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The International Journal of Periodontics & Restorative Dentistry

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The International Journal of Periodontics & Restorative Dentistry The International Journal of Periodontics & Restorative Dentistry © 2013 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 217 Open Flap Debridement in Combination with Acellular Dermal Matrix Allograft for the Prevention of Postsurgical Gingival Recession: A Case Series Ramesh Sundersing Chavan, BDS, MDS1 The therapeutic objective of peri- Manohar Laxman Bhongade, MSc, BDS, MDS2 odontal flap surgery is to provide Ishan Ramakant Tiwari, BDS, MDS1 accessibility to the underlying Priyanka Jaiswal, BDS, MDS1 root surface to reduce the pocket depth,1 arrest further breakdown, and prevent additional attach- Open flap debridement with flap repositioning may result in significant gingival ment loss. Open flap debridement recession. Patients with chronic periodontitis were treated with open flap 2 debridement followed by placement of an acellular dermal matrix allograft (OFD) is a common procedure for (ADMA) underneath the flap to minimize the occurrence of postsurgical gingival the treatment of deep periodontal recession. Ten patients (total, 60 teeth) with periodontal pockets in the anterior pockets associated with horizontal dentition underwent open flap debridement combined with ADMA. Probing bone loss. This procedure is indi- pocket depth, relative attachment level, and relative gingival margin level were cated when pocket elimination is recorded at baseline and 6 months postsurgery. The mean probing pocket undesirable because of esthetic depth at baseline and 6 months was 4.4 and 1.7 mm, respectively (P < .05); the mean relative attachment level at baseline and 6 months was 12.9 and 10.7 mm, considerations, particularly in the respectively (P < .05); and the mean relative gingival margin level at baseline and anterior dentition. However, sur- 6 months was 8.4 and 9.0 mm, respectively. ADMA underneath the flap when gical debridement with flap repo- combined with open flap debridement effectively minimizes postsurgical sitioning may result in significant gingival recession. (Int J Periodontics Restorative Dent 2013;33:217–221. gingival recession.2–4 Becker et al1 doi: 10.11607/prd.0416) reported greater gingival recession in sites with deeper periodontal pockets, and prevention of gingi- val recession should be considered one of the goals of flap debride- ment surgery. In a case series study, Hirsch et 1 Senior Lecturer, Department of Periodontics and Implantology, Sharad Pawar Dental al5 reported that OFD combined College and Hospital, Deemed University, Sawangi (Meghe), Wardha, Maharashtra, India. with a subepithelial connective tis- 2Professor and Head, Department of Periodontics and Implantology, Sharad Pawar Dental College and Hospital, Deemed University, Sawangi (Meghe), Wardha, Maharashtra, India. sue graft (SCTG) for the treatment of suprabony pockets was found to Correspondence to: Dr Ramesh S. Chavan, Department of Periodontics and Implantology, be an effective procedure to pre- Sharad Pawar Dental College, Deemed University, Sawangi (Meghe), Wardha, 442001, vent postsurgical gingival reces- Maharashtra, India; fax: 00 91 7152 287701; email: [email protected] sion. The SCTG offers a dual blood ©2013 by Quintessence Publishing Co Inc.. supply, improved esthetics, and Volume 33, Number 2, 2013 © 2013 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 218 Fig 1 Preoperative clinical view. Fig 2 Preoperative measurement using the Florida Disk Probe. excellent predictability, but this for the treatment of multiple gin- keratinized gingiva (Fig 1). Exclu- procedure utilizes a second surgi- gival recessions has been docu- sion criteria consisted of patients cal site with associated morbid- mented and provides comparable who would not comply with peri- ity.6 Therefore, multiple sites may results between ADMA and SCTG. odontal maintenance, smoking, be required, and the patient may To the best of the authors’ knowl- grade II tooth mobility, malocclu- have to undergo multiple surger- edge, no study has reported the sion in the anterior quadrant, histo- ies in the area to acquire sufficient ability of ADMA implanted be- ry of periodontal surgical treatment, graft tissue.7 In an effort to avoid neath the flap during OFD for the and pregnant or lactating women. the multiple surgical sites required treatment of a suprabony pocket for harvesting a connective tis- to minimize postsurgical gingival sue graft from the palate, acellular recession. This study aimed to do so. Clinical measurements dermal matrix allograft (ADMA) has become increasingly popular The full-mouth plaque score was as- as a substitute for connective tis- Method and materials sessed using the Turesky-Gilmore- sue grafts.8 In a controlled clinical Glickman modification of the study, Harris9 compared the use Ten patients (5 men, 5 women) be- Plaque Index,11 and gingival in- of ADMA and SCTG underneath tween the ages of 31 and 42 years flammation was assessed using the a coronally positioned flap and (mean age, 33.90 ± 3.44 years) with Papillary Bleeding Index12 on the reported equal predictability with chronic periodontitis were select- day of surgery and 6 months post- comparable root coverage in the ed. All patients were systemically operatively. The probing pocket treatment of gingival recession. healthy but possessed the follow- depth (PPD), relative attachment Multiple clinical studies have also ing: presence of a residual probing level (RAL), and relative gingival documented predictable and es- pocket depth (PPD) ≥ 5 mm and at- margin level (RGML) were record- thetic outcomes with ADMA in the tachment loss ≥ 5 mm around more ed for assessment of results. These treatment of multiple gingival re- than one surface of each tooth in measurements were recorded us- cession defects. Recent histologic the anterior dentition, radiographic ing a Florida Disk Probe (Florida evidence of new attachment10 fol- evidence of horizontal bone loss, Probe Corp) (Fig 2). The tip of the lowing root coverage procedures and presence of at least 2 mm of Florida Disk Probe was placed at The International Journal of Periodontics & Restorative Dentistry © 2013 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 219 Fig 3 Flap reflection and debridement after crevicular incisions Fig 4 Placement of ADMA underneath the flap. were performed. the base of the pocket with the esthesia, a conventional approach in the treated area. All patients base of the disk resting at the oc- with a periodontal access flap was were placed on 0.2% chlorhexidine clusal level; the foot pedal was initiated using intrasulcular inci- gluconate mouthrinse (10 mL twice pressed, and the measurement sions on the buccal and lingual as- daily for 1 minute) for 6 weeks. The was recorded as the RAL consider- pects. One tooth mesial and distal periodontal pack and sutures were ing the occlusal level as a fixed ref- to the experimental site were in- removed 8 to 10 days after surgery. erence point. Again, the probe was cluded in the flap. A full-thickness Patients were instructed to clean placed at the gingival margin and flap was reflected, granulation tis- the treated site with a cotton pellet the foot pedal was pressed, and sue was removed, and the roots saturated with 0.2% chlorhexidine the distance from the occlusal level were planed using curettes (Fig 3). gluconate for an additional 3 to to the gingival margin was consid- ADMA was hydrated in ster- 5 weeks in the apicocoronal direc- ered the RGML. PPD was calculat- ile saline for 15 minutes. After flap tion and later using a soft tooth- ed by subtracting the RGML from reflection, debridement, and root brush and the Charter method of the RAL. All measurements were surface management, the graft was brushing. The postoperative clini- recorded at four sites per tooth: trimmed to the shape and size de- cal view can be seen in Fig 6. mesial, distal, buccal, and lingual. signed to cover the exposed root For later calculations, the mean of surface and extended 2 to 3 mm on the four sites was taken into con- the bone surface (Fig 4). The flap Statistical analysis sideration. All probing measure- was then positioned coronally to ments were recorded at baseline completely cover the ADMA. The Statistical analysis was performed and 6 months postoperatively. flap was stabilized with simple inter- using the Student paired t test with rupted 4-0 Vicryl sutures (4-0 non- the help of Statistical Package for absorbable surgical suture; Mersilk, Social Sciences software (SPSS ver- Surgical procedure Johnson & Johnson) (Fig 5), and sion 14.0, IBM). a periodontal pack was placed. The surgical protocol emphasized Amoxicillin (500 mg tds) was pre- complete asepsis and infection scribed for 5 days. Patients were control. After induction of local an- instructed not to brush the teeth Volume 33, Number 2, 2013 © 2013 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 220 Fig 5 Coronally advanced flap sutured into place. Fig 6 Postoperative clinical view. 14 12.9 Baseline 12 6 mo 10.7 10 9.0 8.4 8 6 Mean (mm) 4.4 4 2 1.7 0 PPD RAL RGML Fig 7 Postoperative measurement using the Florida Disk Probe. Fig 8 Comparison of clinical parameters at baseline and 6 months. Results At 6 months, the mean RGML Although no reports are available increased from 8.4 ± 1.21 mm at with use of ADMA underneath the At 6 months, the mean PPD de- baseline to 9.0 ± 1.03 mm, with flap during OFD for elimination creased from 4.4 ± 0.59 mm at base- a mean change of 0.6 ± 0.67 mm of suprabony pockets to prevent line to 1.7 ± 0.37 mm (Fig 7).
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