Modified Vertical Internal Mattress Suture Versus Simple Loop Interrupted Suture.
Condition: Healing Surgical Wounds; Periodontitis
MeSH terms: Periodontitis; Surgical Wound
Study type: Interventional

Summary: 
      Aim of study was clinical comparative evaluation of using modified vertical internal mattress
      suturing technique and simple loop interrupted suturing technique in the outcome of modified
      Widman flap surgery for the management of chronic periodontitis.
    

Detailed description: 
      Periodontitis is inflammation of the periodontal tissues resulting in clinical attachment
      loss, alveolar bone loss, and periodontal pocketing.The destruction of tooth supporting
      tissues is caused by interaction of bacteria present in the dental plaque and the host .The
      elimination of bacterial plaque, calculus ,toxic material adhering to tooth surface and other
      plaque retentive factors can be achieved by nonsurgical and surgical periodontal therapies
      .The primary objective of periodontal therapy is arresting infection, restoring the lost
      structure and to maintain healthy periodontium .

      The requirement of access for scaling and root planning, pocket depth reduction, correction
      of gross gingival aberrations ,and establishment of morphology of the dento-gingival area
      conducive to infection control led to the development of the various surgical procedures. The
      initial surgical procedures used in periodontal therapy involved excision of the diseased
      gingival tissue . The main disadvantages of these procedures are unwanted root exposure, poor
      aesthetics, decrease in width of attached gingiva, excision of frenum attachment and creation
      of shallow vestibular depth.

      Proper management of supracrestal soft tissue flap during suturing appears to be of critical
      importance in ultimate outcome of surgical periodontal pocket management .A number of studies
      advocate the proper management of supra-alveolar component of flap in management of infrabony
      defects employing regenerative techniques with grafts / barrier membrane to minimize
      postoperative exposure, contamination and/or exfoliation of the grafted material and / or
      barrier membrane. However review of the available literature does not reveal studies
      conducted to evaluate the effectiveness of close approximation of flaps by different suturing
      techniques. Sites with suprabony periodontal pocket depth of 4mm have approximately 6 mm
      height of unsupported supracrestal soft tissue flap which increases with further increase in
      pocket depth. Moreover, with advancing probing depth, base of the unsupported soft tissue
      wall of periodontal pocket comes closer to the musculature in the vestibule, thereby
      eliciting requirement of a more efficient suturing technique to resist muscle pull for
      prevention of any disturbance to healing granulation tissue.

      The interrupted suturing encompasses two suturing technique; the simple loop and figure of
      eight. Modified vertical internal mattress suture is a variation of the vertical mattress
      suture which is especially useful in maximizing wound eversion, reducing dead space, and
      minimizing tension across the wound. Wound eversion maximize flap approximation. The
      recommended time for removal of this suture is 5-7 days to reduce the risk of scarring (cross
      hatching).

      Thus the most suitable suturing technique to achieve healing by primary intention and
      connective tissue reattachment/ periodontal regeneration need to be explored. The present
      study is intended to determine the influence of the simple interrupted and modified vertical
      internal mattress suturing technique on the outcome of modified Widman flap surgery .

      STUDY DESIGN This randomized clinical interventional study was conducted in Department of
      Periodontics and Oral Implantology, Post Graduate Institute of Dental Sciences (PGIDS),
      Rohtak.

      STUDY POPULATION Out of 172 patients screened from regular OPD in Department of Periodontics
      and Oral Implantology, the study was conducted in 48 chronic periodontitis participants
      meeting the eligibility criteria for surgical intervention. 45 patients completed the
      treatment protocol (28 males and 17 females, mean age: 35.91±7.67 years). Study period was
      from 01-12-2016 to 31-03-2018.

      METHODOLOGY

      Periodontal examination

      All eligible participants after 8 weeks of phase 1 therapy, were examined in a standardized
      way using illumination by a standard dental light, a mouth mirror, tweezer, manual calibrated
      probe (PCP-UNC 15 Hu-Friedy, Chicago, IL, USA) and explorer. Following parameters were
      recorded at baseline (day of surgery), after 3 months and 6 months follow up.

        -  Plaque index (Silness and Loe) (PI)

        -  Gingival index (Loe and Silness) (GI)

        -  Bleeding on probing (BOP)

        -  Probing pocket depth (PPD)

        -  Clinical attachment level (CAL)

        -  Location of crest of free gingival margin in respect to CEJ.(REC) All clinical
           parameters were recorded at six sites (mesio-buccal, mid-buccal, disto-buccal,
           disto-lingual, mid-lingual and mesio-lingual) per tooth in all teeth except for third
           molars. BOP was assessed as a dichotomous measure (bleeding present or absent) within 15
           seconds of probing. PD was recorded from gingival margin to base of pocket and CAL from
           cementoenamel junction (CEJ) to base of pocket.

      PRIMARY AND SECONDARY OUTCOME VARIABLES Improvement in PPD and CAL over 6 months was
      considered as the primary outcome variable of the study. Secondary variables included
      improvement in PI, GI, BOP and REC.

      PHASE 1 THERAPY Phase 1 therapy included patient education, motivation and plaque control.
      Full mouth supragingival and subgingival scaling and root planning with ultrasonic scaler
      (EMS Piezon 250 ,Switzerland), hand scaler and curettes (Hu-Friedy) was completed . Patients
      were kept on maintenance therapy.

      All clinical parameters were recorded in 48 eligible patients after 8 weeks of SRP. A custom
      made acrylic stent was fabricated to standardized the location and angulations of periodontal
      probe. The study procedure was explained to the patient in their own language. Written and
      verbal informed consent was obtained from each patient. Patients were randomly allocated to
      test group and control group by envelop method. 48 labelled papers, 24 papers with label 1
      and 24 papers with label 2 were placed into an envelope. If the patient picked paper with
      label 1 he or she was assigned to control group, while picking paper with label 2 meant
      assignment into test group.

      PERIODONTAL SURGICAL PROCEDURE Modified Widman flap surgery was performed in both groups.
      After administration of local anaesthesia, first incision which is an internal bevel
      incision, was made 0.5 mm away from the crest of gingival margin to crest of alveolar bone,
      2nd intra-crevicular incision from base of periodontal pocket to crest of alveolar bone and
      3rd incision /horizontal incision follow the contour of the alveolar crest and the
      inter-proximal septum to cut loose the collar of gingival tissues which has been separated
      from the buccal or lingual flap and the teeth. A mucoperiosteal flap was reflected including
      at least one tooth ahead and one tooth behind the tooth/teeth involved. Meticulous
      debridement and root planning was carried out using area specific curettes and scalers to
      remove all the granulation tissue. After instrumentation, the root surface were washed with
      saline solution in attempt to remove any remaining detached fragments from the surgical
      field. After debridement mucoperiosteal flaps were repositioned and secured by using 3-0 non
      absorbable black silk surgical suture. Test group was given modified vertical internal
      mattress suture. The needle was passed through the buccal flap from the external surface,
      across the interdental area and through the lingual flap from the internal surface. The
      suture was run back to the buccal side by passing the needle through the lingual and buccal
      flaps .Thereafter, the suture is brought through the approximal site coronally to the tissue,
      passed through the loop of the suture on the lingual aspect, and then brought back to the
      starting point on the buccal side and tied. The control group was given simple loop
      interrupted interdental suture. The needle is passed through the buccal flap from the
      external surface, across the interdental area and the lingual flap from the internal surface
      or vice versa and tied. Post operative instructions were given.

      Follow up was done after 3 and 6 months post-operatively.

      STATISTICAL ANALYSIS :

      All statistical analysis were carried out using statistical software (SPSS,Version 25.0 for
      Windows,SPSS,Chicago,IL).The normality of distribution of the data was assessed using the
      Shapiro-Wilk test. Data for PI, GI, BOP, PPD, CAL and REC followed non-normal distribution.
      Non-parametric tests were applied for PI, GI, PPD, CAL and REC. Wilcoxon-Signed Ranks test
      was applied for intragroup comparison and Mann Whitney test for intergroup comparison.
      Statistical analysis of BOP was done by McNemar test in intragroup and Chi-square test for
      intergroup comparison. Correlation and association between predictors and dependent variables
      was analysed by using Mixed Model analysis. Statistical significance level was set at P=0.05.
    

Intervention name(s): Modified vertical internal mattress sutures + MWF surgery.; Simple loop interrupted sutures + MWF surgery.
Intervention type(s): Procedure; Procedure
Intervention description(s): Modified vertical internal mattress sutures were given after modified Widman flap surgery.; Simple loop interrupted sutures were given after modified Widman flap surgery.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Chronic periodontitis; Modified Widman flap surgery; Suturing technique