L1 Periodontal Flaps (2) Last L9

Periodontal Flaps
Dr.Essam Dhaifullah
Carranza online – ch 57 pages ( 1365-1381) + Ch 59 pages 1394-1410
Carranza 11ed- Ch 57 + Ch. 59

Objective
To know the definition and classification of flap

To know the design and indications of each flap technique
To discuss different suturing techniques and materials
Mention of the technique used to treat the pocket
Periodontal flap – definition
• Periodontal flap is defined as “ the section of gingiva and /or mucosa
surgically elevated from the underlying tissues to provide visibility
and access to the bone and root surfaces”
Classification of Flaps
Classification of periodontal flaps

1. Bone exposure after flap reflection
a) Full thickness
b) Partial thickness
2. Placement of the flap after surgery

a) Non-displaced
b) Displaced
3. Management of the papilla

a) Conventional
b) Papilla preservation
Classification of periodontal Flaps
A. According to Bone exposure
A. Full thickness flap B. Partial thickness flap

(Split thickness)
Full Thickness Flaps-
(mucoperiosteal flap)
is indicated when resective osseous surgery is

planned
Partial Thickness Flaps- mucosal flap
• A layer of epithelium and underlying

connective tissue are reflected =
Split thickness flap

OR
Partial thickness flap
• Bone covered by CT & periosteum

Indications of Partial thickness flap
• Bone exposure unnecessary/impossible

• Examples:
• Apically positioned flap
• Thin alveolar bone
• Dehiscence or fenestration
0
Classification of periodontal Flaps
B. According to flap placement after surgery

• Non Displaced flap (undisplaced )
The flap is returned and sutured in its original position
• Displaced flap
The flap is placed apically, coronally, or laterally to their original position

Displaced flaps
 Laterally displaced flap

Displaced flaps
 Coronally displaced
flap
Remember
Palatal Flaps
Cannot be Displaced
C. According to management of papilla
• Conventional flap
• Papilla preservation flap
1
Conventional flaps
 Papilla split beneath contact point of
adjacent teeth ; buccal & lingual flaps
reflected
 Indications
 Narrow interdental spaces
 Flap is to be displaced
1A
Papilla Preservation Flaps
 Papilla is preserved (kept attached) to

one of the flaps
 Indication:
 Where esthetics is of concern.
 Where bone regeneration technique

has to be done
Papilla Preservation Flaps
Flap Design
Planning of surgery includes:

 Type of flap
 Exact location & type of incisions
 management of the underlying bone
 and final closure of the flap and sutures
1c
Incisions
There are basically two types of periodontal flap incisions-:
Horizontal incisions Vertical incisions

Horizontal Incisions
It may be purely an intrasulcular (cervicular) incision
or it may course paramarginally (internal bevel ) at Varying
distances form the GM.
1. The internal bevel incision
2. The Crevicular incision
3. The interdental bevel incision (after flap refection )
2 cervicular Paramarginal
starts at a distance from the gingival margin and
is aimed at the bone crest
= Reverse/inverse bevel incision
Objective:
• Removes pocket lining, junctional epithelium
• Relatively preserves keratinised gingiva (outer

surface of gingiva )
• Produces sharp thin flap margins

The Crevicular Incision (second incision)
starts at the bottom of the pocket and is directed to the bone margin
Third (interdental) incision
Vertical Incisions
 Vertical or oblique releasing incisions can be used on one or both ends of the horizontal
incision, depending on the design and purpose of the flap.
 Vertical incisions at both ends are necessary if the flap is to be apically displaced.
 The extension should be beyond the mucogingival line to allow for the release of the flap
to be displaced.
Vertical Incisions
• At One side of the papilla
• Never in the middle of the papilla
• Never over the radicular surface of the root

(prominent area)
• Extending beyond the MGJ
• Diverging apically
Elevation of Full Thickness Flaps
Blunt dissection by periosteal elevator

Elevation of Partial thickness flaps
Sharp dissection by scalpel
3
Suturing technique
The purpose of suturing is to maintain the flap in
the desired position until healing has progressed to
the point in which sutures are no longer needed.
Suture materials may be either nonresorbable or

resorbable and may be further categorized as
braided or monofilament
Monofilament braided
Placement of suture in the interdental space
Needle Holding
How to hold?
The needle holder is held with thumb & ring
finger through the ring & with the index finger
along the length of the needle holder to
provide stability & control
Suturing Techniques
 Interdental (interrupted) suture

 Figure of eight suture
 Horizontal mattress suture
 Sling suture
 Anchor suture
 Closed anchor suture
 Periosteal suture
Interrupted suture
Director loop suture, independent
suture
 It permits a better closure of the interdental

papilla
 Indicated in single tooth extraction , third molar
extraction flaps, biopsies. Implants,… etc.
Figure of eight suture
Single interrupted sling suture
Suspensory suture
used for a flap on one surface of a tooth that involves two

interdental spaces
Continuous sling sutures
 is used when multiple teeth are involved.

 Minimizes the need for multiple knots
 Perform suturing flaps without tying,
 The teeth are used to anchor the flap,
 Greater distribution of forces on the flaps
Disadvantages :if the suture breaks, the flap may

become loose or the suture may come untied from
multiple teeth
Periosteal suture
It is used to hold the apically displaced partial-thickness flaps on the periosteum
Techniques for pocket therapy-
1. The modified Widman flap

2. The undisplaced flap
3. Apical displaced flap
Modified Widman Flap
• introduced by Ramfjord & Nissle, 1974)
• It is not intend to remove the pocket wall but does eliminate the
pocket lining
• Provide access for root debridement (direct vision),
• and preserve the maximum amount of periodontal tissue.
• No ostectomy is performed
• Especially effective with pocket depth ≥5
• It is indicated where aesthetics is a primary concern, especially in the

maxillary anterior sextant.
Incision for undiplaced flap
 The incision is made at the level of the pocket to remove the tissue coronal to the pocket if there is
sufficient remaining attached gingiva
 Full soft tissue pocket wall is removed.
 Consider as internal bevel Gingivectomy.
The apically displaced flap
• Internal bevel incision is made 0.5 to 1mm form the crest

of GM
• Flap completed, reflected off bone
• Flap is apically positioned and sutured
• Removes the pocket wall.
• Increasing the width of attached gingiva
• Can be a full-thickness (mucoperiosteal) or a split-

thickness (mucosal) flap
Summary
• The periodontal flap surgery is the most used surgical procedure to reduce the pocket
depth and to access the subgingival root surfaces for scaling and root planing.
• The surgical procedure should be planned in every detail before the procedure is
initiated
• The type of incisions, type of flap and the selection of suturing design must be planned
and executed to fit the problem.
• Gentle and efficient procedures result in optimum healing and minimal postoperative
pain
• Main objective of periodontal flap surgery are gain access to root surface, reduction ot
elimination of pocket depth and attempt regeneration of PD, alveolar bone and
cementum
• There are three types of horizontal incisions, internal bevel, crevicular and interdental
incision
Quiz
What is the difference between displaced and undisplaced?
 The flap in which the epithelium and part of the underlying connective tissue are reflected is termed:
• Full thickness flap

• Partial thickness flaps
 vertical incision, which is correct

Any question?
Thank you

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Periodontal Flaps

Carranza online – ch 57 pages ( 1365-1381) + Ch 59 pages 1394-1410

Carranza 11ed- Ch 57 + Ch. 59

To know the definition and classification of flap

Classification of periodontal flaps

2. Placement of the flap after surgery

3. Management of the papilla

A. According to Bone exposure

A. Full thickness flap B. Partial thickness flap

is indicated when resective osseous surgery is

• A layer of epithelium and underlying

Split thickness flap

• Bone covered by CT & periosteum

• Bone exposure unnecessary/impossible

B. According to flap placement after surgery

The flap is placed apically, coronally, or laterally to their original position

 Laterally displaced flap

C. According to management of papilla

• Papilla preservation flap

 Papilla is preserved (kept attached) to

 Where esthetics is of concern.

 Where bone regeneration technique

Planning of surgery includes:

 Exact location & type of incisions

 management of the underlying bone

 and final closure of the flap and sutures

Horizontal incisions Vertical incisions

or it may course paramarginally (internal bevel ) at Varying

distances form the GM.

1. The internal bevel incision

2. The Crevicular incision

3. The interdental bevel incision (after flap refection )

= Reverse/inverse bevel incision

• Relatively preserves keratinised gingiva (outer

• Produces sharp thin flap margins

• At One side of the papilla

• Never in the middle of the papilla

• Never over the radicular surface of the root

• Extending beyond the MGJ

Blunt dissection by periosteal elevator

Sharp dissection by scalpel

Suture materials may be either nonresorbable or

 Interdental (interrupted) suture

 It permits a better closure of the interdental

used for a flap on one surface of a tooth that involves two

 is used when multiple teeth are involved.

Disadvantages :if the suture breaks, the flap may

1. The modified Widman flap

• Provide access for root debridement (direct vision),

• and preserve the maximum amount of periodontal tissue.

• Especially effective with pocket depth ≥5

• It is indicated where aesthetics is a primary concern, especially in the

• Internal bevel incision is made 0.5 to 1mm form the crest

• Flap completed, reflected off bone

• Flap is apically positioned and sutured

• Removes the pocket wall.

• Increasing the width of attached gingiva

• Can be a full-thickness (mucoperiosteal) or a split-

• Full thickness flap