Journal Club Presentation - Department of Periodontology and oral implantology - Entire papilla preservation technique in the regenerative treatment of deep intrabony defects: 1-Year results

2. Entire papilla preservation
technique in the
regenerative
treatment of deep
intrabony defects: 1-Year
results
Journal of Clinical Periodontology
- Accepted: 16 July 2017
- Serhat Aslan1 | Nurcan Buduneli2 | Pierpaolo Cortellini3,4
PRESENTATION BY – DR. MD ABDUL HALEEM

3. CONTENTS:
• Introduction
• Material and methods
• Surgical procedure
• Post-surgical care
• Clinical parameters
• Clinical characterization of the intrabony
defects during the surgery
• Data analysis
• Result
• Discussion
• Conclusion
• Reference

4. INTRODUCTION
• Regeneration of periodontal support is one of the goals of periodontal
therapy.
• Nyman, Lindhe, Karring and Rylander (1982) reported new attachment
formation in humans by guided tissue regeneration (GTR) and since then
different types of regenerative materials have been investigated including:
• Non-resorbable and bioresorbable barrier membranes
• Autologous and heterologous grafts
• Biologic factors - Amelogenins
• Combinations

5. • Regenerative therapy outcomes are influenced by various factors such as:
• Patient factors
• Plaque control level
• Percentage of bleeding on probing
• Smoking habit
• Morphology of the defect
• Selected surgical strategy.

6. • Among the surgical factors, early wound failure and consequent
exposure of the regenerating area have been frequently reported and
associated with reduced clinical outcomes.
• This undesired event is reportedly more frequent when biomaterials
like barrier membranes and bone substitutes are used.*
(Cortellini & Tonetti, 2015; Nowzari, Matian, & Slots, 1995; De Sanctis, Zucchelli, & Clauser, 1996a,b; Heijl, 1997 Tonetti et al.,
2002; Wachtel et al., 2003; Sanz et al., 2005; Ribeiro et al., 2011).

7. • To reduce the risk of early wound failure some various sophisticated flap
designs have been developed with minimally invasive surgical approaches
such as papilla preservation flaps with or without papilla elevation*.
• Based on the application of a horizontal or diagonal incision on the defect-
associated papilla all these techniques are designed to provide:
• Protection of the regenerating site
• Facilitate blood clot stability.

8. • Recently, a novel surgical approach, the “entire papilla preservation (EPP)”
technique has been proposed to treat isolated deep intrabony defects with
periodontal regeneration (Aslan, Buduneli, & Cortellini, 2017).
• The overall idea behind this concept is to preserve the whole integrity of the
defect-associated papilla providing a tunnel-like undermining incision.
• The completely preserved inter-dental papilla provides an intact gingival chamber
to stabilize the blood clot and improve the wound healing process.
• To provide adequate access for debridement, EPP requires a short buccal vertical
releasing incision on the buccal side of the neighboring tooth extending just
beyond the mucogingival line.

9. Representative case treated with the entire papilla preservation technique

13. The aim of this prospective cohort study was to evaluate
the clinical applicability and one-year outcomes of this
novel surgical procedure in the regenerative treatment of
isolated deep intrabony defects.

14. MATERIAL AND METHODS
Study population and experimental design:
• Twelve systemically healthy patients with advanced periodontal
disease were included in this prospective cohort study 3 months after
completion of non-surgical periodontal therapy.
• All patients gave written informed consent to participate in this study.

15. Inclusion criteria:
• Good systemic health.
• Presence of at least one isolated two-or three-wall intrabony defect with
• Probing depth (PD) ≥7 mm
• Clinical attachment level (CAL) ≥7 mm
• At least 4 mm intrabony component involving predominantly the interproximal
area of the affected tooth
• Full-mouth plaque score (FMPS) ≤20%.
• Full-mouth bleeding score ≤20%.

16. Exclusion criteria:
• Current smoking habit
• Presence of uncontrolled systemic diseases
hindering periodontal surgery
• Use of medications affecting periodontal tissues
• Pregnancy and lactation.
Dental exclusion criteria:
• One-wall intrabony defects
• Defects involving buccal and/or lingual sites
• Presence of inadequate endodontic treatment
and/or restoration in the experimental teeth.

17. • Clinical periodontal parameters were recorded at baseline (at least 3 months after
completion of cause-related therapy) and 12 months after the regenerative periodontal
surgery.
• During the non-surgical therapy, possible defect morphology was estimated by vertical
bone sounding.
• Experimental sites were accessed with the “EPP” technique and thoroughly debrided.
• Intraoperative measurements were recorded and definitive defect characterization was
made during the surgery.

18. • Ethylenediaminetetraacetic acid (EDTA) gel and enamel
matrix derivative (Emdogain) were applied on the air-dried
root surfaces.
• Then, porcine-derived bone substitutes (Gen-Os, OsteoBiol)
were placed into the defect and the flap was sutured with
simple interrupted sutures.
• Patients were enrolled in a stringent
plaque control programme with recalls on
a weekly basis for the first month and then
monthly controls for professional tooth
cleaning for the following 12 months.

19. Surgical procedure
• The surgical site was anesthetized using articaine–
epinephrine 1:100,000.
• Bone sounding was performed after anesthesia.
• Trans-papillary infiltration was avoided to prevent
physical (needle penetration) and chemical
(prolonged vasoconstriction) trauma to the gingival
tissues.

20. • Surgical loupes (3.3× magnification) with LED light illumination were 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 neighbouring inter-
dental space and extended just beyond the mucogingival line to provide
appropriate mechanical access to the intrabony defect.

21. • A microsurgical periosteal elevator was used to elevate
a buccal full-thickness mucoperiosteal flap extending
from the vertical incision to the defect-associated
papilla.
• A specifically designed angled tunnel elevator
facilitated the inter-dental tunnel preparation under
the papillary tissue.
• Utmost care was taken to elevate the inter-dental
papilla in full-thickness manner up to the intact lingual
bone crest.

22. • A microsurgical scissor was used to remove the
granulation tissue from the inner aspect of the defect-
associated inter-dental papilla.
• Excessive thinning of the papilla was avoided not to
compromise the blood supply.
• The granulation tissue was removed with a
minicurette.
• Any residual subgingival plaque or calculus was gently
removed from the exposed root surface with an
ultrasonic scaler.

23. • The surgical area was thoroughly rinsed with sterile saline and root conditioning of the
exposed surface was performed applying 24% EDTA gel for 2 min to remove the smear
layer.
• Then, the exposed root surface was rinsed with sterile saline and EMD was applied to
the exposed root surface.
• Subsequently, a deproteinized porcine-derived bone substitute was placed into the
intrabony defect.
• Gentle pressure was applied to the surgical area using saline-wetted gauze for 1 min to
readapt the mucoperiosteal flap.
• Microsurgical suturing technique with 7-0 monofilament polypropylene suture materials
was performed for optimal wound closure of the surgical area.

24. Postsurgical care:
• After the surgery, patients received 600 mg ibuprofen and were
instructed to take a subsequent dose 8 hr later.
• Systemic doxycycline (100 mg b.i.d.) was prescribed during the first
postoperative week.
• The patients were asked to refrain from using mechanical oral hygiene
measures for a period of 4 weeks.
• During this period, the patients were requested to rinse with 0.12%
chlorhexidine digluconate mouthrinse for 1 min twice daily.
• The sutures were removed 2 weeks after the surgery.
• Each patient received professional tooth cleaning during the monthly
control appointments for the following 12 months.

25. Clinical parameters:
• Clinical periodontal parameters were recorded at 4 sites (mesial, buccal, distal
and oral) of each tooth present except the third molars.
• All clinical measurements were carried out by a single examiner at baseline and
also 1-year after the surgery.
• Before the study, the examiner was calibrated to reduce intraexaminer error and
to reach reliability and consistency.
• Full-mouth plaque scores (FMPS) were recorded as the percentage of total
surfaces exhibiting plaque (O’Leary, Drake, & Naylor, 1972).
• Bleeding on probing was assessed and BOP was deemed positive if it occurred
within 15 s after periodontal probing.

26. • Full-mouth bleeding scores (FMBS) were then calculated (Cortellini et
al. 1993).
• Probing depth and recession of the gingival margin (REC) were
rounded to the nearest 0.5 mm at the deepest location of the
experimental interproximal site.
• Clinical attachment level was calculated as the sum of PD and REC.
• Primary closure of the surgical sites was evaluated on a weekly basis
for the first month after the surgery.

27. Clinical characterization of the intrabony
defects during the surgery
• Defects were described as 1-, 2-, 3-wall or combination defects
according to Papapanou and Tonetti (2000).
• Depth of the intrabony component (INFRA) was measured as the
distance between the crest of the marginal bone and the deepest
location of the osseous defect and width of the intrabony defect as
the horizontal distance between the crest of the marginal bone and
root surface.

28. Data analysis
• Twelve patients were enrolled in this cohort study.
• Data were expressed as mean ± standard deviation obtained from 12
defects in 12 patients.
• All patients involved in the study completed the 1-year study protocol and
there was no missing data in any patient.
• Comparisons between baseline and 1-year PD, CAL and REC were made
using the paired Student’s t-test (α = .05).
• The primary outcome variables were CAL gain, residual PD and REC change.

29. • Systemically, 12 healthy and non-smoker patients with clinical
diagnosis of advanced periodontitis (nine males and three females;
mean age: 42.6 ± 13.1; range 22–60 years) were included in this
study.
• The 12 intrabony defects were allocated at two maxillary central
incisors, four maxillary lateral incisors, one maxillary premolar, two
mandibular central incisors, one mandibular cuspid and two
mandibular molars.

32. • Primary wound healing of the vertical releasing incision, excellent
continuity of inter-dental papilla and 100% wound closure were
observed in all cases during the early and late phases of wound
healing period.
• No adverse events were noted in any of the treated sites.
• Only one patient reported very limited discomfort for the first 3 days
after the surgery.

34. DISCUSSION:
• The “EPP” is a novel surgical approach designed to provide proper access to deep
interproximal intrabony defects while preserving the integrity of the defect-
associated inter-dental papilla.
• This approach was chosen to reduce the risk of wound healing failure and
exposure of the regenerative biomaterials.
• In this patient population, the EPP resulted in 100% wound closure for the entire
healing period providing protection to the regenerative materials and to the
blood clot in the intrabony defect.
• Previous studies have demonstrated that wound failure and subsequent exposure
of the biomaterials impair the process of regeneration and deteriorate the clinical
outcomes (De Sanctis et al., 1996a,b; Machtei, 2001; Sanz et al., 2005).

35. • To overcome this problem, various innovative surgical procedures have been proposed.
• Modified and simplified papilla preservation techniques have reduced the complication rate to
30% (Cortellini et al., 1995a,b, 1999), whereas minimally invasive surgical techniques reduced it
to less than 10% (Cortellini & Tonetti, 2007, 2009; Harrel, 1998; Trombelli et al., 2009).
• All of these procedures, however, are based on a mesio-distal dissection through defect-
associated papilla ending with the implantation of biomaterials below the incision line.
• The entry incision of EPP, on the contrary, is a vertical releasing incision positioned in a relatively
safe area of the defect-associated tooth that is the papilla contra-lateral to the papilla of the
defect.
• A full-thickness tunnel-like elevation of the buccal flap and of the inter-dental soft tissue gives
access to the interproximal defect.
• By doing so, the defect-associated papilla is completely preserved while the healing of the
vertical incision occurs over the native bone without interferences of biomaterials.

36. • According to the 1-year results of this study, optimal wound healing
was observed along the vertical incision line without any complication
and the defect-associated papilla is fully nourished through its native
uninterrupted vascular supply and healed uneventfully.
• As a consequence, the biomaterials implanted into the defect were
fully protected by the incision-free inter-dental papilla.
• In the present study, EMD in combination with porcine-derived bone
substitutes was implanted into the osseous defects.
• EPP supports the use of EMD or other biologic factors with or without
the combination of bone substitutes.

37. • The benefit of using EMD is supported by human histology and randomized clinical
studies (Mellonig, 1999; Sculean, Chiantella, Windisch, & Donos, 2000; Sculean et
al., 1999, 2001, 2006; Silvestri et al., 2003; Tonetti et al., 2002; Yukna & Mellonig,
2000).
• Besides its biological benefits, the use of EMD significantly reduces the hardship of
regenerative periodontal surgery with respect to GTR (Cortellini, 2012).
• The consistent amount of CAL gain (6.83 ± 2.51 mm) and the minimal increase in
gingival recession (0.16 ± 0.38 mm) observed in this study can be attributed, at
least in part, to the preservation of the original structure of the defect-associated
papilla and also to the inclusion of patients with very deep intrabony defects (7.08
± 0.83 mm).
• These results are comparable with the data reported in previous studies based on
the application of minimally invasive surgery (Cortellini & Tonetti, 2007, 2009,
2015; Trombelli et al., 2009).

38. • It has to be kept in mind that this novel surgical technique cannot be
applied to all kinds of intrabony defects.
• For instance, defects involving multiple sites and/or the lingual aspect of a
tooth require elevation of the defect-associated inter-dental papilla along
with the lingual flap (Cortellini & Tonetti, 2007).
• Thus, accurate diagnosis of the intrabony defect morphology prior to
surgery is of paramount importance for the proper choice of the surgical
approach.
• It is, therefore, strongly suggested to perform vertical bone sounding under
local anesthesia before surgery to forecast the defect morphology, as it has
been done in the present study.

39. • In conclusion, 12-month follow-up of EPP resulted in
enhanced clinical outcomes without any soft tissue
complication.
• EPP is a technique-sensitive approach and requires some
surgical skills for the preparation of a buccal and inter-
dental tunnel through a short buccal vertical releasing
incision.
• Further clinical studies with larger number of patients are
needed to support these preliminary data.

40. REFERENCES
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