GAP Australasian Dentist Sept Oct 2020

Category 78 Australasian Dentist guidelines to follow, such as adjusting the position of the contact area relative to the crestal bone, to reduce the chance of papilla deficiencies and “Black Triangles” being left at the completion of restorative treatment. However despite this knowledge and while various surgical, orthodontic and restorative techniques exist, the maintenance of an interdental papilla and reconstruction once it is lost, remains one of the most challenging and least predictable problems in modern dentistry. The basic idea of intra-oral application of HA for interdental papilla regeneration is based on the concept that using stabilised, cross-linked HA, like that used extraorally for aesthetic defects in skin tissue, could provide a physical structure to the tissue that was otherwise lacking, acting as a structural support for reconstruction. Various techniques have been proposed and this report outlines a new clinical approach, refined by AADFA, called the “Pyramid Technique”. In 1991, Sobocki examined dental gingival dimensions and realized that vertical height can be accomplished if there is sufficient width of the Attached Gingiva. In line with this principle, the “Pyramid Technique” aims to create a “wide” base to provide the opportunity for the papilla to regenerate on its own. Cross-linked HA is used for the injection in the region of the connective tissue attachment in order to achieve responsive papilla height by increasing basal width. This technique has been shown to provide greater longevity within the gingival tissues compared to other approaches. In modern aesthetic dentistry a few millimetres mean the difference between success and failure of the “pink aesthetics” in the highly sensitive aesthetic zone. Despite diverse periodontal, surgical and orthodontic treatment options, the gain of those few millimetres can be extremely difficult and unpredictable. HA can provide modern practitioners with an ace up their sleeves! Long-term success and stability is always the goal of dental practice, yet these materials are temporary and will resorb over time. However, a life span of 18 months is now being achieved in most cases and addition to improving aesthetics in such cases, HA also stabilises gingival health. In this way, although the material resorbs and the defect will return if further enhancement is not delivered, the condition will never return to the original defect size and further tissue deterioration is not observed. On a histological level, we can see why this happens. Following injection of crosslinked HA into inflamed periodontal tissues around tooth 48, Fig 3 shows the tissue 1 year later around the injection site. We can see the particles of HA, a high concentration of fibroblasts and a connective tissue free from inflammation. Comparatively, Fig 4 shows the area 1 cm distal to the site of HA injection, which continues to display destructive inflammatory changes. The pyramid application of HA makes it possible for any dentist in daily practice to easily and safely improve aesthetically compromised cases. It is interesting to note that HA is now being mixed with harvested mesenchymal stem cells and platelet rich plasma by various researchers and it is anticipated that such therapy will lead to even better longevity in the future. To Learn More about the treatment of “Black Triangles” using HA Filler, be sure to attend AADFA’s “FUNDAMENTAL” module. Now you can undergo training from the comfort of your own home and clinic with AADFA’s exciting new online blended learning platform and in-house practical training. Don’t get left behind! u Visit www.AADFA.net to FIND OUT MORE! Step 1. Creation of a wide platform/ base from which to build, via multiple injections of cross-linked HA into the non-attached gingiva Step 2. Volumizing the attached gingiva Step 3. Intra-papillary injection 2-3mm below the highest point of the papilla to stabilse the papilla itself Finished result THE PYRAMID TECHNIQUE Figure 3. Creating a wide base results in papilla height Figure 4. This shows the area 1cm distal to the site of HA injection, which continues to display destructive inflammatory changes. Case 1 Left: Defect left after previous periodontal surgery between the right central and lateral incisors. Right: 25 months after initial injection with HA and will resorb over time. Case 2 Left: Defect following resolution of periodontitis Right: 18 months after injection with HA AS SEEN ON: clinical