Using Papillae-Sparing Incisions in the Esthetic Zone to Restore Form and Function Gary Greenstein, DDS, MS; and Dennis Tarnow, DDS
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CONTINUING EDUCATION 1 PAPILLAE-SPARING INCISIONS Using Papillae-Sparing Incisions in the Esthetic Zone to Restore Form and Function Gary Greenstein, DDS, MS; and Dennis Tarnow, DDS LEARNING OBJECTIVES Abstract: Papillae-sparing incisions can be used to place an implant. This avoids • discuss the techniques used with papillae- inducing interdental tissue recession and facilitates gingival architecture res- sparing incisions toration. Papillae-sparing incisions described in this article are characterized • describe biological aspects pertaining to by bilaterally retaining segments of papillae adjacent to an edentate area when papillae-sparing incisions a pedicle flap is elevated. This is not a novel technique; however, the presented • list several procedures cases illustrate the use of papillae-sparing incisions to accomplish diverse tasks. with which papillae-spar- ing incisions can be used Furthermore, discussion is provided with respect to the width of the retained and discuss potential papillae, length of the incisions, bone loss, healing time, and scar formation. complications his article addresses a type of papilla-sparing incision that important considerations in maintaining gingival form when surgery can be used to place an implant or when soft- or hard- is needed in the esthetic zone. tissue augmentation is needed. These procedures can be performed separately or in combination with each other. Papilla-Sparing Incision Technique The described papilla-sparing incision is not novel; how- In the esthetic zone it is preferable to avoid elevating papillae because Tever, different clinical scenarios (eg, submerged and nonsubmerged flap elevation may induce recession and create unesthetic black tri- implant placement, fixed and removable provisionalization) using angles.4 If a flap is necessary to perform a procedure in an edentate papillary-sparing incisions are presented and background informa- area when adjacent teeth are present, the following technique can tion is provided to help understand the intricacies of this technique. be used to circumvent blunting papillae. Make a horizontal incision First, some background information is provided, then details of the along the midcrestal or palatal aspect of the ridge and terminate papilla-sparing technique are described. the incision 1 mm from the adjacent teeth (Figure 1). The incision is created palatally if it is desired to transpose keratinized tissue Appearance of a Normal, Healthy to the buccal. From the horizontal incision, create bilateral buccal Periodontium in the Maxillary Anterior vertical releasing incisions that extend obliquely at an angle (Figure In a healthy dentition with no bone or clinical attachment loss, the 2). The vertical incisions can also be extended palatally (for access), underlying alveolar crest follows the scallop of the cementoenamel but this is not always necessary (Figure 3). Preserved papillae contain junction (CEJ) and is approximately 2 mm apical to the CEJ. The gingival supracrestal fibers that subsequently help maintain papillary maxillary anterior interdental crests are approximately 3 mm coronal height (Figure 4). The distance the incision is extended vertically to the facial bone height (ranging from 2.1 mm to 4 mm).1 On average, on the buccal is dictated by the task to be accomplished (eg, implant the free gingival margin is approximately 3 mm coronal to the crest insertion only requires short vertical incisions, while bone grafting of the bone (biologic width plus sulcus depth).2,3 Interproximally, needs longer incisions) (Figure 5 and Figure 6). At the end of the interdental papillae between the central incisors is 4.5 mm to 5.5 surgical procedure, the severed papillary segments are sutured to mm coronal to the osseous crest.2,3 The additional papillary height their retained counterparts (Figure 7 and Figure 8). Figure 1 through (1.5 mm to 2.5 mm) is caused by hypertrophy of the interdental tissue Figure 8 demonstrate a submerged implant protocol. and includes the col area when a contact point is present.2,3 These papillae are supported by gingival supracrestal fibers from adjacent Papillae-Sparing Incisions Vs. Flap Elevation with Papillae—In teeth. Therefore, preservation of these fibers and subjacent bone are Figure 1 through Figure 8, tooth No. 8 is missing. If abundant bone and www.compendiumlive.com May 2014 COMPENDIUM 315 CONTINUING EDUCATION 1 | PaPillae-SParing InciSionS keratinized tissue is present, a punch procedure (flapless) can be used completing procedures. However, with this technique there is a risk to access bone to place an implant. However, a flap should be elevated of inducing recession of elevated papillae.5,6 if there is a lack of keratinized tissue or if bone grafting or soft-tissue The decision to use a papilla-sparing incision versus a flap pro- repair is required. There are two available options with respect to rais- cedure is subjective and depends on the clinician’s preference. In ing a flap: elevate it and include the papillae, or use papillae-sparing segments of the arch other than the esthetic zone, a papilla-sparing incisions. Each procedure provides advantages and disadvantages. incision can be used if there is adequate space between the teeth; Papillae-sparing incisions can be made (as previously described) by however, creation of vertical releasing incisions may add to treat- creating vertical releasing incisions that provide a wider base for the flap ment time with respect to closure. Furthermore, the potential of than occurs coronally (Figure 2 and Figure 4 through Figure 6). The inducing recession in the segments of the arch is not as critical as in size of the flap and subsequent working area is initially dictated by the the esthetic zone. Deschner et al7 demonstrated that an insignificant width of the edentate space. The flap can be enlarged by performing a amount of recession occurred (0.4 mm mesial, 0.2 mm buccal, and papilla-sparing incision that is extended laterally by exaggerating the 0.3 mm distal) when flap surgery (eg, apicoectomy) was performed vertical incision angles, or the incisions can cross obliquely (laterally) at sites where the gingiva was healthy. Contrastingly, Velvart et al8 at the mucogingival junction to a desired distance (Figure 9). reported a mean 0.98 mm papillary recession 1 year after flaps and In contrast, a full-thickness flap with papillae elevation can be papillae were elevated, and no recession when a type of papilla- extended across many teeth, thereby providing extended access for sparing incision (incisions made horizontally across the base of the Fig 1. Fig 2. Fig 3. Fig 4. Fig 5. Fig 6. Fig 7. Fig 8. Fig 9. Fig 1. case 1: a horizontal releasing incision across the edentate ridge at the site of tooth no. 8. it terminates 1 mm from the adjacent teeth. Fig 2. Bilateral vertical releasing incisions on the buccal aspect that extend obliquely, slanting away from the ends of the horizontal incision. Fig 3. osteotomy drilled into the ridge, occlusal view. Fig 4. implant inserted into the ridge, buccal view. There was a large labial concavity. The implant is seen on the buccal and terminates within the alveolar bone. Fig 5. Bone graft placed over the implant on the buccal aspect. Fig 6. collagen barrier positioned over bone graft. Fig 7. Vertical releasing incisions sutured to attain primary closure, buccal view. Fig 8. Submerged implant protocol, occlusal view. a horizontal releasing incision was sutured to attain primary closure. note that there are no su- tures through the thin retained papillary segments. Fig 9. This image shows an example of vertical releasing incisions that are extended later- ally across the mucogingival junction of adjacent teeth to attain better access and facilitate large graft procedures. 316 COMPENDIUM May 2014 Volume 35, Number 5 papilla) was used. The reported papillary recession when they were the zone of keratinized tissue on the buccal, the initial horizontal elevated may have been a result of suturing at the base of the papillae incision should be created several millimeters lingual to the center as opposed to close to their tips, which did not ensure primary closure. of the ridge and the tissue should be relocated buccally. Once vertical No studies were found in the literature that compared the amount of releasing incisions are used, the elevated tissue is actually a pedicle recession that occurs when papillae-sparing incisions as described flap. It should always include connective tissue, which contains blood above were contrasted to flaps that elevated papillae. vessels. Furthermore, to ensure adequate flap vascularity, its length- to-width ratio should not exceed 2.5:1.18 Width of Severed Retained Papilla—When performing a papilla- sparing incision, it is recommended that the width of the papilla left Incisions Over Osseous Defects—It is preferable to make vertical adjacent to the tooth be approximately 1 mm.9-11 Selection of 1 mm is releasing incisions over intact bone. Incisions over defects increase an arbitrary thickness. It is possible that a narrower piece of tissue the difficulty of suturing flap margins together and enhance the risk could be left; however, no investigations have addressed this issue. The of getting a soft-tissue dehiscence or fenestration. If an incision is distance from the tooth where the incision is made must be selected inadvertently created over an osseous defect, place a graft material bearing in mind that the retained piece of papilla must encompass into the defect and cover it with a membrane to ensure that the flap the following structures: oral sulcular epithelium (0.2 mm to 0.3 mm), is supported when the margins are coapted. Suturing over bone junctional epithelium (15 to 30 cell layers, which decreases apically), reduces tension on the closed incision line. and the sulcus width (the periodontal ligament being 0.25 mm).12,13 In addition, since the epithelium is avascular, connection with its Duration of Healing—Long incisions will heal at the same rate as short vascular plexus subjacent to the oral and junctional epithelium must ones.19 Healing occurs across the lateral aspects of the incision line.