261

The Modified Papilla Preservation

Technique. A New Surgical Approach
for Interproximal Regenerative
Procedures
Pierpaolo Cortellini, *t Giovanpaolo Pini Prato, * and Maurizio S. Tonetto

A modification of the papilla preservation technique has been applied to achieve

primary closure of the interproximal tissue over barrier membranes placed coronal to the
alveolar crest. Fifteen patients with deep intrabony interproximal defects were treated.
Defects had a probing attachment level loss of 9.9 ± 3.2 mm and a recession of the
gingival margin of 1.7 ± 1.6 mm. The depth of the intrabony component was 5.5 ±
2.9 mm; while the suprabony component was 5.9 ± 2.0 mm. Titanium-reinforced teflon
membranes were placed 1.3 ± 0.7 mm from the cemento-enamel junction, 4.5 ± 1.6
mm coronal to the interproximal alveolar bone crest. Primary closure over the interprox-
imal portion of the membrane was obtained in 93% of cases. In 73% of the cases com-
plete coverage of the membrane was maintained until its removal at 6 weeks. These data
indicate that the modified papilla preservation technique can be successfully applied to
obtain primary closure of the interdental space in regenerative procedures with barrier
membranes. J Periodontol 1995; 66:261-266

Key Words: Guided tissue regeneration; periodontal diseases/surgery; polytetrafluoro-

ethylene/therapeutic use; membranes, barrier; membranes, artificial; periodontal pockets/
surgery.

A key goal in periodontal regenerative procedures is to ob-
tain primary closure over the treated area and thus ensure
adequate protection for the healing events. Satisfactory ap-
proaches are available when the surgical area is located on
the buccal aspect, as in class II furcations12 or recessions.3
Conversely, primary closure of the interdental area is tech-
nically more demanding. Improved closure of the interden-
tal area has been attempted by 1) careful preservation of
of the flaps is required to obtain primary closure of the
interproximal area. This objective can hardly be achieved
with current surgical techniques. Therefore it is necessary
to identify an efficacious and reproducible method to obtain
both coronal positioning of the flap and primary closure of
the interdental space prior to attempting regeneration of the
suprabony component of the defect. This report describes
a modified surgical approach to improve soft tissue han-

the interdental tissue during the initial incision; 2) coronal
positioning of the buccal flap; or 3) using free gingival
grafts over implanted materials.4-9 Takei et al. proposed a
papilla preservation technique to achieve primary closure of
the interproximal space over periodontal bone implants.10
Achieving primary closure in the interdental space and
maintaining it over time, however, is more elusive in most
situations when a barrier membrane is used.1112
Furthermore, whenever regeneration of the suprabony
component is attempted by overfilling the intrabony defect
or by placing a barrier membrane coronal to the interprox-
imal alveolar bone crest, a substantial coronal positioning
*Department of Periodontics, University of Siena, Siena, Italy.
fDépartment of Periodontology and Fixed Prosthodontics, School of Den-
tal Medicine, University of Bern, Bern, Switzerland.
dling to achieve this goal.
MATERIALS AND METHODS
Patient Population
Following completion of an hygienic phase consisting of
scaling and root planing and oral hygiene instructions, 15
patients (5 males, 10 females) aged 30 to 51 years (mean
age 39.3 ± 6.4) in good general health, gave informed con-
sent to participate in this case series. A deep intrabony de-
fect with a suprabony component was identified in each
patient. The involved teeth were 7 incisors, 4 cuspids, 2
bicuspids, and 2 molars. All teeth, except one molar, were
located in the maxillary arch. Defects had to be located in
the interproximal area, and did not extend into a furcation.
 J Periodontal
262 THE PAPILLA PRESERVATION TECHNIQUE April 1995

Figure 1. The modified papilla preservation technique. Initial incisions, elevation of the flaps, and defect
debridement. Upper left. Preoperative buccal view. Upper right. A buccal and interproximal intrasulcular
incision was performed. Subsequently, a horizontal incision with a slight internal bevel was traced in the
buccal gingiva at the base of the papilla. A buccal full thickness flap has been elevated. Note that the papilla
covering the defect is still in place. Lower left. The papilla has been mobilized by performing a buccal
horizontal incision in the interproximal supracrestal connective tissue just coronal to the alveolar crest. Lower
right. The papilla has been elevated with the full thickness palatal flap.

Clinical Characterization of Selected Sites dental tissue. A buccal and interproximal intrasulcular pri-
Full mouth plaque scores (FMPS) were recorded as the per- mary incision to the alveolar crest, involving the two teeth
centage of total surfaces (4 aspects per tooth) which re- neighboring the defect, was performed. A horizontal inci-
vealed the presence of plaque. Bleeding on probing was sion with a slight internal bevel was then traced in the buc-
assessed dichotomously at a force of 0.3 N. with a manual
pressure sensitive probe. Full mouth bleeding scores (FMBS)
were calculated. Probing depth (PD), marginal recession
(REC), and probing attachment level (PAL) were recorded
to the nearest mm by a single investigator. Clinical meas-
urements were taken 1 week before the surgical procedure.

Intrasurgical Clinical Measurements

Intrasurgical clinical measurements were taken following
debridement of the defects essentially as described by Dur-
win et al.13 1) distance from the cemento-enamel junction
(CEJ) to the bottom of the defect (CEJ-BD); and 2) distance
from the CEJ to the most coronal extension of the inter-
proximal bone crest (CEJ-BC). The intrabony component
of the defects (INTRA) was defined as INTRA (CEJ- =

BD) -
(CEJ-BC).

Surgical Procedure Figure 2. The modified papilla preservation technique. Surgical access to
The surgical technique used was a variation of the papilla the interproximal defect. A 5 mm intrabony defect, with a 5 mm suprabony
preservation technique10 modified to allow not only the pri- component, was identified following debridement of the interproximal
mary closure, but also the coronal positioning of the inter- area. Note the optimal visibility.
Volume 66
Number 4 CORTELLINI, PRATO, TONETTI 263

Figure 3. The modified papilla preservation technique. Membrane placement and sutures. Upper left. A tita-
nium reinforced teflon membrane has been secured to the neighboring teeth with sling sutures. Note that the
membrane was positioned supracrestally, close to the CEJ. Upper right. The crossed horizontal internal
mattress suture has been placed. Note the resulting coronal displacement of the buccal flap. Lower left. Note
the horizontal anchorage of the crossed horizontal mattress suture at the base of the palatal papilla. The
papilla has been repositioned in the interproximal space to cover the membrane. Lower right. The vertical
internal mattress suture between the buccal aspect of the interproximal papilla and the most coronal portion
of the buccal keratinized gingiva has resulted in primary closure of the interdental space.

cal gingiva of the interdental space at the base of the pa-
pilla. This incision was connected with the primary incision
in the most apical portion of the buccal gingival margin of
the neighboring teeth. A full thickness buccal flap was el-
evated to the level of the buccal alveolar crest (Fig. 1). The
buccal and interproximal primary incision was then contin-
ued intrasulcularly in the interproximal space to reach the
palatal line angle and extended to the palatal aspect. A buc-
cal horizontal incision was performed in the interproximal
supracrestal connective tissue, just coronal to the bone
crest, to dissect the papilla (Fig. 1). The papilla was ele-
vated towards the palatal aspect. Following extension of the
palatal incision, a full thickness palatal flap including the
interdental papilla was subsequently elevated to fully ex-
pose the interproximal defect (Fig. 1). The tissue thickness
of the papilla was reduced. The defect was fully debrided
and scaling and root planing performed (Fig. 2). To allow
the coronal positioning of the buccal flap in the absence of
tension, vertical releasing incisions extending into the al-
veolar mucosa were placed in the interproximal spaces me-
sial and distal to the teeth neighboring the defect. These
incisions were divergent in a corono-apical direction, and
preserved the interdental tissue. The buccal flap was then
released with a split thickness incision. An interproximal
titanium reinforced teflon membrane§ was adapted and po-
sitioned supracrestally as close as possible to the CEJ. The
occlusive portion of the membrane extended at least 3 mm
beyond the margin of the defect. The membrane was firmly
secured to the neighboring teeth with teflon sling sutures
(Fig. 3). The flaps were sutured as follows to obtain coronal
positioning of the buccal flap and primary closure of the
interdental space over the membrane:
1) A horizontal internal mattress suture was placed be-
tween the base of the palatal papilla and the buccal flap
immediately coronal to the muco-gingival junction. The in-
terproximal portions of the suture ran beneath the muco-
periosteal flaps and crossed each other above the titanium
reinforcement of the membrane. Because the suture was
anchored on the thick palatal tissue, the buccal flap was
coronally displaced (Figs. 3 and 4).
2) A vertical internal mattress suture was subsequently
placed between the buccal aspect of the interproximal pa-
pilla (i.e., the most coronal portion of the palatal flap which
included the interdental papilla) and the most coronal por-
tion of the buccal flap. When this suture was tied, primary
closure of the coronally positioned buccal flap with the pre-
§Goretex, W.L. Gore & Associates, Flagstaff, AZ.
 J Periodontol
264 THE PAPILLA PRESERVATION TECHNIQUE April 1995

Figure 4. Suture to obtain coronal positioning of the buccal flap: schematic illustration of the crossed hori-
zontal internal mattress suture between the base of the palatal papilla and the buccal flap immediately coronal
to the muco-gingival junction. Note that the suture crosses above the titanium reinforcement of the membrane.
A: buccal view. B: mesio-distal view.

Figure 5. Suture to obtain tension-free primary closure of the interdental space: schematic illustration of the
vertical internal mattress suture between the most coronal portion of the palatal flap (which includes the
interdental papilla) and the most coronal portion of the buccal flap. A: buccal view. B: mesio-distal view.

served papilla was achieved in the interproximal area. Cor-
onal positioning of the interdental tissue was obtained over
the membrane (Figs. 3, 5, and 6).
3) The vertical releasing incisions were sutured with a
standard apico-coronal suture to release tension from the
interproximal tissue.
4) Interproximal sutures were placed to close the mesial
and distal extension of the flap. No surgical dressing was
placed.
An infection control regimen was prescribed, essentially
as previously described.11 Patients were instructed to rinse
twice daily with 0.2% Chlorhexidine and to use modified
oral hygiene procedures until the removal of the mem-
branes. In the first postoperative week patients were pre-
scribed tetracycline HCl 250mg four times per day. Profes-
sional tooth cleaning was performed weekly while the
membrane was in place. Membranes were removed 6 weeks
post-operatively.
Outcome Measures
The primary outcome measures were 1) the position of the
membrane immediately following surgery (day 0); 2) the
possibility of obtaining and maintaining coverage of the
membrane with the mucoperiosteal flaps; and 3) the posi-
Volume 66
Number 4 CORTELLINI, PINI PRATO, TONETTI 265

Table 1. Baseline Oral Hygiene and Defect Characteristics

Characteristic Mean ± SD Minimum Maximum

FMPS 11.0 2.3 7 14.4
FMBS' 10.9 3.2 5.5 17.3
PAL 9.9 3.2 7 17
PD 8.4 2.5 6 14
REC 1.7 1.6 0 5
CEJ-BD 11.5 3.9 8 20
CEJ-BC 5.9 2.0 3 9
Intra 5.5 2.9 2 11

Table 2. Position of the Membrane With Reference to the CEJ

(comparison between position at insertion and at removal and
relationship with the interproximal alveolar crest)
Insertion Removal Significance*
CEJ-MEM 1.3 ± 0.7 2.1 ± 1.2 =
0.006
CEJ-BC 5.9 ± 2.0 nd
Significance* < 0.001

*One sample Wilcoxon ranked sum test.

ing of the membrane above the interproximal alveolar

crest at day 0 and of the null hypothesis of no difference
in membrane position between day 0 and membrane re-
moval were tested with the paired Wilcoxon ranked sum
test. All calculations were performed using appropriate
statistical software.11

RESULTS

Figure 6. Soft tissue management and healing above the membrane. Up-
per left. Preoperative view indicating 10 mm of PAL loss on the mesial
aspect of the upper right central incisor. Note the recession of the gingival
margin. Upper right. Defect has been debrided. A deep defect is evident.
Lower left. Following placement of a titanium reinforced membrane just
below the CEJ, coronal positioning of the gingival margin is evident.
Primary closure of the interdental space has been obtained. Lower right.
6 weeks after membrane placement, both coronal positioning and mem-
brane coverage have been maintained. Note the absence of gingival in-
flammation.
tion of the membrane at its removal. The position of the
membrane was measured in the mid-interproximal area as
the distance from the CEJ to the membrane (CEJ-MEM)
after suturing it to the adjacent teeth and following eleva-
tion of a split thickness flap at removal. The coverage of
the membrane with the soft tissue flaps was determined
dichotomously immediately postsurgery and at weekly in-
Defect Characteristics
Patients' oral hygiene and baseline defect characteristics are
shown in Table 1. Patients' FMPS and FMBS were 11.0
± 2.3 and 10.9 ± 3.2, respectively. The selected defects
displayed a PAL of 9.9 ± 3.2 mm with a REC of 1.7 ±
1.6 mm. The intrabony component was 5.5 ± 2.9 mm, with
a suprabony component of 5.9 ± 2.0 mm.
Membrane Position
The titanium reinforced teflon membrane was positioned
1.3 ± 0.7 mm from the CEJ (CEJ-MEM), 4.5 ± 1.6 mm
above the interproximal alveolar crest (coronal). The CEJ-
MEM distance was significantly different from CEJ-BC
both at membrane positioning and at membrane removal (P
<0.001, Wilcoxon ranked sum test; Table 2). At membrane
removal (6 weeks) CEJ-MEM was 2.1 ± 1.2 mm. A sta-
tistically significant difference (0.8 ± 0.8 mm) was ob-
served in terms of CEJ-MEM between membrane position-
ing at baseline and its removal at six weeks (P 0.006, =

tervals thereafter. Wilcoxon ranked sum test; Table 2).

The coronal positioning of the membrane with respect to
Membrane Coverage
the interproximal alveolar crest was defined as coronal =

At baseline, primary closure of the interproxinial soft tis-

(CEJ-BC) -
(CEJ-MEM). sues over the membrane was obtained in 14 of 15 cases
(93%). Exposure occurred in 2 cases at 3 wee cs and in 1
Data Analysis case at 4 weeks. When membranes were removed at 6
Dáta were expressed as means ± standard deviation. The
significance of the null hypothesis of no coronal position- "Statistical Application Software, SAS Version 6.08, Car NC.

266 THE PAPILLA PRESERVATION TECHNIQUE
weeks, 11 sites (73%) still showed complete coverage of
the membrane (Fig. 6).
DISCUSSION
The application of the modified papilla preservation tech-
nique to regenerative procedures allowed complete coverage
of the teflon membrane and primary closure of the muco-
periosteal flaps in the interdental space in 93% of cases. This
result was obtained in sites where the barrier membranes
were coronally positioned 4.5 ± 1.6 mm above the alveolar
crest. Furthermore, in 73% of the cases, the interdental tissue
covered the membrane until its removal at 6 weeks.
The rationale for developing this procedure was twofold.
First, it seems preferable to obtain good protection of the
regenerating tissue through complete covérage of the mem-
brane with the flaps. In fact, membranes exposed to the oral
environment present a substantial degree of bacterial colo-
nization.14'15 Further, the presence of bacteria on the mem-
brane has been associated with lower PAL gains.16 Mem-
brane exposure in the interproximal space has been reported
as a very frequent occurrence;12 this is a consequence of
the difficulties in obtaining primary closure in the interden-
tal area and the subsequent occurrence of a certain degree
of necrosis of the papillary tissue. This is true even when
the membrane is placed at the level of the interproximal
bone crest. Secondly, since the position of the membrane
limits the extent of possible regeneration,17 an attempt to
increase the amount of regeneration would require a more
coronal position of the membrane. Positioning of the mem-
brane coronal to the interproximal alveolar crest makes pri-
mary closure of the flaps in the interdental area even more
difficult. This cannot be predictably achieved with conven-
tional techniques.
The modified papilla preservation technique allowed us
to achieve the above objectives in single-rooted teeth and
in lower molars without neighboring tooth. In molars with
proximal teeth present, application of the described surgical
approach did not result in the desired primary closure.
This method is technically more demanding in sites with
narrow interproximal spaces; in addition, the narrow inter-
dental soft tissue is more likely to undergo a necrosis in
such instances.
Application of this method is contraindicated in situa-
tions where the coronal reposition of the buccal flap has a
poor prognosis; e.g., inadequate vestibular depth.
Although the described surgical technique has been spe-
cifically designed for use with reinforced barrier mem-
branes, it could be adapted to different regenerative ap-
proaches involving the interdental space. A requirement,
however, is the establishment of a stable support for the
crossed horizontal internal mattress suture.
In conclusion, the data presented in this paper indicate
that the modified papilla preservation technique may be a
suitable alternative to conventional surgical approaches for
intérproximal regenerative procedures in single rooted
teeth.
J Periodontol
April 1995
Acknowledgments
The authors express their gratitude to Ms. Cristiana Paoli
for the expert assistance with the artwork. This study was
supported in part by Accademia Toscana di Ricerca Odon-
tostomatologica, Firenze, Italy, and the Clinical Research
Foundation for the Promotion of Oral Health, Bern,
Switzerland.
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Send reprint requests to: Dr. Pierpaolo Cortellini, via A. del Castagno
8, 50132 Firenze, Italy.
Accepted for publication October 7, 1994.