“access flap” surgery, open flap debridement (ofd

309

“Access Flap” Surgery, Open Flap Debridement (OFD)—Modified Widman Flap (MWF)

Of the numerous periodontal surgical techniques, the oft-modified Widman flap (“Modified Wid-man Flap,” MWF) remains the standard procedure for open periodontitis therapy (Widman 1918,Ramfjord & Nissle 1974, Ramfjord 1977). It is classified with the “access flap operations” becausethe goal of the flap reflection is primarily to provide improved visual access to the periodontallyinvolved tissues.The method is characterized by precise incisions, partial flap reflection and an atraumatic proce-dure, whose goal is not necessarily pocket elimination but “healing” (regeneration or a long junc-tional epithelium) of the periodontal pocket with minimum tissue loss. Because the alveolarprocess is only partially exposed, post-operative pain and swelling are rare.The main goals of the procedure include optimum mechanical subgingival root planing and “de-contamination” with direct vision, as well as healing by primary intention following close inter-dental flap adaptation. No ostectomy is performed. However, minor contouring osteoplasty can beperformed to improve the facial or oral osseous morphology, primarily to achieve the desired in-terdental defect closure.

Indications

• The MWF is indicated for the treatment of all types of per-iodontitis, but is especially effective with pocket depths of5–7 mm.

• Dependent upon the pathomorphologic situation on theindividual teeth, the MWF may be combined with largerand fully reflected flaps (resective methods) and specialprocedures such as wedge excisions, root resection, he-misection, osseous implantations etc., and infrequentlyalso with gingivectomy/gingivoplasty (combined surgicalprocedures, p. 366).

Advantages

• Root cleaning with direct vision

• “Tissue friendly”

• Reparative, with healing by primary intention

• Minimal crestal bone resorption

• Lack of post-operative discomfort

Contraindications

There are but few contraindications for the MWF:

• Lack of or very thin and narrow attached gingiva canrender the technique difficult, because a narrow band ofattached gingiva does not permit the initial scalloped in-cision (internal gingivectomy). In such situations, it maybe necessary to employ the classic marginal or even an in-trasulcular incision.

• MWF is contraindicated for osseous surgical procedures(expansive osteoplasty or ostectomy) with very deep os-seous defects and irregular bone loss facially and orally,and if apical flap repositioning is planned (cf. resectivesurgical methods, p. 355).

Disadvantages

See contraindications.

aus: Rateitschak u. a., Periodontology (ISBN 3-13-675003-9) © 2005 Georg Thieme Verlag

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310 “Access Flap”

Principles of the Modified Widman Procedure—Ramfjord Technique

1 Initial incision—continuous, “scalloping,” paramarginal(intragingival) incision; no vertical releasing incisions

2 Partial mobilization of the mucoperiosteal flap (fullthickness flaps both facially and orally) within the at-tached gingiva to the alveolar crest

3 Second incision—sulcular incision4 Third incision—horizontal incision, also interdentally;

removal of the delineated tissue and all granulation tis-sue

5 Root cleaning and planing with direct vision6 Flap adaptation, complete coverage interdentally.

The MWF technique differentiates the typical six treatmentsteps listed at the left:The first incision sharply dissects the pocket epithelium andportions of the subepithelial infiltrate. This effectively thinsthe marginal gingiva, insuring ideal flap repositioning post-surgically. The gingiva is then reflected using an elevator,but only to the extent that the alveolar crest can be visual-ized.The second incision is sulcular/intrasulcular around eachtooth. This separates the pocket epithelium and junctionalepithelium from the root surface, to the fundus of the pocket.

700 First Incision—ScallopingInverse Bevel, ParamarginalThis incision determines theshape of the flap and is per-formed both facially and orallyusing a 12B scalpel. It is an inversebevel incision, extending to thealveolar crest. The distance of theincision from the gingival marginwill vary depending on the widthof the interdental spaces thatmust be covered (0.5 to 1.5 mm).The incision becomes intrasulcu-lar in the interdental areas.

Right: Incision, schematically.

701 Flap ReflectionA small elevator is used to reflecta full thickness yet only partiallymobilized mucoperiostial flap, asatraumatically as possible. Theflap is reflected for one reasononly: To permit direct visualiza-tion of the root surface and thealveolar crest.

Right: The schematic shows clear-ly that the facial flap is not reflec-ted beyond the mucogingival line(black arrow): Conservative flapreflection!

702 Second Incision—IntrasulcularThis incision is a purely intrasulcu-lar incision that is carried aroundeach tooth, between the hardstructure and the gingiva, beyondthe base of the pocket and ex-tending to the apical extent of thepocket epithelium. The 12B scalpel is also indicatedfor this second incision.

Right: Schematic depiction of thesecond, intrasulcular incision(red).

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311Principles of the Modified Widman Procedure—Ramfjord Technique

The final incision is horizontal, and serves, especially in theinterdental area, to release the pocket tissues sharply andatraumatically. The soft tissue and all of the granulation tis-sue within the pocket are thereby removed. The most im-portant element of the procedure now follows: Systematicscaling and planing of the root surfaces using fine curettesor ultrasonic instruments with direct vision. This criticalprocedure requires significant time. Supportive alveolarbone is not removed, but minimal osteoplasty may be per-formed as necessary.

Finally, the flaps are repositioned. Because of the shape ofthe flaps created by the initial scalloping incision, secureand complete coverage of the interdental bone is possible.This enhances healing by primary intention.

Adherence to these principles is routinely associated withexcellent long-term results in terms of maintenance or eventrue gain in periodontal attachment (Knowles et al. 1979;Fig. 727). The principles are therefore also applicable to oth-er flap surgical procedures.

703 Third Incision—HorizontalThe horizontal incision is carriedalong the alveolar crest from thefacial to the oral aspect, or the re-verse, thus separating thesupracrestal pocket tissue fromits supporting subjacent tissues,especially in the interdental area.

Left: The schematic clearly depictsthe bony pocket, especially the in-terdental osseous crater. The hori-zontal incision does not approachthe base of the pocket (note redspears and the profile of the bonyarchitecture apical to it).

704 Root Planing with DirectVisionFine curettes are used in thedepth of interdental craters to re-move remnants of pocket epithe-lium and granulation tissue. Sys-tematic root cleaning and planingis performed with repeated rins-ing (NaCl 0.9 %) and evacuationby the dental assistant, with directvision.

Left: Schematic depiction of theremoval of granulation tissue androot cleaning/planing with a uni-versal curette.

705 Tight Coverage of Interdental DefectsThe facial and oral flaps are tightlyadapted over the bone and be-tween the teeth by means of in-terrupted interdental sutures. Be-cause “new papillae” were createdby the initial scalloping incision, itis usually possible to completelycover interdental bony defects.

Left: The schematic clearly showsthe coverage of the interdentalarea. In the molar regions, this isnot always possible (healing oc-curs by secondary intention).

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Principles of the MWF—Occlusal View

The surgical principles of the Ramfjord technique describedabove will be depicted here schematically from the occlusalview (horizontal section). The geometry of flap design andflap repositioning can be appreciated particularly wellwhen viewed from the occlusal aspect. The initial incision isscalloped, somewhat removed from the free gingival marginbuccally and palatally, creating “new papillae” for subse-quent complete closure of interdental defects.

In the interdental regions, the incision may become a purelyintrasulcular incision, to provide adequate tissue for sub-

sequent complete closure of the interdental space. The scal-loped margin of the flap provides tight closure of the curet-ted interdental osseous craters (e. g., two-wall bony pock-ets).

At the distal end of the arch, the primary incision may endas a wedge excision, providing access to and therapy forpockets or furcation involvement in this region (wedge exci-sions, p. 319). Osseous craters and furcation involvement inthis region also may be treated using regenerative methods(p. 323).

706 Primary Incision –“Scalloping”The first incision is a scalloped, in-verse bevel incision (internal gin-givectomy) in the maxillary poste-rior segment (Fig. 712). Thisincision continues into a wedgeexcision distal to tooth 16.The second (intrasulcular) andthird (horizontal) incisions are notdepicted here.

Right: Instrumentarium (I)—scalpel with blade 12 B, surgicalforceps.

707 Partially Reflected FlapsAfter reflecting mucoperiostealflaps, the excised soft tissues areremoved, the osseous defects arecarefully curetted, and all root sur-faces are cleaned and carefullyplaned with direct vision.

Right: Instrumentarium (II)—nar-row and broad elevators (depict-ed: Prichard elevator).

708 Flap Re-Adaptation, SuturingComplete coverage of the inter-dental bone is accomplished bytension-free fixation of the papillatips using interrupted sutures. Ifsufficient tissue is available, thefacial and oral papilla tips canactually be repositioned side-by-side before fixation. This ensurescomplete coverage of the inter-dental areas.

Right: Instrumentarium (III)—needle holder and needle-suturecombination (4–0 silk).


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313“Access Flap”/Modified Widman Procedure—Case Presentation

“Access Flap”/Modified Widman Procedure—Case Presentation

Surgical Procedure, Step-by-Step

The systematic procedure for conservative flap reflectionaccording to the principles of the Ramfjord technique willbe depicted in the maxillary right sextant.

The 42-year-old female presents with mild to moderatechronic periodontitis. Phase 1 therapy (initial therapy) iscomplete. Patient cooperation/compliance was “only aver-

age.” The goal of a PI and BOP index below 20 % was notachieved.Also in other sextants (not depicted here), minor surgicalprocedures were indicated.

Findings after initial therapy:PI: 30 % BOP: 32 % TM: 0–2See accompanying figures for the clinical picture, prob-ing depths, gingival contour and radiographic survey.

709 After Initial TherapyThe gingivae remain inflamed de-spite initial therapy. Mild hemor-rhage occurs upon probing of thepockets. The patient’s oral hy-giene must be checked repeated-ly and OHI provided even afterthe planned surgical procedures.Additional instructions and moti-vation must be provided to thepatient during each maintenancephase appointment (recall).

Left: Sagittal diagram of the initialcondition. Arrows: Pocket pro-bing depth.

710 Probing Depths FollowingInitial Therapy; Tooth Mobility(TM)Interdental probing depths up to7 mm persist after initial therapy.

Radiographic SurveyMild to moderate attachment lossis observed in the premolar re-gion. Between teeth 17 and 16,the interdental septum has re-sorbed to the midpoint of theroot.

711 Occlusopalatal ViewMild inflammation is also obviousfrom the oral aspect in the sex-tant between 13 and 17, especial-ly in the interdental area. Near thedeep pocket around 16 and 17,signs of pocket activity (exudate)persist despite initial therapy.

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712 Planned First Incision and Flap ReflectionThe planned initial scalloping inci-sion and the extent of the flap tobe reflected are indicated.

Solid red line: Initial scalloping hor-izontal incision.Hatched area: The planned flap re-flection ends coronal to themucogingival junction (dashedred line and arrow).

Right: Surgical protocol.

713 Principles of the Three Incisions

1 Paramarginal first incision:Severing the soft tissue pocketwall with the 12 B scalpel

2 Flap reflection and sulcular in-cision

3 Horizontal incision: Extendsespecially into the interdentalareas

Initial Incisions: Facial and Oral

714 Scalloping ParamarginalInitial Incision—FacialThe first “scalloping incision” is an inverse bevel incision (internalgingivectomy).

If teeth are crowded, this incisionmay become a purely intrasulcu-lar one in interdental areas, to en-sure sufficient tissue for the“new” papillae destined to com-pletely cover the interdental re-gion.

715 Scalloped Primary Paramarginal Incision—Palatal ViewThe incision is performed identi-cally on the palatal surfaces. In or-der to ensure that the rather re-silient palatal flaps can bere-adapted to the tooth and os-seous surfaces, the primary inci-sion should not be made too farremoved from the height of thegingival margin (maximum1–2 mm). The palatal flap is usual-ly non-mobile, and this flap mustbe thin and even.

“Access Flap”—Surgical Protocol

• First incision—paramarginal, scalloping

• Flap reflection (full thickness flaps)

• Second incision—sulcular

• Third incision—horizontal

• Removal of the delineated soft tissues (pocket exudate), “osseous curettage”

• Root planing with direct vision

• Flap repositioning, suturing

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315“Access Flap”/Modified Widman Procedure—Case Presentation

716 Removal of the Sharply Dissected Pocket TissuesOnce the flaps are reflected andthe second and third incisions areperformed (Fig. 713), the sharplydemarcated tissue is easy to re-move. Granulation tissue shouldalso be removed to provide directvision of the root surfaces to becleaned and thoroughly planed.Complete elimination/removal ofall granulation tissue is not per senecessary, but will reduce the riskthat pathogenic microorganisms(e. g., Aa or Pg) will remain in thetissues post-surgically.

717 Debridement—Root Planing with CurettesAfter removal of the pocket softtissues, the root surfaces arecleaned and planed using fine uni-versal or Gracey curettes, thusthoroughly eliminating thebiofilm as far as possible. This pro-cedure can also be accomplishedusing ultrasonic devices. Rootplaning is the most time-consum-ing procedure during flap surgicalprocedures.Left: Schematic depiction of rootsurface cleaning with a universalcurette (M23A; Deppeler).

718 Root Cleaning and Planingwith a Fine Polishing DiamondHard deposits (calculus) can alsobe removed mechanically, e. g.,with rotating diamond stones(Perio-Set; 40 µm abrasiveness),and root planing with the 15 µmdiamonds. Low rpm and constantrinsing/cooling with Ringer’s so-lution must always accompanythe use of rotating diamonds.The diamond stones of the Perio-Set (Fig. 541) should not be con-sidered as replacements forcurettes, but enhancements!

719 Palatal ViewThe resilient palatal tissue mustalso be reflected to permit rootplaning with direct vision. Notethe deep interdental crater be-tween 16 and 17 (cf. Fig. 710).

Left: Rinsing solutions—physiolog-ic NaCl (0.9 %) and H2O2 (3 %), orbetadine for disinfection and toreduce hemorrhage (cf. FMT, Fig.651).


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720 Flap Adaptation Using Interrupted SuturesClose approximation of the flapsupon bone and tooth surfaces is aprerequisite for optimum healing.Fixation of the flaps is accom-plished by means of interdentalinterrupted sutures. The scallop-ing form of the initial incision usu-ally permits tight closure in the in-terdental areas. If the flap tissue isextremely thin, the use of mat-tress suturing is indicated for flapfixation (p. 308).

Right: Palatal view.

721 Suture Removal—Carefully!Sutures should be removed atone week. By this time the woundmargins have adhered to eachother and the healing process iswell underway; however, carelesshandling of the sutures could dis-turb the delicate attachments be-tween and among the flaps, theosseous surface and thetooth/root.

Right: Pointed scissors, fine for-ceps and “two steady hands” min-imize any risk of tissue damage.

722 Tooth CleaningFollowing suture removal, thesurfaces of the teeth are cleanedusing soft rubber cups and mildlyabrasive prophy paste (or denti-frice) (cf. “RCP method,” p. 251).Since wound healing is not yetcomplete (regeneration at thedepth of the pocket, new junc-tional epithelium) care must beexercised that no paste is forcedinto the sulcus, beneath the for-merly reflected soft tissue flap.

Right: Protocol for the post-opera-tive measures.

723 Following Suture Removaland Tooth CleaningTwo weeks post-surgically, thepatient must re-initiate homecare, but carefully. It is recom-mended that the chlorhexidinerinses be continued. The field ofoperation should be professionallycleaned by the dental hygienistduring subsequent appoint-ments, ca. every two weeks.

Right: Despite the effort to closethe interdental area, a small“crater” remains between teeth16 and 17.

Post-operative Measures—Protocol

• Topical disinfection, e. g., CHX0.1–0.2 % for at least two weeks

• Systemic medication only as in-dicated (p. 287)– antiphlogistic for 2–3 days– antibiotics

• Prevention of swelling: Topicalapplication of cold packs or icefor 2–3 days

• Professional evaluation andcleaning 7–10 days post-op,and after suture removal every2–3 weeks for two months


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317“Access Flap”/Modified Widman Procedure

“Access flap”/Modified Widman Procedure

Summary

The 42-year-old patient with mild to moderate chronic peri-odontitis exhibited deficient oral hygiene at the initial ex-amination. Even after initial therapy, mild gingival inflam-mation was in evidence; between molars 16 and 17, signs ofmild pocket activity (exudate) persisted.

Probing depths returned to physiologic levels six monthsfollowing the surgical procedure.

Even the deep defect between 16 and 17 exhibited a probingdepth of only 4 mm. These excellent results can also be attributed to the greatimprovements by the patient in home care. Because of thegingival shrinkage, mainly in the interdental region, specialemphasis should be placed on interdental hygiene.

PI: 10 % BOP: 9 %The initial recall was set at three months; if patient co-operation/compliance continues, subsequent recalls maybe at 4–6 month intervals.

724 Before SurgeryDespite initial therapy, mild gingi-val inflammation persists (BOP:32 %). Application of finger pres-sure between 16 and 17 elicits re-lease of minimal exudate. Thetreatment of choice is surgical(“access flap”) with direct vision.

Left: An untreated pocket (facialsurface of tooth 14). The probingdepth is depicted in red (bar andarrows).

726 Six Months Post-operativeEven after the careful and conser-vative MWF procedure, the teethappear slightly “elongated” andthe interdental spaces are moreopen. Recommendations for in-terdental hygiene are determinedby the anatomic/morphologicsituation.

Left: A slightly deepened sulcuspersists (“residual pocket,” redbar). The former probing depthhas been reduced through shrink-age (1) as well as periodontalhealing (“repair,” 2).

fTM

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fTM

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Before

After

725 Pocket Probings and TM Following Initial Therapy—Before SurgeryFollowing initial therapy, whichconsisted of closed supra- andsubgingival scaling, pockets of4–7 mm persist, especially inter-dentally.

Pocket Probings and TM SixMonths after SurgeryAt the recall examination sixmonths after the surgical proce-dure, no probing depths beyondthe 4 mm level are detected.


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Long-term Results Following Various Treatment Modalities

Periodontitis can be treated “closed” (subgingival scalingand root planing) or “open” (surgically). The therapeuticmodality selected will depend upon the type of periodonti-tis (chronic, aggressive), the severity of the disease, andupon the many factors discussed previously (see etiologyand pathogenesis, p. 21; diagnosis/risk factors, p. 165; treat-ment planning, p. 208). The goal of therapy, however, is thesame for each type of treatment: Reduction of pocket depthand gain of attachment.The clinical results that can be expected from various treat-ment methods and with variably progressive periodontal

disease over the long term were described in the secondhalf of the 1970s by Ramfjord et al. (1975), Ramfjord (1977)as well as Knowles et al. (1979). During those years, the au-thors compared closed root planing with the modified Wid-man procedure (described today as the “access flap” proce-dure), as well as with surgical pocket elimination. The latteris characterized by the resective treatment methods (p. 355).Eight years following treatment, probing depths of7–12 mm pockets were reduced by 3–4 mm by all treatmentmodalities, with attachment gain less than 3 mm!

728 Residual Pockets Following MWFThe deeper the pocket probingdepths initially, the better will beany subsequent pocket depth re-duction (no pocket elimination!).With 7–12 mm pockets (right),reduction was at least 4 mm (ca.2 mm of clinical attachment gainand ca. 2 mm of gingival reces-sion). There remains an averageprobing depth (“residual pocket”)of 4–5 mm; there is a risk of recol-onization by pathogenic anaer-obes if a strict professional recallis not maintained!

Conclusions

As one considers these long-term results, it is important torealize that during the entire 8-year follow-up examina-tions of the patients, 3-month recall intervals were ob-served: The plaque control by the therapist and patient wastherefore quite beyond average. Under these strict condi-tions, it is not surprising that the long-term results with re-gard to pocket reduction (Fig. 727) did not differ dramatical-ly among the three procedures.If one considers the results following MWF therapy alone, itbecomes clear that with physiologic probing depths of1–3 mm, no surgery is necessary. To do so leads to clinical

attachment loss! The deeper the probing depths, the morepronounced will be the pocket reduction and therewith theindication for surgical intervention, e. g., via MWF.Note: Regenerative methods such as bone transplantationand GTR were only in the developmental phases when theselarge clinical trials were performed, and therefore were nottaken into consideration; the same is true for the much-dis-cussed combination of mechanical and medicinal therapiestoday (p. 287). The problem of deep residual pockets has notyet been successfully solved (incomplete regeneration,Fig. 728).

?P

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Pocket depth reduction

Attachment gain

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1 2 3 4 5 6 7 8 Years

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~2.2

~1–2

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MWF – “Residual pockets” after 8 years

mm 1mm 2 mm 3 mm 4 mm 5 mm 6 mm 7 mm 8 mm 7–12 mm

727 Pocket Depth Reductionand Gain of Attachment afterVarious Treatment Methods in7–12 mm Pockets (Knowles et al. 1979)

Modified Widman procedure

________ Root planing and curettage

_ _ _ _ _ _ Surgical pocket elimination

Compare also Fig. 644: Samestudy with shallower pockets. Modified from J. Knowles et al.1979


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“access flap” surgery, open flap debridement (ofd

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