Original Article

Comparison of microsurgical and conventional open flap : A randomized controlled trial Meena Priya Bagavathy Perumal, Aruna Dunthur Ramegowda,1 Avinash Janaki Lingaraju,1 James Johnson Raja2

Department of Abstract: Periodontics, Chettinad Background: Residual exists not only on teeth treated by scaling alone but also on teeth treated by Dental College and flap surgery. Periodontal microsurgery enables more definite removal of calculus, atraumatic handling of tissues Research Institute, through optical magnification. The purpose of this study was to compare the clinical outcomes of microsurgery Kelambakkam, with conventional open flap debridement in patients with .Materials and Methods: Thirteen Chennai, 1Department chronic periodontitis patients were randomly assigned for test (microsurgical) and control (conventional) open flap debridement in a split mouth design. At baseline, 3, 6 and 9 months the following clinical parameters were recorded: of Periodontics, VS Probing pocket depth, relative attachment level, , gingival bleeding index. Postoperative healing Dental College and at 1‑week by early healing index and pain scale for 7 days were assessed. Results: Paired t‑test was used to Hospital, Bengaluru, compare means within the groups, and unpaired t‑test was applied to compare the means of the two groups. At Karnataka, 2Department 3, 6 and 9 months postoperatively there was a significant reduction in gingival bleeding index, probing pocket of Periodontics, depth, relative attachment level within both the groups and there was no significant difference between both Rajas Dental College the groups. level and gingival recession increased in both the groups, but it was not statistically and Hospital, significant. Early healing Index score of 1 was found in 85% of test sites and 28% of control sites. The mean Vadakankulam, pain scale was 0 in test site and 1.07 ± 0.75 in control site. Conclusions: In open flap debridement procedure, a microsurgical approach can substantially improve the early healing index and induce less postoperative pain Tirunelveli, compared with applying a conventional macroscopic approach. Tamil Nadu, India Key words: Flap surgery, open flap debridement, periodontal microsurgery, residual calculus, wound healing

Access this article online Website: www.jisponline.com INTRODUCTION swung away from traditional mechanical and surgical therapy toward advanced treatment DOI: 10.4103/0972-124X.156884 eriodontal disease, an inflammatory disease applications. The application of magnification of multifactorial origin seems to be the leading to periodontics has tremendously refined the Quick Response Code: P cause of tooth loss worldwide. This disease in its periodontal surgical care. As recent developments wake leaves behind a trail of destruction mainly in medicine have shown, magnification and pertaining to the tooth supporting structures. microsurgery can greatly impact clinical Periodontal therapy consists of treatment modalities practice.[3,4] aimed at arresting infection, restoring the lost structure and to maintain a healthy . Microsurgery is a treatment philosophy whose The mechanical removal of bacterial plaque, clinical horizons will continue to improve with calculus and toxic material is an effective means operator experience and willingness to employ of altering the etiology of .[1] previously unused basic optical magnification Address for and ergonomic techniques and technology.[5] As correspondence: Historically, periodontal surgery was used to of today, no clinical study has demonstrated the Dr. Meena Priya use and possible advantages of dental loupes in Bagavathy Perumal, treat patients with generalized disease and Department of because of this the surgical approach was usually periodontal open flap debridement. So the aim Periodontics, Chettinad designed to treat multiple adjacent teeth. The of the present study is to evaluate the treatment Dental College and goal of periodontal surgery has always been to outcomes of microsurgery and compare it with Research Institute, Old alleviate or eliminate the degeneration associated conventional open flap debridement procedures. Mahabalipuram Road, with the progressive periodontal disease. In Kelambakkam, Chennai, order to accomplish this goal, access to the MATERIALS AND METHODS Tamil Nadu, India. periodontal defect for debridement has been an E‑mail: drmeenapriya@ [2] yahoo.com integral part of surgical therapy. Ethical clearance was obtained from the institutional review board. Written informed Submission: 05-11-2013 The current pendulum of clinical opinion in some consent was signed and obtained from all the Accepted: 26-03-2015 areas of periodontal education and research has patients who participated in the study. This study

406 Journal of Indian Society of - Vol 19, Issue 4, Jul-Aug 2015 Perumal, et al.: Conventional versus microsurgery was carried out as a split mouth randomized controlled clinical removed with curettes to provide full access and visibility to trial. Totally, 13 patients (7 male and 6 female) with the age root surfaces. Any remaining plaque and calculus were gently range of 30–50 years were included in the study. removed using hand instruments. Sutures were placed using 6‑0 suture vicryl suture. Patient selection Inclusion criteria Statistical analysis was carried out using SPSS software A total of 13 chronic generalized periodontitis patients version 17.0 (IBM corporation, Chicago, IL, USA). Paired t‑test attending the Department of Periodontics presenting with was used to compare means on the same or related subjects similar horizontal bone loss and probing pocket depth ≥ 5 mm over time or in differing circumstances, and unpaired t‑test in contralateral quadrants were included in the study. was applied to compare the means of the two groups. Early healing index was assessed using frequency distribution. Exclusion criteria Patients with any systemic diseases or under antibiotics in RESULTS the past 6 months, smokers and with poor were excluded. There was no significant difference between the groups for probing pocket depth, relative attachment level, gingival Three teeth per quadrant with identical pattern of bone loss recession, gingival bleeding index, gingival margin level, and probing depth were included for treatment either by as shown in Table 1. The changes in probing pocket depth, microsurgical (test site) or conventional approach (control site) relative attachment level, gingival recession, gingival bleeding in a split mouth design. At baseline, 3, 6 and 9 months, the index, between the groups in different visits are depicted following clinical parameters were evaluated: Probing pocket in Figures 3‑6 respectively. Figure 7 signifies the frequency depth, relative attachment level, gingival recession, gingival distribution of Early Healing Index, with a lesser score of 1 bleeding index ‑ Ainamo and Bay 1975, Patient comfort was was more with the test site (85%), and more percentage of assessed by visual analog scale for 7 days postoperatively. the control site showed a higher score of 2 (71.70%). No sites Postoperative healing was assessed by early wound healing showed scores 3–5. index at 1 week post operatively.[6]

A stent was individually fabricated to create fixed landmarks Table 1: Comparison between the parameters from and to standardize the location and angulation of periodontal baseline and at 3, 6 and 9 months probes at all the six sites. The position of the gingival margin Parameter Time Control site Test site (mm) P was measured from the stent to the gingival margin, and the Relative Baseline 10.77±1.56 10.10±1.50 0.831 relative attachment level from the stent to the bottom of the attachment level 3 months 7.57±1.70 7.29±1.89 0.581 periodontal pocket. The probing depth was calculated based on P 0.000* 0.000* the difference between relative attachment level and gingival 6 months 7.39±1.69 6.98±1.93 0.662 margin level.[7] P 0.000* 0.000* 9 months 6.97±1.66 6.71±1.79 0.790 All periodontal surgical procedures were performed on an P 0.000* 0.000* Probing pocket Baseline 5.01±0.53 5.41±0.77 0.113 outpatient basis under aseptic conditions. The patient was asked depth 3 months 1.99±0.56 1.96±0.59 0.778 to rinse the mouth with 10 ml of 0.2% digluconate P 0.000* 0.000* solution for 60 s. The operative site was anaesthetized with 6 months 1.61±0.47 1.67±0.52 0.478 2% lignocaine HCL with adrenaline (1:80,000). P 0.000* 0.000* 9 months 1.30±0.32 1.30±0.32 0.645 After achieving adequate anesthesia, in the control sites P 0.000* 0.000* Gingival Baseline 5.16±1.68 5.40±1.25 0.684 intracrevicular incisions were made, and full thickness marginal level 3 months 5.28±1.83 5.54±1.43 0.745 mucoperiosteal flaps were elevated. Surgical debridement P 0.318 0.323 was carried out to remove subgingival plaque, calculus, 6 months 5.29±1.83 5.54±1.43 0.757 diseased granulation tissue and pocket epithelium. The surgical P 0.287 0.323 sites were irrigated with sterile saline. Surgical flaps were 9 months 5.29±1.84 5.60±1.55 0.903 sutured to the presurgical level with 3‑0 silk suture utilizing P 0.273 0.297 an interdental, direct suturing technique achieving primary Gingival Baseline 82.61±14.23 82.03±13.54 0.765 ® bleeding index 3 months 24.47±15.31 29.73±16.60 0.566 closure. A noneugenol periodontal dressing Coe‑pack was P 0.000* 0.000* placed. Postoperative instructions were given to the patients. 6 months 27.93±13.64 19.6±13.8 0.478 Antibiotic prescription of amoxicillin 500 mg thrice daily for P 0.000 0.000 5 days and a nonsteroidal anti‑inflammatory agent thrice daily 9 months 24.22±12.58 22.12±13.03 0.645 for 2 days was given. P 0.000* 0.000* Gingival Baseline 0.06±0.47 0.05±0.10 0.765 3 months 24.47±15.31 29.73±15.31 0.566 In test sites, microsurgery was carried out with × 3.5 optical recession P 0.263 0.306 magnification dental loupe. After Local anaesthesia, sulcular 6 months 0.17±0.43 0.21±0.46 0.777 incisions were placed with microsurgical ophthalmic P 0.263 0.284 blades [Figure 1]. Buccal and lingual mucoperiosteal flaps were 9 months 0.21±0.46 0.18±0.43 0.817 elevated using periosteal elevators [Figure 2]. Granulation P 0.259 0.271 tissue adherent to the inner surface of flaps were carefully *Denotes significance, P<0.05 is statistically significant

Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015 407 Perumal, et al.: Conventional versus microsurgery

Figure 1: Conventional versus microsurgical blade Figure 2: Conventional versus microsurgical periosteal elevator

Figure 3: Changes in the relative attachment level between the groups at Figure 4: Changes in the probing pocket depth between the groups at different visits different visits

Figure 5: Changes in the gingival recession between the groups at different visits Figure 6: Changes in the gingival bleeding index between the groups at different visits At day 1 post operatively, the mean pain scale of the test site patients was 0, for the control site was 1.07 ± 0.75 and the of the wound and decreased postoperative pain when difference was statistically significant. From day 2–7, there compared to the clinical performance under conventional was score 0 on the scale for both the groups, and there was no techniques. statistically significant difference. The primary etiologic agent in periodontitis is plaque DISCUSSION and calculus. are widely used techniques to remove the irritants from the surfaces of The present clinical study has demonstrated that open flap teeth and also to reduce root roughness that may facilitate debridement procedures for chronic periodontitis using the the accumulation of irritants.[3,8] Small areas of calculus microsurgical procedures has improved the early healing are often left behind, with anywhere from about 3% to

408 Journal of Indian Society of Periodontology - Vol 19, Issue 4, Jul-Aug 2015 Perumal, et al.: Conventional versus microsurgery

A frequency of once every 3 months recall appears to be sufficient to maintain the beneficial effects of therapy even in the presence of individual variations of personal oral hygiene and gingival inflammation. Although studies demonstrate that healing may continue for a period of 9 months following initial therapy, most of the healing seems to complete at 3 months following therapy.[19]

In our study, although the clinical parameters, probing pocket depth, relative attachment level, gingival margin level showed significant difference from baseline to 3, 6 and 9 months, there was no significant difference between the groups in the present study. Figure 7: Comparison of early healing index between test and control sites at baseline and 1 week post operatively In our study, there was no statistically significant increase in gingival recession between the test and control sites. The test sites showed an increase of 0.12 mm as against 0.14 mm in 80% of instrumented root surfaces showing some residual [9,10] control sites. There was no significant decrease in recession calculus. It was also observed that more residual calculus between the groups. However, studies have shown minimal is left behind on proximal surfaces, in deep sites, and in [10,11] gingival recession (0.4 mm) with microsurgery due to furcation areas. atraumatic manipulation during surgery and excellent soft tissue preservation.[6,17] Complete removal of calculus is a primary part of achieving a biologically acceptable tooth surface in the treatment of However, the mean surgical operation time for test site is periodontitis. However, residual calculus exists not only on 1 h and 30 min that is 6% more than in control sites 1 h and teeth treated by scaling alone but also on teeth treated by flap [12,13] 16 min. In oral surgical procedures, studies have shown surgery followed by scaling and root planing. that the incidence and severity of complications following periodontal surgery correlated well with the duration of the Periodontal flaps for access provide a means to reduce residual procedure. It may be speculated that the extended operation calculus, especially more efficient even in deeper pockets, both [3] time may compensate for the beneficial treatment effect of in anterior and posterior teeth. However, complete removal minimally invasive techniques.[6] However in the present study of calculus from periodontally diseased root surfaces is rare. microsurgical open flap debridement resulted in faster healing Scaling and root planing with flap showed better removal of and less postoperative pain. calculus than after scaling and root planing alone. Surgical access has shown to improve the efficiency of scaling and root [14] The present study has certain limitations. The sample size was planing. kept minimum. The test sites were treated after the control sites, the less postoperative pain may be due to the less apprehension Microsurgical procedures have been studied for various for the second surgery. regenerative procedures, root coverage and papilla reconstruction procedures.[15] The benefits of microsurgical CONCLUSION approaches have been described only in a few case reports,[3,4,16] and one prospective cohort study.[17] A case Within the limitations of the present study, it can be concluded control study was conducted similar to our present study that microsurgical approach resulted in early healing and less design to assess the clinical outcome in localized gingival postoperative pain compared to the conventional approach. recessions.[18] As of today, there is no clinical study to compare Both the procedures were equally effective in improving the microsurgical and conventional open flap debridement clinical parameters. The choice of micro or macro surgical procedures. approaches should be decided based on the treatment outcomes, cost and the patient‑centered parameters. In the present split mouth study, three teeth with probing pocket depth ≥5 mm were considered as test site, and the contralateral teeth with same probing pocket depth were ACKNOWLEDGEMENT considered as controls. Both test and control sites showed Authors would like to acknowledge the principal almost similar radiographic and clinical parameters. Dr. Usha H L, V.S Dental College and Hospital (V. S. D. C and H) and Dr. Sushma Galgali MDS, Professor and Head of the Department of The only difference/variable over conventional technique was Periodontics, V. S. D. C and H, for their support and guidance throughout that there was improved visual and tactile perception through the study. We would like to thank Dr. Shankar, Assistant Professor, microsurgical technique.[18] Department of Public Health and Mr. Patchamuthu, Biostatistician, KSR Dental College for helping in statistical analysis. Postoperative pain and early healing assessed for 7 days after the procedure showed that the test sites were significantly REFERENCES better than the controls. This may be due to delicate handling of the tissues and precise wound closure, which are similar to 1. Drisko CH. Nonsurgical periodontal therapy. Periodontol some of the earlier studies.[6,17] 2000 2001;25:77‑88.

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