Flap management improved

1. Dr R Viswa Chandra MDS;DNB
Professor and Head
Department of Periodontics
SVS Institute of Dental Sciences
Mahabubnagar TS

2. Introduction
Basic Implant Principles include the following
•Conservative flap design
• Evaluation of existing bony architecture
• Esthetic osteotomy preparation
• Knowledge of timing for implant placement
• Correct spacing between adjacent implants or teeth
• Understanding the time needed for implant loading and soft tissue healing
• Formation of the emergence profile
• Knowledge of abutment selection

3. *Zola MB. Methods of designing, elevating, and suturing the intraoral flap. Oral Implantol. 1972 Summer;3(1):5-18.

4. • Full thickness flaps which should
be reflected cleanly
• No tension during procedure
or after suturing
Ideal Flap
• Trapezoidal Flap

5. • The ability to ‘fillet’ or incise the
periosteum to mobilise it coronally
p
f

6. Ideal “Implant Flap”
The minimal the better; don’t “mouse-hole” the flap
Spares the papilla if possible
Effects easy primary closure
Heals without complications
Can replicate papillary anatomy/gingival anatomy

7. Implant Flaps
Location Papilla criteria
Specialized flaps
•Crestal/
Mid-crestal
•Remote
•Papilla inclusion
•Papilla exclusion
•Advancement flaps
Trapezoidal flaps Envelope flaps
•Second stage Surgery

8. TRAPEZOIDAL FLAPS-LOCATION
Crestal Incision
An incision on the crest of the edentulous ridge is extended in
the gingival crevices of the adjacent teeth to allow adequate
exposure of the ridge.

9. No 12 Blade
Crestal Incision

10. TRAPEZOIDAL FLAPS-LOCATION
Remote Incision
If augmentation procedures are thought to be required, it is prudent to
base incision lines more remotely to avoid exposure of grafted
materials.

11. R
C
Remote Incision

12. It is advised to avoid placing oblique
relieving incisions over prominent
root surfaces because recession may
result if there is an underlying bony
dehiscence.
A broad base to the flap is not
necessary for survival because the
blood supply and nutrient bed for
mucosal flaps are excellent so don’t
overextend the vertical incisions.

13. TRAPEZOIDAL FLAPS-PAPILLA CRITERIA
Papilla Saving Incision
Avoidance of papilla reflection aims to preserve the aesthetics of these
structures which are difficult or impossible to reconstruct if lost.
>8mm
5mm

14. PAPILLA SAVING INCISION

15. REMOTE PAPILLA SAVING INCISION

16. Band of
keratinized tissue
Adequate
Tissue Punch
Full-thickness Flap
Sufficient Partial thickness flap-
gingivectomy technique
Deficient Tissue augmentation
ENVELOPE FLAPS
Stage II Surgery

17. Adequate Keratinized Gingiva

18. Sufficient Keratinized Gingiva
Partial Thickness Flap-Gingivectomy Technique
Initial incision to made approximately 2mm coronal to the facial/lingual mucogingival
junction, with vertical incisions both mesially and distally.

19. Sufficient Keratinized Gingiva
Partial Thickness Flap-Gingivectomy Technique
A partial thickness flap (PT) is then raised in such a manner that a
relatively firm periosteum (P) remains. The flap, containing a band of keratinized
tissue, is then placed facial to the emerging head of the implant fixture.
Excess tissue coronal to the cover screw is excised, usually using a
gingivectomy technique
PT
P

20. Sufficient Keratinized Gingiva
Partial Thickness Flap-Gingivectomy Technique
Suturing of the flap and post-operative view

21. Amount of buccal flap advancement required is based on complexity
of the Surgical procedure*
*Greenstein G et al. Flap advancement: practical techniques to attain tension-free primary closure. J Periodontol. 2009 Jan;80(1):4-15.
Minor Flap
Advancement
(<3mm)
Moderate Flap
Advancement
(3 to 6 mm)
Major Flap
Advancement
( ≥7 mm)
SPECIALIZED FLAPS
Advancement flaps

22. Minor Flap Advancement

23. 1. In conjunction with a horizontal
incision across the edentulous
area, create two vertical
releasing incisions on the buccal
aspect.
2. If vertical incisions do not
facilitate optimal tissue
advancement, hold the flap
under tension with a tissue
forceps, and score the
periosteum across the whole
flap.
Moderate Flap Advancement
1
2

24. Moderate Flap Advancement

25. Moderate Flap Advancement

26. • If buccal vertical releasing
incisions and periosteal
fenestrations do not provide
enough flap advancement to
achieve tensionless primary
closure, it is necessary to cut
deeper into the sub mucosa.
• This is done only when necessary
as the patient experiences
increased morbidity with regard
to swelling, hemorrhage, and
discomfort.
Major Flap Advancement

27. Major Flap Advancement

28. Basic Suturing Techniques
Figure-of-8 suturing technique
1. Common and easy
2. Tension free closure
Contraindications:
1. Not suitable in regenerative
procedures
2. Suture microleakage and wicking
are common

29. Basic Suturing Techniques
Direct Vertical Mattress
1. Everts the tissue
2. Best in Regenerative
procedures
Contraindications:
1. Difficult to execute
2. Flap necrosis if knots are tight

30. Basic Suturing Techniques
Coronally Repositioned
Vertical Mattress
1. Virtually no suture in between
the tissue
2. Best in GBR/GTR/Advanced
regenerative procedures
Contraindications:
1. Difficult to execute
2. Sutures loosen easily