T H E P E R I O D O N TA L F L A P

By-
Aananyaa Jhaldiyal
BDS IV year (2009-10)
Roll no. 01
 A periodontal flap is a section of gingiva &/or mucosa
surgically separated from the underlying tissues to provide
visibility of and access to the bone and root surface.

 A flap also allows the gingiva to be displaced to a different

location in patients with mucogingival involvement.
 Periodontal flaps can be classified as follows –
a) Based on bone exposure after flap reflection
- mucoperiosteal or full thickness flap
- partial thickness or mucosal flap
b) Based on placement of flap after surgery
- displaced flap
- non displaced flap
c) Based on management of papilla
- conventional flap
- papilla preservation flap
A ) B a s e d o n b o n e e x p o s u re a f t e r f l a p re f l e c t i o n
1) Full thickness or mucoperiosteal flap-
 All the soft tissue, including the periosteum, is reflected to
expose the bone.
 Indication- need to view the alveolar bone

2) Partial thickness or mucosal flap-

 It includes only the epithelium and a layer of underlying
connective tissue.
 The bone remains covered by a layer of connective tissue,
including the periosteum.
 Also known as split thickness flap.
 Indication- when flap is to be positioned apically, laterally or
coronally; or when the operator does not want to expose the
bone.
Fig :A) internal bevel incision to reflect full thickness
flap. B) internal bevel incision to reflect a partial
thickness flap.
B) Based on flap placement after
surgery
1) Non – displaced flap
 The flap is returned and sutured in its original position.

2) Displaced flap
 The flap is placed apically, coronally, or laterally to its original
position.

C) Based on management of papilla

1) Conventional flap
 In this the interdental papilla is split beneath the contact
point of the two approximating teeth to allow reflection of
buccal and lingual flaps.
 The incision is usually scalloped to maintain gingival
morphology and retain as much papilla as possible.
 Indications-
1) When the interdental spaces are too narrow, thereby
precluding the possibility of preserving the papilla.
2) When the flap is to be displaced.
 Examples- modified Widman flap, the undisplaced flap, the
apically displaced flap, & the flap for reconstructive
procedures.

2) Papilla preservation flap

 In this the entire papilla is incorporated into one of the flaps
by means of 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
flaps.
 Indications-
1) When there are open interdental spaces
2) When esthetics is of concern
3) When bone regeneration techniques are attempted.
 Dictated by the surgical judgment of the operator.
 Depend on the objectives of the procedure.
 Factors to be considered in designing the flap are-
1) Degree of access to the underlying bone and root
surfaces
2) Final position of the flap
3) Preservation of good blood supply to the flap
 Two basic flap designs are used -
1. Conventional flap
2. Papilla preservation flap
1) Conventional flap

 The incisions for the facial, and the lingual or palatal flap
reach the tip of the interdental papilla or its vicinity, thereby
splitting the papilla into facial half and a lingual or palatal
half.

Fig: flap design for

conventional flap
technique.
2) Papilla preservation flap

 papilla is preserved ( not split).

 The entire surgical procedure should be planned in detail

before the procedure is initiated as detailed planning allows
for a better clinical result.
 There are basically two types of periodontal flap
incisions-

Horizontal Vertical incisions

incisions

1) Internal
1) Oblique
bevel
releasing incision
incision
2) Crevicular
incision
3) Interdental
incision
 Horizontal incisions are directed along the margin of the
gingiva in a mesial or a distal direction.

 Types of horizontal incisions recommended are-

1) Internal bevel incision

 It is the incision from which the flap is reflected to expose

the underlying bone and root.
 Objectives of internal bevel incision are -
1. It removes the pocket lining
2. Conserves the relatively uninvolved outer surface of the
gingiva, which when apically positioned, becomes attached
gingiva.
3. Produces a sharp, thin flap margin for adaptation to the
bone tooth junction.

 This incision is also termed as the first incision because it

is the initial incision in the reflection of a periodontal flap.

 Also termed as reverse bevel incision because its bevel is in

reverse direction from that of the gingivectomy incision.
 Blade used for making this incision - #15C or #15 surgical
blade.

Fig: Position of the knife in performing internal bevel incision.

 The internal bevel incision starts from a designated area on

the gingiva and is directed to an area at or near the crest of
the bone.
2) Crevicular incision

 It is made from the base of the pocket to the crest of the

bone.

 The 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 &

granulomatous areas that constitute the lateral wall of the
pocket as well as the junctional epithelium & the connective
tissue fibers that still persist between the bottom of the
pocket & the crest of the bone.
Fig : Position of knife in performing crevicular incision.
3) Interdental incision

 A periosteal elevator is inserted into the initial internal

bevel incision, & the flap is separated from the bone .

 The most apical end of the internal bevel incision is

exposed and visible. With this access, the surgeon is able to
make the interdental incision.

 This incision is made to separate the collar of the gingiva

that is left around the tooth.

 Knife used for this incision- Orban knife.

 The incision is made not only around the facial & the
lingual radicular area but also interdentally, connecting the
facial and the lingual segments to the free the gingiva
completely around the tooth.

Fig : Three incisions necessary for flap surgery. A) internal

bevel incision B) crevicular incision C) interdental incision.
 Vertical or oblique releasing incisions can be used on one
or both ends of the horizontal incision, depending on the
purpose & design of the flap.

 Vertical incisions at both the ends are necessary if the flap

is to be apically displaced.

 Vertical incision must extend beyond the mucogingival

line, reaching the alveolar mucosa, to allow for the release
of the flap to be displaced.
 Vertical incisions are avoided in the lingual or palatal
areas.

 Facial vertical incisions should not be made in the centre of

an interdental papilla or over the radicular surface of a
tooth.

Fig : The incision

should be made at the
line angles.
 Incisions should be made at the line angles of a tooth
either to include the papilla in the flap or to avoid it
completely.

 Vertical incisions should also be designed to avoid short

flaps with long, apically directed incisions because this
could jeopardize the blood supply of the flap.
S.no Type of flap Reflection Instrument
accomplished by used
1) Full thickness Blunt dissection Periosteal
flap or elevator which
mucoperiosteal separates the
flap mucoperiosteu
m from the
bone.

2) Partial thickness Sharp dissection Surgical

flap or mucosal scalpel (#15)
flap
 Fig : Elevation of flap with
periosteal elevator to obtain
full
thickness flap.

Fig: Elevation of flap with BP

knife to obtain a split thickness
flap.
 The purpose of suturing is to maintain the flap in the
desired position until healing has progressed to the point
where sutures are no longer needed.

 Suture materials for periodontal flap are –

1) Non absorbable •Silk: braided
•Nylon: monofilament
(ethilon)
•EPTfe: monofilament
(Gore- tex)
•Polyester: braided
(Ethibond)
2) Absorbable • Surgical: gut
• Plain gut ; monofilament ( 30
days)
• Chromic gut ; monofilament (
45-60 days)

3) Synthetic • Polyglycolic: braided (16 -20

days)
( vicryl; ethicon)
(Dexon; Davis & Geck)
• Polyglecaprone: monofilament
( 90- 120 days)
(Monocryl; Ethicon)
• Polyglyconate: monofilament
(Maxon)
 The resorbable sutures have gained popularity because they
enhance patient comfort & eliminate suture removal
appointments.

 The non resorbable silk braided suture was the most

commonly used in the past due to its ease of use & low
cost.

 The expanded polytetrafluoroethylene synthetic

monofilament is an excellent nonresorbable suture widely
used today.

 The most commonly used resorbable sutures are the natural

plain gut or the chromic gut. Both are mono-
 filaments and are processed from purified collagen of
either sheep or cattle intestine.

 The chromic gut is a plain gut suture processed with

chromic salts to make it resistant to enzymatic resorption,
thereby increasing the resorption time.

Te c h n i q u e o r p r i n c i p l e s o f s u t u r i n g

1) The needle should enter the tissues at right angles and no

less than 2 to 3 mm from the incision.

2) The needle is then carried through the tissue, following

the needle's curvature.
3) The knot should not be placed over the incision.

4) The periodontal flap is closed either with independent

sutures or with continuous, independent sling sutures.

5) Sutures of any type in the interdental papillae should be

placed at a point located below the imaginary line that
forms the base of the triangle of the interdental papilla as
shown in the figure below.
6) The location of sutures for closure of a palatal flap depends
on the extent of flap elevation that has been performed. The
flap is divided in four quadrants as shown in the figure
below. If the elevation of the flap is slight or moderate, the
sutures can be placed in the quadrant closest to the teeth. If
the flap elevation is substantial, the sutures should be placed
in the central quadrants of the palate.
7) The clinician may or may not use periodontal dressings.
When the flaps are not apically displaced, it is not
necessary to use dressings other than for patient comfort.

Ligation

1) Interdental Direct Loop Suture figure-eight suture

ligation permits a better closure
of the interdental papilla .
should be performed
when bone grafts are
used or when close
apposition of the
scalloped incision is
required.
there is thread
between the two flaps.
used when the flaps
are not in close
apposition because of
apical flap position or
non-scalloped
incisions.
2) Sling ligation  The sling ligation can be used for a flap
on one surface of a tooth that involves two
interdental spaces.

Ty p e s O f S u t u r e s

1) Horizontal mattress often used for the

suture interproximal areas of diastema
or for wide interdental spaces to
adapt the interproximal papilla
properly against the bone.
can be incorporated with the
continuous, independent sling
sutures.
2) Continuous, is used when there is both a facial
independent sling and a lingual flap involving many
suture teeth.
This type of suture does not pull on
the lingual flap when this flap is
sutured.
is especially appropriate for the
maxillary arch because the palatal
gingiva is attached and fibrous

3) Anchor suture This suture closes the facial and

lingual flaps and adapts them tightly
against the tooth.
4) Closed-Anchor Another technique to close a flap
Suture located in an edentulous area mesial
or distal to a tooth.
 Consists of tying a direct suture
that closes the proximal flap,
carrying one of the threads around
the tooth to anchor the tissue against
the tooth, and then tying the two
threads.

5) Periosteal suture used to hold the apically displaced

partial-thickness flaps on the
periosteum.
It is of two types-
1. holding suture
2. closing suture
 FIG: Periosteal sutures for an apically displaced flap. Holding
sutures, shown at the bottom, are done first, followed by the
closing sutures, shown at the coronal edge of the flap.

1. The Holding Suture - is a horizontal mattress suture placed at

the base of the displaced flap to secure it into the new
position.
2. The Closing Suture- are used to secure the flap edges to the
periosteum.
1) Immediately  A connection between the flap and the tooth
after suturing or bone surface is established which
( up to 24 contains fibrin reticulum with many PMN
hours) leukocytes, erythrocytes, debris of injured
cells, & capillaries at the edge of the
wound.

2) 1-3 days after  The space between the flap & the tooth or
flap surgery. bone is thinner & epithetlial cells migrate
over the border of the flap, usually
contacting the tooth at this time.
3) One week  An epithelial attachment to the root has been
after surgery. established by means of hemidesmosomes & a
basal lamina.
 Blood clot is replaced by granulation tissue
derived from the gingival connective tissue, the
bone marrow, & the PDL.
4) Two weeks  Collagen fibers begin to appear parallel to the
after surgery. tooth surface.
 Union of the flap to the tooth is still weak
because of presence of immature collagen
collagen fibers.
5) One month  A fully epithelialized gingival crevice with a
after surgery. well defined epithelial attachment is present.
 There is beginning of functional arrangement
of supra crestal fibers.
 Newman, Takei, Klokkevold, Fermin A Carranza.
CLINICAL PERIODONTOLOGY, 11th edition, WB
Saunders 2006.