this presentation covers all the aspects and techniques of flap surgery with relevant diagrams and is made from from authentic text books and articles.

2.  Introduction
 Objectives of periodontal flap
 Indications of periodontal flap
 Classification of periodontal flap
 Principles of flap design
 Flap retraction
 Incisions
 Elevation of the periodontal flap
 Flap design
 Instruments used in periodontal surgery
 Techniques for access & pocket depth reduction/Elimination
 Flap procedures :
 Original widman flap
 Neumann flap
 Modified flap operation

3.  Apically repositioned flap
Modified widman flap operation
Undisplaced flap
Palatal flap
Flaps for reconstrutive surgery
 Papilla preservation flap
 conventional flap operation
Healing after flap surgery
Conclusion

4.  A periodontal flap is a section of gingiva &/or mucosa
surgically separated from the underlying tissues to provide
visibility of and access to the bone and root surface.
(Glickman)
 A flap also allows the gingiva to be displaced to a different
location in patients with mucogingival involvement.

5. OBJECTIVES OF PERIODONTAL FLAP :
Increase accessibility to root deposits for scaling &
root planing
Eliminate or reduce pocket depth by resection of the
pocket wall
Gain access for osseous resective surgery if it is
necessary
Expose the area to perform regenerative methods

6. INDICATIONS :
- Flap procedures are indicated in cases of periodontitis with
active (inflammed) pocket over 5mm deep, which do not respond
to initial therapy.
Grade 2 and 3 furcation involvement

7.  Periodontal flaps can be classified as follows –
a) Based on bone exposure after flap reflection
- mucoperiosteal or full thickness flap
- partial thickness or mucosal flap
b) Based on placement of flap after surgery
- displaced flap
- non displaced flap
c) Based on management of papilla
- conventional flap
- papilla preservation flap

8. 1) Full thickness or mucoperiosteal flap-
 All the soft tissue, including the periosteum, is reflected
to expose the bone.
 Indication- need to view the alveolar bone
2) Partial thickness or mucosal flap-
 It includes only the epithelium and a layer of
underlying connective tissue.
 The bone remains covered by a layer of connective
tissue, including the periosteum.
 Also known as split thickness flap.
 Indication- when flap is to be positioned apically,
laterally or coronally; or when the operator does not
want to expose the bone.
A) Based on bone exposure after flap reflection

9. Fig :A) internal bevel incision to reflect full
thickness flap. B) internal bevel incision to
reflect a partial thickness flap.

10. 1) Non – displaced flap
 The flap is returned and sutured in its original position.
2) Displaced flap
 The flap is placed apically, coronally, or laterally to its original
position.
1) Conventional flap
 In this the interdental papilla is split beneath the contact
point of the two approximating teeth to allow reflection of
buccal and lingual flaps.
B ) B a s e d o n f l a p p l a c e m e n t a f t e r s u r g e r y
C ) B a s e d o n m a n a g e m e n t o f p a p i l l a

11.  The incision is usually scalloped to maintain gingival
morphology and retain as much papilla as possible.
 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.
 Examples- modified Widman flap, the undisplaced flap, the
apically displaced flap, & the flap for reconstructive
procedures.
2) Papilla preservation flap
 In this the entire papilla is incorporated into one of the flaps
by means of crevicular interdental incisions to sever

12. the connective tissue attachment and a horizontal incision
at the base of the papilla, leaving it connected to one of the
flaps.
 Indications-
1) When there are open interdental spaces
2) When esthetics is of concern
3) When bone regeneration techniques are attempted.

14. FLAP RETRACTION
- Retraction should be passive without any
tension.
- It is important that edge of retractor should be
kept on bone.
- Irrigation of surgical field is necessary

16.  There are basically two types of periodontal flap
incisions-
Horizontal
incisions
Vertical incisions
1) Internal bevel
incision
2) Crevicular
incision
3) Interdental
incision
1) Oblique
releasing
incision

17.  Horizontal incisions are directed along the margin of the
gingiva in a mesial or a distal direction.
 Types of horizontal incisions recommended are-
 It is the incision from which the flap is reflected to expose
the underlying bone and root.
1 ) I n t e r n a l b e v e l i n c i s i o n

18.  Objectives of internal bevel incision are -
1. It removes the pocket lining
2. Conserves the relatively uninvolved outer surface of the
gingiva, which when apically positioned, becomes
attached gingiva.
3. Produces a sharp, thin flap margin for adaptation to the
bone tooth junction.
 This incision is also termed as the first incision because it is
the initial incision in the reflection of a periodontal flap.
 Also termed as reverse bevel incision because its bevel is in
reverse direction from that of the gingivectomy incision.

19.  Blade used for making this incision - #15C or #15 surgical
blade.
Fig: Position of the knife in performing internal bevel incision.
 The internal bevel incision starts from a designated area on
the gingiva and is directed to an area at or near the crest of
the bone.

20.  It is made from the base of the pocket to the crest of the
bone.
 The incision together with the initial reverse bevel incision
forms a V- shaped wedge ending at or near the crest of
bone.
 This wedge of tissue contains most of the inflamed &
granulomatous areas that constitute the lateral wall of the
pocket as well as the junctional epithelium & the connective
tissue fibers that still persist between the bottom of the
pocket & the crest of the bone.
2 ) C r e v i c u l a r i n c i s i o n

21. Fig : Position of knife in performing crevicular incision.

22.  A periosteal elevator is inserted into the initial internal
bevel incision, & the flap is separated from the bone .
 The most apical end of the internal bevel incision is
exposed and visible. With this access, the surgeon is able to
make the interdental incision.
 This incision is made to separate the collar of the gingiva
that is left around the tooth.
 Knife used for this incision- Orban knife.
3 ) I n t e r d e n t a l i n c i s i o n

23.  The incision is made not only around the facial & the
lingual radicular area but also interdentally, connecting the
facial and the lingual segments to the free the gingiva
completely around the tooth.
Fig : Three incisions necessary for flap surgery. A) internal
bevel incision B) crevicular incision C) interdental incision.

24.  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 incision must extend beyond the mucogingival
line, reaching the alveolar mucosa, to allow for the release
of the flap to be displaced.

25.  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 surface of a
tooth.
Fig : The incision
should be made at the
line angles.

26.  Incisions should be made at the line angles of a tooth
either to include the papilla in the flap or to avoid it
completely.
 Vertical incisions should also be designed to avoid short
flaps with long, apically directed incisions because this
could jeopardize the blood supply of the flap.

29. S.no Type of flap Reflection
accomplished by
Instrument
used
1) Full thickness
flap or
mucoperiosteal
flap
Blunt dissection Periosteal
elevator
which
separates the
mucoperioste
um from the
bone.
2) Partial thickness
flap or mucosal
flap
Sharp dissection Surgical
scalpel (#15)

30. Fig : Elevation of flap with
periosteal elevator to obtain full
thickness flap.
Fig: Elevation of flap with BP
knife to obtain a split thickness
flap.

31. FLAP DESIGN
Envelope flap: only if linear incisions are given
without vertical releasing incisions.
Pedicle flap: if two vertical releasing incisions
are included.
The major blood supply is from its base .

32. Envelope flap
Pedicle flap

33. INSTRUMENTS USED IN PERIODONTAL
SURGERY
GENERAL CONSIDERATIONS
Surgical procedures used in periodontal therapy often involve the following
measures (instruments):
• Incision and excision (periodontal knives)
• Deflection and re-adaptation of mucosal flaps (periosteal elevators)
• Removal of adherent fibrous and granulomatous tissue (soft tissue rongeurs
and tissue scissors)
• Scaling and root planing (scalers and curettes)
• Removal of bone tissue (bone rongeurs, chisels, and files)
• Root sectioning (burs)
• Suturing (sutures and needle holders, suture scissors)
• Application of wound dressing (plastic instruments)

34. THE INSTRUMENT TRAY
• Mouth mirrors
• Graduated periodontal probe/explorer
• Handles for disposable surgical blades (e.g. Bard-Parker handle)
• Mucoperiosteal elevator and tissue retractor
• Scalers and curettes
• Cotton pliers
• Tissue pliers (ad modum Ewald)
• Tissue scissors
• Needle holder
• Suture scissors
• Plastic instrument
• Hemostat
• Burs.
Additional equipment may include:
• Syringe for local anesthesia
• Syringe for irrigation
• Aspirator tip
• Physiologic saline
• Drapings for the patient
• Surgical gloves, surgical mask, surgeon’s
hood.

35. Set of instruments used for periodontal surgery and included in
a standard tray

36. SURGICAL INSTRUMENTS
Knives
Gingivectomy knives
From left to right:
Kirkland 15/16
Orban 1/2
Waerhaug 1/2.
The shape of the blades are from left to right:
No. 11, No. 12, No. 12D, No. 15, and No. 15C.

37. A universal 360º handle for disposable
blades, which allows the mounting of the
blade in any angulated position of choice.
Double-ended sickle scalers and curettes
useful for root debridement in conjunction
with periodontal surgery.
From left to right:
Curette SG 215/16C Syntette,
Sickle 215-216 Syntette,
mini-curette SG 215/16MC.

38. A set of burs useful in periodontal surgery.
The rotating fine-grained diamond stones
may be used for debridement of infrabony
defects. The round burs are used for bone
recontouring.
Examples of instruments used for bone
recontouring.
From left to right:
Bone chisels Ochsenbein no.1 and 2
(Kirkland 13K/13KL)
Bone chisel Ochsenbein no. 3
Schluger curved file no. 9/10

39. TECHNIQUES FOR ACESS & POCKET DEPTH
REDUCTION / ELIMINATION
The three different categories of flap techniques used in periodontal flap surgery are
 The modified widman flap
 The undisplaced flap
 Apically displaced flap
The modified widman flap facilitates by exposing the root surface for
meticulous instrumentation & for removal of pocket lining . It is not intended to
eliminate or reduce the pocket depth , except for the reduction that occurs in healing
by tissue shrinkage .
The un-displaced flap improves accessibility for instrumentation , but also
removes the pocket wall thereby reducing or eliminating the pocket .
The apically displaced flap provides accessibility & eliminate the pocket,
but it does the latter by apically positioning for soft tissue wall of the pocket .
Therefore it preserves or increases the width of the attached gingiva by transforming
the previously unattached keratinized pocket wall into attached tisssue . This
increases the width of attached gingiva based on the apical shift of the MGJ .

40. Locations of the internal bevel
incisions for the different types of flaps.

41. FLAP PROCEDURES
THE ORIGINAL WIDMAN FLAP
In 1918 Leonard Widman published one of the first detailed
descriptions of the use of a flap procedure for pocket elimination.
In his article “The operative treatment of pyorrhea alveolaris”
Widman described a mucoperiosteal flap design aimed at
removing the pocket epithelium and the inflamed connective
tissue, thereby facilitating optimal cleaning of the root surfaces.

42. Scaling, root planing, and osseous
recontouring are performed in the
surgical area.
The palatal flap is replaced and a
secondary, scalloped, reverse bevel
incision is made to adjust the length of
the flap to the height of the remaining
alveolar bone.
The shortened and thinned flap is
replaced over the alveolar bone and in
close contact with the root surfaces

43. Among a number of suggested advantages of the apically
repositioned flap procedure, the following have been
emphasized:
• 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 muco-gingival complex may be
maintained.
The sacrifice of periodontal tissues by bone resection and the
subsequent exposure of root surfaces (which may cause esthetic
and root sensitivity problems) were regarded as the main
disadvantages of this technique .

45. THE MODIFIED WIDMAN FLAP
In 1965 , Morris revived a technique described early in the 20th
century in the periodontal literature , - “unrepostioned
mucoperiosteal flap” . Same procedure was presented in 1974
by Ramfjord & Nissle who called it the “modified Widman flap” .
It is also recognized as the open flap curettage technique. The
original Widman flap technique included both apical displacement
of the flaps and osseous recontouring (elimination of bony
defects) to obtain proper pocket elimination, the modified
Widman flap technique is not intended to meet these objectives

46. Initial incision is placed 0.5–1
mm from the gingival margin (a)
and parallel to the long axis of
the tooth (b).
Following careful elevation of
the flaps, a second
intracrevicular incision (a) is
made to the alveolar bone
crest (b) to separate the
tissue collar from the root
surface.

47. A third incision is made
perpendicular to the root
surface (a) and as close as
possible to the bone crest
(b), thereby separating the
tissue collar from the
alveolar bone.
(a) Following proper debridement
and currettage of angular bone
defects, the flaps are carefully
adjusted to cover the alveolar
bone and sutured.
(b)Complete coverage of the
interdental bone as well as close
adaptation of the flaps to the
tooth surfaces should be
accomplished.

48. The main advantages of the modified Widman flap technique
in comparison to other procedures previously described are,
according to Ramfjord and Nissle (1974):
• 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.

50. THE UNDISPLACED FLAP
The undisplaced flap is perhaps the most commonly performed type of
periodontal surgery. It differs from the modified Widman flap in that the soft
tissue pocket wall is removed with the initial incision; thus it may be considered
an internal bevel gingivectomy.
The undisplaced flap and the gingivectomy are the two techniques that
surgically remove the pocket wall. To perform this technique without creating a
mucogingival problem it should be determined that enough attached gingiva will
remain after removal of the pocket wall.
The location of 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 it if there is
sufficient remaining attached
gingiva.

51. Step 1: The pockets are measured with the periodontal probe, and a bleeding
point is produced on the outer surface of the gingiva to mark the pocket bottom.
Step 2: The initial, internal bevel incision is made after the scalloping of the
bleeding marks on the gingiva . The incision is usually carried to a point apical
to the alveolar crest, depending on the thickness of the tissue. The thicker the
tissue, the more apical is the ending point of the incision . In addition, thinning
of the flap should be done with the initial incision because at this time, it is
easier to accomplish than later with a loose reflected flap that is difficult to
manage.
Step 3: The second or crevicular incision is made from the bottom of the pocket
to the bone to detach the connective tissue from the bone.
Step 4: The flap is reflected with a periosteal elevator (blunt dissection) from
the internal bevel incision. Usually there is no need for vertical incisions
because the flap is not displaced apically.
Step 5: The interdental incision is made with an interdental knife, separating the
connective tissue from the bone.

53. Step 6: The triangular wedge of tissue created by the three incisions is removed
with a curette.
Step 7: The area is debrided, removing all tissue tags and granulation tissue
using sharp curettes.
Step 8: After the necessary scaling and root planing, the flap edge should rest
on the root-bone junction. If this is not the case, due to improper location of the
initial incision or to the unexpected need for osseous surgery, the edge of the
flap is rescalloped and trimmed to allow the flap edge to end at the root-bone
junction.
Step 9: A continuous sling suture is used to secure the facial and the lingual or
palatal flaps. This type of suture, using the tooth as an anchor, is advantageous
to position and hold the flap edges at the root-bone junction. The area is
covered with a periodontal pack.

54. The Palatal Flap
The surgical approach to the palatal area differs from that for other
areas because of the character of the palatal tissue and the
anatomy of the area. The palatal tissue is all attached, keratinized
tissue and has none of the elastic properties associated with other
gingival tissues. Therefore the palatal tissue cannot be apically
displaced, nor can a partial (split) thickness flap be accomplished.
The initial incision for the palatal flap should be such that when
the flap is sutured, it is precisely adapted at the root-bone
junction. Therefore the location of the initial incision is important
for the final placement of the flap.
Oschenbein and Bohannan(1963,1964) described a palatal approach for
osseous surgery

55. The initial incision for a flap varies with the anatomic situation. The initial
incision may be the usual internal bevel incision, followed by crevicular
and interdental incisions. If the tissue is thick, a horizontal gingivectomy
incision may be made, followed by an internal bevel incision that starts at
the edge of this incision and ends on the lateral surface of the underlying
bone. The placement of the internal bevel incision must be done in such a
way that the flap fits around the tooth without exposing the bone.

56. The angle of the internal bevel incision in the palate and the different ways to
thin the flap.
A, The usual angle and direction of the incision.
B, The thinning of the flap after it has been slightly reflected with a second
internal incision.
C, The beveling and thinning of the flap with the initial incision if the position
and contour of the tooth allow.
D, The problem encountered in thinning the flap once it has been reflected. The
flap is too loose and free for proper positioning and incision.

57. The purpose of the palatal flap should be considered before the incision is
made. If the intent of the surgery is debridement, the internal bevel incision is
planned so that the flap adapts at the root-bone junction when sutured.
If osseous resection is necessary, the incision should be planned to
compensate for the lowered level of the bone when the flap is closed. Probing
and sounding of the osseous level and the depth of the intrabony pocket
should be used to determine the position of the incision.
A, A distal view of incisions made to
eliminate a pocket distal to the maxillary
second molar.
B, Two parallel incisions and the
removal of the intervening tissue.
C, Thinning of the flap and contouring of
the bone.
D, Approximation of the buccal and
palatal flaps.

58. Indications-
Areas that require osseous surgery
Pocket reduction
Reduction in enlarged bulbous tissue

59. FLAPS FOR RECONSTRUCTIVE SURGERY
Two flap designs are available for regenerative surgery:
the papilla preservation flap and the conventional flap with
only crevicular incisions.
The flap design of choice is the papilla preservation flap, which
retains the entire papilla covering the lesion.
However, to use this flap, there must be adequate interdental
space to allow the intact papilla to be reflected with the facial or
lingual/palatal flap.
When the interdental space is very narrow, making it impossible
to perform a papilla preservation flap, a conventional flap with
only crevicular incisions is made.

60. THE PAPILLA PRESERVATION FLAP
In order to preserve the interdental soft tissues for maximum soft
tissue coverage following surgical intervention involving treatment
of proximal osseous defects, Takei et al. (1985) proposed a
surgical approach called papilla preservation technique.
Later, Cortellini et al. (1995b, 1999) described modifications of
the 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

61. Intracrevicular incisions are made at the facial and proximal
aspects of the teeth.

62. (a)An intracrevicular incision is made along the lingual/palatal aspect of the
teeth with a semilunar incision made across each interdental area.
(b) A curette or a papilla elevator is used to carefully free the interdental
papilla from the underlying hard tissue.
(c,d) The detached interdental tissue is pushed through the embrasure with
a blunt instrument to be included in the facial flap.

63. The flap is replaced and sutures are placed on the palatal aspect of the
interdental areas.

65. Cortellini et al in 1995, proposed a modification in the PPF and
named it as Modified Papilla preservation flap
Papillary preservation flap and its modified flap design, both
required a wide interdental space as a pre-requisite to bring
about appreciable functional and esthetic value

66. To apply esthetic value to teeth having narrow interproximal
zone, Cortellini et al in 1999 proposed the Simplified Papilla
preservation flap technique
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.

67. CONVENTIONAL FLAP FOR REGENERATIVE
SURGERY
The technique for employing a conventional flap for regenerative
surgery is as follows:
Step 1: Using a #12 blade, incise the tissue at the bottom of the
pocket and to the crest of the bone, splitting the papilla below the
contact point. Every effort should be made to retain as much
tissue as possible to subsequently protect the area.
Step 2: Reflect the flap maintaining it as thick as possible, not
attempting to thin it as is done for resective surgery. The
maintenance of a thick flap is necessary to prevent exposure of
the graft or the membrane due to necrosis of the flap margins

68. 1) Immediately
after
suturing ( up
to 24 hours)
 A connection between the flap and the
tooth or bone surface is established which
contains fibrin reticulum with many PMN
leukocytes, erythrocytes, debris of injured
cells, & capillaries at the edge of the
wound.
2) 1-3 days
after flap
surgery.
 The space between the flap & the tooth or
bone is thinner & epithetlial cells migrate
over the border of the flap, usually
contacting the tooth at this time.

69. 3) One week
after surgery.
 An epithelial attachment to the root has been
established by means of hemidesmosomes & a
basal lamina.
 Blood clot is replaced by granulation tissue
derived from the gingival connective tissue,
the bone marrow, & the PDL.
4) 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 presence of immature collagen
collagen fibers.
5) One month
after surgery.
 A fully epithelialized gingival crevice with a
well defined epithelial attachment is present.
 There is beginning of functional arrangement
of supra crestal fibers.

70. CONCLUSION
Periodontal surgery requires an organized,
step by step, gentle approach to each
procedure that results in minimal tissue
trauma and expedites completion of surgery
in the least time.