1. Dept of periodontics
Periodontal flaps

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

3. INDICATIONS: Irregular bony contours Deep craters
Pockets on teeth in which a complete removal of root irritants is not clinically possible
Grade II or III furcation involvement
Root resection / hemisection
Intrabony pockets on distal areas of last molars
Persistent inflammation in areas with moderate to deep pockets.

4. CONTRAINDICATIONS ‐unstable angina ‐uncontrolled diabetes
Uncontrolled medical conditions such as
‐unstable angina
‐uncontrolled diabetes
‐uncontrolled hypertension
‐myocardial infarction / stroke within 6 months
Poor plaque control
High caries rate
Unrealistic patient expectations or desires

5. Classification of flaps
Bone exposure after flap reflection
Full thickness (mucoperiosteal)
Partial thickness (mucosal)
Placement of the flap after surgery
Non displaced flaps
Displaced flaps
Management of the papilla
Conventional flaps
Papilla preservation flaps

6. BASED ON BONE EXPOSURE AFTER REFLECTION
FULL THICKNESS FLAP
Periosteum is reflected to expose the underlying bone.
Indicated in resective osseous surgery.

7. PARTIAL THICKNESS FLAP
Split thickness flap.
Periosteum covers the bone.
Indicated when the flap has to be positioned apically.
When the operator does not desire to expose the bone

8. BASED ON FLAP PLACEMENT AFTER SURGERY
Non displaced flaps:
When the flap is returned and sutured in its original position.
Displaced flaps:
When the flap is placed apically, coronally or laterally to their original position

9. DESIGN OF THE FLAP Split the papilla (conventional flap)
•Preserve it (papilla preservation flap)

10. MODIFIED WIDMAN FLAP
Presented by Ramfjord and Nissle
in 1974

11. THE ORIGINAL ‘WIDMAN’ FLAP
The flap was elevated to expose 2-3 mm of the
alveolar bone.
The soft tissue collar incorporating the pocket
epithelium and connective tissue was removed, the
exposed root surface scaled and the bone
recontoured to re-establish a 'physiologic' alveolar
form.
The flap margins were placed at the level of the
bony crest to achieve optimal pocket reduction.

12. THE TERM MODIFIED WIDMAN FLAP
Exposure of the interproximal bone and
elimination of infrabony defects by osseous
recontouring is not carried out (No surgical
pocket elimination and apical displacement of
the flap)
Incase of esthetic considerations,intracrevicular
incisions starting at the free gingival margins are
used to minimize postsurgical gingival shrinkage.
Vertical releasing incisions are usually not used

13. INDICATIONS:
Effective with pocket depths of 5-7 mm
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 (internal
gingivectomy).

14. ADVANTAGES: Root cleaning done with direct vision.
Healing by primary intention.
Minimal crestal bone resorption.
Lack of post operative discomfort.

15. PROCEDURE: Internal bevel incision should be made
to the alveolar crest starting
0.5 to 1 mm away from
the gingival margin.
1- Modified widman flap
2- Undisplaced flap

16. INTERNAL BEVEL INCISION IN FACIAL AND PALATAL ASPECTS

17. 3)Crevicular incision is made from the bottom of the pocket to bone
2) Flap is elevated
3)Crevicular incision is
made from the bottom of
the pocket to bone

18. 4)Interdental incision sectioning
the base of the papilla
5)Tissue tags and granulation
tissue are removed.

19. 6) Scaling and root planing of exposed root surfaces

20. 7)Suturing done and covered
with tetracycline oinment
and with a periodontal
surgical pack

21. Post operative results

22. THE UNDISPLACED FLAP 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 considered an
internal bevel gingivectomy.

23. PROCEDURE 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
PRE OPERATIVE VIEWS

24. 2) Internal bevel incision in the facial and palatal aspects

25. 3)Crevicular incision is made and Flap is elevated

26. 4)Interdental incision is made 5)Triangular wedge of tissues is removed with curette 6)All tissue tags and granulation tissue are removed

27. 7)After the scaling and root planing the flap edge should rest on the root bone junction. 8)Flaps have been placed in their original site and Sutured.

28. Post operative results

29. THE APICALLY DISPLACED FLAP
It can be used for both pocket eradication as well as widening the zone of attached gingiva.
It can be a full thickness (mucoperiosteal) or a split thickness (mucosal) flap.

30. ADVANTAGES: Eliminates periodontal pocket.
Preserves attached gingiva and increases its width.
Establishes gingival morphology facilitating good hygiene.
Ensures healthy root surface necessary for the biologic width on alveolar margin and lengthened clinical crown.

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

32. CONTRAINDICATIONS: 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 unfavorable clinical crown / Root ratio.

33. PROCEDURE for apically displaced flap
An internal bevel incision is made, it should be no more than 1mm from the crest of the gingiva and directed to the crest of gingiva.
2. Crevicular incisions are made, followed by initial elevation of the flap; then interdental incision and the wedge of tissue containing pocket wall is removed

34. 3. Vertical incisions are made extending beyond the mucogingival junction.
Full thickness flap elevated by blunt dissection with periosteal elevator
Split –thickness flap elevated using sharp dissection with a bard- parker knife

35. 4.After debridement of the areas
5.Sutures in place

36. PRE TREATMENT-
POST TREATMENT

37. CROWN LENGTHENING BY APICALLY DISPLACED FLAP
PRE-TREATMENT
BEFORE OSSEOUS RESECTION
FLAP APICALLY POSITIONED AND SUTURED
POST-TREATMENT

38. CROWN LENGTHENING BY APICALLY DISPLACED FLAP
PRE-TREATMENT
Incision
Before debridement After debridement
Sutures in place

39. Pre treatment
Post treatment

40. FLAPS FOR REGENERATIVE SURGERY
Two flap designs are available for regenerative surgery:
The papilla preservation flap&
The conventional flap with only crevicular incisions.

41. THE PAPILLA PRESERVATION FLAP
Entire papilla is incorporated into one of the flaps.
INDICATIONS:
Where esthetics is of concern.
Where bone regeneration techniques are attempted

42. CONVENTIONAL FLAP FOR REGENERATIVE SURGERY
In the conventional flap operation, the incisions for the facial and the lingual or palatal flap reach the tip of the interdental papilla, thereby splitting the papilla into a facial half and a lingual or palatal half.
INDICATIONS:
When the interdental areas are too narrow to permit the preservation of flap.
When there is a need for displacing flaps.
The interdental papilla is split beneath the contact point of the two approximating teeth to allow for reflection of buccal and lingual flaps

43. Distal molar surgery

44. 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.
Operations for this purpose were described by Robinsonand Braden

45. Impaction Of A Third Molar Distal To A Second Molar
Little Or No Bone Distal To The Second Molar.
Often Leads To A Vertical Osseous Defect Distal To The Second Molar.

46. Typical incision design for a surgical procedure distal to the maxillary second molar.

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

48. Distal wedge Triangular Square , parallel or H-design
Linear or pedicle
The size, shape ,thickness and access of the tuberosity or retromolar area determine treatment procedures

49. TRIANGULAR DISTAL WEDGE:
Triangular wedge incisions 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.

50. Triangular incision -Using no.12 0r no.15 scalpel blade
Triangular wedge of tissue removal- using scalers ,hoes , or knives
Walls of the wedge are thinned using scalpel blade- for proper adaptation to underlying bone

51. LINEAR DISTAL WEDGE:
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

52. Two parallel inverse bevel thinning incision –using n0.15 blade
Periosteal elevators are used to raise the flap
Kirkland or orban knives –to remove the wedge of tissue

53. DISTAL POCKET ERADICATION PROCEDURE WITH THE INCISION DISTAL TO THE MOLAR
SCALLOPED INCISION AROUND THE REMAINING TEETH

54. FLAP REFLECTED AND THINNED AROUND THE DISTAL INCISION
FLAP IN POSITION BEFORE SUTURING. IT SHOULD BE CLOSELY APPROXIMATED

55. FLAP SUTURED BOTH DISTALLY AND OVER THE REMAINING SURGICAL AREA

56. PERIODONTAL PACKS
Periodontal dressing or periodontal packs is a productive materials applied over the wound created by periodontal surgical procedure
minimise postoperative infection aand haemorrahage
Facilitates healing
Protects against pai

57. Zinc –oxide eugenol packs
Zno eugenol packs packs based on reaction of zno & eugenol include –wondr pak
The addition of accelerators such as Zinc acetate gives the dressing a betterworking time.
It is supplied as a liquid and a powder that are mixed prior to use.
Eugenol may produce allergic reaction (reddening of area and burning pain )

58. Non eugenol packs
Reaction between metallic oxide and fatty acid is basis for coe-Pak
Supplied in two tubes
One tube contains oxides of various metals (Mainly zinc oxide) and lorothidol (a fungicide) and second tube contains non ionized carboxylic acids and chlorothymol (bacteriostatic agents)

59. Retenton of packs
Mechanically by interlocking in interdental spaces and joining the facial and lingual portion of the pack

60. Antibacterial properties
Improved healing and patient comfort – incorporating antibiotics
Bacitracin, oxytetracycline , neomycin nitrofurazone(hypersensitivity)

61. Preparation and application of periodontal dressing
Equal length of the two paste placed on a paper pad
Mixed with a wooden tongue depressor for 2-3 minutes until paste loses its tackiness

62. Paste is placed in a paper cup of water at room temperature
With lubricated fingers rolled into cylinders and placed on the surgical wound

63. Strip of pack is hooked around last molar and pressed into place anteriorly
Lingual pack is joined to facial strip at the distal surface of last molar and fitted into place anteriorly
Gentle pressure on the facil and lingual surfaces join the pack interproximally

64. Continous pack cover the edentulous space

65. Instructions for patients after surgery
The pack should remain in place until it is removed in the office at the next appointment
2. For the first three hours after the operation avoid hot foods to permit the pack to harden
3. Do not smoke
4. Do not brush over the pack

66. Removal of periodontal pack
After 1 week
Inserting a surgical hoe along the margin and exert gentle lateral pressure
Pieces of pack- removed with scalers
Entire area rinsed with peroxide to remove superficial debris

67. Findings at pack removal
Epithelialized but bleed readily when touched
Pockets should not be probed

68. HEALING AFTER FLAP SURGERY
Immediately after suturing (0 to 24 hours),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.
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
One week after surgery‐The blood clot is replaced by granulation tissue derived from the gingival connective tissue, the bone marrow, and the periodontal ligament.

69. 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 functional arrangement of the supracrestal fibers.