The International Journal of Periodontics & Restorative Dentistry

COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE
REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 31
REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE

Surgical Reconstruction of Interdental

Papilla Using an Interposed Subepithelial
Connective Tissue Graft: A Case Report

João Carnio, DDS, MS* The term “periodontal plastic

surgery” was introduced in the late
1980s1 and consists of a broad range
The unpredictability of current surgical procedures for papilla reconstruction has of procedures aiming at correcting
been a matter of concern for both periodontists and patients. This case report or eliminating anatomic, develop-
presents a complete papilla reconstruction in a 20-year-old woman using an inter- mental, or traumatic deformities of
posed subepithelial connective tissue graft. The results show that this technique the gingiva or alveolar mucosa.2
can be successfully used in treating the loss of papillae and achieving long-term One of the major esthetic challenges
stability. The objective of this report is to describe the surgical technique and in periodontal plastic surgery is
comment on the factors that may have influenced the final result.
related to the ability of rebuilding
(Int J Periodontics Restorative Dent 2004;24:31–37.)
lost papillae in the maxillary ante-
rior segment.3,4 The presence of
such interproximal space results in
esthetic and phonetic problems.
Interdental papillae can be lost
as a result of several distinct clinical
situations.5 The first is the presence
of a naturally occurring midline
diastema. This situation can be
remedied with orthodontic treat-
ment, positioning the teeth closer
together.6 Diverging roots is another
situation that can result in the pres-
ence of an interproximal space when
the contact point between the two
clinical crowns is situated too in-
cisally. Orthodontics may also correct
*Adjunct Professor, Section of Periodontics, State University of Londrina, such a clinical situation by aligning
Paraná; and Private Practice in Periodontics, Londrina, Brazil.
the roots and “squeezing” the inter-
*Correspondence to: Dr João Carnio, Rua Pistoia 245, Jardim Canadá, proximal soft tissue, thereby creating
86020-390 Londrina–Paraná, Brazil. e-mail: jcarnio@onda.com.br a new papilla. A clinical crown that

Volume 24, Number 1, 2004

 32
REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE
Fig 1 Preoperative view of 20-year-old woman with severe loss of interproximal papilla
following failed GTR procedures.
tends to be triangular in shape can
also result in a partial interproximal
space.7 This happens because of an
accentuated discrepancy in the
mesiodistal width at the incisal edge
and gingival line. Reshaping the clin-
ical crowns is helpful in reducing the
interproximal opening.
True loss of a previously existing
interdental papilla can occur as a
result of periodontal disease pro-
cesses or as a result of periodontal
surgical procedures. Tarnow et al8
suggest that partial loss of the soft
tissue might occur with surgical re-
flection of the interproximal tissue in
areas in which the distance between
the contact point and the crest of
the interdental bone is
5 mm.
Therefore, it is not unusual for the
clinician to encounter situations
where reconstruction of a lost
The International Journal of Periodontics & Restorative Dentistry
papilla is desirable. Unfortunately,
while orthodontics and restorative
dentistry are effective in improving
the clinical situation, predictable sur-
gical reconstruction of a lost papilla
is not a reality yet.
Surgical techniques aiming at
correcting the “black hole problem”
have been used mainly with free
epithelialized gingival grafts, re-
peated interproximal curettage, or
displacement of the interproximal
palatal tissue in the buccal direc-
tion.9,10 While limited success has
been achieved with these proce-
dures, the major limiting factor for
the complete and predictable sur-
vival of the graft tissues is the lack of
a minimal source of blood supply.11
The healing principles on which the
subepithelial connective tissue graft
for root coverage12,13 and ridge
Fig 2 Preoperative radiograph shows a
9.5-mm distance from contact point to
bone crest.
augmentation14 are based (double
blood supply) have been applied to
the reconstruction of the interdental
papilla, thus increasing both the suc-
cess rate and predictability.15
The purpose of this article is to
describe a case of complete papilla
reconstruction using a technique
involving an interposed palatal con-
nective tissue graft, and to discuss
the factors that may influence the
final result.
Case report
A healthy 20-year-old nonsmoking
woman was referred to the author for
the reconstruction of the lost inter-
dental papilla between the maxillary
left central and lateral incisors (Figs
1 and 2). The patient reported to

REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE
have undergone two surgical pro-
cedures involving guided tissue
regeneration (GTR) of the area with
limited success. Her complaints were
of an esthetic and phonetic nature.
Clinical examination revealed a high
smile line,16 Class IV gingival reces-
sion on the buccal aspects of the
maxillary left central and lateral
incisors,17 and a Class III18 papillary
loss between these teeth, with com-
plete destruction in the buccal/
palatal direction. The soft tissues
presented a healthy clinical aspect
with a minimal sulcus depth, and the
initial therapy consisted of just oral
hygiene instructions.
The initial clinical measurements
are shown in Table 1. Basically, the
left central and lateral incisors pre-
sented a 2.0-mm recession on the
straight buccal surfaces, with a sulcus
depth not exceeding 3.0 mm. There
was a 5.5-mm interproximal distance
from the contact point to the soft
tissue surface, and a 4.0-mm dis-
tance from the gingival margin to
the bone. There was a 3.5-mm width
measured in the interproximal space
at the level of the existing gingival
tissue, and 6.0 mm of keratinized tis-
sue was measured from the gingival
margin to the mucogingival junction
(Fig 3).
Surgical technique
Following phase one therapy, the
gingival tissue around the maxillary
left central and lateral incisors was
clinically healthy. Since extensive
root planing had been performed as
part of the previous regenerative
33
Table 1 Initial and final measurements (mm)
Measurement Baseline Final
Keratinized gingiva 6.0 9.0
Distance from contact point to bone crest 9.5 9.5
Distance from contact point to gingival margin 5.5 0.0
Horizontal component measured at line angle 3.5 0.0
of adjacent teeth at gingival margin level
Facial recession (central incisor) 2.0 0.0
Facial recession (lateral incisor) 2.0 0.0
procedures, only light mechanical
root instrumentation was performed
before the surgery, and no chemical
root conditioning was used.
After the administration of local
anesthesia, a split-thickness semilu-
nar incision19 was performed 2 mm
coronal to the mucogingival junc-
tion, extending from the mesial
aspect of the central incisor to the
distal aspect of the lateral incisor.
Intrasulcular incisions were then
made with a No. 15C blade around
the necks of these teeth, extending
from the buccal face to the palate.
The existing papilla was fully pre-
served (Fig 4). Immediately after this
procedure, the donor tissue, con- Fig 3 Preoperative measurements. A =
sisting of 2-mm-thick palatal con- facial recession of maxillary left central
incisor; B = facial recession of lateral
nective tissue, was harvested from incisor; C = distance from contact point to
the premolar.20 It was then shaped to gingival margin; D = horizontal distance
fit the interproximal area and pre- between roots; E = distance from contact
point to bone crest.
served in saline gauze.
To release the gingivopapillary
unit from the bone, a split-thick-
ness flap was initiated using an
Orban knife through the semilunar
incision on the buccal face, extend-
ing toward the palate (Fig 5). It is
Volume 24, Number 1, 2004
 34
REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE

Fig 4 Semilunar buccal incision is made Fig 5 Orban knife is used to release gin- Fig 6 Buccal/palatal void is observed
2 mm coronal to mucogingival junction givopapillary unit from the bone. between soft tissue and bone.
and extended from mesial aspect of cen-
tral incisor to distal aspect of lateral incisor.
Intrasulcular incisions are then prepared
around the necks of the teeth involved,
extending from buccal face to palate. Note
that existing interproximal papilla is fully
preserved.

Fig 7 Interposed subepithelial connec- Fig 8 Semilunar incision is sutured to Fig 9 Postoperative view 8 weeks after
tive tissue graft is placed to fill the dead promote healing by first intention. the first procedure.
space and maintain the gingivopapillary
unit coronally. It is introduced and stabi-
lized using a palate-graft-palate suture.

important to note that care must be
exercised to avoid perforating the
palatal tissue or damaging the
interproximal papilla. After the inci-
sions, the soft tissue was com-
pletely released from the root and
bone, and the whole flap became
mobile, allowing for the coronal
displacement of the papillary unit.
A buccal/palatal void (dead space)
could be seen between the soft tis-
sue and the bone structure (Fig 6).
To maintain the whole unit coro-
nally, the dead space was filled with
the connective tissue graft (Fig 7).
It was introduced and stabilized in
place using a palate-graft-palate
No. 6-0 gut suture. The alveolar
mucosa was then dissected to pro-
mote its coronal advancement
without any tension over the pap-
illary structure. Suturing of the
semilunar incision was initiated (Fig
8), and primary closure was
obtained with healing by first inten-
tion. No periodontal dressing was
used, nor was antibiotic therapy
recommended. The postoperative
care consisted of 0.12% chlorhexi-
dine rinses 3 times a day for 4

The International Journal of Periodontics & Restorative Dentistry


REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE
Fig 10 Repeated surgical procedures resulted in excessive coro-
nal migration of the gingival margin. A gingivoplasty was necessary
to relocate gingival margin to level of CEJ.
weeks, with no mechanical clean-
ing of the interproximal area.
Flossing was initiated at the begin-
ning of the ninth postoperative
week.
Two other surgical procedures
with identical protocols were per-
formed in the same area at 8-week
intervals (Fig 9).
Follow-up
Healing following all three surgical
procedures was uneventful (Fig 10).
Four years after the surgical proce-
dures, the interproximal space was
still completely filled, and the
height and volume of the recon-
structed papilla had been main-
tained. The previously existing buc-
cal recessions on both teeth were
covered, and the sulcus depth
around the maxillary left central and
lateral incisors did not exceed 2.5
mm (Fig 11). The keratinized tissue
35
Fig 11 Final result 4 years later shows complete papilla recon-
struction.
increased to 9.0 mm, and the bone
crest remained at the same baseline
level (Fig 12). It is important to men-
tion that the clinical results obtained
after the first 8 postoperative weeks
were the same as those noted 4
years after the last surgery. There-
fore, in this case, 8 postoperative
weeks reflected the long-lasting
result.
Discussion
One of the most undesirable effects
of any periodontal surgical tech-
nique involving interproximal areas is
marginal tissue recession and loss Fig 12 Final radiograph. Note that the
of papillary tissue. This loss can occur bone crest is at the baseline level.
mainly because of blood supply dis-
continuation caused by the incision
made in the papillary area. GTR pro-
cedures in interproximal areas may
compromise blood supply because
of the lack of direct contact between
the flap and underlying bone.
Volume 24, Number 1, 2004
 36
REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE
Therefore, complete collapse of the
interdental papilla might occur.21–25
Since proper root angulations and
proportional size of the crowns were
present, there was no need of ortho-
dontic movement or reshaping the
dental crowns. The only alternative
left to improve the defect found
between the maxillary left central
and lateral incisors was surgical
reconstruction of the papilla.
As a result of significant tooth
structure removal through extensive
scaling and root planing during the
previous GTR procedures, an even
larger interproximal area had to be
filled. This may explain why multiple
surgeries were required. A positive
aspect of having a larger interproxi-
mal area is that it provides a better
source of blood supply from the flap
to the graft. Both the maximized
blood supply and maintenance of
papillary integrity by the flap design
were essential in avoiding flap necro-
sis and enhancing the grafted tissue
“take.” Harvesting of the graft was
performed just before the surgical
detachment of the papilla to pre-
vent the development of a blood
clot between the bone and grafted
connective tissue. Blood clots, even
small ones, might compromise im-
mediate blood supply to the graft
and therefore induce partial necrosis
of the transplanted tissue.
Once the distance from the con-
tact point to the gingival margin was
larger than the buccal marginal
recession, the repeated treatment
in this area using the same flap
design resulted in excessive coronal
migration of the gingival margin on
the straight buccal surfaces of the
The International Journal of Periodontics & Restorative Dentistry
central and lateral incisors. A simple
gingivoplasty was performed to relo-
cate the gingival margin to the level
of the cementoenamel junction
(CEJ).
Conclusions
This case has shown that the surgi-
cal technique using an interposed
subepithelial connective tissue graft
can regenerate a lost interdental
papilla. The reconstructed papilla
remained stable and without any
signs of clinical inflammation 4 years
after the surgery. Clinical studies
using large sample sizes are neces-
sary to determine the success rate
and predictability of this surgical
technique.
• The interposed subepithelial
connective tissue graft technique
can regenerate a lost interdental
papilla.
• To be successful, the surgical
technique must involve the main-
tenance of the integrity of the
interproximal tissue.
• Multiple surgical procedures
may be required.
Acknowledgments
The author is grateful to Drs Thomas G.
Wilson, Jr and Michael K. McGuire for their
advice and support, and to Dr Paulo M.
Camargo for revision of the manuscript.
 37
REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE

References 14. Langer B, Calagna L. The subepithelial

connective graft. J Prosthet Dent 1980;
44:363–367.
1. Miller PD Jr. Regenerative and recon-
structive periodontal plastic surgery. Dent 15. Han TJ, Takei HH. Progress in gingival
Clin North Am 1988;32:287–306. papilla reconstruction. Periodontol 2000
1996;11:65–68.
2. Wennström J. Mucogingival therapy. Ann
Periodontol 1996;1:671–701. 16. Goldstein RE. Esthetics in Dentistry.
Philadelphia: Lippincott, 1976.
3. McGuire MK. Periodontal plastic surgery.
Dent Clin North Am 1998;42:411–465. 17. Miller PD Jr. A classification of marginal
tissue recession. Int J Periodontics
4. Miller PD Jr, Allen EP. The development
Restorative Dent 1985;5(2):8–13.
of periodontal plastic surgery. Periodontol
2000 1996;11:7–17. 18. Nordland WP, Tarnow DP. A classification
system for loss of papillary height. J
5. Kokich VG. Esthetics: The orthodontic-
Periodontol 1998;69:1124–1126.
periodontic restorative connection.
Semin Orthod 1996;2:21–30. 19. Tarnow DP. Semilunar coronally reposi-
tioned flap. J Clin Periodontol 1986;13:
6. Nanda R, Torres Dias MA. Orthodontic
182–185.
space closure. Dent Clin North Am
1981;25:95–107. 20. Reiser GG, Bruno JF, Mahan PE, Larkin LH.
The subepithelial connective tissue graft
7. McGuire MK, Miller L. Maintaining esthet-
palatal donor site: Anatomic considera-
ic restorations in the periodontal prac-
tions for surgeons. Int J Periodontics
tice. Int J Periodontics Restorative Dent
Restorative Dent 1996;16:131–137.
1996;16:231–239.
21. Cortellini P, Pini Prato G, Baldi C, Clauser
8. Tarnow DP, Magner AW, Fletcher P. The
C. Guided tissue regeneration with dif-
effect of the distance from the contact
ferent materials. Int J Periodontics
point to the crest of bone on the presence
Restorative Dent 1990;10:137–151.
or absence of the interproximal dental
papilla. J Periodontol 1992;63:995–1004. 22. Cortellini P, Pini Prato G, Tonetti MS.
Guided tissue regeneration of human
9. Beagle JR. Surgical reconstruction of the
intrabony defects. I. Clinical measures. J
interdental papilla: Case report. Int J
Periodontol 1993;64:254–260.
Periodontics Restorative Dent 1992;12:
145–151. 23. Selvig K, Kersten B, Wikesjö U. Surgical
treatment of intrabony periodontal
10. Shapiro A. Regeneration of interdental
defects using expanded polytetrafluo-
papillae using periodic curettage. Int J
roethylene barrier membranes: Influence
Periodontics Restorative Dent 1985;5(5):
of defect configuration on healing
27–33.
response. J Periodontol 1993;64:
11. Miller PD Jr. Root coverage using a free 730–733.
soft tissue autograft following citric acid
24. Murphy K. Postoperative healing com-
application. Part I: Technique. Int J
plications associated with Gore-Tex
Periodontics Restorative Dent 1982;2(1):
Periodontal Material. Part 1. Incidence
65–70.
and characterization. Int J Periodontics
12. Langer B, Langer L. Subepithelial con- Restorative Dent 1995;15:363–375.
nective tissue graft technique for root cov-
25. DeSanctis M, Zucchelli G, Clauser C.
erage. J Periodontol 1985;56:715–720.
Bacterial colonization of barrier material
13. Raetzke PB. Covering localized areas of and periodontal regeneration. J Clin
root exposure employing the “envelope” Periodontol 1996;23:1039–1046.
technique. J Periodontol 1985;56:
397–402.

Volume 24, Number 1, 2004