Single flap approach combined with periosteal pedicle flap as a regenerative procedure: A case report

Single flap approach (SFA) is a validated procedure for obtaining clinical attachment gain and pocket closure when applied to deep intraosseous defects. However, the presence of an interdental crater as well as the tooth location were associated with a lower rate of primary intention closure, possibly jeopardizing the outcome of the procedure. In order to favor primary closure, the use a periosteum pedicle flap (PPF) was proposed. The present case report showed the effect of a combination of SFA with PPF for the treatment of a severe, isolated intrabony defect at a molar site associated with a deep interproximal crater.

A patient presenting two 6-mm deep bleeding periodontal pockets, in association with an intrabony defect, at the mesio-buccal and mesio-lingual aspect of #19 was treated with the combination of SFA and PPF. Intrabony component of the defect was filled with a combination of deproteinized bovine bone mineral mixed with a gel composed by polynucleotides and hyaluronic acid.

A dehiscence of the primary flap was observed at the interproximal area. Primary closure was still present due to the presence of the underlying periosteal pedicle flap. At the 12-months follow up, pocket closure was observed at both mesio-buccal and mesio-lingual aspects. The radiographical examination showed a substantial remineralization of the infrabony component CONCLUSION: The combination of SFA with PPF may be a promising approach for the treatment of intrabony defects associated with unfavorable conditions of soft tissues located at molar sites.

Why is this case new information? The present case reports that single flap approach may be successfully combined with a periosteal pedicle flap to correct intrabony defects associated with unfavorable conditions of soft tissues located at molar sites. What are the keys to successful management of this case? Careful dissection of the flap to isolate and maintain the integrity pf the periosteal pedicle flap Complete debridement of both the intrabony defects and of the root Stabilization of the periosteal pedicle flap above the defect in order to contribute to the primary intention healing What are the primary limitations to success in this case? Absence of unfavorable anatomical conditions possibly jeopardizing the primary closure of the surgical wound Proximity with mental nerve due to possible lesions during the partial thickness dissection PLAIN LANGUAGE SUMMARY: The present paper explored the use of a surgical technique combining a buccal single flap elevation and a periosteal pedicle to treat a periodontal pocket associated with a deep intrabony defect. A buccal split-thickness incision was performed to both visualize the osseous defect and isolate a periosteal pedicle. The defect was debrided and filled with a combination of a xenograft and gel composed of polynucleotides and hyaluronic acid. The periosteal pedicle was rotated and sutured above the filled defect. The primary split-thickness flap was sutured, covering both the defect and periosteal pedicle. Twelve months after surgery, no periodontal pocket was present. At the radiographic examination, substantial remineralization of the defect was observed.