2007Comparison of gingival blood flow 2007.doc

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JClinPeriodontol2007;34:903911doi:10.1111/j.1600-051X.2007.01119.x

Comparisonofgingivalbloodflowduringhealingofsimplifiedpapillapreservationandmodified

Widmanflapsurgery:aclinicaltrialusinglaserDopplerflowmetry

Retzepi

M,TonettiM,DonosN.Comparisonofgingivalbloodflowduringhealingof

simplifiedpapillapreservationandmodifiedWidmanflapsurgery:aclinical


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trialusinglaserDopplerflowmetry.JClinPeriodontol2007;34:903911.doi:10.1111/j.1600-051X.2007.01119.x.

Abstract

Aim:Thisprospectiverandomized-controlledclinical

trialcomparedthegingivalbloodflowresponsesfollowingsimplifiedpapillapreservation(test)versus

modifiedWidmanflap(control).MaterialsandMethods:Twentycontra-lateraluppersiteswithpocket

depthX5mmafterinitialtreatmentin10chronicperiodontitispatients


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wererandomlyassignedtoeithertestorcontroltreatment,usingasplit-mouthdesign.LaserDopplerflowmetryrecordingswereperformedpre-operatively,followinganaesthesia,immediatelypostoperatively

andondays1,2,3,4,7,15,30and60,at

nineselectedsitesperflap.Results:Significantischaemiawasobservedatallsites

followinganaesthesiaandimmediatelypost-operatively.Atthemucosalflapbasis,


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apeakhyperaemicresponsewasobservedonday1,whichtendedtoresolvebyday4atthetestsites,butpersisteduntilday

7atthecontrolsites.Thebuccalandpalatalpapillaebloodperfusionpresented

themaximumincreaseonday7inbothgroupsandreturnedtobaseline

byday15.Bothsurgicalmodalitiesyieldedsignificantpocketdepth


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reduction,recessionincreaseandclinicalattachmentgain.Conclusions:Periodontalaccessflapsrepresentanischaemiareperfusionflapmodel.Thesimplifiedpapillapreservationflapmaybeassociated

withfasterrecoveryofthegingivalbloodflowpost-operativelycomparedwiththemodified

Widmanflap.

M.Retzepi1,M.Tonetti1,2andN.Donos11

PeriodontologyUnit,EastmanDentalInstitute,UniversityCollegeLondon,London,


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2

UK;EuropeanResearchGrouponPeriodontologyNetwork

Keywords:bloodflow;laserDopplerflowmetry;periodontalaccessflap;woundhealing

Acceptedforpublication19June2007

Periodontalsurgicaltherapy

constituteshavingperiodontaldiseases.Avarietysurgery,inadequatebloodsupplyand

akeyaspectofthetreatmentofpatientsofsurgical


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techniqueshavebeendevel-ischaemiareperfusioninjuryarecriticalopedandtestedfortheirpotentialfactorsassociatedwithdetrimentaltorestoretheperiodontaltissueslostchanges

intheoperatedtissues,which

Conflictofinterestandsourceof

duetodestructiveperiodontaldiseasemayleadtopost-operativecomplica

fundingstatement

(Wennstrometal.2003).tions,


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suchasnecrosis,especiallyatTheauthorsdeclarethattheyhaveno

Theelevationofamucoperiostealthedistantpartsofthe

flap(Carroll&conflictofinterests.

flapinducesanischaemicresponse

par-Esclamado2000,Zhangetal.2004).

Thisstudywassupported

byaClinical

ticularlyinthecoronalparts


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oftheflap,Therefore,itmaybeanticipatedthata

ResearchandDevelopmentCommittee

whichisindicativeofasignificant

vas-periodontalflapdesignthatwouldmini

grantfromtheSpecial

Trustees,Royal

culartraumaoftheoperatedtissuesmizethedamage

ofthemicrovascula-

FreeandUniversityCollegeMedical


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(McLeanetal.1995).Duringtheearlytureoftheoperatedareaandwould

School(CRDCProjectGrantG125).

post-operative

periodfollowingflapensuresufficientbloodsupplytothe

r2007

TheAuthors.Journalcompilationr2007BlackwellMunksgaard


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904Retzepietal.

differentpartsoftheperiodontiummighthaveanessentiallypositiveeffectonthespeedandonthe

qualityofthehealingprocess.Furthermore,animprovedhealingprocesswouldbeof

paramountimportanceforthefinaloutcomeofvariousregenerativeprocedures,asithas

beenshownthatthepresenceofanon-bioresorbablemembraneinterferes


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withthere-vascularizationoftheoperatedarea(Vergaraetal.1997)andincertaincasesitmightcreateischaemiaoftheflaps(Donoset

al.2002)andpartialnecrosisofthesuperficialbone(Grevstad1993).

Thesimplifiedpapillapreservationflap(SPPF)hasbeendesignedandsuccessfullyappliedfor

periodontalsurgery(Cortellinietal.1999).Theadvantagesofthis


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flapincludeeasierapplicationinnarrowinter-dentalspacesandintheposteriorareas,moreeffectiveprimaryclosureoftheflapleadingtoimprovedclinical

woundhealingandmaintenanceoftheoriginalmorphologyoftheinter-dentaltissues.However,

thisflapdesignhasnotbeenquantitativelycomparedwithotherestablishedsurgicalflaps.

LaserDopplerflowmetry(LDF)isanon-invasivemethod


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extensivelyusedtostudytheskinmicrocirculation.SeveralstudieshaveshownahighcorrelationbetweenLDFandothercurrentlyavailabletechniquesforbloodperfusion

measurements(Choi&Bennett2003),andanintra-individualcoefficientofvariationof25%

hasbeenreportedforLDFmeasurementsoftheskinperfusion,whichisconsidered

tobeacceptableforthephysiologicalvariableskinbloodflow


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(Abbinketal.2001).TheLDFtechniquehasbeenwidelyusedinthefieldofplasticsurgeryformonitoringthemicrovascularbloodflowin

skintransplantsandflaps,inordertodetectearlysignsofimpairedcirculation

andthuspredictandpossiblypreventsurgicalcomplications(Svenssonetal.1985,Yuen

&Feng2000).Inthefieldofdentistry,theLDF


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hasbeenused,amongotherapplications,inordertoevaluatetheeffectofperiodontaldisease,smokingandperiostealstimulationongingivalbloodflow(Baab

etal.1986,Meekinetal.2000,Ambrosinietal.2002).Theresults

ofarecentpilotstudyfromourresearchteamhaveindicatedthatLDF

presentsclinicalapplicability,inordertoassessthegingivalblood


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flowchangesfollowingperiodontalaccessflapsurgery(Donosetal.2005).

Theaimofthepresentrandomizedcontrolledclinicaltrialwastocompare

themicrovasculargingivalbloodflowchangesofthealveolarmucosaandthebuccal

andpalatalinter-dentalpapillae,duringthepost-operativehealingperiod,followingSPPFversusmodified

Widmanflap(MWF)inpatientswithchronicperiodontitis,usingLDF.


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MaterialandMethodsSubjectpopulation

Thiswasarandomized-controlledsingle-blindedsplit-mouthclinicaltrialwitha2monthfollow-up.

TheexperimentalprotocolforthisstudywasapprovedbytheEastmanDental

InstituteandHospitalJointResearchandEthicsCommittee.Tenpatients(sixfemales,four

males,meanage40.56.5years)referredtotheDepartment


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ofPeriodontology,EastmanDentalInstitute,forthetreatmentofchronicgeneralizedperiodontitisparticipatedinthestudy.Furtherinclusioncriteriawereasfollows:

.thepresenceofcontra-lateralsitesoftheupperjawwithaprobing

pocketdepthof5mmormoreandbleedingonprobingatthe

re-evaluationappointment3monthsfollowingcompletionoftheinitialperiodontal


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treatment;.non-smokers;.goodsystemichealth;.agebetween35and65years;.lackofprevioustreatmentofperiodontaldisease;and.

nosystemicantibioticsintakeforatleast6monthsbeforethestartof

thestudy.Signedinformedconsentwasobtainedfromallsubjects.

Clinical

measures

Thefollowingclinicalparameterswereassessedat


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thebaselinevisitand2monthsfollowingthesurgicalprocedure:

.Percentageoftotalsurfaces(sixaspectspertooth)thatrevealedthe

presenceofplaque..Percentageoftotalsurfaces(sixaspectspertooth)that

presentedbleedingonprobingfromthebaseofthepocket..pocketprobing

depth(PPD),gingivalrecession(REC)andclinicalattachmentlevel(CAL)


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insixaspectspertoothwererecordedtothenearestmillimetrewithastandardmanualperiodontalprobe(PCP12,Hu-Friedy,Chicago,IL,USA).

Alltheclinicalmeasurementswereperformedbythesamecalibratedexaminer(M.

R.)(%siteswithin2mmagreementforPPD598.9%;forREC

597.8%;forCAL595.4%).

Poweranalysis


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Basedonourpreviousstudy,whichshowedthatattheendofthefirstpostoperativeweektheLDFmeasurementsatthepapillary

andmucosalsitespresentedincreasedby52.661.6perfusionunits(PU)(Retzepietal.

2007),theaimofthepresentstudywastodetectatruedifference

ofatleast50PUbetweenthetestandcontrol


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surgicalprocedures.BasedontheassumptionsofnormaldistributionsoftheLDFmeasurementsandastandarddeviationof114,poweranalysisconfirmedthata

samplesizeof10subjects,eachconferringthreesitestothecontroland

threesitestothetestgroupinasplit-mouthintra-individualdesign,wouldprovide

sufficientpower

(0.9)todetectsignificantdifferencesbetween


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thetwotreatmentgroupsatthetwo-sided5%level.Randomization,surgicalproceduresandpost-operativecare

Asplit-mouthdesignwasapplied.Ineach

patient,eachcontra-lateralareaoftheupperjaw,presentingwithPPDof5

mmormoreandbleedingonprobingfollowingtheinitialphaseofperiodontal

therapy,wasrandomlyassignedtoperiodontalsurgicaltreatmentwithMWF


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(controlgroup)orSPPF(testgroup).Alloperationswereperformedbythesameoperator(M.R.).Acomputer-generatedrandomizationlistwasdrawnup

bytheresearchco-ordinatorandgiventotheoperator.Thetreatmentcodewas

revealedfollowingperformanceoflocalanaesthesiaandimmediatelybeforethesurgicalprocedure.

Eachflapdesignincludedthreeconsecutiveinter-proximalpapillae.Local


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anaesthesiawasperformedbuccallyandpalatallywithdeliveryof3.6and1.8ml,respectively,oflidocaine2%withepinephrine1:80,000(Xylocain,Astra,Molndal,Sweden).

MWFwasperformedontheassignedtothecontrolgroup,asdescribedpreviously

(Ramfjord&

r2007TheAuthors.Journalcompilationr2007Blackwell

Munksgaard


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Flapdesigneffectonpost-operativegingivalbloodflow905

Nissle1974).Inbrief,theinitialincisionwasplaced0.51mmaway

fromthefreegingivalmargininareaswithPPDX5mm,whereasin

areaswithshallowpocketstheincisionwasintra-crevicular.Verticalincisionswerenotperformed.

Buccalandlingualmucoperiostealflapswereraisedandtheexposed


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defectswerecarefullyscaledandrootplanedusingacombinationofmechanicalandhandinstrumentation.Theflapswerethenrepositionedandsingleinter-dentalsutures

wereplacedusingresorbable5.0sutures(VicrylRapide,

Ethicon,Norderstedt,Germany).

SPPFwasperformedontheareasassignedtothetestgroup,

asdescribedpreviously(Cortellinietal.1999).Morespecifically,buccal


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andlingualintracrevicularincisionswereperformed,combinedwithasingleinter-proximalincision.Buccalandlingualmucoperiostealflapswereraisedandtheexposeddefectswere

carefullyscaledandrootplanedusingacombinationofmechanicalandhandinstrumentation.

Theflapswerethenrepositionedandclosedusingatwo-layeredsuturingtechnique:deep

horizontalmattressresorbable5.0sutures(Vicryl,Ethicon,Germany)withthe


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aimofremovingresidualtensionfromtheflapmargins,incombinationwithsingleinter-dentalresorbable6.0sutures(VicrylRapide,Ethicon)withtheaimof

achievingpassiveprimaryclosureofthewoundmarginsintheareaofthe

interdentalpapilla.

Thepatientswereaskedtorefrainfromoralhygiene

forthefirst7daysfollowingtheoperation.Thesutures


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wereremovedonday7followingthesurgicalprocedure.Thepatientswereinstructedtorinsewith0.2%chlorhexidinedigluconatetwiceperdaythroughoutthe

2-monthfollow-upperiod.Thepatientsreceivedprofessionaltoothpolishingatdays15,30

and60followingtheoperation.

LDFmeasurements

Equipment

TheLDFtechniqueisbasedontheDopplerprinciple.


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Specifically,alaserbeamisemittedbyanopticalfibretothetissuetobestudied.Thelighthittingmovingerythrocytesisscatteredback

inshiftedfrequency(Dopplereffect)andiscapturedbyoneormoreoptical

fibres.Thelightsignalsarethenconvertedintoelectricsignalsandtheresulting

photocurrentisprocessedtoprovidearecord

ing


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ofthebloodflow(Sternetal.1977).Althoughthemultiplescatteringeventsthatdeterminethepropagationoflightintissuepreventabsolutevelocity

measurementswhenusedinvivo,relativebloodflowmeasurementscanbeobtained.Therefore,

thetermusedtodescribebloodflowisfluxaquantityproportional

totheaveragespeedofthebloodcellsandtheir


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concentration.ThisisexpressedinarbitraryPU,whicharelinearlyrelatedtoflux.AcommerciallyavailablelaserDopplerflowmeter(5010Periflux,Perimed,Jarfalla,Sweden)

withwavelength780nmequippedwithastandardprobe(PF416withoutsidediameter

1.0mmandfibreseparation

0.25mm)wasusedforall

measurements.Theflowmetretimeconstantwas0.2s,withan


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upperbandwidthat20kHzandlowerbandwidthat20Hz.Theinstrumentsandfibre-opticprobeswerecalibratedbymeansofthePerimedPF

1000MotilityStandardaccordingtothemanufacturersspecificationsbeforeeachmeasurement.Thesignals

wererecordedinarbitraryPUandmonitoredusingthePerisoftsoftware(Version2.10,

PerimedAB).LDFmeasurements

TheLDFmeasurementswere


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performedasdescribedpreviously(Donosetal.2005).Inbrief,a2min.LDFrecordingwasperformedineachofnineselectedmeasurementsites

perflap,including:

.threesiteslocatedonthemucosalflap

basis(onecentrallylocated,oneclosetothemesialandonecloseto

thedistalflapedge);.threebuccalpapillarysites,one


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ateachofthreeadjacentinter-dentalpapillaeincludedintheflapdesign(distal,centreandmesial);and.threecorrespondingpalatalpapillarysites.The

LDFmeasurementsatthetestandcontrolgroupwereperformedontheday

ofthesurgerybeforetheinjectionofthelocalanaesthesia(baseline),5min.

followinglocalanaesthesiainduction,immediatelyfollowingcompletionofthesurgical


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procedureandonpostoperativedays1,2,3,4,7,15,30and60.

StandardizationandreproducibilityoftheLDFrecordings

Inordertostandardizetheposition(locationandangulation)oftheLDF

probeinrelationtothegingivaltissueatallobservationtime

points,theLDFmeasurementswereperformedwiththetipof


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thefibre-opticprobeinsertedintotheholesofanindividualacrylicstentpreparedondentalcastsasdescribedpreviously(Donosetal.2005).Thus,

theLDFprobewasplacedatastandardizedlocationperpendiculartothetissues

andatadistanceof0.5mmfromthegingivaeandremainedmotionless

duringrepetitiveLDFmeasurements.

DuringallLDFmeasurements,


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thesubjectswerecomfortablyseatedandrelaxedinastandardizedsemi-reclinedpositiononthesamedentalchair,inaquietroomwithaconstantly

stabletemperature.AlltheLDFmeasurementswereperformedbythesamepreviouslycalibrated

examiner(M.R.)(Intra-classcorrelationcoefficient50.68,95%confidenceinterval50.500.80).

ThereproducibilityoftheLDFmeasurementswastestedbeforethe


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startofthestudyonsevenperiodontallyhealthyvolunteers,onwhomtwosetsofLDFmeasurementswereperformedatninegingivalareas.Apaired-samples

t-testwasperformedandrevealednosignificantdifferencesbetweenthetwosetsof

recordings.

Statisticalanalysis

Allrecordingperiodsimpairedbythe

artefactscausedbytherelativemotionoftheprobewere


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excluded.Anaverageofthe2-min.periodofeachindividualrecordingwascalculatedbythePerisoftcomputerprogramme(Version2.10,Perimed,Stockholm,Sweden).All

valuesweretransferredtotheMicrosoftExcelprogramforfurthercalculations.Changesof

bloodflowvaluesinthealveolarmucosa,palateandpapillaewereexpressedas

thedifference(DPU)betweenthePUvalueataspecific


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siteataspecificobservationtimepoint(PUt)andtheindividualbaselinevalueofthesamesite(PU0):DPU5PUtPU0

StatisticalanalysiswasperformedusingtheSPSSstatisticalsoftware(SPSS11.0,Chicago,IL,

USA).TheDPUvaluesinthealveolarmucosa,palateandbuccalpapillaewere

analysedusingthegenerallinearmodel(GLM)univariatetest,after


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theassumptionsofhomogeneityofvarianceandnormalityoftheresidualsdistributionwerechecked.Thesurgicaltreatmenttypeandtheobservationtimepointwere

modelledasfixedfactorsandthe

r2007TheAuthors.Journal

compilationr2007BlackwellMunksgaard


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906Retzepietal.

patientasarandomfactor,withtheDPUAlveolar mucosaasthedependentvariable.Theleast180significant

differencestestwasused,150inordertodeterminethedifferences120

TREATMENTMWFSPPF*betweenbaselineandsubsequenttime90pointswithineach

treatmentgroup.60

30

Thesignificanceofdifferences


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in

PPD,RECandCALfrombaselineto

DPU

0

-30

2monthspost-therapybetweenthetest

-60

andcontrolgroupswasevaluatedusing

-90

one-wayanalysisofvariance,withthe

-120

patientmodelled

asarandomfactorand

-150

the


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baselinePPDasacovariate.The

-180

significanceofthedifferencesbetweenbaselineand2monthspost-therapywasevaluatedwiththe

paired-samplest-testforPPD,RECandCALwithineachtreatmentgroupandwith

Wilcoxon

TIME

sign-ranktestforthepercentage-based

measures

ofFMPSandFMBS.

Dataarepresentedas


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meanstandarderrorunlessotherwiseindicated.Statisticalsignificancewasacceptedatpo0.05.

ResultsLDFmeasurements

Alveolarmucosalareas

TheGLMrevealedasignificanteffectoftime(po0.001)andtreatmenttype(p

50.049)ontheDPUvaluesrecordedinthemucosalareas.

Fig.1.Plotofthetimecourseofthegingival


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bloodflowchangesatthealveolarmucosalareasofthesimplifiedpapillapreservationflap(SPPF)andthemodifiedWidmanflap(MWF),expressedasdifference

inperfusionunitsfrombaseline(DPU).Plottedpointsincludemeasurementstakenpreoperatively(baseline),

followinganaesthesia,immediatelypost-operativelyandonpost-operativedays1,2,3,4,7,

15,30and60.Statisticallysignificantdifferencesinperfusionunits


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betweentreatmentsareindicatedbyn.Errorbars5SEM(po0.05).

Buccal Papillae90

60

30

0

thepost-operativehealingperiod.On

*MWFthefirstpost-operativeday,

ahyperae--90micresponsewasindicatedbyamax

-120

imumincreaseofthebloodflow

SPPF


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comparedwiththebaseline,inboth

Bothtreatmentgroupspresented

DPU

-30

overallsimilarpatternsofchange

inPUfollowinganaesthesiaandduring

-60

-150

the

MWFandtheSPPF.Themicrocirculatorybloodperfusionremainedsignificantlyincreaseduntilpost-operative

day7inthecontrolgroup,whereasinthetest


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grouptheperfusionvalues

TIME

remainedsignificantlyincreasedabove

baselineonlyuntilday3.Moreover,onpost-operativeday4,

theincreaseofthePUvaluesabovebaselinewassignificantlyhigherinthe

controlcomparedwiththetestgroup(p50.025)(Fig.1).

Buccalpapillaryareas

TheGLMrevealedasignificant


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effectoftime(po0.001)andtreatmenttype(p50.048)ontheDPUvaluesrecordedinthebuccalpapillaryareas.

Bothtreatment

groupspresentedoverallsimilarpatternsofchangein

Fig.2.Plot

ofthetimecourseofthegingivalbloodflowchangesatthebuccal

papillaryareasofthesimplifiedpapillapreservationflap(SPPF)and


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themodifiedWidmanflap(MWF),expressedasdifferenceinperfusionunitsfrombaseline(DPU).Plottedpointsincludemeasurementstakenpreoperatively(baseline),followinganaesthesia,immediately

postoperativelyandonpost-operativedays1,2,3,4,7,15,30and

60.Statisticallysignificantdifferencesinperfusionunitsbetweentreatmentsareindicatedbyn

.Errorbars5SEM

(po0.05).PUfollowing


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anaesthesiaandduringabovethebaselinewasobservedondaytheearlypost-operativeperiod.The7,inthemicrocirculatoryperfusionatPUvaluesat

thebuccalpapillarysitesboththeMWFandtheSPPFsites.remainedat

baselinelevelsduringtheNotably,thePUvaluesatthepapillaryfirstfour

post-operativedays,inbothsiteswhereSPPFhadbeenperformed


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treatmentgroups.Asignificantincreaseweresignificantlydecreasedcompared

r2007TheAuthors.Journalcompilationr2007BlackwellMunksgaard


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Palatal Papillae creaseinthemicrovascularbloodflow

*150

120

906030

0-30-60

Modified Widman-90-120

SPPF

-150

-180

comparedwiththebaseline,by5072%

atthemucosalsitesandby6772%


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intheinter-dentalpapillaeinboththeMWFandtheSPPFflaps.Theseresultsareinagreementwithsimilarpreviousreports(Ketabi&

Hirsch1997,Ambrosinietal.2002,Donosetal.2005).Theflapischaemia

inducedbytheinjectionofalocalanaestheticwithavasoconstrictortothe

alveolarmucosalastedforatleast2h,asevidenced


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bythesignificantlydecreasedperfusionobservedfollowingcomple-

DPU

tionofthesurgicalprocedure.Therefore,theperiodontalaccessflapmaybeconsidered

asanischaemiareperfusionflapmodel(Carroll&Esclamado2000).Atthemucosalperiphery

oftheflap,

TIME

Fig.3.Plotofthetime

courseofthegingivalbloodflowchangesatthepalatal


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papillaryareasofthesimplifiedpapillapreservationflap(SPPF)andthemodifiedWidmanflap(MWF),expressedasdifferenceinperfusionunitsfrombaseline(DPU).

Plottedpointsincludemeasurementstakenpreoperatively(baseline),followinganaesthesia,immediatelypostoperativelyandon

post-operativedays1,2,3,4,7,15,30and60.Statisticallysignificant

differencesinperfusionunitsbetweentreatmentsareindicatedbyn


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.Errorbars5SEM

(po0.05).

withthebaselineatpost-operativedays30and60(Fig.2).

Palatal

papillaryareas

TheGLMrevealedasignificanteffectoftime(po0.001)

andtreatmenttype(p50.001)ontheDPUvaluesrecordedinthe

palatalpapillaryareas.

Thepalatalsitesinboth


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treatmentgroupspresentedoverallatendencytowardsagradualincreaseinthePUvaluesduringthepost-operativehealingperiod.Asignificantpeakincreaseabove

thebaselinewasobservedonday7atthepalatalpapillaeofboth

treatmentgroups,whichwassignificantlyhigherattheSPPFversustheMWFsites

(p50.024)(Fig.3).

Clinicaloutcomes


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Healingwasuneventfulinallcases(Figs4and5).Table1displaysthePPD,CALandRECvaluesatbaselineand2

monthspost-operativelyforsiteswithPPDX5mmatbaseline,aswellasthe

meanchangesoftheseclinicalparametersbetweenbaselineand2monthspost-therapy.For

siteswithinitialPPDX5mm,theMWFyieldedasignificantly


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greaterPPDreductioncomparedwiththeSPPF(p50.014).The

differencesinRECincreaseandCALgainbetweentreatmentsfailedto

reachstatisticalsignificance(p50.097andp50.609,respectively).Table2

displaystheFMPSandFMBSscoresatbaselineandatthere-evaluation2

monthspost-operatively.TherewerenosignificantchangesintheFMPS


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medianscoresatthere-evaluationvisitcomparedwithbaseline(p50.139).SurgicaltreatmentledtoasignificantreductionintheFMBSmedianvalues

2monthspost-operatively(p50.019).

Discussion

Thepresent

studycomparedthetemporalpatternofthemicrovascularbloodflowchangesofthe

MWFversustheSPPF,inpatientswithchronicperiodontitis,using


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LDF.Theresultsindicatedthattheflapdesignwasassociatedwithtemporalvariationsinthemicrovascularbloodflowresponses,whichwereobservedamongthe

treatmentgroupsduringthewound-healingperiod.Furthermore,ourobservationsconfirmtheresultsof

ourpilotstudy(Donosetal.2005),indicatingthatLDFmaypresentclinical

applicabilityinrecordingthegingivalbloodflowchangesfollowingperiodontal


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surgery.

Theinjectionofalocalanaestheticwithavasoconstrictorinducedade

wherethemicrovasculararchitecturewaspreserved,a

peakhyperaemicresponsewasobservedonpost-operativeday1inboththeMWF

andSPPF,whichisinagreementwithourpreviousreportonpost-operativeblood

flowchangesfollowingaccessflapperiodontalsurgery(Retzepietal.


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2007).Furthermore,theseobservationsareinaccordancewithclinicalandinvivostudies,which,bymeansofLDForimaging,reportedanincrementof

thebloodflowinareasproximaltotheflapbasis,whichpeakedon

thefirstpostoperativeday(Marksetal.1984,Eichhornetal.1994,Aydin

&Mavili2003).Itmaybehypothesizedthattheobserved


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hyperperfusionisassociatedwithvasodilationoccurringasapredominantmicrovascularresponseattheundisturbedwoundperipheryduringtheveryinitialhealingperiod(Rendellet

al.1997),whichisconsideredtobeprincipallymediatedbythesubstantialinduction

ofnitricoxidesynthetase(Rendelletal.2002).

Duringtheelevation

ofamucoperiostealflap,theconnectionofthegingivoperiostealplexus


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withtheperiodontalligamentvascularplexusissevered(Nobutoetal.2005)andsignificantvasculartraumaisinduced,especiallyintheinter-dentalareas(McLean

etal.1995).Ontheotherhand,thepreservationofthearterialinflow

constitutesthemostcriticaldeterminantinachievingoptimalflaphealing(Nakayamaetal.

1982,Grace1994).Inthepresentstudy,thehyperaemicresponse


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observedpostoperativelyatthemucosalsitestendedtoresolvebyday4attheSPPFsites,butpersisteduntilday7attheMWF

sites.Itmaythereforebeanticipatedthattheshorterdurationofthehyperaemic



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908Retzepietal.

Fig.4.Buccalviewofexperimentalcontrolside,whereamodifiedWidmanflapwasperformed;(a)

pre-operativeview;(b)post-operativeview;(c)post-operativeday1;(d)post-operativeday2;

(e)post-operativeday4;(f)post-operativeday7;(g)post-operativeday60.

responseattheperipheryoftheSPPFindicatesfaster


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recoveryofthemicrocirculationandremissionoftheincreasedbloodinflowrequirementsinthisflapdesign.

Incontrasttothemucosalsites,

thebuccalandpalatalpapillarysitespresentedamaximumincreaseoftheblood

perfusionlevelsonpost-operativeday7inbothflapdesigns,whichisin

agreementwithourpreviousreportonpost-operativebloodflowchanges


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observedinthepapillaryareasfollowingaccessflapperiodontalsurgery(Retzepietal.2007).Theseresultsareinaccordancewithobservationsinskinexperimental

flaps,wherebloodflowincreasesatthedistalzonesoftheflapswere

observedonpost-operativedays36andcoincidedwithresolutionofthehyperaemiaat

theareaslocatedproximaltotheflap

periphery


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(Aydin&Mavili2003).Furthermore,takingintoconsiderationthattheLDFlightpenetratesthetissuesvariablytoadepthofabout0.6mm(Fullerton

etal.2002),itmaybeassumedthattheLDFreadingsfromthe

freegingivaeofthepapillaereflectonlybloodperfusionchangesoccurringatthe

supraperiostealgingivalplexus,whichisacoarsenetworkstructureconsisting


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mainlyofsmallarteriolesandvenules(Nobutoetal.1989).Inthiscontext,ourresultsareinagreementwithdatafromanimalexperimentsreporting

asubstantialincreaseofbloodflowobservedontheseventhdayofhealing

inthecentreofwoundscreatedatsitesperfusedbysmallcapillaries(Rendell

etal.1998),whichissimilartothefreegingivae.


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At4days,thevascularproliferationintheorganizing

bloodclotisadvancingwithanastomoticchannelsconnectingthecancellousbonecirculationwith

thoseoftheflapandmucosaandbyday7,thegingivalvessels

showcontinuitywiththoseoftheperiodontalmembrane(Caffesseetal.1981).Therefore,

theincreaseofthebloodflowthatwasobservedon


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post-operativeday7couldbeattributedtotheformationofgranulationtissuewithincreasedvascularizationduetoangiogenesis,assuggestedbyhistologicalobservationsin

animalexperiments(Nobutoetal.2003).Itiswelldocumentedthat,duringthe

earlypostoperativedays,thenewlyformedbloodvesselsintheprovisionalgranulationtissue

willre-establishthemicrovascularnetworkintheconnectivetissueand


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supplynutrientsandoxygentothewoundarea(Folkman&Shing1992).



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Fig.5.Buccalviewofexperimentaltestside,whereasimplified

papillapreservationflapwasperformed;(a)pre-operativeview;(b)postoperativeview;(c)post-operative

day1;(d)post-operativeday2;(e)post-operativeday4;(f)post-operativeday

7;(g)post-operativeday15;

(h)post-operativeday


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60.Table1.Baseline,2monthspost-operativelyanddifference(D)inprobingpocketdepth,couldbeattributedtoabetterpreserrecessionofthegingival

marginandclinicalattachmentlevelatsiteswithinitialPPDX5mmvationofthe

supraperiostealgingival

OutcomeBaseline2monthsp-valueDifferencep-valuevariablepaired

t-test02months

PPDControl5.70.12.8


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0.1o0.0012.80.20.014Test5.80.13.30.1o0.0012.50.2

RECControl1.10.12.60.2o0.0011.50.2

0.097Test1.10.12.20.1o0.0011.10.1

CALControl

6.70.25.40.3o0.0011.30.30.609Test6.90.25.50.2

o0.0011.52.1

Datapresentedinmm;mean


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standarderror(standarddeviation).PPD,probingpocketdepth;REC,recessionofthegingivalmargin;CAL,clinicalattachmentlevel.Studentst-testforpairedobservations.

Itshouldbenoted,however,thatwerenotedinthepalatalpapillae.

Morealthoughthepalatalandbuccalpapillaryspecifically,attheSPPFsites,the

hypersitespresentedasimilarpatternofpost-aemicresponseatthe


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palatalpapillaeoperativebloodflowchanges,somewasobservedasearlyastheseconddifferencesbetweenthetwoflapdesignspost-operativeday.Thisdifference

vascularplexusassociatedwiththeSPPFdesign,thusallowingaprompt

hyperaemicresponseduringtheearlypost-operativedays.Furthermore,thehyperaemicresponseatthe

palatalpapillaewassignificantlyhighercomparedwiththeMWFsites


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onday7.Takingintoconsiderationthatthebloodflowvaluesattheendofthefirstpostoperativeweekreflectchangesintheblood

flowofthenewlyformedgranulationtissue(Caffesseetal.1981,Nobutoet

al.2003),thisdifferencemayagainreflectthelesstraumaticnatureofthe

preservativeSPPFdesign,whichallowsfasterformationandorganizationof


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thegranulationtissue.

Inthepresentstudy,themicrocirculatoryperfusionlevelsofboththebuccalandpalatalpapillaereturnedbacktobaseline

levelsbypost-operativeday15,

r2007TheAuthors.Journalcompilation

r2007BlackwellMunksgaard


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910Retzepietal.

Table2.Baseline,2monthspost-operativelyanddifference(4)infull-mouthplaquescoresandScandinavianJournalof

DentalResearchfull-mouthbleedingonprobingscores101,224228.

Ketabi,M.

&Hirsch,R.S.(1997)Theeffectsof

OutcomevariableBaseline

2monthsp-value

localanestheticcontainingadrenalineon


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FMPS(%)22.6(5.640.1)18.2(2.234.2)0.139FMBS(%)29.4(15.043.8)18.4(4.032.8)0.019

Datapresentedin%:median(interquartile

range).FMPS,full-mouthplaquescore;FMBS,full-mouthbleedingscore.

Wilcoxonsigned-ranks

test.

whichisinagreementwithpreviousinvivostudies,reporting

regressionofthenewlyformedbloodvesselsintherepaired


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gingivaltissuebythe21stpost-operativeday(Nobutoetal.2005).

ThepresenceofgingivalinflammationandincreasedPPDhasbeenshown

toaffecttheLDFrecordingsobtainedfromtheperiodontaltissues(Rodriguez-Martinezet

al.2006).However,ourresultshaveshownthat,inbothtreatmentgroups,resolution

ofthegingivalinflammation,aswellaseliminationofpockets


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withPPD44mmwereachieved.

Conclusively,theresultsofthepresentstudyconfirmthoseofourpreviousstudies(Donosetal.2005,Retzepi

etal.2007),inthatthegingivalbloodflowpresentsspecificpatternsof

dynamicchangespost-operativelyandthatLDFmaypresentclinicalapplicabilityinrecordingchanges

inthemicrocirculatorybloodperfusionfollowingperiodontalsurgery.Furthermore,our


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resultsindicatethatthelocationoftheincisionsandthemanagementoftheSPPF,aimingatpreservingthepapillaryaspects,mayhaveapositive

effectontherecoveryofthegingivalbloodflowpost-operatively.

Acknowledgements

WearegratefultoMrs.JeanSuvan(EastmanDentalInstitute,UCL)

forhersupportintheco-ordinationofthisclinicaltrial


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andtoMs.AvivaPetrie(EastmanDentalInstitute,UCL)forstatisticaladvice.

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Address:

NikolaosDonosPeriodontology

UnitEastmanDentalInstituteUniversityCollegeLondon254GraysInnRoadWC1X8LD

LondonUK

E-mail:[email protected]

ClinicalRelevancePrincipalfindings:The

hyperaemicPracticalimplications:ThelocationScientificrationaleforthestudy:


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Theresponseobservedpost-operativelyoftheincisionsandthemanagementdesignandhandlingofperiodontalatthemucosalperipheryoftheoftheperiodontal

flapinordertoflapsaffecttheextentofthedamageSPPFwas

ofashorterdurationcompreservethepapillaryaspectsmayofthemicrovasculaturein

theoperparedwiththeMWF.Thisfindinghaveanessentially


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positiveeffectonatedareaandthetemporalpatternofwasassociatedwithfasterreperfuthepost-operativerecoveryofthethereperfusion.sionofthe

papillarymicrovascularbloodflow.network.

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2007Comparison of gingival blood flow 2007.doc