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 Periodontology, 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 debridement. 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 junctional epithelium 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 alveolar process 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 Galore International Journal of Health Sciences and Research (www.gijhsr.com) 64 Vol.3; Issue: 4; October-December 2018 Amit Mani et.al. Modified Widman Flap Surgery: At A Glance 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 oral hygiene. [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 cementum. [18] flap. [12] Post-operative discomfort is less. [5] During 1930’s and 1940’s the periodontal surgery included gingivectomy 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 gingival recession 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 gingival margin 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- Galore International Journal of Health Sciences and Research (www.gijhsr.com) 66 Vol.3; Issue: 4; October-December 2018 Amit Mani et.al. Modified Widman Flap Surgery: At A Glance Horizontal