periodontal flap surgery

Periodontal
Flap
Surgeries
Guided by:
Dr. Monica Mahajani
Dr. Chandrahas Goud
Dr. Anup Shelke
Dr. Subodh Gaikwad
Dr. Anup Gore
Dr. Kuldeep Patil
Dr. Amrita Das
Presented by:
Dr. Chavan Sneha S.
(2nd Year PG)
28-07-2023 2

Periodontal flap is defined as
‘ the section of gingiva and/or mucosa surgically
elevated from the underlying tissues to provide visibility and
access to the bone and root surfaces’
-Glickman
28-07-2023 3

OBJECTIVES OF PERIODONTAL FLAP
1. Access for root instrumentation
2. Gingival resection
3. Osseous resection
4. Periodontal regeneration
28-07-2023 4

Indications For Periodontal Surgery
• Access to root and osseous
defects
• Resective surgery
• Regenerative surgery
• Preprosthetic surgery
• Crown lengthening
• Gingival augmentation
• Ridge augmentation
• Tori reduction
• Tuberosity reduction
• Vestibuloplasty
• Gingival enlargement
• Periodontal plastic surgery
• Esthetic anterior crown lengthening
• Soft tissue grafting for root coverage
or to obtain on physiologic gingival
dimension
• Papilla reconstruction
• Biopsy
• Implant surgery
• Treatment of periodontal abscess
• Exploratory surgery
Ref:Kerala Dental Journal Vol. 34 | No. 1 Supplement | March 2011
28-07-2023 5

Contraindications For Periodontal Surgery
• Uncontrolled medical conditions like – uncontrolled asthma,
uncontrolled hypertension, uncontrolled diabetes
• Poor plaque control
• High caries rate
• Unrealistic patient expectations or desires
Ref:Kerala Dental Journal Vol. 34 | No. 1 Supplement | March 2011
28-07-2023 6

Categories of periodontal surgery
Ref:Periodontal Flap Designs for Access and Osseous Surgery, S. Nares (ed.), Advances in Periodontal Surgery ; Antonio Moretti and Karin Schey
28-07-2023 7

Classification
Based on Papilla Management :
CONVENTIONAL FLAPS:
modified widman flap,
undisplaced flap, apically
displaced flap, flap for
reconstructive procedures
PAPILLA PRESERVATION
FLAP
28-07-2023 8

• With the conventional flap,
the interdental papilla is split
beneath the contact point of
the two approximating teeth
to allow for the reflection of
the buccal and lingual flaps.
• The incision is usually
scalloped to maintain gingival
morphology and to retain as
much papilla as possible.
28-07-2023 9

• The papilla preservation flap
incorporates the entire papilla
in one of the flaps by means of
crevicular interdental incisions
to sever the connective tissue
attachment as well as a
horizontal incision at the base
of the papilla to leave it
connected to one of the flaps.
28-07-2023 10

Based on Flap Elevation:
FULL THICKNESS
FLAP:
Mucoperiosteal flap
PARTIAL
THICKNESS FLAP:
Split thickness;
mucosal
28-07-2023 11

Full-thickness flap:
• All of the soft tissue, including the
periosteum, is reflected to expose the
underlying bone.
• This complete exposure of and access
to the underlying bone is indicated
when resective osseous surgery is
contemplated.
28-07-2023 12

Partial-thickness flap-
• It includes only the epithelium and a layer
of the underlying connective tissue.
• The bone remains covered by a layer of
connective tissue that includes the
periosteum.
• The partial-thickness flap is indicated
when the flap is to be positioned apically
or when the operator does not want to
expose bone.
28-07-2023 13

• When bone is stripped of its periosteum, a loss of marginal bone
occurs, and this loss is prevented when the periosteum is left on the
bone.
(Ref: Carranza FA, Jr, Carraro JJ: Effect of removal of periosteum on post- operative result of
mucogingival surgery. J Periodontol 34:223, 1963)
28-07-2023 14

Based on Flap Coaptation:
UNDISPLACED (NON-DISPLACED;
UNREPOSITIONED)
• Eg: Modified Widman,
undisplaced flap
DISPLACED (REPOSITIONED)
• Eg : Coronally positioned
• Laterally positioned
• Apically positioned
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Incisions:
• Periodontal surgery involves the use of horizontal (mesial-distal)
and vertical (occlusal-apical) incisions.
28-07-2023 16

• Horizontal incisions are directed along the margin of the gingiva in
a mesial or distal direction.
• Two types of horizontal incisions have been recommended:
• The internal bevel incision, which starts at a distance from the
gingival margin and which is aimed at the bone crest, and
• The crevicular incision, which starts at the bottom of the pocket
and which is directed to the bone margin.
• In addition, the interdental incision is performed after the flap is
elevated to remove the interdental tissue.
28-07-2023 17

HISTORICAL BACKGROUND
Neumann (1911) 1st introduced mucoperiosteal flap- ‘Neumann flap’
Leonard Widman (1918) Modified the Neumann flap
Kirkland (1931) Modified flap procedure
Nabers (1954) Introduced ‘repositioning of attached gingiva’
Ariaudo & Tyrrell (1962) Modified Nabers procedure
Friedman (1962) Apically positioned flap
Morris (1965) ‘Unrepositioned mucoperiosteal flap’
Ramfjord & Nissel (1974) ‘Modified Widman flap’
28-07-2023 19

FLAP TECHNIQUES FOR
POCKET ELIMINATION
28-07-2023 20

Five different flap techniques are used:
(1) the modified Widman flap,
(2) the undisplaced flap,
(3) the apically displaced flap,
(4) the papilla preservation flap,
(5) and the distal terminal molar flap.
28-07-2023 21

• In his article “The operative treatment of pyorrhea alveolaris”,
Widman described a mucoperiosteal flap design that aimed to
remove the pocket epithelium and the inflamed connective tissue,
thereby facilitating optimal cleaning of the root surfaces.
28-07-2023 23

The original widman flap (Leonard Widman,
1918)
• Full thickness mucoperiosteal flap
• Aimed at removing: Pocket epithelium and the inflamed
connective tissue
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• Two releasing incisions
demarcate the area scheduled
for surgical therapy. A scalloped
reverse bevel incision is made in
the gingival margin to connect
the two releasing incision
28-07-2023 25

• A mucoperiosteal flap is elevated to
expose at least 2–3mm of the
marginal alveolar bone.
• The collar of inflamed tissue around
the neck of the teeth is removed
with curettes and the exposed root
surfaces are carefully instrumented.
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• Bone recontouring is recommended
in order to achieve an ideal anatomic
form of the underlying alveolar bone.
28-07-2023 27

• Following careful debridement
of the teeth in the surgical
area, the buccal and lingual
flaps are laid back over the
alveolar bone and secured in
this position with
interproximal sutures.
28-07-2023 28

Advantages:
• Less discomfort for the patient, healing occurs by primary
intention
• Re-establish a proper contour of the alveolar bone in sites with
angular bony defects
• Possible increase of attached gingiva
28-07-2023 29

• Drawbacks:
Post operative recession
Associated sensitivity
Esthetics compromise, especially in maxillary anterior region
28-07-2023 30

• An intracrevicular incision is made
through the base of the gingival pockets
and the entire gingiva (and part of the
alveolar mucosa) is elevated in a
mucoperiosteal flap.
• Sectional (vertical) releasing incisions
are made to demarcate the area of
surgery.
Gold SI. Robert Neumann: a pioneer in periodontal flap surgery. J Periodontol. 1982
28-07-2023 32

• Following flap elevation, the inside of
the flap is curetted to remove the pocket
epithelium and the granulation tissue.
The root surfaces are subsequently
carefully debrided.
28-07-2023 33

• Any irregularities of the alveolar
bone crest are corrected.
28-07-2023 34

• The flaps are then trimmed to
allow both an optimal adaptation
to the teeth and a proper coverage
of the alveolar bone on both the
buccal/lingual (palatal) and the
interproximal sites.
28-07-2023 35

• replacing the flap at the crest of
the alveolar bone.
28-07-2023 36

• Advantages:
Less discomfort for the patient, since healing occurred by primary
intention.
Possible to re‐establish a proper contour of the alveolar bone in sites
with angular bony defects.
28-07-2023 37

• Drawbacks:
Post operative recession
Associated sensitivity
Esthetics compromise, especially in maxillary anterior region
28-07-2023 38

Modified flap operation (Kirkland flap, 1931)
• Modified flap operation- to be used in the treatment of
“ Periodontal pus pockets”.
He demonstrated the basic gingival mucoperiosteal flap design of
Neumann in 1920 for the original flap, but instead of trimming the
flap for surgical pocket elimination, he attempted to eliminate the
crevicular epithelial lining and the inflamed connective tissue by
curettage of the flap.
28-07-2023 40

• Pocket (sulcular/ crevicular)
incisions are made on both the
labial and the lingual aspects of
the interdental area. The
incisions are extended in a
mesial and a distal direction.
28-07-2023 41

• The gingiva is retracted (mucoperiosteal
flap reflection) labially and lingually to
expose the diseased root surfaces which
are carefully debrided.
28-07-2023 42

• Angular bony defects are curetted
but no bone is removed.
28-07-2023 43

• Following the elimination of the pocket
epithelium and granulation tissue from
the inner surface of the flaps, these are
replaced at their original position and
secured with interproximal sutures.
28-07-2023 44

• DIFFERENCE FROM NEUMANN AND ORIGINAL WIDMAN
FLAP:
Did not include
(1) extensive sacrifice of non-inflamed tissues and
(2) apical displacement of the gingival margin.
28-07-2023 45

Advantages:
• Useful in the anterior regions of the dentition for esthetic reasons,
since the root surfaces were not markedly exposed.
• Potential for bone regeneration in intrabony defects.
• Possible pocket depth reductions due to tissue shrinkage/ wound
contraction during post surgical healing.
28-07-2023 46

• Historical Aspect-
• Nabers in 1954, introduced “apically repositioned flap”.
• The procedure was named as “repositioning of the
attached gingiva”.
• In 1957, Nabers modified the procedure by adding inverse
bevel incision instead of trimming of gingival margins.
• It was done to achieve thin and knife edge gingival
margins.
• He called this incision the “repositioning incision”.
28-07-2023 48

• Nabers(1954) – one vertical incision- ‘repositioning of attached
gingiva’
• Ariaudo and Tyrrell (1957) – two vertical incisions
• Friedman (1962) – coined the term ‘apically repositioned flap’
28-07-2023 49

OBJECTIVES
• Apical displacement of entire mucogingival unit to eliminate the
pockets while retaining the attached gingiva.
• To maintain keratinized gingiva
• Surgical access for osseous surgery, treatment of infrabony
pockets and root planing.
28-07-2023 50

• A reverse bevel incision is made using a scalpel with a Bard– Parker®
blade (No. 12B or No. 15). How far from the buccal/lingual gingival
margin the incision should be made is dependent on the pocket
depth as well as the thickness and the width of the gingiva.
28-07-2023 51

• If preoperatively the gingiva is thin and only a narrow zone of
keratinized tissue is present, the incision should be made close to the
tooth. The beveling incision should be given a scalloped outline, to
ensure maximal interproximal coverage of the alveolar bone when
the flap subsequently is repositioned.
28-07-2023 52

• Vertical releasing incisions extending out into the alveolar mucosa
(i.e. past the mucogingival junction) are made at each of the end
points of the reverse incision, thereby making apical repositioning of
the flap possible.
28-07-2023 53

• A full‐thickness mucoperiosteal flap including buccal/lingual gingiva
and alveolar mucosa is raised by means of a mucoperiosteal elevator.
The flap has to be elevated beyond the mucogingival line in order to
be able later to reposition the soft tissue apically.
28-07-2023 54

• The marginal collar of tissue, including pocket epithelium and
granulation tissue, is removed with curettes and the exposed root
surfaces are carefully scaled and planed.
• The alveolar bone crest is recontoured with the objective of
recapturing the normal form of the alveolar crest, but at a more
apical level. The osseous surgery is performed using burs and/ or
bone chisels
28-07-2023 55

• Following careful adjustment, the buccal/lingual flap is repositioned
to the level of the newly recontoured alveolar bone crest and secured
in this position.
28-07-2023 57

• A periodontal dressing should therefore be applied to protect the exposed
bone and to retain the soft tissue at the level of the bone crest.
• After healing, an “adequate” zone of gingiva is preserved and no residual
pockets should remain.
28-07-2023 58

USED FOR
(1) pocket eradication
(2) widening the zone of attached gingiva.
(3)crown lengthening procedures for cosmetic enhancement and
restorative treatment
28-07-2023 59

Indicated in
• Mandibular buccal and lingual surfaces
• Maxillary buccal surfaces
It can be raised as
• Full thickness flap
• Partial thickness flap
28-07-2023 60

Advantages:
• Minimum pocket depth post-operatively
• If optimal soft tissue coverage of the alveolar bone is obtained, the
post-surgical bone loss is minimal
• The post-operative position of the gingival margin may be controlled
and the entire mucogingival complex may be maintained
28-07-2023 61

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.
28-07-2023 62

Disadvantages:
• Sacrifice of crestal alveolar process and supporting bone
Extensive exposure of root surfaces.
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• A conventional mucoperiosteal flap is first elevated by giving an
intracrevicular incision.
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• Tooth surfaces are debrided and osseous recontouring is performed.
28-07-2023 67

• The palatal flap is subsequently replaced and the gingival margin is
adjusted to the alveolar bone crest by a secondary scalloped and
beveled incision.
28-07-2023 68

• The flap is secured in this position with interdental sutures.
28-07-2023 69

• Ramfjord and Nissle (1974) described the modified Widman flap
technique that is also recognized as the open flap curettage
technique.
Modified Widman flap (ramfjord & Nissle,
1974)
28-07-2023 71

• The initial incision, which may be performed with a Bard–Parker®
knife (No. 11), should be parallel to the long axis of the tooth and
placed approximately 0.5 to 1mm from the buccal gingival margin
in order to properly separate the pocket epithelium from the flap.
28-07-2023 72

• The flap elevation should be limited and allow only a few millimeters
(2 to 3mm) of the alveolar bone crest to become exposed.
28-07-2023 73

• To facilitate the gentle separation of the collar of pocket epithelium and
granulation tissue from the root surfaces, an intracrevicular incision is
made around the teeth to the alveolar crest.
28-07-2023 74

• A third incision (interdental) made in a horizontal direction and in a
position close to the surface of the alveolar bone crest separates
the soft tissue collar of the root surfaces from the bone.
28-07-2023 75

• The pocket epithelium and the granulation tissues are removed by
means of curettes.
• Following the curettage, the flaps are trimmed and adjusted to the
alveolar bone to obtain complete coverage of the interproximal bone.
28-07-2023 76

• The flaps are sutured together with individual interdental sutures.
Surgical dressing may be placed over the area to ensure close
adaptation of the flaps to the alveolar bone and root surfaces.
The dressing, as well as the sutures, is removed after 1 week.
28-07-2023 77

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
28-07-2023 79

Papilla preservation flap
(Takei et al, 1985)
28-07-2023 85

• Probably the first report of a Papilla Preservation procedure was by
Kromer in 1956 which was designed to retain osseous implants.
• App in 1973, reported a similar technique and termed it as Intact
Papilla Flap, which retained the interdental gingival in the buccal flap.
• Evian et al preserved the interdental gingiva in the facial flap, which
exposed osseous margins on the labial and the interproximal zone,
while the palatal tissues were reflected separately.
28-07-2023 86

• Genon and Bender in 1984 also reported a similar technique
indicated for esthetic purposes.
• Takei et al in 1985 introduced a detailed description of the surgical
approach reported earlier by Genon and named the technique as
Papilla Preservation Flap, which ensured optimal interproximal
coverage and facilitated placement and retention of bone grafts
which prevented exfoliation of the graft material.
28-07-2023 87

• Later, Cortellini et al. (1995b, 1999) and Cortellini and Tonetti (2007)
described modifications to the flap design to allow minimally invasive
surgical techniques 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.
28-07-2023 88

Intracrevicular incisions are made at the facial & proximal aspects of teeth.
This method uses sulcular incisions around each tooth with no
incision being made through the interdental papilla facially,
28-07-2023 89

• The papilla preservation flap technique is initiated by an intrasulcular
incision at the facial and proximal aspects of the teeth without
making incisions through the interdental papillae .
28-07-2023 90

• but the lingual/ palatal flap involves a sulcular incisison along each
tooth with a semilunar incision made across each interdental papilla
that dips apically from the line angles of the tooth so that the
papillary incision line is at least 5 mm from the gingival margin
• allowing the interdental tissues to be dissected from the lingual or
palatal aspect so that it can be elevated intact with the facial flap
28-07-2023 91

An intracrevicular incision is made along
the lingual/palatal aspect of the teeth
with a semilunar incision made across
each interdental area.
A curette or papilla elevator is used
to carefully free the interdental
papilla from the underlying hard
tissue.
28-07-2023 92

The detached interdental tissue is pushed through the embrasure with a blunt
instrument to be included in facial flap.
28-07-2023 93

The flap is replaced & sutures are placed on
the palatal aspect of the interdental areas.
28-07-2023 94

Distal molar surgery
28-07-2023 95

INDICATIONS:
• When only limited amounts of keratinized gingiva is present
• Presence of distal angular bony defect Facilitates access to
osseous defect Preserves sufficient amounts of gingiva and
mucosa to achieve soft tissue coverage
Distal wedge procedure (Robinson 1966)
28-07-2023 96

Buccal and lingual vertical incisions
are made through the retromolar
pad to form a triangle behind a
mandibular molar.
The triangular-shaped wedge of
tissue is dissected from the
underlying bone and removed.
28-07-2023 97

The walls of the buccal and
lingual flaps are reduced in
thickness by undermining
incisions (broken lines).
The flaps, which have been
trimmed and shortened to
avoid overlapping wound
margins, are sutured.
28-07-2023 98

Modified distal wedge procedure
A deep periodontal pocket combined
with an angular bone delect at the
distal aspect of a maxillary molar.
28-07-2023 99

Two parallel bevel incisions, one broocal and one
palatal are made from the distil surface of the
molar to the posterior part of the tuberosity.
28-07-2023 100

where they are connected with a bucco lingual incision. The
buccal and palatal incisions are extended in a mesial direction
along the buccal and palatal surfaces of the molar to facilitate
flap elevation.
28-07-2023 101

Buccal and palatal flaps are elevated Rectangular wedge is released from
the tooth and underlying bone by
sharp dissection and then removed
28-07-2023 102

Modified distal wedge procedure. Following bone recontouring
and root debridement, the flaps are trimmed and shortened to
avoid overlapping wound margins and sutured
28-07-2023 103

• Immediately after suturing (≤24 hours), a connection between the
flap and the tooth or bone surface is established by a blood clot,
which consists of a fibrin reticulum with many polymorphonuclear
leukocytes, erythrocytes, debris of injured cells, and capillaries at the
edge of the wound. Bacteria and an exudate or transudate also result
from tissue injury.
28-07-2023 104

• One to 3 days after flap surgery, the space between the flap and the
tooth or bone is thinner. Epithelial cells migrate over the border of
the flap, and they usually contact the tooth at this time. When the
flap is closely adapted to the alveolar process, the inflammatory
response is minimal.
28-07-2023 105

• One week after surgery, an epithelial attachment to the root has
been established by means of hemidesmosomes and a basal lamina.
The blood clot is replaced by granulation tissue derived from the
gingival connective tissue, the bone marrow, and the periodontal
ligament.
28-07-2023 106

• Two weeks after surgery, collagen fibers begin to appear parallel to
the tooth surface. Union of the flap to the tooth is still weak because
of the presence of immature collagen fibers, although the clinical
aspect may be almost normal.
28-07-2023 107

• One month after surgery, a fully epithelialized gingival crevice with a
well-defined epithelial attachment is present. A functional
arrangement of the supracrestal fibers is beginning.
28-07-2023 108

Undisplaced flap
• Pocket elimination procedure using internal bevel incision. Also
called as INTERNAL BEVEL GINGIVECTOMY
• Pocket wall is eliminated with first incision
• Elimination of ‘dead space’ as the flap margin is place over
bone crest postoperatively
• However, sufficient attached gingiva is a pre-requisite
• Usually used for pocket elimination of palatal pockets
28-07-2023 110

The location of two different areas where the internal bevel
incision is made in an undisplaced flap
The incision is made at the level of the pocket to discard the tissue
coronal to the pocket if remaining attached gingiva is sufficient.
28-07-2023 111

Original Widman flap Modified Widman flap
Pocket elimination procedure Pocket reduction procedure
Apical displacement of flap No apical displacement
Osseous recontouring can be done Not designed for osseous contouring
28-07-2023 113

Modified Papilla preservation flap
(cortellini et al, 1995)
28-07-2023 114

• The first modification of PPF was reported by Checchi et al
in 1988, where a horizontal incision over the interproximal
area, in the opposite side of the bone defect was deemed
ideal as it allowed protection of the regenerated area from
the oral environment.
28-07-2023 115

• Cortellini et al in 1995, proposed a modification in the PPF and named
it as Modified Papilla preservation flap.
• The rationale for developing this technique was to achieve and
maintain primary closure of the flap in the interdental space over the
membrane.
• And for complete coverage of the membrane.
28-07-2023 116

• Buccal and interproximal primary incision is continued intrasulcularly
in the interproximal space and extended to the palatal aspect.
• A buccal horizontal incision is performed in the interproximal
supracrestal connective tissue, coronal to the bone crest, to dissect
the papilla.
28-07-2023 117

• Primary intrasulcular incision (buccal and interproximal) involving two
teeth neighboring the defect is made.
• A horizontal incision is traced in the buccal gingiva of the interdental
space at the base of the papilla.
• This horizontal incision is then connected with the primary incision in
the most apical portion of the buccal gingival of the neighboring teeth
and a full thickness buccal flap was elevated to the level of the buccal
alveolar crest.
28-07-2023 118

• The papilla is then elevated towards palatal aspect.
• Following extension of the palatal incision, a full thickness palatal flap
including the interdental papilla was elevated to fully expose the
defect.
• The tissue thickness of papilla is reduced to permit coronal
advancement of the flap.
• Vertical releasing incision divergent in corono-apical direction
extending in to the alveolar mucosa can be placed in the
interproximal spaces neighboring the defect if coronal advancement
of the flap is desired.
28-07-2023 119

The Simplified Papilla preservation flap (SPPF)
28-07-2023 120

• To apply esthetic value to teeth having narrow interproximal zone,
Cortellini et al in 1999 proposed the Simplified Papilla preservation
flap technique.
28-07-2023 121

• An oblique incision is made across the defect associated papilla from
the gingival margin at the buccal line angle of the involved tooth to
reach the mid interproximal portion of the papilla under the contact
point of the adjacent tooth.
• The oblique incision continues intrasulcularly in the buccal aspect of
the teeth neighbouring the defect and extended to partially dissect
the papillae of the adjacent interdental spaces allowing the elevation
of a buccal flap with 2-3 mm exposure of alveolar bone.
28-07-2023 122

• A buccolingual horizontal incision at the base of papilla close to the
interproximal crest is made.
• Intrasulcular incisions are continued in the palatal aspects of the two
teeth neighbouring the defect and extended into the interdental
papilla of adjacent interdental spaces, following which a full thickness
palatal flap including the interdental papilla is elevated.
28-07-2023 123

• Both the modifications of PPF, require utilization of horizontal and/or
vertical internal mattress sutures which relieve the tension in the flap,
permit coronal positioning of the flap and aid in passive closure of the
interdental tissues
28-07-2023 124

periodontal flap surgery

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