Modified widman flap

widman flap

1. MODIFIED WIDMAN
FLAP

4. GINGIVAL CLOSED CURETTAGE By definition a gingival curettage is the use of an
instrument (curett) against the gingival side of a
pocket in order to scrape and debridethe soft
tissue wall.
Its purpose is to remove chronically inflamed tissu e
elements and help maintain a state of periodontal
health.
Gingival curettage is for pocket reduction,
treatment of periodontal abscesses, presurgical
debridementand periodontal maintenance.

5. INDICATION ·Localized, mild to moderate periodontitis
·Shallow pocket depth
·When more extensive surgery is
contraindicated
·Treatment of isolated infrabonypockets

7. SUBGINGIVAL
CURETTAGE
BEFORE AND
FOUR WEEKS
AFTER
PROCEDURE

8. CONTRAINDICATION ·Advancedperiodontitis withdeeperinfrabonypockets
(treatmentrequiresexcellentvisionduringtheoperation)
·Acuteinfection(ANUG)
·Acutelession(periodontitis inpatientswithAIDS)
·Fibrousepithelialenlargement(phenytoinhyperplasia)
·Extensionofthebaseofthepocketapicaltomucogingival
junction

9. Advantage ·Minimum tissue loss
·Posibilityfor complete removal of infected crevicu lar
epithelium and underlying connective tissue
·Minimal discomfort to the patient
·Minimal hemorrhage
·Healing is often uneventful
Disadvantage ·Limited access can be obtained to deep or irregul ar
pockets
·Limited vision compare to flaps

11. MODIFIED WIDMAN FLAP Flap debridementsurgery isdefined:
as surgical debridementof the root
surface and the removal of granulation
tissue following the reflection of the soft
tissue flap.
The most commonly practiced technique is
based upon the 'modified Widmanflap'.

12. The original 'Widmanflap' was comprised of a
mucoperiostealflap.
The flap was elevated to expose 2-3 mm of the alveolar
bone.
The soft tissue collar incorporating the pocket epi thelium
and connective tissue was removed, the exposed root
surface scaled and the bone recontouredto re-establish
a 'physiologic' alveolar form.
The flap margins were placed at the level of the bo ny
crest to achieve optimal pocket reduction.
WIDMAN 1920 USA Widman I. The operative treatment ofpyorrhoe alveolaris . A new
surgical method. Brit Dent J 1920; 1:293.
NEUMANN 1919 GERMANY Neumann R. Die Alveolar-Pyorrhöe und ihre Behandlung.
1920. 3rd ed. Berlin: H. Meusser

13. The original 'Widmanflap' The main advantages of this technique as
compared to gingivectomy were claimed to be
less discomfort, since healing was by primary
intention and re-establishment of a 'physiologic'
bony contour at sites with angular bony defects.

14. The term modified Widmanflap
Exposure of the interproximalbone and elimination o f
infrabonydefects by osseous recontouringis not car ried
out.
When esthetic considerations are paramount,
intracrevicularincisions starting at the free gingi val margins
are used to minimize postsurgicalgingival shrinkage .
Vertical releasing incisions are usually not used
KIRKLAND 1931
Kirkland O. The suppurative periodontal pus pocket; its
treatment by the modified flap operation J Amer Dent Assoc 1 931; 18:1462-1470.
MODIFIED WIDMAN FLAP
Ramfjord SP, Nissle RR. The modified Widman flap. J
Periodontol 1974; 45:601-607.

15. „Módosított Widman-lebeny”
•Ramfjordand Nissle1974-
• modified Widman-flap”technique
•„open curettage”
• aim : • to remove BIOFILM , calculus and plaque retentive
subgingivalfactors
•
• other name „access flap surgery”

21. No 11 No 12 No12 D No 15 No 15C

24. • Sebészikkürett

29. INTERNAL
REVERSE
BEVELED INCISION

31. THE MODIFIED WIDMAN FLAP Purpose: •to make access to the root surface
•to obtain an intimate postoperative
adaptation of healthy collagenousconnective
tissue and normal epithelium to the root
surface.
No surgical pocket elimination and apical
displacement of the flap.

32. the aim of the modified Widman flap
surgery is

healing and reattachment of periodontal
pockets with minimum loss of periodontal
tissues during and after surgery
reduction of probing pocket depth by
shrinkage individually occurs.

33. The modified Widman flap

" open gingival curettage"
to obtain access to the root surface and an intimat e
postoperative adaptation of healthy collagenous con nective
tissue and normal epithelium to the root surface.
do not aim at surgical pocket elimination and apica l
displacement of the flap.

34. The modified Widman flap

to obtain access to the root surface and an intima te
postoperative adaptation of healthy collagenous con nective
tissue and normal epithelium to the root surface.
When esthetic considerations are paramount, intracr evicular
incisions starting at the free gingival margins are used to
minimize postsurgical gingival shrinkage.
Vertical releasing incisions are usually not used

35. Indications The MWF is indicated for the treatment of all types
of periodontitis and provides excellent result with
probing depths up to ca. 6 mm.
- Advantageous use of MWF will depend upon the
pathomorphologic situation on individual teeth and
at various periodontal sites.
- Possibility of establishing an intimate postopera tive
adaptation of healthy collagenous connective tissue
and normal epithelium.
- Minimal or no inflammation is present

36. Advantages
1. Root cleaning with direct vision
2. Protective of tissues, reparative
3. Healing by primary intention
4. Lack of pain or complications postoperatively

37. Procedure The flap surgery should not be initiated until one or
two months after completion of the hygienic phase o f
the periodontal therapy.
The
initial gingival incision
"internal reverse bevel incision" should be made with a knife
that can be directed parallel
to the long axis of the tooth.
Procedure The flap surgery should not be initiated until one or two months after completion of the hygienic phase o f the periodontal therapy.
The initial gingival incision
should be made with a knife
that can be directed parallel
to the long axis of the tooth.

38. VERY
CONSERVATIVE
SURGICAL
APPROACH

40. A
second incision
is made
around the neck of each
tooth from the bottom of
the pocket to the alveolar
crest.
Vertical gingival releasing incision usually is not
needed. A full thickness flap is elevated for only 1-2
mm from the alveolar crest as needed for access to
the root surfaces and the interproximal one.

41. The
third and final incision
is made with a
narrow interproximal knife. The buccal and/or
lingual flaps are deflected by a periosteal
elevator on top of the alveolar crest to dissect
free the collar of
gingival tissues, which is
been separated from the
buccal and lingual gingival
flaps and the teeth.
The separated collar of
gingival tissue is then
removed with curettes.

42. INTRACREVICULARIS METSZÉS

43. VERY
CONSERVATIVE
AND MINIMAL
INVASIVE FLAP
ELEVETION

44. TIGHT FLAP
ADAPTATION

47. Osteoplastica–
osteotomia

48. osteotomy

51. baseline

52. Baselineradiograph

53. Preoperative pocket depth

54. Access flap surgery

55. EMD 
applicationandsuturing

56. Postoperat
ive radiograph

57. The modified Widman flap


Exposure of the interproximal bone and elimination of
infrabony defects by osseous recontouring is not c arried out.

When esthetic considerations are paramount, intracr evicular
incisions starting at the free gingival margins are used to
minimize postsurgical gingival shrinkage.
Vertical releasing incisions are usually not used

58. Indications The MWF is indicated for the treatment of all types
of periodontitis and provides excellent result with
probing depths up to ca. 6 mm.
- Advantageous use of MWF will depend upon the
pathomorphologic situation on individual teeth and
at various periodontal sites.
- Possibility of establishing an intimate postopera tive
adaptation of healthy collagenous connective tissue
and normal epithelium.
- Minimal or no inflammation is present

59. Advantages
1. Root cleaning with direct vision
2. Protective of tissues, reparative
3. Healing by primary intention
4. Lack of pain or complications postoperatively

60. MODIFIED
WIDMAN FLAP
WITH PAPILLA
PRESERVATION
TECHNIQUE
PALATAL
INTERNAL BEVEL
INCISION

61. BASELINE

62. BASELINE

63. MODIFED WIDMAN FLAP

64. MODIFIED WF

65. 1 év POSTOP.

66. (MWF)

67. Baseline

68. BaselineX-ray

69. Periodontalcharting
12
6
3 3
1 0,5 1
6
2,5
5
3 0,5 2
11
4 3 4
1 0 0
4,5
2 4
2 0 1
24 23 22 21 13 14
6
3
5
0 0 0
5 5 5 0 0 0
5 6 5 0 0 1
6
3 4
0 0 1
5
4 4
0 0 1
3 3 4
1 0 1
PD
G
R
Pal
5
2 3
1 1 1
4 2
5
2 2 1
5
3 4
3 3 2
6
2 4
1 0 2
6
2
5
1 2 1
3 1,5
6
1 1,5 1
PD
G
R
Bucc

70. Surgery

71. Removinggranulationtissueand
osteoplasty

72. 3 monthscontrol

73. 7 monthscontrol
23 22 21 11 12 13
3 2 4
2 1 2
3 2 3
3 2 1
4 1 2
2 1 3
3 2 3
2 1 2
4 2 4
2 1 2
2 2 4
1 1 1
PD
GR
Pal
3 2 3
2 5 2
3 1 3
4 5 4
4 2 2
2 1 3
2 2 3
3 2 2
3 1,5 3
2,5 3 2,5
2 1 3
2 4 2,5
PD
GR
Bucc

74. 15 monthscontrol
23 22 21 11 12 13
3 2 2
2 1 2
2 2 3
3 1 2
3 2 2
1 1 2
3 2 3
1 1 1
4 2 3
2 1 1,5
4 1 3
1 1,5 1
PD
GR
Pal
3 2 3
1,5 1 1
3 2 4
2 4 1,5
4 1 3
3 1 2,5
3 2 3
2 2 2
4 1,5 3
2 3 2
3 1,5 3
2 4 2
PD
GR
Bucc

75.
Chronicperiodontisi

77. 1. Quadrant
Buccal
17
16
15
14
13
12
11
PD
6
4
6
4
1
4
4
1
4
5
2
3
3
3
3
3
3
4
4
3
2
GR
2
2
1
1
2
1
1
2
1
1
2
0
1
2
0
0
0
0
0
0
0
Palatinal
17
16
15
14
13
12
11
PD
8
7
6
6
4
5
4
5
6
7
6
4
4
2
4
5
1
5
6
4
4
GR
0
0
0
0
0
0
2
2
0
1
2
0
0
0
0
0
0
0
0
0
0

78. 2. Quadrant
Buccal
21
22
23
24
25
26
27
PD
3
2
3
2
2
5
3
1
2
3
2
3
2
6
7
5
2
5
6
5
6
GR
0
0
0
0
1
1
0
0
0
0
1
0
1
1
2
0
1
2
0
2
1
Palatinal
21
22
23
24
25
26
27
PD
5
1
5
7
7
7
4
2
5
5
2
4
4
2
5
3
3
4
3
5
5
GR
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
1
1

79. 3. Quadrant
Buccal
31
32
33
34
35
36
37
38
PD
4
2
4
4
2
4
7
3
3
5
2
3
3
1
5
7
2
6
6
4
5
GR
1
0
1
0
0
-1
-1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Lingual
31
32
33
34
35
36
37
38
PD
3
2
2
4
2
4
5
5
5
5
5
5
7
6
6
7
5
7
7
5
6
GR
1
1
1
0
0
0
0
1
0
1
1
2
1
0
1
0
0
0
1
0
0

80. 4. Quadrant
Buccal
48
47
46
45
44
43
42
41
PD
3
3
4
5
2
2
3
2
3
4
3
4
5
3
3
4
4
4
GR
1
0
0
1
1
1
0
1
0
0
0
1
1
0
1
1
0
1
Lingual
48
47
46
45
44
43
42
41
PD
6
6
7
6
7
5
5
5
5
4
4
3
5
2
3
2
1
2
GR
0
0
0
0
0
1
1
1
0
2
0
0
1
1
2
1
2
1

84. Buccal
17
16
15
14
PD
4
2
3
2
2
4
2
2
4
3
2
3
G
R
3
4
4
2
2
1
2
2
2
2
2
0
Palatinal
17
16
15
14
PD
8
7
6
6
4
4
3
4
4
5
6
4
G
R
0
0
1
1
1
1
3
2
3
3
2
0

88. 1 yearcontrol
Buccal
17
16
15
14
PD
4
3
4
4
2
3
3
2
3
3
3
3
G
R
3
4
4
2
2
1
2
2
2
2
2
0
Palatinal
17
16
15
14
PD
5
5
4
4
3
4
3
3
4
3
4
4
GR
2
2
2
2
2
1
3
3
3
4
2
0

89. 1,5 yearscontrol

92. 3. Periodontalstatus (1,5 years)
Buccal
17
16
15
14
13
12
11
PD
4
3
4
4
2
3
3
2
3
3
3
3
3
2
3
3
2
3
3
2
3
GR
3
4
4
2
2
1
2
2
2
2
2
0
1
3
1
0
0
1
1
0
1
Palatinal
PD
5
5
4
4
3
4
3
3
4
3
4
4
4
2
4
4
2
4
4
3
4
GR
2
2
2
2
2
1
3
3
3
4
2
0
0
0
1
1
0
1
2
0
1
Buccal
21
22
23
24
25
26
27
PD
3
2
3
2
2
5
3
2
3
3
3
3
4
2
4
4
3
4
GR
1
0
1
2
2
2
0
0
0
0
1
0
1
1
2
2
4
3
Palatinal
PD
4
2
4
5
5
5
2
2
5
4
2
4
4
3
4
4
4
6
GR
1
0
1
1
1
2
2
0
0
1
0
0
1
1
1
2
2
1

93. Prosthodontic rehabilitácion

94. SEPARION OF
INTERDENTAL
PAPILLAE
Modified papailla
preservation technique

95. BUCCAL DISPLACEMENT
OF INTERDENTAL
PAPIALLAE POSTOPERATIVE
VIEW