History and different types of papilla preservation flap designs

1. PAPILLA
PRESERVATION FLAP
DR.VIDYA VISHNU
SENIOR LECTURER
MALABAR DENTAL COLLEGE AND RESEARCH
CENTRE
1

2. *Primary wound closure and uneventful early wound
stability over the biomaterials are the critical parts of a
successful periodontal regeneration.
*Surgical elevation of the interdental papilla to access deep
and wide intrabony defects interferes with the papillary
blood supply that can end up with an impairment in healing
process possibly even preventing the primary closure in the
early healing phase.
*INTRODUCTION
2

3. *Subsequent bacterial contamination may deteriorate the
healing process in later phases.
*Greater crown and root exposure and increase in the
interdental spacing following flap surgery is highly
unacceptable.
*An ideal periodontal therapy must necessarily 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.
3

4. *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.
4

5. *HISTORY
*Probably the first report of a Papilla Preservation
procedure was by Kromer in 1956 which was designed to
retain osseous implants.
*App in 1973, reported a similar technique and termed it as
Intact Papilla Flap, which retained the interdental
gingival in the buccal flap.
5

6. *The App technique utilizes split thickness flaps and has
not been generally used for reconstructive surgery.
*Evian et al preserved the interdental gingiva in the facial
flap, which exposed osseous margins on the labial and
the interproximal zone, while the palatal tissues were
reflected separately.
*Genon and Bender in 1984 also reported a similar
technique indicated for esthetic purposes.
6

7. *Takei et al in 1985 introduced a detailed description of the
surgical approach reported earlier by Genon & 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.
*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.
7

8. Flap designs to achieve primary closure
*The increased predictability of the reconstructive
procedures can be strictly dependent on
i) the surgical design and flap management for better
survival of flap and graft coverage, and
ii) suturing technique to optimize primary closure, thus
ensuring the primary condition for blood clot stabilization
and maturation in a biologic environment protected from
biomechanical and microbiological challenge.
8

9. *Proper flap design and incision placement is of utmost
importance to achieve complete flap closure and flap-to-
root seal at the time of suturing and during postsurgical
healing as well as minimal or absent exposure and
subsequent contamination and/or exfoliation of the grafted
biomaterial or membrane.
9

10. *Therefore, flap designs are classified according to
1) the outline of the incision which affects the preservation
of the interdental supracrestal soft tissues and, thus, the
predictability to ensure primary closure at the interdental
space, and
2) the elevation of a either a single (buccal or oral) or a
double (buccal and oral) flap in relation to the surgical
trauma exerted at the interproximal soft tissues.
10

11. Conventional
flap Papilla
Preservation flap
Based on management of papilla
11

12. 12
Techniques without preservation of the interdental
supracrestal soft tissues & with double flap elevation

13. • It includes MWF, undisplaced flaps and APF.
• splitting the papilla into a facial half and a lingual or palatal
half.
13

14. *The conventional flap is used when:
1) the interdental spaces are too narrow, thereby
precluding the possibility of preserving the papilla
2) when the flap is to be displaced.
14

15. *Leads to a partial loss of the interdental soft tissues with an
increased risk of compromising the primary closure in the
interdental space.
15

16. 16
Techniques with preservation of the
interdental supracrestal soft tissues and with
double flap elevation

17. *Flap designs which provide the preservation of the
integrity of the interdental supracrestal soft tissue by
elevating a buccal and oral flap include the :
Papilla Preservation Technique (PPT)
Interproximal Tissue Maintenance (ITM),
Modified Papilla Preservation Technique (MPPT)
Simplified Papilla Preservation Technique (SPPT).
17

18. *No incisions are made through the interdental papilla.
*Either the buccal or the oral papilla is, therefore,
included in the contralateral oral or buccal flap,
respectively, leaving the volume of the supracrestal soft
tissues intact in the interproximal area.
*PPT, MPPT and ITM techniques place the incision line
away from the bone defect, thus limiting graft or
membrane exposure during the postsurgical healing.
18

19. *PAPILLA PRESERVATION FLAP (PPF)
*By Takei et al in 1985 & later Cortellini et al in 1995,
1999.
*It is the modification of a procedure originally described
by Genon & Bender in 1984 for esthetic maxillary
anteriors.
19

20. INDICATIONS:
* Embrasure wide enough to permit passage of the
interproximal tissue.
*Bone grafting areas
CONTRAINDICATIONS:
*Narrow embrasures
20

21. • Sulcular incisions around each tooth
• no incision through the interdental papilla facially.
• Semilunar incision is made across each IDP so that the
papillary incision line is at least 5 mm away from the crest of
the papilla allowing the interdental tissues to be dissected from
the lingual or palatal aspect so that it can be elevated intact
with the facial flap.
21

22. 22

23. 25

24. ADVANTAGES
• Esthetically pleasing
• Primary coverage of
implant material
• Prevention of post
operative tissue
craters
DISADVANTAGES
• Technically difficult
• Time consuming
• Granulation tissue
attached to the
interdental papillae
26

25. *Modification of the PPT- Murphy KG 1996
* Involves the reflection of a triangular-shaped palatal flap
(so-called “papillar triangle”), along with the isthmus of
interdental tissue, which remains contiguous with the
buccal portion of the flap.
*This allows for the preservation of an adequate amount
of interdental tissue to ensure membrane or graft
protection/coverage.
Interproximal Tissue Maintenance
(ITM)
29

26. *The surgical protocol includes an initial buccal
intracrevicular incision extending one or two teeth on either
side of the defect.
*Vertical releasing incisions are performed as needed.
*The PT is outlined by two inverse-bevelled incisions,
starting from the line angles of the teeth where the
interproximal osseous defect is present, and joining at a
common point 7 to 15 mm directly apical in the palate.
30

27. *A full-thickness flap reflection is made, and the PT is
elevated from the alveolar bone and displaced toward the
buccal aspect under the contact area by means of a small
periosteal elevator.
*After defect and root debridement, the flaps are sutured
using a modified external mattress suturing technique.
31

28. 32

29. *MODIFIED PAPILLA PRESERVATION FLAP
(MPPF)
• By Cortellini 1995
• Rationale: to achieve and maintain primary closure in
interdental spaces over the membrane.
33

30. PROCEDURE
*Primary intrasulcular incision (buccal and interproximal)
involving two teeth neighbouring the defect is made.
*A horizontal incision is traced in the buccal gingiva of
the interdental space at the base of the papilla.
34

31. *This horizontal incision is then connected with the
primary incision in the most apical portion of the buccal
gingiva of the neighbouring teeth and a full thickness
buccal flap was elevated to the level of the buccal
alveolar crest.
35

32. *Buccal and interproximal primary incision is continued
intrasulcularly in the interproximal space and extended to
the palatal aspect .
*A buccal horizontal incision is performed in the
interproximal supracrestal connective tissue, coronal to the
bone crest, to dissect the papilla.
36

33. *The papilla is then elevated 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.
37

34. Incisions Full thickness flap
reflection
Papilla elevated with
palatal flap39

35. Debridement
done
Sutures
placed
40

36. *The tissue thickness of papilla is reduced to permit
coronal advancement of the flap.
*Coronal displacement of the buccal flap, which greatly
contributes to primary closure over the graft/membrane
and may result in clinical attachment gain coronal to the
alveolar crest.
*Vertical releasing incision divergent in corono-apical
direction extending in to the alveolar mucosa can be
placed in the interproximal spaces neighbouring the defect
if coronal advancement of the flap is desired.
41

37. ADVANTAGES
Maintains the
interdental soft
tissues & allows
coronal
repositioning of
the interdental
tissues
DISADVANTAGES
Limited to
interdental areas
wider than 2mm.
Less successful in
narrow &
posterior
interdental spaces
Suturing
difficulties with
non- supportive
barriers.
42
technically more
demanding

38. • Papillary preservation flap and its modified flap design,
both required a wide interdental space as a pre-requisite
to bring about appreciable functional and esthetic value.
• To apply esthetic value to teeth having narrow
interproximal zone, Cortellini et al in 1999 proposed the
Simplified Papilla preservation flap technique.
SIMPLIFIED PAPILLA PRESERVATION
43

39. • Narrow interdental spaces (<2mm ) & posterior areas-
to obtain & maintain primary closure of the flaps.
• Avoid the collapse of non-self supporting barrier
membranes into the interproximal defects.
INDICATIONS
44

40. PROCEDURE
*An oblique incision is made across the defect associated
papilla from the gingival margin at the buccal line angle
of the involved tooth to reach the mid interproximal
portion of the papilla under the contact point of the
adjacent tooth.
45

41. *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 with 2-3 mm exposure of alveolar bone.
*A buccolingual horizontal incision at the base of papilla
close to the interproximal crest is made.
46

42. *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 including the interdental papilla is elevated.
47

43. 48

44. *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.
50

45. *ADVANTAGES
*Allows simple & safe manipulation of interdental tissues
* Facilitates primary closure of the interdental tissues
without tension
* Prevents collapse of the membranes into the defect
because of the tissue compression
51

46. (Cortellini P &Tonetti M. Clinical concepts for regenerative therapy in intrabony
defects. Periodontology 2000, Vol. 68, 2015, 282–307)
52

47. * Bianchi & Bassetti in 2009.
* Designed for the treatment of wide intrabony defects
in the esthetic zone.
* This surgical procedure involves elevation of a large
flap from the buccal to the palatal side to allow access and
visualization of the intrabony defect and was created
especially to perform GTR while maintaining interdental
tissue over grafting material.
WHALE’S TAIL TECHNIQUE
53

48. *Two vertical full-thickness incisions are traced from the
mucogingival line to the distal margin of the tooth
neighbouring the defect on the buccal surface.
*A horizontal incision joined the apical margins of the first
two incisions, and the coronal margins of the vertical
incision were continued intrasulcularly in the buccal,
interproximal, and palatal aspects of the defect-associated
tooth.
54

49. *Flap is reflected from buccal to palatal side.
*Debridement is done and regenerative material
with/without GTR can placed.
*Flap is reapproximated & Sutures are placed.
55

50. 56

51. 57

52. *ADVANTAGES
Preservation of a large amount of soft tissue.
Good primary flap closure.
The use of incisions distant from the defects and
graft margins drastically reduces the percentage of
flap dehiscence especially when membranes are
used.
58

53. *DISADVANTAGES
*Necessity of interdental space in order to allow flap
dislocation to palatal side.
*The flap elevation is delicate and the surgeon must be
careful to preserve the papilla, which will maintain the
vascularization of the flap.
*Chances of recession
59

54. *ENTIRE PAPILLA PRESERVATION
TECHNIQUE
* Serhat Aslan , Nurcan Buduneli 2015
*Used for the regenerative treatment of deep and wide
intrabony defects.
60

55. 61
*This novel surgical procedure is based on a short buccal
flap, a vertical incision positioned in the buccal
gingiva of the neighboring interdental space and a
tunneled interdental papilla.
*Provides an adequate mechanical access to
interproximal deep and wide intrabony defects and an
excellent and uneventful post-operative healing phase.

56. *The completely preserved interdental papilla is meant to
stabilize the blood clot and to improve the wound healing
process.
*Furthermore, the application of this technique supports the
use of amelogenins and bone-like materials.
62

57. *A magnifying loop with 3.3x magnification was used
to increase visibility of the surgical site.
*Following a buccal intra- crevicular incision, a
beveled vertical releasing incision was performed in
the buccal gingiva of the neighboring interdental
space and extended just beyond the mucogingival line
to provide appropriate mechanical access to the
intrabony defect .
63

58. *In the presence of malpositioned tooth with narrow
neighboring interdental space, vertical incision was shifted
one tooth away from the actual incision line.
*Particularly for narrow interdental papilla, an oblique
interdental incision was made, followed by an
intrasulcular incision directed to the adjacent tooth and
vertical releasing incision was then performed.
64

59. *A microsurgical periosteal elevator was used to elevate a
buccal full thickness muco-periosteal flap extending from
the vertical incision to the defect-associated papilla.
*Tunnel-like approach of the defect-associated interdental
papilla : A specially designed angled tunnel elevator
facilitated the interdental tunnel preparation under the
papillary tissue.
* Utmost care was taken to elevate the interdental
papilla in full-thickness manner up to the lingual bone
crest.
65

60. *A microsurgical scissor was used to remove the
granulation tissue from the inner aspect of the
interdental papilla.
*Excessive thinning of the papilla was avoided in order
not to compromise the blood supply. The granulation
tissue was removed with a mini-curette.
*Any residual subgingival plaque or calculus was gently
removed from the exposed root surface with an
ultrasonic scaler.
66

61. *Root conditioning of the exposed surface was done
applying 24% EDTA gel for 2 minutes to remove the
smear layer.
*Then, the exposed root surface was rinsed with sterile
saline and EMD was applied on the exposed root surface.
*Subsequently, a deproteinized porcine-derived bone
substitute was placed into the intrabony defect and
care was taken not to overfill the defect.
67

62. *Microsurgical suturing technique with 7-0 monofilament
polypropylene suture materials was performed for
optimal wound closure of the surgical area.
68

63. 69

64. *MINIMALLY INVASIVE SURGICAL TECHNIQUES IN
PERIODONTAL REGENERATION
* The term minimally invasive surgery (MIS) was
introduced in periodontology by Harrel and Ress, 1995 to
minimize wounds and flap reflection.
*The ideal surgical approach for periodontal regeneration
would be one that allows access to the site to be
regenerated without extending the surgical incision into
adjacent healthy areas.
71

65. *Incisions were aimed at conserving the soft tissue as much
as possible.
*MIS helps in handling hard and soft tissues gently during
periodontal surgery.
72

66. *Tibbetts & Shanelec, 1994 described periodontal
microsurgical technique and concentrated on soft tissue
regeneration and augmentation using a surgical operating
microscope.
*Wickham & Fitzpatric, 1999 described the techniques of
using smaller incisions as “MIS.”
73

67. *INDICATIONS OF MIS
• Isolated, interproximal bone defect, not extending
beyond the interproximal site
• Periodontal defects that border on an edentulous area
• Periodontal defect that extend from buccal/lingual
from interproximal site
• Multiple separate defect sites within a single quadrant.
74

68. *CONTRAINDICATION
• Generalized horizontal bone defect.
• Multiple interconnected vertical defects, walls.
75

69. *General consideration for minimally invasive surgery
• All incisions are designed to conserve soft tissues
• Separate incisions are performed, continuous incisions are
avoided
• Vertical releasing incisions are avoided
• Coverage of graft/membrane by soft tissue is achieved to
promote periodontal regeneration, for example, if the bony
defect is in esthetic areas, incision is given in palatal papilla.
76

70. •Tissues are reflected by sharp dissection or combination
of blunt and sharp
• Adequate visualization of the procedure requires
magnification and light source. Surgical microscope,
loupes ×3.5 magnification can be used.
77

71. *Root surface debridement becomes difficult as minimal
flap reflection is performed to preserve tissues.
*Mechanical debridement can be performed with tip of
curette inserted vertically and shank held parallel to the
tooth surface. Ultrasonic scalers can be used to break
the granulation tissues
*Plastic plunger gun can be used for precise placement
of graft material
*Interproximal site can be closed by vertical mattress
sutures (6-0 resorbable suture).
78

72. *MINIMALLY INVASIVE PERIODONTAL SURGICAL
THERAPY: TECHNIQUES
*MIST- Cortellini and Tonetti in 2007.
*Later, they introduced the concept of space provision for
regeneration with the Modified MIST (M-MIST),
Cortellini et al. 2009.
79

73. 80
*Cortellini and Tonetti proposed a papilla preservation
flap in the context of a minimally invasive, high
power, magnification-assisted surgical technique, in
order to provide even greater wound stability and
protection and to limit patient morbidity further.
*MIST blended the concepts of MIS with the
application of papilla preservation techniques and the
use of passive internal mattress sutures.

74. *The papilla preservation technique, the modified papilla
preservation technique, and the simplified papilla
preservation flap are important elements in terms of MIPS
since they can guarantee minimal access to the periodontal
defect.
81

75. *Cortellini and Tonetti proposed the application of a
single MIS technique to treat multiple adjacent defects.
*The surgical modification includes an extension of the
flap to all the teeth involved by osseous defects.
*The larger flap is minimally reflected in accordance with
the previously described principles.
82

76. *The minimally invasive approach is particularly suited for
treatment in conjunction with biologically active agents,
such as amelogenins or growth factors, which are
eventually associated with grafting materials.
*After elevation of the interdental tissues, the buccal and
the lingual incisions are minimally extended mesial-
distally and the full-thickness flaps are minimally elevated
in order to expose just the coronal edges of the residual
bony walls.
83

77. *Periosteal incisions are never performed. Vertical
releasing incisions are placed in very few instances.
*The suturing approach is based on the use of a single
internal modified mattress suture. Additional sutures can
be applied to further increase primary closure, when
needed.
*All surgical procedures are performed with the aid of an
operating microscope or magnifying loops at 4–16×
magnifications.
84

78. MIST
Minimal buccal flap reflection and the elevation of the interdental
papilla according to the SPPF design provides full access to the 3-wall
intrabony component. 85

79. *More recently, Cortellini and Tonetti proposed M-MIST.
*The MIS and the MIST include the elevation of the
interdental papillary tissues to uncover the interdental
space, gaining complete access to the intrabony defect,
whereas the M-MIST proposes an approach in which the
access to the defect is gained through the elevation of a
small buccal flap, without elevation of the interdental
papilla.
86
M-MIST

80. * The surgical approach consists of a tiny interdental
access in which only buccal intrasulcular incisions are
performed and connected with a buccal horizontal
incision of the papilla performed as close as possible to
the papilla tip.
87

81. *The tiny buccal triangular flap is elevated to expose the
residual buccal bone crest.
*The papillary tissues are left untouched, carefully
preserving the supracrestal attachment apparatus to the
root cement of the crest-associated tooth.
88

82. *Access to the defect is gained through the tiny buccal
“window.”
*The soft tissue filling the defect (granulation tissue) is
sharply dissected from the papillary supracrestal
connective tissue and removed with mini-curettes.
*Then, the root surface is carefully debrided with
mini-curettes and power-driven air instruments avoiding
any trauma to the supracrestal fibers of the
defect-associated papilla.
89

83. *The palatal tissues are not surgically accessed.
*The suturing approach is based on the use of a single
internal modified mattress suture.
90

84. M-MIST
The interdental incision is slightly diagonal (SPPF-like approach).91

85. 92
*DISADVANTAGES:
*M-MIST cannot be applied to all periodontal defects.
*limited access to the diseased root surface.
*Whenever a defect extending to the lingual/palatal side
of a root is difficult to debride, the authors suggest
raising the papilla and performing a MIST approach.

86. *SINGLE- FLAPAPPROACH
*Novel, simplified, minimally-invasive surgical approach to
access intraosseous periodontal defects.
*The basic principle behind the SFA consists of the
elevation of a limited mucoperiosteal flap to allow surgical
access from either the buccal or oral aspect only,
depending on the main buccal or oral extension of the
lesion, and leaving the interproximal supracrestal gingival
tissues intact.
94

87. *A SFA based on a buccal flap provides better surgical
access for soft tissue management, root/defect
debridement, and suturing procedures compared to an
SFA with an oral approach
95

88. *ADVANTAGES:
(1)it may facilitate flap repositioning and suturing; the
flap can easily be stabilized to the undetached papilla,
thus optimizing wound closure for primary intention
healing.
96

89. *(2)By limiting the surgical trauma on the vascular supply
of the interproximal supracrestal soft tissues due to a
limited flap elevation, a faster wound-healing process,
particularly at the level of the incision line, is promoted.
(3)Minimize the post-surgery shrinkage of gingival tissues
and, therefore, limit the esthetic impairment of the patient.
97

90. *DISADVANTAGE:
A limited surgical access may potentially result in an
inadequate root/defect debridement and difficulty in
graft/membrane placement.
98

91. *SURGICAL PROCEDURES
*Sulcular incisions were made following the gingival
margin of the teeth included in the surgical area.
*Elevation of a buccal mucoperiosteal flap without vertical
releasing incisions:
*The mesio-distal extension of the flap was kept limited
while ensuring access for defect debridement.
101

92. *An oblique or horizontal butt-joint incision was made at
the level of the interdental papilla overlying the
intraosseous defect; the greater the distance was from the
tip of the papilla to the underlying bone crest, the more
apical (i.e., close to the base of the papilla) the buccal
incision was in the interdental area.
102

93. *However, the interdental incision was performed ≥1 mm
coronal to the underlying bone crest.
*This provided an adequate amount of pristine supracrestal
soft tissue connected to the undetached oral papilla to
ensure a subsequent flap adaptation and suturing and
permitted a proper surgical access to the intraosseous
defect.
*For each defect, a microsurgical periosteal elevator was
used to raise a flap on the buccal side only, leaving the oral
portion of the interdental supracrestal soft tissues
undetached.
103

94. *Root and defect debridement were performed using hand
and ultrasonic instruments.
*At the completion of the surgical debridement, defects
were left to fill with a blood clot.
*At the wound closure, a horizontal internal mattress suture
was placed between the buccal flap and the base of the
attached oral papilla to ensure the repositioning of the
buccal flap.
104

95. *A wound closure was achieved by means of a second
internal mattress suture (vertical or horizontal) that was
placed between the most coronal portion of the flap and
the most coronal portion of the oral papilla.
* When needed (i.e., in case of a large, thick interdental
papilla), an interrupted suture was performed to ensure the
primary intention healing at the incision line.
105

96. *Advantages of minimally invasive surgical techniques
in periodontal regeneration
• Less postoperative pain
• Improvement in rate of healing
• Chair time required to perform such a surgery is by far
shorter than the chair time required for more
conventional surgical approaches
• Improved retention of soft tissue height and contour
• Periodontal tissue regeneration
• Good patient acceptance.
106

97. Disadvantages
• Technique sensitive
MIS needs improved instruments for root and osseous
defect debridement, “micro” versions of the instruments
• Expensive
• Cannot be universally applied, only in suitable cases
technique can be performed.
107

98. CURTAIN PROCEDURE
*In 1967, Frisch and colleagues developed a surgical
technique that permitted conservation of the maxillary
anterior esthetics.
*Modified Surgical Approach for Maxillary Anterior
Esthetics
108

99. *Attempts to preserve all labial attached gingiva, even the
labial third of the interproximal papillae.
*It was based on their finding that even in the presence of
interproximal disease, a healthy midlabial sulcus can exist
with healthy labial tissue.
*Lie (1992) described the advantages and methodology of
this procedure, which he termed the MODIFIED
RESECTIVE TECHNIQUE.
109

100. *INDICATION
*Gingival tissue appears to be clinically healthy (firm, pink,
and stippled), with a midlabial sulcus depth ≤ 4 mm, even
when deep interproximal pockets are present.
*This technique appears to satisfy all of the necessary
criteria for treating the maxillary anterior teeth if esthetics
are a problem.
110

101. Procedure
*The incisions are designed for maximum conservation of
the facial gingiva and at least one-third of each of the
labial papillae.
*The initial incisions are made with a no. 11 or no. 15
scalpel blade.
*Palatally, either a beveled gingivectomy or a partial-
thickness palatal flap procedure can be performed.
112

102. *The blade is directed interproximally at right angles to
the teeth from both the mesial and distal directions.
*This intersecting incision separates the labial one-third
of the papilla, which, combined with the labial tissue,
forms the tissue curtain. No further labial surgery is
required.
113

103. *Palatally, the need for osseous surgery determine whether
a gingivectomy or flap procedure is used.
*Even though gingivectomy is faster and simpler; if the
bony craters can be ramped palatally, plaque control will
be facilitated.
*Final suturing, can be interrupted or continuous.
114

104. *In this technique, the buccal two-thirds of the
interproximal papillae are still retained to prevent
shrinkage, and there is no need to release or reflect the
papilla from the buccal surface.
*Minimal amount of labial recession even though
significant recession occurs palatally
115

105. CURTAIN PROCEDURE
116Sulcular interdental
incisions maximize the buccal two-thirds of the papillae.

106. 117
Scalloped palatal
incision for flap
preparation
G. Flap reflected and secondary inner flap removed. H, Osseous surgery completed

107. 118After 4 months. minimal reduction of buccal tissue
and esthetic result.

108. *Advantages
1. Conservative
2. Esthetically acceptable
3. Technically simple and easy to do
4. Maintains phonetics, with normal speech
*Disadvantages
1. Some labial shrinkage is unavoidable.
2. Oral physiotherapy is more difficult because
of tissue craters.
119

109. CONCLUSION
*One of the most distressing aspects of periodontal
surgery is the unesthetic maxillary anterior results
obtained after definitive surgical pocket elimination
therapy.
*The elongation of the crowns with greater root
exposure and an increase in interproximal spacing
results in a totally unacceptable picket-fence
appearance, with varying degrees of speech difficulty.
120

110. *It is important to respect papillary integrity during
periodontal surgical therapy.
*Papilla preservation flap method not only maintains
esthetic value but is a better approach for interproximal
regenerative procedures.
*Flap design appear of paramount importance to maximize
the reconstructive potential of membrane, graft
biomaterials, and biological agents.
121

111. *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.
122

112. *MIS has a future potential to become a mainstream and
eventually, the dominant therapeutic approach.
*The combination of positive scientific evidence and
advances in technology will allow rapid advancement in
the field of minimal invasive surgery.
123

113. REFERENCE
*Newman, Takei, Klokkevold, Carranza- Clinical
Periodontology.12th ed. Elsevier publication; 2015.
*Cohen E. Cosmetic and reconstructive periodontal surgery,3rd Edi,
p.103
*Takei H.H, Han T.J, Carranza F.A, Kenney E.B Jr., and Lekovic V.
Flap technique for periodontal bone implants. Papilla preservation
technique. J Periodontol 1985; 56; 204-210.
*Cortellini P, Pini Prato G, Tonetti M. The modified papilla
preservation technique. A new surgical approach for interproximal
regenerative procedures. J Periodontol 1995:06:261-266.
*Lisa N. Chacko, Sathish Abraham, Nilima Landge, Fareedi
Mukram Ali. Papilla Preservation Flap : Revisited. Journal of
dentofacial sciences, 2013; 2(4): 45-48).124

114. *Luigi Checchi, Marco Montevecchi, Vittorio Checchi,
DDS2/Giulio Alessandri Bonetti. A modified papilla preservation
technique, 22 years later. Quintessence international (Berlin,
Germany: 1985) May 2009.
*Bianchi A.E, Bassetti A. Flap Design for Guided Tissue
Regeneration Surgery in the Esthetic Zone: The “Whale’s Tail”
Technique. Int J Periodontics Restorative Dent 2009;29(2)
*Leonardo Trombelli & Roberto Farina. Flap designs for periodontal
healing. Endodontic Topics 2012, 25, 4–15.
*Serhat Aslan , Nurcan Buduneli. Entire papilla preservation
technique: A novel surgical approach for regenerative treatment
of deep and wide intrabony defects. Italian Society of
Periodontology and Implantology March 2015.
125

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*THANKYOU..