Papilla Preservation Techniques.pptx

preserve the papilla using these techniques

1. PAPILLA PRESERVATION TECHNIQUES Dr. Rinisha Sinha Postgraduate Trainee Department of Periodontology and Implantology

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3. INTRODUCTION The interdental gingiva occupies the gingival embrasure, which is the interproximal space beneath the area of tooth contact. Can be pyramidal , or can have a “col” shape. If a diastema is present, the gingiva is firmly bound over the interdental bone and forms a smooth, rounded surface without interdental papillae. A valleylike depression that connects a facial and lingual papilla and conforms to the shape of the interproximal contact The tip of the papilla is located immediately beneath the contact point

4. Anatomy of Interdental Papilla Interdental papillae are the extensions of gingiva filling the spaces between adjacent teeth. Formed by dense connective tissue covered by epithelium . Influenced by the height of alveolar bone , the distance between the teeth and the interdental contact point . Shape in Anterior region : Narrow and Pyramidal because the tooth mass bordering the interdental papilla is less. Shape in Posterior region : Wider and with a ridge shaped concaved area called as ‘Col’ due to the presence of larger tooth mass. Reference : Park JH. Esthetic consideration in interdental papilla: remediation and regeneration. J Esthet Restor Dent; 2010 Reference : Cohen B. pathology of the interdental tissues. Dent Pract ; 1959 Gingival black triangle is a cosmetic deformity which refers to an absence of papilla resulting in black spaces or open embrasures which impairs esthetic features, phonetics problems and food accumulation. Reference : P. Ziahosseini , B. J. Millar, Management Of Gingival Black Triangles; 2014

5. Historical Background Kromer et al (1956) - First report designed to retain osseous implants . App et al (1973) - “ INTACT PAPILLA FLAP ” retained the interdental gingiva in buccal flap. Aimed to provide maximum protection to osseous and transplant recipient sites . Evian et al (1985) - Modified this procedure to preserve anterior esthetics after flap surgery. Genon and Blender (1984) - Reported similar technique indicated for esthetic purpose . Takei et al (1985) - Gave detailed description and termed “ PAPILLA PRESERVATION FLAP ”.

6. CLASSIFICATION OF INTERDENTAL PAPILLA LOSS Based on three anatomical landmarks: The Interdental Contact Point The Apical extent of the Facial Cementoenamel Junction (CEJ) The Coronal extent of the Proximal Cementoenamel Junction (CEJ) Reference : W. P. Nordland And D. P. Tarnow, A Classification System For Loss Of Papillary Height, J. Periodontol ; Oct. 1998

7. The Papilla Presence Index (PPI) A New System to Assess Interproximal Papillary Levels – proposed by Cardaropoli et al. (2004) Reference : C Nemcovsky . Interproximal Papilla Augmentation Procedure: A Novel Surgical Approach And Clinical Evaluation Of 10 Consecutive Procedures. Int J Periodontics Restorative Dent; 2001

8. Papillae Index Score (PIS) Nemcovsky introduced a classification system based on a comparison with adjacent teeth. Reference : C Nemcovsky . Interproximal Papilla Augmentation Procedure: A Novel Surgical Approach And Clinical Evaluation Of 10 Consecutive Procedures. Int J Periodontics Restorative Dent; 2001

9. Factors determining the Presence and Absence of Interdental Papilla Reference : Tornow DP, Magner AW, Fletcher P. the effect of the distance from contact point to the crest of bone on the presence or absence of interdental papilla. J Periodontol; 1992 Reference : Tal H. relationship between the interproximal distance of roots and the prevalence of infrabony pockets. J periodontal; 1984 Reference : Ahmad I. anterior dental esthetics: gingival perspective. Br Dent J; 2005 Reference : Kois JC. Predictable single tooth peri-implant esthetic; five diagnostic keys. Compend Contin Educ Dent; 2001

10. PERIODONTAL BIOTYPE PERIODONTAL BIOFORMS High Normal Flat “5 – mm” Rule CROWN MORPHOLOGY Square Circular Triangular

11. Etiology of Interdental Papilla Loss Reference : Jenabian N, Rahimi Rad M, Bijani A, Ghahari P. The comparison of papilla preservation technique and semilunar incision with sub- epithelial connective tissue graft in dark triangle treatment. Caspian J Dent Res; 2018

12. VASCULAR SUPPLY Since the interdental area is small, the blood supply is also minor, making it a major limiting factor in surgical procedures.

13. The Basic Treatment Modalities for the preservation of interdental papilla If the primary cause of periodontal disease is interdental papilla loss If traumatic tooth brushing If mal-positioning of the teeth If no contact point between the teeth like in the case of midline diastema Every 15 days for 3 months curettage of interdental papilla should be performed repeatedly

14. What is Papilla Preservation Flap ??? The Papilla Preservation Flap incorporates the entire papilla in one of the flaps by means of crevicular interdental incisions to sever the connective tissue attachment and a horizontal incision at the base of the papilla, leaving it connected to one of the flap. Reference : Carranza; 10 th edition

15. Reference : Cohen; 3 rd edition

16. Conventional Papilla Preservation Flap Takei et al; 1985 The first modification of PPF The horizontal incision beneath the interproximal area , on opposite side of bone defect was deemed best because it allowed protection of the regenerated area from the oral environment. Checchi et al; 1988 Reference : Chacko LN, Abraham S, Landge N, Ali FM. Papilla Preservation Flap: Revisited; 2013 Reference : Cortellini P, Prato GP, Tonetti MS. The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent 1999

17. Reference : Dr. Thomas Han, LA

18. Modified Papilla Preservation Flap It is indicated in broad interdental spaces and thick interdental papilla Cortellini et al; 1995

19. Simplified Papilla Preservation Flap Suitable for narrow interdental spaces (≤2 mm) Modification of Modified papilla preservation Reference : Aslan S, Buduneli N, Cortellini P. Entire papilla preservation technique in the regenerative treatment of deep intrabony defects: 1-Year results. J Clin Periodontol ; 2017 Pre-surgical site showing defect on the mesial aspect of the maxillary right lateral incisor Oblique Incision beginning at gingival margin of mesiobuccal line angle of lateral incisor. Blade parallel to the long axis of the tooth and reaches the mid-point of the distal surface of the central incisor below the contact point Oblique Incision continues intrasulcularly in the buccal aspect of the lateral and central incisor. Full thickness buccal flap elevated.

20. Wide interproximal space Horizontal incision Anterior and pre-molar region Narrow interproximal space Oblique incision Anterior and posterior regions Healing of gingival blood flow postoperatively is faster in SPPT than MPPT. Reference : ( Retzepi et al, 2007) Difference between SPPT and MPPT

21. Entire Papilla Preservation Flap Deep intrabony defects with periodontal regeneration have been treated by a novel surgical approach, the “entire papilla preservation (EPP)” technique . Reference : Aslan S, Cortellini P. Entire papilla preservation technique in the regenerative treatment of deep intrabony defects: 1-Year results. J Clin Periodontol ; 2017 Cortellini, Aslan; 2017 Aim : to preserve to affected papilla providing a tunnel like undercut incision Advantage : The entirely conserved inter-dental papilla provides an intact gingival chamber to stabilize the blood clot and also improves the wound healing process EPP : requires a short buccal vertical releasing incision on the buccal side of the adjacent tooth extending just beyond the Mucogingival line

22. Semilunar Coronally Repositioned Flap Placed following the curvature of the gingival margin , using a no.15 scalpel blade. Incision ends into the papilla on each inter-proximal area of the tooth to be treated , but not all the way to the tip of the papilla. Minimum conservation of 2 mm gingiva on each side of the flap to preserve blood supply. Curved apically to an extent to guarantee that the apical part of the flap rests on bone after the coronal development to cover the root. Reference : Aslan S, Cortellini P. Semilunar Periodontal Flap. J Clin Periodontol ; 2017

23. The “Whale’s Tail” Technique Preserves the interdental tissue by guided tissue regeneration Bianchi and Basseti; 2009 The reflected flap looks like a tail of a whale, hence the name Whales Tail technique Reference : Bianchi AE, Bassetti A. Flap design for guided tissue regeneration surgery in the esthetic zone: The “Whale’s tail” technique. Int J Periodontics Restorative Dent 2009

24. Healing Immediate response - clot formation . At edge of flap numerous capillaries are seen. 1-3 days after surgery , space between flap and tooth surface and bone appears reduced and the epithelial cells along border of the flap start migrating . By 1 week after surgery , epithelial cells have migrated and established an attachment to root surface by means of hemidesmosomes . The blood clot is replaced by granulation tissue proliferating from gingival connective tissue, alveolar bone and periodontal ligament. By 2nd week , collagen fibers begins to appear parallel to root surface. By end of 1 month , the epithelial attachment is well formed and gingival crevice is also well epithelized .

25. References Carranza’s Clinical Periodontology : 10 th Edition Cohen B. pathology of the interdental tissues International Journal of Applied Dental Sciences Interdental papilla and various preservation techniques: A review - S. Uma et al; 2020 Treatment of Interdental Papilla: A Review – Jamwal D. et al; 2019 Cortellini , Prato, and M. Tonetti , “The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures” Journal of Dentofacial Sciences Chacko, Neelathil & Abraham, Sathish & Landge , Nilima & Ali, Fareedi . Papilla Preservation Flap : Revisited; 2013 Miscellaneous W. P. Nordland and D. P. Tarnow, “A classification system for loss of papillary height,”  Journal of Periodontology H. H. Takei, T. J. Han, F. A. Carranza Jr., E. B. Kenney, “Flap technique for periodontal bone implants. Papilla preservation technique,” Journal of Periodontology; 1985

26. Landry Index Visual Analogue Scale

27. Esthetic Index