Dept of periodontics

Periodontal flaps

Presented by, S.SHIFAYA NASRIN SHIJI MARGARETD.SAPNAD.SARANYA

CRRI

Definition

“A periodontal flap is a section of gingiva and/or mucosa surgically separated from the underlying tissues to provide visibility and access to the bone and root surface.

INDICATIONS:

•Irregular bony contours

•Pockets on teeth in which a complete removal of

root irritants is not clinically possible

•Grade II or III furcation involvement

•Root resection / hemisection

•Persistent inflammation in areas with moderate

to deep pockets.

CONTRAINDICATIONS

• Uncontrolled medical conditions such as‐unstable angina‐uncontrolled diabetes‐uncontrolled hypertension‐myocardial infarction / stroke within 6

months •Poor plaque control•High caries rate

Bone exposure after flap reflection

•Full thickness (mucoperiosteal)

•Partial thickness (mucosal)

Placement of the flap after surgery

•Non displaced flaps

•Displaced flaps

Management of the papilla

•Conventional flaps

•Papilla preservation flaps

Classification of flaps

BASED ON BONE EXPOSURE AFTER

REFLECTION

FULL THICKNESS FLAP

Periosteum is reflected to expose the

underlying bone.

Indicated in resective osseous surgery.

PARTIAL THICKNESS FLAP

•Periosteum covers the bone.

•Indicated when the flap has to be positioned

apically.

•When the operator does not desire to expose

the bone

BASED ON FLAP PLACEMENT AFTER SURGERY•Non displaced flaps:

When the flap is returned and sutured in

its original position.

•Displaced flaps:

When the flap is placed apically,

coronally or laterally to their original

position

DESIGN OF THE FLAP

•Split the papilla (conventional flap)

•Preserve it (papilla preservation flap)

MODIFIED WIDMAN

FLAP

THE ORIGINAL ‘WIDMAN’ FLAP: In 1918, Leonard Wildman published the

detailed description of this procedure for pocket

elimination

In 1965, Morris revived this technique and called

it as “unrepositioned mucoperiosteal flap”

The flap was elevated to expose 2-3 mm of the

alveolar bone.

The soft tissue collar incorporating the pocket

epithelium and connective tissue was removed,

the exposed root surface scaled and the bone

recontoured to re-establish a 'physiologic'

alveolar form.

The flap margins were placed at the level of

the bony crest to achieve optimal pocket

reduction.

MODIFIED WIDMAN FLAP:

Presented by Ramfjord and Nissle in 1974

Exposing the root surfaces for meticulous

instrumentation and for removal of the pocket

Lining.

INDICATIONS:

Effective with pocket depths of 5-7 mm

CONTRAINDICATIONS:

This technique is difficult incase of very thin

and narrow attached gingiva ,because a narrow

band of attached gingiva does

not permit the initial scalloped incision

ADVANTAGE:

Root cleaning done

with direct vision.

Healing by primary

intention.

Minimal crestal bone

resorption.

Lack of post operative

discomfort.

DISADVANTAGE:

Requires high degree of technical skill

Interproximal flap require exact

placement.

1) Internal bevel incision should be made

to the alveolar crest starting

0.5 to 1 mm away from

the gingival margin.

PROCEDURE:

1- Modified widman flap

2- Undisplaced flap

INTERNAL BEVEL INCISION IN

FACIAL AND PALATAL ASPECTS

2) Flap is elevated

3)Crevicular incision is

made from the bottom of

the pocket to bone

4)Interdental incision sectioning

the base of the papilla

5)Tissue tags and granulation

tissue are removed.

6) Scaling and root

planing of exposed root

surfaces

7)Suturing done and covered

with tetracycline oinment

and with a periodontal

surgical pack

Post operative results

UNDISPLACED FLAP Unrepositioned flap improves accessibility for

instrumentation ,but it also removes the pocket

wall there by reducing or eliminating the pocket.

It differs from the modified Widman flap in

that the soft tissue pocket wall is removed with

the initial incision; thus it considered an

“internal bevel gingivectomy”.

INDICATION:

Used for palatal tissue surgery

ADVANTAGE:

Flap is positioned and sutured in its

original position

PROCEDURE:1) The pockets are measured with periodontal

probe and a bleeding point is produced on the

outer surface of gingiva to mark the pocket

bottom

PRE OPERATIVE VIEWS

2) Internal bevel incision in the facial and

palatal aspects

3)Crevicular incision is made and Flap is

elevated

4)Interdental incision is made

5)Triangular wedge of tissues is removed with

curette

6)All tissue tags and granulation tissue are

removed

7)After the scaling and root planing the flap

edge should rest on the root bone junction.

8)Flaps have been placed in their original site

and Sutured.

Post operative results

It can be used for both pocket eradication as well

as widening the zone of attached gingiva.

It can be a full thickness (mucoperiosteal) or a

split thickness (mucosal) flap.

INDICATIONS:

pocket eradication

increasing the width of attached gingiva

Used in cases of surgery on the buccal surfaces

of upper and lower jaws and

Lingual surfaces of lower jaw

CONTRAINDICATIONS:

Periodontal pockets in severe periodontal disease.

Periodontal pockets in areas where esthetics is critical.

Deep intrabony defects.

Patient at high risk for caries.

Severe hypersensitivity.

Tooth with marked mobility and severe attachment loss.

Palatal aspect of maxillary teeth, this is due to lack of

alveolar mucosa on palatal aspect

Tooth with extremely unfavorable clinical crown / Root

ratio.

DISADVANTAGES:

May cause esthetic problems due to root exposure.

May cause attachment loss due to surgery.

May cause hypersensitivity.

May increase the risk of root caries.

Unsuitable for treatment of deep periodontal

pockets.

Possibility of exposure of furcations and roots,

which complicates post operative supragingival plaque

control.

PROCEDURE for apically displaced flap

1. An internal bevel incision is made, it should be no more than 1mm from the crest of the gingiva and directed to the crest of gingiva.

2. Crevicular incisions are made, followed by initial elevation of the flap; then interdental incision and the wedge of tissue containing pocket wall is removed

3. Vertical incisions are made extending beyond the mucogingival junction.

Full thickness flap elevated by blunt dissection with periosteal elevator

Split –thickness flap elevated using sharp dissection with a bard- parker knife

4.After debridement of the areas

5.Sutures in place

PRE TREATMENT-

POST TREATMENT

PRE-TREATMENT BEFORE OSSEOUS RESECTION

FLAP APICALLY POSITIONED AND

SUTURED

POST-TREATMENT

CROWN LENGTHENING BY APICALLY DISPLACED FLAP

CROWN LENGTHENING BY APICALLY DISPLACED FLAP

PRE-TREATMENT

Before debridement After debridement

Incision

Sutures in place

Pre treatment Post treatment

FLAPS FOR REGENERATIVE SURGERY

Two flap designs are available for

regenerative surgery:

1. The papilla preservation flap&

2. The conventional flap with only crevicular incisions.

Entire papilla is incorporated into one of the flaps.

INDICATIONS:

•Where esthetics is of concern.•Where bone regeneration techniques are attempted

CONVENTIONAL FLAP FOR REGENERATIVE

SURGERY

In the conventional flap operation, the incisions for the facial and the lingual

or palatal flap reach the tip of the interdental papilla, thereby splitting the papilla into a

facial half and a lingual or palatal half.

INDICATIONS:

When the interdental areas are too narrow to permit the preservation of flap.

When there is a need for displacing flaps.

The interdental papilla is split beneath the contact point of the two approximating teeth to allow

for reflection of buccal and lingual flaps

DISTAL MOLAR

SURGERY

Treatment of periodontal pockets on the

distal surface of terminal molars is often

complicated by the presence of bulbous

fibrous tissue over the maxillary

tuberosity or prominent retromolar pads

in the mandible.

Operations for this purpose were

described by Robinson and Braden

Impaction Of A Third

Molar Distal To A

Second MolarLittle Or No

Bone Distal To

The Second

Molar.

Often Leads To A

Vertical Osseous

Defect Distal To The

Second Molar.

Typical incision design for a surgical

procedure distal to the maxillary second

molar.

Incision designs for

surgical procedures

distal to the mandibular

second molar.

The incision should

follow the areas of

greatest attached gingiva

and underlying bone.

Distal wedge

Triangular

Square , parallel or H-design

Linear or pedicle

The size, shape ,thickness and access

of the tuberosity or retromolar area

determine treatment procedures

ADVANTAGES

Maintainence of attached tissue

Access to treatment of both the distal

furcation and underlying osseous

irregularities

Closure by mature thin tissue

Greater opening and access when done

in conjunction with other flap procedures

limitation

Accessability or anatomy(ascending

ramus and external oblique ridge)

TRIANGULAR DISTAL

WEDGE:

Triangular wedge incisions are placed

creating the apex of the triangle close to

the hamular notch and the base of the

triangle next to the distal surface of the

terminal tooth.

Instrument used

no.12 or no.15 scalpel blade

scalers ,hoes , or knives

Outline of triangular

incision distal to molar

Cs view showing

wedge removal and

thick tissue

Undermining

incision used to

thin the tissue

Reflection of flap for

osseous correctionSurured tissue

LINEAR DISTAL WEDGE:

Two parallel incisions over the crest of the

tuberosity that extend from the proximal

surface of the terminal molar to the hamular

notch area.

Instruments used

no.15 blade

Periosteal elevators

Kirkland or orban knives

Two parallel incision

over tuberosity

joined by distal

releasing incision

Proper blade angulation

in making intial incision

C&d )Flap reflected

and tissue being

removed from

tuberosity using

periodontal knife

Bone exposed for

correction of osseous

irregularities Final suturing

preoperative

Probe showing 12mm pocket

Parallel incision made and

joined distally later with

perpendicular incision

Wedge removed

Lingual flap thinned by

secondary incision

Secondary flap

removed and bone

exposed

Wedge sutured

Post operative-3 months later

PERIODONTAL PACKS

Periodontal dressing or periodontal

packs is a productive materials applied

over the wound created by periodontal

surgical procedure

minimize postoperative infection and

hemorrhage

Facilitates healing

Protects against pain

Retention of packs Mechanically by interlocking in interdental

spaces and joining the facial and lingual portion

of the pack

Antibacterial properties

Improved healing and patient comfort –

incorporating antibiotics

Bacitracin, oxytetracycline , neomycin

nitrofurazone(hypersensitivity)

Instructions for patients after

surgery

1. The pack should remain in place until it

is removed in the office at the next

appointment

2. For the first three hours after the

operation avoid hot foods to permit the

pack to harden

3. Do not smoke

4. Do not brush over the pack

Postoperative complication

Persistent bleeding after surgery – pack

removed , bleeding stopped with

pressure ,electro surgery ,

electrocautery

Sensitivity to percussion-

Swelling- soft painless swelling in the

cheek , lymphadenopathy

Feeling of weakness

Removal of periodontal

pack After 1 week

Inserting a surgical hoe along the

margin and exert gentle lateral pressure

Pieces of pack- removed with scalers

Entire area rinsed with peroxide to

remove superficial debris

Findings at pack removal

Epithelialized but bleed readily when

touched

Pockets should not be probed

HEALING AFTER FLAP

SURGERY

Immediately after suturing (0 to 24

hours),established by a blood clot, which

consists of a fibrin reticulum with many

polymorph nuclear leukocytes, erythrocytes,

debris of injured cells, and capillaries at the

edge of the wound.

One to 3 days after flap surgery, the space

between the flap and the tooth or bone is

thinner, and epithelial cells migrate over the

border of the flap

One week after surgery‐The blood clot is

replaced by granulation tissue derived from

the gingival connective tissue, the bone

marrow, and the periodontal ligament.

Two weeks after surgery , collagen fibers

begin to appear parallel to the tooth

surface. Union of the flap to the tooth is

still weak, owing to the presence of

immature collagen fibers, although the

clinical aspect may be almost normal.

One month after surgery, a fully

epithelialized gingival crevice with a

well‐defined epithelial attachment is

present. There is a beginning functional

arrangement of the supra crestal fibers

conclusion

The entire surgical procedure should be planned in every detail before intervention is begun. This include type of flap ,exact location ,type of incisions , management of underlying bone and final closure of flap and suture

Although some details may be modified during actual performance of the procedure detailed planning allows for a better clinical result.

Reference

Atlas of cosmetic and reconstructive

periodontal surgery- EDWARDS

COHEN 3rd edition

Carranza’s Clinical periodontology –

NEWMANN , TAKEI ,CARRANZA- 9th

edition