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Microsurgical Technique for Augmentation of the Interdental Papilla: Three Case Reports
Abstract and Figures
The loss of interdental papillae as the result of trauma or inflammatory periodontal disease creates a significant challenge in the esthetic zone. Conventional surgical techniques are unpredictable because of small working spaces and limited blood supply to the area. Vertical releasing incisions can further jeopardize vascular channels and leave unattractive scarring upon healing. The application of microscopes and microsurgical instruments presents a new frontier for predictable esthetic results. This paper describes a predictable microsurgical technique for reconstruction of the interdental papillae.
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... This means that the surgical site can be accurately focussed [3,24,27,28]. High magnification in surgical microscope gives advantages to treat regenerative [35,42,43,46] and periodontal plastic surgery [23,33,34,49,50] and implant therapy [43,51] successfully over conventional surgery. Clinicians can perform precise work using microsurgical instruments, probably due to fine and sharp blades that extend hard-to-reach areas [31,36,38,47]. ...
... Also, flaps can be elevated atraumatically as the margins of the flap are sharp. This benefits the fine suturing and accelerated healing outcomes [39,41,42]. Hence, the use of microsurgical procedures makes it possible for the clinician to perform completely different from those of conventional procedures [3]. ...
... Results are superior to a traditional approach. Added advantages were noted, such as less traumatic, enhanced revascularization, higher incidence of primary wound closure, and minimally invasive procedure [41,42] Any challenge to visual reality is a fundamental challenge and is not readily believable. ...
... Various surgical and non-surgical procedures have been enumerated in literature for the reconstruction of interdental papilla. The surgical techniques have been aimed at recontouring and reconstructing the deficient interdental papilla which include the pedicle graft procedure [3], envelop type flap prepared for placing a connective tissue graft [4]- [7]or platelet rich fibrin at the recipient site is [8], [9]. Case reports and case series have been done utilizing the connective tissue graft with encouraging results in the form of complete or partial interdental papilla fill [4]- [7]. ...
... The surgical techniques have been aimed at recontouring and reconstructing the deficient interdental papilla which include the pedicle graft procedure [3], envelop type flap prepared for placing a connective tissue graft [4]- [7]or platelet rich fibrin at the recipient site is [8], [9]. Case reports and case series have been done utilizing the connective tissue graft with encouraging results in the form of complete or partial interdental papilla fill [4]- [7]. ...
... These suture aids in maintenance of the papilla in its new position as the surrounding musculature possess a tendency to pull the papilla to its original position. Also, as healing takes place at the surgical site, wound tension can eventually result in generation of forces to the graft and adjacent tissues which could be detrimental to the results obtained [7]. ...
Background: Aesthetics has become a major concern nowadays. Loss of interdental papilla in the anterior region of the oral cavity accounts for a major compromise in aesthetics. Thus, techniques to correct this defect has emerged as a new area of research in dentistry. The present study aims to compare reconstruction of the interdental papilla using subepithelial connective tissue graft (SCTG)and platelet rich fibrin (PRF). Material and Methods: The present randomised clinical trial included 36 patients equally divided into test (platelet rich fibrin) and control groups (subepithelial connective tissue graft). Papilla reconstruction was done and clinical parameters- contact point to interdental papilla distance (CPID), width of keratinized gingiva (WKG), plaque index (PI), gingival index (GI), papillary bleeding index (PBI), pocket depth (PPD) were recorded at baseline, 3 and 6 months. Healing index (HI) was recorded at 1, 2 and 3 weeks. Results: At the end of 6 months, it was found that interdental papillae fill in terms of decrease in distance from the contact point to the interdental papilla tip and gain in WKG was statistically significant in both the groups (p value ≤0.05). On intergroup comparison, however, it was found that the improvement in the abovementioned parameters was significantly greater in the control group (39.32%) as compared to the test group (14.79%). The difference in other clinical parameters at various time intervals were found to be nonsignificant.
... Additionally, gingival tissue thickness was not assessed in the present study, which might be evaluated as a factor possibly affecting the results. In fact, gingival tissue thickness or phenotype is essential for complete root coverage and the stability of the clinical outcome [33,34]. ...
Background:
To evaluate the effectiveness of hyaluronic acid (HA) gel injection with and without plasma rich in growth factors (PRGF) for the management of interdental papillary loss.
Methods:
A single blinded randomized clinical trial was carried out on 21 subjects with 34 sites. Patients within the age group 18-45 years who had Class I and II papillary recession in the maxillary anterior region were selected. The sites involved were randomly assigned to Group HA alone and Group HA + PRGF. The patients were recalled 4 weeks after receiving supragingival and subgingival instrumentation. HA or HA + PRGF was injected into the defective papilla at baseline and at 3 and 6 weeks. Image based measurements of Papillary Width (PW), Papillary Deficient Height (PDH), Deficient Area (DA), Deficient Volume (DV) were registered at baseline, 3 weeks, 6 weeks and 12 weeks. A vernier caliper was used to measure the papillary depth in the impression made using additional silicone impression material pre- and post-intervention.
Results:
There was a significant improvement in the within-group comparison of PW, PDH, DA and DV in both the groups. Group HA + PRGF showed significantly greater improvement in comparison to Group HA alone in terms of PDH, DA and DV at 6 and 12 weeks.
Conclusions:
Even though HA gel has already been established as a promising injectable agent in the minimally invasive treatment of interdental papillary deficiency, PRGF may also have a significant adjuvant effect when used along with HA. Further clinical studies with longer follow up duration, larger sample size and standardization of the tooth shape are required for a better understanding of the adjuvant effect of PRGF when used along with HA.
... [6] The microsurgical techniques are commonly employed in the following periodontal surgeries: 1. Mucogingival surgery: It is critical to conduct exceedingly fine and exact incisions, meticulous suturing to enhance graft stabilization and immobilization, and precise wound margin closure to produce a great result in terms of both esthetics and function. [7] As a result, the use of a surgical microscope in mucogingival therapy may be beneficial in cases when the complete and flawless covering is required in root coverage operations [8] and interdental papilla augmentation [9] 2. Root debridement: The importance of root debridement as a necessary component of periodontal therapy is well acknowledged. Several writers have stressed that the depth of root surface debridement, rather than the grafting modality used, is more important for improved periodontal therapy outcomes [10] Magnification and proper illumination aids root surface debridement by showing morphological characteristics of supragingival and subgingival tooth surfaces and properly recreating working end angles during instrumentation [11] 3. Regenerative periodontal surgeries: The clinical efficiency of modifying existing surgical methods for periodontal regeneration of intrabony lesions has been intensively researched in recent decades. ...
Microsurgery is a minimally invasive procedure that uses a surgical microscope, specially designed equipment, and suture materials. Even though this equipment and expertise of numerous surgeries are required to meet patient esthetic reckoning, doctors must be ready to invest time and effort into becoming familiar with novel surgical methods and devices. The ambition of this case series is to compare conventional macro surgery and microsurgery in terms of clinical approach. This study included four cases, two flap surgery, and two root coverage. Clinical parameters for root coverage, increase in keratinized tissue (KT), gain in clinical attachment level (CAL) and complete root coverage (CRC), dentin hypersensitivity index-Schiff's index and for flap surgery, probing depth, clinical attachment level. Healing and pain analysis were done. There was no significant difference seen between conventional and clinical outcomes of a microsurgical technique such as clinical attachment level, probing depth, increase in KT, gain in clinical attachment level (CAG), and CRC, dentin hypersensitivity index-Schiff's index. When patient-based outcomes such as healing index and Visual Analog Scale, a significant difference was seen. If a microsurgical method is used instead of a traditional macroscopic approach, the early healing index can be significantly improved and there will be less postoperative pain.
... Additionally, the absence of interdental papillae may create aesthetic and phonetic problems and can allow food impaction. The absence of interdental papillae is a challenging case to reconstruct due to the small dimensions and limited vascular supply of the interproximal space [10,11]. To achieve the desired emergence profile and interdental papillae, one can guide the tissue response during the healing phase after the implant placement. ...
Objectives: Today, the focus of implant dentistry has moved from osseointegration to meeting aesthetic prospects. Aesthetic demands may be satisfied with a suitable emergence profile created in peri-implant healthy soft tissue, this could be a challenging and time-consuming stage. In this article, the one-step formation of a peri-implant emergence profile and an indirect impression technique that preserves the obtained soft-tissue form are described through cases. Methods: In the cases with missing teeth in aesthetic areas, all detailed consent was obtained from the patients. After the placement of the implants, individual temporary crowns were placed immediately and were not removed until the osseointegration was completed in order to create a peri-implant soft tissue profile that would meet the aesthetic and biological requirements. After the healing period, impressions were taken using custom-prepared impression posts by adding resin material to support the formed mucosa. Thus, the soft tissue profiles could be reflected in the models, and the emergence profiles of temporary crowns could be transferred to the final restorations. Results: The aesthetic and biological demands were practically satisfied at the expected level by following the present method. Conclusion: It is possible to manage the soft tissue around the implant in one step and transfer it to the impression easily. An ideal soft-tissue form that meets the aesthetic and biological demands can be obtained, and transferred to the permanent prosthesis, while time saved with this effortless clinical technique.
... Trained and skilled Periodontal Micro surgeon offers an evident positive result in root coverage procedures (22) and interdental papilla augmentation. (23) Microsurgical techniques have been shown to offer many advantages when compared with conventional macrosurgical techniques for treating gingival recession. Using micro surgical techniques, increases vascularity of the graft, (24) relatively enhanced root coverage, (24) a efficient increase in thickness and width of keratinized tissue, (25) an appreciable esthetic outcome, with decreased patient morbidity (26) 4. Implant Therapy Different stages of implant treatment ranging from implant placement to implant recovery and peri-implantitis management is done with more precision under magnification. ...
Guided bone regeneration (GBR) is the process of replacing lost tissues with elements to restore normal function and structure for ideal three-dimensional placement of dental implants. GBR is based on guided tissue regeneration and has common mechanical and biological principles; their similarities are obvious throughout the evolution of bone regeneration concepts. There are four fundamental biological principles for successful GBR: primary wound closure, adequate blood supply, clot stability, and space maintenance.Microsurgery was introduced in Periodontology in 1992 for the improvement of surgical techniques. It was made possible by the advancements in visual acuity obtained through the microscope. Microsurgery helps develop motor skills by improving surgical capacity, reduces tissue trauma, and contributes to the primary closure of the wound.The proposed use of the microscope in GBR can aid precision in surgical execution. It has been shown that microsurgery contributes to improved healing and treatment outcomes in other areas of Periodontology.This chapter provides a detailed description of GBR techniques using a surgical microscope (MO) along with information on the elements essential for the application of this technology. The principles of magnification and coaxial light and fundamentals of microsurgery are used for the execution of incisions, release of flaps, preparation of the surgical bed, handling of biomaterials, and membrane fixation, complementing the techniques for flap closure and soft tissue management in regenerative therapy.KeywordsBone regenerationMicrosurgeryMicroscopic periodontal surgeryMicrosurgery in bone regeneration therapyMicrosurgery in process augmentationMicrosurgical flapMicrosurgical regenerative therapies
Accidents and complications are unavoidable from time to time when placing implants, but the surgeon should know how to prevent and treat those complications. The use of microscope, its illumination, and magnification allow the practitioner to increase the predictability of treatment, allowing better precision in managing the tissues. In some narrow and deep spaces, the use of the OM as its coaxial light facilitates a sharp field of view. The surgeon’s abilities and predictability of surgical techniques increase, employing minimally invasive surgeries and solving several problems reducing treatment time, costs, and morbidity for the patient at the same time. This kind of dentistry becomes more gratifying and motivating for the practitioner and the whole team, reducing the patient’s anxiety level.KeywordsImplant complicationsAccidentsImplant malpositionPeriimplantitisEsthetic implant complicationsDental implantsMicroscopy
BACKGROUND: The loss of interdental gingival papillae or the presence of black triangles between the teeth is one of the important problems in aesthetic dentistry, along with the loss of teeth and violation of the integrity of the hard tissues of the tooth. These patients have aesthetic, phonetic disorders, and it is also possible that food gets stuck between the teeth, which causes discomfort in the oral cavity and leads to periodontal diseases. Currently, an increasing percentage of people with orthopedic structures have a recession of the interdental gum. To improve the predicted result, it is necessary to approach this problem in an interdisciplinary way. MATERIAL AND METHODS: The search for publications was conducted in four electronic databases: Pubmed, Google search, eLibrary and dissercat from 2006 to 2021. 157 full-text publications were analyzed, of which 40 publications were included in the systematic review. RESULTS: According to various studies, the restoration of the lost interdental papilla varies from 1.68 to 5 mm. Complete restoration of the interdental papilla occurs when using microsurgical methods of restoration of the interdental gum. The least injury to soft tissues leads to the best results and reduces the risk of complications. CONCLUSION: Restoration of the interdental papilla is a complex surgical manipulation where microsurgical instruments must be used. Any rupture or excessive injury of the isthmus of the interdental papilla leads to a violation of blood supply, which leads to necrosis of the graft and aesthetic dissatisfaction.
This article describes a surgical periodontal plastic procedure for the coverage of multiple adjacent gingival recessions. This surgical technique is based on the construction of a tunnel under the gingival tissue by means of a sulcular incision beyond the mucogingival line without raising the papillae. A large connective tissue graft obtained from the palatal mucosa is introduced through this tunnel, covering the adjacent gingival recessions. A suturing technique to allow this graft to slip through the tunnel under the gingival tissues and to secure and stabilize the graft covering the recessions is described. Twelve-month postoperative results are presented from 21 teeth that were treated with this technique: 100% root coverage was achieved in 66.7% of the recessions treated, with a mean root surface coverage of 91.6%. This study suggests that the use of this surgical procedure allows the treatment of multiple adjacent recessions in a single procedure with adequate early healing and highly predictable root coverage results.
An index to assess the size of the interproximal gingival papillae adjacent to single implant restorations was described and preliminary tested in a pilot study of retrospective material comprising 25 crowns in 21 patients. The result indicated a significant spontaneous regeneration of papillae (P < .001) after a mean follow-up period of 1.5 years. Based on these results, the general conclusion was made that the proposed index allows scientific assessment of soft tissue contour adjacent to single-implant restorations. The results also indicated that soft tissue changed in a systematic manner during the time period between insertion of the crowns and follow-up 1 to 3 years later.
Historically, periodontal treatment has been aimed more at the preservation and restoration of health to the periodontium than at the esthetic outcome of treatment. However, recent advances have enhanced the periodontist's ability to address esthetic concerns. To date, treatment of lost or collapsed interdental papilla has been largely unsuccessful. A case report is presented to demonstrate a technique by which a collapsed interdental papilla can be surgically reconstructed. The technique combines principles of Abram's roll technique for ridge augmentation with Evian's papilla preservation technique.
A new flap design for placement of implants into osseous defects has been described. The flap design can be used in anterior and posterior areas of human subjects. Photographs of representative cases are presented. Wound healing always occurred by primary intention and without evidence of immediate graft exfoliation. Interdental soft tissue craters did not develop, making it easier for patients to maintain optimal oral hygiene. This type of flap design can also be used without grafts in order to improve postoperative soft tissue contour.
A modification of the papilla preservation technique has been applied to achieve primary closure of the interproximal tissue over barrier membranes placed coronal to the alveolar crest. Fifteen patients with deep intrabony interproximal defects were treated. Defects had a probing attachment level loss of 9.9 +/- 3.2 mm and a recession of the gingival margin of 1.7 +/- 1.6 mm. The depth of the intrabony component was 5.5 +/- 2.9 mm; while the suprabony component was 5.9 +/- 2.0 mm. Titanium-reinforced teflon membranes were placed 1.3 +/- 0.7 mm from the cemento-enamel junction, 4.5 +/- 1.6 mm coronal to the interproximal alveolar bone crest. Primary closure over the interproximal portion of the membrane was obtained in 93% of cases. In 73% of the cases complete coverage of the membrane was maintained until its removal at 6 weeks. These data indicate that the modified papilla preservation technique can be successfully applied to obtain primary closure of the interdental space in regenerative procedures with barrier membranes.
The predictable creation of the lost gingival papilla by surgical means must follow the principle of using the most advantageous pattern of blood supply to the newly created tissue. Due to the small, restricted space interdentally, any form of free grafting cannot be utilized since the surface area for blood supply to the donor tissue is minimal. Therefore, a form of pedicle grafting using the semilunar incision and the coronal displacement of the entire gingival-papillary unit, held in place with a section of subepithelial connective tissue beneath the coronally displaced tissue, may be one method that is predictable in reconstructing a lost gingival papilla.
A classification system for loss of papillary height is proposed. It uses readily identifiable anatomical landmarks for reference, and sorts the degree of loss into 3 classes. The 3 broad categories allow for a quick descriptive assessment. In addition to the basic classification, it is suggested that additional and incremental description may be included to further define the defects.
The traditional goal of disease elimination in the anterior region opens the interproximal spaces, causing flattening or cratering of the interdental papilla. Today's patients increasingly demand esthetic results in addition to periodontal treatment, and recent advances in periodontal plastic surgery have enhanced the periodontist's ability to address these concerns. Three case reports demonstrate a proposed surgical technique for the reconstruction of collapsed interdental papillae using a connective tissue graft under the buccal and palatal flaps.