Restoration of Lost Interdental Papilla: A Surgical Technique
W. Peter Nordland, DMD, MS
Abstract: Loss of interdental papilla due to trauma or inflammatory periodontal diseases presents significant esthetic-zone challenges to clinicians. Miniscule working spaces and limited blood supply to these areas render conventional surgical techniques somewhat unpredictable. The implementation of vertical releasing incisions can further jeopardize blood supply and leave unattractive scarring upon healing. This article discusses a surgical technique utilizing microscopes and microsurgical instruments to more effectively achieve esthetic results. Additionally, the article provides a brief overview on the development of periodontal plastic and reconstruction surgery and updated information to support previously published reports by this author.
More than 30 years ago, during an annual meeting of the American Academy of Periodontology, the author met with Dr. Preston D. Miller to compare and contrast differences and similarities in root-coverage surgery procedures they were performing at the time. Until then, root coverage had been considered virtually impossible or, at best, unpredictable. Along with Dr. Pat Allen, the three colleagues decided to meet and share ideas about root-coverage grafting. That meeting laid the foundation for the creation of a study group focused on regenerative surgery. This, in turn, led to a number of talented and inquisitive clinicians wanting to contribute. Though the group did not know it then, this was the start of the pendulum of periodontal surgical procedures beginning to swing considerably in the regenerative and reconstructive direction.
The focus of the organization expanded as international surgeons and educators expressed an interest in participating. Over time, what had been known as the periodontal plastic surgery study club evolved into the International Society of Periodontal Plastic Surgeons (ISPPS), and invitations to attend the annual meeting were offered to surgeon-educators interested in oral plastic surgery. Today, dental specialists throughout the world make up the ISPPS. The society meets annually to present new, innovative, and often unpublished material and techniques or modifications/refinements to existing techniques in the field of periodontal plastic and reconstructive surgery, all aimed at enhancing overall esthetics for patients long-term.
After examining many cases on root-coverage grafting, Drs. Miller, Allen, and Nordland concluded that this procedure was becoming highly predictable and commonplace, and they then decided to attempt to create a reliable technique for restoration of lost interdental papilla. This article focuses on the restoration of interdental papilla with some degree of predictability and minimal trauma.
The reconstruction of lost interdental papilla poses many challenges, including the relatively small size of the area, the vascularity of this end organ, and, oftentimes, excessive scar tissue. Use of a microsurgical approach for placement of a connective tissue graft under an existing papilla will minimally compromise vascularity; however, the confined size of the surgical site necessitates the use of tiny surgical instruments designed specifically for this small, delicate environment.
The surgical technique involves use of a bendable N-6900 microsurgical scalpel blade that is contoured to incise under the interdental papilla. A custom-contoured dense fibrous connective tissue graft is harvested from the palate, and specific suspensory sutures are used to position the graft under the existing papilla that is to be augmented. The sutures help to position the graft in place laterally, incisally, and bucco-lingually. A suspensory suture (ie, Nordland suspensory suture technique)1 begins at the base of the papilla and is anchored around the interproximal contact point. It is used to secure the donor tissue in the desired location and retain it in place for 2 weeks. After 2 weeks, the patient can resume flossing but must avoid use of rigid interdental cleaning aids that could flatten the tissue.
The author has previously co-authored a detailed description of this surgical technique.1 For the purposes of this article, assessment of the preoperative versus postoperative papilla changes was made using the Nordland-Tarnow classification system for loss of papillary height2 and will be cited as a Nordland Class I, II, or III papilla. Four papilla regeneration cases are represented here.
A female patient was referred for augmentation of lost interdental papilla between teeth Nos. 9 and 10 after experiencing root planing trauma at her restorative dental office. A diagnosis of a Nordland Class III papilla defect was made. Microsurgery was planned to place a connective tissue graft of appropriate length and height under the existing papilla to thicken, or "plump," the existing tissue defect. Figure 1 shows the patient's preoperative appearance in 2009. Figure 2 shows the patient's 7-year postoperative appearance with no restorative dental changes. The papillary defect was downgraded from a Nordland Class III defect to a normal papilla.
In the next case, a woman had periodontal pocket elimination surgery performed but was very displeased with the outcome. She saw two periodontists who told her nothing could be done. After repeated discussions with the restorative dentist, she was referred for yet for another opinion. All periodontal probing pocket depths were within normal limits. A diagnosis of a Nordland Class III papillary defect was made. The patient was advised that surgical tissue addition, orthodontic space closure, and esthetic crown lengthening would be necessary to achieve a balanced esthetic result. Her initial appearance following disfiguring periodontal pocket elimination surgery created a Nordland Class III papillary defect (Figure 3).
Papilla augmentation with a custom-shaped connective tissue graft was performed first, followed by orthodontic space closure. Orthodontic closure initially moved the lateral incisor to close the space. After closing the lateral-central space, a new space was formed distal to the lateral incisor. The canine was then advanced forward to create a space distal to the canine. Hiding the space distal to the canine was deemed less problematic, because it could be more readily disguised and would be easier to work with from a restorative perspective (Figure 4).
An esthetic crown-lengthening surgery was performed throughout the maxillary arch to provide a more ideal crown length. The maxillary arch was restored with a combination of crowns and veneers. The patient liked the new appearance so much that she asked the restorative dentist to also restore the mandibular arch. She has remained in the periodontal practice for periodontal maintenance for the past 20 years without any appreciable changes.
A male patient was referred for an unesthetic root exposure of a root-canal-treated, darkened tooth No. 8. The patient presented with what he called a "ghastly" appearance of his front tooth (Figure 7).
A diagnosis of a Nordland Class III papillary defect was made. His dentist was hoping that restoration of the lost interdental papilla could be accomplished. Surgery was planned to perform a connective tissue graft to enhance the missing interdental papilla and also to provide root coverage for tooth No. 8. A contoured connective tissue graft was harvested from the palatal area between teeth Nos. 13 and 14 using a papillary shape of the palatal tissue (Figure 8). This site was chosen because it already included a papillary shape and thickness that would be similar to the desired tissue dimensions between teeth Nos. 7 and 8.
The microsurgical addition of tissue between teeth Nos. 7 and 8 was accomplished through a sulcular incision made around these two teeth. The papilla was elevated using a N-6900 scalpel. The connective tissue graft was gently inserted into a tunnel specifically created for papilla augmentation. Composite was added between teeth Nos. 7 and 8 and a suspensory suture (Figure 9) was placed through the connective tissue graft and anchored around the contact point. The composite allowed the suspensory suture fixed anchorage to provide stabilization for 2 weeks. The suspensory suture is essential to help avoid initial tissue relapse.
Figure 10 shows a 1-year postoperative photograph; after 1 year of successful healing a new crown was placed. Figure 11 shows the outcome 9 years later with the crown on No. 8. The papilla classification was changed from a Nordland Class III papillary defect to a Nordland Class I papillary defect.
This female patient presented with a disfigured papilla between teeth Nos. 10 and 11. Initial consultation revealed an open embrasure space (Nordland Class II papillary defect) that was created by surgical trauma and exaggerated by a teardrop-shaped lateral incisor (Figure 12). The patient reported that she had two surgical procedures performed, with the defect becoming worse with each attempt to repair it. Upon presentation it was explained to the patient that her treatment would require papillary grafting and reshaping of the crowns to close the embrasure space and that orthodontic treatment might be needed to align the roots in a more parallel fashion.
X-rays showed root divergence and root blunting of teeth Nos. 9 through 11 (Figure 13). Because she had already completed orthodontic treatment that contributed to blunting of many roots, it was deemed not in her best interest to attempt orthodontic root alignment again.
A previous incision line was apparent between teeth Nos. 10 and 11, and a wide embrasure space was evident. After options were discussed, the treatment decision was to add gingival tissue to plump and create a normal-shaped papilla, followed by restoration of the teeth to provide a more esthetic shape and to close the embrasure space with the crown form. A palatal connective tissue graft was harvested to match the lost interdental papilla dimensions and to provide a shape for root coverage (Figure 14).
The dimensions of the graft were chosen to mimic the height of missing papillary tissue. The length was determined based on the desire for root coverage. Expanded polytetrafluoroethylene (ePTFE) sutures were used because of their ability to slide on themselves in order to provide appropriate tension without cutting through the tissue. To help stabilize the graft, 6-0 ePTFE positioning sutures were used, and 5-0 ePTFE sutures were used for the suspensory element. The graft was stabilized with lateral positioning sutures, root-coverage grafting stabilization,1 and suspensory sutures for the areas between teeth Nos. 9-10 and 10-11 (Figure 15).
A postoperative view shows plumping of the interdental papilla 9-10, 10-11 areas along with root coverage of Nos. 9 through 11 (Figure 16). As a result, the papillary defect classification was changed from a Nordland Class II to a Class I.
The papilla augmentation technique presented involves careful microsurgical dissection of the papilla and the addition of tissue that can be completely surrounded by a vascular supply to enhance cellular survival. The use of suspensory sutures can assist in achieving initial stability of the papillary tissue and help to avoid tissue relapse.
The author wishes to acknowledge the contributions of Aubrey Brion, RDA, in preparation of this manuscript.
About the Author
W. Peter Nordland, DMD, MS
Former Assistant Professor of Periodontics, Loma Linda University, Loma Linda California; Director of Microsurgery, Newport Coast Oral Facial Institute, Newport Beach, California; Private Practice, La Jolla, California
1. Nordland WP, Sandhu HS. Microsurgical technique for augmentation of the interdental papilla: three case reports. Int J Periodontics Restorative Dent. 2008;28(6):543-549.
2. Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol.1998;69(10):1124-1126.