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Aperiodontal flap is a section of gingiva and/or mucosa

surgically separated from the underlying tissues to provide
visibility of and access to the bone and root surface. The
flap also allows the gingiva to be displaced to a different location
in patients with mucogingival involvement.
Periodontal flaps can be classified based on the following:
• Bone exposure after flap reflection
• Placement of the flap after surgery
• Management of the papilla
Based on bone exposure after reflection, the flaps are classifiedas either full-thickness
mucoperiosteal) or partial-thickness (mucosal) flaps (Figure 57-1). In full-thickness flaps, all the
soft tissue, including the periosteum, is reflected to expose the underlying bone. This complete
exposure of and access to the underlying bone is indicated when resective osseous surgery is
contemplated. The partial-thickness flap 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. This type of flap is also called the split-thickness flap. The partial-
thickness flap is indicated when the flap is to be positioned apically or when the operator does
not want to expose bone. Conflicting data surround the advisability of uncovering the bone when
this is not actually needed. When bone is stripped of its periosteum, a loss of marginal bone
occurs, and this loss is prevented when the periosteum is left on the bone.4 Although usually not
clinically significant,7 the differences may be significant in some cases (Figure 57-2). The
partial-thickness flap may be necessary when the crestal bone margin is thin and exposed with an
apically placed flap, or when dehiscences or fenestrations are present. The periosteum left on the
bone may also be used for suturing the flap when it is displaced apically.
Based on flap placement after surgery, flaps are classified as (1) nondisplaced flaps, when the
flap is returned and sutured in its original position, or (2) displaced flaps, which are placed
apically, coronally, or laterally to their original position. Both full-thickness and partial-thickness
flaps can be displaced, but to do so, the attached gingiva must be totally separated from the
underlying bone, thereby enabling the unattached portion of the gingiva to be movable.
However, palatal flaps cannot be displaced because of the absence of unattached gingiva.
Apically displaced flaps have the important advantage of preserving the outer portion of the
pocket wall and transforming it into attached gingiva. Therefore these flaps accomplish the
double objective of eliminating the pocket and increasing the width of the
attached gingiva. Based on management of the papilla, flaps can be conventional or papilla
preservation flaps. In the conventional flap, the interdental papilla is split beneath the contact
point of the two approximating teeth to allow reflection of the buccal and lingual flaps. The
incision is usually scalloped to maintain gingival morphology and retain as much papilla as
possible. The conventional flap is used (1) when the interdental spaces are too narrow, thereby
precluding the possibility of preserving the papilla and (2) when the flap is to be displaced.
Conventional flaps include the modified Widman flap, the undisplaced flap, the apically
displaced flap, and the flap for reconstructive procedures. These techniques are described in
detail in Chapter 59.The papilla preservation flap incorporates the entire papilla in one of the
flaps by means of crevicular interdental incisions to sever the connective tissue attachment and a
horizontal incision at the base of the papilla, leaving it connected to one of the flaps. possibility
of preserving the papilla and (2) when the flap is to be displaced. Conventional flaps include the
modified Widman flap, the undisplaced flap, the apically displaced flap, and the flap for
reconstructive procedures. These techniques are described in detail in Chapter 59. The papilla
preservation flap incorporates the entire papilla in one of the flaps by means of crevicular
interdental incisions to sever the connective tissue attachment and a horizontal incision at the
base of the papilla, leaving it connected to one of the flaps.
INCISIONSPeriodontal flaps use horizontal and vertical incisions.
Horizontal Incisions
Horizontal incisions are directed along the margin of the gingival in a mesial or a distal direction.
Two types of horizontal incisions have been recommended: the internal bevel incision,6 which
starts at a distance from the gingival margin and is aimed at the bone crest, and the crevicular
incision, which starts at the bottom of the pocket and is directed to the bone margin. In addition,
the interdental incision is performed after the flap is elevated. The internal bevel incision is basic
to most periodontal flap procedures. It is the incision from which the flap is reflected to expose
the underlying bone and root. The internal bevel incision accomplishes three important
objectives: (1) it removes the pocket lining; (2) it conserves the relatively uninvolved outer
surface of the gingiva, which, if apically positioned, becomes attached gingiva; and (3) it
produces a sharp, thin flap margin for adaptation to the bone-tooth junction. This incision has
also been termed the first incision because it is the initial incision in the reflection of a
periodontal flap, and the reverse bevel incision because its bevel is in reverse direction from that
of the gingivectomy incision. The #15C or the #15 surgical blade is used most often to make this
incision. That portion of the gingiva left around the tooth contains the epithelium of the pocket
lining and the adjacent granulomatous tissue. It is discarded after the crevicular (second) and
interdental (third) incisions are performed (Figure 57-5). The internal bevel incision starts from a
designated area on the gingiva and is directed to an area at or near the crest of the bone (Figure
57-6). The starting point on the gingiva is determined by
Figure 57-3 Flap design for conventional or traditional flap technique. A, Design of incisions:
internal bevel incision, splitting the
papilla, and vertical incisions are drawn in interrupted lines. B, The flap has been elevated, and
the wedge of tissue next to the tooth is still in
place. C, All marginal tissue has been removed, exposing the underlying bone (see defect in one
space). D, Tissue returned to its original position. Proximal areas are not totally covered. whether
the flap is apically displaced or not displaced (Figure
57-7). The crevicular incision, also termed the second incision, is made from the base of the
pocket to the crest of the bone (Figure 57-8). This incision, together with the initial reverse bevel
incision, forms a V-shaped wedge ending at or near the crest of 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. The incision is carried around the
entire tooth. The beak-shaped #12D blade is usually used for this incision.
A periosteal elevator is inserted into the initial internal bevel incision, and the flap is separated
from the bone. The most apical end of the internal bevel incision is exposed and visible. With
this access, the surgeon is able to make the third incision, or interdental incision, to separate the
collar of gingiva that is left around the tooth. The Orban knife is usually used for this incision.
The incision is made not only around the facial and lingual radicular area but also interdentally,
connecting the facial and lingual segments to free the gingiva completely around the tooth
(Figure 57-9; see also Figure 57-5). These three incisions allow the removal of the gingiva
around the tooth (i.e., the pocket epithelium and the adjacent granulomatous tissue). A curette or
a large scaler (U15/30) can be used for this purpose. After removal of the large pieces of tissue,
the remaining connective tissue in the osseous lesion should be carefully Figure 57-7 A,
Internal bevel (first) incision can be made at varying locations and angles according to the
different anatomic and pocket situations. B, Occlusal view of the different locations where the
internal bevel incision can be made. Note the scalloped shape of the incisions. Figure 57-10
Incorrect (A) and correct (B) locations of a vertical incision. This incision should be made at the
line angles to prevent splitting of a papilla or incising directly over a radicular surface. curetted
so that the entire root and the bone surface adjacent to the teeth can be observed. Flaps can be
reflected using only the horizontal incision if sufficient access can be obtained in this way and if
apical, lateral, or
coronal displacement of the flap is not anticipated. If vertical incisions are not made, the flap is
called an envelope flap.
Vertical Incisions
Vertical or oblique releasing incisions can be used on one or both ends of the horizontal incision,
depending on the design and
purpose of the flap. Vertical incisions at both ends are necessary if the flap is to be apically
displaced. Vertical incisions must extend beyond the mucogingival line, reaching the alveolar
mucosa, to allow for the release of the flap to be displaced (see Chapter 59). In general, vertical
incisions in the lingual and palatal areas are avoided. Facial vertical incisions should not be made
in the center of an interdental papilla or over the radicular surface of a tooth. Incisions should be
made at the line angles of a tooth either to include the papilla in the flap or to avoid it completely
(Figure 57-10). The vertical incision should also be designed to avoid short flaps (mesiodistal)
with long, apically directed incisions because this could jeopardize the blood supply to the flap.
Several investigators proposed the interdental denudation procedure, which consists of
horizontal, internal bevel, nonscalloped incisions to remove the gingival papillae and denude the
interdental space.1,2,11,12 This technique completely eliminates the inflamed interdental tissue.
Healing is by secondary intention and results in excellent gingival contour. It is contraindicated
when bone grafts are used for the graft material placed interdentally will not be covered.
When a full-thickness flap is desired, reflection of the flap is accomplished by blunt dissection.
A periosteal elevator is used to
separate the mucoperiosteum from the bone by moving it mesially, distally, and apically until the
desired reflection is accomplished (Figure 57-11). Sharp dissection is necessary to reflect a
partial-thickness flap. A surgical scalpel (#15) is used (Figure 57-12). A combination of full-
thickness and partial-thickness flaps may be indicated to obtain the advantages of both. The flap
is started as a full-thickness procedure, then a partial-thickness flap is made at the apical portion.
In this way the corona portion of the bone, which may be subject to osseous remodeling, is
exposed while the remaining bone is protected by the periosteum
Immediately after suturing (up to 24 hours), a connection betweenvthe flap and the tooth or bone
surface is established by a blood clot, which consists of a fibrin reticulum with many
polymorphonuclear leukocytes, erythrocytes, debris of injured cells, and capillaries at the edge of
the wound.3 Bacteria and an exudate or transudate also result from tissue injury. One to 3 days
after flap surgery, the space between the flap and the tooth or bone is thinner and epithelial cells
migrate over the border of the flap, usually contacting the tooth at this time. When the flap is
closely adapted to the alveolar process, there is minimal
inflammatory response.3 One week after surgery, an epithelial attachment to the root has been
established by means of hemidesmosomes and a basal lamina. The blood clot is replaced by
granulation tissue derived from the gingival connective tissue, the bone marrow, and the
periodontal ligament. Two weeks after surgery, collagen fibers begin to appear parallel
to the tooth surface.3 Union of the flap to the tooth is still weak because of the presence of
immature collagen fibers, although the
clinical aspect may be almost normal. One month after surgery, a fully epithelialized gingival
with a well-defined epithelial attachment is present. There is a beginning functional arrangement
of the supracrestal fibers.
Full-thickness flaps, which denude the bone, result in a superficial bone necrosis at 1 to 3 days.
Osteoclastic resorption follows
and reaches a peak at 4 to 6 days, declining thereafter.13 This results in a loss of bone of about 1
mm3 and the bone loss is greater if the bone is thin.14,15 Osteoplasty (thinning of the buccal
bone) using diamond burs, included as part of the 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 This may not be the case when osseous remodeling does not include excessive
thinning of the radicular bone.9 Bone repair reaches its peak at 3 to 4 weeks.15 Loss of bone
occurs in the initial healing stages both in radicular bone and in interdental bone areas. However,
in interdental areas, which have cancellous bone, the subsequent repair stage results in total
restitution without any loss of bone, whereas in radicular bone, particularly if thin and
unsupported by cancellous bone, bone repair results in loss of marginal bone root surfaces for
scaling and root planing. The diagnosis of the periodontal lesion and the objective of the surgery
will dictate the
type of flap procedure which will be utilized to obtain the best result. The incisions, type of flap
and the selection of suturing
design must be planned and executed to fit the problem.

Treatment of Gingival Enlargement
Paulo M. Camargo, Fermin A. Carranza, and Henry H. Takei
Treatment of gingival enlargement is based on an understanding of the cause and underlying
pathologic changes
(see Chapter 9). Gingival enlargements are of special concern to the patient and dentist because
they pose problems in
plaque control, function (including mastication, tooth eruption, and speech), and esthetics.
Because gingival enlargements differ in cause, treatment of each type is best considered
Chronic inflammatory enlargements are soft and discolored and are caused principally by edema
and cellular infiltration. These
gingival enlargements are treated by scaling and root planing, provided the size of the
enlargement does not interfere with complete removal of deposits from the involved tooth
surfaces. When chronic inflammatory gingival enlargements include a
significant fibrotic component that does not undergo shrinkage after scaling and root planing or
are of such size that they obscure
deposits on the tooth surfaces and interfere with access to them, surgical removal is the treatment
of choice. Two techniques are
available for this purpose: gingivectomy and flap operation. Selection of the appropriate
technique depends on the size of
the enlargement and character of the tissue. When the enlarged gingiva remains soft and friable
even after scaling and root planing, a gingivectomy is used to remove it because a flap requires a
firmer tissue to perform the incisions and other steps in the technique. However, if the
gingivectomy incision removes all of the attached, keratinized gingiva, which will create a
mucogingival problem, then the flap technique is indicated. Tumorlike inflammatory
enlargements are treated by gingivectomy
as follows: 1. With the patient under local anesthesia, the tooth surfaces beneath the mass are
scaled to remove calculus and other
debris. 2. The lesion is separated from the mucosa at its base with a #12 Bard-Parker blade. If the
lesion extends interproximally,
the interdental gingiva is included in the incision to ensure exposure of the root deposits. 3. After
the lesion is removed, the involved root surfaces are scaled and planed and the area is cleansed
and irrigated with warm water. 4. A periodontal dressing is applied. It is removed after 1 week,
at which time the patient is instructed in plaque control techniques. For the flap operation, see
Chapters 57 and 59 and the following discussion of the flap technique for drug-induced
The reader is referred to Chapter 42 for a complete discussion of abscess treatment.
Gingival enlargement has been associated with the administration of three different types of
drugs: anticonvulsants, calcium channel blockers, and the immunosuppressant, cyclosporine.
Chapter 9 provides a comprehensive review of the clinical and microscopic features and
pathogenesis of gingival enlargement induced by these drugs. Examination of cases of drug-
induced gingival enlargement reveals the overgrown tissues to have two components: a fibrotic
type caused by the drug and an inflammatory type induced by bacterial plaque. Although the
fibrotic and inflammatory components present in the enlarged gingiva are the result of distinct
pathologic processes, they almost always are observed in combination. The role of bacterial
plaque in the overall pathogenesis of drug-induced gingival enlargement is not clear. Some
studies indicate that plaque is a prerequisite for gingival enlargement,10 whereas others suggest
that the presence of plaque is a consequence of its accumulation
caused by the enlarged gingiva.
Treatment Options
Treatment of drug-induced gingival enlargement should be based on the medication being used
and the clinical features of the case. First, consideration should be given to the possibility of
discontinuing the drug8,11 or changing the medication. These possibilities should be examined
with the patient’s physician. Simple discontinuation of the offending drug is usually not
practical, but its substitution with another medication might be an option. If any drug substitution
is attempted, it is important to allow a 6- to 12-month period to elapse between discontinuation
of the offending drug and the possible resolution of gingival enlargement. The decision to
implement surgical treatment is made after this time period has elapsed. Alternative medications
to the anticonvulsant phenytoin include carbamazepine7 and valproic acid, both of which have
been reported to have a lesser effect in inducing gingival enlargement. For patients taking
nifedipine, which has a reported prevalence of gingival enlargement of up to 44%, other calcium
channel blockers, such as diltiazem or verapamil, may be viable alternatives.22 Their reported
prevalence of inducing gingival enlargement is 20% and 4%, respectively.4,9,15 Also,
consideration may be given to the use of another class of antihypertensive medications rather
than calcium channel blockers, none of which is known to induce gingival enlargement. Drug
substitutions for cyclosporine are more limited. Tacrolimus is another immunosuppressant that
has been used on organ transplant
recipients. The incidence of gingival enlargement in patients under tacrolimus therapy is
approximately 65% lower than in those
taking cyclosporine.2 Clinical trials have also shown that the substitution of cyclosporine by
tacrolimus results in a significant decrease in the severity of gingival enlargement when
compared to patients who are kept on cyclosporine therapy24; in another study,13 the same drug
substitution resulted in a strong decrease or complete resolution of gingival enlargement in over
70% of the patients initially presenting with cyclosporine-induced gingival enlargement. 13
Therefore the dental practitioner should consult with the treating transplantation physician to
investigate the possibility of a change in immunosuppressant therapy as one of the steps in the
treatment of cyclosporine-induced gingival enlargement. Administration of the antibiotic
azithromycin has been shown to decrease the severity of gingival enlargement induced by
administration of cyclosporine. A 3-day course of systemic azithromycin significantly decreased
gingival enlargement, and the effect was observed as early as 7 to 30 days after initiation of
antibiotic therapy.23 The effect of azithromycin in decreasing cyclosporineinduced gingival
enlargement is significantly greater than that observed with an improvement in oral hygiene.18
Topical administration of azithromycin in the form of a toothpaste also decreased the severity of
cyclosporine-induced gingival enlargement.2 Second, the clinician should emphasize plaque
control as the first step in the treatment of drug-induced gingival enlargement. Although the
exact role played by bacterial plaque is not well understood, evidence suggests that good oral
hygiene and frequent professional removal of plaque decrease the degree of gingival enlargement
and improve overall gingival health.8,10,22 The presence of drug-induced enlargement is
associated with pseudopocket formation, frequently with abundant plaque accumulation. This
may lead to the development of periodontitis. Therefore meticulous plaque control helps
maintain attachment levels. Also, adequateplaque control may aid in preventing the recurrence of
gingival enlargement in surgically treated cases. Third, in some patients, gingival enlargement
persists even after careful consideration of the previous approaches. These patients may require
surgery, either gingivectomy or the periodontal flap. Figure 58-1 presents a decision tree
outlining the sequence of events and options in the treatment of drug-induced gingival
Gingivectomy. Gingivectomy has the advantage of simplicity and quickness but presents the
disadvantages of postoperative discomfort and increased chance of postoperative bleeding. It
also sacrifices keratinized tissue and does not allow for osseous recontouring if it is necessary.
The clinician’s decision between the two surgical techniques available must consider the extent
of the area to be operated, the presence of periodontitis and osseous defects, and the location of
the base of the pockets in relation to the mucogingival junction. In general, small areas (up to six
teeth) of drug-induced gingival enlargement with no evidence of attachment loss (and therefore
no anticipated need for osseous surgery) can effectively be treated with the gingivectomy
technique. An important consideration is the amount of keratinized tissue that is present. At least
3 mm of keratinized gingiva in the apicocoronal direction should remain after the surgery is
completed. Chapter 56 describes the gingivectomy technique in detail. Figures 56-6 to 56-8 and
Figure 58-2 depict the procedure diagrammatically, and Figure 58-3 illustrates a case of
cyclosporineinduced gingival enlargement treated with the gingivectomy technique.
Gingivectomy or gingivoplasty can also be performed with electrosurgery, using a laser device
(see Chapter 56). There is some preliminary evidence that the recurrence of drug-induced
gingival enlargement is slower on patients treated via laser when compared to conventional
gingivectomy or flap surgery.14
Flap Technique. Larger areas of gingival enlargement (more than six teeth) or areas where
attachment loss and osseous defects are present should be treated by the flap technique, as should
any situation in which the gingivectomy technique may create a mucogingival problem. The
periodontal flap technique used for the treatment of gingival enlargements is a simple variation
of the one used to treat periodontitis (see Chapters 57 and 59). Figure 58-4 describes the basic
steps in the technique, described as follows: 1. After anesthetizing the area, sounding of the
underlying alveolar bone is performed with a periodontal probe to determine the presence and
extent of osseous defects. 2. With a #15 Bard-Parker blade, the initial scalloped internal bevel
incision is made at least 3 mm coronal to the mucogingival junction, including the creation of
new interdental papillae. 3. The same blade is used to thin the gingival tissues in a buccolingual
direction to the mucogingival junction. At this point the blade establishes contact with the
alveolar bone, and a full-thickness or a split-thickness flap is elevated. 4. Using an Orban knife,
the base of each papilla connecting the facial and the lingual incisions is incised. 5. The excised
marginal and interdental tissues are removed with curettes. 6. Tissue tabs are removed, the roots
are thoroughly scaled and planed, and the bone is recontoured as needed. 7. The flap is replaced
and if necessary, trimmed to reach the bone-tooth junction. The flap is then sutured with an
interrupted or a continuous mattress technique. The surgical area is covered with a periodontal
dressing. Sutures and dressing are removed after 1 week. The patient is then instructed to initiate
plaque control methods. Usually it is convenient for the patient to use chlorhexidine oral rinses
once or twice daily for several weeks. Figure 58-5 illustrates a patient treated with the flap
technique. Recurrence of drug-induced gingival enlargement is a reality in surgically treated
cases.19 As stated previously, meticulous home care,6,16 chlorhexidine gluconate rinses,16,21
and professional recall therapy can decrease the rate and the degree to which recurrence occurs.
A hard, natural rubber fitted bite guard worn at night may help to control the recurrence Even
though the periodontal flap approach may be technically more difficult than the gingivectomy
procedure, the postsurgical healing of the flap technique presents less discomfort and alleviates
hemorrhagic problems. The primary closure of the surgical site with the flap procedure is a great
advantage over the secondary open wound resulting from the gingivectomy technique. Also,
postsurgical home care can be instituted earlier with the periodontal flap.5 Recurrence may occur
as early as 3 to 6 months after the surgical treatment. In general, surgical results are maintained
for at least 12 months. In one study, 6-month postsurgical examination of the recurrence of
cyclosporine-induced gingival enlargement after periodontal flap surgery or gingivectomy
determined the return of increased pocket depth was slower with the flap technique.17 However,
the recurrence of increased thickness of the periodontal tissue has not been objectively evaluated
Figure 58-3 Surgical treatment of cyclosporineinduced gingival enlargement using the
gingivectomy technique on a 16-year-old girl whon had received a kidney allograft 2 years
earlier. A, Presence of enlarged gingival tissues and pseudopocket formation; no attachment loss
or evidence of vertical bone loss existed. B, Initial external bevel incision performed with a
Kirkland knife. C, Interproximal tissue release achieved with an Orban knife. D and E,
Gingivoplasty performed with tissue nippers and a round diamond at high speed with abundant
refrigeration. F, Aspect of the surgical wound at conclusion of the surgical procedure. G,
Placement of noneugenol periodontal dressing. H, Surgical area 3 months postoperatively. Note
the successful elimination of enlarged gingival tissue, restoration of a physiologic gingival
contour, and maintenance of an adequate band of keratinized tissue Figure 58-5 Treatment of
combined cyclosporine and nifedipine–induced gingival enlargement with a periodontal flap on a
35-year-old female who had received a kidney allograft 3 years earlier. A, Presurgical clinical
aspect of the lower anterior teeth, showing severe gingival enlargement. B, Initial scalloped
reverse bevel incision, including maintenance of keratinized tissue and creation of surgical
papillae. C, Elevation of a full-thickness flap and removal of the inner portion of the previously
thinned gingival tissue. After scaling and root planing, osseous recontouring can be performed if
necessary. D, The flap is positioned on top of the alveolar crest. E, Postsurgical aspect of the
treated area at 12 months. Note the reduction of enlarged tissue volume and acceptable
gingival health.
Leukemic enlargement occurs in acute or subacute leukemia and
is uncommon in the chronic leukemic state. The medical care of
leukemic patients is often complicated by gingival enlargement and
superimposed painful acute necrotizing ulcerative gingivitis. This
interferes with masticating and creates toxic systemic reactions. The
patient’s bleeding and clotting times and platelet count should be
checked, and the hematologist should be consulted before periodontal
treatment is instituted (see Chapter 54).
Treatment of acute gingival involvement is described in Chapter
41. After acute symptoms subside, attention is directed to correction
of the gingival enlargement. The rationale for therapy is to
remove the local irritating factors to control the inflammatory
component of the enlargement.
The lesion is treated by scaling and root planing performed in
stages with topical and local anesthesia. The initial treatment consists
of gently removing the loose accumulations of bacterial plaque,
performing superficial scaling, and instructing the patient in oral
hygiene for plaque control. This portion of the therapy may include,
at least initially, the daily use of chlorhexidine mouthwashes. Oral
hygiene procedures are extremely important in these patients and
should be performed by the nurse if necessary. Progressively deeper scaling is carried out at
visits. Treatments are confined to a small area of the mouth to
facilitate the control of bleeding. Antibiotics are administered systemically
the evening before and for 48 hours after each treatment
to reduce the risk of infection.
Treatment requires elimination of all local irritants responsible for
precipitating the gingival changes in pregnancy. Elimination of
local irritants early in pregnancy is a preventive measure against
gingival disease. This is preferable to treatment of gingival enlargement
after it occurs. Marginal and interdental gingival inflammation
and enlargement are treated by scaling and root planing (see
Chapters 45 and 46). Treatment of tumorlike gingival enlargements
consists of surgical excision and scaling and planing of the tooth
surface. The enlargement will recur unless all of the irritants are
removed. Food impaction is frequently an inciting factor.