CHAPTER 57: The Periodontal Flap ●​ The periosteum left on the bone may also be

used for suturing the flap when it is displaced

Periodontal flap - is a section of gingiva and/or apically.
mucosa surgically separated from the underlying
tissues to provide visibility of and access to the bone Based on flap placement after surgery
and root surface. Flaps are classified as:
-​ The flap also allows the gingiva to be displaced 1.​ nondisplaced flaps - when the flap is
to a different location in patients with returned and sutured in its original position
mucogingival involvement. 2.​ displaced flaps - which are placed apically,
coronally, or laterally to their original position.
CLASSIFICATION OF FLAPS
Periodontal flaps can be classified based on the Both full-thickness and partial-thickness flaps can be
following: displaced, but to do so, the attached gingiva must be
●​ Bone exposure after flap reflection totally separated from the underlying bone, thereby
●​ Placement of the flap after surgery enabling the unattached portion of the gingiva to be
●​ Management of the papilla movable. However, palatal flaps cannot be displaced
because of the absence of unattached gingiva.
Based on bone exposure after reflection Apically displaced flaps have the important
-​ flaps are classified as either advantage of preserving the outer portion of the pocket
●​ full-thickness (mucoperiosteal) flaps wall and transforming it into attached gingiva. Therefore
●​ partial-thickness (mucosal) flaps these flaps accomplish the double objective of
eliminating the pocket and increasing the width of the
FULL-THICKNESS FLAPS attached gingiva.
●​ all the soft tissue, including the periosteum, is
reflected to expose the underlying bone. Based on management of the papilla
●​ This complete exposure of and access to the flaps can be conventional or papilla preservation flaps.
underlying bone is indicated when resective
osseous surgery is contemplated. Conventional flap, the interdental papilla is split
PARTIAL THICKNESS FLAPS beneath the contact point of the two approximating
●​ includes only the epithelium and a layer of the teeth to allow reflection of the buccal and lingual flaps.
underlying connective tissue. The incision is usually scalloped to maintain gingival
●​ The bone remains covered by a layer of morphology and retain as much papilla as possible.
connective tissue, including the periosteum. The conventional flap is used:
●​ This type of flap is also called the 1.​ when the interdental spaces are too narrow,
split-thickness flap. thereby precluding the possibility of preserving
●​ The partial-thickness flap is indicated when the the papilla
flap is to be positioned apically or when the 2.​ when the flap is to be displaced.
operator does not want to expose bone. Conventional flaps include the Modified Widman flap,
●​ Conflicting data surround the advisability of the undisplaced flap, the apically displaced flap, and the
uncovering the bone when this is not actually flap for reconstructive procedures.
needed. Papilla preservation flap - incorporates the entire
●​ When bone is stripped of its periosteum, a loss papilla in one of the flaps by means of crevicular
of marginal bone occurs, and this loss is interdental incisions to sever the connective tissue
prevented when the periosteum is left on the attachment and a horizontal incision at the base of the
bone. papilla, leaving it connected to one of the flaps.
●​ Although usually not clinically significant, the
differences may be significant in some cases. FLAP DESIGN
●​ The partial-thickness flap may be necessary ●​ The design of the flap is dictated by the
when the crestal bone margin is thin and surgical judgment of the operator and may
exposed with an apically placed flap, or when depend on the objectives of the procedure.
dehiscences or fenestrations are present.
 ●​ The necessary degree of access to the The internal bevel incision accomplishes three
underlying bone and root surfaces and the final important objectives:
position of the flap must be considered in 1.​ It removes the pocket lining;
designing the flap. 2.​ it conserves the relatively uninvolved outer
●​ Preservation of good blood supply to the flap surface of the gingiva, which, if apically
is also an important consideration. positioned, becomes attached gingiva; and
3.​ It produces a sharp, thin flap margin for
Two basic flap designs are used. Depending on how adaptation to the bone-tooth junction.
the interdental papilla is managed, flaps can either split
the papilla (conventional flap) or preserve it (papilla ●​ This incision has also been termed the first
preservation flap). incision because it is the initial incision in the
●​ In the conventional flap procedure, the reflection of a periodontal flap, and the reverse
incisions for the facial and the lingual or palatal bevel incision because its bevel is in reverse
flap reach the tip of the interdental papilla or its direction from that of the gingivectomy incision.
vicinity, thereby splitting the papilla into a facial ●​ The #15C or the #15 surgical blade is used
half and a lingual or palatal half. most often to make this incision. That portion of
●​ The entire surgical procedure should be the gingiva left around the tooth contains the
planned in every detail before the procedure is epithelium of the pocket lining and the adjacent
initiated. granulomatous tissue.
●​ This should include the type of flap, exact ●​ It is discarded after the crevicular (second) and
location and type of incisions, management of interdental (third) incisions are performed.
the underlying bone, and final closure of the ●​ The internal bevel incision starts from a
flap and sutures. designated area on the gingiva and is directed
●​ Although some details may be modified during to an area at or near the crest of the bone.
the actual performance of the procedure, ●​ The starting point on the gingiva is determined
detailed planning allows for a better clinical by whether the flap is apically displaced or not
result. displaced.

INCISIONS Crevicular incision, also termed the second incision,

is made from the base of the pocket to the crest of the
HORIZONTAL INCISIONS bone (Figure 57-8).
●​ Horizontal incisions are directed along the ●​ This incision, together with the initial reverse
margin of the gingiva in a mesial or a distal bevel incision, forms a V-shaped wedge
direction. ending at or near the crest of bone.
Two types of horizontal incisions have been ●​ This wedge of tissue contains most of the
recommended: inflamed and granulomatous areas that
1.​ the internal bevel incision, which starts at a constitute the lateral wall of the pocket, as well
distance from the gingival margin and is aimed as the junctional epithelium and the connective
at the bone crest, and tissue fibers that still persist between the
2.​ the crevicular incision, which starts at the bottom of the pocket and the crest of the bone.
bottom of the pocket and is directed to the ●​ The incision is carried around the entire tooth.
bone margin. \ The beak-shaped #12D blade is usually used
In addition, for this incision.
3.​ the interdental incision is performed after the ●​ A periosteal elevator is inserted into the initial
flap is elevated. internal bevel incision, and the flap is separated
from the bone.
Internal bevel incision is basic to most periodontal flap ●​ The most apical end of the internal bevel
procedures. incision is exposed and visible.
●​ It is the incision from which the flap is reflected ●​ With this access, the surgeon is able to make
to expose the underlying bone and root. the third incision, or interdental incision, to
separate the collar of gingiva that is left around
 curetted so that the entire root and the bone ●​ The vertical incision should also be designed
surface adjacent to the teeth can be observed. to avoid short flaps (mesiodistal) with long,
●​ Flaps can be reflected using only the horizontal apically directed incisions because this could
incision if sufficient access can be obtained in jeopardize the blood supply to the flap.
this way and if apical, lateral, or coronal ●​ Several investigators proposed the interdental
displacement of the flap is not anticipated. denudation procedure, which consists of
●​ If vertical incisions are not made, the flap is horizontal, internal bevel, nonscalloped
called an envelope flap.the tooth. incisions to remove the gingival papillae and
●​ The Orban knife is usually used for this denude the interdental space.
incision. ●​ This technique completely eliminates the
●​ The incision is made not only around the facial inflamed interdental tissue.
and lingual radicular area but also interdentally, ●​ Healing is by secondary intention and results
connecting the facial and lingual segments to in excellent gingival contour.
free the gingiva completely around the tooth ●​ It is contraindicated when bone grafts are used
●​ These three incisions allow the removal of the for the graft material placed interdentally will
gingiva around the tooth (i.e., the pocket not be covered.
epithelium and the adjacent granulomatous
tissue). ELEVATION OF THE PULP
●​ A curette or a large scaler (U15/30) can be
used for this purpose. ●​ When a full-thickness flap is desired,
●​ After removal of the large pieces of tissue, the reflection of the flap is accomplished by blunt
remaining connective tissue in the osseous dissection.
lesion should be carefully curetted so that the ●​ A periosteal elevator is used to separate the
entire root and the bone surface adjacent to the mucoperiosteum from the bone by moving it
teeth can be observed. mesially, distally, and apically until the desired
●​ Flaps can be reflected using only the horizontal reflection is accomplished
incision if sufficient access can be obtained in ●​ Sharp dissection is necessary to reflect a
this way and if apical, lateral, or coronal partial-thickness flap
displacement of the flap is not anticipated. ●​ A surgical scalpel (#15) is used
●​ If vertical incisions are not made, the flap is ●​ A combination of full-thickness and
called an envelope flap partial-thickness flaps may be indicated to
obtain the advantages of both.
VERTICAL INCISIONS ●​ The flap is started as a full-thickness
●​ Vertical or oblique releasing incisions can be procedure, then a partial-thickness flap is made
used on one or both ends of the horizontal at the apical portion.
incision, depending on the design and purpose ●​ In this way the coronal portion of the bone,
of the flap. which may be subject to osseous remodeling,
●​ Vertical incisions at both ends are necessary if is exposed while the remaining bone is
the flap is to be apically displaced. protected by the periosteum.
●​ Vertical incisions must extend beyond the
mucogingival line, reaching the alveolar HEALING AFTER SURGERY
mucosa, to allow for the release of the flap to Immediately after suturing (up to 24 hours),
be displaced -​ a connection between the flap and the tooth or
●​ In general, vertical incisions in the lingual and bone surface is established by a blood clot,
palatal areas are avoided. which consists of a fibrin reticulum with many
●​ Facial vertical incisions should not be made in polymorphonuclear leukocytes, erythrocytes,
the center of an interdental papilla or over the debris of injured cells, and capillaries at the
radicular surface of a tooth. Incisions should be edge of the wound.
made at the line angles of a tooth either to -​ Bacteria and an exudate or transudate also
include the papilla in the flap or to avoid it result from tissue injury.
completely.
One to 3 days after flap surgery, ●​ When flaps need to be repositioned apically or
-​ the space between the flap and the tooth or less often, coronally, then the flaps must sit
bone is thinner and epithelial cells migrate over passively at the appropriate level before
the border of the flap, usually contacting the suturing.
tooth at this time. ●​ To ensure this, buccal and lingual flaps need to
-​ When the flap is closely adapted to the alveolar be elevated beyond the mucogingival junction
process, there is minimal inflammatory so the elasticity of the mucosa allows for flap
response. mobility.
One week after surgery, ●​ Sometimes it may be necessary to extend the
-​ an epithelial attachment to the root has been flap elevation apically with a split incision
established by means of hemidesmosomes approach to minimize the effect of the less
and a basal lamina. elastic periosteum.
-​ The blood clot is replaced by granulation tissue ●​ Vertical incisions can aid in flap positioning by
derived from the gingival connective tissue, the allowing the clinician to suture the flap at a
bone marrow, and the periodontal ligament. different level to the adjacent untreated gingiva.
Two weeks after surgery, ●​ Palatal flaps are less mobile because of the
-​ collagen fibers begin to appear parallel to the absence of oral mucosa so that the apical
tooth surface. position of the flap depends on how much
-​ Union of the flap to the tooth is still weak marginal gingival tissue is discarded using a
because of the presence of immature collagen reverse bevel incision.
fibers, although the clinical aspect may be ●​ The more apical positioning desired, the more
almost normal. extensive is the reverse bevel cut.
One month after surgery, ●​ Palatal flaps are more difficult to position
-​ a fully epithelialized gingival crevice with a coronally than buccal or lingual flaps and thus if
well-defined epithelial attachment is present. it is required to position flaps coronally or even
-​ There is a beginning functional arrangement of at their original levels, then a sulcular incision is
the supracrestal fibers. used.
Full-thickness flaps, which denude the bone, result in ●​ In osseous periodontal surgery, flaps are
a superficial bone necrosis at 1 to 3 days. apically positioned to minimize postoperative
-​ Osteoclastic resorption follows and reaches pocket depth.
a peak at 4 to 6 days, declining thereafter. ●​ In regenerative periodontal surgery, soft tissue
-​ This results in a loss of bone of about 1 mm coverage of bony defects, graft materials,
and the bone loss is greater if the bone is thi. membranes, and biologic agents is important
Osteoplasty (thinning of the buccal bone) so sulcular incisions and tight suturing
-​ using diamond burs, included as part of the techniques are crucial.
surgical technique, results in areas of bone
necrosis with reduction in bone height, which is
later remodeled by new bone formation.
-​ Therefore, the final shape of the crest is
determined more by osseous remodeling than
by surgical reshaping

SUMMARY:
●​ Periodontal flaps are designed to preserve
gingival integrity and to gain access to root
surfaces for residual calculus removal and to
thoroughly remove granulation tissue so bone
defects can be visualized and treated.
●​ Gentle and efficient procedures result in
optimum healing and minimal postoperative
pain.