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A modified papilla preservation technique, 22 years later

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 Q U I N T E S S E N C E I N T E R N AT I O N A L

A modified papilla preservation technique,

22 years later
Luigi Checchi, MD, DDS1/Marco Montevecchi, DDS1/
Vittorio Checchi, DDS2/Giulio Alessandri Bonetti, MD, DDS1

The contour of the interdental tissues, as well as the color and texture of the keratinized
tissues, are essential elements of anterior esthetics. Tissue loss in the interproximal
regions, with related esthetic concerns, phonetic difficulties, and food impaction, can
occur for a variety of reasons, including treatment of periodontal diseases. In periodontal
surgical procedures, the soft tissues require elevation and resection to gain access to the
root surfaces and osseous supporting structures. Compromised esthetics in the anterior
region of the mouth could be a serious consequence of periodontal surgical procedures.
Several articles have been devoted to flap designs and surgical techniques to maintain full
papillary form and preserve the soft tissues during surgical access. Unfortunately, very
little evidence of long-term results is available. The aims of the present article are to report
a 22-year follow-up case of surgical interdental papilla preservation, discuss the anatomic
variables that conditioned the outcome, and review and compare existing surgical tech-
niques for maintaining the interproximal soft tissues. (Quintessence Int 2009;40:303–311)

Key words: anterior esthetics, interdental papilla, papilla, papilla preservation,

periodontal surgery

An interdental papilla is the gingival portion
that occupies the space between 2 adjacent
teeth. This anatomic entity was first de-
scribed in 1959 by Cohen.1 Its shape and
extension are the result of tight relations
between periodontal tissues, tooth form, and
contact point.2,3
The contour of the interdental tissues, as
well as the color and texture of the kera-
tinized tissues, are essential elements of
anterior esthetics. When open interproximal
spaces are present, not only esthetic con-
cerns but also phonetic difficulties and food
impaction can be expected. The term black
triangles disease has been proposed to
describe this anatomic alteration that repre-
sents one of the most troubling esthetic
dilemmas in dentistry.4
Department of Periodontology and Implantology, School of
1 long-term evidence of a predictable improve-
Dentistry, University of Bologna, Bologna, Italy.
2 Department of Odontostomatological, Orthodontic and
Surgical Sciences, Second University of Naples, Naples, Italy.
Correspondence: Prof Luigi Checchi, Department
Periodontology and Implantology, School of Dentistry, Alma
Mater Studiorum, University of Bologna, Via S. Vitale 59, 40125
Bologna, Italy. Fax: 39-0514391718. Email: luigi.checchi@unibo.it
Tissue loss in the interproximal regions
can occur for a variety of reasons, including,
but not limited to, periodontal diseases, treat-
ment of periodontal diseases, trauma, and
other iatrogenic causes. Many techniques
have been described with the attempt to
resolve this anatomic alteration.
Restorations can be constructed to modi-
fy the tooth form and contact relationship,
and orthodontic movement can be used to
close these open areas in periodontally com-
promised patients.5–9 Many techniques
aimed at grafting hard and soft tissue into
this anatomic area have been described.10–16
Recently, tissue engineering by the injection
of autologous cultured and expanded fibrob-
lasts has been proposed, with interesting
short-term results.17
In spite of the many treatments described,
the complexity of some of them, with limited
ment, stresses the need to prevent this clini-
cal manifestation. Hence, it is important to
respect papillary integrity during all dental
of
procedures and minimize its disappearance
as much as possible, especially during and
after periodontal surgery.

©2009 Quintessence Publishing Co, Inc.

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VOLUME 40 • NUMBER 4 • APRIL 2009 303
Q U I N T E S S E N C E I N T E R N AT I O N A L
Checchi et al
Table 1 Presurgical and 22-year control pocket depths values (mm)
of the maxillary central incisors
Presurgery
Tooth Right central Left central
D Mid M M Mid D D
Buccal 4 2 4 7 2 4
Palatal 4 2 4 9 2 4
(M) mesial, (Mid) medial, (D) distal.
In periodontal surgical procedures, the
soft tissues must be elevated and resected to
gain access to the root surfaces and osseous
supporting structures. Consequently, com-
promised esthetics in the anterior aspect of
the mouth could be a serious consequence
of periodontal surgical procedures.
Several articles have been devoted to
flap designs and surgical techniques to
maintain full papillary form and preserve the
soft tissues during surgical access.18–23
Unfortunately, very little evidence of long-
term results is available. The aims of the
present article are to report a 22-year follow-
up case of surgical interdental papilla preser-
vation, previously described in 198720; to
discuss the anatomic variables that condi-
tioned the outcome; and to review and com-
pare existing surgical techniques to maintain
the interproximal soft tissues.
CASE REPORT
A 37-year-old woman presented with gener-
alized moderate-to-severe periodontitis. She
had not been treated for periodontal disease
previously and was otherwise in good health.
Probing after initial preparation revealed
slight pocketing on the maxillary right central
incisor and moderate to deep pockets on the
maxillary left central incisor, with the deepest
probing depth on the palatal aspect (Table
1). The patient was given oral hygiene
instructions, which included the use of a
chlorhexidine-containing gel. The teeth were
thoroughly scaled and root planed.
©2009 Quintessence Publishing Co, Inc.
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304
6-mo postsurgery 22-y postsurgery
Right central Left central Right central Left central
Mid M M Mid D D Mid M M Mid D
1 1 2 3 2 2 2 2 3 4 2 3
1 1 3 3 1 1 2 2 3 3 2 2
Following this initial phase of therapy
(Fig 1), sulcular incisions were made on the
facial aspects of the maxillary central and
lateral incisors, with the papillae between
the left central/lateral incisors and the right
central/lateral incisors being split. A straight
incision just above the papilla between the
central incisors was then made (Fig 2), and
the flap was elevated by pushing the papilla
through to the lingual aspect (Fig 3). After
careful instrumentation of the roots and
debridement of the infrabony lesion (Fig 4),
particles of unresorbable hydroxyapatite
(Periograft, Sterling-Winthrop Research
Institute) were condensed into the defect
(Fig 5), and the flaps were closed with verti-
cal mattress sutures (Fig 6). A periodontal
dressing was placed, and the patient was
instructed to take 250 mg of tetracycline
hydrochloride 4 times daily for 1 week. She
was also told to continue use of the chlorhex-
idine gel.
Six weeks after surgery, the papillary
space was well-preserved, and the probing
depths around the central incisors were
minimal (see Table 1). A 3-month hygiene
recall was scheduled, and the patient was
compliant.
After 6 months (Fig 7), the interproximal
area was healthy and had a good esthetic
appearance; a similar clinical aspect was
observable 13 years after the surgery (Fig 8).
The interproximal tissues were still stable
after 22 years, but partial exposure of the
buccal root surface of the left central incisor,
lateral incisor, and premolar had occurred
(Fig 9). At that time, the patient referred that
she had modified the restoration on the
VOLUME 40 • NUMBER 4 • APRIL 2009
 Q U I N T E S S E N C E I N T E R N AT I O N A L
Checchi et al

Fig 1 Maxillary anterior sextant before surgery but after initial prepara-
tion. Note the height of the papilla between the central incisors and the
stain caused by chlorhexidine use.

Fig 2 The papilla is freed from the facial aspect because the maximum
depth of the bony lesion is on the lingual aspect.

Fig 3 The palatal flap raised, showing the

retained and reflected papilla.

Fig 4 The bony lesion Fig 5 Alloplastic graft material softly con- Fig 6 Flaps coapted and secured with
on the facial aspect of the densed into the bone defect. vertical mattress sutures.
left central incisor after
root instrumentation and
thorough debridement.

Fig 7 Six-month post-
surgical view. Esthetics
have been maintained.
Fig 8 Thirteen-year control. The gingival
contour is stable, and a good esthetic
result is still present.
Fig 9 Twenty-two-year control. Good sta-
bility of the interproximal tissues is still
present. Gingival recessions and tooth abra-
sions on the left anterior teeth occurred,
probably due to traumatic brushing.

©2009 Quintessence Publishing Co, Inc.

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VOLUME 40 • NUMBER 4 • APRIL 2009 305
Q U I N T E S S E N C E I N T E R N AT I O N A L
Checchi et al

Fig 10 Subepithelial connective tissue

graft and the overhanging buccal flap.

Fig 11 Preoperative radiograph show-

ing radiolucency between the central inci-
sors.

Fig 13 Seven months after surgical

treatment of the gingival recessions. A
harmonious gingival contour has been
obtained. Note the likeness to the base-
line view (see Fig 1).

Fig 12 Twenty-two-year con-

trol radiograph showing allo-
plastic material retained in
the bony lesion.

mesial side of the right central incisor
because the restoration was infiltrated and
pigmented; moreover, with the new restora-
tion, the diastema was closed to improve
esthetics.
The periodontal recessions were treated
with a subepithelial connective tissue graft in
association with a coronally positioned flap
to improve the soft tissue thickness and to
restabilize an esthetic contour (Fig 10).
Presurgical (Fig 11) and 22-year control
(Fig 12) radiographs show that a great deal
of fill was achieved in the bony lesion and
that the biomaterial remained stable inside
the defect.
After 7 months, the probing depths
around the treated teeth remained minimal
(see Table 1), the clinical aspect was good,
and the patient was satisfied (Fig 13).

©2009 Quintessence Publishing Co, Inc.

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306 VOLUME 40 • NUMBER 4 • APRIL 2009

DISCUSSION
Esthetic considerations always pose thera-
peutic dilemmas in the selection of the prop-
er surgical technique in the maxillary anterior
region to prevent or minimize esthetic prob-
lems such as loss of interdental papilla or
increased tooth length without compromis-
ing the main goal of periodontal surgery.
The present report describes a long-term
evaluation (22 years) of a maxillary anterior
sextant periodontally treated with a surgical
technique preserving the interproximal papil-
la and grafting a granular synthetic nonre-
sorbable biomaterial. As shown, a long-term
stability of the interproximal soft tissues was
obtained with patient satisfaction and eradi-
cation of the periodontal pathology.
To critically analyze the case reported, it is
important to keep in mind the anatomic
determining factors that regulate the pres-
ence of a stable and healthy papilla.
The distance between the interproximal
bone crest and the contact point of 2 adjacent
teeth is one of the key factors, and it has been
well-evaluated by Tarnow et al.2 The authors
found that when the distance from the con-
tact point to the alveolar bone was less than
or equal to 5 mm, the papilla was present in
98% of the cases, while at 6 mm, it was pres-
ent 56% of the time, and at 7 mm, 27%.
The horizontal dimension of the interprox-
imal space is recognized as another deter-
mining factor in the stability of the papilla.
The assumption is that in the presence of a
pathologic noxa, a thin cancellous bone has
a greater risk for resorption, decreasing the
interproximal bone height and implicitly the
papillary disappearance. On the contrary,
wide interproximal bone crests tend to devel-
op a vertical bone resorption with angular
defects, maintaining quite unaltered the ini-
tial height and consequently continuing to
support the interproximal gingival architec-
ture even with an impaired anatomy. On the
basis of the observations of Tal24 and
Waerhaug,25 it has been speculated that a
minimal 3-mm interdental distance may be
needed to maintain the papilla.
The periodontal biotypes as far as the
shape of contact areas are ulterior factors
playing a role in the stability and shape of the
©2009 Quintessence Publishing Co, Inc.
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VOLUME 40 • NUMBER 4 • APRIL 2009
Q U I N T E S S E N C E I N T E R N AT I O N A L
Checchi et al
papilla. As reported by Kois, for a more sta-
ble papilla, the contact area of square teeth
is better than that of triangular teeth, and a
thick biotype is better than a thin biotype.3
The reported case showed at the initial
visit an angular defect with a wide interproxi-
mal space lacking the tooth contact above
(see Fig 1). The periodontal biotype was thick
and the teeth triangularly shaped. In spite of
unfavorable influences on the interproximal
tissues by the diastema and tooth shape, the
papilla were still present. Quite probably, the
clinical aspect of the periodontal contour was
the result of 2 factors: the periodontal bio-
type, less prone to destruction by the peri-
odontal infection, and the wide interproximal
space, which induced the alveolar bone to
react to the periodontal infection with an
angular defect, because residual bone walls
were still supporting the overlying soft tissues
at the time of observation.
One of the goals of periodontal therapy is
to eliminate the angular bone defects, given
their predisposition to new periodontal
destruction.26 The elective treatment of a ver-
tical bone defect in esthetic areas is the
filling of the defect with a periodontal regen-
eration approach. Many techniques have
been proposed, but only some of them are
really able to reach this goal.27 The use of an
alloplastic graft alone has been demonstrat-
ed to have a poor, if any, regenerative effect
but good clinical outcome28; indeed, synthet-
ic biomaterials are nowadays considered pri-
marily as biocompatible space fillers.29 In the
present case report, the biomaterial is visible
and distinguishable in radiographic evalua-
tions. Consequently, it is possible to specu-
late that the biomaterial has not been
replaced by new bone, and it has acted
probably as filler with the development of a
long epithelial junction. This good clinical
and esthetic result suggests, however, a
good long-term outcome of this approach,
questioning the indispensability of a peri-
odontal regeneration with short epithelial
junction.30,31
Preservation of the interproximal soft tis-
sues becomes particularly important when a
regenerative therapy is planned. During the
surgical session, a primary closure with opti-
mal interdental closure to seal the area of
307
Q U I N T E S S E N C E I N T E R N AT I O N A L
Checchi et al
regeneration from the oral environment has
to be obtained. In fact, exposure and con-
tamination of the regenerative material is a
critical issue because it has been associated
with reduced clinical outcomes.32–34
In the previous decades, much effort has
been made to develop periodontal surgical
approaches able to minimize esthetic
defects in the anterior areas. These methods
include palatal approach procedures35 and
the “curtain” procedure.36 The palatal
approach accomplishes surgical entry main-
ly from the palatal aspect, with minimal dis-
ruption of the buccal bone and the buccal
gingiva. The curtain procedure retains the
total extent of the labial gingiva and releases
the lingual and interproximal two-thirds of tis-
sue from the labial third. Palatal gingivecto-
my or palatal flap procedures then are used
to treat the palatal and interproximal defects.
These procedures have limitations if the
bone defects extend toward the facial
aspect.
In 1974, Ramfjord and Nissle37 suggested
for esthetic areas a modification of the
Widman flap with a submarginal incision,
removal of granulation tissue, debridement
of the root, and replacing of the flap to its
original position with interrupted sutures.
Unfortunately, even though the facial and
palatal flaps are repositioned, the embrasure
space is left open, resulting in esthetic prob-
lems and causing interdental soft tissue
craters.
Probably the first report of a papilla
preservation procedure was by Kromer in
1956.38 He used the technique to retain
osseous implants. In 1973, App described a
similar procedure to retain the interdental
gingiva in the buccal flap.39 App’s proce-
dure, termed the intact papilla flap, retained
the interproximal tissue in the buccal flap
and was designed to give maximum protec-
tion to osseous and transplant recipient
sites.
A modification of this procedure has been
used by Evian et al18 to maintain anterior
esthetics after periodontal surgery. This tech-
nique preserves the interdental gingiva in the
facial flap, which is reflected to expose the
osseous margins on the labial and interprox-
imal zone while the palatal tissues are reflect-
©2009 Quintessence Publishing Co, Inc.
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308
ed by raising a full-thickness flap or thinning
the tissue with a palatal thickness dissection
and removing the underlying connective tis-
sue and periosteum.18 In the same year, but
3 months later, a publication of Takei et al
introduced a detailed description of a surgi-
cal approach named papilla preservation
technique.19 The authors advocate this tech-
nique for a primary closure in grafted sites.
A palatal semilunar incision at least 3 mm
apical to the margin of the interproximal
bony defect has been proposed to reflect a
full-thickness flap with an intact papilla.
As reported by Takei et al, the papilla inci-
sion design is performed on the palatal side
and only in situations where the osseous
defect has a large extension onto the palatal
or lingual surface; the papillary preservation
procedure is modified so that the semilunar
incision is on the facial aspect. This situa-
tion, however, has not been illustrated in the
article.
The first modification to the techniques of
Evian et al and Takei et al was proposed by
Checchi et al in 1988.20,21 The authors real-
ized that when the maximum depth of the
bony interproximal lesion was on the palatal
aspect, in many cases, the previously
described techniques (Evian et al18 and Takei
et al19) were unable to keep the reconstruc-
tive material completely inside the defect and
below the flap, because of the palatal inci-
sion. On the contrary, as proposed by the 2
aforementioned studies, a buccal incision
was able to do it, allowing the labial flap to be
coronally advanced up to reach the incision.
Checchi et al20,21 suggest consequently to
preserve the papilla in the facial or lingual
aspect depending on the position of the
bone defect. A facial incision straight or
slightly arched across the interproximal
areas is made when the maximum depth of
the bony lesion is on the lingual aspect,
while a lingual incision is made when the
maximum depth is more toward the labial
aspect. A horizontal incision in the opposite
side of the bone defect allows the regenera-
tive area to be protected from the oral envi-
ronment and at the same time makes it pos-
sible to place the margins of the tissue over
sound bone with a favorable nutrient supply
and more stability.
VOLUME 40 • NUMBER 4 • APRIL 2009

In 1995, Cortellini et al published a work
where a modification of the Evian et al and
Takei et al techniques was proposed, naming
it modified papilla preservation technique.22
The authors, exploiting the mobility of the
buccal flap, suggested this buccal approach
for all cases where a regenerative procedure
has to be applied for interproximal space.
The described technique is very similar to
those reported 7 years before by Checchi et
al.20,21 In the Cortellini et al procedure the inci-
sions are only buccal, while in the Checchi et
al technique, they are mainly buccal; the
modified papilla preservation technique has
an interproximal incision always straight
because of specific sutures, while in Checchi
et al’s technique, the incision is scalloped
and more apical; finally, different suture tech-
niques are used.
All the techniques described have as a
prerequisite a wide interdental space to
allow minimal trauma to the interproximal tis-
sue when pushed through.
The presence of an ample embrasure
between the teeth with the absence of a tight
contact point, as the case here described,
represents a favorable condition for the man-
agement of the soft tissues during the surgi-
cal procedures. When the interproximal zone
of gingiva is very narrow because of root
proximity, it may not be possible to retain the
interdental tissue.
To overcome this limitation, Cortellini et al
in 1999 proposed the simplified papilla
preservation flap.23 It is initiated with an
oblique incision across the defect-associat-
ed papilla, from the gingival margin at the
buccal line angle of the involved tooth to the
mid-interproximal portion of the papilla
under the contact point of the adjacent
tooth. A full-thickness palatal flap, including
the papilla, and a split-thickness buccal flap
are then elevated. According to the authors,
this technique is applicable in interdental
spaces of 2 mm or less.
Different suture techniques are described
in the literature. All of them attempt to stabi-
lize the soft tissues, avoiding excessive trac-
tion in the interproximal areas to preserve the
blood supply of this critical area.
In the present case report, notwithstand-
ing the stability of the interproximal soft tis-
sues, some buccal gingival recessions
©2009 Quintessence Publishing Co, Inc.
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VOLUME 40 • NUMBER 4 • APRIL 2009
Q U I N T E S S E N C E I N T E R N AT I O N A L
Checchi et al
appeared on the left anterior teeth during fol-
low-up (see Fig 9). Specific hygiene instruc-
tions with the surgical treatment performed
have, however, resolved the anatomic alter-
ations and achieved patient satisfaction and
an apparent stability after 7 months. The
anatomic distribution of the gingival reces-
sions with the presence of a hard tissue defi-
ciency on the exposed root surfaces led us
to hypothesize a traumatic etiology.40 The
surgical technique with its labial incision line
cannot be responsible for periodontal reces-
sions since they were not present after 13
years (see Fig 8); a symmetric distribution of
the lesions should be expected.
The final aspect of the papilla between
the maxillary central incisors, classified as a
Nordland and Tarnow class,41 is the result of
good management of the interproximal tis-
sues and good response of the biomaterial
inserted as filler. The closure of the diastema
22 years after the first surgery has improved
the clinical appearance and at the same time
may have a protective effect on the papilla
beneath.
Staining of the teeth, as observed in the
figures, occurred because of the regular use
of chlorhexidine and daily consumption of
tea and coffee. Since the patient never com-
plained about the stains, we did not remove
all the pigmentations present during the fol-
low-up, attempting to avoid unnecessary
abrasive actions on tooth surfaces.
CONCLUSION
Notwithstanding the scientific limits of a case
report, the present study shows that this spe-
cific surgical technique used to preserve the
papilla in combination with regular long-term
maintenance was effective to treat the peri-
odontal pathology, retain the biomaterial
used, and preserve the interproximal soft tis-
sues in the long term.
309
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