1. Periodontal Flap Surgery

2. Purpose
To gain access to deeper periodontal structures with direct vision.
Relocation of the frenulum
Maintenance of the attached tissue
Pocket elimination and regeneration

3. Indications Pockets > 5mm persisting after phase I therapy
Bony pockets and interdental craters
Bony lesions in the furcations
Need for surgical crown lengthening
When to open up a flap? complicated morphology like:
Deep and narrow pocket
Difficult to achieve the correct angle

4. Contraindications Shallow, supraalveolar pockets
subgingival scaling/rootplaning
Esthetically sensitive areas
Fibrous thickened gingiva
gingivectomy  more favorable morphology

6. Comparison of open vs. closed

7. Instruments

8. Instruments
Small elevators for mobilization of the mucoperiosteal flap

9. Instruments

10. Principles of Flap Design
Local flap
outlined by a surgical incision
carries its own blood supply
allows surgical access to underlying tissues
can be replaced in the original position
can be maintained with sutures and is expected to heal
Used in oral surgical, periodontic, and endodontic procedures to gain access.

11. Principles of Flap Design
Complications
Flap necrosis
Flap Dehiscence
Flap Tearing
Injury to Local Structures

12. Principles of Flap Design
A. Flap necrosis
Principles of Flap Design
Base > Free margin
to preserve an adequate blood supply
unless a major artery is present in the base
Width of Base > Length of Flap*2
less critical in oral cavity, but length < width
a long, straight incision with adequate flap reflection heals more rapidly than a short, torn incision.
An axial blood supply in the base
Hold the flap with a retractor resting on intact bone to prevent tension.

13. Principles of Flap Design
B. Flap Dehiscence
Principles of Flap Design
The incisions must be made over intact bone
If the pathologic condition has eroded the buccocortical plate, the incision must be at least 6 or 8 mm away from it.
The incision is 6 to 8 mm away from the bony defect created by surgery.
Gently handle the flap's edges
Do not place the flap under tension
Do not cross bony prominences, ex: canine eminence

14. Principles of Flap Design
B. Flap Dehiscence
Principles of Flap Design

15. Principles of Flap Design
C. Flap Tearing
Principles of Flap Design
Envelope flaps
an incision around the necks of several teeth.
extends 2 teeth anterior and 1 tooth posterior.
If not provide sufficient access…
Vertical (oblique) releasing incisions:
extends 1 tooth anterior and 1 tooth posterior.
started at the line angle of a tooth.
carried obliquely apically into the unattached gingiva.
If cross the papilla  localized periodontal problems

16. Principles of Flap Design
D. Injury to Local Structures
Principles of Flap Design
Mandible: lingual n. & mental n.

17. Principles of Flap Design
D. Injury to Local Structures
Principles of Flap Design
Maxilla: greater palatine a. & nasopalatine n./a.

18. Basic Incisions
Can be sulcular, crestal, or inverse bevel

19. Basic Incisions Full thickness a: sulcular b: crestal
(mucoperiosteal)
a: sulcular
b: crestal
Depending on the amount of attached tissue present

20. Split/partial thickness
Basic Incisions
Split/partial thickness
(mucosal)
In areas of thin bony plates and
for mucogingival procedures

21. Basic Incisions 2. inversebeveled Modified flap
(mucoperiosteal)
2. inversebeveled
incision to the crest of bone.
1. gingivectomy
Incision for pocket reduction
Requires adequate attached keratinized gingiva
On the palate, enlarged tissue, or with limited access

22. Comparison of full- vs. partial-

23. Types of Mucoperiosteal Flaps
Envelope/sulcular incision
Envelope with one releasing incision (three-corner flap)
Envelope with two releasing incisions (four-corner flap)
Full-thickness mucoperiosteal flap

24. Types of Mucoperiosteal Flaps
1. Envelope/Sulcular flap
2 teeth anterior
1 tooth posterior

25. Types of Mucoperiosteal Flaps
2. Three-corner flap
1 tooth anterior
1 tooth posterior
Greater access in an apical direction, especially in the posterior aspect of the mouth

26. Types of Mucoperiosteal Flaps
3. Four-corner flap
1 tooth anterior
1 tooth posterior
rarely indicated

27. Common Periodontal Flap

28. 1
Inverse bevel incision 0.5~2mm, extending to the alveolar crest. Thins gingival tissue and permits compete closure of the interdental osseous defects postoperatively.

29. 1
Flap reflection. Full thickness mucoperiosteal flap is reflected to permits visualization.

30. 1
Crevicular incision between the hard tooth and the diseased pocket epi., to the depth of the junctional epi.

31. 1
Horizontal incision carried along the alveolar crest

32. 1
Root planing with direct vision

33. 1
Complete coverage of interdental defects

34. 2
Sulcularly, crestally, or full-thickness flap labially positioned inverse beveled incision to bone
Flap completed, reflected off bone
Flap is apically positioned and sutured

35. 2
A: The internal bevelled, scalloped incision is used for pocket elimination through apical repositioning of the flap.
B: The flap
positioned apically for pocket elimination.

36. Crestal incision with blade, partial-thickness flap parallel to long axis of tooth
Flap raised by sharp dissection, periosteum retained over bone
Flap is apically positioned at or below alveolar crest

37. No alveolar mucosa is present on the palate to permit apical positioning.
Pocket elimination by palatal flap that just covers the contours of the bone to eliminate osseous defects.
Requires skill and experience.

38. Osteoplasty
Osseous grooving, peprmits better adaption of flaps to facilitate plaque removal alter healing

39. Osteoplasty

40. Osteoplasty

41. Suturing for Flap Surgery

42. Simple Loop Modification of Interrupted

43. Figure 8 Modification of Interrupted

44. Vertical mattress suture

45. Horizontal mattress suture

46. Single Interrupted Sling

60. Reference
Contemporary Oral and Maxillofacial Surgery, 4th Edition, Larry J Peterson, DDS, MS, Edward Ellis, III, DDS, MS, James R Hupp, DMD, MD, JD, FACS and Myron R Tucker, DDS
Peterson's principles of oral and maxillofacial surgery, Michael Miloro,G. E. Ghali,Peter Larsen,Peter Waite
An atlas of minor oral surgery: principles and practice, David A. McGowan
Manual of minor oral surgery for the general dentist, Karl R. Koerner
Critical Decisions in Periodontology, 4th Edition, WALTER B. HALL, BA, DDS, MSD
Color Atlas of Periodontology, Klaus H. & Edith M. Rateitschak
Atlas of Cosmetic and Reconstructive Periodontal Surgery 3rd edition, EDWARD S. COHEN, DMD