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Surgical reconstruction of the interdental papilla: 2 case reports

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Surgical reconstruction of the
interdental papilla: 2 case reports
Paulo S.G. Henriques, DDS, MSc, PhD ¢ Luciana S. Okajima, DDS, MSc ¢ Sérgio Siqueira, Jr, DDS, MSc
The loss of interdental papillae may create esthetic
and phonetic problems and facilitates food impaction.
Nonsurgical and surgical approaches can be developed
to restore these areas, depending on the amount of
tissue lost. Periodontal surgical techniques are difficult
to perform in the interdental space because of the
limited amount of tissue and poor blood supply. The
aim of this article is to describe a periodontal plastic
surgical technique in which subepithelial connective
tissue grafts associated with composite restorations are
used to reconstruct interdental papillae. This approach
was followed in 2 patients whose grafts were obtained
from different donor sites: the palate and the retromolar
tuberosity. The 12-month recall examinations of both
patients revealed satisfactory results, including stable
gingival margins and complete, harmonious fill of the
interdental papillary areas.
Received: March 28, 2017
Accepted: May 10, 2017
Key words: interdental papilla, periodontal plastic surgery
Published with permission of the Academy of General Dentistry.
© Copyright 2018 by the Academy of General Dentistry.
All rights reserved. For printed and electronic reprints of this article
for distribution, please contact jkaletha@mossbergco.com.
T he interdental papillae play an important role in the cre-
ation of a harmonious and esthetic smile. According to
Chow et al, the following clinical conditions were found
to favor a gingival papilla that fills the interproximal space:
youth; a long proximal contact of 2.8 mm or greater; a crown
width-length ratio of 0.87 or greater; a bone crest–contact point
distance of 5.0 mm or less; and thick interproximal gingival
tissue of 1.5 mm or greater.1
“Black spaces” are a consequence of the loss of interdental
papillae. This loss can be attributed to various causes, including
traumatic interproximal cleaning, abnormal tooth shape, and
restorations or crowns with improper contour, but the most
common cause is the loss of periodontal support due to plaque-
associated lesions.2 A classification for the loss of papillary height
was proposed by Nordland & Tarnow.3 It is based on 3 anatomical
landmarks: the interdental contact point, the facial apical extent of
the cementoenamel junction (CEJ), and the interproximal coronal
extent of the CEJ. According to Nordland & Tarnow, in normal
papillary height, the interdental papilla fills the embrasure space
to the apical extent of the interdental contact point or area.3 In
Class I loss, the tip of the interdental papilla is located between
the interdental contact point and the most coronal extent of the
interproximal CEJ. A space is present, but the interproximal CEJ
is not visible. In Class II loss, the tip of the interdental papilla is
located at or apical to the interproximal CEJ but coronal to the
apical extent of the facial CEJ, and the interproximal CEJ is visible.
In Class III loss, the tip of the interdental papilla is located level
with or apical to the facial CEJ.3
The loss or absence of interdental papillae may create esthetic
and phonetic problems and can allow food impaction.4 The
small dimensions and limited vascular supply of the interproxi-
mal space make reconstruction of the papilla a real challenge.5
The appropriate treatment depends on the amount of tissue
that has been lost. If only soft tissue is missing, reconstructive
techniques can recreate the papilla completely. If bone resorp-
tion has occurred, a multidisciplinary approach that includes
orthodontic, surgical, and restorative/prosthetic treatment is
required.6
Among the periodontal surgical techniques described for
management of lost papillae are repositioning of the papilla
through coronal repositioning of the flap, guided tissue regen-
eration, connective soft tissue grafting, and bone grafting.7-14
More recently, hyaluronic acid has been used in an attempt to
restore lost papillae.15,16 The aim of this article is to describe a
periodontal plastic surgical technique using subepithelial con-
nective tissue grafts in association with composite restorations
to reconstruct interdental papillae. Two clinical case examples
are presented to demonstrate different approaches to recreate
the lost papilla. In both patients, the surgical technique provided
successful results when used in conjunction with restorative
widening of the mesiodistal tooth dimensions.
agd.org/generaldentistry e1
Surgical reconstruction of the interdental papilla: 2 case reports

Fig 1. Case 1. Preoperative view of a Fig 2. Case 1. Split-thickness semilunar

26-year-old woman with a loss of interdental incision extending from the mucogingival
papilla and root exposure affecting the junction to the vestibule.
maxillary left central and lateral incisors. The
triangular shape of the papilla has been lost.

Fig 3. Case 1. Shaped subepithelial Fig 4. Case 1. Sling suture anchored around Fig 5. Case 1. Clinical view 12 months
connective tissue graft from the palate. The the bonded interproximal contact point. The postoperatively. Note the new formation of
graft is inserted beneath the gingivopapillary alveolar mucosal margin is sutured to the triangular papilla.
complex and stabilized with a suture. mucogingival junction.

Case reports
Case 1
A 26-year-old woman presented with root exposure of her max-
illary left central and lateral incisors along with missing papilla
(Fig 1). The loss of papillary height was judged to be Class III
according to Nordland & Tarnow’s classification.3 It was decided
to harvest a connective tissue graft from the palate to obtain
enough tissue to cover the root exposure and recreate the
papilla. In addition, the donor tissue was to be extended laterally
to create root coverage for the adjacent teeth.
The patient underwent a 1-month preparation that included
instruction in oral hygiene and scaling and root planing of the
entire mouth. On the day of the surgical procedure, the patient
was instructed to rinse with 0.12% chlorhexidine gluconate solu-
tion for 60 seconds. Before the surgical procedure, the contact
points of the affected teeth were temporarily splinted with a
flowable light-curing resin material. Anesthesia was obtained
with lidocaine with epinephrine 1:100,000. Root preparation was
accomplished with root planing and application of 24% ethyl-
enediaminetetraacetic acid.
The design of the incisions and the flap was previously
described by Azzi et al.12 An intrasulcular incision was made
around the necks of both teeth. A second incision was made
buccally across the interdental papilla to be reconstructed. This
incision terminated at the bone crest, leaving the existing papilla
(with full height and thickness) attached to the palatal flap. The
third incision was a split-thickness semilunar incision initiated
at the mucogingival junction and extended to the vestibule,
terminating approximately 5 mm apical to the mucogingival
junction. A fourth incision was performed to connect the apical
extent of the semilunar incision to the bone, allowing coronal
displacement of the gingivopapillary unit without tension (Fig 2).
To avoid compromising the blood supply, care was taken not to
perforate the flap. To mobilize the flap for coronal positioning,
a periosteal elevator was used to free the gingivopapillary com-
plex. The tissue was elevated from the crest of the bone apical
to the second incision, and the interdental papilla was carefully
undermined.
A subepithelial connective tissue graft can be harvested from
the palate or the retromolar tuberosity area.17 A palatal donor
site was chosen for this patient. The donor tissue was shaped to
reproduce the height, width, and pyramidal contour of the defi-
cient papilla. As mentioned previously, lateral extensions of the
donor tissue were used to create root coverage for the adjacent
teeth in this case. The wound in the donor site was closed with
interrupted sutures.
The subepithelial connective tissue graft was placed beneath
the coronally positioned interdental tissue and stabilized with a
5-0 suture (Fig 3). The suture passed through the palatal tissue,
exited into the interdental space, passed through the graft, and

e2 GENERAL DENTISTRY July/August 2018

Fig 6. Case 2. Preoperative view of a 40-year- Fig 7. Case 2. Graft from the retromolar
old man with Class I loss of interdental papilla tuberosity. The graft is shown with a
between his maxillary central incisors. The stabilizing suture prior to positioning in the
papilla has a trapezoidal shape. interdental area.

Fig 8. Case 2. Vertical mattress suture Fig 9. Case 2. Clinical view of the newly
anchored around the bonded interproximal formed papilla, demonstrating a triangular,
contact point. esthetic shape, 12 months postoperatively.

finally passed through the palatal tissue again. The suture was
then tied on the palatal aspect.
A polytetrafluoroethylene suspensory (sling) suture, beginning
at the base of the papilla and looped around the bonded contact
point for anchorage, was placed to maintain the new position and
height of the papilla (Fig 4). This anchoring suture is essential to
the success of this procedure. The sling suture started by piercing
the facial papillary base, passed through the connective tissue
graft, and exited through the base of the palatal papilla. The pre-
surgical addition of composite bonding material may prevent the
suture from slipping through the interproximal contact.
The alveolar mucosa margin was then returned to the muco-
gingival junction and sutured to provide primary closure and
blood supply to the apical aspect of the coronally positioned
flap. This approach provided healing by primary intention and
excellent wound stabilization.
Postoperative medication included a nonopioid analgesic
(metamizole, 500 mg, every 6 hours). The patient was instructed
to institute careful mechanical plaque control with an ultrasoft
toothbrush, to avoid interdental cleaning, and to rinse twice a
day with 0.12% chlorhexidine gluconate, for 2 weeks.
The sutures and the temporary resin splint at the contact
points were removed 2 weeks after the surgery. The patient was
instructed to continue conventional mechanical plaque control
with an ultrasoft toothbrush and to begin careful interdental
cleaning with dental floss. The timing for reinstatement of
these hygiene measures depends on the level of tissue maturity
after surgery.
The patient reported that the postoperative period was
uneventful. Thirty days after grafting, anatomical reconstruction
of the left central and lateral incisors was performed to augment
the results of periodontal plastic surgery. Clinical observa-
tion at 12 months revealed interproximal papillary tissue with
good healing and tissue contour (Fig 5). There were no adverse
sequelae such as keloids.
Case 2
A 40-year-old man demonstrated a cosmetic defect confined
to the papilla between his maxillary central incisors (Fig 6).
The loss of papilla was deemed Class I, and the treatment plan
involved subepithelial connective tissue grafts associated with
composite restorations. It was decided to harvest the graft from
the molar tuberosity, which would provide the opportunity to
shape the tissue to fit under the flaps and provide more bulk
in the papillary space (Fig 7). The surgical procedures for graft
placement and the sutures were similar to those described in
case 1 (Fig 8).
The postoperative course was uneventful. To optimize the
result achieved with the graft, the central incisors were restored
with composite resin 30 days after surgery. At the 12-month
postoperative examination, the well-healed papilla demon-
strated a triangular shape (Fig 9).

agd.org/generaldentistry e3
Surgical reconstruction of the interdental papilla: 2 case reports
Discussion
Surgical reconstruction of the interdental papilla is an important
but technique-sensitive treatment. It requires well-designed and
accurately performed incisions and flaps to ensure the least pos-
sible disturbance to the blood supply. Some techniques described
in the literature use incisions at the base of the papillary unit,
keeping it attached to the buccal or palatal flap; however,
depending on the volume of the remaining papilla, the blood
supply can be interrupted, creating a risk of necrosis.8,11
The technique described in the present article avoids this
complication through the use of a semilunar incision at the muco-
gingival junction that preserves the band of keratinized tissue and
allows a better blood supply.12 This incision, also described by Han
& Takei and Carnio, promotes more esthetic healing because it
eliminates the visible incisions on the buccal aspect of the flap that
can be an esthetic concern for patients with a tendency to develop
keloids.10,18 Kaushik et al pointed out that this semilunar incision
allows the coronal displacement of the flap without tension and
prevents gingiva from rebounding to its original position.19
The mobility of the flap is an essential aspect of this procedure.
Enough space must be provided under the papilla to receive a
dense fibrous connective graft. The dissection must be sufficient
to allow the manipulation of the papillary unit to a coronal posi-
tion without interference in the blood supply from the palatal
base of the interproximal unit.
Thin gingival tissue requires delicate manipulation of the papilla
to avoid inadvertent perforation of the tissue, and the graft must be
trimmed to fit precisely in position. Extensive papillary deficiency
requires a large graft, which could make it difficult to provide suf-
ficient blood supply. In the surgical approach used in the present
cases, the flap provides the graft with nourishment from all direc-
tions, flow of plasma, and ingrowth of capillaries from surrounding
tissue, resulting in better healing and a better final result.20
Carranza & Zogbi stated that reconstruction of the interdental
papilla with an underlying subepithelial connective tissue graft is a
successful technique that minimizes surgical trauma and disrup-
tion of blood supply to the existing papilla.21 Moreover, the subepi-
thelial connective tissue graft is considered the gold standard for
periodontal plastic surgery, especially in long-term follow-up.22
Stabilization of both the recipient site and the graft is impor-
tant to achieve successful papillary reconstruction. Sutures
anchored on fixed points for 2 weeks ensure the coronal position
of the gingival margins, as seen in the present cases.
More recently, injectable hyaluronic acid gel has been proposed
as a minimally invasive technique to correct papillary deficien-
cies. However, long-term results for this procedure are not yet
known.15,16
Anatomical reconstruction of the teeth may be necessary to
optimize the result achieved with periodontal plastic surgery.
Depending on the amount of remaining space, direct compos-
ite restorations or veneers can be chosen.2 For these patients,
composite restorations were used because the area to be recon-
structed was limited, and the technique is less invasive and pro-
vides good esthetic results.
e4 GENERAL DENTISTRY July/August 2018
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Conclusion
When subepithelial connective tissue grafts associated with
composite restorations were used to reconstruct interdental
papillae, 12-month follow-up showed excellent results, which
were demonstrated by the stability of the gingival margins and
complete, harmonious fill of the interdental papillary areas.
Author information
Drs Henriques and Okajima are professors, Department of
Periodontology, São Leopoldo Mandic School of Dentistry,
Campinas, Brazil. Dr Siqueira, Jr, is in private practice special-
izing in periodontology, São Paulo, Brazil.
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