Pierpaolo Cortellini Giovanpaolo Pini Prato Maurizio S. Tonetto J Periodontol 1995; 66:261-266The Modified Papilla Preservation Technique A New Surgical Approach for Interproximal Regenerative Procedures Presenter: R2 鄭瑋之 Instructor: VS 陳娟娟
Introduction • Key goal in periodontal regenerative procedures: primary closure, protection for healing • Easier buccal aspect, class II furcations • Demanding interdental areaIn 1975, Sven-Erik Hamp, Lindhe and Sture Nyman In 1975, Sven-Erik Hamp, Lindhe and Sture Nyman•• Class I: < 3 mm is depth. Class I: < 3 mm is depth.•• Class II: > 3 mm in depth (> 1/2 buccolingual thickness of the tooth) Class II: > 3 mm in depth (> 1/2 buccolingual thickness of the tooth) but not through-and-through. The furcation defect is thus a cul-de-sac. but not through-and-through. The furcation defect is thus a cul-de-sac.•• Class III: encompass the entire width of the tooth so that no bone is Class III: encompass the entire width of the tooth so that no bone is attached to the angle of the furcation. attached to the angle of the furcation.
Papilla preservation flap Intrasulcular incisions at facial and proximal side Pushed through the embrasure with a blunt instrument to be included in the facial flap
Introduction• Improved closure of the interdental area 1) Careful preservation during the initial incision 2) Coronal positioning of the buccal flap 3) Using free gingival grafts over implanted materials• Takei technique is more elusive in most situations when a barrier membrane is used.
Material and Method• Patient population – After scaling, root planing and OHI – 15 patients (5 males, 10 females) aged 30~51 (mean age 39.3 ± 6.4) – A deep intrabony defect with a suprabony component in the interproximal area, and did not extend into a furcation. – Upper 7 incisors, 4 cuspids, 2 bicuspids, and 2 molars
Material and Method• Clinical Characterization of Selected Sites – 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 depth (PD), marginal recession (REC), and probing attachment level (PAL, CEJ~base of the pocket) by a single investigator – Taken 1 week before surgery
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 intrabony component of the defects (INTRA) was defined as INTRA = (CEJ-BD)~(CEJ-BC)
Surgical Procedure– Initial incisions, elevation of the flaps1. Buccal and interproximal intrasulcular incision2. Horizontal incision with a slight internal bevel in the buccal gingiva at the base of the papilla3. Buccal full thickness flap is elevated. The papilla covering the defect is still in place.
Surgical Procedure– Initial incisions, elevation of the flaps1. The papilla is mobilized with a buccal horizontal incision in the interproximal supracrestal connective tissue.2. The papilla is elevated with the full thickness palatal flap.
Surgical Procedure– Surgical access to the interproximal defect1. 5 mm intrabony defect, with a 5 mm suprabony component, was identified after debridement.2. Note the optimal visibility
Surgical Procedure– Membrane placement and sutures1. Titanium reinforced teflon membrane is secured to the neighboring teeth with sling sutures. (positioned supracrestally, close to the CEJ)2. Crossed horizontal internal mattress suture (resulting coronal displacement of the buccal flap)
Surgical Procedure– Membrane placement and sutures1. Crossed horizontal mattress suture at the base of the palatal papilla. Papilla covers the membrane.2. The vertical internal mattress suture between the buccal aspect of the papilla and the most coronal portion of the buccal keratinized gingiva primary closure.
Surgical Procedure– Coronal positioning of the buccal flap• Crossed horizontal internal mattress suture between the base of the palatal papilla and the buccal flap immediately coronal to the mucogingival junction.• Suture crosses above the titanium reinforcement of the membrane.
Surgical Procedure– Tension-free primary closure• Vertical internal mattress suture between the most coronal portion of the palatal flap (includes the interdental papilla) and the most coronal portion of the buccal flap.
Surgical Procedure– Healing above the membrane1. Pre-OP view indicating 10 mm of PAL loss on the mesial aspect of #11. (recession of the gingival margin)2. Defect is debrided. A deep defect is evident.
Surgical Procedure– Healing above the membrane1. Titanium reinforced membrane just below the CEJ coronal positioning of the gingival margin2. 6 weeks later, both coronal positioning and membrane coverage are maintained.
Material and Method• Primary outcome measures 1. Position of the membrane, immediately post-op & after a week 2. Possibility of obtaining and maintaining coverage of the membrane with the mucoperiosteal flaps 3. Position of the membrane at its removal (measured in the mid-interproximal area as CEJ~MEM) 4. Coronal positioning of the membrane with respect to the interproximal alveolar crest was defined as Coronal = (CEJ-BC) ~ (CEJ-MEM).
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)
Results• Membrane Coverage 1. At baseline, primary closure over the membrane was obtained in 14 of 15 cases (93%). 2. Exposure occurred in 2 cases at 3 weeks and in 1 case at 4 weeks. 3. When membranes were removed at 6 weeks, 11 sites (73%) still showed complete coverage of the membrane.
Discussion1. Modified papilla preservation technique allowed complete coverage of the teflon membrane and primary closure of the mucoperiosteal flaps in the interdental space in 93% of cases.2. Barrier membranes coronally positioned 4.5 ± 1.6 mm above the alveolar crest.3. In 73% of the cases, the interdental tissue covered the membrane until its removal at 6 weeks.
Discussion4. Rationales to develop this technique: a) Membrane exposure in the interproximal space bacteria on the membrane with lower PAL gains necrosis of papilla b) More coronal position of the membrane increase the amount of regeneration but interproximal alveolar crest makes primary closure more difficult4. Modified papilla preservation technique can be used in single-rooted teeth and lower molars without neighboring tooth
Discussion6. More demanding in narrow interproximal spaces necrosis7. Contraindication: coronal reposition of the buccal flap has a poor prognosis; e.g., inadequate vestibular depth8. Stable support for the crossed horizontal internal mattress suture
Conclusion• Modified papilla preservation technique may be a suitable alternative to conventional surgical approaches for interproximal regenerative procedures in single rooted teeth.