The Double Split Flap a Surgical Approach for Regenerative Treatment of in Terproximal Defects97

7/31/2019 The Double Split Flap a Surgical Approach for Regenerative Treatment of in Terproximal Defects97

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The double split flap: a surgical approach forregenerative treatment of interproximal defects

Tobias Thalmair, Stefan Fickl,

Wolfgang Bolz and Hannes Wachtel

Journal of Clinical Periodontology

Volume 36, Issue 10, Pages 877-881


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The ultimate goal of regenerative

periodontal therapy is to completelyrestore lost periodontal attachment

Characterized by formation of newroot cementum with inserting

collagen fibres, new periodontal

ligament and new alveolar bone(Karring et al. 2003).


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Various trt modalities to achieve this

goal : Different types of bone grafts

Root surface demineralization

Guided tissue regeneration (GTR)

Growth factors or

Enamel matrix derivative (EMD)


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Membrane exposure

Subsequent bacterial contamination

Soft tissue recession

Microbiological contamination of barrier

membranes have been associated withcompromised clinical outcomes, leading to

a reduced gain in clinical attachment level

Most frequent complications after regenerative procedures


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To prevent these complications the most important

element is to

Achieve and maintain primary soft tissue closurein particular in the inter-dental area.

Thus modified flap designs allowing access to the

defect area while preserving the interdental

papilla have been recently developed and used

Narrow interdental spaces hinders primary flap

closure due to crowding or tooth migration


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This case report presents

A MODIFIED SURGICAL APPROACH

FOR GTR TO MAINTAIN THE

INTEGRITY OF INTERPROXIMAL

SOFT TISSUE ABOVE INTRA-BONY

DEFECTS.


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AIM OF THE STUDY

To Develop a Surgical technique for

Primary wound closure

To facilitate a tension free re-adaptation

of periodontal flaps in order to maintainan uneventful healing process


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Authors reports only 1 case

Medically healthy

Non-smoker

Male 36 yrs

Informed consent

A single infrabony defect in theanterior region of the mandible


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Case Report


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Phase I periodontal therapy

Oral hygiene instructions

Full-mouth scaling and root planning


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Pre-operative


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Bone Defect


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Intrasulcular incision


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Vertical Incision


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Full Thickness Flap raised


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Preparation of the Internal Pedicle Flap, at the base

of the buccal flap a horizontal incision is performed


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The Internal pedicle flap is elevated from the

base of the flap in a coronal direction


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CLINICAL RESULTS

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Group 1

Group 2

Group 3

Group 4

Base line 3 wks after

1st step

6 mths after

2nd step

24 mths after

2nd step

Fig 1.


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0.5

1

1.5

2

2.5

Group 1

Group 2

Group 3

Group 4


1st step

6 mths after

2nd step

24 mths after

2nd step

3

0

Figure 2


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0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

Group 1

Group 2

Group 3

Group 4


1st step

6 mths after

2nd step

24 mths after

2nd step

Fig 3.

0


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Time Gp 1 Gp 2 Gp 3 Gp 4

Baseline 5.5 0.62 5.8 0.73 5.7 1.06 5.9 0.70

3 wks after

1st step

5.4 0.59 5.8 1.00 5.6 0.77 5.5 0.74

6 mths after

2nd step3,9 0.84 3.6 0.78 3.5 0.96 4.6 1.0

24 mths

after 2nd step

4.2 1.10 3.2 0.65 3.4 0.80 5.2 0.77

Table 1

Probing depth (Means SD)


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Baseline 6.0 1.05 6.2 1.0 6.1 0.96 6.3 0.77

3 wks after1st step 5.9

1.03 6.0

0.742 6.4

0.83 6.0

0.91

6 mths after

2nd step

4.8 0.83 4.3 0.74 4.4 1.0 5.7 0.96

24 mthsafter 2nd step

5.1 0.90 4.0 1.07 4.2 0.87 5.9 0.76

Table 2

CAL (Means SD)


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Baseline 8.6 1.21 8.1 1.07 8.4 0.76 8.2 1.03

3 wks after

1st step7.8 1.12 7.6 0.96 8.0 1.00 8.1 0.93

6 mths after

2nd step5.2 0.79 3.6 1.14 4.2 1.06 5.9 1.19

24 mths

after 2nd step6.6 0.87 3.3 1.09 3.6 0.98 7.0 1.03

Table 3

Probing depth (site categories 6 to 9 mm,

> 9 mm means SD)


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Baseline 10.1 1.21 9.8 1.62 10.4 1.04 9.6 0.86

3 wks after1st step

9.6 1.1 9.2 0.96 9.9 1.23 9.0 0.98

6 mths after

2nd step

8.1 0.83 6.7 1.22 7.4 1.0 8.2 0.77

24 mths

after 2nd step

8.7 1.02 6.4 1.12 7.5 1.17 9.1 1.23

Table 4

CAL (site categories 6 to 9 mm,

> 9 mm means SD)


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CF CELL RESULTS

0.5

1

1.5

2

2.5

Group 1Group 2

Group 3

Group 4


1st step

6 mths after

2nd step

24 mths after

2nd step

3

0

Figure 2


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0

10

20

30

40

50

60

70

80

90

Group 1

Group 2Group 3

Group 4


1st step

6 mths after

2nd step

24 mths after

2nd step


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MICROBACTERIAL RESULTS


Baseline 12 (100%) 14 (93%) 11(100%) 9(90%)

3 wks after1st step 10(83%) 11(73%) 8(73%) 8(80%)

6 mths after

2nd step

3(25%) 0(0%) 2(18%) 4(40%)

24 mthsafter 2nd step

7(58%) 0(0%) 1(9%) 7(70%)

Positive samples of P gingivalis


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Baseline 3(25%) 6(40%) 5(45%) 4(40%)

3 wks after1st step

4(33%) 5(33%) 3(27%) 3(30%)

6 mths after

2nd step

2(16%) 1(6%) 1(9%) 4(40%)

24 mths

after 2nd step

4(33%) 0(0%) 1(9%) 3(30%)

Positive sample of Aa


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Second step is called Enhanced Root Planing

Metronidazole & Clindamycin more effective

than Doxycycline in Eradicating Periodontopathic bacteria

Improving host response


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Loesche et al(1992) metronidazole

van Winkelhoeff et al (1992) - metronidazole

& amoxicillin

Saxer et al (1993) metronidazole in LJP

Slots et al (1983)

Tetracycline In LJP

Gordon et al (1993) bacterial resistance


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No antibiotic sensitivity test done

No comparison of LDD

Bacterial Resistance not addressed


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The Double Split Flap a Surgical Approach for Regenerative Treatment of in Terproximal Defects97