Management of Lost Interdental Papilla by a Surgical Approach

Acta Scientific Otolaryngology (ISSN: 2582-5550)

Volume 3 Issue 12 December 2021

Management of Lost Interdental Papilla by a Surgical Approach - A Case Report

Subuhi Mudassar

, Mehvish Saleem

*, Mayur Kaushik

and Sachin

Gupta

Post Graduate Student, Department of Periodontology, Subharti Dental College

and Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India

Assistant Professor, Department of Periodontology, Subharti Dental College and

Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India

Professor and Head, Department of Periodontology, Subharti Dental College and

Hospital, Swami Vivekanand Subharti University, Meerut, Uttar Pradesh, India

*Corresponding Author: Mehvish Saleem, Assistant Professor, Department of

Periodontology, Subharti Dental College and Hospital, Swami Vivekanand Subharti

University, Meerut, Uttar Pradesh, India.

Case Report

Received: September 15, 2021

Published: November 18, 2021

Saleem., et al.

Abstract

Black triangles or absence or loss of interdental papillae (IDP) is one of the most important steps of decision-making process

of clinicians. The IDP is a dense connective tissue that is covered by oral epithelium and is found in the space between the gingival

tissues of two adjacent teeth. It protects the periodontal structures by acting as a biological barrier, and also plays a critical role in

aesthetics. The shape of the IDP between the teeth is determined by three important aspects - contact relationship, the width of the

proximal tooth surfaces, and the course of the cemento-enamel junction (CEJ). The loss of IDP creates esthetic and phonetic problem

and may also lead to food impaction. Orthodontic, prosthetic and restorative procedures are the non-surgical approaches that can





was performed for papilla reconstruction.

Keywords: Interdental Papillae (IDP); Black Triangles; Soft Tissues

Introduction

Aesthetic dentistry is fueled by enchantment, generating com-

pliments, obsession and popularity. A victorious aesthetic pro-

cedure regains the patient’s self-confidence, resuscitate social

skills and knowledge. Restoration of lost teeth in association with

aesthetic dentistry involves the management and reconstruction

of the encasing gingiva [1].

Periodontal treatment aimed more at

preserving and restoring the periodontal health rather than focus-

ing on the aesthetic outcome of the treatment. Recent advances

    -

thetic concerns [2]. Periodontal cosmetic surgery comprises of a

good range of procedures that aims to correct anatomical, develop-

mental or traumatic deformities of the gingiva or alveolar mucosa

[3].

The interdental papilla, a part of the gingiva that’s present

between the proximal surfaces of the teeth which occupies the

cervical embrasure space extending to fill the lingual, buccal,

and occlusal pyramid of the interdental space [4].

The loss or absence of interdental papilla could also be a re-

sult of gingival inflammation, attachment loss, and interproxi-

mal bone resorption. The foremost common cause being loss

         

traumatic oral hygiene [5].

    

support are essential for the upkeep of a healthy papilla [6].

Citation: Mehvish Saleem., et al. “Management of Lost Interdental Papilla by a Surgical Approach - A Case Report". Acta Scientific Otolaryngology 3.12

(2021): 08-12.

The Presence or absence of the IDP primarily depends upon the

space between the interdental contact point and therefore the in-

terproximal crest of bone that’s alleged to be 5 mm [7].

Periodon-

tal surgical procedures like soft tissue grafting, connective tissue

graft/free gingival grafts, use of enhanced conservative new mu-

  -

pography with/without GTR/GBR, enhanced regeneration of lost

interdental hard and soft tissue [8]. Additive materials like Platelet

Rich Fibrin (PRF) as a membrane, etc. have also proven their ef-

[9].

To gain aesthetics reconstruction and regeneration of lost in-

terdental papilla is the aim of the periodontal surgeons. Tissue

deformities in the interproximal areas can be treated by various



periodontal surgeries, orthodontic teeth alignment or combination

of all [5]. The non-surgical procedures modify the interproximal

space whereas the surgical approaches recontour, preserve and

regenerate the soft tissue between the interproximal spaces

[10].

Limited success has been achieved with surgical procedures like

free gingival grafts, interproximal curettage, or displacement of the

interproximal palatal tissue due to the shortage of blood supply to

the graft tissue [11].

-

lent principle of healing on which the subepithelial connective tis-

sue graft for root coverage and ridge augumentation are based,

henceforth increasing both the success rate and predictability of

the procedure [12].

Materials and Methods

A 35-year-old female patient came to the Outpatient Depart-

ment of Periodontology and Implantology, Subharti Dental College

and Hospital, Swami Vivekanand Subharti University, Meerut, Uttar

Pradesh, with the chief complaint of black space between the upper

front tooth and the gum region since 6 months.

On clinical examination, class I papillary loss between both the

maxillary central incisors was found (Figure 1). Clinical evaluation

was done using UNC-15 periodontal probe and the distance from

the contact point to the bone crest came out to be 5 mm.

No bone loss was revealed on radiographic examination hence,

-

pilla reconstruction was anticipated.

Figure 1: Preoperative view showing loss of interdental

papillae in 11 and 21 region.

Surgical procedure

Informed consent was taken after explaining the procedure

followed by phase I therapy and oral hygiene instructions. Imme-

diately prior to the surgical procedure, the patient was instructed

to rinse with 0.2% chlorhexidine digluconate solution for 30 sec-

onds. After administration of local anaesthesia (2% lignocaine

with 1:80000 adrenaline), a split thickness semilunar incision was

performed 3 mm apically from the mucogingival junction facial to

the interdental area, and a pouch-like preparation was performed

into the interdental area. Intrasulcular incisions were made round

the neck of the adjacent teeth extending from the buccal to the pal-

atal surface, to release the connective tissue attachment from the

root surface and to permit coronal displacement of the gingival-

papillary unit (Figure 2).

Figure 2: View of the line of incision.

Harvesting of connective tissue graft



-

sion was made within the area of molar and premolars followed



Management of Lost Interdental Papilla by a Surgical Approach - A Case Report

Citation: Mehvish Saleem., et al. “Management of Lost Interdental Papilla by a Surgical Approach - A Case Report". Acta Scientific Otolaryngology 3.12

(2021): 08-12.

surgical blade no.15 and tissue holding forceps were used to raise a



the underlying connective tissue. The harvested subepithelial con-

nective tissue graft was then preserved within the normal saline.

3-0 black braided silk sutures to obtain primary closure were used

to obtain the primary closure at the donor site (Figure 3).

Figure 3: Donor Site.

The harvested graft was consistent with the recipient site and

was then pushed coronally to support and provide bulk to the coro-

nally positioned interdental tissue (Figure 4). Flap was stabilised

using 5-0 black silk sutures (Figure 5).

Figure 4: Connective tissue graft being tucked into the pouch

created.

Figure 5: Incisions closed with 5-0 silk sutures.

The patient was prescribed with antibiotics and analgesics and

0.2% chlorhexidine digluconate mouthwash twice daily for two

weeks with no mechanical cleaning of the surgically treated area.

Healing

2 weeks after the procedure suture removal was done and

satisfactory healing was found. The patient was reviewed weekly

for 1 month, then monthly for 6 months post-operatively. Normal

anatomy and shape of the IDP was maintained till 6 months with

complete reconstruction of the papilla (Figure 6).

Figure 6: Postoperative view after 6 months.

Discussion

Black triangles within the anterior region of teeth are some

extent of aesthetic concern. Several nonsurgical and surgical tech-

       -

construction [10].

The distance from the bottom of the contact area to the crest of

bone depends on the presence or absence of the interproximal pa-

pilla and if it’s 5 mm or less, the papilla could also be reconstructed

surgically [13]. If the space between the interproximal papilla is

-

construction of the papilla by adding restorative material therein



unpredictable due to minimal blood supply from the recipient site

to the donor site, both of which have minimal contact because of

[14].

The lost papilla is often re-created by surgical means that in-

volves the principle of ample blood supply to the newly created tis-

sue. Therefore, semilunar incision along side with coronal displace-

ment of entire gingivopapillary unit, with subepithelial connective

Management of Lost Interdental Papilla by a Surgical Approach - A Case Report

Citation: Mehvish Saleem., et al. “Management of Lost Interdental Papilla by a Surgical Approach - A Case Report". Acta Scientific Otolaryngology 3.12

(2021): 08-12.

tissue graft may be a most predictable method in reconstructing



reconstruct the interdental papilla offers successful results [12].

The principle of dual blood supply of subepithelial connective

tissue has also been applied to the reconstruction of the interdental

-

age of blood supply to the prevailing papilla by accessories to papil-

[14].

Successful results and improvement in interdental papilla with

reconstruction of interdental papilla was observed by Sawai., et al.

[15].

Semilunar incision allows coronal displacement without cre-

ating tension and prevents gingiva from rebounding back to its

original position while the intrasulcular incision free the connec-

tive tissue from the root surface to permit coronal displacement of

the gingivopapillary unit keeping the prevailing papilla completely

preserved. To eliminate the dead space and to maintain the gingival

-

thelial connective tissue graft. The graft was harvested just before

the surgical detachment of the papilla to prevent the development

of blood clot between the bone and connective tissue because

blood clot might compromise the immediate blood supply to the

graft and therefore can induce partial necrosis of the transplanted

tissue as suggested by Carnio J [16].

The graft in the present case report was harvested from palate

-

[17].

Flow of plasma and ingrowth of capillaries from surrounding

tissue into the subepithelial connective tissue graft leads to aes-



-



Reconstruction of the lost interdental papilla is the most chal-

lenging and least predictable problem because of narrow inter-

proximal space results obliteration, ischemia and ultimately to

necrosis of graft.

Conclusion

The major aesthetic challenge in periodontal plastic surgery is

the reconstruction of the lost IDP. The success and the predictabil-

ity of any surgical procedure for treating papilla loss depends on



connective tissue graft and the maintenance of good oral hygiene

-

terproximal papilla, subepithelial connective tissue graft proved to





-

nective tissue graft. The atraumatic management of the tissues, re-

spect for the blood supply and avoidance of tension and pressure

are critical for the viability of the tissues and the success for the

procedure.

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Volume 3 Issue 12 December 2021

Management of Lost Interdental Papilla by a Surgical Approach - A Case Report

Citation: Mehvish Saleem., et al. “Management of Lost Interdental Papilla by a Surgical Approach - A Case Report". Acta Scientific Otolaryngology 3.12

(2021): 08-12.