The International Journal of Periadontics & Restorative Dentistry

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Surgical Reconstruction of theinterdentai Papiiia

Robert Azzi. DDS'Doniei Etienne. DDS*Fermín Carranza. Dr Odonf

The traditionai goat af disease eliminatian in the anterior regionopens the interpraximal spaces, causing fattening or cratering ot theinterdental papiiia. Today's patients increasingly demand estheticresults in addition to periodontal treotment. and recent advances inperiadontal plastic surgery have enhanced the periadantist's abiiityta address these concerns. Three case reports demanstrate a pra-posed surgicoi technique for the reconstruction of caitapsed inter-dentai popilloe using a conneotive tissue graft under the buccal andpalatal fiaps. (int J Periodont Rest Dent 1998:18:467-473.)

•Deportment of Periodcnfoiogv. University of Paris, Fronce.•Professor Emeritus. University of Caiifornio. Los Angeies.

Reprint requests: Dr Fermín Carranza. 10577 Eastborne Avenue. LosAngeles. California 90024-6045.

Histericaliy, periodontists havebeen able to successfully freatand mainfein cases of ad-venced periodontql diseese. inmony of these coses, however,pocket eliminqfion in the ante-rior region opens the interproxi-mai spaces, elcngeting the visi-ble clinical crcwn ond offencousing flaffening or crqteringof the inferdenfol pepilla.Recent years have seen grcw-ing patient demand fer im-proved esthetic results in addi-tion tc the traditionai goal cfdiseese eliminafion.

Severol procedures havebeen proposed to preserveesthetics in fhe antericr regionof fhe mouth by maintaining theexisting interdentoi pepillae.'"^The reconstruction of an atro-phied interdental popiilq, on theother hand, offers o greaterchallenge. In 1985 Shopiro^desoribed a technique of peri-odic curettoge to stimulate theregrewth of interdenfai papillaedestroyed by acute necrctizingulcerative gingivitis, in a casereport, Beagie"^ described the

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Fig la Intrasulcular incision and buc-cai incision are made across the inter-dental papilla, leaving the existingpapiiia attached to the palatal flop.

Fig Ib Split-thickness flap is elevatedbuc catty ond polataily

Fig lc Buccal and palatai naps oresutured together after connective tis-sue from retromoiar area is piooedunder fiap.

surgioal reconstruction ot theinterdental papilla combiningthe basic principles of Abrams'roll fechnique for ridge aug-mentation ond the papillapreservation technique of Evionet al7 Han and Takei describeda technique consisting of apedicle grqft using q semilunarincision and the coronal dis-placement of fhe enfire gingi-vol-papillary unit.

The use of a ccnnective tis-sue graff placed under o flopfor the purpose of root cover-age has been described byseveral authors.'"" The presentpaper describes a techniquefor surgically reconsfructing theinterdental papilla using buccal

and palotal split-thickness flapsond a connective tissue grott.

Surgical technique

Preparation of the pat ientincludes caretui scaling androof planing of the entiremouth and instruction in oralhygiene. Patients who smokeare requested to stop be-cause smoking deloys healingand impairs clinical results.Smoking should cease from atleast 1 week prior to the surgi-cal procedure to 2 to 3 weeksatter surgery

Immediately prior to the sur-gical procedure the potient is

instructed to rinse for 30 sec-onds with chlorhexidine glu-oonate solution 0.12%. Afteradequate anesthesia of theregion surgery is pertormed.

An infrqsuloulqr incision ismqde qround the necks of themaxillary central incisors (Figsla and 2). Another incision ismade buccally across theinterdental papilla to be re-constructed, at the level ot thecementoenamel junction,leaving the existing papilla at-tached to the palatal flap (Fig2). An envelope-type split-fhickness flop is then elevatedbuccally and palatally (Fig lb).The buccal portion of the flopis dissected well beyond the

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Fig 2 Case Í with Incisions siiown inFig ÍO.

Fig 3 incisions for obtaining distalwedge of tissue combined wilh thin-ning of the palatal flop

Fig 4 Tissue removed from distalwedge with paiatol extension.

muccgingival line, leaving theperiostium and a thin iayer ofconnective tissue on the bone.Care must be taken not to per-forate the flap to avoid com-promising the blood supply. Thepalatal portion of fhe fiap, alsospiif-thickness, includes fheinterdentol papilla.

A second surgical site iscreated to obtain a connec-tive tissue graff of adequatesize and shape for piacemenfunder the fiops in fhe recipientsite. A preferred donor sife forthe groft is fhe retromoiartuberosity.area, aithough othersites can be used. The tech-nique for harvesting tissue fromfhe tuberosity area is as follows.

A wide distai wedge-shoped incision is made, com-bined with fhinning of fhe flopon the paiafai aspect. The twoparollel incisions are begun atthe disfal aspecf of the terminolmolar and extended to themucogingival junction distoi tothe tuberosity (Fig 3). The dis-tance between the incisionsdepends on the depth of thepocket and the amounf offibrous fissue in fhe areo. A thirdincision is carried ouf at the dis-tai end of the two parallel inci-sions. This incision is madestraight down for the first miilime-ter ond continued apically asan inverse bevel incision towardthe bone. The flap is then

reflected and fhe underlying tis-sue is removed to the bone. Thetissue obtained has a lorgefropezoidal shape correspond-ing fo ttie distal wedge, with anextension corresponding to theincisions made on the paiatalaspect (Fig 4). It is preferable toobtoin this enfire specimen inone piece for lafer trimming fothe desired size and shape.Immediately otter removing thetissue from fhe distoi wedge thearea is sutured. Healing is usuallyby first intention.

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Fig S Tissue graft trimmed for plaoe-menf in ¡eoipient sife.

Fig 6 Conneofive tissue graft frcmdonoi site is plaoed under buccal andpalatal flops in interdentdi ared.

Fig 7 Pdiafal and buccai naps aresutured with added connective tissueunderneath.

Fig 8 Three-day postoperative view otodse I.

Fig 9 Cose / with old ceramo-matal crowns.

Fig 10 New in-Ceram orowns havebeen seated. Preaperdtive view of areafor papiiiareconsfrucfion in cdse I.

Fig 11 Postoperative view of oase 1.

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Fig }2 Preoperative view of case 2. Fig 13 Postoperative view of case 2,

The connective tissue har-vested from the tuberosity areais shaped to fif under the flapsand to provide more bulk in thepapiilary region (Fig 5). The tis-sue graft is then placed underfhe buccal flap and in the inter-dental papilla area (Fig 6), Thebuccai and paiatal fiaps arethen brought together andsutured with the conneotive tis-sue graft underneath (Figs Icand 7). The epithelial border otthe graff is nof removed; it is leftin place to cover the segmentof exposed connective tissue.

The area is covered with sur-gioal periodontai dressing. Thepatient is instructed to rinsetwice daiiy with chlorhexidinegluconate, to stop smoking forat least 2 to 3 weeks, and toavoid touching the dressing dur-ing oral hygiene procedures.Antibiotics can be administered

(omoxicillin, 500 mg three timesa day) if necessary. Dressingand sufures are removed 1week after the procedure. Theoreo appears red and irregular(Fig 8) but in a few days if siowlyacquires normai topographyand shape and tilis most of theinterproximai area.

Case reports

Cose 1

A 30-year-old woman wasreferred for the cosmetic treat-ment of the maxiiiary centraiincisors (Fig 9). The first stepin treatment consisted of re-placing fwo oid oeramametalcrowns with two in-Ceramcrowns (Vident) (Fig 10). Twoweeks later ttie patient returnedrequesting that something be

done to hide the "biack hole"between the two oenfral in-cisors. Plastic surgery to recon-struct the interdental papilia wasdiscussed and accepted by thepatient. Figures 2 to 8 show thetechnique as pertarmed in thiscase and Figure 11 shows thefinai resulf (compare with preop-erative view in Figure 10).

Case 2

A 25-year-oid man undergoingorthodontic treatment wasreferred for a gingivai graft onthe right mandibular centralincisor. Surgery was performedto simuitaneousiy correct thegingival recession and recon-struct the papilla. Figure 12shows the case preoperativelyand Figure 13 shows the postop-erative result.

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Fig !4 Preoperative view of case 3. Fig 15 Postoperotive view ot case 3.

Case 3

A 38-yeor-old woman wasreferred for periodentel andcosmetic treatment of themaxiliory central incisors. Attercompletion of the periodontoitreatment, the central incisorswere cqpped with In-Ceramcrowns ond the interdentalpapiiia was surgicoiiy recon-structed following the proce-dure described ebeve. Figures14 ond 15 show the preopere-tive and postoperative views,respectively

Discussion

The technique described in thispaper has been used by thesenicr author in meny caseswith consistentiy good results.The reconstructed interdentalpapillo almost reeches its nor-mal level, solving the estheticproblem posed by its obsence.

The biood suppiy to thegrafted connective tissue is akey element of fhis feohnique.This is assured by the fiap cover-age cf the connective tissueextension, in which only q smallportion at the tip is ieft uncov-ered. The grafted tissue wiilreceive a flow of plasma andan ingrowth of capilieries fromthe periostium, the underlyingccnnective tissue, and the ever-iying flaps.

Probing depths ot the sidesof fhe reconstructed papilloewere 3 to 5 mm in the presentceses, and a heolthy statewithout clinically significantinflqmmaticn can persist indef-initely it oral hygiene proce-dures are adequate, initialcases treated with this tech-nique were performed in 1991.and they have shown thafresuifs can be meintained sat-isfactcrily in reosonably com-pliant potients. Larger series ofcases wifh clinicai measure-ments ere needed to contirmthe findings presented here.The technique proposed offersa soiution to o frequent cliniceiprebiem, using a method eas-ily performed by any skillfulperiodonfist.

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References

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2. App GR. Periodontai treotment forthe removoble partial prosthesispotjeht. Deht Clin North Am 1973:17:001-610.

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4. Genon P Bender JC. Lombeouesthétique d'access en parodon-tle.Dnform Dent 1984:66.1047-1055.

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