The association between radiographic embrasure morphology and interdental papilla reconstruction using injectable hyaluronic acid gel

Histologic Evaluation of Early Papilla Healing after Augmentation with Injectable Hyaluronic Acid-A Proof of Concept

Objectives: This human histological study's purpose was to histologically evaluate papillae's healing after hyaluronic acid (HA) gel augmentation at three healing time points after one injection with hyaDENT BG®. Methods: Fifteen papillae from two patients with stage III, grade B periodontitis have been selected for this study. Every week for three weeks, five papillae were injected once with HA gel, and during the fourth week, the papillae were surgically removed as part of step 3 of the periodontal treatment. The histological analysis was performed on fifteen papillae, with five papillae corresponding to every timepoint of healing (weeks 1, 2, and 3). The primary outcome was considered to be the newly formed collagen fibers. The presence of residual HA, the integrity of epithelium or the presence of erosions/ulcerations, the presence and characteristics of inflammatory infiltrate, the presence of granulomatous reactions, and interstitial edema were considered to be secondary outcomes. Results: From the first to the third week, newly formed connective tissue begins to appear, while the observed HA pools (vesicles) content decreases. The density of inflammatory infiltrate was higher in the first week after injection, decreasing considerably by week 3; however, it was still visible throughout the healing time points. A granulomatous reaction was present in only three samples, while no signs of ulceration or necrosis could be observed; however, epithelial erosions could be observed on some samples after the first week. Conclusions: Papila augmentation with hyaluronic acid promotes new collagen formation from the second week of healing despite some foreign body granulomatous reactions.

Evaluation of Interdental Papilla Regeneration Using Injectable Hyaluronic Acid: A Clinical Study

AIM

This study aimed to assess the efficacy of hyaluronic acid (HA) gel injections in deficient papillae and record the effects for four weeks.

MATERIALS AND METHODS

Fifteen deficient class 1 papilla sites according to Nordland and Tarnow classification were included. After scaling and root planing, 0.5 ml HA gel was injected into the papillae. Measurements of black triangle height (BTH) and black triangle area (BTA) from the contact point to the most coronal level of the visible papilla tip were done on the clinical photographs using ImageJ software at baseline, one week, and four weeks postoperatively, and a comparison was made. Descriptive data were examined using the mean and standard deviation (SD). Paired t-test was used for intragroup comparisons, with p-values <0.05 considered significant. All the data analysis was done using SPSS software version 25.0.

RESULTS

There was a mean decrease in the BTA from baseline (0.54 mm2), one week (0.13 mm2), to four weeks (0.26 mm2) with a slight loss of papilla volume from the first week to the fourthweek, and this decrease in area was statistically significant. A mean decrease in the BTH throughout the follow-ups from baseline (1.36 mm) to the first week (0.30 mm) to the fourth week (0.73) was recorded with a slight loss of papilla volume from the first week to the fourthweek, and this decrease in height was also statistically significant (p < 0.05). However, the decrease in the BTA and BTH recorded was more from baseline to the first week as compared to baseline to the fourth week postoperatively.

CONCLUSION

HA gel is an effective treatment for minimally invasive papilla augmentation, particularly in class I Nordland and Tarnow papilla deficits.

The use of hyaluronic acid injection for treatment of black triangle and reconstruction of lost interdental papilla in anterior teeth: a systematic review

OBJECTIVE

Non-surgical therapeutics to reconstruct lost interdental papilla are evolving; these include hyaluronic acid injection. The aim of this systematic review is to evaluate the efficacy, safety, and long-term outcomes of hyaluronic acid injection in the treatment of black triangles and reconstruction of lost interdental papilla in anterior teeth.

MATERIALS AND METHODS

The protocol was registered in PROSPERO (CRD42023446875) and in accordance with the Cochrane Handbook of Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 'PRISMA'. The search involved four databases, PubMed/MEDLINE, The Cochrane Library, Google Scholar, and ProQuest for ''grey literature' with additional manual search for studies published up to May 2024. Human clinical studies of a prospective nature (randomised clinical trials and prospective cohort studies) were included. Exclusion criteria were case reports, case series, review articles, letter to editor, personal opinion, and animal studies. Furthermore, studies which utilised hyaluronic acid injection in conjunction with other therapeutic material, tissue graft, or any surgical procedure were also excluded. The data were extracted independently by the two authors and incorporated after consensus. The risk of bias was assessed using the RoB2: the revised Cochrane risk of bias tool for randomised clinical trials and the Newcastle Ottawa scale for prospective cohort studies.

RESULTS

24 studies, 15 prospective clinical studies and nine randomised clinical trials, were included with a total of 898 interdental papillae injected with hyaluronic acid. The studies showed promising outcomes in the reconstruction of lost interdental papilla with minimal adverse reactions. Risk of bias assessment among prospective clinical studies revealed 13 good quality studies with only two poor studies while the randomised clinical trials consisted of three with low, one with some concern, and five studies with high risk of bias. However, due to the high heterogeneity, a meta-analysis was not feasible.  Conclusion: Hyaluronic acid injection is an effective minimally invasive approach in treating black triangles and reconstructing lost interdental papilla in the anterior teeth. Further long-term well-designed randomised clinical trials employing standardised procedures are essential to validate this treatment and provide better quality of evidence.

Interdental papilla reconstruction: a systematic review

OBJECTIVES

To assess treatment options for the reconstruction of the lost interdental papilla and to evaluate evidence for their efficacy.

METHODS

An electronic search (Medline, Embase and the Cochrane Library Database and OpenGray) and a hand search were carried out to identify all types of studies investigating interdental papilla reconstruction (except for reviews) with a minimum of 3 months follow-up.

RESULTS

Forty-five studies were included in the study including 7 RCTs, 2 cohort studies, 19 case series and 17 case reports. Fifteen studies reported on the use of hyaluronic acid, 6 studies on platelet-rich fibrin, 16 studies on soft tissue grafting, 4 studies on orthodontics and 4 on additional modalities. The most common outcome measures were black triangle dimensions and papillary fill percentage. Meta-analysis was not possible due to the high heterogeneity of the studies.

CONCLUSION

There are various options for interdental papilla reconstruction of which hyaluronic acid injections, PRF, surgical grafting and orthodontics seem to improve outcomes at a minimum 3 months. The use of soft tissue grafting with sub-epithelial connective tissue graft seems to be associated with the most robust evidence for the longer-term reduction of 'black triangles'. There is insufficient evidence to make recommendations to clinicians. Further research is needed in the form of well conducted RCTs with longer follow ups and patient reported outcome measures.

CLINICAL RELEVANCE

Patients frequently complain about the appearance of black triangles and their management options seem unclear. This systematic review provides insight into the available reconstructive options.

Application of Hyaluronic Acid for Treatment of Interdental Papillary Deficiency: A Systematic Review and Meta-Analysis

Objectives: The focused question of this systematic review was "does hyaluronic acid (HA) injection in areas of interdental papillary deficiency reduce black triangles?" Materials and Methods: A systematic literature search was performed to find clinical studies on human patients with a minimum of 6-month follow-up, published in English from 2005 to May 2020. There were two outcome variables: black triangle area (BTA) change after treatment at different measurement time points compared with baseline, and patient reported outcome measures (PROMs), when available. Results: Of eight eligible articles (2 randomized clinical trials (RCTs) and 6 non-randomized, non-placebo controlled clinical studies), seven reported that HA injections had a positive impact on reduction of BTA and subsequent papillary augmentation. Six studies were included in meta-analysis and showed that the intervention led to a pooled reduction percentage of 57.7% in BTA after 6 months. Although there were clinical diversities between the studies, all the studies applied the same concentration of HA (approximately 2%), 2-3 mm apical to the papilla tip in several intervals. Some degrees of relapse were reported in some studies. Conclusion: Within the limits of this study, this systematic review and meta-analysis showed that HA injection can serve as an efficient minimally-invasive treatment for small interdental papillary deficiencies. It is essential to conduct further randomized clinical studies with prolonged follow-ups in order to support this conclusion.

Effectiveness of Hyaluronic Acid Gel Injection with and without PRGF for Management of Interdental Papillary Loss: A Randomized Clinical Trial

BACKGROUND

To evaluate the effectiveness of hyaluronic acid (HA) gel injection with and without plasma rich in growth factors (PRGF) for the management of interdental papillary loss.

METHODS

A single blinded randomized clinical trial was carried out on 21 subjects with 34 sites. Patients within the age group 18-45 years who had Class I and II papillary recession in the maxillary anterior region were selected. The sites involved were randomly assigned to Group HA alone and Group HA + PRGF. The patients were recalled 4 weeks after receiving supragingival and subgingival instrumentation. HA or HA + PRGF was injected into the defective papilla at baseline and at 3 and 6 weeks. Image based measurements of Papillary Width (PW), Papillary Deficient Height (PDH), Deficient Area (DA), Deficient Volume (DV) were registered at baseline, 3 weeks, 6 weeks and 12 weeks. A vernier caliper was used to measure the papillary depth in the impression made using additional silicone impression material pre- and post-intervention.

RESULTS

There was a significant improvement in the within-group comparison of PW, PDH, DA and DV in both the groups. Group HA + PRGF showed significantly greater improvement in comparison to Group HA alone in terms of PDH, DA and DV at 6 and 12 weeks.

CONCLUSIONS

Even though HA gel has already been established as a promising injectable agent in the minimally invasive treatment of interdental papillary deficiency, PRGF may also have a significant adjuvant effect when used along with HA. Further clinical studies with longer follow up duration, larger sample size and standardization of the tooth shape are required for a better understanding of the adjuvant effect of PRGF when used along with HA.

Papillary Reconstruction using Hyaluronic Acid: A Review

PURPOSE

The aim of this review is to analyse the use of hyaluronic acid injection in the interdental space to reconstruct the papilla in animal models and humans.

MATERIALS AND METHODS

Electronic databases were searched up to May 2022, and additional hand searching was performed. The search strategy was implemented according to the PRISMA guidelines. The inclusion criteria were: studies written in English, studies using hyaluronic acid, in vivo studies, studies with a precise number of specimens, case series with ≥6 patients, and studies published after 2010. The risk of bias was assessed for each study that could be evaluated.

RESULTS

A total of 19 articles were selected and reviewed in this review. Due to the great heterogeneity of the protocols and materials, comparison between studies was not possible. However, using this technique, the studies found statistically significant improvements in most cases. The filling percentages ranged from 19% to 100%. Regarding patient satisfaction, the few studies that evaluated this parameter found statistically significant results with most patients willing to repeat the experience. Regarding side effects, only two studies reported them. Moreover, the procedure does not seem to be very painful.

CONCLUSION

The results suggest that hyaluronic acid injections seem to be effective in reconstructing papillary volume. However, to date, too few clinical trials with a high level of proof have been conducted on this technique. Future studies will have to work on the size of the sample, the concentration of the product, the number of injections and the injection method.

Prosthetic and orthodontic rehabilitation of a patient with severe maxillary central incisor root resorption associated with impacted maxillary canines

OBJECTIVE

This case report describes the orthodontic and prosthetic rehabilitation of a patient with resorption of the roots of the maxillary central incisors due to the ectopic maxillary canines.

CLINICAL CONSIDERATIONS

A 16-year-old woman presented with severe resorption of the roots of the maxillary central incisors due to the ectopic maxillary canines. The impacted canines were orthodontically tracted with a lingual arch-supporting temporary central incisors and vertical elastics, and, undesirable root proximity was later corrected by moving the canines distally 1.5 mm apart. Gingival replacement cords were placed into the gingival sulcus of the canines, and tooth preparation was performed along with rotary gingival curettage of the interdental papilla. Convex form was provided for the mesial and labio-distal subgingival contour of the restorations.

CONCLUSIONS

The creeping attachment of the interdental papilla was successfully achieved by the orthodontic arrangement of interdental distance and the prosthetic stimulus via the retraction cord, rotary curettage, and convex mesial subgingival contours. In addition, selective retraction of the labio-distal gingiva by overcontoured restorations moved the gingival zenith position (GZP) distally. Finally, the canine crown morphology and gingival level mimicked the central incisors.

CLINICAL SIGNIFICANCE

This clinical report introduces a treatment workflow of to recover the esthetic disturbance due to severe root resorption of the maxillary central incisors associated with impacted maxillary canines. The present orthodontic and prosthetic procedure can improve both hard and soft tissue esthetics and could be used in similar cases, such as malformed teeth and tooth autotransplantation or transposition with disturbances in the interdental papilla height or the GZP.

Minimally invasive therapy for reconstruction of lost interdental papilla by using injectable hyaluronic acid filler

Background and Aim:

Reconstruction of interdental papillae (IDP) is among the most difficult periodontal therapy. Papillary recession is multifactorial, and several surgical, nonsurgical, and minimally invasive techniques have been suggested. The purpose of this study was to evaluate the clinical application of injectable hyaluronic acid (HA) gel for the reconstruction of IDP in Nordland and Tarnow's Class I and II papillary recession cases.

Materials and Methods:

In the present in vivo clinical trial, 7 patients (2 males, 5 females) with 25 defects were selected. A volume of 0.2 ml HA gel was injected at the respective areas and massaged for 2–3 min. Photographs were obtained, and the assessment of the data was performed clinically (CP-GM, interproximal width [IPW]) and by Image analysis software (black triangle height [BTH], black triangle width [BTW]). Comparison of mean values was performed using the analysis of variance, followed by Post hoc Bonferroni test. Value of P ≤ 0.05 was considered statistically significant.

Results:

Application of HA gel for the reconstruction of IDP was successful in 6 months. CP-GM, BTH, IPW, and BTW showed a statistically significant difference from baseline to 3 and 6 months interval (P = 0.01). Post hoc Bonferroni test for CP-GM, BTH, BTW, and IPW revealed a statistically significant difference from baseline to 3 months (P ≤ 0.05) and 6 months (P ≤ 0.05) and a nonsignificant difference at 3–6 months (P ≥ 0.05).

Conclusion:

Injectable HA gel is a promising minimally invasive therapy for enhancing papillary esthetics.

Is interdental papilla filling using hyaluronic acid a stable approach to treat black triangles? A systematic review

PURPOSE

To evaluate the stability of interdental papilla filling using hyaluronic acid (HA) to treat black triangles in esthetic regions.

METHODS

The protocol was registered in PROSPERO. Six databases (PubMed, Scopus, Embase, Lilacs, SciELO, and Web of Science) were used as primary search sources, and OpenGrey and OpenThesis were used to capture the "gray literature." Only before-after studies were included. The JBI Checklist assessed the risk of bias. Only four studies met the inclusion criteria and were considered for the analyses. The studies were published from 2010 to 2016. All studies presented a low risk of bias. Considering the studies do not have control groups, a weighted average by sample size was calculated to obtain a general estimate of the percentage of papillary filling after 6 months and the number of HA applications.

RESULTS

The studies showed the percentage of papillary reconstruction after 6 months of application, the weighted average by sample size was 77.41% (SD = 20.68), with an average number of applications of 3.17 (SD = 0.31).

CONCLUSION

The application of HA may be used to repair anesthetic defects in the papilla.

CLINICAL SIGNIFICANCE

Interdental papilla reconstruction with injectable HA is an option of nonsurgical treatment for interdental papilla deficiencies. However, there is still concern about the quality of the evidence available, considering that studies with different experimental designs can produce contradictory results. Moreover, further understanding is required on the stability of tissue gain promoted by HA in black triangles.

Comparative Evaluation of Two Hyaluronic Acid Gel Products for the Treatment of Interdental Papillary Defects

Objectives

The aim was to investigate the efficacy of single injections of two different hyaluronic acid products, Flex Barrier and Revident, in reducing the size of black triangles to treat Nordland-Tarnow Class I and II recessions.

Materials and Methods

Forty adult patients were recruited with at least two upper and two lower interdental papilla defects in the front region between canine teeth. According to the Nordland-Tarnow classification of papillary defects, both Class I and Class II recessions were included in the investigation. Patients were randomly assigned to experimental groups to receive single injections of two different hyaluronic acid products, either Flex Barrier or Revident. The untreated sites served as controls. Photographs were taken before and immediately after the treatment, and again after one week and one month. To determine the size of the black triangles, Image J software was used. For statistical analysis, a mixed-design ANOVA was applied.

Results

Both Flex Barrier and Revident significantly decreased the size of the treated defects immediately after the treatment and also one week later (p<0.001). The beneficial effect of Revident lasted longer than Flex Barrier as it remained significant even after one month in Revident-treated patients, however, not in the Flex Barrier-treated group. Furthermore, Nordland-Tarnow Class I lesions generally showed a greater improvement than Class II lesions.

Conclusion

In this proof-of-concept, randomized clinical trial we have demonstrated the clinical applicability of both Flex Barrier and Revident, although Revident gave longer-lasting improvements than Flex Barrier. Further trials are needed to optimize multiple-application protocols for treating gingival black triangles.

The Use of Botulinum Toxin and Dermal Fillers to Enhance Patients' Perceived Attractiveness: Implications for the Future of Aesthetic Dentistry

Physical appearance and attractiveness consciously and subconsciously, affect patients' quality of life. Traditionally, dentists were tasked with improving a patient's smile, a central aspect of facial aesthetics and physical appearance. More recently, as the scope of practice of the aesthetic dentist has broadened to potentially include other components of facial cosmesis that go hand-in-hand with a patient's smile, new options have emerged with which modern aesthetic dentists should familiarize themselves. As laws surrounding their use in dental offices continue to evolve, Botox and dermal fillers represent natural next steps in aesthetic dentistry.

Treatment of peri-implant soft tissue defects: a narrative review

Soft tissue defects around dental implants, such as papilla or volume loss, peri-implant recession and alterations of the ridge color and/or texture, lead to esthetic and functional complaints. Treatments of these defects in implants are more demanding than in teeth because peri-implant tissue exhibits different anatomical and histological characteristics. This narrative review discusses the proposed treatments for soft tissue defects around implants in the current literature. Several clinical and pre-clinical studies addressed methods to augment the quantity of the peri-implant keratinized mucosa. Autogenous grafts performed better than soft tissue substitutes in the treatment of soft tissue defects, but there is no clinical consensus on the more appropriate donor area for connective tissue grafts. Treatment for facial volume loss, alterations on the mucosa color or texture and shallow peri-implant recessions are more predictable than deep recessions and sites that present loss of papilla. Correction of peri-implant soft tissue defects may be challenging, especially in areas that exhibit larger defects and interproximal loss. Therefore, the regeneration of soft and hard tissues during implant treatment is important to prevent the occurrence of these alterations.

Efficacy Evaluation of Hyaluronic Acid Gel for the Restoration of Gingival Interdental Papilla Defects

PURPOSE

This clinical study aimed to evaluate the long-term efficacy of reconstruction of the gingival interdental papilla via injection of hyaluronic acid gel.

MATERIALS AND METHODS

Eight female participants with Class I or II gingival papilla loss in anterior sites were included in this study. The gingival biotype was evaluated previously. Hyaluronic acid gel was injected into the base of the deficient papilla, which was repeated twice at 3 and 6 weeks after the initial injection. The height of the gingival papilla and the area of papilla loss were examined on clinical photographs before treatment and 3, 6, and 12 months after treatment. The data were tested for a normal distribution and analyzed by the Wilcoxon signed rank test. P < .05 was considered significant.

RESULTS

The height of the gingival papilla increased 0.311, 0.45, and 0.4 mm from baseline at 3, 6, and 12 months, respectively, after treatment (P < .05), whereas the area of the black triangle was reduced by 0.31, 0.41, and 0.36 mm² at the same time points (P < .05). In addition, patients with a thick gingival biotype showed a better effect of treatment on the increase in the height of the gingival papilla and decrease in the area of the black triangle.

CONCLUSIONS

Our study verified a remarkable effect of hyaluronic acid gel injection in restoring the deficient gingival papilla of the natural teeth, especially in patients with a thick gingival biotype.

Esthetic Reconstruction of Diastema with Adhesive Tooth-Colored Restorations and Hyaluronic Acid Fillers

Objective. This report presents a comprehensive esthetic treatment with adhesive tooth-colored restorations in a combination with hyaluronic acid (HA) fillers of diastema in an orthodontic patient with relapse. Case Report. A 36-year-old female patient consulted about 1.5–2 mm midline diastema after an orthodontic relapse of replacing missing central incisors with lateral incisors and dark-colored gingival tissue as a result of a metal post and core with porcelain fused to a metal (PFM) crown at the left lateral incisor. Restorative treatments included replacing the PFM with all-ceramic material and placing a ceramic veneer on the right lateral incisor. To close the space, crown forms of both lateral incisors were altered. A direct resin composite was then used to reform right and left canines to a more ideal lateral incisor shape. An HA fillers injection was used to fill the remaining open gingival embrasure. Eighteen months after treatment, the interdental papilla remained stable and the patient was satisfied with the result. Conclusion. Esthetic reconstruction of diastema and open gingival embrasure in this case can be accomplished without orthodontic retreatment. Tooth-colored restorations and HA filler injection appear as a promising modality to address this patient's esthetic concern.