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The International Journal of Periodontics & Restorative Dentistry

2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 32, Number 1, 2012

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Efficacy of Micronized Acellular Dermal Graft for Use in Interproximal Papillae Regeneration

Nico C. Geurs, DDS, MS*/Alain H. Romanos, DDS, MS** Philip J. Vassilopoulos, DDS***/Michael S. Reddy, DMD, DMSc****

Reconstruction of lost interdental pa-pillae is one of the most difficult and challenging procedures in esthetic periodontal therapy. There are sev-eral challenges and limiting factors for papillary reconstruction, includ-ing limited space for surgical access, a compromised blood supply, the relative tooth position and shape of the interproximal space, biotype of the periodontium, and location of the osseous crest.1 The limited blood supply to the papillary area and re-stricted space in which to operate make surgical grafting procedures difficult. Maintaining the blood sup-ply to the papilla is a surgical chal-lenge, while the limited space makes graft placement, adaptation, and containment complicated.

Different methods have been described using autogenous tis-sue to graft the interdental papilla with varying degrees of success.210 Most of these studies are case re-ports with little data regarding short- and long-term results, but the reconstruction of a lost papilla is not a predictable occurrence.

To overcome some of the limit-ing factors for papillary regeneration,

The aim of this study was to evaluate interdental papillary reconstruction based on a micronized acellular dermal matrix allograft technique. Thirty-eight papillae in 12 patients with esthetic complaints of insufficient papillae were evaluated. Decreased gingival recession values were found postoperatively (P < .001). Chi-square analysis showed significantly higher postoperative Papilla Index values (chi-square = 43, P < .001), further supported by positive symmetry statistical analysis values (positive kappa and weighted kappa values). This procedure shows promise as a method for papillary reconstruction. (Int J Periodontics Restorative Dent 2012;32:4958.)

* Professor, Department of Periodontology, University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama.

** Adjunct Assistant Professor, Department of Periodontology, University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama.

*** Assistant Professor, Department of Periodontology, University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama.

**** Professor, Department of Periodontology, University of Alabama at Birmingham School of Dentistry, Birmingham, Alabama. Correspondence to: Dr Nico Geurs, UAB School of Dentistry, 1530 3rd Avenue South, SDB 412, Birmingham, AL 35294-0007; fax: 205-934-7901; email: [email protected].



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this paper will describe a surgical technique that was developed to maintain the blood supply to the papilla in combination with the use of an adaptable regenerative matrix with good dimensional stability. This regenerative matrix is a micronized particulate form of acellular der-mal matrix (Cymetra, LifeCell). Like sheet-form acellular dermal matrix, it contains all the elements needed to replace tissue (collagens, elastin, proteins, and proteoglycans). The collagens and elastin provide struc-ture for cell repopulation, while the proteoglycans and proteins allow the patients own cells to initiate revascularization and cell repopula-tion. Because of the small particle size, it can be delivered by injection as a minimally invasive tissue graft. Acellular micronized dermal graft is remodeled into normal soft tissue by the body, with low potential for

eliciting an inflammatory response or graft rejection. The use of acel-lular dermal matrix in periodontal esthetic procedures has been well documented.1119 Micronized acel-lular dermal graft has been used for injection laryngoplasty in patients with vocal cord insufficiency. It re-sulted in an increase in the long-term correction of the vocal cord insufficiency and good stability of the augmented tissues.20 Potential advantages of acellular micronized dermal graft over autogenous grafts include lack of donor site morbid-ity, reduced procedure time, ease of use, availability in dimensions need-ed, and predictable postoperative volume maintenance.21,22

The aim of this investigation was to evaluate the efficacy of acellular micronized dermal grafts to regenerate interdental papillae in combination with a minimally

invasive surgical technique that maximizes the blood supply to the atrophic dental papillae.

Method and materials

Patients who presented with es-thetic concerns about the loss of interproximal papillae were se-lected for this investigation. The study was approved by the insti-tutional review board of the Uni-versity of Alabama at Birmingham. Informed consent was obtained prior to enrollment. A total of 12 patients (10 women, 2 men; mean age, 55 years; age range, 40 to 70 years) with a total of 38 insuf-ficient papillae were enrolled in the study. Upon enrollment, medi-cal histories were reviewed. Treat-ment plans were developed by an interdisciplinary team consisting

Fig 1 Baseline assessment of a subject illustrating insufficient soft tissue fill of the interdental embrasure.



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of a surgeon and prosthodontist. The inclusion criterion was at least one atrophic papilla (Fig 1). Exclu-sion criteria included major medi-cal conditions, use of medications affecting the periodontium, diabe-tes, current tobacco use, root sur-face restorations, previous papillary regeneration procedures, and need for antibiotic prophylaxis.

Baseline data included full-mouth Plaque Index,23,24 Gingival In-dex, bleeding on probing, probing depth, recession depth (cemento-enamel junction to gingival mar-gin), distance from crestal bone to point of contact, keratinized tissue width (gingival margin to mucogin-gival line), and Papilla Index values. Standardized radiographs were also taken.

Jemt introduced an index for measuring papillary presence around implants.25 This index was

modified to be used around natu-ral teeth for this investigation. This modified Papilla Index designated five different levels indicating the amount of papilla present: score 0, no papilla is present; score 1, less than half of the height of the papilla is present; score 2, at least half of the height of the papilla is present but not all the way to the contact point between the teeth; score 3, papilla fills the entire proxi-mal space and is in good harmony with the adjacent papillae with op-timal soft tissue contour; and score 4, papilla is hyperplastic and excess tissue is present.

All patients completed an initial therapy that included oral hygiene instructions and scaling and root planing when indicated. The surgi-cal preparation of the recipient site was similar to that described by Reddy.26 In brief, prior to the surgical

procedure, the patient was in-structed to rinse with chlorhexidine gluconate 0.12% for 30 seconds. Adequate anesthesia of the surgical region was obtained. A single verti-cal incision was made in the buccal vestibule apical to the mucogingi-val junction in the midinterproximal area of the papilla to be treated (Fig 2). Intrasulcular releasing incisions were made on the teeth adjacent to the papilla to be augmented and extended to the buccal and pala-tal aspects without altering the in-tegrity of the papilla. The incisions maintained the full height and thick-ness of the gingival component and enabled access beneath the buccal gingiva with a 5-6 Gracey curette (Hu-Friedy) (Fig 3). Papillae were undermined carefully to maintain in-tegrity, and a space was created un-derneath the papilla by elevating it coronally using periodontal curettes.

Fig 2 Initial incisions. Fig 3 Coronal advancement of the flap and creation of space under the papilla obtained using a curette.



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The gingivopapillary complex was released until coronal movement of the papilla to the contact point was possible. Then, the micronized acel-lular dermal allograft was prepared. Powdered dermal matrix (330 mg) was reconstituted to 1 mL with ster-ile saline in a 5-mL syringe (Fig 4). The micronized acellular dermal al-lograft was placed underneath the papilla and mucogingival complex through the vertical incision using

an 18-gauge needle (Fig 5). The syringe was placed at the most in-cisal aspect of the papilla, and the Cymetra graft was delivered while backing the needle out. Incisions were closed with 6.0 Vicryl simple interrupted sutures (Ethicon). The entire gingivopapillary complex (buccal flap, graft material, and pa-pilla) was maintained in a coronal position using cyanoacrylic dress-ings (Fig 6).

Fig 4 Hydration of the micronized dermal graft by mixing with 1 mL sterile saline and connecting to a second syringe.

Fig 5 (left) Injection of the dense dermal graft into the space cre-ated with an 18-gauge needle.

Fig 6 (below) After suturing the vertical incision, the flap was posi-tioned coronally using medical cyanoacrylate adhesive.



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Postoperative management in-cluded pain control and twice-daily rinses with chlorhexidine gluconate. Sutures were removed 1 week after the procedure. Clinical data collec-tion was repeated at 5 months post-surgery. The method for micronized acellular dermal matrix placement is illustrated in Figs 7a to 7c.

Statistical analysis

The various clinical parameters evaluated pre- and postsurgically were analyzed by the means proce-dure at a 95% level of statistical sig-nificance. A frequency procedure for pre- and postoperative Papilla Index values was performed, with significance based on the chi-square test and a test for symmetry. Correlation procedures were also used to investigate the influence of presurgical bone-tocontact point distance and clinical parameters on Papilla Index values of papilla fill.

Results

Surgical effects

The results show that there was an overall decrease in bleeding on probing for the three sites evalu-ated (facial, distal, and mesial) and that these values were significantly lower for the mesial and distal sites. A trend toward decreased Gingi-val Index and Plaque Index values (P = .083 and P = .096, respective-ly) was obtained postoperatively. The decrease in probing, bleeding, plaque, and gingival inflammation was not a surprising finding after periodontal treatment.

Papillary fill and recession outcomes

Gingival recession decreased (P < .0001) and Papilla Index increased (P < .0001) significantly from pre- to postsurgical evaluations. This indicates a significant improvement

in the papillary fill postoperatively, along with coronal advancement of the flap at sites of recession. The width of keratinized tissue also presented significantly decreased postoperative values (P = .038), which indicates that the mucogin-gival junction was advanced coro-nally from the facial to the palatal or lingual aspect.

There was also a general trend toward a decrease in pocket depth after the surgical procedure for the three sites (facial, distal, and me-sial), of which only the facial site presented significantly lower mea-surements after the surgical proce-dure (P = .0053). This may indicate soft tissue attachment to the root surface consistent with the coronal advancement and decreased reces-sion found postoperatively. Clinical results of the methods outlined previously are presented in Fig 8. This outcome indicates a typical re-sult, with a modest improvement in interpapillary fill after 5 months of healing.

Fig 7a Schematic representation of the technique. Initial incision for access to the papilla included a vertical releasing incision extending apically from the mucogingival junction with facial and palatal intrasulcular releasing incisions.

Fig 7b Internal release of the periosteum and attachment of the papilla to the under-lying osseous crest.

Fig 7c Placement of the micronized der-mal graft in the space created to support the papilla.



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A graphic representation of Papilla Index values is presented in Fig 9. These results showed that there was an overall increase in Papilla Index values from pre- to postoperative evaluations. It should be noted that because of the small sample size and distribution, the chi-square test may not have been a valid assumption. Therefore, a symmetry evaluation was per-formed on the data for scores 0 to 4. Pretreatment bars show a more bell-shaped curve for the Papilla Index evaluation, and posttreat-ment bars illustrate a left-skewed curve (higher scores). The distri-bution of the change observed in Papilla Index values for the individ-ual sites based on initial Papilla In-dex scores is presented in Table 1.

For example, of the 19 pretreat-ment sites with a Papilla Index score of 2, 11 sites (57.9%) improved to a Papilla Index score of 3, while 8 sites (42.1%) did not change.

The symmetry evaluations in-dicated that Papilla Index values were not symmetric from pre- to postoperative evaluations. The null hypothesis was that symmetry would be present after the surgical procedure (kappa and weighted kappa values equal to 0). These results further evidenced a posi-tive shift (increase in Papilla Index score) after the surgical procedure compared to preoperative evalua-tions, with positive kappa (0.183) and weighted kappa (0.364) values.

Fig 8 Clinical photograph at the 5-month follow-up illustrating a slightly incomplete yet clinically improved change in papillary volume. Compare to Fig 1.

Fig 9 Pre- and postoperative frequency histograms of Papilla Index scores. In general, there was a shift in Papilla Index scores up one category. For example, score 1 became score 2 and score 2 became score 3. It was rare to see a jump from score 1 to 3.

20

15

10

5

0

No.

of t

eeth

0 1 2 3Papilla Index score

Preoperative

Postoperative



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In an attempt to investigate the influence of presurgical bone-tocontact point distance, reces-sion, width of keratinized tissue, and pocket depth (buccal, mesial, and distal) on bleeding on prob-ing (buccal, mesial, and distal) and Gingival Index, Plaque Index, and Papilla Index scores, correlation analyses were performed. Evalua-tion of statistical data indicated that the correlation procedure showed no statistically significant effects. The lack of correlation should not be interpreted as these parameters being clinically significant variables, but only indicates that within the small population studied, no statis-tically meaningful clinical variables could be identified as influencing the outcome of the procedure.

Discussion

A new approach to reconstructing interdental papillae between teeth in the buccal area using micronized acellular dermal allograft has been presented. The surgical approach was used in a total of 12 patients and 38 sites. After surgery, patients were followed postoperatively for 5 months. All wounds healed by primary intention, and there was no evidence of graft exfoliation or infection. Soft tissue swelling result-ing from the inflammation process was usually found after surgical in-terventions. At the end of the study, the papillae did not pre sent any clinical signs or symptoms of in-flammation; therefore, misinterpre-tation of increased papilla volume

Table 1 Frequency distribution of pre- and postoperative Papilla Index scores

Postoperative

Preoperative Score 0 Score 1 Score 2 Score 3

Papilla Index n % n % n % n % n %

Score 0 3 7.9 2 66.7 1 33.3 0 0.0 0 0.0

Score 1 16 42.1 0 0.0 4 25.0 10 62.5 2 12.5

Score 2 19 50.0 0 0.0 0 0.0 8 42.1 11 57.9

Total 38 100.0 2 5.3 5 13.2 18 47.4 13 34.0



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because of inflammation was un-likely. The 5-month results in all sites presented normal pyramid-shaped interdental papillae with healthy gingiva.

Keratinized tissue width de-creased after the surgical proce-dures. This finding was statistically significant and most likely the result of flap rotation to the palatal or lin-gual surface with coronal advance-ment of the papillae. The clinical significance of the decreased band of keratinized tissue may not be critical in patients with an adequate band of tissue, as long as it does not interfere with oral hygiene pro-cedures.2731

The technique described for interdental papillary reconstruc-tion also impacted buccal reces-sion, since most recession defects were covered in the majority of sites. Again, this was a result of the surgical technique in which the papillae were advanced coro-nally. Along with the papillae, fa-cial flaps were advanced coronally over areas of recession. Facial flaps were released beyond the muco-gingival line, allowing them to be moved coronally without tension. The papillae were then released from the bone. Micronized acel-lular dermal allograft was inserted into the dead space and was completely covered by the buccal flap and the papillae, moving the entire gingivopapillary complex in-cisally and keeping it stabilized in a coronal position during the first period of healing. Atraumatic man-agement of tissues, maintenance of the blood supply, and avoidance

of tension and pressure were criti-cal for success of the procedure. This flap design maximized soft tis-sue vascularity and primary wound closure. Given the outcomes for recession, further investigations are desirable to evaluate the effective-ness of this surgical procedure for mild recession defect coverage. In addition, a surgical approach with-out a vertical access incision could be contemplated as a further re-finement to maintain blood supply.

Distance from the bone crest to the contact point is positively related to the presence of an in-terdental papilla. Tarnow et al1 observed that only 56% of cases showed complete development of a papilla adjacent to natural teeth when a contact point was 6 mm from the osseous crest. As the dis-tance increases to 7 mm or more, a complete papilla is present only 27% of the time or less. In the pres-ent study, the distance between the contact point and bone level at the adjacent teeth was greater than 5 mm at all sites, and only soft tissue was augmented through the surgical procedures. Therefore, the long-term stability of the primar-ily achieved regeneration results and maintenance of the papillae over the 5-month interval may not be guaranteed. Gingival papillary regeneration may be a result of creeping attachment of the tissue graft.32,33 The present data support the concept of the relationship be-tween papillary level and the dis-tance from the contact point to the bone crest. It seems reasonable to confirm the impact of the distance



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from the bone crest to the contact point to predictably determine the presence or absence of papillae.

The presented surgical tech-nique using micronized acellular dermal graft produced an overall increase in the interproximal pap-illary height. However, not all pa-pillae attained better results with micronized acellular dermal al-lograft. The authors have postulat-ed that there is a dynamic process of graft dispersion, invasion, re-sorption, and stabilization that oc-curs after graft material injection. A technique using culture-expanded autologous fibroblast injections in combination with a surgical prim-ing procedure has been shown to be safe.34 Although the increase in volume of the papilla was statisti-cally significant at 2 months, this was not the case after 4 months. The use of an allograft matrix may provide a greater amount of di-mensional stability over time.

Despite the overall good sta-tistical results achieved in the pres-ent study, a control group was not included and would be challenging but desirable in future investiga-tions. The same operator carried out procedures and measurements, avoiding future bias. Further re-search is indicated to determine the impact of other variables such as mesiodistal distance between teeth, embrasure space, and the surgical protocol on postsurgical Papilla Index values.

Conclusions

Reconstruction of lost or collapsed interdental papillae is a real chal-lenge in modern esthetic dentistry. Based on the results and esthetic success obtained, regeneration of interdental papillae using this sur-gical technique with micronized acellular dermal allograft seems promising. The clinical results were stable for the evaluation period (5 months), and the esthetic results satisfied both clinician and patient expectations. The area continued to remain cleansable and free of inflammation. This procedure is relatively easy to perform and of-fers a potentially reliable solution to an esthetic problem. However, larger clinical and histologic follow-up studies are necessary before its long-term predictability can be es-tablished.

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