Present Status of the Modified 4

Cieszynski in 1914 in a discussion referred to peri­

odontal flap surgery for access for scaling and removal
Widman Flap Procedure* of granulation tissue and reduction of pocket depth.
However, no description of the methodology was
given.
3
The English edition of Widman's article in 1918
by gives a detailed description of a mucoperiosteal flap
SIGURD P. RAMFJORD, L.D.S., PH.D.f design which separates the collar of epithelium and
inflamed connective tissue around the neck of the teeth
1
from the flap. Subsequently, this soft tissue collar is
A C C O R D I N G TO W E B S T E R ' S dictionary: "flap is a piece
removed and the bone is trimmed to reconstruct "the
of tissue partly severed from its place of origin for use
same anatomical form as in ordinary alveolar atrophy".
in surgical grafting and repair of body defects". Tradi­
The buccal and lingual flaps do not fit together inter-
tionally flap procedures have been used for three pur­
proximally and the bone is left bare to granulate over in
poses in periodontics: (1) surgical elimination of peri­
a way similar to common practice in current pocket
odontal pockets; (2) to induce reattachment and bone 23
elimination flap surgery.
regeneration in periodontal pockets; (3) to correct gin­ 33
Widman in a modification of his original technique
gival and mucogingival defects and deficiencies. A flap
is the first person to describe the reverse bevel incision,
procedure originally developed for one of these objec­
although it had been alluded to previously by Cieszyn­
tives may later have been used to serve a second or 4
ski.
third purpose. 5
Zentler in 1918 also described the use of a crevic­
HISTORICAL B A C K G R O U N D ular mucoperiosteal flap in a manner similar to what
Neumann described in 1920. A l l of these early flap
It has always been difficult to establish priorities of
procedures were developed for the purpose of surgical
procedures used in dentistry, because oral communica­
pocket elimination.
tions often have preceded written descriptions and the
Apparently the first description of a flap procedure
descriptions have not always been written by the person 6
for the purpose of reattachment was given by K i r k l a n d
who gave the oral communication. Language barriers
in 1931. H e used the basic gingival mucoperiosteal flap
may also have contributed to the numerous misinter­
design of Neumann (1920) for the initial flap, but
pretations and disregard of historical data in the peri­
instead of trimming the flap for surgical pocket elimina­
odontal literature.
2
tion, he attempted to eliminate the crevicular epithelial
Neumann in 1912 and 1915 described a semilunar
lining and the inflamed connective tissues by curettage
incision in the gingiva for access to the root surfaces
of the flap. His method has been used since by several
and the alveolar crest. The description is vague and 7,8
investigators as "open subgingival curettage" or
certainly does not delineate a flap operation for surgical
"flap curettage" and judging on the basis of clinical
pocket elimination. However, in the third edition of
probing, this method has provided a significant reduc­
Neumann's textbook in 1920, a mucoperiosteal peri­
2
tion in pocket depth both from gingival recession and
odontal flap procedure is well described. Following 8
reattachment (average 3 mm in one study).
elevation of a crevicular mucoperiosteal flap, the in­
More often used for reattachment therapy however is
flamed tissues on the inside of the flap are removed 9 - 1 2 , 2 4
the reverse bevel gingival mucoperiosteal f l a p of
with sharp spoons as are tissues adherrent to the teeth
the Widman design, but without Widman's original
and the alveolar process. H e stresses that the surgery
attempt at surgical pocket elimination and without his
should result in horizontal alveolar gingival atrophy.
recommended postsurgical exposure of the interdental
Bony spurs and ledges are removed with a chisel until 12
bone. The method that we have described as modified
the alveolar process has the appearance of horizontal
Widman flap surgery first was brought to my attention
bony atrophy. Then he trims the flap so it fits snugly
in lectures by a Swedish dentist by the name of Birger
over the bone and to the surface of the teeth interproxi-
Oestman during the 1930's. However, I have not been
mally as well as bucally and lingually. H e even recom­
able to find any publication by D r . Oestman describing
mends recontouring of the gingiva with a cauter if the
his flap design which was called a Widman-Oestman
contour following the healing of the flap surgery is not
flap. During the 1930's and 1940's gingivectomy was
as desired.
3
the most popular form of periodontal surgery and Oest-
Widman in 1916 appears to have been the first to man's modification of the Widman flap was used only
describe flap surgery for pocket elimination. Although, for very advanced cases of periodontal disease espe­
cially in the maxillary anterior region in order to
achieve acceptable esthetic results. This procedure as
* This work was in part supported by Grant #DE 02731 used off and on for many years was published in Span­
U.S.P.H.S. 9

† The University of Michigan School of Dentistry, Department of

ish in 1959. A similar flap procedure later was de­
10
Periodontics, Ann Arbor, Mich 48109. scribed by M o r r i s under the designation of "the unre-

558
Volume 48
Number 9 Modified Widman Flap Procedure 559

positioned mucoperiosteal flap", and by H a r v e y as11

only 1 to 2 mm from the alveolar crest as needed for
"surgical reconstruction." access to the root surfaces and the interproximal bone.
The term "modified Widman flap" was adopted to A second incision is made around the neck of each
designate a flap procedure which has been modified by tooth from the bottom of the pocket to the alveolar
several persons and came to designate an open subgin­ crest. This incision should not scratch the surfaces of
gival curettage for reattachment, although the original the teeth. The third and final incision is made with a
purpose of the Widman flap was surgical pocket elimi­ spear shaped narrow interproximal knife, as for in­
nation. Widman's name was retained in the designation stance, an Orban knife which has been sharpened many
since modifications by Oestman and others were based times. The buccal and/or lingual flaps are deflected by
on Widman's original reverse bevel design, and W i d ­ the flat surface of the knife or held aside by the assist­
man apparently deserves the credit for introducing a ant so the knife will be placed on top of the alveolar
reverse bevel mucoperiosteal flap in periodontal sur­ crest to dissect free the collar of gingival tissues, which
gery. It should be understood however, that the modi­ has been separated from the buccal and lingual gingival
fied Widman flap is not identical to the original W i d ­ flaps and the teeth. This last incision should follow as
man flap. Neither is it identical to any other similar flap much as possible the surface of the alveolar crest and
procedure. 9-11
the interproximal bony septa. Care should be taken not
to nick the root surfaces with the knife. The separated
SURGICAL TECHNIQUES
collar of gingival tissue is then removed with curettes.
The parts of the root surfaces that are not covered by
The technique for the modified Widman flap surgery attached periodontal fiber endings should be carefully
12
has been described in detail in 1974, so only a brief planed with curettes. Indiscriminate curettage of resid­
summary will be given here. ual fiber attachment should be avoided since such ac­
The flap surgery should not be initiated until 1 or 2 tion may interfere with connective tissue h e a l i n g . 13,14

months after completion of the hygienic phase of the A l l soft tissues are removed from the bony surfaces of
periodontal therapy. The initial gingival incision should intrabony lesions as recommended in 1931 by K i r k -
be made with a knife that can be directed parallel to the 6
land. The removal of suprabony soft tissues should be
long axis of the tooth. If the'buccal or lingual pockets accomplished with sharp dissection rather than curett­
are deeper than 2 mm this initial incision should be ing the bony surfaces to the extent that bone is re­
placed at least ½ mm away from the free gingival moved. A v o i d prolonged deflection of the flaps and
margin in order to assure complete removal of all drying of the bone. Use a sterile saline solution for
crevicular epithelium, which otherwise would prevent irrigation, and suction rather than sponges when vision
connective tissue reattachment to the tooth following is needed. The flaps should be adapted to the bone and
the surgery. If the buccal crevice is 2 mm or less and/or meet interproximally. H o l d the flaps firmly in position
esthetic considerations are of great importance, one with finger pressure and sterile gauze moistened in
may use an intracrevicular or crestal incision starting at saline. If the adaptation of the flaps to the teeth and to
the free gingival margin to minimize postsurgical gingi­ each other interproximally is incomplete, the flaps may
val shrinkage. The initial incision is continued toward be trimmed or some bone removed from the outer
the interproximal areas with a scalloping outline for the aspects of the alveolar process in order to enhance the
flap, which means that as the interproximal spaces are all important flap adaptation. The flaps are sutured
approached, the incision should be brought close to the together with individual interproximal sutures and 3%
tooth at the gingival margin, since the contour of the Achromycin ointment is placed over the sutures and
tooth determines that an incision parallel with the long along the flap contacts with the teeth, then a surgical
axis of the tooth will reach the alveolar process 2 to 3 dressing is placed. After a week this dressing is re­
mm away from the tooth surface and thus separate the moved, the sutures are removed, the teeth are polished
pocket epithelium from the flap. It is important for and the patient is instructed in oral hygiene. It is advis­
postoperative flap adaptation that only the very mini­ able to have the patient come in for professional polish­
mum of interproximal tissues are removed for elimina­ ing of the teeth once a week for the first month follow­
tion of the epithelial lining of the pockets. When the ing flap surgery in addition to maintaining good oral
roots of the teeth are situated closely together, it is hygiene at home. A recall schedule for prophylaxis
advisable to make the initial incision in such a manner once every 3 months is recommended for the future.
that the interproximal papillae under the contact points
will be separated from the flap and later removed. In
order to assure flap coverage of the interproximal bone A D V A N T A G E S A N D D I S A D V A N T A G E S OF T H E

following the surgery, it is often advisable to exaggerate MODIFIED W I D M A N FLAP

the scalloping effect of the initial incision by staying 1 The main advantage of the modified Widman flap
to 2 mm away from the midpalatal surface of the teeth, procedure compared to curettage is the possibility of
while the interproximal incisions come close to the establishing an intimate postoperative adaptation of
tooth surfaces. Vertical gingival releasing incisions are healthy collagenous connective tissue and normal epi­
usually not needed. A full thickness flap is elevated for thelium to contacting tooth surfaces. It has been shown
 J. Periodontol.
560 Ram fiord September, 1977

23
15 16
in both animals and humans that with close adapta­ with or without apical repositioning, interproximal
tion of the gingival tissues to the tooth surface, a mar­ bone and sometimes the root surfaces are left denuded
ginal new epithelial attachment forms which tends to at the termination of the surgery. Eventually such an
seal off the deeper area of the separation between the area will granulate over and healing occurs at a more
tooth and the surrounding connective tissues. Thus, the apical level than following the modified Widman flap
24
healing connective tissues may adapt as close to the procedure. In order to achieve pocket elimination and
17
clean tooth surface as to an implant. Reattachment minimal return of pocket depth, the conventional type
18
with formation of cementum may develop gradually of reverse bevel flap surgery utilizes much more bone
from the apical aspect of the lesion. Minimal or no removal than the modified Widman procedure. A l ­
inflammation is present in the area of connective tissue though some reduction of pocket depth by shrinkage
adaptation in such cases indicating that the active path­ also follows the modified Widman flap surgery, the
ologic aspect of the pocket has been eliminated as a chief aim of this operation is maximum healing and
source of irritation. Apparently, the new marginal epi­ reattachment of periodontal pockets with minimum
thelial attachment acts as a protective umbrella against loss of periodontal tissues during and after the surgery.
bacterial penetration along the surface of the tooth. Bone may heal into an intrabony lesion following a
Such areas may gradually develop a long thin epithelial 25
variety of periodontal procedures and such results are
14,34,36
attachment, which conceivably with persistant most desirable. However, it also has been found that in
irritation may open up again as a pathologic pocket. many instances when lost bone has not been regener­
It is well established that reattachment can occur ated to any appreciable extent, judged from repeated
19
following lateral sliding flaps. Since the interproximal roentgenograms over several years, there may appear a
tissues are biologically identical to the labial tissues, it consolidation of the bone crests and no indication of
appears that with equally good flap adaptation inter- further bone loss, although, a thin probe may be in­
proximally as is obtained bucally in laterally sliding serted several millimeters along the tooth surface with­
flaps, reattachment and readaptation should be ob­ out bleeding, exudate and/or pain at the location of the
26
tained equally well interproximally as buccally. previous pocket. While in other areas with obvious
A n electron microscopic study by Listgarten has 20
inflamed periodontal pockets there is a continuous loss
elucidated the ultrastructural features of healing be­ of bone with time. It thus appears that the modified
tween a surgical flap and the denuded tooth surface in Widman flap surgery may be successful in maintenance
monkeys. Similar findings in humans also have been of periodontal support and health by the mechanism of
1 8
reported by Frank et a l . Regeneration of the junc­ a long epithelial attachment and close connective tissue
tional epithelium occurred against dentin and cemen­ adaptation with or without reattachment of connective
tum. The ultrastructure of the reformed epithelial at­ tissue, and with or without regeneration of bone. This
tachment was in every way similar to undisturbed junc­ concept of epithelial reattachment and close adaptation
tional epithelium with hemidesmosomes, basement to the tooth, and, connective tissue adaptation with or
lamina and several layers of elongated epithelial cells without reattachment as a substitute for surgical pocket
parallel to the tooth surface. Connective tissue attach­ elimination in the maintenance of periodontal health
ment and cemental regeneration over both exposed and support, has been questioned by many clinicians
21
cementum and dentin was described. The junction who have been trained to equate success of periodontal
27
between the exposed tooth surface and the newly therapy with pocket elimination. Periodontal surgery
formed cementum consisted of a densely stained granu­ traditionally has been considered a failure when a
lar layer free of collagen fibrils which had a tendency to probe could be inserted more than 3 mm during follow-
split during the preparation of sections. During early up examinations.
stages of healing, the collagen fibers within the new It has been established that prior to periodontal
cementum had no specific orientation, but at a later treatment a thin periodontal probe used to measure
stage bundles of fibrils appeared to be connected to pocket depth will penetrate to the connective tissue
gingival fibers. Several groups of two or three collagen attachment at the bottom of the p o c k e t .39,40
However,
fibrils were covered by apatite crystals indicating calci­ following periodontal therapy the probe may or may
fication. Other areas of collagen fibers extended into 38
not penetrate between the entire junctional epithe­
calcified newly formed cementum indicating that calci­ lium and the tooth surface. It is also impossible to tell
fication had occurred at the surface of the cementum whether the probe actually is separating junctional epi­
and had established connective tissue reattachment to thelium from the tooth surface or just moving along
the tooth following treatment. Electron microscopic crevicular epithelium closely adapted but not attached
observations of the dental gingival junction following a to the tooth.
lateral sliding flap operation covering a previously de­ Although of great academic interest, it is of little
nuded labial surface of a tooth has confirmed that clinical significance whether the attachment level re­
healing similar to the experimental flaps also may occur corded post treatment is connective tissue or epithe­
22
to a pathologically exposed tooth surface. lium as long as both the attachment level and the
With the conventional types of reverse bevel flaps underlying bone can be maintained without further loss
 Volume 48
Number 9 Modified Widman Flap Procedure 561

and even with some gain over many years. Admittedly, will eventually reinfect the pocket although there may
4 2
a long epithelial attachment or close epithelial adapta­ be an apparent initial healing
tion may represent an anatomical defect which may be It is becoming more and more evident that success
at least partially penetrated by probing, but as long as following any type of periodontal treatment is beyond
there is no sign of bleeding or secretion during routine everything else dependent on creation and mainte­
probing, the defect should not be considered as an nance of a tooth surface which is biologically acceptable
active pathological pocket. The obvious reason for lack to the adjacent soft tissues. This means elimination and
of clinically visible inflammation in these defects is prevention of subgingival plaque formation.
absence of stainable subgingival plaque on the root The modified Widman flap procedure provides ac­
surfaces when the pocket wall is deflected from the cess for proper instrumentation of the roof surfaces and
tooth. immediate closure at the dentogingival junction be­
According to recent tissue culture studies, close 41
tween the teeth and well fitting flaps. It is important
adaptation of cells to a root surface that has been that this junction also is covered by an Achromycin
exposed in a periodontal pocket requires some removal ointment and a surgical dressing to prevent plaque
or treatment of the cementum in addition to complete invasion during the first week of healing and tissue
plaque and calculus removal. It has been shown that if adaptation to the tooth.
plaque is left on the root surface during root planing it It appears that plaque control and frequent profes-

MESIAL POCKET DEPTH REDUCTION FOR TEETH WITH INITIAL MESIAL

POCKETS OF 7-12 mm BY TREATMENT METHOD

ATTACHMENT LEVEL CHANGE FOR TEETH WITH INITIAL MESIAL POCKETS

OF 7-12 mm BY TREATMENT METHOD

FIGURE 1. (top) Average pocket reduction for 7- to 12-mm pockets. Note that the initial reduction is sustained well for all methods of
treatment, but best following the modified Widman flap surgery. Bottom figure shows an average gain of attachment over 7 years
following all three methods, but better following the modified Widman procedure than following surgical pocket elimination. All
graft illustrations in this paper are based on data from 105 patients studied longitudinally over 7 years.
 J. Periodontol.
562 Ramfjord September, 1977

sional cleaning of the teeth is more important for the INTERPROXIMAL RECESSION FOR MANDIBULAR
success of periodontal surgery than the type of opera­ ANTERIORS BY TREATMENT METHOD-SEVERE DISEASE
tion. However, more attachment and new bone forma­
tion occurred following the modified Widman proce­
dure than following other surgical methods on the basis
of recall every 2 weeks for prophylaxis and strong
35
emphasis on a plaque free mouth in a Swedish study.
However, in our longitudinal studies, often with less
37
than optimal plaque control, and recall for profes-

INTERPROXIMAL ATTACHMENT CHANGE FOR MANDIBULAR

ANTERIORS BY TREATMENT METHOD-SEVERE DISEASE

FIGURE 4. More recession is seen following pocket elimination

surgery than following curettage and modified Widman flap
surgery (mandibular anterior teeth with initial pockets of 7- to
12-mm.

sional prophylaxis every 3 months, excellent results

FIGURE 2. Average gain in interproximal attachment following have been maintained over 7 years of control. It also
treatment of 7- to 12-mm deep pockets. Note no gain following
pocket elimination surgery. Mandibular anterior teeth.
appears that recall t>nce or twice a year for prophylaxis
29
may be inadequate for successful maintenance care.
The key to success of periodontal treatment is optimal
INTERPROXIMAL POCKET REDUCTION FOR MANDIBULAR healing within the pocket and prevention of new
ANTERIORS BY TREATMENT METHOD-SEVERE DISEASE subgingival plaque extension. This may be achieved by
good oral hygiene and frequent recalls for professional
cleaning of the teeth without complete surgical pocket
elimination. The obvious advantage of the modified
Widman flap procedure compared with conventional
reverse bevel flap surgery, including bone surgery, is
conservation of bone and optimal coverage of the root
surfaces by soft tissues following the modified Widman
surgery. This means a more pleasing esthetic result, a
favorable environment for oral hygiene and potentially
less root sensitivity and root caries. It also tends to
30
result in more pocket closure by reattachment and
28,29
bone r e g e n e r a t i o n than following the pocket elimi­
nation procedure over long term follow-ups ( F i g . 1).
For deep pockets in the mandibular anterior region, the
results following subgingival curettage or modified
Widman flap surgery are significantly better with re­
gard to gain of attachment than pocket elimination
surgery which hardly can be justified in that region
(Figs. 2 , 3 , and 4).
The most important finding in our longitudinal stud­
FIGURE 3. Average pocket reduction for 7- to 12-mm pockets
ies is documentation rejecting the old concept that all
(mandibular anterior teeth) is similar for all methods, and well periodontal pockets deeper than 3 mm had to be elimi­
maintained over 7 years. nated surgically in order to provide an acceptable prog-
Volume 48
Number 9 Modified Widman Flap Procedure 563

nosis for the teeth. The pocket as a pathological lesion INTERPROXIMAL RECESSION FOR MAXILLARY
may be treated successfully with various approaches MOLARS BY TREATMENT METHOD-MODERATE DISEASE
and it is not even certain that any soft tissue and/or
bone surgery is needed providing the root surfaces are
30,32
treated p r o p e r l y and new plaque penetration is
prevented.
One apparent disadvantage of the modified Widman
flap surgery is the flat or concave interproximal archi­
tecture immediately following removal of the surgical
dressing, especially in areas of interproximal bony cra­
ters. However, if meticulous oral hygiene is main­
tained, the interproximal tissues will regenerate over a
few months with gain rather than loss of attachment, as
measured clinically from the cementoenamel junction
24
with a calibrated probe (see Fig. 1 ) . In the long run,
there is less interproximal recession following the mod-
F I G U R E 7. The interproximal recession is less following modi­
fied Widman than following pocket elimination surgery (max­
illary molars, 4- to 6-mm pockets).
INTERPROXIMAL POCKET REDUCTION FOR MAXILLARY
MOLARS BY TREATMENT METHOD-MODERATE DISEASE ified Widman procedure than following surgical pocket
elimination.
The merits of the modified Widman flap procedure
may be compared with subgingival curettage, since this
type of flap operation actually presents a modification
of subgingival curettage. The flap procedure provides
better access to the root surfaces than curettage and
allows for removal of the epithelial lining of the pocket
with less trauma and better postoperative adaptation to
the tooth than curettage. However, curettage has the
advantage of not directly affecting the bone and the
subpocket connective tissue attachment to the root.
The short term results regarding maintenance of at­
tachment is better following curettage than following
24,31
the modified Widman p r o c e d u r e . The long term
results are similar following curettage and Widman flap
FIGURE 5. Interproximal pocket reduction (4- to 6-mm pock­ procedures in most areas of the mouth, but in the
ets) is greater and better maintained following modified Wid- maxillary molar areas, the results of the modified W i d ­
man flap procedures than following curettage for maxillary man flap procedures seem to be better than following
molars.
curettage (Figs. 5 , 6 , and 7 ) . Selection of a procedure
for individual cases should be based on convenience
INTERPROXIMAL ATTACHMENT CHANGE FOR MAXILLARY with regard to requirements of time and technical skill
MOLARS BY TREATMENT METHOD-MODERATE DISEASE of the operator as well as esthetic and functional con­
siderations. Minimal pain and discomfort for the pa­
tient also is an important consideration.
Surgical elimination of interproximal bony craters
does not seem to be justified for maintenance of attach­
24
ment level, since it does not offer any greater long
term reduction in pocket depth than subgingival curet­
tage or modified Widman flap surgery and leads to less
gain in attachment (Figs. 8 and 9 ) . O n the basis of the
35
findings of R o s l i n g et al. osteoectomy for elimination
of infrabony lesions also has a questionable rationale.
The modified Widman flap procedure is a basic tech­
nique when implantation of bone or other substances
into intrabony lesions is contemplated.
FIGURE 6. The interproximal attachment level is maintained Although statistical data are not available, it appears
better following the modified Widman flap than following from our longitudinal studies that the response to peri­
curettage in maxillary molars (4- to 6-mm pockets). odontal therapy in partial furcation involvement is bet-
 J. Periodontol.
564 Ramfjord September, 1977

C o . , Publishers, 1961.
POCKET OEPTH REDUCTION FOR TEETH WITH 2. Neumann, R . : Die Alveolar-Pyorrhea und ihre Behan-
INITIAL POCKETS OF 4-6 mm BY TREATMENT METHOD dlung. ed 2, 1912, ed 3, 1920. B e r l i n , Hermann Meusser, ed
1,1912.
3. W i d m a n , L . : The operative treatment of pyorrhea al-
veolaris. A new surgical method. Sven Tandlak Tidskm (spe­
cial issue) D e c . 1918.
4. Cieszynski, A . : Bemerkungen zur Radikal-Chirur-
gischen Behandlung der sogennante Pyorrhea Alveolaris.
Deutsche Monatschr f Zahnheilk 32: 575, 1914.
5. Zentler, A . : Suppurative gingivitis with alveolar in­
volvement. J Am Med Assoc 71: 1530, 1918.
6. K i r k l a n d , O . : The suppurative periodontal pus pocket:
Its treatment by the modified flap operation. J Am Dent
Assoc 18: 1462, 1931.
7. Shaw, J . G . : Treatment of multiple periodontal pockets
by extended flap operation. Paradontologie 16: 121, 1962.
8. Wade, A . B . : A n assessment of the flap operation.
Dent Pract 13: 11, 1962.
9. Ramfjord, S. P . : Reinsercion. Rev Assoc Odont Argent
FIGURE 8. Average pocket reduction is the same over time
47: 275, 1959.
following modified Widman and pocket elimination surgery
10. M o r r i s , M . L . : The unrepositioned mucoperiosteal
(4- to 6-mm pockets).
flap. Periodontics 3: 147, 1965.
11. Harvey, P . M . : Management of advanced periodonti­
tis. Part I. Preliminary report of a method of surgical recon­
ATTACHMENT CHANGE FOR TEETH WITH struction. N Z Dent J 61: 180, 1965.
12. Ramfjord, S. P . , and Nissle, R . R . : The modified
INITIAL POCKETS OF 4 - 6 mm BY TREATMENT METHOD Widman flap. J Periodontol 45: 6 0 1 , 1974.
13. Levine, H . L . : Periodontal flap surgery with gingival
fiber retention. J Periodontol 43: 9 1 , 1972.
14. Levine, H . L . , and Stahl, S. S.: Repair following
periodontal flap surgery with the retention of gingival fibers.
J Periodontol 43: 99, 1972.
15. Caffesse, R . G . , Ramfjord, S. P . , and Nasjleti, C . E . :
Reverse bevel periodontal flaps in monkeys. J Periodontol
39: 219, 1968.
16. Sullivan, H . , Carman, D . , and Dinner, D . : Histologic
evaluation of the laterally positioned flap. IADR Abst N o .
467, 1971.
17. B o d i n e , R . L . , and M o h a m m e d , C . J . : Histologic
FIGURE 9. Attachment changes are most favorable over 7 years studies of the human mandible supporting an implant den­
following modified Widman flap surgery, (4- to 6-mm pock­ ture. Part II. J Prosthet Dent 26: 4 1 5 , 1971.
ets). 18. Frank, R . , et a l . : Gingival reattachment after surgery
in man: A n electron microscopic study. J Periodontol 43:
597, 1972.
19. Sugarman, E . F . : A clinical and histological study of
ter following modified W i d m a n flap surgery than fol­ the attachment of grafted tissues to bone and teeth. J Perio­
lowing either curettage or pocket elimination surgery. dontol 40: 3 8 1 , 1969.
Modified W i d m a n flap surgery provides better access 20. Listgarten, M . A . : Electron microscopic study of the
to the furcation areas for root planing than curettage junction between surgically denuded root surfaces and regen­
erated periodontal tissues. J Peridont Res 7: 68, 1972.
and the residual bone provides a better basis for healing
21. Frank, R . , et a l . : Ultrastructural study of epithelial
than if the bony wall of the pocket was removed during and connective gingival reattachment in man. J Periodontol
the surgery. 45: 626, 1974.
22. Listgarten, M . : Ultrastructural features of repair fol­
INDICATIONS FOR T H E M O D I F I E D WIDMAN FLAP PRO­ lowing periodontal surgery. S. S. Stahl (ed), Periodontal
Surgery, Biologic Basis, and Techniques, Springfield, 111.
CEDURE
Charles C Thomas, Publishers, 1976.
A l t h o u g h the modified W i d m a n flap surgery may be 23. Prichard, J . F . : Advanced Periodontal Disease, ed 2.
applied successfully to the treatment of all types of Philadelphia, W . B . Saunders C o . , 1972.
24. Ramfjord, S. P . , Knowles, J . W . , Nissle, R . R . , Bur­
periodontal pockets anywhere in the mouth, the great­
gett, F . G . , and Shick, R . A . : Results following three modali­
est advantage of this procedure is in the treatment of ties of periodontal therapy. J Periodontol 46: 522, 1975.
(1) deep pockets, (2) intrabony pockets and (3) when 25. Ellegaard, B . , and Löe, H . : New attachment of peri­
minimal gingival recession is desired. odontal tissues after treatment of intrabony lesions. J Perio­
dontol 42: 648, 1971.
26. Ramfjord, S. P . , et a l . : Longitudinal study of peri­
REFERENCES odontal therapy. J Periodontol 44: 66, 1973.
1. G r o o v e , P . B . , and Staff (eds): Webster's Third New 27. Ramfjord, S. P . : Surgical Pocket Therapy. Int Dent J
International Dictionary. Springfield, Mass., S. C . Merriam (in press) 1977.
Volume 48
Number 9 Modified Widman Flap Procedure 565

28. K e l l y , G . P . , C a i n , A . J . , Knowles, J . W . , Nissle, R . healing potential of the periodontal tissues following different
R., Burgett, F . G . , Shick, R . A . , and Ramfjord, S. P . : techniques of periodontal surgery in plaque-free dentitions.
Radiographs in clinical periodontal trials. J Periodontol 46: A 2-year clinical study. J Clin Periodont 3: 233, 1976.
381, 1975. 36. Y u k n a , R . A . , Bowers, G . M . , Lawrence, J . J . , and
29. Rosling, B . , N y m a n , S., and Lindhe, J . : The effect of Fedi, P . F . : A clinical study of healing in humans following
systemic plaque control on bone regeneration in infrabony the excisional new attachment procedure. J Periodontol 47:
pockets. J Clin Periodont 3: 38, 1976. 696,1976.
30. Z a m e t , J . S.: A comparative clinical study of three 37. Knowles, J . W . : O r a l hygiene related to long-term
periodontal surgical techniques. J Clin Periodont 2: 87, 1975. effects of periodontal therapy. J Mich Dent Assoc 55: 147,
31. Burgett, F . G . , Knowles, J . W . , Nissle, R . R . , Shick, 1973.
R. A . , and Ramfjord, S. P . : Short term results of three 38. C a t o n , J . , and Zander, H . A . : Osseous repair of an
modalities of periodontal treatment. J Periodontol 48: 131, infrabony pocket without new attachment of connective tis­
1977. sue. J Clin Periodont 3: 54, 1976.
32. M o r r i s o n , E . C , Ramfjord, S. P . , and H i l l , R . W . : 39. Sivertson, J . F . , and Burgett, F . G . : Probing of pock­
Short term effect of presurgical treatment on attachment level ets related to the attachment level. J Peridontol 47: 2 8 1 ,
and pocket depth. IADR Abstract N o . 516, 1977. 1976.
33. W i d m a n , L . : Einige Erinnerungen hinsichtlich der 40. Listgarten, M . A . , M a o , R . , and Robinson, P . J . :
Arbeit von Neumann: Die radikal-chirurgischen Behandlung Periodontal probing and the relationship of the probe tip to
der Alveolar-Pyorrhea. Vierteljahrshr f Zahnheilk 39: 18, periodontal tissues. J Periodontol 47: 5 1 1 , 1976.
1923. 41. A l e o , J . J . , DeRenzis, F . A . , and Farber, P . A . : In
34. Y u k n a , R . A . : A clinical and histologic study of heal­ vitro attachment of human gingival fibroblasts to root sur­
ing following the excisional new attachment procedure in faces. J Periodontol 46: 639, 1975.
Rhesus monkeys. J Periodontol 47: 701, 1976. 42. Waerhaug, J . : A method for evaluation of periodontal
35. Rosling, B . , N y m a n , S., Lindhe, J . , and Jern, B . : The problems on extracted teeth. J Clin Periodont 2: 160, 1975.

Announcement
BOSTON UNIVERSITY SCHOOL OF G R A D U A T E dontic related problems.
D E N T I S T R Y : N DIVISION O F C O N T I N U I N G E D U C A T I O N DATE: October 2 7 - 2 8 , 1977
FACULTY: HERBERT SCHILDER, D.D.S.
Boston University School of Graduate Dentistry announces the
GERALD A . ISENBERG, D.D.S.
following courses:
TITLE: Periodontics for the General Practitioner TITLE: Periodontal surgery.
1. Understanding periodontal disease and its treatment. DATE: November 1 0 - 1 1 , 1 9 7 7
DATES: September 7 - 8 , 1977 FACULTY: GERALD A . ISENBERG, D.D.S.
2 . Preparation of a case for treatment. ALAN M . SHUMAN, D . M . D .
DATES: October 2 1 - 2 2 , 1977 TITLE: Periodontics for the dental hygienist.
3. Definitive periodontal therapy. DATE: November 3 0 , 1977
DATES: December 8 - 1 0 , 1977. FACULTY: NICHOLAS DELLO RUSSO, D . M . D . , M.Sc.D.
4 . Management of the advanced periodontal disease case. GARY M . REISER, D.D.S.
DATES: March 3 - 4 , 1978.
TITLE: Clinical periodontal surgery
5. Therapy of the occlusal traumatic lesion
DATE: December 1-3, 1 9 7 7
DATES: May 1 2 - 1 3 , 1978.
FACULTY: GERALD M . KRAMER, D . M . D .
6. Participation course in periodontal therapy.
J. DAVID KOHN, D.D.S.
DATES: June 9 - 1 0 , 1 9 7 8
FACULTY: HENRY M . GOLDMAN, D . M . D . , Dean Emeritus of the TITLE: Management of clinical problems. "What to do when — "
School, Professor of Stomatology DATE: December 3 , 1977
TITLE: Occlusal adjustment in the natural dentition. FACULTY: HENRY M . GOLDMAN, D . M . D .
DATES: October 1 3 - 1 4 , 1 9 7 7 HERBERT SCHILDER, D.D.S.
FACULTY: HYMAN SMUKLER, D . M . D . , H . D . D . LEO TALKOV, D . M . D .
GERALD M . KRAMER, D . M . D . TITLE: Periodontal prosthesis
THOMAS MONE, D . M . D . DATE: December 5 - 7 , 1 9 7 7
TITLE: Restorative dentistry and periodontics for the advanced FACULTY: GERALD M . KRAMER, D . M . D .
general practitioner. MYRON NEVINS, D.D.S.
DATE: October 1 5 , 1977 HOWARD M . SKUROW, D.D.S.
FACULTY: HOWARD M . SKUROW, D.D.S. For further information contact: Program Coordinator, Division
MYRON NEVINS, D.D.S. of Continuing Education, Boston University School of Graduate
TITLE: Clinical Solutions for the treatment of endodontic-perio­ Dentistry, 100 E . Newton St., Boston, Mass 0 2 1 1 8 .