A Modification of the Curtain Technique Incorporating

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A Modification of the "Curtain Technique" Incorporating
an Internal Mattress Suture
Donald H. Newell* and Michael A. Brunsvoldt
Accepted for publication 3 April 1985
An internal mattress suture is described for suturing labial papillae to palatal flaps
when using the "curtain technique." The suture is simple to perform and does not violate
the intact labial sulci. It gives stability to both the labial papillae and palatal flap while
maintaining maximum esthetic results.
From a patient's viewpoint, esthetics is one of the
most important aspects of periodontal therapy. This
factor may be overlooked by the conscientious therapist
who strives primarily to control periodontal disease by
pocket reduction methods.
Several surgical procedures have been described
which include preservation of anterior esthetics as one
of their goals.1-4 The "curtain technique" is one of these
procedures. It is designed to retain all labial attached
gingiva and to reduce pockets with a lingual approach.1
On the palate a gingivectomy might be used; if osseous
recontouring is necessary, a palatal flap is indicated.5'6
The original description of the procedure, however,
does not describe a specific method for suturing the
palatal flap.
Clinical observations indicate that conventional in-
terrupted loop sutures are limited in maintaining an-
terior esthetics. They tend to flatten interdental pa-
pillae, especially if the papillae are thin (Fig. 1). As
wound healing progresses, objectionable interproximal
spaces are created (Figs. 2a and 2c).
Interrupted, or continuous sling sutures7 used to
secure the palatal flap in a "curtain technique" can
easily slip into the labial sulci and impinge on the
junctional epithelium and connective tisue attachment.
Such subgingival impingement for a long period causes
rapid conversion of gingivitis to Periodontitis in non-
human primates.8 Therefore, the use of simple loop or
sling sutures to secure palatal flaps in the "curtain
technique" has limitations.
* Assistant Professor. Department of Periodontics. University of
Texas Health Science Center at San Antonio. San Antonio, TX
78284.
t Assistant Professor, Department of Periodontics. University of
Texas Health Science Center at San Antonio.
Purpose
The purpose of this article is to describe an internal
mattress suturing method which preserves the esthetic
results of the "curtain technique." Plastic surgeons have
advocated vertical mattress sutures to produce eversión
of skin edges. The edges gradually flatten during healing
to produce a level surface.9 These sutures are internal
in nature, because the portion traversing the incision is
internal to the surface. In periodontal surgery, however,
a vertical mattress suture usually crosses the incision
external to the wound surface.10 " The method men-
Figure 1. Diagram ofan interrupted loop suture showing apical and
lingual displacement ofa labial papilla.
484
Volume 56
Number 8 Curtain Technique Modification 485
Figure 2. a, Facial papillae before a "curtain procedure. " Note mini-
mal interdental recession, b. Facial papillae sutured with interrupted
loop sutures. Note displacement of papillae, especially between the
central incisors, c. Three-month postoperative result showingflattened
interdental papillae and creation ofesthetically objectional spaces.
tioned by Yukna et al.3 for suturing labial and lingual
papillae in the Excisional New Attachment Procedure
(ENAP) was referred to as a vertical mattress suture but
was not described in detail. It was, however, an internal
mattress suture producing a "purse-string" or everting
effect on the papillae.12 The authors are aware of other
clinicians who have used a similar internal mattress
suture with the "curtain technique." To our knowledge
it has not been described in the literature.
Suturing Technique
Using the "curtain technique" described by Frisch,
et al.1 in the maxillary anterior sextant, the labial one-
third of the interproximal papilla is retained and re-
ferred to as the "curtain" (Figs. 3a-3c). The objective
of suturing is to adapt the palatal flap completely over
the palatal bone and against the root surface, while
Figure 3. a, After incisions and debridement the labial one-third of
the interdental papillae are retained as the "curtain. " Note normal
positions ofthe papillae, b, Internal mattress sutures in place (arrows)
maintain the lips of the papillae in their normal positions, c, One
month postoperative healing shows little change in gingival esthetics.
(Courtesy ofDr. Kent M. Hamilton)
486 Newell, Brimsvold
J. Periodontol.
August. 1985
allowing the tips of the labial papillae to remain in an
undisturbed position. The suture is started by penetrat-
ing the outer surface of the palatal flap; the needle is
then pulled completely through the flap. Next, the labial
papilla is penetrated from the inner surface as far api-
cally as the interdental bone will allow. The needle,
which is protruding from the labial surface of the inter-
dental papilla, is then drawn labially out of the tissue
(Fig. 4a). The technique to this point is identical to that
of a simple interrupted loop suture; the next step con-
verts it to an internal mattress suture.
Instead of passing the needle back through the inter-
dental space apical to the contact area and incisai to
the tip of the papilla, the outer surface of the papilla is
penetrated 2 to 3 mm incisai to the point of initial
penetration (Fig. 4b). The needle is then drawn com-
pletely through the papilla and the interdental space,
and the suture is knotted over the external surface of
the palatal flap. This results in a vertical internal mat-
tress suture on the labial aspect and a simple interrupted
loop on the palatal side (Fig. 5). The same procedure is
then repeated with each papilla involved. The resultant
securing forces on the edges of the palatal flap are in
an apical and labial direction, while on the labial pa-
Figure 4. a. Needle has penetrated the papilla as far apieally as
possible and is drawn labially out of the tissue, b. Outer surface ofthe
papilla is penetrated 2 to 3 mm incisai to point of initial penetration.
Figure 5. Diagram ofa vertical internal mattress suture in the labial
papilla (arrow) and a simple interrupted loop in the palatal flap. Note
support of the labial papilla without displacement.
pillae they are only in a lingual direction. This allows
the tips of the papillae to keep their normal positions
near the incisai contact areas (Fig. 3b).
A vertical internal mattress suture will usually allow
more distance between the adjacent penetrations when
used with long, narrow papillae (Fig. 6a). Short, wide
papillae will better accommodate a horizontal internal
mattress suture (Fig. 6b).
Advantages
1. The labial papillae are supported to resist labial
displacement during the application of palatal surgical
dressing. This eliminates the need for labial dressing to
resist labial displacement.
2. Interproximal recession, and thus poor esthetics,
is avoided since the palatal flap is supported without
depression and displacement of the tips of the labial
papillae.
3. There is no violation of the labial sulci as can
occur with a sling suture.
Disadvantages
1. There may be "dimpling" of the labial surface of
the papillae after suture removal, but this lasts only 2
to 3 weeks (Fig. 3c).
2. The sutures may tear through thin papillae, espe-
cially if tied too tightly. This occurs infrequently, how-
ever, if the labial incisions retain at least one-third of
the labial aspect of each papilla. In over 30 curtain
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Number 8 Curtain Technique Modification 487
b
Figure 6. a. Vertical internal mattress sutures are used with long,
narrow papillae, b. Horizontal internal mattress sutures are used with
short, wide papillae.
procedures with approximately 150 interproximal pa-
pillae sutured by this method, the authors have seen
only four instances of torn tissue.
In summary, the advantages of using an internal
mattress suture in the "curtaintechnique" greatly out-
weigh the disadvantages. Its ease of application makes
it a valuable adjunct in maintaining the esthetic con-
tours of the anterior gingiva.
ACKNOWLEDGMENTS
The authors wish to thank Drs. Elmer Burnette, Olav Alvarez and
James Lane for their constructive help in reviewing the manuscript.
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Send reprint requests to: Donald H. Newell, DDS. MS. Depart-
ment of Periodontics. University of Texas Health Science Center at
San Antonio. 7703 Floyd Curl Drive, San Antonio, TX 78284.