History of Periodontal Surgeries – A Review

INTRODUCTION

"Nature is so varied in her manifestations and phenomena, and the difficulty of elucidating their causes is so great, that many must unite their knowledge and efforts in order to comprehend and force her to reveal her laws."-Laplace.¹ Every important science must be correlated to another. In tracing the evolution of any specialty it becomes necessary to start at its origin, with the basic principle upon which it was founded, and at the same time to mention some of the men, who have contributed to its development. The history of dental literature is largely that of medicine, science, and philosophy, as the growth and evolution of people has been portrayed more or less in parallel lines with art and science.¹

The earliest references to odontology are found in Chinese literature. In a work believed to have been written by the Emperor Hoang-Ti, founder of Chinese medicine, who is supposed to have lived in 2637 B.C.¹ 

Periodontal disease is considered to be as old as the history of mankind with magical, religious and herbal treatments being demonstrated in almost all of the early writings. However, methodical, carefully reasoned therapeutic approaches did not exist until the middle-ages and modern treatment with a scientific base and sophisticated instrumentation did not develop until the 18th century. Prior to 1950s, diseases were mostly treated by root debridement and extraction of affected teeth. Until 1970s, it was primarily the symptoms of periodontal disease that were treated.² The goal was radical elimination of periodontal pocket (resective therapy) by gingivectomy, flap procedures and osseous surgery. 

HISTORY

Fauchard was the first person to originally perform radical gingivectomy for removing excess tissue in 1742.² He was followed later by Pickerill, Zentler, G.V. Black, A.D. Black, Nodine, Crane and Kaplan, Ziesel, and Ward. Gingivectomy became popular; however, its problem of excising the attached gingiva, frenal attachment, and creation of shallow vestibular trough prompted the periodontists to arrive at new techniques and procedures for pocket elimination.

Flap surgery was introduced in Periodontics at the turn of the century by a group of physicians specializing in dentistry such as Widman, Neumann, and Cieszynski. Neumann in 1911^3,4 introduced the Neumann flap where two vertical releasing incisions were made and a intrasulcular incision was made joining them, a full thickness flap was raised, and the area was curetted thoroughly to eliminate all the granulation tissue to prevent re-infection. Root was planed smooth, and bone was superficially removed. Flap was raised up to the level of teeth apices and gingival margins were trimmed approximately 2mm in the area of deep pockets with bone removal.

Widman⁵ introduced the Widman flap in 1918 where a trapezoidal flap was reflected with two vertical releasing incisions at the midline of teeth and reverse bevel incision made parallel to the surfaces of the teeth 1mm from the free gingival margin and extending to the alveolar crest. Bone removal was carried out for better soft tissue adaptation. As in Neuman's procedure, the flaps were sutured back by individual interproximal sutures.⁵

Cieszynski, however, was credited with the introduction of reverse bevel incision. Zentler introduced mucoperiosteal flap in U.S.A. in 1918, with the idea that the procedure allowed access for debridement and elimination of granulation tissue as well as osseous removal by chisels. As we can see, flap surgery was done at the beginning for the purpose of bone removal and pocket elimination.⁶

Apparently the first description of flap procedure for the purpose of reattachment was given by Kirkland in 1931. He used the basic gingival mucoperiosteal flap design by Neumann in 1920 for initial flap, but instead of trimming the flap for surgical pocket elimination, he attempted the elimination of crevicular epithelial lining and inflamed connective tissues by curettage of the flap. This method has been described as “open subgingival curettage.”^{7, 8, 9}

Flap surgery became popular after 1935, when Kronfeld stated that the bone adjacent to periodontal pockets was neither necrotic nor infected but rather destroyed by an inflammatory process. Orban later supported this finding in his own studies.²

In 1939, Dr. Carranza.Sr, proposed in his doctoral thesis the surgical treatment of periodontitis which involved pocket elimination surgery by raising the flap.^2,9

In 1954, Nabers described the “repositioning of attached gingiva.” For the first time, a mucoperiosteal flap was apically positioned after treatment. He utilized one vertical releasing incision which is placed mesially to the area of deepest pocket. Later in 1957, he introduced the inverse bevel incision called the “repositioning incision” which included the placement of internal bevel incision from gingival margin to the alveolar crest. This incision, he stated, would permit an easier flap reflection with thinner gingival margins. In the same year, Ariaudo and Tyrrell modified Nabers' technique, recommending two vertical releasing incisions instead of one to facilitate mobilization of the flap. At this point, the only difference from Widman's flap design was the apical positioning. In 1962, Friedman published the technique in his paper and coined the term “apically reposition flap”. Today, the word “reposition” is replaced by the term “position” since reposition means placing the flap back to where it was before.^6,9,10

Flap surgery was described characterized extensively by Carranza and Ramjford. In 1979, Carranza classified flap as full thickness flap and partial thickness flap. Full thickness flap is a surgical procedure in which all soft tissue and the periosteum are reflected. Partial or split thickness flap is an elevated flap which includes only epithelium and the layer of underlying connective tissue without periosteum. Goldman in 1982 introduced another variation wherein he followed the full thickness flap with a partial dissection, allowing the use of periosteal suture to position his flap. This flap design, he called the tertiary flap or the partial-full-partial-thickness flap.^2,9

Another classification of flap types was proposed by Ramfjord in 1979, according to the main purpose of procedure; such as pocket elimination flap, reattachment flap surgery, and mucogingival repair.^5,10,11

In 1990, Carranza again classified flap according to their placement at the conclusion of a surgical procedure as repositioned, positioned, or displaced flaps (apical, coronal, or lateral to its original position).^2,9,12

Flap for pocket therapy included modified Widman flap, undisplaced (unrepositioned) flap, and the apically displaced flap.

Ramfjord and Nissle in 1974 coined the term modified Widman flap though the procedure was originally employed by Morris in 1965¹² as unrepositioned mucoperiosteal flap. Morris in 1965 described this flap as “the simple mucoperiosteal flap, combined with the inverted beveled incision and osseous resection.” The flap utilized three incisions: an internal bevel incision 1 to 1.5 mm away from the gingival margin following the scalloped outline, the crevicular incision from bottom of the pocket to bone, circumscribing the triangular wedge of tissue containing the pocket lining, and finally, after the flap is reflected, the horizontal incision placed in the interdental spaces, coronal to bone. With a curette or an interproximal knife the gingival collar is removed. Pocket depths were best maintained at shallower levels and attachment level remained higher with the Widman flap.^5,10,11

Ramfjord in 1974 reviewed the present status of the modified Widman procedure and described the procedure in detail. Modified Widman flap (MWF) is the one that eliminates the pocket lining and exposes the root surfaces for instrumentation, debridement and removal of pocket lining. It does not eliminate or reduce pocket depth, though the reduction does occur due to tissue shrinkage following healing. The internal bevel incision starts close (no more than 1 to 2 mm apical) to the gingival margin and follows the scalloped outline.^5,10,11

Ramfjord noted that the key to success of the procedure is to create and maintain the biologically acceptable root surface. The advantage of the procedure is the adaptation of the tissues to root surfaces, access to the root surface, aesthetic result, less root sensitivity and caries, with a favourable environment for oral hygiene maintenance. Disadvantages include flat or concave interproximal soft tissue contour which requires meticulous oral hygiene in the area.

Smith and Svoboda et al 1984 evaluated the MWF and concluded that removal of the sulcular epithelium during periodontal surgery provided no therapeutic advantage. The procedure is indicated for deep infrabony pockets, when minimal recession was desired. The end result is the establishment of an intimate postoperative adaptation of healthy collagenous connective tissue to tooth surfaces and immediate closure of the area.^5,11

REATTACHMENT PROCEDURES

Newly deposited cementum after surgery is cellular, not unlike bone, and can be best described as reparative cementum (Dragoo and Sullivan 1973, Hawley and Miller 1975). Listgarten (1972) spoke of this cementum as devoid of well-defined fibre bundle. The use of a barrier has first been reported by Younger in the Dental Cosmos of 1904.^13,14

Murray in 1957 stated that there were three things necessary for the new growth of bone: the presence of a blood clot, preserved osteoblast, and contact with living tissue. Prichard⁹ in 1957 stated that cells that are necessary for the genesis of periodontal ligament, cementum, and alveolar bone are available in the area that borders the bony deformity. This lead Melcher⁹ in 1976 to classify the four tissue types which repopulate the root surface, which is called Melcher's concept. In dentistry Nyman.S and Gottlow J 1982 first described application of barrier membrane in the mouth in context of regeneration of periodontal tissues as an alternative to resective surgical procedures to reduce pocket depths. Minabe M.1991 postulated that the desire to prevent second surgical intervention led to development of multiple types of absorbable barriers including collagen, cargile membrane, polylactic acid, oxidized cellulose, vicryl and others and clinical success has been reported when these membranes were used.^9,14

The importance of clot establishment and stabilization in Guided Bone Regeneration (GBR) has been investigated by Melcher and Dreyer. The distance to which the blood vessel can branch and allow complete healing of the defect is called the osteogenic jumping distance (Harris 1983). Study of Wickezolze in 1991 with heparinized root surface has shown that regeneration cannot occur without the establishment of the clot.^15,16

Theodore H, Dedolph and Henry B. Clark in 1958 in their study observed that at 3 weeks the epithelial attachment was complete. The attachment of periodontal membrane fibres and other connective tissue elements was restored, and the inflammatory response was mild or absent. Another study in 1972 by Dale L. Wood, Phillip Hoag, O.Walter Donnenfeld, and Leon Rosenfeld revealed the loss of crestal radicular bone after both the full and partial thickness flaps. Caffesse, Ramfjord and Nasjletti in 1968 stated that healing following reverse bevel periodontal flap surgery has been characterized by first, second, or third intention, depending on the state of flap adaptation to teeth. Finally Wirthlin, in his review of the current status of new attachment therapy stated that there are four basic healing processes. These are: shrinkage, excision, healing by scar, and new attachment.^17,18 

Increasing the amount of attached gingiva has been a major issue in the past. Friedman in 1962 stressed that keratinized attached gingiva is capable of withstanding the stresses of mastication, tooth brushing, trauma from the foreign objects, sub-gingival restoration preparation, inflammation, and frenum pull. In 1979, Goldman and Cohen outlined the “tissue barrier” concept, demonstrating that the keratinized attached mucosa consisted of a band of dense collagenous connective tissue and can retard or obstruct the spread of inflammation better than the loose connective tissue fiber arrangement of alveolar mucosa. This zone of keratinized attached gingiva can be augmented to improve the inflammation problem in the area of recession specifically when subjected to prosthetic and orthodontic therapy. It was supported by Lindhe et al. 1973, Maynard and Oschenbein in 1975, Baker and Seymour 1976, Rubin 1979, Lindhe and Nyman 1980, and Ericsson and Lindhe in 1984.^19,20,21

However there is a controversial issue which concerns the importance of keratinized attached gingiva. No minimal width of attached gingiva has been established as the standard necessary for gingival health. This was supported by studies from Dorfman et. al.1980, Hangorsky and Bissada in 1980 and Wennstrom 1987. Lang and Loe in 1972 showed that in people with good oral hygiene, 1 mm or less of keratinized tissue is adequate.^20,21

Carranza⁹ described three situations which may result in a reduced or absence of attached gingiva: a) base of the periodontal pocket being apical or close to muco-gingival line, b) frenal and muscle that encroach on periodontal pockets, and c) gingival recession.

Fox introduced the push back procedure where he demonstrated the concept of functional adaptation (the tissue is genetically programmed to produce keratinized attached gingiva where it is required functionally). Full thickness flap was raised, gingiva was relocated apically, and bone left denuded. Periodontal dressing then was packed to protect the wound. Upon regeneration, the keratinized attached gingiva was re-established by functional adaptation. The procedure could only be performed in the anterior region, where tissue can be relocated apically. Modification of this technique was employed by Schluger in the posterior mandible area. He termed this operation the pouch technique. Instead of relocating the gingival margin of the flap apically, he packed the dressing between bone and flap.¹⁶

Histological studies by Wilderman, Wentz, and Orban showed that tissue heals but bone disappears. The thinner the bone, upon being denuded, the more bone loss resulted. Bone thus needs to be protected. In addressing this issue, Goldman and Stewart developed the technique of periosteal retention. Split thickness flap was raised, leaving periosteum to protect the bone. Harry Staflileno and Orban showed this flap operation healed better than the bone denudation procedure. However, Costich and Ramjford showed that the difference between bone denudation and the periosteal retention technique is mainly quantitative rather than qualitative. If bone is thin, it will necrose. Carranza, Glickman, and Donfefdnian pointed out that the muco-gingival level is initially relocated apically but moves coronally in the case of periosteal retention. However, in the case of bone denudation, scar tissue at the most apical area prevents the coronal movement of new muco-gingival level. Robinson addressed this issue by introducing the periosteal fenestration technique. Finally, Oschenbein introduced the double flap, where he combined both the split thickness flap and the periosteal flap to produce similar results. The concept of bone protection with tissue coverage is also addressed in the Edlan-Mejchar technique of deepening the vestibule, with the flip flop of the raised split thickness flap and periosteal flap to produce a deepened vestibule.^19,20,21,22

FLAPS FOR RECONSTRUCTIVE SURGERY

H. H. Takei 1985 proposed Papilla Preservation Technique, flap design that can be used in anterior and posterior areas. Wound healing always occurred by primary intention and without evidence of immediate graft exfoliation. Interdentally soft tissue craters did not develop, making it easier for patients to maintain optimal oral hygiene. This type of flap design can also be used without grafts in order to improve postoperative soft tissue contour.²³ Pierpaolo Cortellini 1995 proposed the Modified Papilla Preservation Technique. This technique has been applied to achieve primary closure of the interproximal tissue over barrier membranes placed coronal to the alveolar crest.²⁴ Cortellini P 1999 proposed the simplified papilla preservation flap( SPPF) to provide surgical access to interproximal bony defects while preserving interdental soft tissues, even in narrow interdental spaces and posterior teeth.²⁵

MUCOGINGIVAL SURGERY

Cohen described the current technique of the free gingival graft which involved preparation for the recipient site, harvesting of the graft from the donor site, placement of the graft and suture. Four variations to the classic technique have been employed. They are the accordion technique, the strip technique, the connective tissue technique, and the combination technique. The accordion technique involves the use of alternate incisions on opposite sides of the graft to attain graft expansion (Rateitschak 1985). The strip technique consists of obtaining two or three strips of tissue about 1 mm wide and long enough to cover the entire length of the recipient site (Han, Carranza Jr., and Takei, 1993). Thin or intermediate-thickness grafts (0.5-0.75mm) are ideal for increasing the zone of keratinized attached gingiva and undergo minimal primary contraction because of the amount of elastic fibres (Orban, 1966). The connective tissue technique involves the use of connective tissue only as the graft material, since connective tissue carries the genetic message for the overlying epithelium to become keratinized. This technique was originally described by Edel in 1974. The graft is nourished by the process of diffusion of fluid from the host bed, adjacent gingiva, and the alveolar mucosa. On the first day, the connective tissue becomes oedematous and disorganized and undergoes degeneration and lysis of some of its elements. On the second or third day, the graft re-vascularized with the proliferation of the capillaries from the recipient bed (Jansen, Ruben, and Kramer, 1969). This new network of capillaries anastomoses with the pre-existing vessels. As seen microscopically, the healing of the graft of intermediate thickness (.75mm) is complete by 10.2 weeks, and that of the thicker graft (1.75mm) may require 16 weeks or longer (Gordon, Sullivan, and Atkins, 1968). Burton Langer and Laureen Langer described the use of sub-epithelial connective tissue graft as a donor source for root coverage.^7,9,26-30 F. Fagan 1974 proposed the apically Positioned Flap, which can be either partial thickness or full thickness, to increase the zone of keratinized gingiva where there is in adequate of vestibular depth.³¹ Grupe and Warren in 1956 described laterally (horizontally) displaced flap. This technique can be used to cover isolated, denuded roots that have adequate donor tissue laterally and apically.³² Hall WB 1984 proposed coronally displaced Flap. The purpose of the coronally displaced flap operation is to create a split thickness flap in the area apical to the denuded root and position it coronally to cover the root. Tarnow 1986 has described the semilunar coronally repositioned flap to cover denuded root surfaces. This technique is very simple and predictably provides 2 to 3 mm of root coverage. It can be performed on several adjoining teeth, but even though the incision may be continuous, extreme care should be exercised not to dissect the blood supply. This technique is successful for maxilla.³³ Pini Prato 1992 proposed guided tissue regeneration technique for root coverage based on the principle of guided tissue regeneration resulting in reconstruction of the attachment apparatus, along with coverage of the denuded root surface.³⁴ Pouch And Tunnel Technique was developed to minimize incisions and reflection of flaps and to provide abundant blood supply to the donor tissue, the placement of subepithelial donor connective tissue into pouches beneath papillary tunnels allows for intimate contact of donor tissue to the recipient site. After positioning the graft, the coronal placement of the recessed gingival margins completely covers the donor tissue. The aesthetic result is excellent particularly in maxilla. Various surgical procedures have been suggested to increase the width of attached gingiva around teeth/ or deepen the vestibular fornix. Initially, clinicians developed several surgical methods, periosteal retention, denudation procedure, and their modifications, to achieve this goal. These procedures proved to be in effective and with un predictable results. Severe post-operative complications, and pain. Consequently, the investigation of grafting techniques by means of a variety of materials was prompted. Since first introduced in 1963 by Bjorn.H, the autogenous free gingival graft (FGG) procedure has been widely utilized in periodontal surgery for this particular purpose³⁵ .

CONCLUSION

The multitude of achievements of recent years is a source of pride and satisfaction to all dental surgeons, but few could estimate them correctly and keep their true bearings for future progress. We must study the past and appreciate that these developments in dentistry, as in all sciences, have been made possible only by the long, weary toil of those who have gone before, and who carefully gathered crumbs of knowledge and preserved them for the use of future generations. The results of today are but the culmination of untiring efforts of the past, the benefits of which we now reap.