Flap techniques for periodontal pocket therapy

Question 1

Reasons

Answer 1

• Increase visibility of the root surface and deposits
• Improved access for oral hygiene and supportive periodontal therapy
• Eliminate or reduce pocket depth by removal of the pocket wall
• Expose the area to perform regenerative methods
• Allow more accurate determination of the prognosis

Question 2

Indications for flaps

Answer 2

• Pockets greater than 5mm persisting after phase I therapy.
• Bony pockets and interdental craters
• Furcation areas
• Need for crown lengthening
• Complicated morphology such as deep, narrow pockets where access is not possible

1. Gain access for root debridement
2. Reduction or elimination of pocket depth, so that patient can maintain the root surfaces free of plaque.
3. Reshaping soft and hard tissues to attain a harmonious topography (physiologic architecture).
4. Regeneration of alveolar bone, periodontal ligament and cementum.

Question 3

Contraindications

Answer 3

• Shallow supra-alveolar pockets that can be accessed with conventional scaling and rootplaning.
• Areas where aesthetics may be compromised if flaps are to be raised (such as anterior maxilla).

Question 4

Commonly used flap techniques:

Answer 4

• The modified Widman flap
• The undisplaced (unrepositioned) flap
• The apically displaced flap

Question 5

The modified Widman flap

Answer 5

Designed to:
* Remove inflamed pocket wall
* Provide access for root debridement
* Preserve maximum amount of periodontal tissue
* Indicated when aesthetics are main concern (such as anterior maxilla).

Limitations/ drawbacks of technique:
* Inability to achieve pocket elimination
* Heals with a long junctional epithelium

Question 6

Modified Widman technique

Answer 6

An initial internal bevel incision 0.5 to 2 mm away from the gingival margin, directed to the alveolar crest. Vertical releasing incisions are not required (different from Widman flap).

The gingiva is reflected with a periosteal elevator 2-3 mm from bone. Full thickness mucoperiosteal flap is reflected to permit visualization

A (second) crevicular incision is made from the bottom of the pocket to the bone

After the flap is reflected, a third (horizontal) incision is made in the interdental spaces coronal to bone. The gingival collar is then removed

Tissue tags and granulation tissue are removed with a curette. The root surfaces are examined and scaled. (Root planning with direct vision)

Interrupted direct sutures are placed in each interdental space for complete coverage of interdental spaces

Question 7

The undisplaced (unpositioned) flap

Answer 7

Designed to:
* Improve accessibility for instrumentation
* Removes pocket wall
* Elimination of the pocket

Question 8

The apically displaced flap

Answer 8

**Indications: **
* Improves accessibility and eliminates the pocket, but does the latter by apically positioning the soft tissue wall of the pocket.

• It preserves and/or increases the width of the attached gingiva by transforming the previously unattached keratinized pocket wall into attached tissue.
• Increase in the width of the band of attached gingiva is supposedly based on an apical shift of the mucogingival junction, which includes apical displacement of the muscle attachments.