Dr Barbagallo G
Psaila A, D’Urso U, Longo A
Guided Tissue Regeneration of interproximal angular intrabony defect with Simplified Papilla Preservation Technique
Resume
A procedure of guided tissue regeneration applied for the resolution of an angular defect mesial to 1.1 with grade II mobility in a patient with class III skeletal and dental malocclusion. Relying on precise decisional algorithms imposed by literature, we opted for a proper technique with Simplified Papilla Preservation Technique (SPPT).
Introduction
In the last 30 years periodontal regenerative therapy has been enriched with several operative strategies, with great results in the treatment of intrabony defects1. In the field of regenerative procedures of interproximal intrabony defects, the use of bioresorbable barriers showed to be an effective strategy with statistically significant results regarding the improvements of clinical attachment levels (CAL) and probing depth2-6. During pre-operative assessments patient’s related factors such as cigarette’s smoking, oral hygiene and periodontal susceptibility have great importance and can affect on short- and long- term success of guided tissues regeneration (GTR) procedures7-9. Regarding the surgical technique, it has been proposed the Simplified Papilla Preservation Technique. Such approach allows surgical access to interproximal intrabony defects providing, concurrently, the interdental soft tissues preservation, coronal positioning of the buccal flap by a modified mattress suture and the primary closure of the interproximal spaces in absence of tension10.
Case presentation:
Male patient of 47 year old referred by another dental office where has been followed for 2 years, comes to our attention for an increased bleeding caused by brushing, associated with slight pain on dental element 1.1. The patient performed non surgical therapy ended six months before. It is performed a complete periodontal probing and a radiographic status. The clinical exam reveals a traumatic occlusion with class III skeletal and dental malocclusion. Radiographic exam shows a deep angular defect mesially to 1.1 which, moreover, shows a grade II mobility. The patient doesn’t smoke and doesn’t present familiarity for periodontal disease, he’s not affected by other diseases and doesn’t take medications. Considering the excellent plaque and bleeding scores reported in the chart (FMPS 24% FMBS 13%), it is decided for a regenerative procedure through GTR methodic supported by membrane and biomaterial. The choice of a biomaterial-supported procedure is motivated by the unfarovable geometry of the defect which presents is major part as a mixed defect with one and two walls. Furthermore, either the angle of the defect is unfavorable, seen the anatomy of the root which shows a double angulation deflecting distally at half of his lenght. In consideration of the interdental space > 2 mm a SPPT surgical technique was choosen to allow a greater preservation of the papilla’s body, including the interdental soft tissue, in order to obtain an excellent coverage of the barrier and the consequent stabilization of the coagulum. The incision is performed with microblade 6900 with safe tip and double cut, according to the indications reported in literature10. The defect was degranulated with ultrasound and curettes. Once verified the correct debridement, it is proceeded with bovine bone graft. A bioresorbable collagenous membrane is first inserted under the palatine flap and, after filled up the defect, overturned on the buccal aspect making it cross under the interdental contact point. Once the buccal flap was mobilized with periostal incisions, it was ended with a first cross horizontal mattress suture for the deep planes and a second vertical mattress suture, coronal to the first, which brings the papilla back to its original position. The suture was performed with PTFE 5-0. It was concluded with the flap repositioning by a 3-0 silk suspended suture around the 1.1, in order to compress the palatal side of the flap upon the bone crest. Interrupted suture points are performed on the 1.2 papillas. We decided to not splint the 1.1 since the patient did not complain any discomfort about the initial grade II mobility and it is considered that such mobility won’t negatively affect the formation of a new attachment; the eventual splint will be re-evaluated later. At the subsequent check-ups it won’t be revealed any increment of mobility which, instead, will reduce to grade I and at the clinical and radiographic exams performed at 3, 7 and 9 months it is recorded a progressive improvement of the defect with an appreciable filling of the intrabony component.
Discussion
Altough in the follow ups at 7 and 9 months a recession of the soft tissues was observed, this was greater on 1.2 where a residual probing with a sovrabony defect was initially present. The interdental region between 1.1 and 2.1 presents a slight recession of the soft tissues upon the defect (2 mm) and a good maintenance of the papilla eight. The reduction of the periondontal probing and the comparison with endoral radiographs show the almost complete resolution of the intrabony defect with an ongoing maturation of a new attachment apparatus despite the anatomical aspects of the defect did not allow to classify it among the “ideal” defect for GTR.
Conclusions
The correct selection of the case and the appropriate choose of the most indicated surgical technique allow to include the GTR, from the prognostic point of view, among the safest therapeutic choices. The strict control of the patient related, site-related and defect-related factors, united with the benefits given by the most tested biomaterial, guarantee the reaching of those results that, according to the literature, can be guaranteed at 20 years in association with a personalized maintenance protocol. According to the literature also the operator’s experience results significative, since these are methods that require specific knowledge and skills.
Bigliography
1. Cortellini P, Tonetti MS. Long-term tooth survival following regenerative treatment of intrabony defects. J Periodontol 2004;75:672-678.
2. Cortellini P, Pini Prato G, Tonetti MS. Periodontal regeneration of Human intrabony defects With Bioresorbable Membranes. A controlled clinical trial. J Periodontol 1996;67:217-223.
3. Needleman I, Tucker R, Giedrys-Leeper E, Worthington HA. Systematic review of guided tissue regeneration for periodontal infrabony defects. J Periodontal Res 2002;37:380-388.
4. Trombelli L, Heitz-Mayfield LJ, Needleman I, Moles D, Scabbia A. A systematic review of graft materials and biological agents for periodontal intraosseus defects. J Clin Periodontol 2002;29(suppl. 3):117-135.
5. Cortellini P, Tonetti MS. Focus on intrabony defects: guided tissue regeneration. Periodontol 2000 2000;22:104-132.
6. Laurell L, Falk H, Fornell J, Johard G, Gottlow J. Clinical use of a bioresorbable matrix barrier in guided tissue regeneration therapy. J Periodontol 1994;65:967-975.
7. Cortellini P, Pini Prato G, Tonetti MS. Periodontal regeneration of human infrabony defects (V). Effect of oral hygiene on long term stability. J Clin Periodontol 1994;21:606-610.
8. Tonetti MS, Pini Prato G, Cortellini P. Periodontal regeneration of human infrabony defects. IV. Determinants of the healing response. J Clin Periodontol 1993;64:934-940.
9. Tonetti MS, Pini Prato G, Cortellini P. Effect of cigarette smoking on periodontal healing following GTR in infrabony defects. A preliminary retrospective study. J Clin Periodontol 1995;23:229-234.
10. Cortellini P, Pini Prato G, Tonetti MS. The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent 1999;19:589-99
1) OPT at baseline.jpg
2) Frontal view of occlusal relation
3) Initial buccal view of 1.1 with infrabony defect.
4) Initial palatal view of 1.1 with infrabony defect
5) Magnification of figure 4
6) Rx Endo initial
7) Periodontal chart at baseline
8) Intraoperatory view of infrabony defect after raised full thickness flap
9) Occlusal view of buccal and palatal aspect of the defect
10) Buccal view of the defect degranulated
11) Resorbable barrier positionated before the defect was filled up
12) Occlusal view of the filled up defect
13) The barrier was overturned buccaly crossing under the contact point
14) Flap positioned as coronal needed with double layer suture
15) Occlusal view of the suture
16) Sling silk suture palatally positioned to reduce and stabilize the coagulum
17) Rx Endo post op
18) Rx Endo 12 days post op
19) Seven month follow up. Occlusal relation
20) Seven month follow up. Buccal view
21) Seven month follow up. Palatal view
22) Rx Endo seven months post op
23) Nine month follow up. Buccal view
24) Nine month follow up. Palatal view
25) Nine month follow up. Occlusal view
26) Vestibolar probing depth 3 mm
27) Rx Endo nine months post op
28) Periodontal chart nine months post op
