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 »  Home  »  Endodontic Articles 6  »  Papilla base incision: a new approach to recession-free healing of the interdental papilla after endodontic surgery
Papilla base incision: a new approach to recession-free healing of the interdental papilla after endodontic surgery

P. Velvart
Clinic for Periodontology, Endodontology and Cariology, University of Basel, Switzerland.

Loss of the interproximal dental papillae may cause functional, phonetic and aesthetic problems. Complete and predictable restoration of lost interdental papillae remains one of the biggest challenges in periodontal reconstructive surgery (Blatz et al. 1999). It is therefore imperative to maintain the integrity of the papilla during restorative and surgical procedures.
The interdental papilla is the portion of the gingiva between two adjacent teeth. The interdental papilla was at one time considered gingival tissue, roughly pyramidal in shape, with the sole function of deflecting food debris. In reality the function of the papilla is more complex and it is a biologic barrier to protect periodontal ligament, cementum and alveolar bone from the oral environment (Caton 1989). It is important to respect the integrity of the papilla during dental treatment and it may be advantageous to achieve keratinization by interproximal brushing to increase the resistance of the col area (Checchi et al. 1989).
The presence or absence of the interdental papilla depends upon the distance between the contact point to the crest of bone (Tarnow et al. 1992). When the distance from the contact point to the bone was 5 mm or less, the papilla was present almost 100% of the time. With a distance of 6 mm, the papilla was present 56% of the time, and when the distance measured 7 mm or more, the papilla was present 27% of the time or less.
Traditional periodontal surgical treatment opens the interproximal spaces, causing flattening or cratering of the interdental papilla. When a full thickness flap is raised during periodontal surgical treatment in an area with shallow pockets (1–3 mm), loss of attachment results, whereas with deep pockets the attachment level can be maintained or even gained. Re-evaluation after 6.5 years postsurgery found sustained attachment loss in shallow pockets (Pihlstrom et al. 1983).
In anterior periodontal surgery a papillary retention procedure is advocated to maintain the papillary height to maximize postoperative aesthetics (Michaelides & Wilson 1996). Cortellini et al. (1995, 1996) suggested a modification of the papilla preservation technique, which allows primary closure of the interdental space over a bioresorbable membrane. A horizontal incision at the base of the papilla is performed and the papilla subsequently elevated to the buccal side. After coronal repositioning of the buccal flap over the membrane, the interproximal area is covered with the papilla attached to the lingual flap. Primary closure over the membrane was obtained in all treated sites using the modified preservation technique. Probing attachment level gains and pocket depth reduction were observed after 1 year using this technique.
More recently, periodontal surgical procedures around teeth and dental implants have been used to prevent or correct anatomical, developmental, traumatic or plaqueinduced defects of the gingiva. Some of the currently available techniques deal with crown lengthening, alveolar ridge preservation and augmentation, soft tissue grafts and the correction of open interproximal spaces. Soft tissue abnormalities, with the exception of the loss of the interproximal papilla, can be resolved predictably, improving aesthetics and even creating restorative opportunities (McGuire 1998). The functional and especially aesthetic outcome of all periodontal procedures that aim for hard and soft tissue augmentation is technique sensitive. Application of plastic surgery principles is mandatory to achieve satisfactory results. Passive and tension-free wound closure is fundamental for predictable healing results (Pini Prato et al. 2000). Hurzeler & Weng (1999) suggested a series of incisions, buccal and lingual flaps split several times, resulting in a doublepartial thickness flap. In this way several tissue layers are obtained and the passive coronal advancement of flaps becomes possible for the coverage of augmented areas. A multilayer wound closure with microsurgical suture material allows perfect adaptation without any tension on the tissue and dependable positioning of the marginal gingiva.
Endodontic surgery requires exposure of the bone covering the root(s) and the apices. To achieve access, a full thickness flap must be raised, which consists of gingival and mucosal tissue as well as periosteum. To mobilize the flap, various modes of incisions can be selected including horizontal incisions (sulcular and submarginal) and vertical releasing incisions (Gutmann & Harrison 1991a).
Although microsurgical techniques have been applied in endodontic surgery for several years, little attention has been given to soft tissue healing following treatment. There is also little scientific and clinical data on recession of soft tissues during healing, specifically papilla healing, when no pathological changes are present in the periodontal tissues. The care of the healthy periodontal tissues is a very challenging one and it is of utmost importance to prevent attachment loss and recession of the gingiva following endodontic surgery. Even partial loss of the papilla should be avoided, as predictable correction of the interproximal papilla height is difficult.
In periapical surgery the sulcular full thickness flap is often used (Beer et al. 2000). During the marginal incision the scalpel is in constant and direct contact with the tooth and will sever sulcular epithelium and connective tissue fibres of the gingiva, leaving some attached epithelium and connective tissue on the root surface. This tissue is very delicate and can be injured easily, which may delay healing (Harrison & Jurosky 1991). The attached tissue on the root surface must not dry out or be disturbed during flap manipulation as it facilitates the epithelial and connective tissue reattachment. Ideally, the sulcular incision should dissect the buccal from the lingual papilla. In narrow interproximal spaces complete mobilization of the papilla is often difficult causing tissue loss. Shrinkage of the papilla during the healing phase can occur, and may cause the ultimate loss of papilla height. Zimmermann et al. (2001), in a preliminary study, investigated the shrinkage of the papilla after sulcular flaps in patients with healthy periodontal tissues. The loss of height of the papilla increased gradually during healing. Immediately postoperatively the loss of papilla height due to surgical manipulation resulted in 14 sites with a recession within one-quarter and three sites between one-quarter and one-half of the original height. At suture removal the papillae exhibited six sites with a loss of height of up to one-half the original position. None of the 17 sites remained at preoperative levels at any time. These results suggest that the conventional sulcular flap results in moderate, progressive retraction of the papilla.
To prevent the marginal recession of the gingiva, a submarginal incision was suggested (Luebke 1974). This incision is made within the attached gingiva parallel to the marginal contour of the gingiva. The submarginal flap is advocated when there is a broad band of attached gingiva and the expected apical lesion or surgical bony access will not extend to the incision line. This flap design preserves the marginal gingiva and does not expose the crestal bone. In maxillary anterior areas the submarginal incision is preferred in situations with subgingivally placed margin of crowns and bridgework. The main disadvantages of the submarginal incision are the scar formation due to flap shrinkage (Kramper et al. 1984), delayed healing and possible marginal tissue necrosis, when an insufficient blood supply is present.
Though sulcular flaps remain the most frequently used in endodontic surgery (Beer et al. 2000), the main disadvantage of these are recession and, especially, unpredictable shrinkage of the papilla during healing (Zimmermann et al. 2001), although Chindia & Valderhaug (1995) found no difference in attachment loss between trapezoidal and semilunar flaps in apicoectomy.
A persisting endodontic infection following periradicular surgery may be regarded as a contributing risk factor for a progressing marginal attachment loss ( Jansson et al. 1997). The mean clinical attachment loss in teeth with an unsuccessful healing was 0.85 mm and differed significantly from successfully healed cases with a mean of 0.15 mm.
A new incision for the marginal mucoperiosteal flap was designed to prevent loss of interdental papilla height. The technique involves the preservation of the entire papilla, thus eliminating any potential loss of height as a result of the surgical or healing process. The purpose of the study was to describe and evaluate a novel marginal incision technique – the papilla base incision, which preserves the integrity of the interdental papilla during and after endodontic surgery in cases where there is no evidence of marginal periodontitis.