Efficacy of Connective Tissue Graft Versus Titanium Papillary Inserts in the Surgical Reconstruction of Interdental Papilla

INTRODUCTION The human gingiva consists of specific anatomical components: the attached gingiva, which securely connects the gingiva to the underlying bone, and the marginal (free) gingiva, a slender strip of tissue that surrounds the tooth without adhering to hard tissue. Vertically, the marginal gingiva stretches from the (Cemento-enamel junction) CEJ to the free gingival groove. In the interdental space lies the interdental papilla, a vital part of the gingival structure.1,2 Morphologically, the interdental papilla reaches from the interdental alveolar bone to the contact point of neighboring teeth. It is separated from the mesial and distal aspects by sulcular and/or junctional epithelium, whereas the facial and oral surfaces are covered by keratinized gingival oral epithelium. The development of the interdental papilla takes place during tooth eruption, and its shape is affected by the contact points of neighboring teeth, the widths of proximal tooth surfaces, and the configuration of the CEJ.1,2 The interdental papilla can be vulnerable to inflammatory agents through the junctional/sulcular epithelia, leading to localized inflammation even in clinically healthy papillae, which is a frequently observed histologic finding.

A black triangle, which denotes the loss of interdental papillae, continues to be one of the most prevalent conditions leading to not just aesthetic and phonetic issues but also functional challenges as it increases the likelihood of food impaction that negatively impacts periodontal health. The interdental papilla in the incisor area is typically pyramidal in form. Elements that affect the presence or absence of interdental papilla include crestal alveolar bone height, the dimensions of the interproximal space, soft tissue appearance (thick or thin biotype), buccal plate thickness, the type of contact area (triangular versus square), and the biologic width.3 The limited ability of the interdental papilla to regenerate seems to be influenced by various aspects, such as anatomical factors, bone loss, plaque accumulation, and inflammatory phenomena within the interdental area. Moreover, there is an indication that the interdental papilla may have unique functional features resulting from specific cellular or molecular attributes. This idea is supported by ample documentation showing that distinct anatomical tissue units, even within the marginal gingiva, display specific characteristics. 4-9 A range of techniques has been investigated for reconstructing the interdental papilla, encompassing both nonsurgical and surgical strategies. Among the nonsurgical techniques are repeated curettage of the interdental papilla, orthodontic adjustments, restorative fixes, and the application of hyaluronic acid (HA). Although these methods have been tried, they frequently produce less reliable results and provide limited potential for considerable papilla enhancement.

Conversely, surgical approaches have become more prominent due to their effectiveness in papilla reconstruction, despite being more invasive and complex. These surgical options consist of pedicle and free gingival grafts, connective tissue grafts (CTG), subepithelial connective tissue grafts (SCTG), and the application of Choukroun's platelet-rich fibrin (PRF). These techniques involve the manipulation of gum tissues to improve the height and shape of the interdental papilla, targeting more reliable and satisfactory aesthetic results.10 Titanium alloys are highly regarded for their outstanding strength-to-weight ratio, resistance to corrosion, and biocompatibility, which makes them suitable for aerospace, medical implants, and marine uses. Their ability to resist oxygen, water, and chemicals guarantees durability in harsh conditions, while their non-toxic nature makes them ideal for medical applications. The characteristics of titanium alloys can be customized through alloying, heat treatment, and surface modifications to satisfy specific application demands.11 El Askary et al (2000)12 described the papillary titanium insert and emphasized its benefits, manipulation, and handling. To support the soft tissue between two implants and achieve the desired interdental papilla-like form, a papillary titanium insert was created. This method eliminates the necessity for any bone grafting procedures while requiring fewer tools and reducing the number of surgical interventions.

This study seeks to present the use of a titanium insert for reconstructing the interdental papilla, which was previously utilized by El Askary et al12 for forming inter-implant papillae. It also intends to compare this method with the Han and Takei technique13 of papilla reconstruction using a subepithelial connective tissue graft. The research findings hold the potential to provide clinicians with an innovative therapeutic alternative for enhancing periodontal aesthetics and increasing patient satisfaction.

MATERIAL AND METHODS