single flap approach with and without guided tissue
TRANSCRIPT
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Single flap approach with and without
Guided Tissue Regeneration
and a Hydroxyapatite biomaterial in themanagement of intraosseous periodontal defects
Leonardo Trombelli, Anna Simonelli, Mattia Pramstraller,Ulf M.E. Wikesjo, and Roberto Farina
Kim YunJeong
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Single flap approach ?
Minimally invasive surgical technique: lessen surgical trauma with adequate access
: limited or no use of release incisions, limited flap reflection
SFA (single flap approach): unilateral elevation of a limited mucoperiosteal flap to allow
surgical access depending on the main, buccal or oral,extension of the intraosseous defect leaving adjoininggingival tissues intact
Trombelli L 2007
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Single flap approach (SFA)
facilitate flap repositioning and suturing
: can easily be stabilized to the undetached papilla, optimizing wound closure for primary intention healing
accelerated reestablishment of the local vascular supply
preservation of the pre-existing gingival esthetics
SFA combined with a hydroxyapatite (HA) and GTR allowedsubstantial clinical attachment gain,
limited gingival recession (REC),
generally uneventful healing in deep intraosseous defects.
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Background
GTR was more effective than OFD(open flapdebridement) in improving attachment levels
Needleman I, Tucker R, Giedrys-Leeper E, Worthington H..A systematic review of guided tissue regeneration for periodontal
infrabony defectsJ Periodontal Res. 2002
Challenging intraosseous defects, surgicallyaccessed with a buccal SFA and treated with acombined graft/GTR technique, may heal with a
substantial CAL gain.Leonardo Trombelli .. Single-Flap Approach With Buccal Accessin Periodontal Reconstructive Procedures J Periodontol 2009
application of a wound stabilizing element; GTR device ora biomaterial, allowed wound healing progressing onto a
connective tissue attachment , not epithelial attachment
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Needleman%20I%22[Author] -
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single-center randomized-controlled trial
Patients1) diagnosis of chronic or aggressive periodontitis
2) no systemic diseases that contraindicated periodontal surgery3) no medications affecting periodontal status
4) no pregnancy or lactation
5) presence of 1 deep ( PD5 mm, radiographic depth 4 mm)interproximal intraosseous periodontal defect limited to no
extension on the lingual-palatal side as assessed by
preoperative bone sounding
6) full mouth plaque score and bleeding score
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Each intraosseous defect was randomly assignedto receive SFA or SFA + HA/GTR
The patients and the clinical examiner weremasked with respect to treatment allocation
SFA after full mouth SRP and oral hygiene
instruction.
Materials and Methods
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Probing
buccal envelope flap
without vertical
releasing incisions
Sulcular incisions are performed followingthe gingival margin of the teeth
interdental incision is performed >1 mm coronalto the underlying bone crest
Materials and Methods
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Flap elevation Debridement using hand and ultrasonicinstruments
HA-based biomaterial (BIOSTITE) and
resorbable collagen membrane (PAROGUIDE)
Materials and Methods
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horizontal internalmattress suture
second internal mattress suture
Materials and Methods
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2wk post-op
Inhibit 4wks mechanical oral hygiene procedure
0.12% chlorhexidine mouthrinse (10 ml twice a day for 6 weeks)
antimicrobial AmF/SnF2 mouthrinse and toothpaste
Monthly R/C with supragingival plaque control
6mo post-op
Materials and Methods
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Recordings One calibrated masked examiner
manual pressure-sensitive probe with 1-mm increments
approximately 0.3-N force
PD (gingival margin~bottom of the pocket)
CAL (CEJ~bottom of the pocket)
REC (CEJ~gingival margin)
bleeding score (+/-) ->measured at 6 aspects per tooth
presurgery/ post op 6mo
Materials and Methods
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Recordings configuration of the intraosseous defect
depth of the intrabony component
: deepest point of the defect ~most coronal point of thealveolar crest at the adjacent tooth
statistical software program Student t test , x2 test
early wound-healing index (EHI, Wachtel,2003)
1) complete flap closure, no fibrin line in the interproximal area
2) complete flap closure, fine fibrin line in the interproximal area3) complete flap closure, fibrin clot in the interproximal area4) incomplete flap closure, partial necrosis of the interproximal tissue5) incomplete flap closure, complete necrosis of the interproximal tissue.
Materials and Methods
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Results
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Results
5 defects inSFA+HA/GTRgroup showedlimited (
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Results
12 SFA versus 7 SFA + HA/GTR defects
showed a post-surgery PD
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Discussion
HA-based biomaterial: SFA + HA/GTR group displayed considerable
CAL gain (4.7 mm) and PD reduction (5.3 mm)
-> consistent with previous studies of conventional flap + HA/GTR
Five sites in the SFA + HA/GTR group exhibitedsuture-line dehiscences that apparently resolved
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SFA supported considerable clinical improvements asa stand-alone protocol
: CAL gain averaged 4.4 mm, 11 sites >3 mm gain
at 6m post op
The effect of SFA largely exceeded those reportedfor conventional access flaps in the treatment ofintraosseous periodontal defects.
: limited surgical trauma and optimal conditions
for wound closure/wound stability
Discussion
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Variations in supracrestal and osseousdefect characteristics
presurgery supracrestal tissue thickness for the SFA(2.4mm) compared to the SFA +HA/GTR group (1.1 mm)
SFA group exhibited greater prevalence sites with
3-wall component
The depth of the intrabony component
:SFA (6.1mm) vs. SFA +HA/GTR group (8 mm)
Discussion
Treating with barrier membrane, defect
configuration does not seem to significantlyaffect the amount of CAL gain (Trombelli, 1997)
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REC increased 0.8 mm in the SFA group compared
to 0.4 mm in the SFA + HA/GTR group
REC of the interproximal gingival margin occurreddespite the preservation of supracrestal tissues
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Conclusion
SFA with and without HA/GTR seems to bea valuable minimally invasive approach inthe treatment of deep intraosseousperiodontal defects.
Under the present experimental conditions,the additional HA/GTR protocol offers no
significant adjunctive effect.
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Epilogue
Strong point First trial to compare the effects of SFA and
SFA+HA/GTR protocol
Weak point The comparison was not performed in same conditions
In two groups of 12 patients, baseline defectcharacteristics and age, smoking status .
were different in many aspects