flap surgery and the various types, indications. advances in surgeries.

1. FLAP SURGERY CONCEPTS
RATIONALE OF POCKET ELIMINATION

2. • The ultimate goal of periodontal therapy has been aimed to
restore the health and function of the periodontium.
• To achieve this goal, many non surgical and surgical techniques
have been proposed to treat a variety of periodontal conditions,
most commonly – the periodontal pocket

3. PERIODONTAL POCKET
Periodontal pocket is defined as ‘ a pathologically deepened
gingival sulcus’
The etiologic factor for pocket formation is plaque.
Vicious cycle continues
without pocket therapy

4. POCKET THERAPY EFFECTS
ACTIVE POCKET:
Underlying bone is lost
• After Phase I therapy the inflammatory changes in the pocket wall
subside, rendering the pocket inactive and reducing its depth
• The extent of this reduction depends on the depth before treatment and
the degree to which the depth reduces, is the result of the edematous and
inflammatory component of the pocket wall.
INACTIVE POCKET:
• Inactive pockets can sometimes heal with a long junctional epithelium
• Unstable condition, chances of recurrence

5. • Inactive pockets maintained by:
Frequent scaling and root planing
Transforming pocket into healthy sulcus
Bottom of healthy sulcus
either coronal to the bottom of the pocket- re
attachment
at the bottom of the pocket- no gain of attachment

6. TREATMENT OUTCOME
• PERIODONTAL REGENERATION is defined histologically as
regeneration of the tooth’s supporting tissues, including alveolar bone,
periodontal ligament, and cementum over a previously diseased root
surface.
• NEW ATTACHMENT - embedding of new periodontal ligament fibers
into new cementum and the attachment of the gingival epithelium to a
tooth surface previously denuded by disease. (GPT 2001)

7. • RE ATTACHMENT – the attachment of the gingiva or the periodontal
ligament to the areas of the tooth from which they have been
removed in the course of treatment (or during preparation of teeth
for restorations)
• EPITHELIAL ADAPTATION – the close apposition of the gingival
epithelium (long junctional epithelium) to the tooth surface with no
gain in height of gingival fiber attachment.

8. Possible results of pocket therapy. An active pocket can become inactive and heal by means of a long
junctional epithelium. Surgical pocket therapy can result in a healthy sulcus, with or without gain of
attachment. Improved gingival attachment promotes restoration of bone height, with re-formation of
periodontal ligament fibers and layers of cementum.

9. TREATMENT MODALITIES FOR POCKET
ELIMINATION

10. Most common method.
Rationale: The wall of the pocket consists of soft tissue and may also
include bone in the case of intrabony pockets.
It can be removed by the following:
• Retraction or shrinkage: Scaling and root-planing procedures resolve the
inflammatory process gingiva shrinks pocket depth reduction.
• Surgical removal - gingivectomy technique /undisplaced flap.
• Apical displacement with an apically displaced flap.

11. accomplished by tooth extraction or by partial tooth extraction
(hemisection or root resection).

12. Gingival curettage
Excisional new attachment procedure (ENAP)
Flap for debridement (Modified Widman flap)
Gingivectomy
Apically positioned flap, often in conjunction with bone resection
Root resection or amputation

13. Criteria for Method Selection
1 Characteristics of the pocket: depth, relation to bone, and configuration.
2 Accessibility to instrumentation, including presence of furcation involvements.
3 Existence of mucogingival problems.
4 Response to Phase I therapy.
5 Patient cooperation, including ability to perform effective oral hygiene. Smokers
must be willing to stop their habit.

14. 6 Age and general health of the patient.
7 Overall diagnosis of the case: various types of gingival
enlargement and types of periodontitis (e.g., chronic marginal
periodontitis, localized aggressive periodontitis, generalized
aggressive periodontitis).
8 Esthetic considerations.
9 Previous periodontal treatments.

16. NON SURGICAL THERAPY- SCALING AND ROOT
PLANING
• Supra and subgingival debridement results in mechanical disruption of
plaque biofilm
• modality for periodontal treatment
Attributed to:
1) Exposure of cementum, root dentin and pocket epithelium for novel
colonization
2) Species thriving in diseased pocket find new habitat less hospitable
3) Decrease in pocket depth as a result of resolution of inflammation,
decreased edema, and a readaptation of apical junctional epithelium

18. • Healing following non surgical therapy is almost complete at 3 months,
however limited healing continues for 9 or more months.
• Measurements are made at baseline and again at 3 months as a method of
evaluation and effectiveness of therapy( LINDHE)
STUDY INITIAL PROBING DEPTH RESULTS AFTER SRP
Cobb et al. (1996)
Meta- analysis
1-3mm
4-6mm
˃7mm
-0.34mm(attachment loss)
+0.55mm ( gain)
+1.29mm (gain)
Claffey et al. (2000)
˂3.5mm
4- 6.5 mm
˃7mm
-0.5mm attachment loss
0-1mm attachment gain
1-2 mm attachment gain

19. The effectiveness of periodontal therapy is predicated on success in
completely eliminating calculus, plaque, and diseased cementum from the
tooth surface.
LIMITATIONS OF NON SURGICAL THERAPY
The presence of irregularities on the root surface
As the pocket becomes deeper, the surface to be scaled increases, more
irregularities appear on the root surface, and accessibility is impaired
The presence of furcations will also create insurmountable problems for
scaling the root surface

20. • First surgical technique used in periodontal therapy were described as
means of gaining access to diseased root surfaces
Access accomplished without excision of soft tissue pocket by
Open view operations
Diseased gingiva excised by gingivectomy procedures
Concept – not only soft and inflamed tissue but also infected and necrotic bone had to
be eliminated
Required alveolar bone exposure- FLAP
PROCEDURES

21. • Increase accessibility to root surfaces, making it possible to remove all
irritants
• Reduce or eliminate pocket depth ,making it possible for the patient to
maintain root surface free of plaque
• Reshape hard and soft tissues to attain harmonious topography.
Criteria for selection of surgical technique: based on clinical findings
1) Soft tissue pocket wall
2) Tooth surface
3) Underlying bone
4) Attached gingiva

22. • Pocket elimination procedures not involving underlying osseous
structures:
Gingival curettage
ENAP
Gingivectomy

23. CURETTAGE
• Defined as ‘ removal of pocket epithelium and underlying connective
tissue’. (Genco ,1976)
• Subgingival curettage: Pocket epithelium and connective tissue are
removed down to the crest of alveolar bone.

24. INDICATIONS CONTRAINDICATIONS
Can be done as a part of new attachment
attempts in intrabony pockets
As a part of non-definitive therapy prior
to other regenerative procedures
In medically compromised patients
where other extensive flap surgeries are
not indicated
As a part of maintenance therapy
Acute infections
Fibrous pockets
Pockets beyond MGJ
Furcation involvements

25. 1989 World Workshop in Clinical Periodontics concluded that curettage
had ‘no justifiable application during active therapy for chronic adult
periodontitis’
Curettage is a procedure which provides historic interest in the evolution
of periodontal therapy but has no current clinical relevance in the
treatment of chronic periodontitis
• (AAP Academy Report 2002)

26. EXCISIONAL NEW ATTACHMENT PROCEDURE (ENAP)
ENAP is the surgical procedure of which an internal bevel incision is made
to remove the epithelial lining of the crevice and the junctional epithelium,
allowing root preparation
Definitive subgingival curettage
Developed by the U.S Naval Dental Corps based on studies by Yukna (1976),
Yukna and Fedi (1976)
Gain new attachment
Decrease probing depth
Access root surface
Maintenance of esthetics

27. PROCEDURE
• Internal bevel incision from marginal gingiva to a point below the
bottom of the pocket- to cut inner portion of soft tissue wall
• Remove excised tissue with a curette, root planing on exposed root
preserving all CT fibers that are attached to root
• Approximate wound edges, bone recontouring if necessary

28. Author Studies Result
Yukna et al,1976 Excisional new attachment
procedure was used to treat
75 suprabony pockets on
32 teeth in 9 patients
One-year postoperative -
mean pocket reduction
from 4.7 mm to 2.0 mm, of
which 2.1 mm (77%) was
new attachment and 0.6
mm was recession.
Yukna and Williams Jr,1980 Patients treated with the
Excisional New Attachment
Procedure were evaluated 5
years or more following the
procedure
An overall mean net gain in
clinical attachment of 1.5
mm was found at 5 years
after treatment, and
probeable depths
approached 3.0 mm

29. LASER ASSISTED EXCISIONAL NEW ATTACHMENT
PROCEDURE ( LANAP)
• Patterned after the Excisional New Attachment Procedure (ENAP),
LANAP is designed to remove diseased and necrotic tissue selectively
from within the periodontal sulcus
• The first pass with the laser (referred to as laser troughing) is
accomplished by using the short duration pulse.
• Laser troughing affects sulcular debridement and de-epithelialization.
• Executed by moving the fiber continuously, beginning at the gingival crest
and working back and forth systematically, stepping down to the base of
the pocket.

30. • Following laser troughing, SRP is accomplished first by using a piezo-electric
scaler
• Followed by small curettes and root files for removing root surface
accretions. Aggressive root planing is minimized.
• A second pass, using the PerioLase with the 635-μ/sec “long pulse,”
finishes debriding the pocket, completes removal of epithelial tissue,
provides hemostasis, and creates a soft clot.
• The primary goal of LANAP is debridement to remove pocket epithelium
and underlying infected tissue within the periodontal pocket completely
and to remove calcified plaque and calculus adherent to the root surface

31. Clinical steps of LANAP, beginning with charting probe depths (A).
The primary endpoint of LANAP is debridement of inflamed and infected connective tissue within the periodontal
sulcus (B)
Removal of calcified plaque and calculus adherent to the root surface (C). In addition, the bacteriocidal effects of the
FR pulsed Nd:YAG laser plus intraoperative use of topical antibiotics are designed for the reduction of microbiotic
pathogens (antisepsis) within the periodontal sulcus and surrounding tissues.
A second pass with the 635 μ/sec “long pulse” laser finishes debriding the pocket (D).
Gingival tissue is compressed against the root surface to close the pocket and aid with formation and stabilization
of a fibrin clot (E).
Oral hygiene is stressed and continued periodontal maintenance is scheduled. No probing is performed for at least
six months.

32. GINGIVECTOMY
- coined ‘gingivectomy’
- modified the Robicsek technique, proposed a
scalloped incision
described the current gingivectomy
procedure
The excision of the soft tissue wall of a pathogenic periodontal
pocket

33. CONTRAINDICATIONS
Firm, fibrotic suprabony pockets
˃ 5mm, persisting after SRP
Gingival enlargements-pseudopockets
Suprabony abscesses
Presence of alveolar
ledges, irregular
margins
Infrabony pockets
Pockets extending
beyond the MGJ
Anterior aesthetic areas
INDICATIONS

34. • Pocket marking
• Gingivectomy incision
• Knives- No. 12/15 blade, Blake knife, Kirkland, Orban,
• Goldman-Fox
• External bevel incision- at 45°, apical to base of pocket, continuous,
scalloped
• Secondary incisions done with orbans knife.
• Tissue removal- Curette/scaler
• Root scaling and planing
• Periodontal dressing

35. Pocket
marking
Gingivectomy
incision
Tissue removal-curette
/scaler Residual pocket
depth is assessed

36. LIMITATIONS
• Open wound, healing by secondary intention
• Zone of attached gingiva may be reduced/ eliminated
• Alveolar defects not revealed, if present
• Exposure of root -root sensitivity

37. FLAP SURGERY
GLICKMAN
• Periodontal flap is defined as ‘ the section of gingiva
and/or mucosa surgically elevated from the underlying
tissues to provide visibility and access to the bone and
root surfaces’

38. RATIONALE
To enable visual
instrumentation of root
surfaces
To re-establish the healthy,
clinical status of periodontium
with long term maintenance
To restore the periodontal
apparatus when attachment
loss has occurred

39. • Pocket elimination or reduction
• Preservation of adequate zone of attached gingiva
• To permit access to underlying bone for treatment of osseous
defects

40. SPECIAL
INDICATIONS

41. HISTORICAL BACKGROUND
Neumann (1911) 1st introduced mucoperiosteal flap- ‘Neumann flap’
Cieszynski (1911) Reverse bevel incision
Leonard Widman (1918) Modified the Neumann flap
Kirkland (1931) Modified flap procedure
Nabers (1954) Introduced ‘repositioning of attached gingiva’
Ariaudo and Tyrrell (1962) Modified Nabers procedure
Friedman (1962) Apically positioned flap
Morris (1965) ‘Unrepositioned mucoperiosteal flap’
Ramfjord and Nissle (1974) ‘Modified Widman flap’

42. •Mucoperiosteal flap FULL THICKNESS
FLAP
•Split thickness;
PARTIAL mucosal
THICKNESS FLAP

43. UNDISPLACED (NON-DISPLACED; UNREPOSITIONED)
• Eg: Modified Widman, undisplaced flap
DISPLACED (REPOSITIONED)
• Eg : Coronally positioned
• Laterally positioned
• Apically positioned

44. BASED ON THE MANAGEMENT OF PAPILLA
CONVENTIONAL FLAPS: modified widman flap, undisplaced flap, apically
displaced flap, flap for reconstructive procedures
• Papilla is split at center under contact point and included in both buccal
and palatal/lingual flaps
PAPILLA PRESERVATION FLAP
• Papilla is included in one of the flaps by semicircular incision

45. • According to the main purpose of the procedure
Pocket elimination flap
Reattachment flap surgery
Mucogingival repair.
•Widman flap,
The undisplaced (unrepositioned) flap
The apically displaced flap.

46. COMPARISON BETWEEN FULL THICKNESS AND
PARTIAL THICKNESS
Full thickness Partial thickness
Healing Primary intention Secondary intention
Bone defect treatment possible difficult
Blood supply to flaps sufficient decrease
Elimination/ reduction of
possible possible
periodontal pocket
Bleeding less much
Postoperative discomfort less much
Possibility of flap
less much
penetration
Fixation of flaps Firm fixation with
periosteal sutures

47. HORIZONTAL
INCISIONS
VERTICAL
INCISIONS

48. HORIZONTAL INCISIONS
Directed along the margin of the gingiva in a mesial or a distal
direction.
Two types of horizontal incisions have been recommended:
A) starts at a distance from the
gingival margin and is aimed at the bone crest.
B) starts at the bottom of the pocket
and is directed to the bone margin.
C) performed after the flap is
elevated

49. INTERNAL BEVEL INCISION
• First incision/ Reverse bevel incision
• Basic incision
Placement of internal bevel incision- depends
on the objective of treatment

50. • Removal of pocket lining : close to the gingival margin (0.5-1mm) -
Modified Widman flap
• Removal of pocket lining and preservation of the keratinized gingiva : close
to gingival margin- Apically displaced flap
• Removal of pocket lining and minimizing dead space formation : apical to
bottom of pocket -Undisplaced flap

51. • PRIMARY INCISION DEPENDS ON:
Width of attached gingiva
Type of surgery
Esthetics
Osseous reconstruction ,If required
Depth of pockets
Clinical crown lengthening, if required

52. CREVICULAR INCISION
• Second incision
• Starts from base of pocket and is directed to alveolar crest
• Along with the first incision it produces a V shaped wedge of tissue

53. • Third incision
• Directed horizontally from the internal bevel incision to remove the
wedge shaped tissue

54. • Given when flaps have to be displaced
• Directed perpendicularly to gingival margins at the line angles of teeth
• THEY SHOULD NOT BE PLACED :
Pronounced concavities
Prominent bony ledges
Exostoses
Should not cross root prominences
Should not split interdental papilla
• Best to include papilla with the flap to enhance blood supply and facilitate suturing

55. CORRECT INCISION
INCORRECT INCISION

57. • Internal/ undermining incisions extending from gingival margin towards
base of flap to decrease bulk of connective tissue on the underside of flap
• Indicated in Palatal flaps, Distal wedge, Internal bevel gingivectomy,
Bulky papillae
Incisions at base of flap severing underlying periosteum
INDICATED
to release flap tension allowing for coronal/ lateral placement,
to provide primary closure over barrier membranes in GTR and GBR
procedures

59. Full thickness mucoperiosteal flap aimed at removing:
Pocket epithelium and the inflamed connective tissue
ADVANTAGES
Facilitates optimal cleaning of root surfaces
Less discomfort for the patient, healing occurs by primary intention
Re establish a proper contour of the alveolar bone in sites with angular
bony defects

60. Two releasing incisions, scalloped
reverse bevel incision connecting two
releasing incisions
Collar of inflamed gingival tissue is
removed after flap elevation
Bone recontouring suturing

61. • Intracrevicular incision through the base of the gingival pocket
• Entire gingiva (and part of the alveolar mucosa) was elevated in a
mucoperiosteal flap
• Sectional releasing incisions
• Flap elevation, the inside of the flap curetted to remove the pocket epithelium
and the granulation tissue
• The root surfaces were subsequently carefully “cleaned”
• Any irregularities of the alveolar bone corrected to give the bone crest a
horizontal outline
• Flaps trimmed to allow both an optimal adaptation to the teeth and a proper
coverage of the alveolar bone on both the buccal/lingual (palatal) and the
interproximal sites
• Flap replaced at crest of alveolar bone

62. • Modified flap operation- to be used in the treatment of “ Periodontal pus
pockets”.
• Incisions made intracrevicularly through the bottom of the pocket
• Retraction of the gingiva- debridement
• Elimination of the pocket epithelium and granulation tissue from the inner
surface of the flaps

63. Intracrevicular incision Gingiva is retracted to expose the diseased
root surface
Exposed root surfaces are subjected to mechanical
debridement
Suturing

64. DIFFERENCE FROM NEUMANN AND ORIGINAL WIDMAN FLAP

65. • Pocket elimination procedure using internal bevel incision. Also called as
INTERNAL BEVEL GINGIVECTOMY
• Pocket wall is eliminated with first incision
• Elimination of ‘dead space’ as the flap margin is place over bone crest
postoperatively
• However, sufficient attached gingiva is a pre-requisite
• Usually used for pocket elimination of palatal pockets

66. The incision is made at the level of the pocket to discard
the tissue coronal to the pocket if there is sufficient
remaining attached gingiva.

67. Nabers(1954) –
one vertical
incision-
‘repositioning of
attached gingiva’
Ariaudo and
Tyrrell (1957) –
two vertical
incisions
Friedman (1962)
– coined the term
‘apically
repositioned flap’

68. OBJECTIVES
Apical displacement of entire mucogingival unit to eliminate the
pockets while retaining the attached gingiva. To maintain
keratinized gingiva
Surgical access for osseous surgery, treatment of infrabony pockets
and root planing.
USED FOR
The apically displaced flap technique can be used for
(1) pocket eradication and/or
(2) widening the zone of attached gingiva.
(3)crown lengthening procedures for cosmetic enhancement and
restorative treatment

69. Indicated in
• Mandibular buccal and lingual surfaces
• Maxillary buccal surfaces
It can be raised as
• Full thickness flap
• Partial thickness flap

70. Reduction of probing depth,
Preserving or increasing the presurgical zone of gingiva,
Facilitation of healing, accessibility to bone, roots, furcations, subgingival
caries, and other anatomical aberrations,
Controlling the tissue placement,
Usefulness in conjunction with other treatment modalities.
Sacrifice of crestal alveolar process and supporting bone
Extensive exposure of root surfaces.

71. Vertical releasing incision, the reverse bevel
incision is made through the gingiva and
periosteum to separate the inflamed tissue
adjacent to the tooth
Mucoperiosteal flap is raised and the tissue collar remaining
around the teeth, including the pocket epithelium and the
inflamed connective tissue is removed with a curette

72. Osseous surgery is performed
with a rotating bur
Recapture the physiologic contour of the bone
Repositioned in an apical direction to level of the
recontoured bone crest and retained by sutures

73. FRIEDMAN AND LEVIN CLASSIFICATION ,1962
Class I: More than adequate keratinized gingiva width
Labial or buccal incision 1-3mm from crest of gingiva.
Flap apically positioned to cover 1-2mm of cementum
Class II: Adequate keratinized gingiva
Crestal incision used.
Flap apically positioned to the crest of the bone

74. Class III- Insufficient gingival keratinized width
Sulcular incision
Flap is positioned 1-2mm below crest of bone to increase width of
keratinized gingiva.

75. • Ramfjord and Nissle in 1974 coined the term modified Widman flap
• Procedure was employed by Morris in 1965 and was termed the
unrepositioned mucoperiosteal flap.
• Morris in 1965 has described this flap as “the simple mucoperiosteal flap,
combined with the inverted beveled incision and osseous resection.”

76. • Conservative flap design of which includes a reverse bevel incision from
the marginal gingiva to the alveolar crest, the intrasulcular incision to the
bottom of the pocket, and the horizontal incision from the alveolar crest
to the bottom of the pocket.
• It is used whenever reattachment with minimal gingival recession is
desired.
• Moderately deep pockets
• Moderate furcation involvement, and
Patient with a high caries rate and root sensitivity problem.

77. Initial incision is placed:
0.5-1mm from the gingival margin
Parallel to long axis of tooth
Elevation of the flaps,
Intracrevicular incision is made to alveolar bone
crest
To separate the collar tissue from root surface

78. Third incision is made:
Perpendicular to root surface and
As close to possible to the bone crest thereby
separating the tissue collar from alveolar
bone
Flaps are carefully adjusted to cover the alveolar bone
and sutured
Complete coverage of the interdental bone as well as
close adaptation of the flaps to the tooth surfaces should
be accomplished

79. Advantages:
• Possibility of obtaining close adaptation of soft tissues to root surfaces
• Less exposure of root surfaces – esthetic advantage in the anterior
segments ( Ramfjord and Nissle,1974)
• SRP at base of deep pockets can be done with direct vision
• Complete removal of pocket epithelium
• Primary intention healing
• Esthetically superior to gingivectomy/ APF

80. Original Widman flap ModifiedWidman flap
Pocket elimination procedure Pocket reduction procedure
Apical displacement of flap No apical displacement
Osseous recontouring can be done Not designed for osseous contouring

81. • Ramfjord and Nissle performed an extensive longitudinal study
comparing the Widman procedure, as modified by them, with
the curettage technique and the pocket elimination methods that
include bone contouring when needed.
• The patients were assigned randomly to one of the techniques,
and results were analyzed yearly up to 7 years after therapy.
• Similar results with the three methods tested.
• Pocket depth was initially similar for all methods but was
maintained at shallower levels with the Widman flap;
• The attachment level remained higher with the Widman flap.

82. • Pocket lining was removed with the help of a diode laser
• The laser setting used for this procedure was 4 W in continuous mode.
• Crevicular incision was given with a bard parker # 15 blade directed
toward the alveolar crest. Full thickness mucoperiosteal flap was raised
buccally and lingually. The granulation tissue was removed from the
defects by manual debridement
• Reduction in probing depth was from 11 mm to 6 mm
• Radiographs revealed increased bone fill

83. • To preserve the interdental soft tissues for maximum soft tissue coverage
involving treatment of proximal osseous defects
• Cortellini et al. (1995, 1999) – modifications of the flap design to be used
in combination with regenerative procedures.
• For aesthetic reasons, it is often utilized in the surgical treatment of
anterior tooth regions

84. Sulcular incision Semilunar incision- dip 5mm
apically from line angles

85. Papilla elevated in facial
flap
suturing

86. • Access to the interdental defect consists of a horizontal incision
buccal keratinized gingiva at the base of the papilla
• Connected with mesio-distal buccal intrasulcular incisions for
elevation of full-thickness buccal flap
• Residual interdental tissues are dissected from neighboring teeth and
the underlying bone and elevated towards the palatal aspect

87. • Elevation of full thickness palatal flap, including the interdental
papilla, interdental defect exposure
• Debridement of the defect
• Buccal flap is mobilized with vertical and periosteal incisions,
when needed

89. Difficult application in narrow interdental spaces and in posterior areas
Suturing technique not appropriate for use with non supportive barriers
Modified papilla preservation is used in wide interdental spaces (>2mm )
especially in anterior dentition.

90. Sulcular incisions and
buccal flap elevation
Palatal flap reflection
Oblique incision in papilla begins at the gingival
margin line angle, blade parallel to the long axis of
the tooth and reaches the midpoint of the distal
surfaceof adjacent tooth below the contact point

91. • Palatal flaps historically involved reflecting full thickness flap to remove
necrotic and granulomatous tissue.
Oschenbein and Bohannan(1963,1964) described a palatal
approach for osseous surgery
Advantages of palatal approach-
Esthetics
Easier access for osseous surgery
Less resorption because of thicker bone
Wider palatal embrasure space
A natural cleansing area.

92. Indications-
• Areas that require osseous surgery
• Pocket reduction
• Reduction in enlarged bulbous tissue
Contraindications-
• Broad shallow palate- damage to palatal vessels

93. • Full thickness
• Partial thickness
• Modified partial thickness
• Beveled flap
• Undisplaced flap

94. PARTIAL THICKNESS PALATAL FLAP
• Developed by Staffileno et al (1969)
To facilitate treatment of palatal osseous defects
To overcome problems of extensive gingival recession
Minimal trauma
Rapid healing
Ease of palatal tissue manipulation
Establishment of favorable gingival contours

95. MODIFIED PARTIAL THICKNESS PALATAL FLAP
• Oshenbein(1958) ,Oshenbein and Bohannan(1963) described the
technique
• Popularized by Prichard( 1965)
• Also known as

96. • Stage I : Gingivectomy
But no bevel
tissue ledge is created
• Stage II : Partial thickness flap
• Primary partial thickness thinning incision
• Secondary incision - inner flap removal

97. BEVELED FLAP- MODIFICATION OF THE APF
Primary incision is made
intracrevicularly
Scaling, root planing and osseous
recontouring
Secondary, scalloped reverse bevel incision is made to
adjust to the height of the remaining alveolar bone
Shortened and thinned flap
replaced over the alveolar bone

98. • Treatment of periodontal pockets on the distal surface of distal molars is
complicated by the presence of bulbous tissues over the tuberosity
(maxillary) or by a prominent retromolar pad (mandibular)
Factors to be considered for distal-molar surgery
• Pocket depth
• Amount of keratinized gingiva
• Accessibility
• Available distance from distal aspect of tooth to the end of tuberosity/
retromolar pad
• Anatomic considerations : Lingual nerve, Internal oblique ridge, Muscle
attachments

99. DISTAL WEDGE PROCEDURE ( ROBINSON,1966)
INDICATIONS
• When only limited amounts of keratinized gingiva is present
• Presence of distal angular bony defect
Facilitates access to osseous defect
Preserves sufficient amounts of gingiva and mucosa to
achieve soft tissue coverage

100. Buccal and lingual vertical
incisions through the retromolar
pad to form a triangle behind
mandibular molar
Triangular shaped wedge of
tissue is dissected from the
underlying bone and
removed
Flaps are reduced in thickness
by undermining incisions
Suturing

101. FOR MANDIBULAR MOLARS
Incisions are governed by location of keratinized gingiva
Incisions :
• Triangular wedge
• Square, parallel or H design
• Linear or pedicle

102. FOR MAXILLARY MOLARS
Simpler compared to mandibular as more fibrous and attached tissue is
generally present
Incisions may be
• Triangular wedge
• Linear wedge

103. ADVANTAGES OF DISTAL WEDGE
• Maintenance of attached tissue
• Access for treatment of both the distal furcations and underlying
osseous irregularities
• Closure by a mature thin tissue which is especially important in
retromolar area
• Greater access and opening when done in conjunction with other flap
procedures

104. • Principles outline by Schluger(1949) and Goldman( 1950)
• “Gingival contour is dependent on the underlying bony contour and the
elimination of the soft tissue pockets has to be combined with osseous
recontouring”.
• To maintain
Shallow pockets
Optimal gingival contour after surgery

105. OSTEOPLASTY- FRIEDMAN (1955)
• Reshaping of alveolar bone to achieve a more physiological form without
removal of tooth supporting bone
Indications
• Buccal/ lingual bony
• ledges
• Intrabony defect-buccal/lingual,
• tilted molars
• Interproximal defects
• Furcation involvement

106. OSTECTOMY
Removal of tooth supporting bone to reshape the deformities.
INDICATIONS :
• Elimination of interdental craters
• Correction of one walled defects
• Other angular defects not amenable to regeneration
• Horizontal alveolar bone loss with irregular marginal contours

108. a connection between the
flap and the tooth or bone surface is established by a blood clot,
the space between the flap and the tooth
or bone is thinner and epithelial cells migrate over the border of the flap,
usually contacting the tooth at this time.

109. an epithelial attachment to the root has been
established by means of hemidesmosomes and a basal lamina.
The blood clot is replaced by granulation tissue
collagen fibers begin to appear parallel to the
tooth surface.
a fully epithelialized gingival crevice with a
well-defined epithelial attachment is present.
Beginning functional arrangement of the supracrestal fibers

110. • 1 to 3 days- Full-thickness flaps, result in a superficial bone necrosis.
• 4 to 6 days- Osteoclastic resorption follows .Loss of bone of about 1
mm and the bone loss is greater if the bone is thin.
• If Osseous remodeling does not include excessive thinning of the
radicular bone. Bone repair reaches its peak at 3 to 4 weeks.

111. LONG TERM STUDIES COMPARING
SURGICAL AND NON- SURGICAL
THERAPIES

112. MICHIGAN STUDIES
Ramfjord et al. (1968)
32 patients with moderate-severe periodontitis
all patients 1st received nonsurgical therapy and then divided into
 Group 1: subgingival curettage
 Group II: pocket elimination (gingivectomy, APF with osseous resection)

113. Short term observations (1-3 yrs)
• Group 1: slight gain in CAL
• Group II : loss of attachment following pocket elimination procedures
Long term evaluation (4-7 yrs)
• No significant differences between the 2 groups
• Surgical technique – reduction in PD was greater and better sustained

114. Knowles et al. (1979)
78 patients evaluated over 1-8 yrs
Effect of subgingival curettage, Modified Widman flap and pocket elimination
procedure
Results:
All techniques reduced PD with subgingival curettage being the least effective
Moderate pockets (4-6 mm)- similar CA gain
Advanced pockets (7-10mm)- Modified Widman produced greatest gain in CA,
followed by curettage and pocket elimination

115. GOTHENBURG STUDIES
Lindhe et al. (1982)
15 patients, split mouth study
SRP alone vs. SRP + Modified Widman
Results at 2 yrs demonstrated that surgical therapy results in greater probing
depth reduction than nonsurgical therapy
CRITICAL PROBING DEPTH
Root planing : 2.9 mm
Flap : 4.2 mm

116. MINNESOTA STUDY
Pihlstrom et al. (1985)
SRP alone vs. flap in 6 ½ yr follow up
 No significant difference in probing depth reduction and gingival
inflammation
Although attachment gain seemed to be greater with flap procedures
for deeper pockets.

117. AARHUS STUDY
Isidor and Korning (1986)
Root planing and Modified Widman flap to apically positioned flap during 5
year of follow up
 obtained similar results for both the treatment.

118. WASHINGTON STUDY
Oslen et al (1985)
compared apically positioned flap without osseous recontoring to a.p.f.
with osseous recontouring in a 5 year follow up study.
osseous recontouring was more effective in reducing pockets and
controlling the inflammation than flap surgery

119. TUCSON STUDIES
Becker et al. (1988)
Root planing, Modified Widman flap, apically positioned flap with osseous
surgery
1 yr observation period – minimal differences in probing depth reductions and
attachment gain between the 3 procedures

120. NEBRASKA STUDIES
Kaldahl et al. (1988)
 82 patients, split mouth design study for 2 yrs
 SRP vs. Modified Widman flap vs. Modified Widman flap with osseous resection
 All resulted in decrease in PD
Greatest with flap with osseous resection, followed by Modified Widman flap and
SRP

121. INTERPRETATION OF LONGITUDINAL STUDIES
Non-surgical therapy is the “corner stone of periodontal therapy” in all types of
pocket depths.
Surgical techniques have produced greater pocket depth reduction
No difference on long term evaluation
Thus, SRP will always be performed first for any patient with periodontitis

122. • Clinical probing depth and clinical attachment levels evaluated.
• Modified widman flap gave better results for gain in clinical attachment
,while all three modalities significantly reduced probing depth.
( Becker et al,2001)

123. • Effect of root planing alone and with a modified widman flap
• Assessment of resultant level of attachment and in relation to initial pocket
depth
• SRP- loss of attachment in pocket shallower than 2.9mm
• Gain of attachment in deeper pockets
Modified widman flap- loss of attachment in pockets shallower than 4.2mm
Gain of attachment in deeper pockets
Loss of attachment implies true loss of connective tissue
Gain- could be false

124. Failures of flap
surgery

125. • Pre therapeutic causes
• Therapeutic causes
• Post therapeutic causes

126. PRE THERAPEUTIC CAUSES
1) Incorrect patient selection
2) Improper diagnosis
Systemic condition
Type of periodontitis
Involvement of hopeless tooth
Oral hygiene assessment
3) Inappropriate dental restorations

127. 4)Morphology of tooth surfaces
Failure to eliminate aberrations like enamel pearls and grooves which act
as a “guide plane” for a bacterial penetration of deeper periodontal tissues
5)Habits
mouth breathing
bruxism
thumb sucking
Smoking
6)Occlusal trauma

128. THERAPEUTIC CAUSES
Improper selection of surgical technique :
• width of attached gingiva
• height of remaining bone
• pocket depth
• mobility
• co-operation of the patient
• patients systemic back ground

129. • decreased width of attached gingiva- internal bevel incision will further
decrease the width of attached gingiva leading to mucogingival problems
• Surgical technique which does not allow proper adaptation of
interdental tissue will lead to food and plaque accumulation in the
interproximal area and therapy leads to recurrence of periodontal
disease
• Improper asepsis of the surgical field and patient, improper sterilization
of the instruments

130. Improper flap design:
• A properly designed flap will anatomically fall into its correct position
on its bony base following surgery
• If a mucoperiosteal flap is not designed correctly it may
Rise too high coronally- redundant tissue with subsequent repocketing
Fall far short of the osseous margin- resorption or sequestra formation
Inadequately cover the bone graft- minimizing the opportunity for ideal
healing

131. • Inadequate thinning of the full thickness flap (palatal flap), results in an
excessively thick bulky gingival margin -gingivoplasty
• It may also encourage the overzealous tightening of the sutures,
thereby endangering the blood supply and enhancing the possibility of
sloughing of flap and post operative pain
Incomplete debridement
Improper suturing

132. • Improper incision: the rationale of any periodontal flap surgery is to
gain access to underlying root and bone surfaces.
• If incisions are not made upto the bone/root surface and a mucosal
flap is elevated which hinders in gaining proper access to the
underlying root surfaces, It can cause increased amount of bone
resorption.
• Therefore while giving incision the blade should hit the bone in
order to elevate a full thickness flap.

133. • REFLECTION OF THE FLAP: elevation of the periodontal flap should be
such that only around 1 mm of marginal bone is exposed.
Over reflection - bone resorption,
Under reflection - limited access to the underlying root/bone surface.
• DEBRIDEMENT OF THE ROOT SURFACES AND THE BONE: complete
debridement with removal of plaque and calculus from the root surface
• SUTURING of the separated flaps should be done to closely adapt the
flap to the tooth margins.
Failure to properly place the sutures gaping of the wound
and hence recurrence of the disease

134. POST THERAPEUTIC CAUSES
Unsupervised healing :
• Post-operative care
Inadequate restorations post surgically :
• failure to replace missing teeth
• correct overhanging restorations
• correct carious lesions

135. FAILURES ASSOCIATED WITH PALATAL FLAPS
The flap may be too short. This results in delayed healing & increased
patient discomfort.
Poor marginal flap adaptation caused by incomplete thinning of the
tissue.

136. Damage to the palatal artery- Incision beyond the vertical height of the
alveolus, bringing the scalpel blade close to the palatal artery
Extension beveling or thinning of tissue on a low, broad palate.
Tissue placement to high onto the teeth results in poor flap adaptation &
recurrent pocket formation.

137. Selection of
technique???

138. • Suprabony, fibrous pocket with sufficient attached gingiva-
Gingivectomy
• Infrabony pocket, osseous deformities, furcation involvement, muco-gingival
problems- Flap surgery
• Location
Amount of attached gingiva
Need for osseous recontouring

139. • Pocket wall can be
Edematous & soft
Fibrotic
• Edematous pockets shrink after elimination of local factors. Therefore
scaling & root planing and curettage is the preferred treatment.
• Fibrotic pockets do not subside predictably after S.R.P. Hence preferred
method is gingivectomy

140. Therapy for pockets with horizontal bone loss
• N.S.T
• Surgical therapy if required
Therapy for pockets with vertical bone loss
• N.S.T
• Surgical therapy to eliminate the bone defect by resection or
regeneration

141. • Scaling and root planing is the technique of choice
• PAPILLA PRESERVATION FLAP- improved accessibility for root
surfaces
regenerative surgery of osseous defects
• Results in less recession and reduced soft tissue crater formation
interproximally
• SULCULAR INCISION FLAP- teeth too close interproximally
• MODIFIED WIDMAN FLAP- esthetics not the primary consideration
• APICALLY DISPLACED FLAP with bone recontouring

142. • Osseous surgery required for enhanced accessibility or the need of
definitive pocket elimination
• Accessibility- undisplaced flap/ apically displaced flap
• Osseous defects amenable to reconstruction- papilla preservation flap
sulcular flap
modified widman flap
• Osseous defects with no possibility of reconstruction- flap with osseous
recontouring

143. Excisional
surgeries
Resective
surgery
Regenerative
procedures

144. • Tissue attachment procedures , although not capable of generating
predictable new attachment, are effective in controlling the progression
of chronic periodontitis.
• The patient and the dentist have an option between flap debridement
procedures and other debridement approaches to control disease
progression.
• Choice must be made upon a multitude of factors including clinical
expertise, systemic and local etiologic factors, time and economic factors.
Among the tissue attachment procedures, FLAP
DEBRIDEMENT SURGERY remains an important part of
periodontal therapy.