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Anja Ainamo 1992 in his 18 year follow up study after

Apically Repositioned flap surgery on the location of the

Mucogingival junction on 17 patients , 13 arrived for

recall approximately 18 years later 1 subject had died, 1

had lost all his teeth, 2 had moved out of the area, 3
presented with poor oral hygiene and showed

progression of disease


Probing depths in excess of normal often occur distal to the terminal tooth as a result of the adjacent tissue covering a portion of the crown.

presence of impacted third molar,or the soft tissue result of previous surgical removal of third molar frequently contributes to the severity of the probing depth found distal to the maxillary second molars.

existence of such problems is an indication for surgical soft tissue reduction.


The retromolar area of the mandible and the tuberosity area of the maxilla offer unique problems for the clinician. They generally have enlarged tissue, unusual underlying osseous topography and fatty glandular (retromolar area) mucosaltype tissue. Historically, while periodontal surgical techniques were being developed for other areas, gingivectomy was the treatment of choice in this area.


This problem was first addressed by Robinson in 1963 and later by Kramer and Schwartz(1964). But it was Robinsons classic article on the Distal Wedge Operation(1966) that outlined the indications and treatment procedures still used today. Distal Wedge Operation overcame the shortcomings of gingivectomy which did not allow treatment of irregular osseous deformities or access to maxillary distal furcation area.


Maintenance of attached tissue. access for treatment of both the distal furcation and underlying osseous irregularities. Closure by a mature thin tissue, which is especially important in the retromolar area. Greater opening and access when done in conjunction with other flap procedures


Access to the surgical site. Anatomical limitations- eg; ascending ramus or external oblique ridge.

Wedge designs
Triangular square, parallel or H-design. Linear or pedicle Size, shape, thickness, and access of the tuberosity or retromolar area determine treatment procedures.

Wedge design

Triangular wedge requires an adequate zone of keratinized tissue and can be used in a very short or small tuberosity. Square, parallel or H-design allows conservation of keratinized tissue and maximum closure. Also provides greater access to underlying topography and distal furcation. Indicated where tuberosity is longer.

Tuberosity Reductions
Tuberosity reduction procedures are commonly combined with buccal and palatal flap reflection, to gain access to the teeth and underlying bone for both debridement and osseous surgery procedures Inverse bevel triangular distal wedge (Mohawk procedure) Inverse bevel linear distal wedge procedure. Tuberosity pedicle flap (trapdoor) procedure.

Inverse Bevel Triangular Distal Wedge (Mohawk procedure)

This procedure is usually integrated with buccal and palatal inverse access incisions and flap reflection. The probe is used to sound through the mucogingival complex to bone,both horizontally and vertically to map the thickness of overlying tissue and the under lying bone configuration.


The location of the initial incision is dependant on the magnitude and thickness of the gingiva present,the presence and severity of the bone defects and the therapists estimation of where the final tissue position will be.


An initial palatal tracing incision is placed approximately 1mm in depth from the most mesial involvement,distally to the hamular notch. A bleeding line is established for further dissection before flap reflection. The initial tracing incision is extended apically to the bone thinning the flaps as it is made.

Mohawk procedure


The tuberosity tissue and collar of marginal tissue are removed using Ochsenbein #2 chisel. After removal of this soft tissue osseous resective surgery is completed and the distal bony defect is eliminated. The thinned flaps and tuberosity region are closed primarily and sutured

Inverse Bevel Linear Distal Wedge Procedure

Inverse bevel linear distal wedge procedure is similar to triangular distal wedge but the distal incision is made perpendicular to the parallel linear incisions extending past the MGJ buccally to end in mucosa. Palatally the distal incision is extended as far as the palatal tissue will be thinned. The thinned flaps and tuberosity region are closed primarily and sutured


This technique is of greater use in edentulous areas between existing teeth. It is particularly useful when the tuberosity has short anterior posterior dimension.

Tuberosity pedicle flap (trapdoor) procedure.

The trapdoor procedure was designed to manage maxillary tuberosity region in the presence of pockets depths. A straight incision is made from the distopalatal line angle of the terminal molar to the most posterior extant of the tuberosity. Two incisions are then made perpendicular to the initial incision.The first courses buccally through the distal pocket region and into the buccal gingiva and mucosa.


The second extends from the most distal aspect of the straight line incision out into the buccal mucosa. By undermining and thinning the tuberosity, pedicle flap tissue through split thickness dissection from the palatal to the buccal the pedicle flap is elevated and reflected buccally

Trap procedure


Internal bevel incisions are then extended from the distal of the terminal tooth anteriorly. After root debridement and osseous treatment, the flaps are closed primarily and sutured.


Excellent access to bone deformities.

Complete coverage of the tuberosity when properly executed and sutured.

Retromolar Pad Reductions

It is similar to maxillary tuberosity procedures however due to unique anatomical structures like anatomic concavity on the lingual aspect created by lateral flare of the ascending ramus,incisions must always be placed over bone.

Retromolar Inverse Bevel Triangular Distal Wedge

Initial incisions extend from the base of the triangle,at the distal aspect of the terminal molar posterior to the apex,which is skewed some what towards the buccal to maintain contact with the underlying bone.

Retromolar Inverse Bevel Linear Wedge Procedure

The lingual incision must be kept in contact with bone and must not be placed so far lingually as to risk trauma to the lingual nerve The distal perpendicular incision carries great risk to the lingual anatomic region hence most clinicians prefer either triangular or trap door approaches.

Retromolar modified pedicle flap procedure (Braden Modifications)

In 1969 Braden suggested a modification that simplifies the procedure and is particularly useful where the pad is fibrous in nature. Here the retromolar tissue remains either the component of either the buccal or the lingual flap.

Braden buccal retro molar flap reflection

Initial facial scalloped inverse bevel incision is carried around the distal aspect of the tooth to the distolingual line angle where it meets the scalloped lingual incision A secondary incision then extends from the disto lingual line angle distally but parallel and slightly buccal to the lingual border of the retromolar triangle,to the distal of the retromolar pad.

Braden buccal modification

Braden lingual modification

Healing after flap surgery

Immediately after suturing (0 to 24 hours),a connection between the flap and the tooth or the bone surface is established by a blood clot which consists of fibrin reticulum with many polymorphonuclear leucocytes,erythrocytes ,debris of injured cells,and capillaries at the edge of the wound. A bacteria and an exudates or transudate also results from tissue injury.

Healing after flap surgery

One to three days- after flap surgery the space between the flap and the tooth and bone are thinner and epithelial cells migrate over the over the border of the flap usually contacting the tooth at this time. when the flap is closely adapted to the alveolar process there is only a minimal inflammatory response.

Healing after flap surgery

One week after surgery -An epithelial attachment to the root is established by means of hemidesmosomes and a basal lamina.The blood clot is replaced by granulation tissue derived from the CT,The bone marrow and the PDL Two weeks after surgery- collagen fibers bigen 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

Healing after flap surgery

One month after surgery A fully epithelialised gingival crevice with a well defined epithelial attachment is present there is a beginning functional arrangement of the supracrestal fibers

Modified Widman flap

During the healing phase bone resorption takes place together with bone regeneration width ways .A long junctional epithelium is inter posed between the regenerated tissue and the root surface. During tissue maturation (6-12months ) moderate apical migration of the gingival margin occurs.

Apically positioned flap

Bone reshaping is performed and the flap is positioned at the crest

The bone continues to be reabsorbed and there is attachment loss During tissue maturation (6-12 months) a certain amount of regeneration of the bone and coronal attachment apparatus occurs.


Longitudinal studies have shown (1st European Workshop on Periodontology1993) that the various surgical methods are equally effective in decreasing pocket depth and controlling the progression of chronic adult periodontitis.



Surgical approach differs All attached, keratinized and no elastic properties. No apical or coronal displacement is possible

No split thickness flap is possible

If thick may complicate healing Thinning of the flap can be done holding it with mosquito hemostat or Adsons forceps and .


In order to preserve the interdental soft tissues for maximum soft tissue coverage following surgical intervention involving treatment of proximal osseous defects. Takei et al. (1985) proposed a surgical approach called papilla preservation technique. Later, Cortellini et al. (1995, 1999) described modifications of the flap design to be used in combination with regenerative procedures. i.e. modified papilla preservation flap (MPPF) and simplified papilla preservation flap (SPPF). For esthetic reasons, the papilla preservation technique is often utilized in the surgical treatment of anterior tooth regions. Technique :


The surgical approach to the palatal area differs from that for other areas because of the character of the palatal tissue and the anatomy of the area. The palatal tissue is all attached, keratinized tissue and has none of the elastic properties associated with other gingival tissue. Therefore the palatal tissue cannot be apically displaced, nor can a partial (split) thickness flap be accomplished. The initial incision for the palatal flap should be such that when the flap is sutured, it is precisely

The palatal tissue may be thin or thick, it may or may not have osseous defects, and the palatal vault may be high or low. These anatomic variations may require changes in the location, angle, and design of the incision. If the tissue is thick, a horizontal gingivectomy incision may be made, followed by an internal bevel incision that starts at the edge of this incision and ends on the lateral surface of the underlying bone. The placement of the internal bevel incision must be done in such a way that the flap fits around the tooth without exposing the bone. Flaps should be thin to adapt to the underlying

A sharp, thin papilla positioned properly around the interdental areas at the tooth-bone junction is essential to prevent recurrence of soft tissue pockets. The edge of the flap should be thinner than the base; therefore the blade should be angled toward the lateral surface of the palatal bone. The dissected inner connective tissue is removed with a hemostat. As with any flap, the triangular papilla portion should be thin enough to fit snugly against the bone and into the interdental area. The principles for the use of vertical releasing incisions are similar to those for using other

DISTAL WEDGE PROCEDURES OR DISTAL MOLAR SURGERY In many cases the treatment of periodontal pockets on the distal surface of distal molars is complicated by the presence of bulbous tissues over the tuberosity or by a prominent retromolar pad. The most direct approach to pocket elimination in such cases in the maxilla is the gingivectomy procedure. The incision is started on the distal surface of the tuberosity and carried of forward to the base of the pocket of the distal surface of the molar. However, when only limited amounts of keratinized tissue are present, or none at all, or if a distal angular bony defect has been diagnosed, the bulbous tissue should be reduced in size rather than being removed in toto. This may be accomplished by the distal wedge procedure (Robinson 1966). This technique facilitates access


Patient should be given analgesics and antibiotics and told to start the tablets before the effect of anesthesia wears off and continue the tablets for the require duration of time. Aspirin should be avoided as it causes bleeding. Patient should be instructed that he should not consume any food for few hours after the placement of periodontal pack (until it hardens) to prevent it from dislodgment. In case the pack gets dislodge, the patient should immediately consult his periodontist. For the first 24 hours, patient should avoid hot liquids and should have only semisolid or minced

Citrus fruits, fruit juices, alcoholic beverages and highly spiced foods should be avoided. Patient should not smoke. Patient should be asked to take adequate bed rest and avoid speaking. Patient should be advised not to brush on the operated area and use chlorhexidine mouthwash. Patient should not try to remove the periodontal dressing himself. In case of bleeding he should immediately contact the periodontist and avoid spitting. To ease any postoperative swelling, patient should apply cold pack.

THE FIRST POSTOPERATIVE WEEK The periodontal pack is removed after 1 week. The area is irrigated with a sterile saline solution and sutures are removed. Properly performed periodontal surgery does not present any postoperative complications.
After a flap operation, the areas corresponding to the incisions are epithelialized but may bleed when touched. They should not be disturbed and pockets should not be probed. The lingual and facial mucosa may be covered with a grayish yellow or white granular layer of food debris that has spread under the pack. This is

HEALING AFTER FLAP SURGERY: (Carranza and Newman) Immediately after suturing (0 to 24 hours): Connection established between the flap and the tooth / bone surface via blood clot. Blood clot consists of a fibrin reticulum with many PMN leucocytes, erythrocytes, and debris from injured cells and capillaries at the edge of the wound (Caffesse et al 1968). Bacteria and an exudates or transudate as a result of tissue injury are also present. One to three days after surgery: Space between the flap and the tooth or bone is thinner and epithelial cells migrate over the border of the flap usually contacting the tooth at this time. When the flap is closely adapted to the alveolar process, there is only a minimal inflammatory response.

One week after surgery: Epithelial attachment to the root is established by means of hemidesmosomes and a basal lamina. The blood clot is replaced by a granulation tissue derived from a 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. Clinical aspect may appear almost normal. One month after surgery: A fully epithelialized gingival crevice with a well defined epithelial attachment is present. There is a beginning of functional arrangement of


Superficial bone necrosis at one to three


Osteoclastic resorption follows and reaches a peak at four to six days declining thereafter (Staffileno et al 1962).

The resultant bone loss is about 1 mm (Cafesse et al 1968, Wilderman 1970).

Greater bone loss if the bone is thin

Other Flap Designs for Periodontal Plastic Surgeries

The coronally repositioned periodontal flap, has been reported by many different people in the literature. Kalmi (1949), first described a type of coronal repositioned flap that was performed after

a gingivoplasty of the attached gingiva.

Bernimoulin et al. (1975), reported on the clinical evaluation of a two-step Coronally repositioned periodontal flap. Semilunar coronally repositioned flap" (Tarnow



E. Grupe and Richard F. Warren (1956) introduced contiguous soft tissue autografts to the literature under the term "lateral sliding flap".

of the laterally positioned pedicle graft include the double papilla graft (Cohen and Ross 1968) and the oblique rotated graft (Pennel et al

Flaps for Subepithelial Connective Tissue Graft



coronally advanced

technique by eliminating
the vertical incisions and introducing sulcular incisions on adjacent


suggested an envelope technique for isolated root coverage.


sulcular epithelium of the affected tooth is removed. A partial thickness envelope is created in the tissues surrounding the recession. A graft twice the width of the area of recession is placed into


in his

technique elevated

Full thickness pedicle

flaps on either side of

the defective area with

care not to jeopardize the interdental papilla or periodontal coverage of adjacent


presented the supraperiosteal envelope for use in multiple adjacent areas of recession. (Tunnel technique). Blanes and Allen combined a tunnel with lateral pedicle flaps to treat adjacent areas of recession. Double split thickness lateral pedicle flaps are elevated at the level of the CEJ at the proximal extent of the recession and extended apically 10-12 mm. A tunnel is created under the tissue remaining

Clinical periodontology and Implant dentistry Jan Lindhe 5th edn Clinical Periodontology; Carranza 10th edn Outline of Periodontics. Manson and Eley;4th edn

Nevins Periodontal therapy

Periodontal surgery A clinical Atlas Sato Periodontics Genco, Rose, Mealey Atlas of cosmetic and reconstructive periodontal surgery Cohen 2nd edn

Conclusion The success of flap operations depend on multiple clinical considerations such as anatomy, correct flap positioning, adaptation and maintenance, and prevention of bacterial plaque accumulation. Loose sutures or muscular activity may create spaces filled with a large clot that could be temporarily detrimental to reattachment. Digital pressure applied to the flap for several minutes immediately after



Dr.Jyothi S.G.


The palate, unlike other areas, is composed mainly of dense collagenous connective tissue. This fact precludes the palatal tissue from being positioned apically, laterally, or coronally. Therefore, surgical techniques are required that allow the tissue to be thinned and apically positioned at the same time.

Historical Review

The palatal flap procedure historically involved reflecting a full-thickness flap to gain access to the underlying bone and remove necrotic and granulomatous tissue. Ochsenbein and Bohannan (1963, 1964) described a palatal approach for osseous surgery (A) Full-Thickness Flap, (B) Partial-Thickness Palatal Flap. (C) Modified Partial-Thickness Flap,

The objective and result of all three are the same a thin, even-flowing gingival architecture that closely approximates the underlying bone. Ochsenbein and Bohannan, in comparing the palatal and buccal approaches to osseous surgery, noted the following advantages, disadvantages, and indications of the palatal approach.

Advantages of Palatal Approach

1.Esthetics 2.Easier access for osseous surgery 3.Wider palatal embrasure space 4.A naturally cleansing area 5.Less resorption because of thicker bone

Disadvantages of Buccal Approach

1. Esthetics 2.Closeroot proximity 3.Possible involvement of the buccal furcation 4. Thin plate of bone overlying the maxillary molars where dehiscences and fenestrations may be present.

1.Areas that require osseous surgery 2. Pocket elimination 3.Reduction of enlarged and bulbous tissue

when a broad, shallow palate does not permit a partial-thickness flap to be raised without possible damage to the palatal artery.

Diagnostic Probing

Before beginning the operation, but after adequate administration of anesthetic, periodontal probing bone sounding for the underlying osseous topography is indicated (Easley, 1967). This is especially important on the palate, where frequently the tissue is enlarged and bulbous with underlying heavy bony ledges and exostoses. These exostoses frequently occur in second and third molar areas.

Sounding permits one to discriminate between dense fibrotic tissue and enlarged tissue resulting from the osseous irregularities. Furthermore, because palatal tissue cannot be repositioned, failure to access the underlying topography adequately often results in a flap that is either too long or too short.

Note that, even though the tissue appears to be the same in all instances and the results may be the same, the incisions vary according to the underlying osseous topography.

Full thickness palatal flap


This technique was developed by Staffileno (1969) to overcome some of the problems of extensive gingival resection and to facilitate treatment of palatal osseous defects, which until then was approached cautiously.

Advantages: Minimal trauma Rapid healing Ease of palatal tissue manipulation Establishment of favorable gingival contours

Presurgical Phase: the operator sounds for the underlying osseous topography. This is very important because the flap cannot be repositioned after the initial incision. A short flap will result in bone exposure and long flap will have to be trimmed, which is difficult and leaves thick marginal tissue.

The thicker the tissue, the more exaggerated the scalloping of the incision. For this reason, the exact thickness of the tissue must be determined at the start. Underlying osseous irregularities and osseous resection techniques must also be anticipated.

Surgical Phase:

The primary incision is made with a No. 15 (usually) or No. 12 (if access is limited) scalpel blade. It is usually begun at the margin of the last tooth in the tuberosity area as an extension of the distal wedge procedure. It is continued forward, using a scalloped, inverse beveled, partial-thickness incision to create a thin partial-thickness flap.

The blade of the scalpel should always be kept on the vertical height of the alveolus. This prevents unnecessary involvement or cutting of the palatal artery. Once the initial part of the primary incision has been completed, the tissue may be retracted with rat-tail pliers for completion of the incision. Upon completion, the scalpel blade is directed toward the bone to score it at the base of the flap.

This separates the periosteum in this area and permits easy removal of the secondary flap from bone. Without this scoring, it is more difficult to remove the secondary inner flap and generally results in a torn, ragged periosteal tissue with many tags.

A secondary sulcular incision is now completed both facially and interproximally, using a No. 15 or No. 12 scalpel blade down to the crest of the bone. This incision frees the coronal aspects of the inner or secondary flap, permitting removal.

Ochsenbein chisels (Nos. 1 and 2) are now used from both the occlusal and apical extensions of the flap to completely free and remove the secondary inner flap. If the periosteum has not previously been scored, this procedure will be more difficult and leave a torn, ragged periosteum. A Friedman rongeur may also be used to remove the secondary inner flap.

It is important to note that the inner 20 flap of connective tissue that has been removed can now be trimmed and used for a free connective-tissue autograft (Edel, 1974) or as part of a subepithelial connective-tissue graft (Langer and Colagna, 1980 Langer and Langer, 1985).


Ochsenbein 1958, and Ochsenbein and Bohannan in 1963 described this technique, but it was not until 1965 that it became popularized by Prichard. It has also become known as the ledgeand-wedge technique.

This is a two-stage procedure main disadvantage- the fact that healing interdentally is by secondary intention. This fact precludes the use of this procedure with such procedures as the Modified Widman flap, E.N.A.P., osseous grafting, and any others that require primary closure. This procedure also requires a certain degree of technical skill or the palatal artery can be damaged easily

Presurgical Phase:

With the patient under adequate anesthesia, sounding is carried out to determine the underlying osseous topography, pocket depth, and thickness of the tissue. This stage is not as critical as it is in the single-stage procedure because the firststage gingivectomy incision will allow visualization of tissue thickness.

Surgical Phase:

Stage I: Gingivectomy Stage II: Partial-Thickness Flap

It is necessary to mark the base of the pockets with pocket markers. A periodontal probe may be used to estimate pocket depth. A periodontal knife is used to resect the tissue above the crest of bone. Unlike the basic gingivectomy technique, no bevel is placed. A tissue ledge is established to allow visualization of tissue thickness and permit easier placement of the primary palatal incision.

Sometimes it may not be desirable to make the gingivectomy incision down to the base of the pocket, especially on thicker tissue. When such tissue is thinned and falls back against the bone, it will be short of the bony crest. This can result in excessive bone exposure and postoperative discomfort.


Similar to the partial-thickness palatal flap.

Common Mistakes

The short flap: This generally is the result of too deep a primary incision, gingivectomy to the crest of bone of a thick tissue, or use of a beveled gingivectomy. This results in delayed healing and increased patient discomfort. Poor marginal flap adaptation caused by incomplete thinning of the tissue: The margin of the flap stands away from the tooth when the flap is replaced. This can be corrected either by additional thinning of the inner flap surface close to the base of the original incision or by more osteoplasty.

Incision beyond the vertical height of the alveolus, bringing the scalpel blade in the close proximity to the palatal artery: Cutting the palatal artery can be especially dangerous. Extension beveling or thinning of tissue on a low, broad palate invites damages to the palatal artery. Tissue placement high onto the teeth results in poor adaptation and recurrent pocket formation. This can be corrected by proper trimming at the time of flap placement prior to suturing;


The retromolar area of the mandible and the tuberosity area of the maxilla offer unique problems for the clinician. They generally have enlarged tissue, unusual underlying osseous topography, and in the case of the retromolar area, a fatty, glandular, mucosal type tissue. Historically, while periodontal surgical techniques were being developed for all other areas, development in this one area remained stagnant, and gingivectomy was the treatment of choice. This problem was first addressed by Robinson in 1963 and later by Kramer and Schwartz (1964)

Maintenance of attached tissue Access for treatment of both the distal furcation and underlying osseous irregularities. Closure by a mature thin tissue, which is especially important in the retromolar area. Greater opening and access when done in conjunction with other flap procedures. The main limitation is only of access or anatomy (e.g., ascending ramus or external oblique ridge).

Wedge Design :
Triangular Square, parallel, or H-design Linear or pedicle


To avoid the difficult healing with vestibular incisions and at the same time provide adequate implant coverage, especially when augmentation procedures are required, Langer and Langer (1990) recommended a palatal approach.

1. 2.

The use of overlapping flaps prevents flap opening and implant exposure. Facilitates healing and reduces postoperative trauma.


Localized ridge deformities of varying severity usually occur after tooth loss as a result of advanced periodontal disease, root fracture, extensive root caries, and / or periapical pathology. Ridge deformity could also be the result of trauma or traumatic tooth extraction in which the labial plate is fractured, destroying the 4-walled socket in which blood clots form and are protected.


Various modifications of palatal flap designs help in managing special situations like treatment of osseous defects, implant coverage, closure of oroantral fistula, ridge augmentation etc. Thus, designing the palatal flaps benefit a lot to the periodontal plastic surgeries.


The Periodontal Flap Surgery

Presented by Dr. Neeta Bhavsar

Types of Sutures

SUTURING The purpose of suturing is to maintain the flap in the desired position until healing has progressed to the point where sutures are no longer needed.

Suture materials

The resorbable sutures have gained popularity since they enhance patient comfort and eliminate suture removal appointments. The monofilament type of suture alleviates the "wicking effect" of braided sutures that may allow bacteria from the oral cavity to be drawn through the suture to the deeper areas of the wound. classification of the sutures available today: The nonresorbable, braided silk suture was the most commonly used in the past due to its ease of use and low cost. The expanded polytetrafluoroethylene synthetic monofilament is an excellent nonresorbable suture widely used today. The most commonly used resorbable sutures are the natural, plain gut and the chromic gut. Both are monofilaments and are processed from purified collagen of either sheep or cattle intestines. The chromic suture is a plain gut suture processed with chromic salts to make it resistant to enzymatic resorption, thereby increasing the resorption time. The synthetic resorbable sutures are also often used.

Suturing Technique
1 Interdental Ligation a. Direct or loop suture b. Figure Eight suture 2 Sling Ligation 3 Horizontal mattress suture 4 Cjontinuous, Independent Sling suture 5 Anchor Suture 6 Closed Anchor Suture

Suturing Technique

The needle is held with the needle holder and should enter the tissues at right angles and no less than 2 to 3 mm from the incision. The needle is then carried through the tissue, following the needle's curvature. The knot should not be placed over the incision.

The periodontal flap is closed either with independent sutures or with continuous, independent sling sutures. The latter method eliminates the pulling of the buccal and lingual or palatal flaps together and instead, uses the teeth as an anchor for the flaps. There is less tendency for the flaps to buckle, and the forces on the flaps are better distributed. Sutures of any kind placed in the interdental papillae should enter and exit the tissue at a point located below the imaginary line that forms the base of the triangle of the interdental papilla

Fig. If the elevation of the flap is slight or moderate, the sutures can be placed in the quadrant closest to the teeth. If the flap elevation is substantial, the sutures should be placed in the central quadrants of the palate. One may or may not use periodontal dressings. When the flaps are not apically displaced, it is not necessary to use dressings other than for patient comfort.

The location of sutures for closure of a palatal flap depend on the extent of flap elevation that has been performed. The flap is divided in four quadrants as depicted in

Placement of suture in the interdental space below the base of an imaginary triangle in the papilla

Interdental Ligation.

Two types of interdental ligation can be used: 1. the director loop suture (Fig) and 2. the figure-eight suture (Fig).

first flap. B, The undersurface of the opposite flap is engaged, and the suture is brought back to the initial side (C), where the knot is tied (D).

1 the director loop suture The direct suture permits a better closure of the interdental papilla and should be performed when bone grafts are used or when close apposition of the scalloped incision is required. 2 the figure-eight suture In the figureeight suture, there is thread between the two flaps. This suture is therefore used when the flaps are not in close apposition because of apical flap position or nonscalloped incisions. It is simpler to perform than the direct ligation.

and the outer surface of the opposite flap (B). The suture is brought back to the first flap (C), and the knot is tied (D).

Sling Ligation.

The sling ligation can be used for a flap on one surface of a tooth that involves two interdental spaces (Fig.)

C, The outer surface of the same flap of the adjacent interdental area is engaged. D, the suture is returned to the initial site and the knot tied.

Horizontal Mattress Suture.

This suture is often used for the interproximal areas of diastmata or for wide interdental spaces to properly adapt the interproximal papilla against the none. Two sutures are often necessary. The horizontal mattress suture can be incorporated with continuous, independent sling sutures as shown in figure

The penetration of the needle is performed in such a way that the mesial and distal edges of the papilla lie snugly against the bone. The needle enters the outer surface of the gingiva and crosses the undersurface of the gingiva horizontally. The mattress sutures should not be close together at the midpoint of the base of the papilla. The needle reappears on the outer surface at the other base of the papilla and continues around the tooth with the sling sutures.

around diastemata or wide interdental areas (B and C). This mattress suture is utilized on both the buccal (D) and the lingual (E and F) surfaces. Continuation of suture on lingual surfaces (G to 1) and completed suture (J).

Anchor Suture. The closing of a flap mesial or distal to a tooth, as in the mesial or distal wedge procedures, is best accomplished by the anchor suture. This suture closes the facial and lingual flaps and adapts them tightly against the tooth. The needle is placed at the line angle area of the facial or lingual flap adjacent to the tooth, anchored around the tooth, passed beneath the opposite flap, and tied. The anchor suture can be repeated for each area that requires it (Fig).

A to D, Distal wedge suture. This suture is also used to close flaps that are mesial or distal to a lone-standing tooth

Closed Anchor Suture. Another technique to close a flap located in an edentulous area mesial or distal to a tooth consists of tying a direct suture that closes the proximal flap, carrying one of the threads around the tooth to anchor the tissue against the tooth, and then tying the two threads (Fig.).

closed anchor suture, another technique to suture distal wedges.

Periosteal Suture.
This type of suture is used to hold in place apically displaced partial thickness flaps. There are two types of periosteal sutures:
1 the holding suture and The holding suture is a horizontal mattress suture placed at the base of the displaced flap to secure it into the new position. 2 the closing suture. Closing sutures are used to secure the flap edges to the periosteum. Both types of periosteal sutures are shown in Fig.

Periosteal sutures for an apically displaced flap. Holding sutures, shown at the bottom, are done first, followed by the closing sutures, shown at the coronal edge of the flap.


Immediately after suturing (0 to 24 hours), a connection between the flap and the tooth or bone surface is established by a blood clot, which consists of a fibrin reticulum with many polymorphonuclear leukocytes, erythrocytes, debris of injured cells, and capillaries at the edge of the wound. A bacteria and an exudate or transudate also result from tissue injury. 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, usually contacting the tooth at this time. When the flap is closely adapted to the alveolar process, there is only a minimal inflammatory response.

One week after surgery, an 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 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

Full-thickness flaps, which denude the bone, result in a superficial bone necrosis at 1 to 3 days; osteoclastic resorption follows and reaches a peak at 4 to 6 days, declining thereafter. This results in a loss of bone of about 1 mm", the bone loss is greater if the bone is thin.




Flap surgery- Concepts and rationale

Morrison (1980) studied 90 patients with advanced periodontitis over a period of 4 weeks.
Pocket depth Mean initial probing depth 2.29 mm 4.56 mm 7.56 mm Mean final probing depth 2.13 mm 3.59 mm 5.35 mm

1-3mm 4-6mm >7mm

Baderstein (1984) a probing depth reduction of 0.5 mm, 1.0 1.5 mm 2.5 5.0 mm respectively.

Claffey (2000) in his review reported the following attachment levels after N.S.T
Pocket depth 1-3.5 mm 4-6.5 mm >7 mm A.H. gains -0.5 mm (att loss) 0-1 mm 1-2 mm

Probing depth indicated by blue lines before and after N.S.T Recession = green line


Good access to root and bone surface Good post-op adaptation of tissues to tooth surface


Heals by long junctional epithelium and not by new attachment Presence of residual probing depths in the presence of infrabony defects


Removal of the pocket lining allows more access to the periodontal ligament cells to populate in the region and give rise to new attachment

Access to root surface is increased with less morbidity

Undisplaced flap

internal bevel gingivectomy Differs from the modified widman flap in that the soft tissue pocket wall is removed with the initial incision

Ind- adequate amount of attached gingiva even after

elimination of the pocket wall

eg diffuse gingival enlargements, palatal flap

Dead space formation is reduced as flap margin over the alveolar crest To avoid creation of a mucogingival problemadequate attached gingiva should remain after the removal of poket wall

Internal bevel for an undisplaced flap

Apically positioned flap

Naber (1954)repositioning of attached gingiva Ariaudo and Tyrelli (1957)- two vertical incisions Friedman (1962)- apically repositioned flap

Either full thickness or split thickness

Indications Pockets extending beyond mucogingival line Narrow zone of keratinized gingiva Crown lengthening procedure for restorative and prosthodontic purposes

Contraindications Esthetically critical areas Teeth with severe attachment loss Deep infrabony pockets pts with high caries rate/ severe hypersensitivity

Friedman and Levin Classification

Class I: Wide and sufficient keratinized gingiva width (46 mm)

Full thickness flap is reflected which covers the marginal bone and 1-2 mm coronally

Class II: Sufficient keratinized gingiva width

Full or partial thickness flap at the level of the alveolar crest

Class III- Insufficient gingival kertinized width

full or partial thickness flap more augmentation of attached gingiva


Eliminates periodontal pocket Preserves keratinized gingiva Establishes good gingival morphology Provides necessary biologic width for restorative procedures


Results in root exposure May lead to clinical attachment loss Outcome depends on healing

Special anatomic situations

Palatal pockets Distal pockets

1. Palatal pockets

Attached keratinized epithelium No elastic fibres Neurovascular bundles


Gingivectomy Ledge wedge procedure

Beveled flap
Undisplaced flap

Ledge wedge procedure

1. Horizontal incision 2. Internal bevel incision 3. Third incision

Bevelled flap ( Friedman)

Palatal flap

Ochsenbein and Bohannan in 1963, 196

3 designsFull thichness flap Modified partial thickness Partial thickness flap

Advantages of palatal approachEsthetics Less resorption because of thicker bone Wider palatal embrassure space

Full thickness flap Modified partial thickness Partial thickness flap

Partial thickness flap

Indications Areas that require osseous surgery Pocket reduction Reduction in enlarged bulbous tissue Contraindications Broad shallow palate- damage to palatal vessels

Distal wedge procedure

Robinson (1966)

1. Presence of bulbous tissues over the tuberosity 2. A prominent retromolar pad in the mandible 3 .Inadequate attached gingiva 4. Abruptly ascending tuberosity 5. A close ascending ramus of the mandible

Factors Accessibility

Amount of keratinized gingiva Pocket depth Available distance from distal aspect of tooth to end of tuberosity

& retromolar pad

Anatomical considerations

- lingual nerve - Internal oblique ridge - Muscle attachment

Distal wedge- triangular design

Distal wedge- square, parallel or H design

Linear or pedicle design


Access for treatment of distal furcation and underlying osseous irregularities

Maintenance of attached gingiva

Inverted periostel graft

Inverted periosteal flap

Double split flapThalmair (2009)

Osseous surgery for pocket elimination

Schluger (1949), Goldman (1950), Friedman (1955)

Gingival contour is dependent on the underlying bony contour and the elimination of the soft tissue pockets has to be combined with osseous recontouring.


Friedman in 1955 Reshaping of alveolar bone to achieve a more physiological form without removal of tooth supporting bone


Removal of tooth supporting bone to reshape the deformities.

Indications Elimination of interdental craters Correction of one walled defects Other angular defcts not amneable to regeneration

Selection of a surgical technique

Suprabony, fibrous pocket with sufficient attached gingiva- Gingivectomy Infrabony pocket, furcation inv, osseous deformities, muco-gingival problems- Flap surgery

Location Amount of attached gingiva Need for osseous recontouring

Healing of flaps
Caffesse et al. (1968)- reverse bevel flap Histological examination- 2hrs,13hrs and 1, 2, 3, 5, 9, 14, 21, 35 & 72 days

2hrsNarrow zone of necrosis covered by clot Few PMNs Alveolar process show empty lacunae 13 hrsUsual arrangement of cementoblasts missing on root surface0.5mm from flap

1 dayThick band of PMNs Epi cells not started to migrate

2 days-

Epi cells started to migrate & cover 0.1- 0.2 mm of

inner surface of CT Angioblasts & fibroblasts seen Interproximal bone shows necrosis

3 daysEpi makes contact with tooth surface Inflammatory reaction is less severe CT grows betw flap and bone Formation starts from PDL, marrow space & margins

5 daysPartial establishment of contact Granulation tissue is present over PDL & alv crest Osteoclasts at crest originate form marrow space

7 daysEpi attachment to enamel Flap adheres by granulation tissue Osteoclastic activity

9 daysGingival crevice epitheliazed New epi attachment formed Severe osteoclastic activity 14 daysAlternative osteoclastic & osteoblastic activity New periosteum Immature collagen seen

21 daysFully epi gingival crevice & Well defined epi attachment Functional arrangement of supracrestal fibres Periosteum- not fully matured
35 daysOsteoblastic activity at crest

72 daysWell defined epi attachment Keratinization of gingiva Periosteum appears normal Layers of newly formed bone on alveolar crest

Ramfjord et al. (1968)

Partial thickness flapsRepair of epi & CT is same Reaction of alveolar bone Osteoclastic activity starts at 4th day- 2 weeks Full thicknessResorption begins at 7-14 days- several weeks

Long term studies comparing surgical and non- surgical therapies

Study Michigan studies 1. Ramfjord et al. (1968) 32 pts- mod- sev pditis Short term observation -Subgingival curettage (1-3 years)- pocket elimination ( APF with osseous Curettage- slight gain reduction / gingivectomy) Pocket elimination techloss in attachment Long term observation (4-7 yrs)No sig diff More pocket reduction with surgical Method Observations & conclusions

Gothenburg study

Lindhe et al. (1982)

Gothenburg study VI 2 yrs post-op15 pts RP or RP & MWF Split mouth design More PD reduction with surgical Critical probing depth For RP- 2.9mm For flaps 4.2mm

Minnesota Study Ahlstrom et al. (1983) SRP alone vs Flaps 6 yrs follow up No sig pocket depth reduction Attachment gain greater in flap procedures for deeper pockets

Aarhus Study: Isidor and Korning (1986) compared the effect of root planing and modified widman flap to apically positioned flap during 5 year of follow up. They obtained similar results for both the treatment.

Washington Study: Oslen et al (1985) compared apically positioned flap without osseous recontoring to a.p.f. with osseous recontouring in a 5 year follow up study. They concluded that the osseous recontouring was more effective in reducing pockets and controlling the inflammation than flap surgery.

Tucson studies Becker et al. (1988) RP, MWF APF with osseous reduction Min diff betw 3 procedures

1 yr observation

Nebraska studies Kaldahl et al. (1988) 82 pts 2 yrs- split mouth design Sc, RP, MWF, MWF with osseous reduction Reduction in PD- all PocketMWF with red> MWF> RP> Sc Gain in CALMWF & RP- greatest gain All- except scaling

Interpretation of longitudinal studies

Non-surgical therapy is the corner stone of periodontal therapy in all types of pocket depths.

surgical techniques have produced greater pocket depth reduction no difference on long term evaluation.

S.R.P. will always be performed first on any patient suffering from moderate periodontal pockets. Shallow pockets should not treated by surgical therapy as it may result in C.A.L. Moderate/Advanced pockets can be treated by tailor made surgical techniques to suit the patients condition.
proper regular maintenance is paramount for success of therapy.

Failures of flap surgery

Divided into

1)Pretherapeutic causes

2)Therapeutic causes
3)Posttherapeutic causes

Pretherapeutic causes 1) Incorrect patient selection


2) Improper diagnosis Systemic condition

Type of periodontitis
Involvement of hopeless tooth oral hygiene assessment

3) Inappropriate dental restorations

4)Morphology of tooth surfaces

- Failure to eliminate abberations like resorptive lacunae ,

enamel pearls and grooves which act as a guide plane for a bacterial penetration of deeper periodontal tissues


- mouth breathing ,
- bruxism - thumb sucking - smoking

6)Occlusal trauma

Therapeutic causes
1. Improper selection of surgical technique

width of attached gingiva height of remaining bone pocket depth mobility co-operation of the patient patients systemic back ground.

decreased width of attached gingiva- internal bevel

incision will further decrease the width of attached gingiva leading to mucogingival problems.

Surgical technique which does not allow proper adaptation of interdental tissue will lead to food and plaque accumulation in the interproximal area and therapy leads to recurrence of periodontal disease.

Improper asepsis of the surgical field and patient, improper sterilization of the instruments.

2. Improper flap design:

A properly designed flap will anatomically fall into its correct position on its bony base following surgery. If a mucoperiosteal flap is not designed correctly it may

Rise too high coronally- redundant tissue with subsequent repocketing Fall far short of the osseous margin- resorption or sequestra formation Inadequately cover the bone graft- minimizing the opportunity for ideal healing.

Inadequate thinning of the full thickness flap (palatal flap), results in an excessively thick bulky gingival margin -gingivoplasty

It may also encourage the overzeolous tightening of the sutures, thereby

endangering the blood supply and enhancing the possibility of sloughing of

flap and post operative pain

3. Incomplete debridement

4. Improper suturing

Post therapeutic causes

1. Unsupervised healing-

- Post-operative care

2. Inadequate restorations post surgically-

- failure to replace missing teeth - correct overhanging restorations - correct carious lesions


Pocket elimination is considered to be one of the main goals of periodontal therapy.

Clinical studies comparing non- surgical and surgical therapy for the treatment of shallow to moderate pockets showed similar long term results.

However, in cases of deep pockets, surgical therapy showed better results.

Whatever maybe the choice of treatment modality, it is the detailed thoroughness of root debridement and

patients standards of oral hygiene , which determine the

long term maintenance of the periodontium.

Thank you!

Thank you

Surgical Technique For Undisplaced Flap INCISION

Step 1: The pockets are measured with the periodontal probe, and a bleeding point is produced on the outer surface of the gingiva to mark the pocket bottom. Step 2: The initial, internal bevel incision is made after the scalloping of the bleeding marks on the gingiva . The incision is usually carried to a point apical to the alveolar crest, depending on the thickness of the tissue Step 3: The second or crevicular incision is made from the bottom of the pocket to the

ELEVATION OF Step FLAP 4: The flap is reflected with a

periosteal elevator (blunt dissection) from the internal bevel incision. Usually there is no need for vertical incisions because the flap is not displaced apically. Step 5: The interdental incision is made with an interdental knife, separating the connective tissue from the bone. Step 6: The triangular wedge of tissue created by the three incisions is removed with a curette.


Step 7: The area is debrided, removing all tissue tags and granulation tissue using sharp curettes. Step 8: After the necessary scaling and root planing, the flap edge should rest on the root-bone junction. If this is not the case, due to improper location of the initial incision or to the unexpected need for osseous surgery, the edge of the flap is rescalloped and trimmed to allow the flap edge to end at the root-bone junction.

Step 9: A continuous sling suture is used to secure the facial and the lingual or palatal flaps. This type of suture, using the tooth as an anchor, is advantageous to position and hold the flap edges at the root-bone junction. The area is covered with a periodontal pack.



Incision and excision (periodontal knives) Deflection and readaptation of mucosal flaps (periosteal elevators)

Removal of adherent fibrous and granulomatous tissue (tissue scissors, cumin scaler)

Scaling and root planing (scalers and curettes)

Removal of bone tissue (bone rongeurs, chisels and files)

Root sectioning (burs)

Suturing (sutures and needle holders, suture scissors)

Application of wound dressing (plastic instruments)

Newer instrumentslasers, cryosurgery, electosurgery

Classification of periodontal pocket management

I. Nonsurgical pocket therapy: -supra/ subgingival debridement with oral hygiene instructions. - chemotherapeutics. - lasers. II. Pocket elimination procedures: - gingivectomy - apically positioned flap - flap osseous surgery

Classification of periodontal pocket management

Pocket reduction procedures: - Access flap. - Modified Widman flap. - Excisional New Attachment procedure. - Replaced flap.


most commonly performed type of periodontal surgery.

it may be considered an internal bevel gingivectomy

The undisplaced flap and the gingivectomy are the two

techniques that surgically remove the pocket wall

Step 1: The pockets are measured with the periodontal probe, and a bleeding point is produced on the outer surface of the gingiva to mark the pocket bottom.

Step 2: The initial, internal bevel incision is made after

the scalloping of the bleeding marks on the gingiva.

Step 3: The second or crevicular incision is made from

the bottom of the pocket to the bone

Step 4: The flap is reflected with a periosteal elevator from the first incision.

Step5: The interdental incision is made with an

interdental knife, separating the connective tissue from

the bone.

Step 6: The triangular wedge of tissue created by the three incisions is removed with a curette.

Step 7: The area is debrided, removing all tissue tags and granulation tissue using sharp curettes.

Step 8: A continuous sling suture is used to secure the facial and the lingual or palatal flaps.

Gingival Pockets 1) Character of the pocket wall - Edematous or Fibrotic 2) Pocket accessibility. Slight Periodontitis A conservative approach and adequate oral hygiene generally sufficient. Recurrence in previously treated sites - surgical approach. Moderate to Severe Periodontitis in the Anterior Sector -Scaling and root planing - Technique of choice. - Papilla preservation flap - First choice when a surgical approach is needed. - Teeth too close interproximally - Sulcular incision flap - next choice. - Esthetics is not the primary consideration - Modified Widman flap. - In some infrequent cases - Apically displaced flap with bone contouring.


Moderate to Severe Periodontitis in the Posterior Area

Purpose of surgery in the posterior area is either enhanced accessibility or the need for definitive pocket reduction requiring osseous surgery. Accessibility can be obtained by either the undisplaced or apically displaced flap. Osseous defects amenable to regeneration - the papilla preservation flap - Technique of choice because it better protects the interproximal areas where defects are frequently present. Second and third choices are the sulcular flap and the modified Widman flap, maintaining as much of the papilla as possible. Osseous defects with no possibility of reconstruction - Technique of choice - Flap with osseous contouring.