The Double Papillae
formation is absent or minimal in the proximal areas,
Repositioned Flap in
Periodontal Therapy
by
D . W A L T E R C O H E N , * D.D.S.
S T A N L E Y E . R O S S , * * D.D.S.
THE EXPERIENCES OF many clinicians in the past decade
have demonstrated that the restoration of a destroyed
gingival unit about a tooth has become a more predict-
able therapeutic expectation. The several wound healing
studies in this area have influenced the clinical tech-
niques and made their objectives more realistic. Interest
has centered principally on the repair of gingival tissue
about roots of teeth where denudation and exposure of
tooth surfaces has occurred. The laterally repositioned
flap or the pedicle flap from an edentulous donor area
are techniques which have described the use of an adja-
cent donor site. These methods of gingival repositioning
have required a width of gingiva equal to or slightly
greater than the tissue missing at the recipient site.
Frequently a sufficient amount of gingiva is not present
on an adjacent tooth or the gingiva present in a nearby
area is inflamed which decreases the possibility of suc-
cessful replacement of the lost gingival unit. A plastic
and reconstructive surgical approach which has success-
fully demonstrated the restoration of lost gingiva is the
double papillae repositioned flap. The purpose of this
paper will be to review the indications, objectives and
technique of this form of gingival repositioning.
INDICATIONS
The double papillae repositioned flap procedure ap-
pears to be quite useful when there has been recession of
the labial or lingual gingiva, but destruction of the inter-
dental papillae on either side of the denuded area has
not occurred. Recession of this type is observed in areas
where trauma from incorrect toothbrushing has de-
stroyed the gingiva and cleft formation develops. This
pattern of gingival recession is noted on the labial or
buccal surfaces of roots where the involved tooth is in
labial version to the approximating teeth. Prominent
muscle attachments or frena may play a role in causing
or perpetuating clefts of this type. Occasionally gingival
recession may follow orthodontic movement and root
exposure becomes apparent. If the interdental papillae
*Professor and Chairman, Department of Periodontics, Uni-
versity of Pennsylvania, School of Dental Medicine, Philadel-
phia, Pa.
**Associate in Periodontics, University of Pennsylvania,
School of Dental Medicine, Philadelphia, Pa.
Page 5/65
adjacent to the area of recession are intact and pocket
then the clinician can consider joining both papillae to-
gether to form a flap which will repair the area of root
exposure. The restoration of the gingival unit is advan-
tageous not only from the cosmetic standpoint but also
from a functional aspect. A n adequate zone of gingiva
protects the root surface from damage via the toothbrush
or from dental caries. It is a clinical belief that restoring
lost gingiva also helps prevent further mucogingival com-
plications in that site. This plastic and reconstructive
surgical technique can also aid in the treatment of root
sensitivity. Covering the exposed root surface with gin-
giva has helped reduce or eliminate the problem of
hypersensitivity. This procedure may also permit the
covering of the margin of a restoration which has been
exposed by recession.
A t times, the clinician has the choice in his therapeutic
approach to the repair of a denuded tooth. If the adja-
cent gingival unit is healthy and the interdental papillae
are also healthy, then the therapist could select either
the laterally repositioned flap or the double papillae re-
positioned flap. There are advantages in choosing the
double papillae flap procedure over the laterally reposi-
tioned flap. One benefit to the double papillae procedure
is the minimal exposure of underlying periodontium at
the interdental donor sites. The wound healing studies
show that the interdental alveolar process is less suscep-
tible to permanent damage after surgical exposure than
the labial or buccal plates of bone. It is imperative that
the treatment procedure does not result in a deformity at
the donor site and since the interdental septa of bone
are thicker than the buccal and labial plates, the chances
of a defect at the donor areas after the double papillae
repositioned flap are less than after the laterally reposi-
tioned flap. Since the exposure of underlying tissues are
kept to a minimum in the double papillae flap, the healing
at the donor sites is much more rapid and postoperative
sequelae are reduced. Another advantage to the double
papillae approach is the reduction of tension and pull
on the repositioned flap, because a single flap does not
have to be pulled from one root surface over to cover
another. There also seems to be less chance to embarrass
the vascularity in a double papillae flap, since each indi-
vidual papilla has its own blood supply; while in the
laterally repositioned flap, a single pedicle carries the
vascular source for the entire flap. Another advantage to
the double papillae technique is the greater amount of
gingiva in the interdental locations than on the adjacent
labial or buccal surfaces. Since there is a natural rise to
the interdental tissue following the cervical line of the
tooth, the zone of attached gingiva is usually greater
when the two papillae are brought together than when
one uses the labial or buccal gingival tissue from an
adjacent tooth. The interdental papillae are usually
thicker gingival tissues than the labial or buccal gingival
Page 6 / 6 6 C O H E N AND ROSS

and there is less risk of necrosis and loss of the flap

when papillae are used over the labial surface.

We have utilized the double papillae repositioned flap

for the past five years and have had the opportunity to
observe the results of this method of restoring a de-
stroyed gingival unit.

TECHNIQUE OF T H E D O U B L E PAPILLAE
REPOSITIONED F L A P

Transplanting masticatory mucosa may be accom-

plished by completely detaching a portion of tissue from
its donor site and transferring it to a host bed where it
acquires a new blood supply. In contrast, the double
papillae repositioned flap is a method of transplanting
tissue by using two interdental pedicle flaps. These flaps
consist of a portion of attached gingiva which is raised
from the donor site but left attached to the surrounding
mucosa by a bridge of tissue known as the pedicle of
the flap.

A description of the double papillae repositioned

transplant will follow with reference to design, donor
site, preparation of the recipient site, suturing technique
utilized to maintain the graft in position, placement of
dressing to insure immobilization of the graft and causes
of failure.

The procedure is designed to give access to the mas-

ticatory mucosa in the interdental space which then
may be utilized as a graft to the radicular surface of
the denuded tooth.

Initial preparation of the recipient area constitutes an

essential phase of treatment. It consists of (1) scaling
and root planing, (2) tooth movement if necessary,
(3) instruction in oral physiotherapy, (4) temporary
stabilization, (5) definitive occlusal adjustment and (6)
elimination of as many of the local environmental fac-
tors as possible.
The benefits one may gain in initial preparation should
be stressed. Scaling and root planing prior to surgical
techniques may reduce the inflammatory process, change
the quality of the tissue for ease of manipulation, confine
the necessary surgical technique to a more limited area,
provide a wider band of gingiva to utilize than existed
prior to the removal of the deposits and possibly negate
the need for a surgical procedure. B y eliminating occlu-
sal interferences, providing temporary stabilization, and
employing tooth movement procedures to place the tooth
in correct axial position, we are developing an environ-
ment which is more conducive to healing.
Tissue grafts over the convex contour of the tooth
should be firmly and evenly supported if a good "take"
is to be assured. Stabilization of a mobile tooth will
afford the therapist an environment with minimal ten-
sion on the coapted structures. The problem of tooth
FIGURE 1. Denuded mandibular canine. A: Defect extends
into alveolar mucosa. B: Arrow denotes "V" shaped wedge
which will be removed, providing minimal area to be cov-
ered at the recipient site and, therefore, minimum exposure
at the donor region. C: Depicts recipient and donor sites
prepared by partial thickness dissection. Note entire area
covered with periosteum. D: Approximation of donor tissue
at recipient site. E: Precise joining of tissue edges with 6-0
black silk suture insuring primary healing. F: After coapta-
tion, 4-0 suspensory type suture placing margin of the tissue
above the cementoenamel junction. G: One-week healing.
H: Six-months healing.
position may be of prime importance if a situation is
created by a malpositioned tooth which would cause an
exaggerated amount of tension on the graft. This may
well be the cause of a graft failure with teeth that are
in extreme buccal or lingual version. In addition to the
possible undue tension on the graft, one must be con-
cerned with the availability of revascularization sites.
Adequacy of blood supply is paramount to the healing
of any wound and, therefore, the proximity of the adja-
cent periodontal ligaments must be considered. If the
tooth is in extreme buccal version, the tissue may have
to be dependent upon the base of the graft as its sole
 D O U B L E PAPILLAE F L A P
FIGURE 2. Diagrammatic representation of double papillae
repositioned flap utilizing cut-back incisions. A: Original
defect. B: (A) and (B) are the potential donor sites. (D) il-
lustrates the area that will be exposed after "V" shaped
wedge is removed. Note that the vertical incisions are made
so the radicular surfaces of adjacent teeth are not violated. apico-coronal path, paralleling the plane of the alveolar
The cut-back incision (CB) is extended in the direction to
which the graft will be moved. This will relieve undue ten- distal direction at the tip of the interdental papilla. These
sion on the graft. C: Demonstrates complete coaptation
with 6-0 suture material (S) on labial surface with a 4-0
suspensory suture keeping tissue in a coronal position. D:
Healing of the denuded tooth without scar formation at the
donor sites. These diagrams relate to the case shown in
Figure 5.
source of vascularization. Tooth repositioning will not
only eliminate a possible etiologic factor where food
impaction and food retention are concerned, but also
will produce a situation where the graft tissue will be
under less stress and may assure a greater blood supply
during repair.
Oral physiotherapy further eliminates materia alba,
food debris and bacterial plaque which contribute to the
inflammatory process. In addition, faulty toothbrushing
not only may cause abrasion or recession of the gingiva,
but could possibly foster an inflammation already in
process. Hirschfeld pointed out the following problems
one faces when faulty toothbrushing is coupled with ana-
tomic abnormalities:
1. Malposition of individual teeth: as a tooth protrudes
buccally to the arch, to such a degree do its investing tissues
over the protruding part take on greater pressure per unit
area.
2. Alveolar deficiency : over teeth so protruding that there
is usually a corresponding alveolar deficiency: clinical ob-
servation seems to confirm the theory that when exposed to
similar mechanical traumatization gingiva covering a root
surface directly is affected much more rapidly than that
covering the alveolar process.
By this totality of therapeutic measures we are at-
tempting to provide a predictable clinical procedure and
eliminate the possibility of recurrence of the lesion.
Page 7 / 6 7
Using a Bard Parker # 1 5 blade or a Castroviejo
blade-breaker knife, an incision is made so that a " V "
shaped wedge for marginal tissue may be removed ad-
jacent to the recipient site (Fig. l b ) . This provides a
fresh wound surface for approximation and removes the
surrounding ulcerated crevicular epithelium. B y creating
a " V " shaped wedge rather than a square type wedge
less tissue is removed at the base. This establishes a
minimal area to be covered at the recipient site and
minimum exposure at the donor region.
Preparation of the donor sites for a partial thickness
graft consists of vertical incisions at the line angles of
the adjacent teeth (Fig. 1 b ) . These vertical incisions,
which extend into the alveolar mucosa, are produced in
an oblique manner so that the base of the graft is
broader than its margin. Upon completion of the ob-
lique incisions, the Bard Parker or Castroviejo blade is
inserted into the underlying submucosa in a horizontal
manner and the direction of the knife proceeds in an
process. A horizontal incision is then made in a mesio-
horizontal and vertical incisions will meet, leaving con-
nective tissue and periosteum attached to the alveolar
process when the flap is elevated (Fig. 1 c ) . The same
procedure is performed on both sides of the denuded
root surface in the interdental areas. The two interdental
flaps (partial thickness), which are now movable, may
be accurately positioned at their future recipient sites
(Fig. 1 d ) . However, if this is not possible a cut-back
incision (Fig. 2b) is extended in the direction to which
the graft will be moved. This negates any tension on the
graft.
Both grafts are approximated and a 4-0 and 6-0 black
silk suture material may be used. Precise approximation
of tissue edges insures primary healing with minimal dis-
comfort. The grafts are sutured together by starting at
the base with 6-0 sutures and proceeding in a coronal
direction. After complete coaptation is accomplished,
the graft is then placed at or slightly occlusal to the
cementoenamel junction with a 4-0 suspensory type
suture (Fig. 2c). This is achieved by passing the needle
in the buccolingual direction, grasping the tip of the
medial papilla and tying. The free end is then passed
interproximally and around the lingual or palatal surface
of the tooth involved, leaving a sufficient amount of
suture material to tie the suture on itself. The needle
then passes to the buccal surface, the distal margin of
the graft is engaged and the suture is returned to the
lingual or palatal surface and tied. This method affords
the therapist the benefit of not having a suspensory su-
ture between graft and the tooth.
Before periodontal dressing is placed, the tissue is
adapted to the recipient site with a warm moist cotton
Page 8/68 C O H E N AND Ross
FIGURE 3. Cleft formation on a maxillary canine in slight
labial version. A: Upon clinical probing, defect extended
beyond mucogingival junction. B: After joining the donor
tissue and placing it coronal to the cementoenamel junction.
Note close adaptation and hemostasis achieved by applying
a warm, moist cotton pad. This is advantageous for healing.
C: Healing one year postoperative. Original defect is cor-
rected with a significant increase in amount of attached gin- patient. Postsurgical discomfort is minimal. The sutures
giva.
pad. This allows the double papilla graft to remain
against the tooth surface with a minimal amount of ex-
travasation interposed between the tissue and tooth
(Fig. 3 b ) . Pressure is essential to assist in the elimina-
tion of dead space between the tooth and graft, and also
FIGURE 4. Diagrams relating to case described in Figure 3.
A: Cleft formation. B: Vertical and "V" shaped wedge in-
cisions, indicating area covered with periosteum (P). Note
that this area was treated without the use of a cut-back in-
cision. C: Suturing of tissue at recipient site (A) and (B).
D: Healing one year postoperative.
FIGURE 5. Cleft formation extending into mucogingival
junction and complicated by frenum pull. A: Clinical probe
showing minimal attached gingiva and depth past the muco-
gingival junction. Arrow denotes frenum pull. B: Arrow
pointing out additional problem of minimal vestibular
depth. C: Tissue sutured in place. D: Healing eight months
postoperative with correction of muscle pull and increased
vestibular depth.
may prevent the formation of a hematoma under the
portion of the flap supported by periosteum or bone.
The usual postoperative instructions are given to the
are removed and the dressing changed in one week. N o r -
mally, by the second week healing has progressed suffi-
ciently so that no further dressing is necessary.
Our clinical experiences with this procedure over the
past five years have resulted in more than 85 percent
success in repairing denuded root surfaces. Though the
 D O U B L E PAPILLAE F L A P
FIGURE 6. Post-orthodontic therapy with resultant cleft
formation on the mandibular first and second premolars.
A: Defect in premolar region. B: Removal of wedge at the
recipient site. C: Utilization of the interdental septal tissue
between the premolars as donor tissue for both the first and
second premolars. This is accomplished by splitting this
interdental tissue, moving one portion medially and the
other distally. Arrow points out a hazard which can de-
velop if a gauze fiber is allowed to become incorporated
with the donor tissue. D: Healing two years postoperative.
FIGURE 7. Cleft formation on maxillary right premolars
similar to the case described in Figure 6. However, the eti-
ology is one of toothbrush abrasion, and the defect was
corrected in two stages. The first premolar was treated
and after healing of the interdental tissue, the same donor
site was utilized for correction of the second premolar. A:
Cleft formation in maxillary premolar area. B: Initial inci-
sions for correction of cleft on first premolar. C: Donor
tissue in place. D: Healing one year postoperative.
depth of the gingival sulcus on postoperative probing
averages about 1 mm., we do not have histologic ma-
terial to demonstrate the mode of attachment of this
type of flap.
The authors are grateful to Dr. J. George Coslet, Assistant
Professor of Periodontics at the University of Pennsylvania, for
the drawings he made for the paper.
Page 9/69
FIGURE 8. Denuded mandibular left central incisor with the
frenum as a complicating factor. A: Defect on mandibular
left central incisor. B: Initial wedge of tissue removed. C:
Vertical incisions at line angles of adjacent teeth. Arrow
points out frenum being used as part of donor tissue. D:
Tissue brought in place. E: One-week healing. F: Two-year
healing. G: This represents a five-year healing of the
double papillae repositioned flap. Note that clinical probe
demonstrates I mm. of sulcus depth.
BIBLIOGRAPHY
1. Ariaudo, A . and Tyrell, H . : Repositioning and increas-
ing the zone of attached gingiva. J. Periodont., 28:106,
1957.
2. Ariaudo, A . : Problems in treating a denuded labial
root surface of a lower incisor. J. Periodont., 37:274, 1966.
3. Baer, P. N . , Sumner, C . F . and Segliamo, J . : Studies
on a hydrogenated fat-zinc bacitracin periodontal dressing.
Oral Surg., Oral Med. and Oral Path., 13:494, 1960.
4. Beube, F . E . : Interdental tissue resection, an experi-
mental study of a surgical technique which aids in repair of
periodontal tissues to their original contour and function.
Annual J. Orthodontics and Oral Surg., 33:497, 1947.
5. Bowers, G . : A study of the width of attached gingiva.
J. Periodont., 34:201, 1963.
6. Bradley, R., Grant, J. and Ivancie, G . : Mucogingival
surgery. Oral Surg., Oral Med. and Oral Path., 12:1184,
1959.
7. Carranza, F . A . , Jr. and Carraro, J. J . : Effect of re-
moval of periosteum on post-operative results of mucogin-
gival surgery. J. Periodont., 34:332, 1963.
Page 10/70 C O H E N AND Ross
8. Chacker, F . M . and Cohen, D . W.: Regeneration of
gingival tissues in non-human primates. J. D. Res., 39:743,
1960 (abstract).
9. Corn, H . : Technique for repositioning the frenum in
periodontal problems. D . Clinics of No. America, p. 79,
March, 1964.
10. Corn, H . : The use of pedicle grafts from edentulous
areas in periodontal surgery. Presented before the American
Society of Periodontists, June 19, 1964, Swampscott, Mass.
11. Corn, H . : Edentulous area pedicle grafts in muco-
gingival surgery. Periodontics, 2:229, 1964.
12. Dahlberg, W . : Consideration for periodontal flap.
Selection and flap management. Presented before the Amer-
ican Society of Periodontists, June, 1966, Chicago, 111.
13. Friedman, N . : Mucogingival surgery. Texas D. J.,
75:358, 1957.
14. Goldman, H . and Cohen, D . W.: Periodontia, ed. 4.
St. Louis, C . V . Mosby Co., 1957.
15. Goldman, H . , Schluger, S., Fox, L . and Cohen, D.
W.: Periodontal therapy, ed. 3. St. Louis, C. V . Mosby Co.,
1964.
16. Gottsegen, R.: Frenum position and vestibular depth
in relation to gingival health. Oral Surg., Oral Med. and
Oral Path., 7:1069, 1954.
17. Gottsegen, R.: Should the teeth be scaled prior to
surgery? J. Periodont, 32:301, 1961.
18. Grupe, H . E . and Warren, R. F . : Repair of gingival
defects by a sliding flap operation. J. Periodont., 27:290,
1956.
19. Grupe, H . E . : Horizontal sliding flap operation. D.
Clinics of No. America, p. 43-46, March, 1960.
20. Grupe, H . E . : Modified technique for the sliding flap
operation. J. Periodont., 37:491, 1966.
21. Helburn, R. L . , Cohen, D . W. and Chacker, F. M . :
Healing of repositioned mucogingival flaps in monkeys.
I.A.D.R. Abstracts, March, 1963.
Hirschfeld, I.: The toothbrush, its use and abuse. New
York, Dental Items of Interest Co. 1939.
Abstracts
MITOTIC ACTIVITY AND C E L L DENSITIES IN GINGIVAL
EPITHELIUM OF RATS
Hansen, E . R.
Odont. tskr. 75:28, 1967
The present study was an extension of a previous investigation
of mitotic activity of gingival epithelium of colchicinized rats.
The aims were to investigate a possible relationship between
cell density, cell layer thickness, keratin layer thickness and mi-
totic activity of the attached and free gingiva. The following
observations were made: the attached gingiva had greater cell
density, greater cell layer thickness, thinner keratin layer and
lower mitotic activity than the free gingiva: there were no age
changes in cell density, cell layer or keratin layer thickness. The
suggestion is made that cell density and keratin layer thickness
of the gingival epithelium are not related to mitotic activity.
Department of Periodontology and Oral Pathology, Royal Den-
tal College, Copenhagen.
22. King, K . and Pennel, B. M . : Evaluation of attempts
to increase the width of attached gingiva. Presented before
the Philadelphia Society of Periodontology, April 15, 1964.
23. Nabers, C. L . , Spear, G . R. and Beckham, L . C :
Alveolar dehiscence. Texas D. J., 78:4, 1960.
24. Ochsenbein, C : Newer concepts of mucogingival
surgery. J. Periodont., 31:175, 1960.
25. Pennel, B. M . , Higgason, J. D., Towner, J. D., King.
K. O., Fritz, B. D. and Sadler, J. F . : Oblique rotated flap.
J. Periodont., 36:305, 1965.
26. Pennel, B. M . , Higgason, J. D., Towner, J. D., King,
K . O., Fritz, B. D. and Sadler, J. F . : Retention periosteum
in mucogingival surgery. J. Periodont., 36:39, 1965.
27. Pfeifer, J. S.: The growth of gingival tissue over de-
nuded bone. J. Periodont, 34:10, 1963.
28. Pfeifer, J. S.: The reaction of alveolar bone to flap
procedures in man. Periodontics, 3:135, 1965.
29. Robinson, R. E . : Mucogingival junction surgery. J.
Calif. S.D.A. and Nevada S.D.A., 33:379, 1957.
30. Rosenberg, M . M . : Vestibular alterations in perio-
dontics. J. Periodont, 31:231, 1960.
31. Staffileno, H . : Management of gingival recession and
root exposure problems associated with periodontal disease.
D. Clinics of No. America, p. 111, March, 1964.
32. Staffileno, H . , Levy, S. and Gargiulo, A . : Histologic
study of cellular mobilization and repair following a peri-
osteal retention operation via split thickness mucogingival
flap surgery. J. Periodont., 37:117, 1966.
33. Stahl, S. S., Cantor, M . and Zwig, E . : Fenestrations
of the labial alveolar plate in human skulls. Periodontics,
1:199-102, 1963.
34. Wainberg, A . : Personal communication, 1963.
35. Wilderman, M . M . , Wentz, F . M . and Orban, B. J . :
Histogenesis of repair after mucogingival surgery. J. Perio-
dont, 31:283, 1960.
36. Wilderman, M . M . : Exposure of bone in periodontal
surgery. D. Clinics of No. America, p. 23, March, 1964.
ENZYMATIC ACTIVITY IN THE INCISOR AND MOLAR
REGIONS OF THE GUINEA PIG
Charreau, E . H., Kofoed, J. A. and Houssay, A. B.
J. Dent. Res. 46:241-244, 1967
The activities of lactic, isocitric, and glucose-6-phosphate de-
hydrogenases, malic dehydrogenase and glutamic oxaloacetic
transaminase were studied in gingiva and periosteum from the
incisor and molar regions of guinea pigs. The periodontal tissues
of both regions showed high activity of the five enzymes studied.
The activity of these enzymes was significantly higher in the
periosteum of the incisor than of the molar region, whereas, no
significant differences were found between the gingival samples
of both regions. The greater rate of growth of the continuously
erupting incisors is suggested as a possible explanation for the
differences in enzymatic activities in periosteum. School of Den-
tistry, University of Buenos Aires, Buenos Aires, Argentina.