Intrabony Defects, Open-Flap Debridement, and Decortication: A Randomized Clinical Trial

• Localización: Journal of periodontology, ISSN 0022-3492, Nº. 1, 2014, págs. 34-42
• Idioma: inglés
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• Resumen

  • Background: Intramarrow penetration (IMP) is often incorporated in regenerative periodontal surgical procedures. However, the actual benefits of adding IMP to such a procedure remain undocumented. The purpose of this randomized controlled trial was to investigate the contribution of IMP to the outcomes of open-flap debridement (OFD) treatment of intrabony defects.

    Methods: Forty-two chronic periodontitis patients, each contributing a 2-wall, 3-wall, or combined 2- to 3-wall intrabony defect, were treated. Sites were randomly assigned into one of two groups: control (OFD alone) or test (OFD + IMP). Papilla preservation flaps were raised, and defects were thoroughly debrided. In the control group, complete primary closure of flaps was ensured after debridement. In the test group, IMP was performed before flap closure, using a round bur to penetrate the cortical defect wall. Clinical and radiographic parameters were assessed at baseline and 12 months after treatment.

    Results: At baseline, there were no statistically significant differences between groups. At 12 months, both groups experienced significant improvements, in terms of probing depth reduction, clinical attachment level (CAL) gain, and bone level (clinical and radiographic). The test group experienced significantly greater clinical bone gain (3.07 ± 1.74 mm) and prevalence of CAL gain =2 mm (93% of sites) compared with the control group (1.76 ± 2.71 mm, P <0.03; 62%, P = 0.024). The test treatment benefits were particularly evident in mandibular sites, in which OFD + IMP doubled the radiographic bone gain obtained by OFD alone.

    Conclusion: Addition of IMP to an OFD procedure used to treat intrabony defects results in statistically and clinically significant enhancement of both clinical and radiographic outcomes.

    Intrabony defects associated with periodontal pockets represent the anatomic sequelae of the apical spread of plaque in the course of periodontitis.1 Such defects are risk factors for periodontitis progression and additional loss of attachment if left untreated.2 Because intrabony defects are common in periodontitis,3,4 there is considerable interest in approaches that will convert such defects, at risk for disease progression, to easily maintainable shallow probing sites. This can be achieved by either resective5-7 or regenerative8-12 approaches, with the latter considered the ideal treatment.

    Among the various surgical techniques used to achieve the ideal biologic conditions required for periodontal regeneration, open-flap debridement (OFD) or access flap surgery was among the earliest procedures used13-15 and has been shown to result in successful treatment of intrabony defects.16 OFD has been traditionally included as the control procedure in clinical trials evaluating regenerative techniques, such as guided tissue regeneration (GTR),17,18 and use of biologic factors, including enamel matrix derivative.11 Even when used as the control procedure, OFD resulted in significant clinical benefits.17,18 According to a recent systematic review,16 the average clinical attachment level (CAL) gain obtained with OFD alone was 1.65 mm, average probing depth (PD) reduction was 2.80 mm, gingival recession (REC) increase was 1.26 mm, and bone gain at 12 months was clinically 1.04 mm and radiographically 0.95 mm. However, the reported clinical outcomes of OFD may vary, showing variability attributed to surgical technique (e.g., papilla preservation) and to patient- and operator-related factors.16 Therefore, there is opportunity to improve the predictability of OFD in the treatment of intrabony defects.

    Several authors have advocated the use of intramarrow penetration (IMP), also known as decortication, as a means to improve the local blood vessel and progenitor cell supply and, consequently, the outcomes of surgical procedures used to treat intrabony defects.19-23 However, the clinical benefits of this adjunctive procedure remain to be established. Specifically, the adjunctive use of IMP in the treatment of intrabony defects by OFD has not been investigated in clinical trials. Therefore, the purpose of this study is to investigate, using a randomized controlled trial (RCT) approach, the contribution of IMP to the clinical and radiographic outcomes of OFD treatment of intrabony defects.