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ROBICSEK NORBERG
a
¦ a¦

½OUNGER KIRKLAND

¦ aa¦

LEONARD KRONFELD
WIDMAN a¦
aa¦
SCHLUGER
a
¦
GOLDMAN RAMFJORD;

¦ NISSLE

¦

HIRSCHFELD N½MAN et al

¦ a ¦

FRIEDMAN TAKEI et al

a„ a 
· Flap is a piece of tissue parity severed from its place
of origin for use in surgical grafting and repair of body
defectsµ

* Flat portion of tissue, either skin, mucosa or

mucoperiosteum which is partially severed from its
deeper surroundings.µ

· 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.µ

´ Carranza·s Clinical periodontology ninth edition

Widman, Cieszynski, and
Neuman Î



 


  






Widman in 1916 




 
 


   
 
!

 
"  

 
 

 

Ventler 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
   

 

ÿ


   

  
¦

  
¦ 
 
 


all the soft tissue, includes only the epithelium

including the periosteum, and a layer of the underlying

is reflected to expose the connective tissue. The bone

underlying bone remains covered by a layer of

connective tissue, including the
periosteum
 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 

bone so
as to leave a layer of periosteal connective tissue intact,
covering the vestibular surface of the alveolar process
ÿ


   

  
¦

  
¦ 
 
 

 |
   
 
  
  
   

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.
 

  ¦
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
  


  

 
  
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

 

  

 

    

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
  




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.
!

Flap with releasing incisions
Envelope flap
 Œ   
è 
 

 
# 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.
è 
 

   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.

  "


  
$ A rectangular segment of gingiva and
mucosa is used.

 
$ A semicircular segment of gingiva or
mucosa is used.
Prevention of flap necrosis
Prevention of flap tearing
u # 
$¦
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

# %Œ&'
&


  (


-) 
*
1. The internal bevel incision
2. The crevical incision
3. Interdental incisions

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
Interdental incisions

Cervical incision
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.

´ ˜

 „˜ „

 „ „
 
( 
*
Mertical 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

Mertical incisions must extend beyond the

mucogingival line reaching the alveolar
mucosa to allow for the release of the flap
to be displaced

vertical incisions in the lingual and

palatal areas are avoided
( 
*

Incorrect

correct
ÿ

 
 !


w Creating accessibility for proper professional scaling

and root planing

w Establishing a gingival morphology which facilitates

the patient·s self performed infection control.
 j   
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

· 


„
„ „„
„
„ „
u 

    %
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.
 ˜  
·Uncooperative Ë 

· Blood disorders
·Hormonal disorders
·Cardiovascular disease
(Fay & O·Neil 1984).
·Smoking
(Siana et al., 1989),
 The main advantages of the original Widman flapµ
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

 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

· Robert Neuman: A pioneer in periodontal flap surgery ²

J Periodontal 1982 vol 53; 456
Did not include
1) extensive sacrification of non ² inflamed tissues
and
2) apical displacement of the gingival margin
Advantages
Esthetics
Potential for bone regeneration in intrabony
defects
 u+ + 
,


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

Access for proper instrumentation

‰ è 
|

In 1961 the first report from the first longitudinal study

Scaling and root planing, oral hygiene

instruction, and occlusal adjustment.

Subgingival Pocket elimination

curettage surgery
 Subgingival curettage, Modified Widman flap, or
Pocket elimination surgery
when gain in attachment was considered, there were no
differences among techniques.

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.
˜
'
&- ÿ

 

'.**/u# &'Œ*ÿ*0Œ-*Œ&u/

mFor pocket elimination mFor reattachment

mCollar of tissue attached mCollar excised with
to the teeth torn with knives and removed with
curettes curettes
mMertical releasing mNo vertical releasing
incisions incisions
mHigh flap reflection mMinimal flap reflection
mFlaps do not cover mClose interproximal flap
interproximal bone adaptation
mBone remains exposed mNo bone exposed
 u+ 

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.
 Π
, 
.!
11¦

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.
 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

Incomplete tissue coverage of the graft material in

the interproximal areas.

Immediate, partial or complete exfoliation of the implant

materials

· Flap technique for periodontal bone implants (papilla preservation) ²

J Periodontal 1985 vol 56; 204
The Modified papilla preservation technique: A surgical approach for
interproximal regenerative procedure ²
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 ²
IJPRD 1999 vol 19; 589
Grupe and Warren
(1956)
 Norberg (1926);
Bernimoulin et al (1975)
Tarnow (1986)
 Langer and Langer
(1990)

A surgical Modification for Implant Fixture

Installation
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.
Mertical 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 ²
IJPRD 1990 vol 10; 209
 Landsberg (1994)

The eversed crestal flap: A surgical modification in endosseous implant

procedures ²
Qunt int 1994 vol 25; 229
 A new approach to recession ² free healing of the
interdental papilla after endodontic surgery
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 ²
Int Endo Jol 2003 vol 35; 453
Melvart. 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
 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.
Mclvor and Wengraf studied blood loss
calorimetrically during gingivectomies and / or
isolated periodontal flap procedures on 14 patients.
(12 ² 62 ml)
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
 ÿ  !


· Systemic factors
´ Age
´ Blood pressure
´ Bleeding time
· Local factors Duration of Surgery
extent of surgical field
degree of inflammation
· Surgical technique
no of teeth involved
anesthesia
length of incision
ÿ 
 

· Periodontal reconstructive flaps classification and surgical

considerations ² IJPRD 1991 vol 11; 481
ÿ 
 
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
The final pattern should be larger than the area to be
reconstructed.
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 ² IJPRD 1991 vol 11; 481
ÿ 
 

Flap necrosis

· Periodontal reconstructive flaps classification and surgical

considerations ² IJPRD 1991 vol 11; 481
u    
2 

Atraumatic and gentle surgical techniques should be

practiced throughout the surgical procedure
Hot sponges
(66 degrees)

Promote Increase capillary Increase tissue

coagulation bleeding damage

Tissue necrosis Incidence of

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

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.
Ñ  

The relationship between the sutures and wound edges is
important
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.
Tension on the
sutures
Postoperative
swelling
Reduce
circulation
Further edge
separation
Surgical injury creates the environment and stimulus
for cellular differentiation
Primary„wound
healing

Secondarywound
healing

Tertiarywound
healing
ë   

Epithelial cells begin to proliferate at wound margins

at 1-2 days.
The migration takes place at a rate of 0.5 mm per
day
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
˜     

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
 
 

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.
˜  

Cementogenesis delayed in onset; it is also slow to

exert its effect on the overall outcome of
periodontal healing

Proliferating cementoblasts appear adjacent to root

surfaces at the end of month one and proceed with
cementogenesis during the months two and three.

These events are critical to the formation of a new

attachment apparatus and some forms of new
attachment
ë
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