The treatment of periodontitis should be carried out in an incremental manner, first by
achieving adequate patient's oral hygiene practices and risk factor control during the
first step of therapy and then, during the second step of therapy, by professional
elimination (reduction) of supra and subgingival biofilm and calculus.
If the endpoints of therapy (no periodontal pockets >4 mm with bleeding on probing, BoP,
or deep pockets ≥5 mm) have not been achieved, the third step of therapy should be
implemented.
In fact, residual pockets following step 1 and 2 of periodontal treatment are associated
with increased risk of periodontal disease progression in the long-term as reported by
Claffey & Egelberg in1995. Residual probing depth (PPD) ≥5 mm after active therapy is a
risk factor for disease progression and tooth loss during supportive periodontal therapy
(SPT), suggesting that additional treatment of residual pockets is strongly recommended.
The third step of treatment includes the following interventions: repeated subgingival
instrumentation, access flap periodontal surgery, resective periodontal surgery,
regenerative periodontal surgery.
In case of residual pockets associated with shallow-moderate infrabony defects at
posterior teeth, where both regenerative therapy and non-surgical re-instrumentation are
usually not indicated, access flap procedures (i.e., the Modified Widman Flap, MWF) and
the Osseous Resective Surgery (ORS) are considered two of the most viable options.
The value of these surgical techniques has been tested over the years by different
clinical trials, and the choice of a surgical approach still relies mainly on the
decision-making process of the surgeon, since the long-term outcomes of the different
periodontal surgical procedures are similar, as highlighted by a recent systematic
review.
Nevertheless, one the main criticism that have been moved against ORS, lies on the fact
that the side effects (i.e., gingival recessions) seem to be more severe for ORS surgery,
when compared with MWF.
In the early 2000s, Carnevale proposed the Fibre Retention Osseous Resective Surgery
(FibReORS), an approach that leads to a more conservative bone resection to eliminate
infrabony defects and establish a positive bony architecture than the conventional ORS.
Indeed, this one, based on the histological findings by Gargiulo et al. (1961), uses the
level of the connective tissue attachment - rather than the bottom of the osseous defect
- as the reference to apply the principles of ORS.
Two randomized clinical trials demonstrated that FibReORS is similarly effective as ORS
for PPD reduction with less final gingival recessions (REC), clinical attachment loss
(CAL) patient morbidity.
Nevertheless, no studies have ever directly compared FibreORS with MWF. Therefore, the
aim of this randomized clinical trial (RCT) is to compare the efficacy of FibReORS versus
MWF in the treatment of periodontal pockets associated with infrabony defects ≤3 mm at
posterior natural teeth.
Objectives
The experimental hypothesis is:
FibReORS is superior to MWF in achieving PPD closure (PPD <4 mm without BoP) at posterior
teeth associated with shallow-moderate infrabony defects.