Single Flap Approach Research Articles

Single Flap Approach Versus Conventional Flap in the Treatment of Intrabony Defects: A 6-Month Clinico Radiological Study

Abstract Introduction: The comparison of single-flap approach (SFA) and conventional flap (CF) techniques in the treatment of intrabony defects is a significant area of periodontal research. This clinical-radiological study evaluates the effectiveness of these methods over a 6-month period. SFA involves minimal surgical intervention, promoting faster healing and reduced patient discomfort. Conversely, CF is a traditional method with broader exposure to the surgical site for more extensive cleaning and repair. This study aims to provide insights into the relative advantages and clinical outcomes associated with each approach, contributing to evidence-based periodontal therapy practices. Materials and Methods: Thirty sites with chronic/aggressive periodontitis were selected for the present study. Phase I therapy was performed and evaluated after 4 weeks. Clinical parameters such as plaque and gingival index and probing pocket depth (PPD) were measured at baseline and 6 months postoperatively. The mean defect fills and percentage defect fill were calculated with the help of cone-beam computed tomography at baseline and 6 months postoperatively. The subjects were divided into two equal groups with the help of a coin toss. The Group I (test sites) underwent an SFA, whereas the Group II (control) site underwent conventional surgical procedures. Results: The PPD in both groups was reduced over a 6-month post-operative period. The mean defect size and percentage of defect fill between baseline and 6 months postoperatively in both groups were statistically significant. Conclusion: The single-flap approach and the CF are equally effective in treating periodontal intrabony defects.

A Case Report of Periodontal Regeneration in Failing Tooth by Single Flap Approach Using Sticky Bone and Platelet-rich Fibrin Membrane

Periodontal regeneration aims to regenerate the diseased or lost periodontium. Regenerative periodontal therapy utilises growth factors, autogenous soft and hard tissue grafts for the purpose of regeneration. Platelet-rich Fibrin (PRF) is an autologous biomaterial which works on the principle of centrifugation. The injectable PRF (i-PRF) that is formed when centrifuged at low Revolutions Per Minute (RPM) produces an excellent matrix when mixed with bone graft called “sticky bone”. Sticky bone possesses the property of mouldability along with its inherent potential of bone formation. The PRF matrix also enhances the wound healing through the release of various growth factors. PRF membranes which are obtained at higher centrifugation levels also act as a substitute to augment the soft-tissues. The present case is that of a 45-year-old male, who underwent a one-year follow-up for the management of endodontic periodontal lesion in the lower left first molar with sticky bone and PRF membrane by single flap approach. The patient was periodically reviewed clinically and radiographically and prosthetic restoration was given on accessing the radiographic bone fill after six months. After six months there was a significant difference in the radiographic bone fill, along with the reduction in the probing pocket depth from 7 mm to 4 mm and clinical attachment from 9 mm to 7 mm. The results indicate that sticky bone and PRF membrane serves as a predictable source for the management of intrabony defects.

Single-flap approach versus without concentrate growth factor in the treatment of periodontal supra-osseous defects: A randomized controlled clinical trial

ObjectivesWe aimed to compare treatment outcomes of periodontal supra-bony defects using single flap (SFA) plus concentrate growth factor versus SFA alone. Methods32 supra-bony periodontal defects were randomly assigned to test and control groups. Outcome variables were clinical attachment level (primary outcome). Probing pocket depths, gingival recessions, bone gain, post-surgical pain using visual analogue scale and wound healing index were recorded as secondary outcomes. Clinical and radiographic assessments were recorded at baseline and 6 months after treatment, whereas pain score and wound healing index were recorded within 10 days after surgery. ResultsTest group showed a significant improvement in all tested parameters compared to control group (P-value ≤ 0.05). Better patient centered outcomes (wound healing and pain scores) were highly achieved in the test group compared to controls. ConclusionThe tested combined approach offers better periodontal and patient centered treatment outcomes in management of periodontal supra-bony defects.

Treatment of Deep Intrabony Defect with Buccal Gingival Recession using Connective Tissue Graft Combined with Enamel Matrix Derivative and Bone Graft: case reports

<p>It is a challenging situation for clinicians in managing deep non-contained intrabony de¬fects associated simultaneously with soft tissue recession nowadays. Besides, prevention of post-operative gingival recession is one of treatment goals for ideal regenerative surgery as well. The case reports tended to achieve periodontal regeneration and root coverage in teeth affected with both deep intrabony defects and the buccal gingival recession using the concept of connective tissue (CTG) wall technique combined with enamel matrix derivative (EMD) and bone graft materials. The surgeries involved a single flap approach (SFA) and augmentation of soft tissue, attempting to minimize post-operative gingival recession, by suturing the CTG on the inner surface of coronally advanced flap (CAF) as a barrier wall for the coronal portion of the bone defect. The bony defects were filled with allograft and/or xenograft as a space mak¬ing scaffold and followed by primary closure of wound. Significant probing depth (PD) reduc¬tion, clinical attachment level (CAL) gain and improvement in the level of gingiva margin were noticed after 7- and 11- months follow-up respectively. Comparisons of pre-operative and different periods of radiographic images demonstrated that the bone defects were indeed filled. It can be concluded that the CTG does support the bone regeneration and overlying soft tissue flap stability within the periods of observation. This surgical approach provides an alter-native aid on the clinical outcome of bone healing and root coverage simultaneously in deep intrabony defects.</p> <p> </p>

SURGICAL TREATMENT OF PERIODONTAL BONE DEFECTS THROUGH THE APPLICATION OF THE “SINGLE FLAP APPROACH” TECHNIQUE AND BIOMATERIALS

The introduction and application of ad hoc- flap designs for accessing even deep intrabony defects has led to a significant improvement in reconstructive outcomes after the use of guided tissue regeneration (GTR, Guided Tissue Regeneration) or enamel matrix derivatives (EMD). Although the additional beneficial effects of GTR and EMD are now known, in association with open curettage alone, the improvements in surgical techniques, in particular the introduction of new papilla preservation procedures, have resulted in a progressive increase in clinical attachment gain achievable with open curettage alone. The Single Flap Approach (SFA) is a simplified surgical procedure specifically designed for the treatment of periodontal bone defects. The key principle of this procedure consists in the elevation of a single mucoperiosteal access flap (buccal or oral), preserving the integrity of the interproximal supracrustal soft tissues. The article, in addition to the the oretical research and studies to date on the advantages of this surgical technique, brings in a detailed analysis the clinical case treated by the authors, analyzing the entire procedure step by step. Scientific research and their application in clinical cases have shown that SFA allows to minimize the trauma of the interproximal soft tissues by bringing reduced recession after surgery.

POST DENTAL AND ORAL – MAXILLOFACIAL IMPLANT NEUROPATHY OF TRIGEMINAL NERVE

The introduction and application of ad hoc- flap designs for accessing even deep intrabony defects has led to a significant improvement in reconstructive outcomes after the use of guided tissue regeneration (GTR, Guided Tissue Regeneration) or enamel matrix derivatives (EMD). Although the additional beneficial effects of GTR and EMD are now known, in association with open curettage alone, the improvements in surgical techniques, in particular the introduction of new papilla preservation procedures, have resulted in a progressive increase in clinical attachment gain achievable with open curettage alone. The Single Flap Approach (SFA) is a simplified surgical procedure specifically designed for the treatment of periodontal bone defects. The key principle of this procedure consists in the elevation of a single mucoperiosteal access flap (buccal or oral), preserving the integrity of the interproximal supracrustal soft tissues. The article, in addition to the the oretical research and studies to date on the advantages of this surgical technique, brings in a detailed analysis the clinical case treated by the authors, analyzing the entire procedure step by step. Scientific research and their application in clinical cases have shown that SFA allows to minimize the trauma of the interproximal soft tissues by bringing reduced recession after surgery.

The Efficacy of Low-Level Laser Therapy Combined with Single Flap Periodontal Surgery in the Management of Intrabony Periodontal Defects: A Randomized Controlled Trial

This study aimed at assessing the clinical outcomes of the Single Flap Approach (SFA) with the additional use of Low-level laser therapy (LLLT). The defects were treated as per the principles of SFA, whereby 20 defects received only SFA (control group) and 20 defects received additional LLLT for bio stimulation/bio modulation (test group). Stable primary closure of the flaps was obtained with vertical internal mattress sutures. Plaque indices (FMPS), clinical attachment levels (CAL), probing pocket depth (PPD), and gingival bleeding scores (FMBS) were calculated at baseline, and at the 3rd and 6th months in both groups. An EHI score of 1 was observed at all sites except for two, where a score of 2 in the control group at week 2 was observed. In the test group, the PPD reduction at 6 months was 3.60 ± 0.95 and in the control group it was 3.75 ± 0.91 mm. CAL gain at 6 months was 2.70 ± 1.36 mm and 3.45 ± 1.2 mm in the test group and showed no statistical significance. These data suggested the positive effect of LLLT over CAL gain; thus, LLLT may be combined with SFA to potentially enhance the early wound healing and higher clinical outcomes in terms of increase in CAL and decrease in PPD.

Minimally Invasive Surgery Periodontal Therapy for the Treatment of Intrabony Periodontal Defects: A Systematic Review.

Background:Minimally invasive therapeutic approaches have become the standard of care for many medical procedures. Conventional periodontal surgical therapies involve extensive tissue reflection, resulting in increased morbidity which stands to reason out that Minimally invasive surgery (MIS) approach for periodontal therapy would result in less morbidity and better esthetics for the patient. Thus, the aim of this review is to assess the clinical efficacy of MIS periodontal therapy compared to conventional access flap surgery for the treatment of intrabony periodontal defects.Materials and Methods:An electronic and manual search was done to identify and collect studies evaluating MIS periodontal therapy for the treatment of intrabony periodontal defects in terms of periodontal probing depth (PPD) reduction, clinical attachment level (CAL) gain, and gingival recession (REC) with a minimum of 6 month follow-up published in English. Six studies which satisfied the inclusion criteria were included for the review and the data extracted.Results:The six included studies contributed to a total of 193 patients who underwent 93 MIS therapies for treating intrabony defects with at least a 6-month follow-up. Clinical evaluation showed a PPD reduction ranging from 3.55 ± 0.88 mm to 5.2 ± 1.6 mm, while CAL gain ranged from 2.82 ± 1.19 mm to 4.5 ± 1.1 mm, while the change in gingival margin level ranged from 0.06 mm to 0.5 mm. Only one study directly compared single flap approach (SFA) (a type of MIS) to double flap approach (papilla preservation flap) which reported PPD reduction and CAL gain to be better in SFA.Conclusion:Even though the above evidence compels us to believe that minimally invasive periodontal surgery is less invasive, less time consuming, and less morbid, the lack of enough studies directly comparing MIS with conventional access flap surgeries suggest that these conclusions are arbitrary. Thus, there is currently an absence of adequate evidence to substantiate the beneficial effect of minimally invasive periodontal surgical approach compared to a conventional access flap surgery for the treatment of intrabony periodontal defects.

Single flap approach with or without enamel matrix derivative in the treatment of severe supraosseous defects: a retrospective study

AimTo comparatively evaluate the clinical effectiveness of the single flap approach (SFA) with and without enamel matrix derivative (EMD) in the treatment of supraosseous defects (SDs) associated with deep pockets.Materials and methodsTwenty patients, each contributing one SD associated with a deep (≥ 6 mm) pocket and treated with buccal SFA either alone (SFA group; n = 10) or in combination with EMD (SFA+EMD group; n =10), were retrospectively selected. Clinical parameters (probing depth, PD; clinical attachment level, CAL; gingival recession, REC) had been assessed at pre-surgery and 12 months post-surgery.ResultsComplete wound closure was observed in 70% and 80% of defects treated with SFA and SFA+EMD, respectively. Treatments resulted in a significant PD reduction of 3.1±1.0 mm (p=0.005). In SFA+EMD group, 100% of closed pockets was obtained, while 90% of closed pockets was observed in SFA group. Both treatments resulted in a significant CAL gain of 2.1±0.9 mm and 1.9±1.7 mm in SFA and SFA+EMD group, respectively (p= 0.465). In both groups, REC significantly increased 1.0±1.1 mm in SFA group and 1.1±1.1 mm in SFA+EMD group (p= 0.722).ConclusionsWithin their limits, the findings of present study suggest that SFA may represent a valuable option for the surgical treatment of SDs associated with deep pockets. EMD did not result in a significant clinical benefit to the procedure.Clinical relevanceSFA may represent a valuable option in obtaining pocket closure when treating SDs associated with deep residual pockets.

Evaluation of Regenerative Periodontal Therapy in Intrabony Defects with Single Flap Approach Using Bovine Xenograft in Smokers and Non-smokers

Evaluation of Regenerative Periodontal Therapy in Intrabony Defects with Single Flap Approach Using Bovine Xenograft in Smokers and Non-smokers

Healing of intrabony defects following regenerative surgery by means of single-flap approach in conjunction with either hyaluronic acid or an enamel matrix derivative: a 24-month randomized controlled clinical trial

ObjectivesThe aim of this randomized controlled clinical trial was to compare the clinical outcomes obtained in intrabony defects following regenerative periodontal surgery using the single-flap approach (SFA) in conjunction with either hyaluronic acid (HA) or enamel matrix derivative (EMD).Materials and methodsThirty-two intrabony defects in 32 healthy subjects were randomly assigned: HA (test group) or EMD (control group). Clinical attachment level (CAL), probing depth (PD), gingival recession (REC), and bleeding on probing (BOP) were recorded at baseline,12, 18, and 24 months after surgery.ResultsAt 24 months, both treatments resulted in statistically significant clinical improvements evidenced by PD-reduction and CAL-gain (p<0.001). The mean CAL-gain was 2.19±1.11 mm in the test and 2.94±1.12 mm in the control sites (p=0.067). PD-reduction was statistically significantly higher for the control group (4.5±0.97 mm) than the test group (3.31±0.70 mm), (p=0.001). CAL-gain ≤ 3 mm was observed in 87.5% and in 62.5% of the test and control sites, respectively. Test sites showed slightly lower REC values than the control sites. No statistically significant differences were found for BOP between treatments.ConclusionsThe present findings indicate that both treatments led to statistically significant clinical improvements compared to baseline, although the application of EMD resulted in statistically significantly higher PD-reduction compared to the use of HA.Clinical relevanceThe use of HA in conjunction with a SFA resulted in significant PD-reduction and CAL-gain, pointing to the potential clinical relevance of this material in regenerative periodontal surgery.

Single-flap versus double-flap approach for periodontal pocket reduction in supraosseous defects: a comparative study.

PurposeThe single-flap approach (SFA) is a minimally invasive technique with limited mucoperiosteal flap elevation to gain access to the buccal/palatal aspects, thus limiting post-surgical complications. The purpose of the present study was to gain insights into the impact of the SFA over the double-flap approach (DFA) on periodontal flap treatment outcomes and patient compliance in terms of discomfort and time taken for surgical procedures.MethodsTwenty patients with persistent probing pocket depths of ≥5 mm were scheduled for the SFA (test site) and for the DFA (control site). All the clinical periodontal parameters were recorded at baseline, 3 months, and 6 months. Radiographic bone level (cone-beam computed tomography) was evaluated at baseline and 6 months. Patients' postoperative pain perception and wound healing were also assessed.ResultsThe SFA showed a significant reduction in periodontal pocket depth, gain in clinical attachment level (CAL), and gain in bone level when compared with the DFA. The SFA substantially improved wound healing and induced less postoperative pain than the DFA.ConclusionsThe SFA resulted in substantial improvement in the composite outcome measures, as shown by a reduction in pocket depth with minimal gingival recession, gain in CAL, early wound healing, less postoperative discomfort, and better patient-centered outcomes.Trial RegistrationClinical Trials Registry-India Identifier: CTRI/2018/05/013562

Miller Class III root coverage with coronary tissue repositioning associate with conjunctive graft

Miller Class III root coverage with coronary tissue repositioning associate with conjunctive graft

Effect of Flap Design for Enamel Matrix Derivative Application in Intraosseous Defects.

To systematically review the literature addressing the focused question: What is the effectiveness of different surgical and nonsurgical procedures combined with enamel matrix derivative (EMD) on clinical, radiographic, and patient-centered outcomes in intraosseous defects? Electronic (Medline, Scopus, and Cochrane databases) and hand literature searches were performed for studies including at least 1 treatment arm where EMD had been applied according to 1 of the following procedures: modified Widman flap; papilla preservation variants (PPVs), including papilla preservation technique, modified papilla preservation technique, and simplified papilla preservation technique; minimally invasive variants, including minimally invasive surgical approach and minimally invasive surgical technique; single-flap variants (SFVs), including single-flap approach and modified minimally invasive surgical technique; or nonsurgical application (flapless approach). Data from 42 selected articles were used to perform a network meta-analysis, and a hierarchy of surgical and nonsurgical applications of EMD was built separately for EMD and EMD + graft based on 6- to 12-mo clinical and radiographic outcomes. Among surgical approaches, EMD was associated with best regenerative outcomes when applied through SFVs, with a mean clinical attachment level gain of 3.93 mm and a reduction in the intrabony component of the defect of 3.35 mm. For EMD + graft, limited differences in regenerative outcomes were observed among surgical procedures. PPVs were associated with the highest residual probing depth for EMD (4.08 mm) and EMD + graft (4.32 mm). In the treatment of periodontal intraosseous defects, 1) SFVs appear to optimize the regenerative outcomes of EMD; 2) substantial regenerative outcomes can be obtained with SFVs and conservative double flaps (i.e., PPVs and minimally invasive variants) when EMD is combined with a graft; and 3) residual probing depth was higher following PPVs for EMD and EMD + graft. The results of the present systematic review and meta-analysis can be used by clinicians to identify the most effective surgical or nonsurgical procedure to treat an intraosseous defect with EMD or EMD + graft. The main findings indicate that when EMD application is indicated, surgical access based on a single flap seems the most appropriate to optimize clinical outcomes. The application of EMD + graft can be effectively combined with single flaps and conservative double flaps.

A simplified composite outcome measure to assess the effect of periodontal regenerative treatment in intraosseous defects.

To propose a novel composite outcome measure (COM) for periodontal regenerative treatment of intraosseous defects. COM is based on the combination of clinically relevant clinical attachment level (CAL) gain (≥3 mm) and pocket closure (post-surgery probing depth [PD] ≤ 4 mm). Treatment was regarded as successful when a clinically relevant CAL gain was associated with pocket closure, and failing when either clinically relevant CAL gain and pocket closure were not achieved. The effect of the different regenerative treatments was both collectively and separately evaluated according to COM in a defect cohort accessed by Single Flap Approach (SFA). In the entire study cohort, the procedure resulted in a 6-month CAL gain of 3.7 ± 1.9 mm, which was clinically relevant in 71.8% of patients. Six-month residual PD was 3.7 ± 1.1 mm, with pocket closure recorded in 79.6% of patients. COM revealed a successful treatment in 60 patients (58%), and a treatment failure in 7 patients (7%). Mean CAL gain was clinically relevant for each treatment, whereas the residual PD values were consistent with pocket closure for the majority of treatment options. However, when COM was used to rate the treatment outcome of each procedure, it appeared that a successful treatment ranged from 41.5% to 77.5%, whereas treatment failure varied from 3% to 15% for different treatments. Compared to single probing measurements, COM seems (1) more accurate in capturing the overall benefit of the regenerative procedure and (2) to better identify which factor (CAL gain, residual pocket) mainly contributed to determine a treatment failure.

Comparison of Regenerative Potential of Platelet-rich Fibrin Alone and in Combination with Bovine Bone Graft in Intraosseous Defect by Single Flap Approach: A Clinical and Radiographic Study.

ABSTRACTAim:To compare the regenerative potential of platelet-rich fibrin alone and in combination with bovine bone graft in intraosseous defect by the single flap approach.Materials and Methods:A total of 32 sites of intrabony defects were selected and were treated with platelet-rich fibrin (PRF) alone or in combination with bovine bone graft. Clinical parameters [Gingival index (GI), probing depth (PD), clinical attachment level (CAL), Gingival recession, and radiographic parameters (defect fill, alveolar crest level, and defect depth)] were recorded at baseline, 3 months, and 6 months.Results:Statistical analysis was done by independent and paired t-test. There were statistically significant changes in GI, PD reduction, CAL gain, defect fill, alveolar crest level changes, and defect depth resolution from baseline, 3 months, and 6 months in both the groups (P < 0.001). On intergroup comparison, Group II showed statistically significant changes in a reduction in pocket depth and defect depth resolution at P < 0.001.Conclusion:PRF in combination with bovine bone graft was more effective in the treatment of intrabony defects.

Regenerative Periodontal Treatment with the Single Flap Approach in Smokers and Nonsmokers.

The present study was performed to evaluate the impact of smoking status on 6-month clinical outcomes of a regenerative procedure based on enamel matrix derivative and deproteinized bovine bone mineral in the treatment of intraosseous defects accessed with buccal single flap approach. A total of 22 defects were selected in smoking (n = 11) and nonsmoking (n = 11) patients. Regenerative treatment resulted in similar clinical attachment level (CAL) gain in both smokers and nonsmokers. A trend toward lower 6-month CAL gain and probing depth reduction was observed in patients smoking 11 to 20 cigarettes per day compared to those smoking 1 to 10 cigarettes per day.

O062: Regenerative periodontal treatment with the Single Flap Approach in smokers and non‐smokers

O062: Regenerative periodontal treatment with the Single Flap Approach in smokers and non‐smokers

Simplified procedures to treat periodontal intraosseous defects in esthetic areas.

Successful treatment of deep intraosseous defects in esthetic areas implies clinical improvement of the lesion consistent with long-term tooth survival as well as the preservation (or improvement) of esthetics. It is hoped that such treatment end points may be reached through procedures (which we have termed as 'simplified') that, on the one hand can be easily and successfully applied by the majority of clinicians, and, on the other hand, are well tolerated by patients in terms of postsurgical pain and discomfort, adverse events and cost. In this review, we describe the technical aspects of the simplified procedures currently available (i.e. nonsurgical therapy and the single flap approach and its variants). Also, we analyze the effect of such procedures on clinical parameters and patient-centered outcomes. While nonsurgical therapy seems to be appropriate per se in lesions with a probing depth of < 7 mm and a limited intraosseous component, severe intraosseous defects can be successfully treated using simplified surgical procedures. Overall, data support the effectiveness of simplified surgical procedures and indicate that they result in minimal esthetic impairment (i.e. post-treatment recession) and a more tolerable postoperative course when compared with conventional surgical (double flap) approaches. In particular, the single flap approach was shown to be at least as effective as traditional papilla-preservation techniques when evaluated either as a stand-alone protocol or in combination with regenerative devices. Bioactive agents have shown the most appropriate regenerative technology when used in association with simplified surgical procedures.

Weichgewebsaugmentation in der regenerativen Parodontalchirurgie

Trombelli L et al. Effect of a Connective Tissue Graft in Combination with Single Flap Approach in the Regenerative Treatment of Intraosseous Defects. J Periodontol 2017; DOI: 10.1902/jop.2016.160471