This document describes several periodontal flap techniques including the modified Widman flap, undisturbed flap/internal bevel gingivectomy, apically displaced flap, flaps for reconstructive surgery like the papilla preservation flap and conventional flap, and distal molar surgery flap techniques. The techniques aim to gain access to deeper structures, relocate tissues, eliminate pockets, and regenerate bone through incisions, flap reflection and repositioning, granulation tissue removal, and suturing.

1. THE FLAP TECHNIQUE FOR POCKET THERAPY
• BY DR KHUSHALI VASHI (BDS)

2. PURPOSE
1. To gain access to deeper periodontal structures
with direct vision.
2. Relocation of the frenulum.
3. Maintenance of the attached tissue.
4. Pocket elimination and regeneration.

3. INDICATIONS
• Pockets > 5mm persisting after phase 1 therapy.
• Bony pockets and interdental craters.
• Bony lesions in the furcation .
• Need for surgical crown lengthening .
• When to open up a flap ? Complicated morphology
like :
• Deep and narrow pockets
• Difficult to achieve the correct angle

6. MODIFIED WIDMAN FLAP

7. INDICATIONS
• Effective with pocket depth of 5-7mm

8. CONTRAINDICATIONS
• Lack of or very thin and narrow attached gingiva
can render the technique difficult, because a
narrow band of attached gingiva does not permit
the initial scalloped incision.

9. PROCEDURE:
STEP 1: The initial incision is “INTERNAL BEVEL INCISION “ to the
alveolar crest , 0.5-1mm away from the gingival margin along the
gingival scalloped margin .

10. STEP 2: The gingiva is reflected with a periosteal elevator .

11. STEP 3: Crevicular incision is made from the bottom of the
pocket to the bone , encircling the triangular wedges of tissue
containing the pocket lining .

12. STEP 4 : After the reflection of the flap , third incision is
made in the interdental spaces coronal to the bone with
curette or with interproximal knife to remove the gingival
collar .

13. STEP 5: Tissue tag and granulation tissue are removed with a
curette . Scaling and root planing done.

14. STEP 6: Complete coverage of the interdental defect is done
and sling shot suturing is done.

15. MODIFIED WIDMAN FLAP

16. UNDISPLACED FLAP/
(INTERNAL BEVEL GINGIVECTOMY)

17. INDICATIONS
• In cases with optimal width of attached gingiva.
• To eliminate true pockets .

18. PROCEDURE :
STEP 1 :The pockets are measured with periodontal probe
and a bleeding point is produced on the outer surface of
gingiva to mark the pocket bottom.
PREOPERATIVE VIEW

19. STEP 2: Internal bevel incision in the facial and palatal aspects .

20. STEP 3: Crevicular incision is made and flap is elevated .

21. STEP 4 : Interdental incision is made .
STEP 5:Triangular wedge of tissue is removed with curette.
STEP 6: All tissue tags and granulation tissue are removed.

22. STEP 7: After scaling and root planing the flap edge should rest
on the root bone junction .
STEP 8: Flaps have been placed in their original site and
sutured .

23. Post operative results :

24. UNDISPLACED FLAP

25. The Apically Displaced Flap

26. INDICATIONS :
• To increase the width of attached gingiva .
• To facilitate self maintaining oral hygiene .

27. Pre operative :
Buccal and lingual view .

28. Procedure :
STEP 1 : An internal bevel incision is made, it should be more
than 1 mm from the crest of the gingiva and directed to the crest
of gingiva .

29. STEP 2: Crevicular incision are made, followed by initial elevation of the flap ; then
interdental incision are performed and the wedge of tissue containing the pocket wall
is removed .

30. STEP 3 :Vertical incision are made extending beyond the mucogingival
junction
•If the objective is full thickness flap , it is elevated by blunt
dissection with periosteal elevator .
•If a spilt thickness flap is required , it is elevated by using sharp
dissection with a Bard –Parker knife to split it , leaving a layer of
connective tissue , including the periosteum , on the Bone .

31. STEP 4 :After removal of granulation tissue , scaling and root
planing , the flap is displaced apically .

32. STEP 5 : If a full thickness flap was performed , a sling suture
around the tooth prevents the flap from sliding more apically
and maintains periodontal dressing in position.
•Dressing and sutures are to be removed after one week .

33. POST OPERATIVE :
HEALING AFTER ONE WEEK

34. POST OPERATIVE :
HEALING AFTER TWO MONTHS

35. APICALLY DISPLACED FLAP

36. FLAPS FOR RECONSTRUCTIVE SURGERY :
•Two flap designs are available for reconstructive surgery:
1. Papilla preservation flap
2. Conventional flap

37. PAPILLA PRESERVATION FLAP

38. INDICATION :
• Where esthetics is of concern .
•Where bone regeneration techniques are attempted.

39. PROCEDURE :
STEP 1: A crevicular incision is made around each tooth with no
incisions across the interdental papilla .

40. STEP 2: The preserved papilla can be incorporated into the
facial or lingual / palatal flap (mostly integrated in facial
flap).

41. STEP 3: An orban knife is then introduced into this incision
to sever half to two –third the base of the interdental
papilla . The papilla is then dissected from the lingual
/palatal aspect and elevated intact with the facial flap.

42. STEP 4: The flap is reflected without thinning the tissue.

43. Post operative :
Facial and Palatal view after Healing.

44. PAPILLA PRESERVATION FLAP

45. CONVENTIONAL FLAP

46. INDICATIONS :
•When the interdental areas are too narrow to permit preservation
of flap .
•When there is a need of displacing of flaps .

47. PROCEDURE :
•STEP 1 : Using #12 blade incise the tissue at the bottom of the pocket to the
crest of the bone , splitting the papilla beneath the contact point of the two
approximating teeth to allow for reflection of buccal and lingual flap.
STEP 2 : Reflect the flap without thinning as this is necessary to prevent exposure of
graft or membrane due to necrosis of flap margin.

48. DISTAL MOLAR SURGERY

49. INDICATIONS :
• In cases where pockets are present distal to the terminal
molars.

50. INCISION DESIGN
Typical incision design for a surgical procedure distal to the
maxillary second molar .

51. INCISION DESIGNS :
•Incision design for surgical
procedure distal to mandibular
second molar .
•Incision must follow the areas of
greatest attached gingiva and
underlying bone .

52. PROCEDURE :
STEP 1: Distal pocket eradication procedure where the incision is
distal to the molar .

53. STEP 2: Scalloped incision is made around the remaining teeth .

54. STEP 3 : Flap reflected and the flap is thinned around the distal
incision .

55. STEP 4 : Flap is repositioned before suturing and the
flap should be closely approximated .

56. STEP 5 : Flap sutured both distally and over the remaining
surgical area.

57. DISTAL MOLAR SURGERY

58. THANK YOU …