The Flap Technique For Pocket Therapy

THE FLAP TECHNIQUE FOR
POCKET THERAPY
THE FLAP TECHNIQUE
OUTLINE
• The Modified Widman Flap

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

overgrowth, which is handled more efficiently by
means of a gingivectomy or gingivoplasty.
2. When there is little or no attached gingiva.
3. When there are large bony thickenings or exostoses

to be removed.
Advantages
1. Facilitates subgingival scaling & root planing to the base of deeper
pockets with direct vision.
2. Allows complete removal of the pocket epithilium.
3. Flaps can be replaced at the original location.
4. Encourages healing by primary intention.
5. Minimal tissue trauma during surgery.
6. Often esthetically superior to gingivectomy or apically repositioned flaps.

Modified Widman Flap
Presented in 1974 by Ramfjord & Nissle
• Step – 1 : It is an internal bevel incision, 0.5 to 1 mm away from

the gingival margin, directed to the alveolar crest.
• Step – 2 : Gingiva is reflected with a periosteal elevator.
• Step – 3:A crevicular incision is made.
• Step – 4 : After the flap is reflected, third incision is given with
Orban’s knife and the gingival collar is removed.
• Step – 5 : Granulation tissue are removed with a curette. The root
surfaces are checked and scaled.
• Step – 6:Bone architecture is not corrected, good approximation of flaps
is necessary, hence sometimes flaps may have to be thinned.
• Step – 7:Interrupted direct sutures are placed.
Inverse bevel incision Sulcular incision
Interdental incision
Internal bevel incision Elevation of flap
Crevicular incision Interdental incision

Open flap debridement Root planing
Repositioning the flap Suturing

Pre operative
Incisions
Flap reflection
Suturing
Modified Widman Technique
Before After
UNDISPLACED FLAP
• The undisplaced (unrepositioned) flap, in
addition to improving accessibility for
instrumentation, removes the pocket wall,
thereby reducing or eliminating the pocket.
This is essentially an excisional procedure of
the gingiva.
Undisplaced Flap
• Step – 1: The pockets are measured with the periodontal probe
and a bleeding point is produced on the outer surface of the gingiva to
mark the base of the pocket.
• Step – 2: The internal bevel incision is made following the
scalloping bleeding points made on the gingiva.
• Step – 3: The second or crevicular incision is made from the
bottom of the pocket to the bone.
• Step – 4: The flap is then reflected with a periosteal elevator.
• Step – 5: Interdental incision is made with a knife.
• Step – 6: Triangular wedge of tissue is removed with a curette.
• Step – 7: The area is debrided, removing tissue tags and
granulation tissue with curettes. The roots are scaled.
• Step – 8: The flap is then placed back.
• Step – 9: The flaps are sutured together.
Diagram showing the location of different areas where the internal
bevel incision is made in an undisplaced flap. The incision is made at
the level of the pocket to discard the tissue coronal to it if there is
sufficient remaining attached gingiva.
APICALLY DISPLACED FLAP
• The apically displaced flap improves
accessibility and eliminates the pocket, but
does the latter by apically positioning the soft
tissue wall of the pocket. Therefore it
preserves and/or increases the width of the
attached gingiva by transforming the
previously unattached keratinized pocket wall
into attached tissue.
Apically displaced flap
Step – 1 : Internal bevel incision is made, 1 mm from the crest

of the gingiva and directed towards the crest of the bone.
Step – 2 : Crevicular incisions are made followed by initial elevation

of flap and then interdental incision is performed, the wedge of tissue
containing the pocket wall is removed.
Step – 3: Vertical releasing incisions are made extending beyond the

mucogingival junction and flap is elevated with a periosteal elevator (either
split thickness or full thickness).
Step – 4: Remove all the granulation tissue, root planing is done and flap is
positioned apically at the tooth bone junction.
Step – 5: Suturing , followed by pack placement.

• Advantages
– Eliminates periodontal pocket
– Preserves attached gingiva and increases its width
– Establishes gingival morphology facilitating good hygiene
– Ensures healthy root surface necessary for the biologic
– width on alveolar margin and lengthened clinical crown
• Disadvantages
– May cause esthetic problems due to root exposure
– May cause attachment loss due to surgery
– May cause hypersensitivity
– May increase the risk of root caries
– Unsuitable for treatment of deep periodontal pockets
– Possibility of exposure of furcations and roots, which complicates
postoperative supragingival plaque control.
• Contraindications for Apically Positioned Flap
Surgery
– Periodontal pockets in severe periodontal disease

– Periodontal pockets in areas where esthetics is critical
– Deep intrabony defects
– Patient at high risk for caries
– Severe hypersensitivity
– Tooth with marked mobility and severe attachment loss
– Tooth with extremely unfavorable clinical crown/root ratio
Modified Widman Flap Undisplaced Flap Apically Displaced Flap
I.Purpose
1.To expose root surfaces 1. Accessibility for 1.Improves accessibility.

for instrumentation. instrumentation 2.It also eliminates the
2.For removal of pocket 2.To remove the pocket pocket by transforming
lining. wall to reduce or the previously unattached
(It is not indicated to eliminate the pocket. keratinized pocket wall
eliminate / reduce pocket (An excisional procedure into attached tissues.
depth, except for the of the gingiva). (Dual function).
reduction that occurs in
healing by shrinkage)
Modified Undisplaced Flap Apically Displaced
Widman Flap
Flap
Variations in the
Design
It does not intend Internal bevel incision is The internal bevel incision
to remove the started at or near a point just should be placed as close to
pocket wall but coronal to the projection of the tooth as possible (0.5 to 1
eliminate pocket the bottom of the pocket on mm) because the purpose of
lining. Therefore, the outer surface of the this technique is to preserve
internal bevel gingiva. (Only performed maximum amount of
incision starts when sufficient attached keratinized tissue, displace it
close (no more gingiva is to be left behind). apically and transform it into
than 1 to 2 mm The incision should be attached gingiva. The flap is
apical) to the scalloped to preserve as positioned at the tooth bone
gingival margin. much as interdental papilla. junction.
Locations of the internal bevel incisions for the
different types of flaps
Scalloping required for the different types of flaps.
Papilla preservation flap
• Step – 1: Crevicular incision is made around each tooth. No
incisions through the interdental papilla.
• Step – 2: Papilla is usually incorporated facially, hence a semi-

lunar incision across the interdental papilla in the palatal or lingual
surface is made, which is atleast 5 mm from the crest of the
papilla.
• Step – 3: The papilla is dissected from the lingual or palatal aspect

using Orban knife and elevated intact with the facial flap.
• Step – 4: The flap is reflected without thinning the tissue.

Flap design for a papilla preservation flap. A, Incisions for
this type of flap are depicted by interrupted lines. The
preserved papilla can be incorporated into the facial or the
lingual-palatal flap. B, The reflected flap exposes the
underlying bone. Several osseous defects are seen. C, The
flap returned to its original position covering the entire
interdental spaces
Pre operative Incisions
Flap reflection
Conventional Flap for Regeneration
Step 1: Incise the tissue at the bottom of the pocket and to

the crest of the bone splitting the papilla below the contact
point.Every effort should be made to retain as much
tissue as possible to subsequently protect the area.
Step 2: Reflect the flap maintaining it as thick as

possible, not attempting to thin it as is done for resective
surgery. The maintenance of a thick flap is necessary to
prevent exposure of the graft or the membrane due to
necrosis of the flap margins.
DISTAL MOLAR SURGERY
Treatment of periodontal pockets on the distal surface
of terminal molars is often complicated by the
presence of bulbous fibrous tissue over the maxillary
tuberosity or prominent retromolar pads in the
mandible. Deep vertical defects are also commonly
present in conjunction with the redundant fibrous
tissue. Some of these osseous lesions may result
from incomplete repair after the extraction of
impacted third molars.
The impaction of a third molar distal to a second molar with
little or no interdental bone between the two teeth. B,
Removal of the third molar creates a pocket with little or no
bone distal to the second molar. This often leads to a vertical
osseous defect distal to the second molar (C)
Removal of a pocket distal to the maxillary second
molar may be difficult if there is minimal attached
gingiva. If the bone ascends acutely apically, the
removal of this bone may make the procedure
easier. B, A long distal tuberosity with abundant
attached gingiva is an ideal anatomic situation for
distal pocket eradication.
A, Pocket eradication distal to a mandibular second
molar with minimal attached gingiva and a close
ascending ramus is anatomically difficult. B, For surgical
procedures distal to a mandibular second molar, abundant
attached gingiva and distal space are ideal.
Maxillary molars
• Two parallel incisions at the distal surface of terminal tooth

are made. The deeper the pocket, the greater will be the
distance between the two parallel incisions.
• Followed by this a transversal incision is made so that a long
rectangular piece of tissue is removed. This can be confirmed
with the regular flap in the quadrant being treated. These
incisions can be placed using No. 12 blade, after flap
reflection curetting the bone surface, the flaps are sutured
together.
Square Incision for Maxillary Distal Molar
Mandibular molars
• Two parallel incisions at the retromolar pad area are

made.The incisions should follow the areas of
greatest attached gingiva and underlying bone. After
the reflection of the flap and removal of tissue,
osseous surgery may be performed (if necessary )
and flaps are sutured so as to approximate the flap
margins closely to each other .
Triangular Incision for Mandibular Distal Molar

The Flap Technique For Pocket Therapy

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What are the different types of flaps discussed for pocket therapy?

What are the different types of flaps discussed for pocket therapy?

What are the indications for using a Modified Widman Flap?

What are the indications for using a Modified Widman Flap?

THE FLAP TECHNIQUE FOR

• The Modified Widman Flap

1. When there is pronounced gingival enlargement or

2. When there is little or no attached gingiva.

3. When there are large bony thickenings or exostoses

2. Allows complete removal of the pocket epithilium.

3. Flaps can be replaced at the original location.

4. Encourages healing by primary intention.

5. Minimal tissue trauma during surgery.

6. Often esthetically superior to gingivectomy or apically repositioned flaps.

Presented in 1974 by Ramfjord & Nissle

• Step – 1 : It is an internal bevel incision, 0.5 to 1 mm away from

Crevicular incision Interdental incision

Repositioning the flap Suturing

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

Step – 2 : Crevicular incisions are made followed by initial elevation

Step – 3: Vertical releasing incisions are made extending beyond the

Step – 5: Suturing , followed by pack placement.

– Periodontal pockets in severe periodontal disease

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

• Step – 2: Papilla is usually incorporated facially, hence a semi-

• Step – 3: The papilla is dissected from the lingual or palatal aspect

• Step – 4: The flap is reflected without thinning the tissue.

Step 1: Incise the tissue at the bottom of the pocket and to

Step 2: Reflect the flap maintaining it as thick as

• Two parallel incisions at the distal surface of terminal tooth

• Two parallel incisions at the retromolar pad area are

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