Papillary Preservation Approach in The Treatment of Osseous Defects - A Report of 3 Cases
Akriti Mishra1*, Dipanjan Das2 and Avaneendra Talwar3
1,2,3Department of Periodontology, AB Shetty Memorial Institute of Dental Sciences, NITTE (Deemed to be University), Mangalore, Karnataka, India
*Corresponding author: Akriti Mishra. Department of Periodontology, AB Shetty Memorial Institute of Dental Sciences, NITTE (Deemed to be University), Mangalore, Karnataka, India.
Citation: Mishra A. Papillary Preservation Approach in The Treatment of Osseous Defects- A Report of 3 Cases. JOral Med and Dent Res. 5(4):1-7.
Received: August 2, 2024 | Published: August 18, 2024
Copyright© 2024 genesis pub by Mishra A, et al. CC BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives 4.0 International License. This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.
DOI: https://doi.org/10.52793/JOMDR.2024.5(4)-71
Abstract
Managing osseous defects that are a result of periodontal diseases, especially when the preservation of the interdental papilla is critical, presents considerable clinical difficulties. Traditional flap designs, while providing necessary surgical access, often lead to post-operative soft tissue recession and loss of papilla, which negatively affects the aesthetics. Contemporary periodontal surgery focuses on not only removing periodontal pockets but also enhancing clinical attachment with minimal soft tissue shrinkage.The papillary preservation techniques have proven effective in minimizing tissue trauma while preserving soft tissues. This report discusses the application of these methods across three clinical cases, demonstrating their ability to reduce probing depths, encourage bone regeneration, and maintain aesthetic results.
Keywords
Periodontal surgery; Papilla preservation; Periodontal regeneration; Osseous defect
Introduction
Periodontitis, a disease characterized by inflammation due to bacterial infections in the periodontal tissues, leads to the destruction of key structures like the gingiva, periodontal ligament, cementum, and alveolar bone. In 2018, the World Workshop Consensus introduced an updated classification system for periodontal diseases, focusing on staging and grading. Staging is used to determine the severity of the damage and the complexity of treatment required, while grading assesses the extent of harm, the risk of future damage, the likelihood of unfavorable treatment outcomes, and the disease’s connection to the patient’s overall systemic health [1,2].
Periodontal surgery becomes essential when persistent and active periodontal pockets exceeding 5mm are associated with intrabony defects. Such surgeries are conducted to access the deeper areas of the periodontal pocket and to repair the periodontal damage caused by the disease.[3] However, traditional flap designs in periodontal surgery often lead to the retraction of marginal tissues during healing, resulting in soft tissue defects in the interproximal areas.[4]
To address these issues, advanced techniques like microsurgery and the use of new bioactive regenerative agents, alongside papilla preservation techniques have been proposed. These methods aim to minimize wound, reduce flap reflection, and preserve the papilla.[5] The papilla preservation method (PPM), first described by Takei et al. in 1985, has been refined over the years, with notable modifications including the modified papilla preservation technique (MPPT).The modified-minimally invasive surgical technique (M-MIST).[6-9] These techniques are designed to minimize trauma to the papillary tissues, thereby preventing papillary collapse after surgery. However, the selection of a specific technique depends on the defect area in question and the patient’s aesthetic expectations.[10] This case report illustrates the application of various papilla preservation approaches in different clinical scenarios.
Case Presentation
Case 1
A 39-year-old systemically healthy female reported to the outpatient department with esthetic concerns and wanted her teeth to be properly aligned. However, a thorough oral examination revealed that her mandibular anterior teeth were mobile with deep probing depths. The patient was thus referred to the Periodontology department. Further radiographic examination revealed bone loss concerning the teeth 31 and 41. Upon periodontal examination, it was noted that tooth 31 was grade I mobile with a probing depth of 5mm (mesio-buccal) and attachment loss of 6mm (recession = 1mm) and tooth 41 was grade II mobile with a mesiobuccal probing depth and attachment loss of 7mm. The adjacent teeth 32 and 42 also had probing depths of 5mm each. The diagnosis, according to the 2017 classification, was made to be Localized Periodontitis Stage III Grade A. Non-surgical periodontal therapy was performed and further surgical procedure was explained to the patient concerning the mandibular anterior teeth. The patient reported back for the planned surgical procedure after 4 weeks. The interdental incision, between 31 and 41, was placed using MPPT as the distance was more than 2mm. A horizontal incision was, thus, made at the papilla base, followed by elevating a full-thickness flap lingually. Sulcular incisions were placed in the adjacent sites and full-thickness flaps were raised. The area was thoroughly described and the osseous defect was visualized.
Figure 1: Occlusal view of the modified papilla preservation incision and defect visualization.
Xenograft (Geistlich Bio-Oss) was used to fill the defect site, followed by the placement of a resorbable collagen membrane (Geistlich Bio-Gide). Sutures were removed 2 weeks later. The tissues were stable 3 weeks post-surgery and even at 18 months follow-up, with 1mm of recession noted in both the treated teeth (31 and 41). Radiographic examination revealed bone fill and clinical examination showed reduced probing depth.
Case 2
A 35-year-old systemically healthy female reported to the department with the complaint of loose teeth in the lower front region. Upon examination, deep probing depth at the mesio-buccal and mesio-lingual sites (7-8mm) concerning tooth 41 with grade II mobility and recession of 1mm was noted. Furthermore, 5mm of probing depth (mesio-buccal) with grade I mobility concerning 42 was noted (Figures 6a,6b). Thediagnosis, as per the 2017 classification, was made to be Localized Periodontitis Stage III Grade A. Non-surgical periodontal therapy was performed and provisional splinting using a glass-fiber splint (Angelus Interlig) was done. The patient reported back for the planned surgical therapy after 4 weeks. The conventional PPM involves the placement of intrasulcular incisions facially and palatally, sparing the papillary region. A semilunar incision, extending 5mm apically from the line angles of the tooth, was made across the palatal papillary side and the flap is reflected buccally. After thorough debridement, the presence of an interdental crater was noted.
Figure 2: Interdental crater defect visualization post-flap reflection using conventional PPM
A combination of leukocyte-rich-platelet-rich fibrin (L-PRF) and xenograft (Geistlich Bio-Oss) was utilized to fill the defect site. The flap was finally sutured using cross-mattress sutures over the semilunar incision to achieve primary closure. Sutures were removed 2 weeks later. The tissues were stable at 1-month follow-up. Defect fill could be appreciated radiographically at the 3-months follow-up.
Case 3
A 45-year-old systemically healthy male reported to the department with the complaint of loose teeth in the upper right back region. Periodontal examination revealed a probing depth of 7mm on the mesio-palatal aspect of 16 and an attachment loss of 8mm (recession = 1mm) with grade I mobility. Tooth 15 had a probing depth of 5mm at the mid-palatal site.The buccal sites did not reveal significant probing depths. The diagnosis, according to the 2017 classification, was made to be Localized Periodontitis Stage III Grade A. After non-surgical periodontal therapy, the patient was recalled for the planned surgical procedure. M-MIST was used to raise the flap, while preserving the supra-crestal attachment and sparing the interdental papilla, by placing intrasulcular incisions connected by a horizontal incision, and creating a small window for palatal surgical access. Circumferential osseous defect involving the mesial and palatal aspects was noted, post-thorough debridement.