33 GINGIVAL FLAP SURGERY

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Replaced Flap Technique

  • What are the differences and similarities between the modified Widman, open flap curettage, and replaced flaps? What names, if any, do you associate with these procedures?

  • What were the original objectives of these procedures? Are they achievable? Do they differ from the current objectives?

  1. Ramfjord SP, Nissle RR. The modified Widman flap. J Periodontol 1974; 45;601-607

  2. Ramfjord SP: Present status of the mofified Widman Flap procedure. J Periodontol 48:558-565, 1977

  3. Nabers CL. Repositioning the attached gingival. J Periodontol 1954; 25:38-39

  4. Ammons WF, Smith DH: Flap curettage: Rationale, technique, and expectations. Dent Clin NA 20:215-226, 1976

Flap Design

  1. Kaldahl, W., Kalkwarf, K, Patil, K: A review of longitudinal studies that compared periodontal therapies. J Periodontol 64:243-253, 1993

  2. Johnson RH: Basic flap management. Dent. Clin. North Am. 20:3-21, 1976.

  3. Kon S, Caffesse RG, Castelli WA, Nasjleti CE: Vertical releasing incisions for flap design: Clinical and histological study in monkeys. Int. J. Perio. Restorative Dent. 4(1):49, 1984.

  4. Lynch TJ, et al: A comparison of mandibular lingual surgical flaps with and without a vertical releasing incision. J. Periodontol. 59:12-17, 1988.

Replaced Flap Results

  1. Jenkins MM, Wragg PF, Gilmour WH: Formation of interdental soft tissue defects after surgical treatment of periodontitis. J Periodontol 61:564-570, 1990

  2. Cattermole AE, Wade AB: A comparison of the scalloped and linear incisions as used in the reverse bevel technique. J. Clin. Periodontol. 5:41- , 1978.

  3. Newman PS: The effects of the inverse bevel flap procedures on gingival contour and plaque accumulation. J. Clin. Periodontol. 11:361-366, 1984.

  4. Haffajee AD, et al: Effect of modified Widman flap surgery and systemic tetracycline on the subgingival microbiota of periodontal lesions. J. Periodontol. 15:255 -, 1988.

Replaced Flap Healing

  • Describe the wound healing following each of these procedures.

  1. Listgarten MA: Electron microscopic study of the junction between surgically denuded root surfaces and regenerated periodontal tissues. J. Periodontal Res. 7:68-90, 1972.

  2. Caton J, Nyman S: Histometric evaluation of periodontal surgery. I. The modified Widman flap procedures. J. Clin. Periodontol.7:212-223, 1980.

  3. Proye MP, Polson AM: Effect of root surface alterations on periodontal healing. I. Surgical denudation. J. Clin. Periodontol.9:428-440, 1982.

  4. Caffesse RG, Castelli WA, Nasjleti CE: Vascular response to modified Widman flap surgery in monkeys. J. Periodontol. 52:1-7, 1981.

  5. Steiner SS, Crigger M, Egelberg J: Connective tissue regeneration to periodontally diseased teeth II. Histologic observations of cases following replaced flap surgery. J Perio Res. 16:109-1981.

  6. Svoboda PJ, Reeves CM, Sheridan PJ: Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery. J Periodontol. 55:563-566, 1984.

  7. Bahn L, Broxson A, Yukna RA: Evaluation of the purposeful implantation of epithelium on root surfaces under periodontal flaps. Int. J. Perio. Restor.Dent. 7(2): 69-76, 1987.

  8. Yaffe A, Iztkovich M, et al. Local delivery of an amino bisphosphonate prevents the resorptive phase of alveolar bone following mucoperiosteal flap surgery in rats. J Periodontol68:884-889,1997.

  9. Zitzmann NU, Lindhe J, Berglundh T. Host response to microbial challenge following resective/non-resective periodontal therapy. J Clin Periodontol. Nov;32(11):1175-80. 2005

  10. Zitzmann NU, Berglundh T, Lindhe J. Inflammatory lesions in the gingiva following resective/non-resective periodontal therapy. J Clin Periodontol. Feb;32(2):139-46. 2005

  11. Retzepi M, Tonetti M, Donos N. Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry. J Clin Periodontol. Oct;34(10):903-11. 2007

  12. Retzepi M, Tonetti M, Donos N. Gingival blood flow changes following periodontal access flap surgery using laserDoppler flowmetry. J Clin Periodontol. May;34(5):437-43. 2007

Fiber Retention

  • Describe the fiber retention procedure. Does it improve clinical results?

  1. Levine HL, Stahl SS: Periodontal flap surgery with gingival fiber retention. J Periodontol 43:91- 98, 1972.

  2. Levine HL, Stahl SS: Repair following flap surgery with retention of gingival fibers. J. Periodontol. 43:99-103, 1972.

  3. Lindskog S, Lengheden A, Blomlof L. Successive removal of periodontal tissues. Marginal healing without plaque control. J Clin Periodontol 1993; 20:14-19.

Replaced Flap Technique

  • What are the differences and similarities between the modified Widman, open flap curettage, and replaced flaps? What names, if any, do you associate with these procedures?

  • What were the original objectives of these procedures? Are they achievable? Do they differ from the current objectives?

Topic:the modified widman flap                               Article

Authors: Ramfjord SP, Nissle RR

Title:The modified Widman flap

Source: J Periodontol 1974; 45;601-607

Type:Dicussion

Rating: Good

Keywords: modified widman flap, incisions

Background:Widman introduced the reverse (internal) bevel scalloping type of gingival incisions in 1916. 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 re-attachment and re-adaptation of the pocket walls rather than surgical pocket elimination.

Purpose:To discuss the currently used modifications of the Widman flap and their rationale.

Discussion: Following initial scaling, removal of gross overhangs and OHI at least 3-4 weeks should lapse before the MWF is performed. This will allow for healing and maturation of collagen in the inflamed gingiva and thus facilitate precise flap adaptation and optimal wound contraction towards the tooth surface post-operatively.

  1. The initial incision is directed parallel to the long axis of the tooth.

    • If the buccal pocket is >2mm the incision should be placed at least 0.5-1 mm away from FGM (to remove crevicular epithelium).

    • If shallow PDs are present or in esthetic area, the incision should be intrasulcular or at the free gingival margin.

    • The scalloping effect should be exaggerated on the palatal aspect. Be sure to direct the scalpel slightly palatal to the long axis of the tooth aiming for the alveolar process 1-2mm palatally to the alveolar crest otherwise flap adaptation or flap contour will not be satisfactory.

    • It is important to remove only a minimum amount of interproximal soft tissue to ensure complete coverage. Vertical releasing incisions are usually not required; if necessary, through interdental papilla into AG extending 2-3 mm apical to the initial incision at the end of each flap.

    • Avoid vertical incision in the palate in the second bicuspid, first and second molar areas.

    • Use mucoperiosteal elevators to raise a FTF only for 2-3mm or the minimum needed to reflect the flap enough to gain access to the root surface and alveolar bone with very careful full thickness reflection.

  2. The Second incision is made intrasulcular from the bottom of the crevice to the alveolar crest.

  3. The Thirdand last incision is done with a very sharp Orban interproximal knife to cut loose the collar of gingival tissue that has already been separated. Follow contour of alveolar crest and interproximal septum as much as possible. The loosened collar is removed with curettes.

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3

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The part of the root surfaces that have been exposed in the periodontal pockets are thoroughly curetted and planned, trying to leave areas previously unexposed with their PDL attachment. Remove soft tissue from the bony surface on intrabony lesions. Avoid prolonged reflection of the flaps and irrigate with saline to avoid drying of the bone. Flaps should be adapted on the bone and meet interproximally. Finger pressure is applied. If adaptation between buccal and palatal flap is incomplete, thin flaps or remove bone from outer aspects of alveolar process to enhance flap adaptation. Suture with interrupted sutures. Do not take deep bites because the interproximal flap margins may fold and prevent primary healing. Periodontal dressing used to hold flaps tightly against the bone. The dressing is removed after one week, teeth are polished an OHI are given.

Advantages:

  • Access for proper instrumentation of the root surfaces and the furcation areas.

  • Intimate post-op adaptation of healthy collagenous tissue to all tooth surfaces.

  • A marginal new epithelial attachment forms which tends to seal off the deeper areas of separation between tooth and surrounding tissues. Thus, the healing CT may adapt closely to tooth surface and re-attachment with new cementum may develop gradually from the apical aspects of the lesion.

  • In the long run, there is less interproximal recession with MWF than surgical pocket elimination, which is esthetically desirable, facilitates OH, results in less sensitivity and caries.

Disadvantages:the flat or concave interproximal architecture immediately following removal of the surgical dressing, especially in areas of interproximal bony craters.

Indications:i) Deep pockets, ii) intrabony pockets, iii) when minimal recession is desired.

Topic: Periodontal flap                                No Article

Authors: Ramfjord SP:

Title:Present status of the mofified Widman Flap procedure.

Source:J Periodontol 48:558-565, 1977

Type:Discussion paper

Rating: Good

Keywords: periodontitis, flap

Discussion:Widman in a modification of his original technique is the first person to describe the reverse bevel incision. The modified Widman flap procedure provides access for proper instrumentation of the root surfaces and immediate closure at the dentogingival junction between the teeth and well fitting flaps. It is important that an Achromycin ointment and a surgical dressing to prevent plaque invasion during the first week of healing and tissue adaptation to the tooth also cover this junction.

  • Rosling, 1976- Based on data from 105 patients studied longitudinally over 7 years. Comparing pocket elimination, curettage and modified widman flap procedure, average pocket reduction for 7- to 12-mm pockets was best following the modified Widman flap surgery.

  • For deep pockets in the mandibular anterior region, the results following subgingival curettage or modified Widman flap surgeries are significantly better with regard to gain of attachment than pocket elimination surgery.

  • The interproximal attachment level is maintained better following the modified Widman flap than following curettage in maxillary molars (4- to 6-mm pockets).

  • Attachment changes are most favorable over 7 years following modified Widman flap surgery, (4- to 6-mm pockets).

Indications for MWF: The greatest advantage of this procedure is in the treatment of (1) deep pockets, (2) intrabony pockets and (3) when minimal gingival recession is desired.

Topic:Attached gingiva and flap repositioning                               No Article

Authors:Nabers CL

Title:Repositioning the attached gingiva.

Source:J Periodontol 1954; 25:38-39

Type:Commentary

Rating:Good

Keywords:attached gingiva, repositioned flap

Purpose:Discussion article on the repositioned flap

Discussion:Repositioning the attached gingiva is indicated when the periodontal pocket extends beyond to mucogingival junction. In these cases, a gingivectomy is not indicated as the incision will be entirely in the mucosa resulting in a gaping wound, delayed healing, pain, and the margin will be covered by a tissue not resistant to the functional requirements of mastication.

Technique:A vertical incision is made mesial to the area of deepest pocket. The flap reflected, the area debrided, inside of the flap cleaned and the gingiva trimmed along the margin leaving 2mm, and the flap was then sutured further apically. This allows for retention of attached gingiva with elimination of the pocket.

Conclusion:Attached gingiva can be repositioned to the alveolar crest in cases where the base of the deep periodontal pocket was located apically to the mucogingival junction.

Topic:Gingival Flaps                               Article

Authors: Ammons WF, Smith DH

Title:Flap curettage: Rationale, technique, and expectations.

Source:Dent Clin NA 20:215-226, 1976

Type:Discussion

Rating: Good

Keywords:curretage

Purpose:To discuss curettage (conventional and open flap) rationale, technique and expectations.

Discussion:Historically a flap approach was used to provide access to underlying structures. Initially (1884) the purpose was to remove the “necrotic or infected” bone and later to visualize and remove calculus and debris from the deep periodontal pockets.

Thefundamental goal of all periodontal therapy is the retention of the natural dentition in a relative state of health, comfort and function for the life of the patient.

Surgical goals are 1) debridement of the pocket and root surfaces, 2) elimination of periodontal pockets, 3) maintenance or establishment of an adequate functional band of attached gingival tissues and 4) production of a contour and form to the periodontium that can be maintained.

Rationale for flap curettage is related to accessibility, debridement, repair and patient comfort. Advantages include access, facilitation of instrumentation, reattachment by regeneration of new tissues, preservation of periodontal support, elimination or reduction of deep pockets, minimization of postsurgical trauma, pain, root sensitivity and promotion of better home care by the patient.

Technique:With a No 15 blade an inverse bevel incision is made following the contour of the necks of the teeth 1mm lateral to apex of the free gingival margin to produce a thinned and scalloped flap. This incision is made to the crest of the marginal alveolar bone, score the periosteum and directed to removal epithelial lining. It should be extended as far as possible in the interdental areas to retain sufficient interdental papillae to ensure tight closure upon re-adaptation of the flaps. A horizontal incision can then be made to thin the papillae or the papillae may be elevated intact.

Flaps can be extended 1-1.5 half tooth mesially and distally for access. Vertical incisions can also be performed.

Since the prime advantage of the flap is access, the flap should be elevated beyond the MGJ. On the palatal side the usual procedure is to exaggerate the scalloping. The tissues that remain attached to the tooth are then removed with an Orban knife and debridement with ultrasonics is performed.

After debridement the flaps should be placed to only cover the buccal and lingual bony margins. This results in stable post-surgical results. Individual or continuous vertical mattress or interrupted sutures are indicated so good adaptation of interproximal tissues is achieved. Dressing can be placed and sutures are removed after 5-7 days. After suturing Pressure is applied for 3 minutes.

Flap curettage can be used in areas where regeneration can be performed or as initial preparation before orthodontic movement.

Subgingival curettage gives more favorable result regarding preservation of attachment level but less favorable pocket reductions comparing to surgical techniques. It is also more difficult to perform in patients with advanced periodontal disease and deep pockets.

Flap Design

Topic: Comparison of therapy                                No Article

Authors: Kaldahl, W., Kalkwarf, K, Patil, K

Title: A review of longitudinal studies that compared periodontal therapies.

Source: J Periodontol 64:243-253, 1993

Type: Clinical

Rating: Good

Keywords: Osseous surgery, MWF, Scaling, root planing, comparison study

Purpose : Literature review of different studies, comparing the effects of two or more periodontal therapies on various clinical parameters.

Materials and methods:

  • Studies that were reviewed included Michigan studies, Swedish studies, Minnesota study, Washington study, Denmark study, Loma Linda study, Arizona study, Nebraska study etc.

Results:

  • Both surgical and non-surgical treatment produced improvement in periodontal health.

  • Surgical treatment lead to more short term PD reduction than non-surgical treatment. In deeper PD sites, the short term results comparing mean attachment change following non-surgical and surgical treatment were mixed.

  • Surgery produced a greater loss of probing attachment in shallow sites, both short and long term.

  • In most studies, no long term differences in mean probing attachment level change were present between surgical and non-surgical studies.

  • NSSD between surgical and non-surgical in gingival inflammatory indices. When the effects of plaque control alone and plaque control with root planing were compared, root planing produced a superior response in the clinical parameters.

BL:SRP w/ plaque control produces better response in clinical parameters than just plaque control. Both surgical and non-surgical treatment produced improvement in periodontal health.

Topic:Gingival Flap Surgery                               Article

Authors:Johnson RH

Title:Basic flap management

Source:Dent. Clin. North Am.  20:3-21, 1976.

Type:Review article

Rating: Good

Keywords: flap reflection, suturing, retromolar pad area, keratinized gingiva

P:Review article on basic flap management.

D:

1. To Split or Not to Split: Author recommends FTF in most situations; in presence of thin bone & dehiscences, a STF may be indicated. It may be considered that by blunt dissection, a FTF retaining the periosteum is like a STF.

2. Don’t throw gingiva away! Retain as much gingiva as possible during flap reflection. Alveolar mucosa is not designed to withstand insults of tooth brushing or eating.

3. Palatal flap: should be scalloped so that margin ends up at crest of bone. 

4. Primary incisions:  extend far enough M or D so proper access to the underlying bone is exposed (at least 1 tooth each side). Not only is it difficult to see what is going on, but healing is delayed because of the trauma inflicted on the flap. Also, this allows the clinician to drape the relaxed flap while apically repositioning.

5. Flap reflection: reflect in a relaxed manner; vertical releasing incisions should only be used when necessary and not over prominence of roots and not on palatal or ling of third molars; author feels extension of sulcular incision (but do not include uninvolved teeth) is better than vertical releasing incisions that can appear to retard healing. Author discusses exposure of tuberosity region and retromolar pad area- incisions should be kept in keratinized mucosa and regions should be opened adequately to expose bony problems distal to the terminal molar. Do not perforate base of flap this will sever blood supply. Preserve KG; thin very wide tissue to approximate flaps.

6. Suturing:Pay attention to suturing to ensure correct placement. Let sutures hang loose on buccal, snug on the palatal. Author recommends using the continuous sling suture described by Dahlberg when FTF. APF the flap when doing pocket reduction surgery. Apply pressure with a gauze for a few minutes to ensure that the flap is resting in the desired position.

Topic:Vertical releasing incisions                               Article

Author:Lynch TK, et al.

Title:A comparison of Mandibular Lingual Surgical Flaps with and without a Vertical Releasing Incision

Source:J. Periodontol. 59:12-17, 1988

Type:Prospective study

Rating: Fair

Keywords:Mandibular lingual flaps; vertical releasing incision; postoperative pain; clinical healing

Purpose: To compare the short-term post-op pain and healing from surgical flaps with mandibular lingual vertical-releasing incisions vs. envelope flaps.

Methods: 12 patients (7M, 5F) were evaluated using a split mouth design: (1) envelope flap and (2) with lingual vertical releasing incisions. The procedures consisted of debridement alone or debridement plus osseous recontouring. All patients were prescribed 6 tables of 300mg acetaminophen and 30mg codeine, and were instructed to only take if they experience pain. Patients were given a Symptom Data Log to complete for the first 14 days post-op: Patients reported daily pain (scale 0-4) and also the number of prescribed tablets taken each day. Photographs were taken at 1 and 2-week post-operative visits, and were used to assess healing.

Results:NSSD was noted between the 2 procedures with respect to healing and pain, however better access was achieved with the releasing incisions.

Discussion: This study supports the use of vertical incisions. Suturing the vertical incision on the mandibular lingual is usually avoided because of the thinness of the tissue. Vertical releasing incisions (VRI) are contraindicated in areas with prominent ledges, concavities and exostoses due to difficulty in tissue management. Guidelines for VRI: Should be done at line angle, extend beyond MGJ, don’t release distal to 2nd molar, and shallow vestibule is not a contraindication.

Topic:flap healing                               Article

Authors: Kon S, Caffesse RG,

Title:Vertical releasing incisions for flap design: clinical and histological study in monkeys.

Source:Int J Periodontics Restorative Dent. 1984;4(1):48-57.

Type:clinical trial

Rating: good

Keywords:vertical incisions, releasing incisions, healing, periodontium,

Purpose: To investigate the clinical and histological healing process of two different vertical releasing incisions in monkeys: one perpendicular and one beveled to the underlying alveolar bone.

Methods:2 Rhesus monkeys received 10 full thickness flaps in molar/premolar areas with 2 vertical releasing incisions at interproximal areas: one perpendicular, the other beveled to the alveolar bone. They extended from the margin straight down apically to the mucogingival line. Incisions were assigned randomly by flipping a coin. The flaps were reflected and the dento-gingival area was curetted. The flaps were replaced and secured by sutures. No sutures were placed at the vertical releasing incisions. Animals were sacrificed at 9, 14, 21 and 28 days after the procedures. Pelican carbon black ink was injected to evaluate revascularization. Cross-sections were obtained, stained, and histological analysis was performed.

Results:Immediately after surgery the full thickness flap was well adapted and the two different vertical releasing incisions showed no clinical difference.

At 9 days post-op, the marginal tissues associated with the perpendicular incision area showed a groove that could not be observed in beveled incision area.

Histologically, 9 days post-op, at perpendicular incision area the smooth keratinized oral epithelium with regular rete pegs is disrupted, irregular and enlarged rete pegs interrupting the normal vascular arrangement of the loop capillaries are noticed. The perpendicular incision showed more inflammation than the beveled one. The soft tissue groove and the microvascular gap are also quite evident at the perpendicular incision site while the beveled incision exhibits only a slight defect.

14 days post-op, at the perpendicular incision area a groove or depression is still evident, the capillary loops at this site are shorter and irregular compared to the beveled incision site.

21 and 28 days post-op a groove is still present at the perpendicular incision, rete pegs more irregular than in beveled incision area. Connective tissue fibers are completely re-organized at the beveled area.

The healing with both of the incisions was always more advanced in the deeper areas, away from the gingival margin.

Conclusion:Healing in the beveled incision was faster owing to a larger soft tissue interface. Soft tissue grooves were more frequently noted in association with perpendicular incisions.

Replaced Flap Results

Topic:soft tissue defects                               Article

Authors: Jenkins MM, Wragg PF, Gilmour WH

Title:Formation of interdental soft tissue defects after surgical treatment of periodontitis

Source:J Periodontol 61:564-570, 1990

Type:clinical study

Rating: Good

Keywords:gingival/anatomy, tissue/anatomy, periodontal disease/diagnosis, interdental clefts, interdental craters, periodontitis/surgery

Purpose:To evaluate interdental soft tissue healing following repositioned (replaced) flap surgical techniques and determine:

  1. How often do interdental soft tissue defects arise and their capacity for repair

  2. If pre-op probing depth, underlying bone defect, or use of periodontal dressing is related to defect development

  3. If soft tissue defects interfere with establishment of periodontal health after surgical treatment

Methods:21 patients (30-57 years old) were selected with remaining deep pockets with BOP after SRP completed. 46 surgical procedures were completed. No osseous recontouring was done, only root planing. Coe-pak was used in every alternate procedure after suturing (silk). Dressing and sutures were removed 1 week post-operatively. Patients were told to brush carefully for the first 2 weeks and CHX was prescribed for 2 months. Maintenance was completed for the duration of the study based on patient needs. Probing depth and BOP were measured pre-operatively, at 1, 3, and 6 months. Bone defects were assed at the time of surgery. At each post-op visit, interdental space was evaluated for the presence of a “crater” (visible depression within the interdental tissue at least 1 mm in depth) or “cleft” (soft tissue interdental defect with no visible concavity but the buccal and lingual interdental tissues could be separated with a probe to a depth of at least 1 mm). Where craters were detected, an impression was taken and poured up in dental stone. Craters were then measured by a reflex microscope. Crater sites were measured in this fashion at 3 and 6 month visits.

Results:At 1 month, 13 clefts and 30 soft tissue craters were noted. There was evidence of some reduction over time of the clefts. Probing depths were reduced at one month at all sites, as well as bleeding regardless of presence of craters or clefts. Generally there was no obvious association between the use of periodontal dressing and the subsequent occurrence of interdental soft tissue defects. 3 craters exceeding 1 mm were noted in 1 patient. At 18 months, 2 craters had entirely disappeared. No BOP was noted and PD were 2mm.

Conclusion: The development of interdental soft tissue defects, both craters and clefts, during the early stages of healing following periodontal surgery does not seem to adversely affect the ultimate establishment of periodontal health.

Topic:Scalloped and linear incisions                               Article

AuthorsCattermole AE, Wade AB

Title:A comparison of the scalloped and linear incisions as used in the reverse bevel technique.

Source: J. Clin. Periodontol. 5:41- , 1978.

Type:Clinical study

Rating: Good

Keywords:scalloped, linear incisions, healing, inflammation

Purpose:To evaluate the use of scalloped and linear incisions in reverse bevel techniques with regard to pocket elimination, rate of healing and gingival contour produced.

Materials and methods:

  • Split mouth design. 20 patients (22-48 years) needing surgery on each side on one or both jaws were included. 40 FTF were performed.

  • Selection criteria:

    • The area involved was from first bicuspid to 2nd molar. Symmetry with regard to PDs on both right and left sides of the arch involved. PD no greater to 6mm. Radiographic evidence of horizontal bone loss. Absence of any systemic disease.

  • Pre-op therapy: scaling, polishing, OHI. Patients should demonstrate high degree of plaque control.

  • Immediately pre-op GCF was collected (filter paper strips), GI, PI, PD, CAL, gingival contour, study models obtained. Measurements for GCF, GI, PI were repeated at 1, 2, 3, 4, and 12 weeks post-op and for PD, CAL at 12 weeks post-op.

  • Using a split mouth technique both posterior segments of an arch were treated at one appointment. On one side of the arch a linear incision was performed on the buccal and lingual aspect and one the other side ascalloped incision. Ιncisions started 1-2mm from the gingival margin. Tissue collar was removed. FTF was reflected, degranulation, sc/rp, osteoplasty performed. Flaps sutured at the bone level. Perio dressing was placed.

Results:

  • Clinical: it was felt that the flap procedure using the lineal incision was completed in a shorter time and with greater ease than the scalloped incision. When the flaps were sutured, the alveolar bone was completely covered with soft tissue when a scalloped incision was used but the interdental bone was left exposed when a linear incision was used. No bone was left exposed mi-buccally or mid-lingually with either procedure. During suturing of the linear flap there was a tendency for the tissues to pull in slightly into the interdental areas. Linear incision healed at a slower rate. At 12 weeks cannot distinguish between 2 procedures.

  • Higher GI was present after the linear incision during the first 2 weeks. The improvement in GI score continued at weeks 3 and 4 and there was no SSD between the two sides. NSSD in gingival fluid flow between the two sides. Pain was even. Clinically, satisfactory results were achieved for both scalloped and linear incisions, as determined by improvement in gingival contour, reduction in PD, slight gain in attachment, lack of gingivitis and low plaque scores.

C: Initially greater inflammation in the linear incision segments than is scalloped. 3 weeks after the operation there was little difference in the degree of healing. Linear incisions were easier to use and the surgery was completed in less time. 

Topic: Periodontal flap                                Article

Authors: Newman PS

Title:The effects of the inverse bevel flap procedures on gingival contour and plaque accumulation.

Source:J. Clin. Periodontol. 11:361-366, 1984

Type:Clinical study

Rating: Good

Keywords: periodontitis, flap

Purpose:To develop a contour index to record changes in gingival contours relative to treatment of periodontal disease that may predispose to plaque accumulation.

Methods:12 pts (4 M, 8 F; mean age=38 years old). The index is scored by examining buccal, lingual and inter-proximal surfaces of the teeth and gingiva. The new contour score: 0= ideal; 4=grossly enlarged like that seen in hereditary gingival fibromatosis. Pre-op recorded perio index, BI, PI at baseline and 90 days. Sites treated with inverse bevel flaps with no osseous recontouring.

R:

  • Mean gingival contour scores increased from 1.45 to 1.65 (SSD).

  • Perio index decreased (SSD).

  • BI decreased (SSD).

  • PI had small increase (NSS).

  • No correlation b/w plaque accumulation and gingival contour.

  • Good gingival contours were not obtained from sx as measured by this index.

BL: Gingival contour was not improved by inverse bevel flap. PD, BI were decreased and PI was only slightly increased because of this. This study questions the importance of a good gingival contour for the maintenance of periodontal health.

Topic:Systemic tetracycline                               Article

Authors:Haffajee AD, Dzink JL, Socransky SS.

Title:Effect of modified Widman flap surgery and systemic tetracycline on the subgingival microbiota of periodontal lesions.

Source:J Clin Periodontol. 1988 Apr; 15(4):255-62.

Type:Clinical study

Rating:Good

Keywords:periodontal lesions, subgingival microbiota, tetracycline, treatment

Purpose:To compare the subgingival microbiota before and after Modified Widman Surgery and systemic tetracycline administration (1g day/21 days) and to compare the microbiota at successfully and unsuccessfully treated sites.

Method:2 subsets of an original 33 pts were examined.

Group 1: 12 patients had microbiota compared at the same 41 sites before and after therapy (6 mo). All sites gained attachment>2mm.

Group 2: 94 post therapy microbiota samples taken from sites exhibiting different responses to therapy and compared with the microbiotas from 100 active sites of all 33 patients. Site breakdown: 24 lost > 2mm attachment, 23 gained > 2mm of attachment, and 47 did not change.

Results:

Group 1: Marked improvement in mean PD and AL was found after therapy. Mean levels of S.Mitis, S. Sanguis and V. parvula increased after therapy, while mean levels of other species including Actinomyces sp, P. gingivalis, P. interm., S. morbillorum, S. uberis, and W. recta decreased.

Group 2: Sites which lost attachment (24 lost > 2mm) had higher levels of Aa, T forsyth. Pg, Pi, P micros, S. intermedius and W.recta, while sites which gained attachment (23 sites gained > 2mm of attachment) had higher levels of Actinomyces sp. Capnocytophaga, C. ochracea, S. mitis, S.sanguis I & II and V. parvula.

None of the suspected periodontal pathogens were eliminated from all sites, though they were reduced in all sites.

Conclusion:The present investigation supports the concept that specific periodontal infections may be better controlled by different therapeutic regimens. In this study MWF with systemic TCN was effective in controlling Aa. Black pigmented bacteriodes may have to be treated by other means.

Replaced Flap Healing

  • Describe the wound healing following each of these procedures.

Topic:Flap Healing                               Article

Authors: Listgarten MA

Title:Electron microscopic study of the junction between surgically denuded root surfaces and regenerated periodontal tissues.

Source:J. Periodontal Res. 7:68-90, 1972.

Type:Clinical

Rating: Good

Keywords:wound healing

Purpose:To study the ultrastructural features of the junction between experimentally exposed root surfaces of monkey teeth and regenerated periodontal tissues at varying interval after surgery.

Materials and methods: 7 monkeys were used. Flaps were elevated on the buccal side of the teeth and 1/3 – 1/2 of the root was exposed using a bur. Root surfaces were ground to expose dentin and smoothed with curettes. Flaps were closed back and one side served as control. Animals were killed at 1, 2, 3, 6, 9, 12 and 18 months. Teeth of the animals that were sacrificed after 9, 12 and 18 months were scaled every 6 months. Histology under electron and light microscope was performed.

Results:The operated segments appeared more inflamed than the controls up to 6 months. Histological evidence of both epithelial and CT reattachment was found at all time intervals.

Regeneration of JE: JE had regenerated over denuded dentin as well as cementum in all time intervals. It included hemidesmosomes along the cell membrane surface facing the tooth and a basement lamina. This attachment apparatus was similar to that connecting the JE with the underlying CT. Superficial alterations were frequently noted in cementum and dentin. In cementum they had the appearance of a granular layer.

Regeneration of cementum: Cementum repair could be noted at all time interval in most of the specimens examined. It was formed over exposed cementum or dentin. Its formation was more advanced at the apical part. The width of the granular layer of cementum did not appear to be to related to the time of healing. The new cementum was often devoid of well-defined fiber bundles, but in specimens obtained at longer intervals root cementum resembled typical cementum with recognizable fiber bundles in its structures.

Artificial splits were found in association with the granular layer that may be associated with the demineralization process.

Conclusion:Morphological alterations on root surface did not interfere with the regeneration of a new JE that was formed over dentin.

Topic: MWF healing                               Article

Authors: Caton, J

Title: Histometric evaluation of periodontal surgery. I. The modified Widman flap procedures.

Source:J. Clin. Periodontol. 7:212-223, 1980.

Type: Clinical

Rating: Good

Keywords: Modified widman flap, connective tissue, bone

Purpose:To determine the effect of the modified Widman flap on the CT attachmen

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