Flap for Pocket Elimination
by Dinh X. Bui, D.D.S., M.S.

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.

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, FIB. A histological study of mucoperiosteal flap healing. Journal of Oral Surgery: 16:367, 1958.

8. Wood, D.L , Hoag, P.M., Donnenfeld, OW., 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: I, 1981.

13. Becker, W., Becker, B E., Ochsenbein, CO., Kerry, G., Caffesse, R.G., Morrison,
F 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. Wirihlin, M.R. The current status of new attachment therapy. Journal of’ Periodontology, 52: 529, 1981.

17. Froum, S.J., Coran, M., Thaller, B., Kushner, L., Scopp, LW., Stahl, S.S. Periodontal healing following open debridement flap procedures. 1. Clinical assessment of soft tissue and osseous repair. Journal of Periodontology, 53:8, 1982.

18. Stahl, S.S., Froum, Si., Kushner, L. Periodontal healing following open debridement flap procedures. IL. Histologic observation. Journal of Peridontology, 53: I 5, 1982.

19. Barkann, L. A conservative surgical technic for the eradication of the pyorrhea pocket, Journal of the American Dental Association, 26:61. 1939