Pierpaolo Cortellini Giovanpaolo Pini Prato Maurizio S. TonettiThe Simplified Papilla Preservation FlapA Novel Surgical Approach for the Management of Soft Tissues in Regenerative Procedures Presenter: R2 鄭瑋之 Instructor: VS 陳娟娟
Introduction• GTR predictable significant amount of attachment and bone gains at 1 year• Lack of primary closure, flap dehiscence, membrane exposure occurs in 70% ~ 80% of cases.• The modified papilla preservation technique: successtully in wide interdental spaces in the anterior and premolar region• Narrow and/or posterior interdental spaces?
Introduction• Goals 1) Primary closure of the flaps in interdental spaces 2) Avoid the collapse of non-self supporting barrier membranes into interproximal defects 3) Usable in narrow and/or posterior interdental spaces
Material and Method• Subject population – 18 subjects (7 men & 11 women), aged 34 ~ 60 (mean 49.1 ± 7.7) 1) Presence of a deep interproximal detect with an intrabony component ≧ 4 mm 2) Clinical attachment loss ≧ 6 mm 3) No furcation involvement 4) ≧ 2 ~ 3 mm of thick keratinized tissue – 8 incisors, 3 canines, 4 premolars, and 3 molars; 9 teeth were in the maxiiia
Material and Method• Experimental design – After scaiing, root planing, and OHI – Clinical outcomes were evaluated every week for 6 weeks after GTR treatment and at a 1-year f/u visit
Material and Method• Clinical measurements – Immediately prior to the surgery, and 1 year later – Full mouth plaque scores (FMPS), 4 aspects/tooth – Bleeding on probing (BOP) at a force of 0.3 N. with a manual pressure sensitive probe Full mouth bleeding scores (FMBS) – Probing pocket depth (PPD), gingival recessions (REC), and clinical attachment levels (CAL) by a single investigator
• Primary closure of the interdental tissues above the membrane without tension: 1. Repositioning the buccal and lingual/palatal flaps 2. Buccal flap was further extended mesiodistally 3. A periosteal incision in the most apical portion of the buccal flap 4. Vertical releasing incisions used only as a last resort
• Sutures: 1. Narrow interproximal space and thin interdental tissues 1 interrupted suture 2. Wider interproxial space and thicker interdental tissues 2 interrupted sutures 3. Wide interproximal space and thick interdental tissue internal vertical oblique mattress suture
Material and Method• Intrasurgical clinical measurements – Taken after debridement of the defects a. Distance from CEJ to the bottom of the defect (CEJ-BD) b. Distance from CEJ to the most coronal extension of the interproximal bone crest (CEJ-BC) c. The infrabony component of the defects (INTRA) was defined as INFRA = (CEJ-BD) - (CEJ-BC)
Material and Method• Postsurgical instructions and infection control – Rinse 3 times with 0.12% CHX – No mechanical oral hygiene procedure or chewing for 11 weeks – Amoxicillin 500 mg TID for first week – Supragingival prophylaxis with a rubber cup and 1% CHX gel weekly for 11 weeks – Supportive core program at monthly intervals – No probing until the 1-year visit
Material and Method– Full mouth plaque scores (FMPS)– Full mouth bleeding scores (FMBS)– Probing depth (PD), marginal recession (REC), and probing attachment level (PAL, CEJ ~ base of the pocket)– CEJ ~ bottom of the defect (CEJ-BD)– CEJ ~ the most coronal extension of the interproximal bone crest (CEJ-BC)– The intrabony component of the defects (INTRA) was defined as INTRA = (CEJ-BD)~(CEJ-BC)
Discussion1. Simple and safe manipulation of the interdental tissues, not only in wide and/or anterior interdental spaces, but also in narrow and/or posterior ones.2. Primary closure of the interdental tissues over bioresorbable membranes without tension3. Prevent the collapse of the membranes into the defect because of suture compression
Discussion4. The first oblique papillary incision split the interdental papilla in 2 parts, the largest being the lingual/palatal one. Any thinning of the papilla was avoided.5. The amount of interdental tissue elevated through the space did not exceed the amount of tissue originally in that space easy and atraumatic.6. Careful sharp dissection from the root cementum of 2 neighboring teeth and from the underlying connective tissue.
Discussion6. Primary passive closure a) Mesiodistal extension of the buccal incisions and/or with a periosteal incision and/or with buccal vertical incisions b) Coronally position the buccal flap with an internal mattress suture anchored to the lingual/palatal flap c) By rubbing against the root surface and lying on top of the residual bone crest6. Interdental suture lies on the residual proximal bone crest away from the area where the membrane covered the defect.
Discussion8. Primary closure was maintained over time in 67% of the sites. (20%~40% in conventional techniques) But slightiy less than modified papilla preservation technique with titanium-reinforced membranes – This study included maxiliary and mandibular detects in both anterior and posterior parts, with no restrictions of minimal interdental width.8. CAL gains (4.9 ±1.8 mm) and PPD reduction (5.8 ± 2.5 mm) favorably compare with in other studies (different bioresorbable membranes)
Conclusion• Potential to help GTR procedures by providing a predictable coverage of the barrier membranes• The efficiancy and predictability of SPPF should be further evaluated.