HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

PROCEDURE YEAR AUTHOR AIM TECHNIQUE ADVANTAGE LIMITATION

1884 Robicsec Pioneered gingivectomy The line to which the gum is to be Eradication of the open wound.
procedure resected is determined deepened periodontal Healing by secondary
first. pocket and a intention.
Following a straight incision, first local condition which Zone of attached gingiva may
on the labial and then on the lingual could be kept clean more be reduced or eliminated.
GINGIVECTOMY

surface of each tooth, the diseased easily. Alveolar defects may not
tissue should be loosened and lifted revealed if present.
out by means of a hook-shaped Root hypersensitivity
instrument. After elimination
of the soft tissue, the exposed
alveolar bone should be scraped.
The area should then be covered
with some
kind of antibacterial gauze or be
painted with disinfecting
solutions.

1912 Pickerill Coined term

gingivectomy

1918 Zentler Scalloped incision

G.V BLACK
Ward Obliteration method
Crane
Kalpan

1951 Goldman Procedure employed The primary scalloped incision. and Pocket elimination, Possible only in the region of
today the incision is terminated at a level gingival recontouring; the attached
apical to the "bottom" of gingiva
the pocket and is angulated to give open wound; secondary
the cut surface a distinct bevel The healing
secondary incision through possible esthetic
the interdental area is performed with problem
the use of a Waerhaug knife. The no approach to osseous
detached gingiva is removed defects.
with a scaler

1979 Grant et al "the excision of the soft

tissue wall of a
pathologic periodontal
pocket".

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

Flap procedures
PROCEDURE YEAR AUTHOR AIM TECHNIQUE ADVANTAGE LIMITATION
1918 Leonard "The operative Two releasing incisions demarcate less discomfort for the extensive
Widman treatment of pyorrhea the area scheduled for surgical patient, since healing sacrifice of non-
alveolaris" Widman therapy. A occurred inflamed tissues
Original Widman flap

described scalloped reverse bevel incision is by primary intention and and

a mucoperiosteal flap made in the gingival margin to that it was possible to apical
design aimed at connect the two releasing incisions. reestablish a proper displacement of
removing The collar of inflamed contour the gingival
the pocket epithelium gingival tissue is removed of the alveolar bone in margin.
and the inflamed following the elevation of a sites with angular bony
connective mucoperiosteal flap. defects.
tissue, thereby By bone recontouring, a
facilitating optimal "physiologic" contour of the
cleaning of the alveolar bone may be
root surfaces. reestablished.
1920 Neumann an intracrevicular incision was
made through the
base of the gingival pockets, and
elevated
mucoperiosteal flap. Sectional
releasing incisions were made to
demarcate the area of surgery. the
inside of the flap was curetted to
The Neumann flap

remove the pocket epithelium and

the
granulation tissue. The root
surfaces were subsequently
carefully "cleaned". Any
irregularities of
the alveolar bone were corrected to
give the bone crest a horizontal
outline.
• The flaps were then trimmed to
allow both an optimal
adaptation to the teeth and a proper
coverage

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

1931 Kirkland treatment of incisions were made

"periodontal intracrevicularly
pus pockets" an through the bottom of the
access flap for pocket The incisions were
proper extended in a
root debridement. mesial and distal direction.
The modified flap operation

• The gingiva was retracted

labially and lingually to
expose the diseased root
surfaces which
were carefully debrided .
Angular bony
defects were curetted.
• Following the elimination of
the pocket epithelium
and granulation tissue from the
inner surface of the
flaps, these were re-placed to
their original position
and secured with interproximal
sutures

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

The apically importance of

positioned maintaining an
flap adequate zone of
attached
gingiva
1954 Naber’s "repositioning of one vertical releasing incision
attached mesial to area of deepest
gingiva" pocket

1957 Ariaudo & modified Naber’s Two vertical releasing incision

tyrell technique

1962 Friedman proposed the term Following a vertical Minimum pocket The sacrifice of
apically releasing incision, the reverse depth periodontal tissues by
repositioned flap bevel incision is made postoperatively. bone resection
through the gingiva and the • If optimal soft and the subsequent
periosteum to separate the tissue coverage of exposure of root surfaces
inflamed tissue adjacent to the the alveolar bone (which
tooth from the flap A is obtained, the may cause esthetic and
mucoperiosteal postsurgical bone root hypersensitivity
flap is raised and the tissue loss is minimal. problems
collar remaining around • The postoperative
the teeth, including the pocket position of the
epithelium and the inflamed gingival margin
connective tissue, is removed may be controlled
with a curette Osseous surgery and the entire
is performed with the use of a mucogingival
rotating bur to recapture the complex may be
physiologic contour of the maintained
alveolar bone Apically
repositioned flap. The flaps are
repositioned
in an apical direction to the
level of the recontoured
alveolar bone crest and
retained in this position
by sutures.

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

Friedman To handle A primary incision is made

periodontal pockets intracrevicularly through the
on the palatal aspect bottom of the periodontal
of the teeth pocket and a conventional
mucoperiosteal flap is elevated
The palatal flap is replaced and
Beveled flap

a secondary, scalloped, reverse

bevel incision is made to adjust
the length of the flap to the
height of the remaining
alveolar bone.
. The shortened and thinned
flap
is replaced over the alveolar
bone and in close contact
with the root surfaces.
Unrepositio

mucoperios

1965 Morris
teal flap
ned

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

• Root cleaning with

The modified Widman flap (open flap curettage
1974 Ramfjord exposing the The initial incision is placed Lack of or very thin and
& Nissle root surfaces for 0.5-1 direct vision narrow attached gingiva
meticulous mm from the gingival margin • “Tissue friendly” can render the technique
instrumentation and and parallel to the long axis of • Reparative, with difficult
for the removal the tooth. Following careful healing by primary osseous surgical
of the pocket lining elevation of the intention procedures
the flaps, a second • Minimal crestal (expansive osteoplasty or
technique)

intracrevicular bone resorption ostectomy) with very

incision is made to the alveolar • Lack of post- deep osseous
bone crest to separate the operative discomfort defects and irregular
tissue collar from the root bone loss facially and
surface The third incision is orally,
made perpendicular and if apical flap
to the root surface and as close repositioning is planned
as possible to the bone crest
thereby separating the tissue
collar from the alveolar bone.

soft-tissue pocket
Undisplaced flap

wall is removed with

the
initial incision; thus,
it may be considered
an “internal bevel
gingivectomy.”
Preservatio

1956 Kromer designed to retain

Papilla

osseous implant
n

1973 App retained the

Papilla
Intact

interdental gingiva
Flap

in the buccal flap

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

Evian et al preserved the

interdental gingiva
in the facial flap,
which exposed
osseous margins on
the labial and the
interproximal zone,
while the palatal
tissues were
reflected separately

1984 Genon and Esthetic treatment

Bender of the maxillary
anteriors.
1985 Takei et al preserve the An intrasulcular incision is Esthetically pleasing Technically difficult
interdental soft made along the lingual/palatal Prevention of Time consuming
tissues for aspect of the teeth postoperative tissue
The Papilla preservation flap

maximum soft tissue with a semi-lunar incision craters

coverage following made across each interdental
surgical intervention area. A curette or
involving treatment interproximal knife is used to
of proximal osseous carefully
defects free the interdental papilla
from the underlying hard
tissue. The detached interdental
tissue is pushed
through the embrasure with a
blunt instrument to be included
in the facial flap

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

1988 Checchi et horizontal incision

modification of papilla a over the
preservation flap interproximal area,
in the opposite side
of the bone defect
was deemed ideal as
it allowed protection
of the regenerated
area from the oral
environment

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

1995 cortellini Primary intrasulcular

et al incision(buccal and
interproximal) involving two
teeth neighboring the defect is
made. A horizontal incision is
traced in the buccal gingiva of
the interdental space at the
base of the papilla. This
horizontal incision is then
connected with the primary
incision in the most apical
portion of the buccal gingival
of the neighboring teeth and a
Modified Papilla Preservation flap

full thickness buccal flap was

elevated to the level of the
buccal alveolar crest. Buccal
and interproximal primary
incision is continued
intrasulcularly in the
interproximal space and
extended to the palatal aspect
A buccal horizontal incision is
performed in the interproximal
supracrestal connective tissue,
coronal to the bone crest, to
dissect the papilla. The papilla
is then elevated towards
palatal aspect. Following
extension of the palatal
incision, a full thickness palatal
flap including the interdental
papilla was elevated to fully
expose the defect. The tissue
thickness of papilla is reduced
to permit coronal advancement
of the flap. Vertical releasing
incision divergent in corono-
apical direction extending in to
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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

the alveolar mucosa can be

placed in the interproximal
spaces neighboring the defect
if coronal advancement of the
flap is desired

1999 Cortellini An oblique incision is made

et al across the defect associated
papilla from the gingival
margin at the buccal line angle
of the involved tooth to reach
the mid interproximal portion
of the papilla under the contact
point of the adjacent tooth. The
oblique incision continues
intrasulcularly in the buccal
Simplified papilla preservation flap

aspect of the teeth

neighbouring the defect and
extended to partially dissect the
papillae of the adjacent
interdental spaces allowing the
elevation of a buccal flap with
2-3 mm exposure of alveolar
bone. A buccolingual
horizontal incision at the base
of papilla close to the
interproximal crest is made.
Intrasulcular incisions are
continued in the palatal aspects
of the two teeth neighbouring
the defect and extended into
the interdental papilla of
adjacent interdental spaces,
following which a full
thickness palatal flap
including the interdental
papilla is elevated

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

periodontol
surgery(ter
1995 Harell & to minimize wound
Minimal
invasive
Ress & flap reflection

ogy)
m in

1999 Wickham described the

and techniques of using
Fitzpatric smaller incisions

2007 Cortellini to stress the aspects The buccal and the lingual reduce surgical Generalized horizontal
Minimal invasive surgical

& Tonetti of wound and blood intrasulcular incisions are trauma, increase bone defect
clot stability and restricted to the teeth flap/wound stability Multiple interconnected
primary wound neighbouring the defect; the allow stable primary vertical defects, walls.
technique

closure for blood- buccal and lingual full closure of the wound it requires special
clot protection thickness flaps are therefore reduce surgical chair equipment.
elevated with minimal mesio- time, and minimize specialist training is
distal and corono-apical patient discomfort probably required,
extensions, the aim being to and side effects.
expose the coronal edge of the
residual bone crest.

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

2009 Cortellini concept of space The triangular buccal flap is

& Tonetti provision for minimally elevated in order to
regeneration expose the residual buccal
bone crest. According to the
width of the interproximal
space, the incision of the
buccal aspect of the papilla
follows the same principles
described in the MIST
approach. Once the buccal flap
has been elevated, the
supracrestal interdental tissue
Modified MIST

is dissected from the

granulation tissue by means of
a mini-blade. The interdental
papilla is not detached from the
residual interdental bone crest
and supracrestal fibres, and the
palatal flap is not elevated. The
granulation tissue is further
dissected from the bone with
the mini-blade and then
removed by means of mini-
curettes. Then, the root surface
is thoroughly scaled and planed
by the combined action of
mini-curettes and
sonic/ultrasonic instruments.

2014 Harrel et al to evaluate residual

Videoscope Assisted
minimally invasive

defects following
nonsurgical therapy
consisting of root
surgery

planing with local

anesthetic V-MIS was
performed utilizing
the videoscope for
surgical visualization

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 HISTORICAL EVOLUTION OF PERIODONTAL FLAP SURGERY

minimally invasive uses end effectors and cumbersome to use,

Robot-assisted

surgery manipulators of the robotic expensive, and needs

arms to perform the actual expertise
surgery on the patient. These
arms can either be controlled
by a telemanipulator or through
computer control.

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