Periodontal Flap

1. Dept of periodontics
Periodontal flaps
Presented by,
SHIJI MARGARET
D.SAPNA
D.SARANYA
S.SHIFAYA NASRIN
CRRI

2. Definition
“A periodontal flap is a section
of gingiva and/or mucosa
surgically separated from the
underlying tissues to provide
visibility and access to the bone
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 original
position

9. DESIGN OF THE FLAP
•Split the papilla (conventional flap)
•Preserve it (papilla preservation flap)

10. MODIFIED WIDMAN
FLAP
Presented by Ramfjord and Nissle
in 1974

11. THE ORIGINAL ‘WIDMAN’ FLAP
 The flap was elevated to expose 2-3 mm of the
alveolar bone.
 The soft tissue collar incorporating the 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.

12. THE TERM MODIFIED WIDMAN FLAP
Exposure of the interproximal bone and
elimination of infrabony defects by osseous
recontouring is not carried out (No surgical
pocket elimination and apical displacement of
the flap)
Incase of esthetic considerations,intracrevicular
incisions starting at the free gingival margins are
used to minimize postsurgical gingival shrinkage.
Vertical releasing incisions are usually not used

13. INDICATIONS:
 Effective with pocket depths of 5-7 mm
CONTRAINDICATIONS:
 Lack of or very thin and narrow attached
gingiva can render the technique difficult,
because a narrow band of attached gingiva does
not permit the initial scalloped incision (internal
gingivectomy).

14. ADVANTAGES:
Root cleaning done
with direct vision.
Healing by primary
intention.
Minimal crestal
bone resorption.
Lack of post
operative discomfort.

15. PROCEDURE:
1) Internal bevel incision should be made
to the alveolar crest starting
0.5 to 1 mm away from
the gingival margin.
1- Modified widman flap
2- Undisplaced flap

16. INTERNAL BEVEL INCISION IN
FACIAL AND PALATAL ASPECTS

17. 2) Flap is elevated
3)Crevicular incision is
made from the bottom of
the pocket to bone

18. 4)Interdental incision sectioning
the base of the papilla
5)Tissue tags and granulation
tissue are removed.

19. 6) Scaling and root
planing of exposed root
surfaces

20. 7)Suturing done and covered
with tetracycline oinment
and with a periodontal
surgical pack

21. Post operative results

22. THE UNDISPLACED FLAP
 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 considered an
internal bevel gingivectomy.

23. PROCEDURE
1) The pockets are measured with periodontal
probe and a bleeding point is produced on the
outer surface of gingiva to mark the pocket
bottom
PRE OPERATIVE VIEWS

24. 2) Internal bevel incision in the facial and
palatal aspects

25. 3)Crevicular incision is made and Flap is
elevated

26. 4)Interdental incision is made
5)Triangular wedge of tissues is removed with
curette
6)All tissue tags and granulation tissue are
removed

27. 7)After the scaling and root planing the flap
edge should rest on the root bone junction.
8)Flaps have been placed in their original site
and Sutured.

28. Post operative results

29. It can be used for both pocket eradication as well
as widening the zone of attached gingiva.
It can be a full thickness (mucoperiosteal) or a
split thickness (mucosal) flap.

31. DISADVANTAGES:
May cause esthetic problems due to root exposure.
May cause attachment loss due to surgery.
May cause hypersensitivity.
May increase the risk of root caries.
Unsuitable for treatment of deep periodontal
pockets.
Possibility of exposure of furcations and roots,
which complicates post operative supragingival plaque
control.

32. 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.

33. PROCEDURE for apically displaced flap
1. An internal bevel incision is made, it should be no more than 1mm from the
crest of the gingiva and directed to the crest of gingiva.
2. Crevicular incisions are made, followed by initial elevation of the flap; then
interdental incision and the wedge of tissue containing pocket wall is removed

34. 3. Vertical incisions are made extending beyond the mucogingival junction.
Full thickness flap elevated
by blunt dissection with
periosteal elevator
Split –thickness flap elevated
using sharp dissection with a
bard- parker knife

35. 4.After debridement of the areas
5.Sutures in place

36. PRE TREATMENT-POST
TREATMENT

37. CROWN LENGTHENING BY APICALLY DISPLACED FLAP
PRE-TREATMENT BEFORE OSSEOUS RESECTION
FLAP APICALLY POSITIONED AND
SUTURED
POST-TREATMENT

38. CROWN LENGTHENING BY APICALLY DISPLACED FLAP
PRE-TREATMENT
Before debridement After debridement
Incision
Sutures in place

39. Pre treatment Post treatment

40. FLAPS FOR REGENERATIVE SURGERY
Two flap designs are available for
regenerative surgery:
1. The papilla preservation flap&
2. The conventional flap with only crevicular incisions.

41. Entire papilla is incorporated into one of the flaps.
INDICATIONS:
•Where esthetics is of concern.
•Where bone regeneration techniques are attempted

42. CONVENTIONAL FLAP FOR REGENERATIVE
SURGERY
In the conventional flap operation, the incisions for the facial and the lingual
or palatal flap reach the tip of the interdental papilla, thereby splitting the papilla into a
facial half and a lingual or palatal half.
INDICATIONS:
 When the interdental areas are too narrow to permit the preservation of flap.
 When there is a need for displacing flaps.
The interdental papilla is split beneath the contact point of the two approximating teeth to allow
for reflection of buccal and lingual flaps

43. DISTAL MOLAR
SURGERY

44. Treatment of periodontal pockets on the
distal surface of terminal molars is often
complicated by the presence of bulbous
fibrous tissue over the maxillary
tuberosity or prominent retromolar pads
in the mandible.
Operations for this purpose were
described by Robinsonand Braden

45. Impaction Of A Third
Molar Distal To A
Second Molar
Little Or No
Bone Distal To
The Second
Molar.
Often Leads To A
Vertical Osseous
Defect Distal To The
Second Molar.

46. Typical incision design for a surgical
procedure distal to the maxillary second
molar.

47. Incision designs for
surgical procedures
distal to the mandibular
second molar.
•The incision should
follow the areas of
greatest attached gingiva
and underlying bone.

48. Distal wedge
Triangular
Square , parallel or H-design
Linear or pedicle
The size, shape ,thickness and access
of the tuberosity or retromolar area
determine treatment procedures

49. TRIANGULAR DISTAL
WEDGE:
Triangular wedge incisions are placed
creating the apex of the triangle close to
the hamular notch and the base of the
triangle next to the distal surface of the
terminal tooth.

50. Triangular incision -Using no.12 0r no.15
scalpel blade
Triangular wedge of tissue removal-using
scalers ,hoes , or knives
Walls of the wedge are thinned using
scalpel blade- for proper adaptation to
underlying bone

51. LINEAR DISTAL WEDGE:
two parallel incisions over the crest of the
tuberosity that extend from the proximal
surface of the terminal molar to the hamular
notch area.
The distance between the two linear
incisions is determined by the thickness of
the tissues

52. Two parallel inverse bevel thinning
incision –using n0.15 blade
Periosteal elevators are used to raise
the flap
Kirkland or orban knives –to remove the
wedge of tissue

53. DISTAL POCKET
ERADICATION
PROCEDURE WITH THE
INCISION DISTAL TO THE
MOLAR
SCALLOPED INCISION
AROUND THE
REMAINING TEETH

54. FLAP REFLECTED AND THINNED
AROUND THE DISTAL INCISION
FLAP IN POSITION BEFORE
SUTURING. IT SHOULD BE
CLOSELY APPROXIMATED

55. FLAP SUTURED BOTH DISTALLY AND OVER
THE REMAINING SURGICAL AREA

56. PERIODONTAL PACKS
Periodontal dressing or periodontal
packs is a productive materials applied
over the wound created by periodontal
surgical procedure
minimise postoperative infection aand
haemorrahage
Facilitates healing
Protects against pai

57. Zinc –oxide eugenol packs
Zno eugenol packs packs based on
reaction of zno & eugenol include –
wondr pak
The addition of accelerators such as
Zinc acetate gives the dressing a
betterworking time.
It is supplied as a liquid and a powder
that are mixed prior to use.
Eugenol may produce allergic reaction
(reddening of area and burning pain )

58. Non eugenol packs
Reaction between metallic oxide and
fatty acid is basis for coe-Pak
Supplied in two tubes
One tube contains oxides of various
metals (Mainly zinc oxide) and lorothidol
(a fungicide) and second tube contains
non ionized carboxylic acids and
chlorothymol (bacteriostatic agents)

59. Retenton of packs
Mechanically by interlocking in
interdental spaces and joining the facial
and lingual portion of the pack

60. Antibacterial properties
Improved healing and patient comfort –
incorporating antibiotics
Bacitracin, oxytetracycline , neomycin
nitrofurazone(hypersensitivity)

61. Preparation and application of
periodontal dressing
Equal length of the two paste
placed on a paper pad
Mixed with a wooden tongue
depressor for 2-3 minutes until
paste loses its tackiness

62. Paste is placed in a paper cup of water
at room temperature
With lubricated fingers rolled into
cylinders and placed on the surgical
wound

63. Strip of pack is
hooked around last
molar and pressed
into place anteriorly
Lingual pack is joined
to facial strip at the
distal surface of last
molar and fitted into
place anteriorly
Gentle pressure on
the facil and lingual
surfaces join the pack
interproximally

64. Continous pack cover the edentulous
space

65. Instructions for patients after
surgery
1. The pack should remain in place until it
is removed in the office at the next
appointment
2. For the first three hours after the
operation avoid hot foods to permit the
pack to harden
3. Do not smoke
4. Do not brush over the pack

66. Removal of periodontal
pack
After 1 week
Inserting a surgical hoe along the
margin and exert gentle lateral pressure
Pieces of pack- removed with scalers
Entire area rinsed with peroxide to
remove superficial debris

67. Findings at pack removal
Epithelialized but bleed readily when
touched
Pockets should not be probed

68. HEALING AFTER FLAP
SURGERY
Immediately after suturing (0 to 24 hours),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.
One to 3 days after flap surgery,the space between the
flap and the tooth or bone is thinner, and epithelial cells
migrate over the border of the flap
One week after surgery‐The blood clot is replaced by
granulation tissue derived from the gingival connective
tissue, the bone marrow, and the periodontal ligament.

69. Two weeks after surgery,collagen fibers begin to appear parallel
to the tooth surface. Union of the flap to the tooth is still weak,
owing to the presence of immature collagen fibers, although the
clinical aspect may be almost normal.
•One month after surgery,a fully epithelialized gingival crevice
with a well‐defined epithelial attachment is present. There is a
beginning functional arrangement of the supracrestal fibers.