Flap Surgery in Periodontics
Neuman claimed the introduction of the mucoperiosteal flap
in 1911. The technique included a intrasulcular incision
and two releasing incisions on both side of the defect area.
Flap was raised up to the level of apices of the teeth.
Gingival margin was trimmed approximately 2mm in the area
of deep pockets with bone removal. Widman introduced the
Widman flap in 1918. He described 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. The flap assume a scallope appearance.
Bone removal was carried out for better soft tissue adaptation.
As in Neuman’s procedure, the flaps were sutured back
by individual interproximal suture. Cieszynski, however,
was credited with the introduction of reverse bevel incision.
Zentler introduced the mucoperiosteal flap in the U.S.A.
in 1918, with the idea that the procedure was to allow access
for debridement and elimination of granulation tissue as
well as osseous removal by chisels. As we can see 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 in 1931. 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.” Flap surgery became popular after 1935,
when Kronfeld in his autopsy study of which he stated that
the bone adjacent to the periodontal pockets was neither
necrotic nor infected but rather destroyed by an inflammatory
process. Orban later supported this finding in his own studies.
The main culprit of the disease now has shifted to the soft
tissue. Gingivectomy became popular; however, its problem
of excising the attached gingiva, the frenum attachment,
and the creation of shallowed vestibular trough have prompted
the periodontists to arrive at new technique and procedures
for pocket elimination. In 1954, Nabers described the “repositioning
of the attached gingiva.” For the first time, a mucoperiosteal
flap was apically positioned after treatment. He utilized
one vertical releasing incision which is placed mesially
to the area of the deepest pocket. Later in 1957, he introduced
the inverse bevel incision of which he called the “repositioning
incision” which includes the internal incision from
the gingival margin to the alveolar crest. This incision,
he stated, would permit an easier flap reflection and result
in a thinner gingival margin. In that same year, Ariaudo
and Tyrrell modified Nabers’technique and recommending
two vertical releasing incisions instead of just one to
facilitate the mobilization of the flap. At this point,
the only difference from the flap design of Widman is the
apical positioning. Finally, in 1962, Friedman published
the technique in his paper and coined the term “apically
reposition flap”. Today, the word “reposition”
is replaced by the term “position” since reposition
means place the flap back to where it was before
A flap is defined as a loosened section of tissue separated
from the surrounding tissue except at its base. Flap surgery
has been characterized extensively by Carranza and Ramjford
in 1979. In 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. Periosteum was not part of a split thickness
flap. In 1990, Carraza again classified flap according to
their placement at the conclusion of a surgical procedure.
They are repositioned, positioned, or displaced flapes (those
that can be placed apical, coronal, or lateral to its original
position. Unreposition or unreplaced flap are those that
are placed in the position they were found before the surgery.
Another classification of flap types were done by Ramfjord
in 1979, of which he classified periodontal flap surgery
procedure according to the main purpose of the procedure
such as pocket elimination flap, reattachment flap surgery,
and mucogingival repair. Flap for pocket therapy incuded
the modified widman flap, the undisplaced (unrepositioned)
flap, and the apically displaced flap.
The modified widman flap is the one that used for exposing
the root surfaces for instrumentation and debridment and
for removal of poket lining. It is not intended to eliminate
or reduce pocket depth, though the reduction does occur
dure to tissue shrinkage following healing. It does not
intend to remove the pocket wall but does eliminate the
pocket lining. The internal bevel incision start close (no
more than 1 to 2 mm apical) to the gingival margin and follows
the scalloping of the gingival margin. Ramfjord and Nissle
in 1974 coined the term modified Widman flap though the
procedure was employed by Morris in 1965 and was termed
the unrepositioned mucoperiosteal flap. Morris in 1965 has
described this flap as “the simple mucoperiosteal
flap, combined with the inverted bevelled incision and osseous
resection.” 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. Extensive longitudinal
studies has been made to compare the Widman procedure to
the curettage technique and the pocket elimination methods
that included bone contouring when needed. It is the seven
years follow ups longitudinal studies. The investigators
reported approximately similar results with three method
tested. Pocket depths were best maintained at shallower
levels with the Widman flap and the attachment level remained
higher with the Widman flap. Ramfjord in 1974 reviewed the
present status of the modified Widman procedure and detaily
describe the procedure. He notes that the key to success
of the procedure is to create and maintenance of the biologically
acceptable root surface. The advantage of the procedure
is to coapt the tissues to the root surfaces, access to
the root sufaces, esthetic result, less likely to produce
root sensitivity and caries, and a favorable environment
for oral hygiene maintenance. Disadvantages include flat
or concave interproximal soft tissue contour which required
meticulous oral hygiene in the area. Smith and Svoboda et
al (1984) evaluate the MWF and concluded that removal of
the sulcular epithelium during the periodontal surgery provided
no therapeutic advantage. The procedure is indicated for
deep pocket, infrabony pocket, and when minimal recession
was desired. The end result is the establishment of an intimate
postoperative adaptation of healthy collagenous connective
tissue to tooth surfaces and provides access for adequate
instrumentation of the root surfaces and immediate closure
of the area. In 1977, Ramfjord published the paper discussing
the present status of the modified widmen procedure and
detaily discussing the entire technique. Afterward, various
studies by Caffesse, Castelli, and Nasjleti to investigate
the vascular response to the modified widman flap surgery
was carried out. In October 1987, the result of a longitudinal
study comparing scaling, osseous surgery and modified widman
procedures was published. This study documented the difficulty
in achieving primary flap closure after modified widman
flap surgery. Only 26.8% of primary closure was achieved.
There was a tendency for the sites that receives the modified
widman therapy to have a higher percentage of crateres during
healing. However, at six weeks, there were no meaningful
differences between the modified widman and the scaling
and root planing with osseous surgery. The result from this
study indicated that with three month maintenance and 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. Next, the undisplaced
flap is to provide accessibility for debridement and is
an excisional procedure of the gingiva to eliminate the
pocket. It differs from the modified Widman is that soft
tissue pocket wall was removed with an initial incision.
Enough attached gingiva must be present since it is an internal
bevel gingivectomy. In the palatal area, the undisplaced
was used since the palatal tissue is all attached, keratinized
tissue and has none of the elastic properties associated
with other gingival tissues. The palatal tissue, due to
the above reasons, cannot be apically displaced, nor can
a partial thickness flap can be accomplished. Thus the initial
incision is very important in term of location of placement
since it must be designed such that when the flap is sutured,
it is precisely adapted at the root bone junction. Initial
incision is varied depends on the thickness of the palatal
tissue. Normally, the internal bevel incision is used with
the incision placed further away from the gingival margin.
If the tissue is thick, the horizontal gingivectomy incision
is made, following by an internal bevel incision that starts
at the edge of this incision and ends on the lateral surface
of the underlying bone. When the flap is approximate for
suture, bone must not be exposed to stimulate primary healing
response. The apical portion of the scalloping should be
narrower than the line angle area, since the rounded scallop
will result in the flap that cannotfit snugly around the
root upon suturing. Finally, The apically displaced flap
is to improve accessibility for debridement and eliminate
the pocket. It is designed for pocket elimination via repositioning
the soft tissue wall of the pocket. It can also be used
to preserve or widening the zone of the attached gingiva.
It can utilized the partial (mucosal) or full thickness
(mucoperiosteal) flap design. The split thickess flap design
is more complex but can be more accurately positioned and
sutured in an apical position using the periosteal suturing
technique. Again, three incision is used: the reverse bevel
incision, the crevicular incision, and the horizontal releasing
incision. Flap is refected, area is debrided, and tissue
apically displaced to eliminate the pocket. The flap must
be elevated past the mucogingival line junction to provide
adequate mobility to the flap for its apical displacement.
Apically positioned flap surgery can be used alone or combine
with osseous surgery. The indication for the apically positioned
flap without osseous surgery are suprabony and infrabony
pockets, diseased roots which are located subgingivally,
crown lengthening procedures for cosmetic enhancement and
restorative treatment, and finally the need to increase
keratinized tissue. The contraindications are: compromised
esthetic and anatomical preclusion. The major advantages
of the procedure are reduction of probing depth, preserving
or increasing the presurgical zone of gingiva, facilitation
of healing, accessibility to bone, roots, furcations, subgingival
caries, and other anatomical aberrations, controlling the
tissue placement, and finally its usefulness in conjunction
with other treatment modalities. The weakness of the procedure
is that it limits the treatment of intrabony defects. The
therapeutic endpoints for success are: reduced probing depth,
properly prepared roots, adequate clinical crowns, increased
keratinized tissue, improve cosmetics, and facilitate maintenance
care. Similarly, when combine with osseous surgery, the
procedure allows for further reduction or elimination of
infrabony pocket and eliminate anatomic aberrant which rendered
the site susceptible for plaque and bacterial accumulation.
Healing of the flap surgery has been carried out extensively
in numerous histological and longitudinal studies. The healing
sequence is significantly affected by the oral hygiene of
the patient, the tissue adaptation following closure, the
handling of the flap due to surgery. Oral hygiene inadequacy
leads to plaque and bacterial product in the area which
cause infection and compromised the normal healing. Tissue
adaptation distinguished the healing by primary intention
and that of secondary healing intention. The most common
pattern of healing is by secondary intention. The epithelial
adhesion occlusal to the base of the original pocket is
seen at times, but more frequently the collagen adhesion
immediately apical to the newly adhering junctional epithelium
but occlusal to the marginal alveolar crest. In the infrabony
portion of the periodontal lesions, simultaneous and/or
sequential deposition of repair cementum, functionally oriented
ligament fibers and narrowing of the vertical defect by
osteogenesis. It is possible that supracrestal healing following
flap surgery is a connective tissue adherence over a limited
space immediately apical to the junctional epithelial adherence.
Another pattern of healing in connective tissue is the splicing
of fiber ends from the tooth surface with new fibers from
the healing flap wound edge. This occur when the root surface
is not completely devoid of periodontal tissue (whether
due to pathological lesion or mechanical/chemical debridement
). This type of healing can be classified as repair rather
Histologic observation also has indicated that there may
be a newly cementumlike material to be deposited against
the tooth coronal to the crest. This newly deposited cementum
is cellular, not unlike bone, and be best described as repair
cementum (Dragoo and Sullivan 1973, Hawley and Miller 1975).
Listgarten (1972) speaks of this cementum as devoid of well
defined fiber bundle. Again, since the new regenerative
tissue is not exact the same as the original, the healing
process can best be described as repair rather than regeneration.
In a histologic examination of the 13 block sections of
teeth and surrounding tissues which were removed at varying
time interval form the mouth of six patients in the study
of the mucoperiosteal flap healing carried out by Theodore
H. Dedolph and Henry B. Clark in 1958 reveals that at 3
weeks the epithelial attachment was complete, the attachement
of periodontal membrane fibers and other connective tissue
elements was restored, and the inflammatory response was
mild or absent. The appearance was indistinguishable from
that of the control sections and from that of the four week
experimental sections. The flap design should be such that
it should has sufficient size to provide maximum visibility,
wide access, and a broad surface of bone on which the flap
margin may rest for optimum healing. Another study in 1972
by Dale L. Wood, Phillip Hoag, and O. Walter Donnenfeld,
and Leon Rosenfeld reveals of the loss of crestal radicular
bone after both the full thickness and the partial thickness
flap. The mean bone loss for the full thickness flap was
.62 mm, which was statistically significant (p >.01).
The mean bone loss after the partial thickness flaps was
.98mm which was also significant. Thus the bone loss was
greater with the use of partial thickness flap. Other study
has investigated the vascular response and the healing of
the reverse bevel flap. In the study in monkey by Caffesse
and Ramfjord and Nasjletti in 1968, healing following reverse
bevel periodontal flap surgery has been characterized by
first, second, or third intention, depending on the state
of flap adaptation to teeth. Epithelialization regenerate
from the border of the flap is delayed 2 to 4 days due to
the stunning effect of the surgery. Flap separation on top
of the periosteum (split flap) will heal faster than the
mucoperiosteal flap. Finally, the transient lowering of
the attachment level and bone resorption at the alveolar
crest 3 to 4 weeks following flap surgery tend to heal back
to the presurgical level within 10 weeks after the surgery.
Finally, Wirthlin, in his review of the current status of
new attachment therapy, he stated that there are four basic
forms of periodontal therapy used for elimination of the
pocket. These are: shrinkage, excision, healing by scar,
and new attachment. The shrinkage and excision and healing
by scar is demonstrated by examine the tissue side, whereas
the analysis of repair system reveals new attachment on
the tooth side of the periodontal lesions.
Flap surgery has been done as of the beginning of the century.
The technique has evolved very little from the beginning,
though the procedure were carried out for different purpose.
Regardless of different methodology, the healing in flap
surgery can be classified as repair, rather than regeneration.
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.