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Periodontal Flap A periodontal flap is a section of gingiva and/or mucosa surgically-elevated from the underlying tissues to provide visibility of and access to the bone and root surface. INDICATIONS/OBJECTIVES OF FLAP SURGERY 1. Gain access for root debridement. 2. Reduction or elimination of pocket depth, so that patient can maintain the root surfaces free of plaque. 3. Reshaping soft and hard tissues to attain a harmonious topography (physiologic architecture). 4. Regeneration of alveolar bone, periodontal ligament and cementum.
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CLASSIFICATION OF PERIODONTAL FLAPS A. According to flap reflection or tissue content: a. Full thickness flap b. Split-thickness flap B. According to management of papilla: a. Conventional flap b. Papilla preservation flap C. According to flap placement after surgery: a. Non displaced flap b. Displaced flap: • Apical displaced flap • Coronal displaced flap • Lateral displaced flap
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Basic flap requirements: • Base of the flap must be wide enough to maintain an adequate blood supply • Flap must be big enough to expose any underlying bone defects • No important vessels or nerves should be damaged in raising the flap • Incisions must allow movement of flap without tension.
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INCISIONS For Conventional Flap 1. Horizontal Incision: • Internal bevel incision • Crevicular incision • Interdental incision 2. Vertical incision • Oblique releasing incision For Papilla Preservation Flap Crevicular incision with no incisions across the interdental papilla is given.
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Modified Widman Flap Presented in 1974 by Ramfjord and Nissle. Step 1: It is an initial, internal bevel incision 0.5 to 1 mm away from the gingival margin, directed to the alveolar crest. Vertical releasing incisions are not required (different from Widman flap). Step 2: Gingiva is reflected with a periosteal elevator Step 3: A crevicular incision is made. Step 4: After the flap is reflected, third incision is made in the interdental spaces with Orban's knife and the gingival collar is removed. Step 5: Tissue tags and granulation tissue are removed with a curette. The root surfaces are examined and scaled. Step 6: Bone architecture is not corrected, good approximation of flaps is necessary, hence sometimes flaps may have to be thinned. Step 7: Interrupted direct sutures are placed.
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Undisplaced Flap (internal bevel gingivectomy
internal bevel gingivectomy)
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HEALING AFTER FLAP SURGERY 0 to 24 hours blood clot 1-3 days after flap surgery epithelial cells migrate over the border of the flap
One week after flap surgery epithelial attachment to the root has been established by means of hemidesmosomes and a basal lamina
The blood clot is replaced by granulation tissue derived from gingival connective tissue, bone marrow and the periodontal ligament
Two weeks after surgery collagen fibers begin to appear parallel to the tooth surface. Union of the flap and the tooth
is still weak (due to immature collagen fibers) but clinically it appears almost normal
One month after surgery a fully-epithelialized gingival crevice with a
well-defined epithelial attachment is present
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