Pierpaolo Cortellini Giovanpaolo Pini Prato Maurizio S.

Tonetto J Periodontol 1995; 66:261-266

The Modified Papilla Preservation Technique

A New Surgical Approach for Interproximal Regenerative Procedures
Presenter: R2 Instructor: VS

Introduction
Key goal in periodontal regenerative procedures: primary closure, protection for healing Easier buccal aspect, class II furcations Demanding interdental area
In 1975, Sven-Erik Hamp, Lindhe and Sture Nyman Class I: < 3 mm is depth. 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. Class III: encompass the entire width of the tooth so that no bone is 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 flaps

1. 2. 3.

Buccal and interproximal intrasulcular incision Horizontal incision with a slight internal bevel in the buccal gingiva at the base of the papilla Buccal full thickness flap is elevated. The papilla covering the defect is still in place.

Surgical Procedure
Initial incisions, elevation of the flaps

1.

2.

The papilla is mobilized with a buccal horizontal incision in the interproximal supracrestal connective tissue. The papilla is elevated with the full thickness palatal flap.

Surgical Procedure
Surgical access to the interproximal defect

1.
2.

5 mm intrabony defect, with a 5 mm suprabony component, was identified after debridement. Note the optimal visibility

Surgical Procedure
Membrane placement and sutures

1.

2.

Titanium reinforced teflon membrane is secured to the neighboring teeth with sling sutures. (positioned supracrestally, close to the CEJ) Crossed horizontal internal mattress suture (resulting coronal displacement of the buccal flap)

Surgical Procedure
Membrane placement and sutures

1.

2.

Crossed horizontal mattress suture at the base of the palatal papilla. Papilla covers the membrane. 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 membrane

1.

2.

Pre-OP view indicating 10 mm of PAL loss on the mesial aspect of #11. (recession of the gingival margin) Defect is debrided. A deep defect is evident.

Surgical Procedure
Healing above the membrane

1.
2.

Titanium reinforced membrane just below the CEJ coronal positioning of the gingival margin 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).

Results
Defect Characteristics

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 Position

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.

Discussion
1. 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.

Discussion
4. 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 difficult

5. Modified papilla preservation technique can be used in single-rooted teeth and lower molars without neighboring tooth

Discussion
6. More demanding in narrow interproximal spaces necrosis 7. Contraindication: coronal reposition of the buccal flap has a poor prognosis; e.g., inadequate vestibular depth 8. 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.