Flap for Pocket Elimination
By Dinh X. Bui, D.D.S., M.S.
Flap for pocket elimination in the past probably was considered
as the method of choice for eradicating periodontal disease.
Until the advance of guided tissue regenerative technology,
flap for pocket elimination played a major role in disease
control concerning stopping disease progression and provide
a pocket of which the patient can maintain through oral
hygiene. Perhaps it included every surgical therapy possible
since in every surgical therapy whether regenerative or
reattachment or resective for pocket elimination or apically
position flap procedures were done, the end result is always
pocket reduction or elimination. Pocket reduction could
be mainly as a result of the cutting away of the gingival
tissue, gingival recession post op, gaining attachment from
the bottom of gingival pocket, the establishment of the
long junctional epithelium, or the establishment of new
regenerative tissue such as bone, and finally the positioning
of the marginal gingiva during flap closure. Thus flap for
pocket elimination including the original open gingival
curettage, the conservative approach of modified widman
flap, the reverse bevel flap, the apically displaced flap
or apically positioned flap, the distal molar surgery or
distal wedge to eliminate the pocket distally to the last
tooth of the arch. Understanding the rationale, the technique,
and the wound healing allowed us to utilize, alone or combine,
any of the above procedure and more to provide the peridontium
such that can be functioned favorably and maintained by
the patient oral hygiene with the dentist played more of
a supportive role.
Fauchard originally was performing the radical gingivectomy
to remove the excessive tissue in 1742. Followed later was
Pickerill, Zentler, G.V. Black, A.D. Black, Nodine, Crane
and Kaplan, Ziesel, and Ward. Neumann in 1911 introduce
the Neumann flap which the intrasulcular incision was made
along with two vertical releasing incision, a full thickness
flap raised, and the area was curetted thoroughly to eliminate
all the granulation tissue to prevent reinfection. Root
was planed smooth, and bone was superficially removed. Widman
in 1918 introduced his Widman flap which two vertical releasing
and the use of the reverse bevel made parallel to the surfaces
of the teeth 1mm from the the free gingival margin and extending
to the alveolar crest. Only 2 or 3 teeth were included.
Teeth was scaled and bone was conserved unless there is
a need of removal superficially for better soft tissue adaptation
upon closure. The flap was sutured back by interproximal
suture. Zentler in 1918 introduced the flap to America.
The main purpose again was for access for visibility, allowing
complete instrumentation of root and eliminate the granulation
tissue. Up to this time period, there was a popular belief
that bone played a major role or a focal of infection in
the periodontal disease and therefore must be eliminated.
All the surgical procedure, though endpoint was pocket elimination,
was performed with “necrotic” bone removal as
the rationale. This period ends when Kronfeld disprove the
role of bone as the focal source of infection in the etiology
of periodontal disease.
Pocket elimination flap has been a very popular practice
for a long time in the history of Periodontics, dating back
to the day of Kronfeld, who in his paper in 1935 described
the soft tissue lesion rather than bone as the main culprit
of peridontontal disease using bone biopsy taken from the
disease site. Orban briefly later supported this view point
in his own research findings. Periodontist then shifted
the focus from bone to soft tissue and effort were made
to remove the soft tissue via gingivectomy for pocket elimination.
However, several factors have adversely affected the popularity
of this technique: I) the attached gingiva were not preserved,
2) the shallow vestibule as the end result after the surgery,
3) the frenum attachment extending to marginal gingiva,
4) the interest in getting access to the underlying bone
to eliminate infrabony defect, 5) the slow healing of gingivectomy.
In 1939, Lillian Barkann published the paper describing
the conservative surgical technic for the erradication of
the “pyorrhea pocket”. In this procedure, the
pocket contents are evacuated to conserve maximum amount
of tissue. The alveolar process was not touch, and the interproximal
gingiva is more frequently the seat of the infection. The
healthy tissue was not resect and thus with the minimal
surgical incision, there was no need for suture. Lillian
Barkann aimed to “devise a conservative surgical method
for the treatment of Pyorrhea pockets the purpose of which
is the complete removal of proliferated epithelium and the
granulation tissue, so that contact between the root and
the gingiva, in their normal relationship, may be reestablished.
The curetting was prepared with the introduction into the
pocket of strand impregnated with 25% phenol and 7500 camphor.
Phenol act as bactericide, coagulates the pocket lining
and promotes normal granulation. The camphor is analgesic.
This packing was done intermittently with curetting in between,
allow large opening for accessibility. The papilla and pocket
lining then was excised by using the semilunar incision
and reverse bevel respectively. The pocket tissue wall then
was scraped. After all the extraneous matter has been removed,
the pocket is packed with gauze dressing and leaved the
dressing for twenty four hours. The procedure provides the
complete elimination of the infected granulation tissue
within the pocket and a maximum conservation of the gingiva.
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”. In his paper, he described the use
of inverse beveled incision to thin the marginal tissue
and the papillae. This thinning incision eliminates thick
gingival margin and papillae with large triangular pieces
of interdental tissue. A thick tissue would be difficult
to be eliminated from the already raised flap and also created
problem in approximation of tissue for primary intention
healing, resulting in bulbuos or ledging tissue upon healing.
This flap designed could be referred to as the partial full
thickness flap since the marginal papillae was partially
disected with the inverse bevel incision, then this incision
continue to include the mucoperiosteum of the full thickness
flap. Goldman in 1982 introduced another variation of which
he followed the full thickness flap with a partial disection,
allowing the use of periosteal suture to position his flap.
This flap design, he called, the tertiary flap or the partial-full-partial-thickness
flap. Today, the word “reposition” is replaced
by the term “position” since reposition means
place the flap back to where it was before.
Perhaps the flap for pocket elimination therapy should
be subdivided into two categories. The first category is
the conservative approach of which the pocket was eliminated
not
through surgical pocket removal but through the establishment
of reattachment or new attachment at the bottom of the pocket
after healing. This would include all the mucoperiosteal
flap design for reattachment such as modified Widman, ENAP,
open gingival curettage, and the reverse bevel flap. The
second category is the radical approach of which the tissue
was excised or position on the root surface at some point
apically to the original position. This would include the
apical position flap and the distal molar wedge procedures.
The first category was described in the previous paper with
methods, technique, and rationale. This paper will concentrated
more on the second category. The apically positioned full
thickness or partial thickness is the most widely used technique
in Periodontics today. It is used to eliminate pocket, increase
the zone of attached tissue, and relocate the frenula. The
full thickness flap (mucoperiosteal flap) is used when the
bone needed to be access. The partial thickness flap is
used when mucogingival problems as well as in the case of
the bone must be protected due to the problem of dehiscences
or fenestration. The indication for the flap would be for
the case of which the pockets extend beyond the mucogingival
junction, in the areas of minimal keratinized gingiva and
thus this gingiva must be conserved, when the inductive
or resective osseous surgery required, to enhance cleansibility,
to facilitate restorative procedure as in crown lengthening,
and in the case of unesthetic or asymmetrical gingival topography.
The advantages of the use of apical positioned flap is such
that the pocket is eliminated, the keratinized gingiva reserved,
the relocation frenulum can be achieved, the ability to
perform inductive or osseous surgery, the ability to position
the flap at a proper location inducive to primary healing,
the accessibility for root debridement, and tissue manipulation
to allow most favorable position of the flap for optimal
pocket depth, or to expose a furcation area and facilitate
cleaning (tunnelization). The disadvantage would include
the inability to combined with other procedures to increase
the zone of keratinized gingiva without exposure of bone,
the moderate degree of difficulty, the procedure should
not be used in presence of thin periodontium where dehiscences
or fenestrations may exist, and finally the apical positioning
may increase root exposure and sensitivity and cause cosmetic
and phonetic problems, especially anteriorly. Thus the contraindication
would be when the esthetic is the concern especially in
the anterior area, when there is inadequat keratinized gingiva,
when the teeth having a poor prognosis, excessive mobility,
poor crown/root ratio, and advanced attachment loss.
The technique involved placing the proper placement of
the primary or reverse bevel incision base on the amount
of keratinized gingiva present. Friedman divide the patient
into three categories. Class I is when the keratinized gingiva
is more than adequate; the labial or buccal incision was
placed one to three millimeters from the crest of the gingiva;
flap apically positioned to cover one to two millimeters
cementum. Class II is of those patient whom the keratinized
gingiva present is adequate; the crestal incision was used
and the flap positioned to crest of bone. Class Ill is of
those patient whom kereatinized gingiva is inadequate, the
sucular incision with partial thickness flap was used, flap
apically po~ion to one to two millimeter below the crest
of bone to increase the zone of keratinized gingiva. Vertical
incisions are sued to outline the surgical sites and made
at distal or mesial line angles of the terminal teeth. During
the initial incision, the papilla must be thin with the
reverse bevel incision prior to release the flap. This allow
for better adaptation of the flap and better healing. A
secondary incision is made about the necks of the teeth
from the base of the sulcus to the crest of the bone. This
will loosen and allowed for removal of the tissue collar.
Full thickness flap then was raised, followed by scaling
and root planing, degranulation, and osseous surgery was
completed.
The flap can be positioned apically or reposition, depending
on each individualized case. The sling suture is recommended
for better flap placement. Pocket elimination is achieved
only by apically positioning of the flap. Another variation
of this flap technique is the modified apically position
full thickness flap, of which the vertical releasing incision
was not used. This is useful in the anterior area where
a blend of gingival sulcus depth may be desired. The tissue
is undermined and blended into the sulcus of next tooth.
This permits adequate tissue drape so that the vertical
incision becomes unnecessary. The apical position flap usually
are combine with the root surface currettage to allow reattachment
and new attachment to occur. Another variation, the apically
position partial thickness flap is used when there is the
area of thin peridontium or prominent root where dehiscences
or fenestration may be present. The main advantage is allow
for the use of periosteal suture to stabilized the graft,
protect the underlying bone, reduce postop pain and shorten
healing time along with the pocket elimination. The disadvantage
would be cannot be combine with osseous surgery and the
healing is by secondary intention. The good rule of thumb
in deciding whether the partial or full thickness flap should
be use is as followed. If the roots of the teeth can be
palpated or visualized through the tissue, then a partial-thickness
flap should be used. This kind of palpation has been described
as washboard effect and is generally representative of a
thin periodontium with underlying dehiscences or fenestration.
Caranza described in his book of clinical periodontology
the distal molar surgery, used in treatment of the periodontal
pockets on the the distal surface of terminal molars. This
area is complicated by presence of bulbous fibrous tissue
over the maxillary tuberosity or by prominent retromolar
pads in the mandible. Deep vertical defects also might be
occur at the terminal teeth on the distal surface, and this
may result from improper healing of third molar extraction.
In the maxillary arch, the tuberosity preseents the greater
amount of fibrous attached gingiva. Accessibility, amount
of attached gingiva, the pocket depth, and the available
distance from the distal aspect of a tooth to the end of
the tuberosity must be evaluated. The technique most commonly
involved the use of two parallel incision beginning at the
distal portion of the tooth and extending to the mucogingival
junction distal to the tuberosity or retromolar pad. The
width (faciolingual) distance between the two incision dictated
by the depth of the pocket and the amount of the fibrous
tissue involved. The deeper the pocket, the greater the
width. The parallel distal incision should be confined to
the attached gingiva due to the complication of bleeding
and flap management. Next, the transversal incision is placed
at the distal end of the two parallel incisions so that
a long rectangular piece of tissue can be removed. Flap
margin now can be approximate as much as we can to allow
primary healing. In the mandibular molar, the retrmmolar
pad usually does not have that much attached gingiva. This
area of attached gingiva may or may not be found directly
over the bone, or may not be immediately distal to the molar.
The ascending ramus may pose a problem since it recreates
a short horizontal area distal to the molar. Thus the first
two distal incision is placed distobuccally or distolingually,
depending on which area has more attached gingiva. These
two incisions should be the undermining incision to thin
the tissue. The transversal incision may not be used if
there is not enought attached gingiva. The distal incisions
can he joined together distally and should be undermine
directly over the bone. The wedge of tissue (triangular
or rectangular) is removed. Flap can be thinned and osseous
surgery may be perform to allow better flap adaptation.
The indication for the distal molar surgery would be pocket
elimination, reduction of enlarged and bulbous tissue. Contraindication
would be the inadequate attached gingiva or the ramus is
located right next to the distal of the tooth and thus no
area for the wedge to be removed.
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 occurs 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
than regeneration.
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 0. 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 Ramtjord 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.
In 1985, Olsen et al. Published a five year review of the
apically repositioned flap with and without osseous surgery
and found that those areas treated with osseous surgery
had significantly less bleeding and less postoperat1ve~pQcketeing.
Neither treatment produced a gain in attachment. Thus thej~eket
reduction is largely due to the positioning of the flap
apically couple with the gingival recession as the sequelae
of periodontal surgery. In conclusion, regardless the treatment
methodology, all peridontal flap surgery will most likely
produce pocket reduction, whether through gingival recession,
gain in attachment, or positioning of the flap. However,
positioning of the flap at the end of surgery will produce
the most predictable result in term of achieving total pocket
elimination. Apical position flap can be combined with other
surgical procedure to produce an end result of a maintainable
pocket in order to provide a better prognosis in treating
the periodontal disease.
REFERENCE
1. Catl’esse, R.G. Resective procedures. Proceedings
of the world workshop in clinical periodontics, 1989.
2. Caranza, Newman. Textbook of Clinical Periodontology,
WB Saunders, 1996.
3. Cohen, ES. The atlas of cosmetic and reconstructive
periodontal surgery. Lea & Febiger, 1994.
4. Stahl. S.S. Repair or regeneration following periodontal
therapy? Journal of Clinical Peridontology 1979 & 389-396.
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6. Barrington, E.P. An overview of periodontal surgical
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7 Dedolph, T.H., Clark, FIB. A histological study of mucoperiosteal
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thickness flaps, Journal of Periodontology, 43 141,
1972.
9. Caffesse, R.G., Ramfjord, S.P., Nasjleti, C.E. Reverse
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12. Caffesse, R.G, Castelli, W A., and Nasjleti, C.E. Vascular
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15 Ramfjord, S.P., Nissle, R.R. The modified widman flap.
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16. Wirihlin, M.R. The current status of new attachment
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