|Year : 2015 | Volume
| Issue : 1 | Page : 17-22
Comparison of two surgical techniques for the reconstruction of interdental papilla
S Shruthi1, Sheela Kumar Gujjari2, Kiran Prakash Mallya3
1 Department of Periodontology, Sri Siddhartha Dental College and Hospital, A Constituent of Sri Siddhartha University, Agalkote, Tumkur, India
2 Department of Periodontology, JSS Dental College and Hospital, A Constituent of JSS University, Mysore, India
3 Department of Oral and Maxillofacial surgeon, Vasan Dental Care, Bengaluru, Karnataka, India
|Date of Web Publication||12-Aug-2015|
Department of Periodontology, Sri Siddhartha Dental College and Hospital, A Constituent of Sri Siddhartha University, Agalkote, Tumkur
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of the study was to check the effectiveness of both Robert Azzi and Han and Takei technique in reconstructing the lost interdental papilla between maxillary central incisors. It also compared the two techniques. Materials and Methods: Fourteen systemically healthy patients fulfilling the inclusion and exclusion criteria were selected for the study. The clinical parameters were evaluated at baseline, 6 months and 12 months postsurgically. Results: The results showed that there was a statistical significant improvement in both papilla presence index score and papillary height in both the groups from baseline but on comparison, no technique was superior to the other. Conclusion: Both the techniques were equally good in reconstructing the interdental papilla. And no technique was superior to the other.
Clinical Relevance to Interdisciplinary Dentistry
An open gingival embrasure or black triangle occurs as a result of a deficiency of papilla beneath the contact point. The treatment of open embrasures may require restorative, orthodontic and periodontal considerations depending on the underlying etiology. Treatment of open embrasures requires an interdisciplinary approach of orthodontic, periodontic, and restorative treatment. Open gingival embrasures have complex esthetic and functional problems. An interdisciplinary team approach with the general dentist, orthodontist, and periodontist is critical.
Keywords: Han and Takei technique, interdental papilla, papilla presence index, papillary height, Robert Azzi technique
|How to cite this article:|
Shruthi S, Gujjari SK, Mallya KP. Comparison of two surgical techniques for the reconstruction of interdental papilla. J Interdiscip Dentistry 2015;5:17-22
|How to cite this URL:|
Shruthi S, Gujjari SK, Mallya KP. Comparison of two surgical techniques for the reconstruction of interdental papilla. J Interdiscip Dentistry [serial online] 2015 [cited 2019 Dec 12];5:17-22. Available from: http://www.jidonline.com/text.asp?2015/5/1/17/162739
| Introduction|| |
In addition to maintaining dental and periodontal health, dental esthetics has become a great concern for both dental practitioners and patients. In the last decade, esthetics has become a major concern in periodontal therapy with gingival recession resulting in denuded root surface and loss of gingival papilla being the two main concerns in periodontal esthetics.
The contour of the interdental tissues, the color and texture of keratinized tissues play a role in esthetics and the presence of interproximal papilla between the maxillary anterior teeth being the key esthetic component. Hence, one of the major esthetic challenges in periodontal plastic surgery is the ability of rebuilding the lost papilla in the maxillary anterior segment.
Today's dentist face esthetic standards that require a soft tissue contour with an intact papilla and a symmetrical gingival outline, especially in the interdental area of the maxillary central incisors. The loss of interdental papilla can result in what is known as black triangle which can result in various problems such as food impaction, affect esthetics and phonetics.
Loss of interdental papilla solely because of soft tissue damage can be restored completely by reconstructive techniques; but reconstruction is generally incomplete if the loss is due to severe periodontal disease and interdental bone resorption.
The various interdental papilla reconstruction options that have been available for the dentists have been orthodontic, prosthodontic, and restorative dentistry.  Nonsurgical treatment such as repeated curettage  and surgical therapies ,,, have also been advocated. Surgical intervention can be an option if bone crest to contact point distance is <5 mm and papilla <4 mm. 
On reviewing the literature, it was seen that the surgical techniques for papilla reconstruction are basically case presentations and no long-term follow-up was done to evaluate the success of the reconstruction of the papilla surgically. Hence, the aim of the present study was to evaluate the two surgical techniques Azzi et al.  and Han and Takei  using a subepithelial connective tissue graft to augment the soft tissue in the interdental area and to assess the success of reconstruction of the lost interdental papilla in the maxillary anterior region over a period of 1-year. It also compares the two techniques to check the predictability of one technique over the other.
| Materials and methods|| |
Fourteen adult patients both males and females within the age group of 25-35 years who were periodontally healthy and who willingly gave their consent were included in the study. The study was approved by ethical committee JSS University Mysore.
The patients were all systemically healthy, nonsmokers, nonpregnant and nonlactating mothers with a loss of papilla in the maxillary anterior teeth. The other inclusion criteria included a papilla presence index (PPI) score of 2 or 3, probing depth (PD) ≤3 mm, bone crest to contact point ≤5 mm and papillary height (PH) ≤4 mm.
All the patients underwent periodontal phase I therapy and received oral hygiene instructions. Patients were re-evaluated for their periodontal parameters at the end of 2 months and in patients who still had the loss of papilla between the upper central incisors underwent a surgical correction.
Fourteen patients were randomly assigned to the two groups Group A and Group B by lottery method. Group A included patients who underwent the reconstruction of papilla using Robert Azzi technique [Figure 1], and Group B included patients who underwent the reconstruction of papilla using Han and Takei technique [Figure 2].
|Figure 1: Group A (a) Preoperative-papilla presence index (PPI), (b) buccal reflection, (c) connective tissue graft, (d) connective tissue graft sutured in place, (e) 1-week postoperative, (f) PPI at 6 months, (g) PPI at 12 months|
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|Figure 2: Group B (a) Preoperative-papilla presence index (PPI), (b) semilunar incision, (c) connective tissue graft, (d) connective tissue graft sutured in place, (e) 1-week postoperative, (f) PPI at 6 months, (g) PPI at 12 months|
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Clinical measurements were recorded using a calibrated periodontal probe (UNC15). At baseline, 6 months and 12 months postsurgically, the following parameters were recorded plaque index (PI), gingival index (GI), PD, PPI, and PH.
After local anesthesia was achieved, the following surgical techniques were carried out depending on the group they belonged to.
Robert Azzi technique
An intrasulcular incision was made around the necks of the maxillary incisors. An envelope type split thickness flap was then elevated bucally and palatally. A second surgical site was created to obtain a connective tissue graft double the size of missing PH for placement under flaps in the recipient site. The tissue graft was then placed under the buccal and palatal flap and in the interdental papilla area and sutured.
Han and Takei technique
The semilunar labial incision was made from the disto-labial line angle of tooth to the mesio-labial line angle of tooth. After sulcular incisions had been made around the mesial half and the distal half of tooth, the gingival-papillary unit was pushed incisally to move gingiva into the crated area. Subepithelial connective tissue double the size of missing PH was harvested from palate. The connective tissue was placed into the pouch space after gingival-papillary unit was pushed incisally.
| Results|| |
All the parameters were subjected to descriptive statistics, independent sample t-test, repeated measures ANOVA. All the statistical methods were carried out through the Statistical Package for Social Sciences for Windows (version 16.0, 2008).
Fourteen patients were selected for the study who were divided into both the groups comprising 7 patients each. Group A included patients treated by Robert Azzi technique, and Group B included patients treated by Han and Takei technique. Of the 14 patients, 10 were females (4 in Group A and 6 in Group B) and 4 males (3 in Group A and 1 in Group B) with a mean age of 36.287 ± 7.04070 in Group A and 33.2143 ± 6.14164 in Group B.
All the patients who participated in the study were able to complete the follow-up evaluation. [Table 1] shows the clinical parameters at baseline, 6 months and 12 months.
|Table 1: The inter-group comparison of the mean values between various time intervals in various groups using descriptive statistics and independent samples t-test |
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Healing was uneventful for all the patients. There was no statistical significant difference between both the groups in PI and GI at various time intervals but at 12 months Group A (0.1786 ± 0.37401) showed a better PI and GI when compared to Group B (0.7143 ± 0.48795) which was statistically significant.
For both the groups, PD remained the same.
In Group A, PPI decreased from 2.000 ± 0.000 at baseline to 1.4286 ± 53452 at 6 months which remained the same at 12 months.
In Group B, PPI decreased from 2.000 ± 0.000 to 1.5714 ± 0.53452 at 6 months which remained the same at 12 months. There was no statistically significant difference found in PPI between the groups. However, both showed a statistically significant reduction in PPI from baseline.
In Group A, PH decreased from 6.7143 ± 0.75593 to 4.2857 ± 1.11270 at 6 months which further reduced to 4.000 ± 1.000 at 12 months.
In Group B, PH decreased from 6.4286 ± 0.97590 at baseline to 4.8571 ± 1.46385 at 6 months which further reduced to 4.5714 ± 1.27242 at 12 months. No statistically significant difference in PH was found between the groups. However, both the groups showed a statistically significant reduction in PH from baseline.
In Group A, 4 out of 7 patients achieved a 100% interdental papilla reconstruction. Two achieved 83%, and 1 achieved 71% papilla reconstruction. In Group B, 3 patients achieved 100% interdental papilla reconstruction. 2 patients achieved 71%, and 2 patients achieved 85% papilla reconstruction.
| Discussion|| |
This is a comparative study evaluating the effectiveness of the two techniques Azzi et al.  and Han and Takei  in the reconstruction of interdental papilla.
Only case reports are there of Han and Takei  as well as Azzi et al.  Comparison of these two techniques has also not been done. Hence, the results of this study cannot be compared to any previous studies which have used the same techniques.
There is a study by Nemcovsky  where interproximal papilla augmentation was done on 9 patients. This surgical procedure was based on an advanced papillary flap combined with a gingival graft but the follow-up was only for 3 months, and papilla index score was used to assess the outcome. The index used was a modification of the one given by Jemt  in 1997.
In the present study, we have assessed both the PPI score and PH to assess the pre- and post-operative changes in the interdental papilla. The PPI score was given by Cardaropoli et al.  in 2004. This is the newest classification which can also be used in cases of lack of contact points and in the presence of diastema. The index allows for an easy measurement of PH in all clinical situations and allows comparisons between baseline and posttreatment levels thus facilitating in standardizing clinical procedures.
In this study, PH was calculated from the tip of the gingival papilla to the mesial line angle of the incisal edge noting the change in pre- and post-treatment change in PH. This method was done in a study which compared the retention of interdental PH when treated with papillary retention and full thickness flaps with internal mattress sutures. 
From a biologic point of view, the presence or absence of the papilla primarily depends on the distance between the interdental contact point and interproximal crest of bone.  Periodontal disease can produce bone resorption, with the formation of horizontal defects or with the formation of vertical defects. Both patterns of bone resorption can lead to a lengthening of the distance from the bone crest to the contact point. Hence, in this study, only those patients who were periodontally healthy with a PD of 1-3 mm and intraoral periapical radiograph which ruled out the presence of bone loss were selected.
Probing depth miller emphasized the importance of blood supply to the donor tissue. If the principle of abundant blood supply for the predictable take of the graft is to be followed, the creation of a new papilla must be dictated by the same principle.
In a study done on 9 patients,  8 out of 10 sites showed a successful papilla reconstruction. The technique involved was based on an advanced papillary flap combined with a gingival graft comprising of epithelium and connective tissue. Here, free gingival graft was used; the blood supply was mainly from the periosteal bed.
In this study, out of 14 patients, 7 patients showed a successful reconstruction of papilla out of which 4 were of Group A - Robert Azzi group and three were of Group B Han and Takei group. The Robert Azzi technique  comprises a sulcular incision and a connective tissue placed in the envelope created. The blood supply to the grafted connective tissue is a key element of this technique. This is assured by the flap coverage of the connective tissue extension, in which only a small portion at the tip is left uncovered. The grafted tissue receives a flow of plasma and an in growth of capillaries from the periosteum, underlying connective tissue and overlying flaps.
The other technique used was the Han and Takei technique  which is a form of pedicle grafting using a semilunar incision and coronal displacement of the entire gingival-papillary unit, held in place with a section of sub epithelial connective tissue graft beneath the coronally displaced tissue. The use of pedicle graft ensures a predictable blood supply to the graft as the blood supply is derived directly from the base of the mobilized flap.
Robert Azzi technique  might have shown a better improvement clinically even though it was not statistically significant as it could be due to the rich blood supply provided to the graft from both the buccal and palatal flaps. Whereas in Han and Takei technique,  the blood supply was obtained only from the base of the pedicle flap.
Hence, the usage of subepithelial connective tissue in the present study increased the success rate and predictability of donor tissue as it received its blood supply from both the overlying flap and underlying periosteum which is one of the factors influencing surgical reconstruction of papilla.
Both PPI score and PH showed an improvement in both the groups from baseline to 12 months however intergroup comparisons revealed that there was no statistical difference, and hence neither of the technique was superior over the other.
We also noticed that the areas with narrow loss of interdental papilla showed a complete reconstruction of papilla when compared to areas with wide loss. This failure to reconstruct the papilla in wide areas could be due to the donor tissue obtained from the palate. If the tissue was obtained from the tuberosity area, the donor tissue would be thick and fibrous hence improving its outcome. As the availability of donor tissue also play a role in successful reconstruction. 
The other factor which influences the surgical reconstruction of papilla is the tissue biotype.  Outcome of papilla reconstruction will be better in cases with a thick gingival unit. However, in the present study, this was not taken as criteria to select patients.
Even though there are other novel techniques ,, for the reconstruction of the papilla, they are more expensive and require extensive studies to confirm its efficacy. Evaluation of various surgical techniques with longer follow-ups is required so that the best surgical technique can be practiced on a regular basis thereby making it as a more economical and acceptable method of treatment for rebuilding the lost papilla.
| Conclusion|| |
The results of the present study showed that both the techniques individually were effective in reconstructing the papilla. However, on comparison none of the technique was superior over the other. Few cases did not show a complete reconstruction of papilla, but there was a reduction in PH.
Hence, even if these techniques cannot completely rebuild the lost interdental papilla, the black triangle problem can be minimized to achieve patient's demands.
Further studies with a larger sample size are required to confirm the effectiveness of techniques in reconstructing the papilla.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]