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J Periodontol • April 2005
Case Report
Interdental Papilla Augmentation Procedure Following
Orthodontic Treatment in a Periodontal Patient
Daniele Cardaropoli* and Stefania Re*
Background: The absence of the interdental papilla
is a situation that may alter patients’ esthetics. Reces-
sion of interproximal gingival tissues may be a conse-
quence of periodontal disease, but in some cases it may
also be a consequence of periodontal therapy, as a
result of surgical or non-surgical procedures.
Methods: The authors present a new multidiscipli-
nary approach for the treatment of migrated maxillary
incisors presenting infrabony defects, extrusion, and
loss of the interdental papilla.
Results and Conclusion: The proposed clinical pro-
tocol may reconstruct the interproximal soft tissue, with
esthetic improvement of the papillary level, together
with resolution of the periodontal defects. J Periodon-
tol 2005;76:655-661.
KEY WORDS
Bone remodeling; dental esthetics; gingival
recession/adverse effects; interdental papilla;
orthodontics, corrective; periodontitis/adverse
effects; tooth mobility.
* Private practice, Turin, Italy.
C
hronic periodontitis may lead in advanced cases
to dental migration, with a flaring of the frontal
teeth and an open space with loss of the inter-
dental contact points. In these cases, a certain amount
of soft tissue recession is often present due to gingi-
val inflammation and reduction of the periodontal sup-
porting apparatus. Other times, however, soft tissue
recession may be a consequence of periodontal ther-
apy, both surgical and non-surgical, due to the apical
shift of the soft tissues during the healing process. A
similar clinical situation may create significant esthetic,
functional, and phonetic problems for the patient, lead-
ing to enormous difficulties in personal relationships,
self-esteem, and self-perception. These factors have
taken on such importance to dental patients that, now,
in the anterior region we speak about the “white
esthetic,” referring to the natural dentition and its con-
servative or prosthetic restoration, and “pink esthetic,”
referring to the surrounding soft tissues.
One of the most challenging clinical situations to
treat is the absence of the dental papilla and the con-
sequent creation of so-called “black spaces.” The dif-
ficulty in working on the papilla depends on the
anatomy and morphology of this structure, which
receives only a minor blood supply. The antero-pos-
terior view of the papilla shows a buccal and a lingual
peak, with a concave-shaped col. This crest is non-
keratinized or parakeratinized, and it is covered with
stratified squamous epithelium. In the case of diastema,
the interdental soft tissue may show a higher degree
of keratinization. Working with such a delicate struc-
ture is one of the most difficult challenges for perio-
dontists. To avoid interproximal gingival recession in
the anterior zone, special care should be taken when
performing periodontal treatment. During non-surgical
therapy, adequate small-size hand or ultrasonic ins-
truments should be used to avoid damaging the soft
tissues. When surgical therapy is performed, optimal
flap design is required to prevent soft tissue loss and
to maintain natural shaping. A number of papers have
been published that describe techniques to preserve
the papilla and simultaneously allow access to the
periodontal defects in order to perform guided tissue
regeneration.1-6
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Interdental Papilla Augmentation in a Periodontal Patient Volume 76 • Number 4

On the other hand, several authors have described

techniques to rebuild a lost interdental papilla. Both
surgical and non-surgical approaches are present in the
literature but, unfortunately, they refer only to case
reports and no long-term results are available.7-17 So,
until now, reconstruction of the interproximal papilla
has not been a treatment with predictable results.
From an anatomical point of view, the presence or
absence of the interproximal papilla depends on the
distance between the interdental contact point and
the crest of bone.18 When this distance is ≤5 mm,
the papilla is almost always present; however, when
this distance is ≥6 mm, the papilla is often absent. This
study18 indicates that the biological way of treating a
missing papilla is to try reducing the distance between
the contact point and the crest of bone. Bearing Figure 1.
this in mind, in cases of chronic periodontitis with extru- Adult periodontal patient with migration of the frontal teeth, opening
sion of the maxillary central incisors, opening of of the diastema, and loss of the midline papilla.
diastema, and presence of infrabony defects, a multi-
disciplinary approach involving periodontal and
orthodontic therapy would be indicated. In this paper, an
innovative interdisciplinary clinical protocol is presented.

CASE REPORT
Candidate patients affected by advanced chronic perio-
dontitis and previously treated by scaling and root
planing should demonstrate a good home oral hygiene
standard with a full-mouth plaque score ≤15%.19 The
indication for periodontal surgical therapy should be
supported by the presence of infrabony pockets on
the maxillary central incisors, with radiological evi-
dence of a deep infrabony component and probing
depth ≥6 mm. The indication for orthodontic treatment
should be the migration and extrusion of the central
incisors, with diastema opening and loss of the inter-
dental papilla (Figs. 1 and 2).
The patient undergoes surgery under local anesthe-
sia with articain 4% plus epinephrine 1/100,000.† The
type of surgical access is chosen from the papilla
preservation approaches described in the literature.1-6
The periodontal flap design consists of a full-
thickness incision made in order to preserve the tissue
during access to the defects, with buccal or lingual
positioning of the interdental incision (Fig. 3). The abil-
ity to access the defect, apply the regenerative tech-
nology, and seal the wound is a key aspect of the Figure 2.
procedure. The extension of the flap connects the dis- Initial intraoral radiograph showing interproximal bone loss, with vertical
tal sites of the two lateral incisors, and vertical releas- defect on the mesial aspect of the left central incisor.
ing incisions are made only if needed for better surgical
access (Fig. 4). Then, using curets and scalers, con-
ventional ultrasonic devices, and diamond burs mounted gen bovine bone mineral,‡ without the use of barrier
on a low-speed contra-angled handpiece, the granu- membranes (Fig. 5). The suturing technique is chosen
lation tissue is completely eliminated from the defect, according to the anatomy of the defect in order to
followed by complete debridement of the radicular
surface. At this point, the defects may be augmented † Ubistesin, 3M Espe, Seefeld, Germany.
with the use of a bone grafting material20 like colla- ‡ Bio-Oss Collagen, Geistlich, Wolhusen, Switzerland.

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J Periodontol • April 2005
Figure 3.
The flap is designed according to the modified papilla preservation
technique.
Figure 5.
The infrabony defect is augmented with mineral collagen bovine bone
substitute.
achieve a passive closure of the margins of the wound,
with relief of flap tension (Fig. 6). A combination of hor-
izontal mattress sutures and interrupted sutures may
be used, employing non-resorbable 4-0 or 5-0 PTFE
sutures.§
Postoperatively, the patients should use non-steroidal
analgesics like nimesulide
100 mg twice a day for
5 days, oral antibiotics such as amoxicillin/clavulanate
potassium¶ 1 g twice a day for 6 days, and rinse with
chlorhexidine 0.2%# three times a day until the sutures
are removed 2 weeks after surgery.
At this point, active orthodontic treatment may com-
mence, with movement beginning just a few days after
surgery. The use of the segmented arch technique is
recommended21,22 because of its ability to develop light
and continuous forces (10 to 15 g per tooth) and cre-
Cardaropoli, Re
Figure 4.
Intraoperative buccal view of the infrabony defect.
Figure 6.
A combination of mattress and interrupted sutures is used to obtain
primary closure of the flap.
ate forces acting in the center of resistance. The intru-
sive mechanism should consist of a base arch or two
cantilevers made of 0.017″ × 0.025″ TMA wire, while
the anchorage unit is made of a palatal arch and two
0.036″ stainless steel segments connecting posterior
teeth. The fixed appliances should be able to intrude the
migrated teeth and close the diastemas, with a move-
ment of about 0.5 to 1 mm per month.
During orthodontic therapy, the appliance should
be checked every 2 weeks, while oral hygiene main-
tenance with professional prophylaxis should be per-
formed every 3 months.23
§ Tevdek II, Butterfly Italia, Cavenago B.za, Italy.

Aulin, Roche, Milan, Italy.
¶ Augmentin, GlaxoSmithKline, Verona, Italy.
# Corsodyl, GlaxoSmithKline.
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Interdental Papilla Augmentation in a Periodontal Patient
At the end of treatment, tooth realignment may
be achieved, with optimal soft tissue outlines and
coronal migration of the papillae into the interdental
embrasures.
In order to avoid orthodontic relapse, patients may
receive a resin-bonded splint fixed retention. Both metal
Figure 7.
At the conclusion of orthodontic treatment , the soft tissues were
perfectly adapted to the orthodontic alignment, and the interdental
papilla filled the interproximal embrasure.
Figure 8.
Final intraoral radiograph showing resolution of the infrabony defect.
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Volume 76 • Number 4
and esthetic fiber-reinforced Maryland splints can be
used.24
The results presented in this case report are rep-
resentative of the results obtained with a larger num-
ber of patients, six of whom were treated following
the protocol described above. In all cases, the heal-
ing of the flap was uneventful and no post-surgical
complications, such as infections or gingival necrosis,
have been reported. No adverse reactions to the bone
grafting material were noted during the orthodontic
movement. For the most part, patients showed an
improvement of the papillary level at the conclusion
of therapy (Fig. 7), and healthy periodontal condi-
tions were reported, with a reduction of probing depth
and radiological resolution of the augmented defects
(Fig. 8).
DISCUSSION
The protocol presented here represents an alternative
for the treatment of infrabony defects associated with
tooth migration and papilla loss in the maxillary
esthetic area (Figs. 9, 10, and 11). Conventionally, the
literature suggests that infrabony defects in the esthetic
Figure 9.
Schematic drawing of a clinical situation that may benefit from the
described approach: tooth migration with opening of the diastema, loss
of the interdental papilla, and presence of an infrabony defect.
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J Periodontol • April 2005
Figure 10.
Schematic drawing of the treatment objectives.The tooth is
orthodontically moved into the augmented defect , and the periodontol
ligament cells are stimulated to migrate onto the root surface.The
closure of the diastema pushes the papilla coronally into the
interdental space.
zone can be successfully treated with the use of guided
tissue regeneration procedures associated with the
papilla preservation flap design.4-6 This kind of
approach, however, requires two surgical stages: insert-
ing the non-resorbable barrier membrane and then
removing it. In the case of migrated teeth with the
presence of diastemas, orthodontic treatment may start
only at this point, i.e., after complete healing of both
deep and superficial periodontal tissues, with a con-
siderable delay in the timing of the therapy.
A more expedient clinical approach may include the
use of bone grafting biomaterials alone for the treatment
of infrabony defects in a one-stage surgical procedure.20
An experimental study in dogs revealed that aug-
mented bone did not impede tooth movement.25 In
that study, maxillary incisors were moved into bone
compartments augmented with autogenous bone or
beta-tricalcium phosphate. A more recent animal study
confirmed these findings,26 showing the possibility of
moving a tooth, by orthodontic means, into an area of
the jaw previously augmented with bovine bone min-
eral. No adverse effects were reported, and the bio-
Cardaropoli, Re
Figure 11.
Schematic drawing of the final result.The infrabony defect is filled due to
the bone augmentation procedure and the orthodontic movement.The
papilla, correctly stimulated, has filled the interproximal embrasure and is
supported by the regenerated interdental bone crest. A normalization of
the distance between the crest of bone and the contact point is reached.
material was mostly resorbed and eliminated. It was
concluded that the augmented bone region did not
obstruct the orthodontic tooth movement, and that the
rate of degradation of the biomaterial was enhanced
when the augmented site was challenged by physical
means such as the orthodontically moved teeth.
A human case report,27 with surgical reentry at
12 months, supported the positive outcomes of the
experimental papers.25,26
The clinical protocol presented here suggests the
use of bovine bone mineral to augment infrabony
defects on maxillary incisors, followed by orthodontic
movement into the defects at a very early stage.
This new approach reveals excellent potential in
terms of esthetic improvement, due to tooth realign-
ment and soft tissue modification, and periodontal
health, due to a reduction in probing depth and filling
of bone. The final papillary levels have an enormous
impact on patients’ esthetics. In order to achieve such
an optimal outcome, we can suppose that an impor-
tant role is played by the orthodontic movement, which
is able to positively guide the soft tissues during the
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Interdental Papilla Augmentation in a Periodontal Patient
early phases of the post-surgical healing process,
adapting the gingiva to new and more natural dental
emergence profiles. Moreover, both intrusion and
diastema closure cause a normalization of the distance
between the contact point and the crest of bone, cre-
ating the presupposing biological basis for the presence
of the papilla.
The effects of intrusive movement on the periodontal
apparatus have been reported in several papers.28-35
A number of studies were undertaken since conflicting
evidence exists regarding the effect of orthodontic
movement on levels of connective tissue attachment.
In one study, it was concluded that orthodontic tooth
movement into intrabony periodontal defects had no
effect on the levels of connective tissue attachment.36
On the other hand, two animal studies have shown
how orthodontic stimulation may promote the creation
of a connective reattachment or new attachment on
teeth with reduced periodontium.37,38 A possible expla-
nation for this gain in orthodontically induced attach-
ment level may be that the stretching of the periodontal
ligament (PDL) fibers at the marginal level generates
a sort of natural filter, reducing the downgrowth of
epithelium. Moreover, it seems that orthodontic stim-
ulation increases the turnover of periodontal ligament
cells and thereby improves the chances that the perio-
dontal ligament will repopulate the previously infected
root surface.
Animal studies on cell kinetics of PDL during ortho-
dontically induced osteogenesis revealed an increase
of primary growth fraction; the proliferation of PDL
cells migrating toward the bone surface; the presence
of preosteoblasts in the PDL that are capable of form-
ing osteoblasts without synthesizing DNA; osteoblasts
derived from local PDL cells; and a cell death pattern
characteristic of osteogenic response.39-41 Moreover,
a more recent animal study confirmed that orthodon-
tic tooth movement is a stimulating factor of bone
apposition.42 A change in the repair pattern of the
bony defect from apico-occlusal in the control group
(no tooth movement) to occluso-apical in the treated
group (with tooth movement) further supported the
linkage between tooth movement and enhanced bone
deposition.
From a morphologic point of view, orthodontic
realignment with space closure creates a contact point
between the incisors, creating the anatomical basis for
the presence of the interdental papilla. Papillary tissue
reacts like a spring that fills the embrasure when it is
compressed because of interdental space closure, and
expands itself when interdental space opens.
Orthodontic movement initiated at a very early
stage, just 2 weeks after surgery, acts on non-healed
periodontal tissues and gives soft tissues the possi-
bility of adapting to more favorable dental emergence
profiles. In this way, the papilla is pushed into the
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Volume 76 • Number 4
interdental embrasure during the early phases of post-
surgical healing, and the forthcoming intrusion allows
the soft tissues to adapt to the more coronal portion
of the hard structure of the tooth.
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