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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
Results - Discussion - References.

Complete closure of the wound was achieved in all cases and no severe complications such as papilla necrosis occurred. One patient exhibited delayed healing at suture removal along the entire margin of the flap, leading to visible and persistent scar formation. Three other patients displayed irritation around the sutures at the time of their removal (Fig. 8b). Further healing in these patients was uneventful (Fig. 8c). All other patients displayed rapid healing.
The photographs did not reveal any noticeable opening of the space between the papilla and contact area as a result of the loss of papilla height at any observation time. The mean difference between a reference point and the most coronal point of the papilla comparing the preoperative and the one-month postoperative situation was 0.05 0.39 mm. None of the patients exhibited probing depths greater than 3 mm at one month. The visual observation of the incisions at this recall demonstrated four sites with visible defects (grade 1), seven sites with partially detectable incision defect (grade 2) and nine sites with perfect healing (grade 3).

Figure 8. Tissue irritation at suture removal.
(a) Post surgery;
(b) before suture removal; (c) healing at 1 month.

Partially complete healing

It is of utmost importance to preserve epithelial and connective tissue attachment at its original level and traumatize the attachment apparatus as little as possible during the incision in order to obtain rapid healing through primary intention. This can be obtained by:

  1. complete and sharp incision of the tissues;
  2. avoiding crushing of the tissues;
  3. preventing drying of the tissues during the procedure; and
  4. perfect adaptation of wound edges upon closure (Gutmann & Harrison 1991b).

Recession of the papilla after sulcular incisions has not been discussed recently. It remains however, an important problem, which cannot be corrected in a predictable manner. Although advanced restorative procedures and materials have expanded the therapeutic options, anterior hard and soft tissue deformities continue to represent a significant technical and aesthetic challenge (Salama et al. 1998). When semilunar flaps were compared with trapezoidal flaps, no statistically significant change was observed in pocket depth or attachment levels (Chindia & Valderhaug 1995). In another study, despite microsurgical techniques, the mobilization of the papilla resulted in considerable loss of height after 3–5 days (Zimmerman et al. 2001). Besides aesthetic disadvantages, this may create biological and phonetic problems, as well as food impaction. The height of the papilla depends on the distance between the contact point and crestal bone. In a healthy periodontium without any attachment loss, the papilla fills the entire interproximal space between two teeth in almost all instances (Tarnow et al. 1992). In periodontally healthy sites, particularly when subgingivally placed crown margins are present, recession is a risk when a surgical procedure is required to treat apical pathology. With the papilla base incision it is possible to prevent any noticeable recession of the papilla following apical surgery. The mean change in distance of the most coronal point of the papilla between the preoperative and the one-month postoperative situation was 0.05 mm. The standard deviation of 0.39 is most likely due to the measurement technique used. This involved the measurement of the distance with periodontal probe with an approximation to 0.5 mm. It seems that the dimensional changes are less than the precision of the measurement used.
Although the papilla base incision achieved very predictable results, this technique is challenging to perform. First, atraumatic handling of the soft tissues is mandatory to obtain good results. Secondly, two different incisions are needed for good healing and to avoid excessive scar formation or an indentation at the site of the incision. The first shallow incision (1.5 mm) into the tissue will prevent thinning of the coronal aspect of the flap. Thin tissue fins, unsupported by connective tissue, will necrotize and create a defect, which will be repaired by visible scar tissue. The remaining papilla, as well as the raised flap, should be treated with great care, kept moist, and held in place without pressure during suturing. In addition, fine (7/0, preferably 8/0), non-resorbable and tissue tolerated polypropylene suture material should be used to avoid further irritation to the wound margins. The delicate atraumatic needles cause minor injury to the papilla and flap, provided the tissues are not pinched several times during suturing. Finally, the wound edges are perfectly reapproximated without tension on the suture. Tension will compromise blood circulation on both the papilla and the split flap and cause delayed healing. It was shown by Pini Prato et al. (2000) that greater tension reduced root coverage in coronally advanced flaps. Split flaps are routinely used in periodontics. They are applied in mucogingival surgery for subepithelial grafting, augmentation, recession coverage and papilla reconstruction after implant placement.
The number of sutures needed for securing the papilla base flap to the papilla depends on the width of the papilla. A minimum of two sutures is required, one at each side of the papilla base incision for perfect reapproximation of the wound edges. An additional suture will secure close adaptation of the flap, when necessary.
In the buccal cervical area an intrasulcular incision is performed. The scalpel size has to be small enough to move the blade within the sulcus and not cut into the gingiva. Although the scalpel is in constant contact with the tooth, the incision will sever sulcular epithelium and fibres of the connective tissue, leaving some root attached epithelium and connective tissue on the root surface. This tissue is very delicate and can be injured easily, which will delay the healing (Harrison & Jurosky 1991). The attached tissue on the root surface must not dry out, as it facilitates the epithelial and connective tissue reattachment. In the present clinical study, although papilla height could be maintained at its preoperative levels, some recession was noted in the cervical area.
A submarginal incision is often preferred when crowns and bridges are present. The Ochsenbein Luebke flap will preserve the marginal gingiva and will not expose the crestal bone. The blood supply to the marginal tissues is supplied from the crestal bone area and through the papilla from the lingual side. Unfortunately, this flap design cannot always be used, as a minimum of 2 mm of attached gingiva should be present coronal to the prospective line of the incision (Lang & Löe 1972). In addition, the presence of periodontal pockets usually prevents the use of this technique. The main disadvantage of the Ochsenbein Luebke flap is the unpredictable scar formation (Kramper et al. 1984) and the devastating complication of marginal gingival necrosis (personal observation).
A review of the literature indicates a loss of clinical attachment following periodontal flap procedures for shallow pockets (1–3 mm), and sustained attachment loss after modified Widman flap after 6.5 years (Pihlstrom et al. 1983). Probably, part of the attachment loss in these studies occurred because of scaling and root planing during the surgical periodontal treatment. The scaling and root planing removes epithelial and connective tissue attachment, which needs to be reformed, resulting in some attachment loss. In endodontic access flaps no scaling and root planing is performed. The aim of the soft tissue management in apical surgery is to prevent attachment loss and recession of the marginal periodontium, especially when healthy conditions are present.
Based on the results of this study, the recession of the papilla in healthy periodontal sites can be prevented during apical surgery. The papilla base incision displayed excellent healing without noticeable loss of height of the papilla. The mid-term healing of the incision at the base of the papilla was either invisible or slightly visible for the majority of the sites. Only four sites displayed a distinct line of indentation or separation visible at 3magnification 1 month after the surgery. Subjectively, none of the patients with visible graded healing noted any disadvantage aesthetically. Further study will analyse the longterm healing in papilla base incisions and compare it to standard elevation of the papilla in marginal full thickness flaps.


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