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Journal o Clinical and Diagnostic Research. 2011 December, Vol-5(8): 1688-169116881688
Treatment o Black Triangle by Using a
Sub-epithelial Connective Tissue Grat
Ky Ws: Black triangle, Subepithelial connective tissue grat,Inter-dental papilla, Papilla reconstruction
ABSTRACTOne o the most dicult and elusive goals o periodontics in the eld
o reconstruction, regeneration and esthetic aspect o periodontal
therapy is the surgical reconstruction o the lost interdental papilla.
Loss o interdental papilla could result in patient complaints such
as phonetic problems, ood impaction, unctional problems and
esthetic concern. It is clinically represented by open embrasures
and is oten reerred to as the black triangle. Periodontal plastic
surgery oers both surgical and non surgical approaches in the
treatment o Black triangle. This case report demonstrates
complete reconstruction o the lost interdental papilla ollowing a
semilunar coronally repositioned papilla technique with 6 months
ollow-up.
Plato Palathingal, JaideeP Mahendra
dentistrySection
InTRoduCTIonOne o the major aesthetic challenges in periodontal plastic
surgery is related to the ability o rebuilding the lost papilla in the
maxillary anterior segment. Absence o the papilla with opening
o the black spaces result in Black triangles and they are one
o the most important aspects o the decision making process o
a clinician. This condition may create aesthetic impairments and
ood impactions [1,2].
The common causes o the loss o the inter-dental papilla are
midline diastema, diverging roots, tooth extractions, traumatic
interproximal oral hygiene procedures, abnormal crown orms and
periodontal diseases [1].
Several surgical and non-surgical techniques have been proposed
to treat sot tissue deormities and to manage the inter-proximal
space. The non-surgical approaches are orthodontic, prosthetic
and restorative procedures. They modiy the interproximal space,
thereby inducing modications o the sot tissues. The surgical
techniques aim to recontour, preserve or reconstruct the sot tissue
between the teeth and the implants [1].
This case report highlights the importance o the inter-proximal
papilla and its clinical signicance and the progress o the papilla
augmentation, based on the use o a sub-epithelial connective
tissue grat or the treatment o the Black triangle.
MATeRIAlS And MeThodSThis case was undertaken in the Department o Periodontology
at the Meenakshi Ammal Dental College and Hospital, Chennai,
India. A 21 year old patient with the class I loss o the inter-dental
papilla [3] in the maxillary anterior teeth, with the distance between
the bone crest and the Contact point as 5mm and the height o
the inter-dental papilla as < 4mm, was selected or the treatment
[Table/Fig 1]. The patient had normal alignment o the teeth in
the maxillary arch, he was a non smoker and maintained good
oral hygiene and no proximal caries or improper restoration werepresent with respect to the site.
The PReSuRgICAl PRoToColThe treatment protocol was explained to the patient and an
inormed consent was obtained. Ater the phase one therapy, the
clinical parameters such as the Papilla Index Score and the Height
o Interdental Papilla were measured on the 0th-day o the surgery
(baseline) and postoperatively on the 90th day and the 180th day.
t Pp ix Sc (nmcvsky Ce 2001) [4]
PIS 0: No papilla was present and there was no curvature o the
sot tissue contour.
PIS 1: Less than hal the papilla height was present as compared
to that in the proximal teeth; a convex curvature o the sot
tissue contour was observed.
PIS2: At least hal the papilla height was observed, but it was
not in complete harmony with the inter-dental papilla o the
proximal teeth.
PIS 3: The papilla lled the inter-proximal embrasure to the same
level as in the proximal teeth and it was in complete harmony
with the adjacent papilla.
Cas Rprt
[Tab/Fi-1]: Pre-operative view (loss o inter-dental papilla in relation
to 11,21)
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www.jcdr.net Plato Palathingal, Jaideep Mahendra, Treatment of Black Triangle: A Novel Approach
Journal o Clinical and Diagnostic Research. 2011 December, Vol-5(8): 1688-1691 16891689
h f i- Pp (Mcgir MK t a 2007) [5]
The height o inter-dental papilla was determined according to
McGuire MK et al (2007) [7]. In this procedure, the inter-dental
papilla was anaesthetized with 2% lignocaine hydrochloride. A
Williams periodontal probe was used to measure the distance
between the bone crest to the apical end o the contact point (H).
Loss o the papilla was determined by measuring the distance
between the tip o the inter-dental papilla to the apical end o the
contact point (H1). Then, the height o the inter-dental papilla (H2)
was determined by substracing H1 rom H.
The SuRgICAl TeChnIque
Prparati f t Rcipit Sit
The surgical area was anaesthetized with 2% lignocaine hydro-
chloride which contained 1:2,00,000 adrenaline. A semilunar
incision was made 3mm apical to the mucogingival junction acial
to the inter-dental area, ollowed by a pouch like preparation
towards the inter-dental area [Table/Fig 2]. Intra-sulcular incisions
were made around the necks o the adjacent teeth to ree the
connective tissue attachment rom the root surace, to allow the
coronal displacement o the gingivo-papillary unit [Table/Fig 3].
obtaii t graft frm t dr Sit
The sub-epithel ial connective tissue grat was harvested rom the
palate [Table/Fig 4], ollowing a trap door fap design [6]. A No.
15 B.P. blade was used to make a partial thickness horizontal
incision, about 3mm apical to the gingival margin o the rst
premolar, extending towards the rst molar. Two vertical incisions
were made mesiodistally [Table/Fig 5]. A tissue orcep was used
to lit the prepared palatal fap edge. It was refected towards
the centre o the palate and the underlying connective tissue
was exposed. An incision which was perpendicular to the bone
was made around the edge o the connective tissue, acilitating
its refection rom the bone. A small periosteal elevator and anOrbans knie were used to refect the connective tissue which
was harvested. Ater harvesting the grat, the wound was closed
by using 4-0 black silk sutures.
Trasfrri a Immbiizi t graft
The donor sub-epithelial connective tissue grat which was
harvested rom the palate was tucked in and pushed coronally
within the prepared pouch to support and provide bulk to the
coronally positioned interdental papilla [Table/Fig 6]. The gingivo-
papillary unit was then sutured [Table/Fig 7], a tin oil was placed
over the surgical site and a periodontal dressing was applied. The
patient was prescribed analgesics (Ibuproen 400mg bid or 3
days) and 0.2% chlorhexidine digluconate mouthrinse twice daily
or 2 weeks.[Tab/Fi-3]:Intrasulcular incisions given and tunnel prepared
[Tab/Fi-2]: Semilunar incision placed 3mm apical to the mucogingival
junction
[Tab/Fi-5]: Harvested connective tissue grat rom the Palate
[Tab/Fi-4]: Palatal donor site with trap door fap design
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Plato Palathingal, Jaideep Mahendra, Treatment of Black Triangle: A Novel Approach www.jcdr.net
Journal o Clinical and Diagnostic Research. 2011 December, Vol-5(8): 1688-169116901690
Fw up
Post-operatively, the patient was instructed to rinse the mouth
with 0.12% chlorhexidine mouthwash or 10 days and to rerain
rom fossing or interdental brushing or 4 weeks. The sutures wereremoved ater 10 days [Table/Fig 8].The surgical site was evaluated
on ollow up visits post-operatively on the 90th and the 180th day.
Both the clinical parameters were recorded and the post-operative
clinical photographs were taken. For clinical and statistical analyses,
the measurements at 0-day (baseline), the 90th day and the 180th
day were taken into consideration.
ReSulTSThe papilla index score (PIS) o the patient on the day o the surgery
was PIS 2. The PIS on the 90th day was 3, which remained the
same on the 180th day. Hence, there was an increase o 1 PIS unit
in the patient on the 180th day. The height o the interdental papilla
was 3mm on the day o the surgery, which increased to 4mm on
the 90th day and remained the same on the 180th day. There was
an increase o 1mm in the height o the inter-dental papilla rom the
0th day to the 180th day. A 100% papilla ll was obtained on the
180th day.
dISCuSSIonThe success and the predictability o any surgical procedure or
treating papilla loss is based on the amount o the papilla ll. This
procedure is the rst o its kind as it records the height o the inter-
dental papilla, in accordance with the method o McGuire MK et al
(2007) [5].
In this case, there was a complete ll o the papilla in the site due
to the stability o the connective tissue grat and the maintenance
o good oral hygiene.
This procedure was employed in accordance with that oHan TJ
and Takie HH (1996) [7]. A semilunar coronally repositioned papilla
was combined with a sub-epithelial connective tissue grat and
it was ound to be an eective method o achieving predictable
and stable results or treating papilla loss. The success o this
grating procedure was mainly due to the dual blood supply rom
the underlying connective tissue base and the overlying recipient
fap. An excellent colour match and a donor site with a closed
wound which provided less post-operative discomort were the
advantages o this technique.
The main advantage o using a tunnel or a pouch like design or this
case was that it avoided a horizontal or vertical releasing incision,
[Tab/Fi-6]: Gingivo-papillary unit coronally repositioned and sutured [Tab/Fi-7]: 90th day post-operative view
[Tab/Fi-8]: 180th day post-operative view
which helped in maximizing the papillary and the lateral blood
supply to the submerged connective tissue grat. The atraumatic
management o the tissues, respect or the blood supply and
avoidance o tension and pressure are critical or the viability o
the tissues and the success or the procedure. This fap design
maximizes the sot tissue vascularity and the primary wound
closure. The sub-epithelial connective tissue grat was procured
by the Trap door technique, as described by Edel A (1974) [6].
The grated tissue receives a fow o plasma and an ingrowth o
capillaries rom the periosteum, the underlying connective tissue
and the overlying faps.
The use o a sub-epithelial connective tissue grat or interproximal
papilla augmentation oers a reliable solution to an aesthetic
problem. The papilla augmentation procedure is relatively easy and
it is based on the principles o plastic surgery techniques.
Future research is indicated to examine the total volume o the
embrasure space and also in the use o novel methods to measure
the treatment eect in such periodontal plastic procedures.
ReFeRenCeS[1] PiniPrato G, Rotundo R, Cortellini P, Tinti C, Azzi R. Inter-dental
papilla management: A review and classication o the therapeutic
approaches. Int J Periodontics Restorative Dent2004; 24:246-55.
[2] Tarnow DP, Magner AW, Fletcher P. The eect o the distance rom the
contact point to the crest o the bone on the presence or absence o
the inter-proximal papilla.J Periodontol1992; 63:995-96.
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www.jcdr.net Plato Palathingal, Jaideep Mahendra, Treatment of Black Triangle: A Novel Approach
Journal o Clinical and Diagnostic Research. 2011 December, Vol-5(8): 1688-1691 16911691
[3] Nordland WP, Tarnow DP. A classication system or the loss o
papillary height.J Periodontol1998; 69:1124-26.
[4] Nemcovsky CE. Inter-proximal papilla augmentation procedure: A
novel surgical approach and the clinical evaluation o 10 consecutive
procedures. Int J Periodontics Restorative Dent2001; 21:553-59.
[5] McGuire MK, Scheyer ET. A randomized, double-blind, placebo-
controlled study to determine the saety and ecacy o cultured and
expanded autologous broblast injections or the treatment o inter-
dental papillary insuciency which was associated with the papilla
priming procedure.J Periodontol2007; 78: 4-17.
[6] Edel A. Clinical evaluation o ree connective tissue grats which were
used to increase the width o the keratinized gingiva.J Clin Periodontol
1974; 2:185-96.
[7] Han TJ, Takei HH. Progress in gingival papilla reconstruction.
Periodontol2000.1996; 2:65-68.
aUthor(S):1. Dr. Plato Palathingal
2. Dr. Jaideep Mahendra
PartiCUlarS oF ContriBUtorS:
1. MDS, Department o Periodontology,
Meenakshi Ammal Dental College, Chennai-95, India.
2. MDS, Ph.D, PGDHM, Proessor,
Department o Periodontology,
Meenakshi Ammal Dental College, Chennai-95, India.
PlaCe oF StUdY:
1. Meenakshi Ammal Dental College, Chennai-95, India.
2. Meenakshi Ammal Dental College, Chennai-95, India.
naMe, addreSS, telePhone, e-Mail id oF theCorreSPonding aUthor:
Dr. Jaideep Mahendra, MDS., Ph.D., PGDHM.,
Proessor, Dept. o Periodontology,
Meenakshi Ammal Dental College, Maduravoyal, Chennai,
Tamil Nadu, India
Phone: +91- 9444963973
E-mail: [email protected]
deClaration on CoMPeting intereStS:
No competing Interests.
Date o Submission: Sp 30, 2011
Date o peer review: nv 07, 2011Date o acceptance: nv 22, 2011
Date o Publishing: dc 25, 2011
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