportunity for ideal
healing
 Incomplete debridement
 Improper suturing

• Improper incision: the rationale of periodontal flap surgery is to gain access
to underlying root and bone surfaces
• If incisions are not made upto the bone/root surfaces and a mucosal flap is
elevated which hinders in gaining proper access to the underlying root
surface, can cause increased amount of bone resorption
• Reflection of flap: elevation of flap shoud be such that only around 1 mm
of marginal bone is exposed
• Over reflection- bone resoprtion
• Under reflection- limited access to the underlying rot/bone surface

• Debridement of the root surfaces and bone: complete debridement with
removal of plaque and calculus from the root surface
• Suturing of the flaps should be done to closely adapt the flap to tooth
margins
• Failure to properly place suture- gaping of the wound and hence recurrence
of the disease

3. post-therapeutic causes:
• Unsupervised healing
• Inadequate restorations post- surgically:
• Failure to replce the missing teeth
• Correction of overhanging restorations
• Correct carious lesions

conclusion
• The periodontal flap is one of the most commonly employed procedures,
particularly for moderate and deep pockets in posterior areas.
• The design of the flap is dictated by the surgical judgement of the operator
and may depend on the objectives of the operation. The degree of access to
the underlying bone and root surfaces necessary and the final position of
the flap must be considered in designing the flap. Preservation of good
blood supply to the flap is an important consideration.
• The entire surgical procedure should be planned is every detail before the
intervention is begun.

References
• Takei H, Carranza FA, Shin K. the flap technique for pocket therapy In:
carranza’s clinical periodontology, Elsevier, 12, 2012; 593- 603.
• Cohen SE. fundamental of surgical therapy. In: Atlas of cosmetic and
reconstructive periodontal surgery, BC Decker Inc, 3, 2007; 56-72.
• Lindhe J, Karring T, Lang NP. Periodontal surgery: Access therapy In:
Clinical periodontology and implant dentistry, Wiley Blackwell, 6, 2015; 767-
803.
• Homlay W, Greenwell H. Periodontal surgery. J Periodontol 2000, 2001, 25:
89-105.
• Sato N. Periodontal surgery In: A clinical atlas of periodontology, 3, 2003;
353- 392.

• Vijay DM, Deepika P C, Sharma H M. Whale's tail technique. J Int Clin
Dent Res Organ 2019; 11: 110-3.
• Trombelli L, Farina R et al. single flap approach with buccal access in
periodontal reconstructive procedures. J Periodntol 2009; 80 (2): 353-60.
• Trombelli L, Simonelli A et al. Single-flap approach for surgical
debridement of deep intraosseous defects: A randomized controlled trial. J
Periodontol. 2012; 83: 27-35.
• Trombelli L, Farina R et al. single flap approach with and without GTR and
a hydroxyapatite biomaterial in the management of intraosseous
periodontal defects. J Periodontal. 2010; 81: 1256-1263.

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