1. ‫صدق هللا العظيم‬

3. OBJECTIVES OF THE SURGICAL PHASE
1- Improvement of the prognosis of teeth
and their replacements.
2- Improvement of esthetics.
The surgical phase consists of techniques
performed for pocket therapy and for the
correction of related morphologic problems,
namely mucogingival defects.

4. Surgical techniques allow :
1- Increase accessibility to the root
surface, making it possible to remove
all irritants.
2- Reduce or eliminate pocket depth.
3- Reshape soft and hard tissues to attain
a harmonious topography.

6. Indications for periodontal surgery
1- Areas with irregular bony contours, deep
craters, and other defects usually require a
surgical approach.
2- Pockets on teeth in which a complete removal
of root irritants is not considered clinically
possible may call for surgery.
3- In cases of furcation involvement of Grade II or
III, a surgical approach ensures the removal
of irritants; any necessary root resection or
hemisection also requires surgical
intervention.

7. 4- Intrabony pockets on distal areas of last
molars, frequently complicated by
mucogingival problems, are usually
unresponsive to nonsurgical methods.
5- Persistent inflammation in areas with
moderate to deep pockets may require a
surgical approach.

8. Classification of Flaps:
1- Bone exposure after flap reflection.
2- Placement of the flap after surgery.
3- Management of the papilla.
Based on bone exposure after reflection:
** Full thickness (mucoperiosteal) is indicated
when resective osseous surgery is
contemplated.
** Partial thickness (split thickness flap) is
indicated when the flap is to be positioned
apically or when the operator does not
desire to expose bone.

9. Diagram of the internal bevel incision (first incision) to reflect a full
thickness and the split thickness flap.

10. Based on flap placement after surgery, flaps
are classified):
** Nondisplaced flaps, when theflap is returned
and sutured in its original position; or 2)
displaced flas that are placed apically, coronally,
or laterally.
Based on management of the papilla:
** Flaps can be conventional or papilla
preservation flaps.
The conventional flap is used:
(1) The interdental spaces are too narrow.
(2) When the flap is to be displaced.

11. Conventional flaps include the modified
widman and the flap, the undisplaced flap,
the apically displaced flap, and the flap for
regenerative procedure procedures.
Design of the Flap:
The design of the flap is dictated by the
surgical judgement of the operator and
may depend on the objectives of the
operation.

13. Horizontal Incisions:
1- The internal bevel incision.
2- Crevicular incision.
3- Interdental incision.

14. Vertical incisions:
Vertical or oblique releasing incisions can
be used on one or both ends of the
horizontal incision, depending on the
design and purpose of the flap.

17. Elevation of the Flap:
1- Full thickness flap.
The reflection is accomplished by blunt
dissection.
2- Partial thickness flap.
The reflection is accomplished by sharp
dissection.

18. A, Diagram of the internal bevel incision (first incision) to reflect a tull thickness
(mucoperiosteal) flap. Note that the incision ends on the bone to allow for the reflection of the
entire flap. B, Diagram of the internal bevel incision to reflect a partial thickness flap. Note that
the incision ends on the root surface to preserve the periosteum on the bone.

19. Sutures for Periodontal Flaps

20. TYPES
OF
NEEDLES

21. Ligation:
Interdental Ligation:
1- The director loop suture.
2- Figure-eight suture.

22. Sling Ligation:
A single, interrupted sling suture is used to adapt
the flap arount the tooth.

23. Continuous Independent Sling Suture.
The continuous, independent sling suture is used to adapt the buccal and lingual flaps
without tying the buccal flap to the lingual flap. The teeth are used to suspend each flap against
the bone. It is important to anchor the suture on the two teeth at the beginning and end of the
flap so that the suture will not pull the buccal flap to the lingual flap.

24. Anchor Suture
Distal wedge suture. This suture is also used to close
flaps that are mesial or distal to a lone-standing tooth.

25. Periosteal Suture
This type of suture is used to hold in place apically
displaced partial thickness flaps.

27. FLAPS FOR POCKET FLAPS FOR
THERAPY REGENERATIVE
SURGERY
1- The modified widman 1- The papilla
flap. preservation flap.
2- The undisplaced flap 2- Conventional flap for
the palatal flap. regenerative
3- The apically displaced surgery.
flap.

28. FLAPS FOR POCKET THERAPY
Flaps are used for pocket therapy to
accomplish the following:
1- Increase accessibility to root deposits.
2- Eliminate or reduce pocket depth by
resection of the pocket wall.
3- Expose the area to perform regenerative
methods.

29. The modified widman flap.
1- Facilitates instrumentation.
2- Removal of the pocket lining.
3- Not eliminate or reduce pocket depth.

35. The undisplaced (Unrepositioned) flaps.
1- Improving accessibility for instrumentation.
2- Removes the pocket wall.
3- Reducing or eliminating the pocket.
Diagram showing the location of
different areas where the internal bevel
incision is made in an undisplaced flap.

36. The apically displaced flap:
1- Improving accessibility.
2- Removes the pocket wall.
3- It increases the width of the attached gingiva by transforming the
previously unattached keratinized pocket wall into attached tissue.

40. FLAPS FOR REGENERATIVE SURGERY
1- The papilla preservation flap.
2- Conventional flap for regenerative surgery.
The flap using only crevicular or pocket incisions, to retain the
maximum amount of gingival tissue, including the papilla, for
graft or membrane coverage.