Embed Size (px)
Citation preview
MODIFIED WIDMAN FLAP AND PAPILLA PRESERVATION FLAP IN
MAXILLARY ANTERIOR REGION – A COMPARATIVE STUDY
By
DR. B. CHANDRA SHEKAR
Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
In partial fulfillment of the requirements for the degree of
MASTER OF DENTAL SURGERY
In
PERIODONTICS
Under the guidance of
DR. SAVITHA. A. N.
Department of Periodontics
The Oxford Dental College, Hospital and Research Centre Bangalore
2006-2009
MODIFIED WIDMAN FLAP AND PAPILLA PRESERVATION
FLAP IN MAXILLARY ANTERIOR REGION – A
COMPARATIVE STUDY
By
DR.B. CHANDRA SHEKAR
Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
In partial fulfillment of the requirements for the degree of
MASTER OF DENTAL SURGERY
In
PERIODONTICS
Under the guidance of
DR. SAVITHA. A. N.
Department of Periodontics
The Oxford Dental College, Hospital and Research Centre Bangalore
2006-2009
i
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “MODIFIED WIDMAN FLAP
AND PAPILLA PRESERVATION FLAP IN MAXILLARY
ANTERIOR REGION – A COMPARATIVE STUDY” is a bonafide and
genuine research work carried out by me under the guidance of Dr.SAVITHA.A.N ,
Reader, Department of Periodontics, The Oxford Dental college, Hospital and
Research center, Bangalore.
Date: Signature of the Candidate
Place: Bangalore. Dr.B. Chandra Shekar.
ii
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “MODIFIED WIDMAN FLAP AND
PAPILLA PRESERVATION FLAP IN MAXILLARY ANTERIOR REGION-
A COMPARATIVE STUDY ” is a bonafide research work done by Dr. B. Chandra
shekar in partial fulfillment of the requirement for the degree of MDS in
Periodontics.
.
Date: Signature of the Guide
Place: Bangalore. Dr. Savitha.A.N
Reader,
Department of Periodontics,
The Oxford Dental College
Hospital and Research Centre,
Bangalore.
iii
ENDORSEMENT BY THE HOD,PRINCIPAL/HEAD OF THE INSTITUTION
This is to certify that the dissertation entitled “MODIFIED WIDMAN FLAP AND
PAPILLA PRESERVATION FLAP IN MAXILLARY ANTERIOR REGION-
A COMPARATIVE STUDY” is a bonafide research work done by
DR.B.CHANDRA SHEKAR under the guidance of DR.SAVITHA. A. N. Reader,
Department of Periodontics, The Oxford Dental College, Hospital and Research
Centre.
Dr. C. D. Dwarakanath, Dr. K. S. Ganapathy,
Professor and Head, Principal,
Department of Periodontics, The Oxford Dental College
The Oxford Dental College Hospital Hospital and Research
and Research Centre, Centre,
Bangalore. Bangalore.
iv
COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall
have the rights to preserve, use and disseminate this dissertation in print or electronic
format for academic / research purpose.
Date:
Place: Bangalore.
Signature of the Candidate
Dr.B. Chandra shekar.
© Rajiv Gandhi University of Health Sciences, Karnataka
v
ACKNOWLEDGMENTS
It is my pleasure to express my deep gratitude to my guide, Dr.Savitha.A.N,
for her guidance, support, encouragement and immense patience during the
preparation of this dissertation and during the course of study.
I express my sincere gratitude to Dr.C.D.Dwarakanath, Head of Department,
Department of Periodontology, for his constant support, inspiration, and guiding force
throughout the course of this study.
I thank Dr. A.V.Ramesh for his constant kindness, help and encouragement
in conducting this study.
My special thanks to Dr. Roopa and Dr. Gayathri for having helped me in
many ways during my postgraduate career.
I thank Dr.Ahad, Dr.Shoba, Dr.Lakshmi, Dr.Ravikiran and Dr. Zameer
for their valuable suggestions.
My sincere appreciation to Dr. K. S. Ganapathy, Principal, Oxford Dental
College, Hospital and Research Centre, Bangalore for all his support during the study
period.
I also thank the management of Oxford Dental College, Hospital and Research
Centre for giving me permission and providing me the necessary facilities to conduct
this study.
A special thanks to all the patients who participated in the study. This
dissertation would not have been possible without their support and cooperation
vi
I am thankful to Mr. K.P Suresh for helping me in the statistical analysis.
My heartfelt appreciation & love to all my seniors, colleagues, juniors & interns for
their unyielding support during the period of study.
I am infinitely thankful to my parents & all my brothers for their prayers,
encouragement and constant support rendered to me throughout the post graduation
tenure.
Last but not the least, I thank Almighty for giving me the strength to complete
this dissertation.
Date:
Place: Bangalore.
Signature of the Candidate
Dr. B. Chandra Shekar
vii
LIST OF ABBREVIATIONS
AC: Alveolar Crest
BD: Bony Defect
BL: Base line
CAL: Clinical attachment loss
CEJ: Cementoenamel Junction
GR: Gingival recession
GI: Gingival Index
mm: Millimeter
PI: Plaque Index
PPI: Papilla presence Index
PPD: Probing pocket depth
PDL: Periodontal Ligament
SRP: Scaling and root planing
VAS: Visual analogue scale
viii
ABSTRACT
Background & Objectives: The most common surgical procedure performed in
Periodontics is the modified Widman flap particularly in moderately deep pockets
and it often results in gingival recession which could be unesthetic in anterior region.
Papilla preservation flap is performed for the esthetic appearance of maxillary
dentition by minimizing the loss of papilla as well as to maintain a positive gingival
architecture. The aim of this study was to evaluate and compare the healing response
following modified Widman flap and Papilla preservation flap techniques in the
maxillary anterior region.
Methods: 20 patients with moderate to advanced periodontal disease were recruited
and assigned to either of the two surgical techniques (modified Widman flap and
Papilla preservation flap). Patients with spacing in between any two upper anteriors,
with atleast one tooth having probable pocket depth≥ 5mm and clinical attachment
loss≥ 4mm were subjected to periodontal flap surgery. Changes in clinical parameters
such as plaque index, gingival index, probing pocket depth, clinical attachment loss,
recession and radiological measurements along with patients perception of esthetic
outcome using Visual analogue scale were evaluated at baseline and 6 months post
operatively.
Results: Both the treatment modalities resulted in significant improvement in
gingival status, pocket depth reduction, clinical attachment gain and there was mild
increase in recession with decrease in height of interdental papilla in most of the cases
of both the groups. Also, there was no diference in patients perception of esthetic
outcome between the two groups.
ix
Interpretation & Conclusion: Both the PPF and MWF surgical procedures showed
significant improvement in various clinical and radiological parameters evaluated.
However, PPF did not show any significant superiority over MWF when assessed in
terms of esthetic outcome. Also, PPF being technique sensitive and time consuming,
a more conventional surgical technique like modified Widman flap could be a
suitable option for the treatment of periodontitis in the maxillary anterior region.
Keywords: Periodontal disease/surgery; Maxillary anterior diastema; Esthetics;
modified Widman flap; Papilla preservation flap.
x
TABLE OF CONTENTS
1. INTRODUCTION 1
2. OBJECTIVES 4
3. REVIEW OF LITERATURE 5
4. METHODOLOGY 35
5. RESULTS 53
6. DISCUSSION 97
7. CONCLUSION 102
8. SUMMARY 103
9. BIBLIOGRAPHY 105
10. ANNEXURES 111
xi
LIST OF TABLES
SL.NO TABLES PAGE
1. Comparison of age in years between PPF and MWF 60
2. Comparison of gender between PPF and MWF 60
3. Comparison of plaque index between PPF and MWF 61
4 Comparison of gingival index between PPF and MWF 61
5 Comparison of papilla presence index between PPF and MWF
62
6 Comparison of recession between PPF and MWF 63
7 Comparison of mean probing pockets between PPF and MWF
64
8 Comparison of probing pocket depths of mild, moderate and severe between PPF and MWF
65
9 Comparison of mean CAL between PPF and MWF 66
10
Comparison of CAL of mild, moderate and severe between PPF and MWF
67
11 Radiographic measurements 68
12 Comparison of visual analog scale between PPF and MWF 69
13 Comprehensive chart – 1 papilla preservation
Gingival parameters and recession
89
14 Comprehensive chart – 2 papilla preservation
Periodontal parameters
90
15 Comprehensive chart – 3 MWF
Gingival parameters and recession
91
xii
16 Comprehensive chart – 4 MWF
Periodontal parameters
92
17 Comprehensive chart – 5
Visual analogue scale – MWF
93
18 Comprehensive chart – 6
Visual analogue scale – PPF
94
19 Comprehensive chart – 7
Radiographic measurements – PPF
95
20 Comprehensive chart – 8
Radiographic measurements – MWF
96
xiii
LIST OF GRAPHS
SL.NO GRAPHS Page
1. Comparison of age in years between PPF group and MWF group
71
2. Comparison of gender between PPF group and MWF group 71
3 Comparison of plaque index between PPF group and MWF group at baseline and 6 months.
72
4 Percentage change in plaque index between PPF group and MWF group
72
5 Comparison of gingival index between PPF group and MWF group at baseline and 6 months.
73
6 Percentage change in gingival index between PPF group and MWF group
73
7 Comparison of papilla presence index between PPF group and MWF group at baseline and 6 months.
74
8
Percentage change in papilla presence index between PPF group and MWF group
74
9
Comparison of recession between PPF group and MWF group at baseline and 6 months.
75
10 Percentage change in recession between PPF group and MWF group
75
11 Comparison of mean pocket depths between PPF group and MWF group at baseline and 6 months
76
12 Percentage change in mean probing pocket depths between PPF group and MWF group
76
13 Comparison of mild probing pocket depths between PPF group and MWF group at baseline and 6 months
77
xiv
14 Comparison of moderate probing pocket depths between PPFgroup and MWF group at baseline and 6 months
77
15 Comparison of severe probing pocket depths between PPF group and MWF group at baseline and 6 months
78
16 Comparison of percentage change in mild, moderate and severe probing pocket depths between PPF group and MWF group at baseline and 6 months
78
17 Comparison of mean CAL between PPF group and MWF group at baseline and 6 months
79
18 Percentage change in CAL between PPF group and MWF group
79
19 Comparison of mild CAL between PPF group and MWF group at baseline and 6 months
80
20 Comparison of moderate CAL between PPF group and MWF group at baseline and 6 months
80
21 Comparison of severe CAL between PPF group and MWF group at baseline and 6 months
81
22 Comparison of percentage change in mild, moderate and severe CAL between PPF group and MWF group at baseline and 6 months
81
23 Comparison of radiographic measurements in PPF group and MWF group at baseline and 6 months
82
24 Comparison of percentage change in radiographic measurements between PPF group and MWF group at baseline and 6 months
82
xv
LIST OF PHOTOGRAPHS
SL.NO Photographs Page
1. Armamentarium 45
2. Case – 1 Papilla preservation flap at baseline 46
3. Preoperative probing depth of 7mm irt mesial of 21 46
4 Crevicular incisions 46
5 Semilunar incisions 47
6 Flap reflected 47
7 Debridement done 47
8 Angular bony defect irt 21 48
9 Bone graft placed irt 21 48
10 Direct interrupted sutures given 48
11 Case – 1 Modified Widman flap - Preoperative probing depth of 7mm irt mesial of 12 at baseline
49
12 Preoperative probing depth of 7mm irt mesial of 21 at baseline
49
13 Internal bevel incisions 50
14 Flap reflected 50
15 Debridement done 50
16 Direct interrupted sutures given 51
17 Case-1 Papilla preservation flap- At base line 83
18 6 months post operative 83
xvi
SL.NO Photographs Page
19 Case -2 Papilla preservation flap- probing pocket depth of 6mm in relation to mesial of 11 at baseline
84
20 Probing pocket depth of 3mm in relation to mesial of 11 at 6 months post operative
84
21 Case-3 Papilla reservation flap- probing pocket depth of 7mm in relation to mesial of 21 at baseline
85
22 Probing pocket depth of 3mm in relation to mesial of 21 at 6 months
85
23 Case-1 Modified Widman flap- probing pocket depth of 7mm in relation to mesial of 12 at baseline
86
24 Probing pocket depth of 3mm in relation to mesial of 12 at 6 months
86
25 Case -2 Modified Widman flap- Preoperative probing pocket depth of 7mm in relation to distal of 11 at baseline
87
26 Postoperative probing pocket depth of 2mm in relation to distal of 11 at 6 months
87
27 Case 3 Modified Widman flap- Preoperative probing pocket depth of 5mm in relation to mesial of 21 at baseline
88
28 Postoperative probing pocket depth of 3mm in relation to mesial of 21 at 6 months
88
xvii
1
1.INTRODUCTION
Periodontitis can be defined as an inflammatory disease of the supporting tissues of
the teeth caused by specific microorganisms or a group of specific microorganisms
resulting in progressive destruction of the periodontal ligament and alveolar bone
with pocket formation, recession or both.1
The different avenues of periodontal therapy include non surgical procedures
such as meticulous plaque control, scaling and root planing, use of systemic anti
microbials, local drug delivery systems, host modulation therapy and an array of
surgical procedures including regenerative techniques.
While most of the patients with periodontitis can be effectively managed by
non surgical procedures, others require surgical techniques to restore their periodontal
health. One of the most common periodontal surgical techniques that is practised is
the periodontal flap and the modified Widman flap is a standard procedure among
various techniques in the repertoire of a periodontist.
The modified Widman flap as described by Ramfjord and Nissle2 uses an
internal bevel incision for reflection of mucoperiosteal flap in order to obtain access
to underlying tissues with minimal exposure of the bone and the flap is replaced in its
original position with adequate effort made to obtain optimal inter proximal coverage.
Notwithstanding the advantages of this procedure which includes reduction in
probing depth, gain in clinical attachment level and repair of osseous defects if done
along with osseous surgery, a certain amount of gingival recession and change in the
2
gingival contour and exposure of the interdental embrasures occurs with this
procedure.
The degree of gingival recession and the exposure of embrasures depends
upon the prevailing probing depth, osseous topography underneath, thickness of
gingiva, spacing between teeth and surgical procedure including the type of suturing.
Post surgical gingival recession besides causing dentinal hypersensitivity, root
caries, secondary pulpal hyperaemia may also lead to highly unesthetic appearance of
the gingiva particularly in the anterior region. Further, open interproximal embrasures
make plaque control more difficult for the patient, thereby affecting the post surgical
maintenance.
Therefore, many modifications of the conventional periodontal surgical
procedures particularly in the anterior region of the oral cavity have been proposed.
These include minimally invasive procedures, periodontal flap with retention of supra
crestal fibers, coronally advanced flap, papilla preservation flap, modified and
simplified papilla preservation flap.
Papilla preservation flap developed by Takei3and co workers was originally
developed in order to facilitate the success of bone grafts, wherein, optimal
interproximal coverage was enabled. Later, this procedure was also recommended for
preventing post operative recession and to ensure an optimal soft tissue contour,
thereby providing better esthetic result. Despite these stated advantages, there are
many disadvantages and limitations of this technique such as inability to remove
3
pocket epithelium as well as granulation tissue from the under surface of papilla
completely, possibility of creating a dead space leading to recurrence of pockets
besides being highly technique sensitive as well as time consuming. Further, this
procedure cannot be attempted if interdental space is too narrow and when there is
labio lingual discontinuity of interdental papilla or when the interproximal tissues are
very thin, making flap handling difficult.
Many clinicians are of the opinion that this procedure while preserving the
esthetics may not result in appreciable reduction in probing pocket depth. However,
no data is available in the literature wherein, this procedure has been compared to
other periodontal surgical procedures in a randomized clinical trial.
Hence, this study envisages to compare Papilla preservation flap with
modified Widman flap in the maxillary anterior region and evaluate the clinical
outcome using different parameters.
35
4. METHODOLOGY
Patient selection: Patients who visited the Department of Periodontics, The
Oxford Dental College and Hospital, Bangalore and who had moderate to severe
periodontitis with spacing in maxillary anterior teeth were included in the study.
20 patients were selected randomly and assigned to either of the two surgical
techniques (Papilla preservation and modified Widman flap). This was a
prospective comparative study and was carried out for a period of 1 year. The
study protocol was approved by the ethical committee of The Oxford Dental
College, Hospital and Research Centre, Bangalore. The subjects were selected for
the study based on the following inclusion and exclusion criteria.
Inclusion criteria:
1. Patients aged between 25 to 55 years.
2. Patients demonstrating acceptable oral hygiene prior to surgical
therapy.
3. Patients diagnosed with periodontitis and spacing between any two
upper anteriors, with at least one tooth having probable pocket depth
equal to or more than 5mm and clinical attachment loss equal to or
more than 4mm.
Exclusion criteria:
1. Patients with systemic diseases and conditions.
2. Smokers.
36
3. Pregnant women.
4. Teeth with grade III mobility.
5. Patients taking drugs known to interfere with wound healing.
6. Patients who have undergone periodontal therapy during the previous
6 months.
7. Labio lingual discontinuity of interdental papilla.
Study design:
A total of 20 patients fulfilling the above mentioned criteria, were selected for
the study. 10 patients were randomly assigned for the Papilla preservation flap
surgical technique and another 10 patients for the modified Widman flap surgical
technique. All the patients were informed about surgical procedure to be performed
and a written consent was obtained from them. A detailed case history was recorded
in the specially prepared proforma.
Initial therapy consisted of oral hygiene instructions and thorough full mouth
scaling followed by root planing, which was performed under local anesthesia. Four
weeks following phase 1 therapy, a periodontal evaluation was performed to confirm
the suitability of sites for periodontal surgery. Patients with probing pocket depths ≥
5mm were scheduled for periodontal flap surgery.
37
PRESURGICAL CLINICAL MEASUREMENTS
The following parameters were measured at base line (before surgery) and after 6
months following surgery and the same was subjected to statistical evaluation.
Plaque index (PI)45: Recordings for plaque were made for each tooth according to
the criteria for the PI (Silness and Loe 1964).
0- No plaque in the gingival area
1- A film of plaque adhering to free gingival margin and adjacent area
of the tooth. The plaque may be recognized only by running a
probe across the tooth surface or by using a disclosing agent
2- Moderate accumulations of soft deposits within the gingival pocket
and on the gingival margin and/or the adjacent tooth surface, that
can be seen by the naked eye.
3- Abundance of soft matter within the gingival pocket and/or on the
gingival margin and adjacent tooth surface.
The scores for the four areas of tooth were totalled and divided by 4 to obtain
a tooth score. These tooth scores were added and divided by the number of
teeth examined to obtain plaque index of a particular individual.
A Plaque index of 0.1-0.9 indicates good oral hygiene, 1.0-1.9 indicates fair
oral hygiene and 2.0-3.0 indicates poor oral hygiene.
38
Gingival index(GI)46 : Recordings for gingival status were made for each tooth
according to the criteria for the GI ( Loe and Silness 1963)
0- Normal gingiva.
1- Mild inflammation: Slight change in color and slight edema;
no bleeding on probing
2- Moderate inflammation: Redness, edema and glazing;
bleeding on probing
3- Severe inflammation: Marked redness and edema;
ulceration; tendency to spontaneous bleeding.
The scores for the four areas of tooth were totalled and divided by 4 to obtain
a tooth score. These tooth scores were added and divided by the number of
teeth examined to obtain gingival index of a particular individual.
A Gingival index score of 0.1-1.0 indicates mild inflammation, 1.1-2.0
indicates moderate inflammation and 2.1-3.0 indicates severe inflammation.
Papilla presence index:47 The classification system is based on the positional
relationship among the papillae, CEJ and adjacent papillae.
1. PPI score 1: When the papilla is completely present and is at the same level
as the adjacent papillae.
2. PPI score 2: Describes a papilla that is no longer completely present and the
papilla is not at the same level as the adjacent papilla but the interproximal
CEJ is still not visible.
39
3. PPI score 3: It refers to the situation in which the papilla is moved more
apical and the interproximal CEJ becomes visible.
4. PPI score 4: Describes when the papilla lies apical to both the interproximal
CEJ and buccal CEJ. Interproximal soft tissue recession is present together
with buccal gingival recession.
Scores were given according to the above mentioned criteria to the papilla of the
tooth, where diastema is present.
PPI -1 PPI -2
PPI-3 PPI-4
40
Probing pocket depths (PPD):
Probing pocket depths were measured from the crest of gingival margin to the
probable pocket depth at mesiobuccal, midbuccal, distobuccal, mesiolingual,
midlingual and distolingual surfaces of the site selected for surgery.
Clinical attachment loss (CAL):
CAL was measured from the cementoenamel junction, to the probable pocket depth
at the above mentioned surfaces of the site selected for surgery.
Gingival recession (GR): Recession was measured at the above mentioned surfaces
of the tooth with spacing.
Recordings for PPD, CAL, and GR were measured with a Williams probe
and recorded to the nearest millimeter.
These measurements were made one day before surgery and at 6 months following
the surgery. (Baseline and 6th month.)
41
RADIOGRAPHIC MEASUREMENTS48
After initial therapy, intraoral periapical radiographs were taken for both the
groups at baseline and 6 months following surgery. The following landmarks were
identified on the radiographs.
• Cemento enamel junction (CEJ).
• Bony defect (BD) was defined as the most coronal point where the periodontal
ligament space showed a continuous width.
• Alveolar crest (AC) was defined as the crossing of the silhouette of the
alveolar crest with the root surface.
The depth of the intrabony component of the defect was calculated as the
difference of the distances between the cemento enamel junction to the bony defect
and cemento enamel junction to the alveolar crest.
These radiographic measurements were made with the help of vernier
calipers.
Defect = [CEJ to BD] – [CEJ to AC]
42
Visual analogue scale:
A visual analog scale of a prepared questionnaire comprising of 4 questions with
scores ranging from 0-10 was made and the patients were asked to assess and give
scores before and after the surgery, where ‘0’ signifies minimum score and ‘10’
signifies maximum score.
Visual Analogue Scale:
1. Are you happy with the alignment and size of the gums of your upper front teeth ?
0 1 2 3 4 5 6 7 8 9 10
2. Are you happy with the shape of the gums of your front teeth ?
0 1 2 3 4 5 6 7 8 9 10
3. Are your teeth sensitive?
0 1 2 3 4 5 6 7 8 9 10
4. Does your tooth appear longer than adjacent teeth?
0 1 2 3 4 5 6 7 8 9 10
43
SURGICAL PROCEDURE:
The surgical procedure was performed under local anesthesia using 2%
lignocaine containing adrenaline at a concentration of 1: 2, 00,000.
For Papilla preservation flap, facial and palatal crevicular incisions were
given and a semilunar incision given on the palatal aspect of the involved teeth with
diastema. An Orbans interdental knife was used to carefully free the interdental
papilla from the underlying hard tissue. The detached interdental tissue was carefully
pushed through the embrasure with a blunt instrument so that the flap could be easily
reflected with the papilla intact. A full-thickness flap was reflected with a periosteal
elevator on both facial and palatal surfaces and thorough debridement of the
granulation tissue was done followed by scaling and root planing of the exposed root
surfaces. After debridement, bovine derived hydroxyapatite( Bio-ossTM ) bone graft
was placed in sites where angular bony defects were present. The flaps were
approximated and direct interrupted sutures were given using 3-0(MersilkTM) non
absorbable silk sutures. Periodontal dressing was placed over the operated area.
Antibiotics (Amoxicillin 500mg, thrice daily for 5days), analgesics (Ibuprofen
400mg+Paracetamol 325mg, thrice daily for 3 days) and 0.2% chlorhexidine
gluconate rinses (every 12 hours for 2 weeks) were prescribed.
For modified Widman flap, first an internal bevel incision was given 0.5-1mm
from the gingival margin to the crest of alveolar bone and a crevicular incision was
given. The incision was extended as far as possible in between the teeth, to include
44
maximum amounts of the interdental gingiva in the flap. Buccal and palatal full
thickness flaps were carefully elevated with a periosteal elevator following a third
incision which was made in a horizontal direction and in a position close to the
surface of the alveolar bone crest separating the soft tissue collar of the root surfaces
from the bone. The pocket epithelium and the granulation tissues were removed with
curettes. The exposed roots were carefully scaled and planed. The flaps were
approximated and direct interrupted sutures were given using 3-0(MersilkTM) non
absorbable silk sutures. Periodontal dressing was placed over the operated area.
Antibiotics (Amoxicillin 500mg, thrice daily for 5days), analgesics (Ibuprofen
400mg+Paracetamol 325mg, thrice daily for 3 days) and 0.2% chlorhexidine
gluconate rinses (every 12 hours for 2 weeks) were prescribed.
POST OPERATIVE CARE:
Patients were instructed to rinse with 0.2% chlorhexidine gluconate
immediately one day after the surgery upto 2 weeks. Periodontal dressing and sutures
were removed one-week postoperatively. Patients were advised to initiate
mechanical oral hygiene consisting of brushing and flossing or interproximal
brushing from the second postoperative week.
Supportive periodontal therapy was provided at every month and patients
were emphasized to maintain good oral hygiene. Patients were examined again at the
end of 6 months and all the presurgical measurements were repeated.
4
2. OBJECTIVES OF THE STUDY
1. To evaluate and compare the healing response following modified Widman
flap and Papilla preservation flap techniques, using standard periodontal
parameters.
2. To assess and compare the esthetic outcome of these two procedures.
5
3. REVIEW OF LITERATURE
A myraid of periodontal procedures have been used throughout the years in an
attempt to reestablish attachment of periodontal tissues to root surfaces in regions
affected by periodontitis4. The treatment of the various types of periodontal diseases
associated with attachment loss has involved numerous surgical and non-surgical
approaches over the years. Regardless of the therapy selected, methods of dealing
with the periodontal pocket have always been a subject of discussion and controversy.
Several surgical procedures have been proposed to treat the soft tissue lesion of
periodontitis as well as to gain access to the tooth root and supporting bone. The most
often utilized surgical procedures have included the gingivectomy, the apically
positioned flap with or without osseous resection, and several repositioned flap
procedures for gaining access to the tooth root and underlying bone. 5
The ultimate goal of periodontal therapy is to maintain the teeth in relative
health, function, and comfort while, at the same time, maintaining the esthetic
expectations of the patient. The means towards which these ends may be achieved
varies considerably among therapists, depending on their educational background and
their clinical experiences. The periodontal pocket is but one of several sequela of the
periodontal disease process and is presently defined in the Glossary of Periodontal
Terms as “A pathologic fissure between the tooth and the crevicular epithelium
limited at its apex by the junctional epithelium. It is an abnormal apical extension of
the gingival crevice caused by migration of the junctional epithelium along the root as
the periodontal ligament is detached by a disease process6. There are several
objectives for surgical pocket therapy, the first is to eliminate the pocket. Surgical
6
elimination of the pocket with resultant minimal probing depths allows the patient to
have a better access for plaque control and facilitates maintenance by the therapist7.
The procedures which have been utilized to the greatest extent over the years have
been the gingivectomy as described by Stern et al8 and the apically positioned flap as
described by Nabers9. Schluger10 published a description and rationale for using the
ostectomy procedure to achieve and maintain minimal pocket depth in conjunction
with the apically positioned flap.
Another surgical approach directed at treating the periodontal pocket can be
termed “pocket reduction” surgery where the major objective was not to eliminate the
pocket but to gain access to the tooth root and underlying bone for root planing and
soft tissue debridement with the objective of maintaining periodontal attachment
levels and perhaps obtaining “New attachment.” As defined in the Glossary of
Periodontal Terms, New attachment is the union of connective tissue with a root
surface that has been deprived of its original attachment apparatus. This union may
include a connective tissue attachment but may also be via an epithelial attachment.
The following pocket reduction procedures have been proposed to gain access to
underlying bone i.e, Open flap curettage, Widman, modified Widman flaps, and
modified Kirkland procedure. In contrast to the gingivectomy and the apically
positioned flap with or without osseous resection, these procedures postulate that it is
not necessary to eliminate the periodontal pocket to acheive the ultimate goal of
maintaining the presence of periodontally involved teeth in the patient's oral cavity.
7
Most of the progress in periodontal surgery was associated with Robert
Neumann, Leonard Widman and A. Cieszinski11.
Neumann published several papers on various surgical subjects but early in
his career became interested in periodontal disease and proposed a surgical technique
in 191212 which consisted of vertical incisions not bisecting the interdental papilla-
followed by crevicular incisions to the bone margin to separate a flap that was then
elevated to gain clear view of the entire field of operation and the area was
thoroughly debrided. The margin of the flap was then trimmed and scalloped with
scissors to reach exactly the bone margin and sutured.
Leonard Widman13 was a Swedish dentist who published two papers on the
surgical treatment of periodontal disease, one in 1917 and other in 1923. Widmans
technique was similar to Neumann’s. Widman recommended surgery to obtain access
for complete elimination of granulation tissue. Widman’s surgical technique consisted
of oblique vertical incisions outlining an area of about 3 to 4 teeth, followed by a
festooned incision about 1 mm from the gingival margin. This makes him the first to
advocate internal bevel incision currently used. Widman then elevated the flap by
sharp dissection, thinning the flap to separate it from the granulation tissue, but not
too much to avoid flap necrosis, as far as the edge of sound bone. After the flap was
retracted, all granulation tissue and calculus were removed, and rough bone
projections were rounded off with burs to obtain a normal anatomical topography, the
flap was then returned to its place and sutured with interdental silk sutures.
8
In 1918, Arthur Zentler, a Newyork dentist described a technique similar to
Neumann’s. The procedure consisted of two parallel vertical incisions and crevicular
incisions along the contour of gingiva, and the access to the underlying bone was
obtained by reflecting a muco periosteal flap. The area was debrided to remove all
granulation tissue from the pocket and the infected bone was smoothened using chisel
and mallet.14. Then margins of the flap were trimmed and sutured. Zentler claimed
his treatment produced a successful and permanent cure in a short number of visits
and was not painful15.
In 1926, James.L.Zensky, of Newyork city presented a technique that he
called open view operation, which was a flap technique with removal of infected and
sharp edges of bone.
Olin Kirkland, a prominent dentist in Alabama presented in 1932, a technique
that he called a modified flap operation16. It was used for isolated deep periodontal
lesions.The procedure consisted of splitting mesiodistally the papilla of the involved
space and retracting the gingiva using separators to keep the area open, followed by
scaling and removal of granulation tissue on the soft tissue flap and closure of the
wound with suture.
Ramfjord and Nissle 2, modified the technique initially described by Widman,
in 1916, turning it into a conservative procedure. The changes were: Primary incision
which was an inverse beveled, partial-thickness, thinning incision held parallel to the
long axis of the tooth and directed toward the crest of alveolar bone, and intra-
sulcular (secondary) incision was performed. After raising the flaps, the loosened
9
collar of tissue was removed at the alveolar crest. These modifications maintain the
height of the gum, preserve the aesthetics, guarantee the repairing through long
junctional epithelium, besides facilitating plaque control by the patient.
According to Takei et al.,3 the most common postoperative problem
associated with grafting procedures is the immediate, partial or complete exfoliation
of the implant materials. This is most often due to a surgical technique that results in
incomplete tissue coverage of the graft material in the interproximal areas. Even if
there is an apparent tissue approximation at the time of surgical closure, the tissue
shrinkage associated with wound healing will often expose the graft material during
the postoperative period. Because of the observed difficulties, they developed the
Papilla preservation technique for use in conjunction with bone grafts and synthetic
materials in periodontal osseous defects.
Periodontal flap:
Periodontal flap is a section of gingiva and or mucosa surgically separated
from the underlying tissues to provide visibility of and access to the bone and root
surface.
Classification of flaps : 17
Periodontal flaps can be classified based on the following:
1. Bone exposure after flap reflection
2. Placement of the flap after surgery
3. Management of the papilla.
10
Based on bone exposure after reflection: The flaps are classified as either full
thickness ( mucoperiosteal) or partial thickness (mucosal ) flaps.
In full thickness flaps, all the soft tissue, including the periosteum, is reflected to
expose the underlying bone.
The partial thickness flap includes only the epithelium and a layer of the underlying
connective tissue. The bone remains covered by a layer of connective tissue,
including the periosteum. It is also called the split thickness flap.
Based on flap placement after surgery: Flaps are classified as
1. Non displaced flaps: The flap is returned and sutured in its original position.
2. Displaced flaps which are placed apically, coronally or laterally.
Based on the management of papilla: Flaps can be
1. Conventional .
2. Papilla preservation flaps.
In the conventional flap the interdental papilla is split beneath the contact
point of the two approximating teeth to allow reflection of buccal and lingual flaps. It
incudes the modified Widman flap, the undisplaced flap, the apically displaced flap
and the flap for reconstructive procedures.
The papilla preservation flap incorporates the entire papilla in one of the flaps.
11
Incisions : Periodontal flaps use horizontal and vertical incisions.
Horizontal incisions: These are directed along the margin of the gingiva in a mesial or
a distal direction. Two types have been recommended.
1. The internal bevel incision, which starts at a distance from the gingival margin
and is aimed at the alveolar bone crest.
2. Crevicular incision, which starts at the bottom of the pocket and is directed to
the crest of alveolar bone.
The internal bevel incision was the basis to most periodontal flap procedures. It is
the incision from which the flap is reflected to expose the underlying bone and root.
This incision accomplishes three important objectives.
1. It removes the pocket lining.
2. It conserves the relatively uninvolved outer surface of the gingiva, which, if
apically positioned, becomes attached gingiva.
3. It produces a sharp thin flap margin for adaptation to the bone-tooth junction.
This incision has also been termed the first incision because it is the initial incision in
the reflection of a periodontal flap and the reverse bevel incision because its bevel is
in reverse direction from that of the gingivectomy incision.
The crevicular incision, also termed as second incision, is made from the base of the
pocket to the crest of the bone.
12
Vertical incisions: Vertical or oblique releasing incisions can be used on one or both
ends of the horizontal incision, depending on the design and purpose of the flap. In
general, vertical incisions in the lingual and palatal areas are avoided.
Objectives of periodontal surgery:18
1. Accessibility of instruments to root surface.
2. Elimination of inflammation.
3. Creation of oral environment conducive to plaque control.
4. Regenerative periodontal procedures.
5. Preparation of periodontal environment suitable to restorative and
prosthodontic treatment.
6. Esthetic improvement.
Indications of periodontal surgery 19:
1. Presence of persistent inflammation after phase I therapy.
2. Bleeding still present when the base of the pocket is probed after phase I
therapy.
3. Presence of persistent pocket depths ≥ 5mm after phase I therapy.
4. Presence of osseous defects.
5. Grade II and Grade III furcations.
6. To contour the gingiva.
7. Attachment loss following phase I therapy.
13
Contraindications of periodontal surgery :
1. Un cooperative patient.
2. Inadequate plaque control.
3. Poor condition of the tissues.
4. Uncontrolled systemic conditions.
5. Active disease site.
6. Teeth with hopeless prognosis.
7. Borderline cases wherein non surgical therapy may enhance further
periodontal recovery.
8. Questionable endodontic and restorative procedures.
9. Very high esthetic concerns of the patient.
Flap procedures
The original Widman flap 13
One of the first detailed descriptions of the use of a flap procedure for pocket
elimination was published in 1918 by Leonard Widman . In his article “The operative
treatment of pyorrhea alveolaris” Widman described a mucoperiosteal flap design
aimed at removing the pocket epithelium and the inflamed connective tissue, thereby
facilitating optimal cleaning of the root surfaces.
Technique :
1. Sectional releasing incisions were first made to demarcate the area scheduled
for surgery. These incisions were made from the mid-buccal gingival margins
14
of the two peripheral teeth of the treatment area and were continued several
millimeters out into the alveolar mucosa. The two releasing incisions were
connected by a gingival incision which followed the outline of the gingival
margin and separated the pocket epithelium and the inflamed connective
tissue from the non-inflamed gingiva. Similar releasing and gingival incisions
were, if needed, made on the lingual aspect of the teeth.
2. A mucoperiosteal flap was elevated to expose at least 2-3 mm of the marginal
alveolar bone. The collar of inflamed tissue around the neck of the teeth was
removed with curettes and the exposed root surfaces were carefully scaled.
Bone recontouring was recommended in order to achieve an ideal anatomic
form of the underlying alveolar bone .
3. Following careful debridement of the teeth in the surgical area, the buccal and
lingual flaps were laid back over the alveolar bone and secured in this position
with interproximal suture. Widman pointed out the importance of placing the
soft tissue margin at the level of the alveolar bone crest, so that no pockets
would remain. The surgical procedure resulted in the exposure of root
surfaces. Often the interproximal areas were left without soft tissue coverage
of the alveolar bone.
The main advantages of the “Original Widman flap” procedure in comparison
to the gingivectomy procedure included:
A. Less discomfort for the patient, since healing occurred by primary intention
and
15
B. That it was possible to reestablish a proper contour of the alveolar bone in
sites with angular bony defects.
The Neumann flap:
Only a few years later, Neumann suggested the use of a flap procedure which in
some respects was different from that originally described by Widman.
Technique:
1. According to the technique suggested by Neumann, an intracrevicular
incision was made through the base of the gingival pockets, and the entire
gingiva (and part of the alveolar mucosa) was elevated in a mucoperiosteal
flap. Sectional releasing incisions were made to demarcate the area of
surgery.
2. Following flap elevation, the inside of the flap was curetted to remove the
pocket epithelium and the granulation tissue. The root surfaces were
subsequently carefully “cleaned”. Any irregularities of the alveolar bone
were corrected to give the bone crest a horizontal outline.
3. The flaps were then trimmed to allow both an optimal adaptation to the
teeth and a proper coverage of the alveolar bone on both the buccal/lingual
(palatal) and the interproximal sites. With regard to pocket elimination,
Neumann pointed out the importance of removing the soft tissue pockets,
i.e. replacing the flap at the crest of the alveolar
bone.
16
The Modified flap operation :
In 1931 Kirkland16 described a surgical procedure to be used in the treatment of
“periodontal pus pockets”. The procedure was called the modified flap operation, and
is basically an access flap for proper root debridement.
Technique:
1. In this procedure incisions were made intra crevicularly through the bottom of
the pocket on both the labial and the lingual aspects of the interdental area.
The incisions were extended in a mesial and distal direction.
2. The gingiva was retracted labially and lingually to expose the diseased root
surfaces, which were carefully debrided. Angular bony defects were curetted.
3. Following the elimination of the pocket epithelium and granulation tissue
from the inner surface of the flaps, these were replaced to their original
position and secured with interproximal sutures. Thus, no attempt was made
to reduce the preoperative depth of the pockets.
In contrast to the original Widman flap as well as the Neumann flap, the modified
flap operation did not include A) Extensive sacrifice of non inflamed tissues and
B) Apical displacement of the gingival margin. Since the root surfaces were not
markedly exposed, this method could be used in anterior regions for esthetics.
Another advantage was the potential for bone regeneration in intrabony defects.
17
The apically repositioned flap:
In the 1950s and 1960s new surgical techniques for the removal of soft and, when
indicated, hard tissue were described in the literature. Then the importance of
maintaining an adequate zone of attached gingiva after surgery was emphasized. One
of the first authors to describe a technique for the preservation of the gingiva
following surgery was Nabers. The surgical technique developed by Nabers9 was
originally denoted “Repositioning of attached gingiva” and was later modified by
Ariaudo & Tyrrell. In 1962 Friedman20 proposed the term apically repositioned flap
to more appropriately describe the surgical technique introduced by Nabers. Friedman
emphasized the fact that, at the end of the surgical procedure, the entire complex of
the soft tissues (gingiva and alveolar mucosa) rather than the gingiva alone was
displaced in an apical direction. Thus, rather than excising the amount of gingiva
which would be in excess after osseous surgery (if performed), the whole
mucogingival complex was maintained and apically repositioned. This surgical
technique was used on buccal surfaces in both maxilla and mandible and on lingual
surfaces in the mandible, while an excisional technique had to be used on the palatal
aspect of maxillary teeth.
Technique:
According to Friedman the technique should be performed in the following way:
1. A reverse bevel incision is made using a scalpel with a Bard-Parker blade
(No. 12B or No. 15). How far from the buccal/lingual gingival margin the
incision should be made is dependent on the pocket depth as well as the
18
thickness and the width of the gingiva. If the gingiva preoperatively is thin
and only a narrow zone of keratinized tissue is present, the incision should be
made close to the tooth. The beveling incision should be given a scalloped
outline to ensure maximal interproximal coverage of the alveolar bone, when
the flap subsequently is repositioned. Vertical releasing incisions extending
out into the alveolar mucosa (i.e. past the mucogingival junction) are made at
each of the end points of the reverse incision, thereby making possible the
apical repositioning of the flap.
2. A full thickness mucoperiosteal flap including buccal/lingual gingiva and
alveolar mucosa is raised by means of a mucoperiosteal elevator. The flap has
to be elevated beyond the mucogingival line in order to able to reposition the
soft tissue apically. The marginal collar of tissue, including pocket epithelium
and granulation tissue, is removed with curettes, and the exposed root surfaces
are carefully scaled and planed.
3. The alveolar bone crest is recontoured with the objective of recapturing the
normal form of the alveolar process but at a more apical level. The osseous
surgery is performed using burs and/or bone chisels.
4. Following careful adjustment, the buccal/lingual flap is repositioned to the
level of the newly recontoured alveolar bone crest and secured in this position.
It is not always possible to obtain proper soft tissue coverage of the denuded
interproximal alveolar bone with this technique. A periodontal dressing should
therefore be applied to protect the exposed bone and to retain the soft tissue at
19
the level of the bone crest. After healing, an “adequate” zone of gingiva is
preserved and no residual pockets should remain.
To manage periodontal pockets on the palatal aspect of the teeth, Friedman described
a modification of the “Apically repositioned flap”, which he termed the beveled flap.
Since there is no alveolar mucosa present on the palatal aspect of the teeth, it is not
possible to reposition the flap in an apical direction.
1. In order to prepare the tissue at the gingival margin to properly follow the
outline of the alveolar bone crest, a conventional mucoperiosteal flap was
reflected
2. The tooth surfaces are debrided and osseous recontouring is performed.
3. The palatal flap is subsequently replaced and the gingival margin is prepared
and adjusted to the alveolar bone crest by a secondary scalloped and beveled
incision. The flap is secured in this position with interproximal sutures.
The modified Widman flap :
Ramfjord & Nissle2 described the modified Widman flap technique, which is
also recognized as the “Open flap curettage technique”. It should be noted that, while
the original Widman flap technique included both apical displacement of the flaps
and osseous recontouring (elimination of bony defects) to obtain proper pocket
elimination, the modified Widman flap technique is not intended to meet these
objectives.
20
According to Ramfjord & Nissle the main advantages of the modfied Widman flap
technique in comparison with other procedures previously described are:
1. The possibility of obtaining a close adaptation of the soft tissues to the root
surfaces.
2. The minimum of trauma to which the alveolar bone and the soft connective tissues
are exposed.
3. Less exposure of the root surfaces which from an esthetic point of view is an
advantage in the treatment of anterior segments of the dentition.
Technique :
1. According to the description by Ramfjord & Nissle, the initial incision which
may be performed with a Bard-Parker knife (No1I), should be parallel to the
long axis of the tooth and placed approximately lmm from the buccal gingival
margin in order to properly separate the pocket epithelium from the flap. If the
pockets on the buccal aspects of the teeth are less than 2 mm deep or if
esthetic considerations are important, an intracrevicular incision may be made.
Furthermore, the scalloped incision should be extended as far as possible in
between the teeth, to allow maximum amounts of the interdental gingiva to be
included in the flap. A similar incision technique is used on the palatal aspect.
Often, however the scalloped outline of the initial incision may be accentuated
by placing the knife at a distance of 1-2 mm from the midpalatal surface of the
teeth. By extending the incision as far as possible in between the teeth
sufficient amounts of tissue can be included in the palatal flap to allow for
21
proper coverage of the interproximal bone when the flap is sutured. Vertical
releasing incisions are not usually required.
2. Buccal and palatal full thickness flaps are carefully elevated with a
mucoperiosteal elevator. The flap elevation should be limited and allow only a
few millimeters of the alveolar bone crest to become exposed. To facilitate the
gentle separation of the collar of pocket epithelium and granulation tissue
from the root surfaces, an intracrevicular incision is made around the teeth
(second incision) to the alveolar crest.
3. A third incision made in a horizontal direction and in a position close to the
surface of the alveolar bone crest separates the soft tissue collar of the root
surfaces from the bone.
4. The pocket epithelium and the granulation tissues are removed by means of
curettes. The exposed roots are carefully scaled and planed, except for a
narrow area close to the alveolar bone crest in which remnants of attachment
fibers may be preserved. Angular bony defects are carefully curetted.
5. Following the curettage, the flaps are trimmed and adjusted to the alveolar
bone to obtain complete coverage of the interproximal bone . If this adaptation
cannot be achieved by soft tissue recontouring, some bone may be removed
from the outer aspects of the alveolar process in order to facilitate the flap
adaptation. The flaps are sutured together with individual inter- proximal
sutures. Surgical dressing may be placed over the area to ensure close
22
adaptation of the flaps to the alveolar bone and root surfaces. The dressing as
well as the sutures are removed after 1 week.
Many studies were conducted to evaluate the outcome of modified Widman flap
procedure. Treatment of moderate to advanced periodontal disease has traditionally
consisted of both non surgical and surgical therapy. Over the years there have been
several longitudinal studies that compared the effectiveness of various procedures in
arresting the progression of periodontitis.21,22 Similarly, there have been several
retrospective studies that have documented the effectiveness of periodontal therapy.23
Studies that have been reported compared osseous surgery with various surgical and
non surgical procedures.24 A longitudinal study conducted by Becker and Becker,25
compared the effectiveness of scaling and root planing, osseous surgery and modified
Widman flap procedure. When the results were compared after 1 year, plaque and
gingival index were significantly reduced by the three procedures. Osseous surgery
and modified Widman flap had greater pocket reduction when compared with scaling.
It was concluded that, for shallow pockets of 1- 3 mm there was significant gingival
recession. At one year there was significant recession for 4-6 mm pockets for the
three treatment modalities of therapy. Furthermore, osseous surgery and the modified
Widman had greater recession than scaling alone. There was slight soft tissue
rebound at six months, followed by slight recession at one year in modified Widman
flap procedure.
Many clinicians avoid performing modified Widman surgical procedures because soft
tissue craters occur after surgery. This study25 documented the difficulty in achieving
23
primary flap closure after modified Widman flap surgery. Complete closure was
achieved in 15 out of 56 interproximal sites, while complete closure of osseous
surgery sites was not achieved. Craters were measured over 6 weeks. There was a
tendency for sites that received the modified Widman therapy to have a higher
percentage of craters during healing. However, at 6 weeks, there were no meaningful
differences between the two surgical procedures.
Keyes etal19 reported a method of periodontal therapy employing oral
hygiene, scaling and root planing with the adjunctive application of thick paste
containing sodium bicarbonate, salt, hydrogen peroxide and water, and the use of
pulsating water irrigation device. This approach to therapy was accompanied by
microbiological monitoring, retreatment and the occasional use of antibiotics. The
approach of Keyes etal to the mechanical procedures of therapy does not appear to
have been tested as an alternative to surgery in a split mouth trial design. Keyes
method of non surgical therapy was compared with modified Widman flap surgery in
9 patients with symmetrical periodontal disease26. This study has demonstrated a
strong similarity between the results of root planing with Keyes adjunctive techniques
and those of modified Widman flap surgery. Probing depth in deep sites was reduced
slightly more with surgery and there were no differences in bleeding on probing. Both
techniques gave marked improvements in health. It is clear that Keyes technique do
not provide a more advantageous result.
In the evaluation of different treatment modalities for chronic, inflammatory
periodontal disease, by far the most important criteria of success are elimination of
24
the disease and preservation of the teeth. Short term pocket reduction may be
achieved by a wide variety of treatment modalities including sub gingival curettage,
gingivectomy, interdental resection, reverse bevel flap procedure with lingual
gingivectomy and reverse bevel flap procedure with or without osseous contouring.
When procedures have been compared, interdental resection following subgingival
curettage resulted in more pocket reduction than subgingival curettage alone27.
Reverse bevel flap procedures reduced pocket depth similarly with or without osseous
surgery28.
Ramfjord, Nissle and Shick etal29 examined the short term results of 3
modalities of periodontal treatment such as subgingival curettage, pocket elimination
surgery and modified Widman flap surgery. They concluded that in about 4-6 weeks
after the procedures, all three surgical procedures reduced pocket depths. Pocket
elimination surgery reduces pockets more than sub gingival curettage on the buccal,
lingual and proximal and more than the modified Widman flap on the lingual. The
modified Widman flap procedure reduces pockets more interproximally than
subgingival curettage. Subgingival curettage results in a gain of attachment
interproximally and on the lingual side. while the modified widman flap resulted in a
gain of attachment interproximally only. Pocket elimination surgery resulted in a loss
of attachment buccally. Subgingival curettage resulted in a more favourable post
operative attachment level on all surfaces than did pocket elimination surgery.
Some treatment methods such as subgingival curettage and widman flap
surgery are more specifically aimed at reattachment than pocket elimination surgery
25
which basically is aimed at stopping the progress of destructive periodontal disease
through surgical elimination of periodontal disease coronally to the most apical extent
of the pockets and to restore surgically a physiologic gingival contour at that level.
A 5 year follow up study conducted by Ramfjord, Nissle, Shick, Knowles,
Burgett30 compared the results following two methods aimed at combined
reattachment and surgical pocket reduction (sub gingival curettage and modified
Widman flap surgery) with results following attempted complete surgical pocket
elimination and restoration of gingival contour. In this study curettage resulted in the
most favourable response with statistically significant gain of interproximal
attachment upto 3 years following initial treatment. However, there was no significant
difference between the results of these procedures. Significant pocket reduction was
maintained for all methods of treatment. Surgical elimination of bony craters does not
seem to be justified for maintenance of interproximal attachment levels and does not
offer any greater long term reduction in pocket depth than subgingival curettage or
modified Widman flap surgery. Subgingival curettage gave the most favorable result
regarding attachment levels and was least effective in pocket reduction. Although
pocket elimination surgery reduced pocket depth most effectively, it was least
effective in maintenance of attachment levels. The results from the modified Widman
flap procedure assumed a position between these two extremes. Most of these
differences were not statistically significant and from a clinical stand point the
differences do not seem to favor clearly one procedure over the other.
26
In 1968, the first report from the first longitudinal study came from the
university of Michigan.31 Michigan longitudinal study began in 1961 where they
divided the patients in to two groups, one to be treated with subgingival curettage and
the other with pocket elimination surgery.32 After, two years the study switched to a
split mouth design to minimize patients variability. The modified Widman flap was
introduced into the Michigan study in 1966. This study gave results after 8 years of
evaluation of 78 patients33 in which they categorized the initial probing depth into
incipient, moderate, and advanced where they stated that subgingival curettage was
less effective in reducing pocket depth. The greatest gain in attachment was obtained
with the modified Widman flap followed by subgingival curettage and then pocket
elimination surgery. When moderate and severe pockets were considered, all surgical
techniques employed expressed reduced pocket depth. The deeper the pocket, the
greater the reduction obtained.
Regeneration of the periodontal tissues has long been an endeavour in the
treatment of periodontal diseases. A variety of therapeutic procedures such as root
planing and curettage, gingivectomy- curettage, flap- curettage and flap procedures
including transplantation of various materials into periodontal defects have been used
to obtain regeneration of the periodontium34. Most studies on regenerative procedures
described a possibility of achieving denovo formation of the supporting tissues,
particularly within infrabony pockets and present varying degrees of successive
treatment. Methods utilized for assessing regeneration of the periodontal tissues have
been discussed in recent years. Thus, criticism has been directed toward results
presented from trials in humans, because clinical assessments do not provide proof of
27
new attachment35. In order to overcome the limitations of clinical registrations as
evidence of new attachment various animal models have been developed. The
histometric evaluation was performed in Rhesus monkey to determine the effect of
the modified Widman flap procedures on the level of connective tissue attachment
and supporting alveolar bone36. Two adult male rhesus monkeys were used, eighteen
contralateral pairs of periodontal pockets were produced in a standardized manner.
Surgical treatment of the pockets was performed around experimented teeth and the
contralateral teeth were used as the unoperated controls. 12 months following
treatment the animals were sacrificed and histologic sections obtained. Using the
cementoenamel junction as a fixed reference point, linear measurements along the
root surface were made to the most apical cells of the junctional epithelium, to the
crest of the interproximal alveolar bone and to the apical extent of angular bony
defects. These measurements from operated and unoperated pockets were then
compared. The data revealed that treatment of periodontal pockets using the modified
Widman flap procedure produced no gain in connective tissue attachment and no
increase in crestal bone height.
Papilla preservation flap:
A considerable attention has been given to the use of bone grafts in order to improve
the amount of new connective tissue attachment and bone regeneration in vertical
bony defects. Various types of autografts, allografts and xenografts37,38 have been
used over the years with mixed results. Excluding minor individual variations, all
grafting techniques follow a similar management sequence which has been well
28
documented in the literature. Various authors mention the use of an internal bevel full
thickness mucoperiosteal flap or the modified Widman flap39 to preserve a maximum
amount of tissue for graft coverage. The most common postoperative problem
associated with grafting procedures is the immediate, partial or complete exfoliation
of the implant materials.40 This is most often due to a surgical technique that results in
incomplete tissue coverage of the graft material in the interproximal areas. Even if
there is an apparent tissue approximation at the time of surgical closure, the tissue
contraction associated with wound healing will often result in exposure of the graft
material during the postoperative period.
If primary flap closure is not accomplished, the graft survives only if a blood
clot over the graft is organized by connective tissue ingrowth and subsequent epithe
lialization of the wound. During this process, the importance of excellent plaque
control becomes crucial. However, the regular internal bevel flap design or modified
Widman flap design often heals with interdental soft tissue craters. This creates
difficulty for therapist and patients in the performance of plaque control procedures.
In these situations, plaque retention, persistent soft tissue inflammation and/or
delayed sequestration of implant materials are often observed postoperatively. It is
apparent that proper flap design, atraumatic management of tissue and appropriate
suturing techniques are essential if osseous defects are to be successfully treated with
grafting procedures.
Based on these observations, the Papilla preservation technique was developed by
Takei .H.H3 for use in conjunction with implants in periodontal osseous defects.
29
Technique: The gingiva, especially the interdental papilla, must be relatively free of
inflammation and firm. Effective oral hygiene procedures and particularly interdental
cleaning must be carefully taught by the clinician and scrupulously followed by the
patient. After anaesthetizing the area, the extent of the bone defect is determined by
probing. The extension of the osseous defèct to the palatal or lingual aspect of the
interdental papilla will determine the position of the semilunar incision. This incision
must be at least 3 mm apical to the margin of the interproximal bony defect. This will
ensure that the flap margin is well away from the area to be grafted and that the graft
material will be completely covered by intact papillary tissue at the time of suturing.
In situations where the osseous defect has a large extension onto the palatal or lingual
surface the papillary preservation procedure is modified so that the semilunar incision
is on the facial aspect. The incisions should extend to the alveolar crest. When
making the incisions in the interdental areas, the tip of the scalpel blade
remains in contact with the root surface. This avoids compromising the blood supply
to the interdental papillae and ensures a maximum amount of tissue interdentally. In
posterior areas with a narrow interdental space, it may be necessary to trim off the tip
of the papilla in order to effect the intact papilla through the space. The semilunar
incision is made with the scalpel perpendicular to the outer surface of the gingiva and
extends through the periosteum to the alveolar process.
After completing the incisions the flaps are reflected. A curette and/or interproximal
knife is used to carefully free the interdental papilla from the underlying hard tissue.
It is important that the interdental tissue, which is a part of the facial or lingual flap, is
completely free and mobile before proceeding to the reflection of the papilla. The
30
detached interdental tissue is carefully pushed through the embrasure with a blunt
instrument so that the flap can be easily reflected with the papilla intact. A full-
thickness flap is reflected with a periosteal elevator on both facial and lingual (or
palatal) surfaces. Once both flaps are reflected, access to the interdental bony defect
will be obtained. While holding the reflected flap, small back-action chisels are used
to scrape the margins of the flap, including the interdental tissue until firm connective
tissue is reached. This will remove all of the pocket epithelium and excessive
granulation tissue. Any remaining excess granulation tissue is trimmed from the
underside of the interdental tissue using fine tissue scissors. However, the remaining
thickness of the interdental tissue must be at least 2 mm to ensure an adequate blood
supply and to provide the graft materials with an adequate thickness of tissue over
their coronal surface. In anterior areas where there is horizontal bone loss, the
trimming of granulation tissue is minimal in order to maintain the maximum
thickness of tissue so that postoperative gingival recession is minimized. The bony
defect is cleaned out using curettes, and the roots are thoroughly scaled and root-
planed.
Implant materials may be used in granular or solid forms. In both cases retention of
the material in the defect while the suture is being placed may present some
difficulties. In these cases a cross mattress suture is placed prior to the insertion of the
implant. This suture is kept very loose prior to the placement of graft material into the
defect. This suturing prior to graft placement prevents dislodgement of the graft
during the suturing procedure. The cross mattress sutures result in optimal flap
closure without having suture material in direct contact with the graft material. This
31
reduces the risk of graft reflection with subsequent exfoliation. The defect is filled
with the graft material and the flaps are replaced over the graft. The sutures are now
tightened to bring the two flaps in intimate contact along the incision lines. A soft,
surgical dressing, is placed over the surgically treated area. A surgical dressing is
necessary in all graft surgeries as it reduce the likelihood of postoperative flap
displacement by mastication, tongue action or accidental tooth brushing. Sometimes
the outlined loose mattress suturing of the flap may not be needed. A direct suture of
the semilunar incisions can be done in these cases as the only means of flap closure.
The dressing is replaced at 7 days postsurgery at which time the sutures are removed.
The surgical area is gently cleansed with saline and the new dressing is left in place
for another week. Two weeks after surgery the dressing is removed. Oral hygiene
instructions are reinforced at this time.
This surgical approach has been used in 25 cases. In most instances it has been used
in connection with a solid implant but it can also be used with granular type materials
or without implants. The patients have been followed up postoperatively for 6 months
or more. All wounds healed by primary intention and there was no evidence of graft
exfoliation.
A key goal in periodontal regenerative procedures is to obtain primary
closure over the treated area and thus ensure adequate protection for the healing
events. Satisfactory approaches are available when the surgical area is located on
the buccal aspect, as in recessions. Conversely, primary closure of the interdental area
is technically more demanding. Improved closure of the interdental area has been
32
attempted by 1) Careful preservation of the interdental tissue during the initial
incision 2) Coronal positioning of the buccal flap or 3) Using free gingival grafts over
implanted materials.41 Takei et al. proposed a Papilla preservation technique to
achieve primary closure of interproximal space over periodontal bone implants.
Achieving primary closure in the interdental space and maintaining over time
however, is more elusive in most situations when a barrier membrane is used.42
Furthermore, whenever regeneration of the suprabony component is attempted by
overfilling the intrabony defect or by placing a barrier membrane coronal to the
interproximal alveolar bone crest, a substantial coronal positioning
of the flaps is required to obtain primary closure of the interproximal area. This
objective can hardly be achieved with current surgical techniques. Therefore it is
necessary to identify an efficacious and reproducible method to obtain both coronal
positioning of the flap and primary closure of the interdental space prior to attempting
regeneration of the suprabony component of the defect.
Cortellini.P43 described modification of the Papilla preservation technique
which has been applied to achieve primary closure of the interproximal tissue over
barrier membranes placed coronal to the alveolar crest. Fifteen patients with deep
intrabony interproximal defects were treated. Defects had a attachment level loss of
9.9 ± 3.2 mm and a recession of the gingival margin of 1.7 ± 1.6 mm. The depth of
the intrabony component was 5.5 ± 2.9mm; while the suprabony component was 5.9
± 2.0 mm. Titanium-reinforced teflon membranes were placed 1.3 ± 0.7 mm from the
cemento-enamel junction, 4.5 ± 1.6 mm coronal to the interproximal alveolar bone
crest. Primary closure over the interproximal portion of the membrane was obtained
33
in 93% of cases. In 73% of the cases complete coverage of the membrane was
maintained until its removal at 6 weeks. These data
indicate that the modified papilla preservation technique can be successfully applied
to obtain primary closure of the interdental space in regenerative procedures with
barrier membranes.
Cortellini.P44 proposed a Simplified papilla preservation flap procedure
specifically designed to access interdental spaces in the regenerative treatment of
deep intra bony defects, while preserving interdental soft tissues, even in narrow
interdental spaces and posterior teeth. A modified mattress suture allows coronal
positioning of the buccal flap and primary closure of the interdental space without
tension. The modified mattress suture minimizes the collapse of the membrane into
the defect. An experimental population of 18 patients in good general health who
presented with one intra bony defect each was selected for this clinical study. The
application of the Simplified papilla preservation flap in combination with
bioresorbable membranes resulted in clinical attachment level (CAL) gains of 4.9 ±
1,8 mm at 1 year. The difference between baseline CAL and 1 year CAL was highly
clinically and statistically significant. The residual pockets at 1 year measured 3.6±
1.2mm. A slight increase in gingival recession was noted. Primary closure of the flap
in the interdental space over the membrane was obtained in 100% of the
cases after completion of surgery and maintained in 67% of the cases during
the healing period.
34
The application of SPPF in combination with biore-
-sorbable barrier membranes allowed primary closure of the interdental
space in most of the treated sites and resulted in consistent CAL gains at 1
year.
5. RESULTS
A total number of 20 patients were included in the study, of which 10 patients underwent
Papilla preservation flap ( Group A ) and 10 patients underwent modified Widman flap (
Group B) surgeries. The age of the patients who underwent PPF ranged between 25-35
years with a mean age of 28.30 and the age of patients who underwent MWF ranged
between 25-30 years with a mean age of 26.90. (Table 1, Graph 1, 1a).
The PPF group consisted of 4 males & 6 females and MWF group consisted of 5
males & 5 females, with one drop out at 6 months post operative period. (Table 2,
Graph 2, 2a).
All the patients returned regularly for the maintenance program. None of the
patients who underwent surgery had any postoperative complications.
RESULTS – CLINICAL PARAMETERS:
Plaque index: All the patients were regularly monitored and instructed to maintain
meticulous oral hygiene. The mean plaque index, in PPF group which was 0.19 at
baseline, decreased to 0.09 at 6 months postoperative checkup and this decrease was
neither clinically nor statistically significant.
In the MWF group the mean plaque index reduced from 0.17 at baseline to 0.15
at the end of 6 months which was also not significant. There was no statistical significant
difference in the plaque status between the two groups at the end of 6 months period.
(Table 3 and Graph 3 ).
Gingival index: In the PPF group, the mean gingival index which was 0.34 at baseline
reduced to 0.09 at the end of 6 months and in MWF group, the gingival index was0.18 at
baseline which reduced to 0.10 at 6 months postoperative checkup. The amount of
reduction is statistically significant in Papilla preservation flap group and in modified
Widman flap group it is not statistically significant. But the difference between the two
groups was neither clinically nor statistically significant.
( Table 4, Graph:5 ,6)
Papilla presence index: In PPF group, the mean PPI at baseline was 2.90mm which
was increased to 3.30mm at 6 months post operative check up with a 13.8% loss of
papilla which is moderately statistically significant. In MWF group the mean PPI was
2.60mm at baseline which increased to 3.44mm at 6 months postoperative with a 32.3 %
loss of papilla which is strongly statistically significant. Whereas, the difference in the
loss of papilla between two groups was neither clinically nor statistically significant.
(Table 5, Graph 7,8 ).
Gingival recession: In almost all cases, gingival recession was noticed at 6 months post
operative follow up period. The mean gingival recession in PPF group increased from
0.69mm to 0.88mm postoperatively and from 0.32mm to 0.52mm in MWF group. In
both the groups, this increase was moderately statistically significant. But the percentage
increase of recession in PPF group was 27.5% and it was 62.5 % in MWF group. But
there is no statistically significant difference between the two groups. ( Table 6, Graph:
9,10).
Probing depths: In addition to estimating mean probing depths, probing sites were
further classified as having mild (0-4mm), moderate (4-7mm) and severe (≥7mm)
pockets. Changes were evaluated in these groups to ascertain the response of pockets of
different depths to periodontal therapy. The mean probing pocket depth in PPF group was
3.39mm at baseline, which was reduced to 2.21mm at the end of 6 months. In the MWF
group, the mean probing depth was 3.16mm at baseline, which reduced to 2.21mm at the
end of 6 months. This reduction in probing depths in both the groups was strongly
significant. Further when the amount of reduction that took place between the baseline to
the end of 6 months in both the groups was compared, it was similar. i.e. there was no
difference in the probing depth reduction between the 2 groups. (Table 7, Graph :11, 12
)
In PPF group, sites showing mild pockets had a mean probing depth of 2.31mm at
baseline, which reduced to 1.95mm at the end of 6 months. Sites with moderate pockets
had a mean probing depth of 4.87mm at baseline, which later reduced to 2.48mm at the
end of 6 months whereas sites showing deep pockets had a mean probing depth of
7.20mm initially and 3.02mm at the end of 6 months.
In MWF group, sites showing mild pockets had a mean probing depth of 2.45mm at
baseline, which reduced to 2.02mm at the end of 6 months. Sites with moderate pockets
had a mean probing depth of 4.87mm at baseline, which later reduced to 2.73mm
whereas sites showing deep pockets had a mean probing pocket depth of 7.04mm
initially and 3.11mm at the end of 6 months.
The mean reduction in probing pocket depth categories of mild, moderate and
severe periodontitis in both the groups are strongly significant. The difference in
reduction of probing pocket depths between the two groups was neither clinically nor
statistically significant. In other words, there was no difference in probing depth
reduction between the 2 groups in any of the three categories. (Table 8 and Graph
13,14, 15 ,16).
Clinical attachment loss: The mean clinical attachment loss in the PPF group was
3.85mm at baseline, which reduced to a mean of 2.79mm at the end of the 6 months
follow up period. In MWF group the mean clinical attachment loss was 3.40mm at
baseline, which reduced to 2.65mm at 6 months postoperatively. This reduction was
found to be strongly significant in both the groups. But the mean difference in clinical
attachment gain between the 2 groups was neither statistically nor clinically significant.
(Table: 9, Graph: 17, 18)
In PPF group, sites showing mild CAL (1-2mm) had a mean of 1.92mm at
baseline, which increased to 1.94mm at the end of 6 months. Sites with moderate CAL
(3-4mm) had a mean of 3.18mm at baseline, which reduced to 2.62mm at the end of 6
months, and sites showing severe CAL (≥5mm) had a mean of 6.25mm at baseline,
which reduced to 3.72mm at the end of 6 months.
In MWF group, sites showing mild CAL had a mean of 1.92mm at baseline,
which increased to 1.96mm at the end of 6 months. Sites with moderate CAL had a mean
of 3.33mm at baseline, which reduced to 2.71mm at the end of 6 months and sites
showing severe CAL had a mean of 5.53mm at baseline and 3.56mm at the end of 6
months.
In both the groups there was an increase in clinical attachment loss in mild
category but it was neither statistically nor clinically significant.
In moderate category the increase in clinical attachment gain was strongly
significant in PPF group and moderately significant in MWF group but the difference in
attachment gain between the two groups was not significant.
In sites showing severe CAL, the gain in clinical attachment level in both the
groups was strongly statistically significant. Whereas, the difference between the two
groups was neither clinically nor statistically significant. (Table:10, Graph:
19,20,21,22)
Radiographic measurements: Of the 20 patients who participated in the study only 2
patients of PPF group had angular bony defects in whom bone graft (Bio-OssTM) had
been placed. The infra bony component for first patient was 2.10mm at baseline and
1.15mm at the end of 6 months indicating a bone fill of 0.95mm. In the second case the
infra bony component was 4.57mm at baseline and 3.35mm at the end of 6 months with a
bone fill of 1.22mm.
All the remaining 18 patients had horizontal bone loss and the mean bone levels
were measured from the cemento enamel junction to the alveolar crest at baseline and 6
months postoperatively. The mean bone levels were 6.07mm in PPF group and 4.17mm
in the MMF group at baseline, which decreased to 5.93mm in PPF and 3.85mm in MWF
group at the end of 6 months postoperative period. The gain in bone level in PPF group
was not statistically significant and the gain in MWF group was moderately statistically
significant but there was no statistically significant difference between the two groups.
Hence it was concluded that there was neither appreciable gain nor was there any further
loss in the bone levels during the study period in both the groups.
Visual analogue scale: For the first question regarding how happy were the patients with
their alignment and size of the gums of upper front teeth; In PPF group, the mean
baseline value which was 6.0 increased to 7.80 at the end of 6 months and in MWF group
it was 4.0 at baseline which was increased to 7.78 at 6 months. The increase in response
to 1st question in MWF group was strongly significant whereas it was moderately
statistically significant in PPF group.
For the second question regarding how happy were the patients with the shape of
the gums of upper front teeth; the mean score was 4.8 at baseline in PPF group which
increased to 6.0 at the end of 6 months and it was 4.3 which increased to 6.67 in MWF
group with moderate statistical significance in both the groups.
For the third question regarding the sensitivity of teeth, the mean baseline score in
PPF group was 2.60 which increased to 4.67 at the end of 6 months with moderate
statistical significance. In MWF group the mean baseline score was 2.5 which increased
to 4.98 which was strongly statistically significant.
For the fourth question about the presence of longer teeth, the mean baseline score
in PPF group was 3.5 at the baseline which increased to 6.60 at 6 months with strong
statistical significance and in MWF group it was 3.6 which increased to 7.11 at 6 months
which was strongly statistically significant.
Table 1: Comparison of age in years between PPF group and MWF group
Age in years Group A (PPF)
Group B (MWF)
≤30 8 (80.0%) 9 (90.0%)
>30 2(20.0%) 1 (10.0%)
Mean ± SD 28.30±3.59 26.90±3.38
Table 2: Comparison of gender between PPF group and MWF group
Gender Group A (PPF)
Group B (MWF)
Male 4 (40.0%) 5(50.0%)
Female 6 (60.0%) 5(50.0%)
Table 3: Comparison of plaque index between PPF and MWF groups
Plaque index Group A (PPF)
Group B (MWF) P value
Baseline 0.19±0.20
(0-0.68)
0.17±0.10
(0-0.25) 0.292
At 6 months 0.09±0.16
(0-0.50)
0.15±0.21
(0-0.66) 0.122
% Change of improvement
52.6% 11.8%
P value 0.186 0.813 -
Results are presented in Mean ± SD ( Min-Max)
There is no statistically significant difference in the plaque scores between baseline and 6
months postoperative check up within the group nor there exists any difference between
the two groups.
Table 4: Comparison of Gingival index between PPF and MWF groups
Gingival index Group A (PPF)
Group B (MWF) P value
Baseline 0.34±0.26
(0-0.93)
0.18±0.15
(0-0.43) 0.110
At 6 months 0.09±0.09
(0-0.25)
0.10±0.06
(0-0.18) 0.825
% Change of improvement
73.5% 44.4% -
P value 0.030* 0.218 -
Results are presented in Mean ± SD ( Min-Max)
The amount of reduction in gingival index between the baseline and 6 months in PPF
group is statistically significant and in MWF group it is not statistically significant. But
there is no statistical difference in the gingival index between the two groups.
Table 5: Comparison of Papilla presence Index between PPF and MWF groups
Papilla Presence Index
Group A (PPF)
Group B (MWF) P value
Baseline 2.90±0.87
(2-4)
2.60±0.52
(2-3) 0.363
At 6 months 3.30±0.82
(2-4)
3.44±0.73
(2-4) 0.692
% Change in loss of papilla 13.8% 32.3% -
P value 0.037* 0.008** -
Results are presented in Mean ± SD ( Min-Max)
In PPF group the mean PPI increased from base line to 6 months postoperative period
and is moderately statistically significant. In MWF group it increased more with strong
statistical significance.
Table 6: Comparison of Recession between PPF and MWF groups
Recession Group A (PPF)
Group B (MWF) P value
Baseline 0.69±0.49
(0-1.66)
0.32±0.34
(0-0.91) 0.068
At 6 months 0.88±0.59
(0.16-1.91)
0.52±0.45
(0-1.22) 0.151
% Change of increase
27.5% 62.5% -
P value 0.021* 0.019* -
Results are presented in Mean ± SD ( Min-Max)
Gingival recession increased in both the groups from base line to 6 months post
operative with moderate statistical significance but there is no statistically significant
difference in the recession between the two groups.
Table 7: Comparison of Mean Probing pockets between PPF and MWF groups
Mean Probing pockets
Group A (PPF)
Group B (MWF) P value
Baseline 3.39±0.48
(2.83-4.20)
3.16±0.61
(2.74-4.79) 0.340
At 6 months 2.21±0.29
(1.70-2.83)
2.21±0.35
(1.74-2.99) 0.995
% Change in reduction 34.8% 30.1% -
P value <0.001** <0.001** -
Results are presented in Mean ± SD ( Min-Max)
The mean reduction in probing pocket depths from baseline to 6 months post operative
follow up is moderately statistically significant in both the groups but there is no
statistically significant difference between the two groups.
Table 8: Comparison of Mild, Moderate and severe probing pocket depths between
2 groups ( PPF and MWF )
PPD(Probing Pocket depth) Group A
(PPF) Group B (MWF) P value
Baseline
2.31±0.28
(1.81-2.76)
2.45±0.34
(2.00-3.05) 0.431
At 6 months
Results are presented in Mean ± SD ( Min-Max)
1.95±0.19
(0.63-2.23)
2.02±0.25
(1.61-2.55) 0.542
% Change in reduction 15.6% 17.6% -
Mild
(1-3mm)
P value <0.001** 0.006** -
Baseline 4.87±0.43
(3.83-5.25)
4.87±0.23
(4.33-5.00) 0.979
At 6 months 2.48±0.17
(2.25-2.87)
2.73±0.49
(2.00-3.66) 0.155
% Change in reduction 49.1% 43.9% -
Moderate
(4-6mm)
P value <0.001* <0.001** -
Baseline 7.20±0.40
(7-8.00)
7.04±0.08
(7-7.16) 0.461
At 6 months 3.02±0.29
(2.66-3.40)
3.11±0.84
(2.33-4.00) 0.808
% Change in reduction
58.05% 55.82% -
Severe
(≥7mm)
P value <0.001** <0.001+ -
There is statistically significant difference in probing depth reductions in all the 3
categories between baseline and 6 months in both the groups but there is no
statistically significant difference between the two groups.
Table 9: Comparison of Mean CAL between PPF and MWF groups
Mean CAL Group A (PPF)
Group B (MWF) P value
Baseline 3.85±0.56
(2.81-4.78)
3.40±0.59
(2.83-4.83) 0.097
At 6 months 2.79±0.44
(1.69-2.24)
2.65±0.52
(1.91-3.53) 0.508
% Change of reduction 27.5% 22.1% -
P value <0.001** 0.002** -
Results are presented in Mean ± SD ( Min-Max)
The amount of reduction in mean CAL between baseline and 6 months is
statistically significant in both the groups but there is no statistically significant
difference between the two groups.
Table 10: comparison of Mild, Moderate and severe CAL between two groups
CAL Group A (PPF)
Group B (MWF) P value
Baseline 1.92±0.16
(1.60-2.10)
1.92±0.09
(1.75-2.00) 0.948
At 6 months 1.94±0.29
(1.60-2.56)
1.96±0.36
(1.50-2.70) 0.944
% Change in increase
1.1% 2.1% -
Mild(1-2mm)
P value 0.764 0.808 -
Baseline 3.18±0.12
(3.0-3.37)
3.33±0.33
(3.0-4.00) 0.188
At 6 months 2.62±0.35
(2.20-3.14)
2.71±0.67
(1.83-3.85) 0.730
% Change of reduction
17.6% 18.6% -
Moderate (3-4mm)
P value 0.001** 0.016* -
Baseline 6.25±0.63
(5.42-7.25)
5.53±0.33
(5.00-6.00) 0.005
At 6 months 3.72±0.64
(2.71-4.40)
3.56±0.86
(2.50-5.16) 0.644
% Change of reduction 40.4% 35.6% -
Severe
(≥5mm)
P value <0.001** <0.001** -
Results are presented in Mean ± SD ( Min-Max)
There was a marginal increase in attachment loss in mild subcategory in both the
groups from baseline to 6 months, which was statistically insignificant. In moderate
subcategory there is increase in attachment gain but it is strongly significant in
Papilla preservation group whereas it is moderately significant in modified Widman
flap group . It is strongly significant in severe subcategory in both the groups.
Table 11: Radiographic measurements
A. INTRA BONY DEFECTS
SLNO CEJ -BD CEJ – AC DEFECT DEPTH PRE POST PRE POST PRE POST
1 7.95 7 5.85 5.85 2.10 1.15
2 10.42 9.10 5.85 5.65 4.57 3.35
B. COMPARISON OF RADIOGRAPHIC MEASUREMENTS FOR HORIZONTAL BONE LOSS IN PPF AND MWF GROUP
Radiograph measurements PPF Group MWF Group P value
Baseline 6.07±2.74
(3.35-12.17)
4.17±1.51
(2.31-7.34) 0.100
At 6 months 5.93±2.55
(3.35-11.41)
3.85±1.26
(2.30-6.07) 0.047*
% Improvement 2.3% 7.7% -
P value 0.275 0.059+ -
The amount of increase in bone level in PPF was not statistically significant and it was
moderately statistically significant in MWF group at 6 months postoperative period but
the difference of bone levels between the two groups was not statistically significant.
Table 12: comparison of Visual analogue scale between PPF and MWF groups
VAS(Visual Analogue Scale) Group A (PPF)
Group B (MWF) P value
Baseline 6.00±2.11 4.00±2.75 0.105
At 6 months 7.80±1.75 7.78±1.86 0.684
% Change 30.0% 94.5%
Are you happy with the alignment and size of the gums of your upper front teeth?
P value 0.017* 0.001**
Baseline 4.80±2.78 4.30±2.63 0.063
At 6 months 6.00±2.67 6.67±2.31 0.684
% Change 25.0% 54.9%
Are you happy with the shape of the gums of your upper front teeth?
P value 0.068+ 0.068+
Baseline 2.60±2.46 2.50±2.20 0.497
At 6 months 4.67±2.06 4.98±2.49 0.342
% Change 79.6% 99.2% -
Are your teeth Sensitive?
P value 0.0125* 0.001** -
Baseline 3.50±2.41 3.60±2.48 0.342
At 6 months 6.60±2.67 7.11±1.76 0.701
% Change 88.5% 97.5% - Does your tooth appear longer than adjacent teeth?
<0.001** <0.001** -
Results are presented in Mean ± SD ( Min-Max)
In PPF group for the first question, the mean scores were increased from baseline to 6
months postoperative checkup with moderate statistical significance and in MWF group,
the mean scores were increased with strong statistical significance. For the 2nd question
the mean scores were increased in both the groups at 6 months postoperative with
moderate statistical significance. For the 3rd question the mean scores were increased in
both the groups at 6 months postoperative checkup with moderate statistical significance
in PPF group and strongly statistically significant in MWF group. For the 4th question
the mean scores were increased from base line to 6 months postoperative period in both
the groups with strong statistical significance
Graph 1 : Comparison of age in years between PPF and MWF groups
<=3080%
>3020%
PPF group
>3010%
<=3090%
MWF group
Graph 2: Comparison of gender between PPF and MWF groups
Male40%
Female60%
PPF group
Female50%
Male50%
MWF group
Graph 3: Comparison of plaque index between PPF and MWF groups
PPF group MWF group
Graph – 4 Percentage change in Plaque Index
52.6
11.8
0
10
20
30
40
50
60
70
80
90
100
Per
cent
ages
PPFgroup MWF group
Percentage change in Plaque Index
Graph 5: Comparison of Gingival index between PPF and MWF groups
PPF group MWF group
Graph – 6 percentage change in gingival index
73.5
44.4
0
10
20
30
40
50
60
70
80
90
100
Perc
enta
ges
PPFgroup MWFgroup
Percentage change in Gingival Index
Graph 7: Comparison of Papilla presence Index between PPF and MWF groups
PPF group MWF group
Graph 8: Percentage change in papilla presence index
05
101520253035404550
13.8
32.3
Perc
enta
ges
PPF group MWF group
Percentage change in Papilla Presence Index
Graph 9: Comparison of Recession between PPF and MWF groups
PPF group MWF group
Graph 10: Percentage change in recession
0102030405060708090
100
27.5
62.5
Perc
enta
ges
PPF group MWF group
Graph 11: Comparison of Mean Probing pockets between PPF and MWF groups
PPF group MWF group
Graph 12: Percentage change in mean probing pocket depths
05
101520253035404550 34.8 30.1
Perc
enta
ges
PPF group MWF groupPercentage change in Mean pockets
Graph 13: comparison of mild probing pocket depths between PPF and MWF
PPF group MWF group
Probing pocket depth
Graph 14: Comparison of moderate probing pocket depths between PPF and
MWF
PPF group MWF group
Probing pocket depth
Graph 15: Comparison of severe probing pocket depth between PPF and MWF
PPF group MWF group
Probing Pocket depth
Graph 16: Comparison of percentage change in Mild, Moderate and severe PPD
groups between PPF and MWF
0
10
20
30
40
50
60
70
80
90
100
Mild Moderate Severe
Perc
enta
ges
PPF group
MWF group
PPD
Graph 17: comparison of mean CAL between PPF and MWF
PPF group MWF group
Graph 18: Percentage change in CAL
0
5
10
15
20
25
30
35
40
45
50
27.522.1
Perc
enta
ges
PPF group MWF group
Graph 19: Comparison of mild CAL between PPF and MWF
PPF group MWF group
CAL
Graph 20: Comparison of moderate CAL between PPF and MWF
PPF group MWF group
CAL
Graph 21: Comparison of severe CAL between PPF and MWF
PPF group MWF group
CAL
Graph 22: Comparison of percentage change in CAL of mild, moderate and severe groups between PPF and MWF
0
5
10
15
20
25
30
35
40
45
50
Perc
enta
ges
Mild Moderate Severe
PPFgroup
MWFgroup
CAL
Graph – 23 Comparison of radiographic measurements in PPF and MWF group
PPF group MWF group
Graph – 24 Percentage change in the radiographic measurements between PPF group and MWF group
2.3
7.7
0
2
4
6
8
10
Perc
enta
ges
PPFgroup MWFgroup
Percentage change in Radiograph measurements
CASE-1
PAPILLA PRESERVATION FLAP
PHOTOGRAPH-17 AT BASE LINE
PHOTOGRAPH – 18 6 MONTHS POST OPERATIVE
CASE –2
PAPILLA PRESERVATION FLAP
PHOTOGRAPH – 19 PROBING POCKET DEPTH OF 6 MM IN RELATION TO MESIAL OF 11 AT BASELINE
PHOTOGRAPH – 20 PROBING POCKET DEPTH OF 3MM IN RELATION TO MESIAL OF 11 AT 6 MONTHS
CASE – 3
PAPILLA PRESERVATION FLAP
PHOTOGRAPH – 21 PROBING POCKET DEPTH OF 7 MM IN RELATION TO MESIAL OF 21 AT BASELINE
PHOTOGRAPH – 22 PROBING POCKET DEPTH OF 3 MM IN RELATION TO MESIAL OF 21 AT 6 MONTHS
MODIFIED WIDMAN FLAP
53
PHOTOGRAPH 23
PREOPERATIVE PROBING POCKET DEPTH OF 7 MM IN RELATION TO MESIAL OF
12 AT BASELINE
PHOTOGRAPH – 24 PROBING POCKET DEPTH OF 3MM IN RELATION TO MESIAL OF 12 AT 6 MONTHS
CASE – 2
54
PHOTOGRAPH – 25
PREOPERATIVE PROBING POCKET DEPTH OF 7MM IN RELATION TO DISTAL OF 11
AT BASELINE
PHOTOGRAPH – 26
POST OPERATIVE PROBING POCKET DEPTH OF 2MM IN RELATION TO DISTAL OF 11 AT 6 MONTHS
CASE – 3
55
PHOTOGRAPH – 27
PREOPERATIVE PROBING POCKET DEPTH OF 5MM IN RELATION TO MESIAL OF 21
AT BASELINE
PHOTOGRAPH – 28
POST OPERATIVE PROBING POCKET DEPTH OF 3MM IN RELATION TO MESIAL OF 21AT 6 MONTHS
56
52
Statistical Methods49,5o: Descriptive statistical analysis has been carried out in the
present study. Results on continuous measurements are presented on Mean ± SD
(Min-Max) and results on categorical measurements are presented in Number (%).
Significance is assessed at 5 % level of significance. Student t test (two tailed,
independent) has been used to find the significance of study parameters between two
groups, student t test (two tailed, dependent) has been used to find the significance of
change of study parameters between baseline and at 6 months with in each group,
Mann Whitney U test has been used to find the significance of VAS between two
groups and Wilcoxon signed rank test has been used to find the significance of
change in VAS score between Baseline and at 6 months with in each group.
Significant figures
+ Suggestive significance 0.05<P<0.10
* Moderately significant 0.01<P ≤ 0.05
** Strongly significant P≤0.01
COMPREHENSIVE CHART 1 – PAPILLA PRESERVATION FLAP
TABLE 13: GINGIVAL PARAMETERS & RECESSION SL.NO
NAME PLAQUE INDEX GINGIVAL INDEX PAPILLA PRESENCE INDEX RECESSION
BaseLine
6months BaseLine 6months BaseLine 6months BaseLine 6months
1 SUMA 0.25 0.08 0.08 0.08 3 3 0.22 0.19 2 KANTARAJ 0.25 0.25 0.25 0.25 4 4 1.66 1.91 3 ASIA KHANA 0.25 0 0.25 0.08 3 4 0.83 0.83 4 MANJULA 0 0.08 0.41 0.25 4 4 0.66 1.08 5 VIJAY 0.16 0 0.25 0 3 4 0.50 0.58 6 CHITRA 0.33 0.5 0 0.16 2 2 0.61 0.77 7 JAGDEESH 0.06 0 0.37 0.06 2 2 0.25 0.50 8 AIYAPPA 0 0 0.25 0 4 4 1.05 1.72 9 BIBI ASIA 0.68 0 0.93 0.06 2 3 1.16 1.08 10 SAMEER 0 0 0.62 0 2 3 0 0.16
89
COMPREHENSIVE CHART 2 – PAPILLA PRESERVATION FLAP
TABLE 14: PERIODONTAL PARAMETERS SL.NO MEAN
POCKETS MEAN CAL PPD-MILD PPD-
MODERATE PPD-
SEVERE CAL-MILD CAL-
MODERATE CAL-
SEVERE BL 6months BL 6months BL 6months BL 6months BL 6months BL 6months BL 6months BL 6months
1 3.05 2.09 2.81 1.69 2.5 2.18 5 2.5 7 3 2.1 2.1 3.35 2.85 6.33 3.33
2 3.95 2.20 4.78 3.24 2.15 1.69 3.83 2.33 7.2 3.40 1.83 2.16 3.20 2.20 6.76 4.15
3 2.83 2.16 3.66 2.83 1.81 1.9 4.42 2.57 0 0 1.66 1.83 3.2 2.8 5.71 3.71
4 3.33 2.83 3.88 3.11 2.23 2 5 2.5 7 3.3 2 2 3.14 3.14 7 4.4
5 3.44 2.27 3.77 2.66 2.76 2.23 5 2.4 0 0 2 2.5 3.18 2.45 5.8 3.2
6 3.05 1.99 3.77 2.77 2.57 1.92 5.25 2.25 0 0 2 1.66 3.37 2.62 7.25 4.14
7 4.20 2.29 4.33 2.70 2.10 1.9 5 2.5 7 2.75 1.6 1.6 3.2 2.6 5.71 2.92 8 2.83 1.70 3.7 3.12 2.21 1.63 5.2 2.4 0 0 2 1.66 3.11 3.11 5.87 4.37
9 3.91 2.45 4.45 3.04 2.53 2.15 5 2.87 7 2.66 2 2.2 3 2.25 6.63 4.27
10 3.37 2.14 3.37 2.83 2.52 1.94 5 2.5 8 3 2 1.75 3 2.22 5.42 2.71
90
COMPREHENSIVE CHART 3 – MODIFIED WIDMAN FLAP
TABLE 15: GINGIVAL PARAMETERS & RECESSION SL.NO
NAME PLAQUE INDEX GINGIVAL INDEX PAPILLA PRESENCE INDEX RECESSION
BaseLine
6months BaseLine 6months BaseLine 6months BaseLine 6months
1 PARVATHI 0.08 0.16 0 0 3 3 0.16 0.05 2 ANJANEYA 0.25 0.06 0.1 0.12 3 4 0.16 0.33 3 VEDAVATHI 0 0.18 0.18 0.18 3 4 0.91 1.08 4 SUJATHA 0.18 0.18 0.25 0.18 2 2 0 0 5 ANANDI 0.25 0.66 0.41 0.08 2 3 0 0.08 6 GANGADHAR 0 0 0.18 0.12 3 3 0.58 0.74 7 WASEEM 0.16 0.08 0.08 0.08 3 4 0.5 0.75 8 RAGHU 0.2 0 0.1 0.1 2 4 0 0.41 9 VENKATESHWARL
U 0.06 0 0.06 0.06 3 4 0.77 1.22
10 SRIDEVI 0 - 0.43 - 2 - 0.16 -
91
COMPREHENSIVE CHART 4 – MODIFIED WIDMAN FLAP
TABLE 16: PERIODONTAL PARAMETERS SL.NO MEAN
POCKETS MEAN CAL PPD-MILD PPD-
MODERATE PPD-SEVERE CAL-MILD CAL-
MODERATE CAL-
SEVERE BL 6months BL 6months BL 6months BL 6months BL 6months BL 6months BL 6months BL 6months
1 3.27 2.16 3.44 2.22 2.53 2 4.75 2.5 7 3 2 1.5 3.2 2.3 5.5 2.75
2 2.87 1.74 3.24 2.33 2.27 1.66 4.66 2 0 0 2 1.66 3.28 2.42 5.6 3.8
3 3.24 2.04 3.83 2.7 3.05 1.88 4.33 2.5 0 0 2 2 3.5 2.5 5.4 3.6
4 2.91 1.91 2.91 1.91 2.5 1.85 5 2.5 0 0 1.75 1.75 3 1.83 5 2.5
5 3.05 2.21 3.05 2.27 2.66 2.13 5 2.66 0 0 2 2.2 3 2.2 5 2.66
6 2.74 2.29 3.03 2.83 2 1.94 5 3.66 0 0 1.8 1.69 3.2 3 6 5.16
7 3.16 2.27 3.46 2.88 2.08 2 5 2.6 7 4 1.88 2.11 3.66 3.66 5.83 3.66 8 4.79 2.99 4.83 3.19 2.88 2.55 5 3.33 7.16 2.33 2 2 3 2.62 5.61 3.47
9 2.78 2.29 3.41 3.53 2.21 2.15 5 2.8 0 0 1.9 2.7 3.42 3.85 5.71 4.42
10 2.74 - 2.83 - 2.33 - 5 - 7 - 1.9 - 4.0 - 5.66 -
92
COMPREHENSIVE CHART- 5 : TABLE: 17 VISUAL ANALOG SCALE – MODIFIED WIDMAN FLAP BL 6 mon BL 6 mon BL 6 mon BL 6mon
Name Q 1
Q 1 Q 2 Q 2 Q 3 Q 3 Q 4 Q4
PARVATHI 1 10 4 10 7 1 8 8 ANJANEYA 1 9 1 8 2 0 1 9 VEDAVATHI 0 10 0 8 4 0 10 8 SUJATHA 3 7 3 3 1 1 0 1 ANANDI 7 9 8 8 3 1 3 6
GANGADHAR 7 6 4 4 3 5 4 5 WASEEM 5 6 4 4 2 3 5 7 RAGHU 3 5 8 8 0 0 4 6
VENKATESHWARLU 7 8 6 7 0 0 7 7 SRIDEVI 7 5 0 7
93
COMPREHENSIVE CHART- 6 : TABLE: 18 VISUAL ANALOG SCALE – PAPILLA PRESERVATION FLAP BL 6 mon BL 6 mon BL 6 mon BL 6 mon Name Q 1 Q 1 Q 2 Q 2 Q 3 Q 3 Q 4 Q4
SUMA 8 8 4 8 3 9 1 9 KANTARAJ 9 10 10 10 4 1 6 9
ASIA KHANA
4 10 5 5 0 5 6 6
MANJULA 3 6 5 7 0 0 0 0 VIJAY 8 8 6 6 2 9 2 4
CHITRA 5 9 0 0 0 1 2 3 JAGDEESH 4 6 6 6 4 6 5 5 AIYAPPA 8 9 2 7 8 2 7 9 BIBI ASIA 5 5 3 4 3 5 3 4 SAMEER 6 7 7 7 2 3 2 4
94
95
COMPREHENSIVE CHART : 7 TABLE: 19
RADIOGRAPHIC MEASUREMENTS
PAPILLA PRESERVATION FLAP GROUP
Slno Name Baseline measurements
6 months measurements
1 ASIA KHANA 12.17 11.41 2 MANJULA 6.46 6.82 3 VIJAY 4.07 3.9 4 CHITRA 5.78 5.34 5 JAGDEESH 4.52 4.73 6 AIYAPPA 3.35 3.35 7 BIBI ASIA 7.05 7.0 8 SAMEER 5.23 4.86
96
COMPREHENSIVE CHART : 8 TABLE: 20
RADIOGRAPHIC MEASUREMENTS
MODIFIED WIDMAN FLAP GROUP
Slno Name Baseline measurements
6 months measurements
1 PARVATHI 5.0 5.26 2 ANJANEYA 3.16 2.71 3 VEDAVATHI 4.37 3.96 4 SUJATHA 2.31 2.30 5 ANANDI 3.80 3.40 6 GANGADHAR 2.69 2.67 7 WASEEM 3.89 3.75 8 RAGHU 4.93 4.52 9 VENKATESHWARLU 7.34 6.07
97
6. DISCUSSION
The ultimate goal of periodontal therapy is to establish a state of periodontal
health evidenced by absence of inflammation, periodontal pockets and a potential for
the patient to maintain the health in addition to comfort, function and esthetics.
Periodontal therapy for the maxillary anterior dentition must consider esthetic
appearance, which means an effort to maintain as much of the papilla as possible in
the course of the periodontal therapy.
Even though the nonsurgical approach is encouraged for the maxillary anterior
dentition, there are numerous situations in which surgical therapy is unavoidable.
A surgical approach utilizing flap procedures on the facial and palatal sides, no matter
how conservative the incisions are made (modified Widman flap), sometimes results
in shrinkage and decrease in height of the interdental papilla leading to exposure of
interproximal embrasures.
This has led to the development of the Papilla preservation flap technique
particularly where interdental spacing is present, which in addition to providing an
optimal interproximal coverage, claims to provide better esthetic results, especially
in the anterior region of the mouth.
However, there is no data available in the literature comparing the outcome of
these two techniques in a randomized controlled clinical trial. So, it was difficult to
98
interpret the results of clinical and radiological parameters used in this study by way
of comparison.
The results of the present study demonstrated that Papilla preservation group
and modified Widman group patients who were treated for moderate to advanced
forms of periodontitis during the 6 months period showed improvement in their
periodontal conditions. This was disclosed by the fact that both the groups at 6
months post treatment period exhibited low prevalence of sites with plaque, bleeding
on probing, and also had statistically significant reduction in probing depths and gain
in clinical attachment when compared to baseline values. The improvements in the
clinical parameters in Papilla preservation flap group were in accordance to the study
conducted by Takei etal3, where they have studied the effectiveness of Papilla
preservation flap in optimal tissue coverage of the graft material in the interproximal
bony defects and for modified Widman flap group, it was in accordance with study by
Becker and Becker.25
In the present study, there was an overall improvement in the plaque and
gingival index scores in both the groups from base line to six months. This was
mainly due to the strict monthly recall of all the patients with strong emphasis in
reinforcing oral hygiene as any type of periodontal procedure requires sound
supportive periodontal therapy.
When Papilla presence index was assessed, there was decrease in the mean
height of interdental papilla in both the groups at the end of study period. This
99
signifies that there is reduction of papillary height to a degree in most of the patients
irrespective of the procedure being performed.
There was an increase in gingival recession from baseline to 6 months in both
the groups and this might be the normal consequence of any periodontal surgical
procedure. The recession in modified Widman flap procedure is in accordance with
the study conducted by Isidor51 etal where he has compared SRP with modified
Widman flap and stated that there is increased recession in Modified Widman flap
procedure compared to SRP. Contrary to the popular claims, there was some
recession even in PPF group as well and overall there was no difference between the
two groups. This could have been due to resolution of inflammation following the
procedures and the mere presence of papilla didn’t aid in preventing this mild
recession.
Due to the well known problems of periodontal probing ( Philstrom)52 and due
to the difference in long-term prognosis of shallow and deep pockets, probing sites
were divided into 3 different PPD categories. The sites were categorized into 0-4mm
(mild), 4-7mm (moderate) and ≥7mm (severe).
When comparing mean probing depths, the reduction from baseline to 6
months was statistically significant in both the groups, in all the 3 categories and
there was no significant difference in reduction between the two groups during the
study period. This signifies that irrespective of the surgical procedure performed there
was probing pocket depth reduction in all the patients of the two groups.
100
CAL was categorized as 1-2mm (mild), 3-4mm (moderate) and ≥5mm
(severe). When comparing mean CAL, there was a gain in attachment in both the
groups at 6 months post operative period. In the mild category, there was a slight loss
of attachment in both the groups. These results were similar to the studies conducted
by Hill53 etal, PhIlstorm22 etal and Lindhe24 etal, which have shown that attachment
loss occurred in treatment of shallow pockets. Lindhe54 etal have suggested that
instrumentation of shallow crevices may severe the transeptal fibres thereby allowing
for apical migration of the junctional epithelium. This explains why shallow pockets
had increased attachment loss in the present study.
On radiographic evaluation, only 2 patients in PPF group were found to have
intrabony defects for which bone graft was used and the mean radiographic bone fill
in both these cases was 1.08mm at 6 months postoperative follow up. In all the
remaining 18 patients there was horizontal bone loss at base line which after 6 months
post operative period have shown an marginal improvement in the bone levels.
However, there was no significant difference between the two groups. This shows
that there was neither appreciable gain nor was there any further loss in the bone
levels during the study period in both the groups.
Periodontal therapy has both tangible and intangible benefits and in this study
VAS (Visual analogue scale) has been attempted in addition to the clinical parameters
to assess the patients perception of treatment outcome. On analysis of the visual
analog scale, the patients were happy with their tooth alignment, size and shape of the
gums at the end of study period. But, they also expressed that their teeth appeared
101
longer at 6 months postoperative period. Thus, the patients assessment was not
correlating and this shows there was an uncertainity in the patients assessment of
visual analogue scale. This was in accordance with the study conducted by Lysell
etal, where, they have determined the appropriateness of Visual analogue scale to rate
their judgement of indication for therapy of mandibular 3rd molars.55 Also, there was
only a marginal increase in the scores at the end of study period which was not
significant.
The main shortcoming of this study was the small sample size which reduced
the statistical weightage of the results observed. Also, the use of advanced diagnostic
tool like a Florida probe could have minimized the manual errors associated with
sequential probing and also would have enabled small changes to be observed.
Overall, it emanates from this study that the outcome of both the surgical
techniques was similar and the PPF didn’t offer any superiority over the MWF.
Contrary to its claimed advantages, it must be reiterated here that in the previous
studies conducted by Takei3 et al, the authors had mainly emphasized this technique
to facilitate placement of bone grafts and ensuring optimal interproximal coverage.
However, as this was not the objective of the present study, the PPF being technique
sensitive, time consuming and as well as exacting cannot be recommended in the
maxillary anterior region, where a more conventional MWF would perhaps be a
suitable option.
102
7. CONCLUSION
The results of the present study indicate that both PPF and MWF surgical
procedures brought about significant improvement in various clinical and radiological
parameters evaluated, thereby improving the periodontal status. However, PPF didn’t
show any significant superiority over MWF, when assessed in terms of esthetic
outcome, gingival recession, post operative sensitivity etc. From the patients
perspective also, neither technique demonstrated superiority over the other. Hence
PPF being not only technique sensitive, but also time consuming cannot be routinely
recommended in maxillary anterior region purely for esthetic reasons. Wherein,
conventional techniques such as MWF would be more suitable.
However, long term studies with larger sample size are needed to vindicate
the above conclusion.
103
8. SUMMARY
The present study endeavored to determine the outcome of two different
periodontal surgical procedures i.e modified Widman flap and Papilla preservation
flap in Maxillary anterior region. 20 patients with moderate to advanced periodontal
disease were selected for the study and each were randomly assigned either to PPF
group or MWF group with probing pocket depths ≥ 5 mm and clinical attachment
loss≥4mm in maxillary anterior region.
Clinical parameters comprising of plaque index, gingival index, papilla
presence index, probing pocket depths, clinical attachment level, recession and
radiological parameters along with evaluation of patient’s perception of esthetic
outcome using visual analogue scale were assessed at baseline and at the end of 6
months post operative checkup.
The periodontal health in all the patients of both the groups improved as
evidenced by good plaque control, maintenance of gingival health, significant
reductions in probing pocket depths and gain in clinical attachment levels. There was
a marginal increase in recession and decrease in the height of interdental papilla in
both the groups. There was no difference between the two groups in the esthetic
outcome as evaluated from the patients feed back. Radiographic evaluation of
intraoral periapical radiographs revealed that there was no change in the height of
bone levels in both the groups. Overall, the PPF flap did not result in any superiority
over the MWF.
104
Thus, a more conventional surgical technique like modified Widman flap
could be a suitable option for the treatment of periodontitis in maxillary anterior
region.
105
9. BIBLIOGRAPHY
1. Novak MJ. Classification of diseases and conditions affecting the
periodontium. In: Clinical periodontology, 10th edition, Newman, Takei and
Carranza. Saunders. 2007; 100-109.
2. Ramfjord.SP, Nissle. RR. The modified Widman operation. J periodontal
1974; 45:601-607.
3. Takei.H.H, Tan .T.J et.al Flap technique for periodontal bone implants. J
periodontol 1985; 56:204-210.
4. Kalkwarf K.L. Tissue attachment. Proceedings of the world workshop in the
clinical Periodontics: Chicago: The American academy of
periodontology.1989; 1 -19.
5. Palcanis .K.G. Surgical pocket therapy. J periodontol 1996; 6:589-617.
6. The American academy of periodontology: Glossary of periodontal terms, 3rd
ed Chicago; 1992.
7. Lindhe .J, Nyman.S. The effect of plaque control and surgical pocket
elimination on the establishment and maintenance of periodontal health. A
longitudinal study of periodontal therapy in advanced cases. J clin periodontol
1975; 2: 67-79.
8. Stern .T, Everett . F, Robicsek.K.S. Robicsek A pioneer in the surgical
treatment of periodontal disease. J periodontol 1965; 36:265-268.
9. Nabers .CL. Repositioning the attached gingiva. J periodontol 1954; 25:38-39.
10. Schluger .S. Osseous resection- A basic principle in periodontal surgery.
Oralsurg oralmed oral path1949; 2:316-325.
106
11. Carranza. F, Shklar.G etal. Clinical periodontology 1900-1950, Periodontal
surgery. In: History of periodontology. 2003; 150-158.
12. Gold .SI, Neumann.R. A pioneer in periodontal flap surgery.
J periodontol 1982;53:456.
13. Everett .FG, Waerhug.J, Widman.L. Surgical treatment of pyorrhea alveolaris.
J periodontol 1971; 42:571.
14. Zentler.A. Suppurative gingivitis with alveolar involvement. JAMA 1918;
71:1530.
15. Zentler .A. The surgical treatment of suppurative gingivitis, so called pyorrhea.
J Dent Res 1920; 2:xvii.
16. Kirkland .O. The suppurative periodontal pus pocket: Its treatment by the
modified flap operation. J Am Dent Assoc1931; 18:1462.
17. Takei .H.H, Carranza. F.A. The periodontal flap. In: Carranzas clinical
periodontology , 10th edi, pg-926-930.
18. Sato.N. Objectives and methods of periodontal surgery. In: Periodontal surgery
– A clinical atlas.2000; 12-22.
19. Lindhe. J, Karring. T, Lang. N. P. Periodontal surgery: Access therapy. In:
Clinical periodontology and implant dentistry, 4th edition, 2003; 536-537.
20. Friedman .N. Mucogingival surgery. The apically repositioned flap. J
periodontal 1962; 33:328-340.
21. Ramfjord.S.P, Knowles.J.W, Nissle.R.R, etal. Longitudinal study of
periodontal therapy. J Periodontol 1973; 44: 66.
107
22. Pihlstrom.B.L, Ortiz- Campos.C, McHigh.R.B. A randomized four-year study
of periodontal therapy J Periodontol 1981; 52:140.
23. McFall.W.T. Tooth loss in 100 treated patients with periodontal disease J
Periodontol 1982; 53: 539.
24. Lindhe.J, Weatfelt.E, Nyman.S, eatl. Long term effect of surgical/ non surgical
treatment of periodontal disease. J Clin Periodontol 1984; 11: 448.
25. Becker.W, Becker.B.E, Ochsenbein.C etal. A longitudinal study comparing
scaling, osseous surgery and modified widman procedures: Results after one
year. J Periodontol 1988; 59: 351-364.
26. Whitehead.S.P, Watts.T.L.P: Short term effect of Keyes approach to
periodontal therapy compared with modified widman flap surgery. J Clin
Periodontol 1987; 14: 599-604.
27. Beube.F.E. Interdental tissue resection. Am J Orthod Oral Surg 1947; 33: 497.
28. Donnenfeld.O.W, Hoag.P.M, Weissman.D.P. A clinical study in the effects of
osteoplasty. J Periodontol 1970; 41: 131.
29. Burgett.F.G, Knowles.J.W, Nissle.R.R, Shick.R.A etal. Short term results of
three modalities of periodontal treatment. J Periodontol 1977; 48: 131-135.
30. Ramfjord.S.P, Nissle.R.R, Knowles.J.W etal. Results following three
modalities of periodontal therapy. J Periodontol 1975; 46: 522-526.
31. Ramfjord.S.P, Nissle, Shick. R.A etal. Subgingival cutettage Vs Surgical
elimination of periodontal pocket. J Periodontol 1968; 39: 167.
32. Caffesse.R.G, Odont.M.S. Longitudinal evaluation of periodontal surgery.
Dent Clin North Am 1980; 24: 751-766.
108
33. Knowles.J.W, Burgett.S.G, Nissle. R.R. Results of periodontal treatment
related pocket depth and attachment level. J Periodontol 1979; 50: 225.
34. Adell.R. Regeneration of the periodontium. An experimental study in dogs.
Scan J Plastic and Reconstructive Surg 1974; 11:22.
35. Friedman.N. Reattachment and roentgenograms. J Periodontol 1958; 29: 98-
111.
36. Caton.J, Nyman.S. Histometric evaluation of periodontal surgery. The
modified widman flap procedure. J Clin periodontol 1980; 7: 212-223.
37. Dragoo.M.R, Sullivan.H.C. A clinical and histologic evaluation of autogenous
iliac bone grafts in humans. Wound healing after 2 to 8 months. J Periodontol
1973; 44: 599.
38. Sepe.W.W, Bowers.G.M, Lawrence.J.J etal. Clinical evaluation of freeze dried
bone allografts in periodontal osseous defects. J Periodontol 1978; 49: 9.
39. Kenney.E.B, Lekovic.V, Han.T etal. The use of solid implants in periodontal
bony defects. Clinical results after 6 months. J Periodontol 1985; 56: 82.
40. Schallhorn. R.G. Post operative problems associated with iliac transplants. J
Periodontol 1972; 3: 43.
41. Hiatt.W, Stallard.R, Butler.E etal. Repair following mucoperiosteal flap
surgery with full gingival retention. J Periodontol 1968; 39: 96-105.
42. Tonetti.M, Piniprato.G, Cortellini.P. Periodontol regeneration of human
infrabony defects. Determinants of the healing response. J Periodontol 1993;
64: 934-940.
109
43. Cortellini.P, Piniprato.G, Tonetti.M. The modified papilla preservation
technique. A new surgical approach for interproximal regenerative procedures.
J Periodontol 1995; 66: 261-266.
44. Cortellini.P, Piniprato.G, Tonetti.M. The simplified papilla preservation flap. A
novel surgical approach for the management of soft tissues in regenerative
procedures. Int J Perio Restor Dent 1999; 19: 589-599.
45. Silness J and Loe H. Periodontal disease in pregnancy: II. Correlation between
oral hygiene and periodontal condition. Acta Odontol Scand 1964; 22: 121.
46. Loe H and Silness J. Periodontal disease in pregnancy: I. Prevalence and
severity. Acta Odontol Scand 1963; 21: 533.
47. Cardaropoli.D, Re.S, Correnti. G. The Papilla Presence Index (PPI): A new
system to assess interproximal papillary levels. Int J Perio Restor Dent 2004;
24: 489-492.
48. Cortellini .P, PiniPrato GP, Tonetti MS. Periodontal regeneration of human
intrabony defects. I. Clinical measures. J Periodontol 1993; 64:254-260.
49. Rosner .B. In: Fundamentals of Biostatistics, 5th Edition, Duxbury.2000; 80-
240.
50. Reddy.M.V. Statistics for Mental Health Care Research, NIMHANS
publication.2002; 108-144.
51. Isidor.F, Karring.T, Attstrom.R. The effect of root planing as compared to that
of surgical treatment. J Clin Periodontol 1984; 11: 669.
110
52. Philstrom.B.L. Measurement of attachment level in clinical trials: Probing
methods. J Periodontol 1992; 63: 1072-1077.
53. Hill.R, Ramfjord.S.P, Morrison.E.C etal. Four types of periodontal treatment
compared over 2 years. J Periodontol 1981; 52: 655.
54. Lindhe.J, Nyman.S, Karring.T. Scaling and root planing in shallow pockets. J
Clin Periodontol 1982; 9: 415.
55. Lysell.L, Brehmer.B, Knutssson.K.etal. Rating the preventive indication for
mandibular third molar surgery : The appropriateness of the visual analogue
scale. Acta Odontol Scand 1995; 53: 60-64.
10. ANNEXURES
The Oxford Dental college Hospital and research Center. Department of periodontics.
Modified Widman flap and Papilla preservation flap in maxillary Anterior region
A comparative study.
Case history proforma
Technique: Case number: Date: Name of the patient: OP.NO: Age: Sex: Address: Occupation: Chief complaint: History of present illness: Medical history: Dental history:
111
Oral Hygiene Methods: Age of the brush: Method ofbrushing: Frequency of brushing: Estimated time spent: Intra oral examination:
Hard tissue examination: No. of teeth present: Occlusion: Fremitus test: Overjet & Over bite: Loss of contact
112
Gingival Status:
Exudation
Bleeding
Surface Texture
Contour
Position
Size
Consistency
Color
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Color
Consistency
Size
Position
Contour
Surface Texture
Bleeding
Exudation
113
MUCOGINGIVAL PROBLEMS:
Width of attached gingiva: Adequate : Not adequate: Depth of vestibule : Shallow : Adequate: Frenal attachment : RADIOLOGICAL INVESTIGATIONS: Horizontal bone loss : Vertical bone loss: DIAGNOSIS: PROGNOSIS: TREATMENT PLAN: Preliminary phase: Phase I Therapy: Phase II Therapy:
114
Phase III Therapy:
Phase IV Therapy: PHOTOGRAPHS: Pre operative: Post operative: CASE ANALYSIS:
115
At Base line: Plaque index:[Silness & Loe] 13 12 11 21 22 23
Gingival index[Loe & Silness]
Papilla presence index:
13 12 11 21 22 23
13 12 11 21 22 23
B Loss of attachment P
B Pocket Depth P
GINGIVAL RECESSION
Radiological Parameters: Tooth selected: CEJ to bottom of defect[BD] CEJ to bone crest[BC]
[CEJ-BD] – [CEJ-BC]
116
At 6 months post operatively:
Plaque index:[Silness & Loe] 13 12 11 21 22 23
Gingival index[Loe & Silness]
Papilla presence index:
13 12 11 21 22 23
13 12 11 21 22 23
B Loss of attachment P
B Pocket Depth P
GINGIVAL
RECESSION Radiological parameters: Tooth selected: CEJ to bottom of defect[BD] CEJ to bone crest[BC]
[CEJ-BD] – [CEJ-BC]
117
Visual Analogue Scale:
1. Are you happy with the alignment and size of the gums of your upper front
teeth ?
0 1 2 3 4 5 6 7 8 9 10
2. Are you happy with the shape of the gums of your front teeth ?
0 1 2 3 4 5 6 7 8 9 10
3. Are your teeth sensitive?
0 1 2 3 4 5 6 7 8 9 10
4. Does your tooth appear longer than adjacent teeth?
0 1 2 3 4 5 6 7 8 9 10
118
Consent statement
I hereby authorize and request the performance of dental services for myself . I also give my consent to any advisable and necessary dental procedures, medication or anesthetics to be administered by the attending dental surgeon or by his supervised staff for diagnostic purpose or dental treatment.
119
These records include study models, photographs, x- rays and blood investigations. To the best of my knowledge the information provided in this form is accurate.
Signature of patient:……………………………………………………… Signature of doctor:………………………………………………………. Date and place:…………………………………………………………….
120
