1. Pierpaolo Cortellini
Giovanpaolo Pini Prato
Maurizio S. Tonetto
J Periodontol 1995; 66:261-266
The Modified Papilla Preservation Technique
A New Surgical Approach for
Interproximal Regenerative Procedures
Presenter: R2 鄭瑋之
Instructor: VS 陳娟娟

2. Introduction
• Key goal in periodontal regenerative procedures:
primary closure, protection for healing
• Easier  buccal aspect, class II furcations
• Demanding  interdental area
In 1975, Sven-Erik Hamp, Lindhe and Sture Nyman
In 1975, Sven-Erik Hamp, Lindhe and Sture Nyman
•• Class I: < 3 mm is depth.
Class I: < 3 mm is depth.
•• Class II: > 3 mm in depth (> 1/2 buccolingual thickness of the tooth)
Class II: > 3 mm in depth (> 1/2 buccolingual thickness of the tooth)
but not through-and-through. The furcation defect is thus a cul-de-sac.
but not through-and-through. The furcation defect is thus a cul-de-sac.
•• Class III: encompass the entire width of the tooth so that no bone is
Class III: encompass the entire width of the tooth so that no bone is
attached to the angle of the furcation.
attached to the angle of the furcation.

3. Papilla preservation flap
Intrasulcular incisions at facial and proximal side
Pushed through the embrasure with a blunt instrument to be
included in the facial flap

4. Introduction
• Improved closure of the interdental area
1) Careful preservation during the initial incision
2) Coronal positioning of the buccal flap
3) Using free gingival grafts over implanted materials
• Takei technique is more elusive in most situations
when a barrier membrane is used.

5. Material and Method
• Patient population
– After scaling, root planing and OHI
– 15 patients (5 males, 10 females) aged 30~51 (mean
age 39.3 ± 6.4)
– A deep intrabony defect with a suprabony component
in the interproximal area, and did not extend into a
furcation.
– Upper 7 incisors, 4 cuspids, 2 bicuspids, and 2 molars

6. Material and Method
• Clinical Characterization of Selected Sites
– Full mouth plaque scores (FMPS), 4 aspects/tooth
– Bleeding on probing (BOP) at a force of 0.3 N. with a
manual pressure sensitive probe  Full mouth
bleeding scores (FMBS)
– Probing depth (PD), marginal recession (REC), and
probing attachment level (PAL, CEJ~base of the pocket)
by a single investigator
– Taken 1 week before surgery

7. Material and Method
• Intrasurgical Clinical Measurements
– Taken after debridement of the defects
a. Distance from CEJ to the bottom of the defect
(CEJ-BD)
b. Distance from CEJ to the most coronal extension
of the interproximal bone crest (CEJ-BC)
c. The intrabony component of the defects (INTRA)
was defined as INTRA = (CEJ-BD)~(CEJ-BC)

8. Surgical Procedure
– Initial incisions, elevation of the flaps
1. Buccal and interproximal intrasulcular incision
2. Horizontal incision with a slight internal bevel in
the buccal gingiva at the base of the papilla
3. Buccal full thickness flap is elevated. The papilla
covering the defect is still in place.

9. Surgical Procedure
– Initial incisions, elevation of the flaps
1. The papilla is mobilized with a buccal horizontal
incision in the interproximal supracrestal
connective tissue.
2. The papilla is elevated with the full thickness
palatal flap.

10. Surgical Procedure
– Surgical access to the interproximal defect
1. 5 mm intrabony defect, with a 5 mm suprabony
component, was identified after debridement.
2. Note the optimal visibility

11. Surgical Procedure
– Membrane placement and sutures
1. Titanium reinforced teflon membrane is secured
to the neighboring teeth with sling sutures.
(positioned supracrestally, close to the CEJ)
2. Crossed horizontal internal mattress suture
(resulting coronal displacement of the buccal
flap)

12. Surgical Procedure
– Membrane placement and sutures
1. Crossed horizontal mattress suture at the base of
the palatal papilla. Papilla covers the membrane.
2. The vertical internal mattress suture between the
buccal aspect of the papilla and the most coronal
portion of the buccal keratinized gingiva 
primary closure.

13. Surgical Procedure
– Coronal positioning of the buccal flap
• Crossed horizontal internal mattress suture
between the base of the palatal papilla and the
buccal flap immediately coronal to the
mucogingival junction.
• Suture crosses above the titanium reinforcement
of the membrane.

14. Surgical Procedure
– Tension-free primary closure
• Vertical internal mattress suture between the
most coronal portion of the palatal flap (includes
the interdental papilla) and the most coronal
portion of the buccal flap.

15. Surgical Procedure
– Healing above the membrane
1. Pre-OP view indicating 10 mm of PAL loss on the
mesial aspect of #11. (recession of the gingival
margin)
2. Defect is debrided. A deep defect is evident.

16. Surgical Procedure
– Healing above the membrane
1. Titanium reinforced membrane just below the
CEJ  coronal positioning of the gingival margin
2. 6 weeks later, both coronal positioning and
membrane coverage are maintained.

18. Material and Method
• Primary outcome measures
1. Position of the membrane, immediately post-op &
after a week
2. Possibility of obtaining and maintaining coverage of
the membrane with the mucoperiosteal flaps
3. Position of the membrane at its removal (measured
in the mid-interproximal area as CEJ~MEM)
4. Coronal positioning of the membrane with respect
to the interproximal alveolar crest was defined as
Coronal = (CEJ-BC) ~ (CEJ-MEM).

19. Results
• Defect Characteristics

20. Material and Method
– Full mouth plaque scores (FMPS)
– Full mouth bleeding scores (FMBS)
– Probing depth (PD), marginal recession (REC), and
probing attachment level (PAL, CEJ ~ base of the
pocket)
– CEJ ~ bottom of the defect (CEJ-BD)
– CEJ ~ the most coronal extension of the interproximal
bone crest (CEJ-BC)
– The intrabony component of the defects (INTRA) was
defined as INTRA = (CEJ-BD)~(CEJ-BC)

21. Results
• Membrane Position

22. Results
• Membrane Coverage
1. At baseline, primary closure over the membrane
was obtained in 14 of 15 cases (93%).
2. Exposure occurred in 2 cases at 3 weeks and in 1
case at 4 weeks.
3. When membranes were removed at 6 weeks, 11
sites (73%) still showed complete coverage of
the membrane.

23. Discussion
1. Modified papilla preservation technique allowed
complete coverage of the teflon membrane and
primary closure of the mucoperiosteal flaps in the
interdental space in 93% of cases.
2. Barrier membranes coronally positioned 4.5 ± 1.6
mm above the alveolar crest.
3. In 73% of the cases, the interdental tissue covered
the membrane until its removal at 6 weeks.

24. Discussion
4. Rationales to develop this technique:
a) Membrane exposure in the interproximal space 
bacteria on the membrane with lower PAL gains 
necrosis of papilla
b) More coronal position of the membrane  increase the
amount of regeneration  but interproximal alveolar
crest makes primary closure more difficult
4. Modified papilla preservation technique can be
used in single-rooted teeth and lower molars
without neighboring tooth

25. Discussion
6. More demanding in narrow interproximal spaces
 necrosis
7. Contraindication: coronal reposition of the buccal
flap has a poor prognosis; e.g., inadequate
vestibular depth
8. Stable support for the crossed horizontal internal
mattress suture

26. Conclusion
• Modified papilla preservation technique may
be a suitable alternative to conventional
surgical approaches for interproximal
regenerative procedures in single rooted
teeth.