Papilla preservation flap

History and different types of papilla preservation flap designs

1. PAPILLA PRESERVATION FLAP DR.VIDYA VISHNU SENIOR LECTURER MALABAR DENTAL COLLEGE AND RESEARCH CENTRE 1

2. Primary wound closure and uneventful early wound stability over the biomaterials are the critical parts of a successful periodontal regeneration. Surgical elevation of the interdental papilla to access deep and wide intrabony defects interferes with the papillary blood supply that can end up with an impairment in healing process possibly even preventing the primary closure in the early healing phase. INTRODUCTION 2

3. Subsequent bacterial contamination may deteriorate the healing process in later phases. Greater crown and root exposure and increase in the interdental spacing following flap surgery is highly unacceptable. An ideal periodontal therapy must necessarily consider esthetic appearance, which means an effort to maintain gingival marginal anatomy and as much height of papilla as possible along the course of the periodontal therapy. 3

4. A surgical approach that splits the papilla certainly contribute to shrinkage and decrease in the height of interdental papilla leading to exposure of the interproximal embrasures. This led to the development of a flap technique which intended to spare the papilla instead of splitting it. 4

5. HISTORY Probably the first report of a Papilla Preservation procedure was by Kromer in 1956 which was designed to retain osseous implants. App in 1973 , reported a similar technique and termed it as Intact Papilla Flap , which retained the interdental gingival in the buccal flap. 5

6. The App technique utilizes split thickness flaps and has not been generally used for reconstructive surgery. Evian et al preserved the interdental gingiva in the facial flap, which exposed osseous margins on the labial and the interproximal zone, while the palatal tissues were reflected separately. Genon and Bender in 1984 also reported a similar technique indicated for esthetic purposes. 6

7. Takei et al in 1985 introduced a detailed description of the surgical approach reported earlier by Genon & named the technique as Papilla Preservation Flap , which ensured optimal interproximal coverage and facilitated placement and retention of bone grafts which prevented exfoliation of the graft material. However, the presence of ample embrasure between the teeth with the absence of a tight contact point, is a pre-requisite to retain the interdental tissue. 7

8. Flap designs to achieve primary closure The increased predictability of the reconstructive procedures can be strictly dependent on i) the surgical design and flap management for better survival of flap and graft coverage, and ii ) suturing technique to optimize primary closure , thus ensuring the primary condition for blood clot stabilization and maturation in a biologic environment protected from biomechanical and microbiological challenge. 8

9. Proper flap design and incision placement is of utmost importance to achieve complete flap closure and flap-to-root seal at the time of suturing and during postsurgical healing as well as minimal or absent exposure and subsequent contamination and/or exfoliation of the grafted biomaterial or membrane . 9

10. Therefore, flap designs are classified according to 1 ) the outline of the incision which affects the preservation of the interdental supracrestal soft tissues and, thus, the predictability to ensure primary closure at the interdental space, and 2 ) the elevation of a either a single ( buccal or oral) or a double ( buccal and oral) flap in relation to the surgical trauma exerted at the interproximal soft tissues. 10

11. Based on management of papilla 11

12. 12 Techniques without preservation of the interdental supracrestal soft tissues & with double flap elevation

13. CONVENTIONAL FLAP It includes MWF, undisplaced flaps and APF . splitting the papilla into a facial half and a lingual or palatal half. 13

14. The conventional flap is used when: 1) the interdental spaces are too narrow, thereby precluding the possibility of preserving the papilla 2) when the flap is to be displaced. 14

15. L eads to a partial loss of the interdental soft tissues with an increased risk of compromising the primary closure in the interdental space. 15

16. 16 Techniques with preservation of the interdental supracrestal soft tissues and with double flap elevation

17. Flap designs which provide the preservation of the integrity of the interdental supracrestal soft tissue by elevating a buccal and oral flap include the : Papilla Preservation Technique (PPT) Interproximal Tissue Maintenance (ITM ), Modified Papilla Preservation Technique ( MPPT) Simplified Papilla Preservation Technique (SPPT). 17

18. N o incisions are made through the interdental papilla. Either the buccal or the oral papilla is, therefore, included in the contralateral oral or buccal flap, respectively, leaving the volume of the supracrestal soft tissues intact in the interproximal area. PPT, MPPT and ITM techniques place the incision line away from the bone defect , thus limiting graft or membrane exposure during the postsurgical healing. 18

19. PAPILLA PRESERVATION FLAP (PPF) By Takei et al in 1985 & later Cortellini et al in 1995, 1999 . It is the modification of a procedure originally described by Genon & Bender in 1984 for esthetic maxillary anteriors . 19

20. INDICATIONS: Embrasure wide enough to permit passage of the interproximal tissue . Bone grafting areas CONTRAINDICATIONS: Narrow embrasures 20

21. PROCEDURE FOR PPS S ulcular incisions around each tooth no incision through the interdental papilla facially . Semilunar incision is made across each IDP so that the papillary incision line is at least 5 mm away from the crest of the papilla allowing the interdental tissues to be dissected from the lingual or palatal aspect so that it can be elevated intact with the facial flap. 21

22. 22

23. 23

24. 24

25. 25

26. 26

27. PPF has witnessed some modifications in the papilla sparing incisions, either to achieve interproximal tissue coverage over barrier membranes placed coronal to the alveolar crest, to facilitate coronal positioning of the interdental tissues and/or to facilitate placement of implants . 27

28. The first modification of PPF was reported by Checchi et al in 1988 , where in horizontal incision over the interproximal area, in the opposite side of the bone defect was deemed ideal as it allowed protection of the regenerated area from the oral environment. 28

29. M odification of the PPT- Murphy KG 1996 Involves the reflection of a triangular-shaped palatal flap (so-called “ papillar triangle ”), along with the isthmus of interdental tissue, which remains contiguous with the buccal portion of the flap. This allows for the preservation of an adequate amount of interdental tissue to ensure membrane or graft protection/coverage . Interproximal Tissue Maintenance (ITM) 29

30. The surgical protocol includes an initial buccal intracrevicular incision extending one or two teeth on either side of the defect. Vertical releasing incisions are performed as needed. The PT is outlined by two inverse-bevelled incisions, starting from the line angles of the teeth where the interproximal osseous defect is present, and joining at a common point 7 to 15 mm directly apical in the palate . 30

31. A full-thickness flap reflection is made, and the PT is elevated from the alveolar bone and displaced toward the buccal aspect under the contact area by means of a small periosteal elevator . After defect and root debridement, the flaps are sutured using a modified external mattress suturing technique. 31

32. 32

33. MODIFIED PAPILLA PRESERVATION FLAP (MPPF) By Cortellini 1995 Rationale: to achieve and maintain primary closure in interdental spaces over the membrane. 33

34. PROCEDURE Primary intrasulcular incision ( buccal and interproximal) involving two teeth neighbouring the defect is made. A horizontal incision is traced in the buccal gingiva of the interdental space at the base of the papilla. 34

35. This horizontal incision is then connected with the primary incision in the most apical portion of the buccal gingiva of the neighbouring teeth and a full thickness buccal flap was elevated to the level of the buccal alveolar crest. 35

36. Buccal and interproximal primary incision is continued intrasulcularly in the interproximal space and extended to the palatal aspect . A buccal horizontal incision is performed in the interproximal supracrestal connective tissue, coronal to the bone crest, to dissect the papilla. 36

37. The papilla is then elevated towards palatal aspect . Following extension of the palatal incision, a full thickness palatal flap including the interdental papilla was elevated to fully expose the defect. 37

38. MPPT 38

39. Incisions Full thickness flap reflection Papilla elevated with palatal flap 39

40. Debridement done Sutures placed 40

41. The tissue thickness of papilla is reduced to permit coronal advancement of the flap. C oronal displacement of the buccal flap, which greatly contributes to primary closure over the graft/membrane and may result in clinical attachment gain coronal to the alveolar crest. Vertical releasing incision divergent in corono -apical direction extending in to the alveolar mucosa can be placed in the interproximal spaces neighbouring the defect if coronal advancement of the flap is desired. 41

42. 42 technically more demanding

43. Papillary preservation flap and its modified flap design, both required a wide interdental space as a pre-requisite to bring about appreciable functional and esthetic value. To apply esthetic value to teeth having narrow interproximal zone, Cortellini et al in 1999 proposed the Simplified Papilla preservation flap technique. SIMPLIFIED PAPILLA PRESERVATION 43

44. Narrow interdental spaces (<2mm ) & posterior areas- t o obtain & maintain primary closure of the flaps. Avoid the collapse of non-self supporting barrier membranes into the interproximal defects. INDICATIONS 44

45. PROCEDURE An oblique incision is made across the defect associated papilla from the gingival margin at the buccal line angle of the involved tooth to reach the mid interproximal portion of the papilla under the contact point of the adjacent tooth. 45

46. The oblique incision continues intrasulcularly in the buccal aspect of the teeth neighbouring the defect and extended to partially dissect the papillae of the adjacent interdental spaces allowing the elevation of a buccal flap with 2-3 mm exposure of alveolar bone . A buccolingual horizontal incision at the base of papilla close to the interproximal crest is made. 46

47. Intrasulcular incisions are continued in the palatal aspects of the two teeth neighbouring the defect and extended into the interdental papilla of adjacent interdental spaces, following which a full thickness palatal flap including the interdental papilla is elevated. 47

48. 48

49. 49

50. Both the modifications of PPF, require utilization of horizontal and/or vertical internal mattress sutures which relieve the tension in the flap , permit coronal positioning of the flap and aid in passive closure of the interdental tissues. 50

51. ADVANTAGES Allows simple & safe manipulation of interdental tissues Facilitates primary closure of the interdental tissues without tension Prevents collapse of the membranes into the defect because of the tissue compression 51

52. (Cortellini P &Tonetti M. Clinical concepts for regenerative therapy in intrabony defects. Periodontology 2000, Vol. 68, 2015, 282–307) 52

53. Bianchi & Bassetti in 2009 . D esigned for the treatment of wide intrabony defects in the esthetic zone. This surgical procedure involves elevation of a large flap from the buccal to the palatal side to allow access and visualization of the intrabony defect and was created especially to perform GTR while maintaining interdental tissue over grafting material. WHALE’S TAIL TECHNIQUE 53

54. Two vertical full-thickness incisions are traced from the mucogingival line to the distal margin of the tooth neighbouring the defect on the buccal surface . A horizontal incision joined the apical margins of the first two incisions, and the coronal margins of the vertical incision were continued intrasulcularly in the buccal , interproximal, and palatal aspects of the defect-associated tooth. 54

55. Flap is reflected from buccal to palatal side. Debridement is done and regenerative material with/without GTR can placed . Flap is reapproximated & Sutures are placed. 55

56. 56

57. 57

58. ADVANTAGES Preservation of a large amount of soft tissue. G ood primary flap closure. The use of incisions distant from the defects and graft margins drastically reduces the percentage of flap dehiscence especially when membranes are used. 58

59. DISADVANTAGES Necessity of interdental space in order to allow flap dislocation to palatal side. The flap elevation is delicate and the surgeon must be careful to preserve the papilla, which will maintain the vascularization of the flap. Chances of recession 59

60. ENTIRE PAPILLA PRESERVATION TECHNIQUE Serhat Aslan , Nurcan Buduneli 2015 Used for the regenerative treatment of deep and wide intrabony defects. 60

61. 61 This novel surgical procedure is based on a short buccal flap, a vertical incision positioned in the buccal gingiva of the neighboring interdental space and a tunneled interdental papilla. P rovides an adequate mechanical access to interproximal deep and wide intrabony defects and an excellent and uneventful post-operative healing phase.

62. The completely preserved interdental papilla is meant to stabilize the blood clot and to improve the wound healing process. Furthermore , the application of this technique supports the use of amelogenins and bone-like materials. 62

63. A magnifying loop with 3.3x magnification was used to increase visibility of the surgical site. Following a buccal intra- crevicular incision, a beveled vertical releasing incision was performed 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 . 63

64. In the presence of malpositioned tooth with narrow neighboring interdental space, vertical incision was shifted one tooth away from the actual incision line. Particularly for narrow interdental papilla, an oblique interdental incision was made , followed by an intrasulcular incision directed to the adjacent tooth and vertical releasing incision was then performed. 64

65. A microsurgical periosteal elevator was used to elevate a buccal full thickness muco -periosteal flap extending from the vertical incision to the defect-associated papilla. Tunnel-like approach of the defect-associated interdental 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 in full-thickness manner up to the lingual bone crest. 65

66. 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 in order 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 . 66

67. R oot conditioning of the exposed surface was done applying 24% EDTA gel for 2 minutes to remove the smear layer. Then , the exposed root surface was 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. 67

68. Microsurgical suturing technique with 7-0 monofilament polypropylene suture materials was performed for optimal wound closure of the surgical area . 68

69. 69

70. 70

71. MINIMALLY INVASIVE SURGICAL TECHNIQUES IN PERIODONTAL REGENERATION T he term minimally invasive surgery (MIS) was introduced in periodontology by Harrel and Ress , 1995 to minimize wounds and flap reflection. The ideal surgical approach for periodontal regeneration would be one that allows access to the site to be regenerated without extending the surgical incision into adjacent healthy areas . 71

72. Incisions were aimed at conserving the soft tissue as much as possible. MIS helps in handling hard and soft tissues gently during periodontal surgery. 72

73. Tibbetts & Shanelec , 1994 described periodontal microsurgical technique and concentrated on soft tissue regeneration and augmentation using a surgical operating microscope. Wickham & Fitzpatric , 1999 described the techniques of using smaller incisions as “MIS .” 73

74. INDICATIONS OF MIS • Isolated, interproximal bone defect, not extending beyond the interproximal site • Periodontal defects that border on an edentulous area • Periodontal defect that extend from buccal /lingual from interproximal site • Multiple separate defect sites within a single quadrant. 74

75. CONTRAINDICATION • Generalized horizontal bone defect. • Multiple interconnected vertical defects, walls . 75

76. General consideration for minimally invasive surgery • All incisions are designed to conserve soft tissues • Separate incisions are performed, continuous incisions are avoided • Vertical releasing incisions are avoided • Coverage of graft/membrane by soft tissue is achieved to promote periodontal regeneration, for example, if the bony defect is in esthetic areas, incision is given in palatal papilla. 76

77. Tissues are reflected by sharp dissection or combination of blunt and sharp • Adequate visualization of the procedure requires magnification and light source. Surgical microscope, loupes ×3.5 magnification can be used. 77

78. Root surface debridement becomes difficult as minimal flap reflection is performed to preserve tissues. Mechanical debridement can be performed with tip of curette inserted vertically and shank held parallel to the tooth surface. Ultrasonic scalers can be used to break the granulation tissues Plastic plunger gun can be used for precise placement of graft material Interproximal site can be closed by vertical mattress sutures (6‑0 resorbable suture). 78

79. MINIMALLY INVASIVE PERIODONTAL SURGICAL THERAPY: TECHNIQUES MIST- Cortellini and Tonetti in 2007 . Later , they introduced the concept of space provision for regeneration with the M odified MIST ( M‑MIST), Cortellini et al . 2009. 79

80. 80 Cortellini and Tonetti proposed a papilla preservation flap in the context of a minimally invasive, high power, magnification-assisted surgical technique, in order to provide even greater wound stability and protection and to limit patient morbidity further. MIST blended the concepts of MIS with the application of papilla preservation techniques and the use of passive internal mattress sutures.

81. T he papilla preservation technique, the modified papilla preservation technique, and the simplified papilla preservation flap are important elements in terms of MIPS since they can guarantee minimal access to the periodontal defect. 81

82. Cortellini and Tonetti proposed the application of a single MIS technique to treat multiple adjacent defects. The surgical modification includes an extension of the flap to all the teeth involved by osseous defects. The larger flap is minimally reflected in accordance with the previously described principles. 82

83. The minimally invasive approach is particularly suited for treatment in conjunction with biologically active agents, such as amelogenins or growth factors, which are eventually associated with grafting materials. After elevation of the interdental tissues, the buccal and the lingual incisions are minimally extended mesial-distally and the full-thickness flaps are minimally elevated in order to expose just the coronal edges of the residual bony walls. 83

84. Periosteal incisions are never performed. Vertical releasing incisions are placed in very few instances. The suturing approach is based on the use of a single internal modified mattress suture . Additional sutures can be applied to further increase primary closure, when needed. All surgical procedures are performed with the aid of an operating microscope or magnifying loops at 4–16× magnifications. 84

85. MIST Minimal buccal flap reflection and the elevation of the interdental papilla according to the SPPF design provides full access to the 3-wall intrabony component. 85

86. More recently, Cortellini and Tonetti proposed M‑MIST. The MIS and the MIST include the elevation of the interdental papillary tissues to uncover the interdental space , gaining complete access to the intrabony defect, whereas the M‑MIST proposes an approach in which the access to the defect is gained through the elevation of a small buccal flap, without elevation of the interdental papilla . 86 M‑MIST

87. The surgical approach consists of a tiny interdental access in which only buccal intrasulcular incisions are performed and connected with a buccal horizontal incision of the papilla performed as close as possible to the papilla tip. 87

88. The tiny buccal triangular flap is elevated to expose the residual buccal bone crest. The papillary tissues are left untouched , carefully preserving the supracrestal attachment apparatus to the root cement of the crest‑associated tooth. 88

89. Access to the defect is gained through the tiny buccal “window. ” The soft tissue filling the defect (granulation tissue) is sharply dissected from the papillary supracrestal connective tissue and removed with mini‑curettes . Then, the root surface is carefully debrided with mini‑curettes and power‑driven air instruments avoiding any trauma to the supracrestal fibers of the defect‑associated papilla. 89

90. The palatal tissues are not surgically accessed. The suturing approach is based on the use of a single internal modified mattress suture. 90

91. M-MIST The interdental incision is slightly diagonal (SPPF-like approach). 91

92. 92 DISADVANTAGES: M‑MIST cannot be applied to all periodontal defects. limited access to the diseased root surface. Whenever a defect extending to the lingual/palatal side of a root is difficult to debride, the authors suggest raising the papilla and performing a MIST approach.

93. ( Cortellini P &Tonetti M. Clinical concepts for regenerative therapy in intrabony defects. Periodontology 2000, Vol. 68, 2015, 282–307) 93

94. SINGLE- FLAP APPROACH Novel , simplified, minimally-invasive surgical approach to access intraosseous periodontal defects. The basic principle behind the SFA consists of the elevation of a limited mucoperiosteal flap to allow surgical access from either the buccal or oral aspect only, depending on the main buccal or oral extension of the lesion, and leaving the interproximal supracrestal gingival tissues intact. 94

95. A SFA based on a buccal flap provides better surgical access for soft tissue management, root/defect debridement, and suturing procedures compared to an SFA with an oral approach 95

96. ADVANTAGES: (1)it may facilitate flap repositioning and suturing; the flap can easily be stabilized to the undetached papilla, thus optimizing wound closure for primary intention healing. 96

97. (2)By limiting the surgical trauma on the vascular supply of the interproximal supracrestal soft tissues due to a limited flap elevation, a faster wound-healing process, particularly at the level of the incision line, is promoted. (3)Minimize the post-surgery shrinkage of gingival tissues and, therefore, limit the esthetic impairment of the patient. 97

98. DISADVANTAGE: A limited surgical access may potentially result in an inadequate root/defect debridement and difficulty in graft/membrane placement. 98

99. Previous studies demonstrated that the SFA is an effective surgical approach when used in association with various regenerative technologies, including bone biomaterials with or without membrane devices. A successful treatment outcome was also reported when a similar flap design was used in association with EMD. 99

100. The SFA represented a valuable reconstructive procedure even without adjunctive reconstructive technologies. 100

101. SURGICAL PROCEDURES Sulcular incisions were made following the gingival margin of the teeth included in the surgical area. Elevation of a buccal mucoperiosteal flap without vertical releasing incisions: The mesio -distal extension of the flap was kept limited while ensuring access for defect debridement. 101

102. An oblique or horizontal butt-joint incision was made at the level of the interdental papilla overlying the intraosseous defect; the greater the distance was from the tip of the papilla to the underlying bone crest, the more apical (i.e ., close to the base of the papilla) the buccal incision was in the interdental area. 102

103. However, the interdental incision was performed ≥1 mm coronal to the underlying bone crest. This provided an adequate amount of pristine supracrestal soft tissue connected to the undetached oral papilla to ensure a subsequent flap adaptation and suturing and permitted a proper surgical access to the intraosseous defect. For each defect, a microsurgical periosteal elevator was used to raise a flap on the buccal side only, leaving the oral portion of the interdental supracrestal soft tissues undetached . 103

104. Root and defect debridement were performed using hand and ultrasonic instruments. At the completion of the surgical debridement, defects were left to fill with a blood clot. At the wound closure, a horizontal internal mattress suture was placed between the buccal flap and the base of the attached oral papilla to ensure the repositioning of the buccal flap. 104

105. A wound closure was achieved by means of a second internal mattress suture (vertical or horizontal) that was placed between the most coronal portion of the flap and the most coronal portion of the oral papilla . When needed (i.e., in case of a large, thick interdental papilla), an interrupted suture was performed to ensure the primary intention healing at the incision line. 105

106. Advantages of minimally invasive surgical techniques in periodontal regeneration • Less postoperative pain • Improvement in rate of healing • Chair time required to perform such a surgery is by far shorter than the chair time required for more conventional surgical approaches • Improved retention of soft tissue height and contour • Periodontal tissue regeneration • Good patient acceptance . 106

107. Disadvantages • Technique sensitive MIS needs improved instruments for root and osseous defect debridement, “micro” versions of the instruments • Expensive • Cannot be universally applied, only in suitable cases technique can be performed . 107

108. CURTAIN PROCEDURE In 1967, Frisch and colleagues developed a surgical technique that permitted conservation of the maxillary anterior esthetics . Modified Surgical Approach for Maxillary Anterior Esthetics 108

109. A ttempts to preserve all labial attached gingiva, even the labial third of the interproximal papillae . It was based on their finding that even in the presence of interproximal disease, a healthy midlabial sulcus can exist with healthy labial tissue. Lie (1992 ) described the advantages and methodology of this procedure, which he termed the MODIFIED RESECTIVE TECHNIQUE . 109

110. INDICATION G ingival tissue appears to be clinically healthy (firm , pink, and stippled), with a midlabial sulcus depth ≤ 4 mm , even when deep interproximal pockets are present . This technique appears to satisfy all of the necessary criteria for treating the maxillary anterior teeth if esthetics are a problem. 110

111. Long-term success is achieved by ease of access and maintainability of the area for oral hygiene. The round roots allow effective flossing, and palatal access to the longer roots is easy. 111

112. Procedure The incisions are designed for maximum conservation of the facial gingiva and at least one-third of each of the labial papillae. The initial incisions are made with a no. 11 or no. 15 scalpel blade. Palatally , either a beveled gingivectomy or a partial-thickness palatal flap procedure can be performed. 112

113. The blade is directed interproximally at right angles to the teeth from both the mesial and distal directions. This intersecting incision separates the labial one-third of the papilla, which , combined with the labial tissue, forms the tissue curtain . No further labial surgery is required. 113

114. Palatally , the need for osseous surgery determine whether a gingivectomy or flap procedure is used. Even though gingivectomy is faster and simpler; if the bony craters can be ramped palatally , plaque control will be facilitated. Final suturing, can be interrupted or continuous. 114

115. In this technique, the buccal two-thirds of the interproximal papillae are still retained to prevent shrinkage, and there is no need to release or reflect the papilla from the buccal surface. M inimal amount of labial recession even though significant recession occurs palatally 115