This document discusses various flap techniques used in periodontal surgery. It defines flaps as sections of gingiva and mucosa surgically separated from underlying tissues to provide access to bone and roots. Full and partial thickness flaps are classified based on the depth of tissue reflection. Techniques include the modified Widman flap, undisplaced flap, apically displaced flap, papilla preservation flap, and techniques for distal molar surgery. Healing after flap surgery is described in stages from initial clot formation to establishment of new connective tissue attachment after 4 weeks.

2. DEFINATION
INDICATIONS AND CONTRAINDICATIONS
CLASSIFICATION
PLANNING FOR FLAP SURGERY
INCISIONS IN FLAP SURGERY
ELEVATION OF FLAP SURGERY
HEALING AFTER FLAP SURGERY
FLAP TECHNIQUES

3.  Definition
It is a section of gingiva and/or
mucosa surgically separated from the
underlying tissues to provide visibility of
and access to the bone and root surface.

4. INDICATIONS
• 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.
• Infrabony pockets on distal areas of
second molars.

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

6. • Based on bone exposure after reflection
1. Full thickness(mucoperiosteal)flap
2. Partial thickness(split thickness)flap
• Placement of flap after surgery
1. Non-displaced flap
2. Displaced flap
a)Apical displaced flaps
b)Coronal displaced flaps
c)Lateral displaced flaps
• Management of papilla
1. Conventional flap
2. Papilla preservation flap

7. Mucoperiosteal flap
• All the soft tissues,including the periosteum is reflected to
expose the underlying bone.
• Indicated for Osseous surgery.

8. Mucosal flap or split thickness flap
• Includes only the epithelium and a layer of the underlying
connective tissue.
• The bone remains covered by a layer of connective tissue,
including the periosteum.

9. Flap is returned and Sutured in its original
position
• Currently,It is the most commonly performed type of
periodontal surgery.
• Soft tissue pocket wall is removed with the initial
incision.
• Thus,it may be considered an internal bevel
Gingivectomy.

10. They are placed apically, coronally,or laterally to
their original position
• Both full thickness and partial thickness flaps
can be displaced
• The attached gingiva has to be totally separated from the
underlying bone,thereby enabling the unattached portion of
the gingiva to be movable.

11. • Dictated by the surgical judgement of the
operator and may depend on the objectives
of the operation.
• Two basic flap designs are used.
 Conventional flap
 Papilla preservation flap

12. Split papilla flap
• Interdental papilla is split beneath the contact point of the
two approximating teeth to allow reflection of buccal and
lingual flaps.

13. • Incorporates the entire papilla in one of the flaps by means of
crevicular interdental incisions to serve the connective tissue
attachment.
• Horizontal incision at the base of the papilla.

14.  Should be done in detail before procedure
› Based on clinical & radiographic findings of case
› It should include the following
 Type of flap
 Location and type of incisions
 Management of underlying bone
 Final placement of flap
 Sutures used
› Plan may be modified in case of any variations

15.  Horizontal incisions
Types of incisions
 Internal bevel incision
 Crevicular incision
 Interdental incision
 Vertical incision

16. Initial or first incision
Reverse bevel incision.
 Direction of incision
• 2-3mm from gingival margin
• Aimed at Crest of alveolar
bone and Apical to crest of
bone
• BP blade #11 or #15 used

17. • Basic to flap surgery
Exposure of root and
underlying bone
• Removes pocket lining
• Conserves uninvolved
outer gingiva
• Produces a sharp, thin
flap margin
• Places the connective
tissue close to the root.

18. Second incision
Made from base of the sulcus
to the crest of bone
• Forms “V” shaped
wedge of tissue,contains
Infected granulation
tissue,Junctional
epithelium &
Supracrestal fibers.
• BP blade #12 used.

19. Third incision
• A periosteal elevator is inserted into
the initial internal bevel incision, and
the flap is separated from the bone.
• It separates the collar of gingiva that is
left around the tooth.
• The Orban knife is usually used for
this incision.

20. Oblique or releasing incision
• Depend upon flap design and purpose.
• Can be used on one or both sides of the flap.
• Flap without vertical incision is called as
“Envelop Flap”.

21. • Areas of incision
At line angles of papilla

22.  Full thickness flap
Also called as blunt
dissection.
• With periosteal elevator
moved in mesial, distal
and apical direction
• Optimum bone exposure
achieved.
Types
Full thickness flap
Partial thickness flap

23.  0-24 hours
› Clot connects flap and tooth/bone surface
› Contains fibrin network of
 PMNLs and erythrocytes
 Cell debris
 Capillaries at wound edge
› Exudate results
 1-3 days
› Space between bone/tooth and flap is thinner
› Epithelial cells migrate over wound edge
› Minimal inflammatory response seen

24.  1 week
› Epithelial attachment is established by
 Hemidesmosomes and basal lamina
› Blood clot replaced by granulation tissue from
 Gingival connective tissue; bone marrow and PDL
 2 weeks
› Collagen fibers parallel to tooth surface
› Clinically normal but immature junction
 4 weeks
› Fully epithelized sulcus; well defined attachment
› Functional orientation of supra-crestal fibers

25. • The Modified Widman flap
• The Undisplaced flap
• The Apically displaced flap
• Flaps for regenerative surgery
The Papilla preservation flap
Conventional flap
• Distal molar surgery
FLAP TECHNIQUES

26. THE MODIFIED WIDMAN FLAP
Ramfjord and Nissle(1974):
They presented Modified Widman Flap.

27. Technique
STEP 1: The initial incision is an internal bevel incision to
the alveolar crest starting 0.5-1mm away from gingival
margin. Scalloping follows the gingival margin.

28. STEP 2: The gingival is reflected with a periosteal
elevator.

29. STEP 3: A crevicular incision is made from the bottom
of the pocket to the bone,circumscribing the triangular
wedge of tissue containing the pocket lining.

30. Step 4: After the flap is reflected,a third incision is made
in the interdental spaces coronal to the bone with a
curette or an interproximal knife,and the gingival collar
is removed.

31. Step 5: Tissue tags and granulation tissue are
removed with a curette.

32. Step 6: Bone architecture is not corrected except if it
prevents good tissue adaptation to the necks of the
teeth.
Adapt the facial and lingual interproximal
tissue adjacent to each other for no interproximal bone
remains exposed at the time of suturing.

33. Step 7: Interrupted direct sutures are placed in
each interdental space and covered with
tetracycline ointment and with a periodontal
surgical pack.

34. THE UNDISPLACED FLAP TECHNIQUE
Step 1: Measure pockets by periodontal probe,and
a bleeding point is produced on the outer surface of
the gingiva by pocket marker.

35. Step 2: The initial, internal bevel incision is made after
the scalloping of the bleeding marks on
the gingiva.

36. Step 3: Crevicular incision is made from the bottom of the
pocket to the bone to detach the connective tissue from
the bone.

37. Step 4: The flap is reflected with a periosteal elevator (blunt
dissection) from the internal bevel incision.
Step 5: The interdental incision is made with an
interdental knife.

38. Step 6: The triangular wedge of tissue is removed with
curette.
Step 7: The area is debrided,removing all tissue tags
and granulation tissue using sharp curette.

39. Step 8: After the necessary scaling and root planing.
Step 9: Flaps are placed in their original site and sutured.

40. THE APICALLY DISPLACED FLAP
Step 1: An internal bevel incision is made.
Step 2: Crevicular incisions are made, followed by
initial elevation of the flap.

41. Step 3: Vertical incisions are made extending beyond
the mucogingival junction.
Step 4: After removal of all granulation tissue, scaling
and root planing, and osseous surgery if needed, the
flap is displaced apically.

42. Step 5: Suture around the tooth prevents the flap from
sliding to a position more apical.
After 1 week, dressings and sutures are removed. The
area is usually repacked for another week.

43. FLAPS FOR REGENERATIVE SURGERY
1)The Papilla Preservation Flap
Step 1: A crevicular incision is made with no
incisions across the interdental papilla.

44. Step 2: The preserved papilla can be incorporated into
the facial or lingual/palatal flap.
Step 3: An Orban knife is used in interdental papilla.
Step 4: The flap is reflected.

45. 2)Conventional Flap
Step 1: Using a #12 blade,incise the tissue at the
bottom of the pocket and to the crest of the bone.
Step 2: Reflect the flap maintaining it as thick as
possible.

46. Complicated by the presence of bulbous fibrous tissue
over the maxillary tuberosity or prominent retromolar
pads in the mandible.
This surgery was described by “Robinson and Braden”.
DISTAL MOLAR SURGERY

47. Maxillary Molars
• The treatment of distal pockets on the maxillary arch is
usually more simple than the treatment of a similar lesion
on the mandibular arch.
• Tuberosity presents a greater amount of fibrous
attached gingiva.
Technique: Two parallel incisions.

48. Mandibular Molars
• Does not usually present as much fibrous attached
gingiva.
• The two incisions distal to the molar area with the
greatest amount of attached gingiva.
• Incisions directed distolingually or distofacially

49. • Incision designs for surgical procedures distal to the
mandibular second molar.