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Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 111-114

Connective tissue: A gold standard for reconstruction of black triangle

Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India

Date of Submission03-Aug-2017
Date of Acceptance29-Sep-2017
Date of Web Publication8-Jan-2018

Correspondence Address:
Dr. Vineeta Singal
Department of Periodontology, Subharti Dental College and Hospital, Meerut - 250 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_41_17

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Esthetic awareness has improved vastly in the last decade. Periodontal plastic surgery has made it possible to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa. However, till date, the most challenging scenario lies in the enhancement of lost interdental papillae in the maxillary anterior region. An open gingival embrasure or black triangle occurs as a result of a deficiency of papilla beneath the contact point, which causes complex esthetic and functional problems. Several reasons contribute to the loss of interdental papillae, and various surgical and nonsurgical techniques for papillary reconstruction have been proposed till now. The present article describes a case of papilla reconstruction procedure using connective tissue graft. The procedure resulted in nearly 100% fill of the interproximal embrasure.

Keywords: Black triangles, connective tissue graft, papillary reconstruction, periodontal plastic surgery

How to cite this article:
Sharma A, Singal V. Connective tissue: A gold standard for reconstruction of black triangle. J Curr Res Sci Med 2017;3:111-4

How to cite this URL:
Sharma A, Singal V. Connective tissue: A gold standard for reconstruction of black triangle. J Curr Res Sci Med [serial online] 2017 [cited 2023 May 31];3:111-4. Available from: https://www.jcrsmed.org/text.asp?2017/3/2/111/222416

  Introduction Top

In the adult population, the most common reason for the loss of interdental papillae is the loss of periodontal support because of plaque-associated lesions. However, abnormal tooth shape, improper contours of prosthetic restorations, and traumatic oral hygiene procedures may also have negative influence on the interdental soft tissues affecting esthetic and also predisposing to phonetic and functional problems such as food impaction.[1] Factors which influence the presence or absence of interdental papilla include crestal alveolar bone height, dimensions of the interproximal space, soft tissue appearance (thick or thin biotype), minimal buccal plate thickness, type of contact area (triangular versus square), and the biologic width.[2] Some iatrogenic causes such as previous flap surgeries and surgical excision of common gingival condition like pyogenic granuloma may also predispose to recession of interdental soft tissue.[3]

Nordland and Tarnow [4] proposed a classification system regarding the papillary height adjacent to natural teeth, based on three anatomic landmarks [Figure 1].
Figure 1: Classification system regarding papillary height

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  1. The interdental contact point
  2. The apical extent of the facial cementoenamel junction (CEJ), and
  3. The coronal extent of the proximal CEJ.

Loss of interdental papilla solely because of soft tissue damage can be restored completely by reconstructive techniques. However, reconstruction is generally incomplete if the loss is due to severe periodontal disease and interdental bone resorption. A study done by Tarnow et al.[5] became a standard in predicting the stable papilla height according to which reconstruction of interdental papilla was 98% when the distance between the contact point and the crest of interdental bone is ≤5 mm. When the contact was 6 and 7 mm from bone, only 56% and 37% of the papillae could be reconstructed, respectively.

The healing principles on which the subepithelial connective tissue graft (SCTG) for root coverage [6] and ridge augmentation are based (double blood supply) have been applied to the reconstruction of the interdental papilla, thus increasing both the success rate and predictability.[7]

  Case Report Top

A systemically healthy male of age 40 years reported in the outpatient department of Department of Periodontology, Subharti Dental College and Hospital, Meerut, with the chief complaint of black triangles in the upper anterior region causing an esthetic concern.

Clinical examination revealed class I papillary loss between the maxillary central incisors [Figure 2]. The distance from the contact point to the bone crest was evaluated by transgingival probing, using UNC-15 periodontal probe which was found to be 5 mm and the distance between the contact point of adjacent teeth and the existing papilla was found to be 4 mm. Overall gingiva was healthy with normal color, contour, and consistency. There were no other relevant findings present.
Figure 2: Class I papillary loss

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Intraoral periapical radiograph revealed no bone loss and there was only soft tissue deficient. Thus, complete reconstruction of the papilla was expected. The surgical procedure was explained to the patient, and an informed consent was obtained.

Surgical procedure

Intraoral asepsis was performed with 0.2% chlorhexidine digluconate rinse for 30 s, and iodine solution was used to carry out extraoral asepsis. Under local anesthesia (2% lignocaine), a split-thickness semilunar incision was made with a No. 15C blade about 1 mm coronal to the mucogingival junction in the interdental region of 11 and 21. Intrasulcular incisions were also made around the neck of the adjacent teeth extending from midbuccal to the midpalatal surface. Through the semilunar incision, the split thickness flap was continued to create a pouch in the interdental area. A thin periosteal elevator was used to separate the attachment of tissues from the root surface, thus facilitating the coronal displacement of the gingivopapillary unit as a whole [Figure 3]. The donor tissue, consisting of 2-mm thick connective tissue, was harvested from the palate and shaped to fit the pouch, enabling to fill the bulk of the interdental papillae [Figure 4] and [Figure 5].
Figure 3: Preoperative

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Figure 4: Connective tissue

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Figure 5: Donor site

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The incisions were secured by using 5-0 silk suture, and the surgical area was protected by a periodontal dressing [Figure 6] and [Figure 7]. Postoperative instructions were then given to the patient. The patient was prescribed analgesics for 3 days along with chlorhexidine digluconate (0.12%) rinse twice daily for 10 days and recalled after 10 days for suture removal. Clinical examination revealed uneventful healing with papilla completely filling the interproximal embrasure and in complete harmony with adjacent papillae [Figure 8].
Figure 6: Connective tissue graft secured at recipient site

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Figure 7: Suturing at donor site

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Figure 8: Postoperative after 10 days

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  Discussion Top

There are numerous surgical procedures available for reconstruction of interdental soft tissue. According to Tarnow et al.,[5] the distance from the base of the contact area to the crest of bone could be correlated with the presence or absence of the interproximal papilla, and if it is 5 mm or less, the papilla was present almost 100% of the time or may be reconstructed surgically. This was in accordance with the present study in which the distance from the contact point to the bone crest was evaluated to be 5 mm, and there was complete filling of the interproximal embrasures.

Han and Takei [7] stated that due to the small, restricted space interdentally, any form of free grafting cannot be utilized since the surface area for blood supply to the donor tissue is minimal. Therefore, a form of pedicle grafting using the semilunar incision and the coronal displacement of the entire gingivopapillary unit, held in place with a section of SCTG beneath the coronally displaced tissue, may be one method that is predictable in reconstructing a lost gingival papilla. Therefore, similar technique has been utilized in the present study.

To eliminate the dead space created by the coronal displacement of tissues, Han and Takei [7] suggested that the advantages associated with the use of SCTG procedure are availability of double blood supply, improved healing, and increased success rate. Hence, the usage of SCTG in the present study increased the success rate and predictability of donor tissue as it received its blood supply from both the overlying flap and underlying periosteum which is one of the factors influencing surgical reconstruction of the papilla.

According to Carnio,[8] the interposed SCTG technique can regenerate a lost interdental papilla and to be successful, the surgical technique must involve the maintenance of the integrity of the interproximal tissue. This was taken into consideration in the present case and the intrasulcular incisions were then made in such a way that the existing papilla was fully preserved.

  Conclusion Top

This case showed that the advanced papillary flap with interposed SCTG can offer predictable results for the reconstruction of interdental papilla. The success of this clinical case may be attributed to the precise indication of the technique of SCTG. Furthermore, if papilla loss occurs solely due to soft-tissue damage, reconstructive techniques can completely restore it. However, further studies with a larger sample size are required to confirm the effectiveness of the technique in reconstructing the papilla.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Interdental papilla management: A review and classification of the therapeutic approaches. Int J Periodontics Restorative Dent 2004;24:246-55.  Back to cited text no. 1
Zetu L, Wang HL. Management of inter-dental/inter-implant papilla. J Clin Periodontol 2005;32:831-9.  Back to cited text no. 2
Tomar N, Jain A. Pyogenic granuloma. A case report. Uttar Pradesh State Dent J 2010;28:193-5.  Back to cited text no. 3
Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 1998;69:1124-6.  Back to cited text no. 4
Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995-6.  Back to cited text no. 5
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.  Back to cited text no. 6
Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol 2000 1996;11:65-8.  Back to cited text no. 7
Carnio J. Surgical reconstruction of interdental papilla using an interposed subepithelial connective tissue graft: A case report. Int J Periodontics Restorative Dent 2004;24:31-7.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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