|Year : 2015 | Volume
| Issue : 4 | Page : 406-410
Comparison of microsurgical and conventional open flap debridement: A randomized controlled trial
Meena Priya Bagavathy Perumal1, Aruna Dunthur Ramegowda2, Avinash Janaki Lingaraju2, James Johnson Raja3
1 Department of Periodontics, Chettinad Dental College and Research Institute, Kelambakkam, Chennai, India
2 Department of Periodontics, VS Dental College and Hospital, Bengaluru, Karnataka, India
3 Department of Periodontics, Rajas Dental College and Hospital, Vadakankulam, Tirunelveli, Tamil Nadu, India
|Date of Submission||05-Nov-2013|
|Date of Acceptance||26-Mar-2015|
|Date of Web Publication||11-Aug-2015|
Meena Priya Bagavathy Perumal
Department of Periodontics, Chettinad Dental College and Research Institute, Old Mahabalipuram Road, Kelambakkam, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Residual calculus exists not only on teeth treated by scaling alone but also on teeth treated by flap surgery. Periodontal microsurgery enables more definite removal of calculus, atraumatic handling of tissues through optical magnification. The purpose of this study was to compare the clinical outcomes of microsurgery with conventional open flap debridement in patients with chronic periodontitis. Methods: Thirteen chronic periodontitis patients were randomly assigned for test (microsurgical) and control (conventional) open flap debridement in a split mouth design. At baseline, 3, 6 and 9 months the following clinical parameters were recorded: Probing pocket depth, relative attachment level, gingival recession, gingival bleeding index. Postoperative healing at 1-week by early healing index and pain scale for 7 days were assessed. Results: Paired t-test was used to compare means within the groups, and unpaired t-test was applied to compare the means of the two groups. At 3, 6 and 9 months postoperatively there was a significant reduction in gingival bleeding index, probing pocket depth, relative attachment level within both the groups and there was no significant difference between both the groups. Gingival margin level and gingival recession increased in both the groups, but it was not statistically significant. Early healing Index score of 1 was found in 85% of test sites and 28% of control sites. The mean pain scale was 0 in test site and 1.07 0.75 in control site. Conclusions: In open flap debridement procedure, a microsurgical approach can substantially improve the early healing index and induce less postoperative pain compared with applying a conventional macroscopic approach.
Keywords: Flap surgery, open flap debridement, periodontal microsurgery, residual calculus, wound healing
|How to cite this article:|
Perumal MP, Ramegowda AD, Lingaraju AJ, Raja JJ. Comparison of microsurgical and conventional open flap debridement: A randomized controlled trial. J Indian Soc Periodontol 2015;19:406-10
|How to cite this URL:|
Perumal MP, Ramegowda AD, Lingaraju AJ, Raja JJ. Comparison of microsurgical and conventional open flap debridement: A randomized controlled trial. J Indian Soc Periodontol [serial online] 2015 [cited 2019 Dec 16];19:406-10. Available from: http://www.jisponline.com/text.asp?2015/19/4/406/156884
| Introduction|| |
Periodontal disease, an inflammatory disease of multifactorial origin seems to be the leading cause of tooth loss worldwide. This disease in its wake leaves behind a trail of destruction mainly pertaining to the tooth supporting structures. Periodontal therapy consists of treatment modalities aimed at arresting infection, restoring the lost structure and to maintain a healthy periodontium. The mechanical removal of bacterial plaque, calculus and toxic material is an effective means of altering the etiology of periodontal disease. 
Historically, periodontal surgery was used to treat patients with generalized disease and because of this the surgical approach was usually designed to treat multiple adjacent teeth. The goal of periodontal surgery has always been to alleviate or eliminate the degeneration associated with the progressive periodontal disease. In order to accomplish this goal, access to the periodontal defect for debridement has been an integral part of surgical therapy. 
The current pendulum of clinical opinion in some areas of periodontal education and research has swung away from traditional mechanical and surgical therapy toward advanced treatment applications. The application of magnification to periodontics has tremendously refined the periodontal surgical care. As recent developments in medicine have shown, magnification and microsurgery can greatly impact clinical practice. ,
Microsurgery is a treatment philosophy whose clinical horizons will continue to improve with operator experience and willingness to employ previously unused basic optical magnification and ergonomic techniques and technology.  As of today, no clinical study has demonstrated the use and possible advantages of dental loupes in periodontal open flap debridement. So the aim of the present study is to evaluate the treatment outcomes of microsurgery and compare it with conventional open flap debridement procedures.
| Materials and Methods|| |
Ethical clearance was obtained from the institutional review board. Written informed consent was signed and obtained from all the patients who participated in the study. This study was carried out as a split mouth randomized controlled clinical trial. Totally, 13 patients (7 male and 6 female) with the age range of 30-50 years were included in the study.
A total of 13 chronic generalized periodontitis patients attending the Department of Periodontics presenting with similar horizontal bone loss and probing pocket depth ≥ 5 mm in contralateral quadrants were included in the study.
Patients with any systemic diseases or under antibiotics in the past 6 months, smokers and with poor oral hygiene were excluded.
Three teeth per quadrant with identical pattern of bone loss and probing depth were included for treatment either by microsurgical (test site) or conventional approach (control site) in a split mouth design. At baseline, 3, 6 and 9 months, the following clinical parameters were evaluated: Probing pocket depth, relative attachment level, gingival recession, gingival bleeding index - Ainamo and Bay 1975, Patient comfort was assessed by visual analog scale for 7 days postoperatively. Postoperative healing was assessed by early wound healing index at 1 week post operatively. 
A stent was individually fabricated to create ﬁxed landmarks and to standardize the location and angulation of periodontal probes at all the six sites. The position of the gingival margin was measured from the stent to the gingival margin, and the relative attachment level from the stent to the bottom of the periodontal pocket. The probing depth was calculated based on the difference between relative attachment level and gingival margin level. 
All periodontal surgical procedures were performed on an outpatient basis under aseptic conditions. The patient was asked to rinse the mouth with 10 ml of 0.2% chlorhexidine digluconate solution for 60 s. The operative site was anaesthetized with 2% lignocaine HCL with adrenaline (1:80,000).
After achieving adequate anesthesia, in the control sites intracrevicular incisions were made, and full thickness mucoperiosteal flaps were elevated. Surgical debridement was carried out to remove subgingival plaque, calculus, diseased granulation tissue and pocket epithelium. The surgical sites were irrigated with sterile saline. Surgical flaps were sutured to the presurgical level with 3-0 silk suture utilizing an interdental, direct suturing technique achieving primary closure. A noneugenol periodontal dressing Coe-pack ® was placed. Postoperative instructions were given to the patients. Antibiotic prescription of amoxicillin 500 mg thrice daily for 5 days and a nonsteroidal anti-inflammatory agent thrice daily for 2 days was given.
In test sites, microsurgery was carried out with × 3.5 optical magnification dental loupe. After Local anaesthesia, sulcular incisions were placed with microsurgical ophthalmic blades [Figure 1]. Buccal and lingual mucoperiosteal flaps were elevated using periosteal elevators [Figure 2]. Granulation tissue adherent to the inner surface of flaps were carefully removed with curettes to provide full access and visibility to root surfaces. Any remaining plaque and calculus were gently removed using hand instruments. Sutures were placed using 6-0 suture vicryl suture.
Statistical analysis was carried out using SPSS software version 17.0 (IBM corporation, Chicago, IL, USA). Paired t-test was used to compare means on the same or related subjects over time or in differing circumstances, and unpaired t-test was applied to compare the means of the two groups. Early healing index was assessed using frequency distribution.
| Results|| |
There was no significant difference between the groups for probing pocket depth, relative attachment level, gingival recession, gingival bleeding index, gingival margin level, as shown in [Table 1]. The changes in probing pocket depth, relative attachment level, gingival recession, gingival bleeding index, between the groups in different visits are depicted in [Figure 3] [Figure 4] [Figure 5] [Figure 6] respectively. [Figure 7] signifies the frequency distribution of Early Healing Index, with a lesser score of 1 was more with the test site (85%), and more percentage of the control site showed a higher score of 2 (71.70%). No sites showed scores 3-5.
|Figure 3: Changes in the relative attachment level between the groups at different visits|
Click here to view
|Figure 4: Changes in the probing pocket depth between the groups at different visits|
Click here to view
|Figure 5: Changes in the gingival recession between the groups at different visits|
Click here to view
|Figure 6: Changes in the gingival bleeding index between the groups at different visits|
Click here to view
|Figure 7: Comparison of early healing index between test and control sites at baseline and 1 week post operatively|
Click here to view
|Table 1: Comparison between the parameters from baseline and at 3, 6 and 9 months |
Click here to view
At day 1 post operatively, the mean pain scale of the test site patients was 0, for the control site was 1.07 ± 0.75 and the difference was statistically significant. From day 2-7, there was score 0 on the scale for both the groups, and there was no statistically significant difference.
| Discussion|| |
The present clinical study has demonstrated that open flap debridement procedures for chronic periodontitis using the microsurgical procedures has improved the early healing of the wound and decreased postoperative pain when compared to the clinical performance under conventional techniques.
The primary etiologic agent in periodontitis is plaque and calculus. Scaling and root planing are widely used techniques to remove the irritants from the surfaces of teeth and also to reduce root roughness that may facilitate the accumulation of irritants. , Small areas of calculus are often left behind, with anywhere from about 3% to 80% of instrumented root surfaces showing some residual calculus. , It was also observed that more residual calculus is left behind on proximal surfaces, in deep sites, and in furcation areas. ,
Complete removal of calculus is a primary part of achieving a biologically acceptable tooth surface in the treatment of periodontitis. However, residual calculus exists not only on teeth treated by scaling alone but also on teeth treated by flap surgery followed by scaling and root planing. ,
Periodontal flaps for access provide a means to reduce residual calculus, especially more efficient even in deeper pockets, both in anterior and posterior teeth.  However, complete removal of calculus from periodontally diseased root surfaces is rare. Scaling and root planing with flap showed better removal of calculus than after scaling and root planing alone. Surgical access has shown to improve the efficiency of scaling and root planing. 
Microsurgical procedures have been studied for various regenerative procedures, root coverage and papilla reconstruction procedures.  The benefits of microsurgical approaches have been described only in a few case reports, ,, and one prospective cohort study.  A case control study was conducted similar to our present study design to assess the clinical outcome in localized gingival recessions.  As of today, there is no clinical study to compare microsurgical and conventional open flap debridement procedures.
In the present split mouth study, three teeth with probing pocket depth ≥5 mm were considered as test site, and the contralateral teeth with same probing pocket depth were considered as controls. Both test and control sites showed almost similar radiographic and clinical parameters.
The only difference/variable over conventional technique was that there was improved visual and tactile perception through microsurgical technique. 
Postoperative pain and early healing assessed for 7 days after the procedure showed that the test sites were significantly better than the controls. This may be due to delicate handling of the tissues and precise wound closure, which are similar to some of the earlier studies. ,
A frequency of once every 3 months recall appears to be sufficient to maintain the beneficial effects of therapy even in the presence of individual variations of personal oral hygiene and gingival inflammation. Although studies demonstrate that healing may continue for a period of 9 months following initial therapy, most of the healing seems to complete at 3 months following therapy. 
In our study, although the clinical parameters, probing pocket depth, relative attachment level, gingival margin level showed significant difference from baseline to 3, 6 and 9 months, there was no significant difference between the groups in the present study.
In our study, there was no statistically significant increase in gingival recession between the test and control sites. The test sites showed an increase of 0.12 mm as against 0.14 mm in control sites. There was no significant decrease in recession between the groups. However, studies have shown minimal gingival recession (0.4 mm) with microsurgery due to atraumatic manipulation during surgery and excellent soft tissue preservation. ,
However, the mean surgical operation time for test site is 1 h and 30 min that is 6% more than in control sites 1 h and 16 min. In oral surgical procedures, studies have shown that the incidence and severity of complications following periodontal surgery correlated well with the duration of the procedure. It may be speculated that the extended operation time may compensate for the beneficial treatment effect of minimally invasive techniques.  However in the present study microsurgical open flap debridement resulted in faster healing and less postoperative pain.
The present study has certain limitations. The sample size was kept minimum. The test sites were treated after the control sites, the less postoperative pain may be due to the less apprehension for the second surgery.
| Conclusion|| |
Within the limitations of the present study, it can be concluded that microsurgical approach resulted in early healing and less postoperative pain compared to the conventional approach. Both the procedures were equally effective in improving the clinical parameters. The choice of micro or macro surgical approaches should be decided based on the treatment outcomes, cost and the patient-centered parameters.
| Acknowledgement|| |
Authors would like to acknowledge the principal Dr. Usha H L, V.S Dental College and Hospital (V. S. D. C and H) and Dr. Sushma Galgali MDS, Professor and Head of the Department of Periodontics, V. S. D. C and H, for their support and guidance throughout the study. We would like to thank Dr. Shankar, Assistant Professor, Department of Public Health Dentistry and Mr. Patchamuthu, Biostatistician, KSR Dental College for helping in statistical analysis.
| References|| |
Drisko CH. Nonsurgical periodontal therapy. Periodontol 2000 2001;25:77-88.
Harrel SK. A minimally invasive surgical approach for periodontal regeneration: Surgical technique and observations. J Periodontol 1999;70:1547-57.
Tibbetts LS, Shanelec DA. An overview of periodontal microsurgery. Curr Opin Periodontol 1994;2:187-93.
Shanelec DA, Tibbetts LS. A perspective on the future of periodontal microsurgery. Periodontol 2000 1996;11:58-64.
Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North Am 1998;42:339-59.
Wachtel H, Schenk G, Böhm S, Weng D, Zuhr O, Hürzeler MB. Microsurgical access flap and enamel matrix derivative for the treatment of periodontal intrabony defects: A controlled clinical study. J Clin Periodontol 2003;30:496-504.
Del Peloso Ribeiro E, Bittencourt S, Ambrosano GM, Nociti FH Jr, Sallum EA, Sallum AW, et al.
Povidone-iodine used as an adjunct to non-surgical treatment of furcation involvements. J Periodontol 2006;77:211-7.
Burkhart R, Lang NP. Periodontal plastic microsurgery. In: Lang NP, Lindhe J, editors. Clinical Periodontology and Implant Dentistry. 5 th
ed. Oxford: Blackwell Munksgaard Publishers; 2008. p. 1029-44.
Buchanan SA, Robertson PB. Calculus removal by scaling/root planing with and without surgical access. J Periodontol 1987;58:159-63.
Rateitschak-Plüss EM, Schwarz JP, Guggenheim R, Düggelin M, Rateitschak KH. Non-surgical periodontal treatment: Where are the limits? An SEM study. J Clin Periodontol 1992;19:240-4.
Caffesse RG, Sweeney PL, Smith BA. Scaling and root planing with and without periodontal flap surgery. J Clin Periodontol 1986;13:205-10.
Robertson PB. The residual calculus paradox. J Periodontol 1990;61:65-6.
O'Leary TJ. The impact of research on scaling and root planing. J Periodontol 1986;57:69-75.
Kepic TJ, O'Leary TJ, Kafrawy AH. Total calculus removal: An attainable objective? J Periodontol 1990;61:16-20.
Nordland WP, Sandhu HS, Perio C. Microsurgical technique for augmentation of the interdental papilla: Three case reports. Int J Periodontics Restorative Dent 2008;28:543-9.
Axelsson P, Lindhe J. The significance of maintenance care in the treatment of periodontal disease. J Clin Periodontol 1981;8:281-94.
Cortellini P, Tonetti MS. Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol 2001;72:559-69.
Burkhardt R, Lang NP. Coverage of localized gingival recessions: Comparison of micro- and macrosurgical techniques. J Clin Periodontol 2005;32:287-93.
Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy. II. Severely advanced periodontitis. J Clin Periodontol 1984;11:63-76.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]