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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 117-121

Interdisciplinary approach to reconstruct papilla in esthetic zone: A case series


Department of Periodontics, VS Dental College and Hospital, Bengaluru, Karnataka, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Sharma Chhavia
Department of Periodontics, VS Dental College and Hospital, K.R Road, V.V Puram, Bengaluru - 560 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_40_17

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   Abstract 


In today's world, people are more concerned about their beauty, looks and physical appearance. This has brought greater demands to esthetics in dentistry. One of the unaesthetic appearance of the oral cavity is loss of interdental papilla i.e., black triangle between maxillary anterior teeth which can occur due to many reasons and it's a challengeable task to treat it. The present case series demonstrates an interdisciplinary approach with a combination of modified Beagle's technique and composite restoration to reconstruct interdental papilla between maxillary central incisors with 6 months follow- up. Complete reconstruction of the lost papilla was achieved in both the cases 6 months postoperatively.

Keywords: Beagle's technique, black triangle, composite restoration, esthetics, papilla reconstruction


How to cite this article:
Chhavia S, Sandeep J N. Interdisciplinary approach to reconstruct papilla in esthetic zone: A case series. J Interdiscip Dentistry 2017;7:117-21

How to cite this URL:
Chhavia S, Sandeep J N. Interdisciplinary approach to reconstruct papilla in esthetic zone: A case series. J Interdiscip Dentistry [serial online] 2017 [cited 2018 Jul 18];7:117-21. Available from: http://www.jidonline.com/text.asp?2017/7/3/117/221894




   Clinical Relevance to Interdisciplinary Dentistry Top


Black triangle has multifactorial aetiology and treatment of open gingival embrasure requires an orthodontic, periodontal and restorative considerations depending on the underlying etiology. Thus, an interdisciplinary team approach with the general dentist, orthodontist, and periodontist is critical.


   Introduction Top


Smile is a facial expression which plays an important role in social interaction and is most often the need for “esthetics” which pushes the patients toward dental treatment.[1] There are various conditions of the oral cavity which can produce an unesthetic appearance such as missing anterior teeth, midline diastema, gingival recession, anterior crowding, gummy smile, discolored tooth, fractured anterior tooth, and a black triangle.

Black triangle is the loss or absence of interdental papilla (IDP) between two adjacent teeth resulting in lateral food impaction, an obstacle in phonetics, and functional and esthetic problems. The loss of IDP has multifactorial etiology which includes traumatic oral hygiene procedures, abnormal tooth shape, plaque-associated lesions, improper contours of the restorations, loss of teeth, and spacing between teeth. It can be managed through various and surgical and nonsurgical procedures.[2]

Various surgical techniques which have been proposed to reconstruct papilla include free gingival grafts, free connective tissue grafts, and pedicle flaps. Long-term predictability and stability of these surgical techniques have failed to achieve better results because of minor blood supply in the IDP. However, in comparison to free gingival grafts, pedicle flaps have shown better results.[3] One such pedicle flap technique to reconstruct IDP is Beagle's technique which is the combination of two techniques, i.e., Abram's roll technique for ridge augmentation and Evian's papilla preservation technique.[4]

The present study describes cases treated by an interdisciplinary approach using modification of Beagle's technique [Figure 1] to reconstruct IDP followed by composite restoration of that respective tooth.
Figure 1: Diagrammatic representation of surgical procedure

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   Case Reports Top


Case 1

A 27-year-old male came to the Department of Periodontics, Vokkaligara Sangha Dental College and Hospital, Bengaluru, with chief complaint of black space between two maxillary central incisors. Intraoral examination revealed unesthetic black triangle with a small spacing between maxillary central incisors with healthy interdental soft tissue and no gingival recession on 11 and 21. At baseline, a distance of 7 mm was measured from the tip of IDP to incisal edge using an UNC-15 probe [Figure 2]. Initially, Phase I therapy including scaling and root planing was performed and the patient was recalled after 1 month for a surgical procedure.
Figure 2: Preoperative view (missing interdental papilla with gap between maxillary central incisor)

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Surgical procedure

Before the surgical procedure, the patient was instructed to rinse his mouth with 0.2% chlorhexidine digluconate solution for 30 s. After administration of local anesthesia, with 15c blade, a partial thickness vertical incision was given extending from mesiolabial line angle of 11 and 21 toward mucogingival junction that was twice the height of desired papilla reconstruction followed by horizontal incision connecting two vertical incisions. Then, the flap was dissected and was folded upon itself to completely obliterate the open embrasure. The free end of the flap was sutured using 4-0 Vicryl suture so as to suspend the papilla between adjacent teeth [Figure 3]. Postoperative instructions including analgesics and 0.2% chlorhexidine mouthwash to be used twice daily for 15 days were prescribed to the patient. Suture removal was done 1 week after the surgical procedure.
Figure 3: Incision followed by suturing

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Restorative procedure

One month after the surgical procedure, the restorative procedure, i.e., composite restoration was done to close the residual gap between maxillary central incisors.

Follow-up visit

The patient was recalled at 15 days, 1 month, 3 months, and 6 months postoperatively and the distance between the tip of IDP and incisal edge measured was 4.5 mm, 5 mm, 5 mm, and 5 mm, respectively [Figure 4], [Figure 5], [Figure 6], [Figure 7].
Figure 4: Fifteen-day postoperative view

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Figure 5: One-month postoperative view

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Figure 6: Three-month postoperative view with composite restoration

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Figure 7: Six-month postoperative view

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Case 2

A 35-year-old female came to the Department of Periodontics, VSDC and H, Bengaluru, with chief complaint of a gap between two maxillary central incisors. Intraoral examination revealed midline diastema between maxillary central incisors with healthy interdental soft tissue and no gingival recession on 11 and 21. At baseline, a distance of 9 mm was measured from the tip of the IDP to the incisal edge using an UNC-15 probe. Phase I therapy followed by modified Beagle's technique was performed. One month after the surgical procedure, composite restoration was done for closure of remaining maxillary diastema. The patient was recalled at 15 days, 1 month, 3 months, and 6 months postoperatively and the distance between the tip of IDP and incisal edge measured was 7, 7.5, 7.5, and 7.5 mm, respectively [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14].
Figure 8: Preoperative view (missing interdental papilla with gap between maxillary central incisor)

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Figure 9: Incision followed by reflection

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Figure 10: Suturing

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Figure 11: Fifteen-day postoperative view

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Figure 12: One-month postoperative view

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Figure 13: Three-month postoperative view

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Figure 14: Six-month postoperative view

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   Discussion Top


IDP composed of dense connective tissue which fills the interdental space between two approximating teeth. The shape of the IDP depends on a variety of factors such as contact point between two adjacent teeth, presence or absence of degree of recession, and width of proximal tooth surfaces.[5],[6]

Various techniques using connective tissue graft have been used for reconstruction of IDP. Semilunar coronally displacement of gingival-papillary unit with placement of connective tissue graft inside the pouch resulted in complete obliteration of interproximal space and the height and volume of the reconstructed papilla was maintained 4 years postoperatively.[7] The same technique performed by Deepalakshmi et al. also resulted in complete reconstruction of IDP which was maintained 6 months postoperatively.[8]

The two surgical techniques such as Robert Azzi technique and Han-Takei technique followed by placement of connective tissue graft under the flap were compared and the results showed a statistical significant improvement in both papilla presence index score and papillary height in both the groups from baseline to 12 months, but on comparison, no technique was superior to the other.[9]

Semilunar coronally repositioned papilla technique and modification of Nodland's microsurgical technique with placement of free connective tissue graft also resulted in complete reconstruction of the lost papilla in all the three cases of case series done by Muthukumar et al.[10]

Carranza et al. used a different technique to minimize surgical trauma and blockage of blood supply to the existing papilla. The papillary area was accessed through vertical incisions with full-thickness flap elevation and placement of free connective tissue graft beneath the undermined papilla. This had resulted in a significant gain of papillary volume in both coronal and facial direction.[11]

In 1992, Beagle presented a technique to reconstruct IDP by performing a surgical procedure on the palatal side.[4] In the present case series, modification of Beagle's technique, i.e. surgical procedure, was performed on the buccal side to prevent damage to incisal nerves and vessels and to prevent incorporation of fat in the undersurface of flap which could act as hindrance in vascularization of flap.

Grupe and Warren reported that predictable results can be obtained with any form of pedicle grafting if a proper donor tissue is found adjacent to the recipient site because of the abundant blood supply from the base of the pedicle. Modification of Beagle's technique used in the present cases is one of the pedicle flap techniques, which maintains adequate blood supply to the flap as a result of which no necrosis and sloughing was seen at the follow-up visits.[12]

Tarnow et al. correlated the presence or absence of IDP with the distance between the contact point of the approximating teeth and crest of the bone. Almost 100% of the papilla is present when the distance between the contact point to the crest of bone is 5 mm or less. When the distance is 6 mm, the papilla present is about 56%, and when the distance is 7 mm or more, the papilla present is about 27% or less.[13] In both the cases, to reduce the distance between contact point and crest of bone, periodontal plastic procedure was performed first to reconstruct papilla which was followed by composite restoration of both the maxillary central incisors.

In the present case series, the distance between the tip of IDP and incisal edge was measured at follow-up visits. The soft-tissue gain was more at 15 days postoperatively in both cases, but a slight decrease was noted at 1 month after procedure. Furthermore, distance between IDP and incisal edge at 3 months and 6 months remained stable. Hence, the results obtained in the present case series were successful and similar to a clinical study done by Sawai et al. in which modification of Beagle's technique was used to reconstruct IDP. Results had shown an increase in sulcus depth by about 1.19 mm and improvement in the contour of interdental tissues in 51% of cases and in 38.46%, IDP completely obliterated the open embrasures.[14]

However, very less data are available on the long-term predictability and success of various surgical techniques used to reconstruct IDP. However, advantages of the Beagle's technique include adequate blood supply to the flap, less invasive procedure, simple to perform, and less time-consuming.[15]


   Conclusion Top


Interdisciplinary techniques used for reconstruction of IDP in the present case series were fairly successful. However, future clinical studies with larger sample size need to be carried out to confirm the predictability and long-term stability of these treatment approaches.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sudhakar N, Vishwanath A. Smile wsthetics – A literature review. IOSR-JDMS 2014;13:32-6.  Back to cited text no. 1
    
2.
Singh VP, Uppoor AS, Nayak DG, Shah D. Black triangle dilemma and its management in esthetic dentistry. Dent Res J(Isfahan) 2013;10:296-301.  Back to cited text no. 2
    
3.
Agarwal M, Mittal M, Mehrotra S, Agarwal A. Black triangle and its reconstruction: A review. J Dent Sci Oral Rehabil 2011;4:55-6.  Back to cited text no. 3
    
4.
Beagle Jr. Surgical reconstruction of the interdental papilla: Case report. Int J Periodontics Restorative Dent 1992;12:145-51.  Back to cited text no. 4
    
5.
Sawai ML, Kohad RM. An evaluation of a periodontal plastic surgical procedure for the reconstruction of interdental papillae in maxillary anterior region: A clinical study. J Indian Soc Periodontol 2012;16:533-8.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Krishnan IS, Kheur MG. Esthetic considerations for the interdental papilla: Eliminating black triangles around restorations: A literature review. J Indian Prosthodont Soc 2006;6:164-9.  Back to cited text no. 6
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7.
Carnio J. Surgical reconstruction of interdental papilla using an interposed subepithelial connective tissue graft: A case report. Int J Periodontics Restorative Dent 2004 ;24:31-7.  Back to cited text no. 7
    
8.
Deepalakshmi D, Ahathya RS, Raja S, Kumar A. Surgical reconstruction of lost interdental papilla: a case report. PERIO 2007;4:229–34.  Back to cited text no. 8
    
9.
Shruthi S, Gujjari SK, Mallya KP. Comparison of two surgical techniques for the reconstruction of interdental papilla. J Interdiscip Dentistry 2015;5:17-22.  Back to cited text no. 9
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10.
Muthukumar S, Rangarao S. Surgical augmentation of interdental papilla - A case series. Contemp Clin Dent 2015;6:S294-8.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Carranza N, Zogbi C. Reconstruction of the interdental papilla with an underlying subepithelial connective tissue graft: technical considerations and case reports. Int J Periodontics Restorative Dent 2011;31:45-50.  Back to cited text no. 11
    
12.
Grupe HE, Warren RF. Repair of gingival defects by a sliding flap operation. J Periodontol 1957;27:92-5.  Back to cited text no. 12
    
13.
Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995-6.  Back to cited text no. 13
    
14.
Sawai ML, Kohad RM. An evaluation of a periodontal plastic surgical procedure for the reconstruction of interdental papillae in maxillary anterior region: A clinical study. J Indian Soc Periodontol 2012;16:533-8.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Kapoor A, Biban P, Goel S, Kapoor S, Kapoor A. Papilla Reconstruction: A case report. IJSS Case Reports and Reviews 2015;1:24-26.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]



 

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