The International Journal of Periodontics & Restorative Dentistry

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 227

Entire Papilla Preservation Technique:

A Novel Surgical Approach for
Regenerative Treatment of Deep and
Wide Intrabony Defects
Serhat Aslan, DDS, PhD1 Regeneration of lost periodon-
Nurcan Buduneli, DDS, PhD2 tal tissues is the ultimate target of
Pierpaolo Cortellini, MD, DDS3 periodontal treatment. In the early
1980s, Nyman et al1 demonstrated
for the first time new attachment for-
mation using guided tissue regen-
Primary wound closure and uneventful early wound stability over the biomaterials eration (GTR). Both resorbable and
are the most critical elements of successful periodontal regeneration. Yet the nonresorbable barrier membranes
surgical elevation of the interdental papilla to access deep and wide intrabony have been successfully used to ob-
defects entails an impairment of the papillary blood supply that can result in
tain periodontal regeneration. In the
difficult healing due to a lack of primary closure in the early healing period.
This negative event might complicate the healing process, favoring bacterial last three decades, different types of
contamination. A novel modified tunnel surgical technique designed to maintain biomaterials have been investigated
the integrity of the interdental papilla is presented in this article, with the for the same purpose. Use of bar-
aim of providing an optimal environment for wound healing in regenerative rier membranes in combination with
procedures. Entire papilla preservation is described and applied in three bovine-derived bone substitutes has
different cases, in association with the use of a combination of bone substitutes
been suggested to form new ce-
and enamel matrix derivative for periodontal regeneration. The entire papilla
preservation technique was successfully applied to the three selected cases, mentum, new periodontal ligament,
resulting in an uneventful postsurgical period and a substantial defect fill and new alveolar bone.2
over the 8-month follow-up. This tunnel-like technique can be recommended Since the first study by Heijl,3
for further research to support the success identified in this case series. Int J enamel matrix derivative (EMD) has
Periodontics Restorative Dent 2017;37:227–233. doi: 10.11607/prd.2584 attracted great interest in the re-
search for periodontal regeneration.
Human histologic studies have shown
that EMD application enhances for-
mation of new acellular cementum,
periodontal ligament, and alveolar
bone.4 Controlled clinical studies re-
vealed comparable outcomes with
EMD application or GTR in the treat-
Clinical Instructor, Ege University, School of Dentistry, Department of Periodontology,
1 ment of intrabony defects.5–8
İzmir, Turkey. Regenerative therapeutic out-
2Professor, Ege University, School of Dentistry, Department of Periodontology, İzmir, Turkey.
comes are affected by various
3Accademia Toscana di Ricerca Odontostomatologica (ATRO), Florence, Italy;

European Research Group on Periodontology (ERGOPERIO), Berne, Switzerland.

factors, such as plaque control,
percentage of bleeding on prob-
Correspondence to: Dr Serhat Aslan, Department of Periodontology, School of Dentistry, ing, location and morphology of
Ege University, 35100 – Bornova, İzmir, Turkey. Fax: +90 232 388 03 25.
the defect, smoking habit, and ex-
Email: dt.serhataslan@gmail.com
posure of the barrier membrane.9–12
 ©2017 by Quintessence Publishing Co Inc. Membrane exposure may lead to

Volume 37, Number 2, 2017

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
228
bacterial contamination in the sur-
gical area and deteriorate the peri-
odontal regeneration process,
particularly in the interproximal
site.13,14 Different surgical procedures
have been proposed to preserve
the interdental papillary structure
during the early and late phases of
wound healing to prevent contami-
nation of the regenerating area and
subsequent wound failure.15–19 These
procedures, especially the novel
minimally invasive techniques,18–20
aim to provide greater stability to
the blood clot to enhance the regen-
erative potential. All the above-men-
tioned techniques, however, entail
an incision of the defect-associated
interdental papilla that may jeop-
ardize the volume and integrity of
interdental tissues. Azzi et al21 pro-
posed a pouch-and-tunnel tech-
nique for bone regeneration. This
technique focuses on ensuring the
integrity of interdental papillae.
This clinical report describes a
novel tunnel-like surgical approach,
the entire papilla preservation tech-
nique, for the regenerative treatment
of deep and wide intrabony defects.
The completely preserved interden-
tal papilla is meant to stabilize the
blood clot and improve the wound-
healing process. Full access to the
defect is provided with one buccal
vertical releasing incision and the el-
evation of a short flap on the buccal
side of the defect-associated tooth.
EMD and bone substitutes are ap-
plied in the debrided defect to pro-
mote periodontal regeneration.
The International Journal of Periodontics & Restorative Dentistry
© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Clinical Report
Three systemically healthy patients
were included in this clinical report.
Their chief complaints were bleed-
ing and slight mobility of the tooth
affected by periodontal disease.
Initial cause-related therapy was
performed to reduce the inflamma-
tion of the periodontal tissues. Re-
storative or endodontic treatments
were performed as required. The
patients were reevaluated 3 months
after completion of these treatment
procedures. Surgical interventions
were scheduled at this reevaluation
session due to persistence of the
pocket and the associated deep in-
trabony component (Figs 1 and 2).
Clinical periodontal param-
eters were recorded at baseline,
3 months after completion of the
nonsurgical periodontal therapy.
Final clinical outcomes were record-
ed 8 months after the regenerative
periodontal surgery. Experimental
sites were accessed with the entire
papilla preservation technique and
debrided. Intraoperative measure-
ments and defect characterization
were made during the surgery. Eth-
ylenediaminetetraacetic acid (EDTA)
gel (PrefGel, Straumann) and EMD
(Emdogain, Straumann) were ap-
plied on the biologically compatible
and air-dried root surface. Porcine-
derived bone substitutes (Gen-Os,
OsteoBiol) were placed into the de-
fect, and the flap was sutured with
simple interrupted sutures.
Surgical Technique
The surgical site was anesthe-
tized using articaine-epinephrine
1:100,000. Transpapillary infiltration
was avoided to prevent physical
(needle penetration) and chemical
(prolonged vasoconstriction) trauma
to the gingival tissues. Bone sound-
ing was performed after anesthesia.
The entire papilla preservation
technique is a tunnel-like approach
to the defect-associated interdental
papilla. A ×3.3 magnifying loupe
was used to increase visibility of the
surgical site. Following a buccal in-
tracrevicular incision, a beveled ver-
tical releasing incision was made in
the buccal gingiva of the neighbor-
ing interdental space and extended
just beyond the mucogingival line to
provide appropriate mechanical ac-
cess to the intrabony defect (Fig 1b).
In the presence of a malpositioned
tooth with a narrow neighboring
interdental space, the vertical inci-
sion was shifted one tooth away
from the actual incision line. Particu-
larly for narrow interdental papilla,
an oblique interdental incision was
made, followed by an intrasulcular in-
cision directed to the adjacent tooth.
The vertical releasing incision was
then performed (Fig 2b). A microsur-
gical periosteal elevator was used to
elevate a buccal full-thickness muco-
periosteal flap extending from the
vertical incision to the defect-asso-
ciated papilla. A specially designed
angled tunnel elevator facilitated the
interdental tunnel preparation under
the papillary tissue. Utmost care was
taken to elevate the interdental pa-
pilla full thickness up to the lingual
bone crest. A microsurgical scissor
 229

a b c

Fig 1  Representative case 1. (a) Mandibular

right canine with 18 mm of pocket depth.
(b) Full access to the defect with the
entire papilla preservation technique.
(c) Primary wound closure of the surgical
site following the application of EMD and
bone substitutes. (d) Excellent early wound
healing at 10 days. (e) Probing depth of
3 mm obtained at 8 months. (f) Baseline
radiograph. (g) 8-month radiograph. Note
the complete resolution of the extremely
deep intrabony defect.

d e

f g

was used to remove the granula-
tion tissue from the inner aspect of
the interdental papilla. Excessive
thinning of the papilla was avoided
so as not to compromise the blood
supply. The granulation tissue was
removed with a mini-curette (Fig 2c).
Any residual subgingival plaque or
calculus was gently removed from
the exposed root surface with an ul-
trasonic scaler. The surgical area was
rinsed with sterile saline, and root
conditioning of the exposed surface
was done by applying 24% EDTA gel
for 2 minutes to remove the smear
layer (Fig 2d). The exposed root
surface was then rinsed with sterile
saline, and EMD was applied on the
exposed root surface (Fig 2e). Sub-
sequently, a deproteinized porcine-
derived bone substitute was placed

Volume 37, Number 2, 2017

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
230

a b c

d e f

g h i

j k l
Fig 2  Representative case 2. (a) Preoperative probing depth of 12 mm at the mesial side of the mandibular right central incisor. (b) Same
site after elevation of tunneled interdental papilla. Note the elasticity of alveolar mucosa and proper mechanical access to the defect
area with the help of a vertical releasing incision. (c) Gentle removal of granulation tissue over the alveolar bone. (d) Application of 24%
EDTA gel for 2 minutes to remove the smear layer from the exposed root surface. (e) EMD application. (f) Placement of deproteinized
porcine-derived bone substitute into the intrabony defect. Note that overfill of the defect is avoided. (g) Closure of surgical area using 7-0
polypropylene suture material and microsurgical knots. Note the integrity of interdental papilla. (h) Excellent wound healing was seen 1
week after surgery. (i) At 8 months postsurgery, 4.5 mm of probing depth was measured. A 0.5-mm vertical loss of interdental papilla was
calculated by comparing standardized photographs. (j) Initial radiograph before endodontic treatment. (k) Radiograph taken 3 months after
endodontic treatment. Note the apical bone healing. (l) Radiograph taken 8 months after surgery. Substantial regeneration can be seen.

The International Journal of Periodontics & Restorative Dentistry

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 231

into the intrabony defect and care

Table 1 Patient Characteristics and Clinical Parameters Measured at
was taken not to overfill the defect
Baseline and 8 Months After Surgery
(Fig 2f). Contamination with blood
or saliva was prevented during bio- Clinical variable Patient 1 Patient 2 Patient 3
material application. No periosteal Age (y) 55 60 23
releasing incision was performed.
Sex Male Male Male
Gentle pressure was applied to the
Tooth Mandibular Mandibular Mandibular
surgical area using saline-wetted
right canine right central left first molar
gauze for 1 minute to readapt the incisor
mucoperiosteal flap. Microsurgical
PD (mm)
suturing technique with 7-0 mono-  Baseline 18 12 8
filament polypropylene suture ma-   8 mo 3 4.5 2
terials was performed for optimal CAL (mm)
wound closure of the surgical area  Baseline 20 17 9
(Figs 1c and 2g).   8 mo 6 10 3
REC (mm)
 Baseline 2 5 1
  8 mo 3 5.5 1
Postsurgical Care
INFRA (mm) 15 8 5
After the surgery, patients received Defect Combined Combined Combined
600 mg ibuprofen twice daily for 3 characteristics 1–2 wall 1–2 wall 1–2 wall
days. To control bacterial contami- PD = probing depth; CAL = clinical attachment level; REC = gingival recession;
INFRA = depth of the intrabony component of the defect.
nation, patients were prescribed
systemic doxycycline (100 mg bid
for 1 week). The patients were asked
to refrain from using mechanical oral postoperative control visits demon- healing and significant improvement
hygiene measures for 4 weeks post- strated that the interdental papil- in clinical periodontal parameters.
operative. During this period, they lary structure and its volume were
were advised to rinse with 0.12% fully preserved in all cases, and no
chlorhexidine digluconate mouth- wound failure was detected. During Discussion
rinse twice daily for 1 minute. The this postoperative period, patients’
sutures were removed 2 weeks after discomfort and pain were minimal The entire papilla preservation tech-
the surgery. with a limited need for analgesics. nique aims to provide proper me-
Patients were enrolled in a stringent chanical access to deep and wide
plaque control program with week- intrabony defects without disruption
Clinical Outcomes ly recalls for the first month and of the interdental papillary continu-
monthly controls for professional ity. Its unique design, shifting the
Primary wound healing of the ver- tooth cleaning for the subsequent 8 incision line to the adjacent tooth,
tical releasing incision, excellent months. reduces the risk of failure in wound
continuity of interdental papilla, Baseline and 8-month post- healing via exposure of the regen-
and 100% wound closure was ob- operative clinical periodontal pa- erative biomaterials. The proposed
served in all cases during the first 4 rameters of three cases treated surgical design could favor primary
weeks of the early healing period. with the entire papilla preservation healing over the biomaterial and en-
No adverse events were noted in technique are presented in Table 1. hance the stability of blood clot for-
any of the treated sites. The 1-week All three cases revealed uneventful mation in the intrabony defect.

Volume 37, Number 2, 2017

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
232
Exposure of the biomaterial is
a frequent complication associated
with deterioration of the clinical out-
comes of periodontal regeneration
procedures.22 Membrane or wound
exposure during the first weeks of
healing has been reported in up to
50% of sites treated with GTR.14 Spe-
cially designed surgical techniques
have greatly reduced the complica-
tions observed in wound healing.
Papilla preservation techniques16,17
have reduced the complication fre-
quency to 30%, whereas minimally
invasive surgical techniques18–20,23,24
have reduced it to less than 10%.
The entire papilla preservation tech-
nique has been proposed to fur-
ther increase the probability of an
uneventful early healing process.
From an anatomical point of view,
incision of the defect-associated pa-
pilla entails a risk of wound failure,
especially in the treatment of deep
and wide intrabony defects with a
missing buccal wall that will end with
a rather large area that lacks blood
supply from periodontal ligament or
alveolar bone. A tunnel preparation,
which maintains the vascular integri-
ty of the interdental papilla from the
buccal and lingual sides, may further
reduce the risk of wound failure. The
use of a tunnel technique for access
to the papilla region requires a verti-
cal releasing incision on the buccal
side. Verticals might cause esthetic
problems, resulting in unpleasant
white scars.25 On the other hand,
proper access to the intrabony de-
fect can be achieved only with a
beveled vertical incision to gain suf-
ficient mobility of the full-thickness
buccal flap. A careful incision and
flap elevation followed by a precise
The International Journal of Periodontics & Restorative Dentistry
© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
adaptation of the wound margins
and a microsurgical suturing tech-
nique with 7-0 polypropylene suture
materials may help to eliminate or
reduce any negative esthetic impact
of this vertical incision and improve
healing quality with limited scar tis-
sue formation.26,27
The early wound healing index
(EHI), introduced by Wachtel et al,28
provides a method to objectively
evaluate early wound stability. An
EHI of 1 is considered optimal.12
However, this scale is not applicable
to the entire papilla preservation
technique, as this novel surgical ap-
proach does not include a papillary
incision.
Secondary healing due to
wound exposure not only deterio-
rates periodontal regeneration but
leads to collapse in the three-di-
mensional papillary architecture.10,25
The present surgical technique
well maintains the original papillary
structure, which promises to be a
major advantage when preserving
esthetics is one of the major treat-
ment objectives.
The application of this tech-
nique has some limitations related
to the papilla morphology and the
defect configuration. A narrow inter-
dental space where risk of tearing
the fragile interdental papilla is high
might not be an ideal site to apply
this approach, even when the ap-
propriate surgical instrumentation
is used. Moreover, this novel tech-
nique is clearly not applicable to
defects that involve the lingual side
of the tooth, and such defect mor-
phology would require the elevation
of the defect-associated papilla for
debridement.
Conclusions
The entire papilla preservation pro-
cedure, based on a short buccal
flap, a vertical incision shifted to the
adjacent tooth, and a tunneled in-
terdental papilla, provides adequate
mechanical access to interproximal
deep and wide intrabony defects
and an excellent and uneventful
postoperative healing phase. The
application of this technique sup-
ports the use of amelogenins and
grafting materials. Clearly, further
research with evidence is required
to evaluate and clarify the advan-
tages and disadvantages of this
technique.
Acknowledgments
This study was funded solely by the institu-
tions of the authors. The authors declare no
conflicts of interest related to this study.
References
 1. Nyman S, Lindhe J, Karring T, Rylander
H. New attachment following surgical
treatment of human periodontal dis-
ease. J Clin Periodontol 1982;9:290–296.
 2. Camelo M, Nevins ML, Schenk RK, et
al. Clinical, radiographic, and histo-
logic evaluation of human periodontal
defects treated with Bio-Oss and Bio-
Gide. Int J Periodontics Restorative Dent
1998;18:321–331.
 3. Heijl L. Periodontal regeneration with
enamel matrix derivative in one human
experimental defect. A case report.
J Clin Periodontol 1997;24:693–696.
  4. Yukna RA, Mellonig JT. Histologic evalu-
ation of periodontal healing in humans
following regenerative therapy with
enamel matrix derivative. A 10-case se-
ries. J Periodontol 2000;71:752–759.

 5. Pontoriero R, Wennström J, Lindhe J.
The use of barrier membranes and
enamel matrix proteins in the treatment
of angular bone defects. A prospective
controlled clinical study. J Clin Periodon-
tol 1999;26:833–840.
 6. Sculean A, Windisch P, Chiantella GC,
Donos N, Brecx M, Reich E. Treatment
of intrabony defects with enamel matrix
proteins and guided tissue regeneration.
A prospective controlled clinical study.
J Clin Periodontol 2001;28:397–403.
  7. Sculean A, Schwarz F, Miliauskaite A, et
al. Treatment of intrabony defects with
an enamel matrix protein derivative or
bioabsorbable membrane: An 8-year
follow-up split-mouth study. J Periodon-
tol 2006;77:1879–1886.
  8. Minabe M, Kodama T, Kogou T, et al. A
comparative study of combined treat-
ment with a collagen membrane and
enamel matrix proteins for the regen-
eration of intraosseous defects. Int J
Periodontics Restorative Dent 2002;22:
595–605.
 9. Tonetti MS, Pini-Prato G, Cortellini P.
Periodontal regeneration of human in-
trabony defects. IV. Determinants of
healing response. J Periodontol 1993;64:
934–940.
10. Machtei EE, Cho MI, Dunford R, Nor-
deryd J, Zambon JJ, Genco RJ. Clinical,
microbiological, and histological factors
which influence the success of regenera-
tive periodontal therapy. J Periodontol
1994;65:154–161.
11. Kornman KS, Robertson PB. Fundamen-
tal principles affecting the outcomes of
therapy for osseous lesions. Periodontol
2000 2000;22:22–43.
12. Farina R, Simonelli A, Rizzi A, Pramstraller
M, Cucchi A, Trombelli L. Early postoper-
ative healing following buccal single flap
approach to access intraosseous peri-
odontal defects. Clin Oral Investig 2013;
17:1573–1583.
© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
13. Nowzari H, Matian F, Slots J. Periodontal
pathogens on polytetrafluoroethylene
membrane for guided tissue regenera-
tion inhibit healing. J Clin Periodontol
1995;22:469–474.
14. De Sanctis M, Zucchelli G, Clauser C.
Bacterial colonization of barrier mate-
rial and periodontal regeneration. J Clin
Periodontol 1996;23:1039–1046.
15. Takei HH, Han TJ, Carranza FA Jr, Ken-
ney EB, Lekovic V. Flap technique for
periodontal bone implants. Papilla pres-
ervation technique. J Periodontol 1985;
56:204–210.
16. Cortellini P, Prato GP, Tonetti MS. The
modified papilla preservation technique.
A new surgical approach for interproxi-
mal regenerative procedures. J Peri-
odontol 1995;66:261–266.
17. Cortellini P, Prato GP, Tonetti MS. The
simplified papilla preservation flap. A
novel surgical approach for the manage-
ment of soft tissues in regenerative pro-
cedures. Int J Periodontics Restorative
Dent 1999;19:589–599.
18. Cortellini P, Tonetti MS. A minimally in-
vasive surgical technique (MIST) with
enamel matrix derivative in the regener-
ative treatment of intra-bony defects: A
novel approach to limit morbidity. J Clin
Periodontol 2007;34:87–93.
19. Cortellini P, Tonetti MS. Improved
wound stability with a modified mini-
mally invasive surgical technique in the
regenerative treatment of isolated in-
terdental intrabony defects. J Clin Peri-
odontol 2009;36:157–163.
20. Nevins M, Kim SW, Camelo M, Martin IS,
Kim D, Nevins M. A prospective 9-month
human clinical evaluation of Laser-Assist-
ed New Attachment Procedure (LANAP)
therapy. Int J Periodontics Restorative
Dent 2014;34:21–27.
233
21. Azzi R, Etienne D, Takei H, Carranza F.
Bone regeneration using the pouch-
and-tunnel technique. Int J Periodontics
Restorative Dent 2009;29:515–521.
22. Machtei EE. The effect of membrane ex-
posure on the outcome of regenerative
procedures in humans: A meta-analysis.
J Periodontol 2001;72:512–516.
23. Harrel SK. A minimally invasive surgical
approach for periodontal bone graft-
ing. Int J Periodontics Restorative Dent
1998;18:161–169.
24. Trombelli L, Farina R, Franceschetti G,
Calura G. Single-flap approach with
buccal access in periodontal reconstruc-
tive procedures. J Periodontol 2009;80:
353–360.
25. Zucchelli G, Mele M, Mazzotti C, Mar-
zadori M, Montebugnoli L, De Sanctis
M. Coronally advanced flap with and
without vertical releasing incisions for
the treatment of multiple gingival reces-
sions: A comparative controlled random-
ized clinical trial. J Periodontol 2009;80:
1083–1094.
26. Tibbetts LS, Shanelec D. Periodon-
tal microsurgery. Dent Clin North Am
1998;42:339–359.
27. Burkhardt R, Preiss A, Joss A, Lang NP.
Influence of suture tension to the tearing
characteristics of the soft tissues: An in
vitro experiment. Clin Oral Implants Res
2008;19:314–319.
28. Wachtel H, Schenk G, Böhm S, Weng D,
Zuhr O, Hürzeler MB. Microsurgical ac-
cess flap and enamel matrix derivative
for the treatment of periodontal intrabo-
ny defects: A controlled clinical study.
J Clin Periodontol 2003;30:496–504.
Volume 37, Number 2, 2017