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Periodontal Flap
Periodontal Flap
(Fig. 2).
the bone crest, thereby separating the soft tissue collar from the root surfaces and alveolar bone (Fig. 1C). Given by
Orbans knife. The third incision facilitates secondary flap removal as a single piece.
II. Vertical Incision/Oblique releasing incision: Vertical incision must extend beyond the mucogingival
line. It should be made at the line angles of a tooth either to include the papilla in the flap or to avoid it completely.Thus,
vertical incision should be placed on the tooth surface rather than on interdental gingiva (Fig.3). Vertical incision in
lingual and palatal areas are avoided. These should be designed so as to avoid short flap mesiodistally with long apically
directed horizontal incision because this could jeopardize the blood supply to the flap. Given with the help of 11 or 15 no.
surgical blade.
Thinning incision:
Extends from gingiva towards the base of the flap in palatal flap and distal wedge
IV. Cut-back incision: Made at apical aspect of releasing incision and directed towards base of the flap in laterally
positioned flap (Fig. 4). Given with the help of 11 or 15 no. surgical blade.
V. Periosteal releasing incision: Made at the base of flap severing the underlying periosteum. Given with
the help of 15 or 15C no. surgical blade.
It is the portion of gingiva and or alveolar mucosa surgically separated from the underlying tissues to provide visibility and
access to the bone and root surface.
Base of the flap must be wide enough to maintain an adequate blood supply
Flap must be big enough to expose any underlying bone defects
No important vessels or nerves should be damaged in raising the flap
Incisions must allow movement of flap without tension.
b. Split-thickness flap
B. According to management of papilla:
a. Conventional flap
b. Papilla preservation flap
C. According to flap placement after surgery:
a. Non displaced flap
b. Displaced flap:
Apical displaced flap
Coronal displaced flap
Lateral displaced flap
Consists of Consists of
1. Epithelium
2. Connective tissue
3. Periosteum
Incision ends on bone
surface
1. Epithelium
2. Connective tissue
Incision ends on root
1. Area where treatment for osseous defect with mucogingival problem is not required.
2. Thin periodontal tissue with probable osseous dehiscence and osseous fenestration.
3. Area where alveolar bone is thin.
Split-thickness/mucosal flap: Gingiva is dissected from the underlying periosteum which is left on the bone
and consists of epithelium and thin layer of connective tissue (Fig. 5B). Sharp dissection is used to produce a partial
thickness flap. Partial-thickness flap is prepared while holding and pulling the flap edge with tissue pliers, turning the blade
toward the gingival margin. The flap is dissected slowly from an apico-occlusal direction. To prevent flap penetration, use
the side of the blade and hold it parallel to the periosteum to make the incision. Indications: Partial thickness flaps are
especially useful for augmentation of the attached gingiva. This is done by positioning the flap apically or laterally. Partial
thickness flap is employed, when exposure of bone is to be avoided as in the case of fenestration/dehiscence. Advantages:
The flap can be attached firmly to the desired position with a periosteal suture if the reflected flap is displaced apically and
the thin marginal bone can be protected by the periosteum-connective tissue bed. Disadvantages: The biggest problem of a
partialthickness flap is with the thickness of the remaining periosteum-connective tissue bed on the bone. If it is less than
0.5 mm, the remaining periosteum-connective tissue may become necrotic, with decreased protective effect for the
alveolar bone. However, the partial-thickness flap is a difficult technique and causes much discomfort because of
postoperative swelling.
Historical perspective: In 1918, Widman introduced Widman flap surgery. In 1965, Morris revived this technique and called
it as unrepositioned mucoperiosteal flap. The same procedure was presented in 1974 by Ramfjord and Nissle who called it
the modified Widman flap.
The advantages of Modified Widman flap over Original Widman flap procedure are i) close adaptation of soft tissue to root
surface, ii) minimum trauma to alveolar bone and iii) access to adequate instrumentation of the root surface.
Objectives: The main purpose of the modified widman technique is to facilitate instrumentation on root surfaces by
exposing them and to remove the pocket lining. Resdiual deposits of subgingival calculus left in deep pockets are thus
removed.
Surgical Instruments
Blade no. 11, 12, 15, Bard Parker handle no. 3, Periosteal elevator and Curettes.
Procedure
Incision and flap reflection: The internal bevel incision is the initial incision starting 0.5 to 1 mm from the gingival
margin to the alveolar crest (Fig. 6A).
Scalloping follows the gingival margin. Care should be taken to insert the blade in such a way that the papilla is left with a
thickness similar to that of the remaining facial flap. The gingiva is reflected with a periosteal elevator . A crevicular
incision
circumscribing the triangular wedge of tissue containing the pocket lining. After the flap is reflected, a
made in the interdental space, coronal to the bone, with an interproximal
knife (Fig. 6B).
third incision
is
Fig. 6B: Crevicular incision and interdental incision of modified widman flap
Cervical wedge: The gingival collar is removed with the help of curette.
Curettage, scaling and root planing: Tissue tags and granulation tissue are removed with a curette. The root
surfaces are checked and are scaled and planed, if necessary. Residual periodontal fibers attached to the tooth surface
should not be disturbed.
Bone architecture is not corrected unless it prevents good tissue adaptation to the neck 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. The flaps may be thinned to allow for close adaptation of the gingiva around the entire
circumference of the tooth and to each other interproximally.
Suturing: The flaps are replaced in their origina position and secured by interdental suturing (Fig. 6C).
Postoperative management: The operated site is covered with periodontal surgical pack and postoperative
instructions are given thereafter.
Surgical Instruments
Pocket marker, Blade no. 11, 12, 15, Bard Parker handle no. 3, Periosteal elevator and Curettes.
Procedure (Fig. 7)
Mark bleeding points: The pockets are measured with a periodontal probe and bleeding points are produced on the
outer surface of the gingiva to mark the pocket bottom with the help of pocket marker.
Incision and flap reflection: The initial, internal bevel incision is made following 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. The thicker the tissue is, the more apical will be the ending point of the incision.
Then crevicular incision is made from the bottom of the pocket to the bone to detach the connective tissue from the tooth.
Full thickness flap
is reflected with a periosteal elevator. The third incision, i.e. interdental incision is made with an interdental knife,
separating the connective tissue from the bone. The triangular wedge of tissue created by the three incisions is removed
with a curette.
Removal of granulation tissue: The area is debrided, removing all tissue tags and granulation tissue with sharp
curettes.
Curettage, scaling and root planing: After the necessary scaling and root planing, the flap edge should rest on
the rootbone junction.
Suturing: A continuous sling suture is utilized to secure the facial and the lingual or palatal flaps. This
type of suture, which uses the tooth as an anchor, is advantageous to position and hold the flap edges at the rootbone
junction. The area is covered with a periodontal pack.
Postoperative instructions are given thereafter.
Procedure (Figs 8A to D)
Incisions and flap reflection: First incision, internal bevel incision is made 1 mm from the crest of the gingiva and
to contract and fold up so that apical positioning takes place. Flap is displaced apically so that edge just covers the newly
recontoured alveolar crest. Interrupted sutures should be placed first at the mesial and distal vertical incisions. Full
thickness flap is sutured using sling suture while partial
thickness flap is secured with direct loop suture or a combination of loop and anchor suture. Periodontal dressing is applied
on the operated site over the dry foil.
Postoperative instructions are given thereafter.
Advantages:
1. Eliminates periodontal pocket- Apically repositioned flap results in pocket elimination and the formation of a
normal/physiological length of junctional epithelium whereas the replaced flap results in the formation of a long junctional
epithelium which may adhere to the root surface. The long junctional epithelium is inherently less stable than the
physiological junctional epithelium and demands much higher frequencies of recall for maintenance than pocket elimination
procedures.
2. Preserves attached gingiva and increases its width.
3. Establishes gingival morphology facilitating good hygiene.
4. Ensures healthy root surface necessary for the biologic width on alveolar margin and lengthen clinical crown.
Disadvantages:
In 1985, Takei et al proposed surgical approach called as Papilla preservation technique. Later, Cortellini et al described
modifications of this flap designs. It is the procedure which incorporates the entire papilla in one of the flaps by means of
crevicular and 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.
Indications:
i. Diastema region.
ii. Bone grafting areas.
Contraindication:
i. Narrow embrasures.
Procedure
Incisions: Crevicular incisions are made at the facial and proximal aspects of the teeth without making incisions
through the interdental papillae. Subsequently, crevicular incision is made along the
lingual/palatal aspect of teeth with a semilunar incision made across each interdental area with the blade perpendicular to
the outer surface of gingiva and extending through the periosteum to the alveolar process (Fig. 9A). Semilunar incision
should dip apically atleast 5 mm from the line angles of teeth, which will allow the interdental tissue to be dissected from
the lingual/palatal aspect so that it can be elevated intact with the facial flap.
Reflection of flap: A curette or interproximal knife is used to carefully free the interdental papilla from the underlying
hard tissue. The detached interdental tissue is pushed through the embrasure with a blunt instrument (Fig. 9B). A full
thickness flap is reflected with a periosteal elevator on both facial/ palatal surfaces. The exposed root surfaces are
thoroughly scaled and root planed and bone defects carefully curetted.
Removal of granulomatous tissue: While holding the reflected flap, the margins of the flap and the
interdental tissue are scrapped to remove pocket epithelium and excessive granulation tissue. In
anterior areas, the trimming of granulation tissue should be limited so as to maintain the thickness of tissue. After reflection
of flap, access to the interdental bony defect will be obtained. The bony defect is cleaned out using curette. The bone graft
material is placed if required.
Advantages:
i. Esthetically pleasing.
ii. Primary coverage of implant.
iii. Prevents postoperative tissue craters.
Disadvantages:
i. Technically difficult.
ii. Time consuming.
PALATAL FLAP
The surgical approach for palatal flap is different from other flaps because of the nature of palatal tissue which is attached
and keratinized with no elastic properties.
The apical portion of the scalloping should be narrower than the line angle area because of the taper of palatal root apically.
Palatal flap cannot be displaced apically nor can a split-thickness palatal flap be accomplished.
Indications:
i. Areas that require osseous surgery.
ii. Pocket elimination.
iii. Reduction of enlarged and bulbous tissue.
Contraindication:
It is contraindicated when the palate is broad andshallow. Special care must be taken performing a palatal flap due to
several anatomic structures:
Greater palatine artery and nerve may be damaged if flap reflection is extensive in molar region.
Palatal exostoses present in molar region in 1/3rd of the patient. It creates thin tissue in the region and make proper flap
margin placement difficult.
Incisive papilla present in anterior palate.
Presence of palatal rugae at or near the flap margin create poor gingival margin contours postsurgically.
Procedure
Incisions: The outline of initial incision for palatal flap varies and is determined with consideration for the:
i) thickness of palatal soft tissue; ii) depth of periodontal pocket; iii) necessity for osteoplasty; and
iv) clinical crown length required for restorative treatment. If the purpose of surgery is debridement then internal bevel
incision is given such that palatal flap is adapted at root bone junction, when sutured. If osseous resection is to be done,
then palatal incision is planned to compensate for lowered level of bone when the flap is closed.
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. The blade should be parallel to the palatal soft tissue to prepare a thin and uniform primary flap
(1.52.0-mm thickness). Caution must be taken to avoid perforating the flap or making the flap too thin, which will cut off
the necessary blood supply.
Flap reflection: Before the flap is reflected to the final position for scaling and management of the osseous lesions, its
thickness must be checked. Flaps should be thin to adapt to the underlying osseous tissue and provide a thin, knife like
gingival margin.
Scaling, root planing: With the help of scalers and curettes scaling, root planing is performed. Osteoplasty is done
only if required.
Suturing: Suture the flaps edge at the level of the bone margin or slightly over the alveolar crest (approximately 12
mm above the bone margin).
Post operative instructions are given thereafter.
Beveled Flap
Friedman developed the beveled flap, a modification of the apically repositioned flap for the periodontal pockets on the
palatal aspect of the teeth. As there is no alveolar mucosa present on the palatal aspect of the teeth, it is not possible to
reposition the flap in an apical direction.
A primary incision is made intracrevicularly through the bottom of the periodontal pocket and a mucoperiosteal flap is
elevated. Scaling, root planing and osseous recontouring is performed in the surgical area. The palatal flap is replaced and
a secondary, scalloped, reverse bevel incision is made to adjust the length of the flap to the height of the remaining
alveolar bone.The shortened and thinned flap is replaced over the alveolar bone and in close contact with the root surface
(Fig10).
Advantages of palatal approach procedures are esthetics, easier access for osseous surgery, wider palatal embrassure
space and less resorption because of thicker bone. The only disadvantage is close root proximity.
Long and large edentulous ridge, maxillary tuberosity and retromolar triangle
Much tissue to be removed in the wedge area
Sufficient existing band of attached gingiva
Deep periodontal pockets and osseous defects on the mesial and distal aspects of the abutment.
Maxillary molars: Two parallel incisions, beginning at the distal portion of the tooth and extending to the mucogingival
junction distal to the tuberosity, are made.
These incisions are usually interconnected with the incisions for the remainder of the surgery in the quadrant involved. The
amount of wedge tissue to be removed (the distance between the two internal bevel incisions) is determined by a number
of factors, such as i) depth of periodontal pocket, ii) thickness of the soft tissue wedge, iii) whether osteoplasty or osseous
resection is necessary and, iv) clinical crown length required for abutment. A transversal incision is made at the distal end
of the two parallel incisions so that a long, rectangular piece of tissue can be removed. The parallel distal incisions should
be confined to the attached gingiva because bleeding and flap management becomes problem when the incision is
extended into the alveolar mucosa. When the tissue between the two incisions is removed and the flaps are thinned, the
two flap edges must approximate each other at a new apical position without overlapping.
Mandibular molars: Incisions for the mandibular arch differ from those used for the tuberosity, owing to differences in
the anatomy and histologic features of the areas. The retromolar pad area does not usually present as much fibrous
attached gingiva. The two incisions distal to the molar should follow the area with the greatest amount of attached gingiva.
Therefore, the incisions could be directed distolingually or distofacially, depending on which area has more attached
gingiva. Before the flap is completely reflected, it is thinned with a 15 no. blade. It is easier to thin the flap before it is
completely free and mobile. After the reflection of the flap and the removal of the redundant fibrous tissue, any necessary
osseous surgery is performed. The flaps are approximated similarly to those in the maxillary tuberosity area.
It was originally developed by Grupe and Warren in 1956. In this procedure a pedicle graft is taken from a donor site and is
placed on the adjoining site by moving the flap towards the recipient site and suture are placed (Rest is described in
chapter no. 50 Periodontal Plastic Surgery).
POINTS TO PONDER
- Incisions are either coronally directed incision(external bevel incision) or apically directed incisions (Internal bevel,
sulcular incision).
- Undisplaced flap is considered as Internal bevel gingivectomy. Undisplaced flap and gingivectomy procedures surgically
remove the pocket wall.
- Apically positioned flap surgery, is one of the most reliable technique for the elimination of periodontal pockets.
- The flap without vertical incision is called envelope flap.
- The tissue which is left on the surface of tooth when the flap is raised is called as cervical wedge.
- Neumann flap: Neumann in 1911, introduced the flap in which the intrasulcular incision was made along with two vertical
releasing incision, a full thickness flap raised and the area was curetted thoroughly to eliminate all the granulation tissue to
prevent reinfection. Root was planed smooth and bone was superficially removed.
Conventional flap is the flap in which the papilla is split into facial half and lingual/palatal half.