single flap approach with and without guided tissue

8/13/2019 Single Flap Approach With and Without Guided Tissue

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Single flap approach with and without

Guided Tissue Regeneration

and a Hydroxyapatite biomaterial in themanagement of intraosseous periodontal defects

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

Kim YunJeong


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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 adjoininggingival tissues intact

Trombelli L 2007


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Single flap approach (SFA)

facilitate flap repositioning and suturing

: can easily be stabilized to the undetached papilla, optimizing wound 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 allowedsubstantial clinical attachment gain,

limited gingival recession (REC),

generally uneventful healing in deep intraosseous defects.


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Background

GTR was more effective than OFD(open flapdebridement) in improving attachment levels

Needleman I, Tucker R, Giedrys-Leeper E, Worthington H..A systematic review of guided tissue regeneration for periodontal

infrabony defectsJ Periodontal Res. 2002

Challenging intraosseous defects, surgicallyaccessed with a buccal SFA and treated with acombined graft/GTR technique, may heal with a

substantial CAL gain.Leonardo Trombelli .. Single-Flap Approach With Buccal Accessin Periodontal Reconstructive Procedures J Periodontol 2009

application of a wound stabilizing element; GTR device ora biomaterial, allowed wound healing progressing onto a

connective tissue attachment , not epithelial attachment
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Needleman%20I%22[Author]


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single-center randomized-controlled trial

Patients1) diagnosis of chronic or aggressive periodontitis

2) no systemic diseases that contraindicated periodontal surgery3) no medications affecting periodontal status

4) no pregnancy or lactation

5) 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


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Each intraosseous defect was randomly assignedto receive SFA or SFA + HA/GTR

The patients and the clinical examiner weremasked with respect to treatment allocation

SFA after full mouth SRP and oral hygiene

instruction.

Materials and Methods


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Probing

buccal envelope flap

without vertical

releasing incisions

Sulcular incisions are performed followingthe gingival margin of the teeth

interdental incision is performed >1 mm coronalto the underlying bone crest



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Flap elevation Debridement using hand and ultrasonicinstruments

HA-based biomaterial (BIOSTITE) and

resorbable collagen membrane (PAROGUIDE)



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horizontal internalmattress suture

second internal mattress suture



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2wk 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

6mo post-op



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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



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Recordings configuration of the intraosseous defect

depth of the intrabony component

: deepest point of the defect ~most coronal point of thealveolar crest at the adjacent tooth

statistical software program Student t test , x2 test

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 area3) complete flap closure, fibrin clot in the interproximal area4) incomplete flap closure, partial necrosis of the interproximal tissue5) incomplete flap closure, complete necrosis of the interproximal tissue.



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Results


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Results

5 defects inSFA+HA/GTRgroup showedlimited (


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Results

12 SFA versus 7 SFA + HA/GTR defects

showed a post-surgery PD


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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 exhibitedsuture-line dehiscences that apparently resolved


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SFA supported considerable clinical improvements asa 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 reportedfor conventional access flaps in the treatment ofintraosseous periodontal defects.

: limited surgical trauma and optimal conditions

for wound closure/wound stability

Discussion


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Variations in supracrestal and osseousdefect 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

The depth of the intrabony component

:SFA (6.1mm) vs. SFA +HA/GTR group (8 mm)

Discussion

Treating with barrier membrane, defect

configuration does not seem to significantlyaffect the amount of CAL gain (Trombelli, 1997)


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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 occurreddespite the preservation of supracrestal tissues


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Conclusion

SFA with and without HA/GTR seems to bea valuable minimally invasive approach inthe treatment of deep intraosseousperiodontal defects.

Under the present experimental conditions,the additional HA/GTR protocol offers no

significant adjunctive effect.


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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 defectcharacteristics and age, smoking status .

were different in many aspects

single flap approach with and without guided tissue

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