Gingivectomy versus flap surgery: George Proestakis', Goran

S6derholm\ Gunilla Bratthair,

Boel Kuilendorff, Kerslin

the effect of the treatment of GrondahP, Madeleine Rohlin^ and

Rolf Attstrom'
Departments of 'Periodontology and "Oral

infrabony defects
Radiology, Faculty ot Odontology, University
of Lund, ^Department of Oral Radiology,
Faculty of Odontology; University of
Goteborg, Sweden
A clinical and radiographic study

Proestakis G. Soderholm G. Brattkall G, Kullendorff B. Grondahl K. Rohlin M

and Attstrom R: Gingivectomy versus flap surgery: the effect of the treatment of
infrabony defects. A ctinical and radiographic study. J Clin Periodontol 1992: 19:
497-508.

Abstract. The aim of this paper was to compare the short-term results of
gingivectomy (GV) and modified Widman flap (MWF) surgery in the treatment
of infrabony defects. 14 patients with 68 bilateral infrabony defects were selected.
At baseline, and 3 and 6 months postoperatively. assessments of oral hygiene,
gingival conditions, bleeding on probing, probing pocket depth and attachment
level, were recorded. Conventional radiograps were obtained in a way that assured
a reproducible projection geometry. In a split-mouth design, one jaw quadrant was
randomly treated with GV. while the contralateral with a MWF. The changes of
the bone tissue were assessed by means of conventional and subtraction images
by 2 observers. The interobserver agreement of the conventional and subtraction
technique was studied. The majority of the sites demonstrated a significant improve-
ment in gingival conditions and a reduction in bleeding. For both treatments,
probing depths were reduced by an average of 3 mm. while a mean of 1.22-1.35
mm of probing attachment gain was obtained. The GV resulted in slightly more
gingival recession (1.90 mm) than the MWF {1,60 mm). The radiographic
examination demonstrated gain of bone in 7 defects treated with GV and in 9 Key words: periodontal healing; infrabony de-
defects treated with MWF, This study demonstrated that pockets associated with fects; surgical treatment; clinicai measure-
infrabony defects can be successfully treated by both treatment modalities. Fur- ments; subtraction radiography.
thermore, bone gain can occur after treatment but not in a predictable manner. Accepted for publication 6 August 1991

Periodontal surgery is a valuable tool
to achieve healing of the periodontal
tissues. The need for accomplishing di-
rect access to the root during the treat-
ment of periodontally compromised
teeth justifies the incorporation of dif-
ferent surgical procedures in the oper-
ators armamentarium.
This need is particularly acute in
cases where infrabony pockets are pres-
ent. Following treatment of these de-
fects, discrepancy between the form of
the soft tissues and the irregularly re-
sorbed alveolar bone can be expressed
as increased pocket depth (Prichard
1961. Ochsenbein 1977). Thus, it may be
necessary either to recontour the bony
structures or the soft tissue in order to
overcome this discrepancy, or to achieve
repair or regeneration of the perio-
dontal tissues,
A large number of studies has been
performed to evaluate the healing poten-
tial of the periodontal tissues after surgi-
cal treatment of infrabony defects. Elle-
gaard & Loe (1971) treated 191 infra-
bony defects with flap procedues. They
found. 6 months postoperatively, com-
plete bone fill, assessed by periapical
radiographs, and gain in probing attach-
ment in 70% of the teeth exhibiting 3-
wail defects. 40% of the teeth with com-
bined 3- and 2-wali defects and in 45%»of
the teeth with 2-wall defects. Poison &
Heijl (1978). treated surgically 15 defects
(seven 3-wall and eight 2-i-3-wall ones).
The mean initial defect depth was 3,5
mm. At the time of re-entry operation,
regeneration of bone tissue was ob-
served, with a mean amount of bone fill
of 2,5 mm. The same successful outcome
regarding bone regenerat was achieved
by Rosling et al. (1976a. b) in patients
with a high standard of oral hygiene.
Smaller amounts of bone fill (1.2-1,4
mm) and gain of probing attachment
(1,2-2.0 mm), were achieved m other
studies (Renvert & Egelberg 1981.
Renvert e t a l 1981). Isidor et al, (1985).
treated 43 angular bony defects with
flap procedures in 3 of the 4 quadrants
tested, while the 4th quadrant was
treated with root planing alone. 1 year
post-treatment, the mean coronal re-
growth of bone was found to be at a
level of 0.5 mm. The probing attach-
ment gain ranged from 0.5 to 1,9 m.
depending on the treatment modahty.
As can be concluded from previous
studies, the results regarding the pre-
dictability of the healing outcome after
surgical treatment of intraosseous
lesions are contradictory.
The aim of the present study was to
compare clinically and radiographically
the healing of infrabony defects treated
with the gingivectomy (GV) with the
healing after modified Widman flap
(MWF) technique.
498 Proestakis et at.
Table I. Experimental design
2 months
Seieclion Baseline
PU
GI
BOP
PPD
PAL
Radiography
Photos
Defect class.
Material and Methods
14 patients, 6 female and 8 tnales, 17-57
years of age (tnean age 40 years) partici-
pated in the study. The selection criteria
were: (a) uncomplicated tnedical his-
tory; (b) at least 2 teeth with proximal
infrabony defects located bilaterally; the
defects should be revealed radiograph-
ically; teeth with furcation involvements
or deep root furrows were excluded; (c)
ability to follow regularly the recall ap-
pointments.
The initiai treatment was performed
by a dental hygienist 2 months prior
to the surgical procedure. It comprised
instructions in oral hygiene measures
and scaling of the entire dentition. Fol-
lowing that, the patients returned for a
basehne examination,
A total of 68 teeth exhibiting a defect
site with probing pocket depth > 5 mm
2 months after scaling was selected for
surgical treatment. Each patient con-
tributed to the study with between 2 and
13 teeth located at 2 or 4 quadrants of
the dentition,
A split-mouth design was applied,
with 32 teeth randomly selected to be
treated with the gingivectomy pro-
cedure (GV) while 36 contralateral teeth
were treated with a modified Widman
nap (MWF) procedure,
Crinical examination
The experimental design is presented in
Table 1,
At the baseline examination and at
the 3- and 6-month postoperative exam-
inations, assessment of the periodontal
status was performed by one observer
(G,P,j in the following sequence:
(1) gingival conditions (gingival
index, GI, Loe 1967);
(2) probing pocket depth, (PPD);
(3) probing attachment level, (PAL);
(4) bleeding on probing to the bottom
of the pocket, (BOP);
Maintenance treatment
Surgery 3 months 6 months
(5) oral hygiene status (plaque index,
PH, Silness & Loe 1964),
Measurements were obtained at 4
sites of each tooth: mesiobuccal, mid-
buccal, distobuccal and mid-lingual.
Probing was performed with a cali-
brated periodontal probe (LL 20, Hu
Friedy, USA) to the nearest mm (diam-
eter of the probe tip 0,5 mm, 1 mm
increments). The margin of a vacuum
adapted soft acrylic onlay (0,7 mm
thickness, Erkoien, Germany) was used
as fixed reference level for the PAL
measurements. For the proximal meas-
urements, the probe was guided by the
interdental indentations of the splint as-
suring a standardized angulation of the
probe towards the deepest part of the
defect.
To estimate the gingival recession, the
distance from the acrylic onlay margin
to the gingival margin at the baseline
examination was compared with the
same distance at 3- and 6-months post-
operatively.
Sources of error
In order to assess the intra-examiner
measurement performance, repeated
measurements of the probing pocket
depths and probing attachment levels
were performed at the 3- or the 6-month
postoperative examination in 60 teeth
(240 surfaces). The measurements were
Table 2. Intra-examiner performance for duplicate measurements of probing pocket depth
(PPD) and probmg attachment level (PAL) expressed in number of sites and in % of Jotal
number of sites {A'=240 sites)
Probing pocket depth
Difference
(mm) no. (%)
-3 2 0,8
2 5 2,0
„_! 42 17,5
0 164 68,5
-n 26 10,8
+2 1 0,4
0 0
x + S,D,= -0,125±0,667
repeated with a 2-week interval between
the 1st and 2nd examination. Table 2
presents the intra-examiner perform-
ance.
Complete agreement was achieved in
68,5% of the sites for the measurements
of PPD and in 63,8% for the PAL meas-
urements. The measurements of FPD
and PAL were reproduced within I mm
in 96,8'yij and 95,4% of the sites, respec-
tively. The standard deviation of the
duplicate measurements was 0,667 mm
and 0,723 mm for the PPD and the
PAL, respectively,
Radiograpiiic examination
Conventional radiography
To obtain a reproducible projection ge-
ometry, a hard acrylic splint was made
on each individual plaster cast, A plastic
film holder (Twix*, ASDI, Sweden),
was attached with cold cured acrylic
resin to the splint on the sites to be
examined. Care was taken to attach the
film holder as parallel as possible to the
tooth under examination, E-speed film
No, 0 (Ektaspeed, Kodak, Rochester,
USA) was used. As X-ray source, a ce-
phalostat with a focus-film distance of
150 cm and an object-film distance of
0,5-1,0 cm was utilized. Different angu-
lations ( 1 5 ' ^ 5 ) in the horizontal plane
were used, depending on the site to be
examined. The exposure parameters
were 100-120 mAs and 60 kV, The films
were processed in an automatic pro-
cessor (Diirr Periomat, Germany) with
a processing time of 7 min. The conven-
tional radiographs were mounted in
pairs (Fig, l-3a, b), in opaque film
frames (Trollhatteplast, TroUhattan,
Sweden),
Subtraction technique
The conventional radiographs were
converted to video signals and digitized
by an 8-bit analog to digital converter
Probing attachment level
no. (%)
0 0
6 2,5
38 15,8
153 63,8
38 15,8
4 1,7
1 0,4
,£ + S,D, = -0,004±0,723
 Surgical treatment of infrabony defects 499

Fig. I. Subtraction image (c) based on conventional radiographs

taken at ba.ieline (a) and 6 months postoperatively (b) of a mandibu-
lar 1st molar treated by GV. The distal site (arrow) was assessed by
the 2 observers to present gain of bone tissue.

(256 grey-levels), resulting in images of
512 X 512 pixels corresponding to about
3 x 3 cm- in the original image. The
baseline radiographs were digitally sub-
tracted according to Grondahl et al.
(1983), from the subsequent radio-
graphs obtained 6 months postopera-
tively. Before the subtraction, a grey-
level value of 128 was added to each
pixel of the subsequent image. There-
fore, the resultant subtraction image re-
ceived a background grey-level of 128.
against which any differences between
the original radiographs showed up.
Areas darker than the background cor-
responded to areas with a loss of bone
tissue, while those which appeared
brighter corresponded to areas with
gain of bone tissue (Fig. 1), Figs, 2 and
3 are examples of resultant subtractioti
images demonstrating loss and un-
changed appearance of botie tisstie, re-
spectively.
The bone tissue of each site was classi-
fied into 1 of the 3 categories: gain (Fig,
1), continued loss (Fig, 2) or unchanged
appearance of the bone (Fig. 3),
The conventional radiographs from
the baseline examinatioti were compared
with those taken 6 months postopera-
tively for an analysis of both the distal,
mesial and the buccalingual sites. The
subtraction images were interpreted di-
rectly as presented on the TV screen. The
conventional radiographs and the sub-
traction images were first independently
and separately assessed by 2 oral radiol-
ogists (BK and KG), Then, each exam-
iner ititerpreted the bone tissue with ac-
cess to both the conventional and the
subtraction images. For the final evalu-
ation of the bone tissue, all infortnation
from the conventional and the subtrac-
tion images was evaluated by both ob-
servers together until they came tc an
agreement. The inter-observer agree-
ment for the 2 observers is expressed as
overall agreement and as Cohen's K
index (Nuttall & McPaul 1985).
Surgrcal procedures
Gingivectonty procedure
The gingivectomy operations in the
same patient were carried out by 1 of 2
operators (GS and RA). according to
the basic principles described by Gold-
man (1946, 1951), The excision of the
soft tissues was performed in 2 stages.
Firstly, after marking the base of the
pockets buccaliy and lingually the sup-
racrestal portion of the soft tissue
pocket was removed by an externally
bevelled incision. The incision was end-
ed just above the bone crest in such a
way that part of the buccal and lingual
soft tissue was also excised. In patients
with a shallow palatal vault, minimal
bevelling was performed in order not
to produce an extended wound surface.
Secondly, the inner contents of the bony
pocket were removed using a scaier or
a heavy surgical curette until the botiy
walls covering the defects were felt. All
granulation tissue was removed. The
depth of the defect was measured with
a calibrated periodontal probe, 2 teeth
with defects shallower than 2 mm and
1 tooth with furcation involvement were
excluded. The infrabony defects were
classified according to the number of
os,seous walls surrounding the defects
(Goldman & Cohen 1958), All root sur-
faces were scaled and planed smooth
with ultrasonic and hand instruments.
Bone removal was not performed. The
wound was irrigated with sterile saline,
Periodontal pack (Coe pack", COE
Lab,, Inc, Chicago, USA) was applied,
first interdentally into the bone defects
and then buccally and lingually.
500 Proestakis et ai.

Fig. 2. Subtraction image (c) based on conventional radiographs

taken at haselitie (a) and 6-months postoperalively (b) of the man-
dibular premolars treated by MWF. The distal sites (arrows! were
assessed by the 2 observers to present contitiued loss of bone tissue.

The patients returned for pack re-
moval after ! week. Pack reappiication
was performed weekly for a minimum
of 2 weeks.
Modified Widman flap procedure
The MWF operations were peformed
by another operator (GB) according to
the principles described by Ramfjord &
Nissle (1974). During the initial in-
cision, care was taken to preserve as
much as possible of the interdental
tissue. Mucoperiosteal flaps v/ere elev-
ated 3-5 mm apically to the alveolar
crest. After the granulation tissue was
removed from the defects, the same
measurements were taken as those dur-
ing the gingivectomy operations. 1
tooth presented furcation involvement
and was excluded from further evalu-
ation. The root surfaces were scaled and
root planed. Osteoplasty was not per-
formed in any case. The flaps were re-
placed at or near to their presurgical
positions and sutured with interrupted
sutures. Periodontal pack was not ap-
plied. Sutures were removed 7-10 days
after surgery.
Maintenance care
All patients, except 1. were instructed
to rinse. 2 x daily, for a period of 4
weeks postoperativeiy with 0.2% solu-
tion of chlorhexidine digluconate (Hibi-
tane«. ICl, Great Britain).
The patients were followed on a
weekly basis during the 1st postopera-
tive month. For the rest of the healing
period, they were maintained on a
plaque control programme which in-
cluded oral hygiene reinforcement and
professional tooth cleaning every 3-4
weeks. Subgingival scaling was not per-
formed at any of the recall appoint-
ments.
Statistical analysis
Changes in plaque and gingiva) scores
were analyzed with the /" test. The Wil-
coxon signed rank test was used to ana-
lyze the bleeding scores and the soft
tissue changes between treatments at the
different examinations, as well as to
analyze the effect of each treatment
from the baseline. The patient was
chosen as the computational unit. The
hypothesis of equal treatment effects
was rejected at the 0.05 level of signifi-
cance. In addition, the 95'K. non-para-
metric confidence interval for the differ-
ences was calculated.
Results
Piaque index
A statistically significant improvement
m the oral hygiene status occurred dur-
ing the postoperative period for both
treatment modalities (^< 0.001). At the
baseline examination, only 17-21% of
all sites of the experimental teeth were
free of plaque (PlI 0). The plaque-free
sites increased to 48-52% at the 3-
month examination and to 52-54°/i> at
the 6-month postoperative examination
(Fig. 4a). No differences were found in
the distribution of plaque indices of the
tooth sites (interproximal and defect)
treated with GV and MWF at any of
the time intervals (/'>0.10).
Gingival index
At the baseline examination, none of
the sites in the GV or MWF groups
 Surgica! treatmeni of infrabony defects 501

Fig, 3. Subtraction image (c) based on convenliona! radiographs

laken at hasvline (a) and 6 months post ope rative]y (b) of a mandibu-
lar lsi molar treated with MWF The distal sile (arrow) was assessed
by the 2 observers lo present unchanged appearance of bone tissue.

PLAQUE INDEX exhibited dinically healthy gingiva (GI

AtL SITES INTERPBOXIMAL SrTES DEFECT SITES 0). At the 3-month postoperative exam-
ination, the";. of inflamtnation-free gin-
BL 3M >BL 3M I
givai units was 46^9°/ij, and 6 months
postoperatively, this was further in-
creased to 54-59'/ii for the GV and
MWF groups, respectively (Fig. 4b),
Only 6-10% of the sites exhibited GI 2
6 months after the treatment com-
pletion. The improvement in the gin-
GV MWF CSV MWF GV MWF QV MWF QV tJMF gival status was, for both treatments,
statistically significant compared to
baseline (/><0.001). When the distri-
bution of the GI scores was analyzed
GlNGiVAL INDEX separately for the interproximal and the
ALL SITES INTERPROXIMAL SITES DEFECT SITES defect sites, it was shown that the defect
sites exhibited a smaller "/« (n-AS'Yo)
3M 6M 3K/I 3M 6M of inflammation-free sites. While a
QGIO
OGII statistically significant improvement
ao
(/><0.001) for the GI scores was shown
within treatments for each of the site
categories examined, the differences be-
tween treatments were not significant

OV MWF GV MV»F GV GV tMfF SV MWF GV MWF QV MVWF GV MWF GV MWF

B
Bleeding on probing
Fig. 4, % distribution of plaque index (Fig. 4a) and gingival index (Fig, 4b) scores at the
liaseline exatnination and the exatninations 3 and 5 months postoperatively, for the different During the maintenance period, a
site categories treated with gingivectomy (GV) or n^odified Widman flap (MWF). marked reduction in the % of sites with
502 Proestakis et al.
BIDDING ON PROBING
ALL SITES INTEHPROXIMAL STTES
BASEUNE 3 MOHTHS 8 MDKTHS 3 MONTHS « MONTHS
Fig 5. % dislribulion of individual mean bleeding on probing (BOP) scores at the baseiine
examinalion and the examinations 3 and 6 months postoperatively for the different site
categories treated with GV or MWF.
bleeding on probing occurred, from
64-53% at the baseline examination to
23-29% at the 3-nionth examination,
and to 12-21% at the examination 6
months postoperatively (Fig. 5). The re-
duction in the bleeding scores was statis-
tically significant ( / J < 0 . 0 1 ) for both
groups. Analysis of the pooled data
concerning the bleeding tendency
showed that the MWF group had. 6
months postoperatively, significantly
fewer ( / J < 0 . 0 5 ) sites that bled on prob-
ing than the GV group (;)<0.05). The
results of the site-specific analysis
showed that greater reduction in the
BOP scores could also be seen during
the postoperative period in the inter-
proximal sites of the MWF group
Probing pocket depths
When all tooth sites were examined, a
mean of 1.50 mm reduction in PPD oc-
curred during the postoperative period
(Fig. 6a). The reduction was the same
for both treatment modalities and stat-
istically significant cotiipared to the
PROBING POCKET DEPTHS
ALL SITES DEFECT SITES
man (mil
Fig. 6. Individual mean probing pocket depths at the baseline examination and the examin-
ations 3 and 6 months postoperatively for the different site categories treated with GV or
MWF
DEFECT srres
BASELINE 3 MOMTHS B MONTHS
baseline values (p < 0.001). The separate
analysis of the restilts for each site cat-
egory showed that the largest reduction
in PPD occurred in the sites exhibiting
infrabony defects (Fig. 6b). The initial
PPD values or 6.35 mm for the GV
group and 6.40 mm for the MWF group
were reduced by 3.00 mm and 2.60 mm.
respectively, at the 3-month examin-
ation. This reduction was statistically
significant (jP< 0.001) compared to
baseline for both groups. Minor alter-
ations m the PPD occurred between the
3- and 6-month postoperative examin-
ations. For the interproximal sites, sig-
nificant reduction was shown amount-
ing to between 2,36 mm for the sites
treated with GV and 2.10 mm for those
treated with MWF (Fig. 6c). The com-
parison between the GV and MWF
groups showed that in none of the site
categories did a significant difference in
the amount of PPD reduction exist. Fig.
7 presents the % distribution of PPD
for the defect sites at the different exam-
ination intervals. In the GV group, 21
(65%) of the infrabony pockets were 4-6
mm deep and 11 (35%) > 6 mm deep at
INTERPROXIMAL SITES
the baseline examination. The corre-
sponding numbers were 21 (58%) and
15 {42-y«) for the MWF group, 3 months
after treatment, none of the sites in the
GV group was deeper than 6 mm,
whereas only 9 (28%) of the remaining
pockets were in the 4-6 mm category.
The same distribution was noted for the
6-month examination. 3 months after
treatment, none of the MWF sites was
deeper than 6 mm. The prevalence of
moderately deep sites dropped to 47%.
At the 6 months re-examination, only 1
surface was > 6 mm deep, whereas the
sites at the 4-6 mm category were
ftjrther reduced to 14 (39%).
Probing attachment levels
A small but significant (p<0.05) gain
of probing attachment was noted post-
surgically when all sites of the GV and
MWF groups are analyzed (Fig. 8a).
The amount of attachment gain was
0.44 mm and 0.36 mm (3 months post-
operatively). and 0,36 and 0.50 mm at
the 6-month examination for the GV
and MWF groups, respectively. The de-
fect sites of both groups showed a mean
gain of probing attachment at the level
of 1.22 mm to 1,35 mm 6 months post-
operatively (Fig. gb). This gain was stat-
istically significant compared to base-
line (/7<0.01). The differences between
the groups, however, were not statisti-
cally significant (/)>0.05). A smaller
gain was recorded for the interproximal
sites (Fig. 8c) compared to the defect
sites. This gain, though, was significant
at every examination compared to base-
line for both treatment groups
Fig. 9 presents the % distribution of
different classes of PAL change for the
defect sites, 10 (3r/o) of the sites sub-
jected to GV and 14 (39%) of the total
defect sites subjected to MWF gained
2 mm or more of probing attachment
compared to baseline. Of the defect sites
in both groups. 30-40% gained 1 mm
of probing attachment. Only 2 (6%) and
1 (3%,) of the sites treated with GV and
MWF, re.spectively, displayed loss of
probing attachment 6 months post-
operatively. This loss never exceeded 2
mm.
When the changes in PAL were ana-
lyzed according to the initial PPD of
the sites (Fig. 10), a significant loss of
probing attachment occurred for the
sites initially 1-3 mm deep (/)<0.05).
For the moderately deep sites of both
treatment groups, a significant
 Surgical treatment of infrabony defects 503

PERCENTAGE DISTRIBUTION OF PPD changes were seen. Smaller amounts of

recession were calculated, 6 months
DEFECT SITES postoperatively, for the interproximal
sites (1,33 mm and 1,49 mm for the GV
and MWF, respectively) compared to
the defect sites; the GV procedure re-
sulted in an average 1,92 mm of root
exposure in contrast to the 1,57 mm of
the MWF (Ftg, l i b , c). The amount of
gingival recession on the defect surfaces
GVBL
was signiftcant for both procedures
GV3M GV GM
MWFBL
compared to baseline (p<0,01), but the
MWF3M MWF6M
^ 1 - 3 mm
difference between the procedures was
i'vi 4-6 mm
not statistically significant (/)>0,05),
Fig 7. % distribution of probing pocket depth categories at the baseline examination and the The % distribution of the changes in
examinations 3 and 6 months postoperatively for the defect sites treated with GV or MWF,
recession for the defect sites compared
to baseiine is presented in Fig, 12, The
GV had 66% of the sites tn the 2-3
mm level compared to the MWF 61% 3
PAL C H A N G E S
months postoperatively. Similar pat-
ALL SITES DEFECT SrTES INTERPFIOXIMAL SfTES terns of changes in recession was noted
mean (mm) mean (min) mean (mm) for both groups 6 months postopera-
tively,

Radiographic examination

The image quality of the radiographs of

10 teeth precluded the assessment of the
3 MONTHS 6 MONTHS 3 MONTHS 6 MONTHS 3 MONTHS 6 MONTHS bone tissue. Therefore, the assessment
S GV & MWF S GV Q MWF Ea MWF of the bone tissue was performed in 25
Fig. H. Individual mean probing attachment level changes compared !o baseline for the teeth of the GV group (28 mfrabony
different site categories treated with GV or MWF. defects) and in 29 teeth of the MWF
group (30 infrabony defects).
Table 3 presents the observer per-
formance for all assessed sites. The
PERCENTAGE DISTRIBUTION OF PAL CHANGES oveall inter-observer agreement and the
DEFECT SITES corresponding h: index values were 64%
and 0,12 for the conventional radio-
graphic technique, 78% and 0,50 for the
100 subtraction technique, and 86% and
80 0,62 for the simultaneous interpretation
ao of both conventional and subtraction
images. The overall inter-observer
40 agreement for the assessment of the de-
20 fect sites was, however, lower than the
agreement for all sites. For the conven-
QV3M MWF3M MWF6M tional radiographic technique, the over-
>- 2 mm S? 1 m m ^ 0 mm ; < - -1 min all agreement for the defect sites was
Fig. 9 % distribution of probing attachment level changes at the 3 and 6 months postoperative 38%, for the subtraction technique 69%
examinations compared to baseline for the defect sites treated with GV or MWF, and for the simultaneous interpretations
of both conventional and subtraction
technique, 80%,
(/'<0,05) gain of attachment could be The simultaneous interpretation of
Gingival recession
observed (0,78 mm for the GV and 0,55 conventional and subtraction images of
mm for the MWF) 6 months postopera- Similar and statistically significant the defect sites by both observers is pre-
tively. The largest gain of attachment (p< 0,001) amounts of gmgival re- sented in Table 4, 7 (25%) of the defects
occurred, for both treatment groups, at cession, compared to baseline, were treated with GV gained bone tissue (Fig,
the initially deeper site category ( > 6 found at the tooth surfaces of each I) compared to 9 (30%) treated with
mm); the GV treated sites gained on group at both postoperative examin- MWF, 1 defect of the GV group and 5
the average 1,90 mm while the MWF ations, 3 months postoperatively, the of the MWF group lost bone tissue dur-
treated sites gained 2,00 mm compared amount of gingival recession was 1,15 ing the 6 months period (Fig, 2), In the
to baseline (p<0,05 for both treat- mm for both groups (Fig, 1 la). For the remaining defect sites of both groups,
ments). rest of the study period, only minor the appearance of the bone tissue was
504 Proestakis et al.

PALCHANGES PAL CHANGES judged as unchanged (Fig, 3), Frotn the

other interproximal sites in each group.
ALL SITES ALL SITES
i,e,. all interproximal sites besides those
GINGIVECTOMY MODIFIED WIDMAN FLAP with irtfrabony defects. 1 site in the GV
group and 2 in the MWF group showed
gain of bone tissue, 3 of the sites treated
with GV and 6 treated with MWF pre-
sented continued bone loss. Analysis of
the bone changes for the bucco-lingual
sites revealed that I site in each surgical
group showed gain, and 1 more loss of
3 MONTHS 6 MONTHS 3 MONTHS 6 MONTHS bone tissue. The majority of these sites
1-3 mm O 4-6 mm Q > 6 mm 1-3 mm B 4-G mm Q > e mm remained unchanged.
Fig. JO. Individual mean probing attachment level changes compared to ba.^eline according Variations were seen in the individual
to the initial PPD of all sites treated with GV or MWF, bone tissue changes. Thus, 1 of the sub-
jects accounted for 25V(, of the defect
sites, showing gain of bone, whereas 4
of the 14 subjects had 50% o( the sites
GINGIVAL RECESSION with bone gain. On the other hand. 1 of
the participants is responsible for 50%
ALL SITES DEFECT SITES INTCRPROXIfcML SITES
of the sites showing continumg loss of
iTwan (inin) Riaan (mm) mean (mm)
bone tissue. When the changes m bone
2,5 2,5 2,5
tissue were analyzed tn accordance with
2 2

1i
the number of defects walls (Table 4).
1,5 1,5 no relation could be found {/- = 11,162.
1 1
0,5 0,5 Table 5 compares the changes in PAL
0 0 and the bone changes between the base-
3 MONTHS 6 MONTHS 3 MONTHS 6 MONTHS 3 MONTTHS 6 MONTKS
Une and the 6 months postoperative
S QV S MWF S GV B MWF S GV @ MWF
examination, 19% of the sites that
Fig. I!. Individual mean changes in gingival recession compared to baseline for the different gained bone tissue also showed gain in
site categories treated with GV or MWF, PAL > 2 tnm, compared to only 3%
of the sites in the group that showed
unchanged appearance of the bone
tissue. Furthermore, none of the sites
PERCENTAGE DISTRIBLmC»J OF RECESSION CHANGES that gained bone tissue lost probing
attachment 6 months postoperatively.
DEFECT SITES
However, no statistically significant as-
sociation was shown between bone and
PAL changes (/-= 8,599, /)>0,05),

Discussion
The present study has shown that there
was no significant difference in the heal-
GV3M UWF3U GVSU ing response in infrabony pockets be-
E 0 / 1 mm fS 2 / 3 mm » > 3 mm tween the 2 treatment modalities, nor
Fig. 12. % distribution of changes in gingival recession at the 3 and 6 months postoperative was there any difference when all
examinations compared to baseline for the defect sites treated with GV or MWF, treated sites were induced. This is in
accordance with Zamet (1967), Rosling
et al, (1976b), Westfelt et al, (1985) and
Lindhe et aL (1987), In the study by
Table S. Overall inter-observer performance for 2 observers assessing conventional radio- Rosling et a!, (1976b). however, the
graphs, subtraction images and conventional and subtraction images together: numbers of attachment level changes of approximal
sites on which the 2 observers were unanimous or disagreed in their assessments surfaces treated with the GV technique
No, sites were evaluated. They found a loss of
attachment with a mean of 0,4 mm. This
Disagreement
Unanimous is in contrast to the present study, where
Imaging Technique decision 1 step 2 steps Total GV in approximal surfaces resulted in
conventional radiography 87 46 4 137 a gain of attachment (mean 0.93 mm).
subtraction technique 112 30 1 143 One reason for the differences between
conventional and subtraction 123 21 0 144 the 2 studies might be that in our study,

Table 4. Radiographic bone tissue changes 6 months postoperatively compared to baseline as
related to the defect type and the surgical modality
GV
Bone tissue
Defect type loss unchanged
1 wall 0 0
1 + 2 walls 0 0
2 walls 1 7
3 + 2 walls 0 6
3 walls 0 7
total 20
only teeth presenting infrabony defects
were included.
Pocket reduction was achieved by a
combination of gingival recession and
gain in probing attachment. Pockets as-
sociated with infrabony defects gained
on average 1,35 mm of probing attach-
ment after treatment with MWF, while
an average of 1,60 mm of gingival re-
cession was calculated. The amount of
probing attachment gain is somewhat
more than that obtained by Isidor et al,
(1985) and Becker et al, (1988), but less
than in the studies by Rosling et al,
(1976a), Froum et al, (1982) and Becker
et al, (1986), The levet of attachment
gain though, is consistent with Renvert
et ai, (1981), Renvert & Egelberg (1981),
Westfelt et al, (1985), Lindhe et al,
(1987), In the study by Isidor et al,
(1985), a gain of probing attachment of
0,5-0,9 mm was obtained after treat-
ment of infrabony defects, while the
amount of gingival recession in those
sites was 2,6-3,4 mm, Froum et al,
(1982) reported a mean 1,4 mm of PAL
gain and 2,0 mm of gingival recession
in infrabony pockets treated with open
debridement procedures, and Renvert &
Egelberg (1981) achieved 1,20 mm of
probing attachment gain and 1,60 mm
of recession. In the studies by Rosiing
et al, (i976a), a high standard of oral
hygiene was maintained during the en-
Tabk 5. Association between radiographic
bone tissue and probing attachment level
changes 6 months postoperatively compared
to baseiine for Ihe defect sites (A' = 58): num-
ber (Vn) of sites within each bone tissue
change category and the corresponding
changes in probing attachment level
Probing attachment level
Bone <-l
tissue mm 0 mm 1-2 mm > 2 mm
gain 0 (0) 2 (12) 11 (69) 3 (19)
unchanged 1 (3) 7 (19) 27 (75) 1 (3)
loss 1 (17) 1 (17) 4 (66) 0 (0)
Surgical treatment of infrabony defects
MWF
Bone tissue
gain loss unchanged gain
0 1 0 !
0
0 3 0
i 1 10 2 tenance period for both treatment mo-
3 1 1 3
3 2 •?
16
tire postoperative period, A gain of
attachment amounting to 3 mm was
achieved for the interproximal sites
treated with MWF, Variations in the pa-
tient and defect selection, preoperative
probing pocket and defect depths and
oral hygiene levels may account for
these differences.
The attachment level changes suggest
that the alterations are related to the
initial PPD of the sites. Shallow (1-3
tnm) pockets tend to lose probing
attachment, whereas deeper pockets
seem to gain. The biggest gam occurred
in initially deeper pockets. This obser-
vation corroborates the results from
similar studies (Rosling et al, 1976b,
Hill et ai, 1981, Pihlstrom et al, 1981.
Lindhe, et al, 1982a, b, Westfelt et al,
1985, Lindhe et al, 1987. Becker et ai,
1988), It should be noted, however, that
while attachment loss at initially shai-
lower sites mainly represents a true ioss
of connective tissue attachment, the
gain of attachment seen in deeper
pockets is due to tlie relative resistance
of the healthy periodontal tissues to api-
cal probe penetration (Armitage et al,
1977, Robinson & Vitek 1979. Van der
Velden 1979, Listgarten 1980),
The degree of gingival recession was
similar at all site categories for the two
treatment modalities (Fig, 11), When
the changes were analyzed separately
for the defect sites (Fig, 12), no differ-
ences could be seen in the distribution
of different degrees of root exposure be-
tween the procedures. These fmdings
are in accordance with those of Lindhe
et al, (1987), These authors studied the
post-surgical alterations of the perio-
donta] tissues utilizing, besides GV, 5
treatment modalities. They concluded
that irrespective of the treatment mo-
dality, heaiing is likely to produce simi-
lar degree of root exposure.
It was suggested that gingivectomy
results in uneven gingival contour (Za-
met 1967), This condition might have
505
posed an obstacle in the efftcacy of the
oral hygiene measures. In the present
study, however, no differences in Pll and
Gi were observed between the sites
treated with GV or MWF A significant
improvement in the plaque and gingivai
index scores occurred during the main-
dalities. It must be noted that this im-
provement would have been more dis-
tinct if the comparisons had been made
with the pre-hygiene plaque scores.
Substantial reduction in the sites that
bled on probing was observed during
the post-surgical examinations for both
treatments, ,A large number of inter-
proximal and defect sites though,
treated with GV, were still bleeding 6
months after treatment. For the defect
sites, however, the difference in the
bleeding tendency was not statistically
significant. No apparent explanation
can be given for that phenomenon, since
the prevalence of plaque and the gin-
gival index scores of these sites do not
verify a plaque induced inflammatory
response. It is possible that lateral probe
penetration into the connective tissue
(Spray et al, 1978) or disruption of the
vessels can be responsible for this reac-
tion,
A 6-month period was chosen for the
evaiuation of the treamtent outcome,
since previous studies have shown that
the major part of the soft tissue changes
were completed within 6 months follow-
ing treatment (Rosling et al, 1976a, b,
Lindhe et al, i982a, Lindhe & Nyman
i985, Westfelt et al, 1985, Lmdhe'et al,
i987).
In the present study, bone changes
were evaluated in both conventionai
radiographs and subtraction images.
The subtraction technique has been
proven to be a sensitive and accurate
method in evaluating alveolar bone
changes (Grondahl & Grondah! 1983.
Grondahl et al, 1983, Hausmann et al,
1985, Schmidt et al, 1988), It should be
noted that the possibility to detect
changes in the subtraction images is very
ciosely dependent on the level of stan-
dardization between the 2 radiographs
available for the subtraction technique
and the accuracy of their alignment
(Grondahl et al, 1984, Janssen et al,
1989), In order to overcome the problem
of geometric misalignment of some of
the images, a simultaneous interpreta-
tion of both conventional and subtrac-
tion images was applied. As the results
of overall agreement and K index values
indicate, higher agreement rates were ac-
 506 Proestakis et al.
complished when the subtraction tech-
nique was employed and even better
when the simultaneous interpretation
was applied. Similar values to these
found in the present study were demon-
strated by Grondahl et al. (1987).
In order to obtain a reproducible pro-
jection geometry of the radiographic im-
ages, a cephalostat was utilized. In a
study by Jeffcoat et al. (1987). it is stated
that the use of a cephalostat for a repro-
ducible patient positioning can give
even better results than when a stent
coupled to an X-ray tube is used. With
the cephalostat technique, the relation-
ship between the X-ray beam and the
object can stay nearly identical and the
long focus-film distance results in a uni-
form magnification, minimizing distor-
tion. However, the experiments by
Jeffcoat were carried out with strictly
lateral projections and only with bite-
wing films. In the present study, when
applying the cephalometric technique
together with a stent and not only in
lateral regions, equally good results
could not be achieved. One possible ex-
planation could be the selection of pa-
tients in the present study. Some of them
had such advanced bone loss that bite-
wing radiographs could not be used.
Periapical radiographs introducing a
higher risk for differences in film place-
ment and consequently projection dif-
ferences had to be used. Because the
teeth were used to secure film place-
ment, changes in their position over the
6-month period may have caused geo-
metric differences between the radio-
graphs.
Thus, the results indicate that in or-
der to use the cephalometric technique
for oblique projections, a more rigid
placement of the patient with some kind
of exact registration of the position at
the baseline examination is necessary.
Of the infrabony defects treated. 16
(28%) showed gain and only 6 (10%)
showed continued ioss of bone tissue
during the 6 months postoperative
period for both treatment modalities.
The variance in the bone changes is in
accordance with the results of the
studies by Renvert & Egelberg (1981),
Renvert et al. (1985a). Froum et al.
(1982), Isidor et al. (1985). In those
studies, bone changes after flap pro-
cedures were assessed by re-entry meas-
urements (Froum et al. 1982), transgin-
givai bone level measurements
(Renvert & Egelberg 1981, Renvert et
al. 1985a, b) or assessment of alveolar
bone height on standardized radio-
graphs (Isidor et al. 1985). Limited
amounts of bone gain (0.5-1.2 mm)
were obtained and the degree of bone
fill varied within the defects studied. In
contrast Rosling et al. (1976a, b) and
Poison & Heijl (1978) reported bone
gain in nearly all defects treated,
amounting 70°4.-80% of the initial de-
fect depth. Moreover, in the study by
Rosling et al. (1976b). 9 out of the 39
defects treated with gingivectomy ex-
perienced loss of bone tissue (mean 0.7
mm) postsurgically. it is possible that
variations in the level of post-surgical
plaque control, depth of the defects
studied and the method of evaluation
may account for the differences. In the
studies by Rosling et al. (1976a. b). the
assessment of the alveolar bone height
was performed by measurements on
standardized radiographs. Radio-
graphic measurements, though, are the
least accurate way of estimating changes
of alveolar bone height (Renverl et al.
1981, Benn 1990).
Studies of bone regeneration in infra-
bony defects suggested that 3-wall de-
fects have a higher osieogenic potential
than the 2- or 1-wall defects (Prichard
1957, Patur & Giickman 1962. Elle-
gaard & Loe 1971). In the present study,
no such relation was found (Table 4).
This observation is in accordance with
Rosling et al. (1976a. b). Poison & HeijI
(19781. Renvert et al. (1985b). Further-
more, according to Renvert et al.
(1985b). a high degree of correlation
exists between the depth of the bony
defect and the postoperative changes in
bone levels (p < 0.01). Even though stan-
dardized defect measurements were not
obtained in the present study, it was
observed that the defects that gained
bone tissue were more than 4 mm deep.
Moreover, there was no association be-
tween the bone tissue and the probing
attachment level changes 6-months
postoperatively. This observation is in
agreement with Payot et al. (1987) and
Bragger et al. (1988).
It seems resonable to conclude from
the present study that both treatment
modalities would induce the same de-
gree of soft and hard tissue changes in
infrabony defects. This means that GV
and MWF would both induce gain of
probing attachment and possibly bone
gain 6 months postoperativeiy.
Acknowledgements
Sincere thanks are due to Siv Jacobson
for ora! hygiene treatment and to Mika-
e! Astrom for help with the statistical
analysis.
Zusammenfassung
Gingivektomie oder Luppenchirurgie: Der Er-
folg hei der Behandlung intraussoser Defekie
Das Ziel der vorliegenden Studie war, Kurz-
zeitresuliate nach der Behandlung iniraossa-
rer Defek'te mil Gingivektomie (GV), mit Be-
handlungsresultaten nach der modifizierten
Widman'schen Lappenoperation (MWF =
modified Widman flap) zu vergleichen. Fiir
diese Untersuchung wurden 14 Patienten mit
68 bilaieralen. intraossaren Defekten ausge-
wahh. AnlaBlich der Eingangsuntersuchung
und postopcrativer Untersuchungen nacb 3
und 6 Monaten wurde die Mundpflege, der
Zustand der Gingiva. die Zahnneischblutung
nach dem Sondieren, die sondierte Taschen-
tiefe und das sondierle Atiachmenlniveau be-
urleill und regi.slrieri. Konventionelle Ronl-
genaufnahmen mit reproduzierbarer Projek-
tionsgeometrie wurden angefertigt. lm
Rahmen des Versuchsansatzes nach dem
split-mouth Model! wurde ein Kieferqua-
drani zufalJig mil der G\\ und der kontraJale-
rale mit der MWF-Operation hehandeit. Ver-
anderungen der Knochengewebe wurden mil
Hilfe von konventioneSSen und Subtraktions-
Rontgenbildern von 2 Untersuchenden be-
gutbachcet. Ausserdem wurde die ijbererein-
slimmung zwischen den Resultaten der kon-
ventionellen und der Subtraktionstechnik un-
tersucht. An den meisten Stellen hatten sich
die gingivalen Verhalinisse erheblich verbes-
sert und die Zahnfleischblutung nach dem
Sondieren war geringer. Bei beiden Behand-
lungsformen waren die Sondierungsliefen um
etwa y mm geringer und der sondierte At-
tachmentgewinn behef sich auf 1.22-1.35
mm. Bei der GV war die Rezession der Gingi-
va (1.90 mm) ein wenig hoher als bei der
.MWF (].6O mm). Die Rontenuntersuchung
zeigte. dafi nach der GV ein Knochengewinn
an 7 Defekten und nach der MWF an 9 De-
feklen vorlag. Diese Untersuchungen zeigen.
dafi mit intraossdsen Defekten verbundene
Taschen mit beiden Behandlungsformen
erfolgreich behandeit werden konnen und
weiterhin, daB Knochengewinn als Behand-
lungsfolge vorkommen. aber nicht vorausge-
sagt werden kann.
Effet du irailemeni des IHiotts infraosseuses
par gingivectomie ou operation a lambeau. Une
etude clinique ei radiographique
14 patients avec 68 lesions infraosseu&es bila-
terales ont ete selectionnes. Lors de I'examen
iniiial ainsi que 3 el 6 moi.s apres Toperation
les indices cliniques suivanls ont ete mesures:
hygiene buccale, condition gingivale. saigne-
ment au sondage, profondeur de poche au
sondage et niveau d'attache. Des radiogra-
phies conventioneJIes reproductibles ont ete
oblenues. Un quadrant a ete Iraite par gingi-
vectomie el le contralateral par operation de

Widman modifiee. Les variations de tissu os-
seux ont ete mesurees a l'aide d'images
conventionelles et de soustraction par deux
observateurs. La variation interobservateur
des techniques conventionelle et de soustrac-
tion a egalement ete etudiee. La majorite des
sites out montre une amelioration des condi-
tions ging]vales et une reduction du saigne-
ment. Pour ies 2 types de traitement les pro-
fondeurs au sondage ont ete reduites d'une
moyenne de 3 mm tandis qu'un gain d'atta-
che moyen de 1.22 a ! ,35 mm a ete obtenu.
La gingivectomie etait suivie d'un peu plus
de recession gingivale (1.90 mm) que I'opera-
tion a lambeau (1.60 mm). L'analyse radio-
graphique a mis en evidence un gain osseux
dans sept lesions traitees par gingivectomie
et 9 lesions soignees par operation a iambeau.
Les poches associees aux lesions infraosseu-
ses peuvent done etre traitees avec succes par
les 2 types d'operation. De plus, un gain os-
seux peut survenir apres traitement mais de
maniere imprevisible.
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Address:
Gunilla Bratthall
Department of Periodontology
Faculty of Odontology
Cart Gustafs vdg 34
S-2I4 21 Maims
Sweden