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The Flap Technique for

Pocket Therapy

Flaps are used for pocket therapy to accomplish the


following:

1. Increase accessibility to root deposits


for scaling and root planing.
2. Eliminate or reduce pocket depth by
resection of the pocket wall.
3. Gain access for osseous resective
surgery if it is necessary.
4. Expose
the
area
to
perform
regenerative methods.

MODIFIED WIDMAN FLAP


This technique offers the possibility
of
establishing
an
intimate
postoperative adaptation of healthy
collagenous connective tissue to
tooth surfaces and provides access
for adequate instrumentation of the
root surfaces and immediate closure
of the area.

MODIFIED WIDMAN FLAP


Step 1: The initial incision is an internal
bevel incision to the alveolar crest
starting 0.5 to 1 mm away from the
gingival
margin
(Figure
59-3,
C).
Scalloping follows the gingival margin.
Care should be taken to insert the blade
in such a way that the papilla is left with
a thickness similar to that of the
remaining facial flap. Vertical relaxing
incisions are usually not needed.

MODIFIED WIDMAN FLAP


Step 2: The gingiva is reflected with
a periosteal elevator (Figure 59-3, D).
Step 3: A crevicular incision is made
from the bottom of the pocket to the
bone, circumscribing the triangular
wedge of tissue containing the
pocket lining.

MODIFIED WIDMAN FLAP


Step 4: After the flap is reflected, a third
incision is made in theinterdental spaces
coronal to the bone with a curette or an
interproximal knife and the gingival
collar is removed (Figure 59-3, E and F).
Step 5: Tissue tags and granulation
tissue are removed with a curette. The
root surfaces are checked, then scaled
and planed if needed (Figure 59-3, G and
H). Residual periodontal fibers attached

MODIFIED WIDMAN FLAP


Step 6: Bone architecture is not
corrected, except if it prevents good
tissue adaptation to the necks of the
teeth. Every effort is made to adapt
the facial and lingual interproximal
tissue adjacent to each other in such
a way that no interproximal bone
remains exposed at the time of
suturing. The flaps may be thinned to
allow for close adaptation of the

MODIFIED WIDMAN FLAP


Step 7: Continuous, independent
sling sutures are placed in both the
facial and palatal (Figure 59-3, I and
J) and covered with a periodontal
surgical pack.

UNDISPLACED FLAP
Currently, the undisplaced flap may
be the most frequently performed
type of periodontal surgery. It differs
from the modified Widman flap in
that the soft tissue pocket wall is
removed with the initial incision; thus
it may be considered an internal
bevel gingivectomy.

UNDISPLACED FLAP
Step 1: The pockets are measured
with the periodontal probe, and a
bleeding point is produced on the
outer surface of the gingiva to mark
the pocket bottom.

UNDISPLACED FLAP
Step 2: The initial, or internal bevel,
incision is made (Figure 59-4) after
scalloping the bleeding marks on the
gingiva (Figure 59-5). The incision is
usually carried to a point apical to the
alveolar crest, depending on the thickness
of the tissue. The thicker the tissue is the
more apical the ending point of the
incision (see Figure 59-4). In addition,
thinning of the flap should be done with
the initial incision because it is easier to
accomplish at this time than later, with a

UNDISPLACED FLAP
Step 3: The second, or crevicular,
incision is made from the bottom of
the pocket to the bone to detach the
connective tissue from the bone.
Step 4: The 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.

UNDISPLACED FLAP
Step 5: The third, or interdental,
incision is made with an interdental
knife, separating the connective
tissue from the bone.
Step 6: The triangular wedge of
tissue created by the three incisions
is removed with a curette.
Step 7: The area is debrided,
removing
all
tissue
tags
and
granulation
tissue
using
sharp

UNDISPLACED FLAP
Step 8: After the necessary scaling
and root planing, the flap edge
should rest on the root-bone junction.
If this is not the case, because of
improper location of the initial
incision or the unexpected need for
osseous surgery, the edge of the flap
is scalloped again and trimmed to
allow the flap edge to end at the
root-bone junction.

UNDISPLACED FLAP
Step 9: 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. The area is covered with a
periodontal pack.

APICALLY DISPLACED
FLAP
With some variants, the apically displaced
flap technique can be used for (1) pocket
eradication and/or (2) widening the zone
of attached gingiva. Depending on the
purpose, it can be a fullthickness
(mucoperiosteal) or a split-thickness
(mucosal) flap. The split-thickness flap
requires more precision and time, as well
as a gingival tissue thick enough to split,
but it can be more accuratel positioned
and sutured in an apical position using a
periosteal suturing technique.

APICALLY DISPLACED
FLAP
Step 1: An internal bevel incision is made
(Figure 59-9). To preserve as much of the
keratinized and attached gingiva as
possible, it should be no more than about
1 mm from the crest of the gingiva and
directed to the crest of the bone (see
Figure 59-1). The incision is made after the
existing scalloping, and there is no need to
mark the bottom of the pocket in the
external gingival surface because the
incision is unrelated to pocket depth. It is
also not necessary to accentuate the

APICALLY DISPLACED
FLAP
Step 2: Crevicular incisions are
made, followed by initial elevation of
the flap; then interdental incisions
are performed, and the wedge of
tissue that contains the pocket wall is
removed.

APICALLY DISPLACED
FLAP
Step 3: Vertical incisions are made
extending beyond the mucogingival
junction. If the objective is a fullthickness flap, it is elevated by blunt
dissection with a periosteal elevator.
If a split-thickness flap is required, it
is elevated using sharp dissection
with a Bard-Parker knife to split it,
leaving a layer of connective tissue,
including the periosteum, on the

APICALLY DISPLACED
FLAP
Step 4: After removal of all
granulation tissue, scaling and root
planing, and osseous surgery if
needed, the flap is displaced apically.
It is important that the vertical
incisions an therefore the flap
elevation,
reach
past
the
mucogingival junction to provide
adequate mobility to the flap for its
apical displacement.

APICALLY DISPLACED
FLAP
Step 5: If a full-thickness flap was
performed, a sling suture around the tooth
prevents the flap from sliding to a position
more apical than that desired, and the
periodontal
dressing
can
avoid
its
movement in a coronal direction. A
partialthickness flap is sutured to the
periosteum using a direct loop suture or a
combination of loop and anchor suture. A
dry foil is placed over the flap before
covering it with the dressing to prevent
the introduction of pack under the flap.

APICALLY DISPLACED
FLAP
After 1 week, dressings and sutures
are removed. The area is usually
repacked for another week, after
which the patient is instructed to use
chlorhexidine mouth rinse or to apply
chlorhexidine topically with cottontipped applicators for another 2 or 3
weeks.

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Papilla Preservation Flap
The technique for employing a
papilla preservation flap (Figures 5910 and 59-11) is as follows:
. Step 1: A crevicular incision is made
around each tooth with no incisions
across the interdental papilla.

FLAPS FOR RECONSTRUCTIVE


SURGERY
Step 2: The preserved papilla can be
incorporated into the facial or
lingual/palatal flap, although it is
most often integrated into the facial
flap. In these cases, the lingual or
palatal
incision
consists
of
a
semilunar
incision
across
the
interdental papilla in its palatal or
lingual
aspect;
this
incision
dipsapically from the line angles of

FLAPS FOR RECONSTRUCTIVE


SURGERY
Step 3: An Orban knife is then
introduced into this incision to sever
half to two-thirds the base of the
interdental papilla. The papilla is
then dissected from the lingual or
palatal aspect and elevated intact
with the facial flap.
Step 4: The flap is reflected without
thinning the tissue.

FLAPS FOR RECONSTRUCTIVE


SURGERY
b. Conventional Flap
The technique for employing a
conventional flap for reconstructive
surgery is as follows:
. Step 1: Using a #12 blade, incise the
tissue at the bottom of the pocket
and to the crest of the bone, splitting
the papilla below the contact point.
Every effort should be made to retain
as much tissue as possible to protect

FLAPS FOR RECONSTRUCTIVE


SURGERY
Step 2: Reflect the flap, maintaining
it as thick as possible, not attempting
to thin it as is done for resective
surgery. The maintenance of a thick
flap is necessary to prevent exposure
of the graft or the membrane
resulting from necrosis of the flap
margins.

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Maxillary Molars
The treatment of distal pockets on the
maxillary arch is usually simpler than
the treatment of a similar lesion on the
mandibular
arch
because
the
tuberosity presents a greater amount
of fibrous attached gingiva than does
the area of the retromolar pad.

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Maxillary Molars
In addition, the anatomy of the
tuberosity extending distally is more
adaptable to pocket elimination than is
that of the mandibular molar arch,
where the tissue extends coronally.
However, the lack of a broad area of
attached gingiva and the abruptly
ascending
tuberosity
sometimes
complicate therapy (Figure 59-13).

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Maxillary Molars
The following considerations determine
the location of the incision for distal
molar surgery: accessibility, amount of
attached gingiva, pocket depth, and
available distance from the distal
aspect of the tooth to the end of the
tuberosity or retromolar pad.

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Mandibular Molars
Incisions for the mandibular arch differ
from those used for the tuberosity
because of differences in the anatomy
and histologic features of the areas.
The retromolar pad area does not
usually present as much fibrous
attached gingiva. The keratinized
gingiva, if present, may not be found
directly distal to the molar.

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Mandibular Molars
The
greatest
amount
may
be
distolingual or distofacial and may not
be over the bony crest. The ascending
ramus of the mandible may also create
a short, horizontal area distal to the
terminal molar (Figure 59-16). The
shorter this area, the more difficult it is
to treat any deep distal lesion around
the terminal molar.

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Mandibular Molars
The two incisions distal to the molar
should follow the area with the
greatest amount of attached gingiva
(Figure 59-17). Therefore the incisions
could be directed distolingually or
distofacially, depending on which area
has more attached gingiva.

FLAPS FOR RECONSTRUCTIVE


SURGERY
a. Mandibular Molars
Before the flap is completely reflected,
it is thinned with a #15 blade. It
iseasier to thin the flap before it is
completely free and mobile After the
reflection of the flap and the removal
of the redundant fibrous tissue, any
necessary
osseous
surgery
is
performed. The flaps are approximated
similarly to those in the maxillary