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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: jaideep_m_23@yahoo.co.in

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