Dentistry, Periodontics, Entire Papilla Preservation Technique, Novel Surgical Approach, Regenerative Treatment, Deep Intrabony Defects, Wide Intrabony Defects, preserve papilla, Regenerate bone

1. Entire Papilla Preservation Technique: A
Novel Surgical Approach for Regenerative
Treatment of Deep and Wide Intrabony
Defects.
Aslan, S., Buduneli, N., & Cortellini, P. (2017).
The International Journal of Periodontics & Restorative Dentistry, 37(2), 227–233.

2. Introduction.
THE GOALS OF
PERIODONTAL
THERAPY
arresting the disease
process,
preventing disease
recurrence.
regenerating
periodontium lost as
a result of
periodontal disease.
Periodontitis is an inflammatory disease that causes pathological
alterations in the teeth and their supporting tissues, potentially
leading to tooth loss.
Periodontal regeneration: is defined as a reproduction or
reconstruction of a lost or injured part in such a way that the
architecture and function of the lost or injured tissues are
completely restored.(Glossary of periodontal term)

3. Tissue compartment hypothesis.
After therapy, the clot formed is
invaded by cells from:
Epithelial cells: Healing
with long junctional
epithelium
Cells derived from bone:
Ankylosis of the bone
and tooth
Cells derived from gingival
connective tissue: pocket
recurrence.
Cells derived from PDL:
New attachment with
new PDL inserted into
new bone & new
cementum
In 1976 – Melcher described the basic concept
that led to development of GTR.

4. • In 1982 – Nyman et al first described the clinical procedure of GTR using a
non absorbable barrier, used in periodontal surgery which allowed
regeneration of cementum, periodontal ligament and alveolar bone was a
cellulose acetate (paper) laboratory filter (Millipore filter).

5. • Gotlow et al. 1986 coined the term Guided Tissue Regeneration
and it is also referred to as selective cell repopulation or
controlled tissue regeneration.
• THE BIOLOGIC CONCEPT/FOUNDATION OF GTR
Principle of GTR is based on
the assumption that only the
periodontal ligament cells
have the potential for the
regeneration of the
attachment apparatus of
tooth.
It consists of placing barriers
of different types to cover
the bone and periodontal
ligament thus temporarily
separating them from
gingival epithelium.
Excluding the epithelium
and the gingival connective
tissue from the root surface
during the post surgical
healing phase
Prevents epithelial migration
into the wound.
Favours repopulation of the
area by cells from the
periodontal ligament and
bone cells.

6. • Both resorbable and nonresorbable barrier membranes
have been successfully used to obtain periodontal
regeneration.
Classification by Minabe in 1991
Nonabsorbable
-
Polytetrafluoroethyle
ne (e-PTFE) type
-Titanium reinforced
polytetrafluoroethyle
ne type
Bioabsorbable:
Synthetic
-Alloderm
-Polyurethanes
-Polylactic acid
-Polyglycolic acid
Bioabsorbable
Natural
-Collagen type
-Connective tissue
graft
-Durameter
-Oxidized cellulose

7. FIRST GENERATION MEMBRANES: NON-
RESORBABLE MEBRANE.
Millipore Filter
Expanded polytetrafluoroethylene
membrane (e- PTFE) GORE-TEX
Nucleopore membrane.
Rubber Dam.
Ethyl cellulose.
Semi-permeable silicon barrier.
SECOND GENERATION MEMBRANES:
RESORBABLE MEBRANE.
Collagen – Biomend, Periogen,
Paroguide, Biostite, Tissue guide.
Polylactic acid Membrane – Guidor,
Vicryl, Atrisorb, Resolut, Epiguide, Biofix.
Vicryl Mesh.
Oxidised Cellulose Membrane
Third generation membrane: They are the resorbable membrane with added growth
factor incorporated with an aim of improving early bone healing.
I) Barrier membranes with Antimicrobial activity
Amoxicillin, Tetracycline, 25% Doxycycline, Metronidazole.
II) Barrier membranes with Bioactive Calcium Phosphate incorporation
Nano-sized hydroxyapatite (HA) particles nano -carbonated hydroxyapatite (nCHAC).
III) Barrier membranes with Growth Factor release.
Transforming growth factor (TGF-1), Bone morphogenic protein( BMP-2, 4,7 and 12)
and enamel matrix derivative (EMD).
Classification by Gottlow in
1993:

8. • Since the first study by Heijl, enamel matrix
derivative (EMD) has attracted great interest in
the research for periodontal regeneration.
• Human histologic studies have shown that EMD
application enhances formation of new acellular
cementum, periodontal ligament, and alveolar
bone.
• Controlled clinical studies revealed comparable
outcomes with EMD application or GTR in the
treatment of intrabony defects.

9. Following application of EMD, decreased production of
IL1band IL8 (1) and increased levels of PGE 2 (2) are
observed with little differences in TNF-alpha
expression.
EMD also substantially changes the OPG/RANKL
balance by increasing OPG and decreasing RANKL
levels, resulting in diminished osteoclast
formation/activity (3).
EMD also increases the proliferation and migration of
T-lymphocytes (4), which enable tissue debridement
by macrophages (5).
Furthermore, EMD promotes mesenchymal cell
differentiation into hard tissue-forming cells and also
improves PDL cell regeneration (6).
Microvascular cell differentiation and angiogenesis are
improved following EMD application (7) and
studies demonstrate that EMD also lowers bacterial
numbers (8), resulting in a reduced inflammatory state

10. • Regenerative therapeutic outcomes are affected by various
factors, such as plaque control, percentage of bleeding on probing,
location and morphology of the defect, smoking habit, and
exposure of the barrier membrane
• Membrane exposure might lead to bacterial contamination in the
surgical area and deteriorate the periodontal regeneration process,
particularly in the interproximal site.
• Different procedures have been proposed to preserve the
interdental papillary structure during the early and late phases of
wound healing to prevent contamination of the regenerating area
and subsequent wound failure.

11. • These procedures, aim to provide greater stability to the
blood clot to enhance the regenerative potential.
• All the techniques, however, entail an incision of the defect-
associated interdental papilla that may jeopardize the volume
and integrity of interdental tissues.
• This clinical report describes a novel tunnel-like surgical
approach, the entire papilla preservation technique, for the
regenerative treatment of deep and wide intrabony defects.
• The completely preserved interdental papilla is meant to
stabilize the blood clot and improve the wound- healing
process.

12. • Full access to the defect is provided with one buccal vertical
releasing incision and the elevation of a short flap on the buccal
side of the defect-associated tooth.
• EMD and bone substitutes are applied in the debrided defect to
promote periodontal regeneration.
• Azzi et al proposed a pouch-and-tunnel technique for bone
regeneration. This technique focuses on ensuring the integrity of
interdental papillae.

13. • Three systemically healthy patients were included in this clinical
report.
• Their chief complaints were bleeding and slight mobility of the
tooth affected by periodontal disease.
• Initial cause-related therapy was performed to reduce the
inflammation of the periodontal tissues.
• Restorative or endodontic treatments were performed as
required.
• The patients were reevaluated 3 months after completion of these
treatment procedures.

14. • Surgical interventions were scheduled at this reevaluation
session due to persistence of the pocket and the associated
deep intrabony component
• Clinical periodontal parameters were recorded at baseline, 3
months after completion of the nonsurgical periodontal
therapy.
• Final clinical outcomes were recorded 8 months after the
regenerative periodontal surgery.

15. • Experimental sites were accessed with the entire papilla
preservation technique and debrided.
• Intraoperative measurements and defect characterization
were made during the surgery.
• Ethylene diamine tetra acetic acid (EDTA) gel (PrefGel,
Straumann) and EMD (Emdogain, Straumann) were applied on
the biologically compatible and air-dried root surface.
• Porcine- derived bone substitutes (Gen-Os, OsteoBiol) were
placed into the defect, and the flap was sutured with simple
interrupted sutures.

16. SURGICAL TECHNIQUE
The surgical site was anesthetized
Bone sounding was performed after
anesthesia
A ×3.3 magnifying loupe was used to
increase visibility of the surgical site.
Following a buccal intracrevicular incision, a
beveled vertical releasing incision was made
in the buccal gingiva of the neighboring
interdental space and extended just beyond
the mucogingival line to provide
appropriate mechanical access to the
intrabony defect

17. case 1.
(a) Mandibular right canine with
18 mm of pocket depth.
b) Full access to the defect with
the entire papilla preservation
technique.
c) Primary wound closure of the
surgical site following the
application of EMD and bone
substitutes.
(d) Excellent early wound healing
at 10 days.
(e) Probing depth of
3 mm obtained at 8 months.
(f) Baseline radiograph.
(g) 8-month radiograph. Note the
complete resolution of the
extremely deep intrabony defect.

18. Representative case 2. (a) Preoperative probing depth of 12 mm at the mesial side of the
mandibular right central incisor. (b) Same site after elevation of tunneled interdental papilla.
Note the elasticity of alveolar mucosa and proper mechanical access to the defect area with
the help of a vertical releasing incision. (c) Gentle removal of granulation tissue over the
alveolar bone. (d) Application of 24% EDTA gel for 2 minutes to remove the smear layer from
the exposed root surface. (e) EMD application. (f) Placement of deproteinized porcine-derived
bone substitute into the intrabony defect. Note that overfill of the defect is avoided

19. g) Closure of surgical area using 7-0 polypropylene suture material and microsurgical knots. Note
the integrity of interdental papilla. (h) Excellent wound healing was seen 1 week after surgery. (i)
At 8 months postsurgery, 4.5 mm of probing depth was measured. A 0.5-mm vertical loss of
interdental papilla was calculated by comparing standardized photographs. (j) Initial radiograph
before endodontic treatment. (k) Radiograph taken 3 months after endodontic treatment. Note
the apical bone healing. (l) Radiograph taken 8 months after surgery.

20. • In the presence of a malpositioned tooth with a narrow
neighboring interdental space, the vertical incision was
shifted one tooth away from the actual incision line.
• A microsurgical periosteal elevator was used to elevate a
buccal full-thickness mucoperiosteal flap extending from the
vertical incision to the defect-associated papilla.
• A specially designed angled tunnel elevator facilitated the
interdental tunnel preparation under the papillary tissue.
• Utmost care was taken to elevate the interdental papilla full
thickness up to the lingual bone crest.

21. • A microsurgical scissor was used to remove the granulation
tissue from the inner aspect of the interdental papilla.
Excessive thinning of the papilla was avoided so as not to
compromise the blood supply. The granulation tissue was
removed with a mini-curette
• Any residual subgingival plaque or calculus was gently
removed from the exposed root surface with an ultrasonic
scaler.
• The surgical area was rinsed with sterile saline, and root
conditioning of the exposed surface was done by applying
24% EDTA gel for 2 minutes to remove the smear layer

22. • The exposed root surface was then rinsed with sterile saline, and
EMD was applied on the exposed root surface.
• Subsequently, a deproteinized porcine- derived bone substitute was
placed into the intrabony defect and care was taken not to overfill
the defect.
• Contamination with blood or saliva was prevented during bio-
material application. No periosteal releasing incision was
performed.
• Gentle pressure was applied to the surgical area using saline-wetted
gauze for 1 min to readapt the mucoperiosteal flap. Microsurgical
suturing technique with 7-0 mono- filament polypropylene suture
materials was performed for optimal wound closure of the surgical
area

23. Clinical outcomes
• Primary wound healing of the vertical releasing incision,
excellent continuity of interdental papilla, and 100% wound
closure was observed in all cases during the first 4 weeks of
the early healing period.
• No adverse events were noted in any of the treated sites. The
1-week postoperative control visits demonstrated that the
interdental papillary structure and its volume were fully
preserved in all cases, and no wound failure was detected.
• All three cases revealed uneventful healing and significant
improvement in clinical periodontal parameters.

25. Discussion.
• The entire papilla preservation technique aims to provide
proper mechanical access to deep and wide intrabony defects
without disruption of the interdental papillary continuity.
• Its unique design, shifting the incision line to the adjacent
tooth, reduces the risk of failure in wound healing via
exposure of the regenerative biomaterials.
• The proposed surgical design could favor primary healing over
the biomaterial and enhance the stability of blood clot
formation in the intrabony defect.

26. • Exposure of the biomaterial is a frequent complication
associated with deterioration of the clinical outcomes of
periodontal regeneration procedures
• Membrane or wound exposure during the first weeks of
healing has been reported in up to 50% of sites treated
with GTR.
• Specially designed surgical techniques have greatly reduced
the complications observed in wound healing.
• Papilla preservation techniques have reduced the
complication frequency to 30%, whereas minimally invasive
surgical techniques have reduced it to less than 10%.

27. • The entire papilla preservation technique has been
proposed to further increase the probability of an
uneventful early healing process.
• From an anatomical point of view, incision of the defect-
associated papilla entails a risk of wound failure, especially
in the treatment of deep and wide intrabony defects with a
missing buccal wall that will end with a rather large area
that lacks blood supply from periodontal ligament or
alveolar bone.
• A tunnel preparation, which maintains the vascular
integrity of the interdental papilla from the buccal and
lingual sides, may further reduce the risk of wound failure.

28. The use of a tunnel technique for access to the papilla region requires a vertical
releasing incision on the buccal side. Verticals might cause esthetic problems,
resulting in unpleasant white scars
On the other hand, proper access to the intrabony defect can be achieved only
with a beveled vertical incision to gain sufficient mobility of the full-thickness
buccal flap.
A careful incision and flap elevation followed by a precise adaptation of the
wound margins and a microsurgical suturing technique with 7-0 polypropylene
suture materials may help to eliminate or reduce any negative esthetic impact of
this vertical incision and improve healing quality with limited scar tissue
formation.
The present surgical technique well maintains the original papillary structure,
which promises to be a major advantage when preserving esthetics is one of the
major treatment objectives.

29. • Conclusions
• The entire papilla preservation procedure, based on a short
buccal flap, a vertical incision shifted to the adjacent tooth,
and a tunneled interdental papilla, provides adequate
mechanical access to interproximal deep and wide
intrabony defects and an excellent and uneventful
postoperative healing phase.
• Clearly, further research with evidence is required to
evaluate and clarify the advantages and disadvantages of
this technique.

30. Limitations.
• The application of this technique has some limitations related
to the papilla morphology and the defect configuration.
• A narrow interdental space where risk of tearing the fragile
interdental papilla is high might not be an ideal site to apply
this approach, even when the appropriate surgical
instrumentation is used.
• Moreover, this novel technique is clearly not applicable to
defects that involve the lingual side of the tooth, and such
defect morphology would require the elevation of the defect-
associated papilla for debridement.

31. THANK-YOU…