Dr. Sapnil MDS Reader

1. Presented by
Dr. Sapnil, MDS
Reader

2. DEFINITION
A periodontal flap is a section of gingiva
or mucosa surgically separated from the
underlying tissues to provide visibility and
access to the bone and root surface

3. CLASSIFICATION
based on
Bone exposure after flap reflection
Placement of flap after surgery
Management of the papilla

4. BASED ON BONE EXPOSURE AFTER REFLECTION
A. Full thickness [ mucoperiosteal ] flap
B. Partial thickness[ mucosal ] flap

5. Full thickness flap
All the soft tissue including the periosteum is
reflected to expose the underlying bone
Indicated :
When resective osseous surgery is contemplated

6. Partial thickness flap
Includes only the epithelium and a layer of
underlying connective tissue
The bone remains covered by a layer of
connective tissue, including the periosteum
This type of flap is also called as the
split thickness
flap

7. Indicated :
when the flap is to be positioned apically
exposure of bone is not required
crestal bone margin is thin
dehiscences or fenestrations are present

8. BASED ON FLAP PLACEMENT AFTER SURGERY
Non-displaced flaps Displaced flaps

9. Non displaced flaps
When flap is returned and sutured in its
original position

10. Displaced flaps
Apically
Coronally
Laterally
Apically displaced flaps -- advantages :
Preserves the outer portion of pocket wall
Eliminates the pocket
Increases the width of attached gingiva

11. BASED ON MANAGEMENT OF THE PAPILLA
Conventional flap
Papilla preservation flap

12. Conventional flap
Indicated :
Interdental spaces are too narrow
The flap is to be displaced
Example :
Modified widman flap
Undisplaced flap
Apically displaced flap
Flap for regenerative procedures

13. DESIGN OF THE FLAP
TWO
Conventional [ split the papilla ]
Papilla preservation flap [ preserve papilla ]

14. INCISIONS
HORIZANTAL VERTICAL

15. HORIZANTAL
Two
Internal bevel incision Crevicular incision

16. The internal bevel incision :
The basic to most periodontal procedures
Called as first incision / reverse bevel incision
Starts at a distance from gingival margin,
and is aimed at the bone crest

17. Accomplishes three important objectives :
removes the pocket lining
conserves relatively uninvolved outer surface
of the
gingiva
produces a sharp, thin flap margin for
adaptation to the bone-tooth junction
The # 11 or # 15 surgical scalpel is used
most commonly

18. Crevicular incision :
Also termed as second incision is made
from the base of the pocket to crest of the
bone

19. This incision together with the initial reverse
bevel incision forms a V- shaped wedge
This wedge of tissue contains most of the
inflamed and granulation tissue that constitute
the lateral wall of the pocket
The beak - shaped # 12 blade is usually
used for this incision

20. Interdental incision :
Made to separate the collar of gingiva that
is left around the tooth
Orban knife is used for this incision

21. 1. INTERNAL BEVEL INCISION
2. CREVICULAR INCISION
3. INTERDENTAL INCISION

22. VERTICAL INCISIONS
Vertical or oblique releasing incisions must
extend beyond the mucogingival line, reaching
the alveolar mucosa to allow for the release of
the flap to be displaced
Vertical incisions in the lingual and palatal
areas are avoided

23. Incisions should be made at the line angles
of a tooth either to include the papilla in
the flap or to avoid it completely
If no vertical incisions are made the flap
is called an “envelope” flap

24. INTERDENTAL DENUDATION PROCEDURE
(ENAP)
Consists :
Horizontal,internal bevel, nonscalloped incision
Heal by secondary intention
Results in excellent gingival contour
Contraindicated :
When bone grafts are used

25. MWF ENAP

26. ELEVATION OF THE FLAP
When full thickness flap is desired a periosteal
elevator is used to separate the mucoperiosteum
from the bone by moving it mesially, distally,and
apically until the desired reflection is gained
Sharp dissection is necessary for partial thickness flap
A surgical scalpel # 11 or # 15 is used

27. SUTURING TECHNIQUES
The purpose of suturing is to maintain the flap in
the desired position until healing has progressed
The resorbable sutures have gained popularity
since they enhance patient comfort and eliminate
suture removal appointments
The most commonly used resorbable sutures
are the natural, plain gut and chromic gut

28. The nonresorbable braided silk suture was the
most commonly used in the past due to its ease
of use and
low cost
The expanded polytetra fluoroethylene synthetic
monofilament is an excellent non resorbable
suture widely used today

29. TECHNIQUE
Sutures of any kind placed in the
interdental papillae should enter and exit
the tissue at a point located below the
imaginary line that forms the base of the
triangle of the interdental papilla

30. LIGATION
INTERDENTAL LIGATION
TWO TYPES
DIRECT or LOOP SUTURE FIGURE- EIGHT SUTURE

31. DIRECT or LOOP SUTURE
Permits better closure of interdental papilla
Bone grafts are used
Close apposition of scalloped incision is required

32. FIGURE - EIGHT SUTURE
Simpler to perform

33. SLING LIGATION
Used for a flap on one surface of a tooth
that involves two interdental spaces

34. TYPES OF SUTURES
HORIZANTAL MATTRESS SUTURE
Interproximal areas of diastema
Wide interdental spaces
CONTINUOUS INDEPENDENT SLING SUTURE
Both facial and lingual flap involving many teeth
ANCHOR SUTURE
Mesial or distal wedge procedures
Closes the facial and lingual flaps and adapts
them tightly against the tooth

35. HEALING AFTER PERIODONTAL SURGERY
Immediately after suturing [0 to 24 hours]
Blood clot which consists of fibrin reticulum
with polymorphonuclear leukocytes, erythrocytes,
debris of injured cells, capillaries, bacteria and
an exudate also result from tissue injury

36. One to 3 days after flap surgery
Epithelial cells migrate over the border of flap
Minimal inflammatory response

37. One week after surgery
Epithelial attachment to the root has been
established by hemidesmosomes and basal lamina
The blood clot is replaced by granulation tissue
derived from the gingival CT, the bone marrow,
and periodontal ligament

38. Two weeks after surgery
Immature collagen fibers begin to appear
parallel to the tooth surface
Union of the flap to the tooth is still weak

39. One month after the surgery
A fully epithelialized gingival crevice with a
well-defined epithelial attachment is present