Jan Lindhe. Clinical Periodontology

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PERIODONTAL SURGERY: ACCESS THERAPY • 525

The apically repositioned flap

In the 1950s and 1960s new surgical techniques for the

removal of soft and, when indicated, hard tissue peri-

odontal pockets were described in the literature. The

importance of maintaining

an adequate zone of attached

gingiva

after surgery was now emphasized. One of the

first authors to describe a technique for the preserva-

tion of the gingiva following surgery was

Nabers

(

1954). The surgical technique developed by Nabers

was originally denoted "repositioning of attached

gingiva" and was later modified by Ariaudo & Tyrrell

(

1957). In 1962

Friedman

proposed the term

apically

repositioned flap

to more appropriately describe the

surgical technique introduced by Nabers. Friedman

emphasized the fact that, at the end of the surgical

procedure, the entire complex of the soft tissues

(

gingiva and alveolar mucosa) rather than the gingiva

alone was displaced in an apical direction. Thus,

rather than excising the amount of gingiva which

would be in excess

after

osseous surgery (if per-

formed), the whole mucogingival complex was main-

tained and apically repositioned. This surgical tech-

nique was used on buccal surfaces in both maxillas

and mandibles and on lingual surfaces in the mandi-

ble, while an excisional technique had to be used on

the palatal aspect of maxillary teeth.

Technique

According to Friedman (1962) the technique should be

performed in the following way:

•

A reverse bevel incision is made using a scalpel with

a Bard-Parker blade (No. 12B or No. 15). How far

from the buccal/lingual gingival margin the inci-

sion should be made is dependent on the pocket

depth as well as the thickness and the width of the

gingiva (Fig. 25-17). If the gingiva preoperatively is

thin and only a narrow zone of keratinized tissue is

present, the incision should be made close to the

tooth. The beveling incision should be given a scal-

loped outline to ensure maximal interproximal cov-

erage of the alveolar bone, when the flap sub-

sequently is repositioned. Vertical releasing inci-

sions extending out into the alveolar mucosa (i.e.

past the mucogingival junction) are made at each of

the end points of the reverse incision, thereby mak

ing possible the apical repositioning of the flap.

•

A full thickness mucoperiosteal flap including buc-

cal/lingual gingiva and alveolar mucosa is raised

means of a mucoperiosteal elevator. The flap has

be elevated beyond the mucogingival line in

order to

later be able to reposition the soft tissue

apically.

The marginal collar of tissue, including

pocket

epithelium and granulation tissue, is re-

moved with

curettes (Fig. 25-18), and the exposed

root surfaces

are carefully scaled and planed.

•

The alveolar bone crest is recontoured with the

objective of recapturing the normal form of the

alveolar process but at a more apical level (Fig.

25-

19). The osseous surgery is performed using burs

and/or bone chisels.

•

Following careful adjustment, the buccal/lingual

flap is repositioned to the level of the newly recon-

toured alveolar bone crest and secured in this posi-

tion (Fig. 25-20). The incisional and excisional tech-

nique used means that it is not always possible to

obtain proper soft tissue coverage of the denuded

interproximal alveolar bone. A periodontal dressing

should therefore be applied to protect the exposed

bone and to retain the soft tissue at the level of the

bone crest (Fig. 25-21). After healing, an "adequate"

zone of gingiva is preserved and no residual pock-

ets should remain.

To handle periodontal pockets on the palatal aspect of

the teeth, Friedman described a modification of the

apically repositioned flap", which he termed the

bev-

eled flap.

Since there is no alveolar mucosa present on

the palatal aspect of the teeth, it is not possible to

reposition the flap in an apical direction.

•

In order to prepare the tissue at the gingival margin

to properly follow the outline of the alveolar bone

crest, a conventional mucoperiosteal flap is first

resected (Fig. 25-22).

•

The tooth surfaces are debrided and osseous recon-

touring is performed (Fig. 25-23).

•

The palatal flap is subsequently replaced and the

gingival margin is prepared and adjusted to the

alveolar bone crest by a secondary scalloped and

beveled incision (Fig. 25-24). The flap is secured in

this position with interproximal sutures (Fig. 25-25).

Among a number of suggested advantages of the

apically

repositioned flap

procedure, the following have

been emphasized:

•

Minimum pocket depth postoperatively.

•

If optimal soft tissue coverage of the alveolar bone

is obtained, the postsurgical bone loss is minimal.

•

The postoperative position of the gingival margin

may be controlled and the entire mucogingival

complex may be maintained.

The sacrifice of periodontal tissues by bone resection

and the subsequent exposure of root surfaces (which

may cause esthetic and root hypersensitivity prob-

lems) were regarded as the main disadvantages of this

technique.

526 • CHAPTER 25

Fig. 25-17.

Apically

repositioned

flap.

Following a vertical

releasing incision, the reverse bevel incision is made

through the gingiva and the periosteum to separate the

inflamed tissue adjacent to the tooth from the flap.

Fig. 25-18.

Apically

repositioned

flap.

A mucoperiosteal

flap is raised and the tissue collar remaining around

the teeth, including the pocket epithelium and the in-

flamed connective tissue, is removed with a currette.

Fig. 25-19.

Apically

repositioned

flap.

Osseous surgery is performed with the use of a rotating bur (a) to recapture the

physiologic contour of the alveolar bone (b).

Fig. 25-20.

Apically repositioned flap.

The flaps are reposi-

tioned in an apical direction to the level of the recon-

toured alveolar bone crest and retained in this position

by sutures.

Fig. 25-21.

Apically

repositioned

flap.

A periodontal dress-

ing is placed over the surgical area to ensure that the

flaps remain in the correct position during healing.

PERIODONTAL SURGERY: ACCESS THERAPY • 527

Fig. 25-22.

Beveled

flap.

A primary incision is made intracrevicularly through the bottom of the periodontal pocket

(

a) and a conventional mucoperiosteal flap is elevated (b).

Fig. 25-23.

Beveled

flap.

Scaling, root planing and osse- Fig. 25-24.

Beveled

flap.

The palatal flap is replaced and

ous recontouring is performed in the surgical area. a secondary, scalloped, reverse bevel incision is made

to adjust

the length of the flap to the height of the re

maining

alveolar bone.

Fig. 25-25.

Beveled

flap.

The shortened and thinned flap

is replaced over the alveolar bone and in close contact

with the root surfaces.

528 • CHAPTER 25

Fig. 25-26.

Modified Widman flap.

The initial incision is placed 0.5-1

mm from the gingival margin (a)

and parallel to the long axis of the

tooth.

Fig. 25-27.

Modified Widman flap.

Following careful elevation of the

the flaps, a second intracrevicular

incision (a) is made to the alveolar

bone crest (b) to separate the tis-

sue

collar from the root surface.

Fig. 25-28.

Modified Widman flap.

The third incision is made perpen-

dicular to the root surface (a) and

close as possible to the bone

crest (

b), thereby separating the

tissue

collar from the alveolar

bone.

Fig. 25-29.

Modified Widman flap.

(a) Following proper debridement

and currettage of angular bone de-

fects, the flaps are carefully ad-

justed to cover the alveolar bone

and sutured. (b) Complete cover-

age

of the interdental bone as well

close adaptation of the flaps to

the

tooth surfaces should be ac-

complished.

PERIODONTAL SURGERY: ACCESS THERAPY • 529

The modified Widman flap

Ramfjord & Nissle (1974) described the

modified Wid-

man flap

technique, which is also recognized as the

open flap curettage

technique. It should be noted that,

while the

original Widman flap

technique included both

apical displacement of the flaps and osseous recon-

touring (elimination of bony defects) to obtain proper

pocket elimination, the

modified Widman flap

technique

is not intended to meet these objectives.

Technique

•

According to the description by Ramfjord & Nissle

(

1974) the

initial incision

(Fig. 25-26), which may be

performed with a Bard-Parker knife (No. 11),

should be parallel to the long axis of the tooth and

placed approximately 1 mm from the buccal gingi-

val margin in order to properly separate the pocket

epithelium from the flap. If the pockets on the buc-

cal aspects of the teeth are less than 2 mm deep or if

esthetic considerations are important, an intracre-

vicular incision may be made. Furthermore, the

scalloped incision should be extended as far as pos

sible in between the teeth, to allow maximum

amounts of the interdental gingiva to be included

in the flap. A similar incision technique is used on

the palatal aspect. Often, however, the scalloped

outline of the initial incision may be accentuated by

placing the knife at a distance of 1-2 mm from the

midpalatal surface of the teeth. By extending the

incision as far as possible in between the teeth suf-

ficient amounts of tissue can be included in the

palatal flap to allow for proper coverage of the

interproximal bone when the flap is sutured. Verti-

cal releasing incisions are not usually required.

•

Buccal and palatal full thickness flaps are carefully

elevated with a mucoperiosteal elevator. The flap

elevation should be limited and allow only a few

millimeters of the alveolar bone crest to become

exposed. To facilitate the gentle separation of the

collar of pocket epithelium and granulation tissue

from the root surfaces, an intracrevicular incision is

made around the teeth

(second incision)

to the alveo-

lar crest (Fig. 25-27).

• A

third incision

(Fig. 25-28) made in a horizontal

direction and in a position close to the surface of the

alveolar bone crest separates the soft tissue collar of

the root surfaces from the bone.

•

The pocket epithelium and the granulation tissues

are removed by means of curettes. The exposed

roots are carefully scaled and planed, except for a

narrow area close to the alveolar bone crest in which

remnants of attachment fibers may be preserved.

Angular bony defects are carefully curetted.

•

Following the curettage, the flaps are trimmed and

adjusted to the alveolar bone to obtain complete

coverage of the interproximal bone (Fig. 25-29). If

this adaptation cannot be achieved by soft tissue

recontouring, some bone may be removed from the

outer aspects of the alveolar process in order to

facilitate the all-important flap adaptation. The

flaps are sutured together with individual inter-

proximal sutures. Surgical dressing may be placed

over the area to ensure close adaptation of the flaps

to the alveolar bone and root surfaces. The dressing,

as well as the sutures, are removed after 1 week.

The main advantages of the

modified Widman

flap

tech

nique in comparison with other procedures pre-

viously described are, according to Ramfjord & Nissle

(1974):

•

the possibility of obtaining a close adaptation of the

soft tissues to the root surfaces,

•

the minimum of trauma to which the alveolar bone

and the soft connective tissues are exposed and

•

less exposure of the root surfaces, which from an

esthetic point of view is an advantage in the treat-

ment of anterior segments of the dentition.

530 • CHAPTER 25

Fig. 25-30.

Papilla preservation flap.

Intrasulcular incisions are made at the facial and proximal aspects of the teeth.

Fig. 25-31.

Papilla preservation flap.

(a) An intrasulcular incision is made along the lingual/palatal aspect of the teeth

with a semi-lunar incision made across each interdental area. (b) A curette or interproximal knife is used to care

fully free the interdental papilla from the underlying hard tissue. (c-d) The detached interdental tissue is pushed

through the embrasure with a blunt instrument to be included in the facial flap.

The papilla preservation flap

In order to preserve the interdental soft tissues for

maximum soft tissue coverage following surgical in-

tervention involving treatment of proximal osseous

defects, Takei et al. (1985) proposed a surgical ap-

proach called

papilla

preservation technique.

Later,

Cortellini et al. (1995b, 1999) described modifications

of the flap design to be used in combination with

regenerative procedures. For esthetic reasons, the pa-

pilla preservation technique is often utilized in the

surgical treatment of anterior tooth regions.

Technique

• According to the description by Takei et al. (1985)

the

papilla preservation flap technique

is initiated by an

intrasulcular incision at the facial and proximal as-

pects of the teeth without making incisions through

the interdental papillae (Fig. 25-30a,b). Subsequen-

tly, an intrasulcular incision is made along the lin-

gual/palatal aspect of the teeth with a semi-lunar

incision made across each interdental area (Fig. 25-

31a). The semi-lunar incision should dip apically at

least 5 mm from the line-angles of the teeth, which

will allow the interdental tissue to be dissected from

the lingual/palatal aspect so that it can be elevated

intact with the facial flap. In situations where an

osseous defect has a wide extension into the lin-

gual/palatal area, the semi-lunar incision may be

placed on the facial aspect of the interdental area to

have the papillae included with the lingual/palatal

flap.

•

A curette or interproximal knife is used to carefully

free the interdental papilla from the underlying

hard

tissue (Fig. 25-31b). The detached interdental

tissue

is pushed through the embrasure with a blunt

instrument (Fig. 25-31c,d).

•

A full-thickness flap is reflected with a periosteal

elevator on both facial and lingual/palatal surfaces.

The exposed root surfaces are thoroughly scaled

PERIODONTAL SURGERY: ACCESS THERAPY • 531

Fig. 25-32.

Papilla preservation flap.

The flap is replaced and sutures are placed on the palatal aspect of the interden

tal areas.

and root planed and bone defects carefully curetted

(Fig. 25-31d).

•

While holding the reflected flap, the margins of the

flap and the interdental tissue are scraped to remove

pocket epithelium and excessive granulation tissue.

In anterior areas, the trimming of granulation tissue

should be limited in order to maintain the maxi-

mum thickness of tissue.

•

The flaps are repositioned and sutured using cross

mattress sutures (Fig. 25-32). Alternatively, a direct

suture of the semi-lunar incisions can be done as the

only means of flap closure. A surgical dressing may

be placed to protect the surgical area. The dressing

and sutures are removed after 1 week.

Regenerative procedures

In the 1980s treatment of periodontal pockets was

given a new dimension when it was shown that with

specific surgical handling of the periodontal wound a

significant amount of new connective tissue attach-

ment is achievable following surgical treatment (Ny-

man et al. 1982, Bowers et al. 1989).

To obtain periodontal regeneration has always been

a major challenge to the periodontist and several ap-

proaches to periodontal regeneration have been used

throughout the years. The earliest attempts involved

various bone grafting procedures, such as the use of

autogenous grafts from both extraoral and intraoral

donor sites, allogenic marrow grafts and non-decalci-

fied/decalcified lyophilized bone grafts, or "implant"

procedures utilizing slowly resorbable tri-calcium-

phosphate and non-resorbable, non-porous hydroxy-

apatite. Other approaches to periodontal regeneration

involved the use of citric acid for root surface demin-

eralization or the use of methods for improved root

surface biocompatibility or to enhance cellular re-

sponses.

The use of physical barriers, such as membranes

(

non-biodegradable or biodegradable), to retard or

prevent apical migration of epithelium as well as ex-

clude gingival connective tissue from the healing

wound, formed the basis for the concept known as

guided tissue regeneration" (Gottlow et al. 1986). The

procedure can be described as a coronally reposi-

tioned flap procedure without bone recontouring,

with

the adjunctive use of a membrane tightened to the

tooth to cover the exposed root surface and adja

cent

intrabony defect before repositioning of the soft

tissue

flaps.

In the late 1990s a new approach to periodontal

regeneration was presented, which involves the use of

a derivate of enamel matrix proteins (Hammarstrom

1997, Heijl et al. 1997). These proteins are involved in

the embryogenesis of cementum, periodontal liga-

ment and supporting bone, and when applied to the

exposed root surface facing an intrabony periodontal

defect they mediate regeneration of a new attachment

apparatus. The surgical procedure is performed as a

coronally repositioned flap procedure without bone

recontouring. Before repositioning of the soft tissue

flaps, the exposed roots are treated with EDTA for

removal of the "smear layer", followed by the appli-

cation of the derivate of enamel matrix proteins.

Various regenerative procedures for surgical treat-

ment of periodontal lesions, as well as the biological

basis for periodontal regeneration, are discussed in

detail in Chapter 28.

DISTAL WEDGE PROCEDURES

In many cases the treatment of periodontal pockets on

the distal surface of distal molars is complicated by

the presence of bulbous tissues over the tuberosity or

by a prominent retromolar pad. The most direct ap-

proach to pocket elimination in such cases in the

maxilla is the gingivectomy procedure. The incision is

started on the distal surface of the tuberosity and

carried forward to the base of the pocket of the distal

surface of the molar (Fig. 25-33).

However, when only limited amounts of kerati-

nized tissue are present, or none at all, or if a distal

angular bony defect has been diagnosed, the bulbous

tissue should be reduced in size rather than being

removed

in toto.

This may be accomplished by the

distal wedge procedure

(Robinson 1966). This technique

facilitates access to the osseous defect and makes it

possible to preserve sufficient amounts of gingiva and

mucosa to achieve soft tissue coverage.

532 • CHAPTER 25

Fig. 25-33.

Distal wedge procedure.

Simple gingivectomy

incision (broken line) can be used to eliminate a soft tis-

sue pocket and adjacent fibrous tissue pad behind a

maxillary molar.

Fig. 25-35.

Modified distal wedge pro-

cedure. A

deep periodontal pocket

combined with an angular bone

defect at the distal aspect of a max-

illary molar (a). Two parallel re-

verse bevel incisions, one buccal

and one palatal, are made from the

distal surface of the molar to

the

posterior part of the tuberosity

(b-

d), where they are connected with a

buccolingual incision (d).

The

buccal and palatal incisions

are

extended in a mesial direction

along the buccal and palatal sur-

faces of the molar to facilitate flap

elevation.

Fig. 25-34.

Distal

wedge procedure.

(a) Buccal and lingual vertical incisions are made through the retromolar pad to

form a triangle behind a mandibular molar. (b) The triangular-shaped wedge of tissue is dissected from the under-

lying bone and removed. (c) The walls of the buccal and lingual flaps are reduced in thickness by undermining inci-

sions (broken lines). (d) The flaps, which have been trimmed and shortened to avoid overlapping wound margins,

are sutured.

PERIODONTAL SURGERY: ACCESS THERAPY •

533

Fig. 25-36.

Modified distal wedge procedure.

Buccal and palatal flaps are elevated (a) and the rectangular wedge is re-

leased from the tooth and underlying bone by sharp dissection and removed (b).

Fig. 25-37.

Modified distal wedge procedure.

Following bone recontouring and root debridement, the flaps are

trimmed and shortened to avoid overlapping wound margins and sutured (a). A close soft tissue adaptation

should be accomplished to the distal surface of the molar. The remaining fibrous tissue pad distal to the buccolin

gual incision line is "leveled" by the use of a gingivectomy incision (b, c).

Fig. 25-38.

Modified incision tech-

niques in distal wedge procedures.

ensure optimal flap adaptation at

the furcation site the incision tech-

nique may be modified. The

amount of attached keratinized tis-

sue present as well as the accessi-

bility to the retromolar area has to

be considered when placing the in-

cision.

Technique

•

Buccal and lingual incisions are made in a vertical

direction through the tuberosity or retromolar pad

form a triangular wedge (Fig. 25-34a). The facial

and

lingual incisions should be extended in a mesial

direction along the buccal and lingual surfaces of

the

distal molar to facilitate flap elevation.

•

The facial and lingual walls of the tuberosity or

retromolar pad are deflected and the incised wedge

tissue is dissected and separated from the bone

(Fig.

25-34b).

•

The walls of the facial and lingual flaps are then

reduced in thickness by undermining incisions (Fig.

25-34c). Loose tags of tissue are removed and the

root

surfaces are scaled and planed. If necessary, the bone

is recontoured.

•

The buccal and lingual flaps are replaced over the

exposed alveolar bone, and the edges trimmed to

avoid overlapping wound margins. The flaps are

secured in this position with interrupted sutures

(Fig.

25-34d). The sutures are removed after ap

proximately

1 week.

534 • CHAPTER 25

The original distal wedge procedure may be modified

according to individual requirements. Some com-

monly used modifications of the incision technique

are illustrated in Figs. 25-35 to 25-38, all having as a

goal to eliminate the deep pocket and to achieve mu-

cosal coverage of the remaining periodontium.

OSSEOUS SURGERY

The principles of osseous surgery in periodontal ther

apy were outlined by Schluger (1949) and Goldman (

1950). They pointed out that alveolar bone loss

caused by inflammatory periodontal disease often

results in an uneven outline of the bone crest. Since,

according to these authors, the gingival contour is

closely dependent on the contour of the underlying

bone as well as the proximity and anatomy of adjacent

tooth surfaces, the elimination of soft tissue pockets

often has to be combined with osseous reshaping and

the elimination of osseous craters and angular bony

defects to establish and maintain shallow pockets and

optimal gingival contour after surgery.

Osteoplasty

The term

osteoplasty

was introduced by Friedman in

1955. The purpose of osteoplasty is to create a physi

ologic form of the alveolar bone

without

removing any

supporting" bone. Osteoplasty therefore is a tech-

nique analogous to gingivoplasty. Examples of osteo-

plasty are the thinning of thick osseous ledges and the

establishment of a scalloped contour of the buccal

(

lingual and palatal) bone crest (Fig. 25-39). In flap

surgery without bone recontouring, interdental mor-

phology may sometimes preclude optimal mucosal

coverage of the bone postsurgically, even if pro-

nounced scalloping of soft tissue flaps is performed.

In such a situation, removal of non-supporting bone

by vertical grooving to reduce the faciolingual dimen-

sion of the bone in the interdental areas may facilitate

flap adaptation, thereby reducing the risk of bone

denudation as well as reducing the risk of ischemic

necrosis of unsupported mucosal flaps due to flap

margin deficiencies.

Removal of non-supporting bone may sometimes

also be required to gain access for intrabony root

surface debridement. The leveling of interproximal

craters and the elimination (or reduction) of bony

walls of circumferential osseous defects are often re-

ferred to as "osteoplasty" since usually no resection of

supporting bone is required (Fig. 25-40).

Ostectomy

ostectomy,

supporting bone, i.e. bone directly in-

volved in the attachment of the tooth, is removed to

reshape deformities caused by periodontitis in the

Fig. 25-39.

Osteoplasty.

Thick osseous ledges in a

mandibular molar region area are eliminated with the

use of a round bur to facilitate optimal flap adaptation.

Fig. 25-40.

Osteoplasty.

Leveling of an interproximal

bone crater through the removal of the palatal bone

wall. For esthetic reasons the buccal bone wall is main

tained to support the height of the soft tissue.

marginal and interdental bone. Ostectomy is consid

ered to be an important part of surgical techniques

aimed at pocket elimination. As a general rule, how-

ever, care must be exercised when supporting bone is

to be removed.

After exposing the alveolar bone by elevation of a

flap, buccal and/or lingual crater walls are reduced to

the base of the osseous defect using bone chisels and

bone rongeurs (Fig. 25-41). A round bur or a diamond

stone under continuous saline irrigation can also be

used. If bone resection has been carried out in the

interdental area, the buccal and lingual/palatal bone

margins may subsequently have to be recontoured to

compensate for discrepancies in bone height resulting

from the interdental bone resection (Fig. 25-41b). It is

considered important to remove the small peaks of

bone which often remain in the area of the line angles.

The objective of bone surgery is thus to establish a

physiologic" anatomy of the alveolar bone, but at a

more apical level.