Various Periodontal Flap Techniques

1. By
Archana. B
II yr PG

2. A periodontal flap is a section of gingiva and/or mucosa
surgically separated from the underlying tissues to provide
visibility of and access to the bone and root surface. The
flap also allows the gingiva to be displaced to a different
location in patients with mucogingival involvement

3. To enable visual
instrumentation of root
surface
To re-establish healthy
clinical status of the
periodontium with long term
maintenance
To restore the periodontal
apparatus when attachment
loss has occured
Rationale of periodontal surgery

4. CLASSIFICATION OF FLAPS
Periodontal flaps can be classified based on the following:
• Bone exposure after flap reflection
• Placement of the flap after surgery
• Management of the papilla

5. Based on bone exposure after
reflection:
full thickness (mucoperiosteal)
partial thickness (mucosal) flaps
full thickness flaps
• all the soft tissue, including
the periosteum, is reflected
to expose the underlying
bone
partial thickness flap
• includes only the epithelium and a
layer of the underlying connective
tissue. The bone remains covered
by a layer of connective tissue,
including the periosteum.
• ALSO CALLED split thickness
flap

6. Based on flap placement after surgery:
Nondisplaced flaps
Displaced flaps
They can be placed apically, coronally, or laterally to their original
position.

7. Both full thickness and partial thickness flaps can
be displaced, but to do so, the attached gingiva has
to be totally separated from the underlying bone,
thereby enabling the unattached portion of the
gingiva to be oveable.
palatal flaps cannot be displaced owing to the
absence of unattached gingiva.

8. Based on management of the papilla:
conventional
papilla preservation flaps

9. In the conventional
flap the interdental
papilla is split beneath
the
contact point of the two
approximating teeth to
allow
reflection of buccal and
lingual flaps.
The papilla
preservation flap
incorporates the entire
papilla in one of the
flaps by means of
crevicular interdental
incisions to sever the
connective tissue
attachment and a
horizontal incision at
the base of the papilla,
leaving it connected to
one of the flaps

10. The conventional flap is used when
1) the interdental spaces are too narrow, thereby
precluding the possibility of preserving the papilla,
2) when the flap is to be displaced.
Conventional flaps include the modified Widman, flap, the
undisplaced flap, the apically displaced flap, and the flap for
regenerative procedures.

11. Pocket elimination flap
• Widman flap
• The un displaced flap
• Apically displaced flap
Re-attachment flap surgery
Mucogingival repair
Classifcation based on the main purpose of the procedure- Ramjford
1979

12. DESIGN OF THE FLAP
The design of the flap is dictated by the surgical judgement of the
operator and may depend on the objectives of the operation. The
degree of access to the underlying bone and root surfaces necessary
and the final position of the flap must be considered in designing the
flap.
Preservation of good blood supply to the flap is an important
consideration.

13. Depending on how .the interdental papilla is dealt with,
flaps can either
Split the papilla - conventional flap or
preserve it - papilla preservation flap.

14. A flap that is released in a linear fashion at the gingival margin
but has no vertical releasing incision(s) is called an envelope flap
Depending on the incisions made

15. If two vertical releasing incisions are included in the
flap design, it becomes a pedicle flap

16. If one vertical releasing incision is included in the flap design, some
clinicians refer to this as a triangular flap. The teeth, flap, and
vertical releasing incision form the sides of the triangle

17. On the basis of this concept, the recommended
flap length (height)-to-base ratio
should be no greater than 2:1

18. INCISIONS
Horizontal Incisions
Horizontal incisions are directed along the margin
of the gingiva in a mesial or a distal direction.
Two types of horizontal incisions have
been recommended:
the internal bevel incision –
which starts at a distance
from the gingival margin and is aimed at the bone crest,
and the crevicular incision- which starts at
the bottom of the pocket and is directed to the bone margin the interdental
incision is performed after the flap is elevated.

19. The internal bevel incision is basic to most periodontal
flap procedures. It is the incision from which the flap is
reflected to expose the underlying bone and root. Also termed as
the first incision and the reverse bevel incision, because its bevel is
in reverse direction from that of the gingivectomy incision.

20. OBJECTIVES:
1) it removes the pocket lining;
2) it conserves the relatively uninvolved outer surface
of the gingiva, which, if apically positioned,
becomes attached gingiva;
3) it produces a sharp, thin flap margin
for adaptation to the bone-tooth junction.
The #11 or #15 surgical scalpel is used most
commonly.

21. The crevicular incision, also termed the second incision,
is made from the base of the pocket to the crest of the bone.
This incision, together with the initial reverse bevel incision, forms a V-
shaped wedge ending at or near the crest of bone; this wedge of tissue
contains most of the inflamed and granulomatous areas that constitute the
lateral wall of the pocket, as well as the junctional epithelium and the
connective tissue fibers that still persist between the bottom of the pocket
and the crest of the bone.
The incision is carried around the
entire tooth.
The beak-shaped #12D blade is
usually used for this incision.

22. A periosteal elevator is inserted into the initial internal bevel
incision, and the flap is separated from the bone. The most apical
end of the internal bevel incision is more exposed and visible. With
this access, the surgeon is able to make the third or interdental
incision to separate the collar of gingiva that is left around the
tooth.

23. Vertical Incisions
Vertical or oblique releasing incisions can be used on one or both
ends of the horizontal incision, depending on the design and
purpose of the flap. Vertical incisions at both ends are necessary if
the flap is to be apically displaced.
Vertical incisions must extend beyond the mucogingival line,
reaching the alveolar mucosa, to allow for the release of the flap to
be displaced

26. The Neumann flap:
Neumann in 1920 suggested the use of flap procedures which in
some respect was different from that originally described by widmann
Technique:
An intercrevicular incision is made through the base of the gingival
pocket and the entire gingiva was elevated in the mucoperiosteal flap.
Sectional releasing incisions were made to demarcate the area of
surgery.
Inside of the flap is curetted to remove the pocket epithelium and the
granulation tissue, irregularities in the bone was corrected to give the
bone crest a horizontal outline

27. Flaps were then then trimmed to allow an optimal
adaptation to the teeth and proper coverage of
alveolar bone on both buccal/lingual or palatal and
interproximal sites
With regard to pocket elimination Neumann pointed
out the importance of removing the soft tissue
pockets i.e; replacing the flap at the crest of the
alveolar bone

28. The original widman flap:
In 1918 Leonard Widman published on of the detailed description
on “ The Operative Treatment of Pyorrhea alveolaris”
Technique:
Sectional incisions were made to demarcate the area of surgery
The incisions were made from the mid buccal gingival marginsof
the two pheripheral teeth of the treatment area and were
continued several millimeters into the alveolar mucosa the two
releiving incisions are connected by gingival incisions

29. Mucoperiosteal flap was elevated to expose at least 2-3mm of the
marginal alveolar bone. Bone recontouring is recommended in order to
achieve ideal anatomic form of the underlying bone.
Following careful debridement of the teeth in the surgical area the buccal
and the lingual flaps were laid back over the alveolar bone and secured
with interproximal sutures.
Advantage:
Less discomfort when compared to gingivectomy procedure as the
wound healing occurs by primary intention
It was possible to re-establish a proper contour
of the alveolar bone in sites with angular
bony defects.

30. THE MODIFIED WIDMAN FLAP
In 1965, Morris revived a technique described early in this century in the
periodontal literature; he called it the unrepositioned mucoperiosteal flap
Essentially the same procedure was presented in 1974 by Ramfjord and
Nissle who called it the modified Widman flap
This technique offers the possibility of establishing an intimate
postoperative adaptation of healthy collagenous connective tissue to tooth
surfaces and provides access for adequate instrumentation of the root
surfaces and immediate closure of the area.

31.  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. Scalloping
follows 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, circumscribing the triangular
wedge of tissue containing the
pocket lining

32. Step 4: After the flap is reflected, a third
incision is made in the interdental spaces
coronal to the bone with a curette or an
interproximal knife, and the gingival collar is
removed
Step 5: Tissue tags and granulation tissue are
removed with a curette. The root surfaces are
checked, and then scaled and planed if needed.
Step 6: Bone architecture is not corrected
except if it prevents good tissue adaptation to
the necks of the teeth.
Every effort is made to 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
Step 7: Interrupted direct sutures are placed in
each interdental Space

33. Original
Widman flap
Pocket
elimination
procedure
Apical
displacement
of flap
Osseous
recontouring
can be done
Modified
Widman flap
Pocket lining
elimination
procedure
No apical
displacement
osseous
contouring may
or may not be
done

34. Kirkland Flap:
In a publication from 1931, Kirkland described a surgical procedure to be
used in the treatment of “periodontal pus pockets”. The procedure was
called the modified flap operation, and is basically an access
flap used to allow proper root debridement.
Technique
1. Pocket incisions are made on both the labial and the lingual aspects of
the interdental area. The incisions are extended in a mesial and a
distal direction.
2. The gingiva is retracted labially and lingually to expose the diseased
root surfaces which are carefully debrided .
Angular bony defects are curetted but no bone is removed.
3. Following the elimination of the pocket epithelium
and granulation tissue from the inner surface of the flaps,
these are replaced at their original position and
secured with interproximal sutures

35. THE UNDISPLACED FLAP
Currently, the undisplaced flap is perhaps the
most commonly performed type of periodontal
surgery. 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.
Step 1: The pockets are measured with the periodontal
probe, and a bleeding point is produced on the outer
surface of the gingiva to mark the pocket bottom.
Step 2: The initial, internal bevel incision is made after the scalloping of
the bleeding marks on the gingiva . The incision is usually carried
to a point apical to the alveolar crest, depending on the thickness of the
tissue.
Step 3: The second or crevicular incision is made from the bottom of the
pocket to the bone to detach the connective tissue from the bone.

36. Step 4: The flap is reflected with a periosteal elevator (blunt dissection)
from the internal bevel incision. Usually there is no need for vertical
incisions because the flap is not displaced apically.
Step 5: The interdental incision is made with an interdental knife,
separating the connective tissue from the bone.
Step 6: The triangular wedge of tissue created by the three incisions is
removed with a curette.
Step 7: The area is debrided, removing all tissue tags and granulation
tissue using sharp curettes.

37. Step 8: After the necessary scaling and root planing, the flap
edge should rest on the root-bone junction.
Step 9: A continuous sling suture is used to secure the facial
and the lingual or palatal flaps. This type of suture, using the
tooth as an anchor, is advantageous to position and hold the
flap edges at the root-bone junction.

38. The Palatal Flap
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, nor
can a partial (split) thickness flap be accomplished.

39. changes in the location, angle, and design of the incision.
The initial incision for a flap varies with the anatomic situation., the
Initial incision may be the usual internal bevel incision, followed by
crevicular and interdental incisions.
If the tissue is thick, a horizontal gingivectomy incision may be made,
followed by an internal bevel incision that starts at the edge of this
incision and ends on the lateral surface of the underlying bone.
The placement of the internal bevel incision must be done in such a
way that the flap fits around the tooth without exposing the bone.

40. The purpose of the palatal flap should be considered
before the incision is made. If the intent of the surgery is debridement,
the internal bevel incision is planned so that the flap adapts at the root-
bone junction when sutured.
If osseous resection is necessary, the incision should be planned to
compensate for the lowered level of the bone when the flap is closed.
Probing and sounding of the osseous level and the depth of the intrabony
pocket should be used to determine
the position of the incision.

41. It is sometimes necessary to thin the palatal flap after
it has been reflected. This can be accomplished by holding
the inner portion of the flap with a mosquito hemostat
or Adson forceps as the inner connective tissue is
carefully dissected away with a sharp #15 scalpel blade.
Care must be taken not to perforate or
overthin the flap.
The edge of the flap should be thinner than
the base; therefore the blade should be
angled toward the lateral surface of the
palatal bone.

42. Modified partial thickness palatal flap
Oshenbein 1958, Oshenbein and Bohannan 1963
described this technique
Popularized by Prichard 1965
Aso known as Ledge and Wedge technique

43. Technique:
Step 1: gingivectomy with out
bevel is done, and tissue
ledges are created
Step 2: partial thickness flap
is raised followed by thinning
incision and inner flap
removal

44. THE APICALLY DISPLACED FLAP
This technique with some variants can be used for one or both
of the following purposes: pocket eradication or widening the
zone of attached gingiva.
Depending on the purpose, it can be a full thickness
(mucoperiosteal) or a split thickness (mucosal) flap.

45. Step 1: An internal bevel incision is made. To preserve as much of the
keratinized and attached gingiva as possible, it should be no more than
about 1 mm from the crest of the gingiva and directed to the
crest of the bone.
Step 2: Crevicular incisions are made, followed by initial elevation of the
flap, and then interdental incisions are performed and the wedge of tissue
that contains the pocket wall is removed.
Step 3: Vertical incisions are made extending beyond the mucogingival
junction, if the objective is a full thickness flap it is elevated by blunt
dissection with a periosteal elevator.
Step 4: After removal of all granulation tissue, scaling and root planing, and
osseous surgery if needed, the flap is displaced apically. It is important that
the vertical incisions, and consequently, the flap elevation, reach past the
mucogingival junction to provide adequate mobility to the flap for its apical
displacement.

46. Step 5: If a full thickness flap was performed, a sling suture around
the tooth prevents the flap from sliding to a position more apical than
that desired, and the periodontal dressing can avoid its movement in a
coronal direction.

47. The flaps that are apically displaced can be repositioned:
1. Slightly coronal to the crest of the bone. This location attempts
to preserve the attachment of supracrestal fibers; it may also result
in thick gingival margins and interdental papillae with deep sulci
and may create the risk of recurrent pockets.
2. At the level of the crest . This results in a satisfactory gingival
contour, provided that the flap is adequately thinned.
3. Two millimeters short of the crest . This position produces the
most desirable gingival contour and the same posttreatment level
of gingival attachment, as is obtained by placing the flap at
the crest of the bone . 31 New tissue covers the crest of
the bone to produce a firm, tapered gingival margin

49. Two flap designs are available for regenerative surgery:
the papilla preservation flap and the conventional flap
with only crevicular incisions. The flap design of choice is
the papilla preservation flap, which retains the entire
papilla covering the lesion.

50. Step 1: A crevicular incision is made
around each tooth
with no incisions across the interdental
papilla.
Step 2: The preserved papilla can be
incorporated into the facial or
lingual/palatal flap, although it is most
commonly integrated into the facial flap.
Step 3: An Orban knife is then introduced
into this incision to sever one-half to two-
thirds of the base of the interdental papilla.
Step 4: The flap is reflected without
thinning the tissue.

51. The modified papilla preservation technique (MPPT)
developed in order to increase the space for regeneration and to
achieve and maintain primary closure of the flap in the interdental
area (Cortellini et al. 1995).
Technique:
The technique involves the elevation of a full‐thickness palatal flap
which includes the entire interdental papilla.
The buccal flap is mobilized with vertical and periosteal incisions,
coronally positioned to cover the membrane, and sutured to the
palatal flap through a horizontal internal crossed mattress
suture over the membrane.
Primary closure between the flap and the interdental papilla is
obtained with a second internal mattress suture.

53. MPPT can be successfully applied in sites where the interdental space
width is at least 2 mm at the most coronal portion of the papilla.
When interdental sites are narrower, the reported technique is difficult
to apply.
In order to overcome this problem, a different papilla preservation
procedure [the simplified papilla preservation flap (SPPF)] has been
proposed for narrow interdental spaces (Cortellini et al. 1999).

54. Simplified papilla preservation flap (SPPF):
This approach includes an oblique incision across the defect‐associated
papilla, starting from the buccal angle of the defect‐associated tooth
and continuing to the mid‐interdental part of the papilla at the adjacent
tooth under the contact point.
In this way, the papilla is cut into two equal parts of which the buccal
part is elevated with the buccal flap and the lingual part with the lingual
flap.

55. Access to the defect is gained through the tiny buccal
triangular flap: from the buccal “window”, the soft tissue filling
the defect is sharply dissected from the papillary supracrestal
connective tissue and from the bony walls with a microblade,
and removed with a mini‐curette.

56. Conventional Flap for Regenerative Surgery
The technique for employing a conventional flap for regenerative
surgery is as follows:
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
subsequently protect the area.
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 due
to necrosis of the flap margins.

57. DISTAL MOLAR SURGERY
Treatment of periodontal pockets on the distal surface of
terminal molars is often complicated by the presence of
bulbous fibrous tissue over the maxillary tuberosity or
prominent retromolar pads in the mandible. Deep vertical
defects are also commonly present in conjunction
with the redundant fibrous tissue. Some of these osseous
lesions may result from incomplete repair after the extraction
of impacted third molars
The gingivectomy incision is the most
direct approach in treating distal pockets
that have adequate attached gingiva
and no osseous lesions.

61. Maxillary Molars. The treatment of distal pockets on the maxillary arch
is usually more simple than the treatment of a similar lesion on the
mandibular arch because the tuberosity presents a greater amount of
fibrous attached gingiva than does the area of the retromolar
pad.
Technique. Two parallel incisions, beginning at the
distal portion of the tooth and extending to the mucogingival
junction distal to the tuberosity or retromolar
pad, are made. The faciolingual distance between
these two incisions depends on the depth of the
pocket and the amount of fibrous tissue involved.

63. 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 reticulum
with many polymorphonuclear leukocytes, erythrocytes,
debris of injured cells, and capillaries at the edge
of the wound. A bacteria and an exudate or transudate
also result from tissue injury

64. One 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, usually contacting
the tooth at this time. When the flap is closely adapted
to the alveolar process, there is only a minimal inflammatory
response .

65. One week after surgery, 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 derived from the gingival connective tissue,
the bone marrow, and the periodontal ligament.

66. 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.

67. One month after surgery, a fully epithelialized gingival
crevice with a well-defined epithelial attachment is
present.
There is a beginning functional arrangement of the
supracrestal fibers.