SURGICAL RECONSTRUCTION OF INTERDENTAL PAPILLA USING AN INTERPOSED SUBEPITHELIAL CONNECTIVE TISSUE GRAFT:
A CLINICAL STUDY.
Brief resume of the intended work :
6.1 Need for the study :
Esthetics has become a major concern in periodontal therapy. Gingival recession resulting in denuded root surface and the loss of the gingival papillae are the two main concerns in periodontal esthetics.
Interdental papillae can be lost as a result of several distinct clinical situations. True loss of existing interdental papilla can occur as a result of periodontal disease process or as a result of periodontal surgical procedures.
The poor esthetics appearance due to loss of interdental papillae has been a dilemma for both the patient and the therapist. One of the most difficult and elusive goals for the periodontist in the reconstructive, regenerative and esthetic aspect of periodontal therapy is the reconstruction of the interdental papillae that has been lost from the disease or previous pocket eradication periodontal therapy.
Periodontal plastic surgery enables enhanced esthetics in the anterior maxillary region. Reconstruction of the interdental papillae is one of the most challenging and least predictable of treatments. Several surgical procedures to rebuild lost papillae have been presented.
The purpose of the intended study is to observe clinical outcome of the interdental papilla augmentation using sub epithelial connective tissue graft.
6.2 Review of Literature :
In a clinical report, three cases of reconstruction of lost interdental papilla in between any two adjacent maxillary anterior teeth to improve the esthetics were reported. It was observed that by submerging the grafted tissue, both autogenous bone and the connective tissue, beneath the flap and primary closure of the graft site provided an environment of maximum blood supply to the grafted tissues and satisfactory augmentation of interdental papilla.1
Another report stated that the predictable creation of lost gingival papilla by surgical means must follow the principle of using the most advantageous pattern of blood supply to the newly created tissue. Due to the small, restricted space interdentally, any form of free grafting cannot be utilized since the surface area for the blood supply to the donor tissue is minimal. Therefore, a form of pedicle grafting using the semilunar incision and 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.2
In a clinical case report, the surgical technique using an interposed sub-epithelial connective tissue graft which can regenerate a lost interdental papilla was described. The reconstructed papilla remained stable and without any sign of clinical inflammation for 4 years after the surgery.3
In a clinical evaluation of ten cases of interdental papilla augmentation, the authors observed satisfactory results and concluded that the surgical technique for interproximal papilla augmentation offers a reliable solution to this esthetic problem4
6.3 Objectives of the study :
To observe the clinical outcome of the interdental papilla augmentation using sub epithelial connective tissue graft.
To evaluate the role of interposed sub epithelial connective tissue graft for papillary reconstruction in improving the esthetics.
Material and methods :
7.1 Source of data :
The patients for this proposed study will be selected from the out patient department of Periodontics, Bapuji Dental College & Hospital, Davangere. A total of 10 patients will be considered for this study.
The study will be carried out on subjects between the age group 20-50years with loss of interdental papilla as assessed by the clinical examination.
Inclusion criteria :
Patients with loss of interdental papillae in between any two adjacent maxillary anterior teeth with Class I & II defect according to Norland & Tarnow׳s Classification.
Patients free from systemic disease.
Normal alignment in the arch.
Patient showing tendency to maintain good oral hygiene.
Exclusion criteria :
Extensive Interdental bone loss leading to tooth mobility.
Patient with smoking habits.
Teeth with occlussal interferences or restoration.
Pregnancy and lactating mother.
7.2 method of collection of data :
All the subjects will be explained about the nature and period of the study. A written consent will be obtained from all the participating patients.
Clinical parameters :
The clinical parameters which will be recorded are:
1. Plaque Index (Silness & Loe, 1964).
2. Gingival Index (Loe & Silness, 1963).
3. Papillae recession.
4. Keratinized Gingiva.
5. Distance from contact point to bone crest
6. Distance from contact point to gingival margin
7. Facial recession
8. Horizontal distance at the proximal cemento-enamel junctions on intra oral periapical radiographs.
These parameters will be recorded at baseline and at 3, 6 and 9 months postoperatively.
Study design :
After selection of the cases, all the patients will be subjected to scaling and root planing and on obtaining the desired results, the planned surgical procedure will be undertaken.
After obtaining adequate local anesthesia, using B.P.knife (Blade.No.15), incisions will be placed and the entire gingival-papillary unit will be elevated and displaced coronally. To fill the dead space created by the coronal displacement of the tissue, a section of subepithelial connective tissue will be obtained from the palate. The harvested graft will be placed into the space created due to incision. The graft and the coronally placed tissue will be stabilized with sutures. Postoperative instructions will be given and the patient will be maintained on strict plaque control regime. If required, the same procedure will be repeated after 3 months to get desired results.
The postoperative follow-ups will be undertaken at 3 months, 6 months and 9 months postoperatively and clinical parameters will be recorded.
Statistical analysis :