Surgery has been defined as the act and art of treating diseases or injuries

by manual operation

ROBICSEK (1884)

YOUNGER (1902)

KIRKLAND (1931)

NORBERG (1926)

LEONARD WIDMAN (1916)

KRONFELD (1935)

SCHLUGER (1949)

NYMAN et al (1982)

GOLDMAN (1950)

RAMFJORD; NISSLE (1974)

HIRSCHFELD (1952)

TAKEI et al (1985)

FRIEDMAN (1955;196

2)

• “Flap is a piece of tissue parity severed from its place of origin for use in surgical grafting and

repair of body defects”

“Flat portion of tissue, either skin, mucosa or mucoperiosteum which is partially severed from its

deeper surroundings.”

• Webster’s Dictionary F. J Harty Rogston Concise Illustrated Dental Dictionary

A Periodontal flap is defined as, “a section of the gingiva and or oral mucosa, surgically

elevated from the underlying tissues to provide visibility of the bone and root surface.”

Carranza’s Clinical periodontology ninth edition

Widman, Cieszynski, andNeuman “pyorrhea Alveolar and its

Treatment Published in Berlin in 1912”

Widman in 1916 flap surgery for pocket elimination

The English edition of widman’s article in 1918 gives

a detailed description of a mucoperiosteal flap design

Zentler in 1918 use of a crevicular mucoperiosteal flap in a manner similar to what Neuman

Kirkland in 1931

flap procedure for the purpose of reattachment

Periodontal flaps can be classified based on the following:

Bone exposure after flap reflection. Placement of the flap after surgery Management of the papilla Presence / absence of releasing incisions

Full thickness (mucoperiosteal)

all the soft tissue,

including the

periosteum, is reflected

to expose the

underlying bone

Partial thickness (mucosal) flaps /split thickness flap

includes only the epithelium

and a layer of the underlying

connective tissue. The bone

remains covered by a layer of

connective tissue, including

the periosteum

Bone exposure after flap reflection.

full thickness or mucoperiosteal flap an incision generally is made in or near the gingival sulcus region and carried apically toward the crest of the bone from which point there is total reflection of all soft tissue from the surface of the alveolar process.

By contrast the split thickness or mucosal flap is prepared by initiating an incision at or near the gingival sulcus region and proceeding apically through the connective tissue past the crest of the alveolar bone so as to leave a layer of periosteal connective tissue intact, covering the vestibular surface of the alveolar process

Full thickness (mucoperiosteal)

Partial thickness (mucosal) flaps /split thickness flap

Significant difference and Advantages between full thickness and partial thickness:

The epithelial tissue repairs itself similarly in both procedures.

In both flap procedures there is no significant variation as to the repair of the connective tissue

The difference in repair between the two flaps becomes manifest in the region of the alveolar

process

In the full thickness flap-the resorbtive activity at the six to eight-day period affects the entire layers of circumferential lamellae and a portion of the Haversian systems that are immediately subjacent to those lamellae, so it is a distinct quantitative difference as to the amount of bone that is resorbed.

(J Periodontal 1972; 141)

Histologically The full thickness flap is a few days behind the split thickness flap in the repair rate

There are many more osteoclasts and Osteoblasts in action during their respective times of activity

with the full thickness flap. This again is related to the degree of damage or trauma by surgery.

Reflecting a split thickness flap achieves thinness with body and permits its reapposition at the gingival

margin region with it being better contoured and much more adaptable than the heavy-bodied full

thickness mucoperiosteal flap

Alveolar crest reduction following full and partial thickness flap:

Kohler and Ramfjord, after full thickness flaps, found only slight crestal bone loss

Donnenfeld, Marks, and Glickman reported a loss of crestal alveolar bone after full thickness flaps (1.05 to 1.2 mm)

Pfeifer, in a 21-day study on four patients, reported very little osteoclastic activity in response to a partial thickness flap

J Periodontal 1972; 141

Based on flap placement after surgery

Undisplaced flaps

Displaced flaps

Displaced flaps have the important advantage of preserving the outer portion of the pocket wall

and transforming it into attached gingiva

Based on management of the papilla

conventional

papilla preservation flaps.

conventional flap is used when, the interdental spaces are too narrow, thereby precluding the papilla, and When the flap is to be displaced.

Presence / absence of releasing incisions Flap with releasing incisions

Envelope flap

Depending on direction of transfer and geometryMode of

transfer Rotational: All rotational flaps share the common characteristic of movement around a pivot point. The radius of the arc of rotation is the line of greatest tension. The greater the rotation, the greater the actual shortening of the flap.

Mode of transfer Advancement: Advanced flaps reach their final site without rotation or any lateral movement. They can consist of one or more pedicles. Consists of two straight-line, vertical incisions with or without 100 to 110 degree back cuts

Both the advanced flap and the rotational flap can be further classified according to the geometry of the

flap.

Geometry:Transposition, A rectangular segment of gingiva and

mucosa is used.Rotational, A semicircular segment of gingiva or

mucosa is used.

Prevention of flap necrosis

Prevention of flap tearing

According to Laskin(1980)

Incision should start adjacent to the operative area

Incision should avoid transection of major nerves and vessels

An adequate blood supply

Avoid incisions in an area of thinned mucosa

Releasing incisions if access is inadequate

Laskin, D.M. Oral and Maxillofacial surgery. Vol 1

Three important objectives:

• it removes the pocket lining:

• it conceives the relatively uninvolved positioned becomes attached gingival. Which, if apical positioned, becomes attached gingiva and

• it produces a sharp thin flap margin for adaptation to the bone- tooth junction

Horizontal Incisions

1. The internal bevel incision

2. The crevical incision

3. Interdental incisions

Cervical incision

Interdental incisions

These three incisions allow the removal of the gingival around the tooth (i.e. the pocket epithelium and the adjacent granulomatous tissue) A curette can be used for this purpose.

If no vertical incisions are made the flap is called an envelope flap.

Carranza’s Clinical periodontology ninth edition

Vertical incisions must extend beyond the mucogingival line reaching the

alveolar mucosa to allow for the release of the flap to be displaced

Vertical Incisions

Vertical or oblique releasing incision can be used on one or both ends of the horizontal incision depending on the design and purpose of the flap

vertical incisions in the lingual and palatal areas are avoided

Vertical Incisions

Incorrect

correct

Flap reflection

Objectives

Creating accessibility for proper professional

scaling and root planing

Establishing a gingival morphology which

facilitates the patient’s self performed infection

control.

Indications:

Increased depth of the periodontal pockets

Increased width of the tooth surfaces

The presence of root fissures, root concavities, furcations, and defective margins of dental restorations in the subgingival area

Reduced accessibility and the presence of one or several of the above mentioned conditions may prevent proper debridement of shallow pockets

• Badersten et al. 1981, Lindhe et al., 1982

At the completion of treatment,

No sub or supragingival dental deposits.

No pathologic pockets (no bleeding on probing

to the bottom of the pockets)

No plaque retaining aberrations of gingival

morphology.

No plaque-retaining parts of restorations in

relation to the gingival margin.

Contraindications • Uncooperative Patient

• Blood disorders

• Hormonal disorders

• Cardiovascular disease

(Fay & O’Neil 1984).

• Smoking

(Siana et al., 1989),

The main advantages of the “original Widman

flap” Healing with primary intention and

That it was possible to reestablish a proper

contour of the alveolar bone in sites with angular

bony defects.

• Clinical periodontology and Implantology - Jan Lindhe fifth edition

• Robert Neuman: A pioneer in periodontal flap surgery – J Periodontal 1982 vol 53; 456

An intracrevicular incision was made through the base of the gingival pockets

Any irregularities of the alveolar bone were corrected by osteoplasty

Splinting

Surgery in sextants

Did not include

1)extensive sacrification of non – inflamed tissues and

2)apical displacement of the gingival margin

Advantages

Esthetics

Potential for bone regeneration in intrabony defects

The ultrastucture of the reformed epithelium with hemidesmosomes, basement lamina and several layers of elongated epithelial cells parallel to the tooth surface. (Listgarten; Frank et al)

Advantages and disadvantages of the modified widman flap

Establishing an intimate post operative adaptation of healthy connective tissue and normal epithelium to contacting tooth surface

Access for proper instrumentation

The Michigan Study

In 1961 the first report from the first longitudinal study

Scaling and root planing, oral hygiene instruction, and occlusal adjustment.

Subgingival curettage

Pocket elimination surgery

The greatest gain was obtained with the modified Widman flap, followed by subgingival curettage, and

then pockets elimination surgery. When severe pockets were treated, the modified Widman flap

produced a gain that was significantly better than that obtained with the other two techniques.

Subgingival curettage, Modified Widman flap, or Pocket elimination surgery

when gain in attachment was considered, there were no differences among techniques.

Comparison of the Original and Modified Widman Flap Procedures

ORIGINAL MODIFIED WIDMAN

For pocket elimination Collar of tissue attached to the teeth torn with curettes Vertical releasing incisionsHigh flap reflection Flaps do not cover interproximal bone Bone remains exposed

For reattachment Collar excised with knives and removed with curettes No vertical releasing incisionsMinimal flap reflection Close interproximal flap adaptation No bone exposed

Minimum pocket depth postoperatively.

optimal soft tissue coverage of the alveolar bone is

obtained and the post surgical bone loss is minimal.

The postoperative position of the gingiva margin

may be controlled and the entire mucogingival

complex may be maintained.

Advantages

Treatment of periodontal pockets on the distal

surface of distal molars is complicated by a

presence of bulbous tissues over the tuberosity or

by a prominent retromolar pad.

Distal wedge procedure

(Robinson 1966)

Incomplete tissue coverage of the graft material in the interproximal areas.

Considerable attention has been given to the use of bone grafts in order to improve the amount of new

connective tissue attachment and bone regeneration in vertical defects.

The most common postoperative problem

Immediate, partial or complete exfoliation of the implant materials

• Flap technique for periodontal bone implants (papilla preservation) –

J Periodontal 1985 vol 56; 204

The Modified papilla preservation technique: A surgical approach for interproximal regenerative procedure – J Periodontal 1995 vol 66; 261

Horizontal and vertical mattress suturing is done

The simplified papilla preservation flap: A novel surgical approach for the management of soft tissues in regenerative procedures –IJPRD 1999 vol 19; 589

Grupe and Warren (1956)

Norberg (1926); Bernimoulin et al

(1975)

Tarnow (1986)

This design minimizes the amount of vascular embarrassment and sloughing of the coronal edge

of the flap because the base of the flap is wider preserving an adequate blood supply.

A surgical Modification for Implant Fixture Installation

Vertical incisions can be placed to ease the outer buccal flap elevation with out any significant compromise in

blood supply.

• The overlapped flap: A surgical modification for implant fixture installation –

IJPRD 1990 vol 10; 209

Langer and Langer (1990)

The eversed crestal flap: A surgical modification in endosseous implant procedures –Qunt int 1994 vol 25; 229

Landsberg (1994)

Sulcular flaps remain the most frequently used in endodontic surgery

(Beer et al 2000)

The main disadvantage of these are recession and especially, unpredictable shrinkage of the papilla during healing

(zimmermann et al 2001)

• Papilla base incision: a new approach to recession free healing of the interdental papilla after endodontic surgery –

Int Endo Jol 2003 vol 35; 453

A new approach to recession – free healing of the interdental papilla after endodontic surgery

Velvart. P

Hemorrhage associated with surgery is a common problem which requires proper management.

Definitive data regarding surgical blood loss was unavailable until 1924 first studied operative

hemorrhage during general surgery.

Gatch and Little in 1924 first studied operative hemorrhage during general surgery

• Baab, D. A., Ammons, W. F., Selipsky, H. Blood loss during periodontal surgery. J Periodontol 1977; 48: 693

Mclvor and Wengraf studied blood loss calorimetrically during gingivectomies and / or

isolated periodontal flap procedures on 14 patients. (12 – 62 ml)

Berdon 12 published the first report on hemorrhage during periodontal surgery. Using a

cyanmethemoglobin comparison technique. He established that approximately 5 ml to 149 ml of

blood was lost.

Ariaudo (1970) estimated that full mouth periodontal flap procedures resulted in 350ml blood

loss.

• Baab, D. A., Ammons, W. F., Selipsky, H. Blood loss during periodontal surgery. J Periodontol 1977; 48: 693

Factors affecting blood loss

• Systemic factors

Age

Blood pressure

Bleeding time

Duration of Surgeryextent of surgical

fielddegree of

inflammationno of teeth involvedanesthesialength of incision

• Local factors

• Surgical technique

Flap survival

• Periodontal reconstructive flaps classification and surgical considerations – IJPRD 1991 vol 11; 481

The final pattern should be larger than the area to be reconstructed.

Flap survival

The surgeon should consider all possible designs and factors that may increase flap survival.

All phases of flap transformation should be considered including possible shortening of the flap and the desired angles and vectors of movement

Specific attention should be given to the length of the pattern to avoid tension or sinking of the flap.

• Periodontal reconstructive flaps classification and surgical considerations – IJPRD 1991 vol 11; 481

Flap survival

• Periodontal reconstructive flaps classification and surgical considerations – IJPRD 1991 vol 11; 481

Flap necrosis

Atraumatic technique

Atraumatic and gentle surgical techniques should be practiced throughout the surgical procedure

Hot sponges

(66 degrees)

Promote coagulation

Increase capillary bleeding

Increase tissue damage

Incidence of wound infection

Tissue necrosis

When the outline crosses two dissimilar surfaces, for example,

Gingiva and mucosa, the surgeon should place the mucosa under tension and commence incisions from the

less firm surface, from mucosa to gingiva.

The initial phase of Atraumatic surgery consists of an outline of the recipient and donor sites as well

as the transfer phases

The optimal time for suture removal is when the tensile strength of the healing wound exceeds the strength of the suture and is sufficient to maintain

the approximation without assistance.

Wound closure

The relationship between the sutures and wound edges is important

Tension on the sutures

Postoperative swelling

Reduce circulation

Further edge separation

Surgical injury creates the environment and stimulus for cellular differentiation

Primary wound healing

Secondary wound healing

Tertiary wound healing

The migration takes place at a rate of 0.5 mm per day

Epithelium

Epithelial cells begin to proliferate at wound margins at 1-2 days.

A replaced flap may be sealed to the tooth in 2-4 days.

Epithelialization and the formation of a junctional epithelium are complete by the end

of the second week

Connective tissue

Fibroblasts begin to proliferate after day 2 with evidence of collagen synthesis in the wound by day 4.

In the most uncomplicated periodontal surgery, restoration of gingival connective tissue will be complete

in 4-6 weeks

Alveolar bone

Reactive bone resorption Osteoclasts appear in the wound at about day 4 and display peak osteoclastic

activity at day 10

Osteoblasts begin to appear and proliferate in the wound during the second week, and they

display peak osteoblastic activity by the end of the third week.

Bone remodeling and maturation is a feature of the third post-operative month.

Proliferating cementoblasts appear adjacent to root surfaces at the end of month one and proceed with cementogenesis during the months two and three.

Cementum

Cementogenesis delayed in onset; it is also slow to exert its effect on the overall outcome of

periodontal healing

These events are critical to the formation of a new attachment apparatus and some forms of

new attachment

New techniques in periodontal surgery are being developed which aim to conserve rather than discard periodontal tissue.

Surgical procedures should be designed with these facts in mind:

• Use of full thickness and partial thickness

• Reflecting flap as much gingiva as possible should be retained

• Flap should be reflected in relaxed manner

• Vertical releasing incisions should be given where they are

necessary

• Prevent perforation of the flap

• Attention should be paid during suturing of the flaps

Thank you