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Comparison of Microsurgical and Conventional Open Flap Debridement

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Comparison of Microsurgical and Conventional Open Flap Debridement Original Article Comparison of microsurgical and conventional open flap debridement: 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 calculus 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 chronic periodontitis.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 recession, 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. Gingival margin 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 periodontium. 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 periodontal disease.[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 Periodontology - 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 oral hygiene 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% chlorhexidine 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.
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