Periodontal Flaps

Hisham AlShorman
Eman Dylawani
20 10 2016

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 The Periodontal Flap
This script include summery for chapter #57 from the book + the dr. notes in the lecture.

What is a FLAP ?
basically we mean the soft tissue, we need to have an access to the bone just to get that access we
release a flap which is section of the soft tissue that is left away from under laying bone , so it is
surgically separate from the under laying tissues in most of cases the reason for that is to reshape
or to add bone or to place an implant, to see things under soft tissue or for soft tissue augmentation
as well.

CLASSIFICATION OF FLAPS
~ Periodontal flaps can be classified based on the following:

1. Based on Bone exposure after flap reflection.

a. Full thickness (mucoperiosteal).
> All the soft tissue, including the periosteum, is reflected to expose the underlying bone.
> Indicated when resective osseous surgery is contemplate & if we need to get an access to the bone.
> much easier than partial thickness flap.
> When we do implant & when remove a root we use full thickness flap

b. Partial thickness (mucosal).

> Includes only the epithelium and a layer of the underlying connective tissue.
> Indicated when the flap is to be positioned apically or we does not desire to expose bone & may be
necessary in cases in which the crestal bone margin is thin and is exposed, or when dehiscences
or fenestrations are present.
> It takes more times more meticulous but the end result is having more blood perfusion to the area.
> Also called the split thickness flap.

which is better a full thickness or a partial thickness flap ?

It Depends on indications, if u want to displace the gingiva to make it stretchable u have to had partial
thickness because the periosteum is very tuff connective tissue can't be stretched so if u want to
remove the gingiva "repositioned flap" u better do partial thickness , some times we do implant; can u
put bone in partial thickness ? no u have to expose the original bone , so we go for full thickness in case
if we need to expose bone.

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 In case of bone graft , we put bone & we want to suture the flap back , the bulk of the bone
prevent us from putting the flap back in its original position , so we need to stretch it more, to do
that we make periosteal incision to slice the periosteum just to enable the soft tissue to stretch a
little bit.

When bone is stripped of its periosteum, a loss of marginal bone occurs, and this loss is prevented when
the periosteum is left on the bone however, are usually not clinically significant.

Full thickness Partial thickness

2. Based on placement of the flap after surgery.

a. Nondisplaced flaps: when the flap is returned and sutured in its original
position.
b. Displaced flaps: that are placed apically, coronally, or laterally to their original
position.
For example: if you originally had recession and you want to cover this recession this mean ,
you should put the flap up which called " coronally repositioned or displaced flap"

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 Both full thickness and partial thickness flaps can be displaced, but to do so, the attached
gingiva has to be totally separated from the underlying bone, thereby enabling the
unattached portion of the gingiva to be moveable. However, palatal flaps cannot be
displaced owing to the absence of unattached gingiva.

Apically displaced flaps :

> Have the important advantage
of preserving the outer portion
of the pocket wall and transforming
it into attached gingiva. Therefore
they accomplish the double objective
of eliminating the pocket and increasing the width of the attached gingiva.
> We can use it also to do crown lengthening.
Semilunar Flap
A curved incision over the tooth root. The flap is displaced coronally. Used In case of apexictomy
to reach the apex of the root ,sinus lifting, extraction of impacted canine when we need surgical
exposure. It is not part of our periodontal incision.

3. Based on Management of the papilla.

Two basic flap designs are used:

a. Conventional flap (split the papilla)

> The interdental papilla is split beneath the contact point of the two approximating teeth.
> Used when 1) the interdental spaces are too narrow, thereby precluding the possibility of
preserving the papilla, and when 2) the flap is to be displaced.
> Conventional flaps include the modified Widman flap, the undisplaced flap, the apically
displaced flap and the flap for regenerative procedures.

Modified Widman flap Widman:

described a mucoperiosteal flap designed to remove the pocket epithelium and the inflamed
connective tissue & granulation tissue , and facilitating optimal cleaning of the root surfaces,
without removing thick part of the gingiva.

b. Papilla preservation flap (preserve the papilla)

> The papilla preservation flap incorporates the entire papilla in one of the flaps by means of

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crevicular interdental incisions to sever the connective tissue attachment and a horizontal
incision at the base of the papilla leaving it connected to one of the flap.

Conventional flap Papilla preservation flap

DESIGN OF THE FLAP

> The degree of access to the underlying bone and root surfaces necessary and
the final position of the flap must be considered in designing the flap.
> Preservation of good blood supply to the flap is an important
consideration.
> The entire surgical procedure should be planned in every detail before the
intervention is begun, detailed planning allows for a better clinical result.

INCISIONS
1. Horizontal Incisions
> Directed along the margin of the gingiva in a mesial or a distal direction.
> types of horizontal incisions have been recommended(1,2,3)

a. The internal bevel incision (first incision):

> most commonly use in perio.
> Which starts at a distance from the gingival margin and is aimed at the bone
crest.
> It is the initial incision in the reflection of a periodontal flap.
> internal bevel incision accomplishes three important objectives:
1) It removes the pocket lining.
2) It conserves the relatively uninvolved outer surface of the gingiva, which, if apically

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positioned, becomes attached gingiva.
3) It produces a sharp, thin flap margin for adaptation to the bone-tooth junction.
> This incision has also been termed reverse bevel incision, because its bevel is
in reverse direction from that of the gingivectomy incision.
> #15C or #15 surgical scalpel is used.

The internal bevel (first)

incision can be made at
varying locations and
angles according to the
different anatomic and
pocket situations.
The starting point on the
gingiva is determined by
whether the flap is
apically displaced or not
displaced.

b. The crevicular incision (second incision):

which starts at the bottom of the pocket and is directed to the crest
of the bone (is inserting the blade within the sulcus).
This incision, together with the initial reverse bevel incision, forms a V-
shaped wedge ending at or near the crest of bone. This wedge of tissue
contains most of the inflamed and granulomatous areas that constitute the
lateral wall of the pocket, as well as the junctional epithelium and the
connective tissue fibers that still persist between the bottom of the pocket
and the crest of the bone. The incision is carried around the entire tooth.
The beak-shaped #12D blade is usually used for this incision.

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 c. The interdental incision (third incision):
Is performed after the flap is elevated, after a periosteal elevator is inserted
into the initial internal bevel incision, and the flap is separated from the
bone, With this access, the surgeon is able to make the third or interdental
incision to separate the collar of gingiva that is left around the tooth.
So this incision is made not only around the facial and lingual radicular
area but also interdentally, connecting the facial and lingual segments, to
completely free the gingiva around the tooth.

These three incisions allow the removal of the gingiva around the tooth (i.e., the pocket
epithelium and the adjacent granulomatous tissue), and the remaining connective tissue in the
osseous lesion should be carefully curetted out so that the entire root and the bone surface
adjacent to the teeth can be observed.
Flaps can be reflected using only the horizontal incision if sufficient access can be obtained by
this means and if apical, lateral, or coronal displacement of the flap is not anticipated. If vertical
incisions are not made, the flap is called an envelope flap.

2. Vertical Incisions or oblique releasing incisions:

> in perio. we not encourage releasing incision because it is difficult to
reposition to return it back to its original place , if I feel my access is not
enough and I need this vertical incision some times I would extend my
horizontal incision to more teeth just to avoid vertical (releasing) incision.

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 > Vertical incision 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.
> Vertical incisions must extend beyond the mucogingival line, reaching the
alveolar mucosa, to allow for the release of the flap to be displaced.
> Vertical incisions in the lingual and palatal areas are avoided.
> 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.
>>why do we avoid placing the vertical incision at the
mid of the root ?
If we place the vertical incision on the mid of the root
there is increase the likelihood for recession.

>>Why do we avoid placing the vertical incision at the

mid of the papilla ?

imagine that if u section the papilla like this it will be

very difficult to suture it , so our route always incise the
papilla in one piece.
**so the best case is to incise lateral to papilla and away
from the mid of the root**

> The vertical incision should also be designed so as to avoid short flaps
(mesiodistal) with long, apically directed horizontal incisions because these
could jeopardize the blood supply to the flap

A combination of full and partial thickness flaps can often be indicated to obtain the
advantages of both. The flap is started as a full thickness procedure, and then partial
thickness flap is made at the apical portion. In this way the coronal portion of the bone,
which may be subject to osseous remodeling, is exposed while the remaining bone remains
protected by its periosteum.

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 ELEVATION OF THE FLAP

In full thickness flap, the reflection is

accomplished by blunt dissection. A
periosteal elevator is used to separate the
mucoperiosteum from the bone by moving
it mesially, distally, and apically until the
desired reflection is accomplished.
Sharp dissection is necessary to reflect
a partial thickness flap. A surgical
scalpel (#11 or #15) is used.

SUTURING TECHNIQUE
> The purpose of suturing is to maintain the flap in the desired position where it
should remain without tension until healing has progressed to the point where
sutures are no longer needed.
There are many types of sutures, suture needles, and materials. Suture materials may
be either:
1. Nonresorbable:
- The most common nonresorbable is silk & nylon.
2. or resorbable:
- They enhance patient comfort and eliminate suture removal appointments.
- Vicryl (polyglactin 910) suture : is an absorbable,synthetic suture.

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 And they may be further categorized as
1. braided
2. or monofilaments.
alleviates the "wicking
effect" of braided
sutures that may allow
bacteria from the oral
cavity to be drawn
through the suture to the
deeper areas of the
wound.

When u buy your suture there is information that u need to know:

The bigger the number the smaller the size )4-0 size is smaller than 3-0 size).
The curvature of the needle can be 1/2 circle or some thing else and in dentistry we always prefer
3/8 circle curvature of the needle for better access , 1/2 circle would be too much curved this is
good for GI or skin suture .
You have to know cutting or non-cutting needles , in non-cutting the cross section is circle it only
cut at the tip , they used for GI difficult surgery's they do not use in oral tissue , because the tissue
in the mouth very fragile we do not want to put pressure , so we use cutting needle which cut from
3 sides, the cross section of it is triangle like a scaler.
Reverse cutting is the most commonly used in perio; because when u start suturing u push the
needle u will not harm the tissue because the sharp edge of the needle is down word.
Smaller the suture (diameter) the less likelihood the inflammation ,silk type can cause
inflammation which is a not desirable thing to happen afterwards.

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 Non-absorbable

This triangle mean that the cross section of this

needle is triangle and if the tip of the triangle is
up this is for regular cutting if it is down revers
cutting .

Suturing Technique
The needle is held with the needle holder and should enter the tissues at
right angles (90 degree) and no less than 2 to 3 mm from the incision,
needle is held around the middle for better access and to avoid bending.
The needle is then carried through the tissue, following the needle's
curvature (so you enter at 90 then after penetration follow the curvature).
The knot should not be placed over the incision, should be in either side of
incision..

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 Sutures of any kind placed in the
interdental papillae should enter and exit
the tissue at a point located below the
imaginary line that forms the base of the
triangle of the interdental papilla.

______________________________________________________________
Ligation:

1. Interdental Ligation.
Two types of interdental ligation can be used:
a. The direct or loop suture:
Is basically join the two pieces of
the flap in one loop, which permits
a better closure of the interdental
papilla .
b. The figure-eight suture:
The needle penetrates the outer surface of
the first flap and the outer surface of the
opposite flap. The suture is brought back
to the first flap, and the knot is tied.

Types of Sutures
Horizontal Mattress Suture:
Is inserting the needle in 2 points rather than one point
in the two sides of the flap. So we have 2 point on buccal
flap & 2 point on the lingual flap.
If our direction vertically we call it vertical Mattress,

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 or if double stitch that is made perpendicular
we call it vertical Mattress if made parallel we call it
(horizontal mattress).
Mattress mean : 2 point in the tissue.
Often used for the interproximal areas of diastemata
or for wide interdental spaces .
*suture can be made continuous which give more strength to the suture.

HEALING AFTER FLAP SURGER

Immediately after suturing (0 to 24 hours),

A connection between the flap and the tooth or bone surface is established by a blood clot.
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, usually contacting the tooth at this time. When the flap is closely adapted to the
alveolar process, there is only a minimal inflammatory response .
One week after surgery,
> An epithelial attachment to the root has been established.
> The blood clot is replaced by granulation tissue.
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.

Full-thickness flaps, which denude the bone, result in a superficial bone necrosis at 1 to 3 days;
This results in a loss of bone of about 1 mm, the bone loss is greater if the bone is thin .

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 Loss of bone occurs in the initial healing stages both in radicular bone and in interdental bone areas:
interdental areas, which have cancellous bone, the subsequent repair stage results in total restitution
without any loss of bone.
whereas in radicular bone, particularly if thin and unsupported by cancellous bone, bone repair results in
loss of marginal bone.

Osteoplasty (thinning of the buccal bone) using diamond burs, included as part of the surgical technique,
results in areas of bone necrosis with reduction in bone height, which is later remodeled by new bone
formation. Therefore, the final shape of the crest is determined more by osseous remodeling than by
surgical reshaping.

The end ..
Eman Dylawani
A lot of thanks to Sara Al-Ajrashi

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