The 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

Pierpaolo CortelliniGiovanpaolo Pini Prato

Maurizio S. Tonetti

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

• Goals1) Primary closure of the flaps in interdental spaces2) Avoid the collapse of non-self supporting barrier

membranes into interproximal defects3) 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 involvement4) ≧ 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

Surgical Procedure

Surgical Procedure

Surgical Procedure

Surgical Procedure

Surgical Procedure

Surgical Procedure

Surgical Procedure

Surgical Procedure

• 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

• Defect Characteristics

Results

– 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)

Material and Method

• Defect characteristics

Results

• Defect characteristics

Results

• Membrane coverage

Results

• One-year outcome measures

Results

1. 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 tension

3. Prevent the collapse of the membranes into the defect because of suture compression

Discussion

Discussion

4. 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.

Discussion

6. Primary passive closurea) 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 crest

7. Interdental suture lies on the residual proximal bone crest away from the area where the membrane covered the defect.

Discussion

8. 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.

9. 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.