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

the interdental tissue during the initial incision; 2) coronal dling to achieve this goal.
positioning of the buccal flap; or 3) using free gingival
grafts over implanted materials.4-9 Takei et al. proposed a MATERIALS AND METHODS
papilla preservation technique to achieve primary closure of
the interproximal space over periodontal bone implants.10
Achieving primary closure in the interdental space and Patient Population
maintaining it over time, however, is more elusive in most Following completion of an hygienic phase consisting of
situations when a barrier membrane is used.1112 scaling and root planing and oral hygiene instructions, 15
Furthermore, whenever regeneration of the suprabony patients (5 males, 10 females) aged 30 to 51 years (mean
component is attempted by overfilling the intrabony defect age 39.3 ± 6.4) in good general health, gave informed con-
or by placing a barrier membrane coronal to the interprox- sent to participate in this case series. A deep intrabony de-
imal alveolar bone crest, a substantial coronal positioning fect with a suprabony component was identified in each
patient. The involved teeth were 7 incisors, 4 cuspids, 2
*Department of Periodontics, University of Siena, Siena, Italy. bicuspids, and 2 molars. All teeth, except one molar, were
fDépartment of Periodontology and Fixed Prosthodontics, School of Den- located in the maxillary arch. Defects had to be located in
tal Medicine, University of Bern, Bern, Switzerland. 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- titanium reinforced teflon membrane§ was adapted and po-
pilla. This incision was connected with the primary incision sitioned supracrestally as close as possible to the CEJ. The
in the most apical portion of the buccal gingival margin of occlusive portion of the membrane extended at least 3 mm
the neighboring teeth. A full thickness buccal flap was el- beyond the margin of the defect. The membrane was firmly
evated to the level of the buccal alveolar crest (Fig. 1). The secured to the neighboring teeth with teflon sling sutures
buccal and interproximal primary incision was then contin- (Fig. 3). The flaps were sutured as follows to obtain coronal
ued intrasulcularly in the interproximal space to reach the positioning of the buccal flap and primary closure of the
palatal line angle and extended to the palatal aspect. A buc- interdental space over the membrane:
cal horizontal incision was performed in the interproximal 1) A horizontal internal mattress suture was placed be-
supracrestal connective tissue, just coronal to the bone tween the base of the palatal papilla and the buccal flap
crest, to dissect the papilla (Fig. 1). The papilla was ele- immediately coronal to the muco-gingival junction. The in-
vated towards the palatal aspect. Following extension of the terproximal portions of the suture ran beneath the muco-
palatal incision, a full thickness palatal flap including the periosteal flaps and crossed each other above the titanium
interdental papilla was subsequently elevated to fully ex- reinforcement of the membrane. Because the suture was
pose the interproximal defect (Fig. 1). The tissue thickness anchored on the thick palatal tissue, the buccal flap was
of the papilla was reduced. The defect was fully debrided coronally displaced (Figs. 3 and 4).
and scaling and root planing performed (Fig. 2). To allow 2) A vertical internal mattress suture was subsequently
the coronal positioning of the buccal flap in the absence of placed between the buccal aspect of the interproximal pa-
tension, vertical releasing incisions extending into the al- pilla (i.e., the most coronal portion of the palatal flap which
veolar mucosa were placed in the interproximal spaces me- included the interdental papilla) and the most coronal por-
sial and distal to the teeth neighboring the defect. These tion of the buccal flap. When this suture was tied, primary
incisions were divergent in a corono-apical direction, and closure of the coronally positioned buccal flap with the pre-
preserved the interdental tissue. The buccal flap was then
released with a split thickness incision. An interproximal §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- oral hygiene procedures until the removal of the mem-
onal positioning of the interdental tissue was obtained over branes. In the first postoperative week patients were pre-
the membrane (Figs. 3, 5, and 6). scribed tetracycline HCl 250mg four times per day. Profes-
3) The vertical releasing incisions were sutured with a sional tooth cleaning was performed weekly while the
standard apico-coronal suture to release tension from the membrane was in place. Membranes were removed 6 weeks
interproximal tissue. post-operatively.
4) Interproximal sutures were placed to close the mesial
and distal extension of the flap. No surgical dressing was Outcome Measures
placed. The primary outcome measures were 1) the position of the
An infection control regimen was prescribed, essentially membrane immediately following surgery (day 0); 2) the
as previously described.11 Patients were instructed to rinse possibility of obtaining and maintaining coverage of the
twice daily with 0.2% Chlorhexidine and to use modified 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

Defect Characteristics
Patients' oral hygiene and baseline defect characteristics are
Figure 6. Soft tissue management and healing above the membrane. Up-
shown in Table 1. Patients' FMPS and FMBS were 11.0
per left. Preoperative view indicating 10 mm of PAL loss on the mesial
± 2.3 and 10.9 ± 3.2, respectively. The selected defects
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. displayed a PAL of 9.9 ± 3.2 mm with a REC of 1.7 ±
Lower left. Following placement of a titanium reinforced membrane just 1.6 mm. The intrabony component was 5.5 ± 2.9 mm, with
below the CEJ, coronal positioning of the gingival margin is evident. a suprabony component of 5.9 ± 2.0 mm.
Primary closure of the interdental space has been obtained. Lower right.
6 weeks after membrane placement, both coronal positioning and mem- Membrane Position
brane coverage have been maintained. Note the absence of gingival in-
The titanium reinforced teflon membrane was positioned
flammation.
1.3 ± 0.7 mm from the CEJ (CEJ-MEM), 4.5 ± 1.6 mm
above the interproximal alveolar crest (coronal). The CEJ-
tion of the membrane at its removal. The position of the MEM distance was significantly different from CEJ-BC
membrane was measured in the mid-interproximal area as both at membrane positioning and at membrane removal (P
the distance from the CEJ to the membrane (CEJ-MEM) <0.001, Wilcoxon ranked sum test; Table 2). At membrane
after suturing it to the adjacent teeth and following eleva- removal (6 weeks) CEJ-MEM was 2.1 ± 1.2 mm. A sta-
tion of a split thickness flap at removal. The coverage of tistically significant difference (0.8 ± 0.8 mm) was ob-
the membrane with the soft tissue flaps was determined served in terms of CEJ-MEM between membrane position-
dichotomously immediately postsurgery and at weekly in- 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.
 J Periodontol
266 THE PAPILLA PRESERVATION TECHNIQUE April 1995

weeks, 11 sites (73%) still showed complete coverage of Acknowledgments

the membrane (Fig. 6). The authors express their gratitude to Ms. Cristiana Paoli
for the expert assistance with the artwork. This study was
DISCUSSION supported in part by Accademia Toscana di Ricerca Odon-
The application of the modified papilla preservation tech- tostomatologica, Firenze, Italy, and the Clinical Research
nique to regenerative procedures allowed complete coverage Foundation for the Promotion of Oral Health, Bern,
of the teflon membrane and primary closure of the muco- Switzerland.
periosteal flaps in the interdental space in 93% of cases. This
result was obtained in sites where the barrier membranes REFERENCES
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that the modified papilla preservation technique may be a
suitable alternative to conventional surgical approaches for Send reprint requests to: Dr. Pierpaolo Cortellini, via A. del Castagno
intérproximal regenerative procedures in single rooted 8, 50132 Firenze, Italy.
teeth. Accepted for publication October 7, 1994.