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

Tobias Thalmair, Stefan Fickl, Wolfgang Bolz and Hannes Wachtel

Journal of Clinical Periodontology Volume 36, Issue 10, Pages 877-881

The ultimate goal of regenerative periodontal therapy is to completely restore lost periodontal attachment Characterized by formation of new root cementum with inserting collagen fibres, new periodontal ligament and new alveolar bone (Karring et al. 2003).

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)

Most frequent complications after regenerative procedures

Membrane exposure Subsequent bacterial contamination Soft tissue recession

Microbiological contamination of barrier membranes have been associated with compromised clinical outcomes, leading to a reduced gain in clinical attachment level

To prevent these complications the most important element is to Achieve and maintain primary soft tissue closure in 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

This case report presents

A MODIFIED SURGICAL APPROACH FOR GTR TO MAINTAIN THE INTEGRITY OF INTERPROXIMAL SOFT TISSUE ABOVE INTRA-BONY DEFECTS.

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 maintain

an uneventful healing process

Authors reports only 1 case Medically healthy Non-smoker


Male 36 yrs

Informed consent
A single infrabony defect in the

anterior region of the mandible

Case Report

Phase I periodontal therapy


Oral hygiene instructions

Full-mouth scaling and root planning

Pre-operative

Bone Defect

Intrasulcular incision

Vertical Incision

Full Thickness Flap raised

Preparation of the Internal Pedicle Flap, at the base of the buccal flap a horizontal incision is performed

The Internal pedicle flap is elevated from the base of the flap in a coronal direction

CLINICAL RESULTS
2 1.8 1.6 Group 1 Group 2 Group 3 Group 4

1.4
1.2 1 0.8 0.6 0.4 0.2 0

Base line

3 wks after 1st step

6 mths after 2nd step

24 mths after 2nd step

Fig 1.

3
Group 1 Group 2 Group 3 Group 4

2.5

1.5

0.5

Base line

3 wks after 1st step

6 mths after 2nd step

24 mths after 2nd step

Figure 2

0.5 0.45 0.4 Group 1 Group 2 Group 3 Group 4

0.35
0.3 0.25 0.2 0.15 0.1 0.05 0

Base line

3 wks after 1st step

6 mths after 2nd step

24 mths after 2nd step

Fig 3.

Table 1 Probing depth (Means SD)


Time Baseline 3 wks after 1st step 6 mths after 2nd step Gp 1 Gp 2 Gp 3 Gp 4

5.5 0.62 5.8 0.73 5.4 0.59 5.8 1.00 3,9 0.84 3.6 0.78

5.7 1.06 5.9 0.70 5.6 0.77 5.5 0.74 3.5 0.96 4.6 1.0 3.4 0.80 5.2 0.77

24 mths 4.2 1.10 3.2 0.65 after 2nd step

Table 2 CAL (Means SD)


Time
Baseline

Gp 1

Gp 2

Gp 3

Gp 4

6.0 1.05 6.2 1.0

6.1 0.96 6.3 0.77

3 wks after 5.9 1.03 6.0 0.742 6.4 0.83 6.0 0.91 1st step 6 mths after 4.8 0.83 4.3 0.74 4.4 1.0 5.7 0.96 2nd step 24 mths 5.1 0.90 4.0 1.07 4.2 0.87 5.9 0.76 after 2nd step

Table 3 Probing depth (site categories 6 to 9 mm, > 9 mm means SD)


Time Baseline 3 wks after 1st step 6 mths after 2nd step Gp 1 Gp 2 Gp 3 Gp 4

8.6 1.21 8.1 1.07

8.4 0.76 8.2 1.03

7.8 1.12 7.6 0.96 5.2 0.79 3.6 1.14

8.0 1.00 8.1 0.93 4.2 1.06 5.9 1.19 3.6 0.98 7.0 1.03

24 mths 6.6 0.87 3.3 1.09 after 2nd step

Table 4 CAL (site categories 6 to 9 mm, > 9 mm means SD)


Time Baseline Gp 1 Gp 2 Gp 3 Gp 4

10.1 1.21 9.8 1.62 10.4 1.04 9.6 0.86

3 wks after 9.6 1.1 1st step 6 mths after 8.1 0.83 2nd step 24 mths 8.7 1.02 after 2nd step

9.2 0.96 9.9 1.23


6.7 1.22 7.4 1.0 6.4 1.12 7.5 1.17

9.0 0.98
8.2 0.77 9.1 1.23

CF CELL RESULTS
3 Group 1 Group 2 Group 3 Group 4

2.5

1.5

0.5

Base line

3 wks after 1st step

6 mths after 2nd step

24 mths after 2nd step

Figure 2

90 80 70 60 50 40 30 20 10 0 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

MICROBACTERIAL RESULTS
Positive samples of P gingivalis

Time
Baseline 3 wks after 1st step

Gp 1
10(83%)

Gp 2
11(73%)

Gp 3
8(73%)

Gp 4
9(90%) 8(80%)

12 (100%) 14 (93%) 11(100%)

6 mths after 3(25%) 2nd step 24 mths 7(58%) after 2nd step

0(0%)
0(0%)

2(18%)
1(9%)

4(40%)
7(70%)

Positive sample of Aa

Time Baseline

Gp 1 3(25%)

Gp 2 6(40%)

Gp 3 5(45%)

Gp 4 4(40%)

3 wks after 4(33%) 1st step 6 mths after 2(16%) 2nd step 24 mths 4(33%) after 2nd step

5(33%)
1(6%) 0(0%)

3(27%)
1(9%) 1(9%)

3(30%)
4(40%) 3(30%)

Second step is called Enhanced Root Planing

Metronidazole & Clindamycin more effective


than Doxycycline in
Eradicating Periodontopathic bacteria
Improving host response

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

No antibiotic sensitivity test done No comparison of LDD Bacterial Resistance not addressed