Intraoperative bleeding during open flap debridement and regenerative periodontal surgery

Background: The objective of this study was to measure the intraoperative bleeding during periodontal flap surgery. Methods: Patients scheduled for periodontal surgery were recruited for this study. Data regarding smoking habits, general health, and medications were collected. The amount of the local anesthetic that was injected was then recorded, as well as the number of teeth in the operative field and the duration of the procedure. During surgery, the liquids from the oral cavity were suctioned and collected into a sterile empty vial. To calculate the net amount of blood volume in the liquids, colorimetric assay using capillary blood fructosamine as a reference molecule was used. Results: Twenty‐six patients were included in this study. The amount of blood lost during the procedure ranged from 6.0 to 145.1 mL, with an overall mean of 59.47 ± 38.2 mL. Patients taking aspirin (acetylsalicylic acid) showed mean blood loss of 43.26 ± 31.5 mL, whereas the mean blood loss among patients that did not use this medication was higher (65.4 ± 39.4 mL) but not statistically significant. Local anesthetic amount, surgical field size, and the operation duration did not relate to blood‐loss volume. The mean blood loss among current smokers was significantly higher (96.47 ± 44.2 mL) compared to former (12 ± 8.4 mL) or never (54.74 ± 30.5 mL, P = 0.011) smokers. Conclusion: The results of the current study support previous papers and confirm that blood loss during periodontal surgery is minimal.     

Prefabrication of vascularized bone flap by demineralized bone matrix

Demineralized bone matrix (DBM) has been reported to have osteoconductive and osteoinductive properties and has been clinically used as a bone graft alternative. In the present study we attempted to generate a vascularized bone flap by subcutaneous implantation of DBM with a vascular loop to provide blood supply in a rat model. Thirty male Sprague-Dawley rats were divided into two groups according to the presence or absence of blood supply. In the experimental group, the bone flap was created by application of 0.4 mL of DBM onto two pieces of gelatin sponge sheets between which a vascular loop was sandwiched. A prefabricated flap without a vascular loop served as the control. The flaps were biopsied at three different time intervals postoperatively (2, 4, and 6 weeks). The results showed that DBM induced subcutaneous bone formation in both of the groups. However, in the nonvascularized group, the amount of bony tissue had decreased at four postoperative weeks and continued to do so afterwards. In contrast, bone formation was active at four weeks in the vascularized group. Our study indicated that implantation of DBM can prefabricate a bone flap. Blood supply to the flap is considered a key factor of the success of this prefabrication.     

Comparison of injectable calcium phosphate bone cement grafting and open flap debridement in periodontal intrabony defects: a randomized clinical trial

BACKGROUND: Regeneration of lost periodontium is the ultimate goal of periodontal therapy. Bone grafts, guided tissue regeneration, and application of growth factors are used for periodontal regeneration. This study aimed to evaluate the clinical efficacy of a new, injectable calcium phosphate bone cement (CPC) in human periodontal intrabony defects. METHODS: Thirty subjects (mean age, 53.4 +/- 9.1 years) with periodontitis and narrow intrabony defects were enrolled in the study. Subjects were classified randomly into the CPC graft group (N = 15) or the open flap debridement (OFD) alone group (N = 15). Clinical measurements were performed at baseline and at 3, 6, 9, and 12 months; radiographs were taken at baseline, 2 weeks, and 6 and 12 months after surgery. The Student t test was used for statistical analysis. RESULTS: In the CPC group, six cases showed exposure or loss of the CPC within 12 months, whereas the remaining nine cases (CPC-R group) showed no adverse reaction, including infection or suppuration. Overall, CPC-R and OFD treatment groups exhibited a significant reduction in probing depth and a significant gain in clinical attachment level at 3, 6, 9, and 12 months compared to baseline values. However, there were no significant differences in any of the clinical parameters between the groups. In the CPC-R group, radiographic bone level gain appeared to be greater than in the OFD group. CONCLUSIONS: The present study failed to demonstrate any superior clinical outcomes for the CPC group compared to the OFD group; however, radiographs revealed more favorable results in the CPC-R group. The filling volume and stiffness of CPC may compromise the clinical outcomes for periodontal intrabony defects.     

Cranioplasty with auto-purified bone flap after infection

Cranioplasty of cranial bone defects can generally be accomplished with autogeneous bones as well as with nonbiological materials. Autologous living-bone grafts are ideal but require sacrifice of donor bone, and synthetic materials might have possible exposure of the materials, delayed infection, and/or allergic reaction. The authors report cranioplasty with a bone graft after auto-purification by subcutaneous preservation of the contaminated bone fragment. A 47-year-old man was given a frontal cranioplasty with a split parietal bone and rib. Epidural abscess ensued, and debridement was performed to control the infection. The largest bone fragment was subcutaneously preserved in the chest wall and reused for cranioplasty. Subcutaneous preservation of bone is a promising strategy for cranioplasty after neurosurgery. The condition of the bone fragment can be inferred from the condition of the site at which it is preserved. If the bone flap is contaminated, it can be purified by the patient's immune system.     

Osseous defect responses to hydroxylapatite grafting versus open flap debridement

Abstract Data from a large number of defects (152) treated with hydroxylapatite (HA) grafts were compared to those from a large number of defects (111) treated by surgical debridement alone (DEBR). Comparison of initial and re-entry surgery measurements showed that both the analysis of relative defect fill and the intrapatient comparisons demonstrated an advantage to the use of HA graft material, 58% of the HA-grafted defects were judged to have a positive (≥50% defect fill) hard tissue response compared to 30% for DEBR. Minimal responses (failures) were 4 times as numerous with DEBR. Similarly, within each patient, HA grafting proved of benefit, particularly regarding hard tissue changes. The use of HA graft materials appears to be of clinical benefit in a majority of defects and a majority of patients.     

Clinical and volumetric analysis of three-wall intrabony defects following open flap debridement

Fourteen defects were treated with flap debridement procedures using the Prichard principle of epithelial exclusion. Six defects were considered to be medium in width (3-4 mm), seven defects were wide (greater than 4 mm), and one defect was narrow (1-2 mm). The parameters studied were changes in gingival and plaque scores, attachment levels, and bone scores. All defects were reentered 9 to 16 months after surgery and changes between the pretreatment and posttreatment bone levels were recorded. The mean gain in probing attachment level was 2.76 mm. The mean amount of defect fill measured from models was 2.56 mm, while the mean defect fill from direct measurements was 3.26 mm. The percentage defect fill measured from study models was 61%. Crestal resorption was 9.7%. The average change in defect volume unadjusted for crestal resorption was 61.8 cu mm. Seven defects had a 50% or greater decrease in defect volume, while seven defects had less than a 50% change. Intrabony defects where calculus is present on the involved tooth surface prior to therapy will repair with substantial amounts of bone as a result of open debridement.     

种植体修复时间超过1年,碟形骨吸收至种植体平台下3 mm,不需要翻瓣植骨

种植体周围骨吸收是种植修复后的常见现象。当种植体修复时间超过1年出现碟形骨吸收达到种植体平台下3mm时,是否需要进行翻瓣植骨是值得探讨的临床问题。本文根据最新种植修复生物学并发症临床治疗指南,从评估和诊断、排除和控制风险因素、非手术治疗清创、早期再评估、手术治疗、临床维护和支持等多方面对此进行论述,总结认为种植修复时间超过1年,碟形骨吸收至种植体肩台下3 mm时并不需要进行翻瓣植骨。     

Maxillary reconstruction using rectus abdominis free flap and bone grafts

We did total maxillectomies for cancer in 22 patients and reconstructed the face with rectus abdominis free flaps and bone grafts. The functional and aesthetic results have been satisfactory. The use of rectus abdominis free flap with nonvascularised bone grafts is a useful technique after excision of the maxilla and orbital floor. It permits a reliable, safe, one-stage reconstruction of complex three-dimensional anatomy with stable functional and aesthetic results.     

Prefabrication of vascularized bone flap using bone morphogenetic protein (BMP)

The purpose of this study was to produce newly vascularized bone, and to form the bone into the desired shape. Silicone molds given the shape of a cylinder were used to deliver collagen sheets impregnated with or without rhBMP-2. The superficial inferior epigastric neurovascular bundle in a Wistar rat was identified and sandwiched between the silicone molds. The molds containing collagen sheets impregnated with 10 micrograms of rhBMP-2 were used for the experimental purpose, and those without rhBMP-2 were used as a control. In some of the experimental molds, the neurovascular bundle was ligated at both proximal and distal sites of the molds. After 2 and 4 weeks operation, bone formation was detected macroscopically, radiologically, and histologically. As a result, newly formed bone was observed in all experimental sites without the ligation, and the shape of the bone was exactly the same shape as the silicone mold. Newly formed bone was supplied by the superficial inferior epigastric artery, whereas newly formed bone was not observed in the control and the ligated flaps. Newly vascularized and shaped bone was created by applying an osteoinductive factor to a neurovascular bundle. This study demonstrates that this experimental model could be a therapeutically potential approach for effective bone reconstruction.     

The effectiveness of different root debridement modalities in open flap surgery

Abstract. It is unclear what degree of roughness or smoothness result from use of hand instruments alone in comparison to the use of hand instruments in combination with other aids and how it may effect the grade of cleanliness. The aim of this study was to determine in vivo whether the combination of hand instruments with other aids can increase the effectiveness of root debridement. 11 patients with holpless 4 mandibular incisors were involved in this study. After elevating a lingual and buccal mucoperiosteal flap, the 4 incisors were randomly treated with either: (1) no treatment (control); (2) 5-niin scaling (method 1); (3) 4-min scaling and 1-min instrumentation with a perio-diamond bur (15 μm) (method 2); (4) 3-min scaling, 1-min instrumentation with a perio-diamond bur (15 μm) and 1 min with an air abrasive system (method 3). The cleanliness of the surface was determined using the method of Eschler and -Rapley. The degree of roughness (Ra and Rt) were measured with a laser beam (computer supported optical surface sensor system). In addition, an SEM analysis was performed. With regard to the remaining calculus (surface cleanliness), method 3 yielded significantly better results than the other 2 methods. The roughness analyses also exhibited that method 3 is superior to methods 1 and 2. The qualitative results of the SEM investigations demonstrated the most homogenous and smooth surfaces with method 3. Root debridement in vivo was most significant using a combination of different treatment modalities (i. e., curettes, perio-diamond bur and air abrasive system).     

Mucogingival pouch flap for sandwich bone augmentation: technique and rationale

This article introduces a novel flap design, mucogingival pouch flap (MPF), to enhance the clinical outcome of sandwich bone augmentation. MPF uses a pouch flap reflection via mucogingival junction extension incisions to provide an improved graft retention, minimized membrane exposure, preserved papilla dimension, and soft tissue camouflage for improved esthetics.There are 4 implant-associated buccal dehiscence defects in 3 patients treated with sandwich bone augmentation technique in conjunction with MPF. All cases yielded an adequate new bone thickness of 1.5-3.5 mm as well as a height of 84% to 100% at 6 months. Rationales, indications, contraindications, advantages, and disadvantages for MPF designs are further discussed.     

The effectiveness of hand versus ultrasonic instrumentation in open flap root planing

The primary purpose of the study was to determine if, with an open flap approach, ultrasonic or hand instrumentation could remove all calculus from previously untreated teeth with moderate to severe loss of attachment. To be included in the study, teeth had to have at least 5 mm of attachment loss, be scheduled for extraction and be graded 2 or 3 on the Calculus Index of the Periodontal Disease Index system. Under local anesthesia, full-thickness, envelope-type flaps were elevated apical to the crest of bone to allow access to the root surfaces which were then treated with hand or ultrasonic instrumentation until the roots felt hard and smooth to a Hartzell explorer. The teeth were then removed, rinsed, and lightly scrubbed to remove debris and a No. 14 wheel bur was used to place a groove along the coronal extent of the connective tissue attachment. A stereomicroscope at magnification X 4.6 was used to quantitate the percentage of residual calculus on 25 teeth treated by each method. Overall, hand-scaled root surfaces demonstrated less residual calculus (5.78%) than ultrasonically treated surfaces (6.17%). Twenty teeth treated by each method were then prepared for histologic evaluation and evaluated under the light microscope at magnification X 100 for residual calculus and relative smoothness. Residual calculus was found on four ultrasonically and 12 hand-treated teeth and was almost evenly distributed between anterior and posterior teeth for both methods. The finding of considerably less calculus on histologic than on stereomicroscopic examination may have been due to the loosening of deposits by instrumentation, especially ultrasonic vibration, and their subsequent release during histologic preparation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hydroxylapatite reconstruction of alveolar ridge deficiency with an open mucosal flap technique

A preliminary report on an open surgical technique for mandibular augmentation with hydroxylapatite has been presented. Twelve patients were evaluated from 2 to 20 months postoperatively. Advantages are thought to include better ridge form, maintenance of vestibular depth, and visualization of the mental nerve. In addition, splints usually are not necessary. Disadvantages include increased surgical time, possible lower lip inversion, and soft-tissue characteristics that may require secondary revisions.     

Periodontal healing following open debridement flap procedures. II. Histologic observations

Four tooth-containing blocks were obtained from patients being treated for infraosseous lesions of significant depth as part of their periodontal therapy. Treatment consisted of open flap debridement and professional cleansing at least every 4 weeks. Teeth in block were removed for histologic study 4 to 6 months after surgery. Histologic evaluation of the repair process showed pocket closure by epithelial and connective tissue adhesions in the form of an elongated junction epithelium, beneath which parallel-oriented fibers adhered to the root for a limited distance. Apical to this adhesion, functionally inserted fibers were present. Since no cementogenesis was seen at these latter areas, it must be assumed that the inserted fibers were present before the surgery and were not significantly affected by the procedure. No significant evidence of crestal osteogenesis was noted. However, comparison of the clinical osseous profile recorded at the time of surgical debridement with the flat crest seen in two of our cases histologically, suggests that significant crestal resorption had taken place postsurgically in some of these lesions.