FLAP TECHNIQUES FOR PERIODONTAL

THERAPYDr. Hassan Baleegh Ur Rehman

Definition Of Flap

Tongues of tissue (skin and subcutaneous tissue, sometimes including muscle) cut away from the underlying parts but attached at one end. They retain their own blood supply during transfer to the new site.

Periodontal FlapsA TIMELINE!

1911, Neuman claimed the introduction of a mucoperiosteal flap. An intrasulcular incision and two releasing

incisions on both side of the defect area 1918, Widman introduced his version

of the flap. A trapezoidal flap with two vertical

releasing incisions at the midline of the teeth and the reverse bebel incision made parallel to the surfaces of the teeth 1mm from the free gingival margin and extending to the alveolar crest. Cieszynski, however, was credited with the introduction of reverse bevel incision.

Periodontal Flaps

1931, Until now flap surgery was done at the beginning but for the difference purpose of bone removal and pocket elimination. Apparently the first description of the flap procedure for the purpose of reattachment was given by Kirkland He used the basic gingival mucoperiosteal flap

design by Neumann in 1920 for initial flap, but instead of trimming the flap for surgical pocket elimination, he attempted to eliminate the crevicular epithelial lining and the inflamed connective tissues by curettage of the flap. His method has been used as “open subgingival curettage.”

Periodontal Flaps

1954, Nabers described the “repositioning of the attached gingiva.” For the first time, a mucoperiosteal flap was apically positioned after treatment. Avoided excising the attached gingiva, the

frenum attachment, and the creation of shallowed vestibular trough

1962, Friedman published the technique in his paper and coined the term “apically reposition flap”

Periodontal Flaps

1979, Carranza classified flap as full thickness flap and partial thickness flap. Full thickness flap is surgical procedure of which all soft tissue and the periosteum are reflected. Partial or split thickness flap is an elevated flap which includes only epithelium and the layer of underlying connective tissue.

Periodontal Flaps  1974, Ramfjord and Nissle coined the term

modified Widman flap though the procedure was employed by Morris in 1965 and was termed the unrepositioned mucoperiosteal flap.  The flap utilized three incisions: the internal bevel

incision starting 1 to 1.5 mm away from the gingival margin and follows the gingival margin scalloping, the crevicular incision from the bottom of the pocket to bone, circumscribing the triangular wedge of tissue containing the pocket lining, and finally, after the flap is reflected, the horizontal incision is placed in the interdental spaces, coronal to the bone, with a curette or an interproximal knife, and the gingival collar is removed.

Objectives for using Periodontal Flaps

Increase root access Reduce pocket depth Expose Area for regeneration Crown Lenghtening

Types of Incisions

Horizontal incisions1. Internal Bevel Incision (#11 or #15)2. Crevicular Incision3. Interdental Incision Vertical Incisions1. Mesial2. Distal

References 1. Caffesse, R.G. Resective procedures. Proceedings of the world workshop in clinical periodontics, 1989. 2. Caranza, Newman. Textbook of Clinical Periodontology, WB Saunders, 1996. 3. Morris, M.L. The unrepositioned muco-periosteal flap, Journal of Periodontics: 3: 147, 1965. 4. Stahl, S.S. Repair or regeneration following periodontal therapy? Journal of Clinical Peridontology:

1979: 6: 389-396. 5. Levine, Leslie. Periodontal flap surgery and the gingival fiber retention. Journal of Peridontology, 1972:

43: 91-98. 6. Barrington, E.P. An overview of periodontal surgical procedure, Journal of Periodontology: 52: 518,

1981. 7. Dedolph, T.H., Clark, H.B. A histological study of mucoperiosteal flap healing. Journal of Oral Surgery:

16:367, 1958. 8. Wood, D.L., Hoag, P.M., Donnenfeld, O.W., Rosenfeld, L.D. Alveolar crest reduction following full and

partial thickness flaps, Journal of Periodontology, 43:141, 1972. 9. Caffesse, R.G., Ramfjord, S.P., Nasjleti, C.E. Reverse bevel periodontal flaps in monkeys. Journal of

Periodontology, 39: 219, 1968. 10. Levine, H.L., Stahl, S.S. Repair following peridontal flap surgery with the retention of gingival fibers.

Journal of Periodontology, 41:99, 1972. 11. Ramfjord, S.P. Present status of the modified widman flap procedure. Journal of Peridontology, 48:

558, 1977. 12. Caffesse, R.G., Castelli, W.A., and Nasjleti, C.E. Vascular response to modified Widman flap surgery in

monkeys. Journal of Periodontology, 52: 1, 1981. 13. Becker, W., Becker, B.E., Ochsenbein, C.O., Kerry, G., Caffesse, R.G., Morrison, E.C., Prichard, J. A

longitudinal study comparing scaling, osseous surgery and modified widman procedures. Results after one year. Journal of Periodontology, 59: 351, 1987.

14. Caffesse, R.G., Ramfjord, S.P., Nasjleti, C.E. Reverse bevel periodontal flaps in monkeys. Journal of Periodontology, 39: 219, 1968.

15. Ramfjord, S.P., Nissle, R.R. The modified widman flap. Journal of Periodontology, 45: 601, 1974. 16. Wirthlin, M.R. The current status of new attachment therapy. Journal of Periodontology, 52: 529,

1981.

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