1. Flap Surgery
Presenter: R2 鄭瑋之 Instructor: Dr. 陳娟娟 2012/11/14

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 I therapy
• Bony pockets and interdental craters
• Bony lesions in the furcations
• Need for surgical crown lengthening
• When to open up a flap? complicated
morphology like:
– Deep and narrow pocket
– Difficult to achieve the correct angle

4. Contraindications
• Shallow, supraalveolar pockets
– subgingival scaling/rootplaning
• Esthetically sensitive areas
• Fibrous thickened gingiva
– gingivectomy  more favorable morphology

6. Comparison of open vs. closed

7. Instruments

8. Instruments
Small elevators for
mobilization of the
mucoperiosteal flap

9. Instruments

10. Principles of Flap Design
• Local flap
1.outlined by a surgical incision
2.carries its own blood supply
3.allows surgical access to underlying tissues
4.can be replaced in the original position
5.can be maintained with sutures and is expected
to heal
 Used in oral surgical, periodontic, and
endodontic procedures to gain access.

11. Principles of Flap Design
• Complications
A. Flap necrosis
B. Flap Dehiscence
C. Flap Tearing
D. Injury to Local Structures

12. Principles of Flap Design
A. Flap necrosis
1. Base > Free margin
• to preserve an adequate blood supply
• unless a major artery is present in the base
2. Width of Base > Length of Flap*2
• less critical in oral cavity, but length < width
• a long, straight incision with adequate flap reflection
heals more rapidly than a short, torn incision.
3. An axial blood supply in the base
4. Hold the flap with a retractor resting on intact
bone to prevent tension.

13. Principles of Flap Design
B. Flap Dehiscence
1. The incisions must be made over intact bone
2. If the pathologic condition has eroded the
buccocortical plate, the incision must be at least 6 or 8
mm away from it.
3. The incision is 6 to 8 mm away from the bony defect
created by surgery.
4. Gently handle the flap's edges
5. Do not place the flap under tension
6. Do not cross bony prominences, ex: canine eminence

14. Principles of Flap Design
B. Flap Dehiscence

15. Principles of Flap Design
C. Flap Tearing
• Envelope flaps
– an incision around the necks of several teeth.
– extends 2 teeth anterior and 1 tooth posterior.
If not provide sufficient access…
• Vertical (oblique) releasing incisions:
– extends 1 tooth anterior and 1 tooth posterior.
– started at the line angle of a tooth.
– carried obliquely apically into the unattached gingiva.
– If cross the papilla  localized periodontal problems

16. Principles of Flap Design
D. Injury to Local Structures
• Mandible: lingual n. & mental n.

17. Principles of Flap Design
D. Injury to Local Structures
• Maxilla: greater palatine a. & nasopalatine n./a.

18. Basic Incisions
• Can be sulcular, crestal, or inverse bevel

19. Basic Incisions
Full
thickness
(mucoperiosteal)
a: sulcular
Depending on b: crestal
the amount of
attached tissue
present

20. Basic Incisions
Split/partial
thickness
(mucosal)
In areas of thin
bony plates and
for mucogingival
procedures

21. Basic Incisions
2. inversebeveled
Modified flap
incision to the crest
(mucoperiosteal)
of bone.
Requires adequate 1. gingivectomy
attached Incision for
keratinized gingiva pocket reduction
On the palate,
enlarged tissue, or
with limited access

22. Comparison of full- vs. partial-

23. Types of Mucoperiosteal Flaps
1. Envelope/sulcular incision
2. Envelope with one releasing incision (three-
corner flap)
3. Envelope with two releasing incisions (four-
corner flap)
Full-thickness
Full-thickness
mucoperiosteal flap
mucoperiosteal flap

24. Types of Mucoperiosteal Flaps
1. Envelope/Sulcular flap
2 teeth anterior
1 tooth posterior

25. Types of Mucoperiosteal Flaps
2. Three-corner flap
1 tooth anterior
1 tooth posterior
Greater access in an apical direction,
especially in the posterior aspect of the
mouth

26. Types of Mucoperiosteal Flaps
3. Four-corner flap
1 tooth anterior
1 tooth posterior
rarely indicated

27. Common Periodontal Flap

28. 1. Inverse bevel incision 0.5~2mm, extending to the alveolar
crest. Thins gingival tissue and permits compete closure of
the interdental osseous defects postoperatively.

29. 2. Flap reflection. Full thickness mucoperiosteal flap is
reflected to permits visualization.

30. 3. Crevicular incision between the hard tooth and the
diseased pocket epi., to the depth of the junctional epi.

31. 4. Horizontal incision carried along the alveolar crest

32. 5. Root planing with direct vision

33. 6. Complete coverage of interdental defects

34. 1. Sulcularly, crestally, or full-thickness flap labially positioned
inverse beveled incision to bone
2. Flap completed, reflected off bone
3. Flap is apically positioned and sutured

35. A: The internal bevelled,
scalloped incision is used
for pocket elimination
through apical
repositioning of the flap.
B: The flap
positioned apically for
pocket elimination.

36. 1. Crestal incision with blade, partial-thickness flap parallel to long
axis of tooth
2. Flap raised by sharp dissection, periosteum retained over bone
3. Flap is apically positioned at or below alveolar crest

37. 1. No alveolar mucosa is
present on the palate to
permit apical positioning.
2. Pocket elimination by
palatal flap that just
covers the contours of
the bone to eliminate
osseous defects.
3. Requires skill and
experience.

38. Osteoplasty
Osseous grooving,
peprmits better
adaption of flaps to
facilitate plaque
removal alter
healing

39. Osteoplasty

40. Osteoplasty

41. Suturing for Flap Surgery

42. Simple Loop Modification of
Interrupted

43. Figure 8 Modification of Interrupted

44. Vertical mattress suture

45. Horizontal mattress suture

46. Single Interrupted Sling

60. Reference
1. Contemporary Oral and Maxillofacial Surgery, 4th Edition, Larry J
Peterson, DDS, MS, Edward Ellis, III, DDS, MS, James R Hupp, DMD, MD,
JD, FACS and Myron R Tucker, DDS
2. Peterson's principles of oral and maxillofacial surgery, Michael
Miloro,G. E. Ghali,Peter Larsen,Peter Waite
3. An atlas of minor oral surgery: principles and practice, David A.
McGowan
4. Manual of minor oral surgery for the general dentist, Karl R. Koerner
5. Critical Decisions in Periodontology, 4th Edition, WALTER B. HALL, BA,
DDS, MSD
6. Color Atlas of Periodontology, Klaus H. & Edith M. Rateitschak
7. Atlas of Cosmetic and Reconstructive Periodontal Surgery 3rd edition,
EDWARD S. COHEN, DMD

61. Thanks for your attention!