Acknowledgement

The research work is a product of hardships with amalgamation of knowledge and effort
through the participation and support of significant person . I would like to extent my
profound gratitude for their invaluable contribution, help and support

My sincere gratitude goes to my main supervisor Dr. Chetan Chandra, Professor, Dept
of Periodontology, Saraswati Dental College, Lucknow, for all this help and
encouragement, tiredless, dedication, constructive comments and understanding. His
expertise, generous guidance and support made it possible for me to work on this topic.

I am highly indebted and thoroughly grateful to Dr. Vivek Kumar Bains, Professor &
HOD, Dept of Periodontology, Saraswati Dental College, Lucknow, for all his advice and
immence interest, spending time with me to ensure that I have developed a good
understanding of the topic. His dedication and keen interest above all his overwhelming
attitude to help students had been solely and mainly responsible for completing my
dissertation. As my teacher and mentor he has taught me more than I could ever give him
credit for here.

With deepest gratitude and appreciation, I humbly give thanks to Dr. Ruchi Srivastava,
Reader, Dept of Periodontology, Saraswati Dental College, Lucknow, offer excellent
assistance and positive attitude. Her continuous optimisum, enthusiasm, encouragement
and support concerning this work, has helped, inspired and given me moral support and
encouragement in various ways in completing this task.

Its an honour to express my gratefulness to my beloved seniors Dr. Sunakshi Soi & Dr.
Shashank Yadav, my co-pg Dr. Shubhranil Chakrabarty and my juniors Dr. Ananya
Sharma and Dr. Sarda Tokpam, for their company. They have given me their valuable
time, advice, support and encouragement and kept me laughing during my PG days.
Walking with them has been was rewarding and enjoyable experience for me because for
their helping nature.

To my parents, Mr. Mukhtar Ahmad and Mrs. Mahe Darakhshan and brother Mr.
Anaan Ahmad without whom this dissertation could not have been completed. Thanks for
their unconditional love, encouragement, Dua, support and unending believe in me.

Last but not the least I would like mention special thanks to my one and only best friend,
sister from another mother Dr. Danish Bilal for her constant support, encouragement
and making me mentaly stable. Thank you so much danu.

Finally, I thank Allah for giving me the strength, both mentally and physically to
complete this task and for surrounding me with such wonderful people.
 CONTENTS
1. INTRODUCTION

2. REVIEW OF LITERATURE

3. HISTORICAL BACKGROUND

4. GENERAL REVIEW

I. DEFINITIONS

II. OBJECTIVES OF PERIODONTAL SURGICAL PHASE-

III. CLASSIFICATION OF FLAPS

IV. PRINCIPLES OF FLAP DESIGN

V. PRINCIPLES GOVERNING INCISION PLACEMENT

VI. FLAP MANAGEMENT

VII. PURPOSE & OBJECTIVES OF FLAP ELEVATION

VIII. PRINCIPLES OF PERIODONTAL SURGERY

IX. CRITERIA FOR SURGICAL METHOD SELECTION

5. FLAPS FOR POCKET ELIMINATION

I. ORIGINAL WIDMAN FLAP

II. NEUMANN FLAP

III. MODIFIED FLAP OPERATION (KIRKLAND 1931)

IV. UNDISPLACED FLAP

V. MODIFIED WIDMAN FLAP

VI. APICALLY REPOSITIONED FLAP

VII. BEVELED FLAP

VIII. PALATAL FLAP

6. FLAPS TO INDUCE RE-ATTACHMENT & REGENERATION

I. DISTAL WEDGE PROCEDURE

II. PAPILLA PRESERVATION TECHNIQUE

III. MODIFIED PAPILLA PRESERVATION TECHNIQUE

IV. SIMPLIFIED PAPILLA PRESERVATION FLAP

V. MINIMAL INVASIVE SURGICAL TECHNIQUE (MIST)

6. FLAPS TO CORRECT MUCOGINGIVAL DEFORMITIES

I. LATERALLY SLIDING FLAP

II. TRANSPOSITIONAL FLAPS

III. DOUBLE PAPILLA FLAPS

IV. CORONALLY POSITIONED FLAP

V. SEMILUNAR CORONALLY POSITIONED FLAP

VI. ENHANCEMENT OF PERIODONTAL FLAP SURGERY BY

PLASTIC
SURGERY PRINCIPLE

7. SUMMARY & CONCLUSION

 INTRODUCTION

Chronic periodontitis is defined as an inflammatory disease of the supporting tissues of teeth

caused by groups of specific microorganisms, resulting in progressive destruction of the

periodontal ligament and alveolar bone with either pocket formation or recession, or both.

The aim of effective treatment of periodontal diseases is to arrest the inflammatory disease

process by removing the subgingival biofilm to establish a local environment compatible

with periodontal health. Reduction in probing pocket depth, maintenance or improvement of

clinical attachment level, defect fill as well as reduction in bleeding on probing are the most

common outcome used to determine the success of treatment. The treatment offered to the

periodontal patient by the clinician may be nonsurgical or surgical mechanical

debridement48. A nonsurgical mechanical approach may be deemed more conservative.

However, it may have limited efficacy in advanced diseased sites since it does not fully

eliminate pathogenic bacteria from all infected areas like deeper pockets, furcation areas etc.

Flap reflection is considered more invasive, but can be more effective in increasing the

clinician’s ability to debride the roots in these difficult areas 49. Surgical access therapy can

only be considered as adjunctive to cause-related therapy. Therefore, various surgical

methods & techniques should be evaluated on the basis of their potential to facilitate

removal of subgingival deposits & self-performed plaque control & thereby enhance the

long-term preservation of the periodontium3. Periodontics today has emerged and grown to

engulf such a wide spread area, from diagnostic to nonsurgical treatment, occlusal therapy,

resective procedures, hard and soft tissue regeneration procedures which include gingival

augmentation, bone graft, and mucogingival surgery, implant therapy, supportive and finally

adjunctive therapy. Periodontal therapy is directed at disease prevention, slowing or

arresting disease progression, regenerating lost periodontium, and maintaining achieved

therapeutic objectives51. Scaling, root planing, subgingival curettage, ENAP and

 gingivectomy are all procedures done without elevating the mucoperiosteal flap. Procedures

which require elevation and reflection of the gingival soft tissues from the surface of the

bone are referred to as flap procedures. Broadly stated, the main reasons for doing flap

procedures are-

1) To secure access for root planning & to underlying osseous defects.

2) To facilitate removal of diseased pocket lining & granulation tissue that may interfere with

healing.

3) To facilitate attempts to re-establish gingival health by either new attachment or close

adaptation of the connective tissue to the root5.

Several techniques can be used for the treatment of infrabony periodontal pockets. The

periodontal flap is one of the most frequently employed procedures, particularly for

moderate & deep intrabony pockets. The design of the flap is primarily dictated by

preservation of good blood supply to the flap, by the surgical judgement of the operator &

may also depend on the objectives of the procedure. The necessary degree of access to the

underlying bone & root surfaces & the final position of the flap must be considered in

designing the flap6.

Hence, in this library dissertation, an attempt has been made to review the available

literature on periodontal flap.

HISTORICAL BACKGROUND

19th CENTURY PERIODONTICS

Periodontal surgical techniques used in the nineteenth century were essentially

gingivectomies with straight line incisions followed by an aggressive curettage to remove

the crestal bone & thorough scaling of the root surface. Riggs had called these techniques

barbaric, although apparently he practiced them. Such operations were performed while the

patient was under general anesthesia with chloroform 7. In 1884, clinician Robicsek, was the

first to describe the radical technique of gingivectomy with bone exposure. The nature of his

contribution is neither the flap, nor the gingivectomy as we know, but rather the radical

gingivectomy which is an excision of the gingiva, exposing the marginal and interseptal

alveolar bone in order to remove granulation tissue and change the shape of this bone by a

proper instrumentation8.

Robicsek in 1884 proposed deep gingivectomies with removal of bones. Bone surgery was

a part of periodontal therapy for a different reason: it was thought to be infected or necrotic

in areas of periodontitis and thus the only possible rational treatment at the time was its

removal. Flap surgery at the time was considered to be radical, with removal of all tissue

(except the teeth) in the areas of disease. Most of the practitioners, including

Neumann, G.V.Black, Zentler, Zemsky, Ward and Kirkland accepted this concept9.

Carl Partsch, professor of the oral surgery at the University of Berslau, developed a

technique in later half of nineteenth century, performed under cocaine local anesthesia,

for the surgical treatment of periapical lesions and cysts. The procedure involved

 A curved incision with the convexity towards crown of the teeth, known to this day as

the Partsch incision, 1896.

 Tissues were separated and the flap was elevated.

 After removing the cyst the flap was returned to its original position.

In the first half of the twentieth century, techniques for the treatment of periodontal diseases were

proposed on the basis of clinical experience and the ingenuity of the proponent to develop new

technical approaches and design new instruments. This of course, gave great importance to personal

opinions, experience, prestige and position for proposing the method7.

20th CENTURY PERIODONTICS

Flap procedure was introduced in periodontics during the beginning of the 20th century. Before the

turn of century, Fauchard recommended removal of diseased tissue by surgical mean10.

After 1907, suturing the flap was recommended7.

Most of the progress in the periodontal surgery in this period came from Germany as well as Central

European countries, and it’s associated with:

A) Robert Neumann

B) Leonard Widman

C) Cieszynski.

In the United States, several clinicians also advocated surgical techniques for the treatment of

periodontal disease. G.V. Black famous for his development of the systematized approach for the

treatment of dental caries also turned his interest towards periodontal therapy & proposed a technique

for the treatment of periodontal pockets.

Black’s technique was a gingival resection operation, using a straight incision following the bottom

of the pockets at the bone margin. He recommended the use of cautery or a knife.
Black admitted that in some cases pockets may recur but usually will be shallower, allowing more

effective cleaning by the patient. The treatment is contraindicated in maxillary incisors on account of

unsightly appearance of the denuded root. Black also mentioned that there was a little hope for those

cases in which pockets of considerable depth have formed on proximal surfaces7.

Neumann claimed to use the mucoperiosteal flap in periodontal surgery as early as 1911. He

described his technique as “the radical treatment of alveolar pyorrhea.” 9. Cieszynski, in 1914 is

credited with the introduction of the reverse bevel incision in the periodontal flap operation. It is

important to note that these flap techniques all advocated thorough scaling of the teeth, removal of

granulomatous tissue & bone10.

In 1916, Leonard Widman in the entitled monograph "The Operative Treatment of Pyorrhea

Alveolaris" was one of the first researchers to describe in detail the use of flaps to eliminate

periodontal pockets.

Widman11, Cieszynski12, Neumann13 et al. are associated with the initial descriptions of periodontal

flap surgery.

In 1918, Arthur Zentler, a New York dentist described a technique similar to the Neumann

technique. It was as follows:

 Two parallel incisions and a festooned incision that follows the original festoons of the gum.

 Flap was lifted to allow root scaling and curettage to remove all granulation tissue from the pocket

area and the underside of the flap.

 Trimming and smoothing of all the “infected bone” with chisel and mallet.
 Margins of the flaps were cut away with scissors.

 Vertical or interdental sutures were given7.

The surgical wound was not protected postoperatively since periodontal dressings were not

developed until 1920s7.

Then in 1926, James L. Zemsky presented a technique which was called the “open view operation”,

which was a flap technique for the removal of “infected and sharp edges of bone”7.

According to Wennström et al., in 1931, Kirkland published a surgical procedure to be used in the

treatment of "periodontal pus pockets". The procedure was called the modified flap operation, and it

was basically an access flap for proper root debridement by intracrevicular incisions through the

bottom of the pocket on both the labial and lingual aspects of interdental area14.

Olin Kirkland presented the modified flap operation technique in the year 1932.

In 1954, Nabers described a procedure he called “repositioning of the attached gingiva.” For the first

time, a mucoperiosteal flap was apically positioned after treatment 10.

In 1957, Nabers proposed, replacing the marginal trimming of the gingiva with an internal incision

from the gingival margin to the alveolar crest. This resulted in a thinner gingival margin that was

positioned apically and sutured loosely without leaving alveolar bone uncovered.

Also in 1957, Ariaudo and Tyrrell modified Nabers’ technique by using 2 vertical releasing

incisions, which provided greater flexibility in flap management. The only difference between this

technique and that proposed by Widman was the apical positioning. The same
authors later recommended small vertical incisions through the flap in the center of the

interproximal spaces. This allowed the flaps to collapse. The resulting depressions would

favor good gingival contour10.

According to Robinson in 1966, the periodontal pockets adjacent to distal root surfaces of

the second and third molars are aspects of the periodontal therapy of difficult solution and

they have been denied frequently for many periodontists. The periodontal pocket on the

distal surface of molars can be extremely deep due to the anatomy of this area. When the

pocket becomes deeper, that depth is larger than in other areas and the inaccessibility of the

area leads to the inability in the mechanical control of bacterial plaque executed by the

patient. Regarding to these aspects, he developed the Distal Wedge procedure in order to

treat periodontal pockets adjacent to the distal surfaces of the molars. This technique uses

internal bevel incisions and it has as objectives: to obtain access to the bone tissue, to

preserve attached gingiva, to eliminate periodontal pockets, to reduce the healing period and

to minimize the postoperative pain15.

Ramfjord & Nissle in 1974, concerned about bone tissue preserving, obtaining a perfect

closure of the flaps with minimal root exposure and facilitating the oral hygiene executed by

the patient, they modified the technique initially described by Widman in 1916, turning it

into a conservative procedure. The changes were: primary incision is inverse beveled,

partial- thickness, thinning incision held parallel to the long axis of the tooth and directed

toward the crest of bone, and intra-sulcular (secondary) incision was performed around the

dental surfaces. After raising the flaps, the loosened collar of tissue was removed at the

alveolar crest. These modifications try to maintain the height of the gum, preserve the

aesthetics, guarantee the repair through long junctional epithelium, besides it facilitate the

mechanical control of bacterial plaque executed by the patient16.

GENERAL REVIEW

DEFINITIONS

Periodontal flap is defined as a section of gingiva and/or mucosa surgically separated from the

underlying tissues to provide visibility and access to the bone and root surface6.

Flap is defined as the separation of a section of tissue from the surrounding tissue except at

its base17.

A flap is defined as a piece of tissue partly severed from its place of origin for use in surgical

grafting18.

A flap is defined as a mass of tissue, usually including skin, only partially removed from one

part of the body so that it retains its own blood supply during transfer to another site19.

A flap is defined as a section of gingiva and or mucosa surgically elevated from the

underlying tissues to provide visibility and access to the bone and root surface20.

OBJECTIVES OF PERIODONTAL SURGICAL PHASE

The surgical phase of periodontal therapy has the following main objectives:

1. Improve the prognosis of teeth & their replacements.

2. Improvement of esthetics.

The purpose of surgical pocket therapy is to eliminate the pathologic changes in the pocket

walls; to create a stable, easily maintainable state, and, if possible, to promote periodontal

regeneration.

To fulfil these objectives, surgical techniques-

1. Increase accessibility to the root surface, making it possible to remove all irritants;

2. To reduce or eliminate pocket depth, making it possible for the patient to maintain the root

surface free of plaque;

3. Reshape soft and the hard tissues to attain a harmonious topography.

To attain these objectives, various flap designs & techniques have been proposed6.

The periodontal flap can be made in many different ways depending on the desired outcome.

The flap can involve attached and nonattached tissues and involves removal of all the tissues

from the bone and teeth (full thickness) or incising the tissue and leaving the connective tissues

overlying the bone (partial thickness).

 CLASSIFICATION OF FLAPS

Based on bone exposure after flap reflection:

A)Full-thickness flaps (mucoperiosoteal)- In this, all the soft tissue along with the

periosteum is reflected to expose the underlying bone. The complete exposure, and access to

the underlying bone is indicated when osseous resective or regenerative surgery is

contemplated6.

B) Partial thickness (split thickness)- In this only the epithelium and a layer of the

underlying connective tissue are included. The bone remains covered by a layer of connective

tissue, including the periosteum. Indicated when the flap is to be positioned apically or when

the operator does not want to expose the bone6.

Based on flap placement after surgery:

A) Undisplaced flap- when flap is returned to its original position e.g. Conventional

flaps, Periapical surgeries etc.

B) Displaced flap- which are placed apically, coronally or laterally to their original

position.

Both the partial thickness and full 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 movable6.

Based on management of papilla:

A) Conventional flap- The interdental gingiva is split beneath the contact point of the two

approximating teeth to allow for the reflection of the buccal and the lingual flaps. The incision

is scalloped to maintain gingival morphology with as much papillae as possible .e.g. Modified

Widman, Apically displaced, Flap for reconstructive purposes.

B) Papilla preservation flap- Incorporates the entire papillae in one of the flaps by means

of crevicular interdental incisions to severe the connective tissue attachment and a horizontal

incision at the base of the papillae, leaving it connected to the flap6.

In addition to flaps being classified as full or partial thickness and as envelop or pedicle, they

are also classified by the anatomic type of mucosa. These are:

A) Gingival Flap: Includes only the gingival tissue.

B) Mucogingival flap: extends beyond the mucogingival junction to include the alveolar mucosa21.

Flap operations can be used in all cases where surgical treatment of periodontal disease is

indicated. These are particularly useful at sites where the pockets extend beyond the

mucogingival border and where the treatment of bony lesions and furcation involvement is

required.

According to Franklin. S. Weine

A. Semilunar

B. Full vertical

C. Leubke-Oschenbein22

According to Ottohofer in 1935

A. Csernyi flap or Osteoplastischen- which involved raising a partial thickness flap and

selectively raising the periosteum and bone intact over the area of lesion.

B. Periostalplastischen flaps

a. Pichler flap

b. Wassmund flap.
 In both these techniques the flaps are split and layered into the osseous cavity with the

anticipation of providing drainage and stimulating the internal to external granulation and

enhancing healing. In Pichler technique the flap is split before the root apex is exposed and

lesion is removed. In Wassmund technique the flap is split after the root end treatment is

finished23.

Based on Presence/Absence of releasing incisions

A. Flap with releasing incision(s)

B. Envelope flap.

Releasing incisions are made to mobilize the flap in order to relocate it apically, laterally or

coronally to its pre-operative location. Certain flaps do not require the use of releasing

incisions; these are referred to as envelope flaps. In these flaps, undermining of the tissues is

done as well as underlying bone & root surfaces are degranulated under this ‘envelope’ of

tissue & then flap is placed back to its original position24.

The advantages of flap operations include:

A) Existing gingiva is preserved.

B) The marginal alveolar bone is exposed whereby the morphology of bone defects can be

identified and the proper treatment is rendered.

C) Furcation areas are exposed, the degree of “tooth- bone” relationship can be identified.

D) The flap can be repositioned at its original level or shifted apically, thereby making it possible

to adjust the gingival margin suiting to the local conditions.

E) The flap procedure preserves the oral epithelium and often makes the use of the surgical

dressing.

F) The post operative period is less unpleasant to the patient when compared to gingivectomy3.
 Treatment decisions for soft and hard tissue pockets in flap surgery

Classifications of different flap modalities used in the treatment of periodontal disease often

makes distinction between methods involving the marginal tissues and those involving the

mucogingival area and further between tissue eliminating/resective varieties and tissue

preserving/reconstructive types (access flaps for debridement). However, these

classifications do not appear precise since several techniques are combined in the treatment

of individual cases, and since there is no clear cut relationship between disease

characteristics and selection of surgical methods. Thus it becomes more appropriate to

discuss surgical therapy with regards to how to deal with

 The soft tissue component

 The hard tissue component of the periodontal pocket at the specific tooth site

The soft tissue component :

Depending upon the surgical techniques used , the soft tissue flaps can be

 The difference in the final positioning Apically positioned at the level of the bone crest

( original Widman flap, Neumann flap and Apically repositioned flap)

 Maintained in a coronal position (Kirkland flap, Modified Widman flap and Papilla

preservation flap)

of the gingival margin between the surgical techniques is attributed to osseous recontouring.

Independent of the flap positioning, the goal should be to achieve complete soft tissue

coverage of the alveolar bone, not at buccal/lingual sites but also in the proximal sites. Thus

the incisions should be planned in such a way that this goal is achieved3.
 The hard tissue component of the periodontal pocket at the specific tooth site: During conventional

periodontal surgery one would usually opt for the conversion of an intrabony defect into a suprabony

defect by an apical repositioning of the soft tissue. There are a number of factors that need to be

considered in the treatment decision, such as:

 Esthetics

 Tooth/ tooth site involved

 Defect morphology

 Amount of remaining periodontium

Since alveolar bone supports the soft tissue so the alveolar bone recontouring will lead to recession

of the soft tissue margin. Thus for esthetic reasons one must be conservative in eliminating proximal

bone defects in the anterior tooth region. The various treatment options available for the defect may

include:

C) Elimination of the osseous defect be resection of bone (osteoplasty and / or ostectomy)

D) Maintenance of the area without osseous resection.

E) Compromising the amount of bone removal and accepting that a certain pocket depth will remain.

F) Extraction of the involved tooth if the bony defect is considered too advanced.
After careful consideration, indications for osseous surgery in conjunction with apical repositioning

of flaps may also include subgingival caries, perforations of the root as well as inadequate retention

for the fixed prosthetic restorations due to short clinical crown (crown lengthening procedures).

The crown lengthening needed in such cases is performed by removing significant amount of

supporting bone and by recontouring. A “biologic width” of approximately 3mm is needed between

the alveolar bone crest to be established and the anticipated restoration margin for successful results3.
PRINCIPLES OF FLAP DESIGN

According to Hupp (1933) the following principles should be followed in order to prevent

flap necrosis, flap dehiscence & flap tearing.

1. Prevention of flap necrosis:

a. The apex of the flap should never be wider than the base, unless a major artery is

present in the base.

b. Flap should either run parallel to each other or preferably converge from the base

of the flap to its apex.

c. In general the length of the flap should be no more than twice the width of the

base.

d. Whenever possible, an axial blood supply should be included in the base of the

flap.

e. The base of the flap should not be excessively twisted or stretched (as either of

these will compromise the supplying vessels).

2. Prevention of flap tearing:

a. It is preferable to create a flap at the onset of surgery that is enough to avoid either

tearing it or interrupting surgery to modify it.

b. If an envelope flap does not provide sufficient access, another incision should be

made to prevent it from tearing.

c. Vertical (oblique) releasing incisions should be placed one full tooth anterior to

the area of any anticipated bone removal.

d. The incision should be started at the line angle of the tooth or in the adjacent

interdental papilla & carried obliquely apically into the unattached gingiva.

e. It is uncommon to need more than one releasing incision when using a flap to gain

surgical access25
PRINCIPLES GOVERNING INCISION PLACEMENT

Because intraoral scars are not visible, mainly convenience, access, avoidance of damage to

the nerves & blood vessels determine the placement of incisions as well as flaps in this

region. According LASKIN (1980), they are-:

 The incision should not be made over the operative site but rather in the adjacent,

undisturbed areas so that the flap will be supported by normal tissue & the potential for rapid

revascularization is preserved.

 The incision should be placed so that major nerves are not transected unless necessary.

 An adequate blood supply should be maintained by incising parallel to the major vessels,

minimizing the number of side cuts & having the base of the flap as wider than the apex.

 Incisions should not be made in areas of thinned mucosa like that found over an exostosis or

other prominence because the blood supply is reduced, suturing is difficult & rate of

dehiscence is very high.

 When developing flaps around teeth, the incisions should be made in the gingival crevice.

 It is also important to maintain the integrity of the interdental papillae & do not include them

within the flap because of the difficulty in precise reapproximation of the same.

 If access is inadequate, the surgeon may extend the length of the incision or make a releasing

incision. The releasing incision is usually made at about at an angle of 450 from the direction

of the parent incision. Generally, releasing incisions should be avoided if an envelope flap

will provide adequate access. Releasing incisions reduce blood supply to the flaps & cause

added discomfort. If possible, the releasing incision should not be made at a sharp angle to

the primary incision but instead curve gradually from it.

 If the flap is to include both mucosa & the periosteum, the incision should be made directly

to the bone with one cut & it should be elevated in one piece without tearing the periosteum.

 After the necessary surgery, the clotted blood should be removed from beneath the flap to

lessen the possibility of infection & permit tissue fluid to penetrate more readily26.
FLAP MANAGEMENT

A surgeon must be deft, delicate and accurate in the management of all tissue within the

surgical field. There are several elements in flap management that require planning and

atraumatic execution.

INCISIONS6

Incisions used for conventional flaps are classified as:

1. Horizontal incisions

i. Internal bevel

a. Scalloping

b. Linear

ii. Crevicular

iii. Interdental

2. Vertical incisions

1. Horizontal incisions- these are directed along the margin of the gingiva in the mesial

or distal direction.

i. Internal bevel incision (1st incision, Reverse bevel incision): This is basic to

most of the periodontal flap procedures & starts at a distance from the gingival

margin & is aimed at the bone crest. It is the incision from which the flap will

be reflected to expose the underlying bone & root. It accomplishes three

important objectives:

 It removes the diseased pocket lining.

  It conserves the relatively uninvolved outer surface of the gingiva

which, if apically positioned, converts to attached gingival.

 It produces a sharp & thin flap margin for adaptation to the bone-tooth

junction.

The number 15 or 11 surgical scalpel is used most commonly. The portion of the

gingival that is left around the tooth contains the diseased pocket lining & the

adjacent granulomatous tissue. It will be discarded after the crevicular (second)

incision & the interdental (third) incision is performed. The internal bevel incision

starts from the designated area on the gingiva & is directed to an area at or near the

crest of the bone. 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 & the reverse bevel as the

bevel is in a reverse direction from that of the gingivectomy incision.

 A

Internal bevel incision. A- Schematic demonstration B- #11

Scalpel blade used from the gingival margin to angle the blade
toward the alveolar crest. (Source: Clinical periodontology,
Carranza’s 10th edition)

ii. Crevicular incision (2nd incision, Sulcular incision): is made from the base of

the pocket to the crest of the alveolar bone. The 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 & granulomatous areas

that constitute the lateral wall of the pocket, as well as

 the junctional epithelium & connective tissue fibres that still persist

between the bottom of the pocket & the crest of the bone. The incision is

carried around the entire tooth. The beak-shaped #12 blade is usually

used for this incision.

Crevicular incision. A- Schematic of sulcular incision. The incision is

placed within the sulcus and angled toward the alveolar crest. B- Scalpel
placed in the sulcus and extended to the alveolar crest. The incision is carried
into the interdental area where the papilla is either thinned or reflected full
thickness. (Source:Clinical periodontology, Carranza’s 10th edition)

iii. Interdental incision (3rd incision, Supraalveolar incision): After the first

& the second incisions & the elevation of the flap, collar/wedge of tissue

that is left around the tooth is removed utilizing the interdental incision. A

very sharp Orban knife that has been repeatedly sharpened carries out this
 incision. The incision is made, not only around the facial & lingual radicular

area, but also interdentally connecting the facial & lingual segments to

completely free the gingiva around the tooth. Care should be exercised

while making the third incision as applying too much pressure results in

nicking or gauging of the fragile cemental layer.

These three incisions allow the removal of gingiva around the tooth

(the pocket epithelium & the adjacent granulomatous tissue). A curette or

a large sickle scaler (U 15/30) can be used for this purpose. After removal

of the large pieces of the tissue, the remaining connective tissue as well as

the granulation tissue in the osseous lesion should be carefully curetted out

so that the entire root & the bone surface adjacent to the teeth can be

observed.

2. Vertical incision (Oblique releasing incision): these can be utilized in

either one or both ends of flap. They are necessary at both ends if the flap has

to be apically displaced. These must extend beyond the mucogingival

junction to the alveolar mucosa to allow for the release of the flap to be

displaced. The following points should be considered in planning vertical

incisions:

 In general, vertical incisions are avoided in lingual & palatal areas.

 Facial vertical incisions should not be made in the centre of the

interdental papilla or over the radicular surface of the tooth. They

should be made at the line angles of the tooth either completely

including the papilla or totally avoiding it.

 Vertical incisions should be planned so that the flap is not short

(mesio- distally) with long apically directed horizontal incisions as

these could jeopardise the blood supply to the flap
 A B

C D

Correct and incorrect placement of vertical releasing incisions.

A- Correct vertical releasing incision at the line angle. The papilla is included
in the flap.
B- Correct vertical releasing incision at the line angle. The papilla is not
included in the flap.
C- Incorrect vertical releasing incision splitting the papilla.
D- Incorrect vertical releasing incision over the root prominence. (Source:
Clinical periodontology, Carranza’s 10th edition)

FLAP PREPARATION21

The surgical flap is defined as the separation of a section of tissue from the surrounding

tissues except at its base. A flap that includes epithelium, connective tissue, and periosteum is

referred to as a full-thickness or mucoperiosteal flap, and it is the most common type of flap

used when access to the bone is indicated for resective or regenerative procedures. When the

periosteum is not included in the flap, it is called a partial-thickness or split thickness flap.

This type of flap is used extensively in mucogingival surgery to leave an underlying blood
supply where soft tissue grafting is performed to correct deformities in the

morphology, position, or amount of gingiva. There are also instances in which part of

a flap may be full thickness and the other part may be partial thickness. This

combined technique is used in some mucogingival and esthetic crown lengthening

procedures.

FLAP DESIGN21

Flap design should be based on the principle of maintaining an optimal blood supply

to the tissue. There are generally two basic flap designs: those with and those without

vertical releasing incisions. A flap that is released in a linear fashion at the gingival

margin but has no vertical releasing incision(s) is called an envelope flap. If two

vertical releasing incisions are included in the flap design, it becomes a pedicle flap.

If one vertical releasing incision is included in the flap design, some clinicians refer

to this as a triangular flap. The teeth, flap, and vertical releasing incision form the

sides of the triangle. This flap design should not be confused with the triangular

wedge usually associated with the removal of a soft tissue wedge in the tuberosity or

retromolar area. Alterations in gingival circulation resulting from various periodontal

flap designs have been studied in human subjects using fluorescein angiography

techniques. The major blood supply to a flap was found to exist at its base and travels

in an apical to coronal direction. It was also determined that the greater the ratio of

flap length to flap base, the greater the vascular compromise at the flap margins. On

the basis of this concept, the recommended flap length (height)-to-base ratio should

be no greater than 2:1.

 Flap height-to-base ratio. To maintain

adequate blood supply to the flap, the ratio of

FLAP RETRACTION21

Another element in good flap management that is often given little consideration

involves the use of surgical retractors to hold the flap back from the teeth and bone. If

the flap has been properly designed and reflected adequately, retraction should be

passive without any tension. Force should not be necessary to keep the flap retracted.

It is also critically important that the edge of the retractor always be kept on bone.

Trapping the flap between the retractor and bone can cause tissue ischemia and lead

to postoperative flap necrosis. Continuous flap retraction for long periods also is not

advised. Such a practice will desiccate the soft tissue and bone causing a delay in

wound healing. When the flap is retracted, the surgical assistant should frequently

irrigate the surgical field with sterile saline, to keep the tissues moistened, to reduce

contamination, and to improve visibility.

OPEN FLAP DEBRIDEMENT21

The prototypical periodontal flap surgery is called open flap debridement or flap

curettage. It is against this well established surgical technique that new surgical
interventions in clinical trials are often compared. The rationale for this basic surgical

approach is the same as all flap surgery: to provide access to root surfaces and

marginal alveolar bone. Direct visualization of these structures will increase the

effectiveness of scaling and root planing and allow debridement of granulomatous

tissue from osseous defects. Open flap debridement does not use resective techniques,

osseous grafts, or barrier membranes to eliminate osseous defects. Simply stated,

roots are planed, defects are degranulated, and flaps are closed either at or apical to

their original position. Access is initiated with either crevicular or step-back, inverse

bevel incisions. Flaps are usually full thickness and reflected beyond the alveolar

crest and mucogingival junction to fully expose the alveolar bone and osseous defect.

FLAP REPOSITIONING21

Once the planned treatment has been completed, surgical flaps may be repositioned,

apically positioned, coronally positioned, or laterally positioned. When possible, the

decision as to the final location of the flap margin should be planned before the start

of surgery. The final flap location is usually determined by the goal(s) of therapy and

the specific periodontal surgical technique performed. A repositioned or replaced flap

is in theory designed to be returned to its original position. It is used most often when

surgical access for debridement of the roots is the primary goal, as in flap curettage.

A repositioned flap also is frequently used in periodontal regeneration procedures

where primary closure over a bone graft, with or without a barrier membrane, is of

utmost importance. An apically positioned flap is one that is apically displaced from

its original position to the level of the alveolar crest or about 1 mm coronal to the

crest. This position is chosen when performing "pocket elimination" procedures,

which may or may not involve the removal of bone. The coronally positioned flap is
advanced coronal to its original position. This technique is typically used when

performing mucogingival surgery where the flap is advanced to cover the exposed

root, a connective tissue graft, or a barrier membrane. To achieve passive positioning

of the coronally advanced flap before suturing, the underlying periosteum is released

with a sharp scalpel blade. Also used in mucogingival procedures is the laterally

positioned flap. This involves the lateral positioning of the flap to an adjacent or

contiguous site for the purpose of increasing the width of keratinized tissue or

covering of an exposed root.

PURPOSE & OBJECTIVES OF FLAP ELEVATION

 To control & eliminate periodontal disease.

 To eliminate pocket.

 To maintain root surface accessible for scaling & self-performed tooth cleaning

after healing.

 To correct anatomic condition that may favour periodontal disease, impair esthetics

or impede placement of correct prosthetic appliances.

 To place implants to replace lost tooth.

 To aim at regeneration of periodontal attachment, lost due to destruction by disease.

 To improve the prognosis of the teeth & their replacements.

 To improve esthetics.

INDICATIONS OF PERIODONTAL SURGERY

 Accessibility for proper scaling & root planning.

 Establishment of morphology of the dentogingival area conducive to infection

control.

 Correction of gross gingival aberrations.

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

 Areas with irregular bony contours & deep craters.

 In cases of furcation involvement of grade II & III, where surgical approach ensures

the removal of irritants & any necessary root resection or hemisection.

 Intrabony pockets on distal areas of last molars, complicated by mucogingival

problems.

 Persistent inflammation in areas with moderate to deep pockets.

 PRINCIPLES OF PERIODONTAL SURGERY

 Know your patient for his/her medical status.

 Develop a thorough & complete treatment plan.

 Know anatomy of surgical site.

 Follow aseptic surgical techniques.

 Provide profound anaesthesia.

 Practice atraumatic tissue management.

 Sharp & sterile instruments.

 Careful flap reflection & retraction.

 Avoid flap tension.

 Attain haemostasis.

 Use atraumatic suturing techniques.

 Smallest needle & suture that can be used in the area.

 Place sutures in the keratinized tissue when possible.

 Minimum number of sutures to achieve closure.

 Obliterate dead space between flap & bone.

 Promote stable wound healing.

 CRITERIA FOR SURGICAL METHOD SELECTION

 Characteristics of pocket.

 Depth.

 Relation to bone.

 Configuration.

 Accessibility to instrumentation.

 Existence of mucogingival problems.

 Response to phase I therapy.

 Patient co-operation.

 Age & general health of patient.

 Esthetic consideration.

 Previous periodontal treatments.

 FLAPS FOR POCKET ELIMINATION

ORIGINAL WIDMAN FLAP3

One of the first detailed descriptions of the use of a flap procedure for pocket elimination was

published in 1918 by Leonard Widman. In his article “The operative treatment of pyorrhea

alveolaris” Widman described a mucoperiosteal flap design aimed at removing the pocket

epithelium and the inflamed connective tissue, thereby facilitating optimal cleaning of the

root surfaces.

Technique:

 Sectional releasing incisions were first made to demarcate the areas scheduled for

surgery. These incisions were made from the mid-buccal gingival margins of the two

peripheral teeth of the treatment area and were continued several millimeters into the

alveolar mucosa. The two releasing incisions were connected by a gingival incision

which followed the outline of the gingival margin and separated the pocket epithelium

and the inflamed connective tissue from the non-inflamed gingiva. Similar releasing

and gingival incisions were, if needed, made on the lingual aspect of the teeth.

 A mucoperiosteal flap was elevated to expose at least 2-3 mm of the marginal alveolar

bone. The collar of inflamed tissue around the neck of the teeth was removed with

curettes and the exposed root surfaces were carefully scaled. Bone recontouring was

recommended in order to achieve an ideal anatomic form of the underlying alveolar

bone.

 Following careful debridement of the teeth in the surgical area, the buccal and lingual

flaps were laid back over the alveolar bone and secured in this position with

interproximal sutures. Widman pointed out the importance of placing the soft tissue

margin at the level of the alveolar bone crest, so that no pockets would remain. The
 surgical procedure resulted in the exposure of root surfaces. Often the

interproximal areas were left without soft tissue coverage of the alveolar bone.

The main advantages of the: original Widman flap” procedure in comparison to the

gingivectomy procedure included, according to Widman (1918):

 Less discomfort for the patient, since healing occurred by primary intention.

 That it was possible to reestablish a proper contour of the alveolar bone in sites

with angular bony defects.

Original Widman flap- Two releasing incisions demarcate the area

scheduled for surgical therapy. A scalloped reverse bevel incision is
made in the gingival margin to connect the two releasing incisions.

Original Widman flap- The collar of inflamed gingival tissue is

removed following the elevation of a mucoperiosteal flap.
 Original Widman flap- By bone recontouring, a “physiologic”
contour of the alveolar bone may be re-established.

Original Widman flap- The coronal ends of the buccal and lingual
flaps are placed at the alveolar bone crest and secured in this position
by interdentally placed sutures. (Source: Ramfjord SP; Nissle RR.
The modified Widman operation. J Periodontol 1974; 45: 601-607)

NEUMANN FLAP

Neumann’s first mention of flap surgery in the treatment of periodontal disease

appears in the first edition of his text “Pyorrhea Alveolaris and its Treatment”

published in Berlin in 1912. The late 19th and early 20th century saw the emergence of

two modalities that facilitated progress in the surgical treatment of periodontal

disease:
 Dental radiology

 Practical use of local anesthesia

During this era many methods were advocated for the treatment of periodontal disease.

These included the use of caustics, radium- containing waters vaccines, scaling,

gingivectomy and what was then called “radical surgical treatment”.

Neumann (1920) suggested the use of flap procedure, which in some respects was

different from that originally described by Widman.

Technique:

 The first incision is vertical along the long axis of the tooth and incorporates

five to six teeth (sextants).

 The papilla is not bisected by the vertical incision.

 The interproximal mucosa is severed by (“papilla scalpel”) means of a

vertically directed incision through the periosteum to bone.

 The mucoperiosteal flap thus outlined is then reflected sufficiently far to gain

accessibility & visibility.

 The flap is drawn aside with a sharp hook (retractor).

 Sickle and spoon shaped curettes are used to remove all granulation tissue.

 Bone is smoothed with chisels and a rotating bur in a dental headpiece.

 Pockets in bone are removed and the bone itself is given as far as possible the

normal shape intended for it.

 The mucous membrane is scalloped with a very fine pair of gingival scissors.

The operator must be careful to leave sufficient mucous membrane to cover the

interdental space.

 Before suturing, the field of operation is sprayed with carbonic acid atomizer

and inspected for concretions or granulation tissue.

When the bone has been completely smoothed, the mucosal flap is trimmed so that after

suturing (using a curved or a straight needle and silk thread), it just covers the bone exactly

above the boundary of the bone27.

Neumann Flap- Initial incision & flap design

for maxillary anterior sextant

Neumann Flap- Use of curette to remove granulation

tissue following reflection of mucoperiosteal flap

Neumann Flap- Round bur in a straight hand-

piece to recontour bone

 Neumann Flap-

Fine scissors used to create

scalloped gingival margin to cover properly

contoured bone

Neumann Flap- Curved needle used in closing

vertical incisions (Source: Robert Neumann: A

pioneer in periodontal surgery. Steven I. Gold.

J. Periodontol 1982; 53( 7).

DIFFERENCE BETWEEN ORIGINAL WIDMAN FLAP & NEUMANN FLAP28

Widman procedure Neumann procedure

1) Advocated a radical surgical treatment. In 1) According to him if no lingual or palatal

all the cases of periodontitis both the
buccal and the lingual flaps were to be
raised.
2) Divided the mouth into three tooth areas.
pockets existed then only a buccal or labial
flap could be raised.
2) Divided the mouth into sextants. Thus the
results were better in terms of gingival
contours.

3) More tiring for the patients 3) Less tiring for the patients.

4) Recommended the stabilization of the 4) Recommended the stabilization of the teeth

teeth postsurgically. presurgically.

5) Did not give it the importance to mucous 5) Positioned the mucous membrane exactly over
membrane. the bone.

6) Mainly used hand instruments 6) Used dental drill to accomplish the osseous
recontouring
MODIFIED FLAP OPERATION (KIRKLAND 1931)

Olin Kirkland (1876-1969), a prominent dentist in Montogomery, Alabama, presented in

1932, a technique which he called the modified flap operation. "Modified flap operation" is

basically an access flap for proper root debridement7. In a publication from 1931 Kirkland

described a surgical procedure to be used in the treatment of “periodontal pus pockets”.

Technique:27

In this procedure incisions were made intracrevicularly through the bottom of the pocket on

both the labial and the lingual aspects of the interdental area. The incisions were extended in

a mesial and distal direction.

 The gingiva was retracted labially and lingually to expose the diseased root surfaces

which were carefully debrided. Angular bony defects were curetted.

 Following the elimination of the pocket epithelium and granulation tissue from the

inner surface of the flaps, these were replaced to their original position and secured

with interproximal sutures. Thus, no attempt was made to reduce the pre-operative

depth of the pockets.

In contrast to the original Widman flap as well as the Neumann flap, the modified flap

operation did not include-:

 Extensive sacrifice of non-inflamed tissues.

 Apical displacement of the gingival margin.

Advantages of Modified Flap Operation-:

 The method could be useful in the anterior regions of the dentition for esthetic

reasons, since the root surfaces were not markedly exposed.

  It has the potential for bone regeneration in intrabony defects which frequently

occurred according to Kirkland (1931).

The first description of the flap procedure for the purpose of reattachment was given by

Kirkland in 1931, when he demonstrated the basic gingival mucoperiosteal flap design of

Neumann in 1920 for the original flap, but instead of trimming the flap for surgical pocket

elimination, he attempted to eliminate the crevicular epithelial lining and the inflamed

connective tissue by curettage the flap9.

Modified flap operation (the Kirkland

flap) - Intracrevicular incision.

Modified flap operation (the Kirkland

flap). -The gingiva is retracted to expose the
“diseased” root surface.

Modified flap operation (the Kirkland

 Modified flap operation (the Kirkland
flap) - The flaps are replaced to their
original position and sutured. (Source: Jan
Lindhe Thorkild Karring. Niklaus P. Lang.
Clinical Periodontology and Implant
Dentistry. Fourth Edition.)

UNDISPLACED FLAP6

In 1965, Morris described a technique known as “Unrepositioned Mucoperiosteal Flap”.

Currently, the Undisplaced flap may be the most frequently performed type of periodontal

surgery. In this technique, the soft tissue pocket wall is removed with the initial incision, thus

it may be considered as an “internal bevel gingivectomy”. To perform this technique without

creating mucogingival problem, the clinician should determine that enough attached gingiva

will remain after removal of the pocket wall.

The following steps outline the Undisplaced flap technique:

Step 1: the pockets are measured with the periodontal probe & a bleeding point is produced

on the outer surface of the gingiva to mark the pocket bottom.

Step 2: the initial or internal bevel incision is made after scalloping of the bleeding marks on

the gingiva. The incision is usually carried out 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. 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 loose & reflected flap that is

difficult to manage.
Step 3: the second or the 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 the periosteal elevator from the internal bevel incision.

Usually there is no need for vertical incisions because the flap is not displaced apically.

Step 5: the third or the interdental incision is made with the interdental knife, separating the

connective tissue from the bone.

Step 6: the triangular wedge of tissue is created by the three incisions is removed with the

curette.

Step 7: the area is debrided, removing all the tissue tags & granulation tissue using sharp

curettes.

Step 8: after the necessary scaling & root planing, the flap edge 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 the osseous surgery, the edge of the flap is rescalloped & trimmed to

allow the flap edge to end at the root-bone junction.

Step 9: a continuous sling suture is used to secure the facial & lingual flaps. This type of

suture, using the tooth as the anchor, is advantageous to position & hold the flap edges at the

root-bone junction. The area is covered with a periodontal pack.

ADVANTAGES:

 Improved accessibility for instrumentation.

 Removes the pocket wall lining.

DISADVANTAGES:

 Poor esthetics.

 Root exposure leading to sensitivity and caries.

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.

Internal bevel incision is made after the

scalloping of the bleeding marks on the gingiva

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.

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.

(Source: J. S. Zamet. Journal of Clinical

Periodontology. 1974; 2(2):87 – 97)
MODIFIED WIDMAN FLAP

The method that was described as the modified Widman flap surgery was actually first

described by a Swedish dentist by the name of Dr. Oestman during the 1930s, but there was

no publication by Dr. Oestman describing his flap design which was called as the Widman-

Oestman flap. During the 1930s and 1940s gingivectomy was the most popular form of

periodontal surgery and Oestman’s modification of the Widman flap was used for very

advanced cases of periodontal disease. This procedure was acceptable especially in the

maxillary anterior regions wherein it achieved esthetic results.

A similar flap procedure was described by Morris as the “unrepositioned mucoperiosteal

flap” and by Harvey as surgical reconstruction29.

In 1965, Morris revived a technique described in the twentieth century in the periodontal

literature; he called it the “unrepositioned mucoperiosteal flap” by Harvey as “surgical

reconstruction”.

Essentially, the same procedure was presented in 1974 by Ramford and Nissle, who called it

the “Modified Widman Flap”. This is also recognized as the “open flap curettage”6.

The term “modified Widman flap” was adopted to designate a flap procedure which has been

modified by several persons and came to designate an open subgingival curettage for

reattachment, although the original purpose of the Widman flap was surgical pocket

elimination.

Widman’s name was retained in the designation since modifications by Oestman and others

were based on Widman’s original reverse bevel design, and Widman apparently deserves the

credit for introducing a reverse bevel mucoperiosteal flap in periodontal surgery.

It should be understood however that the modified Widman flap is not identical to the

original Widman flap. Neither is it similar to any other similar flap procedure29.

Objectives of Modified Widman Procedure

This procedure was designed to:

 Provide access for root debridement

 Preserve the maximum amount of periodontal tissue.

 Remove the inflamed pocket wall4.

Indications for Modified Widman Procedure

 Deep pockets

 Intrabony pockets. This is the basic technique when implantation of bone or other

substances into intrabony lesions is contemplated.

 When minimum gingival recession is required29.

Technique:6

Step1

 The initial incision is the internal bevel incision to the alveolar crest starting 0.5mm to

1mm away from the gingival margin.

 The initial gingival incision should be made with a knife that can be directed parallel

to the long axis of the tooth

 If the buccal or lingual pockets are deeper than 2 mm, this initial incision should be

placed at least ½ mm away from the free gingival margin in order to assure complete

removal of all crevicular epithelium.

 If the buccal crevice is 2 mm or less and/or esthetic considerations are of great

importance, one may use an intracrevicular / crestal incision starting at the free
 gingival margin to minimize post surgical gingival shrinkage27.

 Scalloping follows the gingival margin6.

In order to assure flap coverage of the interproximal bone following the surgery, it is

often advisable to exaggerate the scalloping effect of the initial incision by staying 1 to 2

mm away from the mid-palatal surface of the teeth, while the interproximal incisions

come close to the tooth surfaces27.

 Care should be taken to insert the blade in such a way that the papillae are left with

the thickness similar to that of the remaining facial flap6.

 Vertical relaxing incisions are not needed.

Step2

 Gingiva is reflected with a periosteal elevator.

Step3

 A crevicular incision is made from the bottom of the pocket to the bone,

circumscribing the triangular wedge of tissue containing the pocket lining

Step4

 After the flap is reflected, a third incision is made in the interdental space coronal to

the bone with a curette or an interproximal knife, and the gingival collar is removed

Step5

 Tissue tabs and the granulation tissue are removed with a curette. The root surface are

checked, then scaled and planed if needed. Residual periodontal fibers attached to the

tooth surface should not be disturbed.

Step6

 Bone architecture is not corrected except if it prevents the close adaptation to the

necks of the teeth.

 The flap is adapted in such a way that the interproximal bone is in no way exposed at
 the time of suturing.

 The flap may be thinned to allow for the close adaptation of the gingiva around the

entire circumference of the tooth and to each other interproximally.

Step7

 Interrupted direct sutures are placed in each interdental space and covered with

tetracycline (Achromycin) ointment and with a periodontal surgical pack6.

Initial incision is made parallel to the long axis of the tooth.

When buccal pockets are shallow /esthetics are important

–intracrevicular incision /incise at free gingival margin
 On palatal aspect –scalloping effect

of the incision should be exagerrated

to ensure falp adaptation

interproximally
later

Also direct the scalpel slightly palatal to the long

axis of the tooth aiming for the alveolar process
1-2 mm palatally to the alveolar crest

Second incision made around the neck of the

tooth from bottom of the crevice to the alvoelar
crest
Third incision –made in the horizontal direction
with the interproximal knife separating soft
tissue collar of root surface s from the bone

Suture the flap together with interproximal

Important points to remember

 When buccal pockets are shallow, and/or esthetic considerations are important, one may

use an intracrevicular incision or incise at the free gingival margin.

 The scalloping effect of the incision should be exaggerated on the palatal aspect in order to

ensure flap adaptation interproximally later.

 Also the scalpel should be directed palatally to the long axis of the tooth aiming for the

alveolar crest, otherwise flap adaptation and flap contour will not be satisfactory16.

Differences from the “Original Widman Flap”16

Mainly an open subgingival curettage was done for reattachment whereas the main purpose

of the Original Widman flap was pocket elimination.

 Primary incision is an inverse beveled, partial-thickness, thinning incision held

parallel to the long axis of the tooth and directed toward the crest of bone

 Secondary incision is the intra-sulcular incision and is performed around the dental

surfaces.

 After raising the flaps the loosened collar of tissue was removed at the alveolar crest.

There was no apical displacement of the flap.

 No osseous recontouring (elimination of pockets)27

 Exaggerated palatal scalloping for optimal flap adaptation16.

Advantages:

 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 dentition3.

 It provides access for proper instrumentation of the root surfaces & immediate closure

at the dentogingival junction between the teeth & well fitting flaps.

 Conservation of bone & optimal coverage of the root surfaces by soft tissues.

 It results in more pocket closure by reattachment & bone regeneration29.

Disadvantages:4

 Inability to achieve pocket elimination.

 Healing by long junctional epithelium.

 Difficult to perform in thin and narrow attached gingiva.

 Flat or concave interproximal architecture immediately following removal of the

surgical dressing, especially in the areas of the interproximal bony craters.

 Failure in completely approximating buccal or lingual flaps or inadequate fit of the

flaps to the teeth following attempts to perform modified Widman flap often gives

poor results with residual inflamed and deep periodontal pockets.

Merits of Modified Widman Flap procedure over subgingival curettage

This type of flap actually presents a modification of the subgingival curettage. It provides:

- Better access to the root surface than curettage.

- Allows for the removal of the epithelial lining of the pocket with less trauma and

discomfort. Also provides better adaptation to the tooth than the curettag
 DIFFERENCE BETWEEN MODIFIED WIDMAN FLAP & WIDMAN FLAP

MODIFIED WIDMAN FLAP WIDMAN FLAP

Given by Ramjford and Nissle,1974 Leonard widman,1918

Aim Gain access to the roots and the Total pocket elimination

alveolar crest

Flap reflection Mucoperiosteal flap is raised Beyond the apices of the teeth.

only 2 to 3 mm from the alveolar

crest

Initial incision is parallel to the Initial incision not parallel to the

long axis of the teeth & flaps are long axis of the tooth
Incision separated from the bone to a

lesser extent

Collarof tissue Cut loose with sharp knives Tearing with curettes
around the neck of the (second incision)
teeth

Releasing incision Not given Given

Palatal scalloping Exaggerated palatal scalloping of Less attention

the flaps is given much more
attention

Bone contouring No bone countouring Bone contouring done

After suturing Flaps cover interproximal bone Flaps do not cover interproximal

bone, remains exposed

APICALLY REPOSITIONED FLAP30

The apically positioned flap is one of the most widely used techniques for eliminating

periodontal pockets. A flap made by an internal bevel incision is displaced apically from the

original position, and the suture is made on the alveolar crest or in a slightly coronal position.

The position of the flap displacement varies depending on the:

l. Thickness of alveolar margin in operating area.

2. Width of attached gingiva.

3. Clinical crown length necessary for an abutment.

Apically positioned flap surgery is used widely to eliminate periodontal pockets, to increase

the width of the attached gingiva, to lengthen the clinical crown for prosthetic treatment, and

to improve gingival and gingival-alveolar bone morphology. It is not, however, suitable for

severe periodontal disease or for the esthetic zone.

INDICATIONS:

 Pocket eradication.

 Widening the zone of attached gingiva.

 Areas of thin periodontium or prominent roots where dehiscence or fenestrations may

be present6

CONTRAINDICATIONS:

 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.

ADVANTAGES:30

 Healing by primary intention.

 Maximum coverage of the bone.

 Accurate control of the post operative amount of the attached gingiva.

 Maintenance of the normal relationships of all the structures because the gingival

tissue is to be apically positioned.

 Rapid healing minimizing undesirable postoperative sequelae.

 Minimum bone loss and stable results.

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.

Technique:

The surgical technique developed by Nabers (1954) was originally denoted “repositioning of

attached gingiva” and was later modified by Ariaudo and Tyrrell (1957). In 1962 Friedman

proposed the term apically repositioned flap to describe more appropriately the surgical

technique introduced by Nabers. This surgical technique was used on buccal surfaces in both

upper and lower jaws and on lingual surfaces in the lower jaw, while an excisional technique

had to be used on the palatal aspect of maxillary teeth where the lack of alveolar mucosa

made it impossible to reposition the flap in an apical direction.

According to Friedman (1962) the technique should be performed in the following way:

 A reverse bevel incision is made using a scalpel with a Bard-Parker blade (No. 12B or

No. 15). How far from the buccal/lingual gingival margin the incision should be made

is dependent on the pocket depth as well as the thickness and the width of the gingiva.

If pre-operatively the gingiva is thin and only a narrow zone of keratinized tissue is

present, the incision should be made close to the tooth. The bevelling incision should

be given a scalloped outline, to ensure maximal interproximal coverage of the alveolar bone

when the flap subsequently is repositioned. Vertical releasing incisions extending out into the

alveolar mucosa are made at each of the end points of the reverse incision, thereby making

apical repositioning of the flap possible.

 A full-thickness mucoperiosteal flap including buccal/lingual gingiva and alveolar

mucosa is raised by means of a mucoperiosteal elevator. The flap has to be elevated

beyond the mucogingival line in order to be able to reposition the soft tissue apically.

The marginal collar of tissue, including pocket epithelium and granulation tissue, is

removed with curettes, and the exposed root surfaces are carefully scaled and planed.
 The alveolar bone crest is recontoured with the objective of recapturing the normal

form of the alveolar process but at a more apical level. The osseous surgery is

performed using surgical burs and/or bone chisels & files.

 Following careful adjustment, the buccal/lingual flap is repositioned to the level of the

newly recontoured alveolar bone crest and secured in this position. 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.

Following a vertical releasing incision,
the reverse bevel incision is made 1mm
from the crest of the gingiva and
directed towards the crest of the bone.
Crevicular incisions are made

A mucoperiosteal flap is raised and

the tissue collar remaining around the
teeth, including the pocket epithelium
and the inflamed connective tissue, is
removed with a curette.

Osseous surgery is performed with

the use of a rotating bur
The flaps are repositioned in an apical
direction to the level of the recontoured
alveolar bone crest and retained in this
position by sutures.

The flaps are repositioned in an apical

direction to the level of the recontoured
alveolar bone crest & retained in this
position by sutures. (Source: Haffajee AD,
Levy RM, Giannobile WV, Feres M, ,
Smith C, Socransky SS. The short-term
effect of apically repositioned flap surgery
on the composition of the subgingival
microbiota. Int J Periodontics Restorative
Dent. 1999 Dec; 19(6): 555- 67.
BEVELED FLAP

To handle periodontal pockets on the palatal aspect of the maxillary teeth, Friedman

described a modification of the “apically repositioned flap”, which he termed the beveled

flap.

Technique:

 In order to prepare the tissue at the gingival margin to follow the outline of the

alveolar bone crest properly, a conventional mucoperiosteal flap is first resected.

 The tooth surfaces are debrided and osseous recontouring is performed

 The palatal flap is subsequently replaced and the gingival margin is prepared and adjusted to the
alveolar bone crest by a secondary scalloped and beveled incision. The flap is secured in this
position with interproximal sutures.
A primary incision is made intracrevicularly
Conventional mucoperiosteal flap is elevated
through the bottom of the periodontal pocket

Scaling, root planing, and osseous The palatal flap is replaced and a secondary,
recontouring are performed in the surgical scalloped, reverse bevel incision is made to
area. adjust the length of the flap to the height of the
remaining alveolar bone.

The shortened and thinned flap is replaced over the alveolar bone and in close contact with the root
surfaces. (Adapted: Haffajee AD, Levy RM, Giannobile WV, Feres M, , Smith C, Socransky SS. The
short-term effect of apically repositioned flap surgery on the composition of the subgingival microbiota.
Int J Periodontics Restorative Dent. 1999 Dec; 19(6): 555- 67.
PALATAL FLAP

The process of elevating a palatal flap is different from that of a buccal flap. Because of the

structure of the palatal mucosa, it is not possible to apically position the palatal flap. The

palatal flap, therefore, must be incised precisely so that any soft tissue pocket depth will be

eliminated and the flap will cover the bony margin when it is sutured. When the palatal tissue

is thick and the bulk of the flap is to be reduced, the flap will have to be thinned. Palatal

flaps, therefore, are commonly of partial-thickness. A properly dissected flap should have a

flaccid nature and should not have a thickened base that is resistant to flap coaptation21.

Anatomic Characteristics of Palatal Tissue:

Because of the anatomic characteristics of the palate, palatal flaps require different designs.

It is desirable to remove deep palatal periodontal pockets entirely and establish a shallow

physiologic gingival sulcus for the following reasons:

 Palatal tissue is masticatory mucosa and immobile; it has no elastic fibres and loose

connective tissues. Therefore, it is impossible to displace a palatal flap apically.

 Palatal tissue is thick, keratinized tissue; therefore, accurate close adaptation to the

tooth surface and bone margin is difficult, and postoperative gingival morphology

may be unfavorable. A gingival crater, a thick shelf-shape that makes tooth brushing

difficult, may be created. Such periodontal pockets tend to recur postoperatively.

 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.

 Inaccessibility of cleaning instruments may cause inadequate self-care.

If the gingiva is thick in the palatal flap, a partial-thickness internal bevel incision is made,

the flaps prepared with thin and uniform thickness, and the flap adapted closely to the tooth

surface and alveolar bone. It is necessary to achieve a form that is easy to clean

postoperatively.

Partial-Thickness Palatal Flap Surgery:

Partial-thickness palatal flap surgery was developed by Staffileno and improved by Corn et

al. It is used for the elimination of periodontal pockets where thick palatal tissues occur. This

procedure is valuable because it can be used in areas of thick gingival tissues. Advantages

include:

 Flap thickness may be adjusted.

 Palatal flap may be adapted to the proper position.

 Better postoperative gingival morphology is possible with a thin flap design.

 Treatments may be combined (osseous resection and wedge procedure).

 Rapid healing.

 Easy management of palatal tissue.

 Minimal damage to palatal tissue.

Considerations for determining the position of the primary incision in palatal flap surgery are:

 Thickness of palatal tissue.

 Depth of periodontal pocket.

 Degree of osseous defect.

 Necessity of osteoplasty and required clinical crown length.

 Surgical methods (or techniques) applied30.

Technique:

 The initial incision may be usual internal bevel incision, followed by crevicular &

interdental incisions. If the tissue is thick, a horizontal gingivectomy incision may be

made, followed by an internal bevel incision that starts at the edge of this incision &

ends on the lateral surface of the underlying bone.

 The placement of the internal bevel incision must be done in such a way that flap fits

around the tooth without exposing the bone.

 Before the flap is reflected to the final position for scaling & management of osseous

lesions, its thickness must be checked.

 Flaps should be thin to adapt to the underlying osseous tissue & provide a thin,

knifelike gingival margin.

 A sharp, thin papilla positioned poorly around the interdental areas at the tooth-bone

junction is essential to prevent recurrence of soft tissue pockets.

 The apical portion of the scalloping should be narrower than the line-angle area

because the palatal root tapers apically. A round scallop results in a palatal flap that

does not fit snugly around the root. This procedure should be done before the

complete reflection of the palatal flap, as a loose flap is difficult to grasp & stabilize

for dissection.

 Thinning of the palatal flap is done by holding the inner portion the flap with a

mosquito hemostat & dissected away with a sharp #15 scalpel blade. Care must be

taken not to perforate or overthin the flap.

 The edge of the flap must be thinner than the base; therefore the blade should be

angled towards the lateral surface of the palatal bone.

 The dissected inner connective tissue is removed with a hemostat.

 Flap is re-approximated & sutured.

The purpose of palatal flap should be considered before the incision is made. If the intent of

the surgery is debridement, the internal bevel incision is planned so that the flap adapts at the

root-bone junction when sutured. If osseous resection is necessary, the incision should be

planned to compensate for the lowered level of the bone when the flap is closed. Probing &

sounding of the osseous level & the depth of the intrabony pocket should be used to

determine the position of the incision6.

Primary incision given

Outline of primary incision

 Thin primary flap preparation

..

Secondary incision given

 Secondary flap removal

Sutures placed (Source: Clinical

periodontology, Carranza’s 10th edition.
Advantages include:

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.

Contraindications :

 When a broad, shallow palate does not permit a partial-thickness flap to be raised

without possible damage to the palatal artery.

 FLAPS TO INDUCE RE-ATTACHMENT & REGENERATION

DISTAL WEDGE PROCEDURE

Treatment of periodontal pockets on the distal surface of terminal molars is often complicated

by the presence of bulbous tissue over the maxillary or prominent retromolar pads in the

mandible. Deep vertical defects are also often 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 gingivectomy incision is the most direct approach in treating distal pockets that have

adequate attached gingiva & no osseous lesions. However, the flap approach is less traumatic

post-surgically, because it produces a primary closure wound rather than the open secondary

wound left by a gingivectomy incision. In addition, it results in attached gingiva as well as

provides access for examination &, if needed, correction of the osseous defects. Procedures

for this purpose were described by Robinson, 1966 & Braden, 1969 & modified by several

investigators6.

This technique facilitates access to the osseous defect and makes it possible to preserve

sufficient amount of gingiva and mucosa to achieve soft tissue coverage.

OBJECTIVES OF DISTAL WEDGE PROCEDURE

1. To eliminate periodontal pockets.

2. Maintain & preserve attached gingiva.

3. Make area accessible to instruments.

4. Lengthen clinical crown.

5. Create easily cleansable gingiva-alveolar form.

The procedure enables the removal of thick gingival tissue on the edentulous site adjacent to

the abutment. If there is an osseous defect, it also corrects the bone morphology by flattening

it and the intrabony defect may be eliminated. The periodontal pocket is eliminated and a

shallow gingival sulcus favourable for postoperative maintenance is created. For a primary

closure, a thin flap offers best adaptation to the tooth and bone. This not only ensures the

elimination of the periodontal pocket, but alleviates pain and reduces the healing period.

Factors that determine the flap design of a wedge procedure

1. Size and shape

2. Thickness of soft tissue

3. Difficulty of access

4. Band of attached gingiva of the abutment tooth

5. Depth of periodontal pocket and degree of osseous defect on the edentulous side of the

abutment

6. Clinical crown length required as an abutment for restorative/prosthetic treatment

Factors that determine the amount of wedge tissue removed

1. Thickness of the soft tissue

2. Depth of periodontal pocket and osseous defect

3. Amount of bone to be removed (whether by osteoplasty or ostectomy if necessary)

4. Clinical crown length necessary for the abutment

5. Pontic form30.
Technique:
 Buccal and lingual incisions are made in a vertical direction through the tuberosity or

retromolar pad to form a triangular wedge. The facial and lingual incisions should be

extended in a mesial direction along the buccal and lingual surfaces of the distal molar

to facilitate flap elevation.

 The facial and lingual walls of the tuberosity or retromolar pad are reflected and the

incised wedge of tissue is dissected and separated from the bone.

 The walls of the facial and lingual flaps are then reduced in thickness by undermining

incisions. Loose tags of tissue are removed and the root surfaces are scaled and

planed. If necessary, the bone is re-contoured.

 The buccal and lingual flaps are replaced over the exposed alveolar bone, and the

edges trimmed to avoid overlapping wound margins. The flaps are secured in this

position with interrupted sutures. The sutures are removed after approximately 1

week3.

Buccal and lingual vertical incisions are made through the retromolar pad to form a triangle
behind a mandibular molar.

The triangular-shaped wedge of tissue is dissected from the underlying bone and removed.
 The walls of the buccal and lingual flaps are reduced
in thickness by undermining incisions (broken
lines).

The flaps, which have been trimmed and shortened to avoid overlapping wound

margins, are sutured. (Source:Fermin A. Carranza, Michael G. Newman (1996)

Clinical Periodontology, 8edition.

Modifications of flap Design for the Wedge Procedure30

Four flap designs are used in the wedge procedure: square, linear, triangular, and pedicle. A

flap design is determined by the size of the edentulous ridge, maxillary tuberosity, and

retromolar triangle, and the thickness of the soft tissue.

 Selection of incision in the wedge procedure

Indications for the square incision

1. Long and large edentulous ridge, maxillary tuberosity, and retromolar triangle.

2. Much tissue to be removed in the wedge area.

3. Sufficient existing band of attached gingiva.

4. Deep periodontal pockets and osseous defects on the mesial and distal aspects of the

abutment.

A square incision is made with two parallel internal bevel incisions and one vertical incision.

The vertical incision is a release incision to help the flap adapt closer to the source. The
amount of wedge tissue to be removed (the distance between the two internal bevel incisions)

is determined by a number of factors.

The pedicle incision is a difficult technique, but it has many advantages.

Advantages of the pedicle incision

1. Rapid postoperative healing.

2. Less postoperative discomfort.

3. Complete coverage of the osseous defect of the wedge area.

4. Reliable access to furcation and osseous defect area.

5. Smooth alveolar ridge preparation, easing pontic adaptation.

6. No attachment loss.

Indications for the pedicle incision

1. Narrow band of attached gingiva.

2. Thick soft tissue.

3. A piece of bone as donor site for bone graft is to be harvested.

4. Osseous defect close to maxillary sinus.

5. Regenerative procedure (bone graft, GTR) indicated due to deep intrabony defect.

THE WEDGE PROCEDURE IN THE EDENTULOUS RIDGE

To maintain healthy periodontal tissue in the edentulous arch, consideration for the

edentulous ridge shape adjacent to the abutment tooth is important. The wedge procedure is a

method used to eliminate periodontal pockets in edentulous areas. It is also used to recontour

periodontal tissues that form on the abutment tooth adjacent to the maxillary tuberosity or the

retromolar triangle. An edentulous space adjacent to an abutment tooth tends to form deep

periodontal pockets with recurrent periodontal disease after periodontal therapy.

Problems of an edentulous space adjacent to an abutment

 1. Plaque hard to control.

2. Effects of initial therapy may be suboptimal because of limited accessibility of

instruments during scaling & root planing.

3. Maxillary tuberosity & retromolar triangle are covered with thick gingiva & tend to

form deep periodontal pockets. Therefore, advanced furcation involvement is often

observed.

4. Abutment adjacent to edentulous space is a key tooth for occlusion & bears stress in

function. Hence, it is at high risk to advance to severe periodontal disease.

Therefore, to maintain a good periodontal environment around the abutment adjacent to the

edentulous ridge, periodontal pocket elimination using the wedge procedure is recommended.

PAPILLA PRESERVATION TECHNIQUE

In order to preserve the interdental soft tissues for maximum soft tissue coverage following

surgical intervention involving treatment of proximal osseous defects, Takei et al. (1985)

proposed a surgical approach called papilla preservation technique. Later, Cortellini et al.

(1995, 1999) described modifications of the flap design to be used in combination with

regenerative procedures. For esthetic reasons, the papilla preservation technique is often

utilized in the surgical treatment of anterior tooth regions.

Objective

- To preserve the interdental soft tissue for maximum soft tissue coverage following

surgical intervention involving treatment of proximal osseous defects.

Indications:

- In the surgical treatment of anterior teeth27.

Technique (Takei 1985):

 Intrasulcular incision is given at the facial and the proximal aspects of the teeth

without making incisions through the interdental papilla.

 Subsequently, an intrasulcular incision is made along the lingual/palatal aspect of

the teeth.

 A semilunar incision made across each interdental area.

 The semilunar incision dips apically at least 5mm from the line angles of the teeth.

This will allow the interdental tissue to be dissected form the lingual/palatal aspect

so that it can be elevated intact with the facial flap.

 The semilunar incision can also be placed on the facial side on the interdental area

where an osseous defect can has a wide extension into the lingual/palatal area.

 A curette or an interproximal knife is used to carefully free the interdental papillae

from the underlying hard tissue. The detached interdental tissue is pushed through

the embrasure with a blunt instrument.

 A full thickness flap is reflected with a periosteal elevator on both facial and the

lingual surfaces.

 The exposed root surfaces are thoroughly scaled, planed and the bone defects are

carefully curetted.

 The margins of the flap and the interdental tissue are scraped to remove the pocket

epithelium and excessive granulation tissue.

 In the anterior regions the trimming of the granulation tissue should be limited in

order to maintain the maximum thickness of the tissue.

 The flaps are repositioned and apply cross mattress suture.

 Alternatively a direct suture of the semilunar incision can be done as the only

means of flap closure.

 A surgical dressing may be placed to protect the surgical area.

 The dressings and sutures are removed after 1 week27.

Disadvantage:31

Not very effective in closing of the interproximal space when a barrier membrane is

used (this would require the coronal positioning of the flaps to close the interproximal

space)

Crevicular incision is made around each tooth with

no incision across the interdental papilla
Lingual/palatal incision consists of semilunar incision made across interdental papilla
in its palatal or lingual aspect .incision dips from line angle of the tooth so that
papillary incision is atleast 5 mm from the crest of the papilla.

A curette or interproximal knife is used to carefully free the

interdental papilla from the underlying hard tissue.
 The detached interdental tissue is pushed through the embrasure
with a blunt instrument to be included in the facial flap.

Flaps are sutured . (Source: Cortellini P, Prato GP, Tonetti MS. The simplified papilla
preservation flap. A novel surgical approach for the management of soft tissues in
regenerative procedures. Int J Periodontics Restorative Dent. 1999 Dec; 19(6): 589-99.)
MODIFIED PAPILLA PRESERVATION TECHNIQUE

To overcome the disadvantage of papilla preservation technique developed by Takei,

Cortellini et al. developed a modification of the above mentioned technique in

1995. Rationale:

 To achieve and maintain primary closure of the flap in the interdental space over

the membrane

 To obtain good protection of the regenerating tissue through complete coverage of

the membrane with the flaps.

 To increase the amount of regeneration32.

Indications:

- For different regenerative approaches involving the interdental space.

Contraindications:

- Where the coronal repositioning of the buccal flap has a poor prognosis (inadequate

vestibular depth)31.

Advantages:

- Allowed complete coverage of the Teflon membrane.

- Primary closure of the mucoperiosteal flaps in the interdental space in 93% of the

cases.

- Interdental tissue covers the membrane until its removal for 6 weeks.
Disadvantages:

- Technique sensitive

- In molars with interproximal space present, application of the desired surgical

technique did not result in the desired primary closure.

- The narrow interdental soft tissue is more likely to undergo a necrosis31.

Technique:

 A buccal and interproximal primary incision is given to the alveolar crest.

 A horizontal incision with a slight internal bevel is then traced in the buccal gingiva

of the interdental space at the base of the papilla.

 This incision is connected with the primary incision in the most apical portion of the

buccal gingival margin of the neighboring teeth.

 A full thickness buccal flap is elevated to the level of the buccal alveolar crest.

 The buccal and interproximal primary incision is then continued intrasulculary in the

interproximal space to reach the palatal line angle and is extended to the palatal

aspect.

 A buccal horizontal incision is performed in the interproximal supracrestal connective

tissue, just coronal to the bone crest, to dissect the papilla.

 The papilla is dissected towards the palatal aspect.

 Following extension of the palatal incision, a full thickness palatal flap including the

interdental papilla is subsequently elevated. This fully exposes the interproximal

defect.

 Subsequently the tissue thickness of the papilla is exposed.

 The defect is fully debrided and scaling and root planing is performed.
  To allow the coronal positioning of the buccal flap in the absence of the tension,

vertical releasing incisions extending into the alveolar mucosa are placed in the

interproximal spaces mesial and distal to the teeth neighboring the defect.

 The incisions are divergent in the corono-apical direction and preserve the interdental

tissue.

 The buccal flap is then released with a split thickness incision.

 An interproximal titanium Teflon membrane is adapted and positioned supracrestally

as close as possible to the CEJ.

 The occlusive portion of the membrane extends at least 3 mm beyond the margin of

the defect.

 The membrane is firmly secured to the neighboring teeth with Teflon sling sutures.

The flaps are sutured to obtain coronal positioning of the buccal flap and primary closure of

the interdental space over the membrane in the following ways:

a) A horizontal internal mattress suture is placed between the base of the palatal papilla

and the buccal flap immediately coronal to the mucogingival junction. Because the

suture is anchored on the thick palatal tissue, the buccal flap is coronally displaced.

b) A vertical internal mattress suture is subsequently placed between the buccal aspect of

the interproximal papilla (i.e., the most coronal portion of the palatal flap which

includes the interdental papilla) and the most coronal portion of the buccal flap. When

the suture is tied, primary closure of the coronally positioned buccal flap with the

preserved papilla is achieved in the interproximal area. Coronal positioning of the

interdental tissue is obtained over the membrane.

c) The vertical releasing incisions are sutured with a standard apico-coronal suture to

release tension from the interproximal tissue.

 d) Interproximal sutures are placed to close the mesial and the distal extension of the

flap.

e) No surgical dressing is placed31.

SIMPLIFIED PAPILLA PRESERVATION FLAP

To overcome some of the technical problems encountered with the MPPT a different

approach i.e. Simplified Papilla Preservation Flap, SPPF, was subsequently developed

(Cortellini et al. 1999).

Technique:

 This different and simplified approach to the interdental papilla includes a first

incision across the defect-associated papilla, starting from the gingival margin at the

buccal-line angle of the involved tooth to reach the mid-interdental portion of the

papilla under the contact point of the adjacent tooth.

 This oblique incision is carried out keeping the blade parallel to the long axis of the

teeth in order to avoid excessive thinning of the remaining interdental tissues.

 The first oblique interdental incision is continued intrasulcularly in the buccal aspect

of the teeth neighbouring the defect.

 After elevation of a full-thickness buccal flap, the remaining tissues of the papilla are

carefully dissected from the neighbouring teeth and the underlying bone crest.

 The interdental papillary tissues at the defect site are gently elevated along with the

lingual/palatal flap to fully expose the interdental defect.

 Following defect debridement and root planing, vertical releasing incisions and/or

periosteal incisions are performed, when needed, to improve the mobility of the

buccal flap.

 After application of a barrier membrane, primary closure of the interdental tissues

above the membrane is attempted in the absence of tension, with the help of sutures3
Presurgical appearance of the area that
will be accessed with the SPPF. The
defect is located on the mesial aspect of
the maxillary right lateral incisor.

First oblique incision in defect associated

papilla begins at gingival margin of
mesiobuccal line angle of lateral incisor
Blade is kept parallel to the long axis of the
tooth and reaches the midpoint of the distal
surface of the central incisor just below the

First oblique incision continues intrasulcularly

in the buccal aspect of the lateral and central
incisors, extending until the adjacent papillae,
and a buccal full-thickness flap is elevated to
expose 2 to 3 mm of bone. Note the defect-
associated papilla still in place.
Buccolingual horizontal incision at base
of the papilla is as close as possible to the
interproximal bone crest. Care is taken to
avoid a lingual/palatal perforation

Intrasulcular interdental incisions continue in

the palatal aspect of the incisors until the
adjacent partially dissected papillae. Full-
thickness palatal flap including the interdental
papilla is elevated.

Infrabony defect following debridement.

Note the position of the bone crest on the
distal aspect of the central incisor.
Membrane is positioned to cover defect and 2 to
3 mm of remaining bone and secured to
neighbouring teeth. Horizontal internal mattress
suture runs from the base of the keratinized tissue
at the midbuccal side of the central incisor to a
symmetric location at the base of the palatal flap.
This suture causes no direct compression of the
mid portion of the membrane, preventing its
collapse into the defect.

Suture is given & primary closure is

obtained. . (Source: Cortellini P, Prato GP,
Tonetti MS. The simplified papilla
preservation flap. A novel surgical approach
for the management of soft tissues in
regenerative procedures. Int J Periodontics
Restorative Dent. 1999 Dec; 19(6): 589-99.)
 MINIMAL INVASIVE SURGICAL TECHNIQUE (MIST)

A minimally invasive surgery (MIS) has been proposed in 1995 (Harrel & Ress) with the aim to

produce minimal wounds, minimal flap reflection and gentle handling of the soft and hard tissues

in periodontal surgery.

Data had shown clinical improvements in terms of pocket depth reduction, attachment level

gain, and minimal increase of recession after application of the MIS in different types of defects

(Harrel 1998, Harrel & Nunn 2001).

‘‘MIS technique (MIST)’’, has been specifically designed to treat isolated intrabony defects with

periodontal regeneration. Background foundations for this technique are the concepts of the MIS

(Harrel & Ress 1995), the application of largely tested papilla preservation techniques [modified

papilla preservation technique (MPPT) Cortellini et al. 1995, simplified papilla preservation flap

(SPPF)], and the application of passive internal mattress sutures to seal the regenerating wound

from the oral environment.

The main objectives of the MIST are-:

(1) Reduce surgical trauma

(2) Increase flap/wound stability

(3) Allow stable primary closure of the wound

(4) Reduce surgical chair time

(5) Minimize patient discomfort and side effects.

Technique:

 The defect-associated interdental papilla was accessed either with the SPPF

(Cortellini et al. 1999) or the MPPT (Cortellini et al. 1995).

 The SPPF was performed whenever the width of the interdental space was 2mm or

narrower, while the MPPT was applied at inter-dental sites wider than 2 mm.

 The interdental incision (SPPF or MPPT) was extended to the buccal and lingual

aspects of the two teeth adjacent to the defect. These incisions were strictly intra

sulcular to preserve all the height and width of the gingiva, and their mesio-distal

extension was kept at a minimum to allow the corono-apical elevation of a very small

full-thickness flap with the objective to expose just 1–2mm of the defect-associated

residual bone crest.

 When possible, only the defect-associated papilla was accessed and vertical releasing

incisions were avoided.

 The shortest mesio-distal extension of the incision and the minimal flap reflection

occurred when the intra-bony defect was a pure three-wall, or had shallow two and/or

one-wall sub-components allocated entirely in the inter-proximal area. In these

instances, the mesio-distal incision involved only the defect-associated papilla and

part of the buccal and lingual aspects of the two teeth neighbouring the defect.

 The full-thickness flap was elevated minimally, just to expose the buccal and lingual

bone crest delimiting the defect in the inter-dental area. A larger corono-apical

elevation of the full-thickness flap was necessary when the coronal portion of the

intrabony defect had a deep two-wall component.

 The corono-apical extension of the flap was kept to a minimum at the aspect where

the bony wall was preserved (either buccal or lingual), and extended more apically at

the site where the bony wall was missing (lingual or buccal), the objective being to

reach and expose 1–2mm of the residual bone crest.

 When a deep one-wall defect was approached, the full-thickness flap was elevated to

the same extent on both the buccal and the lingual aspects.

 When the position of the residual buccal/lingual bony wall(s) was very deep and

difficult or impossible to reach with the above-described minimal incision of the

defect-associated inter-dental space, the flap(s) was (were) further extended mesially

or distally involving one extra inter-dental space to obtain a larger flap reflection.

 The same approach was used when the bony defect also extended to the buccal or the

palatal side of the involved tooth, or when it involved the two inter-proximal spaces

of the same tooth.

 In the latter instance, a second interproximal papilla was accessed, either with an

SPPF or an MPPT, according to indications. Vertical releasing incisions were

performed when flap reflection caused tension at the extremities of the flap(s).

 The vertical- releasing incisions were always kept very short and within the attached

gingiva (never involving the mucogingival junction).

 The overall aim of this approach was to avoid using vertical incisions whenever

possible or to reduce at minimum their number and extent when there was a clear

indication for them. Periosteal incisions were never performed3.

The ideal flap design suggested to access a pure

interproximal three-wall intra-bony defect. It
includes the incision through the inter-dental
papilla (MPPT) and the intra-sulcular incision
running from the inter- proximal space to the
mid-buccal and mid-lingual sides of the defect-
associated teeth.

The access to the buccal portion of the defect

requires an extension of the flap to the
neighbouring inter-dental papilla.(Source:
Cortellini P, Prato GP, Tonetti MS. The
simplified papilla preservation flap. A novel
surgical approach for the management of soft
tissues in regenerative procedures. Int J
Periodontics Restorative Dent. 1999 Dec; 19(6):
 FLAPS TO CORRECT MUCOGINGIVAL DEFORMITIES

Flaps to correct mucogingival deformities are classified according to the direction of flap

migration-:

1. Rotational flaps- Flap rotated or displaced laterally.

 Laterally positioned flap.

 Transpositional flap.

 Double papilla flap.

2. Advanced flaps-Flap placed without rotation or lateral migration.

 Coronally positioned flap.

 Semilunar coronally positioned flap.

ROTATIONAL FLAP PROCEDURES

LATERALLY SLIDING FLAP

This technique, originally described by Grupe & Warren in 1956, was a standard technique

for many years. Still, laterally positioned flaps have been widely used for the treatment of

localized gingival recession cases, denuded roots that have adequate donor tissue laterally &

vestibular depth6. In this procedure, the adjacent keratinized gingiva is positioned laterally,

and the exposed root surface in the localized gingival recession is covered30.

Indications:

1. Sufficient width, length & thickness of keratinized tissue adjacent to the area of

gingival recession.

2. Coverage of the exposed roots limited to one or two teeth.

3. Root coverage in areas of gingival recession with narrow mesio-distal dimensions.

Contraindications:

1. Insufficient width & thickness of keratinized tissue in the adjacent donor site.

2. Extremely thin bone in the donor site or the osseous defect such as dehiscence or

fenestration.

3. Gingival recession area extremely protrusive.

4. Deep periodontal pocket & remarkable loss of interdental alveolar bone in the

adjacent area.

5. Narrow oral vestibule.

6. Multiple teeth involved30.

The disadvantages of this method are possible bone loss and gingival recession on the donor

site. Guinard and Caffesse reported an average of 1 mm of postoperative gingival recession

on the adjacent donor site. This method is therefore contraindicated where the width, height,

and thickness of the adjacent keratinized gingiva of the donor tissue is inadequate or where

an osseous dehiscence or fenestration exists.

Technique:

 The first step in this technique is to determine the bone level at the facial of the donor

site by sounding to bone after local anaesthesia. The distance from the bone to the

CEJ should not exceed 1 to 2 mm on the facial unless root exposure of the donor tooth

is acceptable. This one disadvantage of the laterally positioned flap can be overcome

by leaving a collar of tissue.

 The recipient tooth also should be evaluated to confirm the location of the proximal

and facial bone.

 The recipient root should be smoothened to eliminate all hard and soft tissue deposits

and any present root defects. If chemical root treatment is to be performed, it should

be done at this point.

 The next step is to visualize the incisions and even sketch a design of the procedure

before any incisions are made.

 The parallel incisions will be made at an oblique angle toward the recipient tooth to

position the base of the rotation as close to the recipient tooth as possible.

 The first incision is made beginning at the papilla on the leading edge of the pedicle

graft between the donor and recipient teeth at the height of CEJ, continuing parallel to

the sulcus of the recipient tooth, and terminating at the opposite side of the recipient

tooth at a point apical to the opposite papilla.

 The incision will end well beyond the mucogingival junction.

 The second incision begins at the papilla between the recipient tooth and the tooth on

the non donor side and extends only 1 to 2 mm horizontally at the proposed height of

the graft.

 The incision then changes direction and extends apically to join the previous first

incision well beyond the mucogingival junction.

 A thin split-thickness dissection to remove the sulcular epithelium of the recipient

tooth and the overlying epithelial layer between the first two incisions exposes the

recipient bed for the donor flap.

 The third incision is made from the line angle of the tooth adjacent to the donor site

and parallel to the first incision.

 A fourth incision extends perpendicular to and connects the first and third incisions,

ideally leaving 0.5 mm of attached gingiva (sulcus depth + 0.5 mm of keratinized

gingiva) over the donor tooth, which usually means 1.5 to 2 mm of keratinized

gingiva remains.

 If there is not enough gingiva to meet these criteria, the entire gingival collar can be

moved with the pedicle.

 The fourth incision can be made in the gingival sulcus, but the donor tooth may end

up with recession of 1 to 2 mm depending on the underlying bone levels.

 Flap reflection is split-thickness over the papillae and over the facial of the donor

tooth if the thickness is adequate (1 mm minimum).

 Usually a full thickness flap is necessary over the facial surface of the donor tooth to

insure adequate thickness of the donor tissue. Presence of thin donor tissue is a

contraindication to this technique because it will not hold up to traumatic brushing,

which often is the original cause of recession.

 Careful attention to the thickness of the donor tissue and the cause of recession will

aid in choosing the proper technique.

 The tissue is now rotated for a trial fit to the donor site.

 The closer the base of the pedicle is to the recipient tooth, the smaller the arc of

rotation is and the less shortening of the flap will be observed.

 If the base of the flap is over the donor tooth instead of the recipient tooth, the rotation

of the flap will cause shortening of the leading edge of the flap, and this will cause

inadequate tissue on the leading edge of the flap in the papillary region. If this occurs

and a full thickness rather than a partial thickness flap was used, a periosteal releasing

incision can be made to allow more mobility of the flap.

 Once the flap will lie passively in the desired position, sutures are given21.
Make a V-shaped incision in the peripheral gingiva in the gingival recession area
while preserving sufficient interdental papilla on the distal aspect of 10.

A wide external bevel incision on the

mesial aspect and an internal bevel
incision on the distal aspect create close
adaptation of the flap.
Remove the V-shaped gingiva and make a Make an internal bevel incision toward the alveolar
bevel for flap adaptation. bone crest from the free gingival margin of the donor
site. A vertical incision from one and one- half teeth
from the recipient site.

Prepare a full-thickness pedicle flap. If the flap is strained after displacement to the
recipient site, make a releasing incision of the
periosteum or cut back the incision at the base of the
flap.
 Cover the exposed root surface completely
with the pedicle flap and suture the flap
coronal to the CEJ.

To minimize postoperative gingival recession at the donor site, place

a free autogenous gingival graft. (Source: Carlos E. Nemcovsky et al.
Rotated split palatal flap for soft tissue primary coverage over
extraction sites with immediate implant placement. Description of
surgical procedure & clinical results. J Periodontol 1999; 70: 926-934
MODIFICATIONS

But this method is contraindicated where the width, height, and thickness of the adjacent

keratinized gingiva of the donor tissue is inadequate or where an osseous dehiscence or

fenestration exists.

Many modified methods of Grupe and Warren have been developed to avoid gingival

recession on the donor site.

Staffileno advocated the use of a partial-thickness flap to avoid recession on the donor site.

Grupe reported a modified technique to preserve the marginal gingiva by making a

submarginal incision on the donor site. However, laterally positioned full-thickness flaps

have the best prognosis for exposed root surface coverage.

Pfeifer and Heller reported that reattachment on the exposed root surface is more likely to

occur with full-thickness laterally positioned flaps than with partial-thickness flaps.

Therefore, full-thickness flaps are appropriate for root coverage, and partial-thickness

laterally positioned flaps are suitable for increasing the width of the attached gingiva.

Ruben et al demonstrated the method of the partial and full-thickness pedicle flap; a full-

thickness flap is prepared to cover the exposed root and a partial-thickness flap is prepared

near the donor site to protect the exposed root site and to prevent bone loss by preserving

periosteum.

Knowles and Ramfjord used a free autogenous gingival graft to cover the donor site.

Espinel and Caffesse compared these two procedures and found minimal gingival recession

on the donor site with the free autogenous gingival graft. They found that if the free gingival

autogenous graft was used, there was no reduction of the width of keratinized gingiva on the

donor site. If, however, the free gingival autogenous graft was not used, more than 1 mm of

keratinized tissue on the donor site was lost. Therefore, laterally positioned flaps with free

autogenous gingival grafts on the donor site are the clinical methods most favored currently.
Studies on clinical root coverage by the laterally positioned flap report about a 70% success

rate30.

Other modifications of the procedure presented are the double papilla flap (Cohen & Ross

1968), the oblique rotational flap (Pennel et al. 1965), the rotation flap (Patur 1977) and the

transpositionl flap (Bahat et al. 1990)3.

TRANSPOSITIONAL FLAPS

Bahat et al modified the oblique rotated flap introduced by Pennel et al. It is called the

transpositional flap.

Advantages:

1. Predictability in areas of narrow root exposure.

2. Possible to avoid gingival recession at the donor site.

Disadvantages:

1. Sufficient length and width of the interdental papilla adjacent to the gingival recession area

necessary.

2. Not suitable for multiple tooth root coverage30.

Make two vertical incisions including sufficient

interdental papilla.
Prepare the pedicle flap using a partial

thickness incision. Resect the epithelium of

Suture the pedicle flap on the mesial interdental

papilla area of the recipient site.

Using partial thickness, extend the pedicle

flap preparation apically beyond the MGJ
so that it may be displaced to the exposed
root surface.
 Complete the suture. Make a

periosteal suture on the mesial

DOUBLE PAPILLA FLAPS

Cohen and Ross introduced the method in which bilateral interdental papilla is used as donor

tissue for localized root coverage. In this technique, there is less chance of flap necrosis and

suture is easy because interdental papilla is thicker and wider than labial gingiva on the root

surface. Therefore, double papilla flaps are useful in cases where there is no gingiva on sites

adjacent to areas of gingival recession or where there are periodontal pockets on the labial

surfaces of the adjacent tooth. Laterally positioned flap surgery is not indicated in these

cases30.

Technique:

 The first incision removes the sulcular epithelium adjacent to the exposed root and

extends to the mucogingival junction, which is at the apex of the incision.

 The second incision is repeated on the opposite side of the exposed root.

 The third incision begins at the level of the desired soft tissue height, usually at the

CEJ, and extends horizontally on each side of the tooth stopping no less than 0.5 mm

from the gingival margin of the adjacent tooth to avoid creating gingival recession on

adjacent teeth.
  The fourth and fifth incisions are vertical incisions that extend from the termination of

the horizontal incisions and extend into the alveolar mucosa. Partial thickness pedicle

flaps are reflected to mobilize the papillary pedicles.

 The pedicle flaps are positioned to ensure they will touch and remain passively in

position and then the two pedicles are sutured together with 5–0 or 6–0 chromic gut

suture21.

Indication:

1. Sufficient width and length of the interdental papilla on both sides of the area of

gingival recession.

Advantages:

1. The amount of donor tissue is small because interdental papilla adjacent to the

gingival recession area is displaced. Therefore, the procedure can be achieved with

less tension to the pedicle flap.

2. While interdental bone is exposed if a full-thickness pedicle flap including

interdental papilla is used, there is little damage to the alveolar bone because

interdental alveolar bone is thick.

Disadvantages:

1. Technically demanding.

2. Limited application. The technique is generally used for multiple interdental

papillae grafting, not for root coverage. The objective is to increase the width of

the attached gingiva30.

3. It is primarily used for single tooth root coverage and multiple adjacent teeth are

difficult to effectively treat with this technique.

4. The healing of the keratinized gingiva can be irregular and a gingivoplasty of the

irregular tissue may be necessary21.

Make a V-shaped incision with a

bevel on the mesial interdental
papilla surface.

Remove the V-shaped tissue. The

flap design includes a horizontal
incision to the mesiodistal
interdental papilla on the coronal
side and two vertical incisions.
 Prepare a full-thickness pedicle
flap including sufficient interdental
papilla on the mesial and distal
sides.

Make a partial-thickness flap on the

apical part of the flap for easy flap
migration.
 Flaps reflected

Suture each flap and make a

double papilla flap
 Cover the exposed root with the double
papilla flap. Stabilize the flap coronal to
the CEJ with a sling suture.
(Source:Cohen E.S.: Atlas of cosmetic &
Reconstructive periodontal surgery. 2nd
Edition 1994.)

ADVANCED FLAPS

According to Harvey 1965; Sumner 1969; Brustein 1979; Allen & Miller 1989; Wennström

& Zucchelli 1996; De Sanctis & Zucchelli 2007, the lining mucosa is elastic, a mucosal flap

raised beyond the mucogingival junction can be stretched in coronal direction to cover

exposed root surfaces3. Advanced flaps move vertically in a coronal direction and do not

deviate laterally. These flaps are used to cover exposed root surfaces, and when teeth are not

present, this type of flap is used for reconstructive surgery, such as ridge augmentation21.

The coronally repositioned periodontal flap has been reported by many different people in the

literature. Kalmi (1949) first described a type of coronal repositioned flap that was performed

after a gingivoplasty of the attached gingiva. Nordenram (1969) and Harvey (1965, 1970)

also employed surgical techniques to cover denuded roots by coronally repositioning

mucoperiosteal flaps. In addition, Sumner (1969) and Ward (1973) have modifications of

the coronal repositioned flap to repair gingival recession using straight horizontal incisions in

the alveolar mucosa. Bernimoulin et al. (1975), reported on the clinical evaluation of a two-

step coronally repositioned periodontal flap. They describe doing vertical incisions, and

coronally repositioning the tissue 2 months after placing the free gingival graft33.
CORONALLY POSITIONED FLAP

The ideal case for a coronally positioned flap has adequate thickness and width of the gingiva

on the leading edge of the flap to be advanced. This can be native tissue or it can be the result

of a previous procedure used to increase the thickness of tissue to at least 1 mm. The

keratinized gingiva has to be wide enough to secure a suture and maintain a stable and secure

gingival flap during the healing process. Frenum attachments can limit the amount of coronal

positioning and often must be eliminated before a coronally positioned flap can be attempted.

There should be adequate quality and height of tissue adjacent to the recipient site to anchor

the suture to the desired height21.

Technique:

 The coronally advanced flap procedure is initiated with the placement of two apically

divergent vertical releasing incisions, extending from a point coronal to the CEJ at the

mesial and distal line axis of the tooth and apically into the lining mucosa.

 A split-thickness flap is prepared by sharp dissection mesial and distal to the recession

and connected with an intracrevicular incision. Apical to the receded soft tissue

margin on the facial aspect of the tooth, a full-thickness flap is elevated to maintain

maximal thickness of the tissue flap to be used for root coverage.

 Approximately 3 mm apical to the bone dehiscence, a horizontal incision is made

through the periosteum, followed by blunt dissection into the vestibular lining mucosa

to release muscle tension. The blunt dissection is extended buccally and laterally to

such an extent that the mucosal graft is tension-free when positioned coronally at the

level of the CEJ. The facial portion of the interdental papillae may be de-

epithelialized to allow the final placement of the flap margin coronal to the CEJ.
 The tissue flap is coronally advanced, adjusted for optimal fit to the prepared recipient

bed, and secured at the level of the CEJ by suturing the flap to the connective tissue

bed in the papillary regions. Additional lateral sutures are placed to carefully close the

wound of the releasing incisions3.

The two horizontal incisions are placed the same distance apart as the amount of
root to be covered. The vertical incisions can be either parallel or trapezoidal.

The flap is sutured after being adequately advanced and remaining passively in
place. (Source: G. Zucchelli et al. Laterally Moved, Coronally Advanced Flap: A
Modified Surgical Approach for Isolated Recession-Type Defects. J. Periodontal
2004; 75; (12): 1734-1741
Coronally positioned flap without vertical incisions

The coronally positioned flap without vertical incisions can be performed when multiple teeth

are involved with decreasing amounts of recession from the central tooth, which allows for

progressive advancement of the flap. Generally, this technique cannot advance flaps as far as

flap advancement with vertical incisions can. This technique requires Class I recession

defects with at least 2 mm of attached gingiva with a thickness of 0.8 mm or greater over

each tooth in the proposed graft. Root preparation is performed as discussed previously to

remove any bacterial or mineralized deposits along with any root defects. The initial

horizontal incision is made at the CEJ and extends from the mesial to the distal papilla at

each end of the graft. The second incision begins at the termination of the first incision, and

this horizontal incision is made apical to the first incision and the radicular level of recession

over each tooth. The gingival epithelium is removed over each papilla between the two

horizontal incisions leaving a connective tissue bed for the coronally positioned flap. The

apical flap is dissected with a split-thickness dissection and is coronally positioned until it

passively rests on the prepared bed. One or two sutures are placed at each interdental site to

secure the flap into place21.

The coronally advanced flap can be used for root coverage of a single tooth as well as

multiple teeth, provided suitable donor tissue is available. In situations with only shallow

recession defects and minimal probing pocket depth labially, the semilunar coronally

repositioned flap may offer an alternative approach (Harlan 1907; Tarnow 1986). For the

treatment of an isolated deep gingival recession affecting a lower incisor, or the mesial root

of the first maxillary molar, Zucchelli et al. (2004) suggested the use of a laterally moved and

coronally advanced flap3.

SEMILUNAR CORONALLY POSITIONED FLAP33

A semilunar coronally positioned flap has been first described by Tarnow in 1985. The

technique involves a semilunar incision made parallel to the free gingival margin of the facial

tissue, and coronally positioning this tissue over the denuded root. This technique has the

advantage over other coronally positioned flaps, in that no sutures are required, there is no

tension on the flap, there is no shortening of the vestibule, and the existing papillae are not

interfered with.

Technique:

 Initial preparation including plaque control instruction, scaling and root planing 2

weeks prior to surgery is done if gingival inflammation is present. There should be

minimal pocket depth labially at the time of surgery.

 Exposed root surfaces to be covered are planed.

 Make semilunar incision following the curvature of the free gingival margin. The

incision may have to extend into the alveolar mucosa if there is not enough

keratinized tissue to cover the recession. The incision should curve apically far

enough mid-facially to ensure that the apical part of the (lap rests on bone after it is

brought down to cover the exposed root. The incision should end into the papilla on

each end of the tooth, but not all the way to the tip of the papilla. At least 2 mm must

be left on either side of the flap, since this is the main area from which the blood

supply will come.

 Using a number 15c blade, a split thickness dissection is made from the initial

incision line coronally. This is connected with an intrasulcular incision, made mid-

facially.

 The mid-facial tissue is then coronally positioned to the CEJ, or to the height of the

adjacent papilla in cases of interproximal recession.

 The tissue is held in place with moist gauze against the tooth for 5 min.

 A free gingival graft may have to be placed if a fenestration is present in the donor

site.

 The area is packed.

 The patient is placed on a soft diet for a period of 10 days, at which time the packing

is changed for another 5 to 7 days.

 The patient is told to use minimal pressure when brushing, and to use a soft nylon

bristle brush during the next 2 to 3 weeks following pack removal.

 Recession present on labial of
maxillary cuspid.

Semilunar incision made.

Split thickness dissection with 15C

scalpel blade

Tissue in final coronal position. (Source:

G. Zucchelli et al. Laterally Moved,
Coronally Advanced Flap: A Modified
Surgical Approach for Isolated
Recession-Type Defects. J. Periodontal
2004; 75; (12): 1734-1741)
 ENHANCEMENT OF PERIODONTAL FLAP SURGERY BY PLASTIC SURGERY

PRINCIPLE

HURZELER & WENG 199934

To produce predictable functional and esthetic outcomes, the application of plastic surgery

principles to periodontal surgery can be helpful because these disciplines share common

characteristics such as emphasis on esthetics, flap advancement, and rotation; grafting

techniques; and the wish to prevent scarring. It is the purpose of this article to present a

multilayer approach to flap handling in periodontal surgery to enhance functional and esthetic

outcomes.

OBJECTIVE

The main objective of the following flap design is to allow the passive advancement of both

the lingual and the buccal flap.

Indication:

Whenever, passive closure of flaps is crucial for a successful outcome, eg: when covering

barrier membranes after guided bone regeneration or when gaining tissue height for the

creation at papillae.

Special instruments required:

1. Microsurgical instruments

2. Suture material (plastic surgery sutures no. 7-0 or 8-0)

3. Surgical loupes.

ADVANTAGES:

 The technique ensures proper adaptation of the same kind of tissues, which

subsequently has to bridge smaller gaps to achieve true regeneration.

 Method of multiple suturing distributes the tensile forces over several sutures & it

allows the most passive adaptation possible in the outermost tissue layer.
Technique:

 After delivery of a local anaesthetic agent, C-shaped vertical releasing incisions are

placed on the buccal aspect at individual discretion, depending on accessibility of the

area for a specific procedure and on the necessity for flap advancement.

 The C-shaped incision allows advancement of the flap coronally by reducing tension

on the nourishing blood vessels at the base of the flap (Stark 1955).

 A slightly lingually placed paracrestal incision is then made to the bone at a 90-degree

angle toward the outer surface.

 Starting from this paracrestal incision, a full-thickness flap is elevated 2 to 3 mm

beyond the mucogingival junction.

 From this point, the flap is continued as a partial-thickness preparation into the

vestibule. In contrast to the traditional full-partial thickness flap design, it is necessary

to leave as much connective tissue as possible on the periosteum during this

preparation.

 Thereafter, the remaining layer of connective tissue and periosteum is elevated 2 to 3

mm from the bone surface and then split a second time into the vestibule. It is thus

possible to obtain an inner flap that is 1.5 to 2.0 mm thick.

 By positioning the inner flap coronally, the outer flap will move coronally as well,

and a tension free adaptation will be possible.

 On the palatal aspect ct the maxilla, a coronally positioned palatal sliding flap (Tinti

and Parma- Benfenati 1995) is recommended.

 Briefly, vertical releasing incisions are made on the mesial and distal ends of the

previously described paracrestal incision.

 An "accordion" flap is then prepared, i.e. 2 undermining sharp preparations are started

in different planes.
 The first preparation is started within the paracrestal incision line and runs corono-

apically approximately 1.5 mm below the surface.

 The second preparation starts inside a second horizontal incision line that connects the

apical extensions of the vertical incisions. This preparation runs apico-coronally and

is also parallel to the outer flap contour, but it is located at a deeper level than the first

one.

 Care has to be taken that the higher dissection line does not meet the second

horizontal incision, and that the deeper dissection line does not meet the original

paracrestal incision.

 The palatal flap can then be unfolded like an accordion, and advancement toward the

buccal side is facilitated.

 This flap design allows an inner flap and an outer flap, which is crucial for using

plastic surgery principles such as suturing different layers of tissues during wound

closure.

 The coronally positioned sliding flap design cannot be used on the lingual aspect of

the mandible. In this area, a combined full-partial thickness flap must be raised: after

elevating a full-thickness flap approximately 2 to 3 mm beyond the mucogingival

junction, a partial-thickness dissection is carried out so that the flap can be easily

positioned as far coronally as needed.

 After preparation of these flaps, any necessary augmentation procedure (barrier

membrane, bone graft, connective tissue graft, or any combination of these) is

performed.

 Repositioning and suturing of the flaps is accomplished in a multilayer approach, it is

thus possible to suture net only in different planes but also in different layers, which is

one of the concepts of plastic surgery.

 The material of choice has a suture size of # 7-0 or 8-0, and should be resorbable for

the inner layer and non-resorbable for the outer layer.

 Whenever possible, non-resorbable sutures should be used, since a resorbable suture

will always increase the inflammatory response during the healing process.

 First, the inner lingual and buccal flaps are readapted and sutured with a crossed

horizontal mattress suture. Because of the vertical and horizontal augmentation of the

site, complete closure of this tissue layer will not be achievable in all cases.

 After suturing the 2 inner flaps, the 2 outer flaps can be readapted without any tension

because the inner flaps are connected at their base with the outer flaps. This will allow

suturing with # 7-0 and 8-0 sutures without the potential danger of tearing the flaps.

 A horizontal mattress suture is performed at the level of the mucogingival junction to

adapt the 2 outer flaps. Since both the buccal and lingual flaps consist of connective

tissue and epithelium only, the approximation is additionally simplified.

 Within the outer flaps, but more coronally 1 or 2 additional horizontal mattress

sutures are placed, each suture bringing the buccal and lingual tissue margins closer

together.

 Finally, interrupted or continuous sutures are performed at the top of the incision.

This final suture layer will be done without any tension.

Full-thickness preparation is carried out 2 to 3

mm beyond the mucogingival junction (blue dot)
and then continued as a partial-thickness
dissection into the vestibule, it is important to
leave a sufficient amount of connective tissue and
the periosteum.
Second sharp preparation is started in an apical

direction within the remaining layer of periosteum

Resulting double-partial thickness flap with an

outer and an inner flap. The periosteum in the
apical part is still attached to the bone. (Blue dot =
mucogingival junction.)

Coronally positioned palatal sliding flap

('accordion " flap) is prepared on the palatal
aspect of the maxilla creating 2 tissue layers.
(Blue dot = mucogingival junction.)

There is no tension in the outer top upon

suturing in multiple layers over the augmented
area; the flaps adapt passively. (Source: Hom-
Lay Wang & Henry Greenwell: Surgical
Periodontal Therapy: Periodontol 2000;
2001; .25: 89-99.
Ramford and Nissle (1974)35 compared the modified Widman procedure, with the curettage

technique and the pocket elimination methods that include bone contouring when needed.

The patients were assigned randomly to one of the techniques and results were analysed

yearly upto 7 years after therapy. The pocket depth was initially similar for all the procedures

but was well maintained at shallower levels in the sites treated with modified Widman Flap;

the attachment level remained higher with the modified Widman procedure compared to

other procedures performed.

J.S. Zamet (1974)36conducted a comparative 4-month trial using curettage, replaced flap and

apically repositioned flap procedures with osseous recontouring respectively in a split-mouth

technique in a total of 40 patients. Following clinical parameters were assessed with plaque

and gingival indices, and measurements of pocket depths, attachment levels and tissue

contours. He found that changes in attachment levels post-operatively showed only a small

degree of variation among the three surgical procedures, and would not affect the choice of

the apically repositioned flap as the most effective method for pocket reduction as well as

marked improvement in tissue contour was obtained in areas treated by apically repositioned

flap procedures with osseous recontouring. He concluded that apically repositioned flaps

were the most successful.

Ramfjord (1977)37 in his study concluded that initially the short term results regarding the

maintenance of attachment was better following curettage than modified Widman Technique

but the long term results are similar following curettage and Widman flap procedures in most
areas of the mouth, but in the maxillary molar areas, the results of the modified Widman

procedure seem to be better than curettage procedure.

Lindhe J (1985)38 performed a study, whether subgingival scaling & root planing is a

method of therapy which is equally effective as "access" flaps in reducing gingivitis, probing

depths and in improving probing attachment levels. By random selection of 4 jaw quadrants

in each patient, they were treated for periodontal disease by the use of the modified Widman

flap procedure, the modified Kirkland flap procedure or by nonsurgical scaling and root

planing. It was observed, that following surgical treatment, a significant reduction of pocket

depth was seen than following non-surgical therapy.

Anne D. Haffajee et al. (1988)39 studied the effect of modified Widman flap surgery and

systemic tetracycline on the subgingival microbiota of periodontal lesions. For this, 33

subjects with evidence of active destructive periodontal disease were treated by modified

Widman flap surgery and systemic tetracycline (1 g/day for 21 days). Subgingival plaque

samples were taken from 41 sites in 12 of these subjects before and 6 months after therapy

for predominant cultivable microbiota studies. The results included B.

melaninogenicus and V. parvula were more frequently detected in samples taken after

therapy, while S. intermedius, S. morbillorum, S. uberis and W. recta were less

frequently detected after therapy. A. actinomycetemcomitans was detected in 7 sites

pretherapy and 1 site post therapy. The frequency ofdetection of B. gingivalis and B.

intermedius was virtually unchanged.

Gantes B (1988)40 had done a study where the coronally positioned flaps have been used in

the treatment of mandibular class II furcation defects in 14 of the 30 defects including citric

acid root conditioning. In this technique the flap margin is positioned coronally to the

furcation and remains in that position during the early stages of healing. In addition to

coronally advanced flaps, grafts of freeze-dried, decalcified allogenic bone were placed in

other 16 of the 30 defects. It was concluded that no statistically significant difference was

observed between defects treated with and without bone grafts.

Becker W (1988)41 compared longitudinally, the effectiveness of scaling and root planing,

osseous surgery, and the modified Widman procedure. Sixteen adult patients with moderate

to advanced adult periodontitis were treated with initial scaling and oral hygiene procedures.

Post-hygiene data were used for comparison of changes in probing depth, clinical attachment

levels and gingival recession. The authors concluded that with three-month maintenance

recalls, both the modified Widman and osseous surgery are effective for pocket reduction,

and each will produce a slight gain of clinical attachment over one year. Scaling was effective

at maintaining attachment levels but was not as effective in reducing pocket depth.

Haffajee AD (1999)42 examined the short-term effect of apically repositioned flap surgery on

clinical and microbiologic parameters in patients with adult periodontitis. There was a

significant reduction in mean pocket depth and gingival redness. Significant reduction was

seen in sites that had probing pocket depth of 4-6 mm, with a little reduction in sites with a

probing pocket of 4 mm, after surgical therapy. There was a significant increase in mean
attachment levels at sites where pockets depth < 4 mm receiving surgery, although sites with

≤ 4-6 mm initial pockets showed no significant change in mean attachment postsurgery.

Microbiologically, P gingivalis and B forsythus, previously shown to be susceptible to

mechanical therapy, but in this study, surgical therapy also decreased the levels of the

suspected periodontal pathogens like C rectus, P nigrescens, and C gracilis. Therefore, it was

speculated that there was a potential added beneficial effect of surgery on the periodontal

microbiota.

Cortellini P (1999)43 presented a novel surgical procedure specifically designed to access

interdental spaces in the regenerative treatment of deep intrabony defects. This procedure

(simplified papilla preservation flap, SPPF) was designed to provide surgical access to

interproximal bony defects while preserving interdental soft tissues, even in narrow

interdental spaces and posterior teeth. It was concluded that the application of SPPF in

combination with bioresorbable barrier membranes allowed primary closure of the interdental

space in most of the treated sites and resulted in consistent CAL gains at 1 year.

Miller PD Jr (1999)44 described a modification in the apically repositioned flap technique.

Unlike the original technique, this technique preserved the marginal gingiva thus avoiding the

risk of recession. The results of this study demonstrated that this modification of the apically

repositioned flap is effective and efficient for increasing the height of attached gingiva,

decreasing the probing pocket depth & minimal tissue recession. Thus, the advantage of this

surgical procedure are-: minimal surgical trauma, do not require palatal donor tissue or
membrane placement, simple technique since it is less time-consuming, requires no suturing,

and results in an ideal color match of tissue.

Dr. João Carnio et al. (1999)45 did a study to describe a modification in the apically

repositioned flap technique. Unlike the original technique, this technique preserved the

marginal gingiva thus avoiding the risk of recession. It is recommended in cases where an

increase in attached gingiva is desired. They concluded that this modification of the apically

repositioned flap is effective and efficient for increasing the height of attached gingiva. This

surgical procedure produces minor surgical trauma and does not require palatal donor tissue

or membrane placement. It is simpler since it is less time-consuming, requires no suturing,

and results in an ideal color match of tissue.

Carlos E. Nemcovsky et al. (1999) 46did a case series using rotated deep split thickness

palatal flap in 29 patients in which 33 consecutive implants were placed immediately post-

extraction of 1 or 2 anterior or maxillary premolar teeth. Patients were divided into Groups

A & Group B, treated without & with resorbable collagen membrane respectively. It resulted

in crestal bone formation relative to initial bone crest-implant distance at time of implant

placement was approximately 85% in both the groups. Thus, it can be concluded that this

procedure offers a predictable treatment approach in achieving complete soft tissue coverage

while allowing for healing of bony defects in immediate implantation procedures.

Cortellini P (2001)47 did a study to compare the efficacy of the simplified papilla

preservation flap with and without a barrier membrane in deep intrabony defects. In this

study, 112 patients with deep intrabony defects were assessed using SPPF. In the test defects,
a bioabsorbable membrane was positioned, whereas, in control group, no membrane was

used. The study resulted the significant gain in clinical attachment level as well as decrease in

probing depth in the test group. Thus the study supported the added benefits of guided tissue

regeneration with respect to access flap alone in the treatment of deep intrabony defects, as

well as the general efficacy of GTR in different clinical settings.

Becker W (2001)48 reported 5-year result from a longitudinal study comparing scaling and

root planing (SRP), osseous surgery (OS), and modified Widman (MW) therapies. This

clinical trial demonstrates that with good patient maintenance excellent clinical results can be

achieved with various methods of treatment. Within the limits of this study, SRP, OS, and

MW were effective in reducing probing depths with slight changes in clinical attachment

levels.

Dr. Stuart J. Froum (2001)49 compared sites treated with open flap debridement (OFD)

alone to those treated with OFD and EMD at 12 months postsurgery. Soft tissue

measurements were recorded prior to initial surgery and prior to re-entry for gingival (GI)

and plaque (PI) indices, probing depth (PD), gingival margin position, and clinical

attachment level (CAL).It was concluded that OFD treatment of periodontal intraosseous

defects treated with EMD is clinically superior to the site without EMD in every parameter

that was evaluated.

Rustin M. Levy (2002)50 examined the clinical and microbiologic effects of apically

repositioned flap surgery & followed-up for 1 year. Subjects were monitored clinically and
microbiologically at baseline, 3 months after IP, and at 3, 6, 9, and 12 months postsurgery. It

was concluded that significant reduction was seen in mean pocket depth, gingival redness and

bleeding on probing in both groups that received initial preparation (IP) only and in sites

receiving IP followed by surgery. There was statistically significant increase in mean

attachment level for both groups, but greater increase was observed at the surgically treated

sites. Microbiologically, total DNA probe counts were significantly reduced at sites in both

treatment groups. At surgically treated sites, 19 of 40 taxa were significantly reduced

posttherapy. At sites receiving IP only, 16 species were significantly reduced over time.

Therefore, it was concluded that the reduction in pocket depth by surgical means and the

associated decrease in reservoirs of periodontal pathogens may be important in achieving

sustained periodontal stability.

Dr. G. Zucchelli et al. (2004) 51 conducted a study to evaluate the effectiveness of a modified

surgical approach i.e. laterally moved flap procedure for the treatment of an isolated type of

recession (Miller Class I or II). For this, one hundred and twenty (120) isolated gingival

recessions were treated with a new approach to the laterally moved flap. The main surgical

modifications consisted of the coronal advancement of the laterally moved flap and the

different thickness during flap elevation. Clinical evaluation was made 1 year after the

surgery. The results concluded that the laterally moved, coronally advanced surgical

technique was very effective in treating isolated gingival recessions. It combined the esthetic

and root coverage advantages of the coronally advanced flap with the increase in gingival

thickness and keratinized tissue associated with the laterally moved flap. The ideal gingival

conditions must be present lateral to an isolated recession defect in order to render the
proposed surgical technique an highly effective and predictable root coverage surgical

procedure.

Antonio Wilson (2005)52 investigated the influence of cementum removal on periodontal

repair. Full-thickness flaps were reflected and the instrumentation was performed under a

clinical microscope. Probing depth (PD), relative gingival margin level (RGML) and relative

attachment level(RAL) were registered at five experimental periods: baseline and 30, 60, 90

and 120 days postoperative. The results showed that all the approaches were able to markedly

reduce the PD values from the baseline to the other evaluation periods (p<0.0001), also there

was significant increase in gingival margin level (RGML) and relative attachment level

(RAL). Therefore, it was concluded that the conventional scaling and root planing and the

calculus deattachment were effective in reducing the probing depth values, regardless of the

instrumentation method.

Güllü Cigdem et al. (2005)53 aimed to examine the correlation between the arginase and

NOS activity in patients with chronic periodontitis and to compare the effects of scaling and

root planing and modified Widman flap procedures on enzyme activity. Results showed that

although inflamed periodontal tissues demonstrated a strong inducible NOS (iNOS)

expression at baseline, immunostaining decreased after periodontal treatment. iNOS

expression intensity and the number of inflammatory cells showing iNOS expression were

found to be higher in the scaling and root planing group compared to the modified Widman

flap group. After periodontal therapy, the enzyme level was found to be lower in the group

treated with modified Widman flap as compared to the group treated with scaling and root
planing group. Thus it was concluded that arginase is in negative correlation with NOS in

periodontitis cases.

Del Pizzo (2005)54 assessed the ability of enamel matrix derivative (EMD) to improve root

coverage when used with a coronally advanced flap (CAF) during a 2-year follow-up. Fifteen

patients each with two single and similar bilateral Miller Class I or II gingival recessions (30

recessions) were selected. Each recession was randomly assigned to the test group

(CAF+EMD) or the control group (CAF only).It was concluded that root coverage outcomes

were similar in both groups and no statistically significant differences were found at all

between both the groups. Hence, the additional use of EMD with CAF is not justified for

clinical benefits of root coverage, but as an attempt of achieving periodontal regeneration

rather than repair.

Leknes KN (2005)55 compared 12-month and 6-year follow-up results for coronally

positioned flap procedures with or without biodegradable membranes. It was concluded that

the coronally positioned flap procedure offered a simple and reliable treatment alternative as

a root coverage procedure in Class I and Class II recession type defects. Placement of a

biodegradable membrane underneath the flap does not improve the short-term or the long-

term results. Long-term outcome stability seems to be critically dependent on a continuous

follow-up program with re-instruction in non-traumatic brushing habits.

Jack Caton et al. (2005)56 presented an investigation to determine the effect of the modified

Widman flap procedure on the level of the connective tissue attachment and supporting
alveolar bone in animal model. For this, eighteen contralateral pairs of periodontal pockets

were produced in a standardized manner & surgical treatment of the pockets was performed

around experimental teeth and the contra-lateral teeth were used as the unoperated controls.

The data summarized that treatment of periodontal pockets using the modified Widman flap

procedure produced no gain in connective tissue attachment and no increase in crestal bone

height. In angular bony defects a certain degree "bone fill" was noted. This bone repair was

never accompanied by new connective tissue attachment.

Marius Steigmann et al. (2006)57 did a study with the aim to present a new flap design, the

esthetic buccal flap (EBF), aimed at overcoming the inability to correct localized

horizontal/vertical defect, deficiency, dehiscence, or fenestration without jeopardizing

esthetic outcomes. Clinical measurements were taken at the time of prosthesis insertion & 6

& 12 months after surgery. These included soft tissue height, papilla appearance, scar

appearance, & mid-buccal probing depth. The results indicated that EBF, together with

simultaneously guided bone augmentation allows the clinician to correct apical buccal

fenestration defects while maintaining the supraosseous soft tissue during flapless immediate

implant surgery.

Antonio Linares et al. (2006)58 conducted a study to treat intrabony defects using

GTR/analyze deproteinized bovine bone or papilla preservation flaps alone. The treatment

consisted of simplified or modified papilla preservation flaps to access the defect, after

debridement of the area, a deproteinized bovine mineral and a collagen membrane were

applied in the test subjects, and omitted in the controls. Main outcome measures were

radiographic bone fill and defect resolution 1 year after surgery. The study concluded that

regenerative periodontal surgery with a deproteinized bovine bone mineral and a collagen
membrane offered additional benefits in terms of radiographic resolution of the intrabony

defect and predictability of outcomes with respect to papilla preservation flaps alone.

Kamran Haghighat (2006)59 described a modified semilunar coronally advanced flap when

used with soft tissue autografts for the treatment of recession defects on multiple adjacent

teeth. Semilunar incisions were made apical to the recession defects, arching more coronally

to terminate apical to the papillae mesial and distal to the teeth exhibiting the defects. The

papilla between the teeth with recession was coronally advanced after a split-thickness

dissection and sutured more coronally, over the de-epithelialized portion of the original

papilla. Results concluded that this technique will be particularly valuable in treating gingival

recession with soft tissue autografts and in a thicker-tissue biotype. This technique provides

better control over flap repositioning than previously described semilunar coronally advanced

flaps.

Giovanni Zucchelli et al. (2006)60 reported a case to describe the regenerative surgical

treatment of periodontal and bone lesions associated with the subgingival extension of a

palatal groove affecting a maxillary lateral incisor. Treatment procedures consisted of: 1) the

papilla amplification flap with the use of enamel matrix proteins as the regenerative

periodontal material; 2) the elimination/flattening of the radicular portion of the palatal

groove; and 3) the sealing of the coronal portion of the groove with composite flow. The

results at 1 year revealed a clinical attachment gain (8 mm) with a shallow residual probing

depth (2 mm) and no increase in gingival recession. The radiographic examination showed

the complete disappearance of the radiolucent area suggesting bone fill. Thus is can be
concluded that localized periodontal defects associated with a palatal groove can be

successfully treated by means of the papilla amplification flap with the use of enamel matrix

protein as the regenerative material.

João Carnio (2006)61 described a surgical technique directed to increase the dimensions of

attached gingiva over multiple adjacent teeth. The described technique is a variation of the

modified apically repositioned flap (MARF) technique. The modification of MARF technique

uses one single horizontal incision within keratinized tissue, elevation of a split-thickness flap,

and suturing of the flap to the periosteum in an apical position. The advantages associated with

this surgical technique include its simplicity: It employs one single horizontal incision, generates

minimal morbidity since it does not involve any palatal donor tissue, and provides predictable

gingival color match as well as gain in dimensions of attached gingiva.

Sandro Bittencourt et al. (2006)62 conducted a study to compare the outcome of gingival

recession therapy using the semilunar coronally positioned flap(SCPF) or the subepithelial

connective tissue graft (SCTG) in Miller grade I recession. The findings from this study

concluded that SCPF and SCTG can be successfully used to treat Class I gingival recession

equally.

Sandro Bittencourt et al. (2007)63 did a clinical trial to evaluate the outcome of gingival

recession therapy using the semilunar coronally repositioned flap (SCRF) with or without

EDTA application for root surface biomodification in bilateral Miller Class I buccal gingival

recessions (≤4.0 mm). The results showed that SCRF group had better clinical outcomes as
compared to SCRF-E group. Thus it was concluded that the use of EDTA gel as a root

surface biomodifier agent negatively affected the outcome of root coverage with the SCRF.

Carnio Joao (2007)64 reported a case series on the effectiveness of the modified apically

repositioned flap (MARF) in increasing the apico-coronal dimension of attached gingiva over

multiple adjacent teeth. Treatment with MARF effectively resulted in a significant increase in

the apico-coronal dimension of the keratinized tissue and attached gingiva. The increase in

keratinized tissue ranged from 2.20 to 4.28 mm, and the increase in attached gingiva ranged

from 1.0 to 3.14 mm was observed. MARF offers considerable advantages over other

mucogingival surgery techniques: simplicity, limited chair time for the patient and the

operator, low morbidity because of the absence of palatal donor tissue, and a predictable

tissue color match.

Retzepi, M (2007)65 compared the gingival blood flow responses following simplified papilla

preservation (test) versus modified Widman flap (control). It was shown that the buccal and

palatal papillae blood perfusion presented the maximum increase on day 7 in both groups and

returned to baseline by day 15. Both surgical modalities yielded significant pocket depth

reduction, recession increase and clinical attachment gain. It was concluded that periodontal

access flaps represented an ischaemia–reperfusion flap model. The simplified papilla

preservation flap may be associated with faster recovery of the gingival blood flow post-

operatively compared with the modified Widman flap.

M. Retzepi et al. (2007)66 did a study to investigate the pattern of gingival blood flow changes

following periodontal access flap surgery by laser Doppler flowmetry (LDF). They concluded

that topographically distinct areas of the periodontal access flap consistently present different

patterns of microvascular blood flow alterations during the wound-healing period.

Y.-F. Cheng et al. (2007)67did a systemic review on coronally positioned flap, coronally

positioned flap + chemical root surface conditioning, or coronally positioned flap + enamel

matrix derivative (EMD) for the treatment of Miller class I and II gingival recession. Mean

clinical attachment level, keratinized tissue, probing pocket depth, gingival recession and root

coverage percentage were assessed before and after treatment They concluded that root

coverage by the coronally positioned flap and coronally positioned flap + chemical root

surface conditioning procedures were unpredictable but became more predictable when the

coronally positioned flap procedure was used along with EMD.

Juliana Antico Lucchesi et al. (2007)68 conducted a study to evaluate clinically the treatment

of gingival recession associated with non-carious cervical lesions (NCCLs) restored by resin

modified glass ionomer cement (RMGI) or microfilled resin composite (MRC) and coronally

positioned flap (CPF) at 6 months following surgery. The study showed root coverage

improvement without causing any damage to periodontal tissues, thereby supporting the use

of CPF for treatment of root surfaces restored with RMGI or MRC as being effective over the

6-month period.
Cortellini P et al. (2007)69 studied a new surgical approach (minimally invasive surgical

technique, MIST) to evaluate preliminarily its clinical performance and patient perception

associated with the application of enamel matrix derivative (EMD) in the treatment of

isolated deep intra-bony defects. The study showed early uneventful wound healing, primary

wound closure & the same had been maintained in all sites with the exception of one site with

a small wound dehiscence at week 1. Patient did not report any pain, swelling etc. So, this

case cohort indicated that MIST associated with EMD resulted in excellent clinical

improvements while limiting patient morbidity.

Pierpaolo Cortellini et al. (2008)70 evaluated the clinical performance and the intra-operative

and post-operative morbidity of the “minimally invasive surgical technique” (MIST)

associated with the application of an enamel matrix derivative (EMD) in the treatment of

multiple deep intra-bony defects in a single surgical procedure. Clinical outcomes were

collected at baseline and at 1 year. The data indicated that a MIST in combination with EMD

can be applied successfully for the treatment of multiple deep intra-bony defects in the same

surgical procedure with excellent clinical outcomes and very limited patient morbidity.

G. Zucchelli et al. (2009)71 conducted a study to compare root coverage and esthetic

outcomes of the coronally advanced flap (CAF) with and without vertical releasing incisions

in the treatment of multiple grade I & II gingival recessions. The study concluded that both

CAF techniques were effective in reducing recession depth, but the envelope type of CAF

was associated with an increased probability of achieving complete root coverage in

comparison to CAF with releasing incisions.

Jesse M. Sorrentino et al. (2009)72 reported a case describing a method for coronal

repositioning of gingiva for root coverage over the maxillary central incisors while

simultaneously performing a frenectomy. The surgical technique used to treat the areas of

recession involved making semilunar incisions over the maxillary central incisors that

blended into a frenectomy. It resulted in complete root coverage over the maxillary central

incisors that initially presented with 2 mm of recession on the facial surface. Thus it can be

concluded that there is a possibility of applying a combined semilunar coronally repositioned

flap with a frenectomy in a case in which maxillary central incisors were impinged upon by a

broad aberrant frenum with Miller Class I mucogingival defects.

Leonardo Trombelli et al. (2009)73 developed a new surgical technique to optimize primary

closure as well as to minimize the surgical trauma in the reconstructive procedures of

periodontal intraosseous defects. They proposed a minimally invasive procedure, the single-

flap approach (SFA), specifically indicated when the defect extension is prevalent on the

buccal or oral side. The basic principle of the SFA is the elevation of a flap to access the

defect only on one side (buccal or oral), leaving the opposite side intact. The results

concluded that surgically accessed with a buccal SFA and treated with a combination of hard

tissue graft & guided tissue regeneration technique, may heal with a substantial CAL gain.

Limited postsurgical recession indicates that SFA may represent a suitable option to

surgically treat defects in areas with high esthetic demands.

Ronaldo B. Santana et al. (2010)74 presented a study to compare the clinical outcomes of

the Semilunar Coronally Repositioned Flap (SCLRF) and coronally advanced flap

(CAF) procedure in the treatment of 22 contralateral maxillary Miller class I recession

(GR) defects. The CAF resulted in clinical improvements significantly better than SLCRF,

frequency of complete RC and gain in clinical attachment level. Thus, it was concluded that

root coverage is significantly better with CAF compared with the original SLCRF technique

in obtaining root coverage & clinical attachment level case of Miller class I GR defects.

Ronaldo B. Santana et al. (2010) 75 did a study with the aim to compare the efficacy of

single-stage Laterally Positioned Flap and Coronally Advanced Flap techniques in the

treatment of localized Miller grade II gingival recession. Both the surgical techniques

resulted in reducing gingival recession. Thus the study concluded that CAF in the treatment

of Miller Class II maxillary GR are clinically similar to the LPF with more limited gains in

width of keratinized tissue.

Robert N. Bitter (2010)76 conducted a study using rotated palatal flap for ridge preservation

to enhance restorative hard & soft tissue esthetics for tooth replacement in anterior maxilla.

It resulted in vastly improved restorative emergence profiles with minimal or no change in

the height of the labial gingival margin, the form & height of the interproximal papillae with

adjacent teeth. Thus, it was concluded that the use of a rotated palatal flap ridge

preservation procedure provide significant functional and esthetic advantages as healing and

repair occur at the extraction site. In instances where this procedure is combined with

conventional fixed partial denture treatment, preservation of the crestal ridge architecture

allows for improved esthetics in the treatment outcome.

Yong Hur et al. (2010)77 conducted a study on a novel incision-flap design used to advance

the flap to enhance tension-free primary closure for the vertical ridge augmentation. A

partial-thickness flap, separating the mucosal flap from the periosteum overlying the alveolar

bone, was used to advance the flap. They concluded that this technique facilitates flap

advancement by the tension-free nature of the design and enhances soft tissue maintenance

during the course of regeneration. Using this approach, the separation of the periosteal layer

and the mucosal layer, can be used as an alternative to overcome some of the limitations with

conventional technique.

Leonardo Trombelli et al. (2010)78 evaluated the adjunctive effect of guided tissue

regeneration (GTR) combined with a hydroxyapatite (HA) biomaterial in the management of

intraosseous periodontal defects accessed with Single flap (SFA) compared to SFA alone.

The results concluded that both SFA with and without HA/GTR seems to be equally valuable

minimally invasive approach in the treatment of deep intraosseous periodontal defects.

Shilpa Kolhatkar et al. (2010)79 reported a case in which a severe recession defect and its

associated carious lesion were managed using the combination of a lateral sliding flap and a

resin modified glass ionomer restoration in a 53 year old with a history of 25 years of HIV

infection. Results concluded that successful root coverage can be obtained on a resin

modified glass ionomer-restored surface in an HIV-positive individual.

Santiago Mareque-Bueno (2011)80 described a surgical procedure for coronally advancing

the peri-implant mucosa to treat a soft tissue dehiscence in a single-tooth implant-supported

restoration in combination with an acellular dermal matrix graft. The results showed a

complete coverage of dehiscence in single-tooth implant-supported restoration when used

with alloderm. Thus it was concluded that there is a possibility of achieving partial soft tissue

coverage over an implant-supported restoration with the combined use of an acellular dermal

matrix and a coronally positioned flap.

CONCLUSIONS

The discipline of periodontal surgery is a specialized domain, which is now approaching its

zenith in development. New techniques are being developed which aim to conserve rather

than discard periodontal tissue. In the initial years this mode of therapy was a type of

standardized procedure for periodontal diseases. However, with the advent of newer

technologies, we now understand the mechanisms associated with periodontal breakdown

much better than what we knew before. This had led us now to ‘decide’ upon the most

appropriate surgical therapy depending upon the type of periodontal disease we are dealing

with.

Breakthroughs have been made in the understanding of the pathogenic processes associated

with the development of periodontal diseases & these have enabled us to practice an evidence

based approach towards their treatment. With the advent of the specific plaque hypothesis we

now understand better that we have to deal with specific microorganisms involved in

periodontal destruction. This has led to the development of an antimicrobial therapy in the

cover of which periodontal surgery is carried out with the aim to mechanically cleanse the

area with minimal invasion of periodontal tissues & to attempt regeneration of the lost

periodontium with the aid of regenerative materials like GTR, developmental proteins, bone

grafts, etc.

Many of the technical problems experienced in periodontal surgery stem from the difficulties

in assessing accurately the degree & type of breakdown that has occurred prior to surgery,

previously undiagnosed defects may be recognized or some defects may have a more

complex outline than initially anticipated. Since each of the surgical procedure described is

designed to deal with a specific situation or to meet a certain objective, it must be understood

that no single standardized technique alone can be applied when periodontal surgery is
undertaken in a patient. Therefore, in each surgical field, different techniques are often used

& combined in such a way that the overall objectives of the surgical part of the periodontal

therapy are met. As a general rule, surgical modalities of therapy, which preserves or induce

the formation of periodontal tissues should be preferred over those which resect or eliminate

tissues.

Postoperative plaque control is the most variable in determining the net outcome of

periodontal surgery. Provided proper postoperative plaque control levels are established, most

surgical treatment techniques will result in conditions which favour the long-term

maintenance of the periodontium. If postoperative hygiene fails, progressive loss of

supporting tissues will take place regardless of surgical technique used.

Finally, surgical procedures should be designed with these facts in mind. The results will be

more predictable & there will be less permanent surgical damage to the periodontium.

The following points should be kept in mind -:

a. In most situations a full thickness flap can be used.

b. In the presence of a thin bone & dehiscence, a partial thickness flap may be indicated.

c. In reflecting a flap, as much gingiva as possible should be retained.

d. The palatal flap should be scalloped so that margin ends up at the crest of the bone.

e. A flap must be reflected in a relaxed manner.

f. Careful use of scalpel is necessary to prevent perforating the base of the flap.

g. Prudence is in order trying to gain additional gingiva through apical position of the

flap.

h. Attention must be paid to suturing of the flaps to ensure correct flap placement.
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