from caranza 10th edition

1. MUNAWAR AZIZ
BDS 3RD PROF
FLAP SURGERY

2. Definition
“A periodontal flap is a section of gingiva and/
or
mucosa surgically separated from the underlyi
ng
tissues to provide visibility and access to the bo
ne and root surface.

3. 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 involvement
•Root resection / hemisection
•Intrabony pockets on distal areas of last molars
•Persistent inflammation in areas with moderate to deep pockets.

4. CONTRAINDICATIONS:
• Uncontrolled medical conditions such as
‐unstable angina
‐uncontrolled diabetes
‐uncontrolled hypertension
‐myocardial infarction / stroke within 6 months
•Poor plaque control
•High caries rate
•Unrealistic patient expectations or desires

5. Classification of flaps
Bone exposure after flap reflection
•Full thickness (mucoperiosteal)
•Partial thickness (mucosal)
Placement of the flap after surgery
•Non displaced flaps
•Displaced flaps
Management of the papilla
•Conventional flaps
•Papilla preservation flaps

6. BASED ON BONE EXPOSURE AFTER REFLECTION
FULL THICKNESS FLAP
• Periosteum is reflected to expose the underlying bone.
• Indicated in resective osseous surgery.

7. PARTIAL THICKNESS FLAP
•Split thickness flap.
•Periosteum covers the bone.
•Indicated when the flap has to be positioned apically.
•When the operator does not desire to expose the bone

8. BASED ON FLAP PLACEMENT AFTER SURGERY
•Non displaced flaps:
 When the flap is returned and sutured in its original position.
•Displaced flaps:
 When the flap is placed apically, coronally or laterally to their or
iginal position

9. BASED ON MANAGEMENT OF PAPILLA
1) Conventional flap
In this the interdental papilla is split beneath the contact point of the two approximat
ing teeth to allow reflection of buccal and lingual flaps.
Indications-
1) When the interdental spaces are too narrow, thereby precluding the possibility
of preserving the papilla.
2) When the flap is to be displaced.

10. 2) Papilla preservation flap
In this the entire papilla is incorporated into one of the flaps by means of crevicular
interdental incisions to sever
the connective tissue attachment and a horizontal incision at the base of the papilla,
leaving it connected to one of the flaps.
Indications-
When there are open interdental spaces
When esthetics is of concern
When bone regeneration techniques are attempted.

11. F L A P D E S I G N
Dictated by the surgical judgment of the operator.
Depend on the objectives of the procedure.
Factors to be considered in designing the flap are-
1) Degree of access to the underlying bone and root surfaces
2) Final position of the flap
3) Preservation of good blood supply to the flap
 Two basic flap designs are used -
1. Conventional flap
2. Papilla preservation flap

12. CONVENSTIONAL FLAP
The incisions for the facial, and the lingual or palatal flap reach the tip of the
interdental papilla or its vicinity, thereby splitting the papilla into facial half
and a lingual or palatal half.
Fig: flap design for
conventional flap
technique.

13. PAPILLA PRESERVATION FLAP
papilla is preserved ( not split).
The entire surgical procedure should be planned in detail before the procedure is initiated as detailed plannin
g allows for a better clinical result.

14. I N C I S I O N S
There are basically two types of periodontal flap incisions-
Horizontal incisions
1) Internal bevel incision
2) Crevicular incision
3) Interdental incision
Vertical incisions
1) Oblique releasing incision

15. H O R I Z O N T A L I N C I S I O N S
Horizontal incisions are directed along the margin of the gingiva in a mesial or a distal direction.
Types of horizontal incisions recommended are-
1 ) I n t e r n a l b e v e l i n c i s i o n
It is the incision from which the flap is reflected to expose the underlying bone and root.
2 ) C r e v i c u l a r i n c i s i o n
It is made from the base of the pocket to the crest of the bone.
3 ) I n t e r d e n t a l i n c i s i o n
A periosteal elevator is inserted into the initial internal bevel incision, & the flap is separated from the
bone .

16. Fig : Three incisions necessary for flap surgery. A) internal bevel incisio
n B) crevicular incision C) interdental incision.

17. V E R T I C A L I N C I S I O N S
Vertical or oblique releasing incisions can be used on one or both ends of the horizontal incision, depending
on the purpose & design of the flap.
Vertical incisions at both the ends are necessary if the flap is to be apically displaced.
Vertical incisions are avoided in the lingual or palatal areas.
Facial vertical incisions should not be made in the centre of an interdental papilla or over the radicular surf
ace of a tooth.
Fig : The incision
Should be made at the
line angles

18. R E F E R E N C E S
Newman, Takei, Klokkevold, Fermin A Carranza.
CLINICAL PERIODONTOLOGY, 10th edition,