The contour of the interdental tissues, as well as the color and texture of the keratinized tissues, are essential elements of anterior esthetics. Tissue loss in the interproximal regions, with related esthetic concerns, phonetic difficulties, and food impaction, can occur for a variety of reasons, including treatment of periodontal diseases. In periodontal surgical procedures, the soft tissues require elevation and resection to gain access to the root surfaces and osseous supporting structures. Compromised esthetics in the anterior region of the mouth could be a serious consequence of periodontal surgical procedures. Several articles have been devoted to flap designs and surgical techniques to maintain full papillary form and preserve the soft tissues during surgical access. Unfortunately, very little evidence of long-term results is available. The aims of the present article are to report a 22-year follow-up case of surgical interdental papilla preservation, discuss the anatomic variables that conditioned the outcome, and review and compare existing surgical techniques for maintaining the interproximal soft tissues. Keywords: anterior esthetics, interdental papilla, papilla, papilla preservation, periodontal surgery