The connective tissue cube for treatment of papillary deficiencies: A case report

Prevention and treatment of interproximal recessions after periodontal therapy has been challenging and is important because the resulting black triangles are unesthetic. Traditional treatment options include orthodontic, restorative, surgical, and combined approaches. This case report aims to describe an approach using periodontal plastic surgery combined with prosthetic treatment for the management of a papillary deficiency in the esthetic zone.

A healthy, 64-year-old female presented with esthetic concerns related to a black triangle between the maxillary right canine and first premolar as a result of periodontal therapy. A Class III recession defect was present. A de-epithelialized connective tissue graft harvested from the maxillary tuberosity was placed interproximally and combined with a coronally advanced flap and enamel matrix derivative. Following 6 months, the restorative phase was initiated including diagnostic wax-up, direct composite restoration the mesial of the premolar, followed by facial veneer preparation on the canine using an incisal butt joint design. After the provisional phase, a lithium disilicate ceramic veneer was fabricated and cemented with adhesive technique.

Following 18 months of follow-up, we observed a nearly complete closure of the embrasure space.

The successful closure of the interproximal tissue deficiency, as evidenced by this case report, demonstrates the potential of this approach utilizing an interproximal connective tissue graft along with prosthetic treatment to manage significant papillary defects; this report reinforces the role combined prosthodontic and periodontic approaches may have in treatment outcomes.

The connective tissue cube technique showed potential for treatment of severe papillary deficiencies. Combined surgical-restorative approaches might be needed for complete closure of black triangles. Further clinical studies with stronger level of evidence are needed.

This case report discusses a treatment for a common issue after periodontal therapy: black triangles (open gingival embrasures) between teeth that can be unappealing. The patient, a 64-year-old woman, had a black triangle between her maxillary right canine and first premolar due to loss of interproximal periodontal support. The treatment combined surgery (tissue and bone grafting with biologic material) and restorative treatment. After 6 months, dental restorations were complete, with a provisional period prior to definitive restoration to evaluate tissue fill and esthetics. The restorative treatment involved the use of a single veneer and single interproximal composite restoration. Eighteen months postsurgical therapy, the gap was nearly closed and remained stable for an additional 6 months. The report highlights that combining gingival surgery and restorative treatment may effectively treat significant papillary deficiencies.