Periodontitis is defined as an inflammatory disease of supporting tissues of teeth caused by
specific microorganisms or groups of specific microorganisms, resulting in progressive
destruction of the periodontal ligament and alveolar bone with periodontal pocket formation,
gingival recession or both 1. Its severe form affects 11% of the population worldwide 2.
Periodontitis influence oral health related quality of life (OHRQoL) and thus is a major
public health problem3. Treatment of periodontal disease includes non-surgical and surgical
procedures. Reduction in pocket depth and gain in clinical attachment level are usually
considered as successful outcomes of periodontal therapy. While Non-surgical therapy is
effective in shallow pockets, significant gain of clinical attachment is usually observed in
deep pockets after surgical therapy 4.
There are various surgical procedures for the management of periodontal pocket which include
curettage, gingivectomy, periodontal flap surgery and guided tissue regeneration. Among
these, periodontal flap surgery is used widely. The primary objective of periodontal flap
surgery is to obtain access for root instrumentation so that plaque can be removed and the
secondary objective is pocket reduction via soft and hard tissue resection to facilitate home
care5. Neumann was the pioneer of periodontal flap6 surgery then Widman described the
different incision technique for periodontal flap in 1966. A modification of Widman flap was
described by Ramfjord and Nissle in 19747. This modification includes initial incision which
is parallel to the long axis to the tooth and a second crevicular incision which surrounds
the neck of teeth. Advantages of modified Widman flap surgery are that it conserves bone and
there is optimal root coverage which is esthetically acceptable and also permits oral
hygiene. It also results in more pocket closure and more bone regeneration. But one of the
major disadvantage of modified Widman flap procedure is unfavourable interproximal
architecture immediately after removal of dressing7.
With time it has been seen that outcomes of surgical periodontal therapy is effectively
influenced by various factors such as pocket depth, severity of gingival inflammation,
marginal alveolar bone, systemic diseases and smoking8-10. As per the literature available
these factors need to be further explored. Biologic width, which is now known as supracrestal
tissue attachment (SCTA) is described as a variable entity comprising of junctional
epithelium and connective tissue attachment coronal to the alveolar crest11. A landmark
histologic study by Gargiulo et al which was done on human autopsy specimens has given an
average of 2.04 mm for this entity12, though a study by Vacek et al stated that it may range
from 0.75 mm to as large as 4 mm in a healthy periodontium13. But these studies did not tell
about the clinical significance of BW and then Inger et al were the first to describe the
clinical significance of biological width in dentistry. Another human histometric study has
demonstrated mean measurement of supracrestal tissue as 2.75+/-0.59mm. however these studies
were only conducted on healthy periodontium14. Only a few studies have attempted to assess
the dimensions of SCTA in periodontal disease. According to a study by Novak et al, average
clinical biologic width in case of severe, generalized, chronic periodontitis was observed to
be nearly twice as previously reported for histological width which was 2.04mm (1.94
-1.97mm). In this study 44% of all measured sites were had PD and CAL less than equal to 3mm.
Its observations suggested that even in the presence of a severe, generalized, horizontal
pattern of alveolar bone loss, nearly half of the clinical sites in the mouth showed minimal
clinical signs of disease but extensive radiographic evidence of alveolar bone loss15. One of
the study by Abullais et al suggest that clinical and radiographic findings of the SCTA
showed a significant difference in patients with periodontitis16. Various clinical and
experimental studies are available in the literature about the effect of periodontal surgical
procedure on healing and regeneration of SCTA but there is no study in the literature which
demonstrate the effect of SCTA on scaling and root planning and open flap debridement. Thus,
the aim of this study is to evaluate the impact of supracrestal tissue attachment dimension
on the outcomes of scaling and root planing followed by open flap debridement in patients
with stage 2 and stage 3 periodontitis between thick versus thin periodontal phenotypes.
MATERIALS AND METHODOLOGY
SETTINGS: The present prospective clinical trial will be conducted in the Department of
Periodontics, Post Graduate Institute of Dental Sciences, Rohtak STUDY DESIGN: Interventional
study TIME FRAME: 12-14 months SAMPLE SIZE Sample size determination was done by using G
power software. Results of a previous study by Gumber et al. taking changes in clinical
attachment gain as the clinical outcome at the end of 6 months between thick and thin PP was
used to compute the effect size, taking power as 80% and α as 0.05. Sample of 18 patients per
group was calculated as the minimum sample size for the study. Considering 30% patient
attrition, a total of 24 patients will be recruited per group.
METHOD OF RECRUITMENT:
Patients will be recruited from out patient clinic of Department of Periodontics, PGIDS,
Rohtak after screening based on given inclusion and exclusion criteria.
RANDOMIZATION & ALLOCATION CONCEALMENT-Not applicable BLINDING/MASKING-single blind
INTERVENTION All the participants will undergo phase-I therapy with a combination of hand
scalers and curettes (Hu Friedy) and ultrasonic scaler (EMS Piezon,250, Switzerland). Oral
hygiene instructions will be imparted and will be reinforced at each appointment.
After a period of 6 weeks of scaling and root planing, patients having residual probing depth
of ≥ 5 mm at ≥ 4 sites along ≥ 2 maxillary or mandibular incisors teeth will be recalled for
open flap debridement. Patients will be recalled at the end of 3 months and 6 months for
recording of parameters.
METHODOLOGY:
Patients fulfilling the eligibility criteria will be enrolled in the study after obtaining
the informed consent. Periodontal parameters will be assessed which include Plaque index
(PI), Gingival index (GI), clinical attachment level (CAL) , periodontal pocket depth (PPD),
bleeding on probing (BOP), Periodontal phenotype (PP), keratinized tissue width (KTW) and
supracrestal tissue attachment (SCTA).
KTW will be evaluated before supracrestal tissue attachment (SCTA) measurement and SCTA will
be measured under local anesthesia.
The transgingival probing depth will be measured till the alveolar crest (from the free
gingival margin to the alveolar crest under LA). SCTA will be obtained after subtracting the
probing depth (free gingival margin to base of the periodontal pocket) from supracrestal
gingiva.
Evaluation of PP will be done after completion of Phase I therapy using probe transparency
method.
