Mucoperiosteal Flap Assessment Form
Please complete this form to document and assess the mucoperiosteal flap procedure.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinical Indication for Flap Procedure
*
Please Select
Periodontal Surgery
Implant Placement
Tooth Extraction
Biopsy
Other
Flap Design Used
*
Please Select
Envelope Flap
Triangular Flap
Semilunar Flap
Pedicle Flap
Other
Assessment of Flap Parameters
*
Rows
Excellent
Good
Fair
Poor
Flap Thickness
1
2
3
4
Flap Vascularity
5
6
7
8
Flap Tension
9
10
11
12
Flap Adaptation
13
14
15
16
Flap Size
17
18
19
20
Intraoperative Findings
Adequate Flap Reflection
Bleeding Controlled
Tissue Trauma
Flap Tear
Other
Complications Observed
None
Excessive Bleeding
Flap Necrosis
Dehiscence
Infection
Other
Post-Operative Flap Healing (1 = Poor, 5 = Excellent)
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Additional Comments or Observations
Signature of Assessor
*
Submit Assessment
Submit Assessment
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