30268.

qxd

4/15/05

4:04 PM

Page 655

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. Recession of interproximal gingival tissues may be a consequence 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 multidisciplinary approach for the treatment of migrated maxillary
incisors presenting infrabony defects, extrusion, and
loss of the interdental papilla.
Results and Conclusion: The proposed clinical protocol may reconstruct the interproximal soft tissue, with
esthetic improvement of the papillary level, together
with resolution of the periodontal defects. J Periodontol 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.

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 interdental contact points. In these cases, a certain amount
of soft tissue recession is often present due to gingival inflammation and reduction of the periodontal supporting apparatus. Other times, however, soft tissue
recession may be a consequence of periodontal therapy, 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, leading 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 conservative 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 consequent creation of so-called black spaces. The difficulty in working on the papilla depends on the
anatomy and morphology of this structure, which
receives only a minor blood supply. The antero-posterior view of the papilla shows a buccal and a lingual
peak, with a concave-shaped col. This crest is nonkeratinized 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 structure is one of the most difficult challenges for periodontists. 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 instruments 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
655

30268.qxd

4/15/05

4:04 PM

Page 656

Interdental Papilla Augmentation in a Periodontal Patient

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
this in mind, in cases of chronic periodontitis with extrusion of the maxillary central incisors, opening of
diastema, and presence of infrabony defects, a multidisciplinary 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 periodontitis 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 evidence 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 interdental papilla (Figs. 1 and 2).
The patient undergoes surgery under local anesthesia 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 fullthickness 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 ability to access the defect, apply the regenerative technology, and seal the wound is a key aspect of the
procedure. The extension of the flap connects the distal sites of the two lateral incisors, and vertical releasing incisions are made only if needed for better surgical
access (Fig. 4). Then, using curets and scalers, conventional ultrasonic devices, and diamond burs mounted
on a low-speed contra-angled handpiece, the granulation tissue is completely eliminated from the defect,
followed by complete debridement of the radicular
surface. At this point, the defects may be augmented
with the use of a bone grafting material20 like colla656

Volume 76 Number 4

Figure 1.
Adult periodontal patient with migration of the frontal teeth, opening
of the diastema, and loss of the midline papilla.

Figure 2.
Initial intraoral radiograph showing interproximal bone loss, with vertical
defect on the mesial aspect of the left central incisor.

gen bovine bone mineral, without the use of barrier

membranes (Fig. 5). The suturing technique is chosen
according to the anatomy of the defect in order to
Ubistesin, 3M Espe, Seefeld, Germany.
Bio-Oss Collagen, Geistlich, Wolhusen, Switzerland.

30268.qxd

4/15/05

4:04 PM

Page 657

Cardaropoli, Re

J Periodontol April 2005

Figure 3.

Figure 4.

The flap is designed according to the modified papilla preservation

technique.

Intraoperative buccal view of the infrabony defect.

Figure 5.

Figure 6.

The infrabony defect is augmented with mineral collagen bovine bone

substitute.

A combination of mattress and interrupted sutures is used to obtain

primary closure of the flap.

achieve a passive closure of the margins of the wound,

with relief of flap tension (Fig. 6). A combination of horizontal 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 commence, 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-

ate forces acting in the center of resistance. The intrusive 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 movement of about 0.5 to 1 mm per month.
During orthodontic therapy, the appliance should
be checked every 2 weeks, while oral hygiene maintenance with professional prophylaxis should be performed every 3 months.23

Tevdek II, Butterfly Italia, Cavenago B.za, Italy.

Aulin, Roche, Milan, Italy.
Augmentin, GlaxoSmithKline, Verona, Italy.
Corsodyl, GlaxoSmithKline.

657

30268.qxd

4/15/05

4:04 PM

Page 658

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

Volume 76 Number 4

and esthetic fiber-reinforced Maryland splints can be

used.24
The results presented in this case report are representative of the results obtained with a larger number of patients, six of whom were treated following
the protocol described above. In all cases, the healing 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 conditions 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 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 9.
Figure 8.
Final intraoral radiograph showing resolution of the infrabony defect.
658

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.

30268.qxd

4/15/05

4:04 PM

Page 659

Cardaropoli, Re

J Periodontol April 2005

Figure 10.

Figure 11.

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.

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.

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: inserting 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 considerable 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 augmented 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 mineral. No adverse effects were reported, and the bio-

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 realignment 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 important role is played by the orthodontic movement, which
is able to positively guide the soft tissues during the
659

30268.qxd

4/15/05

4:04 PM

Page 660

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, creating 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 explanation for this gain in orthodontically induced attachment 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 stimulation increases the turnover of periodontal ligament
cells and thereby improves the chances that the periodontal ligament will repopulate the previously infected
root surface.
Animal studies on cell kinetics of PDL during orthodontically 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 forming 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 orthodontic 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 possibility of adapting to more favorable dental emergence
profiles. In this way, the papilla is pushed into the
660

Volume 76 Number 4

interdental embrasure during the early phases of postsurgical healing, and the forthcoming intrusion allows
the soft tissues to adapt to the more coronal portion
of the hard structure of the tooth.
REFERENCES
1. Takei HH, Han TJ, Carranza FA Jr., Kenney EB,
Lekovic V. Flap technique for periodontal bone implants.
Papilla preservation technique. J Periodontol 1985;56:
204-210.
2. Takei H, Yamada H, Hau T. Maxillary anterior esthetics.
Preservation of the interdental papilla. Dent Clin North
Am 1989;33:263-273.
3. Talamante E, Valencia J. Preservation of the papilla.
Surgical technique. Rev ADM 1991;48:115-120.
4. Cortellini P, Pini Prato GP, Tonetti MS. The modified
papilla preservation technique. A new surgical approach
for interproximal regenerative procedures. J Periodontol 1995;66:261-266.
5. Cortellini P, Pini Prato G, Tonetti MS. The modified papilla
preservation technique with bioresorbable barrier membranes in the treatment of intrabony defects. Case reports.
Int J Periodontics Restorative Dent 1996;16:546-559.
6. Cortellini P, Pini Prato GP, Tonetti MS. The simplified papilla
preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J
Periodontics Restorative Dent 1999;19:589-599.
7. Pini Prato GP, Agudio G, Cortellini PP, Clauser C. Reconstruction of the interdental papilla. Dent Cadmos 1986;54:
127-130.
8. Beagle JR. Surgical reconstruction of the interdental
papilla: Case report. Int J Periodontics Restorative Dent
1992;12:145-151.
9. Aubert H, Bertrand G, Orlando S, Benguigui F, Acocella G.
Deep rotated connective tissue flap for the reconstruction of the interdental papilla. Minerva Stomatol 1994;43:
351-357.
10. Seibert JS, Louis JV. Soft tissue ridge augmentation utilizing a combination onlay-interpositional graft procedure: A case report. Int J Periodontics Restorative Dent
1996;16:310-321.
11. Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol 2000 1996;11:65-68.
12. Azzi R, Etienne D, Carranza F. Surgical reconstruction
of the interdental papilla. Int J Periodontics Restorative
Dent 1998;18:466-473.
13. Blatz MB, Hurzeler MB, Strub JR. Reconstruction of the
lost interproximal papilla presentation of surgical and
nonsurgical approaches. Int J Periodontics Restorative
Dent 1999;19:395-406.
14. Azzi R, Etienne D, Sauvan JL, Miller PD. Root coverage
and papilla reconstruction in Class IV recession: A case
report. Int J Periodontics Restorative Dent 1999;19:
449-455.
15. Bijlani M. Surgical reconstruction of the interdental papillae. Dent Implantol Update 1999;10:53-54.
16. Nemcovsky CE. Interproximal papilla augmentation
procedure: A novel surgical approach and clinical
evaluation of 10 consecutive procedures. Int J Periodontics Restorative Dent 2001;21:553-559.
17. Azzi R, Takei HH, Etienne D, Carranza FA. Root coverage and papilla reconstruction using autogenous osseous
and connective tissue grafts. Int J Periodontics Restorative
Dent 2001;21:141-147.
18. Tarnow DP, Magner AW, Fletcher P. The effect of the
distance from the contact point to the crest of bone on

30268.qxd

4/15/05

4:04 PM

Page 661

Cardaropoli, Re

J Periodontol April 2005

19.
20.

21.
22.
23.
24.

25.

26.

27.

28.
29.
30.

31.
32.
33.

34.

the presence or absence of the interproximal dental

papilla. J Periodontol 1992;63:995-996.
OLeary TJ, Drake RB, Naylor JE. The plaque control
record. J Periodontol 1972;43:38.
Nevins ML, Camelo M, Lynch SE, Schenk RK, Nevins M.
Evaluation of periodontal regeneration following grafting
intrabony defects with Bio-Oss collagen: A human histologic report. Int J Periodontics Restorative Dent 2003;
23:9-17.
Burstone CJ. The segmented arch approach to space
closure. Am J Orthod 1982;82:361-378.
Braun S, Marcotte MR. Rationale of the segmented
approach to orthodontic treatment. Am J Orthod Dentofacial Orthop 1995;108:1-8.
Axelsson P, Lindhe J. The significance of maintenance
care in the treatment of periodontal disease. J Clin Periodontol 1981;8:281-294.
Corrente G, Vergnano L, Re S, Cardaropoli D, Abundo R.
Resin-bonded fixed partial dentures and splints in periodontally compromised patients: A 10-year follow-up. Int
J Periodontics Restorative Dent 2000;20:628-636.
Hossain MZ, Kyomen S, Tanne K. Biologic responses of
autogenous bone and beta-tricalcium phosphate ceramics transplanted into bone defects to orthodontic forces.
Cleft Palate Craniofac J 1996;33:277-283.
Araujo MG, Carmagnola D, Berglundh T, Thilander B,
Lindhe J. Orthodontic movement in bone defects augmented with Bio-Oss. An experimental study in dogs.
J Clin Periodontol 2001;28:73-80.
Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic
movement into bone defects augmented with bovine
bone mineral and fibrin sealer: A reentry case report. Int
J Periodontics Restorative Dent 2002;22:138-145.
Melsen B. Tissue reaction following application of extrusive and intrusive forces to teeth in adult monkeys. Am
J Orthod 1986;89:469-475.
Melsen B, Agerbaek N, Markenstam G. Intrusion of
incisors in adult patients with marginal bone loss. Am J
Orthod Dentofacial Orthop 1989;96:232-241.
Murakami T, Yokota S, Takahama Y. Periodontal changes
after experimentally induced intrusion of the upper
incisors in Macaca fuscata monkeys. Am J Orthod Dentofacial Orthop 1989;95:115-126.
Duncan WJ. Realignment of periodontally-affected
maxillary teeth a periodontists perspective. Part II: Case
reports. N Z Dent J 1997;93:117-123.
Rabie AB, Deng YM, Jin LJ. Adjunctive orthodontic treatment of periodontally involved teeth: Case reports. Quintessence Int 1998;29:13-19.
Cardaropoli D, Re S, Corrente G, Abundo R. Intrusion
of migrated incisors with infrabony defects in adult periodontal patients. Am J Orthod Dentofacial Orthop 2001;
120:671-675.
Re S, Corrente G, Abundo R, Cardaropoli D. The use of
orthodontic intrusive movement to reduce infrabony

35.

36.
37.
38.

39.
40.
41.
42.

pockets in adult periodontal patients: A case report. Int

J Periodontics Restorative Dent 2002;22:365-371.
Corrente G, Abundo R, Re S, Cardaropoli D, Cardaropoli G.
Orthodontic movement into infrabony defects in patients
with advanced periodontal disease: A clinical and radiological study. J Periodontol 2003;74:1104-1109.
Polson A, Caton J, Polson AP, Nyman S, Novak J, Reed B.
Periodontal response after tooth movement into intrabony
defects. J Periodontol 1984;55:197-202.
Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment through periodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:104-116.
Geraci TF, Nevins M, Crossetti HW, Drizen K, Ruben MP.
Reattachment of the periodontium after tooth movement
into an osseous defect in a monkey. 1. Int J Periodontics Restorative Dent 1990;10:184-197.
Roberts WE, Chase DC. Cell kinetics of orthodontically stimulated osteogenesis. Calcif Tissue Res 1977;22:
439-441.
Smith RK, Roberts WE. Cell kinetics of the initial response
to orthodontically induced osteogenesis in rat molar
periodontal ligament. Calcif Tissue Int 1980;30:51-56.
Roberts WE, Chase DC. Kinetics of cell proliferation and
migration associated with orthodontically-induced osteogenesis. J Dent Res 1981;60:174-181.
Vardimon AD, Nemcovsky CE, Dre E. Orthodontic tooth
movement enhances bone healing of surgical bony
defects in rats. J Periodontol 2001;72:858-864.

Correspondence: Dr. Daniele Cardaropoli, Via Baltimora 122,

10137 Turin, Italy. Fax: 39-011-32-36-83; e-mail: dacardar@
tin.it.
Accepted for publication July 30, 2004.

661