The Periodontal Flap

Chap# 57

Dr. Salva Asif Rishi

Lecturer DIDC
Periodontology
The Periodontal Flap

 Periodontal flap is a section of gingiva,

mucosa, or both that is surgically
separated from the underlying tissues to
provide for the visibility of and access to
the bone and root surface.
Classification of Flaps

Periodontal flaps can be classified on the

basis of the following:

1. Bone exposure after flap reflection

2. Placement of the flap after surgery

3. Management of the papilla

1. For bone exposure after reflection

The flaps are classified as:

A. Full-thickness (mucoperiosteal flap).

B. Partial-thickness (mucosal) flaps.

 A. Full-thickness Flap
 In a Full-thickness flap, all of the soft
tissue, including the periosteum, is
reflected to expose the underlying bone.
Indicated in resective osseous surgery or
when bone need to be examined.
 Partial-thickness Flap
B.
(Mucosal, Split thickness) Flap

 The 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 that

includes the periosteum.

 The partial-thickness flap is indicated

 when the flap is to be positioned apically, or

 when the operator does not want to expose bone.

 Advantage of this.????
Partial-thickness flap
 The partial-thickness flap is indicated
 when the flap is to be positioned apically, or
 when the operator does not want to expose
the bone.
 Advantage of this.????
2.For Flap Placement After
Surgery
 For flap placement after surgery, flaps are
classified as either:
 A) Nondisplaced flaps, when the flap is returned
and sutured in its original position.

 B) Displaced flaps, which are placed apically,

coronally, or laterally to their original position.

 Both full-thickness and partial-thickness flaps

can also be displaced.
Palatal flap
2.For Flap Placement After
Surgery
 Palatal flaps cannot be displaced because
of the absence of unattached gingiva.

 Apically displaced flaps have the

advantage of preserving the outer
portion of the pocket wall and
transforming it into attached gingiva.
 Eliminate pocket
 Increased width of attached gingiva
3.For the management of
the papilla
For the management of the papilla, flaps
can be:

 A) Conventional
 B) Papilla preservation flaps
A. Conventional Flap
 The interdental papilla is split beneath the
contact point of the two approximating
teeth.
The incision is usually scalloped to maintain
gingival morphology and to retain the papilla.
. Conventional Flap

 Indications:
 when the interdental spaces are too narrow,
thereby precluding the possibility of preserving
the papilla.
 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
reconstructive procedures
B. Papilla Preservation Flap

 Incorporates the entire papilla.

Flap Design

Depends upon:

 Degree of access to the underlying bone and root

surfaces.

 The final position of the flap.

 Aesthetic concerns of the area of surgery.

 Preservation of good blood supply to the flap.

Incisions

Periodontal flaps involve the use of

 Horizontal (mesial– distal).

 Vertical (occlusal– apical) incisions.
Basic Flap Designs
 Two basic flap designs are used, depending on how the
interdental papilla is managed. They can be either:

 Split the papilla (conventional flap)

 Preserve it (papilla preservation flap).
A.Horizontal Incisions
(mesial- distal)
Two types:

 The internal bevel incision which starts at a distance

from the gingival margin and aimed at the bone crest.

 the crevicular incision which starts at the bottom of

the pocket and directed to the bone margin.

 In addition, the interdental incision is performed after

the flap is elevated to remove the interdental tissue.
First
Crevicular
Internal Bevel Incision
 Basic incision, carried out by using no. 15 or 15C
surgical blade, starts from gingiva and directed at or
near the bone crest.
 It is the incision from which the flap is reflected to
expose the underlying bone and root.
 Also called first incision or reverse bevel incision.

 Accomplish 3 objectives:
 1. removes the pocket lining.
 2. conserves uninvolved outer surface of the gingiva.
 3. produces a sharp, thin flap margin for adaptation to the
bone–tooth junction.
Crevicular Incision
 also called the Second incision

 is made from the base of the pocket to the crest of the

bone using a 12-D blade.

 This incision, together with the initial reverse bevel

incision, forms a V-shaped wedge that ends at or near
the crest of bone.
Interdental Incision

 also known as the third incision.

 It is used to separate the collar of gingiva (wedge

shaped) that is left around the tooth using Orban
knife.

 The incision is made not only around the facial

and lingual radicular area but also interdentally,
where it connects the facial and lingual segments
to free the gingiva completely around the tooth.
Envelope Flap

 If vertical incisions are not made, the flap

is called an envelope flap.
B. Vertical (Occluso- Apical)
Incisions
 Also called Oblique releasing incisions.

 can be used on one or both ends of the horizontal

incision.

 Necessary on both sides for Apically Displaced flap.

 must extend beyond the mucogingival line to reach the
alveolar mucosa to allows the release of the flap to be
displaced.

 Should not be given in lingual or palatal areas.

 Facial vertical incisions should not be made in the
center of an interdental papilla or over the radicular
surface of a tooth.

 Incisions should be made at the line angles of a tooth

either to include the papilla in the flap or to avoid it
completely.

 should also be designed to avoid short flaps

(mesiodistal) with long, apically directed incisions,
because this could jeopardize the blood supply to the
flap.
Interdental Denudation
Procedure
 which consists of horizontal, internal bevel, non-scalloped incisions
to remove the gingival papillae and to denude the interdental space.

 This technique completely eliminates the inflamed interdental

tissue.

 Healing is by secondary intention and results in excellent gingival

contour.

 Contraindicated:
 when bone grafts are used and the graft material placed interdentally will not
be covered.
 in aesthetic areas such as the maxillary anterior segment, because the papilla
will be lost.
Elevation of the Flap

 When a full-thickness flap is accomplished

via blunt dissection.
 A periosteal elevator is used to separate the
mucoperiosteum from the bone.

 Sharp dissection is necessary to reflect a

partial-thickness flap using surgical
scalpel (no. 15).

 Combination of full thickness in the

coronal area and partial thickness flap in
Healing After Flap
Surgery
 Immediately after suturing (≤24 hours),
a blood clot formed, consists of a fibrin
reticulum with PMN leukocytes,
erythrocytes, debris of injured cells, and
capillaries at the edge of the wound.

 1 to 3 days after flap surgery, the space

gets thinner. Epithelial cells migrate over
the border of the flap, and contact the
tooth. When the flap is closely adapted to
the alveolar process, there is a minimal
inflammatory response.
Healing After Flap
Surgery
 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.
 Two weeks after surgery, collagen fibers appear
parallel to the tooth surface. Union is weak because
of the presence of immature collagen fibers,
although clinically, it may be 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.
Healing After Flap
Surgery
 Full-thickness flaps, which denude the bone,
result in a superficial bone necrosis after 1 to
3 days.

 Osteoclastic resorption follows and reaches a

peak at 4 to 6 days and then declines
thereafter.

 This results in a loss of bone of about 1 mm;

the bone loss is greater if the bone is thin.
Healing After Flap
Surgery
 Osteoplasty (thinning of the buccal bone) with the
use of diamond burs.

 A surgical technique results for bone necrosis with a

reduction in bone height, which is remodeled by new
bone formation.

 Final shape of the crest is determined by osseous

remodeling than by surgical reshaping.

 Achieves its peak at 3 to 4 week