1. THE PERIODONTAL FLAP

2. INTRODUCTION
DEFINITION
CLASSIFICATION OF FLAPS
DESIGN OF FLAPS
INCISIONS (HORIZONTAL AND VERTICAL)
ELEVATION OF THE FLAP

3. THE VARIOUS FLAP TECNIQUE FOR POCKET THERAPY
GENERAL INDICATIONS FOR FLAPS
TREATMENT DECISIONS FOR SOFT AND HARD TISSUE POCKETS
SUTURING
PERIODONTAL DRESSINGS

4. INTRODUCTION

5. DEFINITION
A PERIODONTAL FLAP IS A SECTION OF THE GINGIVA AND/OR MUCOSA SURGICALLY SEPARATED FROM THE UNDERLYING TISSUES TO PROVIDE VISIBILTY OF AND ACCESS TO THE BONE AND ROOT SURFACE

6. CLASSIFICATION OF FLAPS
1)BASED ON BONE EXPOSURE AFTER FLAP REFLECTION
FULL THICKNESS(MUCOPERIOSTEAL)FLAPS
PARTIAL THICKNESS(MUCOSAL) FLAPS

7. Full Thickness Flap

8. Partial Thickness Flap

9. INDICATIONS OF PARTIAL THICKNESS FLAP
WHEN THE FLAP IS TO BE PLACED APICALLY
CRESTAL BONE MARGIN IS THIN.
WHEN DEHISCENCES OR FENESTRATIONS ARE PRESENT

10. CLASSIFICATION OF FLAPS
2)BASED ON PLACEMENT OF FLAP AFTER SURGERY
NON-DISPLACED FLAPS
DISPLACED FLAPS

11. CLASSIFICATION OF FLAPS
3)BASED ON MANAGEMENT OF PAPILLA
CONVENTIONAL FLAPS
PAPILLA PRESERVATION FLAPS

13. DESIGN OF THE FLAPS DICTATED BY:- SURGICAL JUGDEMENT OF THE OPERATOR
OBJECTIVES OF THE OPERATION
DEGREE OF ACCESS TO THE UNDERLYING BONE AND ROOT SURFACES NECESSARY
FINAL POSITION OF THE FLAP

14. INCISIONS HORIZONTAL INCISIONS
THE INTERNAL BEVEL/REVERSE BEVEL/INTIAL INCISION

15. Primary Incision

19. MOST BASIC INCISION FOR MOST OF THE PERIODONTAL FLAP PROCEDURES
IT ACHIEVES 3 IMPORTANT OBJECTIVES:-
1)REMOVES THE POCKET LINING
2)CONSERVES THE RELATIVELY UNINVOLVED OUTER SURFACE OF THE GINGIVA
3)IT PRODUCES A SHARP THIN FLAP MARGIN FOR ADAPTATION TO THE TOOTH-BONE JUNCTION

20. INDICATIONS OF PRIMARY INCISION
SUFFICIENT BAND OF ATTACHED GINGIVA
TO CORRECT BONE MORPHOLOGY
THICK GINGIVA
DEEP PERIODONTAL POCKETS AND BONE DEFECT
TO LENTHEN CLINICAL CROWN

21. HORIZONTAL INCISIONS
2) THE CREVICULAR/SULCULAR/SECOND INCISION

23. THIS INCISION ALONG WITH THE INTERNAL BEVEL INCISION, FORMS A V-SHAPED WEDGE ENDING AT OR NEAR THE CREST OF THE BONE.
THIS WEDGE OF TISSUE CONTAINS INFLAMMED OR GRANULOMATOUS AREAS OF LATERAL WALL OF THE POCKET,AS WELL AS THE JUNCTIONAL EPITHELIUM & THE CONNECTIVE TISSUE FIBRES THAT STILL PERSIST BETWEEN THE BOTTOM OF THE POCKET & THE CREST OF THE BONE.

24. THE PERIOSTEAL ELEVATOR IS INSERTED IN TO THE INTITIAL INTERNAL BEVEL INCISION, AND THE FLAP IS SEPERATED FROM THE BONE, WITH THIS ACCESS, THE THIRD INCISION IS MADE.

25. HORIZONTAL INCISIONS
3)THE THIRD/INTERDENTAL INCISION

27. VERTICAL INCISIONS
INCISIONS ARE MADE AT THE LINE ANGLES OF A TOOTH EITHER TO INCLUDE THE PAPILLA OR EXCLUDE
THESE INCISIONS MUST REACH BEYOND THE MUCOGINGIVAL LINE

29. ELEVATION OF THE FLAP
ELEVATION OF FLAP IS DONE WITH A PERIOSTEAL ELEVATOR TO OBTAIN A FULL THICKNESS FLAP
ELEVATION OF FLAP IS DONE WITH A BARD-PARKER KNIFE TO OBTAIN A SPLIT THICKNESS FLAP

32. THE FLAP TECHNIQUE FOR POCKET THERAPY
FLAPS USED FOR POCKET THERAPY ACCOMPLISH THE FOLLOWING:-
INCREASED ACCESSIBILITY TO THE ROOT DEPOSITS.
ELIMINATE OR REDUCE THE POCKET DEPTH.
EXPOSE THE AREA TO PERFORM REGENERATIVE METHODS.

33. FLAP PROCEDURES
THE ORIGINAL WIDMAN FLAP (1918)

37. THE NEUMANN FLAP(1920,1926) AN INTRACREVICULAR INCISION WAS MADE
THROUGH THE BASE OF THE POCKETS, AND THE
ENTIRE GINGIVA(& PART OF THE ALVEOLAR
MUCOSA) WAS ELEVATED IN A MUCOPERIOSTEAL
FLAP.

38. THE MODIFIED FLAP OPERATION(THE KIRKLAND FLAP,1931)
IT IS A SURGICAL PROCEDURE TO BE USED IN THE
TREATMENT OF “PERIODONTAL PUS POCKETS”, ITS
BASICALLY AN ACCESS FLAP FOR PROPER ROOT
DEBRIDEMENT.

39. THE INTRACREVICULAR INCISION

40. THE GINGIVA IS RETRACTED TO EXPOSE
THE DISEASED ROOT SURFACE

41. MECHANICAL DEBRIDEMENT

43. IN CONTRAST TO THE PREVIOUS TWO FLAPS THIS FLAP DID NOT INCLUDE:-
EXTENSIVE SACRIFICE OF NON INFLAMED TISSUES.
APICAL DISPLACEMENT OF THE GINGIVAL MARGIN.
ANOTHER ADVANTAGE OF THIS FLAP WAS THE POTENTIAL FOR BONE REGENERATION IN INRABONY DEFECTS WHICH OCCURRED FREQUENTLY ACCORDING TO KIRKLAND(1931)

44. THE MAIN OBJECTIVES OF FLAP PROCEDURES SO FAR WERE TO:-
FACILITATE DEBRIDEMENT OF THE ROOT SURFACES AS WELL AS THE REMOVAL OF THE POCKET EPITHELIUM & THE INFLAMED CONNECTIVE TISSUE.
ELIMINATE THE DEEPENED POCKETS(THE ORIGINAL WIDMAN FLAP& THE NEUMANN FLAP)
CAUSE A MINIMAL AMOUNT OF TRAUMA TO THE PERIODONTAL TISSUES & DISCOMFORT TO THE PATIENT.

45. IN 1950’s& 1960’s NEW SURGICAL TECHNIQUES
FOR REMOVAL OF SOFT & HARD TISSUE POCKETS WERE DESCRIBED.
IMPORTANCE OF MAINTAINING AN ADEQUATE ZONE OF ATTCHED GINGIVA WERE EMPHASIZED.
NABERS(1954)-DESCRIBED TECHNIQUE FOR PRESERVATION OF GINGIVA FOLLOWING SURGERY,DENOTED AS “REPOSITIONING OF ATTACHED GINGIVA”
LATER MODIFIED BY ARIAUDO & TYRRELL(1957)

46. THE APICALLY REPOSITIONED FLAP(FRIEDMAN,1962)

47. THE APICALLY REPOSITIONED FLAP
FOLLOWING A VERTICAL INCISION A REVERSE BEVEL
INCISION MADE

48. THE APICALLY REPOSITIONED FLAP
A MUCOPERIOSTEAL FLAP RASED AND TISSUE COLLAR
AROUND THE TEETH IS REMOVED WITH A CURETTE

49. THE APICALLY REPOSITIONED FLAP
OSSEOUS SURGERY IS PERFORMED WITH ROTATING BUR

50. THE APICALLY REPOSITIONED FLAP
RECAPTURE THE PHYSIOLOGIC CONTOUR OF THE
ALVEOLAR BONE

51. THE APICALLY REPOSITIONED FLAP
FLAPS REPOSITIONED IN AN APICAL DIRECTION

52. THE APICALLY REPOSITIONED FLAP
PERIODONTAL DRESSING PLACED

53. THE BEVELED FLAP
INTRACREVICULAR INCISION

54. BEVELED FLAP
MUCOPERIOSTEAL FLAP IS RAISED

55. BEVELED FLAP
SCALING,ROOT PLANING AND OSSOEUS RECONTOURING
DONE

56. BEVELED FLAP
PALATAL FLAP REPLACED AND A SECONDARY SCALLOPED REVERSE BEVELED INCISION IS MADE TO ADJUST FLAP TO THE REMAINING ALVEOLAR BONE

57. BEVELED FLAP SHORTENED AND THINNED FLAP IS REPLACED OVER
ALVEOLAR BONE IN CLOSE CONTACT WITH THE ROOT SURFACE

58. ADVANTAGES OF APICALLY POSITIONED FLAP
MINIMUM POCKET DEPTH POST OPERATIVELY
IF OPTIMAL SOFT TISSUE COVERAGE OF THE ALVEOLAR BONE IS OBTAINED, THE POST SURGICAL BONE LOSS IS MINIMAL.
POSTOPERATIVE POSITION OF THE GINGIVAL MARGIN MAY BE CONTROLLED AND THE ENTIRE MUCOGINGIVAL COMPLEX MAY BE MAINTAINED.

59. DISADVANTAGES SACRIFICE OF PERIODONTAL TISSUES BY BONE RESECTION.
SUBSEQUENT EXPOSURE OF ROOT SURFACES.(WHICH CAUSES ESTHETIC AND ROOT HYPERSENSITIVITY PROBLEMS)

60. IN 1965,MORRIS REVIVED THE TECHNIQUE DESCRIBED IN EARLY LITERATURE, AND CALLED IT UNREPOSITIONED MUCOPERIOSTEAL FLAP.
RAMFJORD & NISSLE(1974) DESCRIBED THE MODIFIED WIDMAN FLAP TECHNIQUE, WHICH IS ALSO RECOGNISED AS THE “OPEN CURETTAGE TECHNIQUE”
IT OFFERS THE POSSIBILITY OF OBTAINING AN INTIMATE POSTOPERATIVE ADAPTATION OF HEALTHY COLLAGENOUS CONNECTIVE TISSUE TO THE TOOTH SURFACES,ALSO PROVIDES ACCESS FOR PROPER ROOT INSTRUMENTATION & IMMEDIATE CLOSURE OF THE AREA.

61. THE MODIFIED WIDMAN FLAP TECHNIQUE(RAMFJORD & NISSLE,1974)

62. MODIFIED WIDMAN FLAP INITIAL INCISION IS PLACED 0.5-1mm FROM
GINGIVAL MARGIN AND PARALLEL TO LONG AXIS OF TOOTH

63. MODIFIED WIDMAN FLAP
FOLLOWING ELEVATION OF THE FLAP,SECONDARY INCISION IS MADE

64. MODIFIED WIDMAN FLAP
THIRD INCISION IS MADE PERPENDICULAR TO ROOT SURFACE

65. MODIFIED WIDMAN FLAP
DEBRIDEMENT AND CURETTAGE OF ANGULAR BONE DEFECTS,FLAPS REPLACED AND SUTURED

71. ADVANTAGES:-
POSSIBILITY OF OBTAINING A CLOSE ADAPTATION OF THE SOFT TISSUES TO THE ROOT SURFACES.
MINIMUM OF TRAUMA TO WHICH THE ALVEOLAR BONE AND THE SOFT CONNECTIVE TISSUES ARE EXPOSED.
LESS EXPOSURE OF ROOT SURFACES, WHICH FORM AN ESTHETIC POINT OF VIEW IS AN ADVANTAGE IN TREATMENT OF ANTERIOR SEGMENTS OF DENTITION.

72. TO PRESERVE THE INTERDENTAL SOFT TISSSUES FOR MAXIMUM SOFT TISSUE COVERAGE FOLLOWING SURGICAL INTERVENTION INVOLVING TREATMENT OF PROXIMAL OSSEOUS DEFECTS,TAKEI et al.,1985 PROPOSED PAPILLA PRESERVATION TECHNIQUE.
THIS TECHNIQUE OFTEN USED IN SURGICAL
TREATMENT OF ANTERIOR TOOTH REGIONS FOR ESTHETIC REASONS.

73. PAPILLA PRESERVATION FLAP
INTRASULCULAR INCISIONS MADE AT FACIAL AND PROXIMAL ASPECTS

74. PAPILLA PRESERVATION FLAP
AN INTRASULCULAR INCISION ON LINGUAL/PALATAL ASPECT OF TEETH WITH SEMILUNAR INCISION ACROSS INTERDENTAL AREA

75. PAPILLA PRESERVATION FLAP
A CURETTE OR INTERDENTAL KNIFE IS USED TO FREE THE INTERDENTAL PAPILLA FROM UNDERLYING HARD TISSUE

76. PAPILLA PRESERVATION FLAP
DETACHED INTERDENTAL TISSUE IS PUSHED THROUGH THE EMBRASSURE WITH BLUNT INSTRUMENT TO BE INCLUDED IN FACIAL FLAP

77. PAPILLA PRESERVATION FLAP
FLAP REPLACED, SUTURES PLACED ON THE PALATAL ASPECT OF INTERDENTAL AREA

78. THE UNDISPLACED FLAP

79. PALATAL FLAP

81. CONVENTIONAL FLAP FOR REGENERATIVE SURGERY

83. DISTAL WEDGE PROCEDURE
SIMPLE GINGIVECTOMY INCISION TO ELIMINATE A SOFT
TISSUE POCKET BEHIND MAXILLARY MOLAR

84. DISTAL WEDGE PROCEDURE
BUCCAL AND LINGUAL INCISION,TRIANGULARWEDGE
SHAPED TISSUE REMOVED

85. DISTAL WEDGE PROCEDURE
FLAPS REDUCED IN THICKNESS,TRIMMED & SHORTENED&
SUTURED

86. MODIFIED DISTAL WEDGE PROCEDURE

87. MODIFIED DISTAL WEDGE PROCEDURE

88. MODIFIED DISTAL WEDGE PROCEDURE

89. MODIFIED DISTAL WEDGE PROCEDURE

90. MODIFIED INCISION
TECNIQUES
IN DISTAL WEDGE
PROCEDURE

91. GENERAL INDICATIONS OF FLAPS
FLAP OPERATIONS CAN BE USED IN ALL CASES WHERE
TREATMENT OF PERIODONTAL DISEASE IS INDICATED.
FLAP PROCEDURES ARE PARTICULARLY USEFUL AT SITES WHERE POCKETS EXTEND BEYOND MUCOGINGIVAL BORDER AND/OR WHERE TREATMENT OF BONY LESIONS AND FURCATION INVOLVEMENT IS REQUIRED.

92. ADVANTAGES OF FLAP OPERATIONS:-
EXISTING GINGIVA IS PRESERVED.
MARGINAL ALVEOLAR BONE IS EXPOSED WHEREBY THE MORPHOLOGY OF BONY DEFECTS CAN BE IDENTIFIED AND PROPER TREATMENT RENDERED.
FURCATION AREAS ARE EXPOSED, THE DEGREE OF INVOLVEMENT & THE “TOOTH-BONE” RELATIONSHIP CAN BE IDENTIFIED .

93. THE FLAP CAN BE REPOSITIONED AT ITS ORIGINAL LEVEL OR SHIFTED APICALLY, THEREBY MAKING IT POSSIBLE TO ADJUST GINGIVAL MARGINS TO THE LOCAL CONDITIONS.
THE FLAP PROCEDURE PRESERVES THE ORAL
EPITHELIUM & OFTEN MAKES THE USE OF SURGICAL DRESSING SUPERFLUOUS.
PREOPERATIVE PERIOD IS LESS UNPLEASANT FOR PATIENT WHEN COMPARED TO GINGIVECTOMY.

94. TREATMENT DECISIONS FOR SOFT
AND HARD TISSUE POCKETS

95. SOFT TISSUE POCKETS
DEPENDING ON THE SURGICAL TECHNIQUE USED, THE SOFT TISSUE FLAP SOULD BE EITHER APICALLY POSITIONED AT THE LEVEL OF THE BONE CREST(ORIGINAL WIDMAN FLAP,NEUMAN FLAP& APICALLY POSITIONED FLAP) OR
MAINTAINED IN A CORONAL POSITION(KIRKLAND FLAP,MODIFIED WIDMAN FLAP& PAPILLA PRESERVATION FLAP)
IN THE ANTERIOR TOOTH REGION AESTHETICS IS IMPORTANT CONSIDERATION,SO MAINTAIN PRESURGICAL SOFT TISSUE HEIGHT

96. LONG TERM CLINICAL RESULTS HAVE SHOWN THAT MAJOR DIFFERENCES IN THE FINAL POSITION OF SOFT TISSUE MARGIN ARE NOT EVIDENT BETWEEN SURGICAL PROCEDURES INVOLVING CORONAL & APICAL POSITIONING OF FLAP MARGIN.
REPORTED DIFFERENCES IN FINAL POSITIONING OF GINGIVAL MARGIN IS ATTRIBUTED TO OSSEOUS RECONTOURING.
GOAL SHOULD BE TO ACHIEVE COMPLETE SOFT TISSUE COVERAGE OF ALVEOLAR BONE.

97. HARD TISSUE POCKETS
OPT FOR CONVERSION OF AN INTRABONY DEFECT IN TO SUPRABONY DEFECT,WHICH IS THEN ELIMINATED BY AN APICAL REPOSITIONING OF THE SOFT TISSUE.
FACTORS CONSIDERED IN TREATMENT DECISION ARE
ESTHETICS
TOOTH/TOOTH SITE INVOLVED
DEFECT MORPHOLOGY
AMOUNT OF REMAINING PERIODONTIUM

98. THE VARIOUS TREATMENT OPTIONS AVAILABLE FOR HARD TISSUE POCKETS ARE
ELIMINATION OF THE OSSEOUS DEFECT BY RESECTION OF BONE.
MAINTENANCE OF THE AREA WITH OUT OSSEOUS RESECTION
COMPROMISING THE AMOUNT OF BONE REMOVAL AND ACCEPTING THAT A CERTAIN POCKET DEPTH WILL REMAIN.
AN ATTEMPT TO IMPROVE HEALING THROUGH THE USE OF A REGENERATIVE PROCEDURE
EXTRACTION OF THE INVOLVED TOOTH IF THE BONY DEFECT CONSIDERED TOO ADVANCED.

99. INTERRUPTED INTERDENTAL SUTURES

100. MODIFIED INTERRUPTED INTERDENTAL
SUTURES

101. MODIFIED MATTRESS SUTURE

102. SUSPENSORY
SUTURE

103. CONTINUOUS SUTURE

104. PERIODONTAL DRESSING

105. THANK YOU