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Periodontal Flap
Surgical Procedures
Chapter 57

Lecture Outline

Classification of the periodontal flaps

Different periodontal Incisions
Flap design
Periodontal flap elevation
Healing process after periodontal flap surgery

Periodontal Flap

Periodontal Flap

Definition:
A section of gingiva and/or mucosa surgically separated
from the underlying tissues

Advantages:

Provides visibility & access to the bone & root surface.

Allows the gingiva to be displaced to a different

location.

Classification of Periodontal Flap

Based on:
Bone exposure after flap reflection
Full thickness flap
Partial thickness flap

Placement of the flap after surgery

Displaced flap
Non-displaced flap

Management of the papilla

Conventional flap
Papilla preservation flap

Bone Exposure After Reflection

Full-thickness
flap

(mucoperiosteal)

Partial-thickness (mucosal/split)
flaps

Full-thickness Flap
All soft tissue is reflected
Indicated in resective osseous surgery.
Contraindicated

if

treatment

for

osseous defect is not required, thin

periodontal

tissue

with

probable

osseous dehiscence or fenestration &

area where alveolar bone is thin.

Partial-thickness Flap
Periosteum covers the bone.
Indicated if the flap has to be
positioned

apically

exposure is not desired

and

bone

What is this flap?

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Flap Placement After Surgery

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Nondisplaced flap:
The flap is returned & sutured in its original position.

Displaced flap:
The flap is placed apically, coronally, or laterally to its original
position. It can be a full-thickness or partial-thickness flap.

Note:

The attached gingiva must be totally separated from the

underlying bone

Nondisplaced Flap

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Apically Displaced Flap

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Coronally Displaced Flap

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Coronally Displaced Flap

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Laterally Displaced Flap

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Laterally Displaced Flap

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Is the displaced flap applicable on the palate?

Why?

Management of Papilla
Conventional flap

Papilla preservation flap

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Conventional Flap
Indications:

1- Narrow interdental spaces that prevents papilla preservation

2- When the flap is to be displaced.

Types:
Modified Widman flap
Nondisplaced flap
Apically displaced flap
The flap for reconstructive procedures.

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Incisions

Incisions

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Horizontal incisions:
Can be used without vertical incisions if the flap reflection

ensures sufficient access & if displaced flap is not needed.

Vertical (oblique) releasing incisions:
Can be used on one or both ends of the horizontal incision,
depending on the design and purpose of the flap (eg. vertical
incisions at both ends are necessary for apically displaced
flap).

Horizontal Incisions

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Are directed along the margin of the gingiva in a mesial or a

distal direction.
Types:

Internal bevel incision: starts at a distance from the gingival

margin and is aimed at near the bone crest.
Crevicular incision: starts at the base of the pocket and is
directed to the bone crest.
Interdental incision is performed after the flap is elevated.

Horizontal Incisions

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Pocket epithelium &

granulation tissue

First (internal bevel)

incision

Second (crevicular)
incision

Third (interdental)
incision.

Internal Bevel Incision

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The basic incision to most periodontal flaps.

It is the incision from which the flap is reflected.
3 important objectives:
1) It removes the pocket lining
2) It conserves the outer surface of the gingiva,
3) It produces a sharp, thin flap margin for adaptation to bonetooth junction.
It is termed
first incision, Why?
reverse bevel incision, Why?
Surgical blades #15C or #15 are used to
make this incision.

Internal Bevel Incision

Various locations & angles of internal bevel incision

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Crevicular Incision

The beak-shaped #12D blade

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Incision Procedure

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1. Surgical blade #15 or #15C to do internal bevel incision.

2. Beak-shaped# 12D blade to do crevicular incision.

3. Periosteal elevator is inserted into the internal bevel incision &
the flap is separated from the bone
4. Orban knife to do interdental incision around facially, lingually &
interdentally connecting the facial & lingual segments to free
the gingival collar
5. Curette or a large scaler (U15/30) to remove the gingival collar.

6. The remaining connective tissue is carefully curetted to observe

the entire root and adjacent bone

Vertical Incisions

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Must extend beyond the mucogingival line to allow for the

release of the flap.
Facial vertical incisions should be made at the line angles to

prevent splitting of a papilla or incising directly over a radicular

surface.

Is the vertical incision applicable on the lingual

& palatal areas? Why?

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Why should a short flap (mesiodistally) with

long, vertical incisions be avoided ?

Is it applicable to do facial vertical incisions in the

center of an interdental papilla or over the radicular
surface of a tooth? Why?

Vertical Incisions

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Flap Design

Flap Design

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Depends on:
Surgical judgment of the operator
Objectives of the procedure.
Necessary degree of access to the underlying bone and root
Final position of the flap
Good blood supply
Requires:
Careful planning that includes the type of flap, exact location,
type of incisions, management of the underlying bone, and final
closure of the flap and sutures.

Flap Design

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Depending on papilla preservation

Conventional flap (split the papilla).
Papilla preservation flap (preserve papilla).
Depending on the types of incisions:
Envelope Flap:
it is released horizontally & has no vertical releasing incision(s).

Pedicle Flap:
Two vertical releasing incisions are included in the flap design
Triangular Flap:
One vertical releasing incision is included in the flap design.

Flap Design

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Periodontal Flap Elevation

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Blunt dissection with periosteal elevator

For reflection of full thickness flap

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Sharp dissection with surgical scalpel # 11 or # 15
For reflection of partial thickness flap

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Healing After Flap Surgery

Healing after Flap Surgery

Time interval
up to 24 hrs
1 to 3 days
Day 7th

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Healing Process
Blood clot
Epithelial cells migration on the tooth.
Epithelial attachment to the root by hemidesmosomes & basal lamina. The blood clot is
replaced by granulation tissue derived from
gingival connective tissue, bone marrow & PDL.

2 weeks

immature collagen fibers parallel to the tooth

surface

One month

Fully epithelialized gingival crevice, well-defined

epithelial attachment & beginning of functional
arrangement of the supracrestal fibers.

Healing after Flap Surgery

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In full-thickness flaps:
Superficial bone necrosis (at 1 to 3 days)
osteoclastic resorption
(peak at 4 to 6 days) resulting in > 1 mm bone loss if the bone is thin.

In osteoplasty: areas of bone necrosis & reduction in bone height,

remodeled later by new bone formation.

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