THE FLAP TECHNIQUE

FOR POCKET THERAPY

 THE FLAP TECHNIQUE
 OUTLINE
 The Modified Widman Flap
 The Undisplaced Flap
• The Palatal Flap
 The Apically Displaced Flap
 Flaps For Regenerative Surgery
• The Papilla Preservation Flap
• Conventional Flap For Regenerative
Surgery
 Distal Molar Surgery
 Flaps are used for pocket therapy to
accomplish the following:
• Increase accessibility to root deposits
• Eliminate or reduce pocket depth by
resection of the pocket wall
• Expose the area to perform regenerative
methods
 MODIFIED WIDMANS FLAP
 The modified Widman flap has been
described for exposing the root
surfaces for meticulous
instrumentation and for removal of
the pocket lining; it is not intended
to eliminate or reduce pocket depth,
except for the reduction that occurs
in healing by tissue shrinkage.
 Indications
 1. Pockets where the bases are located
coronal to the MGJ.
 2. Where there is little or no thickening of
the marginal bone.
 3. When shallow to moderate pocket
depths can be reduced.
 4. Where esthetics is important, such as in
the anterior region of patients with a high
smile line.
 Contra – indications

 1. When there is pronounced gingival

enlargement or overgrowth, which is
handled more efficiently by means of a
gingivectomy or gingivoplasty.

 2. When there is little or no attached

gingiva.

 3. When there are large bony thickenings

or exostoses to be removed.
 Advantages
 1. Facilitate subgingival scaling & root planing to the base
of deeper pockets with direct vision.

 2. Allows complete removal of the pocket epithilium.

 3. Flaps can be replaced at the original location.

 4. Encourage healing by primary intention.

 5. Minimal tissue trauma during surgery.

 6. Often esthetically superior to gingivectomy or apically

repositioned flaps.
 Modified Widman Flap
• Presented in 1974 by Ramfjord & Nissle
 Step – 1 : It is an internal bevel incision, 0.5 to 1 mm away from
the gingival margin, directed to the alveolar crest.
 Step – 2 : Gingiva is reflected with a periosteal elevator.
 Step – 3: A crevicular incision is made.
 Step – 4 : After the flap is reflected, third incision is given with
Orban’s knife and the gingival collar is removed.
 Step – 5 : Granulation tissue are removed with a curette. The root
surfaces are checked and scaled.
 Step – 6: Bone architecture is not corrected, good approximation
of flaps is necessary, hence sometimes flaps may have to be thinned.
 Step – 7: Interrupted direct sutures are placed.
Inverse bevel incision

Sulcular incision

Interdental incision
Internal bevel incision Elevation of flap

Crevicular incision Inter dental incision

Open flap debridement Root planing

Repositioning the flap Suturing

Pre operative

Incisions
Flap reflection

Suturing
Modified Widman Technique

Before After
 UNDISPLACED FLAP
 The undisplaced (unrepositioned)
flap, in addition to improving
accessibility for instrumentation,
removes the pocket wall, thereby
reducing or eliminating the pocket.
This is essentially an excisional
procedure of the gingiva.
 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 base
of the pocket.
 Step – 2: The internal bevel incision is made following the scalloping
bleeding points made on the gingiva.
 Step – 3: The second or crevicular incision is made from the bottom of the
pocket to the bone.
 Step – 4: The flap is then reflected with a periosteal elevator.
 Step – 5: Interdental incision is made with a knife.
 Step – 6: Triangular wedge of tissue is removed with a curette.
 Step – 7: The area is debrided, removing tissue tags and granulation tissue
with curettes. The roots are scaled.
 Step – 8: The flap is then placed back.
 Step – 9: The flaps are sutured together.
Diagram showing the location of different areas where the
internal bevel incision is made in an undisplaced flap. The
incision is made at the level of the pocket to discard the tissue
coronal to it if there is sufficient remaining attached gingiva.
APICALLY DISPLACED FLAP
 The apically displaced flap improves
accessibility and eliminates the
pocket, but does the latter by
apically positioning the soft tissue
wall of the pocket. Therefore it
preserves and/or increases the width
of the attached gingiva by
transforming the previously
unattached keratinized pocket wall
into attached tissue.
 Apically displaced flap

Step – 1 : Internal bevel incision is made, 1 mm from the

crest of the gingiva and directed towards the crest of
the bone.
Step – 2 : Crevicular incisions are made followed by initial
elevation of flap and then interdental incision is
performed, the wedge of tissue containing the pocket wall
is removed.
Step – 3: Vertical releasing incisions are made extending
beyond the mucogingival junction and flap is elevated
with a periosteal elevator (either split thickness or full
thickness).
Step – 4: Remove all the granulation tissue, root
planning is done and flap is positioned apically at the
tooth bone junction.
Step – 5: Suturing , followed by pack placement.
 Advantages
• Eliminates periodontal pocket
• Preserves attached gingiva and increases its width
• Establishes gingival morphology facilitating good
hygiene
• Ensures healthy root surface necessary for the biologic
• width on alveolar margin and lengthened clinical crown
 Disadvantages
• May cause esthetic problems due to root exposure
• May cause attachment loss due to surgery
• May cause hypersensitivity
• May increase the risk of root caries
• Unsuitable for treatment of deep periodontal pockets
• Possibility of exposure of furcations and roots, which
complicates postoperative supragingival plaque control.
 Contraindications for Apically Positioned
Flap Surgery
• Periodontal pockets in severe periodontal
disease
• Periodontal pockets in areas where esthetics is
critical
• Deep intrabony defects
• Patient at high risk for caries
• Severe hypersensitivity
• Tooth with marked mobility and severe
attachment loss
• Tooth with extremely unfavorable clinical
crown/root ratio
Modified Widman Undisplaced Flap Apically Displaced
Flap Flap
I. Purpose

1.To expose root 1. Accessibility for 1.Improves

surfaces for instrumentation accessibility.
instrumentation. 2.To remove the 2.It also eliminates the
2.For removal of pocket pocket wall to reduce pocket by transforming
lining. or eliminate the the previously
(It is not indicated to pocket. unattached keratinized
eliminate / reduce (An excisional pocket wall into
pocket depth, except procedure of the attached tissues.
for the reduction that gingiva). (Dual function).
occurs in healing by
shrinkage)
Modified Undisplaced Flap Apically Displaced
Widman Flap Flap
Variations in
the Design
It does not Internal bevel incision is The internal bevel
intend to remove started at or near a point incision should be placed
the pocket wall just coronal to the as close to the tooth as
but eliminate projection of the bottom possible (0.5 to 1 mm)
pocket lining. of the pocket on the outer because the purpose of
Therefore, surface of the gingiva. this technique is to
internal bevel (Only performed when preserve maximum
incision starts sufficient attached gingiva amount of keratinized
close (no more is to be left behind). The tissue, displace it apically
than 1 to 2 mm incision should be and transform it into
apical) to the scalloped to preserve as attached gingiva. The
gingival margin. much as interdental flap is positioned at the
papilla. tooth bone junction.
Locations of the internal bevel incisions for the
different types of flaps.
Scalloping required for the different types of flaps.
 Papilla preservation flap
 Step – 1: Crevicular incision is made around
each tooth. No incisions through the
interdental papilla.
 Step – 2: Papilla is usually incorporated
facially, hence a semi-lunar incision across
the interdental papilla in the palatal or lingual
surface is made, which is atleast 5 mm from
the crest of the papilla.
 Step – 3: The papilla is dissected from the
lingual or palatal aspect using Orban knife
and elevated intact with the facial flap.
 Step – 4: The flap is reflected without thinning
the tissue.
Flap design for a papilla preservation flap. A, Incisions for
this type of flap are depicted by interrupted lines. The
preserved papilla can be incorporated into the facial or the
lingual-palatal flap. B, The reflected flap exposes the
underlying bone. Several osseous defects are seen. C, The
flap returned to its original position covering the entire
interdental spaces.
Pre operative Incisions

Flap reflection
 Conventional Flap for Regeneration
Step 1: 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 subsequently protect the area.
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 due to necrosis of the flap
margins.
 DISTAL MOLAR SURGERY
Treatment of periodontal pockets on the
distal surface of terminal molars is often
complicated by the presence of bulbous
fibrous tissue over the maxillary tuberosity
or prominent retromolar pads in the
mandible. Deep vertical defects are also
commonly present in conjunction with the
redundant fibrous tissue. Some of these
osseous lesions may result from
incomplete repair after the extraction of
impacted third molars.
The impaction of a third molar distal to a second molar with
little or no interdental bone between the two teeth. B,
Removal of the third molar creates a pocket with little or no
bone distal to the second molar. This often leads to a vertical
osseous defect distal to the second molar (C).
Removal of a pocket distal to the maxillary second
molar may be difficult if there is minimal attached
gingiva. If the bone ascends acutely apically, the
removal of this bone may make the procedure
easier. B, A long distal tuberosity with abundant
attached gingiva is an ideal anatomic situation for
distal pocket eradication.
A, Pocket eradication distal to a mandibular second
molar with minimal attached gingiva and a close
ascending ramus is anatomically difficult. B, For surgical
procedures distal to a mandibular second molar, abundant
attached gingiva and distal space are ideal.
 Maxillary molars:
 Two parallel incisions at the distal surface of
terminal tooth are made. The deeper the pocket,
the greater will be the distance between the two
parallel incisions.
 Followed by this a transversal incision is made so
that a long rectangular piece of tissue is
removed. This can be confirmed with the regular
flap in the quadrant being treated. These
incisions can be placed using No. 12 blade, after
flap reflection curetting the bone surface, the
flaps are sutured together.
Square Incision for Maxillary Distal Molar
 Mandibular molars:
 Two parallel incisions at the retromolar
pad area are made.The incisions should
follow the areas of greatest attached
gingiva and underlying bone. After the
reflection of the flap and removal of
tissue, osseous surgery may be performed
(if necessary ) and flaps are sutured so as
to approximate the flap margins closely to
each other .
Triangular Incision for Mandibular Distal Molar