This document provides an overview of periodontal flap procedures. It defines a periodontal flap as a section of gingiva and mucosa surgically separated to provide access to the bone and root surfaces. It classifies flaps based on bone exposure and placement after surgery. It discusses indications, contraindications, and techniques for various flap designs including papilla preservation flaps, apically positioned flaps, and distal molar flaps. It also covers incision types, flap elevation, debridement, suturing, and healing. The goal of flap procedures is to access and treat periodontal pockets, defects, and furcations.

1. THE PERIODONTAL FLAP
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2. LEARNING OBJECTIVES
• DEFINITION
• INDICATIONS AND CONTRAINDICATIONS
• CLASSIFICATION OF FLAP
• FLAP DESIGN
• INCISIONS IN FLAP SURGERY
• ELEVATION OF FLAP SURGERY
• DEBRIDEMENT
• OSSEOUS MANAGEMENT
• SUTURES AND SUTURING TECHNIQUES
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3. • HEALING AFTER FLAP SURGERY
• FLAP TECHNIQUES
• FLAP TECHNIQUE FOR POCKET THERAPY
• UNDISPLACED
• DISPLACED
• FLAPS FOR RECONSTRUCTIVE THERAPY
• DISTAL MOLAR SURGERY
• CONCLUSION
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4. DEFINITION
• The periodontal flap is a section of gingiva
and/ mucosa that is surgically separated form
the underlying tissues to provide visibility and
access to the bone and root surface
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5. INDICATIONS
1. Presence of moderate to deep pockets even after phase I
therapy
2. Presence of osseous defects
3. Presence of inflammation and disease activity at the base
of the sulcus as seen by bleeding on probing
4. Furcation involvement
5. Regeneration of periodontal tissues by the use of bone
grafts and membrane
6. Gingival overgrowth
7. Periodontal pockets adjacent to distal molars
8. Other periodontal procedures, such as Crown Lengthening
Procedure and apicectomy
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6. CONTRAINDICATIONS
1. Poor plaque control
2. High caries rate
3. Unrealistic patient expectations or desires
4. Uncontrolled medical conditions such as ‐unstable
angina ‐uncontrolled diabetes ‐uncontrolled
5. Hypertension ‐myocardial infarction / stroke within 6
months.
6. Teeth with hopeless prognosis
7. When surgery can lead to extreme disfigurement
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7. CLASSIFICATION
• Based on bone exposure after reflection
1. Full thickness(mucoperiosteal)flap
2. Partial thickness(split thickness)flap
• Placement of flap after surgery
• 1. Non-displaced flap 2. Displaced flap a)Apical
displaced flaps b)Coronal displaced flaps
c)Lateral displaced flaps
3. Management of papilla 1. Conventional flap 2.
Papilla preservation flap
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9. FLAP DESIGN
• The design is Dictated by the surgical judgement of the
operator and may depend on the objectives of the
operation.
• Two basic flap designs are used. Conventional flap and
Papilla preservation flap
• Split papilla flap -Interdental papilla is split beneath
the contact point of the two approximating teeth to
allow reflection of buccal and lingual flaps.
• Full thickness Incorporates the entire papilla in one of
the flaps by means of crevicular interdental incisions to
serve the connective tissue attachment.
• Horizontal incision at the base of the papilla.
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10. • Flap design should be done in detail before
procedure
• › Based on clinical & radiographic findings of case
• › It should include the following
1. Type of flap
2. Location and type of incisions
3. Management of underlying bone
4. Final placement of flap
5. Sutures used
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11. Horizontal incisions
• Internal bevel
• Crevicular incision
• Interdental incision
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12. Internal bevel incision
• Starts at a distance from the gingival margin and
which is aimed at the bone crest using 15
number BP blade
• Basic to flap surgery
• Exposure of root and underlying bone
• Removes pocket lining
• Conserves uninvolved outer gingiva
• Produces a sharp, thin flap margin
• Places the connective tissue close to the root.
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13. Horizontal incisions
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14. Crevicular incision
• Second incision Made from base of the sulcus
to the crest of bone
• Forms “V” shaped wedge of tissue, contains
Infected granulation tissue, Junctional
epithelium & Supracrestal fibers.
• BP blade #12 used.
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15. Interdental incision
• Third incision : A periosteal elevator is
inserted into the initial internal bevel incision,
and the flap is separated from the bone.
• It separates the collar of gingiva that is left
around the tooth.
• The Orban knife is usually used for this
incision.
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16. Vertical incisions
• They 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 or coronally displaced
• In general vertical incisions are avoided in
lingual and palatal areas
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19. Elevation of flap
• When a full thickness flap is desired, reflection
of the flap is accomplished with blunt incision.
• Periosteal elevator is used to separate the
mucoperiosteum from the bone by moving it
mesially, distally and apically until desired
reflection is reached
• No more than 1-2mm bone needs to be
exposed while reflection
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20. Debridement
• Granulation tissue is removed using sharp
Gracey curettes
• Once this is done the bleeding stops
considerably allowing operator to visualize the
surgical field better
• It is important that flap should not be allowed
to dry during surgery therefore frequent
irrigation with saline is needed
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21. Osseous management
• Resective or regenerative procedure can be
chosen
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22. Sutures and suturing techniques
Suture materials for periodontal flap
NON ABSORBABLE
• SILK
• NYLON
• ePTFE
• POLYESTER
ABSORBABLE
• SURGICAL GUT
• PLAIN GUT
• CHROMIC GUT
SYNTHETIC
• PGA
• VICRYL
• POLIGLECAPRONE
• MONOACRYL
• POLYGLYCONATE
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23. Interdental ligation
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25. Simple interuppted sling suture
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26. Horizontal mattress suture
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28. Anchor suture
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29. Closed anchor suture
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30. Periosteal suture
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31. HEALING AFTER THE FLAP
SURGERY
• Immediately after suturing: clot formed between
tooth and bone surface. Contains PMNs leukocytes,
erythocytes debris of injured cells and capillaries at the
end of the wound
• 1-3 days after surgery: epithelial cells migrate over the
border of flap and usually contact tooth at this time
• One week after surgery: Epithelial attachment to the
root has been established by means of
hemidesmosomes and a basal lamina. Clot replaced by
granulation tissue derived from gingival connective
tissue, bone marrow and PDL
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32. • Two weeks after surgery: collagen fibers begin
to form. Union is weak and has immature
collagen
• One month after surgery: Fully epithelized
gingival crevice with a well defined epithelial
attachment is present. Beginning of functional
attachment of supracrestal fibers
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33. Different flap techniques
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34. LRM 17, IV BDS U.G CURRICULUM- DEPT OF
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• Various clinicians have devised various flap
designs like Newman flap, krikland flap, flap
curettage, open flap curettage and so on
• But the most commonly used is Modified
Widman flap, conventional or access flap,
undisplaced flap and apically positioned flap
• Modified widman flap has been described for
exposing the root surfaces for meticulous
instrumentation and for the removal of
pocket lining

35. • Conventional or access flap attempts to conserve the
tissues as much as possible so as to ensure optimal
coverage of graft materials and barrier membranes.
• The undisplaced (unrepositioned) flap improves
accessibility for instrumentation, but it also removes
the pocket wall thereby reducing or eliminating pocket
• The apically positioned flap provides accessibility and
elimination of the pocket but it does the latter by
apically positioning the soft tissue wall of the pocket
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36. Flap technique for pocket therapy
• Modified widman flap: In 1965 Morris revived
a technique described early during 20th
century he called it as unrepositioned
mucoperiosteal flap.
• Essentially same procedure was presented in
1974 by Ramfjord and Nissle called it as
Modified widman flap
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37. Modified widman technique
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39. Undisplaced flap
• It differs form modified widman flap in that
the soft tissue pocket wall is removed with
initial incision thus it may be considered as
internal bevel gingivectomy
• The undisplaced flap and gingivectomy are
two procedures used to remove pocket lining
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40. • Step 1: Pockets are measured and bleeding points
are marked
• Step 2: Internal bevel incision is made after
scalloping the bleeding marks on the gingiva. The
incision is usually carried to a point apical to
alveolar crest depending on the thickness of the
tissue
• Step 3: The second or crevicular incision is made
form the bottom of the pocket to the bone to
detach the connective tissue from the bone
• Step 4: The flap is reflected with blunt end
•
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41. • Step 5: The third or interdental incision is made
with an interdental knife to separate the
connective tissue from the bone
• Step 6: The triangular wedge is removed
• Step 7: The area is debrided to remove all tissue
tags and granulation tissue with sharp curettes
• Step 8:The edge of the flaps are trimmed and
approximated
• step 9: A continuous sling suture is given
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42. Palatal flap
• The palatal tissue is all attached and keratinized,
therefore it cannot be apically positioned and a
partial thickness flap cannot be accomplished
• The initial incision of flap should allow the flap,
when sutured to be precisely adapted at the root-
bone junction
• The palatal tissue may be thick thin, it may have
osseous defects or may not have. Palatal vault
may be high or low. These anatomic variations
may require changes in the location, angle and
design of the incision
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43. • The initial incision for flap is internal bevel,
and this may be followed by crevicular and
interdental incisions.
• If tissue is thick, a horizontal gingivectomy
incision is made and this may be followed by
internal bevel incision that starts at the edge
of this incision and ends on the lateral surface
of the underlying bone.
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44. LRM 17, IV BDS U.G CURRICULUM- DEPT OF
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45. LRM 17, IV BDS U.G CURRICULUM- DEPT OF
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46. LRM 17, IV BDS U.G CURRICULUM- DEPT OF
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47. Flaps for reconstructive surgery
• Papilla preservation
• Conventional flap/access flap
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48. Conventional flap
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50. DISTAL MOLAR SURGERY
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51. Distal wedge suture
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52. Distal wedge suture
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53. Questions
Long question
1. Define and classify flap. Write in detail about
apically positioned flap
2. Methods to increase width of attached
gingiva
Short Notes
1. Palatal flap
2. Unrepositioned flap
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54. THANK YOU
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