Galore International Journal of Health Sciences and Research Vol.3; Issue: 4; Oct.-Dec. 2018 Website: www.gijhsr.com Review Article P-ISSN: 2456-9321

Modified Widman Flap Surgery: At A Glance

Dr. Amit Mani1, Dr Shalakha Devkisan Maniyar2, Dr. Preeti Kale2, Dr. Anurags S2, Dr Komal Thange3

1Professor & HOD, Department of , Rural Dental College, Loni. 2Post-Graduate student, Department of Periodontology, Rural Dental College Loni. 3Post-Graduate student, Department of Orthodontics, Rural Dental College Loni.

Corresponding Author: Dr Shalakha Devkisan Maniyar

ABSTRACT tissues. [5] The aim of the procedure is maximum healing and reattachment of There are numerous surgical procedures of periodontal pockets with minimum loss of which modified Widman flap is a standard periodontal tissues during and after the procedure for open . It was given by surgery. [2] The main characteristics are (Widman 1918, Ramfjord & Nissle 1974, precise incisions, partial flap reflection and Ramfjord 1977). It is classified as access flap operation as the main goal of this is to provide an atraumatic procedure. The main goal is to provide improved visual access to access and visibility to the periodontally [10] involved tissues. It is characterized by precise periodontally involved tissues and incision, partial flap reflection with an “healing” by regeneration or a long atraumatic procedure. The main aim is to with minimum tissue provide healing (regeneration or long junctional loss [5] and Post-operative pain and swelling epithelium formation) and not necessarily are less as is only partially pocket elimination. Post-operative pain and exposed. [5] swelling are minimal as the as the alveolar bone Bone repair within the boundaries of is partially exposed. This article gives an outline lesion occur if procedure is carried out in about the history, indications, contraindications, deep infrabony pockets. [6,7] The amount of advantages, disadvantages, procedure and the healing. bone fill is dependent upon (a) osseous defect anatomy(three-walled defect provide Key words: modified Widman flap, surgical better mold for repair than two-walled), (b) procedure, open debridement. remaining crestal bone, (c) extent of chronic inflammation. Long junctional epithelium is INTRODUCTION found interposed between the regenerated According to Webster's - "Flap is a bone tissue and the root surface. [8,9] It is piece of tissue partly severed from its place also called as access flap operation. [10] of origin for use in surgical grafting and repair of body defects. [1] Flap procedures HISTORICAL BACKGROUND have been used mainly for three purposes Neuman introduced mucoperiosteal flap in (1) surgical elimination of periodontal 1911 pockets; (2) to induce reattachment and The procedure involved up to 6 bone regeneration in periodontal pockets; teeth, also involved intrasulcular incision (3) to correct gingival and mucogingival and two vertical releasing incisions adjacent defects and deficiencies. [2] Widman [3] gave to defect. The flaps were raised up to the reverse bevel scalloping type of gingival mucogingival fold and approximately 2mm incision in 1916 as a modification of of gingiva and bone was removed in the Neumann’s periodontal flap surgery. [4] areas of deep pocket and the flaps were Modified Widman Flap is classified with the sutured back to their position. [4] “access flap operations” as the goal is to Widman in 1916 presented modification of provide access to periodontally involved Neuman’s flap to the Scandinavian Dental

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Association and the same was published in hemisection, root resection, wedge 1918. excisions, osseous implantations etc. [5] Procedure involved an inverse bevel incision 1mm away from the free gingival CONTRAINDICATIONS: margin, extending to alveolar crest and  Narrow band of attached gingiva. [5] continues to interdental papilla with two  Osseous surgical procedures. [5] vertical releasing incisions at the midline of  Insufficient attached gingiva. [3] the teeth to raise a trapezoidal flap. Cieszynskiin in 1914, introduced reverse ADVANTAGES: bevel incision in the periodontal flap  Less sensitivity. [19] operation for access for scaling and removal [11]  Active pathologic aspects of pocket are of granulation tissue and bone. eliminated. [2] Ramfjord and Nissle in 1974 modified the  Less mechanical trauma when compared original Widman flap procedure and coined [19] [12] to closed curettage. the term “Modified Widman flap”.  Root planning with direct vision. [5] Zentler in 1918 gave the use of a crevicular  Minimal bone removal. [19] mucoperiosteal flap for the surgical pocket [19] elimination. [13]  Conservation of periodontal tissue. Kirkland in 1931first described flap  There is an intimate healthy adaptation procedure for reattachment and called it as of tooth surface collagenous connective tissue and epithelium. [5] “Modified flap operation”. The procedure [19] involved incisions made intracrevicularly  Facilitates . [5] through the bottom of the pocket and  Healing with primary intention. [5] scaling and curettage after the elevation of  Crestal bone resorption is minimal. [20] flap. [14]  Pocket closure by reattachment and [21,22] Modified Widman flap surgery first was bone regeneration. brought in by Birger Oestman during the  Reattachment with formation of 1930's and was called a Widman-Oestman . [18] flap. [12]  Post-operative discomfort is less. [5] During 1930’s and 1940’s the periodontal surgery included and DISADVANTAGES: especially in maxillary anterior region  Higher skills required. [19] Oestman’s modification of Widman flap  Exact placement of interproximal flaps. [2] was used for acceptable aesthetic results. [19] The term “modified Widman flap” was  Areas of interproximal bony craters adopted as the procedure was modified by shows flat or concave architecture several persons which included open immediately after removal of surgical [2] subgingival curettage for reattachment. dressing. [2] It should be known that the modified Widman flap is not identical to the original RAMFJORD TECHNIQUE: Widman flap nor to any other similar flap [15,16,17]  Principles of the Three Incisions: procedure. 1. Paramarginal first incision: Severing the soft tissue pocketwall with the 12 INDICATIONS: B scalpel.  Deeper interdental defects and pocket 2. Flap reflection and sulcular incision. [5] depth more than 5-7mm. 3. Horizontal incision: Extends into the  When minimal is interdental areas. [2] desired.  Surgical Protocol:  Can be combined with respective 1. First incision-Paramarginal, methods and special procedures such as scalloping.

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 65 Vol.3; Issue: 4; October-December 2018 Amit Mani et.al. Modified Widman Flap Surgery: At A Glance

2. Full thickness flap reflection. For proper adaptation of flap palatally the 3. Second incision-sulcular scalpel should be slightly directed parallel to 4. Third incision-horizontal. long axis of tooth. [12] (Figure:2) 5. Removal of the delineated soft tissues and osseous curettage. 6. Root planning. 7. Flap repositioning. 8. Suturing.

PROCEDURE: 1. Hygienic and preparatory phase- The procedure should lapse at least 3-4 weeks after hygienic and preparatory phase as it facilitates healing, collagen (Figure:2- Initial incision parallel to long axis of tooth on maturation, precise flap adaptation and palatal aspect.) [12] optimal wound contraction. The gingival shrinkage makes it easy to establish how far Location of this incision is based on the initial incision should be placed for good the thickness of gingiva, width of attached [12] esthetic results. gingiva, contour of marginal gingiva, 2. Sterile technique. gingival objectives and esthetic 3. Adequate anesthesia for pain control. considerations. [10] Incision is started from 4. Initial Incision- the greatest scallop of gingiva around the Scalloped inverse bevel incision using Bard tooth that is distal aspect of tooth. [10] Parker # 11 is given which starts from 0.5 to 5. Flap Reflection- 1.5mm from the margin of gingiva and Full thickness flap only for 2-3 mm is raised extends to the alveolar crest. (Figure:1) with mucoperiosteal elevators to access the It the pockets are greater than 2mm then surface of teeth, alveolar crest and incision is placed at least ½-1mm away interproximal alveolar process. [12] To [12] from the margin. Intracrevicular incision protect the bone from drying out the flap is or incision at the free is allowed to rest against the bone. [12] used when esthetics are important or buccal 6. Second Incision- pockets are shallow. Scalloping incision is Intrasulcular incision is carried around each given on the palatal aspect in order to insure tooth with 12B surgical blade. [5] It is made [12] interproximal adaptation of flap. This between the gingiva and hard structure and incision continues as a wedge excision distal apically extends beyond the base of the [5] to the last tooth. pocket. [5] (Figure:3)

(Figure:3- second Incision)

(Figure:1- Initial Incision) 7. Third incision-

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Horizontal incision is done with a blade in permits tight closure in the interdental areas. the interproximal area. The knife is placed [5] Mattress sutures can be used if the flaps on the alveolar process to cut the collar of are extremely thin. [5] gingival tissues which have been separated 12. Post-operative Measures-Protocol. [5] from buccal or lingual flaps of teeth. [5]  Topical disinfection, e. g., CHX0.1–0.2 (Figure:4) % for at least two weeks.  Systemic medication if indicated; antiphlogistic for 2–3 days, antibiotics.  Topical application of cold packs or ice for 2–3 days to prevent swelling.  Professional evaluation and cleaning 7– 10 days post-operative and after suture removal every 2–3 weeks for two months.

HEALING: (Figure:4- Third Incision) It is by regeneration or by formation of long junctional epithelium. [8,9] There will be soft 8. Removal of Dissected Tissues- tissue recession during healing. [23] Major Curettes are used to remove loosened collar [12] apical shift of soft tissue will occur during of gingival tissue. first 6 months and continues for >1 year. [24] 9. Debridement and Root Planing- Factors influencing the degree of soft tissue Root surface should be cleaned and planed recession and remodeling includes initial in direct vision with the help of curettes and height and thickness of supracresstal flap ultrasonic devices after removal of [5] tissue and amount of crestal bone granulation tissue. Compete removal of resorption. Bone repair occurs within the granulation tissue is not necessary, but if boundaries of infrabony lesions. [7,22] removed will reduce the risk of pathogenic [5] Crestalbone resorption can also be seen. microorganisms. Soft tissues are removed The bone fill amount depends upon; even from the bony surface of intrabony [12] a. Anatomy of osseous defect ( three- lesions. Curettage is done without walled intrabony defect provides better holding the flaps away from the bone for [12] mold) any length of time. Curettage is not done b. The amount of crestal bone resorption, in the region of residual periodontal and membrane attached to roots of teeth which [12] c. Chronic inflammation extent. are close to alveolar crest. Apical cells of junctional epithelium are 10. Flap Adaptation- at the same level on the root that closely Flaps are adapted to each other coincides with presurgical attachment level. interproximally and to the bone with digital [23] [12] A small amount of new cementum can pressure. If the adaptation is incomplete be seen coronal to the apical areas of healed between the flaps and teeth or between periodontal wound. [9] Early stages of buccal and lingual flaps then the flaps have healing, collagen fibers within new to be thinned or some bone may be removed cementum have no specific orientation but from the outer aspects of alveolar processes [12] in later stage fibrils are connected to in order to enhance adaptation. . [2] 11. Suturing- Collagen fibrils are covered by Individual interproximal sutures are to be [2] [12] apatite crystals indicating calcification. given. Deep bites should not be taken as Areas of collagen fibers extended into it will fold the flap margins and prevent [12] calcified newly formed cementum primary healing. The initial incision suggesting that calcification had occurred at

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 67 Vol.3; Issue: 4; October-December 2018 Amit Mani et.al. Modified Widman Flap Surgery: At A Glance the surface of the cementum and had walls rather than the surgical eradication of established connective tissue reattachment the outer walls of the pockets. to the tooth following treatment. [2] REFERENCES DIFFERENCE BETWEEN ORIGINAL 1. Groove P. B. Webster's Third New AND MODIFIED WIDMAN FLAP International Dictionary. Springfield; S. C. SURGERY: Merriam Co; 1961. 1. Initial incision is parallel to long axis of 2. Ramfjord SP. Present Status of the Modified Widman Flap Procedure. J Periodontol. teeth and flaps are less separated from 1977; 48(9):558-65. underlying bone in modified procedure 3. Widman L. The operative treatment of to prevent unnecessary bone resorption. pyorrhea alveolaris, A new surgical method: [12] a paper read at the fifty years' jubilee of the 2. Vertical incisions are not used in Scandinavian dental association Modified Widman procedure. [14] 1916.University of Michigan Library;1918. 3. First incision is at 0.5- 1mm from the 4. Neumann R. Die Alveolarpyorrhoe und ihre margin in Modified Widman procedure Behandlung. Berlin: Meusser; 1920. where as in Original Widman flap it 5. Harpenau A. Hall’s Critical Decisions in starts 1-2mm from the margin. Periodontology and implantology. USA 4. Bone architecture is not corrected in People's Medical Publishing House; 2013. 6. Bengt Rosling, Store Nyman, , Modified Widman procedure whereas Barbro Jern. The healing potential of the minimal recontouring is indicated in periodontal tissues following different Original Widman procedure. techniques of periodontal surgery in 5. After second incision the loose collar of plaque‐free dentitions.A 2‐year clinical tissue is cut with sharp knife which will study. J clin Periodontol. 1976;3(4):233- avoid excessive curettement on root 250. surfaces with intact 7. Polson A.M, Heiji L.C. Osseous repair in attachment. [12] infrabony periodontal defects. J clin 6. Third incision allows removal of collar Periodontol. 1978;5(1):13-23. of tissue in the interproximal area 8. Caton J.G, Zander H.A. Osseous repair of without trauma to the alveolar crest and an infrabony pocket without new attachment of connective tissue. J clin periodontal. interproximal bone. [12] 1976;3(1):54-8. 7. Close interproximal flap adaptation with 9. Caton J, Nyman S, Zander H. Histometric exaggerated palatal scalloping of flap is evaluation of periodontal surgery. II. given much attention in original Connective tissue attachment levels after [12] Widman procedure. four regenerative procedures. J clin periodontal.1980;7(1):224–31. CONCLUSION 10. Saroch N. Periobasics. A textbook of It is well established fact that perridontics and implantology. India; periodontitis is caused by a group of highly Himachal Pradesh: Sushrut;2017. specific microorganisms, organized as a bio- 11. Cieszynski A. Bemerkungen zur Radikal- film on the tooth surface. Hence, therapeutic Chirurgischen Behandlung der sogennante Pyorrhea Alveolaris. Deutsche Monatschr f modalities such as maintenance of oral Zahnheilk.1914;32(1):575. hygiene, debridement by scaling and root 12. Ramjord SP, Nissle RR. Modified Widman planning or open flap debridement in deeper flap. Jperiodontol 1974; 45(8):601-7. and inaccessible areas can be done. Open- 13. Zentler A. Suppurative with flap debridement includes conventional alveolar involvement. J Am Med surgical procedures such as the modified Assoc.1918;71: 1530. Widman flap procedure which mainly aims 14. Kirkland O. The supportive periodontal pus at reattachment and readaptation of pocket pocket; its treatment by modified flap

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operation. J Am Dent Assoc 1931;18(8): 21. Kelly G. P, Cain A. J, Knowles J. W, Nissle 1462-70. R. R, Burgett F. G, Shick R. A, and 15. Ramfjord S. P. Reinsercion. Rev Assoc Ramfjord S. P. Radiographs in clinical Odont Argent.1959; 47(1):275. periodontal trials. J Periodontol.1975; 16. Morris M. L. The unrepositioned 46(1):381-86, 1975. mucoperiosteal flap. Periodontics. 1965;3: 22. Rosling. B, Nyman. S, and Lindhe. J. The 147. effect of systemic plaque control on bone 17. Harvey P. M. Management of advanced regeneration in infrabony pockets. J Clin periodontitis. Part I. Preliminary report of a Periodontol.1976; 3(1): 38-53. method of surgical reconstruction. N Z Dent 23. Lindhe. J, Lang. N.P. Clinical J. 1965;61(285):180-7. periodontology and implant . 18. Frank. R, Fiore-Donno G, Cimasoni G, London: Wiley-Blackwell;2015. Ogilvie A. Gingival reattachment after 24. Lindhe. J, Socransky. S.S, Nyman. S and surgery in man: An electron microscopic Westfelt E. (1987). Dimensional alteration study. J Periodontol.1972;43(10):597-605. of the periodontal tissues following therapy. 19. Cohen. Atlas of cosmetic and reconstructive Inl J of Periodontics Restorative Dent. periodontal surgery. Massachusetts: BC 1987;7(2):9–22. Décor; 2017. 20. Zamet J. S. A comparative clinical study of How to cite this article: Mani A, Maniyar SD, three periodontal surgical techniques. J Clin Kale P et.al. Modified Widman flap surgery: at Periodontol. 1975;2(2):87-97. a glance. Galore International Journal of Health Sciences & Research. 2018; 3(4): 64-69.

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