Modified Widman Flap Procedure Research Articles

Surgical Management of Plaque Induced Gingival Enlargement: A Case Report

Introduction: Gingival enlargement or gingival overgrowth, a common trait of gingival disease, is characterized by an increase in the size of gingiva with multifactorial etiology. Purpose: This case report aimed to discuss gingival enlargement case along with the treatment plan of the patient.Case presentation: A 50-year-old female patient reported the swelling in the gums of teeth in lower front region since six months ago. Gingival enlargement was treated with modified Widman flap procedure, internal bevel incision, and bone recontouring. These treatment modalities showed significant clinical improvement in the form of pocket depth reduction and gingival contour Conclusion: Dental plaque bacteria served as initial factor of inflammation which induce the occurrence of gingival enlargement. Surgical treatment can be done if the initial phase still presenting gingival enlargement with firm consistency with minimum inflammation.

Unilateral Inflammatory Fibro-Epithelial Hyperplasia: A Case Report

Gingival enlargement is one of the common features of gingival disease which can be seen in the form of fibrous and/or, inflammatory overgrowth or, combination of both. Gingival enlargement is most commonly seen due to the presence of local factors such as plaque and calculus. These local factors result in the inflammatory hyperplasia of marginal gingiva and interdental papilla and may be localized or, generalized. Such type of enlargements may lead to difficulty in mastication, altered speech and unesthetic appearance which may cause psychological problems. The present case report reveals the successful management of a case with gingival enlargement which was treated with Kirkland flap for the upper anterior and right posterior regions while modified Widman flap procedure that was performed for lower anterior region to excise the tissue along with the pocket lining.

Modified Widman flap procedure: With or without periodontal dressing?

Aim: The purpose of this study was to evaluate the postoperative pain experience and gingival indexes with and without the use of periodontal dressing after Modified Widman flap procedure. Materials and Methods: Twenty patients requiring comparable bilateral flap procedures were selected. One quadrant of each jaw randomly received periodontal dressing after the surgery while the other one didn’t. Plaque Index (PI), Sulcus Bleeding Index (SBI) and Probing Depth (PD) were measured prior to the surgery, one week and 2 weeks after the surgery. Postoperative pain experience also was assessed at the conclusion of study. Results: Results showed no significant differences between dressed and undressed segments regarding changes in probing depth, plaque index or sulcus bleeding index. However patients reported significantly less pain postoperatively when the dressing was used Conclusion: Pain is reduced by periodontal dressing but No significant differences between dressed and undressed segments regarding changes in probing depth, plaque index or sulcus bleeding index.

Modified Widman flap and non-surgical therapy using chlorhexidine chip in the treatment of moderate to deep periodontal pockets: A comparative study

Introduction:It is a well established fact that periodontitis is caused by a group of highly specific microorganisms, organized as a bio-film on the tooth surface. Hence, therapeutic modalities are directed against elimination or adequate suppression of these organisms. Thorough debridement of these sites is possible mainly by scaling and root planing (SRP) and open- flap debridement in deeper sites. Open- flap debridement includes conventional surgical procedures such as the modified Widman flap procedure. Surgical procedures, however, have a number of disadvantages and hence efforts have been on at improving various non-surgical approaches, which are directed more specifically at the microbial nature of periodontal disease. Use of local drug-delivery devices is one such approach. The combined therapy of SRP and local drug delivery has been showing promising results in improving all the parameters in periodontal disease.Materials and Methods:This study compares the clinical, as well as, microbiological results of a split-mouth trial using modified Widman flap and non-surgical therapy of SRP and the use of a controlled release drug-delivery device (Chlorhexidine chip), in the management of moderate to deep pockets.Results and Conclusion:The results showed that the non-surgical most sites subjected to the non-surgical treatment were found to be maintainable without further deterioration, during the study period.

Pain Experienced by Patients Undergoing Different Periodontal Therapies

The authors assessed the levels of postoperative pain, postoperative dentin hypersensitivity and discomfort patients experienced during various periodontal treatments by using a visual analog scale (VAS). They aimed to determine whether VAS scores could be predicted by patient's age and sex and to evaluate the factors associated with the pain. The study was carried out with 56 patients who had chronic periodontitis. Using a split-mouth design, the authors selected one quadrant in each patient and treated it with scaling and root planing (SRP). They treated other quadrants with the surgical therapies of modified Widman flap (MWF), flap with osseous resection (OF) and gingivectomy (GV), depending on the patient's diagnosis and treatment needs. They measured patients' discomfort during periodontal treatments, postoperative pain and postoperative dentin hypersensitivity by asking patients to mark a VAS. The authors' analysis showed no statistically significant differences between the patients' discomfort levels associated with the four therapy types during periodontal treatment. However, postoperative pain was significantly higher for OF (P < .01) and GV (P < .05) procedures than for SRP and MWF procedures. All surgical procedures produced significantly more dentin hypersensitivity than did nonsurgical therapy. The analysis showed no statistically significant differences between male and female patients' discomfort during periodontal treatments. For all periodontal treatments, VAS scores decreased with increasing age. Discomfort during periodontal treatments, postoperative pain and postoperative dentin hypersensitivity were associated significantly with age, type of therapy and higher scores on Corah's Dental Anxiety Scale. Periodontal treatment is experienced as painful by substantial numbers of patients. Therefore, the dentist should count the pain responses during and after treatment and estimate the degree of pain according to sex, age and therapy type.

Clinical Evaluation of Periodontal Surgical Treatment With an Er:YAG Laser: 5‐Year Results

The aim of the present study was to evaluate and compare the long-term clinical outcomes of erbium-doped:yttrium, aluminum, and garnet (Er:YAG) laser-assisted periodontal flap surgery versus conventional treatment with the modified Widman flap procedure. A total of 146 single-rooted periodontally involved teeth from 25 patients were included in this study. In each patient, left or right maxillary single-rooted teeth were assigned randomly to one of two groups: group A (Er:YAG laser) and group B (modified Widman flap surgery). Er:YAG laser was used to debride the bone pockets, scale the root surface, and trim the periodontal flap. Recession, probing depth (PD), clinical attachment level (CAL), plaque index (PI), gingival index (GI), and bleeding on probing (BOP) scores were recorded at baseline and at 3, 6, 12, 24, 36, 48, and 60 months. Both treatments resulted in decreases in PD, PI, GI, and BOP, increases in gingival recession, and gains in CAL. PD reduction in group A versus group B was statistically significant at 6, 12, 24, and 36 months (P < 0.05). Gains in CAL were significantly greater in group A versus group B at 6, 12, 24, and 36 months. BOP scores were significantly lower in group A versus group B at 3 and 6 months (P < 0.05). All other differences between treatment groups were not statistically significant. Surgical treatment of single-rooted teeth with chronic periodontitis using the Er:YAG laser yields greater PD reduction and gains in CAL for up to 3 years compared to conventional Widman flap surgery. The short-term results obtained with both treatments can be maintained over 5 years.

Effectiveness of scaling and root planing versus modified Widman flap on nitric oxide synthase and arginase activity in patients with chronic periodontitis

Nitric oxide (NO) is synthesized from the conversion of L-arginine to L-citrulline by NO synthase (NOS). Arginase, which is an arginine-depleting enzyme, can compete with NOS for the common substrate L-arginine and thus inhibit NO production. In the present study, we aimed to examine the correlation between the arginase and NOS activity in patients with chronic periodontitis and to compare the effects of scaling and root planing and modified Widman flap procedures on enzyme activity. The study included 13 patients diagnosed with chronic periodontitis. Using a split-mouth design, the defects showing>or=7 mm of attachment loss were treated either with scaling and root planing or with modified Widman flap. Gingival biopsies from both sites were obtained at baseline and 2 months after periodontal treatment. Immunohistochemical staining was performed for evaluating NOS expression and specific arginase activity was determined spectrophotometrically. Although inflamed periodontal tissues demonstrated a strong inducible NOS (iNOS) expression at baseline, immunostaining decreased after periodontal treatment. iNOS expression intensity and the number of inflammatory cells showing iNOS expression were found to be higher in the scaling and root planing group compared to the modified Widman flap group. The specific activity of arginase was measured as 0.18+/-0.07 IU/mg protein in the modified Widman flap group and 0.25+/-0.11 IU/mg protein in the scaling and root planing group at baseline. After periodontal therapy, the enzyme level was increased to 0.68+/-0.14 IU/mg protein in the modified Widman flap and to 1.10+/-0.23 IU/mg protein in the scaling and root planing group. This study was the first report of evaluating the involvement of the arginine-NO pathway in chronic periodontitis and this might be considered to be of value in understanding the periodontal disease mechanisms.

Evaluation of clinical and radiographic scoring methods before and after initial periodontal therapy

Abstract The purpose of the present study was to compare the determination of the attachment level by probing and by measuring bone heights prior to and after the completion of a hygienic phase of periodontal therapy. 68 patients with moderate to severely advanced periodontitis underwent initial (hygienic phase) therapy including scaling and root planing, oral hygiene instructions and the elimination of plaque retention factors. Measurements of pocket probing depths, probing attachment levels and the location of gingival margins in relation to the cemento-enamel junction were performed at 4 aspects of each tooth with a thin calibrated probe at a baseline examination and 3 to 5 months following treatment. During these 3 to 5 months, the patients were kept in a maintenance care program. On the full-mouth radiographs obtained at baseline, the distance from the cemento-enamel junction to the marginal alveolar crest was measured in millimeters and as a % of the root length. Furthermore, a subgroup of 11 patients, who were scheduled for modified Widman flap procedures, received another full-mouth radiographic examination before the surgical treatment. In addition, the level of the alveolar crest was assessed with a periodontal probe during the surgical procedure. The comparison of the different clinical and radiographic parameters showed the best correlations between the various radiographic measurements of bone heights (r = 0.87; r = 0.86). Clinical measurements of probing attachment level and probing level of the alveolar crest revealed slightly weaker correlations (r = 0.72). When comparing radiographic bone heights with clinical measurements of probing attachment levels, the lowest correlations were found (r = 0.65; r = 0.61; r = 0.61).

Evaluation of clinical and radiographic scoring methods before and after initial periodontal therapy

The purpose of the present study was to compare the determination of the attachment level by probing and by measuring bone heights prior to and after the completion of a hygienic phase of periodontal therapy. 68 patients with moderate to severely advanced periodontitis underwent initial (hygiene phase) therapy including scaling and root planing, oral hygiene instructions and the elimination of plaque retention factors. Measurements of pocket probing depths, probing attachment levels and the location of gingival margins in relation to the cemento-enamel junction were performed at 4 aspects of each tooth with a thin calibrated probe at a baseline examination and 3 to 5 months following treatment. During these 3 to 5 months, the patients were kept in a maintenance care program. On the full-mouth radiographs obtained at baseline, the distance from the cement-to-enamel junction to the marginal alveolar crest was measured in millimeters and as a % of the root length. Furthermore, a subgroup of 11 patients, who were scheduled for modified Widman flap procedures, received another full-mouth radiographic examination before the surgical treatment. In addition, the level of the alveolar crest was assessed with a periodontal probe during the surgical procedure. The comparison of the different clinical and radiographic parameters showed the best correlations between the various radiographic measurements of bone heights (r = 0.87; r = 0.86). Clinical measurements of probing attachment level and probing level of the alveolar crest revealed slightly weaker correlations (r = 0.72). When comparing radiographic bone heights with clinical measurements of probing attachment levels, the lowest correlations were found (r = 0.65; r = 0.61; r = 0.61).

Effect of citric acid and lyophilized autologous plasma on healing following periodontal flap surgery in monkeys.

The purpose of this histologic, histometric, and autoradiographic study was to examine the effect of citric acid conditioning and lyophilized autologous plasma (LAP) application on healing following periodontal flap surgery. Mucoperiosteal flaps were elevated in six rhesus monkeys using the modified Widman flap procedure. A total of 24 quadrants were treated, each included the first and second premolar and first and second molar teeth. Cementum was removed from the exposed root surfaces, and reference notches were inscribed into the roots at the alveolar bone margin. Two treatment modalities were employed: (1) surgery plus citric acid conditioning, to serve as control and (2) surgery plus citric acid followed by LAP application (400 mg/ml saline). Flaps were returned to their preoperative positions and sutured. Animal sacrifices were scheduled to provide observations 3, 7, 14, 21, 28, and 45 days after surgery. Each monkey received an intravenous injection of tritiated thymidine, 1 microCi/gm of body weight, 1 hour before it was killed. Tissue specimens were processed for evaluation following standard procedures. Histologically, tissue sections were examined for: (1) proliferation and attachment of epithelium, (2) organization and maturation of periodontal fibers, (3) inflammatory cell types, (4) presence or absence of new cementum deposition, and (5) degree of vascularity of the tissues. For histometric evaluation, the radicular notches were used as reference points. The distances examined histometrically were: (1) from the root surface notch to the alveolar bone crest, (2) from the root surface notch to the apical extent of the junctional epithelium, and (3) from the free gingival margin to the apical extent of the junctional epithelium. For autoradiographic evaluation labeled cells were counted in five spatial compartments at 400 X magnification: (1) oral epithelium, (2) crevicular area, (3) supracrestal connective tissue, (4) coronal periodontal membrane, and (5) coronal bone marrow. For each the histometric and autoradiographic evaluation involved a total of 36 tissue sections per quadrant (9 sections per tooth). Tooth and quadrant means were obtained for each monkey. The plasma-treated and control quadrants were compared at each time point by the paired t test. N = 2 monkeys were used for each comparison. Histologic results showed that in teeth that were acid-conditioned after root planing, the epithelium often migrated apically reaching the radicular notch. Those teeth that were conditioned and subsequently treated with LAP demonstrated fiber attachment to the planed root surface and little or no epithelial downgrowth.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of age on healing following periodontal therapy.

The present investigation was performed in order to analyze the effect of age on healing of the periodontal tissues following treatment. The patients included in the present analysis consisted of 2 different samples. One group of 62 patients (sample A) was examined and treated between 1980 and 1982. 13 of these subjects were less than 40 years of age, 26 subjects were 40-49 years of age and 23 subjects were greater than 49 years old. The patients were subjected to periodontal surgery using the modified Widman flap procedure. During the active phase of treatment and for the subsequent 6 months of healing, all 62 patients were subjected to professional tooth cleaning. Instruction in proper oral hygiene measures was repeated and scaling was carried out when indicated. Sample B consisted of 21 subjects treated for advanced periodontal disease in 1969. Six of these patients were between 26 and 29 years of age at the start of treatment and 15 were at least 60 years old. The criterion for acceptance for the study in 1969 was that the patient should have lost 50% or more of his/her periodontal tissues. Following an initial examination, all patients were subjected to scaling and root planing and surgical elimination of pathologically deepened pockets. After the termination of active treatment, the patients were placed in a maintenance care program which included recall appointments every 3-6 months. Once a year after the completion of active treatment, all patients in this sample were examined regarding probing depths and clinical attachment levels. The findings from the present retrospective analyses failed to demonstrate that the age of patients with moderately advanced or advanced forms of periodontal tissue breakdown had an influence on the results of periodontal therapy. If anything, the younger patients appeared to heal with a higher frequency of shallow pockets and more gain of probing attachment than older patients.

Regeneration of alveolar bone following surgical and non‐surgical periodontal treatment

The purpose of this investigation was to examine the regeneration of alveolar bone following surgical and non-surgical periodontal treatment. A total of 16 patients who had advanced periodontitis and demonstrated angular bony defects on radiographs participated in the study. After the initial examination, they received instruction in oral hygiene and had their teeth thoroughly scaled. When the individual patient at 2 succeeding appointments had plaque on less than 20% of the tooth surfaces, one maxillary and one mandibular quadrant was treated with the modified Widman flap procedure while one of the remaining quadrants was treated with the reverse bevel flap procedure. The last quadrant was treated with root planing under local anesthesia. None of these procedures included bone contouring. Following treatment, the patients were recalled every 2 weeks for professional tooth cleaning. Radiographs taken 12 months following treatment revealed that only minor changes in the bone level had occurred in areas with horizontal bone loss following the various treatment modalities. Following the modified Widman flap procedure, however, a statistically significant coronal regrowth of bone (0.5 mm) had occurred in angular bony defects. The majority of the angular bony defects persisted following all 3 treatment modalities.

Scaling and granulation tissue removal in periodontal therapy*

The present clinical trial was performed to study whether subgingival scaling is a method of therapy which is equally effective as "access" flaps in reducing gingivitis and probing depths and in improving probing attachment levels. The study was also designed to assess whether granulation tissue removal is a determining factor for proper healing in the treatment of periodontal disease. 15 patients with advanced periodontal disease were included in the study. Each patient had at least 4 sites in each quadrant of the jaws with probing depths exceeding 6 mm. A baseline examination was performed to assess the following parameters: the oral hygiene status, the gingival conditions, the probing pocket depths and the probing attachment levels. In addition, in each quadrant, 3 approximal sites were selected for analysis of the subgingival microbiota. All of these sites showed signs of gingivitis. One site had a probing depth of less than 4 mm, another a probing depth between 4 and 6 mm and the third site had a probing depth exceeding 6 mm. The subgingival bacterial samples were studied by dark-field microscopy and the % of spirochetes and motile rods was assessed. By random selection the 4 jaw quadrants in each patient were treated for periodontal disease by the use of (1) the modified Widman flap procedure, (2) the modified Kirkland flap procedure or by (3) nonsurgical scaling and root planing. In all, 20 quadrants were treated with each of the 3 procedures. After the termination of active periodontal treatment, all patients were recalled for professional tooth cleaning once every 2 weeks during a 12-week period. Subsequently, they were recalled for prophylaxis every 3 months. The patients were examined 6 and 12 months after treatment using the same parameters as used at baseline. The data from the examinations demonstrated that subgingival scaling is an effective measure in the treatment of periodontal disease. Both in terms of average gingivitis resolution and average probing depth reduction, non-surgical therapy appeared to be equally effective as a surgical approach to treatment. It was also observed, however, that following non-surgical treatment, a larger number of sites with pockets exceeding 6 mm remained than following surgical therapy. Most of these deep pockets in non-surgically treated quadrants bled on probing to the base of the pocket. In addition, the subgingival microbiota of such sites were found to harbor more than 20% spirochetes and motile rods.(ABSTRACT TRUNCATED AT 400 WORDS)

Vascular response to modified Widman flap surgery in monkeys.

Revascularization of the periodontal tissues was studied after flap surgery. Modified Widman flap procedures were performed in four young Rhesus monkeys. All premolars and molars were involved. Experimental periods covered from 1 day to 90 days. The animals were sacrificed by exsanguination and perfused through the carotid arteries with a combined solution of equal parts of India ink and 10% buffered formalin solution. After fixation and decalcification, part of the blocks were processed to obtain cleared specimens following the Spalteholtz method. The remaining blocks were processed for routine histologic examination. The findings, mainly from the cleared specimens, showed that 1 day after surgery the supraperiosteal vessels in the flap demonstrated an overt hyperemic response. Patency of the vessels in the periodontal membrane and cancellous bone was evident; however, vessels were not depicted in the exposed cortical bone, nor in the clot. Vascular continuity apical to the surgical detachment was observed. In 3 to 4 days vascular proliferation within the organizing clot was observed and anastomosis between the gingiva and cancellous bone or periodontal membrane started to develop. At 7 days anastomoses were evident and vasodilation was present throughout the tissues. At 15 days and thereafter, vascular organization started to decrease, and the only hyperemic foci remaining were associated with areas of delayed bone remodeling, cementum remodeling or persistent marginal inflammation.

Histometric evaluation of periodontal surgery. II. Connective tissue attachment levels after four regenerative procedures.

The present study was undertaken to determine the effect of four periodontal regenerative procedures on the connective tissue attachment level. The procedures tested were: 1) the modified Widman flap procedure, 2) the modified Widman flap procedure combined with transplantation of previously frozen autogenous red marrow and cancellous bone, 3) the modified Widman flap procedure in combination with implantation of beta tricalcium phosphate, and 4) periodic root planing and soft tissue curettage. Eight adult Rhesus monkeys, divided into four equal groups, were used. Periodontal pockets were produced around contralateral teeth in a standardized manner. In each group of animals, the pockets on one side of the jaws were subjected to one of the above-mentioned surgical treatments, while the contralateral pockets remained as unoperated controls. Three weeks before surgery, a carefully designed plaque control program was instituted and continued until the animals were sacrificed 12 months after surgery. In histologic sections, linear measurements along the root surfaces were made from the cemento-enamel junction (CEJ) to the most apical cells of the junctional epithelium (JE). These measurements from operated and unoperated sites were then compared. The data revealed that healing following the four different regenerative procedures resulted in the reformation of an epithelial lining (long junctional epithelium) along the treated root surfaces, with no new connective tissue attachment.

Histometric evaluation of periodontal surgery. I. The modified Widman flap procedure.

The present investigation was performed in the Rhesus monkey to determine the effect of the modified Widman flap procedure on the level of the connective tissue attachment and supporting alveolar bone. Two adult male Rhesus monkeys were used. Eighteen contralateral pairs of periodontal pockets were produced in a standardized manner. Surgical treatment of the pockets was performed around experimental teeth and the contralateral teeth were used as the unoperated controls. Twelve months following treatment the animals were sacrificed and histological sections obtained. Using the cemento-enamel junction (CEJ) as a fixed reference point, linear measurements along the root surface were made to the most apical cells of the junctional epithelium (JE), to the crest of the interproximal alveolar bone (CR), and to the apical extent of angular bony defects (AAD). These measurements from operated and unoperated pockets were then compared. The data revealed that treatment of periodontal pockets using the modified Widman flap procedure produced no gain in connective tissue attachment and no increase in crestal bone height. In angular bony defects a certain degree "bone fill" was noted. This bone repair was never accompanied by new connective tissue attachment.

Present Status of the Modified Widman Flap Procedure

Present Status of the Modified Widman Flap Procedure

Short Term Results of Three Modalities of Periodontal Treatment

Short term data were obtained from 74 patients who recieved comprehensive periodontal treatment using a split mouth approach to test three variables; subgingival curettage, pocket elimination surgery, and modified Widman flap procedure. The patients initially had an average interproximal loss of attachment of 3.2 mm and an average interproximal pocket depth of 3.9 mm. Evaluation of the data indicate that after 4 to 6 weeks: 1. All three surgical procedures reduce pocket depths. In order of effectiveness they are: pocket elimination surgery, modified Widman flap, and subgingival curettage. 2. Pocket elimination surgery reduces pockets more than subgingival curettage on the buccal, lingual and interproximal, and more than the modified Widman flap on the lingual. The modified Widman flap procedure reduces pockets more interproximally than subgingival curettage. 3. Subgingival curettage results in a gain of attachment interproximally, and on the lingual side, while the modified Widman flap resulted in a gain of attachment interproximally only. 4 Pocket elimination surgery resulted in a loss of attachment buccally. 5 Subgingival curettage results in a more favorable postoperative attachment level on all surfaces than did pocket elimination surgery.