|Year : 2016 | Volume
| Issue : 2 | Page : 112-115
Reconstruction of interdental papilla with platelet-rich fibrin membrane
Nitin Tomar, Vineeta Singal, Divya Dureja, Amit Wadhawan
Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
|Date of Submission||26-Jul-2016|
|Date of Acceptance||16-Oct-2016|
|Date of Web Publication||13-Jan-2017|
Department of Periodontology, Subharti Dental College and Hospital, Meerut - 250 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Search for aesthetic treatment and smile enhancement has persisted in the routine of dental professionals. However, the appearance of black triangles in the anterior region compromises aesthetic looks and hampers one's self-esteem. Etiological factors for open gingival embrasures include aging, periodontal disease, loss of height of the alveolar bone relative to the interproximal contact, length of embrasure area, root angulations, interproximal contact position, and triangular-shaped crowns. Several surgical and non-surgical techniques have been proposed to treat soft tissue deformities and to manage the interproximal space. The surgical techniques aim to recontour, preserve, or reconstruct the soft tissue between the teeth. The aim of the present case report is to present a minimally invasive papillary regenerative procedure using platelet-rich fibrin membrane which was tucked into the pouch, followed by coronal displacement of the entire gingival-papillary unit.
Keywords: Black triangles, papillary reconstruction, platelet-rich fibrin, semilunar flap
|How to cite this article:|
Tomar N, Singal V, Dureja D, Wadhawan A. Reconstruction of interdental papilla with platelet-rich fibrin membrane. J Curr Res Sci Med 2016;2:112-5
|How to cite this URL:|
Tomar N, Singal V, Dureja D, Wadhawan A. Reconstruction of interdental papilla with platelet-rich fibrin membrane. J Curr Res Sci Med [serial online] 2016 [cited 2020 Jul 10];2:112-5. Available from: http://www.jcrsmed.org/text.asp?2016/2/2/112/198369
| Introduction|| |
Dental esthetics is just not confined to the tooth as such but also to the gingival component (soft-tissue). Iatrogenic causes such as flap surgeries and excision of pyogenic granuloma may also predispose to recession of interdental soft tissue. Tarnow et al., proposed that the post-surgical augmentation interdental papillae filled the interdental space completely when the distance between the crest of alveolar bone and contact point was ≤5 mm. Platelet-rich fibrin (PRF), promotes wound healing and hemostasis by gradual release of growth factors from fibrin matrix. Hence, it possess a potential regenerative capacity for interdental papillary augmentation.
| Case Report|| |
A 25-year-old healthy male patient reported to the Department of Periodontology with the chief complaint of the presence of black triangle between the maxillary central incisors [Figure 1].
|Figure 1: Preoperative view showing loss of interdental papillae in 11 and 21 region|
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- Clinical examination revealed class I papillary loss between both the maxillary central incisors. 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
- Intraoral periapical radiograph revealed no bone loss hence, only soft tissue was deficient. Therefore, complete papilla reconstruction was expected. The surgical procedure was explained to the patient, and informed consent was obtained. Routine blood investigations were done.
| Methodology|| |
Preparation of platelet-rich fibrin
The PRF was prepared in accordance with the protocol developed by Dohan et al. Ten-milliliter blood drawn intravenously was centrifuged in sterile test tube for 10 min at 3000 rpm. The resultant product consisted of three layers – topmost layer of acellular platelet poor plasma, PRF clot in the middle, and RBC's at the bottom. PRF clot is separated and is compressed uniformly to form the membrane in Choukroun PRF box [Figure 2].
Intraoral asepsis was performed with 0.2% chlorhexidine digluconate rinse for 30 s, and Betadine solution was used to carry out extraoral asepsis. Under local anesthesia (2% lignocaine), a split thickness semilunar incision was given 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 buccal to the palatal surface [Figure 3]. 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 4]. The prepared PRF membrane was eased into the pouch created and pushed coronally, thereby filling the bulk of the interdental papillae [Figure 5].
The incisions were secured by 5-0 silk suture [Figure 6] followed by placement of periodontal dressing at surgical site. Postoperative instructions were then given to the patient. The patient was prescribed analgesics (paracetamol t.d.s) and antibiotics (amoxicillin 500 mg b.d) for 3 days along with chlorhexidine digluconate (0.2%) rinse twice daily for 10 days. Sutures were removed after 10 days.
Clinical examination post-1 month revealed papilla completely filling the interproximal embrasure and in complete harmony with adjacent papillae [Figure 7].
| Discussion|| |
There are numerous surgical procedures available for reconstruction of interdental soft tissue. According to Tarnowet al., 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.
Arunachalam et al., also used PRF along with the surgical procedures in the reconstruction of papillae and stated that papilla regenerated was structurally stable. This was also seen in the present study that papillae reconstructed to new position was stable and was in harmony with adjacent tissues.
According to Han and Takei, 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 gingival-papillary unit, held in place with a section of sub-epithelial connective tissue 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, used a section of subepithelial connective tissue, removed from the palate and placed beneath the coronally displaced gingiva. The disadvantages associated with subepithelial connective tissue graft procedure include the need for a second surgical site, morbidity linked with autogenous palatal donor mucosa, it is time-consuming and technique sensitive.
Also, study done by Tomar et al., evaluated the outcome of Beagle's technique which is also a minimally invasive procedure and no second surgical site is involved.
However, in the present study, PRF is utilized in place of connective tissue in Han and Takei technique which has an advantage as it promotes wound healing and hemostasis and not additional surgical site is involved thus, increasing patient compliance.
| Conclusion|| |
Although many sophisticated approaches showing good clinical results, have been proposed to restore interdental papilla, use of PRF may be the panacea for interdental papilla augmentation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tomar N, Jain A. Pyogenic granuloma. A case report. Uttar Pradesh State Dent J 2010;28:193-5.
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.
Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun's platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part I: A new grafting protocol. Implant Dent 2009;18:102-11.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al.
Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e45-50.
Arunachalam LT, Merugu S, Sudhakar U. A novel surgical procedure for papilla reconstruction using platelet rich fibrin. Contemp Clin Dent 2012;3:467-70.
Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol 2000 1996;11:65-8.
Harris RJ. Root coverage with a connective tissue with partial thickness double pedicle graft and an acellular dermal matrix graft: A clinical and histological evaluation of a case report. J Periodontol 1998;69:1305-11.
Tomar N, Bansal T, Kaushik M. Smile enhancement with reconstruction of interdental papilla – A case report. TMU J Dent 2014;1:33-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]