Flap Surgery

Presenter: R2 鄭瑋之 Instructor: Dr. 陳娟娟 2012/11/14

 Purpose

1. To gain access to deeper periodontal

structures with direct vision.
2. Relocation of the frenulum
3. Maintenance of the attached tissue
4. Pocket elimination and regeneration
 Indications

• Pockets > 5mm persisting after phase I therapy

• Bony pockets and interdental craters
• Bony lesions in the furcations
• Need for surgical crown lengthening
• When to open up a flap? complicated
morphology like:
– Deep and narrow pocket
– Difficult to achieve the correct angle
 Contraindications

• Shallow, supraalveolar pockets

– subgingival scaling/rootplaning
• Esthetically sensitive areas
• Fibrous thickened gingiva
– gingivectomy  more favorable morphology
 Advantages Disadvantages

• Direct vision • Apical resposition 

• Pocket epi. is entirely postoperative sensitivity
removed by the internal and esthetics
bevel incision
• Flaps can be repositioned
• Interdental bone or
infrabony defects can be
covered
• No open wound
• Little periodontal tissue is
lost
Comparison of open vs. closed
Instruments
Instruments

Small elevators for

mobilization of the
mucoperiosteal flap
Instruments
 Principles of Flap Design

• Local flap
1.outlined by a surgical incision
2.carries its own blood supply
3.allows surgical access to underlying tissues
4.can be replaced in the original position
5.can be maintained with sutures and is expected
to heal
 Used in oral surgical, periodontic, and
endodontic procedures to gain access.
 Principles of Flap Design

• Complications
A. Flap necrosis
B. Flap Dehiscence
C. Flap Tearing
D. Injury to Local Structures
 Principles of Flap Design
A. Flap necrosis
1. Base > Free margin
• to preserve an adequate blood supply
• unless a major artery is present in the base
2. Width of Base > Length of Flap*2
• less critical in oral cavity, but length < width
• a long, straight incision with adequate flap reflection
heals more rapidly than a short, torn incision.
3. An axial blood supply in the base
4. Hold the flap with a retractor resting on intact
bone to prevent tension.
 Principles of Flap Design
B. Flap Dehiscence
1. The incisions must be made over intact bone
2. If the pathologic condition has eroded the
buccocortical plate, the incision must be at least 6 or 8
mm away from it.
3. The incision is 6 to 8 mm away from the bony defect
created by surgery.
4. Gently handle the flap's edges
5. Do not place the flap under tension
6. Do not cross bony prominences, ex: canine eminence
Principles of Flap Design
B. Flap Dehiscence
 Principles of Flap Design
C. Flap Tearing
• Envelope flaps
– an incision around the necks of several teeth.
– extends 2 teeth anterior and 1 tooth posterior.
If not provide sufficient access…
• Vertical (oblique) releasing incisions:
– extends 1 tooth anterior and 1 tooth posterior.
– started at the line angle of a tooth.
– carried obliquely apically into the unattached gingiva.
– If cross the papilla  localized periodontal problems
 Principles of Flap Design
D. Injury to Local Structures
• Mandible: lingual n. & mental n.
 Principles of Flap Design
D. Injury to Local Structures
• Maxilla: greater palatine a. & nasopalatine n./a.
 Basic Incisions

• Can be sulcular, crestal, or inverse bevel

Full • adequate vascular supply

thickness and regeneration
(mucoperiosteal) • gingiva+mucosa+periosteum

Split/partial
thickness • gingiva+mucosa
(mucosal)
 Basic Incisions
Full
thickness
(mucoperiosteal)

a: sulcular
Depending on b: crestal
the amount of
attached tissue
present
 Basic Incisions
Split/partial
thickness
(mucosal)

In areas of thin
bony plates and
for mucogingival
procedures
 Basic Incisions
2. inversebeveled
Modified flap
incision to the crest
(mucoperiosteal)
of bone.

Requires adequate 1. gingivectomy

attached Incision for
keratinized gingiva pocket reduction

On the palate,
enlarged tissue, or
with limited access
Comparison of full- vs. partial-
Types of Mucoperiosteal Flaps

1. Envelope/sulcular incision
2. Envelope with one releasing incision (three-
corner flap)
3. Envelope with two releasing incisions (four-
corner flap)

Full-thickness
mucoperiosteal flap
Types of Mucoperiosteal Flaps

1. Envelope/Sulcular flap
2 teeth anterior
1 tooth posterior
Types of Mucoperiosteal Flaps

2. Three-corner flap
1 tooth anterior
1 tooth posterior

Greater access in an apical direction,

especially in the posterior aspect of the
mouth
Types of Mucoperiosteal Flaps

3. Four-corner flap
1 tooth anterior
1 tooth posterior

rarely indicated
Common Periodontal Flap

•1 Modified Widman Flap

• Apically positioned
2
(full-thickness)
• Apically positioned
3
• (partial-thickness)

•4 Palatal Flap
 •1 Modified Widman Flap

1. Inverse bevel incision 0.5~2mm, extending to the alveolar

crest. Thins gingival tissue and permits compete closure of
the interdental osseous defects postoperatively.
 •1 Modified Widman Flap

2. Flap reflection. Full thickness mucoperiosteal flap is

reflected to permits visualization.
 •1 Modified Widman Flap

3. Crevicular incision between the hard tooth and the

diseased pocket epi., to the depth of the junctional epi.
 •1 Modified Widman Flap

4. Horizontal incision carried along the alveolar crest

 •1 Modified Widman Flap

5. Root planing with direct vision

 •1 Modified Widman Flap

6. Complete coverage of interdental defects

 • Apically positioned
2
(full-thickness)

1. Sulcularly, crestally, or full-thickness flap labially positioned

inverse beveled incision to bone
2. Flap completed, reflected off bone
3. Flap is apically positioned and sutured
• Apically positioned
2
(full-thickness)

A: The internal bevelled,

scalloped incision is used
for pocket elimination
through apical
repositioning of the flap.

B: The flap
positioned apically for
pocket elimination.
 • Apically positioned
3
• (partial-thickness)

1. Crestal incision with blade, partial-thickness flap parallel to long

axis of tooth
2. Flap raised by sharp dissection, periosteum retained over bone
3. Flap is apically positioned at or below alveolar crest
•4 Palatal Flap

1. No alveolar mucosa is
present on the palate to
permit apical positioning.
2. Pocket elimination by
palatal flap that just
covers the contours of
the bone to eliminate
osseous defects.
3. Requires skill and
experience.
Osteoplasty

Osseous grooving,
peprmits better
adaption of flaps to
facilitate plaque
removal alter
healing
Osteoplasty
Osteoplasty
Suturing for Flap Surgery
Simple Loop Modification of
Interrupted
Figure 8 Modification of Interrupted
Vertical mattress suture
Horizontal mattress suture
Single Interrupted Sling
 Reference

1. Contemporary Oral and Maxillofacial Surgery, 4th Edition, Larry J

Peterson, DDS, MS, Edward Ellis, III, DDS, MS, James R Hupp, DMD, MD,
JD, FACS and Myron R Tucker, DDS
2. Peterson's principles of oral and maxillofacial surgery, Michael Miloro,G.
E. Ghali,Peter Larsen,Peter Waite
3. An atlas of minor oral surgery: principles and practice, David A.
McGowan
4. Manual of minor oral surgery for the general dentist, Karl R. Koerner
5. Critical Decisions in Periodontology, 4th Edition, WALTER B. HALL, BA,
DDS, MSD
6. Color Atlas of Periodontology, Klaus H. & Edith M. Rateitschak
7. Atlas of Cosmetic and Reconstructive Periodontal Surgery 3rd edition,
EDWARD S. COHEN, DMD
Thanks for your attention!