OBJECTIVES INDICATIONS CONTRAINDICATIONS INCISIONS & ELEVATION CLASSIFICATION TECHNIQUES HEALING AFTER FLAP SURGERY POST OPERATIVE COMPLICATIONS

1. FLAP TECHNIQUES
DR. BEENA VIJAYAN PARVATHY
2ND YEAR POST GRADUATE
DEPT OF PERIODONTICS AND IMPLANTOLOGY

2. CONTENTS
INTRODUCTION
OBJECTIVES
INDICATIONS
CONTRAINDICATIONS
INCISIONS & ELEVATION
CLASSIFICATION
TECHNIQUES
HEALING AFTER FLAP SURGERY
POST OPERATIVE COMPLICATIONS

3. INTRODUCTION
PERIODONTAL FLAP
It is a section of gingiva and/or mucosa surgically seperated from the underlying
tissues to provide visibility of and access to the bone and root surface.
{Newman et al, Carranza,2006}

4. OBJECTIVES
• Access to roots-cleaning.
• Removal of periodontal pocket lining.
• Treat irregularities of bone
• Helps in reduction of pockets, infections and inflmmation.
• Self-performed oral hygiene measures by patient.
• Reduction of bacterial load and inflammation, thus give better prognosis of
teeth.
• Regenerate lost periodontal apparatus.
• Improves esthetics by recountouring the soft and hard tissue in the esthetic
zone.

5. INDICATIONS
• Periodontitis with active deep pockets, that do not respond satatisfactorly to
initial therapy.
• Irregular bony contours
• Pockets on teeth in which a complete removal of root irritants is not clinically
possible
• Grade II or III furcation involvement
• Root resection / hemisection
• Persistent inflammation in areas with moderate
• Crown lengthening.
• Recurrent periodontal abscess.

6. CONTRAINDICATIONS
• Uncontrolled medical conditions such as
‐Unstable angina
‐Uncontrolled diabetes
‐Uncontrolled hypertension
‐Myocardial infarction / stroke within 6 months
• Poor plaque control
• Pronounced gingival overgrowth.
• Unrealistic patient expectation or desires.

7. INCISIONS
EXTERNAL BEVEL INCISION

8. INTERNAL BEVEL INCISION
(1st Incision)
SULCULAR/CREVICULAR INCISION
(2nd Incision)

9. INTERDENTAL INCISION
(3rd Incision)

11. ELEVATION

12. CLASSIFICATION
FULL THICKNESS FLAP (Mucoperiosteal)
PARTIAL/SPLIT THICKNESS FLAP (Mucosal)
According to flap reflection or tissue contact

13. According to management of papilla
CONVENTIONAL FLAP
Modified Widman Flap
Modified Flap Operation
Undisplaced Flap
Apically Displaced Flap
PAPILLA PRESERVATION FLAP(Flap For Regenerative Procedures)

14. According to flap placement after surgery
DISPLACED FLAP
 Apically Displaced Flap
 Coronally Displaced Flap
 Laterally Displaced Flap
UN/NONDISPLACED FLAP

15. ORIGINAL WIDMAN FLAP
• In 1918, Leonard Wildman published the detailed description of this procedure for pocket
elimination
• In 1965, Morris revived this technique and called it as “Unrepositioned mucoperiosteal flap”
The flap was elevated to expose 2-3 mm of the alveolar bone.
The soft tissue collar with pocket epithelium and connective tissue was removed, the exposed
root surface scaled and the bone recontoured to re-establish a 'physiologic‘ alveolar form.
The flap margins were placed at the level of the bony crest to achieve optimal pocket reduction.

16. 1 2
3 4

17. MODIFIED FLAP OPERATION
• Described by Kirkland (1931).
• Used in the treatment of“Periodontal pus pockets”.
Intracrevicular incision
The gingiva is retracted to expose the “diseased” root surface
The exposed root surfaces are subjected to mechanical debridement
The flaps are replaced to their original position and sutured

19. APICALLY DISPLACED FLAP
• Norberg (1926) first advocated this technique for mucogingival problems in periodontal
disease.
• Nabers (1954) described this technique for the preservation of the gingiva following surgery,
denoted as “Repositioning of attached gingiva”.
• Friedman (1962) proposed the term “Apically repositioned flap”.
• Beveled flap in palatal aspect [Modification].
Following vertical incision, internal bevel incision given
Followed by initial elevation of the flap, the wedge of tissue containing pocket wall is removed
Debridement and Osseous recontouring
Flap replaced apically to the level of recontoured bone crest and sutured

22. MODIFIED WIDMAN FLAP
• Presented by Ramfjord and Nissle in 1974, also recognized as “open flap curettage
technique”.
• Also called as “Access flap operation”.
Internal bevel incision, made 0.5 to 1 mm away from the gingival margin
Flap is elevated
Crevicular incision is made from the bottom of the pocket to bone
Interdental incision sectioning the base of the papilla
Tissue tags and granulation tissue are removed
Scaling and root planing of exposed root surfaces

23. Suturing done and covered with tetracycline oinment and with a periodontal surgical pack

24. UN/NON DISPLACED FLAP
• Unrepositioned flap
• It differs from the modified Widman flap such that the soft tissue pocket wall is removed with
the initial incision; thus it considered an “Internal bevel gingivectomy”.
Internal bevel incisions in the facial and palatal aspects.
Flap elevated
Osseous correction
Flaps have been placed in their original site and sutured.

26. PALATAL FLAP
• Two methods for eliminating a palatal pocket.
 One incision is an internal bevel incision made at the area of the apical extent of the pocket.
 The other procedure uses a gingivectomy incision, which is followed by an internal bevel incision.

27. FLAPS FOR REGENERATIVE SURGERY
THE PAPILLA PRESERVATION FLAP
• 1st docmented report by Kromer (1956) designed to retain osseous implants.
• In 1973,App reported similar technique and termed as “Intact Papilla Flap” it retained
gingiva in buccal flap.
• Evian et al (1985) modified this procedure to preserve anterior esthetics after flap surgery.
• Proposed by Takei et al (1985) later, Cortellini et al (1995,1999) described modifications of
flap design to be used in combination of MIST with regenerative procedures.
An intrasulcular incision is made along the lingual/palatal aspect of the teeth with a semi-lunar
incision made across each interdental area.
Curette or interproximal knife is used to carefully free the interdental papilla from the underlying
hard tissue.

28. The detached interdental tissue is pushed through the embrasure with a blunt instrument to be
included in the facial flap
The flap is replaced and sutures are placed on the palatal aspect of the interdental areas.

30. MODIFICATIONS

31. DISTO MOLAR SURGERY
• Procedures for this purpose were described by Robinson and Braden in 1966, termed as
“Distal Wedge Operation”.
• Shapes are:
 Triangular
 Square, parallel or H-design
DISTAL TO MAXILLARY 2nd MOLAR

32. DISTAL TO MANDIBULAR 2nd MOLAR
Should follow the areas of greatest
attached gingiva and underlying bone.

33. HEALING AFTER FLAP SURGERY

34. POST OPERATIVE COMPLICATIONS
• Post-operative bleeding
• Swelling
• Trismus
• Post surgical pain

35. SUMMARY
Full thickness flap- Complete bone access (Osseous resection)
Split/partial thickness flap- to apically position flap and bone not needed to be exposed
Modified Widman flap- Deep pockets ,root hemisection, regeneration, osseous resection
Undisplaced flap- Palatal tissue surgery
Apically displaced flap- Pocket eradication, width of attached gingiva
Papilla preservation flap- Osseous resection, palatal access, to serve interdental papilla
Kirkland flap- Root debridement, regenerative procedures
Distal molar surgery-pockets on distal surface, gingival overgrowth

36. REFERENCE
• CARRANZA’S CLINICAL PERIODONTOLOGY
• CLINICAL PERIODONTOLOGYAND IMPLANTOLOGY – LINDHE
• ATLAS OF COSMETIC AND RECONSTRUCTIVE PERIODONTAL SURGERY-COHEN
• PERIODONTOL SURGERY:A CLINICAL ATLAS - SATO