Modified Widman Flap and Papilla Preservation Flap in Maxillary Anterior Region: A Comparative Study

Headnote

Abstract

This study compared the healing response and esthetic outcome following the Modified Widman Flap (MWF) and Papilla Preservation Flap (PPF) in maxillary anterior region with diastema. 20 patients with moderate to advanced periodontal disease were selected for the study and each was randomly assigned either to PPF group or MWF group with probing pocket depths ≥5mm and clinical attachment loss ≥4mm in maxillary anterior region. Clinical parameters comprising of plaque index, gingival index, papilla presence index, probing pocket depths,clinical attachment level, and recession, aLg with evaluation of patient's perception of esthetic outcomefusingvisual analogue scale were assessed at baseline and at the endof 6 months post-operative checkup. The periodontal health in all the patients of both the groups improved as evidenced by good plaque control, maintenance of gingival health, significant reductions in probing pocket depths and gain in clinical attachment levels. There was a marginal increase in recession and decrease in the height of interdental papilla in both the groups. There was no difference between the two groups in the esthetic outcome as evaluated from the patient's feedback. Overall, the PPF flap did not result in any superiority over the MWF.

Keywords: Modified Widman Flap, Papilla Preservation Flap, probing pocket depth, papilla presence index, clininal attachment loss.

Introduction

Periodontitis can be defined as an inflammatory disease of the supporting tissues of the teeth caused by specific micro-organisms or a group of specific micro-organisms resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession or both.1 While most of the patients with periodontitis can be effectively managed by non surgical procedures, others require surgical techniques to restore their periodontal health. One of the most common periodontal surgical techniques that are practised is the periodontal flap and the modified Widman flap as described by Ramfjord and Nissle. They are the standard procedures among various techniques in the repertoire of a periodontist.2 The advantages of these procedures includes reduction in probing depth, gain in clinical attachment level and repair of osseous defects if done along with osseous surgery. Certain amount of gingival recession and change in the gingival contour and exposure of the interdental embrasures occurs with this procedure. Post surgical gingival recession besides causing dentinal hypersensitivity, root caries, secondary pulpal hyperemia may also lead to highly unesthetic appearance of The gingiva particularly in the anterior region. Further, open interproximal embrasures make plaque control more difficult for the patient, thereby affecting the post surgical maintenance. Therefore, many modifications of the conventional periodontal surgical procedures particularly in the anterior region of the oral cavity have been proposed. These include minimally invasive procedures, periodontal flap with retention of supra crestal fibers, coronally advanced flap, papilla preservation flap, modified and simplified papilla preservation flap.

Papilla preservation flap developed by Takei and coworkers was originally developed in order to facilitate the success of bone grafts, wherein, optimal interproximal coverage was enabled.3 Later, this procedure was also recommended for preventing post operative recession and to ensure an optimal soft tissue contour, thereby providing better esthetic result.

Many clinicians are of the opinion that this procedure while preserving the esthetics may not result in appreciable reduction in probing pocket depth. However, no data is available in the literature wherein, this procedure has been compared to other periodontal surgical procedures in a randomized clinical trial.

Hence, this study envisages comparing the healing response following modified Widman flap and papilla preservation flap techniques, using standard periodontal parameters and to assess and compare the esthetic outcome of these two procedures.

Materials and methods

Patient selection: Patients visiting the Department of Periodontics, The Oxford Dental College and Hospital, Bengaluru with moderate to severe periodontitis and spacing in maxillary anterior teeth were included in the study. 20 patients were selected randomly and assigned to either of the two surgical techniques (PPF and MWF) with the following inclusion and exclusion criteria. This was a prospective comparative study and was carried out for a period of 1 year.

Inclusion criteria:

- Patients agedbetween 25 to 55 years

- Patients demonstrating acceptable oral hygiene prior to surgical therapy

- Patients diagnosed with periodontitis and spacing between any two upper anteriors

- With at least one tooth having probable pocket depth ≥5mm

- Clinical attachment loss ≥4mm

Exclusion criteria:

- Patients with systemic diseases and conditions, smokers and pregnant women

- Teeth with grade III mobility

- Patients taking drugs known to interfere with wound healing

- Patients who have undergone periodontal therapy during the previous 6 months

- Labio-lingual discontinuity of interdental papilla

Study design: All the patients were informed about the surgical procedure to be performed and a written consent was obtained from them. A detailed case history was recorded. Initial therapy consisted of oral hygiene instructions and thorough full mouth scaling followed by root planing, which was performed under local anesthesia. 4 weeks following phase I therapy, a periodontal evaluation was performed to confirm the suitability of sites for periodontal surgery. Patients with probing pocket depths ≥5mm were scheduled for periodontal flap surgery.

Clinical measurements: The following parameters were measured at base line (before surgery) and after 6 months following surgery and the same were subjected to statistical evaluation. They were Plaque Index, Gingival Index, Papilla Presence Index (PPI), probing pocket depth, clinical attachment loss and gingival recession.4 6

VAS (Visual analogue scale) has been attempted in addition to the clinical parameters to assess the patient's perception of treatment outcome.

Surgical procedure: The surgical procedure was performed under local anesthesia using 2% lignocaine containing adrenaline at a concentration of 1:2,00,000.

For modified Widman flap, after measuring the preoperative probing depth, (Figure 1), an internal bevel incision was given 0.5-lmm from the gingival margin to the crest of alveolar bone and then a crevicular incision was given. The incision was extended as far as possible in between the teeth (interdental area) to maintain even thickness of flap (Figure 2). Buccal and palatal full thickness flaps were carefully elevated with a periosteal elevator following a third incision which was made in a horizontal direction and in a position close to the surface of the alveolar bone crest separating the soft tissue collar of the root surfaces from the bone. The pocket epithelium and the granulation tissues were removed with curettes. The exposed roots were carefully scaled and planed (Figure 3). The flaps were approximated and direct interrupted sutures were given using 3-0 (Mersilk(TM)) non absorbable silk sutures (Figure 4). Post-operative probing pocket depth was recorded during the 6 months follow up period (Figure 5).

For papilla preservation flap, after the pre-operative probing pocketdepth was measured (Figure 6), crevicular incisions were given around the teeth involved and a semilunar incision given across the interdental papilla from the line angles of the tooth on the palatal aspect of the involved teeth with diastema (Figure 7). A full-thickness flap was reflected with a periosteal elevator and thorough debridement of the granulation tissue was done followed by scaling and root planing of the exposed root surfaces (Figure 8). The flaps were approximated and direct interrupted sutures were given using 3-0 (Mersilk(TM)) non absorbable silk sutures (Figure 9). Post-operative probing pocket depth was recorded during the follow up period (Figure 10).

Periodontal dressing was placed over the operated area. Antibiotics (Amoxicillin 500mg, thrice daily for 5days), analgesics (Ibuprofen 400mg+Paracetamol 325mg, thrice daily for 3 days) and 10ml of 0.2% chlorhexidine gluconate rinses (every 12 hours for 2 weeks) were prescribed.

Statistical Methods: Descriptive statistical analysis has been carried out in the present study. Significance is assessed at 5% level of significance. Student t test (two tailed, independent) had been used to find the significance of study parameters between two groups and student t test (two tailed, dependent) has been used to find the significance of change in study parameters within each group.

Results

The PPF group consisted of 4 males and 6 females and MWF group consisted of 5 males and 5 females, with one dropoutat6monthspost-operativeperiod.Allthepatients returned regularly for the maintenance program. None of the patients who underwent surgery had any postoperative complications.

The mean plaque index and gingival index values were reduced at 6 months post-operative period. But there was no statistically significant difference in the plaque and gingival status between the two groups at the end of the 6 month post-operative period. In PPF group the mean PPI was increased with a 13.8% loss of papilla. In MWF group the mean PPI was increased with a 32.3% loss of papilla (Table 1). In almost all cases, gingival recession was noticed at 6 months post-operative follow up period. But there was no statistically significant difference between the two groups. The mean probing pocket depths were reduced in both the groups and when the amount of reduction that took place in both the groups was compared, it was similar, i.e., they were neither clinically nor statistically significant (Table 2). The mean reduction in probing pocket depth categories of mild, moderate and severe periodontitis in both the groups are strongly significant (Table 4). The mean CAL was reduced in both the groups but there is no statistically significant difference between the two groups (Table 3). CAL has been categorized into mild, moderate and severe. In both the groups there was an increased clinical attachment loss in mild category, but it was neither statistically nor clinically significant (Table 5). Whereas, in the moderate and severe category there was clinical attachment gain in both the groups which was neither statistically nor clinically significant.

Discussion

The ultimate goal of periodontal therapy is to establish a state of periodontal health evidenced by absence of inflammation, periodontal pockets and a potential for the patient to maintain the health in addition to comfort, function and esthetics. Periodontal therapy for the maxillary anterior dentition must consider esthetic appearance, which means an effort to maintain as much of the papilla as possible in the course of the periodontal therapy. A surgical approach utilizing flap procedures on the facial and palatal sides, no matter how conservative the incisions are made (modified Widman flap), sometimes results in shrinkage andreductioninheightoftheinter-dentalpapillaleadingto exposure of the interproximal embrasures. This has led to the development of the papilla preservation flap technique particularly where interdental spacing is present, which in addition to providing an optimal interproximal coverage, claims to provide better esthetic results, especially in the anterior region of the mouth.

However, there is no data available in the literature comparing the outcome of these two techniques in a randomized controlled clinical trial. So, it was difficult to interpret the resultsofthisstudybywayofcomparison.

The results of the present study demonstrated that during the 6 months period, patients showed improvement in plaque index, gingival health, reduction in pocket depth and clinical attachment gain.Thiswasdisclosedbythefact that both the groups exhibited low prevalence of sites with plaque, bleeding on probing, and also had statistically significant reduction in probing depths and gain in clinical attachment when compared to baseline values. The improvements in the clinical parameters in papilla preservation flap group were in accordance to the study conducted by Takei et al., where he found improvement in plaque and gingival index, reduction in pocket depth and gain in clinical attachment.3 When compared papilla preservation flap with conventional flap technique and MWF group, it was in accordance with a study by Becker and Becker where they have compared scaling, osseous surgery and MWF in a 1 year longitudinal study and found better reduction of pocket depth and similar improvement in plaque and gingival index when compared to scaling and osseous surgery.7 When PPI was assessed, there was decrease in the mean height of interdental papilla in both the groups at the end of study period. This signifies that there is reduction in papillary height irrespective of the procedure being performed.

There was an increase in gingival recession from baseline to 6 months in both the groups and this might be the normal consequence of any periodontal surgical procedure as there will be resolution of inflammation following the procedure. The recession in MWF procedure is in accordance with the study conducted by Isidor et al., where they have compared the effect ofroot planing to that of surgical treatment in patients with advanced periodontal disease and they found considerable reduction in pocket depth following surgery and root planing but clinical attachment gain was more in root planing and there was mild recession in MWF surgery.8 Contrary to the popular claims, there was some recession even in PPF group as well due to resolution of inflammation following the procedure and overall there was no difference between the two groups. So, the mere presence of papilla didn't aid in preventing this mild recession interproximally.

Due to the well known problems of periodontal probing and due to the difference in long-term prognosis of shallow and deep pockets, probing sites were divided into 3 different PPD categories.9 The sites were categorized into 0-4mm (mild), 4-7mm (moderate) and ≥7mm (severe).

When comparing probing depths in all the 3 categories, there was no significant difference in reduction between the two groups during the study period. This signifies that irrespective of the surgical procedure performed there was probing pocket depth reduction in all the patients of the two groups. CAL was categorized as l-2mm (mild), 3-4mm (moderate) and ≥5mm (severe). In the mild category, there was a slight loss of attachment in both the groups These results were similar to the studies conducted by Hill et al., Philstorm et al., and Lindhe et al., which have shown that attachment loss, occurred in treatment of shallow pockets.10 42 This explains why shallow pockets had increased attachment loss in the present study. Periodontal therapy has both tangible and intangible benefits and in this study VAS (Visual analogue scale) has been attempted in addition to the clinical parameters to assess the patient's perception of treatment outcome. On analysis of the visual analogue scale, the patients were happy with their tooth alignment, size and shape of the gums at the end of study period (Table 6). But, they also expressed that their teeth appeared longer at 6 months post-operative period. Thus, thepatient'sassessmentwasnotcorrelating and this shows that there was an uncertainty in the patient's assessment of visual analogue scale. This was in accordance with the study conducted by Lysell et al.13 Also, there was only a marginal increase in the scores at the end of the study period which was not significant. The main shortcoming of this study was the small sample size which reduced the statistical weightage of the results observed. Also, the use of advanced diagnostic tools like a Florida probe could have minimized the manual errors associated with sequential probing and also would have enabled small changes to be observed.

Overall, it emanates from this study that the outcome of both the surgical techniques was similar and the PPF didn't offer any superiority over the MWF. Contrary to its claimed advantages, it must be reiterated here that in the previous studies conducted by Takei et al., the authors had mainly emphasized this technique to facilitate placement of bone grafts and ensuring optimal interproximal coverage.3

Conclusion

The results of the present study indicate that both PPF and MWF surgical procedures brought about significant improvement in various clinical and radiological parameters evaluated, thereby improving the periodontal status. However, PPF didn't show any significant superiority over MWF, when assessed in terms of esthetic outcome, gingival recession, post operative sensitivity etc. From the patients perspective also, neither technique demonstrated superiority over the other. Hence PPF being not only technique sensitive, but also time consuming cannot be routinely recommended in maxillary anterior region purely for esthetic reasons. Wherein, conventional techniques such as MWF would be more suitable. However, long term studies with larger sample size are needed to indicate the above conclusion.

References

References

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Disclosure : The authors report no conflicts of interest.