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FLAP TECHNIQUES FORPOCKET ELIMINATION

Guided By:-

Dr. Prashant Bhusari

Prof. & Guide

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Instruments used in flap surgery.

Treatment decisions for soft & hard tissue pockets in flap surgery.

Flap techniques for pocket elimination.

Flap techniques for reconstructive & regenerative surgery.

Suturing techniques.

Periodontal dressing.

Post surgical care.

Healing following flap surgery.

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Introduction

The type of periodontal surgery & how

many sites should be included is made

after the initial cause-related measures

has been evaluated.

The time lapse between this initial cause-

related phase of therapy and this

evaluation may be 1 to 6 months. This

time lapse has following advantages:-

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1. Removal of calculus & plaque will reduce the

inflammatory cell infiltrate in the gingiva (edema,

hyperemia, flabby tissue consistency) so thatassessment of the true gingival contour & pocket depths

possible.

2. Reduction of gingival inflammation makes the softtissue more fibrous & firmer facilitates surgical handling

of the soft tissue so that bleeding is reduced.

3. A proper assessment of the prognosis has beenestablished. The effectiveness of the patients home

care, can be properly evaluated. Lack of effective self-

performed infection control mean patient should be

excluded from surgical treatment.

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The first surgical technique used in periodontal therapy

were described as means of gaining access to diseased

root surfaces. Such access could be accomplished

without excision of the soft tissue pocket (open-viewoperations).

Later, procedures were described by which the

diseased gingiva was excised (gingivectomyprocedures)

The concept that not only inflamed soft tissue but also

infected and necrotic bone had to be eliminated calledfor the development of surgical techniques by which the

alveolar bone could be exposed and resected (flap

procedures).

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A Periodontal flap is defined as, a section of the

gingiva and or oral mucosa, surgically elevatedfrom the underlying tissues to provide visibility of the

bone and root surface. (Carranza 1996)

Flap is a piece of tissue parity severed from its placeof origin for use in surgical grafting and repair of

body defects. (Ramfjord)

A flap is a segment of gingiva and adjoiningalveolar mucosa raised from the underlying tissues

by surgical meansGrant.

Surgery has been defined as the act and art oftreating diseases or injuries by manual operation.

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History of Periodontal Flap

The history begins with Athens, Rome &extending to Vienna in late 19thcentury &

the Berlin in the early 20thcentury.

The Berlin group was originally led by menlike Partsh (1900) & Sachs (1913) but was

dominated by Robert Neumann for the

Radical surgical treatment for pyorrhoea

In the 1920s, a controversy concerning the

priority of periodontal flap surgery invoved

(Cieszynski 1926, Widman 1923,

Neumann 1923). Each claiming to have

been first to publish of flap design.

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Carl partsh (1855-1932) known to this days for Partsh

incision which is a curved incision with the convexity

toward the crown of the tooth.

After 1907, Partsch recommended for the first time that

the flap be sutured.

Most of the progress in periodontal surgery in this periodcame from Germany & other European countries & was

associates with three names: Robert Neumann, Leonard

Widman & A. Cieszinski.

The surgical treatment Neumann proposed in 1912 but

in 1920 mucoperiosteal flap procedure is well described

by Neummann in his 3rdedition.

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Widman in 1916 appears to have been the first to describe flap

surgery for pocket elimination, although Cieszinski in a

discussion in 1914 referred to periodontal flap surgery foraccess for scaling, removal of granulation tissue and reduction

of pocket depth. However no description of the methodology

was given.

The English translation of Widmansarticle in 1918 gave a

detailed description of a mucoperiosteal flap design, which

leaves a collar of epithelium and inflamed connective tissues

around the necks of the teeth from the gingival margin to thebone.

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Widman in a modification of his original technique is the first

person to describe the reverse bevel incision, although it had

been alluded to previously by cieszynski.

Zentler described in 1918 the use of a crevicular

mucoperiosteal flap for access to remove infected bone and

infected granulomatous tissue. The method is very similar to

what Neumann described in 1920.

During the 1930s and 1940s, gingivectomy become the most

popular method of surgical pocket elimination, but as pointed

out by Schluger in 1949, this operation did not offer anacceptable solution for the elimination of intrabony pockets and

craters and for pockets extending apically beyond the attached

gingiva.

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Schluger recommended doing a gingivectomy first andthen a mucoperiosteal flap to expose the alveolar crest

and part of the alveolar process.

Later Schlugersapproach was modified to the push

back and the pouch operations with an extensive

exposure of the alveolar process and a mucobuccal fold

extension following surgical remodeling of the bone forpocket elimination.

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A new approach to surgical elimination of the periodontal

pocket extending beyond the mucogingival line was

proposed by Nabers in 1954. He used essentially theNeumann flap approach with a crevicular mucoperiosteal

flap and trimming of the inside of the gingival margin of the

flap.

This method was modified by Ariando and Tyrell to include

two instead of the one vertical releasing incision as

suggested by Nabers. Later Nabers modified the procedureby recommending Widmansreverse bevel incision as the

initial approach to the flap design and Friedman suggested

calling this procedure the apcially repositioned flap.

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Main objectives of flap surgery

Surgical elimination or reduction of periodontal pockets.

To induce reattachment and bone regeneration in

periodontal pockets.

To correct gingival, mucogingival defects and deficiencies.

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Flap for pocket therapy

1. Original Widman flap.

2. Neumann flap.

3. Undisplaced flap.

4. Kirkland flap.

5. Modified Widman flap .

6. Apically positioned flap.

7. Palatal flap

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Flap for reconstructive and regenerative

surgery :

Distal wedge procedure.

Papilla preservation flap :-

1. Modified papilla preservation.

2. Simplified papilla preservation.

3. Minimally Invasive Surgical Technique (MIST).

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Flaps to correct gingival and mucogingival

defects and deficiencies :

Pedicle graft procedures

Rotational flap procedures (e.g. Laterally sliding flap,

Double papilla flap, Oblique rotated flap)

Advanced flap procedures (e.g. Coronally repositioned

flap, Semilunar coronally repositioned flap).

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Other objectives of Flap Surgery

Creating accessibility for proper professional scaling and

root planning.

Establishing a gingival morphology which facilitates the

patients self performed plaque control.

To correct gingival contour that interferes with oral hygiene.

To establish drainage for gingival or periodontal abscess.

To prepare for restorative dentistry.

To improve the esthetic appearance of the tissue

overgrowth.

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Objectives of flaps used for Pocket Therapy

Increase accessibility to root deposits.

Eliminate or reduce pocket depth by resection of the

pocket wall.

Expose the area to perform regenerative methods.

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Classification of Flap

Bone exposure after flap reflection.

Placement of the flap after surgery.

Management of the papilla.

Presence / absence of releasing

incisions.

Depending on the direction of transferand geometry (Bahat and

Handelsman 1991).

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Bone exposure after flap reflection.

Full thickness (mucoperiosteal)

All the soft tissue, including the periosteum, isreflected to expose the underlying bone.

Partial thickness (mucosal) flaps /split thickness flap

It includes only the epithelium and a layer of theunderlying connective tissue. The bone remains

covered by a layer of connective tissue, including theperiosteum

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Full thickness or mucoperiosteal flap:- Anincision generally is made in or near thegingival sulcus region and carried apically

toward the crest of the bone from which pointthere is total reflection of all soft tissue from thesurface of the alveolar process.

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By contrast the split thickness or mucosal flap isprepared by initiating an incision at or near the gingivalsulcus region and proceeding apically through the

connective tissue past the crest of the alveolar bone soas to leave a layer of periosteal connective tissueintact, covering the vestibular surface of the alveolarprocess.

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In the full thickness flap-the resorptive activity at the six

to eight-day period affects the entire layers ofcircumferential lamellae and a portion of thehaversian systems that are immediately subjacent tothose lamellae, so it is a distinct quantitative differenceas to the amount of bone that is resorbed.

Twenty-one day period, where now definiteosteogenesis is characteristic of the alveolar processassociated with the split thickness flap, it is at this timethat one can observe that very little change that tookplace by resorption at the crest of the process andonly some on the vestibular surface.

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There are many more osteoclasts and osteoblasts inaction during their respective times of activity with the fullthickness flap. This again is related to the degree ofdamage or trauma by surgery.

Reflecting a split thickness flap achieves thinness withbody and permits its reapposition at the gingival marginregion with it being better contoured and much moreadaptable than the heavy-bodied full thickness

mucoperiosteal flap .

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Placement of the flap after surgery

Undisplaced or Nondisplaced Flaps :- when the flap isreturned & sutured in its original position.

Displaced flaps :- when the flap placed apically,coronally or laterally to its original position.

Palatal flap cannot be displaced because of absence of unattached gingiva.

Importance of Apically displaced flap:-

Apically Displaced flaps have the important advantage of preserving theouter portion of the pocket wall and transforming it into attached gingiva soit fulfills 2 objectives :-

1. Pocket Elimination

2. Width of Attached gingiva increase.

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Management of the papilla

Conventional Flap :- Interdental papilla is split beneaththe contact point of the two approximating teeth toallow reflection of buccal & lingual flap.

used :-

1. interdental space is too narrow.

2. when the flap is to be displaced.

Conventional flaps include:

The modified Widman flap,

The undisplaced flap,

The apically displaced flap,

The flap for regenerative procedures.

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Papilla Preservation Flaps :- itincorporates the entire papilla in oneof the flap by means of crevicularinterdental incison to sever the

connective tissue attachment & ahorizontal incision at the base of thepapilla, leaving it connected to one ofthe flaps .

/ b f l i i i i

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Presence / absence of releasing incisions

Flap with releasing incisions Envelope flap

(with Vertical incision) ( without Vertical incision)

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Advantages Disadvantages

Flap with Vertical

incision

Used if the osseous defect is

very deep or of it is isolated to

one or two teeth

Delayed healing

Limit the surgical field to only

those teeth that are

pathologically involved

Greater post operative

pain and bleeding

Flap can be move to another

position without causing

excessive tension

Cannot be given in palatal

as well as lingual area

Envelop flap Quicker to heal and are

associated with less postoperative pain and bleeding

Limit access to the bony

tissues

Used in situations where

esthetics is a major

consideration

Cannot be easily moved or

repositioned to other

locations

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Depending on the direction of transfer and

geometry

Rotational flap

Advancement flap

Rotational Flap e.g.

Lateral Positioned Flap

Advancement Flap e.g.

Coronally Advanced Flap

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Indications

Accessibility for proper scaling and rootplanning.

Establishment of a morphology of the

dentogingival area conductive to plaquecontrol.

Pocket depth reduction.

Correction of gross gingival aberrations

Shift of the gingival margin to a position

apical to plaque retaining restorations.

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Contraindications

Patient cooperation :- Till the patient achieved

adequate plaque control the surgery must be delayed

which is assessed in the pre-surgical phase & in

general most of the systemic disease under control by

medication which are also not contraindicated for

surgery after physician concern.

Cardiovascular Diseases :

1. Arterial hypertensionnormally does not preclude

periodontal surgery. The patients medical history should

be checked for any previous untoward reaction to local

anesthesia. Local anesthetics free from or low in

adrenaline may be used and an aspirating syringe should

be adopted to safeguard against intravascular injection.

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2. Angina Pectoris :Does not influence the periodontal

surgery. Premedication's with sedatives and use of local

anesthetics low in adrenaline are recommended.

3. Myocardial Infarctionpatients should not be subjected to

periodontal surgery with in 6 months following hospitalization

until well after cardiac rehabilitation.

4. Anticoagulant therapy have the potential for bleeding

after surgical procedures. This include patients taking Aspirin

as a prophylaxis for heart disease and such patients should

stop taking Aspirin temporarily before undergoing periodontalsurgery. Adjustments of the anticoagulants drug therapy

usually needs to initiated 2-3 days prior to the dental

appointment. Aspirin & NSAIDs should not be used post-

operatively pain control since they increase bleeding

tendency & tetracycline is contraindiated.

5 Rheumatic Endocarditis congenital heart lesions and

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5. Rheumatic Endocarditis, congenital heart lesions and

heart and vascular implants involve risk of transmission of

bacteria to heart tissue and vascular implants during the

transient bacteremia. Treatment of patients with these

conditions should be preceded by antiseptic mouth rinsing(0.2% Chlorhexidine) and an appropriate antibiotic should

be prescribed and administered a few hours before.

Blood Disorders :

Patients suffering from acute leukemias, agranulocytosis,

and lymphogranulomatosis must not be subjected to

periodontal surgery. Anaemias in mild and compensated forms do not preclude

surgical treatment. More severe and less compensated

forms may entail lowered resistance to infection and

increased propensity for bleeding.

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Hormonal Disturbances :

Diabetes Mellitusis often associated with delayed wound

healing and lowered resistance to infection andpredisposition for atherosclerosis. Well compensated

patients may be subjected to periodontal surgery provided

precautions are taken with dietary and insulin routines.

Adrenal function may be impeded in patient receiving large

doses of corticosteroids over an extended period. These

conditions involve reduced resistance to physical and

mental stress and the doses of corticosteroid may have tobe altered during and after the period of periodontal surgery.

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Neurological Disorders :

1. Multiple sclerosis and Parkinsons Disease :may in

severe cases, make ambulatory periodontal surgeryimpossible. Paralesis, impaired muscular function, tremor

and uncontrollable reflexes may necessitate treatment under

general anesthesia.

2. Epilepsyis often treated with phenytoin which in

approximately 50% of cases may mediate the formation of

gingival hyperplasia. These patients may, without special

restrictions, be subjected to periodontal surgery for correctionof the hyperplasia.

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Organ Transplantation:

Prophylactic antibiotics are recommended in transplant

patients taking immunosuppressive drugs, and the patients

physician should be consulted before any periodontal therapy

is performed. In addition, antiseptic matrix rinsing (0.2%

Chlorhexidine) should proceed the surgical treatment.

Smoking :

Although smoking negatively affects wound healing (Siana et

al 1989), it may not be considered a contraindication for

surgical periodontal treatment. The clinician should be

aware, however, that less resolution of probing pocket depthand smaller improvements in clinical attachment may be

observed in smokes than in non-smokers. (Preber &

Bergstorm 1990)

General Surgical Considerations

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General Surgical Considerations Procedural selection should be based on the following :

1. Simplicity

2. Predictability3. Efficiency

4. Underlying osseous topography

5. Anatomic and physical limitations (e.g. small mouth,

gagging, mental foramen)

All incisions should be bold, clean, smooth and definite. An

uneven ragged incision requires more healing time.

An incision should be on bone or tooth surface & on healthy

tissue adjacent to the lesion otherwise it hampers the

operative site due to profuse bleeding.

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Flap design should allow for adequate access and visibility.

Flap design should prevent unnecessary bone exposure withresultant possible loss and dehiscence or fenestration

formation.

Where possible, primary intention procedures are preferredto those of secondary intention.

The base of a flap should be as wide as the coronal aspect to

allow for adequate vascularity.

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Tissue tags should be removed to allow for rapid healing and

to prevent regrowth of granulation tissue.

Adequate flap stabilization is necessary to prevent

displacement, unnecessary bleeding, hematoma formation,

bone exposure and possible infection.

All flaps should be designed for maximum utilization and

retention of keratinized gingival tissue so as to maintain a

functional zone of attached keratinized gingiva and prevent

needless secondary procedures.

PERIODONTAL SURGICAL INSTRUMENTS

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PERIODONTAL SURGICAL INSTRUMENTS

(Armamentarium) : Periodontal surgery is

accomplished with numerousinstruments. Periodontal surgical

instruments are classified as

follows (Carranza and Newman

1996)

Excisional and incisional

instruments:-

1. Surgical blades e.g. Bard

Parker blades (39 mm) No.11, 12,

12D, 15, 15c.

2. Interdental knives e.g. Orban

Knive No.1-2.

Surgical curettes and sickles e.g.

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g g

Prichard curette, Kirkland surgical

instruments.

Periosteal elevators e.g. No.24 G

and Goldman Fox No.14.

Surgical chisels and Hoes.

Surgical files e.g. Schluger and

Sugarman files.

Scissors and Nippers e.g. Goldman

Fox No.16 and Castroveijo scissors

N dl h ld

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Needle holders e.g.

conventional and Castroveijo

needle holders.

Hemostats and tissue

forceps.

Soft tissue and Bonerongeurs.

Surgical burs.

Local anesthetic syringe.

Irrigating syringe.

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Apprehension :

Medication with a tranquilizer, barbiturate or antihistaminicmay be indicated. It may be given at the time of surgery.

Intramuscular or IV administration of scopalamine or

meperidineantihistamine and meperidine - diazepamcombinations are widely used. Some practitioners use intense

oxide analgesia.

If premedication for sedation is used in the office, it should beadministered 30-48 minutes before local anesthetic injections

S l ti C it i f Fl T h i

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Selection Criteria for Flap Technique

The selection of a technique for treatment of a particular

lesion is based on a number of considerations.

1. Characteristics of the pocket :-

a. Depth

b. Relations to the underlying bone

c. Configuration

2. Accessibility to instrumentation including presence of

furcation involvement.

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3. Existence of mucogingival problems.

4. Response to phase I therapy.

5. Patient cooperation and ability to perform effective oral

hygiene.

6. Age of the patient and general health.

7. Overall diagnosis of the case.

8. Esthetic considerations.

9. Previous periodontal treatment.

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Treatment decisions for soft & hard tissue

pockets in flap surgery

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Incisions used in Flap Surgery

Incisions used for the conventional flaps are classified as :

Horizontal incisions

1. Internal bevela. Scalloping

b. Linear

2. Crevicular

3. Interdental

Vertical Incisions

Horizontal Incision

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Horizontal Incision

Internal Bevel incision or reverse bevel or inverse bevel incision:-

It starts at a distance from the gingival margin & is aimed at the bone

crest. The portion of the gingiva that is left around the tooth containsthe epithelium of the pocket lining and the adjacent granulomatous

tissue.

It is the incision from which the flap will be reflected to expose theunderlying bone and root.

It accomplishes three important objectives (Carranza and Newman

1996).

1. It removes the pocket lining.

2. It conserves the relatively uninvolved outer surface of the gingiva

which, if apically positioned, converts to attached gingiva.

3. It produces a sharp and thin flap margin for adaptation to the bone

tooth junction.

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The starting point on the gingiva is determined by whether

the flap will be apically displaced or not. It is called first

incision because it is the initial incision in the reflection of the

periodontal flap and the reverse bevel as the bevel is in areverse direction from that of the gingivectomy incision.

The principle of the reverse bevel incision was thought to

have arisen early in the 1900s but the person who actually

introduced it is controversial as Neumann (1912), Cieszynski

(1914) and Widman (1917); all used it. When utilizing

reverse bevel procedures, both scalloped and linear incisionshave been described.

The scalloped incision is s ch that it follo s the conto rs of

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The scalloped incision is such that it follows the contours of

the gingival margins at varying distances form the margin

depending on how much tissue is to be removed.

After the flap is reflected and the surgical corrective

procedures completed, the flap is usually replaced or

repositioned so that the marginal soft tissue covers the

marginal and interdental bone and hence minimized thehealing by secondary intention.

The linear incision does not follow the contours of the

gingival margins and hence does not provide any interdentalsoft tissue coverage for bone when the flap is replaced or

repositioned, and therefore osseous tissue is left exposed

interdentally and healing in these areas is by secondary

intention only.

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Indications :-

1. Original widman flap.

2. Modified Widman flap.

3. Apically repositioned flap.

4. Undisplaced flap.

Instruments :-

Surgical scalpel blade No. #11 or #15

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Crevicular or sulcuar incision (second incision) :

This starts form the base of the pocket to the crest of the bone.

This, along with the first incision, forms a V-shaped wedge

ending at or near the crest of the bone; this wedge of tissuecontains most of the inflamed and granulomatous areas that

constitute the lateral wall of the pocket, as well as the junctional

epithelium and the connective tissue fibers that still persist

between the bottom of the pocket and the crest of the bone.

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Indicatios :-

1. when preservation of gingiva is critical,as in esthetic area. E.g kirkland flap

2. when minimum keratinized tissue.

Instruments :-

The incision is carried around the entire

tooth. The beak shaped No.12 B blade isusually used for this incision.

Ad t

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Advantages :

It is the easiest to perform and is accomplished by placing

the scalpel blade into the gingival sulcus and severing boththe epithelial and connective tissue attachments from the

tooth. It is followed by a full thickness flap, which is

relatively easy to reflect and suture.

It can be used when the surgeon is extracting a tooth or a

root fragment, placing a dental implant or performing an

apicoectomy.

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Disadvantage :

The epithelial lining is incorporated into the flap and then

sutured back onto the root when the flap is closed. This

might be acceptable as long as the gingival attachment is

healthy, but if a periodontal pocket is present and the

sulcular epithelium is diseased, a sulcular incision is

contraindicated.

I t d t l Thi d i i i

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Interdental or Third incision

To separate the collar of gingiva that is left around the tooth .

The orbans knife is used for this incision.

The incision is made not only around the facial & lingual

radicular area but also interdentally, connecting the facial &

lingual segments, to free the gingiva completely around thetooth.

Orbans Knife

Incisions Description Indications Instruments

V ti l R l i P di l t 1 T i S l l bl d 11

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Vertical or Releasing Perpendicular to

gingival margin at the

line angles of teeth

1. To increase access.

2. To allow apical or

coronal positioning of

flap

Scalpel blades no. 11

or 15

Thinning Internal or undermining

incision extending from

gingival margin toward

the base of the flap to

decrease the bulk of

the connective tissueon the underside of the

flap

1. Palatal flap

2. Distal wedge

procedure

3. Internal bevel

gingivectomy

4. Bulky papilla

Scalpel blade no. 12 or

15

Cutback Small incision made at

the apical aspect of a

releasing incision &directed towards the

base of the flap

Pedicle flap that are

laterally positioned

Scalpel bladed no. 11

or 15

Periosteal releasing Incision at the base of

the flap severing the

underlying periosteum

To release flap tension

allowing coronal

advancement of the

flap

Scalpel blade no. 15

Original widman flap

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g p

A Swedish dentist Leonard widman in 1918 first time use a

flap procedure for pocket elimination.

In his article The Operative treatment of pyorrhea alveolaris

He described a mucoperiosteal flap design aimed at removing

the pocket epithelium & the inflamed connective tissue,

thereby facilitating optimal cleaning of the root surface.

He introduced the reverse bevel scalloping type of gingival

incision in 1916 as modification of Neumanns periodontal flap

surgery.

This procedure was aimed at reattachment and readaptation

of the pocket walls rather than just the surgical eradication of

the outer walls of the pocket.

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Indications :

Moderate to deep periodontal pockets.

As a surgical treatment of pyorrhea alveolaris.

Advantages :

Excellent direct vision.

Good access to all root surfaces and furcation.

Flap repositioning possible.

Reestablishment of bony contours possible in sites withangular bony defects.

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Disadvantages :

Root exposure.

Post operative pain and edema.

Superficial resorption of exposed bone.

Bony exposure in interproximal areas.

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Technique for original widman flap

Sectional releasing incisions were first made todemarcate the area scheduled for surgery.

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Neumann Flap

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Neumann Flap

Robert Neumann developed principle of periodontal flap

surgery between 1914 and 1916

Crevicular incision to the bone margin & Vertical incisionnot

bisecting the interdental papilla.

Separation of flap was done then elevated to gain clear view

of the entire field of operation, all granulation tissue & calculus

were removed & bone margin smoothened with the chisels &

burs to reshape the normal topography.

The margin of the flap was then trimmed & scalloped with the

scissors to reach exactly the bone margin and sutured using

straight & curved needle & silk thread.

Diff b t O i i l id &

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Difference between Original widman &

Neumann Flap

Original widman Flap Neumann Flap

No Lingual / palatal

pocket

Both buccal & lingual flap

should be reflected

Only buccal flap should

be reflected

Area for surgery Three tooth at a time Sextant

Type of incision Reverse bevel Intracrevicular

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UNDISPLACED FLAP

One of the most commonly performed type of pdl surgery.

Soft tissue pocket wall is removed with the initial incision; thus it

may be considered an internal bevel gingivectomy.

surgically remove the pocket wall.

To avoid mucogingival problem -important to determine :

enough attached gingiva will remain after removal of the pocket wall.so pocket

depth and location of MGJ is important.

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Stage I :- pockets - measured with the pdl probe, and a bleeding point is produced

on the outer surface of the gingiva to mark the pocket bottom.

Internal bevel incision is made after the scalloping of the bleeding marks on the

gingiva.

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Stage II :- 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 thethickness of the tissue.

The thicker the tissue, the more apical is the ending point of the incision.

Stage III :- The second or crevicular incision is made from the bottom of the pocket to

detach the connective tissue from the bone.

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Stage IV :- 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.

Stage V :- The interdental incision is made with an interdental knife, separating

the connective tissue from the bone.

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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 toposition and hold the flap edges at the root-bone junction.

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Advantages :

1. Improved accessibility for instrumentation.

2. Removes the pocket wallreducing or eliminating the

pocket .

Disadvantage :

1. Poor esthetics

2. Root exposuresensitivity and caries

M difi d Fl O ti

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Modified Flap Operation

In 1931 Kirkland described a surgical procedure to be

used in the treatment of PeriodontalPus Pockets.

This procedure was called as Modified Flap Operation,and is basically an access flap for proper root

debridement & no attempt was made to reduce the pre-

operative depth of the pockets.

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Ad antage of Modified Flap

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Advantage of Modified Flap

1. Useful in anterior region of the dentition for the

esthetic regions, since root surface was not exposed.

2. Potential for bone regeneration in intrabony defects.

In contrast to the original Widman flap as well as theNeumann flap, the modified flap operation did not

include :-

(1) Extensive sacrifice of non-inflamed tissues.

(2) Apical displacement of the gingival margin.

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Modified Widman Flap

Ramfjord & Nissle (1974) described the modifiedWidman flap technique.

Also recognized as the open flap curettage technique.

Original Widman flap technique included both apical

displacement of the flaps and osseous recontouring

(elimination of bony defects) to obtain proper pocket

elimination, the modified Widman flap technique is notintended to meet these objectives

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Indications for the Modified Widman Flap

Adequate width of attached gingiva.

Deep Pockets.

Intrabony Pockets.

Need to minimize recession, as in the anterior regions.

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Initial incision is made parallel to the long axis of the tooth .

If pockets are deeper than 3 mm-incision is placed -1mm away from the

gingival margin to ensure removal of all crevicular epithelium .

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Second incision i.e crevicular incision is made around the neck of the toothfrom bottom of the crevice to the alveolar crest.

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Third incisionmade in the horizontal direction to separate the soft tissue

collar of root surface s from the bone

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Following proper debridement and curettage of angular bone defects,

the flaps are carefully adjusted to cover the alveolar bone and sutured

Advantage of Modified Widman Flap

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Advantage of Modified Widman Flap

Access & visualization of the root surfaces.

The possibility of obtaining a close adaptation of the soft

tissues to the root surfaces.

The minimum of trauma to which the alveolar bone and

the soft connective tissues are exposed.

Less exposure of the root surfaces, which from an

esthetic point of view is an advantage in the treatment of

anterior segments of the dentition.

Preservation of gingival width.

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Minimal or no inflammationin the area of connectivetissue adaptation indicating that the active pathologic

aspect of the pocket is eliminated acting as a source of

irritation.

f f

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Disadvantages of Modified Widman Flap

Postoperative soft tissue craters.

Residual probing depth in the presence of intrabony

defects.

New attachment is unpredictable.

Unstable junctional epithelial attachment long term.

There will be some post operative tissue shrinkage once

healing occurs.

Comparison of the Original andM difi d Wid Fl P d

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Modified Widman Flap Procedures

Original Widman Flap Modified Widman Flap

For Pocket Elimination Gain access to the roots and the

alveolar crest

Collar of tissue attached to theteeth torn with curettes

Collar excised with sharp knives(Second incision) and removedwith curettes

High flap reflection i.e. raisedbeyond the apex of tooth

Minimal flap reflection i.e.Mucoperiosteal flap is raised only 2 to

3 mm from the alveolar crest

Flaps do not cover interproximalbone

Close interproximal flapadaptation because exageratedpalatal scalloping of the flaps

Bone remains exposed No bone exposed

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Apically Repositioned Flap

In the 1950s & 1960s removal of soft & hard tissueperiodontal pockets were described. This decade was

also important because of maintaining an adequate zone

of attached gingiva after surgery was emphasized.

The first technique for the preservation of the gingiva

following surgery denoted as Repositioned of attached

gingiva by Nabersin 1954 and modified by Ariaudo &

Tyrrell in 1957.

In 1962 Friedman proposed the term apically

repositioned flap for the Naberstechnique.

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According to Friedman the entire complex of the softtissues (gingiva & alveolar mucosa) rather than the

gingiva alone was displaced in apical direction & the

whole muco-gingival complex was maintained &

repositioned apically.

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The incisional and excisional technique used means that

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The incisional and excisional technique used means that

it is not always possible to obtain proper soft tissue

coverage of the denuded interproximal alveolar bone.

A periodontal dressing should therefore be applied to

protect the exposed bone and to retain the soft tissue at

the level of the bone crest.

After healing, an adequate zone of gingiva is

preserved and no residual pockets should remain.

Indications :

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Indications:

Pocket eradication and/or widening the zone of attached

gingiva.

Areas of thin periodontium or prominent roots where

dehiscence or fenestrations may be present.

Contraindications:

Labial anterior areas where tooth exposure is

unaesthetic.

Patient who are prone for root caries.

Advantages :Mi i k t d th t ti l

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Minimum pocket depth post-operatively.

If optimal soft tissue coverage of the alveolar bone isobtained, the post-surgical bone loss is minimal.

The post-operative position of the gingival margin may

be controlled and the entire muco-gingival complex maybe maintained.

Disadvantage :

The sacrifice of periodontal tissues by bone resection

and the subsequent exposure of root surfaces (may

cause esthetic root caries and root sensitivity problems).

Palatal Flap Su rgery

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p g y

Because of the anatom ic character ist ics of the palate, palatal flaps require

different designs.

Desirable to remove deep pdl pockets entirely and establish shallow

physiological sulcus for the following reasons:

1. Palatal tissue - masticatory mucosa and immobile; it has no elasticfibers and loose connective tissues. Therefore, it is impossible to

displace a palatal flap apically.

2. Thick, keratinized tissue; therefore, accurate close adaptation to the

tooth surface and bone margin is difficult, and postoperative gingivalmorphology may be unfavorable. Periodontal pockets tend to recur

postoperatively.

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3. Reduction of the periodontal pocket in a thickgingival wall in the palatal aspect is uncommon

because of the minimal gingival shrinkage achieved

by initial therapy such as brushing or scaling.

4. Inaccessibility of cleaning instruments may cause

inadequate self-care.

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Considerations for determining the position of the primary

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Considerations for determining the position of the primary

incision in palatal flap surgery are:

l. Thickness of palatal tissue

2. Depth of periodontal pocket

3. Degree of osseous defect

4. Necessity of osteoplasty and required clinical crown length

5. Surgical methods (or techniques) applied

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Advantages :

1. Flap thickness may be adjusted.

2. Palatal flap may be adapted to the proper position.

3. Better postoperative gingival morphology is possible with a thin flap design.

4. Treatments may be combined (osseous resection and wedge procedure).

5. Rapid healing.

6. Easy management of palatal tissue.

7. Minimal damage to palatal tissue.

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Contraindicated :

when a broad, shallow palate does not permit a

partial-thickness flap to be raised without

possible damage to the palatal artery.