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

Envelop flap

Disadvantages

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

Quicker to heal and are

associated with less post
operative 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

Depending on the direction of transfer and

geometry
Rotational flap
Advancement flap

Rotational Flap e.g.

Advancement Flap e.g.

Lateral Positioned Flap

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

Description

Indications

Instruments

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 tissue
on 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

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

No Lingual / palatal
pocket

Original widman Flap

Neumann Flap

Both buccal & lingual flap

should be reflected

Only buccal flap should

be reflected

Area for surgery

Three tooth at a time

Type of incision

Reverse bevel

Sextant

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.