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Dept of periodontics
“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.
•Irregular bony contours
•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.
• Uncontrolled medical conditions such as
‐myocardial infarction / stroke within 6
•Poor plaque control
•High caries rate
•Unrealistic patient expectations or desires
Classification of flaps
Bone exposure after flap reflection
•Full thickness (mucoperiosteal)
•Partial thickness (mucosal)
Placement of the flap after surgery
•Non displaced flaps
Management of the papilla
•Papilla preservation flaps
BASED ON BONE EXPOSURE AFTER
FULL THICKNESS FLAP
Periosteum is reflected to expose the
Indicated in resective osseous surgery.
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
BASED ON FLAP PLACEMENT AFTER
•Non displaced flaps:
When the flap is returned and sutured in
its original position.
When the flap is placed apically,
coronally or laterally to their original
DESIGN OF THE FLAP
•Split the papilla (conventional flap)
•Preserve it (papilla preservation flap)
Presented by Ramfjord and Nissle
THE ORIGINAL ‘WIDMAN’ FLAP
The flap was elevated to expose 2-3 mm of the
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
The flap margins were placed at the level of the
bony crest to achieve optimal pocket reduction.
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
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
Effective with pocket depths of 5-7 mm
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
Root cleaning done
with direct vision.
Healing by primary
Lack of post
1) 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
INTERNAL BEVEL INCISION IN
FACIAL AND PALATAL ASPECTS
2) Flap is elevated
3)Crevicular incision is
made from the bottom of
the pocket to bone
4)Interdental incision sectioning
the base of the papilla
5)Tissue tags and granulation
tissue are removed.
6) Scaling and root
planing of exposed root
7)Suturing done and covered
with tetracycline oinment
and with a periodontal
THE UNDISPLACED FLAP
Most commonly performed type of
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.
1) The pockets are measured with periodontal
probe and a bleeding point is produced on the
outer surface of gingiva to mark the pocket
PRE OPERATIVE VIEWS
2) Internal bevel incision in the facial and
3)Crevicular incision is made and Flap is
4)Interdental incision is made
5)Triangular wedge of tissues is removed with
6)All tissue tags and granulation tissue are
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
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.
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
Possibility of exposure of furcations and roots,
which complicates post operative supragingival plaque
Periodontal pockets in severe periodontal disease.
Periodontal pockets in areas where esthetics is
Deep intrabony defects.
Patient at high risk for caries.
Tooth with marked mobility and severe attachment
Tooth with extremely unfavorable clinical crown /
PROCEDURE for apically displaced flap
1. 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
3. Vertical incisions are made extending beyond the mucogingival junction.
Full thickness flap elevated
by blunt dissection with
Split –thickness flap elevated
using sharp dissection with a
bard- parker knife
4.After debridement of the areas
5.Sutures in place
FLAPS FOR REGENERATIVE SURGERY
Two flap designs are available for
1. The papilla preservation flap&
2. The conventional flap with only crevicular incisions.
Entire papilla is incorporated into one of the flaps.
•Where esthetics is of concern.
•Where bone regeneration techniques are attempted
CONVENTIONAL FLAP FOR REGENERATIVE
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.
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
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
Impaction Of A Third
Molar Distal To A
Little Or No
Bone Distal To
Often Leads To A
Defect Distal To The
Typical incision design for a surgical
procedure distal to the maxillary second
Incision designs for
distal to the mandibular
•The incision should
follow the areas of
greatest attached gingiva
and underlying bone.
Square , parallel or H-design
Linear or pedicle
The size, shape ,thickness and access
of the tuberosity or retromolar area
determine treatment procedures
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
Triangular incision -Using no.12 0r no.15
Triangular wedge of tissue removal-using
scalers ,hoes , or knives
Walls of the wedge are thinned using
scalpel blade- for proper adaptation to
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
The distance between the two linear
incisions is determined by the thickness of
Two parallel inverse bevel thinning
incision –using n0.15 blade
Periosteal elevators are used to raise
Kirkland or orban knives –to remove the
wedge of tissue
PROCEDURE WITH THE
INCISION DISTAL TO THE
FLAP REFLECTED AND THINNED
AROUND THE DISTAL INCISION
FLAP IN POSITION BEFORE
SUTURING. IT SHOULD BE
FLAP SUTURED BOTH DISTALLY AND OVER
THE REMAINING SURGICAL AREA
Periodontal dressing or periodontal
packs is a productive materials applied
over the wound created by periodontal
minimise postoperative infection aand
Protects against pai
Zinc –oxide eugenol packs
Zno eugenol packs packs based on
reaction of zno & eugenol include –
The addition of accelerators such as
Zinc acetate gives the dressing a
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 )
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)
Retenton of packs
Mechanically by interlocking in
interdental spaces and joining the facial
and lingual portion of the pack
Preparation and application of
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
Paste is placed in a paper cup of water
at room temperature
With lubricated fingers rolled into
cylinders and placed on the surgical
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
Gentle pressure on
the facil and lingual
surfaces join the pack
Instructions for patients after
1. The pack should remain in place until it
is removed in the office at the next
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
Removal of periodontal
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
Findings at pack removal
Epithelialized but bleed readily when
Pockets should not be probed
HEALING AFTER FLAP
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
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.
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.