1. Pierpaolo Cortellini
Giovanpaolo Pini Prato
Maurizio S. Tonetti
The Simplified Papilla Preservation Flap
A Novel Surgical Approach for the Management of
Soft Tissues in Regenerative Procedures
Presenter: R2 鄭瑋之
Instructor: VS 陳娟娟

2. Introduction
• GTR  predictable significant amount of attachment
and bone gains at 1 year
• Lack of primary closure, flap dehiscence, membrane
exposure occurs in 70% ~ 80% of cases.
• The modified papilla preservation technique:
successtully in wide interdental spaces in the
anterior and premolar region
• Narrow and/or posterior interdental spaces?

3. Introduction
• Goals
1) Primary closure of the flaps in interdental spaces
2) Avoid the collapse of non-self supporting barrier
membranes into interproximal defects
3) Usable in narrow and/or posterior interdental
spaces

4. Material and Method
• Subject population
– 18 subjects (7 men & 11 women), aged 34 ~ 60 (mean
49.1 ± 7.7)
1) Presence of a deep interproximal detect with an
intrabony component ≧ 4 mm
2) Clinical attachment loss ≧ 6 mm
3) No furcation involvement
4) ≧ 2 ~ 3 mm of thick keratinized tissue
– 8 incisors, 3 canines, 4 premolars, and 3 molars; 9
teeth were in the maxiiia

5. Material and Method
• Experimental design
– After scaiing, root planing, and OHI
– Clinical outcomes were evaluated every week for
6 weeks after GTR treatment and at a 1-year f/u
visit

6. Material and Method
• Clinical measurements
– Immediately prior to the surgery, and 1 year later
– Full mouth plaque scores (FMPS), 4 aspects/tooth
– Bleeding on probing (BOP) at a force of 0.3 N. with a
manual pressure sensitive probe  Full mouth
bleeding scores (FMBS)
– Probing pocket depth (PPD), gingival recessions
(REC), and clinical attachment levels (CAL) by a
single investigator

7. Surgical Procedure

8. Surgical Procedure

9. Surgical Procedure

10. Surgical Procedure

11. Surgical Procedure

12. Surgical Procedure

13. Surgical Procedure

14. Surgical Procedure

15. • Primary closure of the interdental
tissues above the membrane
without tension:
1. Repositioning the buccal and
lingual/palatal flaps
2. Buccal flap was further extended
mesiodistally
3. A periosteal incision in the most apical
portion of the buccal flap
4. Vertical releasing incisions used only as
a last resort

16. • Sutures:
1. Narrow interproximal space and thin
interdental tissues  1 interrupted
suture
2. Wider interproxial space and thicker
interdental tissues  2 interrupted
sutures
3. Wide interproximal space and thick
interdental tissue  internal vertical
oblique mattress suture

17. Material and Method
• Intrasurgical clinical measurements
– Taken after debridement of the defects
a. Distance from CEJ to the bottom of the defect
(CEJ-BD)
b. Distance from CEJ to the most coronal extension
of the interproximal bone crest (CEJ-BC)
c. The infrabony component of the defects (INTRA)
was defined as INFRA = (CEJ-BD) - (CEJ-BC)

18. Material and Method
• Postsurgical instructions and infection control
– Rinse 3 times with 0.12% CHX
– No mechanical oral hygiene procedure or chewing
for 11 weeks
– Amoxicillin 500 mg TID for first week
– Supragingival prophylaxis with a rubber cup and 1%
CHX gel weekly for 11 weeks
– Supportive core program at monthly intervals
– No probing until the 1-year visit

19. Results
• Defect Characteristics

20. Material and Method
– Full mouth plaque scores (FMPS)
– Full mouth bleeding scores (FMBS)
– Probing depth (PD), marginal recession (REC), and
probing attachment level (PAL, CEJ ~ base of the
pocket)
– CEJ ~ bottom of the defect (CEJ-BD)
– CEJ ~ the most coronal extension of the interproximal
bone crest (CEJ-BC)
– The intrabony component of the defects (INTRA) was
defined as INTRA = (CEJ-BD)~(CEJ-BC)

21. Results
• Defect characteristics

22. Results
• Defect characteristics

23. Results
• Membrane coverage

24. Results
• One-year outcome measures

25. Discussion
1. Simple and safe manipulation of the interdental
tissues, not only in wide and/or anterior
interdental spaces, but also in narrow and/or
posterior ones.
2. Primary closure of the interdental tissues over
bioresorbable membranes without tension
3. Prevent the collapse of the membranes into the
defect because of suture compression

26. Discussion
4. The first oblique papillary incision  split the
interdental papilla in 2 parts, the largest being the
lingual/palatal one. Any thinning of the papilla was
avoided.
5. The amount of interdental tissue elevated through
the space did not exceed the amount of tissue
originally in that space  easy and atraumatic.
6. Careful sharp dissection from the root cementum
of 2 neighboring teeth and from the underlying
connective tissue.

27. Discussion
6. Primary passive closure
a) Mesiodistal extension of the buccal incisions and/or
with a periosteal incision and/or with buccal vertical
incisions
b) Coronally position the buccal flap with an internal
mattress suture anchored to the lingual/palatal flap
c) By rubbing against the root surface and lying on top of
the residual bone crest
6. Interdental suture lies on the residual proximal
bone crest away from the area where the
membrane covered the defect.

28. Discussion
8. Primary closure was maintained over time in 67%
of the sites. (20%~40% in conventional techniques)
But slightiy less than modified papilla preservation
technique with titanium-reinforced membranes
– This study included maxiliary and mandibular detects in
both anterior and posterior parts, with no restrictions of
minimal interdental width.
8. CAL gains (4.9 ±1.8 mm) and PPD reduction (5.8 ±
2.5 mm) favorably compare with in other studies
(different bioresorbable membranes)

29. Conclusion
• Potential to help GTR procedures by providing
a predictable coverage of the barrier
membranes
• The efficiancy and predictability of SPPF
should be further evaluated.