Access Flap Research Articles

Expression of gingival crevicular fluid markers during early and late healing of intrabony defects after surgical treatment: a systematic review

BackgroundSurgical treatments such as guided tissue regeneration (GTR) and access flap surgery are widely employed for the treatment of intrabony defects. However, little is known regarding the postoperative expression of gingival crevicular fluid (GCF) markers.ObjectiveThe aim of this systematic review was to compare the expression of GCF markers following treatment of periodontal intrabony defects with guided tissue regeneration or access surgery. The association of the markers’ expression with the clinical outcome was also assessed.MethodsAn electronic literature search was conducted in MEDLINE, EMBASE, OpenGrey, LILACS and Cochrane Library up to December 2018 complemented by a manual search. Human, prospective clinical studies were identified. The changes from baseline up to 30 days (early healing) and 3 months (late healing) were assessed.ResultsA total of 164 publications were identified and reviewed for eligibility. Of these, 10 publications fulfilled the inclusion criteria. The included studies evaluated 15 different GCF markers with a follow-up time between 21 and 360 days postoperatively. PDGF, VEGF and TIMP-1 changes were often investigated in the included studies; however, contrasting results were reported. Two studies agreed that both GTR and OFD lead to similar OPG level changes. TGF-β1 is increased early postoperatively, irrespective of the surgical technique employed.ConclusionThere is limited evidence available on the expression of GCF markers after surgical interventions of intrabony periodontal defects. However, OPG and TGF-β1 tend to increase early post-operatively, irrespective of the surgical technique employed, irrespective of the surgical technique employed.Clinical relevanceMore well-designed, powered studies with sampling periods reflecting the regenerative process are needed, and future research should focus on employing standardised protocols for collecting, storing and analysing GCF markers.

Successful Management of Peri-Implantitis around Short and Ultrashort Single-Crown Implants: A Case Series with a 3-Year Follow-Up.

Introduction and Aim In case of peri-implantitis, resective surgery is contraindicated for short and ultrashort implants, limiting the treatment options to regenerative surgery or to implant removal. This retrospective case series presents the clinical and radiographic outcomes of a surgical regenerative procedure to treat peri-implantitis around short and ultrashort implants. Materials and Methods The study is a retrospective evaluation of patients suffering from peri-implantitis and those who underwent access flap surgery, concomitant chemical and mechanical decontamination of implant surface, and bone grafting using a self-hardening mixture of bone substitutes and biphasic calcium sulfate. No membranes were applied to cover the grafting material, and primary tension-free closure was achieved. The retrospective protocol was reviewed and approved by the Ethics Committee for Clinical Sperimentation (CESC) of Verona and Rovigo, Italy (based in the University of Verona) (Prog. 1863CESC. Date of approval: 2018-07-04). Results 15 patients (17 implants) have been diagnosed with peri-implantitis after a mean follow-up of 24 months after loading. Implant length was between 5 and 8 mm. 8 patients (10 implants) had a history of periodontitis. At baseline, the mean PD (probing pocket dept) at the deepest site was 8.12 mm, with an average mBI (modified bleeding index) of 2.35 and a mean BD (bone defect depth) of 3.04 mm. At the 3-year follow-up, the CSR was 100%, the mean mBI was 0.88 (average reduction: −1.47), the mean PD was 3.35 mm (mean PD reduction: 4.77 mm), and the mean bone defect was reduced by 1.74 mm, with a mean bone fill of 55%. Conclusions The results of the present case series suggest that if accurate surface decontamination is achieved, high survival rate and good clinical and radiographic results can be obtained after 3 years. However, only the histological examination could confirm the growth of new bone in direct contact with the implant surface or if the grafted material only fills the space left by the peri-implant defect.

Guided biopsy of osseous pathologies in the jaw bone using a 3D-printed, tooth-supported drilling template

Suspicious radiological findings in the jaw bone require histopathological examination for the confirmation of a diagnosis. As pathologies in this region are difficult to reach or are in close proximity to relevant anatomical structures, e.g. tooth roots or nerves, they often represent a challenge. Such factors may adversely affect the predictability of the surgical outcome of a biopsy of the osseous tissues. This technical note introduces a novel method for performing a digitally planned, guided biopsy. For this purpose, a cone beam computed tomography scan and an intraoral scan are superimposed using specific planning software. The resulting three-dimensionally printed, tooth-supported drilling template is designed for a trephine biopsy. It allows a precise, minimally invasive approach, with an exact three-dimensional determination of the biopsy location prior to surgery. The risk of devitalization of the neighbouring teeth or possible damage to the nerve structures can be minimized. Furthermore, a small access flap can be sufficient. In summary, the method of bone biopsy presented here allows high precision and greater predictability for biopsy sampling and is minimally invasive for the patient.

Expression of growth mediators in the gingival crevicular fluid of patients with aggressive periodontitis undergoing periodontal surgery.

To describe changes in growth factor mediators in the gingival crevicular fluid (GCF) of patients with aggressive periodontitis (AgP) undergoing regenerative (GTR) and access flap (AF) surgery. This was a 12-month, single-blind, split-mouth RCT involving 18 AgP patients with a bilateral intrabony defect which was treated with GTR or AF. GCF was collected prior to surgery and at subsequent follow-up visits from 3days to 12months post-operatively, and the levels of angiopoietin-1 (Ang-1), vascular-endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), bone morphogenetic protein-2 (BMP-2), osteoprotegerin (OPG), tissue inhibitor of metalloproteinase1 (TIMP-1), keratinocyte growth factor (KGF) and platelet-derived growth factor-AB (PDGF-AB) were measured. At baseline, 6 and 12months post-surgery, periodontal clinical parameters were evaluated. ANOVA was applied to test for differences in the amount of mediators (p < 0.05). Higher amounts of BMP-2 and OPG and a higher area under the curve (AUC) of KGF at the GTR versus AF sites were observed. The maximum change in the amount of KGF correlated significantly with periodontal clinical parameters at the GTR sites at 6 and 12months. The AUC over 30days of the amount of Ang-1, VEGF and KGF significantly correlated with periodontal clinical parameters at the AF sites at 6months. AF and GTR differentially affected the profile of the growth mediators in GCF, and significant correlations between certain GCF mediators and periodontal clinical outcomes were identified. GCF components represent attractive prognostic markers for periodontal tissues undergoing repair or regeneration. However, the available evidence is not robust enough to suggest the use of a specific marker, and future adequately powered studies are warranted to identify the most relevant mediators that could be applied in clinical practice.

PR706: Surgical treatment of peri‐implantitis using apically repositioned flap versus access flap in conjunction with local application of chlorhexidine gel. A comparative clinical study

PR706: Surgical treatment of peri‐implantitis using apically repositioned flap versus access flap in conjunction with local application of chlorhexidine gel. A comparative clinical study

Combination therapy in chronic periodontitis: a case report

Background: The aim of periodontal treatment is to provide healthy and functional dentition for the whole life. Cases Report : A 42 year old female with sever chronic periodontitis, treated medically and surgically, is reported. She initially received antibiotic, Scaling and root planning in addition to oral hygiene instruction. After four weeks, periodontal Surgery, root canal Therapy, extraction of excess tooth and restoration of some teeth were performed, because of remaining residual pockets, and bone loss, flap Surgery and Access flap, with papilla preservation flap method, also modified Widmann flap, were done. After one month, favorable clinical improvement was obtained. C onclusion: It can be concluded that high oral hygiene level in accompanied with Suitable medical and surgical treatment, enhanced the success of periodontal treatment outcomes even in sever disease.

Periodontal education and assessment in the undergraduate dental curriculum-A questionnaire-based survey in European countries.

This survey aimed to evaluate whether periodontal education and assessment in undergraduate dental curricula amongst the member countries of the European Federation of Periodontology (EFP) follow the competency-based curricular guidelines and recommendations developed by the Association for Dental Education in Europe. A multiple-choice questionnaire was emailed to 244 dental institutes amongst the 24 EFP member countries between November 2014 and July 2015. Data were received from 16 (66.7%) EFP member countries. Out of 117 responding dental institutes, 76 (64.95%) were included as valid responders. In most of the institutes (86.3%), a minimum set of competencies in periodontology was taken into account when constructing their dental education programmes. Out of 76 responders, 98.1% included lecture-based, 74.1% case-based and 57.1% problem-based teaching in their periodontal curricula, whilst a minority (15.9%) also used other methods. A similar pattern was also seen in the time allocation for these four educational methods, that is, the highest proportion (51.8%) was dedicated to lecture-based teaching and only a small proportion (5.7%) to other methods. Periodontal competencies and skills were most frequently assessed by clinical grading on clinic, multiple-choice examination (written examination) and oral examination, whereas competency tests and self-assessment were rarely used. Only in 11 (14.5%) cases, access flap procedures were performed by students. Great diversity in teaching methodology amongst the surveyed schools was demonstrated, and thus, to harmonise undergraduate periodontal education and assessment across Europe, a minimum set of recommendations could be developed and disseminated by the EFP.

Effect of Diode Laser-assisted Flap Surgery on Postoperative Healing and Clinical Parameters: A Randomized Controlled Clinical Trial.

Background and Objectives:Lasers have been widely used because of several potential benefits such as antibacterial effect and stimulation of wound healing. In addition, lasers help in hemostasis and delaying epithelial migration which may facilitate the outcome of flap surgery. Hence, this study is aimed to investigate the adjunctive effect of diode laser irradiation on conventional access flap surgery in the treatment of periodontal disease.Materials and Methods:A total of 23 patients requiring periodontal flap surgery in two sextants with probing pocket depth ≥5 mm in at least three teeth post-phase I therapy were selected for a split-mouth study. Flap surgery with adjunctive diode laser irradiation was performed in the test quadrant while conventional access flap surgery was done in the control quadrant. Procedural pain and tissue response of the patients were evaluated at 3, 7, and 14 days postoperatively. Clinical parameters including probing depth, clinical attachment level, plaque index, and gingival index were recorded at baseline, 3 months, and 6 months following treatment.Results:There is no significant difference between the groups with respect to healing response of tissues; however, patients experienced more pain in test sites compared to control sites. Intragroup comparisons showed a statistically significant reduction of all clinical parameters from baseline to 6 months without any significant difference between the groups.Conclusion:Overall within the limitations of the study, diode lasers did not show any significant added benefits over conventional access flap surgery.

Anesthetic efficacy of 4% articaine and 2% lignocaine in achieving palatal anesthesia following a single buccal infiltration during periodontal therapy: A randomized double-blind split-mouth study.

Background:The aim of this randomized split-mouth double-blind study was to evaluate whether 4% articaine hydrochloride with 1:100,000 epinephrine administered as a single buccal infiltration in the maxillary posterior sextant can provide palatal anesthesia when compared with 2% lignocaine with 1:100,000 epinephrine during scaling and root planing and access flap surgery (AFS).Material and Methods:A total of 40 patients with chronic generalized periodontitis requiring periodontal therapy in the maxillary posterior sextants were recruited in this study. About 4% articaine and 2% lignocaine were administered as buccal infiltration in a split-mouth design randomly. The pain scores in the palatal aspect were recorded during scaling and root planing and open flap debridement using Heft-Parker visual analog scale. The onset of anesthesia was also recorded and compared.Results:The success rate for maxillary buccal infiltration to induce palatal anesthesia using articaine was 90% during scaling and root planing and 82.5% during AFS and for lignocaine solution was 20% and 15%, respectively. The difference between the two agents was statistically significant (P < 0.05). The onset of anesthesia between articaine and lignocaine was also found to be statistically significant (P < 0.05).Conclusion:In this study, we observed that the efficacy of 4% articaine was superior to 2% lignocaine to induce palatal anesthesia following maxillary buccal infiltration in maxillary posterior sextants.

Early Wound Healing Score: a system to evaluate the early healing of periodontal soft tissue wounds.

PurposeNumerous indices have been proposed to analyse wound healing in oral soft tissues, but each has specific shortcomings. A new method of analysis, the Early Wound Healing Score (EHS), was evaluated in the present study. The aim was to assess more accurately early healing by primary intention of surgical incisions in periodontal soft tissues.MethodsTwenty-one patients were treated with different surgical procedures comprising 1 or 2 vertical releasing incisions as part of a surgical access flap. Twenty-four hours after surgery, early wound healing at the vertical releasing incisions was assessed using the EHS. This score assessed clinical signs of re-epithelialization (CSR), clinical signs of haemostasis (CSH), and clinical signs of inflammation (CSI). Since complete wound epithelialization was the main outcome, the CSR score was weighted to be 60% of the total final score. Accordingly, a score of 0, 3, or 6 points was possible for the assessment of CSR, whereas scores of 0, 1, or 2 points were possible for CSH and CSI. Higher values indicated better healing. Accordingly, the score for ideal early wound healing was 10.ResultsThirty vertical releasing incisions were assessed in 21 patients. At 24 hours after incision, 16 vertical releasing incisions (53.33%) received the maximum score of CSR, while 6 cases (20%) received an EHS of 10. None of the cases received 0 points.ConclusionThe EHS system may be a useful tool for assessing early wound healing in periodontal soft tissue by primary intention after surgery.

Evaluation of diode laser and stannous fluoride in the treatment of root sensitivity after access flap surgery: Randomized controlled clinical trial.

Background:Postsurgical root sensitivity has always been an enigma to the periodontists. There is a plethora of evidence suggesting the presence of root sensitivity following periodontal flap surgical procedures. Thus, the aim of the present study was to compare and evaluate the effect of low-power diode lasers with and without topical application of stannous fluoride (SnF2) gel in the treatment of root sensitivity and also evaluate whether laser creates any placebo effect in the control group or not.Materials and Methods:Thirty patients participated in this study and 99 teeth were included. Root sensitivity was assessed for all groups with a Verbal Rating Scale (VRS). For each patient, the teeth were randomized into three groups. In the test Group I, sensitive teeth were treated with SnF2 and diode laser. In the test Group II, sensitive teeth were irradiated with laser only. In the control group, no treatment was performed.Results:The mean ± standard deviation (SD) score for VRS and Visual Analog Scale at baseline was not statistically significant (P > 0.05) between the three groups. After 15 min, statistical significant difference was seen in test Group I and test Group II, although no difference was found in the control group. At 15th day and 30th day, the mean ± SD scores were statistically significant (P < 0.05).Conclusion:Within the limitations of the study, it can be concluded that diode lasers alone and in combination with 0.4% SnF2 was effective in the treatment of root sensitivity after access flap surgery.

Reentry After Combined Surgical Resective and Regenerative Therapy of Advanced Peri-implantitis: A Retrospective Analysis of Five Cases.

This retrospective analysis of five reentry cases reports on the clinical defect healing after combined surgical resective/regenerative therapy of advanced peri-implantitis. A second surgery was necessary because of a clinical need for additional treatment procedures at the respective implant sites after healing periods of 8 months to 6.5 years. All patients underwent the same standardized procedure including access flap surgery, implantoplasty at bucally and supracrestally (> 1 mm) exposed implant parts, surface decontamination, and augmentation of the intrabony (Class I) components using a natural bone mineral and a native collagen membrane. Clinical defect resolution (DR) of the Class I component was evaluated. In two patients, clinical and radiographic signs suggested a reinfection (ie, case 3-mesial aspect; case 5-mesial and distal aspects). Mean DR values ± standard deviation were 59.4% ± 47.59% (95% confidence interval [CI], 0.31%-118.49%). When infected aspects were excluded, resulting values were 85.76% ± 4.86% (95% CI, 78.02%-93.50%). The presented surgical procedure was associated with a clinically important DR in advanced peri-implantitis defects.

Changes of Periodontal Parameters after Apical Surgery: Correlation of Clinical and Cone-beam Computed Tomographic Data

IntroductionThe purpose of this study was to evaluate the changes of the marginal periodontium 1 year after apical surgery. MethodsClinical and radiographic (cone-beam computed tomographic) examinations of 54 teeth treated with buccal access flaps for apical surgery were performed at baseline and after 1 year. Clinical assessment included measurements of probing pocket depth, the level of gingival margin (GM), and the width of keratinized tissue. Subsequently, the clinical attachment level (CAL) and the width of the attached gingiva were calculated. On bucco-oral cone-beam computed tomographic sections, the height and thickness of the crestal bone and the thickness of the alveolar bone were measured at different levels. ResultsIn general, the calculated mean changes of periodontal tissue and crestal/alveolar bone were only minimal. Significant mean changes included only GM and CAL on midoral aspects and the distance from the cementoenamel junction or restoration margin on midbuccal sites. CAL was further correlated with the thickness of the alveolar bone at 3 mm below the cementoenamel junction or restoration margin. None of the clinically and radiographically calculated mean changes were correlated with sex, biotype, or incision techniques. With regard to age, older patients showed significantly more gingival recession on the buccal aspect compared with younger individuals. Furthermore, mean changes of the midbuccal width of the attached gingiva were positively correlated with the healing outcome, whereas mean changes of the midoral GM and CAL were negatively correlated with the healing outcome. ConclusionsWithin an observation period of 1 year, the marginal periodontium and its underlying bone structures did not suffer from significant changes after apical surgery.

Combined surgical therapy of advanced peri-implantitis evaluating two methods of surface decontamination: a 7-year follow-up observation.

To assess the long-term outcomes (>4years) following combined surgical resective/regenerative therapy of advanced peri-implantitis lesions using two surface decontamination methods. Fifteen patients (n=15 combined supra- and intrabony defects) completed a follow-up observation period of 7years. The treatment procedure included access flap surgery, granulation tissue removal and implantoplasty at buccally and supracrestally exposed implant parts, and a randomly assigned decontamination of the unmodified intrabony implant surface areas using either (i) an Er:YAG laser (ERL) or (ii) plastic curettes+cotton pellets+sterile saline (CPS). Intrabony defects were filled using a natural bone mineral and covered by a native collagen membrane. At 7years, both ERL and CPS were associated with similar mean bleeding on probing reductions (CPS: 89.99±11.65% versus ERL: 86.66±18.26%) and clinical attachment level gains (CPS: 2.76±1.92mm versus ERL: 2.06±2.52mm). Combined surgical resective/regenerative therapy of advanced peri-implantitiswas effective on the long-term, but not influenced by the initial method of surface decontamination.

Periodontal treatment and maintenance of molars affected with severe periodontitis (DPSI = 4): An up to 27-year retrospective study in a private practice.

This retrospective study aimed to evaluate the long-term response of molars affected with severe periodontitis to periodontal treatment, to analyze the differences in response between molars with and without furcation involvement (FI) and to reevaluate the usefulness of the existing classification of FI in determining the prognosis. A total of 402 patients from a single private practice were included. The observation period was 27 years (mean 16.5 years). The average frequency of the supportive periodontal therapy (SPT) visits was 1.76 ± 0.57 per year (median 1.95/ year). Inclusion criteria were: at least 10 years of periodontal follow-up, at least one tooth with probing depth ≥ 6 mm, level 4 of the Dutch Periodontal Screening Index (DPSI). Of the 2,559 molars present at the initial examination, 125 were extracted immediately. Degrees III or II FI were found in 37.2% molars, while 62.8% exhibited degree I or had no FI. The performed periodontal treatments were: nonsurgical therapy of scaling and root planing (77.6%), eventually repeated scaling and root planing (11.6%), access flap (7.8%), tunnellization (0.2%), and root resection (2.8%). The survival rate was 83.9% (77.5% molars with FI; 87.8% without FI). The presence or absence of FI did not exhibit a significant effect in any of the treatments provided. Simple treatments can successfully be applied to treat molars affected with severe periodontitis, even with FI, yielding good long-term survival rates. The classification of FI was not of great use in determining the prognosis except in case of degree III FI.

Langzeitstabilität von parodontaler Regeneration über 20 Jahre

Cortellini P, Buti J, Pini Prato G, Tonetti MS. Periodontal Regeneration Compared with Access Flap Surgery in Human Intrabony Defects 20-year Follow-up of a Randomized Clinical Trial: Tooth retention, Periodontitis Recurrence and Costs. J Clin Periodontol 2016, DOI: 10.1111/jcpe.12638

Treatment of Select Intrabony Defects by Periodontal Regeneration Could Be Cost-effective Long Term in Compliant Patients

Periodontal regeneration compared with access flap surgery in human intrabony defects: 20-year follow-up of a randomized clinical trial: tooth regeneration, periodontitis recurrence and costs. Cortellini P, Buti J, Prato GP, Tonetti MS.JClin Periodontolhttp://dx.doi.org/10.1111/jcpe.12638 [Pre pub/accepted manuscript] SOURCE OF FUNDING: Nonprofit, foundations: European Research Group on Periodontology, Genova, Italy; other: Accademia Toscana di Ricerca Odontostomatologica, Florence, Italy TYPE OF STUDY/DESIGN: Randomized controlled trial.

Peri-Implant Mucositis and Peri-Implantitis: A Current Understanding of Their Diagnosis, Clinical Implications, and a Report of Treatment Using a Combined Therapy Approach.

Abstract The clinical condition involving dental implants, characterized by soft tissue inflammation, bleeding, suppuration and rapid bone loss is widely known as peri implantitis. The main objective in the treatment of peri-implantis is to arrest the progression of the disease and at the same time to keep the dental implant in the mouth solving the inflammations signs of bleeding and pain. The aim of this paper is to highlight the effectiveness of the use of titanium brush and antimicrobial photodynamic therapy (aPDT) to decontaminate the implant surface, in association with regenerative procedures by means of autologous bone and demineralized bovine bone mineral (DBBM) in the treatment of peri-implantitis defects.

Minimizing complications associated with coronal approach by application of various modifications in surgical technique for treating facial trauma: A prospective study.

Background:Coronal incision is a popular and versatile surgical approach to the anterior cranial vault and upper and middle third facial skeleton. The flap itself permits widespread exposure of the fractures in this region. The bicoronal flap was first described by Hartley and Kenyon (neurosurgeons) to gain access to the anterior cranium in 1907. It extension as an access flap to the upper and lateral aspect of the face was pioneered by Tessier (1971). Esthetically, it is pleasing as the surgical scar is hidden within the hair.Aims:To evaluate the versatility of coronal incision using various modifications advocated in incision, exposure to fractured site, and closure of flap in treating the upper and middle third facial fractures.Materials and Methods:A total of ten patients diagnosed with upper and middle third facial fractures requiring open reduction and internal fixation/correction of contour defect were selected after preoperative clinical and radiographic (computed tomography scan) evaluation. All the cases were operated by coronal approach to gain the access to the fracture/defect site for reduction/correction of the defect. Advantages and complication are evaluated.Results:Excellent access and anatomical reduction by this approach with least number of complications; if it is performed with healthy knowledge of anatomy of the scalp and temporal region. Certain minimal complications have also been noted using various modifications used in the procedure.Conclusion:Despite of prolonged surgical time for the exposure, it is very advantages in treating upper and middle third facial fractures due to wide access and discreet scar (minimal).

Treatment of intrabony defects with guided tissue regeneration in aggressive periodontitis: clinical outcomes at 6 and 12months.

The aim of this study was to compare clinical outcomes between guided tissue regeneration (GTR) and access flap (AF) surgery in patients with aggressive periodontitis (AgP). Eighteen AgP patients with similar bilateral intrabony defects were treated in this split-mouth, single-blinded, randomised, controlled clinical trial. All patients presented with ≥3mm intrabony defects and ≥5mm periodontal pocket depths (PPD). In each patient, one defect was treated with a polyglycolide membrane according to the GTR principle, whereas the contralateral side was treated with AF. For both sides, a simplified papilla preservation flap was used. At baseline, 6 and 12months post-surgery, the clinical attachment levels (CAL) and PPD were evaluated. At 6 and 12months, at the GTR sites, the mean [95% CI] CAL gain was 1.7mm [1.1, 2.3] and 1.6mm [0.9, 2.1], respectively, while the mean [95% CI] PPD reduction was 2.3mm [1.9, 2.8] and 2.4mm [1.9, 2.8], respectively. Similar CAL (1.6mm [1.0, 2.2] and 2.1mm [1.4, 2.7]) and PPD (2.0mm [1.5, 2.4] and 2.5mm [2.0, 3.0]) outcomes were observed at the control sites at 6 and 12months, respectively. Notably, at the GTR-treated sites, 13 subjects presented with various degrees of membrane exposure. Both therapies were effective in the treatment of intrabony defects in AgP patients, and no statistically significant differences between them could be demonstrated, possibly as a result of the differing degrees of membrane exposure at the GTR sites. Both periodontal regeneration and conventional periodontal surgery are effective treatments for AgP patients.