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J Periodontol April 2005
Interdental Papilla Augmentation Procedure FollowingOrthodontic Treatment in a Periodontal PatientDaniele Cardaropoli* and Stefania Re*
Background: The absence of the interdental papillais a situation that may alter patients esthetics. Reces-sion of interproximal gingival tissues may be a conse-quence of periodontal disease, but in some cases it mayalso be a consequence of periodontal therapy, as aresult of surgical or non-surgical procedures.
Methods: The authors present a new multidiscipli-nary approach for the treatment of migrated maxillaryincisors presenting infrabony defects, extrusion, andloss of the interdental papilla.
Results and Conclusion: The proposed clinical pro-tocol may reconstruct the interproximal soft tissue, withesthetic improvement of the papillary level, togetherwith resolution of the periodontal defects. J Periodon-tol 2005;76:655-661.
KEY WORDSBone remodeling; dental esthetics; gingivalrecession/adverse effects; interdental papilla;orthodontics, corrective; periodontitis/adverseeffects; tooth mobility.
Chronic periodontitis may lead in advanced casesto dental migration, with a flaring of the frontalteeth and an open space with loss of the inter-dental contact points. In these cases, a certain amountof soft tissue recession is often present due to gingi-val inflammation and reduction of the periodontal sup-porting apparatus. Other times, however, soft tissuerecession may be a consequence of periodontal ther-apy, both surgical and non-surgical, due to the apicalshift of the soft tissues during the healing process. Asimilar clinical situation may create significant esthetic,functional, and phonetic problems for the patient, lead-ing to enormous difficulties in personal relationships,self-esteem, and self-perception. These factors havetaken on such importance to dental patients that, now,in the anterior region we speak about the whiteesthetic, referring to the natural dentition and its con-servative or prosthetic restoration, and pink esthetic,referring to the surrounding soft tissues.
One of the most challenging clinical situations totreat is the absence of the dental papilla and the con-sequent creation of so-called black spaces. The dif-ficulty in working on the papilla depends on theanatomy and morphology of this structure, whichreceives only a minor blood supply. The antero-pos-terior view of the papilla shows a buccal and a lingualpeak, with a concave-shaped col. This crest is non-keratinized or parakeratinized, and it is covered withstratified squamous epithelium. In the case of diastema,the interdental soft tissue may show a higher degreeof keratinization. Working with such a delicate struc-ture is one of the most difficult challenges for perio-dontists. To avoid interproximal gingival recession inthe anterior zone, special care should be taken whenperforming periodontal treatment. During non-surgicaltherapy, adequate small-size hand or ultrasonic ins-truments should be used to avoid damaging the softtissues. When surgical therapy is performed, optimalflap design is required to prevent soft tissue loss andto maintain natural shaping. A number of papers havebeen published that describe techniques to preservethe papilla and simultaneously allow access to theperiodontal defects in order to perform guided tissueregeneration.1-6* Private practice, Turin, Italy.
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Figure 1.Adult periodontal patient with migration of the frontal teeth, openingof the diastema, and loss of the midline papilla.
Figure 2.Initial intraoral radiograph showing interproximal bone loss, with verticaldefect on the mesial aspect of the left central incisor.
On the other hand, several authors have describedtechniques to rebuild a lost interdental papilla. Bothsurgical and non-surgical approaches are present in theliterature but, unfortunately, they refer only to casereports and no long-term results are available.7-17 So,until now, reconstruction of the interproximal papillahas not been a treatment with predictable results.
From an anatomical point of view, the presence orabsence of the interproximal papilla depends on thedistance between the interdental contact point andthe crest of bone.18 When this distance is 5 mm,the papilla is almost always present; however, whenthis distance is 6 mm, the papilla is often absent. Thisstudy18 indicates that the biological way of treating amissing papilla is to try reducing the distance betweenthe contact point and the crest of bone. Bearing this in mind, in cases of chronic periodontitis with extru-sion of the maxillary central incisors, opening ofdiastema, and presence of infrabony defects, a multi-disciplinary approach involving periodontal andorthodontic therapy would be indicated. In this paper, aninnovative interdisciplinary clinical protocol is presented.
CASE REPORTCandidate patients affected by advanced chronic perio-dontitis and previously treated by scaling and rootplaning should demonstrate a good home oral hygienestandard with a full-mouth plaque score 15%.19 Theindication for periodontal surgical therapy should besupported by the presence of infrabony pockets onthe maxillary central incisors, with radiological evi-dence of a deep infrabony component and probingdepth 6 mm. The indication for orthodontic treatmentshould be the migration and extrusion of the centralincisors, with diastema opening and loss of the inter-dental papilla (Figs. 1 and 2).
The patient undergoes surgery under local anesthe-sia with articain 4% plus epinephrine 1/100,000. Thetype of surgical access is chosen from the papillapreservation approaches described in the literature.1-6
The periodontal flap design consists of a full-thickness incision made in order to preserve the tissueduring access to the defects, with buccal or lingualpositioning of the interdental incision (Fig. 3). The abil-ity to access the defect, apply the regenerative tech-nology, and seal the wound is a key aspect of theprocedure. The extension of the flap connects the dis-tal sites of the two lateral incisors, and vertical releas-ing incisions are made only if needed for better surgicalaccess (Fig. 4). Then, using curets and scalers, con-ventional ultrasonic devices, and diamond burs mountedon a low-speed contra-angled handpiece, the granu-lation tissue is completely eliminated from the defect,followed by complete debridement of the radicularsurface. At this point, the defects may be augmentedwith the use of a bone grafting material20 like colla-
gen bovine bone mineral, without the use of barriermembranes (Fig. 5). The suturing technique is chosenaccording to the anatomy of the defect in order to
Ubistesin, 3M Espe, Seefeld, Germany. Bio-Oss Collagen, Geistlich, Wolhusen, Switzerland.
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Figure 3.The flap is designed according to the modified papilla preservationtechnique.
Figure 4.Intraoperative buccal view of the infrabony defect.
Figure 5.The infrabony defect is augmented with mineral collagen bovine bonesubstitute.
Figure 6.A combination of mattress and interrupted sutures is used to obtainprimary closure of the flap.
achieve a passive closure of the margins of the wound,with relief of flap tension (Fig. 6). A combination of hor-izontal mattress sutures and interrupted sutures maybe used, employing non-resorbable 4-0 or 5-0 PTFEsutures.
Postoperatively, the patients should use non-steroidalanalgesics like nimesulide 100 mg twice a day for5 days, oral antibiotics such as amoxicillin/clavulanatepotassium 1 g twice a day for 6 days, and rinse withchlorhexidine 0.2%# three times a day until the suturesare removed 2 weeks after surgery.
At this point, active orthodontic treatment may com-mence, with movement beginning just a few days aftersurgery. The use of the segmented arch technique isrecommended21,22 because of its ability to develop lightand continuous forces (10 to 15 g per tooth) and cre-
ate forces acting in the center of resistance. The intru-sive mechanism should consist of a base arch or twocantilevers made of 0.017 0.025 TMA wire, whilethe anchorage unit is made of a palatal arch and two0.036 stainless steel segments connecting posteriorteeth. The fixed appliances should be able to intrude themigrated teeth and close the diastemas, with a move-ment of about 0.5 to 1 mm per month.
During orthodontic therapy, the appliance shouldbe checked every 2 weeks, while oral hygiene main-tenance with professional prophylaxis should be per-formed every 3 months.23
Tevdek II, Butterfly Italia, Cavenago B.za, Italy. Aulin, Roche, Milan, Italy. Augmentin, GlaxoSmithKline, Verona, Italy.# Corsodyl, GlaxoSmithKline.
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Figure 8.Final intraoral radiograph showing resolution of the infrabony defect.
At the end of treatment, tooth realignment maybe achieved, with optimal soft tissue outlines andcoronal migration of the papillae into the interdentalembrasures.
In order to avoid orthodontic relapse, patients mayreceive a resin-bonded splint fixed retention. Both metal
and esthetic fiber-reinforced Maryland splints can beused.24
The results presented in this case report are rep-resentative of the results obtained with a larger num-ber of patients, six of whom were treated followingthe protocol described above. In all cases, the heal-ing of the flap was uneventful and no post-surgicalcomplications, such as infections or gingival necrosis,have been reported. No adverse reactions to the bonegrafting material were noted during the orthodonticmovement. For the most part, patients showed animprovement of the papillary level at the conclusionof therapy (Fig. 7), and healthy periodontal condi-tions were reported, with a reduction of probing depthand radiological resolution of the augmented defects(Fig. 8).
DISCUSSIONThe protocol presented here represents an alternativefor the treatment of infrabony defects associated withtooth migration and papilla loss in the maxillaryesthetic area (Figs. 9, 10, and 11). Conventionally, theliterature suggests that infrabony defects in the esthetic
Figure 7.At the conclusion of orthodontic treatment , the soft tissues wereperfectly adapted to the orthodontic alignment , and the interdentalpapilla filled the interproximal embrasure.
Figure 9.Schematic drawing of a clinical situation that may benefit from thedescribed approach: tooth migration with opening of the diastema, lossof the interdental papilla, and presence of an infrabony defect.
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Figure 11.Schematic drawing of the final result.The infrabony defect is filled due tothe bone augmentation procedure and the orthodontic movement.Thepapilla, correctly stimulated, has filled the interproximal embrasure and issupported by the regenerated interdental bone crest. A normalization ofthe distance between the crest of bone and the contact point is reached.
zone can be successfully treated with the use of guidedtissue regeneration procedures associated with thepapilla preservation flap design.4-6 This kind ofapproach, however, requires two surgical stages: insert-ing the non-resorbable barrier membrane and thenremoving it. In the case of migrated teeth with thepresence of diastemas, orthodontic treatment may startonly at this point, i.e., after complete healing of bothdeep and superficial periodontal tissues, with a con-siderable delay in the timing of the therapy.
A more expedient clinical approach may include theuse of bone grafting biomaterials alone for the treatmentof infrabony defects in a one-stage surgical procedure.20
An experimental study in dogs revealed that aug-mented bone did not impede tooth movement.25 Inthat study, maxillary incisors were moved into bonecompartments augmented with autogenous bone orbeta-tricalcium phosphate. A more recent animal studyconfirmed these findings,26 showing the possibility ofmoving a tooth, by orthodontic means, into an area ofthe jaw previously augmented with bovine bone min-eral. No adverse effects were reported, and the bio-
material was mostly resorbed and eliminated. It wasconcluded that the augmented bone region did notobstruct the orthodontic tooth movement, and that therate of degradation of the biomaterial was enhancedwhen the augmented site was challenged by physicalmeans such as the orthodontically moved teeth.
A human case report,27 with surgical reentry at12 months, supported the positive outcomes of theexperimental papers.25,26
The clinical protocol presented here suggests theuse of bovine bone mineral to augment infrabonydefects on maxillary incisors, followed by orthodonticmovement into the defects at a very early stage.
This new approach reveals excellent potential interms of esthetic improvement, due to tooth realign-ment and soft tissue modification, and periodontalhealth, due to a reduction in probing depth and fillingof bone. The final papillary levels have an enormousimpact on patients esthetics. In order to achieve suchan optimal outcome, we can suppose that an impor-tant role is played by the orthodontic movement, whichis able to positively guide the soft tissues during the
Figure 10.Schematic drawing of the treatment objectives.The tooth isorthodontically moved into the augmented defect , and the periodontolligament cells are stimulated to migrate onto the root surface.Theclosure of the diastema pushes the papilla coronally into theinterdental space.
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early phases of the post-surgical healing process,adapting the gingiva to new and more natural dentalemergence profiles. Moreover, both intrusion anddiastema closure cause a normalization of the distancebetween the contact point and the crest of bone, cre-ating the presupposing biological basis for the presenceof the papilla.
The effects of intrusive movement on the periodontalapparatus have been reported in several papers.28-35
A number of studies were undertaken since conflictingevidence exists regarding the effect of orthodonticmovement on levels of connective tissue attachment.In one study, it was concluded that orthodontic toothmovement into intrabony periodontal defects had noeffect on the levels of connective tissue attachment.36
On the other hand, two animal studies have shownhow orthodontic stimulation may promote the creationof a connective reattachment or new attachment onteeth with reduced periodontium.37,38 A possible expla-nation for this gain in orthodontically induced attach-ment level may be that the stretching of the periodontalligament (PDL) fibers at the marginal level generatesa sort of natural filter, reducing the downgrowth ofepithelium. Moreover, it seems that orthodontic stim-ulation increases the turnover of periodontal ligamentcells and thereby improves the chances that the perio-dontal ligament will repopulate the previously infectedroot surface.
Animal studies on cell kinetics of PDL during ortho-dontically induced osteogenesis revealed an increaseof primary growth fraction; the proliferation of PDLcells migrating toward the bone surface; the presenceof preosteoblasts in the PDL that are capable of form-ing osteoblasts without synthesizing DNA; osteoblastsderived from local PDL cells; and a cell death patterncharacteristic of osteogenic response.39-41 Moreover,a more recent animal study confirmed that orthodon-tic tooth movement is a stimulating factor of boneapposition.42 A change in the repair pattern of thebony defect from apico-occlusal in the control group(no tooth movement) to occluso-apical in the treatedgroup (with tooth movement) further supported thelinkage between tooth movement and enhanced bonedeposition.
From a morphologic point of view, orthodonticrealignment with space closure creates a contact pointbetween the incisors, creating the anatomical basis forthe presence of the interdental papilla. Papillary tissuereacts like a spring that fills the embrasure when it iscompressed because of interdental space closure, andexpands itself when interdental space opens.
Orthodontic movement initiated at a very earlystage, just 2 weeks after surgery, acts on non-healedperiodontal tissues and gives soft tissues the possi-bility of adapting to more favorable dental emergenceprofiles. In this way, the papilla is pushed into the
interdental embrasure during the early phases of post-surgical healing, and the forthcoming intrusion allowsthe soft tissues to adapt to the more coronal portionof the hard structure of the tooth.
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Correspondence: Dr. Daniele Cardaropoli, Via Baltimora 122,10137 Turin, Italy. Fax: 39-011-32-36-83; e-mail: [email protected].
Accepted for publication July 30, 2004.
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