FLAP TECHNIQUES FOR POCKET ELIMINATION

Guided By:Dr. Prashant Bhusari Prof. & Guide

Index
Introduction.
Definitions of Flap.

History of Flap techniques.

Objectives of Flap procedure. Classification of periodontal Flap. Indications of Flap. Contraindications of Flap.

 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.

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 causerelated phase of therapy and this evaluation may be 1 to 6 months. This time lapse has following advantages:-

 1. Removal of calculus & plaque will reduce the inflammatory cell infiltrate in the gingiva (edema, hyperemia, flabby tissue consistency) so that assessment of the true gingival contour & pocket depths possible. 2. Reduction of gingival inflammation makes the soft tissue more fibrous & firmer facilitates surgical handling of the soft tissue so that bleeding is reduced. 3. A proper assessment of the prognosis has been established. The effectiveness of the patients home care, can be properly evaluated. Lack of effective selfperformed infection control mean patient should be excluded from surgical treatment.

 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-view operations).
Later, procedures were described by which the diseased gingiva was excised (gingivectomy procedures)

The concept that not only inflamed soft tissue but also infected and necrotic bone had to be eliminated called for the development of surgical techniques by which the alveolar bone could be exposed and resected (flap procedures).

 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. (Carranza 1996)
Flap is a piece of tissue parity severed from its place of origin for use in surgical grafting and repair of body defects. (Ramfjord) A flap is a segment of gingiva and adjoining alveolar mucosa raised from the underlying tissues by surgical means Grant. Surgery has been defined as the act and art of treating diseases or injuries by manual operation.

History of Periodontal Flap

The history begins with Athens, Rome & extending to Vienna in late 19th century & the Berlin in the early 20th century. The Berlin group was originally led by men like 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.

 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 period came 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 3rd edition.

 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 for access for scaling, removal of granulation tissue and reduction of pocket depth. However no description of the methodology was given.

The English translation of Widmans article 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 the bone.

 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 an acceptable solution for the elimination of intrabony pockets and craters and for pockets extending apically beyond the attached gingiva.

 Schluger recommended doing a gingivectomy first and then a mucoperiosteal flap to expose the alveolar crest and part of the alveolar process.

Later Schlugers approach 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 for pocket elimination.

 A new approach to surgical elimination of the periodontal pocket extending beyond the mucogingival line was proposed by Nabers in 1954. He used essentially the Neumann 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 procedure by recommending Widmans reverse bevel incision as the initial approach to the flap design and Friedman suggested calling this procedure the apcially repositioned flap.

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.

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

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).

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).

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.

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.

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 transfer and geometry (Bahat and Handelsman 1991).

Bone exposure after flap reflection.

Full thickness (mucoperiosteal) All the soft tissue, including the periosteum, is reflected to expose the underlying bone. Partial thickness (mucosal) flaps /split thickness flap

It includes only the epithelium and a layer of the underlying connective tissue. The 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 past the crest of the alveolar bone so as to leave a layer of periosteal connective tissue intact, covering the vestibular surface of the alveolar process.

 In the full thickness flap-the resorptive 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. Twenty-one day period, where now definite osteogenesis is characteristic of the alveolar process associated with the split thickness flap, it is at this time that one can observe that very little change that took place by resorption at the crest of the process and only some on the vestibular surface.

 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 .

Placement of the flap after surgery

Undisplaced or Nondisplaced Flaps :- when the flap is returned & 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 the outer portion of the pocket wall and transforming it into attached gingiva so it fulfills 2 objectives :1. Pocket Elimination 2. Width of Attached gingiva increase.

Management of the papilla

Conventional Flap :- Interdental papilla is split beneath the contact point of the two approximating teeth to allow 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.

 Papilla Preservation Flaps :it incorporates the entire papilla in one of the flap by means of crevicular interdental incison to sever the connective tissue attachment & a horizontal incision at the base of the papilla, leaving it connected to one of the flaps .

Presence / absence of releasing incisions

Flap with releasing incisions

(with Vertical incision)

Envelope flap
( without Vertical incision)

Advantages Flap with Vertical incision Used if the osseous defect is very deep or of it is isolated to one or two teeth Limit the surgical field to only those teeth that are pathologically involved Flap can be move to another position without causing excessive tension

Disadvantages Delayed healing

Greater post operative pain and bleeding

Cannot be given in palatal as well as lingual area

Envelop flap

Quicker to heal and are associated with less post operative pain and bleeding Used in situations where esthetics is a major consideration

Limit access to the bony tissues

Cannot be easily moved or repositioned to other locations

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

Indications
Accessibility for proper scaling and root planning. Establishment of a morphology of the dentogingival area conductive to plaque control. Pocket depth reduction.

Correction of gross gingival aberrations

Shift of the gingival margin to a position apical to plaque retaining restorations.

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 hypertension normally 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.

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 Infarction patients 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 periodontal surgery. Adjustments of the anticoagulants drug therapy usually needs to initiated 2-3 days prior to the dental appointment. Aspirin & NSAIDs should not be used postoperatively pain control since they increase bleeding tendency & tetracycline is contraindiated.

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.

 Hormonal Disturbances : Diabetes Mellitus is often associated with delayed wound healing and lowered resistance to infection and predisposition 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 to be altered during and after the period of periodontal surgery.

 Neurological Disorders : 1. Multiple sclerosis and Parkinsons Disease : may in severe cases, make ambulatory periodontal surgery impossible. Paralesis, impaired muscular function, tremor and uncontrollable reflexes may necessitate treatment under general anesthesia. 2. Epilepsy is 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 correction of the hyperplasia.

 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 depth and smaller improvements in clinical attachment may be observed in smokes than in non-smokers. (Preber & Bergstorm 1990)

General Surgical Considerations

Procedural selection should be based on the following : 1. Simplicity 2. Predictability 3. 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.

 Flap design should allow for adequate access and visibility.

Flap design should prevent unnecessary bone exposure with resultant possible loss and dehiscence or fenestration formation. Where possible, primary intention procedures are preferred to those of secondary intention. The base of a flap should be as wide as the coronal aspect to allow for adequate vascularity.

 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 (Armamentarium) :

Periodontal surgery is accomplished with numerous instruments. 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. 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

 Needle holders e.g. conventional and Castroveijo needle holders. Hemostats and tissue forceps.
Soft tissue and Bone rongeurs. Surgical burs. Local anesthetic syringe.

Irrigating syringe.

Premedication for Surgery :

It should be given when indicated and may include the administration of antibiotics to patients with valvular heart disease or other conditions requiring antibiotics. Accoridng to ADA in such cases 2 gm of amoxicillin should be started 1 hour before surgery to provide adequate levels and minimize bacterial resistance. Antibiotic medication should be adequate in amount and should be continued for several days after surgery. Patient on anticoagulant therapy or aspirin should stop such medications 3 or 4 days before surgery and 3 or 4 days afterwards with their physician approval.

 Apprehension :
Medication with a tranquilizer, barbiturate or antihistaminic may be indicated. It may be given at the time of surgery. Intramuscular or IV administration of scopalamine or meperidine antihistamine and meperidine - diazepam combinations are widely used. Some practitioners use intense oxide analgesia. If premedication for sedation is used in the office, it should be administered 30-48 minutes before local anesthetic injections

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.

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.

Treatment decisions for soft & hard tissue pockets in flap surgery

Incisions used in Flap Surgery

Incisions used for the conventional flaps are classified as : Horizontal incisions 1. Internal bevel a. Scalloping b. Linear 2. Crevicular 3. Interdental Vertical Incisions

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 contains the epithelium of the pocket lining and the adjacent granulomatous tissue. It is the incision from which the flap will be reflected to expose the underlying 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.

 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 a reverse 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 incisions have been described.

 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 the healing by secondary intention. The linear incision does not follow the contours of the gingival margins and hence does not provide any interdental soft 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.

 Indications :1. Original widman flap. 2. Modified Widman flap. 3. Apically repositioned flap. 4. Undisplaced flap.

Instruments :Surgical scalpel blade No. #11 or #15

 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 tissue contains 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.

 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 is usually used for this incision.

 Advantages :
It is the easiest to perform and is accomplished by placing the scalpel blade into the gingival sulcus and severing both the 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.

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.

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 the tooth.

Orbans Knife

Incisions Vertical or Releasing

Description Perpendicular to gingival margin at the line angles of teeth

Indications 1. To increase access. 2. To allow apical or coronal positioning of flap

Instruments 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 tissue on the underside of the flap Small incision made at the apical aspect of a releasing incision & directed towards the base of the flap Incision at the base of the flap severing the underlying periosteum

1. Palatal flap 2. Distal wedge procedure 3. Internal bevel gingivectomy 4. Bulky papilla

Scalpel blade no. 12 or 15

Cutback

Pedicle flap that are laterally positioned

Scalpel bladed no. 11 or 15

Periosteal releasing

To release flap tension allowing coronal advancement of the flap

Scalpel blade no. 15

Original widman flap

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.

 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 with angular bony defects.

 Disadvantages :

Root exposure. Post operative pain and edema. Superficial resorption of exposed bone. Bony exposure in interproximal areas.

Technique for original widman flap

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

Advantage of original widman flap over gingivectomy procedure

Less discomfort to the patient, since healing occurred by primary intention. It was re-establish a proper contour of the alveolar bone in sites with angular bony defects.

Neumann Flap
Robert Neumann developed principle of periodontal flap surgery between 1914 and 1916
Crevicular incision to the bone margin & Vertical incision not 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.

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

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.

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.

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 the thickness 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.

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.

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 to position and hold the flap edges at the root-bone junction.

Advantages : 1. Improved accessibility for instrumentation. 2. Removes the pocket wall reducing or eliminating the pocket .

Disadvantage : 1. Poor esthetics 2. Root exposure sensitivity and caries

Modified Flap Operation

In 1931 Kirkland described a surgical procedure to be used in the treatment of Periodontal Pus 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 preoperative depth of the pockets.

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 the Neumann flap, the modified flap operation did not include :(1) Extensive sacrifice of non-inflamed tissues.

(2) Apical displacement of the gingival margin.

Modified Widman Flap

Ramfjord & Nissle (1974) described the modified Widman 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 not intended to meet these objectives

Indications for the Modified Widman Flap

Adequate width of attached gingiva.
Deep Pockets. Intrabony Pockets. Need to minimize recession, as in the anterior regions.

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 .

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

Third incision made in the horizontal direction to separate the soft tissue collar of root surface s from the bone

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

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.

 Minimal or no inflammation in the area of connective tissue adaptation indicating that the active pathologic aspect of the pocket is eliminated acting as a source of irritation.

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 and Modified Widman Flap Procedures

Original Widman Flap For Pocket Elimination Modified Widman Flap Gain access to the roots and the alveolar crest

Collar of tissue attached to the Collar excised with sharp knives teeth torn with curettes (Second incision) and removed with curettes High flap reflection i.e. beyond the apex of tooth raised Minimal flap reflection i.e. Mucoperiosteal flap is raised only 2 to 3 mm from the alveolar crest

Flaps do not cover interproximal Close interproximal flap adaptation because exagerated bone palatal scalloping of the flaps Bone remains exposed No bone exposed

Apically Repositioned Flap

In the 1950s & 1960s removal of soft & hard tissue periodontal 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 Nabers in 1954 and modified by Ariaudo & Tyrrell in 1957.
In 1962 Friedman proposed the term apically repositioned flap for the Nabers technique.

 According to Friedman the entire complex of the soft tissues (gingiva & alveolar mucosa) rather than the gingiva alone was displaced in apical direction & the whole muco-gingival complex was maintained & repositioned apically.

 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 :
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 :
Minimum pocket depth post-operatively. If optimal soft tissue coverage of the alveolar bone is obtained, the post-surgical bone loss is minimal. The post-operative position of the gingival margin may be controlled and the entire muco-gingival complex may be 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 Surgery

Because of the anatomic characteristics 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 elastic fibers 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 gingival morphology may be unfavorable. Periodontal pockets tend to recur postoperatively.

3. Reduction of the periodontal pocket in a thick gingival 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.

Partial-Thickness Palatal Flap Surgery

By Staffileno" and improved by Corn et al used for the
elimination of periodontal pockets where thick palatal

tissues occur.

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

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.

Contraindicated : when a broad, shallow palate does not permit a

partial-thickness flap to be raised without

possible damage to the palatal artery.