Various Incisions &

Periodontal Flaps
Dr. Handren Hunar Najeeb
10th lec 5th grade
2019-2020
 VARIOUS INCISIONS USED IN PERIODONTAL
SURGERY

1. Horizontal Incisions. (mesial-distal)

2. Vertical Incision/Oblique releasing incision. (occlusal-apical)
3. Thinning incision.
4. Cut-back incision.
5. Periosteal releasing incision.
1. Horizontal Incisions
A. Scalloped and Straight Incisions
B. External Bevel & Internal bevel incision—First/ basic incision.
C. Crevicular, Crestal, and Submarginal Incision—Second incision.
D. Interdental incision: Third incision.
 1. Horizontal Incisions
A. Scalloped and Straight Incisions
 Scalloped incision: A horizontal incision that
follows the scalloped morphology of the gingival
architecture.
 Straight incision: A horizontal incision that
follows a straight line.
• The advantage of scalloped incision are:
 Preserving the interdental architecture in gingivectomy.
 In creating surgical papillae and preserving soft tissue over
the interdental areas to allow coverage of the interdental
bone in flap surgery.
 1. Horizontal Incisions
B. External Bevel & Internal bevel incision—First/ basic incision.
I. External Bevel
• Also called Bevel incision.
• Starts at the surface of the gingiva apical to the periodontal
pocket and is directed coronally toward the tooth apical to the
bottom of the periodontal pocket.
• Used primarily in Gingivectomy.
• Given with the help of 11 or 15
no. surgical blade.
 1. Horizontal Incisions
B. External Bevel & Internal bevel incision—First/ basic incision.
II. Internal bevel incision
• Also called as reverse bevel incision
because its bevel is in reverse
direction from that of Gingivectomy
incision.
• It starts from a designated area on
the gingiva and is directed apically to
an area at or near the crest of the
alveolar bone.
• Given with the help of 11 or 15 no.
surgical blade.
Varying
locations of
internal
 1. Horizontal Incisions
II. Internal bevel incision
– Objectives:
1) It removes the pocket lining.
2) It conserves the relatively uninvolved outer surface of the
gingiva.
3) It produces a sharp, thin flap margin for adaptation to the
bone–tooth junction.
– Indications:
1) There is a sufficient band of attached gingiva.
2) Thick gingiva (such as palatal gingiva).
3) Deep periodontal pockets and bone defect.
4) Desire to lengthen clinical crown.
 1. Horizontal Incisions
C. Crevicular, Crestal, and Submarginal Incision— Second incision
 1. Horizontal Incisions
I. Crevicular incision:
– Is also called intercrevicular incision,
intracrevicular incision, sulcular incision,
intrasulcular incision, and intersulcular
incision.
– It is made from the base of the pocket
through the junctional epithelium and
connective tissue attachment and down
to the crest of the alveolar bone.
– This incision is carried around the entire
tooth with the help of 12 no. surgical
blade.
 1. Horizontal Incisions
I. Crevicular incision
– Indications:
1) Narrow band of attached gingiva.
2) Thin gingiva and alveolar process.
3) Shallow periodontal pocket.
4) Desire to lessen postoperative gingival
recession for esthetic reasons in the maxillary
anterior region.
5) As a secondary incision of usual flap surgery.
6) Bone graft or GTR procedure:
– Desire to preserve as much periodontal tissue (especially
interdental papilla) as possible to completely cover
grafted bone and membrane by flap and to maximize
blood supply.
 1. Horizontal Incisions
II. Crestal incision
– Is also called the marginal incision.
– It starts at the surface of the gingiva at
the gingival margin and is directed
apically down through the epithelium
and connective tissue to the crest of
the alveolar bone.
– It maximizes the remaining keratinized
tissue.
– It is internal bevel incisions.
 1. Horizontal Incisions
III. Submarginal incision
– Starts at the surface of the
gingiva apical to the gingival margin.
– Submarginal scalloped incision
allows
for more aggressive soft tissue
resection and reduction of the
periodontal pocket.
– It can beexternal bevel or
internal bevel incisions.
 1. Horizontal Incisions
D. Interdental incision—Third incision.
– This incision is made in a horizontal
direction and close to the surface of the
bone crest, thereby separating the soft
tissue collar from the root surfaces and
alveolar bone.
– Given by Orban’s knife.
– The third incision facilitates secondary
flap removal as a single piece.
2. Vertical Incision/Oblique releasing incision:
– Vertical incision must extend beyond the mucogingival line.
– Given with the help of 11 or 15 no. surgical blade.
– Vertical incision should be placed on the tooth surface rather
than on interdental gingiva.
– It should be made at the line angles of a tooth
either to include the papilla in the flap or to avoid it
completely.
– Vertical incision in lingual and palatal areas are avoided.
3. Thinning incision:
– Extends from gingiva towards the base of the flap in palatal flap
and distal wedge procedures.
– Given with the help of 11 or 15 no. surgical blade.

4. Cut-back incision:
– Made at apical aspect of releasing incision
and directed towards base of the flap in
laterally positioned flap.
– Given with the help of or 15 no.
11 surgical blade.
5. Periosteal releasing incision:
– Made at the base of flap severing
the underlying periosteum.
– Given with the help of 15 or 15C
no. surgical blade.
 DEFINITION OF PERIODONTAL FLAP
• 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.
 OBJECTIVES OF PERIODONTAL FLAP
I. Provide access for root surface detoxification.
II. Reducing probing depth including those that extend
to or beyond the mucogingival junction.
III. Preserve/create an adequate zone of attached gingiva.
IV. Permits access to underlying bone for treatment of osseous
defects.
V. Facilitate regenerative procedures.
 PRINCIPLES OF FLAP DESIGN
Prevention of flap necrosis:
• The apex of the flap should never be wider than the base.
• The flap sides should either run parallel to each other or
preferably converge moving from the base of the flap to the
apex of the flap.
• Length of the flap should be no more than twice the width of
the base.
• The base of the flaps should not be excessively twisted or
stretched.
• Whenever possible, an axial blood supply should be included
in the base of the flap.
 PRINCIPLES OF FLAP DESIGN
Prevention of flap tearing:
• Vertical releasing incisions should be placed one full tooth
anterior to the sites of any anticipated bone removal.
• Vertical incision should be started at the line angle of the
tooth or in the adjacent interdental papilla and carried
obliquely apically into the unattached gingiva.
 Basic flap requirements:
• 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.
 CLASSIFICATION OF PERIODONTAL FLAPS
I. According to flap reflection or tissue content or bone
exposure:
A. Full thickness flap
B. Split-thickness flap
II. According to management of papilla:
A. Conventional flap
B. Papilla preservation flap
III. According to flap placement after surgery:
A. Non displaced flap
B. Displaced flap:
• Apical displaced flap
• Coronal displaced flap
• Lateral displaced flap
• Full-thickness/mucoperiosteal flap:

– It consists of the complete

mucoperiosteum i.e surface
epithelium, connective tissue and
periosteum which is raised by a
periosteal elevator.
 Full-thickness/mucoperiosteal flap:
• Indication:
– A full-thickness flap is used to expose the bone surface in osseous
surgery.
• Contraindications:
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
connective tissue of

3.periosteum
 Split-thickness/mucosal flap:
• 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.
 Split-thickness/mucosal flap:
• 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.
– The partial-thickness flap is a difficult technique and causes much
discomfort because of postoperative swelling.
 VARIOUS FLAP PROCEDURES FOR
POCKET ELIMINATION
1. MODIFIED WIDMAN FLAP PROCEDURE
2. UNDISPLACED FLAP PROCEDURE
3. APICALLY DISPLACED FLAP PROCEDURE
4. PAPILLA PRESERVATION FLAP
5. PALATAL FLAP
6. DISTAL MOLAR SURGERY
– These Periodontal flaps are also used in periodontal
surgical therapy to accomplish the following:
1.Access for root instrumentation 2. Gingival resection
3. Osseous resection 4. Periodontal regeneration
 VARIOUS FLAP PROCEDURES FOR
POCKET ELIMINATION
1. MODIFIED WIDMAN FLAP PROCEDURE
• Objectives:
– Facilitate instrumentation on root surfaces by exposing them.
– To remove the pocket lining.
– Possibility of establishing an intimate postoperative
adaptation of healthy collagenous connective tissue to tooth
surfaces.
• Surgical Instruments:
– Blade no. 11, 12, 15.
– Bard Parker handle no. 3.
– Periosteal elevator and Curettes.
MODIFIED WIDMAN FLAP PROCEDURE
• Procedure
– Incision and flap reflection: ( next slide )
• Horizontal incisions used only .
– 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.
• Residual periodontal fibers attached to the tooth surface should
not be disturbed.
– Suturing:
• The flaps are replaced in their original position and secured by
interdental suturing
– Postoperative management:
• Periodontal surgical pack and postoperative instructions
 The Initial incision
• MODIFIED WIDMAN FLAP PROCEDURE internal bevel incision
– Incision and flap reflection:
• The Initial incision is The internal bevel incision,
is starting 0.5 to 1 mm from the gingival margin
to the alveolar crest.
– Scalloping follows the gingival margin.
• The second incision is a crevicular incision is
made from the bottom of the pocket to the
alveolar bone.
– Circumscribing the triangular wedge of tissue
containing the pocket lining.
• The third incision is made in the interdental
space, after the flap is reflected, coronal to the
bone, with an interproximal knife.
crevicular incision

Modified widman flap

sutured
 VARIOUS FLAP PROCEDURES FOR
POCKET ELIMINATION
2. UNDISPLACED FLAP PROCEDURE
• It is also called as internal bevel Gingivectomy because the
soft tissue pocket wall is removed with the initial incision.
• Objectives:
– To improve accessibility for instrumentation.
– To reduce or eliminate pocket by removing pocket wall.
• Surgical Instruments:
– Pocket marker.
– Blade no. 11, 12, 15, Bard Parker handle no. 3.
– Periosteal elevator and Curettes.
UNDISPLACED FLAP PROCEDURE
• Procedure:
I. Mark bleeding points:
• The pockets are measured with a
periodontal probe (The periodontal
the probe
gingival
is inserted
and into
penetrates the
junctional
crevice epithelium and connective tissue
down to bone).
• Bleeding points are produced on the outer
surface the gingiva to mark the
bottom
of with pocket
the help of pocket marker.
UNDISPLACED FLAP PROCEDURES

II. 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.
• This incision can be accomplished only if sufficient
attached gingiva remains apical to the incision.
• The two anatomic landmarks:
1. The transgingival interdental probing depth.
2. The mucogingival junction.
must be considered to evaluate the amount of attached gingiva that
will remain after surgery.
 The second incision; 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.
UNDISPLACED FLAP PROCEDURES
III. Removal of granulation tissue:
– The area is debrided, removing all tissue tags and granulation tissue
with sharp curettes.
IV. Curettage, scaling and root planing:
– After the necessary scaling and root planing, the flap edge should
rest on the root—bone junction.
V. Suturing:
– A continuous sling suture is utilized to secure the facial and the
lingual or palatal flaps.
 VARIOUS FLAP PROCEDURES FOR
POCKET ELIMINATION
3. APICALLY DISPLACED FLAP PROCEDURE
• Indication:
– The apically displaced flap is selected for cases that present with a
minimal amount (<3 mm) of attached gingiva.
• Objectives:
– To eliminate pocket by apically positioning the soft tissue wall of the
pocket.
– To preserve/increase the width of attached gingiva.
– To improve accessibility.
• The position of the flap displacement varies depending on
the:
– Thickness of alveolar margin in operating area.
– Width of attached gingiva.
– Clinical crown length necessary for an abutment.
APICALLY DISPLACED FLAP PROCEDURE
Procedure:
I. Incisions and flap reflection:
 First incision, internal bevel incision:
• Is made (0.5 to 1 mm) from the crest of the gingiva
and directed towards the crest of the alveolar bone.
 Second incision, crevicular incision is made.
 Third incision, interdental incisions are made, and the
marginal collar of tissue is removed.
 Vertical incision extending out into alveolar mucosa
(i.e. past the mucogingival junction) are made at each
end points of the internal bevel incision, making the
apical positioning of the flap.
II. Removal of granulation tissue:
• Marginal collar tissue and granulation tissue are removed with curettes.
III. Scaling and root planing:
• Scaling and root planing is done carefully with scalers and curettes.
IV. Osseous recontouring:
• Alveolar bone crest is recontoured with the help of bur and bone chisels.
V. Apical positioning and suturing:
• 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.
• Partial thickness flap is secured with an independent sling
suture, and further stabilized with periosteal sutures.
VI. Postoperative instructions are given thereafter.
APICALLY DISPLACED FLAP PROCEDURE
4. PAPILLA PRESERVATION FLAP
• Indications:
– Diastema region.
– Bone grafting areas.
• Contraindication:
– Narrow embrasures.
PAPILLA PRESERVATION FLAP
• Procedure:
– Incisions:
– Reflection of flap:
– Removal of granulomatous tissue:
– Suturing:
– Postoperative instructions are given thereafter.
 Intrasulcular incision
Facial aspect 1. Intrasulcular incision 2. semilunar incision

• Incisions: palatal aspect

– Crevicular incisions are made at the facial and proximal aspects of the
teeth without making incisions through the interdental papillae.
– Crevicular incision is made along the lingual/palatal aspect of teeth.
– 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.
– Semilunar incision should dip apically at least 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.
– A full–thickness flap is reflected with a periosteal elevator on both
facial/ palatal surfaces.

Reflected papilla preservation flap

• 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.
– The bony defect is cleaned out using curette.
• Suturing:
– The flaps are repositioned and sutured using criss cross mattress.
5. PALATAL FLAP
• Indications:
– Areas that require osseous surgery.
– Pocket elimination.
– Reduction of enlarged and bulbous tissue.
• Contraindication:
– It is contraindicated when the palate is broad and shallow.
• 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: ( next slide )
– Flap reflection:
• Flaps should be thin to adapt to the underlying osseous tissue
and provide a thin, knife like gingival margin.
– Scaling, root planing:
• Osteoplasty is done only if required.
– Suturing:
• Suture the flap’s edge at the level of the bone margin or slightly
over the alveolar crest (approximately 1–2 mm above the bone
margin).
– Post operative instructions are given thereafter.
–
• The outline of initial incision for palatal flap varies and
Incisions:
is determined with consideration for the:
– Thickness of palatal soft tissue.
– Depth of periodontal pocket.
– Necessity for osteoplasty.
– Clinical crown length required for restorative treatment.
• Internal bevel incision; if the purpose of surgery is
debridement.
• Internal bevel incision, followed by crevicular and
interdental incisions; If osseous resection is to be done.
• A horizontal Gingivectomy incision may be made,
followed by an internal bevel incision; If the tissue is
thick.
6. DISTAL MOLAR SURGERY
• Treatment of periodontal pocket on the distal surface
of terminal molar is often complicated by:
– The presence of bulbous fibrous tissue over the
maxillary tuberosity.
– Prominent retromolar pad in the mandible.
• Objectives of distal molar procedure:
1. To maintain and preserve attached gingiva.
2. To eliminate periodontal pocket.
3. To lengthen clinical crown.
4. To create easily cleansable gingiva-alveolar form.
• The various incisions for distal molar surgery:
1. Linear incision (single horizontal incision ).
• If the secondary objective of surgery is regenerative or the
buccolingual width of the distal keratinized tissue is limited.
2. Triangular incision (distal wedge) (two
converging horizontal incisions).
3. Pedicle incision
4. Square, parallel incision ( The modified distal wedge ).
• If the secondary objective of surgery is resective
and adequate keratinized tissue is present
buccolingually.
The various incisions for distal molar surgery:
1. Linear incision 2. Triangular incision
3. Pedicle incision 4. Square, parallel incision
• The amount of wedge tissue to be removed (The
buccolingual distance between the two horizontal incisions in
both techniques ) is determined by a number of factors, such
as:
1. Depth of periodontal pocket.
2. Thickness of the soft tissue wedge.
3. Whether osteoplasty or osseous resection is necessary.
4. Clinical crown length required for abutment.
• Generally, the distance between the two parallel incisions is
roughly one-half to two-thirds the distal transgingival
probing depth and should never be farther apart than the
distance between the buccal and lingual line angles of the
tooth.
(A) Coronal view from behind a maxillary second molar with an osseous
defect. (B) Distal terminal flap surgery employing two horizontal incisions;
both buccal and lingual flaps are thinned. (C) Buccal and lingual flaps are
elevated, and the “wedge” of tissue is removed. (D) The bone is sloped to
the palatal side to eliminate the osseous defect. (E) The flaps are coapted on
the bone in the apical position.
(A) Sagittal view of a distal defect on a maxillary second molar.
(B)Treatment with a distal wedge results in an acute angle
between the tuberosity and the distal surface of the second
molar. That is biofilm retentive and difficult to clean.
(C)Treatment with a modified distal wedge results in a wider
angle between the tuberosity and the distal surface of the
second molar that is more accessible for hygiene.
• Maxillary molars:
– The modified distal wedge is preferred in the maxilla
– Two parallel incisions, beginning at the distal portion of the tooth
and extending to the mucogingival junction distal to the tuberosity,
are made.
– The two parallel incisions are usually made at the midline of the
tuberosity where the tissue is the thickest or slightly to the palatal
side to maximize buccal keratinized tissue.
– 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:
– The two incisions distal to the molar should follow the area with
the greatest amount of attached gingiva.
– The incisions could be directed distolingually or distofacially,
depending on which area has more attached gingiva.
• The attached gingiva, if present, may not be found directly distal to
the molar. The greatest amount may be distolingual or distobuccal,
and it may not be over the bony crest.
• The ascending ramus of the mandible may also create a short or
completely eliminate the horizontal area distal to the terminal molar.
– Before the flap is completely reflected, it is thinned with a 15 no.
blade.
– Necessary osseous surgery is performed.
– The two flap edges must approximate each other at a new apical
position without overlapping.
Incision designs for surgical procedures distal to the
mandibular second molar. The incision should follow
the areas of greatest attached gingiva and underlying
bone.
(A)Pocket eradication distal to a mandibular second molar
with minimal attached gingiva and a close ascending
ramus is anatomically difficult.
(B) For surgical procedures distal to a mandibular second
molar, abundant attached gingiva and distal space are
ideal.
Thank you