1. / NAME OF THE CANDIDATE AND ADDRESS / DR. NIRJHAR BHOWMIK
POSTGRADUATE STUDENT,
DEPARTMENT OF PERIODONTICS & ORAL IMPLANTOLOGY
DR SYAMALA REDDY DENTALCOLLEGE, HOSPITAL & RESEARCH CENTRE
2. / NAME OF THE INSTITUTION / Dr. SYAMALA REDDY DENTALCOLLEGE,HOSPITAL & RESEARCH CENTRE,BANGALORE-560037
3. / COURSE OF STUDY AND
SUBJECT / MASTER OF DENTAL SURGERY IN PERIODONTICS
4. / DATE OF ADMISSION TO COURSE / 30th April 2010
5. / TITLE OF THE TOPIC / ASSESSMENT OF POST-SURGICAL CLINICAL OUTCOME OF MUCOPERIOSTEAL FLAP WITH/WITHOUT THE REMOVAL OF POCKET EPITHELIUM: A CLINICAL STUDY.

RAJIV GANDHIUNIVERSITY OF HEALTH SCIENCES, BANGALORE,

KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.

6.
7
8 / BRIEF RESUME OF THE INTENDED WORK
6.1 NEED FOR STUDY
Periodontitis, which is an inflammatory condition of the supporting tissues of the teeth, is characterized by pocket formation and progressive attachment and bone loss. Various treatment modalities have been proposed for treatment of periodontal pockets, mucoperiosteal flap surgery being one such modality. A flap surgery may be performed with or without sacrificing the pocket epithelium1. Researchers, who have advocated the complete removal of pocket epithelium in a periodontal flap surgery considered periodontal pocket as an infected wound and the epithelial attachment a weak barrier to prevent entry of microorganisms into the gingival sulcus, thus they suggested that in order to achieve re-attachment with connective tissue, it is necessary to eliminate pocket epithelium2. However, certain studies have shown good long term clinical` results inspite of incomplete removal of pocket epithelium thus questioning the need to accomplish complete removal of pocket epithelium8.
Hence, the present study is done to compare the post surgical outcome with modified Widman flap and crevicular mucoperiosteal flap procedures.
6.2 REVIEW OF LITERATURE
A split mouth study was done to clinically evaluate the need for elimination of pocket epithelium during mucoperiosteal flap surgery aimed at reattachment or readaptation.A total of 13 patients with two bicuspids and two molars included in each quadrant ,one of the quadrant received a modified Widman flap with removal of pocket epithelium , while the contralateral flap received a crevicular flap without removing the pocket epithelium .The biometric results showed that without the removal of pocket epithelium , good clinical results relative to gain in clinical attachment levels and reduction in probing depth were achieved , but greater gingival recession occurred on crevicular flap side postsurgically when compared to modified Widman flap1.
A split mouth study was done to evaluate the effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery. The experimental sample consisted of five men and seven women; 34-60 years age (mean age, 44 years).The results showed no clinically significant difference in results for pocket depth reduction, attachment level gain, gingival margin location and mobility. The intrasulcular incision had a slightly higher baseline value for plaque index than modified Widman flap and gingival index was initially significantly higher for modified Widman flap but no significant difference was reported between treatments at 6 months2.
A study was undertaken to determine if all pocket epithelium could be removed in humans using internally bevelled incision as described in Epithelial new attachment procedure (ENAP).A total of eight patients with pocket depth ranging from 3-5 mm were selected for this study consisting of three females and five males whose age ranged from 16-40 years. The results showed that the internally bevelled incision utilised in ENAP failed to remove all epithelium from the soft tissue wall adjacent to the tooth3.
The following study was done to find the fate of pocket epithelium when sulcular incisions are used in apically positioned flaps. Human subjects received apically positioned flap segments on the facial aspect of anterior teeth timed to give 1, 3, 5, 7, 21 and 35 days of healing on the day of extraction. Companion surgeries for comparison consisted of similar flaps, but utilized an inverse bevel primary incision. The results showed that the inverse bevel incision was consistently effective in removing the pocket epithelium and resulted in healing by a connective tissue union of the flap to the alveolar bone, though the difference wasn’t histologically significant at the end of 21 days of healing4.
The following study was conducted to study the effects of the inverse bevel flap procedure on gingival contour and plaque accumulation. This study attempts to measure these parameters by developing a contour index designed to record changes in gingival contour5.
6.3 OBJECTIVE OF THE STUDY
1) Comparison of modified Widman flap and mucoperiosteal crevicular flap procedures for post-surgical gingival contour and plaque accumulation and dentinal hypersensitivity.
2) Comparison of modified Widman flap and mucoperiosteal crevicular flap for post-surgical marginal recession and papillary recession.
3) Comparison of modified Widman flap and mucoperiosteal crevicular flap for measurement of post-operative probing depth reduction, clinical attachment level gain, reduction in mobility,changes in furcation involvement,and reduction in plaque and gingival index scores.
MATERIAL AND METHODS
7.1 SOURCES OF THE DATA
Patient’s reporting to outpatient department of Dr. Syamala Reddy Dental College Hospital And Research Centre, Bangalore.
7.2 METHODS OF COLLECTION OF DATA
A total of 50 patients with periodontitis will be subjected to the study after obtaining informed consent from the patients.
INCLUSION CRITERION
  • Compliant patients in the age group of 30-60 years.
  • Patients with moderate to advanced periodontitis.
  • Patients with pocket depth of ≥ 5mm.
  • Patients with similar bilateral bone loss.
EXCLUSION CRITERION
  • Patients who have undergone periodontal treatment in last 6 months.
  • Pregnant women and lactating mothers.
  • Patients who are known smokers.
  • Medically compromised patients.
  • Long term use of drugs which can affect the treatment and final outcome of the surgery.
  • Patients with aggressive periodontitis.
STUDY DESIGN
It is a clinical split mouth study comprising of 50 patients. The cases selected will be of moderate to severe periodontitis. The choice of flap surgery technique (ie.modified Widman flap or mucoperiosteal crevicular flap)will be decided by the toss of a coin. The following parameters will be taken into account for the flap surgeries:
  • Gingival contour index (Newman’s).
  • Test to measure dentinal hypersensitivity.
  • Pocket depth.
  • Level of attachment.
  • Recession width and Recession depth.
  • Papillary recession index.
  • Plaque index (Sillness and Loe).
  • Gingival index (Loe and Sillness).
  • Furcation involvement (Glickman’s grades).
  • Mobility (Miller’s grade).
The above mentioned measurements will be recorded at baseline (After phase 1 therapy), 1 month, 3&6 months postsurgically.
SURGICAL PROCEDURE
Following completion of the phase I therapy, the need for additional therapy will be evaluated clinically and radiographically. The surgical site will be anesthetised and modified Widman flap or crevicular mucoperiosteal flap surgery will be done as decided by the toss of coin method. The required incisions will be given, a full thickness mucoperiosteal flap will be raised and debridement of the root surfaces will be done. The flaps will then be reapproximated with appropriate suturing technique and periodontal pack will be placed. Oral hygiene instructions will be given and antibiotic and analgesics will be prescribed to the patient. Patient would be recalled after 1week for removal of sutures.
STATISTICAL ANALYSIS
Analysis of the clinical parameters obtained at baseline 1, 3&6 months would be carried out. Results will be evaluated statistically by paired’t’ test and sign test.
7.3DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON THE PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO,DESCRIBE BRIEFLY
Yes, pre and post surgical radiographic evaluation, complete hemogram would be conducted.
7.4HAS THE ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?
Yes.
LIST OF REFERENCES:
1) Smith BA, Echeverri M, Caffesse RG: Mucoperiosteal flap with and without removal of pocket epithelium. J Periodontol1987 ;( 2):78-85.
2) Svoboda PJ, Charles M, Sheridan PJ: Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery. J Periodontol; 55(10):563-6.
3) Caton J, Nyman S: Histometric evaluation of periodontal flap surgery I. The modified Widman flap procedure. J Clin Periodontol 1980; 7:212-223.
4) Pippin DJ: Fate of pocket epithelium in an apically positioned flap. J Periodontol.1990;17(6):
385–391.
5)Newman PS: The effects of inverse bevel flap procedure on gingival contour and plaque accumulation. J Clin Periodontol 1984;11:361-366
6) Bowen WJ, Bowers GM, Bergquist JJ, Organ R: Removal of pocket epithelium in humans using an internally bevelled incision. Int J Periodontics Restorative Dent.1981; 1(5):8-19.
7) Ramjford SP: Present status of modified Widman flap. J Periodontol 1977;48(9):558-565
8) Smith BA, Echeverri M: The removal of pocket epithelium: A review. J West Soc Periodontol.1984; 32(2):45-59.
9. / Signature of Candidate: / DR. NIRJHAR BHOWMIK
10. /

Remarks of the guide

/ SATISFACTORY
11. / 11.1 Guide / Dr. SANJAY KAUL
PROFESSOR
DEPT. OF PERIODONTICS &
ORAL IMPLANTOLOGY DR SYAMALA REDDY DENTALCOLLEGE,HOSPITAL & RESEARCH CENTRE,
BANGALORE-560037
11.2 Signature
11.3 co-guide (if any) / Dr. SHANTIPRIYA REDDY
PROFESSOR AND HEAD,
DEPT. OF PERIODONTICS & ORAL IMPLANTOLOGY DR SYAMALA REDDY DENTALCOLLEGE,HOSPITAL & RESEARCH CENTRE,
BANGALORE-560037
11.4 Signature
11.5 Head of the Department / Dr. SHANTIPRIYA REDDY
PROFESSOR AND HEAD,
DEPT. OF PERIODONTICS & ORAL IMPLANTOLOGY DR SYAMALA REDDY DENTALCOLLEGE,HOSPITAL & RESEARCH CENTRE,
BANGALORE-560037
11.6 Signature
12. / 12.1 Remarks of the Chairman & Principal
12.2 Signature

1