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Azerbaycan Saytlari

 »  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
Materials and methods.



Twenty patients (eight women and twelve men) in good general health referred for surgical treatment of persistent apical periodontitis were included in the study. The age of the patients ranged between 25 and 80 years, with a mean age of 47.8 13.6 years. The teeth consisted of mandibular and maxillary anteriors, premolars and molars (Table 1). All teeth had previously been root filled at various times and with different methods, but all were failing with persisting symptoms, and/or apical radiolucency. A conventional retreatment had either been performed and failed, or was not feasible because of canal obstruction, or the patient refused to sacrifice the coronal restoration for retreatment. Only patients without signs of periodontal disease were included in the study. Periodontal health was defined as absence of bleeding on probing and probing depths not exceeding 3 mm on any of the teeth in the area of the surgery. Interdental papillae were occupying the interproximal space below the contact area.
All teeth were anaesthetized with 4% articaine with 1 : 100 000 adrenaline infiltration and in the designated flap area additionally lidocaine with 1 : 50 000 adrenaline was administered for profound haemostasis. A mandibular block together with infiltration anaesthesia was given for the mandibular teeth and for maxillary teeth only infiltration anaesthesia was applied. The entire surgical procedure was performed with microsurgical instruments and magnified vision of at least 4.3 , using loupes and an operating microscope.

Table 1. Frequency distribution of treated teeth according to tooth type.

Frequency distribution of treated teeth according to tooth type

The papilla base flap consisted of two releasing vertical incisions, connected by the papilla base incision and intrasulcular incision in the following way. Initially, the vertical incisions were placed at least one tooth distal and mesial to the tooth to be treated. The marginal incision started with the preparation of the papilla base incision using a microsurgical blade (BB 369, Aesculap, Tuttlingen, Germany). The 2.5 mm wide blade with a round configuration at the tip has cutting edges on both sides and all around the tip. The papilla base incision required two different incisions at the base of the papilla.
1 The first shallow incision severed the epithelium and connective tissue to the depth of 1.5 mm from the surface of the gingiva. The incision was placed at the level of the lower third of the papilla in a slight curved line going from one side of the papilla to the other (Fig. 1). The incision started and ended in a 90 degree angle between the border of the tooth and the gingiva (see lines in Fig. 1).
2 The scalpel was then placed to the base of the previously created shallow incision at the base of the papilla and subsequently inclined apically, almost parallel to the long axis of the tooth, aiming at the crestal bone margin. With this second incision a split thickness flap was prepared in the apical third of the base of the papilla. The incision ended at the crestal bone level, where the periosteum was separated from the bone (Fig. 2). From there on the preparation continued in a full thickness muco periosteal flap (Fig. 3). Buccally over the tooth the vertical incision and papilla base incision were joined by an intrasulcular incision. The scalpel was moved within the sulcus, dissecting the gingiva to the crestal bone. The sulcular incision reached from the releasing incision to the start of the papilla base incision, or from one papilla to the next papilla. The flap was mobilized and retracted, during the root-end resection and filling.

Figure 1. Papilla base flap consisting of two releasing incisions and the papilla base incision. The papilla base incision is placed in the lower third of the interdental papilla. The incision starts and ends at a 90 degree angle (see lines) to the gingival margin, resulting in a curved line at the base of the papilla.

Papilla base flap consisting of two releasing incisions and the papilla base incision

Figure 2. Schematic drawing of the longitudinal section through the interdental papilla.
*marks the initial shallow incision through the epithelium and connective tissue to the depth of 1.5 mm.
**demonstrates the second incision directed to the crestal bone. The scalpel blade is inserted into the base of the first incision and directed nearly parallel to the long axis of the tooth. The second incision will prepare a split thickness flap reaching from the first incision to the crestal bone level.

Schematic drawing of the longitudinal section through the interdental papillaFigure 3. Clinical photograph after complete reflection of the papilla base flap. Note the elevated split thickness flap from the incision to the crestal bone level. Apical to the crestal bone area the full thickness flap exposes the bone over the roots.

Clinical photograph after complete reflection of the papilla base flap

Figure 4. (a) Wound closure of the papilla base incision with three polypropylene sutures; (b) sutures removed after 4 days.

Wound closure of the papilla base incision with three polypropylene sutures

Figure 5. Incomplete healing. Clearly detectable incision wound.
(a) Post surgery;
(b) healing at 1 month.

Incomplete healing. Clearly detectable incision wound

The flap closure was initiated from the releasing incisions. For the vertical incisions 6/0 (Supramid, B. Braun, Neuhausen, Switzerland) interrupted polyamide sutures were used. The papilla base incision was sutured with two or three polypropylene 7/0 (Prolene, Ethicon, Norderstedt, Germany) interrupted sutures depending on the width of the papilla. Great care was taken in passive reapproximation and perfect adaptation of the wound margins without tension to the sutures (Fig. 4a). The flap was compressed for 1 min at the conclusion of the surgery. Patients were instructed to apply a cold compress to the face for 10 min every 30 min for the rest of the day and were prescribed NSAID (Ponstan, Parke Davis, Baar, Switzerland), 250 mg three times per day for 48 h. Following this, patients only took the analgesics when required. Patients were instructed to refrain from mechanical oral hygiene in the operated area and rinse twice daily with 0.2% chlorhexidine during the first week after the surgery. The sutures were removed 3–5 days post operatively (Fig. 4b).
Twenty sites were evaluated. The surgical areas were photographed perpendiculy to the interproximal area: 1 before surgery; 2 immediately postoperatively; 3 at 3 to 5 days after suture removal; and 4 at a recall appointment 1 month postoperatively.
Great care was taken to maintain the same angulation and magnification of the photographs. The photographs were digitized in a slide scanner (LS 2000, Nikon Corporation, Japan), imported as TIFF files into the Photoshop 6.0 (Adobe Systems Incorporated, USA) and the pictures enlarged to 3magnification. The images were compared for increase of the space between the papilla and contact area as a sign of loss of height. The change of the position of the most coronal point of the papilla was determined by measuring the distance between a reproducible point on the tooth and papilla tip using a perio probe. The precision of the measurement reading was an approximation to 0.5 mm. Wound healing complications, such as excessive swelling, infections, wound dehiscence and necrosis, were recorded at all times. Probing depths were measured at recall appointments, except at the suture removal.
One month post operatively the experimental sites were observed with a 3magnification and graded as to whether a visible defect resulting from the incision could be detected. Incomplete healing (grade 1) described a clearly visible defect along the entire incision (Fig. 5b). Partially complete healing (grade 2) was noted, when parts of the incision were visible and at the same time there were also areas with undetectable healing patterns (Fig. 6b). Perfect healing (grade 3) was given for undetectable incision lines (Fig. 7b).

Figure 6. Partially complete healing. There are areas in which the incision can be still detected, where as in other parts the healing is undetectable.
(a) Post surgery;
(b) healing at 1 month.

Partially complete healing

Figure 7. Perfect healing. The place of the incision can not be detected.
(a) Post surgery;
(b) healing at 1 month.

Perfect healing