|Year : 2022 | Volume
| Issue : 1 | Page : 49-52
Comparison of effectiveness of novel vestibular incision for papilla reconstruction with semilunar flap technique. A randomized controlled study
Akhilesh Shewale, Sneha S Puri
Department of Periodontics, Swargiya Dadasaheb Kalmegh Smruti Dental College, Affiliated to MUHS University, Nagpur, Maharashtra, India
|Date of Submission||15-Jan-2021|
|Date of Acceptance||19-Dec-2021|
|Date of Web Publication||06-Apr-2022|
Sneha S Puri
Department of Periodontics, Swargiya Dadasaheb Kalmegh Smruti Dental College, Nagpur - 441 110, Maharashtra; Affiliated to MUHS University, Nagpur - 441 110, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The presence or absence of the interdental papilla is a topic of great esthetic concern. Several surgical and nonsurgical techniques have been proposed to rebuild lost papilla. However, there is a paucity in the literature assessing comparative studies. Aims and Objective: The aim to evaluate and compare the effectiveness of novel vestibular incision for papilla reconstruction with semilunar flap technique. Objectives: To compare effectiveness of novel vestibular incision for papilla reconstruction with semilunar flap technique. Material and Methods: Fourteen patients with the age range of 20–40 years who were conscious for their esthetics with total or partial loss of the interdental papilla were selected for the study. The patients were randomly divided into two groups, namely Group A (vestibular incision subperiosteal tunnel access [VISTA] technique) and Group B (semilunar flap technique). Result: At 6-month postsurgery, there was a statistically significant reduction in vertical dimension, mesiodistal dimension, and area of the papilla defect in Group A as compared to Group B. At 6-month postsurgery, there was an increase in the height of the papilla in Group A, whereas there was a decrease in the height of the papilla in Group B. Both the techniques exhibited satisfactory results in terms of papillary defect fill over a 6-month period. Conclusion: The novel VISTA approach for papillary reconstruction could be a better alternative owing to less postoperative scarring and predictable results.
Keywords: Connective tissue graft, coronally advanced flap, interdental papilla, papilla reconstruction, VISTA technique
|How to cite this article:|
Shewale A, Puri SS. Comparison of effectiveness of novel vestibular incision for papilla reconstruction with semilunar flap technique. A randomized controlled study. J Dent Res Rev 2022;9:49-52
|How to cite this URL:|
Shewale A, Puri SS. Comparison of effectiveness of novel vestibular incision for papilla reconstruction with semilunar flap technique. A randomized controlled study. J Dent Res Rev [serial online] 2022 [cited 2022 Oct 5];9:49-52. Available from: https://www.jdrr.org/text.asp?2022/9/1/49/342711
| Introduction|| |
One of the major esthetic challenges in periodontal plastic surgery is related to the ability of rebuilding lost papillae in the maxillary anterior segment. Interdental papillae can be lost as a result of several distinct clinical situations. The most common reason in the adult population is the loss of periodontal support. Others are abnormal tooth shape, improper contours of prosthetic restorations, and traumatic oral hygiene procedures.
Several surgical and nonsurgical techniques have been proposed to rebuild lost papilla. The nonsurgical approaches (using orthodontic, prosthetic, and restorative procedures) modify the interproximal space, thereby reducing interproximal spaces. Han and Takei described a technique consisting of a pedicle graft using a semilunar incision and coronal displacement of the entire gingivopapillary unit. Azzi et al. demonstrated a surgical technique using a connective tissue graft under the buccal and palatal flaps and reported consistently good results, thereby improving the esthetics. Insufficient blood supply is the major limiting factor in all surgical papilla reconstructive techniques. Carranza and Zogbi used epithelial graft with sulcular and two vertical incisions on each side of the papilla, which had improvement from both coronal and facial views with no color mismatch. Palathingal and Mahendra used subepithelial computed tomography (CT) graft with semilunar incisions as a result of the height of the papilla improved 1 mm, and the interdental papilla was completely filled. Zadeh introduced a conservative modification in tunnel technique; vestibular incision subperiosteal tunnel access (VISTA), which preserves the papillary integrity and enhances patient compliance. VISTA technique allows gingival tissue regeneration through subperiosteal undermining of soft tissues using a vestibular incision instead of elevating the whole flap. Currently, there is no predictable surgical procedure to retrieve the interdental papilla. Hence, we have introduced VISTA approach for papilla reconstruction and compared its effectiveness with the most commonly used semilunar flap technique for papilla reconstruction.
| Materials and Methods|| |
Fourteen patients with the age range of 20–40 years who were conscious for their esthetics with total or partial loss of the interdental papilla, a width of keratinized gingiva (WKG) >2 mm, and vertical distance ≥6 mm were included in the study. However, patients with unacceptable oral hygiene, periodontal pocket or attachment loss, smokers, interdental spacing, pregnant females, and inadequate endodontic or restorative treatment were excluded from the study.
The patients were randomly divided into two groups using coin flip, namely A and B. Group A patients (7) were treated with VISTA technique and Group B (7) were treated with semilunar flap.
The clinical measurements, including vertical distance from the tip of the papilla to the alveolar crest, base of the contact area to the alveolar crest, and tip of the papilla to the base of the contact point, interproximal width of the papilla, and WKG were recorded at baseline and at 6 months [Figure 1]a, [Figure 2]a and [Figure 2]b.
|Figure 1: Surgical Procedure for Group A (vestibular incision subperiosteal tunnel access technique). (a) is a preoperative view can be cited in clinical measurements at baseline. . (b) Incision given. (c) Reflection done by usingWV-3:Vista 3(Walden, USA). (d) is suture place. (e) Postoperative view after 3 months. (f) Postoperative view after 6 months|
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|Figure 2: Surgical procedure for Group B (semilunar flap technique). (a) Preoperative view. (b) Preoperative measurement. (c) Incisions given. (d) Reflection of flap. (e) Sutures placed. (f) Postoperative view after 6 months|
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Surgical procedure for Group A
The VISTA approach began with a vestibular access incision in the midline of the maxillary frenum, which provided access to the entire anterior maxilla [Figure 1]b. Subperiosteal tunnel was created by passing the incision through the periosteum beginning from the mucogingival junction and ending perpendicular to a line passing through the gingival margin of the upper central incisors. A periosteal elevator is then inserted between the periosteum and bone through the vestibular access incision [Figure 1]c. To mobilize the papilla and facilitate its coronal repositioning and achieve a low-tension coronal repositioning of the gingiva, incision was given in gingival sulcus of mesial and distal line angles of respective central incisors [Figure 1]d.
Surgical procedure for Group B
After the administration of local anesthesia, a split-thickness semilunar incision was performed 2 mm coronal to the mucogingival junction, extending from the mesial aspect of the central incisor to the distal aspect of the lateral incisor [Figure 2]c. Intrasulcular incisions were then made with a No. 15C blade around the necks of these teeth, extending from the buccal face to the palate [Figure 1]c. The existing papilla was fully preserved. To release the gingivopapillary unit from the bone, a split-thickness flap was initiated using an orban knife through the semilunar incision on the buccal face, extending toward the palate. After the incisions, the soft tissue was completely released from the root and bone, and the whole flap became mobile, allowing for the coronal displacement of the papillary unit [Figure 2]d. Sutures were placed [Figure 2]e.
All patients were prescribed a course of antibiotics (capsule amoxicillin 500 mg, thrice a day for 5 days) and analgesic (tablet diclofenac sodium 50 mg + paracetamol 500 mg, twice a day for 3 days). Posttreatment instructions were given. All the surgeries were performed by the same individual.
| Results|| |
It was observed from the results that both the groups showed a statistically significant improvement in the height of the interdental papilla. At 6-month postsurgery, there was a reduction in the mean vertical dimension of the papillary defect in Group A, whereas there was a slight increase in the mean vertical dimension of the papillary defect in Group B, but the results were statistically nonsignificant (P < 0.001) [Table 1].
|Table 1: Comparison of the vertical and mesiodistal dimension of the papillary defect|
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At 6-month postsurgery, there was a slight reduction in the mean area of the papillary defect in both the groups indicating papillary shrinkage in due course of time.
Observations showed that there is a slight reduction in the height of the papilla in both the groups at 3- and 6-month postsurgery [Figure 1]e. When the change in the mean papilla, height was compared between Group A and Group B, the difference was a statistically nonsignificant at both 3- and 6-month postsurgery, as P > 0.05 [Table 2].
| Discussion|| |
This is a comparative study evaluating the effectiveness of the two techniques for interdental papilla reconstruction, namely most commonly used semilunar flap technique by Han and Takei and other being a novel technique by approaching the papilla through vestibular incision approach.
In the present study, we used the novel VISTA approach for papilla reconstruction, keeping in mind the limitation of currently employed techniques, i.e., unpleasant postoperative scarring and chances of relapse due to muscle pull during the healing period. The VISTA approach overcomes these shortcomings and reduces the possibility of traumatizing the gingiva of the teeth being treated. Critical to the success of VISTA is a careful subperiosteal dissection that reduces the tension of the gingival margin during coronal advancement while at the same time maintaining the anatomical integrity of the interdental papillae by avoiding papillary reflection. Furthermore, placement of the initial incision and a tunnel entrance within the maxillary frenum results in little to no visible scarring, assisting in maximizing the esthetic outcome in this critical restorative area.
From a biologic point of view, the presence or absence of the papilla primarily depends on the distance between the interdental contact point and interproximal crest of bone. Periodontal disease can produce bone resorption with the formation of horizontal defects or with the formation of vertical defects. Both patterns of bone resorption can lead to a lengthening of the distance from the bone crest to the contact point. Hence, in this study, only those patients who were periodontally healthy with a Probing depth (PD) of 1–3 mm and intraoral periapical radiograph which ruled out the presence of bone loss were selected.
In the present study, we have observed that both the groups exhibited a statistically significant defect fill over the studied period of time over the baseline. The results could be attributed to the success of pedicle grafting, which provides abundant blood supply to the coronally repositioned flap, thereby resulting in acceptance of the pedicled flap in its new location.
Our findings also observed slight papillary shrinkage at the end of 6 months. This could be due to the presence of dead space between the coronally displaced flap and underlying tissues in the embrasure area.
We also noticed that the areas with narrow loss of interdental papilla showed a complete reconstruction of papilla when compared to areas with wide loss. This failure to reconstruct the papilla in wide areas could be due to the donor tissue obtained from the palate. If the tissue was obtained from the tuberosity area, the donor tissue would be thick and fibrous hence improving its outcome. As the availability of donor tissue also plays a role in successful reconstruction.
We also noticed that tissue biotype also influences the surgical reconstruction of the papilla. The outcome of papilla reconstruction was found to be better in cases with a thick gingival unit. However, in the present study, this was not taken as criterion to select patients.
Even though there are other techniques for the reconstruction of the papilla, they are more expensive and require extensive studies to confirm its efficacy. The evaluation of various surgical techniques with longer follow-ups is required so that the best surgical technique can be practiced on a regular basis, thereby making it as a more economical and acceptable method of treatment for rebuilding the lost papilla.
| Conclusion|| |
Both the techniques exhibited satisfactory results in terms of papillary defect fill over the 6-month period. However, the novel VISTA approach for papillary reconstruction could be a better alternative owing to less postoperative scarring and predictable results. More studies with longer follow-ups are necessary to validate our outcomes.
The ethical clearance was sought from the ethical committee of SDKS dental college and hospital, Nagpur before starting the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol 2000 1996;11:65-8.
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Carranza N, Zogbi C. Reconstruction of the interdental papilla with an underlying subepithelial connective tissue graft: Technical considerations and case reports. Int J Periodontics Restorative Dent 2011;31:e45-50.
Palathingal P, Mahendra J. Treatment of black triangle by using a sub-epithelial connective tissue graft. J Clin Diagn Res 2011;5:1688-91.
Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restorative Dent 2011;31:653-60.
Azzi R, Etienne D. Root coverage and papilla reconstruction by connective tissue graft inserted under a vestibular coronally advanced tunnelized flap. J de Parodontol Implantol Oralee 2001;17:71-7.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]