THE PERIODONTAL

FLAP
 OUTLINE
 CLASSIFICATION OF FLAPS
 DESIGN OF THE FLAP
 INCISIONS
 Horizontal Incisions
 Vertical Incisions
 ELEVATION OF THE FLAP
 SUTURING TECHNIQUES
 Technique
 Ligation
 Types of Sutures
 HEALING AFTER FLAP SURGERY
 Definition :
 A periodontal flap is a section of gingiva and / or
mucosa surgically elevated from the underlying
tissues to provide visibility of and access to the bone
and root surface.

 Indications / Objectives of flap surgery :

 Gain access for root debridement.
 Reduction or elimination of pocket depth, so that
patient can maintain the root surfaces free of plaque.
 Reshaping soft and hard tissues to attain a
harmonious topography (physiologic architecture).
 Regeneration of alveolar bone, periodontal ligament
and cementum.
 CLASSIFICATION OF FLAPS
 According to the thickness of the flap/ Bone
exposure after flap reflection
 Full thickness / mucoperiosteal flap.
 Partial thickness / mucosal flap / split thickness flap.
 According to the placement of flap after
surgery
 Nondisplaced flap
 Displaced flaps
 According to design of the flap / management
of the papilla
 Conventional flaps –E.g. Modified Widman flap,
undisplaced flap, apically displaced flap.
 Papilla preservation flaps.
Comparison between full – thickness
and partial – thickness flaps
 Incisions:
 For Conventional flap,
 Horizontal Incision can be,
 Internal bevel incision
 Crevicular incision
 Interdental incision
 Vertical Incision
 Oblique releasing incision
 For Papilla Preservation flap,
 Crevicular incision with no incisions across the
interdental papilla is given.
 Indications for the Internal Bevel
Incision
 Primary incision of flap surgery if there is a
sufficient band of attached gingiva
 Desire to correct bone morphology
(osteoplasty, osseous resection)
 Thick gingiva (such as palatal gingiva)
 Deep periodontal pockets and bone defect
 Desire to lengthen clinical crown
 Indications for the Sulcular Incision
 Narrow band of attached gingiva
 Thin gingiva and alveolar process
 Shallow periodontal pocket
 Desire to lessen postoperative gingival
recession for esthetic reasons in the maxillary
anterior region
 As a secondary incision of usual flap surgery
 Bone graft or GTR: desire to preserve as
much periodontal tissue (especially
interdental papilla) as possible to completely
cover grafted bone and membrane by flaps.
 Flap Elevation:
 Can be done either by blunt dissection ( full
thickness or mucoperiosteal flap) or sharp
dissection ( partial thickness or mucosal flap).
 Suturing:
 Goals of suturing:
 Maintains haemostasis
 Permits healing by primary intention
 Reduces post operative pain
 Permits proper flap position
 Prevents bone exposure resulting in delayed
healing and unnecessary resorption.
 Interrupted suture
 Direct or loop suture
 Figure eight
 Horizontal mattress
 Vertical mattress
 Distal wedge or Anchor suture
 Periosteal suturing
 II Continuous suture
 Papillary sling
 Horizontal mattress
 Vertical mattress
Sutures for Periodontal Flaps
 HEALING AFTER FLAP SURGERY

 Immediately after suturing (0 to 24 hours)

 A blood clot consisting of a fibrin reticulum with many
polymorphonuclear leukocytes, erythrocytes, debris of injured
cells, and capillaries at the edge of the wound is seen. A bacteria
and an exudate or transudate also result from tissue injury.
 One to 3 days after flap surgery
 The epithelial cells migrate over the border of the flap, usually
contacting the tooth at this time.
 One week after surgery
 The epithelial attachment to the root is established by means of
hemidesmosomes and a basal lamina. The blood clot is replaced
by granulation tissue derived from the gingival connective tissue,
the bone marrow, and the periodontal ligament.
 Two weeks after surgery
 The 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.