Open Flap Debridement Procedures Research Articles

Comparison of Conventional and Microsurgical Access Flap Procedure in Managing Chronic Periodontitis: A Randomized Controlled Trial.

The aim of the study was to evaluate and compare the periodontal treatment outcomes in patients with periodontitis treated using conventional and microsurgical access flap procedure. Fifty chronic periodontitis patients were randomly assigned to conventional (Group I) and microsurgical (Group II) open flap debridement procedure. The parameters measured were probing pocket depth, clinical attachment loss (CAL), gingival recession (GR), bleeding on probing (BOP), wound healing, and postoperative pain. PD, CAL, GR, and BOP were assessed at pretreatment (baseline) and 3 months postoperatively. Wound healing was assessed using Landrey et al. healing index at 7th day and 3 months postoperatively and postoperative pain was assessed using number of analgesics taken for 7 days following surgery. Healing Index score of 4 (very good healing) was found in 40% of sites of Group I and 95% of sites of Group II. Comparison of number of analgesics taken between groups on day 7 showed a statistically significant difference (P < 0.01), indicating that pain was significantly reduced in Group II compared to Group I. At 3 months postoperatively, there was no significant reduction in PD, CAL, GR, and BOP between the groups. In open flap debridement procedure, a microsurgical approach can substantially improve the early healing and induce less postoperative pain when compared to a conventional macroscopic approach.

Effect of advanced-platelet rich-fibrin combined with rosuvastatin application after open flap debridement of infrabony pocket

Open flap debridement (OFD) is an invasive therapy for chronic periodontitis with pocket 5 mm or more. However, it is difficult to achieve regeneration and new attachment with this therapy. Periodontitis starts to add growth factors and local drugs delivery as host modulation therapy. Advanced-PRF (A-PRF) contains more growth factor than PRF which plays a role in promoting fibroblast proliferation, reepithelization, extracellular matrix production, and endothelial cell migration. 1.2% rosuvastatin gel (RSV) is a local delivery drug with a pleiotropic effect that can modify host response to promoting BMSCs, BMP-2, OPG, ALP, RANKL, and osteoblasts. This study aimed to examine the effect of the application of A-PRF+RSV in OFD therapy of which the parameters were probing depth (PD), relative attachment loss (RAL), and alveolar bone height. The study samples consisted of 24 periodontal pockets which were divided into 2 groups of 12 pockets each, namely A-PRF+RSV for group 1 and PRF+RSV for group 2. Clinical evaluations were carried out on baseline, day-30, and day-90 for PD and RAL, and on baseline and day -90 for alveolar bone height. Data of PD and RAL reduction were analyzed with non-parametric test Mann-Withney, while data of reduction of alveolar bone height were analyzed with parametric Independent-T test. Group 1 obtained a statistically more significant result in reducing PD, RAL, and alveolar bone height compared to group 2 (p&lt;0.05) To conclude, the application of A-PRF and 1.2% rosuvastatin gel in OFD procedure promotes a higher PD and RAL reduction and alveolar bone height increase than the application of PRF coupled with 1.2% rosuvastatin gel.

English

BACKGROUND The present study was conducted to compare clinical outcomes and gingival crevicular fluid (GCF) interleukin (IL)-6 cytokine levels in microsurgical and conventional open flap debridement procedure. METHODS Thirty sites in chronic periodontitis patients were randomly assigned into Group I (microsurgical) and Group II (conventional) open flap debridement in a split-mouth design. Gingival bleeding index (GBI), probing pocket depth (PPD), relative attachment level (RAL) were recorded at baseline and 3 months. GCF IL-6 cytokine levels were assessed at baseline and on 3rd day postoperatively. Pain perception using visual analog score (VAS) and soft tissue healing using early healing index (EHI) were assessed after on 7th day post-surgery. RESULTS There was a significant reduction in gingival bleeding index, probing pocket depth, relative attachment level within both the groups. Intergroup gingival bleeding index scores were statistically significant at the end of 3 months. The difference in visual analog scores between the two groups was found to be statistically insignificant whereas early healing index scores between the groups was found to be statistically significant. Group I showed lower levels of IL-6 on 3rd day postoperatively. It was also found that there was positive correlation of IL-6 levels with clinical parameters such as PPD and RAL. CONCLUSIONS Open flap debridement using microsurgical approach can substantially improve clinical parameters and wound healing compared with conventional macrosurgical approach. IL-6 levels were lower in microsurgical group indicating less invasive surgical approach. KEY WORDS Open Flap Debridement, Periodontal Microsurgery, Wound Healing, IL-6, Cytokine, GCF.

Effect of Periodontal Surgery on Tissue Plasminogen Activator and Plasminogen Activator Inhibitor Type-1 Gene Expression in Gingival Tissues of Periodontitis Patients: A Controlled Before-And-After Study

Background: Regulation of the plasminogen activation system (PAS) is a vital component in governing proteolytic events within the extracellular matrix (ECM). PAS is believed to play a substantial role in the destruction and healing of periodontal tissues. Thus, the current work aimed to study the histopathological effect of open flap debridement (OFD) on periodontitis, as well as its effect on tissue plasminogen activator (t-PA) and plasminogen activator inhibitor type-1 (PAI-1) gene levels in gingival tissues. Methods: A total of 30 subjects were enrolled in the present study. They were divided into two groups: Group I (control group) included 10 periodontally healthy volunteers and group II (periodontitis group) comprised 20 patients suffering from stage III grade B periodontitis. Gingival tissue samples were collected from all periodontitis patients, before and after OFD, and from healthy controls. Hematoxylin and eosin (H&amp;E) stained slides were subsequently examined and gene expression levels of t-PA and PAI-1 were assessed in the gingiva through quantitative reverse transcription polymerase chain reaction (RT-PCR). Results: Gingival tissue samples from periodontitis patients showed widely dilated blood vessels, diffuse hemorrhage, areas of edema, and disorganized collagen fibers together with large amounts of inflammatory cells in between. Following OFD, smaller sized blood vessels, a restored collagen fiber distribution, and an obvious decrease in the inflammatory infiltrate were noted. Gene expression levels of t-PA and PAI-1 were significantly higher in the periodontitis patients compared to the healthy controls. Although their levels showed a significant decrease following OFD in the periodontitis group, they were still significantly higher than the control group. Conclusion: OFD procedures resulted in down regulation of t-PA and PAI-1 expression levels in the gingiva of periodontitis patients, which could signify an important role of these proteins on periodontal disease progression.

Periodontal regeneration - intrabony defects: a systematic review from the AAP Regeneration Workshop.

Previous systematic reviews of periodontal regeneration with bone replacement grafts and guided tissue regeneration (GTR) were defined as state of the art for clinical periodontal regeneration as of 2002. The purpose of this systematic review is to update those consensus reports by reviewing periodontal regeneration approaches developed for the correction of intrabony defects with the focus on patient-, tooth-, and site-centered factors, surgical approaches, surgical determinants, and biologics. This review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews. A computerized search of the PubMed and Cochrane databases was performed to evaluate the clinically available regenerative approaches for intrabony defects. The search included screening of original reports, review articles, and reference lists of retrieved articles and hand searches of selected journals. All searches were focused on clinically available regenerative approaches with histologic evidence of periodontal regeneration in humans published in English. For topics in which the literature is lacking, non-randomized observational and experimental animal model studies were used. Therapeutic endpoints examined included changes in clinical attachment level, changes in bone level/fill, and probing depth. For purposes of analysis, change in bone fill was used as the primary outcome measure, except in cases in which this information was not available. The SORT (Strength of Recommendation Taxonomy) grading scale was used in evaluating the body of knowledge. 1) Fifty-eight studies provided data on patient, tooth, and surgical-site considerations in the treatment of intrabony defects. 2) Forty-five controlled studies provided outcome analysis on the use of biologics for the treatment of intrabony defects. 1) Biologics (enamel matrix derivative and recombinant human platelet-derived growth factor-BB plus β-tricalcium phosphate) are generally comparable with demineralized freeze-dried bone allograft and GTR and superior to open flap debridement procedures in improving clinical parameters in the treatment of intrabony defects. 2) Histologic evidence of regeneration has been demonstrated with laser therapy; however, data are limited on clinical predictability and effectiveness. 3) Clinical outcomes appear most appreciably influenced by patient behaviors and surgical approach rather than by tooth and defect characteristics. 4) Long-term studies indicate that improvements in clinical parameters are maintainable up to 10 years, even in severely compromised teeth, consistent with a favorable/good long-term prognosis.

Comparison of microsurgical and conventional open flap debridement: A randomized controlled trial.

Background:Residual calculus exists not only on teeth treated by scaling alone but also on teeth treated by flap surgery. Periodontal microsurgery enables more definite removal of calculus, atraumatic handling of tissues through optical magnification. The purpose of this study was to compare the clinical outcomes of microsurgery with conventional open flap debridement in patients with chronic periodontitis.Materials and Methods:Thirteen chronic periodontitis patients were randomly assigned for test (microsurgical) and control (conventional) open flap debridement in a split mouth design. At baseline, 3, 6 and 9 months the following clinical parameters were recorded: Probing pocket depth, relative attachment level, gingival recession, gingival bleeding index. Postoperative healing at 1-week by early healing index and pain scale for 7 days were assessed.Results:Paired t-test was used to compare means within the groups, and unpaired t-test was applied to compare the means of the two groups. At 3, 6 and 9 months postoperatively there was a significant reduction in gingival bleeding index, probing pocket depth, relative attachment level within both the groups and there was no significant difference between both the groups. Gingival margin level and gingival recession increased in both the groups, but it was not statistically significant. Early healing Index score of 1 was found in 85% of test sites and 28% of control sites. The mean pain scale was 0 in test site and 1.07 ± 0.75 in control site.Conclusions:In open flap debridement procedure, a microsurgical approach can substantially improve the early healing index and induce less postoperative pain compared with applying a conventional macroscopic approach.

Periosteum as a barrier membrane in the treatment of intrabony defect: A new technique.

Objective:The purpose of the study was to evaluate the clinical effectiveness of periosteum as a barrier membrane for the treatment of intrabony defects.Materials and Methods:The study was conducted in patients having bilateral intrabony defects. A total of 20 intrabony defects in 10 patients were treated, out of which 10 defects received periosteal barrier and the other 10 defects received conventional open flap debridement procedure. The efficacy of the treatment was assessed using clinical parameters and dentascan.Results:Statistically significant gain in clinical attachment level (CAL) was found in the test group (2.00 ± 0.26 mm) as compared to the control group (0.60 ± 0.22 mm). In both the treatment modalities (test and control groups), a significant decrease in probing pocket depth of 3.90 ± 0.35 mm and 2.90 ± 0.31 mm was observed, respectively. The difference between the two groups was not statistically significant. Bone defect fill was 1.40 ± 0.16 mm for the test group and 0.90 ± 0.18 mm for the control group, but the difference observed was not statistically significant.Conclusion:The results of this study show that periosteal barrier membrane can be a better alternative of barrier membranes for the treatment of intrabony defects.

Effectiveness of autologous platelet-rich fibrin in the treatment of intra-bony defects: A systematic review and meta-analysis.

The aim of the present meta-analysis is to determine the clinical and radiographic outcomes of using platelet-rich fibrin (PRF) for the treatment of periodontal intra-bony defect (IBD) compared with open flap debridement (OFD). MEDLINE/PubMed, EBSCO and Cochrane database were used to identify studies in English language published from January 1, 2005 to January 31, 2013. An additional hand search of the relevant journals and of the bibliographies of the paper identified was also performed. Articles retrieved were screened using specific inclusion criteria by five independent reviewers: Studies investigating the effect of platelet concentrate in surgical procedure for the treatment of periodontal intra osseous defects compared with the control group in which platelet concentrate was not used were included. Five relevant articles were selected for the meta-analysis of which 3 articles were retrieved after electronic search and two articles were included after hand search. The number of patients in studies ranged from 15 to 62 (32-90 sites) with mean age ranging from 29.47 to 39.7. A total of 298 sites were treated using PRF either in combination with graft or as a monotherapy in comparison to traditional OFD procedure. The meta-analysis showed a standard mean difference of 0.95 mm; 95% confidence interval (CI): 0.20-1.71 in clinical attachment level (CAL) and 2.33 mm; 95% CI: 1.43-3.23 in IBD after treatment of IBD with PRF compared with OFD. The meta-analysis showed clinically significant improvements in periodontal parameters such as CAL, IBD, and reduction in probing depth when IBDs were treated with PRF alone when compared to OFD.

Intrabony Defects, Open‐Flap Debridement, and Decortication: A Randomized Clinical Trial

Intramarrow penetration (IMP) is often incorporated in regenerative periodontal surgical procedures. However, the actual benefits of adding IMP to such a procedure remain undocumented. The purpose of this randomized controlled trial was to investigate the contribution of IMP to the outcomes of open-flap debridement (OFD) treatment of intrabony defects. Forty-two chronic periodontitis patients, each contributing a 2-wall, 3-wall, or combined 2- to 3-wall intrabony defect, were treated. Sites were randomly assigned into one of two groups: control (OFD alone) or test (OFD + IMP). Papilla preservation flaps were raised, and defects were thoroughly debrided. In the control group, complete primary closure of flaps was ensured after debridement. In the test group, IMP was performed before flap closure, using a round bur to penetrate the cortical defect wall. Clinical and radiographic parameters were assessed at baseline and 12 months after treatment. At baseline, there were no statistically significant differences between groups. At 12 months, both groups experienced significant improvements, in terms of probing depth reduction, clinical attachment level (CAL) gain, and bone level (clinical and radiographic). The test group experienced significantly greater clinical bone gain (3.07 ± 1.74 mm) and prevalence of CAL gain ≥2 mm (93% of sites) compared with the control group (1.76 ± 2.71 mm, P <0.03; 62%, P = 0.024). The test treatment benefits were particularly evident in mandibular sites, in which OFD + IMP doubled the radiographic bone gain obtained by OFD alone. Addition of IMP to an OFD procedure used to treat intrabony defects results in statistically and clinically significant enhancement of both clinical and radiographic outcomes.

Clinical and radiographic evaluation of intrabony periodontal defect treatment by open flap debridement alone or in combination with nanocrystalline hydroxyapatite bone substitute

The aim of this study has been to compare the clinical and radiographic outcome of periodontal intrabony defect treatment by open flap debridement alone or in combination with nanocrystalline hydroxyapatite bone substitute application. Thirty patients diagnosed with advanced periodontits were divided into two groups: the control group (OFD), in which an open flap debridement procedure was performed and the test group (OFD+NHA), in which defects were additionally filled with nanocrystalline hydroxyapatite bone substitute material. Plaque index (PI), gingival index (GI), bleeding on probing (BOP), pocket depth (PD), gingival recession (GR) and clinical attachment level (CAL) were measured prior to, then 6 and 12months following treatment. Radiographic depth and width of defects were also evaluated. There were no differences in any clinical and radiographic parameters between the examined groups prior to treatment. After treatment, BOP, GI, PD, CAL, radiographic depth and width parameter values improved statistically significantly in both groups. The PI value did not change, but the GR value increased significantly after treatment. There were no statistical differences in evaluated parameters between OFD and OFD+NHA groups 6 and 12months after treatment. Within the limits of the study, it can be concluded that the additional use of nanocrystalline hydroxyapatite bone substitute material after open flap procedure does not improve clinical and radiographic treatment outcome.

Healing of acute alveolar bone dehiscence following treatment with porous biphasic calcium phosphate in beagle dogs

The purpose of the present study was to evaluate histologically in beagle dogs the healing in acute dehiscence type defects following treatment with open flap debridement (OFD) with or without porous biphasic calcium phosphate (PBCP). Alveolar bone dehiscence defects were surgically created bilaterally at the labial aspects of maxillary third incisors in 12 beagle dogs. After root conditioning with ethylenediaminetetraacetate, PBCP was filled in the defects and the contralaterals were cured with OFD. Two fluorochrome labelings were administered at the 7th and 11th weeks, respectively. Four dogs were killed at the 12, 16, and 24weeks, respectively. Histological observations were processed through microcomputed tomographic imaging, fluorescence microscope, and light microscopy. The formation of new regenerated tissues was assessed histomorphometrically. The results revealed the healing after treatments with PBCP evidenced a new attachment apparatus and that with OFD supported periodontal repair. In PBCP groups, the amount of new bone varied from 1.15 to 3.86mm (23-77.2% of the original defect size), while only 0.3 to 1.04mm (6-20.8%) in OFD group. The amount of new cementum in PBCP varied from 1.18 to 4.16mm (23.6-82.3%), while only 0.67 to 1.15mm (13.4-23%) in OFD group. The amount of periodontal ligament in PBCP varied from 1.03 to 4.12mm (20.6-82.4%), while only 0 to 0.93mm (0-18.6%) in OFD group. There was significantly more regenerated tissue in PBCP groups compared to OFD procedures (p < 0.01). The present results indicate that PBCP may enhance periodontal regeneration in acute-type labial dehiscence defects.

Identification of immunological parameters associated with the alveolar bone level in periodontal patients

PurposeThe present study was performed to clarify the relationship between periodontal disease severity and selected immunological parameters consisting of serum IgG titer against periodontopathogenic bacteria, the expression of the helper T-cell cytokine by gingival mononuclear cells, and patients' immunoreactivity to cross-reactive heat shock protein (HSP) epitope peptide from P. gingivalis HSP60.MethodsTwenty-five patients with moderate periodontitis had their gingival connective tissue harvested of gingival mononuclear cells during an open flap debridement procedure and peripheral blood was drawn by venipuncture to collect serum. The mean level of interproximal alveolar bone was calculated to be used as an index for periodontal disease severity for a given patient. Each of selected immunologic parameters was subject to statistical management to seek their correlations with the severity of periodontal disease.ResultsA significant correlation could not be identified between serum IgG titers against specific bacteria (Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Actinobacillus actinomycetemcomitans, and Streptococcus mutans) and the severity of periodontal disease. Expression of interleukin (IL)-10 by gingival mononuclear cells was statistically significant in the group of patients who had higher levels of alveolar bone height. However, a similar correlation could not be demonstrated in cases for IL-4 or interferon-γ. Patients' serum reactivity to cross-reactive epitope peptide showed a significant correlation with the amount of alveolar bone.ConclusionsIt was concluded that expression of IL-10 by gingival mononuclear cells and patients' sero-reactivity to the cross-reactive HSP peptide of P. gingivalis HSP60 were significantly correlated with alveolar bone height.

Adjunctive effect of a polylactide/polyglycolide copolymer in the treatment of deep periodontal intra‐osseous defects: a randomized clinical trial

The aim of this study was to evaluate the clinical outcome of re-constructive surgery in human deep intra-osseous defects with the use of a polylactide/polyglycolide (PLA/PGA) copolymer graft in conjunction with an open flap debridement (OFD) procedure (test group) as compared with OFD procedure alone (control group). Thirty-two patients, each contributing one defect, were selected and completed the 12-month follow-up period. Sixteen patients (eight males, mean age: 49.9 years) received the test treatment, 16 patients (nine males, mean age: 42.8 years) received the control treatment. Clinical recordings, assessed at baseline, 6 and 12 months post-surgery, included defect-specific plaque score, defect-specific bleeding score, probing depth (PD), clinical attachment level (CAL), and recession depth. Surgical procedure aimed to preserve supra-crestal soft tissues at defect site in order to ensure primary closure was used in all cases. Test and control treatment produced a significant CAL decrease and PD reduction at both 6 and 12 months with respect to baseline value (p<0.000). At 6 months CAL was significantly greater in test compared with control group (p=0.019). Twelve-month CAL gain was 3.6+/-1.5 and 3.4+/-1.4 mm for the test and control group, respectively. At 12 months no significant differences in any of the clinical parameters were observed between groups. The results indicate that OFD with and without PLA/PGA graft provide clinically and statistically significant improvements in PD and CAL measurements. However, the additional use of PLA/PGA did not provide an additional benefit in terms of CAL gain and PD reduction compared with OFD procedure.

Inflammatory lesions in the gingiva following resective/non‐resective periodontal therapy

Findings from previous experiments have revealed that inflammatory cell infiltrates may remain in the gingiva following clinically successful non-surgical periodontal therapy. 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). Fifteen patients with advanced generalized chronic periodontitis were recruited. Following oral hygiene instruction and supragingival debridement, one tooth site in each quadrant (non-molar, probing pocket depth>5 mm, bleeding on probing(+) and >50% bone loss) was selected and a soft-tissue biopsy was obtained and prepared for immunohistochemical analysis. Using a split-mouth design, two quadrants were randomly selected for periodontal therapy including GV, while the two remaining quadrants were exposed to non-resective OFD procedure. Six months after completion of surgical treatment, a new set of biopsies was obtained from GV and OFD sites. The inflammatory lesions residing in the gingival biopsies obtained prior to surgical therapy were 1.33-1.41 mm(2) large and contained similar proportions of CD19(+)- (B-cells, 15%), CD3(+)- (T-cells, 7%) and elastase(+)- (polymorphonuclear cells, 2%) cells in the two treatment groups. The corresponding lesions identified in the soft-tissue specimens obtained after 6 months of healing were twice as large at OFD as at GV sites (0.19 versus 0.08 mm(2), p=0.002). The densities of CD19(+)- and elastase(+)-cells in these lesions were significantly greater at OFD than at GV sites. The findings of the present study indicate that surgical therapy including soft-tissue resection 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 means.