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 gingival recession should be considered one of the goals of flap debridement surgery. In a case series study, Hirsch et 1Senior 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

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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

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

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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

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). The (not significant) (Fig 8). postsurgical gingival recession, in paired Student t test indicated that this study, statistically significant the mean PPD reduction of 2.7 ± reductions in mean PPD were ob- 0.49 mm was statistically signifi- Discussion served and noted to be compa- cant (P < .05) (Fig 8). rable with previous case series The mean RAL decreased from A primary goal of periodontal ther- studies using SCTG.5,1415 12.9 ± 1.12 mm at baseline to apy is to reduce PPD to limit the The change in RAL following 10.7 ± 1.15 mm at 6 months, com- risk of local reinfection. Shallow periodontal therapy and surgery prising a mean RAL gain of 2.1 ± pockets have a strong, negative is the single most commonly used 0.76 mm. The paired Student t test predictive value for future disease clinical outcome variable. In this indicated that the mean RAL at 6 progression, while deep pockets study, a significant gain in mean at- months was statistically significant in treated areas present a risk for tachment level of 2.1 mm was ob- (P < .05) (Fig 8). periodontal disease progression.13 served at 6 months using ADMA.

The International Journal of Periodontics & Restorative Dentistry

However, there are no reports ADMA replaces inflamed granula- 6. Reiser GM, Bruno JF, Mahan PE, Larkin available to support these findings, tion tissue and pocket epithelium LH. The subepithelial connective tissue graft palatal donor site: Anatomic con- which are comparable with those of approximately the same dimen- siderations for surgeons. Int J Periodon- of other single-arm studies without sions as the tissue removed and tics Restorative Dent 1996:16;130–137. 5,14,15 7. Cetiner D, Bodur A, Uraz A. Expanded a control group using SCTG. fills the void between the flap and mesh connective tissue graft for the Based on the literature, ADMA root surface so that the flap posi- treatment of multiple gingival reces- revascularizes via preserved vascu- tion is not changed, thus minimiz- sions. J Periodontol 2004;75:1167–1172. 8. Bruno JF. Connective tissue graft tech- lar channels and integrates into the ing postsurgical recession. nique assuring wide root coverage. Int J host tissue.16,17 At the same time, Periodontics Restorative Dent 1994;14: 126–137. ADMA also acts as a barrier equiv- 9. Harris RJ. A comparative study of root alent to a selective cell repopula- Conclusion coverage obtained with an acellular der- tion membrane, thus encouraging mal matrix versus a connective tissue graft: Results of 107 recession defects 10 new attachment. Cummings et al Within the limitations of this study, in 50 consecutively treated patients. Int showed histologically that the graft- it is reasonable to conclude that J Periodontics Restorative Dent 2000;20: 51–59. ed ADMA formed an attachment ADMA in combination with OFD 10. Cummings LC, Kaldahl WB, Allen EP. His- directly to the root surface by the resulted in a statistically significant tologic evaluation of autogenous con- combination of connective tissue improvement in terms of RAL gain nective tissue and acellular dermal matrix grafts in humans. J Periodontol 2005; adhesion and long junctional epi- and PPD reduction, with minimal 76:178–186. thelium, similar to an SCTG. Based change in RGML. 11. Turesky S, Gilmore ND, Glickman I. Re- duced plaque formation by the chlo- on their human histologic evidence, romethyl analogue of victamine C. it may be assumed that ADMA used J Periodontol 1970;41:41–43. as grafting material over root surfac- Acknowledgment 12. Mühlemann HR. Psychological and chemical mediators of gingival health. es underneath the flap could have J Prev Dent 1977;4:6–17. been attached in a similar way to im- The authors reported no conflicts of interest 13. Armitage C. Periodontal diseases: Diag- related to this study. nosis. Ann Periodontol 1996;1:37–215. prove the clinical attachment level. 14. Nelson SW. Subperiosteal connec- Isidor et al18 reported signifi- tive tissue grafts for pocket reduction cant postsurgical recessions fol- and preservation of gingival esthetics: A case report. J Periodontol 2001;72: lowing the treatment of suprabony References 1092–1099. pockets. In a longitudinal study, 15. Castellani R, Wolffe GN, Renggli HH. Pocket elimination surgery with simul- 1 1. Becker W, Becker BE, Caffesse R, et al. Becker et al compared the clini- taneous connective tissue graft. A case A longitudinal study comparing scaling, cal outcomes of scaling, osseous report with 3-year follow-up. J Clin Peri- osseous surgery, and modified Widman odontol 2001;28:365–371. surgery, and modified Widman flap procedures: Results after 5 years. J Peri- 16. Bernimoulin JP, Lüscher B, Mühlemann odontol 2001;72:1675–1684. procedures after 5 years and found HR. Coronally repositioned periodontal 2. Palacanis KG. Surgical pocket therapy. flap. Clinical indication after one year. significant postsurgical recessions Ann Periodontol 1996;1:589–617. J Clin Periodontol 1975;2:1–13. 3. Becker W, Becker BE, Ochsenbein C, et of 1.28, 2.18, and 1.70 mm, respec- 17. Yukna RA, Tow HD, Carroll PB, Vernino al. A longitudinal study comparing scal- tively, for each treatment modal- AR, Bright RW. Comparative clinical eval- ing, osseous surgery and modified Wid- uation of freeze dried skin allografts and ity. The combination of OFD and man procedures. Results after one year. autogenous gingival grafts in humans. J Periodontol 1988;59:351–365. ADMA was found to be effective J Clin Periodontol 1977;4:191–199. 4. Hall WB. Gingival augmentation/muco- 18. Isidor F, Karring T, Nyman S, Lindhe J. in preventing postsurgical gingival gingival surgery. In: Proceedings of the New attachment-reattachment following World Workshop in Clinical Periodontics. recession. A minimum postsurgical reconstructive periodontal surgery. J Clin Chicago: American Academy of Peri- gingival recession of 0.6 mm was Periodontol 1985;12:728–735. odontology, 1989:VII/1–VII–VII/23. observed at 6 months with ADMA. 5. Hirsch A, Brayer L, Shapira L, Goldstein M. The findings of this study are in Prevention of gingival recession following flap debridement surgery by subepithelial agreement with those of other sin- connective tissue graft: Consecutive case gle-armed studies using SCTG.5,14 series. J Periodontol 2004:75:757–761.

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