Dr. Abhishek Gaur BDS, MDS Some of the slides may appear Blank/White/Black, those are the Videos that I added in the presentation. Kindly Ignore those slides.

2. The Periodontal Flap
Dr. Abhishek Gaur
Asst. professor
R. R. Dental College & Hospital, Umarda, Udaipur

3. What is this Flap ???What is this Flap ???What is this Flap ???

4. Definition
“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.

5. INDICATIONS
1.Irregular bony contours.
2.Deep craters.
3.Grade II or III furcation involvement.
4.Root resection / hemisection.
5.Intrabony pockets.
6.Persistent inflammation in areas with moderate to
deep pockets.

6. CONTRAINDICATIONS
1. Uncontrolled medical conditions such as
1. Un-stable angina
2. Un-controlled diabetes
3. Un-controlled hypertension
4. Myocardial infarction / stroke within 6 months
2. Poor plaque control
3. High caries rate
4. Unrealistic patient expectations or desires

7. Classification

8. 1. Bone exposure after flap reflection
1. Full thickness (mucoperiosteal)
2. Partial thickness (mucosal)
2. Placement of the flap after surgery
1. Non displaced flaps
2. Displaced flaps
3. Management of the papilla
1. Conventional flaps
2. Papilla preservation flaps

9. BASED ON BONE EXPOSURE
AFTER REFLECTION
FULL THICKNESS FLAP
• Periosteum is reflected to expose the underlying bone.
• Indicated in resective osseous surgery.

11. 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

13. BASED ON FLAP
PLACEMENT AFTER
SURGERY
BASED ON FLAP
PLACEMENT AFTER
SURGERY

14. Non displaced flaps
When the flap is returned and
sutured in its original position.

15. Displaced Flap
The flap is placed apically, coronally, or laterally to
it’s original position.
It can be a full-thickness or partial thickness flap.
Note : The attached gingiva must be totally
separated from the underlying bone.
Displaced Flap

16. Apically Displaced Flap

17. Coronally Displaced Flap

18. 1.
2.

19. Laterally Displaced FlapLaterally Displaced Flap

20. 1. Pre-operative

21. 2.

22. 3.

23. 4. Post-operative

24. DESIGN
OF
THE FLAP
DESIGN
OF
THE FLAP

25. Split the papilla (conventional flap)

26. Preserve it (papilla preservation flap)

27. MODIFIED WIDMAN
FLAP
Presented by Ramfjord and Nissle in 1974

28. THE ORIGINAL ‘WIDMAN’ FLAP
• The flap was elevated to expose 2-3 mm off the
alveolar bone.
• The soft tissue collar incorporating the pocket
epithelium and connective tissue was removed, the
exposed root surface scaled and the bone re-
contoured to re-establish a 'physiologic' alveolar
form.
• The flap margins were placed at the level of the
bony crest to achieve optimal pocket reduction.

29. THE TERM “MODIFIED WIDMAN
FLAP”
Incase of esthetic considerations, intra-
crevicular incisions starting at the free
gingival margins are used to minimize
post-surgical gingival shrinkage.
Vertical releasing incisions are usually not
used.

30. INDICATIONS:
Effective with pocket depths of 5-7 mm
CONTRAINDICATIONS:
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 gingivectomy).

31. ADVANTAGES
1.Root cleaning done with direct vision.
2.Healing by primary intention.
3.Minimal crestal bone resorption.
4.Lack of post operative discomfort.

32. Procedure
Internal bevel incision should be made to the alveolar crest starting
0.5 to 1 mm away from the gingival margin.

33. Flap is elevated
Crevicular incision is
made from the bottom of
the pocket to bone

34. Interdental incision
sectioning the base of the
papilla.
Tissue tags and granulation
tissue are removed.

35. Scaling
and
root planing
of
exposed root surfaces
Suturing done and
covered with
tetracycline ointment
and with a periodontal
surgical pack

36. THE UN-DISPLACED FLAP
1. Most commonly performed type of periodontal surgery.
2. 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.
PROCEDURE
The pockets are measured with periodontal probe and a
bleeding point is produced on the outer surface of gingiva to
mark the pocket bottom.

37. Internal bevel incision in the
facial and palatal aspects

38. Interdental incision is
made.
Triangular wedge of
tissues is removed with
curette.
All tissue tags and
granulation tissue are
removed

39. After the scaling and root planing the flap edge should rest
on the root bone junction.
Flaps have been placed in their original site and Sutured.

40. Post-Operative Results

41. FLAPS
FOR
REGENERATIVE
SURGERY
Two flap designs are available for regenerative surgery:
1. The papilla preservation flap &
2. The conventional flap with only crevicular incisions.

42. The papilla preservation flap
INDICATIONS:
• Where esthetics is of concern.
• Where bone regeneration techniques are attempted.

43. CONVENTIONAL FLAP FOR
REGENERATIVE
SURGERYIn 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.
INDICATIONS:
1. When the interdental areas are too narrow to permit the
preservation of flap.
2. When there is a need for displacing flaps.
3. The interdental papilla is split beneath the contact point of the
two approximating teeth to allow for reflection of buccal and
lingual flaps.

45. HEALING AFTER FLAP
SURGERY
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 wound. 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.

46. Time Interval Healing Process
Up to 24 hours Blood Clot
1 - 3 days Epithelial cell migration on the tooth
7th Day
Epithelial attachment to the tooth surface.
Blood clot replaced by granulation tissue derived from gingival
C.T., bone marrow & PDL.
2 weeks Immature collagen fibres : Parallel to the Tooth Surface.
1 month Well defined epithelial attachment.