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OBJECTIVES OF THE SURGICAL PHASE

1- Improvement of the prognosis of teeth

and their replacements.

2- Improvement of esthetics.

The surgical phase consists of techniques

performed for pocket therapy and for the

correction of related morphologic problems,

namely mucogingival defects.

Surgical techniques allow :

1- Increase accessibility to the root

surface, making it possible to remove

all irritants.

2- Reduce or eliminate pocket depth.

3- Reshape soft and hard tissues to attain

a harmonious topography.

Indications for periodontal surgery

1- Areas with irregular bony contours, deep

craters, and other defects usually require a

surgical approach.

2- Pockets on teeth in which a complete removal

of root irritants is not considered clinically

possible may call for surgery.

3- In cases of furcation involvement of Grade II or

III, a surgical approach ensures the removal

of irritants; any necessary root resection or

hemisection also requires surgical

intervention.

4- Intrabony pockets on distal areas of last

molars, frequently complicated by

mucogingival problems, are usually

unresponsive to nonsurgical methods.

5- Persistent inflammation in areas with

moderate to deep pockets may require a

surgical approach.

Classification of Flaps:1- Bone exposure after flap reflection.

2- Placement of the flap after surgery.

3- Management of the papilla.

Based on bone exposure after reflection:

** Full thickness (mucoperiosteal) is indicated

when resective osseous surgery is

contemplated.

** Partial thickness (split thickness flap) is

indicated when the flap is to be positioned

apically or when the operator does not

desire to expose bone.

Diagram of the internal bevel incision (first incision) to reflect a full

thickness and the split thickness flap.

Based on flap placement after surgery, flaps

are classified):

** Nondisplaced flaps, when theflap is returned

and sutured in its original position; or 2)

displaced flas that are placed apically, coronally,

or laterally.

Based on management of the papilla:

** Flaps can be conventional or papilla

preservation flaps.

The conventional flap is used:

(1) The interdental spaces are too narrow.

(2) When the flap is to be displaced.

Conventional flaps include the modified

widman and the flap, the undisplaced flap,

the apically displaced flap, and the flap for

regenerative procedure procedures.

Design of the Flap:

The design of the flap is dictated by the

surgical judgement of the operator and

may depend on the objectives of the

operation.

Horizontal Incisions:

1- The internal bevel incision.

2- Crevicular incision.

3- Interdental incision.

Vertical incisions:

Vertical or oblique releasing incisions can

be used on one or both ends of the

horizontal incision, depending on the

design and purpose of the flap.

Elevation of the Flap:

1- Full thickness flap.

The reflection is accomplished by blunt

dissection.

2- Partial thickness flap.

The reflection is accomplished by sharp

dissection.

A, Diagram of the internal bevel incision (first incision) to reflect a tull thickness

(mucoperiosteal) flap. Note that the incision ends on the bone to allow for the reflection of the

entire flap. B, Diagram of the internal bevel incision to reflect a partial thickness flap. Note that

the incision ends on the root surface to preserve the periosteum on the bone.

Sutures for Periodontal Flaps

TYPES

OF

NEEDLES

Ligation:

Interdental Ligation:

1- The director loop suture.

2- Figure-eight suture.

Sling Ligation:

A single, interrupted sling suture is used to adapt

the flap arount the tooth.

Continuous Independent Sling Suture.

The continuous, independent sling suture is used to adapt the buccal and lingual flaps

without tying the buccal flap to the lingual flap. The teeth are used to suspend each flap against

the bone. It is important to anchor the suture on the two teeth at the beginning and end of the

flap so that the suture will not pull the buccal flap to the lingual flap.

Anchor Suture

Distal wedge suture. This suture is also used to close

flaps that are mesial or distal to a lone-standing tooth.

Periosteal Suture

This type of suture is used to hold in place apically

displaced partial thickness flaps.

1- The modified widman

flap.

2- The undisplaced flap

the palatal flap.

3- The apically displaced

flap.

1- The papilla

preservation flap.

2- Conventional flap for

regenerative

surgery.

FLAPS FOR POCKET

THERAPY

FLAPS FOR

REGENERATIVE

SURGERY

FLAPS FOR POCKET THERAPY

Flaps are used for pocket therapy toaccomplish the following:

1- Increase accessibility to root deposits.

2- Eliminate or reduce pocket depth by

resection of the pocket wall.

3- Expose the area to perform regenerative

methods.

The modified widman flap.

1- Facilitates instrumentation.

2- Removal of the pocket lining.

3- Not eliminate or reduce pocket depth.

The undisplaced (Unrepositioned) flaps.

1- Improving accessibility for instrumentation.

2- Removes the pocket wall.

3- Reducing or eliminating the pocket.

Diagram showing the location of

different areas where the internal bevel

incision is made in an undisplaced flap.

The apically displaced flap:

1- Improving accessibility.

2- Removes the pocket wall.

3- It increases the width of the attached gingiva by transforming the

previously unattached keratinized pocket wall into attached tissue.

1- The papilla preservation flap.

2- Conventional flap for regenerative surgery.

The flap using only crevicular or pocket incisions, to retain the

maximum amount of gingival tissue, including the papilla, for

graft or membrane coverage.

FLAPS FOR REGENERATIVE SURGERY