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Pierpaolo Cortellini Giovanpaolo Pini Prato Maurizio S.

Tonetti

The Simplified Papilla Preservation Flap


A Novel Surgical Approach for the Management of Soft Tissues in Regenerative Procedures
Presenter: R2 Instructor: VS

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

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

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
Defect characteristics

Results
Defect characteristics

Results
Membrane coverage

Results
One-year outcome measures

Discussion
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
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 closure
a)
b)

c)

Mesiodistal extension of the buccal incisions and/or with a periosteal incision and/or with buccal vertical incisions Coronally position the buccal flap with an internal mattress suture anchored to the lingual/palatal flap 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.