Guided Tissue Regeneration and Papilla Preservation with the “Wale’s Tail” Flap
- 1. Discipline of Periodontics, Bauru Dental School, Brazil
Introduction: The “whale’s tail” flap technique is designed to preserve interdental tissue in guided tissue regeneration. This is the first report to describe the use of this flap associated to autogenous bone graft.
Case presentation: This paper describes a case where the “whale’s tail” flap was used associated to autologous osseous graft and bovine collagen membrane in an esthetic zone with a vertical defect. A 56-years old patient presented the mesial aspect of de lateral incisor with vestibular probing depth (PPD) of 7mm and palatal PPD of 8mm. After treatment there was a gain in attachment level of 4mm.
Conclusion: The technique presents good outcome when used with osseous grafts and guided tissue regeneration
• Guided tissue regeneration, Periodontal
• Wound healing
Damante CA, Sant’Ana ACP, de Rezende MLR, Aguiar Greghi SL, Passanezi E (2013) Guided Tissue Regeneration and Papilla Preservation with the “Wale’s Tail” Flap. JSM Dent 1(3): 1017
Guided tissue regeneration (GTR) comprises procedures attempting to regenerate lost periodontal structures through differential tissue responses. It refers to regeneration of periodontal attachment through barrier techniques, using materials such as expanded polytetrafluoroethylene, polyglactin, polylactic acid, calcium sulfate and collagen, are employed in the hope of excluding epithelium and the gingival corium from the root or existing bone surface in the belief that they interfere with regeneration . On the cellular level, periodontal regeneration is a complex process requiring coordinated proliferation, differentiation, and development of various cells types to form the periodontal attachment apparatus. The concept of periodontal regeneration arose from Melcher’s theory which proposed that the cell type that repopulates the exposed surface at the periodontal repair site will define the nature of attachment that takes place . Cells from both periodontal ligament and alveolar bone are important to the formation of new bone, cementum and periodontal ligament .
The classical approach to periodontal regeneration in the last 30 years has been the use of bone grafts in repairing periodontal defects. The association of guided tissue regeneration with graft materials has been reported with success . To optimize the regeneration and preserve soft tissues many techniques of papilla preservation have been described in literature [5-10].
Bianchi and Basseti  described, in 2009, a surgical technique designed to preserve interdental tissue in guided tissue regeneration called the “whale’s tail” technique. It was intended for the treatment of wide intrabony defects in the esthetic zone involving the elevation of a large flap from the buccal to the palatal side to allow access and visualization of the intrabony defect and to perform GTR while maintaining interdental tissue over grafting material. Authors described a significant improvement on clinical parameters and soft tissue healing with primary closure .
The aim of this study is to describe a clinical case where the “Whale’s tail” technique was employed to obtain periodontal regeneration.
A 56-years old man presenting a diastema between central and lateral right incisors was referred to the clinic of periodontics to treat periodontal defects (Figure 1). The patient didn’t have systemic problems but smoked 3 cigarettes a day for the last 20 years. There was a clinical and radiographic evidence of an intrabony defect associated with the maxillary right incisors. Lateral incisor had a mesial vestibular probing depth of 7 mm, a mesial palatal probing depth of 8 mm and attachment loss of 7 and 8 mm respectively.
Before the surgical procedure, full-mouth plaque score, fullmouth bleeding score, periodontal probing depth (PPD), clinical attachment level (CAL), and gingival recessions were recorded.
The patient received oral hygiene instructions and full mouth scaling and root planning.
Two vertical incisions were performed from the mucogingival line to the distal margin of the lateral incisor and mesial margin of the central incisor on the buccal surface (Figure 2). A horizontal incision joined the vertical incisions at the apical aspect of the flap. In the coronal aspect of the flap intrasulcular incisions were made at buccal, interproximal and palatal sides. A full-thickness flap was elevated from buccal to palatal side through the diastema (Figure 3 and 4). The defect was debrided, the root was scaled, planned and conditioned with citric acid for 3 minutes (Figure 5). Autogenous bone was removed from the palatal side with a chisel and it was used to fill the defect (Figure 6). A bioresorbable bovine collagen membrane (GenDerm®, Baumer, São Paulo) was used to cover the graft (Figure 7). The flap was repositioned from the palatal to the buccal side, and its margins were sutured without tension, far away from defect (Figure 8). Antibiotics were prescribed (Amoxicilin, three times a day) for one week. Healing was uneventful. Recall appointments were performed once per week for the first 4 weeks and once per month at the following period (Figure 9 and 10).
After 16 months the mesial vestibular and palatal probing depths were 3mm with a gain in attachment of 4 and 5 mm respectively (Figure 11 and 12).
The preservation of papillary integrity during all dental procedures to minimize its disappearance as much as possible is essential for maintaining esthetics especially during and after periodontal surgery .
The surgical technique presented in this paper allows regeneration of wide intrabony defects involving the maxillary anterior teeth with notable interdental diastemas, maintaining interproximal tissue to recreate a functional attachment with esthetic results . The advantages of “Whale’s tail” flap are the elevation of a large flap from buccal to palatal, allowing the preservation of a large amount of soft tissue. Thus it results in good primary flap closure . The use of incisions distant from the defects and graft margins drastically reduces the percentage of flap dehiscence mainly when membranes are used. The disadvantages of the technique are the necessity of a diastema in order to allow flap dislocation to palatal side. The flap elevation is delicate and the surgeon must be careful to preserve the papilla, which will maintain the vascularization of the flap. Bianchi and Basseti  reported a CAL gain (4.57 ± 0.65 mm) and PPD reduction (5.14 ± 0.95 mm) with the “Wale’s tail” flap.
The first description of a surgical approach named papilla preservation was published by Takei et al.  and the technique was designed to obtain a primary closure in grafted sites. In 1995, Cortellini et al.  published a modification of the Takei et al technique naming it modified papilla preservation technique. Other techniques described in literature were designed to maintain primary closure of the flaps at the interdental space. One of them is the simplified papilla preservation flap . Additional advantages of this technique are the limitation of membrane collapse, and the applicability in narrow and/or posterior interdental spaces . With this technique authors showed a mean CAL gain of 4.9 ± 1.8 mm and a PPD reduction of 5,8 ± 2.5 mm. Cortellini et al.  described the modified minimally invasive surgical technique that has been recently designed to further reduce the surgical invasiveness, minimize the interdental tissue tendency to collapse, enhance the wound/soft tissue stability and reduce patient morbidity. The authors described a 1-year CAL of 5.1±1mm and residual PPD of 3.1±0.6mm with an average pocket reduction of 4.6 ± 1.5mm with this technique. These results are in accordance with ours since we had a pocket reduction of 5mm and a CAL of 4mm.
Checchi et al.  described a long term evaluation period (22 years) after the use of surgical interdental papilla preservation technique. The interproximal tissues were still stable after this period, although a partial exposure of the buccal root surface of the left central incisor, lateral incisor, and premolar had occurred.
An interesting result was showed when the gingival blood flow during healing was compared between the modified Widman flap and the simplified papilla preservation flap . The later technique may be associated with faster recovery of the gingival blood flow post-operatively. A higher gingival blood flow to different parts of the periodontium might have an essentially positive effect on the speed and on the quality of the healing process. Furthermore, an improved healing process would be of paramount importance for the final outcome of various regenerative procedures .
A systematic review evaluating the clinical performance, in terms of tooth survival and clinical periodontal surrogate outcomes, of conservative surgical treatment of periodontal intrabony defect was published recently and included papers on papilla preservation technique . Authors stated that a sub-analysis, assessing surrogate outcomes as a function of flap design, revealed that better outcomes seemed to be associated with papilla-preservation flaps. Furthermore, the use of papilla preservation flap as the standard surgical approach in randomized clinical trials is strongly encouraged .
In the light of these findings we may suggest that the “Whale tale” technique has a good foresee ability when used associated to osseous grafts and guided tissue regeneration.
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