Whale's tail technique: A case series.

The Whale's tail technique performed to obtain maximum interdental papilla fill in the anterior region after placement of bone grafts. This study aims to assess the clinical efficacy of this new technique. This report describes a series of three cases with a probing depth of 6-7 mm in the maxillary anterior teeth and their treatment with Whale's tail technique to obtain regeneration and maximum papilla preservation. The cases in this report showed a pocket depth reduction of 3-4mm and a clinical attachment gain of 3-4mm. The application of the "Whale's tail" flap leads to clinically significant improvement of hard and soft tissue conditions and 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.

INTRODUCTION

The primary goal of periodontal treatment is the maintenance of the natural dentition in health and comfortable function. When periodontal disease has caused a loss of the attachment apparatus, optimal care seeks to regenerate the periodontium to its predisease state.[1] Complete and predictable restoration of the periodontium following trauma or infection remains a critical objective in periodontics and bone replacement grafts remain among the most widely used therapeutic strategies for the correction of periodontal osseous defects.[2]

To preserve the interdental soft tissue for maximum soft tissue coverage following surgical intervention involving the treatment of proximal osseous defects, Takei et al., proposed a surgical approach called papilla preservation technique.[3] Later Cortellini et al. gave modifications of the flap design – modified papilla preservation flap and simplified papilla preservation flap to be used in combination with regenerative procedures.[45]

In 2009, Bianchi and Bassetti described a new surgical technique – the “Whale's tail” technique, which was designed for the treatment of wide intrabony defects in the esthetic zone. This technique involved the elevation of a large flap from the buccal to the palatal side to facilitate access and visualization of the intrabony defect and was created, especially to perform regeneration while maintaining interdental tissue over grafting material.[6]

The aim of our study is to assess the clinical efficacy of this new surgical technique – the Whale's tail technique in a series of three cases.

MATERIALS AND METHODS

Subject selection

Three systemically healthy subjects with probing depths 6–7 mm and radiographic evidence of bone loss in relation to the maxillary anterior teeth were included in the study. Informed consent was taken from the subjects. Probing depths and attachment loss were recorded, and complete scaling and root planing were done for all the subjects. Probing depths were assessed after Phase I therapy [Figure 1].

Figure 1

Preoperative probing depth

Surgical technique

Incision points were marked [Figure 2], and two vertical full-thickness incisions were traced from the mucogingival line to the distal margin of the tooth neighboring the defect on the buccal surface. A horizontal incision – Whale's tail-shaped incision joined the apical margins of the first two incisions, and the coronal margins of the vertical incision were continued intrasulcularly in the buccal, interproximal, and palatal aspects of the defect-associated tooth [Figure 3]. A full thickness mucoperiosteal flap was reflected from the buccal to the palatal side following which complete removal of granulation tissue and scaling and root planing was done [Figure 4]. Bone graft (Perioglas) was placed in the intrabony defect, [Figure 5] following which flap was repositioned from the palatal to buccal [Figure 6]. 4-0 ethicon, nonresorbable, perimeter sutures were placed, without tension, away from the margins [Figure 7]. Periodontal dressing was placed [Figure 8]. Postoperative instructions were given, and the patient was asked to use 0.2% chlorhexidine mouth rinse 48 h after the procedure for a period of 2 weeks. The patients were prescribed amoxicillin (500 mg – TID for 5 days) and ibuprofen (400 mg – BID for 5 days). The subjects were recalled after 2 weeks for suture removal and were recalled after the duration of 3 months and 6 months [Figure 9]. Pre-operative and 6 months post operative IOPAR were taken. Subjects 2 and 3 were treated similarly and per-operative and post-operative probing depths were recorded [Figures 10–15].

Figure 2

Incision points marked

Figure 3

Two vertical and one horizontal – Whale's tail incision placed

Figure 4

Flap reflected from buccal to palatal aspect with intrabony defect with relation to 11

Figure 5

Debridement done and bone graft placed

Figure 6

Flap repositioned

Figure 7

perimeter sutures placed away from incision lines

Figure 8

Periodontal dressing

Figure 9

Six months postoperatively

Figure 10

Preoperative IOPAR

Figure 15

Postoperative probing depth = 3 mm with recession (subject 3)

Postoperative IOPAR

Preoperative probing depth = 7 mm (subject 2)

Postoperative probing depth = 3 mm (subject 2)

Preoperative probing depth = 7 mm (subject 3)

DISCUSSION

Following the treatment, 6 months postoperatively, patient 1 had a probing depth reduction of 3 mm and a gain in clinical attachment of 3 mm; patient 2 had a probing depth reduction of 4 mm and a gain in attachment of 4 mm; and patient 3 had a probing depth reduction of 4 mm and a gain in attachment of 1 mm but an increase in recession by 3 mm.

The surgical technique, we used in this case series, 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.[7] It was possible to elevate a large flap from buccal to palatal, which allowed the preservation of a large amount of soft tissue and resulted in good primary closure. Besides, positioning of incisions away from the defect area and placement of sutures distant from the regenerated defects decreased the chances of bacterial colonization of the biomaterials, which is often responsible for regenerative failures.[6]

Bianchi and Bassetti used this technique and showed a mean probing attachment level[8] gain of 4.9 ± 1.8 mm and a probing pocket depth reduction of 5.8 ± 2.5 mm. Our cases showed similar results with a mean probing depth reduction of 4 mm and a mean gain in the clinical attachment of 3 mm. Furthermore, the systematic use of incisions distant from the defects and biomaterial margins drastically reduced the percentage of flap dehiscence. Primary closure of the interdental space after surgery and during the follow-up period was achieved in 100% of treated sites.[6] Another case report by Damante et al. showed recession in the maxillary right central incisor.[7] Our cases showed similar results with recession in one subject (subject 3).

Esthetic considerations always pose therapeutic dilemmas in the selection of the appropriate surgical technique in the maxillary anterior region to prevent or minimize esthetic problems such as loss of interdental papilla or increased tooth length without compromising the main goal of periodontal surgery.[9]

To overcome the disadvantage of conventional papilla preservation technique (Takei et al.,) Cortellini modified the technique by reflecting the flap from buccal to the palatal aspect (modified papilla preservation technique).

A study done by Retzepi et al., to compare the gingival blood flow during healing of simplified papilla preservation flap and modified Widman flap, showed when the gingival blood flow during healing was compared between the two, the simplified papilla preservation technique may be associated with faster recovery of the gingival blood flow postoperatively. A higher gingival blood flow to different parts of the periodontium can have a 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.[10]

One of the limitations of this case series is the occurrence of recession associated with subject 3 which increased postsurgically. This could be attributed to the relatively thin gingival biotype,[1112] handling of the tissue, and placement of the incision. However, the main advantages of the technique include good access to the defect area and placement of margins away from the regenerative material, which will prevent the inflammatory response near the regenerative material, thereby increasing the chances of graft uptake. Furthermore, the handling of the interdental papilla is easier and more convenient than the conventional papilla preservation technique. The indications of this technique include therapies aimed at regeneration of periodontal defects such as bone grafts, membrane, or combination of these materials, surgical treatment of anterior tooth region with diastema present. The contraindications include high frenal attachment, recession, and diastema <2 mm.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.