Several techniques have been proposed to maintain full papillary form and preserve soft tissue during periodontal surgical access. However, very little evidence of long-term results is available. The aim of the present paper is to report the 15- to 20-year follow-up outcomes of a case series study of papillae preservation flap surgery in esthetic areas. Twenty-two patients (10 women, 12 men; mean age: 41.3 years) with moderate to advanced generalized periodontitis were included in this study carried out in a private office from 1994 to 1996. In each patient, nonsurgical therapy with scaling and root planing was performed. Following this initial phase of therapy and the periodontal re-evalutaion, a papillae preservation flap surgery was performed in the anterior maxillary area in each subject. Full-mouth Plaque Index (FMPI), Gingival Index (GI), full-mouth Bleeding Score (FMBS), probing depth (PD), bleeding on probing (BOP), clinical attachment level (CAL), gingival recession (GR), and papilla height (PH) were assessed at the baseline and at each year of the follow-up. GI and BOP decreased with a statistical difference after surgery (P .05) and remained low over the entire observation period. At the end of the follow-up period, PD and CAL decreased significantly (P .05) compared to baseline (PD from 7.18 ± 0.91 mm to 2.98 ± 0.49 mm; CAL from 8.06 ± 1.2 mm to 4.01 ± 0.28 mm). Gingival recession and papilla height did not change significantly after surgery compared to baseline (GR from 0.88 ± 0.42 mm to 0.92 ± 0.36 mm; PH from 5.6 ± 1.1 mm to 4.2 ± 0.8 mm) and remained stable over the 15 to 20 years of the study (GR = 1.12 ± 0.36 mm; PH = 4.9 ± 0.9 mm) (P > .05). Results of the present long-term study show that the papillae preservation flap procedure may be applied successfully to the treatment of periodontal pockets in the maxillary anterior region.