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Papilla Preservation Flap : Revisited

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REVIEW ARTICLE

Papilla Preservation Flap : Revisited

Lisa N. Chacko*, Sathish Abraham**, Nilima Landge***, Fareedi Mukram Ali****

Abstract
An ideal periodontal therapy should establish a state of periodontal health evidenced by absence
of inflammation, periodontal pockets and a potential for the patient to maintain the health in
addition to function and esthetics. Surgical approach to treat periodontal defects with maxillary
anterior dentition in an esthetically pleasing manner is possible only when papillary integrity is
preserved. This case report describes Papilla sparing flap method to treat anterior maxillary dentition
affected with periodontitis. The modifications in Papilla preservation flap designs are also discussed
with its applicability.
(Chacko LN, Abraham S, Landge N, Ali FM. Papilla Preservation Flap : Revisited.
www.journalofdentofacialsciences.com, 2013; 2(4): 45-48).

Key words: Papilla preservation techniques, Simplified papilla preservation flap, Modified Papilla
preservation flap, esthetics

Introduction An ideal periodontal therapy must necessarily

One of the most distressing aspects of
periodontal surgery is the unesthetic maxillary
anterior gingival architecture after definitive pocket
elimination therapy. Greater crown and root
exposure and increase in the interdental spacing
results in a picket fence appearance which is highly
unacceptable[1].
1
Reader, Department of Periodontics,
2
Prof., Dept of Conservative Dentistry & Endodontics
4
Reader, Department of Oral & Maxillofacial Surgery
SMBT Dental College, Sangamner Taluka, Maharashtra.
3
Senior Lecturer, Department of Periodontics
Saraswati Dhanwantari Dental College & Hospital,
Parbhani, Maharashtra
Address for Correspondence:
2
Dr Sathish Abraham
e-mail: abrahamsathish@yahoo.in
consider esthetic appearance, which means an
effort to maintain gingival marginal anatomy and
as much height of papilla as possible along the
course of the periodontal therapy. Often, non
surgical approach is encouraged for maxillary
anterior dentition. However, there are situations in
which surgical therapy is unavoidable. A surgical
approach that splits the papilla certainly contribute
to shrinkage and decrease in the height of
interdental papilla leading to exposure of the
interproximal embrasures.
This led to the development of a flap
technique which intended to spare the papilla
instead of splitting it. Probably the first report of a
Papilla Preservation procedure was by Kromer in
1956 which was designed to retain osseous
implants[2]. App in 1973, reported a similar
technique and termed it as Intact Papilla Flap,
46
which retained the interdental gingival in the
buccal flap [3]. Evian et al preserved the
interdental gingival in the facial flap, which
exposed osseous margins on the labial and the
interproximal zone, while the palatal tissues were
reflected separately [4]. Genon and Bender in
1984 also reported a similar technique indicated
for esthetic purposes. Takei et al in 1985
introduced a detailed description of the surgical
approach reported earlier by Genon and named
the technique as Papilla Preservation Flap, which
ensured optimal interproximal coverage and
facilitated placement and retention of bone grafts
which prevented exfoliation of the graft material[5].
However, the presence of ample embrasure
between the teeth with the absence of a tight
contact point, is a pre-requisite to retain the
interdental tissue[2].
Papilla Preservation Flap (PPF)
This method uses sulcular incisions (Fig.1a)
around each tooth with no incision being made
through the interdental papilla facially, but the
lingual/ palatal flap involves a sulcular incisison
(fig.1b) along each tooth with a semilunar incision
(fig.1c) made across each interdental papilla that
dips apically from the line angles of the tooth so
that the papillary incision line is at least 5 mm from
the gingival margin allowing the interdental tissues
to be dissected from the lingual or palatal aspect so
that it can be elevated (fig.1d) intact with the facial
flap [5].PPF has witnessed some modifications in
the papilla sparing incisions, either to achieve
interproximal tissue coverage over barrier
membranes placed coronal to the alveolar crest, to
facilitate coronal positioning of the interdental
tissues and/or to facilitate placement of implants.
The first modification of PPF was reported by
Checchi et al in 1988, where in horizontal incision
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Chacko et al.
over the interproximal area, in the opposite side of
the bone defect was deemed ideal as it allowed
protection of the regenerated area from the oral
environment[6].
Cortellini et al in 1995, proposed a
modification in the PPF and named it as Modified
Papilla preservation flap[7].
Modified Papilla Preservation flap (MPPF) -
Primary intrasulcular incision (Fig.2a) (buccal
and interproximal) involving two teeth neighboring
the defect is made. A horizontal incision (fig.2b) is
traced in the buccal gingiva of the interdental
space at the base of the papilla. This horizontal
incision is then connected (fig.2c) with the primary
incision in the most apical portion of the buccal
gingival of the neighboring teeth and a full
thickness buccal flap (fig.2d) was elevated to the
level of the buccal alveolar crest. Buccal and
interproximal primary incision is continued
intrasulcularly in the interproximal space and
extended to the palatal aspect (Fig.2e).
A buccal horizontal incision (Fig. 2f) is
performed in the interproximal supracrestal
connective tissue, coronal to the bone crest, to
dissect the papilla. The papilla is then elevated
(Fig. 2g) towards palatal aspect. Following
extension of the palatal incision, a full thickness
palatal flap including the interdental papilla was
elevated to fully expose the defect. The tissue
thickness of papilla is reduced to permit coronal
advancement of the flap. Vertical releasing incision
divergent in corono-apical direction extending in
to the alveolar mucosa can be placed in the
interproximal spaces neighboring the defect if
coronal advancement of the flap is desired[7].
Vol. 2 Issue 3
Chacko et al. 47

Papillary preservation flap and its modified oral hygiene, reported of bleeding gums which he
flap design, both required a wide interdental space had observed for two years. Intraoral examination
as a pre-requisite to bring about appreciable revealed periodontal pockets in relation to
functional and esthetic value. To apply esthetic maxillary teeth with pocket probing depth of more
value to teeth having narrow interproximal zone, than 8mm (Fig.4a, 4b) which bled upon probing.
Cortellini et al in 1999 proposed the Simplified The maxillary anterior teeth exhibited Grade I
Papilla preservation flap technique[8]. Miller’s recession, interdental spacing between
The Simplified Papilla preservation flap teeth 11 and 21. Adequate keratinized tissue and
(SPPF) papillary frenal attachment was exhibited in this
area. The radiographs revealed horizontal bone
An oblique incision (Fig 3a) is made across the
defects in relation with maxillary anterior teeth.
defect associated papilla from the gingival margin
Based on the clinical and radiographic data,
at the buccal line angle of the involved tooth to
patient was diagnosed to have chronic
reach the mid interproximal portion of the papilla
periodontitis.
under the contact point of the adjacent tooth. The
oblique incision continues intrasulcularly in the
buccal aspect of the teeth neighbouring the defect
and extended to partially dissect the papillae of the
adjacent interdental spaces allowing the elevation
of a buccal flap (Fig 3b) with 2-3 mm exposure of
alveolar bone.
A buccolingual horizontal incision (Fig 3c) at
the base of papilla close to the interproximal crest
is made. Intrasulcular incisions are continued in
the palatal aspects of the two teeth neighbouring
the defect and extended into the interdental papilla
of adjacent interdental spaces, following which a
full thickness palatal flap (Fig 3d) including the
interdental papilla is elevated[8].

Fig.4a, 4b Preoperative photograph showing

Both the modifications of PPF, require
utilization of horizontal and/or vertical internal
mattress sutures which relieve the tension in the
flap, permit coronal positioning of the flap and aid
in passive closure of the interdental tissues.
Case Report of Papilla preservation flap
technique (PPF) -
A 38 year old, male patient, in good
general health with no known allergies and good
presence of periodontal pockets
Subsequent scaling and root planing was
achieved and patient was motivated for oral
hygiene care. The areas were re-assessed for
gingival health, pocket probing depths and gingival
bleeding during supportive periodontal care, which
indicated a need for surgical intervention with
predictable esthetic value. Papilla preservation flap
surgery was the ideal choice in relation to the two
central incisor teeth, as these teeth presented wide
interdental spacing with a broad interproximal

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48
gingival zone which is a pre-requisite for Papilla
preservation flap technique. Conventional flap was
planned with teeth 12,13,14 and 22,23,24.The
patient gave his consent to the treatment protocol
after the form of therapy was explained to him.
Adequate anesthesia using 2% lignocaine
with a concentration of 1:20,0000 epinephrine
was obtained. The extent of bone defect was
probed as the extension of the osseous defect in
relation to the palatal or lingual aspect of the
interdental papilla determines the position of
semilunar incision. The facial surface was prepared
with a sulcular incision (Fig.4c) around teeth 11
and 21 with no incisions made through the
interdental papilla.
Fig.4c Sulcular incisions
The palatal flap design consisted of sulcular
incisions along the palatal aspect of the teeth in
relation to the central incisors with a semilunar
incision (Fig.4d) made across the interdental
papilla in relation to the teeth 11 and 21.This
semilunar incision was made such that it dipped
apically from the line angles of the tooth so that
the papillary incision line was at least 5 mm from
the gingival margin which allowed the interdental
tissue to be dissected from the palatal aspect
facilitating intact elevation with the facial flap
(Fig.4e). The other areas in the maxillary anterior
segment exhibited no interdental spacing and
hence were approached with conventional flap
approach where papilla was split with a facial and
palatal flap.
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Chacko et al.
Fig.4d Semilunar incision
Fig.4e Papilla encorporated in facial flap
Once the incisions were completed, the flaps
were reflected and the interdental papilla was freed
from the underlying hard tissue using
interproximal knife. The detached interdental
tissue was pushed through the embrasures with a
periosteal elevator such that the flap could be
easily reflected with an intact papilla. The
underside of the reflected flap (Fig. 4f) was scraped
and trimmed to remove pocket epithelium and
granulation tissue. The thickness of the interdental
tissue maintained adequate blood supply,
minimized chances of post operative gingival
recession. The defect was debrided with curettes
and thorough scaling and root planing (Fig. 4g,
4h, 4i) was performed. The flaps raised by
conventional method were sutured by interrupted
sutures (Fig. 4j) and the facial flap containing the
papilla was brought to contact well with the
incision line on the palatal aspect and a direct
suture was placed (Fig.4k). A surgical dressing
(Fig.4l) was placed as it reduces the chances of
flap displacement by mastication, accidental tooth
brushing or interferences by tongue action.
Vol. 2 Issue 3
Chacko et al. 49

Fig.4f Flap reflection

Fig.4j ,4k Buccal and palatal of sutured

flaps

Fig.4l Periodontal pack placed

Fig.4g,4h,4i Defects on debridement

Patient was instructed to rinse with 0.2%
chlorhexidene twice a day for two weeks.
Periodontal dressing and sutures were removed
one week postoperatively. The healing was
uneventful. Patient was advised to initiate
mechanical oral hygiene from the second post
operative week. Supportive periodontal therapy Fig.4m Post operative view at 6 months
was provided every month and oral hygiene Discussion
instructions were reinforced at that time. The
The modern periodontal paradigm is
patient was followed up post operatively for one predicated on papillary preservation maintainable
year duration. on gingival esthetics [1]. Therefore, while

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 50
considering treatment in the esthetic zone, a flap
method that preserves the anatomy of the gingival
margin with optimal function and esthetics is
desirable. The papilla plays a fundamental role in
aesthetic and phonetic functionalities and also
serves as a biological barrier to protect the
attachment apparatus [9]. The papilla preservation
flap incorporates the entire papilla in one of the
flaps. Papillary preservation flap method not only
preserves the interdental papilla but also focusses
on the preservation of the soft tissues guaranteeing
a result very similar to a situation preceeding
surgery.
The present case utilized papillary preservation
flap method in the anterior maxillary dentition with
teeth 11 and 21 to obtain reduction of the
periodontal pockets with an esthetically pleasing
result. Post operative, it was noted that soft tissue
craters did not develop in the area where papilla
was spared but small dip was observed in the tips
of papilla where conventional flap incisions were
made. During the course of supportive periodontal
care, the gingiva exhibited health with normal
pyramidal shaped interdental papilla and no
gingival bleeding. The pockets were probed at 6
months which revealed significant reduction in the
pocket depth (residual probing depth 3mm), and
with very minimal gingival recession and improved
soft tissue contour (Fig.4m).
Variations in the papillary preservation flap
designs can be appropriately used when coronal
advancement of flap over bone graft and barrier
membrane placements is considered. Simplified
papilla preservation flap can offer better esthetic
results with teeth exhibiting narrow interdental
spaces even in posterior teeth [8]. Though these
flap methods are technique sensitive, time
consuming and have specific clinical indications,
their applicability should be utilized when
regenerative therapy is considered.
Conclusion
It is important to respect papillary integrity
during periodontal surgical therapy. Papilla
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Chacko et al.
preservation flap method not only maintains
esthetic value but is a better approach for
interproximal regenerative procedures. Earlier
methods proposed it for wide interdental spaces in
the anterior and pre-molar region. However,
Simplified papilla preservation flap method can
also render applicability to narrow and /or
posterior interdental spaces achieving both
functional and esthetic value.
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1. Cohen E. Cosmetic and reconstructive periodontal
surgery,3rd Edi, p.103
2. Checchi L, Schonfeld SE. A technique for esthetic
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