33 GINGIVAL FLAP SURGERY

Rapid Search Terms

modified widman flap	repositioning the attached gingiva
comparisons of flap therapies	flap healing
vertical releasing incisions	scalloped vs. linear incisions
retention of gingival sulcular epithelium on attachment	blood flow during healing of flap
fiber retention procedure	flap and systemic tetracycline

Study Questions:

Describe the various flap designs and the indications for each.
What are the differences and similarities between the modified Widman, open flap curettage, and replaced flaps?
What names, if any, do you associate with these procedures?
What were the original objectives of these procedures? Are they achievable?
Do they differ from the current objectives?
How do the results compare for various flap desgns describes above.
Describe the wound healing following each of these procedures.
Describe the fiber retention procedure. Does it improve clinical results?

References:

Replaced Flap Technique

Ramfjord SP, Nissle RR. The modified Widman flap. J Periodontol 1974; 45;601-607
Ramfjord SP: Present status of the mofified Widman Flap procedure. J Periodontol 48:558-565, 1977
NabersCL. Repositioning the attached gingival. J Periodontol 1954; 25:38-39
Ammons WF, Smith DH: Flap curettage: Rationale, technique, and expectations. Dent Clin NA 20:215-226, 1976

Flap Design

Kaldahl, W., Kalkwarf, K, Patil, K: A review of longitudinal studies that compared periodontal therapies. J Periodontol 64:243-253, 1993
Johnson RH: Basic flap management. Dent. Clin. North Am. 20:3-21, 1976.
Kon S, Caffesse RG, Castelli WA, Nasjleti CE: Vertical releasing incisions for flap design: Clinical and histological study in monkeys. Int. J. Perio. Restorative Dent. 4(1):49, 1984.
Lynch TJ, et al: A comparison of mandibular lingual surgical flaps with and without a vertical releasing incision. J. Periodontol. 59:12-17, 1988.

Replaced Flap Results

Jenkins MM, Wragg PF, Gilmour WH: Formation of interdental soft tissue defects after surgical treatment of periodontitis. J Periodontol 61:564-570, 1990
Cattermole AE, Wade AB: A comparison of the scalloped and linear incisions as used in the reverse bevel technique. J. Clin. Periodontol. 5:41- , 1978.
Newman PS: The effects of the inverse bevel flap procedures on gingival contour and plaque accumulation. J. Clin. Periodontol. 11:361-366, 1984.
Haffajee AD, et al: Effect of modified Widman flap surgery and systemic tetracycline on the subgingival microbiota of periodontal lesions. J. Periodontol. 15:255 -, 1988.
Becker W1, Becker BE, Caffesse R, Kerry G, Ochsenbein C, Morrison E, Prichard J. Replaced Flap Healing. A longitudinal study comparing scaling, osseous surgery, and modified Widman procedures: results after 5 years. J Periodontol. 2001 Dec;72(12):1675-84.x

Replaced Flap Healing

Listgarten MA: Electron microscopic study of the junction between surgically denuded root surfaces and regenerated periodontal tissues. J. Periodontal Res. 7:68-90, 1972.
Caton J, Nyman S: Histometric evaluation of periodontal surgery. I. The modified Widman flap procedures. J. Clin. Periodontol.7:212-223, 1980.
Proye MP, Polson AM: Effect of root surface alterations on periodontal healing. I. Surgical denudation. J. Clin. Periodontol.9:428-440, 1982.
Caffesse RG, Castelli WA, Nasjleti CE: Vascular response to modified Widman flap surgery in monkeys. J. Periodontol. 52:1-7, 1981.
Steiner SS, Crigger M, Egelberg J: Connective tissue regeneration to periodontally diseased teeth II. Histologic observations of cases following replaced flap surgery. J Perio Res. 16:109-1981.
Svoboda PJ, Reeves CM, Sheridan PJ: Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery. J Periodontol. 55:563-566, 1984.
Bahn L, Broxson A, Yukna RA: Evaluation of the purposeful implantation of epithelium on root surfaces under periodontal flaps. Int. J. Perio. Restor.Dent. 7(2): 69-76, 1987.
Yaffe A, Iztkovich M, et al. Local delivery of an amino bisphosphonate prevents the resorptive phase of alveolar bone following mucoperiosteal flap surgery in rats. J Periodontol68:884-889,1997.
Zitzmann NU, Lindhe J, Berglundh T. Host response to microbial challenge following resective/non-resective periodontal therapy. J Clin Periodontol. Nov;32(11):1175-80. 2005
Zitzmann NU, Berglundh T, Lindhe J. Inflammatory lesions in the gingiva following resective/non-resective periodontal therapy. J Clin Periodontol. Feb;32(2):139-46. 2005
Retzepi M, Tonetti M, Donos N. Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry. J Clin Periodontol. Oct;34(10):903-11. 2007
Retzepi M, Tonetti M, Donos N. Gingival blood flow changes following periodontal access flap surgery using laserDoppler flowmetry. J Clin Periodontol. May;34(5):437-43. 2007.
Werfully S, Areibi G, Toner M, Bergquist J, Walker J, Renvert S, Claffey N. Tensile
strength, histological and immunohistochemical observations of periodontal wound
healing in the dog. J Periodont Res 2002; 37; 366–374. x

Fiber Retention

Levine HL, Stahl SS: Periodontal flap surgery with gingival fiber retention. J Periodontol 43:91- 98, 1972.
Levine HL, Stahl SS: Repair following flap surgery with retention of gingival fibers. J. Periodontol. 43:99-103, 1972.
Lindskog S, Lengheden A, Blomlof L. Successive removal of periodontal tissues. Marginal healing without plaque control. J Clin Periodontol 1993; 20:14-19.
Dello Russo NM. Use of the fiber retention procedure in treating the maxillary anterior region. J Periodontol. 1981 Apr;52(4):208-13x
Carnevale G. Fibre retention osseous resective surgery: a novel conservativeapproach for pocket elimination. J Clin Periodontol 2007; 34: 182–187.doi: 10.1111/j.1600-051X.2006.01027.x.
Cairo F, Carnevale G, Billi M, Prato GP. Fiber retention and papilla preservation technique in the treatment of infrabony defects: a microsurgical approach. Int J Periodontics Restorative Dent. 2008 Jun;28(3):257-63.x
Cairo F, Carnevale G, Nieri M, Mervelt J, Cincinelli S, Martinolli C, Pini-PratoGP, Tonetti MS. Benefits of fibre retention osseous resective surgery in thetreatment of shallow infrabony defects. a double-blind, randomized, clinical trialdescribing clinical, radiographic and patient-reported outcomes. J Clin Periodontol2013; 40: 163–171. doi: 10.1111/jcpe.12042.x
Cairo F, Carnevale G, Buti J, Nieri M, Mervelt J, Tonelli P, Pagavino G,Tonetti M. Soft-tissue regrowth following ﬁbre retention osseous resective surgeryor osseous resective surgery. A multilevel analysis. J Clin Periodontol 2015;doi: 10.1111/jcpe.12383 42: 373–379x
Aimetti M, Mariani GM, Ferrarotti F, Ercoli E, Audagna M, Bignardi C, Romano F. Osseous resective surgery with and without fibre retention technique in the treatment of shallow intrabony defects: a split-mouth randomized clinical trial. J Clin Periodontol 2015; 42: 182–189. doi: 10.1111/jcpe.12343.x

Abstracts:

Replaced Flap Technique

What are the differences and similarities between the modified Widman, open flap curettage, and replaced flaps? What names, if any, do you associate with these procedures?
What were the original objectives of these procedures? Are they achievable? Do they differ from the current objectives?

Topic: the modified widman flap Article

Authors: Ramfjord SP, Nissle RR

Title: The 1974; 45;601-607

Type:Dicussion

Rating: Good

Keywords: modified widman flap, incisions

Background:Widman introduced the reverse (internal) bevel scalloping type of gingival incisions in 1916. The term Modified Widman flap was adopted to designate a flap procedure which has been modified by several persons and came to designate an open subgingival curettage for re-attachment and re-adaptation of the pocket walls rather than surgical pocket elimination.

Purpose:To discuss the currently used modifications of the Widman flap and their rationale.

Discussion: Following initial scaling, removal of gross overhangs and OHI at least 3-4 weeks should lapse before the MWF is performed. This will allow for healing and maturation of collagen in the inflamed gingiva and thus facilitate precise flap adaptation and optimal wound contraction towards the tooth surface post-operatively.

The initial incision is directed parallel to the long axis of the tooth.
- If the buccal pocket is >2mm the incision should be placed at least 0.5-1 mm away from FGM (to remove crevicular epithelium).
- If shallow PDs are present or in esthetic area, the incision should be intrasulcular or at the free gingival margin.
- The scalloping effect should be exaggerated on the palatal aspect. Be sure to direct the scalpel slightly palatal to the long axis of the tooth aiming for the alveolar process 1-2mm palatally to the alveolar crest otherwise flap adaptation or flap contour will not be satisfactory.
- It is important to remove only a minimum amount of interproximal soft tissue to ensure complete coverage. Vertical releasing incisions are usually not required; if necessary, through interdental papilla into AG extending 2-3 mm apical to the initial incision at the end of each flap.
- Avoid vertical incision in the palate in the second bicuspid, first and second molar areas.
- Use mucoperiosteal elevators to raise a FTF only for 2-3mm or the minimum needed to reflect the flap enough to gain access to the root surface and alveolar bone with very careful full thickness reflection.
The Second incision is made intrasulcular from the bottom of the crevice to the alveolar crest.
The Thirdand last incision is done with a very sharp Orban interproximal knife to cut loose the collar of gingival tissue that has already been separated. Follow contour of alveolar crest and interproximal septum as much as possible. The loosened collar is removed with curettes.

The part of the root surfaces that have been exposed in the periodontal pockets are thoroughly curetted and planned, trying to leave areas previously unexposed with their PDL attachment. Remove soft tissue from the bony surface on intrabony lesions. Avoid prolonged reflection of the flaps and irrigate with saline to avoid drying of the bone. Flaps should be adapted on the bone and meet interproximally. Finger pressure is applied. If adaptation between buccal and palatal flap is incomplete, thin flaps or remove bone from outer aspects of alveolar process to enhance flap adaptation. Suture with interrupted sutures. Do not take deep bites because the interproximal flap margins may fold and prevent primary healing. Periodontal dressing used to hold flaps tightly against the bone. The dressing is removed after one week, teeth are polished an OHI are given.

Advantages:

Access for proper instrumentation of the root surfaces and the furcation areas.
Intimate post-op adaptation of healthy collagenous tissue to all tooth surfaces.
A marginal new epithelial attachment forms which tends to seal off the deeper areas of separation between tooth and surrounding tissues. Thus, the healing CT may adapt closely to tooth surface and re-attachment with new cementum may develop gradually from the apical aspects of the lesion.
In the long run, there is less interproximal recession with MWF than surgical pocket elimination, which is esthetically desirable, facilitates OH, results in less sensitivity and caries.

Disadvantages:the flat or concave interproximal architecture immediately following removal of the surgical dressing, especially in areas of interproximal bony craters.

Indications:i) Deep pockets, ii) intrabony pockets, iii) when minimal recession is desired.

Topic: Periodontal flap

Authors: Ramjford

Title:Present status of the mofified Widman Flap procedure.

Source:J Periodontol 48:558-565, 1977

Type:Discussion paper

Keywords: periodontitis, flap

Discussion:Widman in a modification of his original technique is the first person to describe the reverse bevel incision. The modified Widman flap procedure provides access for proper instrumentation of the root surfaces and immediate closure at the dentogingival junction between the teeth and well fitting flaps. It is important that an Achromycin ointment and a surgical dressing to prevent plaque invasion during the first week of healing and tissue adaptation to the tooth also cover this junction.

Rosling, 1976- Based on data from 105 patients studied longitudinally over 7 years. Comparing pocket elimination, curettage and modified widman flap procedure, average pocket reduction for 7- to 12-mm pockets was best following the modified Widman flap surgery.

For deep pockets in the mandibular anterior region, the results following subgingival curettage or modified Widman flap surgeries are significantly better with regard to gain of attachment than pocket elimination surgery.
The interproximal attachment level is maintained better following the modified Widman flap than following curettage in maxillary molars (4- to 6-mm pockets).
Attachment changes are most favorable over 7 years following modified Widman flap surgery, (4- to 6-mm pockets).

Indications for MWF: The greatest advantage of this procedure is in the treatment of (1) deep pockets, (2) intrabony pockets and (3) when minimal gingival recession is desired.

Topic: Attached gingiva and flap repositioning No Article

Authors: Nabers CL

Title: Repositioning the attached gingiva.

Source:J Periodontol 1954; 25:38-39

Type:Commentary

Keywords:attached gingiva, repositioned flap

Purpose:Discussion article on the repositioned flap

Discussion:Repositioning the attached gingiva is indicated when the

periodontal pocket extends beyond to mucogingival junction. In these cases, a gingivectomy is not indicated as the incision will be entirely in the mucosa resulting in a gaping wound, delayed healing, pain, and the margin will be covered by a tissue not resistant to the functional requirements of mastication.

Technique:A vertical incision is made mesial to the area of deepest pocket. The flap reflected, the area debrided, inside of the flap cleaned and the gingiva trimmed along the margin leaving 2mm, and the flap was then sutured further apically. This allows for retention of attached gingiva with elimination of the pocket.

Conclusion:Attached gingiva can be repositioned to the alveolar crest in cases where the base of the deep periodontal pocket was located apically to the mucogingival junction.

Authors: Ammons WF, Smith DH

Title:Flap curettage: Rationale, technique, and expectations.

Source:Dent Clin NA 20:215-226, 1976

Type:Discussion

Keywords:curretage

Purpose:To discuss curettage (conventional and open flap) rationale, technique and expectations.

Discussion:Historically a flap approach was used to provide access to underlying structures. Initially (1884) the purpose was to remove the “necrotic or infected” bone and later to visualize and remove calculus and debris from the deep periodontal pockets.

Thefundamental goal of all periodontal therapy is the retention of the natural dentition in a relative state of health, comfort and function for the life of the patient.

Surgical goals are 1) debridement of the pocket and root surfaces, 2) elimination of periodontal pockets, 3) maintenance or establishment of an adequate functional band of attached gingival tissues and 4) production of a contour and form to the periodontium that can be maintained.

Rationale for flap curettage is related to accessibility, debridement, repair and patient comfort. Advantages include access, facilitation of instrumentation, reattachment by regeneration of new tissues, preservation of periodontal support, elimination or reduction of deep pockets, minimization of postsurgical trauma, pain, root sensitivity and promotion of better home care by the patient.

Technique:With a No 15 blade an inverse bevel incision is made following the contour of the necks of the teeth 1mm lateral to apex of the free gingival margin to produce a thinned and scalloped flap. This incision is made to the crest of the marginal alveolar bone, score the periosteum and directed to removal epithelial lining. It should be extended as far as possible in the interdental areas to retain sufficient interdental papillae to ensure tight closure upon re-adaptation of the flaps. A horizontal incision can then be made to thin the papillae or the papillae may be elevated intact.

Flaps can be extended 1-1.5 half tooth mesially and distally for access. Vertical incisions can also be performed.

Since the prime advantage of the flap is access, the flap should be elevated beyond the MGJ. On the palatal side the usual procedure is to exaggerate the scalloping. The tissues that remain attached to the tooth are then removed with an Orban knife and debridement with ultrasonics is performed.

After debridement the flaps should be placed to only cover the buccal and lingual bony margins. This results in stable post-surgical results. Individual or continuous vertical mattress or interrupted sutures are indicated so good adaptation of interproximal tissues is achieved. Dressing can be placed and sutures are removed after 5-7 days. After suturing Pressure is applied for 3 minutes.

Flap curettage can be used in areas where regeneration can be performed or as initial preparation before orthodontic movement.

Subgingival curettage gives more favorable result regarding preservation of attachment level but less favorable pocket reductions comparing to surgical techniques. It is also more difficult to perform in patients with advanced periodontal disease and deep pockets.

Flap Design

Topic: Comparison of therapy

Authors: Kaldahl, W., Kalkwarf, K, Patil, K

Title: A review of longitudinal studies that compared periodontal therapies.

Source: J Periodontol 64:243-253, 1993

Type: Clinical

Keywords: Osseous surgery, MWF, Scaling, root planing, comparison study

Purpose : Literature review of different studies, comparing the effects of two or more periodontal therapies on various clinical parameters.

Materials and methods:

Studies that were reviewed included Michigan studies, Swedish studies, Minnesota study, Washington study, Denmark study, Loma Linda study, Arizona study, Nebraska study etc.

Results:

Both surgical and non-surgical treatment produced improvement in periodontal health.
Surgical treatment lead to more short term PD reduction than non-surgical treatment. In deeper PD sites, the short term results comparing mean attachment change following non-surgical and surgical treatment were mixed.
Surgery produced a greater loss of probing attachment in shallow sites, both short and long term.
In most studies, no long term differences in mean probing attachment level change were present between surgical and non-surgical studies.
NSSD between surgical and non-surgical in gingival inflammatory indices. When the effects of plaque control alone and plaque control with root planing were compared, root planing produced a superior response in the clinical parameters.

BL: SRP w/ plaque control produces better response in clinical parameters than just plaque control. Both surgical and non-surgical treatment produced improvement in periodontal health.

Topic: Gingival Flap Surgery Article
Authors:Johnson RH
Title:Basic flap management
Source:Dent. Clin. North Am. 20:3-21, 1976.
Type:Review article
Keywords: flap reflection, suturing, retromolar pad area, keratinized gingiva

P:Review article on basic flap management.

1. To Split or Not to Split: Author recommends FTF in most situations; in presence of thin bone & dehiscences, a STF may be indicated. It may be considered that by blunt dissection, a FTF retaining the periosteum is like a STF.

2. Don’t throw gingiva away! Retain as much gingiva as possible during flap reflection. Alveolar mucosa is not designed to withstand insults of tooth brushing or eating.

3. Palatal flap: should be scalloped so that margin ends up at crest of bone.

4. Primary incisions: extend far enough M or D so proper access to the underlying bone is exposed (at least 1 tooth each side). Not only is it difficult to see what is going on, but healing is delayed because of the trauma inflicted on the flap. Also, this allows the clinician to drape the relaxed flap while apically repositioning.

5. Flap reflection: reflect in a relaxed manner; vertical releasing incisions should only be used when necessary and not over prominence of roots and not on palatal or ling of third molars; author feels extension of sulcular incision (but do not include uninvolved teeth) is better than vertical releasing incisions that can appear to retard healing. Author discusses exposure of tuberosity region and retromolar pad area- incisions should be kept in keratinized mucosa and regions should be opened adequately to expose bony problems distal to the terminal molar. Do not perforate base of flap this will sever blood supply. Preserve KG; thin very wide tissue to approximate flaps.

6. Suturing:Pay attention to suturing to ensure correct placement. Let sutures hang loose on buccal, snug on the palatal. Author recommends using the continuous sling suture described by Dahlberg when FTF. APF the flap when doing pocket reduction surgery. Apply pressure with a gauze for a few minutes to ensure that the flap is resting in the desired position.

Topic:Vertical releasing incisions

Author:Lynch TK, et al.

Title:A comparison of Mandibular Lingual Surgical Flaps with and without a Vertical Releasing Incision

Source:J. Periodontol. 59:12-17, 1988

Type:Prospective study

Keywords:Mandibular lingual flaps; vertical releasing incision; postoperative pain; clinical healing

Purpose: To compare the short-term post-op pain and healing from surgical flaps with mandibular lingual vertical-releasing incisions vs. envelope flaps.

Methods: 12 patients (7M, 5F) were evaluated using a split mouth design: (1) envelope flap and (2) with lingual vertical releasing incisions. The procedures consisted of debridement alone or debridement plus osseous recontouring. All patients were prescribed 6 tables of 300mg acetaminophen and 30mg codeine, and were instructed to only take if they experience pain. Patients were given a Symptom Data Log to complete for the first 14 days post-op: Patients reported daily pain (scale 0-4) and also the number of prescribed tablets taken each day. Photographs were taken at 1 and 2-week post-operative visits, and were used to assess healing.

Results:NSSD was noted between the 2 procedures with respect to healing and pain, however better access was achieved with the releasing incisions.

Discussion: This study supports the use of vertical incisions. Suturing the vertical incision on the mandibular lingual is usually avoided because of the thinness of the tissue. Vertical releasing incisions (VRI) are contraindicated in areas with prominent ledges, concavities and exostoses due to difficulty in tissue management. Guidelines for VRI: Should be done at line angle, extend beyond MGJ, don’t release distal to 2^nd molar, and shallow vestibule is not a contraindication.

Topic:flap healing

Authors: Kon S, Caffesse RG,

Title:Vertical releasing incisions for flap design: clinical and histological study in monkeys.

Source:Int J Periodontics Restorative Dent. 1984;4(1):48-57.

Type:clinical trial

Keywords:vertical incisions, releasing incisions, healing, periodontium,

Purpose: To investigate the clinical and histological healing process of two different vertical releasing incisions in monkeys: one perpendicular and one beveled to the underlying alveolar bone.

Methods:2 Rhesus monkeys received 10 full thickness flaps in molar/premolar areas with 2 vertical releasing incisions at interproximal areas: one perpendicular, the other beveled to the alveolar bone. They extended from the margin straight down apically to the mucogingival line. Incisions were assigned randomly by flipping a coin. The flaps were reflected and the dento-gingival area was curetted. The flaps were replaced and secured by sutures. No sutures were placed at the vertical releasing incisions. Animals were sacrificed at 9, 14, 21 and 28 days after the procedures. Pelican carbon black ink was injected to evaluate revascularization. Cross-sections were obtained, stained, and histological analysis was performed.

Results:Immediately after surgery the full thickness flap was well adapted and the two different vertical releasing incisions showed no clinical difference.

At 9 days post-op, the marginal tissues associated with the perpendicular incision area showed a groove that could not be observed in beveled incision area.

Histologically, 9 days post-op, at perpendicular incision area the smooth keratinized oral epithelium with regular rete pegs is disrupted, irregular and enlarged rete pegs interrupting the normal vascular arrangement of the loop capillaries are noticed. The perpendicular incision showed more inflammation than the beveled one. The soft tissue groove and the microvascular gap are also quite evident at the perpendicular incision site while the beveled incision exhibits only a slight defect.

14 days post-op, at the perpendicular incision area a groove or depression is still evident, the capillary loops at this site are shorter and irregular compared to the beveled incision site.

21 and 28 days post-op a groove is still present at the perpendicular incision, rete pegs more irregular than in beveled incision area. Connective tissue fibers are completely re-organized at the beveled area.

The healing with both of the incisions was always more advanced in the deeper areas, away from the gingival margin.

Conclusion:Healing in the beveled incision was faster owing to a larger soft tissue interface. Soft tissue grooves were more frequently noted in association with perpendicular incisions.

Replaced Flap Results

Topic:soft tissue defects

Authors: Jenkins MM, Wragg PF, Gilmour WH

Title:Formation of interdental soft tissue defects after surgical treatment of periodontitis

Source:J Periodontol 61:564-570, 1990

Type:clinical study

Keywords:gingival/anatomy, tissue/anatomy, periodontal disease/diagnosis, interdental clefts, interdental craters, periodontitis/surgery

Purpose:To evaluate interdental soft tissue healing following repositioned (replaced) flap surgical techniques and determine:

How often do interdental soft tissue defects arise and their capacity for repair
If pre-op probing depth, underlying bone defect, or use of periodontal dressing is related to defect development
If soft tissue defects interfere with establishment of periodontal health after surgical treatment

Methods:21 patients (30-57 years old) were selected with remaining deep pockets with BOP after SRP completed. 46 surgical procedures were completed. No osseous recontouring was done, only root planing. Coe-pak was used in every alternate procedure after suturing (silk). Dressing and sutures were removed 1 week post-operatively. Patients were told to brush carefully for the first 2 weeks and CHX was prescribed for 2 months. Maintenance was completed for the duration of the study based on patient needs. Probing depth and BOP were measured pre-operatively, at 1, 3, and 6 months. Bone defects were assed at the time of surgery. At each post-op visit, interdental space was evaluated for the presence of a “crater” (visible depression within the interdental tissue at least 1 mm in depth) or “cleft” (soft tissue interdental defect with no visible concavity but the buccal and lingual interdental tissues could be separated with a probe to a depth of at least 1 mm). Where craters were detected, an impression was taken and poured up in dental stone. Craters were then measured by a reflex microscope. Crater sites were measured in this fashion at 3 and 6 month visits.

Results:At 1 month, 13 clefts and 30 soft tissue craters were noted. There was evidence of some reduction over time of the clefts. Probing depths were reduced at one month at all sites, as well as bleeding regardless of presence of craters or clefts. Generally there was no obvious association between the use of periodontal dressing and the subsequent occurrence of interdental soft tissue defects. 3 craters exceeding 1 mm were noted in 1 patient. At 18 months, 2 craters had entirely disappeared. No BOP was noted and PD were 2mm.

Conclusion: The development of interdental soft tissue defects, both craters and clefts, during the early stages of healing following periodontal surgery does not seem to adversely affect the ultimate establishment of periodontal health.

Topic: Scalloped and linear incisions

Authors: Cattermole AE, Wade AB

Title:A comparison of the scalloped and linear incisions as used in the reverse bevel technique.

Source: J. Clin. Periodontol. 5:41- , 1978.

Type:Clinical study

Rating: Good

Keywords:scalloped, linear incisions, healing, inflammation

Purpose:To evaluate the use of scalloped and linear incisions in reverse bevel techniques with regard to pocket elimination, rate of healing and gingival contour produced.

Materials and methods:

Split mouth design. 20 patients (22-48 years) needing surgery on each side on one or both jaws were included. 40 FTF were performed.
Selection criteria:
- The area involved was from first bicuspid to 2^nd molar. Symmetry with regard to PDs on both right and left sides of the arch involved. PD no greater to 6mm. Radiographic evidence of horizontal bone loss. Absence of any systemic disease.
Pre-op therapy: scaling, polishing, OHI. Patients should demonstrate high degree of plaque control.
Immediately pre-op GCF was collected (filter paper strips), GI, PI, PD, CAL, gingival contour, study models obtained. Measurements for GCF, GI, PI were repeated at 1, 2, 3, 4, and 12 weeks post-op and for PD, CAL at 12 weeks post-op.
Using a split mouth technique both posterior segments of an arch were treated at one appointment. On one side of the arch a linear incision was performed on the buccal and lingual aspect and one the other side ascalloped incision. Ιncisions started 1-2mm from the gingival margin. Tissue collar was removed. FTF was reflected, degranulation, sc/rp, osteoplasty performed. Flaps sutured at the bone level. Perio dressing was placed.

Results:

Clinical: it was felt that the flap procedure using the lineal incision was completed in a shorter time and with greater ease than the scalloped incision. When the flaps were sutured, the alveolar bone was completely covered with soft tissue when a scalloped incision was used but the interdental bone was left exposed when a linear incision was used. No bone was left exposed mi-buccally or mid-lingually with either procedure. During suturing of the linear flap there was a tendency for the tissues to pull in slightly into the interdental areas. Linear incision healed at a slower rate. At 12 weeks cannot distinguish between 2 procedures.

Higher GI was present after the linear incision during the first 2 weeks. The improvement in GI score continued at weeks 3 and 4 and there was no SSD between the two sides. NSSD in gingival fluid flow between the two sides. Pain was even. Clinically, satisfactory results were achieved for both scalloped and linear incisions, as determined by improvement in gingival contour, reduction in PD, slight gain in attachment, lack of gingivitis and low plaque scores.

C: Initially greater inflammation in the linear incision segments than is scalloped. 3 weeks after the operation there was little difference in the degree of healing. Linear incisions were easier to use and the surgery was completed in less time.

Topic: Periodontal flap

Authors: Newman PS

Title:The effects of the inverse bevel flap procedures on gingival contour and plaque accumulation.

Source:J. Clin. Periodontol. 11:361-366, 1984

Type:Clinical study

Keywords: periodontitis, flap

Purpose:To develop a contour index to record changes in gingival contours relative to treatment of periodontal disease that may predispose to plaque accumulation.

Methods:12 pts (4 M, 8 F; mean age=38 years old). The index is scored by examining buccal, lingual and inter-proximal surfaces of the teeth and gingiva. The new contour score: 0= ideal; 4=grossly enlarged like that seen in hereditary gingival fibromatosis. Pre-op recorded perio index, BI, PI at baseline and 90 days. Sites treated with inverse bevel flaps with no osseous recontouring.

Mean gingival contour scores increased from 1.45 to 1.65 (SSD).
Perio index decreased (SSD).
BI decreased (SSD).
PI had small increase (NSS).
No correlation b/w plaque accumulation and gingival contour.
Good gingival contours were not obtained from sx as measured by this index.

BL: Gingival contour was not improved by inverse bevel flap. PD, BI were decreased and PI was only slightly increased because of this. This study questions the importance of a good gingival contour for the maintenance of periodontal health.

Topic: Systemic tetracycline

Authors: Haffajee AD, Dzink JL, Socransky SS.

Title:Effect of modified Widman flap surgery and systemic tetracycline on the subgingival microbiota of periodontal lesions.

Source: J Clin Periodontol. 1988 Apr; 15(4):255-62.

Type: Clinical study

Keywords:periodontal lesions, subgingival microbiota, tetracycline, treatment

Purpose:To compare the subgingival microbiota before and after Modified Widman Surgery and systemic tetracycline administration (1g day/21 days) and to compare the microbiota at successfully and unsuccessfully treated sites.

Method:2 subsets of an original 33 pts were examined.

Group 1: 12 patients had microbiota compared at the same 41 sites before and after therapy (6 mo). All sites gained attachment>2mm.

Group 2: 94 post therapy microbiota samples taken from sites exhibiting different responses to therapy and compared with the microbiotas from 100 active sites of all 33 patients. Site breakdown: 24 lost > 2mm attachment, 23 gained > 2mm of attachment, and 47 did not change.

Results:

Group 1: Marked improvement in mean PD and AL was found after therapy. Mean levels of S.Mitis, S. Sanguis and V. parvula increased after therapy, while mean levels of other species including Actinomyces sp, P. gingivalis, P. interm., S. morbillorum, S. uberis, and W. recta decreased.

Group 2: Sites which lost attachment (24 lost > 2mm) had higher levels of Aa, T forsyth. Pg, Pi, P micros, S. intermedius and W.recta, while sites which gained attachment (23 sites gained > 2mm of attachment) had higher levels of Actinomyces sp. Capnocytophaga, C. ochracea, S. mitis, S.sanguis I & II and V. parvula.

None of the suspected periodontal pathogens were eliminated from all sites, though they were reduced in all sites.

Conclusion:The present investigation supports the concept that specific periodontal infections may be better controlled by different therapeutic regimens. In this study MWF with systemic TCN was effective in controlling Aa. Black pigmented bacteriodes may have to be treated by other means.

Topic: replaced flaps
Authors: Becker W, Becker BE, Caffesse R, Kerry G, Ochsenbein C, Morrison E, Prichard J.
Title: Replaced Flap Healing. A longitudinal study comparing scaling, osseous surgery, and modified Widman procedures: results after 5 years.
Source: J Periodontol. 2001 Dec;72(12):1675-84.x
DOI: 10.1902/jop.2001.72.12.1675
Type: longitudinal
Keywords: Follow-up studies; oral hygiene; planing; scaling; periodontal diseases/
surgery; periodontal diseases/therapy; outcome assessment.

Purpose: to present 5-year results from a longitudinal study comparing scaling and root planing (SRP), osseous surgery (OS), and modified Widman (MW) therapies. The study has been completed for 12 years.

Methods: 16 adult patients with moderate to advanced periodontal disease were treated with initial scaling and oral hygiene procedures in a private practice. Post-hygiene data were used to compare changes in plaque and gingival indices, probing depth (PD), clinical attachment levels (CAL), and recession. Maxillary or mandibular aches were selected randomly. Osseous sx was performed using the guidelines described by Ochsenbein. The modified Widman flap was performed as described by Ramfjord. 8 weeks post-sx the clinical data were taken again. Pts were placed on 3 months recalls and examined annually.Frequency distributions were used to compare changes at individual sites. The first published report was from baseline to one year. This follow-up report is from baseline through 5 years.

Results: At 5 years, there were significant decreases in gingival and plaque scores. For the 3 procedures, there were significant decreases in baseline 4 to 6 mm PD; however, there were no differences between the methods. Similar findings were noted for PD initially greater than 7 mm. At 5 years, OS had the greatest number of 1 to 3 mm sites (332 sites, 73.2%), while MW had the fewest number of 4 to 6 mm PD (98 sites, 21.8%). SRP had the fewest 7 mm and greater sites (15 sites, 3.4%). At 5 years, CAL loss for 1 to 3 mm PD was statistically significant for the 3 procedures. There were slight gains in CAL for 4 to 6 mm probing depths. These gains were not significant. Similar findings were seen for CAL for probing depths greater than 7 mm. OS had the greatest number of sites losing more than 2 mm of CAL (64 sites), followed by SRP (21 sites) and MW (34 sites), respectively. Recession for 1 to 3 mm probing depths was greatest for sites receiving osseous surgery. At 5 years the 3 procedures had significant recession for 4 to 6 mm and ≥ 7 mm probing depths.

Conclusion: This 5-year clinical trial demonstrates that with good patient maintenance excellent clinical results can be achieved with various methods of treatment. Within the limits of this study, SRP, OS, and MW were effective at reducing probing depths with slight changes in clinical attachment levels.

Replaced Flap Healing

Describe the wound healing following each of these procedures.

Topic:Flap Healing

Authors: Listgarten MA

Title:Electron microscopic study of the junction between surgically denuded root surfaces and regenerated periodontal tissues.

Source:J. Periodontal Res. 7:68-90, 1972.

Type:Clinical

Keywords:wound healing

Purpose:To study the ultrastructural features of the junction between experimentally exposed root surfaces of monkey teeth and regenerated periodontal tissues at varying interval after surgery.

Materials and methods: 7 monkeys were used. Flaps were elevated on the buccal side of the teeth and 1/3 – 1/2 of the root was exposed using a bur. Root surfaces were ground to expose dentin and smoothed with curettes. Flaps were closed back and one side served as control. Animals were killed at 1, 2, 3, 6, 9, 12 and 18 months. Teeth of the animals that were sacrificed after 9, 12 and 18 months were scaled every 6 months. Histology under electron and light microscope was performed.

Results:The operated segments appeared more inflamed than the controls up to 6 months. Histological evidence of both epithelial and CT reattachment was found at all time intervals.

Regeneration of JE: JE had regenerated over denuded dentin as well as cementum in all time intervals. It included hemidesmosomes along the cell membrane surface facing the tooth and a basement lamina. This attachment apparatus was similar to that connecting the JE with the underlying CT. Superficial alterations were frequently noted in cementum and dentin. In cementum they had the appearance of a granular layer.

Regeneration of cementum: Cementum repair could be noted at all time interval in most of the specimens examined. It was formed over exposed cementum or dentin. Its formation was more advanced at the apical part. The width of the granular layer of cementum did not appear to be to related to the time of healing. The new cementum was often devoid of well-defined fiber bundles, but in specimens obtained at longer intervals root cementum resembled typical cementum with recognizable fiber bundles in its structures.

Artificial splits were found in association with the granular layer that may be associated with the demineralization process.

Conclusion:Morphological alterations on root surface did not interfere with the regeneration of a new JE that was formed over dentin.

Topic: MWF healing

Authors: Caton, J

Title: Histometric evaluation of periodontal surgery. I. The modified Widman flap procedures.

Source:J. Clin. Periodontol. 7:212-223, 1980.

Type: Clinical

Keywords: Modified widman flap, connective tissue, bone

Purpose:To determine the effect of the modified Widman flap on the CT attachment level and supporting alveolar bone.

Materials and methods:

2 adult Rhesus monkeys. 18 contralateral pairs of periodontal pockets were produced with orthodontic elastics.
Surgical treatment of pockets was performed around experimental and no treatment around control. Sacrificed 1 year after surgery. Histologic analysis performed under light microscope.

Results:

MWF produced no gain in connective tissue attachment and no increase in crestal bone height.
In angular bony defects a certain degree of “bone fill” was noted, but never accompanied by a new connective tissue attachment.
Bone regrowth was accompanied by no signs of obvious inflammation in the connective tissue adjacent to the bony wall.

BL:Results indicate repair via long junctional epithelium. New connective tissue attachment or gain in bone height was never seen.

Topic:Gingival Flap Surgery Article
Authors:Proye MP, Polson AM
Title:Effect of root surface alterations on periodontal healing. I. Surgical denudation.
Source:J. Clin. Periodontol.9:428-440, 1982.
Type:Animal Experiment
Keywords: new attachment, periodontal healing, root surface, tooth reimplantation

BG:It is believed that the periodontitis affected root surface is the principal factor in preventing new CT attachment. It has been proven that when teeth are extracted and rapidly re-implanted the periodontium reestablishes a normal morphology (Loe & Waerhaug 1961, Fong 1967)
P:To evaluate the effect of root surface alterations on periodontal healing.
M&M:12 teeth (not perio-involved), distributed in 4 squirrel monkeys, were extracted and re-implanted after surgically denuding the coronal third of the root surface of CT fibers and cementum by root planing. Teeth were out of the mouth for <15 minutes. No stabilization. Monkeys had OH 3 times per week. The re-implantation schedule provided 3 teeth for histologic analysis at 1, 3, 7, and 21 days after re-implantation.
R/D:The mobility was moderate prior to sacrificing the animals, except for the 21-day specimen (had vertical mobility). The gingival tissues were well adapted to the teeth and only showed mild inflammation. 1 day after re-implantation a zone of fibrin enmeshing erythrocytes and inflammatory cells was interposed between the root surface and the remaining periodontal fibers attached to the alveolar bone. Epithelium migrated rapidly along the denuded root, had reached the alveolar crest at 3 days, and was within the ligament space at 7 days. At 21 days, the epithelium was at the apical limit of root instrumentation, which corresponded to the level of attached CT fibers on the root surface. No evidence of new CT attachment was observed on the denuded root surface.
BL:The absence of fibers on the root surface resulted in apical migration of the epithelium, and precluded formation of new CT attachment (in healthy teeth).

Topic:vascular response

Authors:Caffesse RG, Castelli WA,

Title:Vascular response to modified Widman flap surgery in monkeys.

Source:J Periodontol. 1981 Jan;52(1):1-7. DOI: 10.1902/jop.1981.52.1.1

Type:clinical trial

Keywords:modified Widman flap, vascular response, healing, periodontium,

Purpose:To examine vascular changes observed in monkeys after modified Widman flaps.

Methods:4 young adult Rhesus monkeys were used. 1 week before the surgery, they received dental prophylaxis. In each monkey MWFs were performed on the 4 quadrants of the mouth. All premolars and molars were involved. Monkeys 1 and 2 were used to evaluate healing after 1 ,3, 4 and 7 days. Monkeys 2 and 3 were used to evaluate healing after 15, 21, 30 and 90 days post-surgery. The animals were sacrificed and perfused through the carotid arteries with India ink and 10% buffered formalin solution (to visualize the vascularization of the surgical area). Tissue blocks were removed; histological analysis was performed.

Results:

1 day	Theseparation of the mucoperiosteal flaps from the tooth and underlying structure is evident from the space left by the fibrinous clot. The vascular network within the mucoperiosteal flaps shows a hyperemic response. Patency of the vessels in the PDL and cancellous bone was evident, however, vessels were not fully patent in the exposed cortical bone. Vascular continuity apical to the surgical detachment was observed.
3 days	There is a vascular proliferation within the organizing blood clot at the bottom of the mucoperiosteal flaps, especially in areas where good adaptation was achieved. The vessels of both vestibular and lingual flaps, adjacent cancellous bone and cervical PDL are hyperemic.
7 days	Anastomoses were evident and vasodilatation was present. Vascular network of palatal flap appears to be more profuse and extensive than vestibular flap. Multiple alveolar cortical vessels are feeding the bed of both surgical flaps. At the vestibular side however, in areas where thin buccal bone is present, it is already perforated by patent vascular channels connecting the periodontal vessels and those of the flap throughout.
15-30 days	Periosteal networks adjacent to surgical interface appears normal. However, at the alveolar crest, there are localized hyperemicareas which are related to ongoing process of bone remodeling.
21 days and 30 days	Vascular proliferation has been completed. Isolated areas of increased vascularity are associated with localized process of alveolar crest remodeling
90 days	The vasculature of periodontal tissues has been restored. The periosteal vascular network, however, continues to be modified by local remodeling processes occurring at the alveolar cortical bone and alveolar crest

Conclusion:

Vascular anastomoses will be restored early in the healing period after mucoperiosteal flap surgery.
Good flap adaptation is fundamental to rapid revascularization and fast, uneventful healing.

When flaps are properly adapted, a fibrinous clot will help stabilize the tissues in position, and at the same time favor its nutrition.

By 21-30 days a normal vascular network was found.
Isolated hyperemic foci may remain associated with areas of marginal inflammation or delayed remodeling.

Topic:Connective tissue regeneration

Author:Steiner SS, Crigger M, Egelberg J.

Title:Connective tissue regeneration to periodontally diseased teeth II: Histologic observations of cases following replaced flap surgery

Source:J Perio Res. 16:109-1981

Type:Histological study

Keywords:connective tissue; regeneration; histological

Background:New attachment (regeneration) describes the reunion of connective tissues to root surfaces previously exposed in an epithelial lined pathological pocket. Re-attachment is the reuniting of CT and root surfaces, which have been separated by surgery. Regeneration has been recorded in past studies of replaced flap procedures using citric acid.

Purpose:To describe histologically the healing after conventional replaced flap procedure (w/o citric acid conditioning.)

Methods:Six pts with 7 single rooted teeth with advanced perio (>6mm) scheduled for extraction were studied. Supragingival reference groove was placed on the aspect of the tooth to help evaluate recession. Full thickness flaps were reflected and a notch was placed at apical extent of subgingival calculus. SRP was completed to remove all calculus and cementum. Flaps were reposition and sutured. Tetracycline was prescribed (250 mg q 6 hrs x 7 days), as well as CHX rinse BID x 4 mos. OH & evaluation appointment every other week for 4 mos. Block sections were then obtained at 4 month & examined (grafting in sites of Bx).

Results:Healing occurred by LJE w/ its base 0.6 to 2.4mm apical to the calculus notch, (in one specimen, LJE measured 8.2 mm). None of the specimens demonstrated histological regeneration of CT or new cementum coronal to notch.

Discussion:In contrast to a previous study (Cole et al. 1980) this study failed to show any CT regeneration (Coles study included topical application of citric acid at the time of surgery to root surfaces). The teeth included in this study had advance adult perio and some of them had to be splinted prior to surgery due to excessive mobility.

Bottom Line: After replaced flap surgery w/o chemical root tx, healing occurs by LJE

Topic: periodontal surgery

Authors: Svoboda PJ, Reeves CM, Sheridan PJ

Title: Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery

Source: J Periodontol. 55:563-566, 1984

Type:Clinical study

Keywords: intrasulcular incision, modified Widman flap, sulcular epithelium

Purpose:To determine whether any quantitative differences in pocket depth, attachment level, or recession resulted from the utilization of surgical techniques that either retained or removed the gingival sulcular epithelium.

Methods:12 subjects (34-60 years old) were included in this study. Central/lateral incisors and cuspids were used, with one side being used as the experimental side and the other being the control group. Complete periodontal evaluation performed. SRP completed before surgery, as well as occlusal adjustment and removal of other predisposing factors. Control teeth received treatment via modified Widman flap. In the experimental group, an intrasulcular incision was used and the sulcular epithelium was maintained. Roots were thoroughly planed in both groups. Interrupted sutured were used and perio pack placed. Measurement stents were made prior to surgery and were used to maintain position of probe for subsequent measurements.

Results:At 3 and 6 months, pocket depths were significantly less than the initial depths, but no difference was noted between groups. Attachment level was also significantly greater at 3 and 6 months, but no difference was seen between treatment groups. No significant change was noted in location of gingival margin, mobility, or recession between groups at 6 months.

Conclusion: No significant differences in pocket depth, attachment level, recession, mobility, plaque accumulation or gingival inflammation were found at 6 months postoperatively. The removal of sulcular epithelium in the course of periodontal surgery provided no therapeutic advantage.

Topic: implantation of epithelium

Authors: Bahn L, Broxson A, Yukna RA

Title:Evaluation of the purposeful implantation of epithelium on root surfaces under periodontal flaps.

Source: Int. J. Perio. Restor.Dent. 7(2): 69-76, 1987.

Type: Clinical study

Rating: Good

Keywords: epithelium attachment, epithelium implanted, alveolar mucosa, periodontal flap

Purpose: To evaluate healing and type of attachment with and without epithelium implanted on root surface under periodontal flaps.

Material and methods: 4 crabeater monkeys. A rectangular window was made on the buccal aspect of 2^nd premolar and 1^st and 2^nd molars on bone over each root surface. Teeth in each quadrant randomly selected: 1^st group (1 root): cementum and PDL left undisturbed (control). 2^nd group (2 roots): SC/RP only. 3^rd group (2 roots) SC/RP + epithelium implanted from alveolar mucosa (epithelium side against the root). Flaps replaced in all groups. Animals sacrificed at1, 2, and 8 weeks.

Results:

1^stControl group: New cementum, new bone (later) and connective tissue along root surface

2^ndRP group: Areas of root resorption, new cementum. Immature CT along root, migrating from PDL.

3^rdEpithelium implanted group: Most implants completely surrounded by CT. Epithelium rarely contacted the root. Some implants appeared as healthy islands; others showed signs of degeneration. No evidence of ankylosis.

Discussion:No evidence of epithelial proliferation. The key to obtain CT attachment to the root would be the inhibition of marginal flap epithelial migration.

BL:Epithelium remnants left on inner flap surface may not attach to the root and may not endanger CT attachment.

Topic:topical bisphosphonate and flap

Authors:Yaffe A, Iztkovich M, et al.

Title:Local delivery of an amino bisphosphonate prevents the resorptive phase of alveolar bone following mucoperiosteal flap surgery in rats.

Source:J Periodontol 68:884-889,1997.

Type:In-vitro study

Keywords: Alveolar bone loss; bone résorption; bone remodeling; osteoclasts; sur- gical flaps; amino bisphosphonate/therapeutic use; animal studies.

BG:Amino Bisphosphonate (AB) given systemically has been shown to reduce significantly active bone resorption without interfering with bone formation.

Purpose:To evaluate the effectiveness of topical treatment with Amino Bisphosphonate (AB) in preventing bone resorption using an absorbent pellet to deliver the drug.

Methods: 25 wistar rats. Surgery of mucoperiosteal flaps on both buccal and lingual aspects in molar/premolar region of mandible. Right side served as experimental side (AB) and left side was control. Experimental side had pellets 1mm in diameter formed from sheet of Gelfoam using a rubber dam punch. Pellet soaked in .0025ml of AB solution and applied to alveolar bone on buccal and lingual side. Flap then readapted immediately in place without sutures. Pellet remained in situ for 2 hrs. High-resolution microradiographs and photographs and a digitizer to measure bone levels.

Results: Topical application of pellet soaked in 00.25ml of AB solution demonstrated marked reduction of bone resorption.

Mean bone surface in topically treated side is 18.96 mm^2. Control side was 12.50.
AB reduced bone loss by 52%. (SSD).
Only small areas of resorption confined to coronal 1mm of inner aspect of alveolar bone crest were still be observed.

Conclusion: AB topically applied at surgery can reduce resorption of bone that results from flap reflection.

Topic: host response No Article

Authors: Zitzmann NU, Lindhe J, Berglundh T.

Title:Host response to microbial challenge following resective/non-resective periodontal therapy. J

Source: J Clin Periodontol. Nov; 32 (11):1175-80. 2005

Type: Clinical study

Keywords:B-lymphocytes, cell adhesion molecules, experimental gingivitis, immune chemistry, immunology, periodontal therapy, periodontitis

Purpose:To investigate the soft tissue reactions to plaque formation at sites treated with either open flap debridement or with the use of resective means during periodontal therapy.

Method:15 pts with chronic generalized severe periodontitis. Each patient was treated with OFD in 1 quadrant and gingivectomy in another. After 6 months, two gingival biopsies were obtained, one from the GV- and one from the OFD-treated sites. Pts were then instructed to abstain from OH for 3wks. New biopsies were obtained from the OFD and GV sites on day 21 of plaque formation.

Results:Following 3 weeks of plaque accumulation, the size of the lesion in OFD sites was more than 2x the size in GV sites (0.42 versus 0.19 mm²). The GV lesion was characterized by almost similar proportions of T cells (CD3+, 6.0%) and B cells (CD19+, 6.6%). The OFD sites were dominated by B cells (13.8%). During the 3-week period of plaque formation the increase in cell densities of T and B cells was three times larger in OFD than in GV sites.

Conclusion:The host response that occurred in the gingival sites treated with OFD was more pronounced than the reaction in gingivectomy sites

Topic: Flap Healing

Authors: Zitzmann NU, Berglundh T, Lindhe J

Title:Inflammatory lesions in the gingiva following resective/non-resective periodontal therapy.

Source: J Clin Periodontol. Feb;32(2):139-46. 2005.

Type: Clinical

Keywords: cell adhesion molecule; B-lymphocytes; immunohistochemistry; immunology; periodontal therapy; periodontitis

Purpose:To investigate the presence of inflammatory lesions in the gingiva following a periodontal treatment procedure that included either soft-tissue resection [gingivectomy (GV)] or non-resective open-flap debridement (OFD).

Materials and methods: 15 patients with advanced chronic periodontitis were recruited for the study.

They received professional cleaning and teeth that couldn’t be maintained were extracted. If indicated provisional partial dentures were produced and inserted. Clinical parameters were recorded.

Two means of access treatment in each patient to perform SRP: internal bevel gingivectomy (resective) and open – flap debridement (non-resective).

Biopsy sites were selected among proximal surfaces of non-molar teeth and had probing depths more than 5mm at baseline. Soft tissue biopsies were obtained from one disease site in each of two quadrants.

After performing of surgeries sutures were placed and were removed after 10 days. SPT was provided every 2-3 weeks and six months after completion of the surgeries clinical and radiological re-examination was performed and soft tissue biopsies were obtained, one from GV-treated and one from OFD-treated sites.

Sections were created, stained and monoclonal antibodies were used to identify the type of cells. Histological and statistical analyses were performed.

Results:Clinical observations: At 6 months after surgery both groups showed clinically gingiva. GV group showed mean additional recession of 3.7mm, mean PPD 1.9mm and OFD had additional recession of 2.5mm and mean PD 2.9mm.

Histological findings: Baseline: In all sites ulcerated pocket epithelium was present and CT was infiltrated by inflammatory cells. The inflammatory cell infiltrate (ICT) was similar to the sites assigned to GV and OFD. In both sites B cellsdominated in the lesions and occupied a proportion twice as large as CD3⁺-cells. PMNs were 1.9% of GV ICT and 2.2% of OFD ICT and were also observed within the pocket epithelium.

Healing (Day 180): On average the size of residual lesion in OFD group (0.19mm²) was significantly larger than the size of the newly formed lesion in GV (0.08mm^2). Statistically significant difference was observed in the density of PMNs and Bcells being larger at OFD group.

Conclusion:The findings of the present study indicate that surgical therapy including soft-tissue resection (GV) results in regenerated gingival units that contain smaller lesions with lower densities of immunocompetent cells when compared with the lesions remaining in sites treated by non-resective (OFD) means.

Topic: Comparison of therapy No Article

Authors: Retzepi M, Tonetti M, Donos N. blood flow during healing of flap

Title: Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry.

Source: J Clin Periodontol. Oct;34(10):903-11. 2000

Type: Clinical

Keywords: blood flow, healing, papilla preservation, modified widman flap

Purpose:To compare the microvascular gingival blood flow changes of the alveolar mucosa and the buccal and palatal interdental papillae, during healing period following simplified papilla preservation (SPPF) technique versus Modified Widman Flap (MWF) in patients with chronic periodontitis, using Laser Doppler Flowmetry (LDF).

Materials and methods:

Randomized controlled, single blinded, split mouth clinical trial with a 2 month follow-up. 10 patients (6F, 4M, mean age 40.5 years). Inclusion criteria: Healthy, non-smokers, lack of previous perio disease, with contralateral sites in the maxilla with PD >5mm 3 months after initial therapy. Parameters measured were: PI, BOP, PPD, CAL, and recession. Each flap design included 3 consecutive interdental papillae. Test group= SPPF, Control group=MWF. Doppler measurements were taken on the mucosal flap base (mesial, buccal and distal), 3 buccal papillary sites and the corresponding palatal papillary sites. Measurements were performed on the day of the surgery prior to local anesthesia, 5 minutes following local anesthesia induction, immediately after sx, and on days 1, 2, 3, 4, 7, 15, 30 and 60 post-op. Statistical analysis was done.

Results:

Both treatments presented similar patterns of gingival blood flow following anesthesia and during the post-op healing period.

At the mucosal flap, a peak hyperemic response was observed on day 1, which tended to resolve by day 4 at the test sites (SPPF), but persisted until day 7 at the control sites (MWF).

The palatal sites in both treatment groups presented overall a tendency towards a gradual increase in the perfusion values during the post-operative healing period.

A significant peak increase above the baseline was observed on day 7 at the palatal papillae of both treatment groups, which was significantly higher at the SPPF versus the MWF sites. Clinically, MWF yielded a significantly greater PPD reduction, but there was NSSD regarding the CAL and recession.

BL: Gingival blood flow presents specific patterns of dynamic changes post-op and Doppler may present clinical applicability in recording changes in the microcirculatory blood perfusion following periodontal surgery. The management of the SPPF, aiming at preserving the papillary aspects, may have a positive effect on the recovery of the gingival blood flow post-operatively.

Topic: Gingival Flap Surgery

Authors: Retzepi M, Tonetti M, Donos N.

Title: Gingival blood flow changes following periodontal access flap surgery using laser Doppler flowmetry.

Source: J Clin Periodontol. May;34(5):437-43. 2007

Type: Clinical Study

Keywords: blood flow, laser Doppler flowmetry, periodontal flap surgery, wound healing

BG: The LDF technique is based on the Doppler principle. Specifically, a laser beam is emitted by an optical fiber to the tissue to be studied. The light hitting moving erythrocytes is scattered back in shifted frequency (Doppler effect) and is captured by one or more optical fibers. The light signals are then converted into electric signals and the resulting photocurrent is processed to provide a recording of the blood flow. Although the multiple scattering events that determine the propagation of light in tissue prevent absolute velocity measurements when used in vivo, relative blood flow measurements can be obtained. Therefore, the term used to describe blood flow is flux – a quantity proportional to the average speed of the blood cells and their concentration. This is expressed in arbitrary perfusion units (PU), which are linearly related to flux.

P: To investigate the pattern of gingival blood flow changes of the alveolar mucosa and the buccal and palatal papilla during the healing period following perio access flap sx by Laser Doppler Flowmetry (LDF).

M&M: 14 healthy pts with chronic perio presenting at least one upper anterior site with a PD 5mm after initial therapy were included. Pts were anesthetized buccally and palatally with 3.6 and 1.8mL, respectively, of lido 2% with epi 1:80,000. Perio access flap sx was performed (intrasulcular incisions, no osseous) and LDF recordings were taken at baseline, following anesthesia, immediately POT, and on days 1, 2, 3, 4, 7, 15, 30, and 60 days at 9 predetermined sites per flap. These measurements were taken at 3 sites (with an acrylic stent previously made on a model): mucosal flap base, buccal and palatal papilla. Pts received polishing at 15, 30, and 60 days.

R: Alveolar mucosa: overall, the blood flow decreased immediately following anesthesia and remained at lower values, compared with baseline. The peak increase of blood flow was on day 1 POT, and persisted until day 7. The perfusion values returned to baseline by the 15

Buccal papillary areas: The blood flow decreased immediately following anesthesia and remained at lower values, compared with baseline. The perfusion values reached their peak at day 7 and returned to baseline by day 15.

Palatal papillary sites: The blood flow decreased immediately following anesthesia and remained at lower values, compared with baseline. The same as the buccal, except that perfusion did not return to baseline until 30 days. Also, the distal sites had higher increases in the perfusion values than the central and mesial sites. The anesthesia decreased the blood flow 66-75% in the mucosa and papilla.

BL: Different areas of the perio access flap present different patterns of microvascular blood flow alterations during wound healing.

Topic: wound healing

Authors: Werfully S, Areibi G, Toner M, Bergquist J, Walker J , Renvert S, Claffey N

Title: Tensile strength, histological and immunohistochemical observations of periodontal wound healing in the dog

Source: J Periodont Res 2002; 37:366-374

Type: animal study

Keywords: collagen, histology, periodontium, wound healing

Purpose: Study in beagle dogs to measure wound tensile strength at the dentin/connective tissue and bone/connective tissue interface following flap surgery at different time points and to histologically and histochemically evaluat features of flaps at each time point.

Methods: 4 beagle dogs were used for the study. Standardized flaps were outlined and made in maxillary and mandibular areas. Certain sites were used for flap replacement on dentin and others for flap replacement on bone. Plaque control was maintained during healing. A tensile force was applied using a microprocessor force gauge (50N) at 1, 2, 3, 7, 10, 14, 21 and 28 days. A loop of 3-0 silk suture was introduced 3mm from the gingival margin and 2mm from the lateral edge to apply pressure. Force was gradually applied until the flap separated from the surface. Animals were sacrificed at 28days. Flaps were sequenced to enable analysis of all time points. Histology and histochemical analysis were done for each flap area.

Results:

Tensile Strength
- Tensile strength increased with time for both surfaces.
- Tensile strength for flap/dentin was less than half that of flap/bone for all time points through day 7, tensile strength for flap/bone was significantly greater through day 28.
- Max tensile strength of 17N which correlated with the suture pulling through the tissue was seen at 10 days for the flap/bone.
Inflammatory cell counts were initially high and fell after 3 days but were significantly higher for flap/dentin interface than flap/bone.
Fibroblast density did not vary between type of flap.
Fibrin levels were initially high and then reduced after 2 days, they returned to control levels around day 28
Collagen Type 3 and 5
- Collagen 3 was seen at its highest synthesis at day 1-7 and gradually declined and leveled off
- Collagen 5 varied over time with a general decreasing trend, but increase near day 28
  - More foci of collagen were seen on dentin than bone

Conclusion: The study showed that wounds to dentin are weaker than wounds to bone at all time points up to 28 days following periodontal surgery. Wound strength greatly increased after day 7. Early wound stabilization is therefore important.

Fiber Retention

Describe the fiber retention procedure. Does it improve clinical results?

Topic:flap healing

Authors:Levine HL,

Title:Periodontal flap surgery with gingival fiber retention.

Source:J Periodontol. 1972 Feb;43(2):91-8. DOI:10.1902/jop.1972.43.2.91

Type:clinical trial

Keywords:gingival fibers, periodontal flap, gingival fiber retention

Purpose: To describe a surgical technique that is designed to retain part of the gingival fiber apparatus and its cemental insertions (Sharpey’s fibers). The advantage of retaining inserted collagen fibers is that fusion of these retained gingival fibers with newly forming connective tissue fibers from the healing margin may provide a connective tissue barrier to prevent apical migration of the epithelial attachment.

Methods:

Operative Procedure: Periodontal Flap Surgery with Gingival Fiber Retention

Internal bevel incision is made in the gingiva in a scalloped line. Vertical releasing incisions may be utilized. Gingivo-mucoperiosteal flap is then reflected.
Pocket depths, having been previously noted are now rechecked. Markings may be made on that portion of the gingiva remaining attached to the tooth to outline and record pocket depth just as one does in a gingivectomy.
Excision of the detached gingiva coronal to the attached epithelial cuff is accomplished with a 12 Bard Parker blade or other suitable instruments. This latter procedure should be performed with precision so that the gingival unit attached to the tooth is not excised. Perform osseous recontouring if necessary.
Flap is replaced and sutured into desired position. Interrupted or suspensory sutures.
A surgical dressing is placed over the operated area and may remain in position for 10 days.

Conclusion: Retention of viable collagen fibers already inserted into the cementum may insure the most coronal postsurgical repair with maximum protection against the loss of supporting bone.

This procedure can be done with apically positioned flap and pocket elimination requiring osseous surgery without mucogingival problems. Extensive osseous surgical procedures, in association with intrabony defects requiring ostectomy or grafting procedures may be more difficult to perform without laceration or removal of the attached gingival fibers.

Topic:Healing

Author:Levine HL, Stahl SS

Title:Repair Following Periodontal Flap Surgery with the Retention of Gingival Fibers

Source:J. Periodontol. 43:99-103, 1972.

Type:Histological study

Keywords:Repair; gingival flap; histological; gingival fibers

Purpose: To determine the type of repair histologically of gingival wounds in patients were attached supracrestal fibers were allowed to remain on the root surface during surgery.

Methods:8 periodontally involved teeth in 2 white females (45 and 52). 4 teeth: Retained the gingival fibers and had flaps sutured at a level close to the level prior to surgery. 2 teeth: had all the supracrestal gingival fibers removed, root was planned to the crest of the bone and then flap replaced to original level. 1 tooth: was extracted prior to flap placement and 1 tooth: was left as un-operated (control). The 7 remaining teeth were then extracted 3 weeks post-operatively, and prepared histologically for assessment.

Results: The specimen removed immediately prior to flap replacement showed inserted collagen fibers. The teeth that were root-planed during flap surgery demonstrated marked apical migration of the epithelium, with a long adherent epithelial cuff. The tooth on which gingival fibers were retained, but which did not receive root-planing during surgery, demonstrated limited epithelial apical migration and attached and functionally oriented gingival fibers immediately apical to the cuff.

Bottom Line: This study demonstrated that the maintenance of attached gingival fibers aided in predicting post-surgery attachment levels. The severed gingival fibers allowed to remain attached to the root joined in some manner with newly forming fibers from the soft tissue wound border.

Topic:periodontal surgery

Authors: Lindskog S, Lengheden A, Blomlof L

Title:Successive removal of periodontal tissues. Marginal healing without plaque control

Source:J Clin Periodontol 1993; 20:14-19

Type:animal study

Keywords:healing, monkey, periodontal tissues, surgery

Purpose:To compare periodontal healing after successive removal of periodontal tissue components, from the alveolar bone to the dentin surface.

Methods:12 upper permanent first and second premolars from 3-4 year old monkeys were used in the experiment. After surgical procedures were performed, tissues were allowed to heal for 8 weeks with no plaque control. Experimental teeth were distributed between 4 treatment groups. A full thickness flap was raised on the buccal surface of the teeth. Experimental layers included adhering periodontal ligament, etched cementum, dentin, and etched dentin. Flaps were repositioned and sutured. After the 8 week healing period, animals were sacrificed and the premolar regions were fixed for histologic examination.

Results:Adhering PDL: 4 of the 6 roots showed bone regeneration & PDL reestablished; 2 of 6 roots showed gingival retraction apically.

Etched cementum: 2 prevailing healing results: 3 of 6 roots showed CT fibers parallel to roots, mineralized tissue in the apical 1.0 mm. LJE was seen in the other 3 roots.

Denuded dentin: 4 of 6 roots showed gingival retraction with LJE, rete pegs, and inflamed cells in adjacent connective tissue. 2 of 6 roots showed gingival retraction apically.

Etched dentin: 5 of 6 roots showed gingival retraction with epithelium lining, inflamed connective tissue and mineralized tissue in the apical 1.0 mm. Remaining root showed gingival retraction to the apical extension of the defect.

Conclusion:Etched cementum appeared to be less susceptible to epithelial down growth compared to the 2 dentin preparations. PDL has an osteogenic capacity. Etching dentin surfaces did not appear to have any effect on epithelial down growth in this study.

Topic: Fiber Retention

Authors : Dello Russo NM

Title: Use of the fiber retention procedure in treating the maxillary anterior region

Source: J Periodontol. 1981 Apr ;52 (4):208-13
Type: Clinical

Keywords: fiber retention

Purpose : To describe the use of fiber retention procedure in treating the maxillary anterior region.

Material and methods:

Case1:

A partial thickness flap was reflected from the mesial line angle of the right first bicuspid to the mesial line angle of the left firs t bicuspid . A full thickness palatal flap involving the same teeth was also reflected. Because an adequate zone of attached gingiva was present, the labial incision was made approximately 1 mm apical to the free gingival margin, effectively eliminating the sulcular epithelium from the inside surface of the flap. This tissue, consisting of the free gingiva and the junctional epithelium, was then carefully remo ved with sharp curettes. Normal parabolic architecture was recreated within the connective tissue fibers which were inserted into the root. The healthy supracrestal connective tissue was found to be approximately 2 mm in width. Because bone loss was horizontal in nature, no resective osseous procedures were indicated but the intact transeptal fibers were maintained . The flap was then sutured with its free margin approximately 1 mm coronal to the retained connective tissue fibers . The gingival contour and presence of interdental papillae even at this relatively early stage of healing were esthetically pleasing .

Case 2:

For complete therapy it was decided to reconstruct his upper arch. Temporary crowns were placed prior to periodontal therapy to stabilize the teeth, eliminate the ill-fitting restorations, and establish proper occlusion. The temporary bridge was removed prior to the surgical treatment of the anterior region and the sulci were probed. A partial thickness labial flap and full thickness palatal flap were reflected from the distal of the left first bicuspid to the distal of the right canine. The junctional epithelium and free gingiva were removed with curettes recreating a normal parabolic architecture in the attached supracrestal connective tissue fibers. The flap was sutured, using periosteal sutures, 1 mm coronal to the retained connective tissue fibers .

Discussion : While a definitive concept of cure for Periodontitis is elusive, most clinicians would agree that a connective tissue attachment is a far superior therapeutic result t han an epithelial attachment. Histologie studies have shown how difficult and unpredictable it is to achieve true reattachment.14 A more common surgical result may be the so-called long epithelial attachment15’16 especially when full thickness flaps and aggressive root planing are utilized. It seems obvious that if a patient has several millimeters of intact supracrestal connective tissue attachment, a superior and more pre dictable surgical result is possible if these fibers are retained and used to reconstruct the periodontium.

T he fiber retention procedure has certain disadvantages. Performing a partial thickness flap in the maxillary anterior region is very difficult because the anatomy of the area often includes prominent roots, thin labial plates and very thin tissue overlying this bone.

Topic : Gingival Surgery

Authors : Carnevale G.

Title Fibre retention osseous resective surgery: a novel conservative approach for pocket elimination
Source : J Clin Periodontol 2007; 34: 182–187.doi: 10.1111/j.1600-051X.2006.01027.x.

Type : Clinical study

Keywords : gingival surgery, periodontal surgery, chronic periodontitis, pocket elimination

Purpose: The aim of this paper is to report a novel surgical approach that combines the classical method of osseous resection with the gingival fibre retention technique.

Materials and Methods:

Surgical technique:

Flap Design: Flap design should be carefully planned before the surgical procedure in order to predict and achieve the apical of the gingival margin at the level of the reshaped osseous crest. The surgical technique first requires the delineation of the primary incision. At the buccal sites, this is an internally bevelled incision and can be intra-sulcular or extra-sulcular. The probing depth and the apico-coronal dimension of the keratinized tissue indicate the position of the incision. A split-thickness flap is then incised beyond the mucogingival junction; mesial and/or distal vertical realizing incisions extending into the alveolar mucosa may be useful to augment flap mobility. At the mandibular lingual sites, a split-thickness flap is generally contraindicated. At the palatal area, the thinned palatal flap is recommended.

Soft Tissue Removal: Soft tissue removal begins at the buccal and lingual sites. The apical end of this sharp dissection is positioned at the apical level of the pocket. This gentle removal is performed by using a blade number 15 . At inter-dental sites, an inter-proximal knife is used. The identification of the attachment fibre system within the bony defect is then performed by using a periodontal probe with a magnifying system . All the soft tissue not attached to the root surface is carefully removed by the use of a 15 blade, a diamond-round bur or a curette, leaving only fibres connected to the root cementum in the infrabony defect.

Osseous Resection: Traditional approaches to inter-proximal ORS firstly suggest to identify the base of the defect and secondly to reshape the bony anatomy by eliminating the buccal and lingual walls. The base of the defect is then levelled to the adjacent bone. With the fibre retention technique, the vision of the inter-proximal defect changes: the coronal level of the fibre system is considered as the bottom of the defect. This reference point, being more coronal than the real base of the bony defect, minimizes bony removal in order to level the adjacent buccal/lingual bone to the inter-proximal retained fibres. Final root instrumentation by means of curettes must be carefully performed, depending on the area, to the fibre system or to the bone crest. Alveolar bone and fibres are considered as one tissue during the procedure and at the end of the osseous resection at the circumferential base of the tooth only bone and preserved fibres attached to the root should be identified

Suturing: When an ‘ ‘adequate’’ dimension of gingiva is present, the flap margin is positioned at the level of the alveolar crest.

Conclusions : The clinical effectiveness and long The proposed technique shifts the bottom of the defect in a more coronal position at the level of the connective tissue fibre attachment, establishing a more conservative supporting bone resection. Long term results of this technique are provided in two companion papers (Carnevale et al., unpublished results) demonstrating that shallow probing depths achieved by FibReORS ( Fibre retention osseous resective surgery ) can be maintained over time and clinical complications in terms of tooth loss are negligible when a careful SPC programme is established. Further investigations are needed in order to evaluate the healing process in terms of coronal re-growth of soft tissues following FibReORS and clinical performance in terms of pocket elimination compared with the traditional respective approach.

Topic: Papilla preservation technique

Authors: Cairo F, Carnevale G, Billi M, Prato GP

Title: Fiber retention and papilla preservation technique in the treatment of infrabony defects: a microsurgical approach.

Source: Int J Periodontics Restorative Dent. 2008 Jun ;28 (3):257-63.

Type: Microsurgical study

Keywords: attached gingiva, repositioned flap

Purpose: To describe microsurgical flap access for the shallow to moderate intrabony defects.

Methods: 7 non smoking pts with moderate chronic perio dz, mean age 45 yrs, were selected in private practice setting. Inclusion criteria- no systemic dz, atleast 1 PD>5mm, presence of atleast 2mm interdental space in the surgical area, full mouth plaque score <20%.

15 c blade used to make intrasulcular incision, horizontal incision at the base of the papilla, FTF reflected and STF beyond MGJ, palatal flap raised till 2-3mm bone exposed. Under 18x magnification, soft tissue not attached to root degranulated in the intrabony defect, root planning performed and flap repositioned slightly coronal to the presurgical levels with interrupted sutures.

Results: The mean initial PD was 6 + 0.58mm, while mean recession was1.28 + 0.98mm. Mean intrabony defect (dis between bone crest and defect bottom)- 2.42 + 0.53mm and mean (dis between bone crest and coronal level of attached fibres) was 1.42 + 0.54mm. Healing was uneventful, flap dehiscence or lack of primary closure not detected. At follow up at 12 months, mean residual PD was 2.85 + 0.38mm and mean residual recession was 1.43 + 0.78mm.

Conclusion: Microsurgical approach can be successfully indicated for aesthetic areas with high aesthetic outcome.

Topic: fiber retention

Authors : Cairo F, Carnevale G, Nieri M, Mervelt J, Cincinelli S, Martinolli C, Pini-PratoGP, Tonetti MS.

Title: Benefits of fiber retention osseous resective surgery in the treatment of shallow infrabony defects. a double-blind, randomized, clinical trialdescribing clinical, radiographic and patient-reported outcomes.

Source: J Clin Periodontol2013; 40: 163–171.

DOI : 10.1111/jcpe.12042.x

Type: RCT

Keywords: Bone loss/Periodontal; Periodontal Pocket; Periodontitis/surgery; Periodontitis/therapy; Randomized Clinical Trial

Purpose: to evaluate the efficacy of Apically Positioned Flap with Fibre Retention Osseous Resective Surgery (FibReORS , Carnevale et al, 2007 ) or Osseous Resective Surgery (ORS) to treat periodontal pockets associated with infrabony defect ≤3 mm at posterior natural teeth.

Methods: 30 patients with chronic periodontitis showing persistent periodontal pockets were enrolled; 15 patients were randomly assigned to FibReORS (test group) and 15 to ORS (control group).

FibReORS was performed by the guidelines described by Carnevale and ORS was perfomed by the guidelines described by Ochsenbein. After sx, CHX 0.2% was prescribed bid.

Outcome measures included intra-operative and post-operative morbidity and root sensitivity (measured by VAS) , 1-year probing depth (PD), gingival recession (Rec) and radiographic bone changes.

Results:

No differences in clinical and bone defect parameters were observed at baseline.
Marginal bone resection was reduced by 0.9-1.6 mm in the FibReORS group.
ORS was associated with patient perception of greater surgical hardship, higher 1-week pain experience and greater dental hypersensitivity.
After 1 year, shallow, maintainable PD with NSSD between the two procedures was obtained.
FibReORS was associated with less final Rec and less radiographic bone loss than ORS. Dental hypersensitivity remained significantly higher in the ORS group.

Conclusion:

The two techniques were similarly effective in term of PD reduction at the 1-year follow-up.
FibReORS determined less Rec than ORS at the 1-year follow – up.
FibReORS determined less supporting bone removal during surgery.

FibReORS was associated with less patient morbidity after surgery, less dental hypersensitivity and higher aesthetic satisfaction than ORS at the last follow-up.

Topic: Healing

Author: Cairo F, Carnevale G, Buti J, Nieri M, Mervelt J, Tonelli P, Pagavino G ,Tonetti M.

Title: Soft-tissue regrowth following ﬁbre retention osseous ressective surgery or osseous ressective surgery. A multilevel analysis

Source: J Clin Periodontol 2015 ;doi: 10.1111/jcpe.12383 42: 373–379x

Type: Randomized controlled trial

Keywords: Fibre retention osseous ressective surgery; gingival recession; periodontal disease; soft tissue; treatment

Purpose: The purpose of this study was to investigate factors associated with soft-tissue re-growth following Fibre Retention Osseous Resective Surgery (FibReORS) or Osseous Ressective Surgery (ORS) over a 12-month healing period.

Methods:

30 patients with chronic periodontitis
Periodontal pockets were associated with infrabony defects < 3mm

Patients were randomly assigned to one of two groups:

Test Group: FibReORS (n=15)-9 were smokers
Control Group: ORS (n=15)-6 were smokers

Clinical measurements were taken by a blind examiner at baseline, 3, 6, and 12 months: Rec, PD, BOP, PI, KG, mobility
Soft tissue rebound following surgery was monitored by measuring variations in Recession Reduction (RecRed)

Statistical analysis was performed

Results:

	Test Group	Control Group
1-Year PD	2.5 + 0.7mm	2.9 + 0.5mm
1-Year REC	2.6 + 0.5mm	3.7 + 1.4mm
After 1-Year PD	2.1 + 0.8mm	2.2 + 0.8mm
After 1-Year REC	2.1 + 0.8mm	3.5 + 1.2mm

After 1 year, shallow, maintainable PD with NSSD between the two procedures was obtained.
FibReORS was associated with less REC and radiographic bone loss than ORS at 1 year (SS)
Both techniques were associated with a coronal re-growth of the gingival margin, with 2.5 + 1.2mm mean RecRed for ORS-treated sites and 2.2 + 1.2mm for FibReORS-treated sites.
80% of the coronal re-growth was detected after 3 months
A Higher soft-tissue rebound after 12 months was noted in the ORS group.

Bottom Line: Both procedures showed a similar coronal soft-tissue re-growth with a significant higher recession reduction for ORS-treated sites. Significant clinical stability of the gingival margin is obtained 6 months after surgery for both procedures.

Topic: Fiber retention

Author : Aimetti M, Mariani GM, Ferrarotti F, Ercoli E, Audagna M, Bignardi C, Romano F

Title : Osseous resective surgery with and without fibre retention technique in the treatment of shallow intrabony defects: a split-mouth randomized clinical trial

Source : J Clin Periodontol 2015; 42: 182–189

DOI : 10.1111/jcpe.12343

Type: Randomized clinical trial

Keywords: Bone loss, periodontal: periodontal pocket, periodontitis, randomized clinical trial, surgery

Purpose: To compare clinical and radiographic effectiveness of apically positioned flap plus fiber retention osseous resective surgery (FibReORS) or osseous resective surgery (ORS) in the treatment of shallow intrabony defects (<3 mm) at posterior natural teeth with a split mouth design.

Methods: Non-smoking chronic periodontitis patients were selected for this study. Patients had at least one probing depth greater than 5 mm after initial therapy, with at most a 3 mm associated intrabony defect on radiographs. Clinical parameters (plaque index, bleeding on probing, probing depth, recession, clinical attachment loss, mobility width of keratinized tissue) were collected at baseline as well as 6 and 12 months after surgery. Radiographs were taken at baseline as well as 10 days, 6 and 12 months after surgery. Surgeries were performed at the same time with a split mouth design.

Results: Both test and control groups did not show any post-operative complications. Interproximal fibrin clots were frequent in the control group (ORS). At 2 weeks, the test group (FibReORS) was fully sealed whereas the control group was not healed until 4 weeks. Parameters improved in both treatment groups, though the test group showed less ostectomy and apical apical displacement of the gingival margin, lower clinical attachment loss but comparable PD reduction and KT changes. Less bone resorption was seen radiographically at 12 months in the test group as well. Significantly greater pain was experienced in the control site compared to the test site in the early healing phase.

Discussion: The FibReORS procedure was more effective in limiting the intra-surgical ostectomy, the apical displacement of gingival margin and the amount of bone remodeling than ORS over a 12 month period and was associated with negligible morbidity and suitable patient satisfaction.