Simplified procedures to treat periodontal intraosseous defects in esthetic areas

Prognostic value of a composite outcome measure for periodontal stability following periodontal regenerative treatment: A retrospective analysis at 4 years

BACKGROUND

Recently, a composite outcome measure (COM) was proposed to describe the short-term results of periodontal regenerative treatment. The present retrospective study aimed at evaluating the prognostic value of COM on clinical attachment level (CAL) change over a 4-year period of supportive periodontal care (SPC).

METHODS

Seventy-four intraosseous defects in 59 patients were evaluated at 6 months and 4 years following regenerative treatment. Based on 6-month CAL change and probing depth (PD), defects were classified as: COM1 (CAL gain ≥3 mm, PD ≤4 mm); COM2 (CAL gain <3 mm, PD ≤4 mm); COM3 (CAL gain ≥3 mm, PD >4 mm); or COM4 (CAL gain <3 mm, PD >4 mm). COM groups were compared for "stability" (i.e., CAL gain, no change in CAL or CAL loss <1 mm) at 4 years. Also, groups were compared for mean change in PD and CAL, need for surgical retreatment, and tooth survival.

RESULTS

At 4 years, the proportion of stable defects in COM1, COM2, COM3, and COM4 group was 69.2%, 75%, 50%, and 28.6%, respectively, with a substantially higher probability for a defect to show stability for COM1, COM2, and COM3 compared with COM4 (odds ratio 4.6, 9.1, and 2.4, respectively). Although higher prevalence of surgical reinterventions and lower tooth survival were observed in COM4, no significant differences were detected among COM groups.

CONCLUSIONS

COM may be of value in predicting CAL change at sites undergoing SPC following periodontal regenerative surgery. Studies on larger cohorts, however, are needed to substantiate the present findings.

Minimal invasiveness in the surgical treatment of intraosseous defects: A systematic review

The modern approach to regenerative treatment of periodontal intraosseous defects should aim at maximizing the clinical outcomes while minimizing the invasiveness (pain, complications, aesthetic impairment, chair time, and costs) of the procedure. The present systematic review evaluated the effect of flap design, regenerative technology, and perioperative and postoperative adjunctive protocols on invasiveness. Overall, the results of the 13 included trials indicate that: (a) the elevation of a single (buccal or lingual) flap positively influences the intensity of postoperative pain and improves the quality of early wound healing compared with double flaps; (b) while the adjunctive use of a membrane is associated with significantly longer surgery-related chair time and higher postoperative pain, the adjunctive use of enamel matrix derivative at sites receiving a graft significantly reduces postoperative pain; also, graft materials showed no significant impact on invasiveness; (c) open flap debridement performed through the elevation of a single flap may lead to substantial clinical improvements of the lesion with reduced surgery-related chair time and costs, thus representing a promising alternative to regenerative treatment. However, for such an approach, a histological evaluation of the nature of the reconstructed tissues is still lacking, and the presurgery conditions (eg, probing depth, defect severity, and defect morphology), which may benefit in terms of invasiveness, have not yet been defined; and (d) intraoperative and postoperative low-level laser biostimulation of the defect site may favorably modulate the postoperative course.

The effect of non-surgical and surgical mechanical root debridement on infrabony defects: a retrospective study

The aim of this retrospective study was to assess the outcomes of non-surgical and surgical mechanical root debridement for the treatment of infrabony defects and explore potential prognostic factors. Treated infrabony defects followed for at least 1 year were selected. All data pertaining to the clinical outcomes were recorded. Multi-level regression analysis and Cox Proportional-Hazards Models were used to assess the immediate (3-6 months) clinical outcomes, survival of the treated teeth, and factors influencing these results. 132 patients were included in the analysis. The analysis showed 1.42 ± 1.71 and 2.23 ± 1.64 mm in pocket depth (PD) reduction, 0.13 ± 1.83 and 0.08 ± 1.76 mm in clinical attachment level (CAL) gain, and 1.29 ± 1.56 and 2.15 ± 1.33 mm increase in gingival recession (REC) for the non-surgical and surgical groups, respectively. The 5-year survival rates were 93% for the non-surgically and 90% for the surgically treated teeth. Several factors affected clinical outcomes and tooth survival. Within its limitations, the treatment of infrabony defects with non-surgical and surgical mechanical root debridement was found to result in moderate but significant PD reduction, nevertheless, this may also be attributable to the resultant REC.

Single-flap versus double-flap approach for periodontal pocket reduction in supraosseous defects: a comparative study

PURPOSE

The single-flap approach (SFA) is a minimally invasive technique with limited mucoperiosteal flap elevation to gain access to the buccal/palatal aspects, thus limiting post-surgical complications. The purpose of the present study was to gain insights into the impact of the SFA over the double-flap approach (DFA) on periodontal flap treatment outcomes and patient compliance in terms of discomfort and time taken for surgical procedures.

METHODS

Twenty patients with persistent probing pocket depths of ≥5 mm were scheduled for the SFA (test site) and for the DFA (control site). All the clinical periodontal parameters were recorded at baseline, 3 months, and 6 months. Radiographic bone level (cone-beam computed tomography) was evaluated at baseline and 6 months. Patients' postoperative pain perception and wound healing were also assessed.

RESULTS

The SFA showed a significant reduction in periodontal pocket depth, gain in clinical attachment level (CAL), and gain in bone level when compared with the DFA. The SFA substantially improved wound healing and induced less postoperative pain than the DFA.

CONCLUSIONS

The SFA resulted in substantial improvement in the composite outcome measures, as shown by a reduction in pocket depth with minimal gingival recession, gain in CAL, early wound healing, less postoperative discomfort, and better patient-centered outcomes.

TRIAL REGISTRATION

Clinical Trials Registry-India Identifier: CTRI/2018/05/013562.

Single flap approach with or without enamel matrix derivative in the treatment of severe supraosseous defects: a retrospective study

Aim

To comparatively evaluate the clinical effectiveness of the single flap approach (SFA) with and without enamel matrix derivative (EMD) in the treatment of supraosseous defects (SDs) associated with deep pockets.

Materials and methods

Twenty patients, each contributing one SD associated with a deep (≥ 6 mm) pocket and treated with buccal SFA either alone (SFA group; n = 10) or in combination with EMD (SFA+EMD group; n =10), were retrospectively selected. Clinical parameters (probing depth, PD; clinical attachment level, CAL; gingival recession, REC) had been assessed at pre-surgery and 12 months post-surgery.

Results

Complete wound closure was observed in 70% and 80% of defects treated with SFA and SFA+EMD, respectively. Treatments resulted in a significant PD reduction of 3.1±1.0 mm (p=0.005). In SFA+EMD group, 100% of closed pockets was obtained, while 90% of closed pockets was observed in SFA group. Both treatments resulted in a significant CAL gain of 2.1±0.9 mm and 1.9±1.7 mm in SFA and SFA+EMD group, respectively (p= 0.465). In both groups, REC significantly increased 1.0±1.1 mm in SFA group and 1.1±1.1 mm in SFA+EMD group (p= 0.722).

Conclusions

Within their limits, the findings of present study suggest that SFA may represent a valuable option for the surgical treatment of SDs associated with deep pockets. EMD did not result in a significant clinical benefit to the procedure.

Clinical relevance

SFA may represent a valuable option in obtaining pocket closure when treating SDs associated with deep residual pockets.

Healing of intrabony defects following regenerative surgery by means of single-flap approach in conjunction with either hyaluronic acid or an enamel matrix derivative: a 24-month randomized controlled clinical trial

Objectives

The aim of this randomized controlled clinical trial was to compare the clinical outcomes obtained in intrabony defects following regenerative periodontal surgery using the single-flap approach (SFA) in conjunction with either hyaluronic acid (HA) or enamel matrix derivative (EMD).

Materials and methods

Thirty-two intrabony defects in 32 healthy subjects were randomly assigned: HA (test group) or EMD (control group). Clinical attachment level (CAL), probing depth (PD), gingival recession (REC), and bleeding on probing (BOP) were recorded at baseline,12, 18, and 24 months after surgery.

Results

At 24 months, both treatments resulted in statistically significant clinical improvements evidenced by PD-reduction and CAL-gain (p<0.001). The mean CAL-gain was 2.19±1.11 mm in the test and 2.94±1.12 mm in the control sites (p=0.067). PD-reduction was statistically significantly higher for the control group (4.5±0.97 mm) than the test group (3.31±0.70 mm), (p=0.001). CAL-gain ≤ 3 mm was observed in 87.5% and in 62.5% of the test and control sites, respectively. Test sites showed slightly lower REC values than the control sites. No statistically significant differences were found for BOP between treatments.

Conclusions

The present findings indicate that both treatments led to statistically significant clinical improvements compared to baseline, although the application of EMD resulted in statistically significantly higher PD-reduction compared to the use of HA.

Clinical relevance

The use of HA in conjunction with a SFA resulted in significant PD-reduction and CAL-gain, pointing to the potential clinical relevance of this material in regenerative periodontal surgery.

Effect of Flap Design for Enamel Matrix Derivative Application in Intraosseous Defects

Objective:

To systematically review the literature addressing the focused question: What is the effectiveness of different surgical and nonsurgical procedures combined with enamel matrix derivative (EMD) on clinical, radiographic, and patient-centered outcomes in intraosseous defects?

Methods:

Electronic (Medline, Scopus, and Cochrane databases) and hand literature searches were performed for studies including at least 1 treatment arm where EMD had been applied according to 1 of the following procedures: modified Widman flap; papilla preservation variants (PPVs), including papilla preservation technique, modified papilla preservation technique, and simplified papilla preservation technique; minimally invasive variants, including minimally invasive surgical approach and minimally invasive surgical technique; single-flap variants (SFVs), including single-flap approach and modified minimally invasive surgical technique; or nonsurgical application (flapless approach). Data from 42 selected articles were used to perform a network meta-analysis, and a hierarchy of surgical and nonsurgical applications of EMD was built separately for EMD and EMD + graft based on 6- to 12-mo clinical and radiographic outcomes.

Results:

Among surgical approaches, EMD was associated with best regenerative outcomes when applied through SFVs, with a mean clinical attachment level gain of 3.93 mm and a reduction in the intrabony component of the defect of 3.35 mm. For EMD + graft, limited differences in regenerative outcomes were observed among surgical procedures. PPVs were associated with the highest residual probing depth for EMD (4.08 mm) and EMD + graft (4.32 mm).

Conclusions:

In the treatment of periodontal intraosseous defects, 1) SFVs appear to optimize the regenerative outcomes of EMD; 2) substantial regenerative outcomes can be obtained with SFVs and conservative double flaps (i.e., PPVs and minimally invasive variants) when EMD is combined with a graft; and 3) residual probing depth was higher following PPVs for EMD and EMD + graft.

Knowledge Transfer Statement:

The results of the present systematic review and meta-analysis can be used by clinicians to identify the most effective surgical or nonsurgical procedure to treat an intraosseous defect with EMD or EMD + graft. The main findings indicate that when EMD application is indicated, surgical access based on a single flap seems the most appropriate to optimize clinical outcomes. The application of EMD + graft can be effectively combined with single flaps and conservative double flaps.