Principles of flap surgery copy

 The ultimate aim of periodontal therapy is to
establish a healthy dentition with sound
attachment apparatus resulting in proper form,
function and esthetics.
 Periodontal therapy comprises of initial non-
surgical debridement followed by a re-
evaluation, at which stage the need for further
treatment, usually surgical in nature is
established.

 Periodontal flap is defined as 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. (Carranza
10th edition).
 Flap is defined as the separation of a section of
tissue from the surrounding tissue except at its
base. (Glossary of periodontal terms).

 A flap is defined as a mass of tissue, usually
including skin, only partially removed from one
part of the body so that it retains its own blood
supply during transfer to another site. (Dorland’s
medical dictionary)

 Periodontal surgical techniques used in the
nineteenth century were essentially
gingivectomies with straight line incisions
followed by an aggressive curettage to remove
the crestal bone & thorough scaling of the root
surface.

Carl Parstch 19th cntry
Parstch
incision
Neumann
1912
Leonard
Widman in
1918
A.
Cyszeinsky
G.V. Black
Olin Kirkland
in 1931

 Pierre Fauchard, who has
been called “ the father of
modern dentistry” 1723,
said that “little or no care as
to the cleanliness of the
teeth is ordinalrily the
cause of all the maladies
that destroy them”- one of
the earliest expression
recorded in history of the
importance of oral hygiene.
 He described a procedure in
1742 and designed specific
instrumentation to remove
the excessive gingival tissue.

John W. Riggs (1811-1885). (From Hoffman-
Axthelm W: History of dentistry, Chicago,
1981,uintessence.)
 Riggs(1810-1885)
known as “the father
of periodontology”
credited the cause of
periodontal disease to
the calculary deposits
over the teeth and
advocated their
removal followed by
curettage of the
alveolar process.John W. Riggs (1811-1885).
(From Hoffman-Axthelm W:
History of dentistry, Chicago,
1981,Quintessence.)

 Carl Partsh developed a technique in nineteenth
century, for the surgical treatment of periapical
lesions and cysts.( performed under cocaine local
anesthesia)
 The procedure involved a curved incision with
convexity toward the crown of the teeth, called
the Partsch incision. After separating the tissues
and elevating the flap, a cyst could be removed
and the flap was returned to its original position.

 After 1907, Partsch recommended that the flap
be sutured.
 Most of the progress in periodontal surgery in
this period came from germany and other central
European countries, and is associated with three
names: Robert Neumann, Leonard Widmann
and A. Cieszinski.

 Robert Neumann , born in 1882;advocated “the
radical surgical treatment of pyorrhoea”.
 He introduced mucoperiosteal flap in 1912.
 In a famous article titled “Robert Neumann: a
pioneer in periodontal surgery”, the
contributions of Neumann to the development of
periodontal surgery was acknowledged.

 In 1918, Leonard Widman introduced Widman
flap. He described his technic in his article “The
operative treatment of pyorrhoea alveolaris”.
 The reverse bevel incision was introduced by A.
Ciezynski.

 Arthur Zentler of USA in 1918 were first to
describe the mucoperiosteal flap operation.
 He allowed access for debridement and
elimination of granulation tissue as well as
osseous removal by chisels.

 Kirkland described a procedure to be used in the
treatment of “ periodontal pus pockets”
 The procedure was called the modified flap
operation or a vest pocket edition of the radical
flap operation and was basically an access flap
for root debridement.

 In 1935, Kronfeld performed autopsy studies of
bone and found that bone is not necrotic and
inflamed but destroyed by an inflammatory
process. .
 Orban conducted similar studies.
 Dr. Carranza in 1939 proposed in his doctoral
thesis “ the surgical treatment of periodontitis”
which involved pocket elimination surgery by
raising the flap.

 In 1954, Naber described “repositioning of
attached gingiva”. He placed flap apically for
the first time and utilized one vertical releasing
incision mesial to the area of deepest periodontal
pocket.
 In 1957 , Ariaudo and Tyrell, modified Nabers
technique by giving two vertical incisions and
resembled Widmans technic, except that it was
positioned apically.

 In 1962, Friedman proposed the term “apically
repositioned flap”. Today, the word “reposition”
is replaced by the term “position”. So, now it is
called “apically positioned flap”.
 1963, 1964- Ochsenbein and Bohannan
described the palatal flap approach as an
alterative to buccal approach.

 In 1985, Takei et al. proposed a surgical
approach called papilla preservation technique.

 Pocket
ReductionSurgery:
 Resective (gingivectomy,
apically displaced flap and
undisplaced flap with or
without osseous resection.
 Regenerative( flaps with
grafts, membranes)
 Correction of
anatomic/morphologic
defects:
 Plastic Surgery techniques
to widen attached gingiva.
 Esthetic surgical
techniques(root coverage)
 Preprosthetic
considerations
 Placement of dental
implants.

Unaccesible areas like root concavities,
furcation areas etc,
Deep periodontal pockets:- Waerhaug
stated that pocket depth greater than 5mm
demonstrated only an 11% efficacy in removal of
plaque and calculus.
Osseous defects:- the morphology of
osseous defects can limit the effectiveness of
nonsurgical therapy.eg: narrow intrabony
defects.

-Esthetic considerations
-Implant surgeries
-patient co-operation
-systemic health of the
patient

a. Patient non co-operation:
 Since, optimal post-operative infection control is
decisive for the success of periodontal treatment
( Axelsson & Lindhe,1981), a patient who fails
to co-operate during the cause related phase of
therapy should not be exposed to surgical
treatment.

 B. Systemic conditions:
 Cardiovascular disease:
 arterial hypertension: patient’s consent should
be taken and local anesthesia with low adrenaline
or without adrenaline (as it has ionotropic effect
on heart muscles) must be used.
 Angina pectoris: premedication with sedatives
and L.A, low in adrenaline is recommended.

 Myocardial Infarction: MI patients should not
be subjected within 6 months following
hospitalization and thereafter only in co-
operation with the physician of the patient.
 Anticoagulant treatment: The range within
which scaling & surgical procedures can be
safely performed is one and half to two times
the average normal prothrombin time (12-14
sec). (Lindhe 5th edition)

 Aspirin and other NSAID drugs should not be
used for post-operative pain control.
 Rheumatic Endocarditis, Congenital heart
lesions and heart/vascular implants involve
risk of transient bacteremia that follows
manipulation of infected periodontal pockets.
 ADA- recommeded antibiotic prophylaxis and
antiseptic mouthrinsing 0.2% chlorhexidine prior
to surgery .
 AHA (1997), 2 grams of amoxicillin
administerated orally 1 hour before the treatment,
if allergic to penicillin, clindamycin (600 mg)
orally 1 hour before treatment is recommended.

 Organ Transplantation:
 Prophylactic antibiotics are recommended in
transplant patients taking immunosuppressive
drugs.
 Blood Disorders:patients suffering from acute
leukemias, agranulocytosis, and
lymphogranulomatosis must not be subjected to
periodontal surgery.

 Diabetes: well controlled diabetics(Hb A1c6-
8%) may be subjected to periodontal surgery
provided precautions are taken taken. (Seymour
and Heasman,1992).
 Neurologic disorders:multiple sclerosis and
Parkinson’s disease in severe cases,make
ambulatory periodontal surgery impossible.
 Epilepsy : drugs used to treat epilepsy may cause
gingival enlargements. These patients may
without special restrictions be subjected to
periodontal surgery.

 Based on bone exposure after flap reflection
(by Carranza, 1979):
Full thickness Partial thickness Combination
flap flap flap

 Based on Presence/Absence of releasing
incisions
Flap with flap without
releasing incision releasing incision
(relaxed flaps) (envelope flaps)

1. Access to roots and alveolar bone
• enhance visibility
• increase scaling and root planing effectiveness
• less tissue trauma
2. Modification of osseous defect
• establish physiologic architecture of hard tissues
through regeneration or resection
• augment alveolar ridge defects
3. Repair or regeneration of the periodontium

4. Pocket reduction
• enhance maintenance by patient and therapist
• improve long-term stability
5. Provide acceptable soft tissue contours
• enhance plaque control and maintenance
• improve esthetics

 According to Hupp (1933) the following
principles should be followed:
 Prevention of flap necrosis:
1.) The apex of the flap should never be wider
than the base.
2.) Flap should either run parallel to each other or
preferably converge from the base of the flap to
its apex.

3. Flap length to base ratio should be no greater
than 2:1
 The major blood supply to a flap was found to
exist at its base and travels in an apical to
coronal direction. So,It was also determined that
the greater the ratio of flap length to flap base,
the greater the vascular compromise at the flap
margins.

 Whenever possible, an axial blood supply should
be included in the base of the flap.
 The base of the flap should not be excessively
twisted or stretched (as either of these will
compromise the supplying vessels).

 The access of the flap should be enough to avoid
tearing.
 If an envelope flap does not provide sufficient
access, another incision should be made.
 Vertical (oblique) releasing incisions should be
placed one full tooth anterior to the area of any
anticipated bone removal.

 The incision should be started at the line
angle of the tooth & carried obliquely
apically into the unattached gingiva.

 Procedural selection should be based on the
following:
a. Simplicity
b. Predictability
c. Efficiency
d. Mucogingival considerations
e. Underlying osseous topography
f. Anatomic and physical limitations
g. Age and systemic factors

 All incisions should be clear, smooth, and
denifite.
 All flaps should be designed for maximum use
and retention of keratinized gingiva.
 The flap design should allow for adequate access
and visibility.
 Involvement of adjacent non involved areas
should be avoided.
 The flap design should prevent unnecessary
bone exposure, with resultant possible loss and
dehiscence or fenestration formation.

 Where possible, primary intention procedures
are preferred to those of secondary intention.
 The base of a flap should be as wide for adequate
vascularity.
 Tissue tags should be removed to allow for rapid
healing and prevent regrowth of granulation
tissue.
 Adequate flap stabilization is necessary to
prevent displacement, unnecessary bleeding,
hematoma formation, bone exposure, and
possible infection.

 According LASKIN (1980), they are-:
 The incision should not be made over the operative
site but in the adjacent, undisturbed areas so that the
flap will be supported by normal tissue & the
potential for rapid revascularization is preserved.
 The incision should be placed so that major nerves
are not transected unless necessary.
 An adequate blood supply should be maintained by
incising parallel to the major vessels, minimizing
the number of side cuts, & having the base of the
flap as wider than the apex.

 Incisions should not be made in areas of thinned
mucosa like that found over an exostosis because
the blood supply is reduced, suturing is difficult
& rate of dehiscence is very high.
 When developing flaps around teeth, the
incisions should be made in the gingival crevice.
 It is also important to maintain the integrity of
the interdental papillae.

 If access is inadequate, the surgeon may extend
the length of the incision or make a releasing
incision. The releasing incision is usually made
at about at an angle of 450 from the direction of
the parent incision.
 If the flap is to include both mucosa & the
periosteum, the incision should be made directly
to the bone with one cut & it should be elevated
in one piece without tearing the periosteum.
 After the necessary surgery, the clotted blood
should be removed from beneath the flap to
lessen the possibility of infection & permit tissue
fluid to penetrate more readily.

1. THE EXTERNAL BEVEL OR
GINGIVECTOMY INCISION :
 It is contained in the gingiva and coronally
directed with the surgical objectives of pocket
elimination, access to roots, and improved
gingival contours.
 Indications: to treat gingival enlargement and to
perform esthetic crown lengthening when access
to the underlying bone is not required.

 It is sometimes used in conjunction with flap
surgery when there is need to thin the tissues
externally before flap reflection.
An example would be a case of severe gingival
enlargement with lobulated gingiva and highly
irregular gingival margins.
Recontouring gingiva with an irregular surface
morphology is difficult if attempted using an
internal thinning technique on the underside of
the flap.

The dotted line
represents the
external bevel
incision, and the
shaded area
corresponds to the
tissue to be
excised.

 A) The internal bevel
incision, which starts at a
distance from the gingival
margin and is aimed at
the bone crest.
 B) The crevicular
incision, which starts at
the bottom of the pocket
and is directed to the
bone margin.
 C) interdental incision is
performed after the flap
is elevated.

 This incision has been termed as the first
incision because it is the initial incision in the
reflection of the flap &
 the reverse bevel incision, because its bevel is in
reverse direction from the gingivectomy incision.
 the # 11 or #15 surgical scalpel is used most
commonly.

 Objectives of internal bevel incision:
 It removes the pocket lining and the area of the
tissue invaded by microorganisms (Bacterial
invasion can occur up to a distance of 400
microns- Nisengard and Bascons, 1987. In an
SEM study bacteria have been observed to
penetrate even the subepithelial connective tissue
in periodontitis- Saglie, 1982.
 Therefore the chief advantage of this incision is
that it eliminates the part of the gingival margin
which has been penetrated by pathogens.

 It conserves the relatively less involved outer
surface of the gingiva.
 It produces a sharp, thin flap margin for
adaptation to the bone tooth junction.

 Indications:
 Primary incision of the flap surgery if there is a
sufficient band of attached gingiva.
 Desire to correct bone morphology (osteoplasty,
osseous resection)
 Thick gingiva (such as palatal gingiva)
 Deep periodontal pockets and bone defect
 Desire to lengthen clinical crown

 INCISION DESIGN:
The placement of the primary incision is determined by
the following factors:
l. Band of attached gingiva.
2. Method of periodontal surgery.
3. periodontal pocket depth.
4. Whether osteoplasty and ostectomy are necessary
5. Esthetics
6. Whether restorative treatment is necessary after
periodontal surgery
7. Clinical crown length needed for abutment

 A scalloped incision design is incorporated in the
flap when this incision is used.
 The shape of this scallop is dictated by the anatomy
of the tooth and underlying root form.

variations in the type of internal bevel incision for
the different types of flaps.
 Modified Widman flap does not intend to remove
the pocket wall, but eliminates the pocket lining.
Therefore the internal bevel incision starts close, no
more than 1 to 2 mm apically to the gingival margin
and follows the normal scalloping of the gingival
margin.
 For apically displaced flap, the pocket wall is to be
preserved to be positioned apically while its lining is
removed. So, the internal bevel incision is to be
made as close to the tooth as possible 0.5 to 1mm.
 For an undisplaced flap, the internal bevel incision
is initiated at or near a point just coronal to the
projection of the bottom of the pocket on the outer
surface of the gingiva.

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

Diagram showing the
location of two
different areas where
the internal bevel
incision is made in
an undisplaced flap.
The incision is
made at the level of
the pocket .

Morris 1949 stated
that the removal of
pocket epithelium is
necessary for new
connective tissue
attachment.
Stone 1966 postulated that
any residual epithelium on the
wound edge could serve as a
“seed area” and result in rapid
proliferation of the junctional
epithelium along the root
surface.

Yukna 1976
successfully
removed all
epithelium with
internal bevel
incison as described
by ENAP .
Caffesse et al 1968
observed that all
pocket epithelium was
removed with the
reverse bevel incision
as described in the
Modified Widman
Flap procedure.

Carranza has stated that placement of the scalloped
internal bevel incison 1mm subcrestally will remove
most of the granulation tissue contained in the lateral
wall of pocket.

Bowen et al,
observed
residual
epithelium with
the internal bevel
incision in ENAP
used by Yukna in
1976.
Fischer et al 1982
also established
the inability of the
reverse bevel
incision in Modified
Widman Flap
Procedure to
remove all pocket
epithelium.
Litch et al 1984
stated that neither
crestal nor
subcrestal internal
bevel incisions
consistently
eliminated all
pocket epithelium.

 It is selected if preservation of
all the existing keratinized
tissue is desirable.
 The scalpel blade is inserted
into the gingival crevice,
aligned parallel to the long axis
of the tooth, and angled toward
the alveolar crest.
Interproximally, the incision is
extended into the embrasure
space to include as much papilla
as possible.

 INDICATIONS :
 Narrow band of attached gingiva
 Thin gingiva and alveolar process
 Shallow periodontal pocket
 Desire to lessen post operative gingival recession
for esthetic reasons in the maxillary anterior
region
 As a secondary incision of usual flap surgery
 Bone graft or GTR: desire to preserve as much
periodontal tissue (especially interdental papilla)
as possible to completely cover grafted bone and
membrane by flaps.

 Its purpose is to facilitate the removal of the
inflammatory granulation tissue surrounding the
cervical area and the secondary flap of soft tissue
walls of the periodontal pocket (after reflecting
the primary flap).
 A no. 12 blade, is recommended.

 After the first two
incisions have been
placed, periosteal
elevator is inserted into
the initial internal bevel
incision, and the flap is
separated from the bone.
With this access the
interdental incision is
placed to separate the
collar of gingiva(around
facial,lingual &
interdental areas that is
left around the tooth.
 Orban Knife is used

 They are normally perpendicular to the gingival
margin and placed at the line angles of the teeth.
ADVANTAGES:
 increase access to alveolar bone,
 decrease tension on retracted flaps,
 allow apical and coronal positioning of flaps,

 Vertical incisions in the lingual and palatal areas
are avoided.
 Facial vertical incision should always be placed
at the line angles of the teeth and never over the
height of contour of the root. This accomplishes
two things:
i) It protects the interdental papilla adjacent to the
surgical site.
ii) It allows the vertical incision to be sutured
without having to stretch the flap over the
cervical convexity of the tooth.

 As a rule, when trying to
decide on what side of
the interproximal space
to place the releasing
incision, it is best to
include the papilla with
the flap to enhance the
blood supply to the flap
and to allow for ease of
suturing.
 Suture vertical incisions
before horizontal portion
of flap.

 Vertical incisions may be used to move the flap
laterally (as in pedicle flap.)
 In this situation vertical incision is made at an acute
angle to the horizontal incision, in the direction
toward which flap is moved, placing the base of the
pedicle at the recipient site. This is termed as
cutback incision.
 care must be taken not to extend cutback incisions
more than 2 to 3 mm to minimize disruption of the
remaining blood supply to the flap.

 It reduces the bulk of connective tissue from the
underside of the flap and are used to reduce the
thickness of flaps before reflection.
 Such incisions are used as part of distal wedge
procedures and to thin bulky papillae.
 Thinning incisions are performed either in
conjunction with flap reflection (i.e., reflecting
the flap as it is thinned) or after completing flap
reflection.

 Triangular: These 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.
 The thinning or undermining incisions are
accomplished before full reflection of tissue and
are extended 2 to 3 mm apical to the crestal
aspect of the tuberosity.

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

 The linear distal wedge
incorporates 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,
with wider separation of
the incisions in thicker
tissue.

 These are used when coronal or lateral
advancement of a flap onto the root or crown of
the tooth is indicated.
 This incision, which severs the underlying
periosteum at the base of full-thickness flaps,
allows tension-free coronal positioning of the
flap to cover exposed root surfaces and to
provide primary closure over barrier membranes
used in guided tissue and guided bone
regeneration procedures.

 Method:
 The periosteum on the underside of the flap is
scored with a scalpel blade to increase flap
mobility, allowing passive coronal advancement
of the flap.

 Once the initial incisions have been made, the
body of the flap is reflected one of the 3 ways:
 Full thickness Partial combination
Thickness flap

 Full-thickness flaps are prepared by making an
incision through the mucosal layers and the
periosteum until the bone is felt. A periosteal
elevator is then used to gently separate the
periosteum along with the superficial mucosal
layers from the bone.
 The partial-thickness flap is technically more
challenging than a full-thickness flap and should
not be attempted in areas where the gingiva is
thin (1-2 mm).

 It is also contraindicated in posterior areas of the
mandible where the vestibule is shallow and
access is difficult.
 When performing a partial thickness flap, the tip
of the surgical blade is used to split the
connective tissue layer into two parts: one, which
is left covering the periosteum, and the other,
which becomes part of the tissue flap.

 If the flap has been properly designed and
reflected adequately, retraction should be passive
without any tension.
 It is also critically important that the edge of the
retractor always be kept on bone. Trapping the
flap between the retractor and bone can cause
tissue ischemia and lead to postoperative flap
necrosis.

 Continuous flap retraction for long periods also is
not advised. Such a practice will desiccate the
soft tissue and bone causing a delay in wound
healing.
 When the flap is retracted, the surgical assistant
should frequently irrigate the surgical field with
sterile saline, to keep the tissues moistened, to
reduce contamination, and to improve visibility.

ELEVATION
OF THE FLAP
Blunt dissection
with periosteal
elevator
For reflection of
full thickness
flap

Sharp
dissection
with surgical
scalpel (#11
or #15)
For reflection
of partial
thickness flap

 The rationale for this basic surgical approach is
the same as all flap surgery: to provide access to
root surfaces and marginal alveolar bone. Direct
visualization of these structures will increase the
effectiveness of scaling and root planing and
allow debridement of granulomatous tissue from
osseous defects.

 Granulation tissue consists of angioblastic and
fibroblastic components which proliferate in
response to the bacterial challenge from plaque,
areas of chronic inflammation and pieces of
dislodged calculus and bacterial colonies.
 This may perpetuate the pathologic features of
the tissue and hinder healing.
 This granulation tissue lined by epithelium is
construed as a barrier to the attachment of new
fibers in the area.

 The concept of complete removal of this granulation
tissue dominated the therapeutic procedures.
 But lately it has been shown that when root is planed
and all bacterial plaque has been removed, the major
source of bacteria disappears and the pathologic changes
resolve with no need to eliminate the inflamed
granulation tissue.
 The existing granulation tissue is slowly resorbed: the
bacteria present in the absence of replenishment of their
numbers by the pocket plaque, are destroyed by defence
mechanisms of the host and this granulation tissue , in an
environment free of plaque and calculus, matures into
connective tissue.

 The current concept however, is still the
complete removal of granulation tissue during
flap surgery for technical rather than biological
reasons( Newman et al., 2007)
 Granulation tissue is a source of bleeding during
the surgery and may obstruct proper visualization
of calculus deposits and root as well bone defect
morphology. Therefore, its removal is important
during surgery. However, complete elimination
of the nidus of infection is more important than
the removal of granulation tissue

 Transseptal fibers should be removed completely during the
surgery:
 Transseptal fibers regenerate soon after they are destroyed by
the disease process & they lie just coronal to the alveolar bone.
So, there removal is essential to see the exact topography of
bone defects.
 These fibers extend in an angular course over the surface of
osseous defects in infrabony pockets occupying space between
the wall of defect on one side and root on the other. The removal
of these fibers permits the flow of blood, undifferentiated
mesenchymal cells from pdl and osteogenic cells into the
osseous defect thus favouring new attachment.
 When inflamed these fibers undergo degeneration and are partly
or completely replaced by granulation tissue. So, granulation
tissue may get entagled with these fibers which necessitate their
removal.

 Once the debridement treatment has been
completed, surgical flaps may be repositioned,
apically positioned, coronally positioned, or
laterally positioned.
 The final flap location is usually determined by
the goal(s) of therapy and the specific
periodontal surgical technique performed.

 In 1979, Carranza classified flap as
 Full thickness- In this, all the soft tissue along
with the periosteum is reflected to expose the
underlying bone.
 Advantages:
 They offer improved visibility of the alveolar
bone.
 They are generally associated with less
bleeding and post operative pain.

 It is the most common type of flap used when
access to the bone is indicated for resective or
regenerative procedures.
 The full-thickness flap can be used to reduce or
eliminate periodontal pockets, but there must be
a sufficient band of attached gingiva and
sufficient alveolar crest width to achieve this

Contraindications:
Area where treatment for osseous defect with mucogingival problem is
not required.
Thin periodontal tissue with probable osseous dehiscence and osseous
fenestration.
Area where alveolar bone is thin.

 Partial/Split thickness:In this
only the epithelium and a layer of
the underlying connective tissue
are included. The bone remains
covered by a layer of connective
tissue, including the periosteum.
 Indications:
 when the flap is to be positioned
apically or when the operator does
not want to expose the bone.
 Indicated on buccal surfaces.
Palatal and lingual surfaces , with
their wide zones of attached
gingiva and thick alveolar bone do
not require split thickness flaps.

 Contraindications:
 The partial-thickness flap should not be
attempted in areas where the gingiva is thin
(1mm).
 It is also contraindicated in posterior areas of
the mandible where the vestibule is shallow and
access is difficult.
 ADVANTAGES:
 The partial-thickness flap is favorable in
augmentation of attached gingiva with thin bone
(done by positioning the flap apically or
laterally)

 DISADVANTAGE:
 The biggest problem of a partial-thickness flap is
with the thickness of the remaining periosteum-
connective tissue bed on the bone. If it is less
than 0.5-1 mm, the remaining periosteum-
connective tissue may become necrotic.

FULL THICKNESS PARTIAL THICKNESS
Healing Primary healing Secondary healing
Technical difficulty Relatively easy Difficult
Bone defect
treatment
Possible Difficult
Blood supply to
flaps
Sufficient Decrease
Elimination of
periodontal pocket
Possible Possible

FULL THICKNESS PARTIAL THICKNESS
Bleeding Less More
Postoperative
swelling
Less more
Postoperative pain
and discomfort
Use with
mucogingival
surgery
Less
Impossible
Much
Possible

 A useful variation of these two flaps is the
combination or “ Split-full-split” flap.
 First, a crevicular incision is made lateral to the
periodontal pocket and down to the crest of the
alveolar bone (Split).
periodontal elevator is used to bluntly dissect the
flap down to the approximate level of the
mucogingival junction (full).
scalpel is again used to split the alveolar mucosa
apically beyond the mucogingival junction (split).

 This type of flap design exposes alveolar bone,
which can then be recontoured or
augmented,while it maintain periosteum in the
apical part of the surgical site for the protection
and to aid in suturing and flap reattachment.

 One of the first detailed descriptions of the use of
a flap procedure for pocket elimination was
published in 1916 by Leonard Widman.
 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.

Two releasing incisions
demarcate the area scheduled for
surgical therapy. A scalloped reverse
bevel incision is made in the gingival
margin to connect the two releasing
incisions.
The collar of inflamed
gingival tissue is
removed following the
elevation of a
mucoperiosteal flap.

By bone recontouring, a
"physiologic" contour of
the alveolar bone may be
reestablished.
The coronal ends of the
buccal and lingual flaps
are placed at the
alveolar bone crest and
secured in this position
by interdentally placed
sutures

 Advantages of ‘original widman flap”
procedures were:
 Less discomfort for the patient, since healing was
by primary intention and
 It was possible to re-establish a proper contour of
the alveolar bone in sites with angular bony
defects.

 Neumann in 1912 suggested the use of a flap
procedure which was:
Technique:
 The first incisions are vertical incisions made in
long axis of the tooth, generally in sextants
without bisecting the papilla.
 An intracrevicular incision was made through the
base of the gingival pockets, and the entire
gingiva was elevated in a mucoperiosteal flap to
gain a clear view of the field being operated.

 Following flap elevation, the inside of the flap
was curetted to remove the pocket epithelium
and granulation tissue.
 The root surfaces were subsequently carefully
“cleaned:. Any irregularities of the alveolar bone
were corrected to give the bone crest as far as
possible the “normal shape nature intended for
it”.
 The flaps were trimmed to allow both an optimal
adaptation to the teeth and a proper coverage of
the bone at the alveolar crest margin.

NEWMANN FLAP WIDMAN FLAP
Neumann advocated flap elevation
only in the areas of pocket and
said that where no lingual or
palatal pockets existed, only a
buccal or labial flap should be
used
Widman advocated treatment
with both buccal and lingual
flaps in all cases of
periodontitis.
Neumann advocated elevation
of flap in sextants
Widman said that surgical field
should not extend beyond 2 or 3
teeth except in the region of the
lower anteriors where he
operated from cuspid to cuspid.

NEWMANN FLAP WIDMAN FLAP
Neumann used sulcular
incisions
Widman used reverse bevel
incision for pocket elimination.
Neumann advocated vertical
releasing incisions at the line
angles of the teeth.
Widman placed them at centre
of the tooth surfaces to have a
clear view of interproximal
area.
Neumann always recommended
provisional splinting prior to
surgery
Widman felt that it interfered
with his surgical approach and
only stabilized teeth post
operatively.

 In a publication from 1931 Kirkland described
surgical procedure to be used in the treatment of
“periodontal pus pockets”.
 The procedure was called as the modified flap
operation, and is basically an access flap for
proper root debridement.

Modified flap operation
(the Kirkland flap) -
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.

 The advantages are:
 Less extensive procedure, thus preserving the
non inflamed tissues from unnecessary trauma.
 Less postoperative pain and swelling.
 No apical displacement of the gingival margins.
 More esthetic results postoperatively.
 More chances of bone regeneration.

 Ramfjord and Nissle (1974) described the
Modified Widman technique, which is also
recognized as OPEN FLAP CURETTAGE
TECHNIQUE. While the original Widman Flap
technique included both apical displacement of
the flaps and osseous reontouring to obtain
proper pocket elimination, the modified Widman
flap technique is not intended to meet these
objectives.

116
Step 1: The initial incision is an
internal bevel incision to the alveolar
crest starting 0.5 to 1 mm away from
the gingival margin
Step 2: The gingiva is reflected with a
periosteal elevator .
Step 3: A crevicular incision is made
from the bottom of the pocket to the
bone,

117
Step 4: 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 .
Step 5:Tissue tags and granulation
tissue are removed with a curette.
Step 6: adapt the facial and lingual
interproximal tissue adjacent to each
other in such a way that no
interproximal bone remains exposed at
the time of suturing . Interrupted
direct sutures are placed .

MODIFIED WIDMAN FLAP ORIGINAL WIDMAN FLAP
Main aim is access for root debridement
with pocket reduction
Main aim is pocket elimination.
Flaps are elevated to a much lesser extent Flaps are elevated to a larger extent.
The crevicular and third incision is also a
modification allowing removal of the
collar of tissues around teeth
Flaps are placed at alveolar crest margins
Less postoperative pain and swelling
Flaps are placed apically
More post operative pain and swellling

ADVANTAGES of Modified Widman flap as
compared to other procedures:
Intimate post operative adaptation of healthy
collagenous tissue to all tooth surfaces leading
to new attachment.
The minimum of trauma to which alveolar bone
and soft connective tissues are exposed.
Less exposure of the root surfaces, this form an
esthetic point of view & is advantageous in the
treatment of anterior segments of the dentition.
Less exposure of the root surfaces also means
potentially less root sensitivity and fewer
caries. It facilitates oral hygiene.

Unfavourable proximal architecture
immediately following surgery.
However, it has been shown that if
meticulous oral hygiene is maintained,
the proximal tissues will regenerate.
Pockets are not completely eliminated.
Cannot be used for regenerative
purposes.

 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.
 Advantage :
 It can be used to increase the width of
keratinized gingival

Undisplaced flap. A and
B, Preoperative facial
and palatal views. C and
D, Internal bevel
incisions
in the facial and palatal
aspects. Note the deeper
scalloping palatally for
the replaced flap. E and
F, Flap elevated
showing osseous
defects. G and H,
Osseous surgery has
been performed. I and J,
Flaps have been placed
in their original site and
sutured. K and L,
Postoperative results.

 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,
and a partial-thickness (split-thickness) flap
cannot be accomplished.

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.

primary incision is made intracrevicularly through
the bottom of the periodontal pocket

The palatal flap is replaced and
Osseous recontouring is performed in the surgical
area. 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.

 In 1950s and 1960s new surgical techniques for
the removal of soft tissue were described.The
importance of maintaining an adequate zone of
attached gingival after surgery was emphasized.
 Apically positioned flap surgery, in which flaps
are reflected with an internal bevel incision and
sutured apical to pre-operative position.
 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.

Following a vertical releasing
incision, the reverse bevel incision is
made
through the gingiva and the
periosteum to separate the
inflamed tissue adjacent to the tooth
from the flap.
A 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 currette.

Osseous surgery is performed with the use of a rotating bur

The flaps are repositioned
in an apical direction to the level of
the recontoured
alveolar bone crest and retained in
this position
by sutures.
A periodontal dressing
is placed over the surgical
area to ensure that the
flaps remain in the correct
position during healing.

INDICATIONS:
i. To eliminate periodontal pockets.
ii. To increase the width of
attached gingiva.
iii. To lengthen the clinical crown
for prosthetic treatment.
iv. To improve gingiva and alveolar
bone morphology.

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 unfavourable clinical
crown/root ratio.

Minimum pocket depth postoperatively.
If optimal soft tissue coverage of the
alveolar bone is obtained, the postsurgical
bone loss is minimum.
Preserves attached gingiva and increase its
width.
Establishes gingival morphology
facilitating good hygiene.
Ensures healthy root surface necessary for
the biologic width on alveolar margin and
lengthened clinical crown.

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

 Here a partial thickness flap is raised, displaced apically
and a periosteal suture placed. This technique increases
the width of the attached gingival on the exposed
periosteum connective tissue.
 Factors in determining the position of the apically
postioned flap:
 Width and thickness of gingiva.
 Thickness of marginal alveolar bone.
 Amount of periodontal pocket to be eliminated.
 Clinical crown length required for restorative/prosthetic
treatment and esthetics.
 Length of root trunk.

Conditions necessary for partial thickness,
apically positioned flap surgery:
partial thickness flap must be of adequate
thickness (1-1.5 mm) where there is adequate
blood supply.
Absence of thick alveolar bone margin,
marginal alveolar bone defect, bony
protuberance or exostoses, which require
extensive osseous resection.

Sufficient oral vestibule depth.
Adequate alveolar bone covering the root.
Little attached gingiva on gingival margin
preoperatively.
No shallow deep intrabony defect.

 Ability to fix flap to optimal position with periosteal suture.
 Periosteal pocket eliminated and width of the attached gingiva
increased with one treatment.
 Thin marginal alveolar bone can be protected by periosteum-
connective tissue site.
 Easily combined with other forms of mucogingival surgery.
 Clinical crown length extended while biologic width gained.
 Treatment may be complicated if combined with osseous
resection.

Increase of the attached gingiva in an area with
narrow attached gingival and sufficient oral
vestibule depth.
Avoid exposing areas where the alveolar bone is thin
because of the protruding tooth and where there is
likelihood of osseous dehiscence or osseous fenestration.
Elimination of a periodontal pocket that extends beyond
the mucogingival junction with narrow attached gingival.
Extension of clinical crown length for restorative/prosthetic
treatment (crown lengthening surgery).

Thin gingiva.
Lack of keratinized gingiva at gingival margin.
Narrow oral vestibule.
Extremely thin alveolar process.
Extensive osseous surgery required.
Deep intra bony defect requiring bone regeneration or
restoration.

Two flap designs are
available for
reconstructive surgery:
Papilla preservation flap
Conventional flap with
only crevicular incisions

i.) PAPILLA PRESERVATION FLAP:
 Proposed by Takei et al (1985) later, Cortellini et
al (1995,1999) described modifications of 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.

(a) An intrasulcular incision is made along the lingual/palatal aspect of the
teeth with a semi-lunar incision made across each interdental area. (b) A
curette or interproximal knife 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.

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

II. CONVENTIONAL FLAP FOR
REGENERATIVE SURGERY:
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 protect the area subsequently.
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 resulting from necrosis of the flap
margins.

III. DISTAL MOLAR SURGERY
 The gingivectomy incision is the most direct
approach in treating distal pockets that have
adequate attached gingiva and no osseous
lesions. However, the flap approach is less
traumatic postsurgically, because it produces a
primary closure incision.
 In addition, it results in attached gingiva and
provides access for examination and, if needed,
correction of the osseous defect.

 Procedures for this purpose were described by
Robinson and Braden and modified by several
other investigators.
Objectives of wedge procedure:
1. Eliminate periodontal pockets.
2.Maintain and preserve attached gingiva.
3.Make area accessible to the instruments.
4.Lengthen clinical crown.
5.Create easily clearable gingival – alveolar form.

Factors that determine the flap design of a wedge:
 Size and shape.
 Thickness of soft tissue.
 Difficulty of access.
 Band of attached gingival of the abutment teeth.
 Depth of periodontal pocket and degree of
osseous depth on the edentulous side of
abutment.
 Clinical crown length required as an abutment
for restorative/ prosthetic treatment.

 Maxillary Molars.
 Usually simpler than mandibular molars because
of the following reasons:
 The tuberosity presents a greater amount of
fibrous attached gingiva than does the area of
retromolar pad.
 The anatomy of tuberosity extending distally is
more adaptable to pocket elimination than is that
of mandibular molar.

A, Removal of a pocket distal
to the maxillary second molar
may be difficult if there is
minimal attached gingiva. If
the bone ascends acutely
apically, the removal of this
bone may make the procedure
easier.
B, Long distal tuberosity with
abundant attached gingiva is
an ideal anatomic situation for
distal pocket eradication.

B. MANDIBULAR MOLARS:
 Differences from the treatment in the maxillary
tuberosity region due to to the following reasons:
 The retromolar pad area does not usually present as
much fibrous attached gingiva.
 The keratinized gingiva, if present may not be found
directly to the molar.
 The greatest amount may be distolingual or
distofacial and may be over the bony crest.
 The ascending ramus of the mandible may also
create a short horizontal area distal to the terminal
molar. The shorter this area, the more difficult it is to
treat any deep distal lesion around the terminal
molar.

A, Pocket eradication
distal to a mandibular
second molar with
minimal attached
gingiva and a
close ascending
ramus is anatomically
difficult.
B, For surgical
procedures distal to a
mandibular second
molar, abundant
attached gingiva and
distal space are ideal.

Modified distal
wedge
procedure
Buccal and palatal
flaps are elevated
(a) and the
rectangular wedge
is released from
the tooth and
underlying bone
by sharp
dissection and
removed (b).

Modified distal wedge procedure. Following bone recontouring
and root debridement, the flaps are
trimmed and shortened to avoid overlapping wound margins and
sutured (a). A close soft tissue adaptation
should be accomplished to the distal surface of the molar. The
remaining fibrous tissue pad distal to the buccolingual incision
line is "leveled" by the use of a gingivectomy incision .

 A surgical suture is one that approximates the adjacent
cut surfaces or compresses blood vessels to stop bleeding.
 Goals of suturing
 Provide an adequate tension of wound closure
without dead space but loose enough to obviate
ischaemia and necrosis.
 Maintain hemostasis.
 Permit primary intention healing.
 Provide support for tissue margins until they
have healed and support is no longer needed.

 Reduce post – operative pain.
 Prevent bone exposure resulting in delayed
healing and unnecessary resorption.
 Permit proper flap position.

 The needle consists of 3 parts
 Needle point
 Body (grasping area)
 Eye / Swaged end

 Depending on the presence or
absence of eye
 Eyed/Traumatic –Has an eye .(tying
the suture to the eye is not
recommended , as it increases the bulk
of suture material drawn through the
tissues).
 Eyeless (swaged)/atraumatic –
swaged needles do not require
threading and permit a single strand of
suture material to be drawn through
tissues. Inserted into the hollow end
during manufacture& the metal
iscompressed around it.This doesn’t
cause injury to the tissues compared to
eyed needle ‐Atraumatic needles

 Depending on the shape of the body:
Round oval rectangular trapezoid side
flattened.
Depending on the shape of the point;

 Depending on the curvature:

 Depending upon cutting surface:
 Conventional cutting: cutting edges along the
inner curvature of the needle.
 Reverse cutting needle: doesn’t have any cutting
edge along its inner curvature & has flat internal
surface.
 This needle will cut less tissue in its path through
that issue, and thus its use will present needless
tissue damage and wound enlargement.

 In periodontal
surgeries-always use
Reverse cutting
needles.
 This prevents the suture
material from tearing
through the papillae or
surgical flap edges ,
referred to as “cut-out”,
which most commonly
happens while using
conventional cutting
needles

 Depending on material-steel, carbon steel.

The following qualities of the ideal suture material
are compiled from Postlethwait (1971),Varma
and colleagues (1974), and Ethicon (1985):
1. Pliability, for ease of handling
2. Knot security
3. Sterilizability
4. Appropriate elasticity
5. Nonreactivity
6. Adequate tensile strength for wound healing
7. Chemical biodegradability as opposed to
foreign body breakdown

 Non absorbable
 Silk : braided(It consists of many thinner filaments , twisted
together to form a string of desired diameter.) Monofilament
suture is advantageous over the Braided suture as, the Braided
suture does have the “ wicking effect ” . ” i.e, it pulls the
bacteria & fluid into the wound site .
 Nylon : monofilament(ethilon)
 EPTFE : monofilament(Gore-tex) (used in with implants, bone
grafts, guided tissue regeneration, or guided bone regeneration)
 Polyester : braided (Ethibond)

 Absorbable
 Plain gut : monofilament (30 days)
 Chromic gut : monofilament (45-60 days.)
 Synthetic
 Polyglycolic : braided (16-20 days) (Vicryl) ( Dexon)
 Polyglecaprone : Monofilament (90-120 days) (monocryl)
 Polyglyconate : monofilament (Maxon)

 The needle holder should
grasp the needle at
approximately 3/4th of
the distance from the
needle point.

 The needle should enter
the tissue perpendicular
to the surface .
 Sutures should be located
2-3mm below the
imaginary line that forms
the base of the triangle of
the interdental papillae.

 The suture should be placed at an equal distance
[ 2‐3 mm ] on both sides of the incision .
 Suture should be always inserted through the
more mobile & from thinner flap first.
 The suture should be tied so the tissue is merely
approximated & not blanched.
 The knot shouldn’t be placed on the incision line
to avoid wicking effect.

 Sutures should be placed 3-4 mm apart. The
closeness of sutures depend upon the underlying
tension across the suture line. Closer spaced
sutures are indicated in areas of underlying
muscular activity such as tongue or in other areas
of increased tension.

 Vertical incision
 Tuberosity and retromolar areas.
 Bone regeneration procedures with or without GTR
 Widman flaps , open flap curettage, unrepositioned
flaps, or apically positioned flaps where maximum
interproximal coverage is required.
 Edentulous areas.
 Partial or split thickness flaps.
 Osseointegrated implants.

 Most commonly used
suture because of its
simplicity.
 Suture forms a simple
circular loop uniting the
two edges of the surgical
incision.
 This suture permits a better
closure of the interdental
papilla and should be
performed when bone
grafts are used.

 FIGURE – 8 SUTURE
 As the name tells, this
suture forms a loop with
a figure of eight, with the
criss‐cross limbs of eight
placed between the two
flap edges.

 Interrupted vertical
mattress:
The vertical mattress
(nonperiosteal) suture is
recommended for use with
bone regeneration procedures
because it permits maximum
tissue closure while avoiding
suture contact with the
implant material, thus
preventing wicking.

 Laurell modified
mattress suture (1993)for
coronal flap positioning
and primary flap
coverage is a technique
which, although capable
of being employed for all
regenerative techniques,
is used predominantly
when standard
interproximal incisions
are used.

 This technique (Cortellini et
al 1995) was introduced for
achieving maximum
interproximal coverage and
primary closure over
intrabony defect is treated by
GTR.
 It requires the initial incision
be made at the buccal line
angles in the area of the
interproximal defect. It is a
papillary preservation
technique. The suturing
permits coronal positioning,
flap stabilization, and primary
interproximal closure.

This technique is
recommended
for use only with
modified Widman
flaps and
regeneration
procedures in
which there is
adequate
thickness of the
papillary tissue.

 The sling suture is primarily used for a flap that
has been raised on only one side of a tooth,
involving only one or two adjacent papillae.
 It is most often used in coronally and laterally
positioned flaps. The technique involves use of
one of the interrupted sutures, which is either
anchored about the adjacent or slung around the
tooth to hold both papillae.

When multiple
teeth are
involved, this
is preferred.

 Advantages:
 Can include as many teeth as required.
 Minimizes the need for multiple knots.
 Simplicity.
 The teeth are used to anchor the flap.
 Permits precise flap placement.
 Avoids the need for periosteal sutures.
 Allows independent placement and tension of
buccal and lingual/palatal flaps.

The main disadvantage of continuous sutures is
that if the suture breaks, the flap may become
loose or the suture may come untied from
multiple teeth.

 Indication:
1.This suture is often used for the interproximal
areas of diastema
2.for wide interdental spaces to properly adapt the
interproximal papilla against the bone.

 When greater papillary control and stability and
more precise placement are required or to
prevent flap movement, vertical or horizontal
mattress sutures are used. This is most often the
case on the palate, where additional tension is
often required, or when the papillary tissue is thin
and friable.

 Locking. The continuous locking suture is
indicated
 primarily for long edentulous areas,
 tuberosities, or retromolar areas.
 It has the advantage of avoiding the multiple
knots of interrupted sutures.
 If the suture is broken, however, it may
completely untie.

Continuous locking suture
used primarily for edentulous areas.

 Indication:
 This is used when there is both a facial and a
lingual flap involving many teeth.
 This type of suturing is used for the maxillary
arch because the palatal gingiva is attached
and fibrous, whereas the facial tissue is thinner
and mobile.

 The closing of a flap mesial or distal to a tooth,
as in the mesial or distal wedge procedures, is
best accomplished by the anchor suture.
 This suture closes the facial and lingual flaps and
adapts them tightly against the tooth. The needle
is placed at the line angle area of the facial or
lingual flap adjacent to the tooth, anchored
around the tooth, passed beneath the opposite
flap, and tied.

A to D, Distal
wedge suture.
This suture is
also used to
close flaps that
are mesial or
distal to a
lone-standing
tooth.

 Another technique to close a flap located in an
edentulous area mesial or distal to a tooth
consists of tying a direct suture that closes them
proximal flap, carrying one of the threads around
the tooth to anchor the tissue against the tooth,
and then tying the two threads.

The closed
anchor suture,
another
technique to
suture distal
wedges.

 This type of suture is used to hold in place
apically displaced partial thickness flaps.
 There are two types of periosteal sutures:
 the holding suture and
 the closing suture.
 The holding suture is a horizontal mattress suture
placed at the base of the displaced flap to secure
it into the new position.
 Closing sutures are used to secure the flap edges
to the periosteum.

 1.Penetration : the
needle point is positioned
perpendicular to the
tissue surface and
underlying bone. It is the
inserted completely
through the tissue until
bone is engaged.

 2.Rotation : the body is
now rotated about the
needle point in the
direction opposite to that
in which the needle is
intended to travel. The
needle point is held
lightly against the bone
so as not to damage or
dull the needle point.

 Glide: The needle point
is now permitted to
glide against the bone
for only a short
distance. Care must be
taken not to lift or
damage the periosteum.

 Rotation: As the
needle glides against
the bone, it is rotated
about the body,
following its
circumferenced
outline. In this way, the
needle will not be
pushed through the
tissue.

 5.Exit : the final
stage of gliding and
rotation is needle
exit.it is made to exit
the tissue through
gentle application of
pressure from above
allowing the tip to
pierce the tissue.

Periosteal sutures
for an apically
displaced flap.
Holding sutures,
shown at the
bottom, are done
first, followed by
the closing
sutures, shown at
the coronal edge
of the flap.

 The knot may be tied in 2
techniques
 INSTRUMENT TIE
:Using needle holder
 ONE‐HANDED &
TWO‐HANDED TIE:
Using fingers
 As periodontal surgeries
instrument tie is the most
appropriate & extensively
used technique.

1.Knot must be firm ….no slippage.
2.Knot should not be placed on incision lines
..avoid wicking.
3.Avoid excessive tension…..crimping of suture.
5. Knot ends must be 2‐3mm.
6. An added throw does not increase the strength
of the knot.
7. Final tension or final throw should be as nearly
horizontal as possible.

1. The area should be swabbed with hydrogen
peroxide for removal of encrusted necrotic
debris, blood, and serum from about the
sutures.
2. A sharp suture scissors should be used to
cut the loops of individual or continuous
sutures about the teeth.

 A cotton pliers is now used to remove the
sutures. The location of the knots should be
noted so that they can be removed first. This
will prevent unnecessary entrapment under
the flap.
 Sutures should be removed in 7 to 10 days
to prevent epithelialization or wicking about
the suture. (Cohen)

 Square surgeons slip or granny knot
knot knot

 This knot appears
squarish before
tightening the knot.
 Technique:
 It is formed by tying 2
ties.
 The first one in one
direction & the second
tie by throwing the
suture in opposite
direction

ADVANTAGES
Quick and simple
useful when surgeon is using silk suture
which has good frictional resistance to
loosening
DISADVANTAGES
When the flaps are not lying passively against
the bone, the square knot cannot be used
because the tension of the flaps will pull them
apart.

 It is the most commonly
used knot as it reduces
slippage of the first tie,
while the 2nd tie is placed.
 Technique:
 It is formed by tying 2 ties.
 The first tie is formed by 2
throws in one direction &
the 2nd tie in opposite
direction.

 Technique:
 It involves a first tie in
one direction followed by
a second tie in the same
direction as first.
 Later a third tie is made
to hold the knot
permanently.

Once it is tightened to
the desired extent, it
can be locked into place
by another over hand
knot, made in opposite
direction of first two.
This ability to be tightened
makes the slip knot
extremely useful in many
surgical situations
example it can be used to
stretch flaps to achieve
primary healing over a
surgical site.

 SUTURE REMOVAL
› As a rule Intra oral sutures are removed 5‐7 days
after the suturing.
Complications following Suturing
 The knot slips gives rise to 90% of the
complications following suturing, leading to
dehiscence of wound.
 If the non‐resorbable sutures like silk, are left in
place for longer duration the lead to abcess
formation. Here termed as “ Stich Abcess ”

 In case of braided
sutures,because of
the“wicking‐effect”there
can be spread of infection
all along the suture line.
 If the suture material is left
in‐situ for longer periods
than 3 weeks, the epithelial
cells migrate down the
suture pathway leading to
Epithelial inclusion cysts“
& Railroad track ” scar

 Defined as surgical dressings, after periodontal
surgery, applied to the necks of teeth and
adjacent tissue to cover and protect the surgical
wound.
 Forms a physical barrier and is placed in the
surgical site to protect the healing tissues from
the forces of mastication.

Introduced in 1923 by Dr. A.W.
Ward. In the form of
“wonderpack”
1942 Box & Ham used ZnO
Eugenol dressing to perform
chemical curettage in treatment
of NUG
1943- Orban used ZnO
Eugenol &
Paraformaldehyde to
perform gingivectomy
by chemosurgery.
1947- Bernier &
Kaplan for wound
protections.
1962- Blanquie-control
postoperative bleeding-
splint loose teeth-
desensitize cementum

1964 Gold-splint teeth, as it
was cement dressing that set
hard.
1964- Weinreb & Shapiro-
ZnO Eugenol impregnated
cords into periodontal
pockets, but found less
effective than gingivectomy
1969- Baer et al stated that
primary purpose of a
dressing –patient comfort,
protect wound from further
injury during healing-hold
flap in position

 Eugenol containing without eugenol
 I. Zinc oxide eugenol dressings:
 Powder & liquid form (Kirkland pack)
 Setting occurs as a result of chemical interaction
between zinc oxide & eugenol form zinc eugenolate.
 Paste form: two separate tubes- base & accelerator
**ward’s Wonder pack

 II. Non Eugenol packs:
 Coepak
• Supplied as 2 pastes-
base& accelerator or as an
auto – mixing system
conatined within a syringe.
• Base: Metallic (zinc
oxide),oil for plasticity,gum
for cohesiveness &
lorothidiol(fungicide).
• Catalyst: liquid coconut
fatty acid thickened with
resin
&chlorothymol(bacteriostat
ic agent).

periocare – available in form of paste-gel &setting
occurs by chemical reaction.
Perio putty- contains methyl & propyl parabens for
effective bactricidal & fungicidal properties&
benzocaine as topical anesthetic.
Peripac – this is a pre mixed dressing.when this material
is exposed to air or moisture, it sets by loss of organic
solvent.
Vocopac- contains 90 gm base & 90 gm catalyst.
Adheres excellently to teeth & promote healing.

Tissue conditioners/methacrylic gel dressing.
Methacrylic gels exhibit clase adaptation, constant flow
for 3 days and excellent compatibilty with wound site.
Collagen dressing: it is a collagen sponge. Eg:
Collacote –type I collagen derived from bovine Achilles
tendon.Completely resorbable dressing that is used to
cover & protect palatal graft sites.
Cyanoacrylates: with the spray, an application of
cyanoacrylate can be completed in 0.3sec. The material
adheres easily to the outer surface of tissue & results in
instant hemostasis.

 Available in syringe for direct application or
dispensing on a mixing pad, and placed
intraorally.
 Curing of material is then accomplished with
a visible light curing unit .

Ingredients:
Polyether urethane dimethacrylate resin, silanated silica,visible
right (VLC)photo initiator & accelerator stabilizer.
ADVANTAGES:
Offers a translucent pink colour on setting which is esthetically
pleasing.
Limitations:
Not the choice of dressing to be used in situations where the flap
has to be apically retained ,due to its soft state before curing.
Contain polymerisable monomers which may cause skin
sensitization.(allergic contact dermatitis)

In
favour
ward in
1923
advocated
the use of
wonder
pack to
avoid pain,
infection,
root
sensitivity.
bernier
and
kaplan in
1947,
reported
that
dressing
facilitate
s healing
process.
Linghorne in
1949, studied
different
periodontal
dressings to
determine
their
bacteriostatic
properties
and found it
to be an
effective
bacteriostatic
agent.

Loe and Slilness
1957, reported that
dressing provided
more favorable
environment for
healing.
Blanquie 1962 stated
that porpose of
dressing is to control
post operative
discomfort, act as a
splint for losse teeth,
allow tissue healing
under aseptic
conditions,prevent re
establishment of
periodontal pocket and
desenitize denuded
cementum.

waerhaug 1955 ,
Baer et al 1969
pointed out that
application of
periodontal
dressing did not
influence the final
outcome of
healing.
Jones and Cassingham
1979 in their study
concluded that dressings
caused more pain and
discomfort to the patients
without serving any useful
purpose in flap surgery.

Allen &Caffesse
1983 pointed out that
periodontal packs did
not improve healing
and its use is a matter
of personal choice.
Some studies have shown
that dressings promote
bacterial colonisation and
compromise patient’s oral
hygiene.well adapted flaps
serve as a barrier to
bacteria & thus provide
better protection than
dressings.

 For the 1st 3 hours, hot foods should be avoided.
 Semisolid diet is preferable and should be chewed from
non operated side.
 Citrus fruits, fruit juices and highly spiced foods and
alcoholic beverages should be avoided as they will
cause irritation and pain of the wound.
 Food supplements or vitamins are prescribed if needed,
but not mandatory.
 Mouthwash rinsing ( chlorhexidine 0.12%) twice a day
is prescribed following toothbrushing. It refreshes the
mouth and decrease plaque formation in the oral cavity
which is usually increased postoperatively because of the
compromised toothbrushing of the patient.

DAY 1 Analgesics,cold packs, avoidance of
wound disturbance
After day 1 Pain , swelling, bleeding should
diminish or disappear.
Chemical plaque control
recommended.
After 5 – 10 days: Remove dressing and sutures,
Professionally de – plaque
supragingivally.
After 4 – 6 weeks: Weekly or biweekly recall for de-
plaquing & oral hygiene
instructions.
The dento gingival junction should
not be probed or instrumented for 6
to 8 weeks following surgery.

 Immediately after suturing (0 to 24 hours) a
connection between the flap and the tooth or bone
surface is established by a blood clot (which consists
of a fibrin reticular with many PMNs, RBCs, debris
of injured cells, and capillaries at the edge of the
wound. There are also bacteria and an exudates or
transudate as a result of tissue injury.)
 1 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 ,epithelial attachment to
the root has been established by means of
hemidesmosomes and a basal lamina. The blood
clot is replaced by granulation tissue derived
from the gingival connective tissue, the bone
marrow and periodontal ligament.
 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 of
functional arrangement of the supra crestal
fibers.
 Full thickness flaps, which denude the bone,
result in a superficial bone necrosis at 1 to 3
days; osteoclastic resorpion follows and reaches
a peak at 4 to 6 days, declining thereafter. This
results in a bone loss of about 1 mm; the bone
loss is greater if the bone is thin.

 Bone repair reaches its peak at 3 to 4 weeks.
 Loss of bone occurs in the initial healing stages
both in radicular and in interdental bone areas.
However, in interdental areas, which have
cancellous bone, the subsequent repair results in
total restitution without any loss of bone, bone
repair results in loss of marginal bone.

 VASCULAR HEALING
 Cutright (JP,1969) : Proliferation of blood vessels in
gingival wounds
 Day 1 : withdrawal and blockage of cut ends of the
vessels at wound margin.
 Day 2 : new sprouts, club – shaped stubs at bottom of
wound.

 Day 3 : Short capillary loops forming , arising from the
cut surfaces of existing vessels which anastomose. No
regeneration at the edges of the wound.

 Day 5 : Increased capillary loops with dilation of one
limb. Corners of the wound show revascularization.
 Day 7 : General contour of gingival re established,
floor and edges show completion of capillary loops.
 Day 9 : Capillary loops almost reach height of
normal loops, density less than normal.
 Day 11 : Further restoration of normal pattern and
size, density stil not equal to normal gingival.

 Kon ( JP, 1969) :
 0 hour : Thin blood clot over exposed bone and CT.
 2 days : increased flap vascularization / vasodilation.
Rete pegs flat.
 6 – 7 days : increased inflammatory reaction, flap
still prone to separation, bloot clot replaced by
immature CT.

 7 days : Osteoclastic activity reaches peak at day
7.
12 days : Flap is reattached to bone and tooth,
osteoblastic activity predominates at day 12.
 23 – 31 : Bone reformed at crest and buccal
septum, organized CT.
 55 – 85 : Periodontal tissues reconstructed ,DGJ
renewed, buccal plate is rebuilt.

 Vogel et al. (1984):

 Zinc : stabilizes membranes and decreases lysosomal
enzyme and histamine release.
 Vitamin C : May alter PMN function, needed for collagen
synthesis ( cross link process).
 Iron : Collagen metabolism, may alter macrophage function
and PMN
 Protein : epithelial barrier
 Folic acid : epithelial barrier. Collagen metabolism

 Carranza 10th edition
 Lindhe 5th edition
 Cohen
 Atlas of periodontal surgery( Sato)
 Laskin’s book of surgery.

Principles of flap surgery copy

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