preserve the papilla using these techniques

1. PAPILLA PRESERVATION
TECHNIQUES
Dr. Rinisha Sinha
Postgraduate Trainee
Department of Periodontology and Implantology

2. Introduction
Historical
Background
Classification
of Interdental
Papilla Loss
Etiology for
the loss of
Interdental
Papilla
Papilla
Preservation
Techniques
Healing References

3. 


A valleylike
depression that
connects a facial
and lingual
papilla and
conforms to the
shape of the
interproximal
contact
The tip of the
papilla is located
immediately
beneath the
contact point

4. 




Reference : Park JH. Esthetic consideration in
interdental papilla: remediation and regeneration. J
Esthet Restor Dent; 2010
Reference : Cohen B. pathology of the interdental
tissues. Dent Pract; 1959
Gingival black triangle is a cosmetic deformity
which refers to an absence of papilla resulting in
black spaces or open embrasures which impairs
esthetic features, phonetics problems and food
accumulation.
Reference : P.
Ziahosseini, B. J. Millar,
Management Of Gingival
Black Triangles; 2014

5. 





6.  The Interdental Contact
Point
 The Apical extent of the
Facial Cementoenamel
Junction (CEJ)
 The Coronal extent of the
Proximal Cementoenamel
Junction (CEJ)
Reference : W. P. Nordland And D. P.
Tarnow, A Classification System For
Loss Of Papillary Height, J. Periodontol;
Oct. 1998

7. PPI score 1 • Papilla completely present
PPI score 2 • Apical to contact point
PPI score 3 • Apical and CEJ visible
PPI score 4 • Apical to both CEJ.
Reference : C Nemcovsky. Interproximal Papilla Augmentation Procedure: A Novel
Surgical Approach And Clinical Evaluation Of 10 Consecutive Procedures. Int J
Periodontics Restorative Dent; 2001

8. PIS 0
• Papilla not present and no curvature of the
soft tissue contour.
PIS 1
• Present papillae height less than half the
height of the papilla in the proximal teeth
and a convex curvature of the soft tissue
contour.
PIS 2
• Presence of at least half the height of the
papilla in the proximal teeth, but not in
complete harmony with the interdental
papilla of the proximal teeth.
PIS 3
• Papillae able to fill the interproximal
embrasure to the same level as in the
proximal teeth and in complete harmony
with the adjacent papillae.
Reference : C Nemcovsky. Interproximal Papilla
Augmentation Procedure: A Novel Surgical Approach And
Clinical Evaluation Of 10 Consecutive Procedures. Int J
Periodontics Restorative Dent; 2001

10. Alveolar Bone
Interproximal Contact
Distance / Periodontal
Bone Loss / Age
Root Divergence
Triangular Crown Morphology
Embrasure Morphology
Initial position of teeth (Diastema, Crowding, Imbrication )
Reference : Tornow DP, Magner AW, Fletcher P. the effect of the
distance from contact point to the crest of bone on the presence
or absence of interdental papilla. J Periodontol; 1992
Reference : Tal H. relationship between the
interproximal distance of roots and the prevalence of
infrabony pockets. J periodontal; 1984
Reference : Ahmad I. anterior dental
esthetics: gingival perspective. Br Dent
J; 2005
Reference : Kois JC.
Predictable single tooth peri-
implant esthetic; five
diagnostic keys. Compend
Contin Educ Dent; 2001

11. PERIODONTAL BIOTYPE
PERIODONTAL BIOFORMS
High Normal
Flat
“5 – mm” Rule
CROWN MORPHOLOGY
Square Circular Triangular

12. Abnormal form and size of the tooth
Irregular restorations and prosthetic crowns
Traumatic oral hygiene measures like improper tooth brushing technique
and flossing in the interdental space
Periodontal disease.
Acute necrotizing ulcerative gingivitis which results in punched out crater
like depression of the interdental papilla.
After periodontal therapy during healing.
Missing of teeth or spacing between the teeth
Reference : Jenabian N, Rahimi Rad M, Bijani A, Ghahari P. The comparison of papilla preservation technique and
semilunar incision with sub- epithelial connective tissue graft in dark triangle treatment. Caspian J Dent Res; 2018

13. The
blood
supply
is
mainly
by
Periodontal ligament
vessels
Alveolar vessels
Supraperiosteal vessels
Since the interdental area is small, the blood
supply is also minor, making it a major limiting
factor in surgical procedures.

14. Non-Surgical
• Scaling and root planing is to be
done prior to any treatment procedures.
• Reinforcement of oral hygiene
procedures and oral health
education should be given to the
patients.
• Correction and relocation of the
contact point should be established.
• Orthodontic treatment should be
carried out to create a contact point.
Surgical
• Conventional Papilla Preservation Flap
• Modified Papilla Preservation Flap
• Simplified Papilla Preservation Flap
• Entire Papilla Preservation Flap
• Semilunar Coronally Repositioned Flap
• The “Whale’s Tail” Technique
If the primary cause of
periodontal disease is
interdental papilla loss
If traumatic tooth
brushing
If mal-positioning of the
teeth
If no contact point
between the teeth like in
the case of midline
diastema Every 15 days for 3 months curettage of
interdental papilla should be performed
repeatedly

15. Reference : Carranza; 10th edition

16. Reference : Cohen; 3rd edition
ADVANTAGES
• Esthetically pleasing.
• Primary coverage of
implant material.
• Prevention of
postoperative tissue
craters.
DIS-ADVANTAGES
• Technically difficult.
• Time consuming.

17. Takei et al; 1985
The first modification of PPF
The horizontal incision beneath the
interproximal area, on opposite side of
bone defect was deemed best because it
allowed protection of the regenerated
area from the oral environment.
Checchi et al; 1988
Reference : Chacko LN, Abraham S, Landge N, Ali FM. Papilla Preservation
Flap: Revisited; 2013
Reference : Cortellini P, Prato GP, Tonetti MS. The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J
Periodontics Restorative Dent 1999

18. Reference : Dr. Thomas Han, LA

19. Cortellini et al; 1995
Step 1
• In the
interdental
space at the
base of the
papilla, a
horizontal
incision is
made at
buccally and it
is extended
towards
palataly.
Step 2
• After placing a
horizontal
incision,
oblique
releasing
incision is
placed in the
alveolar
mucosa and it
is extended to
the interdental
papilla in
corono-apical
direction.

20. Reference : Aslan S, Buduneli N, Cortellini P. Entire papilla preservation
technique in the regenerative treatment of deep intrabony defects: 1-Year
results. J Clin Periodontol; 2017
Pre-surgical site showing defect
on the mesial aspect of the
maxillary right lateral incisor
Oblique Incision beginning at
gingival margin of mesiobuccal
line angle of lateral incisor.
Blade parallel to the long axis of
the tooth and reaches the mid-
point of the distal surface of the
central incisor below the
contact point
Oblique Incision continues
intrasulcularly in the buccal
aspect of the lateral and central
incisor.
Full thickness buccal flap
elevated.

21. Wide interproximal
space
Horizontal incision
Anterior and
pre-molar region
Narrow interproximal
space
Oblique incision
Anterior and
posterior regions
Healing of gingival blood flow postoperatively is faster in SPPT than MPPT.
Reference : (Retzepi et al, 2007)
SPPT MPP
T

22. Reference : Aslan S, Cortellini P. Entire papilla preservation technique in the regenerative treatment of deep intrabony defects: 1-Year results. J Clin Periodontol; 2017
Cortellini, Aslan; 2017
Aim : to preserve to affected papilla providing a
tunnel like undercut incision
Advantage : The entirely conserved inter-dental
papilla provides an intact gingival chamber to
stabilize the blood clot and also improves the wound
healing process
EPP : requires a short buccal vertical releasing
incision on the buccal side of the adjacent tooth
extending just beyond the Mucogingival line

23. 



Reference : Aslan S, Cortellini P. Semilunar Periodontal Flap. J Clin Periodontol; 2017

24. Bianchi and Basseti; 2009
Indications
• for the treatment of wide intrabony defects
in the esthetic zone that involves the
elevation of a large flap from the buccal to
the palatal side allowing accessibility and
visibility of the intrabony defect
• to perform GTR while maintaining
interdental tissue over grafting material
The reflected flap looks like a tail of a whale,
hence the name Whales Tail technique
Reference : Bianchi AE, Bassetti A. Flap design for guided tissue regeneration surgery in the
esthetic zone: The “Whale’s tail” technique. Int J Periodontics Restorative Dent 2009

25. 

 1-3 days after surgery





26.  Carranza’s Clinical
Periodontology :
10th Edition
 Cohen B.
pathology of the
interdental
tissues
 International
Journal of Applied
Dental Sciences
Interdental papilla and
various preservation
techniques: A review - S.
Uma et al; 2020
Treatment of Interdental
Papilla: A Review – Jamwal
D. et al; 2019
Cortellini, Prato, and M.
Tonetti, “The simplified
papilla preservation flap. A
novel surgical approach for
the management of soft
tissues in regenerative
procedures”
 Journal of
Dentofacial
Sciences
Chacko, Neelathil &
Abraham, Sathish &
Landge, Nilima & Ali,
Fareedi. Papilla
Preservation Flap :
Revisited; 2013
 Miscellaneous
• W. P. Nordland and
D. P. Tarnow, “A
classification
system for loss of
papillary
height,” Journal of
Periodontology
• H. H. Takei, T. J.
Han, F. A. Carranza
Jr., E. B. Kenney,
“Flap technique for
periodontal bone
implants. Papilla
preservation
technique,” Journal
of Periodontology;
1985