A concise edition of the topic periodontal flaps which is an important topic for any dentist

1. Periodontal Flap
1
Presented by
S M Sivaraman

2. Contents
 Definition
 Historical backdrop
 Objectives of periodontal surgical phase
 Classification of flaps
 Principles of flap designing
 Principles governing incision placement
 Flap management
 Objectives of flap elevation
 Flaps for pocket elimination
 Flaps to induce Re-attachment &
regeneration
 Summary and conclusion
 References
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3. Definition
 Periodontal flap is defined as a section of gingiva and/or mucosa surgically separated from
underlying tissues to provide visibility and access to bone and root surface.
Carranza’s clinical periodontology 11th edition 3

4. Historical backdrop
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19th century - Riggs – Gingivectomies – straight line incisions – ‘Barbaric’
1884 – Robiseck – Radical technique of gingivectomy with bone exposure
20th century – Flap surgery and suturing of flap
1911 – Robert Neumann – “The radical treatment of alveolar pyorrhea”
1914 – Cieszynski – Reverse bevel incision
1916 – Leonard Widman- “The operative treatment of pyorrhea alveolaris”
1931 – Kirkland – Procedure – “periodontal pus pockets”
1954 – Nabers – Repositioning of attached gingiva – Apically repositioned flap
1966 – Robinson - Distal wedge procedure
1974 – Ramfjord & Nissle – Modified Widman flap

5. Objectives of periodontal surgical phase
Improve prognosis of teeth & their replacements
Improvement of esthetics
 Increase the accessibility to the root surface – remove – all irritants.
 To reduce or eliminate pocket depth – Free of plaque.
 Reshape soft and hard tissues to attain a harmonious topography.
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6. Classification of Flaps
Based on bone exposure after flap reflection
A)Full thickness flaps (Mucoperiosteal):
 In this , all the soft tissue along with the periosteum is
reflected to expose the underlying bone – Osseous
resective or regenerative surgery
B)Partial thickness (Split thickness):
 In this only the epithelium and a layer of connective
tissue is included . The bone remains covered by a layer
of connective tissue including the periodontium –
Displaced flaps
Carranza’s clinical periodontology 11th edition
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7. Based of flap placement after surgery
A)Undisplaced flap:
 When flap is returned to its original position (eg) Conventional flaps
B)Displaced flap:
 Which are placed apically, Coronally or laterally to their original position
Carranza’s clinical periodontology 11th edition
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8. Based on management of papilla:
A)conventional flap:
 The interdental gingiva split beneath
the contact point of the two
approximating teeth to allow for the
reflection of buccal and lingual flaps the
incision is scalloped to maintain gingival
morphology with as much papillae as
possible (eg) Modified Widman.
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9. B)Papilla preservation flap:
 Incorporates the entire papillae in
one of the flaps by means of
interdental Crevicular incisions to
severe the connective tissue
attachment and horizontal incision
at the base of papillae leaving it
connected to the flap.
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10. Flap designs
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Envelope Flap:
A flap that is released in a
linear fashion at the
gingival margin but has no
vertical releasing
incision(s).
Pedicle Flap:
If two vertical releasing
incisions are included
in the flap design.
Triangular Flap:
If one vertical
releasing incision is
included in the flap
design.
Two basic flap designs,
with and those without
vertical releasing incisions

11. Principles of flap designing
Prevention of flap necrosis
The apex of the flap should never be wider than the base, unless major artery is present in the base
Flap should either run parallel to each other or preferably converge from the base of the flap to its apex
In general the length of the flap should be no more than twice the width of the base
Whenever possible, an 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).
Louis F. Bose, Brian L. Mealy, Robert J. Genco. Principles and practice of periodontal surgery. Periodontics Medicine, Surgery, and implants. 11

12. Prevention of flap tearing
It is preferable to create a flap at the onset of surgery that is enough to avoid either tearing it or
interrupting surgery to modify it.
If an envelope flap does not provide sufficient access, another incision should be made to prevent it
from tearing.
Vertical (oblique) releasing incision should be placed one full tooth anterior to the area of any
anticipated bone removal
The incision should be started at the line angle the tooth or in the adjacent interdental papilla &
carried obliquely apically into the unattached gingiva.
It is uncommon to need more than one releasing incision when using a flap to gain surgical access.
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13. PRINCIPLES GOVERNING INCISION PLACEMENT
According LASKIN (1980)
The incision should not be made over the operative site rather in the adjacent, undisturbed areas so that the flap will be supported by
normal tissue& the potential for rapid revascularization is preserved.
The incision should be placed so that major nerves are not transected unless necessary.
An adequate blood supply should be maintained by incising parallel to the major vessels, minimizing the number of side cuts & having
the base of the flap as wider than the apex.
Incisions should not be made in areas of thinned mucosa like that found over an exostosis or other prominence because the blood
is reduced, suturing is difficult & rate of dehiscence is very high.
When developing flaps around teeth, the incisions should be made in the gingival crevice.
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14. It is also important to maintain the integrity of the interdental papillae & do not include them within the flap because of the
difficulty in precise re-approximation of the same.
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 at an angle of 45° from the direction of the parent incision.
Releasing incisions reduce blood supply to the flap & cause added discomfort. If possible, the releasing incision should not
be made at a sharp angle to the primary incision but instead curve gradually from it.
If the flap is to include both mucosa & the periosteum, the incision should be made directly to the bone with one cut & 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
& permit tissue fluid to penetrate more readily.
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15. Flap management & Flap Retraction
Another element in good flap management that is often given line consideration involves the use of surgical retractors to hold the flap back from the teeth and bone.
If the flap has been properly designed and reflected adequately, retraction should be passive without any tension, Force should not be necessary to keep the flap retracted. It is also critically
that the edge of the retractor always be kept on bone.
Trapping the flap between the retractor and bone can cause tissue ischemia and lead to postoperative flap necrosis.
Continuous flap retraction for long periods also is not advised.
Such a practice will desiccate the soft tissue and bone causing a delay in wound healing.
When the flap is retracted the surgical assistant should frequently irrigate the surgical field with
sterile saline, to keep the tissues moistened, to reduce contamination, and to improve visibility.
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16. Incisions
Two major types of incisions exist
 Horizontal incisions
 Vertical incisions
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17. Horizontal Incisions
Horizontal incisions are directed along the margin of the
gingiva in a mesial or a distal direction. Two types of horizontal
incisions have been recommended:
A) The internal bevel incision, which starts at a distance from
the gingival margin and is aimed at the bone crest, and
B) The crevicular incision, which starts at the bottom of the
pocket and is directed to the bone margin.
C) In addition, the interdental incision is performed after the
flap is elevated.
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18. INTERNAL BEVEL INCISION
 1st incision
 1º incision
 Reverse bevel incision
 11 or 15 surgical scalpel used
 Starts at a distance from the gingival
margin aiming at the bone crest.
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19.  Removes pocket lining.
 Produces a sharp thin flap
margin.
 Starts from a designated
area on the gingiva and is
directed to an area at or
near the crest of the bone.
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Various locations and angles of
internal bevel incision

20. CREVICULAR INCISION
 Also known as second incision
 Made from the base of the pocket
to the crest of the bone
 This incision, together with the
initial reverse bevel incision, forms a
V-shaped wedge ending at or near
the crest of bone
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Beak-shaped #12D blade is
used

21. INTERDENTAL INCISION
 Also known as third incision
 To separate the collar of gingiva that is
left around the tooth
 Incision made facially, lingually &
interdentally connecting the 2
segments.
 Orbans knife is used
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22. VERTICAL INCISIONS
 Can be used on one or both ends of
the horizontal incision
 Must extend beyond the mucogingival
line, reaching the alveolar mucosa, to
allow for the release of the flap to be
displaced
 Vertical incisions in the lingual and
palatal areas are avoided
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This incision should be made at the line angles to
prevent splitting of a papilla or incising directly over
a radicular surface.

23. Thinning incision
Internal or undermining incision extending from gingival margin toward the base of the flap to
decrease bulk of the connective tissue on the underside of the flap
Indication:
Palatal flaps
Distal wedge
Internal bevel gingivectomy
Bulky papillae
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24. Cutback incision
 Small incision made at the apex of the releasing incision and directed towards the base of the
flap
Indication:
Pedicle flaps that are laterally positioned
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25. ELEVATION OF THE FLAP
Blunt dissection
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Periosteal elevator
Full thickness flap
Sharp dissection
BP Blade
Partial thickness flap

26. PURPOSE & OBJECTIVES OF FLAP ELEVATION
 To control & eliminate periodontal disease.
 To eliminate pocket
 To maintain root surface accessible for scaling & self-performed tooth cleaning after healing
 To correct anatomic condition that may favour periodontal disease, impair esthetics or impede
placement of correct prosthetic appliances
 To place implants to replace lost tooth.
 To sim at regeneration of periodontal attachment, lost due destruction by disease.
 To improve the prognosis of the teeth & their replacements.
 To improve esthetics.
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27. FLAPS FOR POCKET ELIMINATION
I.ORIGINAL WIDMAN FLAP
II. NEUMANN FLAP
III. MODIFIED FLAP OPERATION (KIRKLAND 1931)
IV. UNDISPLACED FLAP
V. MODIFIED WIDMAN FLAP
VI. APICALLY REPOSITIONED FLAP
VII.BEVELED FLAP
VIII.PALATAL FLAP
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28. Original Widman Flap
1918 - Leonard Widman – “The operative treatment of pyorrhoea alveolaris” described a mucoperiosteal
flap design aimed at removing the pocket epithelium and the inflamed connective tissue, thereby facilitating
optimal cleaning of the root surfaces.
 Less discomfort for the patient, since healing occurred by primary intention
 That it was possible to re-establish a proper contour of the alveolar bone in sites with angular bony
defects.
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29. Technique
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30. Neumann Flap
Neumann's first mention - flap surgery - first edition of his text "Pyorrhea Alveolaris and ts
Treatment“ – 1912.
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31. 31
Technique

32. MODIFIED FLAP OPERATION KIRKLAND 1931
Olin Kirkland – “Modified flap operation”- treatment of "periodontal pus pockets“. Basically
modification of Neumann flap.
Technique:
 In this procedure incisions were made intracrevicular through the bottom of the pocket on both
the labial and the lingual aspects of the interdental area. The incisions were extended in a mesial
and distal direction.
 The gingiva was retracted labially and lingually to expose the diseased root surfaces which were
carefully debrided
 Following the elimination of the pocket epithelium and granulation tissue from the inner surface
of the flaps, these were replaced to their original position and secured with interproximal suture
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33. 33
1 2
3 4

34. Difference:
 Does not include extensive sacrifice of non-inflamed tissues
 Apical displacement of the gingival margin.
Advantages:
 The method could be useful in the anterior regions of the dentition for esthetic reasons, since the
root surfaces were not markedly exposed.
 It has the potential for bone regeneration in intrabony defects which frequently occurred
to Kirkland.
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35. Undisplaced flap
 In 1965 -Morris - "Unrepositioned Mucoperiosteal Flap“- Currently most performed periodontal
surgery.
 In this technique, the soft tissue pocket wall is removed with the initial incision, thus it may be
considered as an internal bevel gingivectomy“
Advantages
 Improved accessibility for instrumentation.
 Removes the pocket wall lining.
Disadvantages
 Poor esthetics.
 Root exposure leading to sensitivity and caries.
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36. 36
Technique

37. MODIFIED WIDMAN FLAP
 1974 - Ramjford and Nissle - "Modified Widman Flap".
 This is also recognized as the “open flap curettage”
Objectives :
 Provide access for root debridement
 Preserve the maximum amount of periodontal tissue.
 Remove the inflamed pocket wall
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38. Indications:
 Deep pockets.
 Intrabony pockets.
 This is the basic technique when implantation of bone or other substances into intrabony lesions
contemplated.
 When minimum gingival recession is required.
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39. Technique
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40. 40

41. 41
Advantages:
The possibility of obtaining a close adaptation of the soft tissues to the root
surfaces.
The minimum of trauma to which the alveolar bone and the soft connective
tissues are exposed.
Less exposure of the root surfaces, which, from an esthetic point of view is an
advantage in the treatment of anterior segments of the dentition.
It provides access for proper instrumentation of the root surfaces &
immediate closure at the dentogingival junction between the teeth & well
fitting flaps.
Conservation of bone & optimal coverage of the root surfaces by soft
tissues.
It results in more pocket closure by reattachment & bone regeneration

42. Disadvantages
Inability to achieve pocket elimination.
Healing by long junctional epithelium.
Difficult to perform in thin and narrow attached gingiva.
Flat or concave interproximal architecture immediately following removal of the surgical dressing,
especially in the areas of the interproximal bony craters.
Failure in completely approximating buccal or lingual flaps or inadequate fit of the flaps to the teeth
following attempts to perform modified Widman flap often gives poor results with residual inflamed and
deep periodontal pockets.
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43. Apically repositioned flap
1962-Friedman
The apically positioned flap is one of the most widely used techniques for eliminating
periodontal pockets.
A flap made by an internal bevel incision is displaced apically from the original position,
and the suture is made on the alveolar crest or in a slightly coronal position
The position of the flap displacement varies depending on:
 Thickness of alveolar margin in operating area.
 Width of attached gingiva.
 Clinical crown length necessary for an abutment.
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44. Indications:
 Pocket eradication.
 Widening the zone of attached gingiva.
 Areas of thin periodontium or prominent roots
where dehiscence or fenestrations may be
present
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 unfavourable clinical
crown/root ratio.
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45. Technique
45
1 2
3
4

46. Advantages
 Healing by primary intention.
 Maximum coverage of the bone.
 Accurate control of the post operative
amount of the attached gingiva.
 Maintenance of the normal relationships of
all the structures because the gingival tissue
is to be apically positioned.
 Rapid healing minimizing undesirable
postoperative sequelae.
 Minimum bone loss and stable results.
Disadvantages
 May cause esthetic problems due to root
exposure.
 May cause attachment Loss due to surgery.
 May cause hypersensitivity.
 May increase the risk of root caries.
 Unsuitable for treatment of deep periodontal
pockets.
 Possibility of exposure of furcations and roots,
which complicates postoperative
supragingival plaque control.
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5

47. Partial – Thickness Palatal Flap
Partial-thickness palatal flap surgery was developed by Staffileno and improved by Corn et al.
Indications:
 It is used for the elimination of periodontal pockets where thick palatal tissues occur.
Advantages:
 Flap thickness may be adjusted.
 Palatal flap may be adapted to the proper position
 Better postoperative gingival morphology is possible with a thin flap design.
 Treatments may be combined (osseous resection and wedge procedure).
 Easy management and Minimal damage to palatal tissue. (Rapid healing).
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48. Considerations for determining the position of the
primary incision in palatal flap surgery:
Thickness of palatal tissue.
Depth of periodontal pocket.
Degree of osseous defect
Necessity of osteoplasty and required clinical crown length
Surgical methods (or techniques) applied
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49. Technique
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1 2
3 4

50. Contraindications :
• When a broad, shallow palate does not
a partial-thickness flap to be raised without
possible damage to the palatal artery.
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5
6

51. FLAPS TO INDUCE RE-ATTACHMENT & REGENERATION
Distal wedge
procedure
Papilla preservation
technique
Modified papilla
preservation
technique
Simplified papilla
preservation flap
Minimal invasive
surgical technique
(mist)
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52. Distal wedge procedure
This procedure was first described by Robinson -1966 & Braden - 1969
Objectives of distal
wedge procedure
To eliminate
pockets.
Maintain & preserve
attached gingiva.
Make area accessible to
instruments.
Lengthen clinical crown.
Create easily cleansable
gingiva-alveolar form.
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53. Factors that determine the flap design of
a wedge procedure
• Size and shape
• Thickness of soft tissue
• Difficulty of access
• Band of attached gingiva of the abutment tooth
• Depth of periodontal pocket and degree of
osseous defect on the edentulous side of the
abutment
• Clinical crown length required as an abutment for
restorative/prosthetic treatment
Factors that determine the amount of wedge
tissue removed
• Thickness of the soft tissue
• Depth of periodontal pocket and osseous defect
• Amount of bone to be removed (whether by osteoplasty or
ostectomy if necessary)
• Clinical crown length necessary for the abutment
• Pontic form
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54. Technique
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55. Modification of flap design for wedge
procedure
Problems of an edentulous space adjacent to
an abutment
 Plaque hard to control.
 Effects of initial therapy may be suboptimal
because of limited accessibility of instruments
during scaling & root planing.
 Maxillary tuberosity & retro molar triangle are
covered with thick gingiva & tend to form deep
periodontal pockets. Therefore, advanced
furcation involvement is often observed.
 Abutment adjacent to edentulous space is a
key tooth for occlusion & bears stress in
function. Hence, it is at high risk to advance to
severe periodontal disease.
55

56. Papilla preservation technique
Takei et al. (1985) - papilla preservation technique. Cortellini et al. - 1995,1999 – modifications of flap design
to be used in combination with regenerative procedures.
For esthetic reasons, the papilla preservation technique is often utilized in the surgical treatment of anterior
tooth regions.
Objectives:
To preserve the interdental soft tissue for maximum soft tissue coverage following surgical intervention
involving treatment of proximal osseous defects.
Indications:
In the surgical treatment of anterior teeth.
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57. Technique
57
1
3
2

58. 58
4
5
Disadvantage:
Not very effective in closing of the
interproximal space when a barrier membrane
is used this would require the coronal
positioning of the flaps to close the
interproximal space

59. MODIFIED PAPILLA PRESERVATION TECHNIQUE
To overcome the disadvantage of papilla preservation technique developed by Takei, Cortellini et al.
developed a modification of the above mentioned technique in 1995.
Rationale:
 To achieve and maintain primary closure of the flap in the interdental space over the membrane
 To obtain good protection of the regenerating tissue through complete coverage of the membrane with the
flaps.
 To increase the amount of regeneration.
Indications:
 For different regenerative approaches involving the interdental space.
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60. Advantages
 Allowed complete coverage of the Teflon
membrane.
 Primary closure of the muco-periosteal flaps
in the interdental space in 93% of the cases.
 Interdental tissue covers the membrane until
its removal for 6 weeks.
Disadvantages
 Technique sensitive
 In molars with interproximal space present,
application of the desired surgical technique
did not result in the desired primary closure.
 The narrow interdental soft tissue is more
likely to undergo a necrosis.
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61. SIMPLIFIED PAPILLA PRESERVATION FLAP
To overcome some of the technical problems encountered with the MPPT a
approach i.e. Simplified Papilla Preservation Flap, SPPF, was subsequently
(Cortellini et al. 1999).
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63. 63

64. MINIMAL INVASIVE SURGICAL TECHNIQUE
(MIST)
A minimally invasive surgery (MIS) has been proposed in 1995 (Harrel & Ress) with the aim to produce minimal
minimal flap reflection and gentle handling of the soft and hard tissues in periodontal surgery.
"MIS technique (MIST)", has been specifically designed to treat isolated intrabony defects with periodontal
Basis for this technique are the concepts of the MIS + papilla preservation techniques[modified papilla preservation
technique + simplified papilla preservation flap + application of passive internal mattress sutures to seal the
wound from the oral environment.
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65. Objectives
Reduce surgical trauma
Increase flap/wound stability
Allow stable primary closure of the wound
Reduce surgical chair time
Minimize patient discomfort and side effects.
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Technique

66. Conclusion
 The periodontal flap surgery is the most widely utilized surgical procedure to reduce
the pocket depth and to access the subgingival root surfaces for scaling and root
planing.
 The diagnosis of the periodontal lesion and the objective of the surgery will dictate
the type of flap procedure which will be utilized to obtain the best result.
 The incisions, type of flap and the selection of suturing design must be planned and
executed to fit the problem.
 Periodontal flap procedures for pocket therapy include flaps solely for access to root
surfaces and bone margins, flaps for the precise processes of osseous surgery, and
flaps for periodontal regeneration.
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67.  Each of these approaches have specific flap designs, step-by-step elements, and all of them have
calculus removal and root planing as an essential treatment protocol.
 Flaps should allow adequate access and should be reflected so that at least 3 mm of bone crestal is
exposed.
 If flaps are to be positioned apically, flap mobility is obtained by extending facial and lingual flap elevation
beyond the mucogingival junction, which enables the elasticity of the mucosa to be applied.
 Sometimes it may be necessary to extend the flap elevation apically with a split incision approach to
minimize the effect of the less elastic periosteum.
 Vertical incisions can aid in flap positioning by allowing the clinician to suture the flap at a different level to
to the adjacent untreated gingiva
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68.  Palatal flaps are more difficult to position coronally than buccal or lingual flaps
 If it is required to position flaps coronally or even at their original levels, then a sulcular incision is
used.
 Palatal flaps are less mobile because of the absence of oral mucosa so that the apical position of
the flap depends on how much marginal gingival tissue is discarded using a reverse bevel
 The more apical positioning desired, the more extensive is the reverse bevel cut.
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