Single flap approach with and without Guided Tissue Regeneration and a Hydroxyapatite biomaterial in the management of intraosseous

periodontal defects
Leonardo Trombelli, Anna Simonelli, Mattia Pramstraller, Ulf M.E. Wikesjo, and Roberto Farina

Kim YunJeong

Single flap approach ?

Minimally invasive surgical technique
: lessen surgical trauma with adequate access : limited or no use of release incisions, limited flap reflection

SFA (single flap approach)

: unilateral elevation of a limited mucoperiosteal flap to allow surgical access depending on the main, buccal or oral, extension of the intraosseous defect leaving adjoining gingival tissues intact Trombelli L 2007

Single flap approach (SFA)

facilitate flap repositioning and suturing
: can easily be stabilized to the undetached papilla, optimizing wo und closure for primary intention healing

accelerated reestablishment of the local vascular supply preservation of the pre-existing gingival esthetics
SFA combined with a hydroxyapatite (HA) and GTR allowed substantial clinical attachment gain,

limited gingival recession (REC),

generally uneventful healing in deep intraosseous defects.

Background
GTR was more effective than OFD(open flap debridement) in improving attachment levels
Needleman I, Tucker R, Giedrys-Leeper E, Worthington H.. A systematic review of guided tissue regeneration for periodontal infrabony defects J Periodontal Res. 2002

Challenging intraosseous defects, surgically accessed with a buccal SFA and treated with a combined graft/GTR technique, may heal with a substantial CAL gain.
Leonardo Trombelli .. Single-Flap Approach With Buccal Access in Periodontal Reconstructive Procedures J Periodontol 2009

application of a wound stabilizing element; GTR device or a biomaterial, allowed wound healing progressing onto a connective tissue attachment , not epithelial attachment

Materials and Methods

single-center randomized-controlled trial Patients
1) 2) 3) 4) 5) diagnosis of chronic or aggressive periodontitis no systemic diseases that contraindicated periodontal surgery no medications affecting periodontal status no pregnancy or lactation presence of 1 deep ( PD5 mm, radiographic depth 4 mm) interproximal intraosseous periodontal defect limited to no extension on the lingual-palatal side as assessed by preoperative bone sounding 6) full mouth plaque score and bleeding score <20%

Exclusion : Third molars ,teeth with degree III mobility, furcation involvement, inadequate treatment /restoration

Materials and Methods

Each intraosseous defect was randomly assigned to receive SFA or SFA + HA/GTR The patients and the clinical examiner were masked with respect to treatment allocation SFA after full mouth SRP and oral hygiene instruction.

Materials and Methods

buccal envelope flap without vertical releasing incisions

Probing

Sulcular incisions are performed following the gingival margin of the teeth interdental incision is performed >1 mm coronal to the underlying bone crest

Materials and Methods

Flap elevation

Debridement using hand and ultrasonic instruments

HA-based biomaterial (BIOSTITE) and resorbable collagen membrane (PAROGUIDE)

Materials and Methods

horizontal internal mattress suture

second internal mattress suture

Materials and Methods

2wk post-op

6mo post-op

Inhibit 4wks mechanical oral hygiene procedure 0.12% chlorhexidine mouthrinse (10 ml twice a day for 6 weeks) antimicrobial AmF/SnF2 mouthrinse and toothpaste Monthly R/C with supragingival plaque control

Materials and Methods

Recordings
One calibrated masked examiner manual pressure-sensitive probe with 1-mm increments approximately 0.3-N force PD (gingival margin~bottom of the pocket) CAL (CEJ~bottom of the pocket) REC (CEJ~gingival margin) bleeding score (+/-) ->measured at 6 aspects per tooth presurgery/ post op 6mo

Materials and Methods

Recordings
configuration of the intraosseous defect depth of the intrabony component : deepest point of the defect ~most coronal point of the alveolar crest at the adjacent tooth early wound-healing index (EHI, Wachtel,2003)
1) complete flap closure, no fibrin line in the interproximal area 2) complete flap closure, fine fibrin line in the interproximal area 3) complete flap closure, fibrin clot in the interproximal area 4) incomplete flap closure, partial necrosis of the interproximal tissue 5) incomplete flap closure, complete necrosis of the interproximal tissue.

statistical software program Student t test , x2 test

Results

Results
5 defects in SFA+HA/GTR group showed limited (<2mm) suture line dehiscences without evidence of memb. exposure or exfoliation of the biomaterial
1) complete flap closure, no fibrin line in the interproximal area 2) complete flap closure, fine fibrin line in the interproximal area 3) complete flap closure, fibrin clot in the interproximal area 4) incomplete flap closure, partial necrosis of the interproximal tissue 5) incomplete flap closure, complete necrosis of the interproximal tissue.

Results

12 SFA versus 7 SFA + HA/GTR defects showed a post-surgery PD <4 mm(P = 0.037)

Discussion
HA-based biomaterial : SFA + HA/GTR group displayed considerable
CAL gain (4.7 mm) and PD reduction (5.3 mm)

-> consistent with previous studies of conventional flap + HA/GTR

Five sites in the SFA + HA/GTR group exhibited suture-line dehiscences that apparently resolved
<- compromised revascularization of the surgical site
: not associated with clinical membrane exposure or graft exfoation, and appeared resolved within 1 month post-surgery! strict personal plaque control reduce bacterial load Christgau M 1997

Discussion
SFA supported considerable clinical improvements as a stand-alone protocol : CAL gain averaged 4.4 mm, 11 sites >3 mm gain
at 6m post op

The effect of SFA largely exceeded those reported for conventional access flaps in the treatment of intraosseous periodontal defects.
: limited surgical trauma and optimal conditions for wound closure/wound stability

Discussion
Variations in supracrestal and osseous defect characteristics
presurgery supracrestal tissue thickness for the SFA (2.4mm) compared to the SFA +HA/GTR group (1.1 mm) SFA group exhibited greater prevalence sites with 3-wall component Treating with barrier membrane, defect
configuration does not seem to significantly affect the amount of CAL gain (Trombelli, 1997)

The depth of the intrabony component :SFA (6.1mm) vs. SFA +HA/GTR group (8 mm)

Discussion
REC increased 0.8 mm in the SFA group compared
to 0.4 mm in the SFA + HA/GTR group
REC of the interproximal gingival margin occurred despite the preservation of supracrestal tissues
<- increased REC is ascribed to post-surgery tissue remodeling.

Smaller increase in REC for the SFA+HA/GTR compared to the SFA group
<- presence of the HA biomaterial limiting collapse of the overlying gingiva

Conclusion
SFA with and without HA/GTR seems to be a valuable minimally invasive approach in the treatment of deep intraosseous periodontal defects. Under the present experimental conditions, the additional HA/GTR protocol offers no significant adjunctive effect.

Epilogue
Strong point
First trial to compare the effects of SFA and SFA+HA/GTR protocol

Weak point
The comparison was not performed in same conditions In two groups of 12 patients, baseline defect characteristics and age, smoking status . were different in many aspects