|Year : 2012 | Volume
| Issue : 4 | Page : 533-538
An evaluation of a periodontal plastic surgical procedure for the reconstruction of interdental papillae in maxillary anterior region: A clinical study
Madhuri Lokhande Sawai1, RM Kohad2
1 Department of Periodontics, Govt. Dental College and Hospital, Nagpur, Maharashtra; Department of Periodontology, Faculty of Dentistry, Jamia MIllia Islamia, New Delhi, India
2 Department of Periodontics, Govt. Dental College and Hospital, Nagpur, Maharashtra; Department of Periodontics, Bhabha College of Dental Sciences, Bhopal, Madhya Pradesh, India
|Date of Submission||24-Apr-2011|
|Date of Acceptance||16-Sep-2012|
|Date of Web Publication||7-Feb-2013|
Madhuri Lokhande Sawai
Department of Periodontology, Faculty of Dentistry, Jamia MIllia Islamia, Jamia Nagar, Mohammad Ali Jauhar Marg, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: In today's world, people are very much aware about their looks and personality. They are getting more concerned about the esthetics and thus are not ready to compromise the appearance of black holes, especially in the anterior region of the mouth. Various techniques like orthodontic correction, prosthetic veneers and various periodontal surgical methods have been used to cover these unaesthetic open embrasures. In the present study, a variant technique given by Beagle in 1992 was used to cover these open gingival embrasures. The technique uses a gingival flap from the labial aspect to close the open gingival embrasures thus solving the problem of black holes. Aims and Objectives: This clinical study was aimed to reconstruct the lost or blunted interdental papillae with gingival tissue for esthetic purpose and for maintaining oral health with the objective to determine the extent to which the procedure can revert the maxillary esthetics. Materials and Methods: The patients selected were those who were having a complaint of at least one black hole in the maxillary anterior region with grade '0' or '1' type of contour of interdental tissues. A total of 39 open embrasures were surgically closed using this technique. Various indices were taken pre-surgically and then again post surgically. Results: Plaque index and gingival index showed an initial increase in the scores at the end of 1 week. Later, there was a gradual fall till the end of the study. Bleeding index significantly increased at the end of 12 weeks ( P<0.001) but reduced to insignificant levels at the end of 24 weeks ( P<0.09). The sulcus depth increased by about 1.19 mm. There was improvement in the contour of interdental tissues in 51% of cases and in 38.46% the interdental papillae completely obliterated the open embrasures. Conclusion: The surgical technique used here for reconstruction of interdental papilla was fairly successful. However, use of bone grafts or soft tissue grafts would have improved the results further.
Keywords: Black holes, gingival flap, open embrasures, periodontal plastic surgery, unaesthetic appearance
|How to cite this article:|
Sawai ML, Kohad R M. 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
|How to cite this URL:|
Sawai ML, Kohad R M. 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 [serial online] 2012 [cited 2019 Nov 18];16:533-8. Available from: http://www.jisponline.com/text.asp?2012/16/4/533/106897
| Introduction|| |
Smile plays an important role in improving esthetics and radiates health and self-confidence. The perfect smile requires an optimal relationship between the teeth, surrounding oral tissues and periodontal complex. When a disharmony exists between any of these components, the result is a smile that is likely to be perceived as unaesthetic. Disease of the periodontium changes the relation of teeth and gingiva. Periodontal treatment has always aimed primarily at preservation and restoration of periodontal health rather than at achieving an esthetic outcome. In fact, most surgical treatments performed are directed towards eliminating pocket depth, tooth mobility, to arrest alveolar bone resorption and to induce regeneration in the periodontium.
These procedures prove detrimental to the patient's cosmetic value as they result in extensive loss of gingiva both around the radicular as well as the interdental areas, leading to large, open embrasures. Thus, despite of our achievement in reducing pocket depth, we often fail to deliver cosmetically excellent results in the form of interproximal spacing, elongated crowns and wide exposure of root surface (Aguido,  Frisch et al.,  Kozlovsky et al.  ). This loss of interdental papillae commonly known as "black holes"  or "black triangles"  may cause functional, phonetic and devastating esthetic problem.
In recent years, patients are increasingly interested in esthetic results in addition to periodontal treatment. Various techniques have been given in the past to reconstruct the papilla by surgical methods or by the use of prosthetic veneers. But very little data is known about the long-term success and predictability of these techniques.
Hence the present study was undertaken to evaluate clinically the feasibility and predictability of the technique to reconstruct the lost interproximal papilla to solve the patient's problem of an unaesthetic smile of "dark triangles" or "black holes" between the maxillary anterior teeth.
| Aims and Objectives|| |
This clinical study was aimed to reconstruct the lost or blunted interdental papillae with gingival tissue for esthetic purpose and for maintaining oral health with the objective to determine the extent to which the procedure can revert the maxillary esthetics i.e. the gingival architecture to as close to normal as possible, to be acceptable to the patient.
| Materials and Methods|| |
The sample for the present clinical study comprised of 19 patients-7 males and 12 females with a total of 39 open embrasures. The age of the patients ranged from 18-40 years, with the mean of 29 years. The patients were selected from amongst those visiting the Out Patient Department of Periodontics, at Govt. Dental College and Hospital, Nagpur, India.
- Presence of at least one unaesthetic open embrasure with the contour of interdental tissues having index score '0' or '1' in the maxillary anterior interdental areas [Figure 1]
- Patients with esthetic consciousness and complaint of food lodgment in the embrasure area
- Patients having adequate zone of attached gingiva with minimal probing depth adjacent to the open embrasure.
The patients were explained the importance of maintaining oral hygiene. They were demonstrated proper brushing technique and were motivated to maintain good oral hygiene. Initial preparation to improve gingival health was carried out. A preliminary case history was taken, along with oral examination and complete hemogram. Surgical procedure was performed only after the patients demonstrated an acceptable oral hygiene standard and restoration of gingival health.
- Unaesthetic open embrasures in the mandibular anterior region
- Patients having any kind of systemic illness, drug usage, allergy, smoking etc., which can alter the healing process
- Patients having gingival recession on the labial surface of the teeth adjacent to the open embrasure.
The following data was recorded:
The surgical treatment was carried out and the patients were examined post-surgically at 24 hours and subsequently at 1, 2, 4, 8, 12 and 24 weeks for Plaque index, gingival index, bleeding index, sulcus depth and contour of interdental tissues.
- Plaque index (Silness and Loe, 1964) 
- Gingival index (Loe and silness, 1963) 
- Gingival bleeding index (Ainamo and Bay, 1975) 
- Crevicular sulcus depth (in mm)
- Contour of interdental tissues (Jemt, 1997) 
The surgical procedure employed was a variant of the Beagle's technique (1992). 
Local infiltration anesthesia was administered and an incision was given in a particular manner so as to raise a partial thickness flap from the attached gingiva apical to the open embrasure using two vertical and one horizontal incision. The flap was then folded upon itself to completely obliterate the open embrasure. The free end of the flap was sutured with the adjacent gingiva with a 4-0 silk suture so as to suspend the papilla between adjacent teeth. Periodontal dressing was applied to the labial aspect of the surgical site. Antibiotics and analgesics were administered.
The dressing and the sutures were removed after 1 week and the Plaque index, gingival index and contour of interdental tissues were recorded. Subsequently, the patients were evaluated at 2, 4, 8, 12 and 24 weeks for Plaque index, gingival index and contour of interdental tissues. The sulcus depth and bleeding index were recorded only at 12 and 24 weeks postoperatively [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8] and [Figure 9].
| Observations and Results|| |
The present study included 19 patients of both sexes with a total of 39 sites with grade '0' and grade '1' type of contour of proximal papillae in the maxillary anterior region.
Plaque index, gingival index, gingival bleeding index, sulcus depth and contour of interdental tissues were assessed preoperatively and at 1, 2, 4, 8, 12 and 24 weeks postoperatively.
The data collected was then subjected to statistical analysis:
There was an increase in the Plaque index score at 1 week postoperatively by 2.9±0.04, after which there was a steady fall in the values to 0.18±0.03 at 24 weeks. Both the initial increase and the subsequent fall in the Plaque index score, as compared to the preoperative score was statistically highly significant ( P<0.001) [Table 1].
- For comparing the measurements of each patient at each observation period
- To compare the changes at different time intervals, analysis of variance ANOVA (F test) was used.
There was significant increase in the gingival index score at 1 week after surgery (0.8±0.02). But after that, the score showed a gradual decrease till the end of 24 weeks when it was 0.07±0.02. This decrease in the score was statistically significant ( P<0.001) at each postoperative score when compared to preoperative score [Table 2].
When the postoperative bleeding index scores were compared with preoperative scores, it was found that there was significant increase in bleeding index score (0.03±0.004) at 12 weeks, but was 0.02±0.01 at 24 weeks which was statistically insignificant. These changes indicate that bleeding reduced from 12 to 24 weeks [Table 3].
There was increase in sulcus depth at 12 and 24 weeks postoperatively which was statistically significant (P<0.001). But the average sulcus depth at 24 weeks (0.51±0.08) was less than that at 12 weeks (0.52±0.1) [Table 4].
The average contour of interdental tissues, over the time intervals in both Grade '0' and Grade '1' cases along with their standard errors is shown in the table. It shows that both in grade '0' and '1', there was an increase in mean contour of interdental tissues i.e., 1.12±0.15 for grade '0' and 1.75±0.19 for grade '1' cases. These values decreased over 24 weeks to 0.91±0.2 for grade '0' cases and 1.52±0.16 for grade '1' indicating that there was some shrinkage in the interdental tissues [Table 5].
When the contour of interdental tissues preoperatively was compared to 12 and 24 week postoperative score, it was found that in grade '0' cases, there was statistically highly significant increase (P<0.001) in the contour of interdental papilla. Grade '1' cases showed statistically highly significant increase (P<0.001) in the contour at 12 weeks postoperatively. When compared with the preoperative contour of the interdental papilla there was statistically significant increase in contour at 24 weeks postoperatively (P<0.01).
There was improvement in the contour of interdental tissues in 51% of cases and in 38.46%, the interdental papillae completely obliterated the open embrasures [Table 6].
|Table 6: Percentage changes in contour of interdental tissues at different time intervals|
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| Discussion|| |
The interdental gingiva, in health, completely fills the embrasure space created by the two approximating teeth. The normal contour, shape and consistency of the gingival tissues, especially the interdental papilla, change dramatically with the beginning of gingival inflammation. The sharp, knife-edged gingival margins and the interdental papilla begins to swell overfilling the interdental spaces creating initial pseudo-pockets without the migration of the attachment apparatus. The interdental area, thus becomes a perfect area for accumulation of plaque and further inflammatory changes (Cohen 1959).  Eventually, the migration of junctional epithelium in the interdental area leads to the breakdown of the interdental bone.
At this stage, traditional periodontal therapy i.e. scaling and root planing leads to the shrinkage of gingiva which is more pronounced in the interdental areas. If pocket elimination therapy is pursued, the removal of the pockets would lead to loss of interdental papilla, which conforms to the flat anatomy of the underlying bone. Most patients regard the open embrasures as disfiguring especially if it is present in the maxillary anterior region.
In the past, orthodontic means, repeated subgingival curettage, papilla preservation techniques etc., were used to change the contour of interdental tissues.
Han and Takie,  Azzi et al.  etc., proposed different surgical techniques to predictably reconstruct the missing interdental papilla. All these techniques required a second surgical site to obtain the connective tissue graft to obliterate the open embrasure space.
Beagle (1992) presented a technique to reconstruct interdental papilla using the principles of Abram's roll technique and Evian papilla preservation technique. But this technique has certain disadvantages. There is a risk of damage to the incisive nerves and vessels and incorporation of fat in the undersurface of flap thereby, preventing it's vascularization. Also, obtaining a uniform thickness of flap from the palate and retention of periodontal dressing is difficult.
All the techniques described were case reports and very few controlled clinical studies have been carried out to determine the predictability of the procedures and therefore, the present study was designed using a variant of the technique proposed by Beagle with the aim to reconstruct the lost or blunted interdental papillae for esthetic purpose and to maintain oral hygiene.
39 sites from 19 patients were treated for closure of unaesthetic open gingival embrasure and their results were evaluated at 1, 2, 4, 8, 12 and 24 weeks postoperatively.
During the course of the study, it was seen that the Plaque index, gingival index for all patients improved post-surgically. This change could be due to motivation of the patients to maintain oral hygiene. Similar results have been observed in the study by Nayak. 
Preoperatively, there was no bleeding at the surgical site. However, at 12 weeks postsurgery, 12.8% cases showed bleeding on probing. With motivation of patients to maintain oral hygiene, the bleeding index reduced at 24 weeks postoperatively. This value was insignificant when compared to the preoperative score. These findings are comparable to the findings of Nayak. 
The contour of the interdental papilla increased 1 week postoperatively in 66.6% cases, but then showed slight gingival shrinkage. At 12 weeks, 48.7% cases showed increased gingival contour in the interdental area. Nayak  observed increase in the contour of interdental tissues in 22.73% cases at 3 months postsurgery. In this study, at 24 weeks postoperatively, 51% sites showed increased contour of interdental tissues. Jemt  reported that the interproximal papilla regenerated to some extent without any clinical manipulation over a period of time due to maturation and reorganization of inflamed hyperplastic tissue. Thus, in the present study, the increase in the percentage at 24 weeks over 12 weeks results could be because the papilla underwent reorganization so as to obliterate the open embrasure due to continuous stimulation with proper brushing.
Grupe and Warren  documented that any form of pedicle grafting is much more predictable if a proper donor tissue is found adjacent to the recipient site, as abundant blood supply from the base of the pedicle can be obtained for the predictable "take" of the graft. As the interdental space is narrow, the movement of gingival tissue in a pedicle like manner provides a small surface area in terms of blood supply to the donor tissue. This increases the chances of sloughing of the flap due to inadequate blood supply to form the papilla. In this study, 33.4% of cases showed no change in the contour of the interdental papilla from 1 week postoperatively till the end of the study. This may be due to the loss of the gingival graft by sloughing because of inadequate blood supply to the flap.
Tarnow et al.  reported that the distance from the base of the contact area to the crest of the bone could be correlated with the presence or absence of the interproximal papilla. When the distance between bone and contact area is 7 mm or more, the papilla was present only 27% of the times.
Presence of dead space between the graft and the underlying tissues retard the vascularization and jeopardizes the success of the graft (H. de Wall 1988).  Hence, another reason for the shrinkage on the interdental papilla could be the presence of a dead space between the coronally displaced flap and underlying tissues in the embrasure area.
When the sulcus depth was evaluated at 12 and 24 weeks post-surgically, it was observed that in the cases where reconstruction of interdental papilla occurred, there was a creation of pseudo-pocket of about 3-5 mm. Though, there was an increase in sulcus depth, the oral hygiene could be properly maintained with toothbrush and dental floss to prevent recurrence of the problem. Similar results have been observed by various clinicians like Beagle,  and Azzi et al.  In the study by Nayak  18.18% of sites showed decrease in sulcular depth at the end of 3 months due to gingival atrophy thereby increasing the embrasure spaces. However, in 22.73% of the cases showed a creation of a pseudo-pocket of about 3-4 mm the end of the study where the surgical procedure partially covered the unaesthetic defect.
Thus, in the present study, the Plaque index, gingival index and gingival bleeding index scores significantly reduced at the end of 24 weeks. 51% sites showed increase in the contour of the interdental papilla at the end of the study. In 38.46% cases, the papilla almost obliterated the open gingival embrasure.
However, in these cases, the sulcus depth increased due the creation of a pseudo-pocket of about 3-5 mm.
| Conclusion|| |
Thus, at the end of the study, it was concluded that the surgical technique evaluated for reconstruction of interdental papilla was fairly successful. However, if bone grafting techniques or connective tissue grafting techniques are used in conjunction with this surgical technique, there may be increased chances of obtaining better results so as to aid in restoring gingival esthetics, thereby, satisfying the patients' esthetic demands.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]