Variations in Flap Design

• Thinned palatal flaps• Wedges

– Distal wedge– Proximal wedge– Edentulous area

• Conservative flap approaches

Thinned palatal flap Pre-treatment considerations

Designing a thinned palatal flap• Probe depths• Gingival contour• Pocket location• Objective

– Pocket elimination (resection)– Regeneration

• Underlying tissues– Soft tissue – Osseous tissues

Palatal flap views

Initial incisions

Removal of tissue collar

Undermining incisions

Tissue removal

Flap closure

Pre-treatment Primary incisions

Soft tissue removed Osseous resection

Sutured Healed

Distal Wedge Designs

Distal Wedge

• A periodontal surgical procedure for removal of excessive soft tissue distal to a terminal tooth in an arch

• A “wedge” refers to internal thinning by removal of a block of tissue

Special areas for wedges

• Maxillary tuberosity• Mandibular retromolar area• Edentulous ridges

Distal wedge advantages

• Provide access to bone and furcations• Allow internal thinning of bulky tissue• It is possible to obtain primary closure of

the wound after reduction of bulky tissue

Anatomical limitations

• Access• Vasculature and nerves

– Lingual nerve (mandibular)– Greater palatine foramen (maxillary)– Loose connective tissues, raphe

Distal wedge designs

• Triangular: least difficult, least invasive• Square cut: provides best access • Linear: most effective at preserving

keratinized gingiva

triangular square

linear

Proximal wedges are similar in design to square cut distal wedges

Conservative Flap Designs

• Intended to minimize recession• Good for maxillary anterior teeth• Types

– Flap curettage (open flap debridement/ flap curettage)

– Modified Widman Flap– Excisional New Attachment Procedure

(ENAP)

Modified Widman Flap

• Provides access for root planing• Requires primary closure of the flap

Initial incision has 0.5 to 1 mm scallop, but may also be intrasulcular

The modified Widman flap is elevated only 2 to 3 mm apical to the alveolar crest

Intrasulcular incision

Interdental incision

Soft tissue debridement and root planing

With conservative flaps, there is little or no bone resection. The flap is adapted to obtain primary

closure