|Year : 2010 | Volume
| Issue : 2 | Page : 86-91
A novel tissue engineering technique for regeneration of lost interdental papillary height
Rutuj Surana1, Vaishali Ashtaputre1, Satish Doiphode1, Kiran Kharat2, Purshottam Rakhewar1, Maya Mhaske1
1 Department of Periodontics, C.S.M.S.S Dental College, Aurangabad, India
2 Department of Biotechnology, Deogiri College, Aurangabad, India
|Date of Web Publication||20-Apr-2012|
Duplex No. 6, Raheja Residency, Opp. Gajanan Gas, Salisbury Park, Pune - 411 037
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Open interdental spaces caused by papillary gingival recession are one of the most common problems faced in dentistry. Surgical and nonsurgical periodontal treatments for regeneration of lost papillary height have been reported with limited success. The present study reports effectiveness of autologous cultured fibroblast injections, a tissue engineering technique for papillary regeneration. A black triangle caused by Tarnow's and Nordland's class I papillary gingival loss was reported in maxillary anterior region of a young male patient. An autologous gingival biopsy was cultured in a biotechnology lab for the growth and expansion of fibroblasts. Cultured fibroblast suspension was injected into the receded papilla twice at an interval of 5 days. Follow-ups were recorded on the 6th day, 15 th day, at 1 month and at 2 months. Complete fill of black triangle was noted at the end of 2 months. No inflammatory or immune reactions were noted at the site of injection. Autologous cultured fibroblast injections are safe, efficacious, and an acceptable treatment option for the regeneration of lost papillary height.
Keywords: Autologous, cultured, regeneration
|How to cite this article:|
Surana R, Ashtaputre V, Doiphode S, Kharat K, Rakhewar P, Mhaske M. A novel tissue engineering technique for regeneration of lost interdental papillary height. J Int Clin Dent Res Organ 2010;2:86-91
|How to cite this URL:|
Surana R, Ashtaputre V, Doiphode S, Kharat K, Rakhewar P, Mhaske M. A novel tissue engineering technique for regeneration of lost interdental papillary height. J Int Clin Dent Res Organ [serial online] 2010 [cited 2020 Jan 23];2:86-91. Available from: http://www.jicdro.org/text.asp?2010/2/2/86/95273
| Introduction|| |
Open interdental spaces (OIS) caused by papillary gingival recession are one of the most common problems faced in dentistry. Causes include divergent roots, diastema, abnormal crown form, loss of gingival or periodontal structures. OIS usually cause esthetic and phonetic problems, food impaction etc. , In periodontics various surgical and nonsurgical treatment options have been tried for papillary regeneration. ,,,,, Surgical approaches include various flap designs and grafting techniques to augment hard or soft tissues. Limited blood supply and accesses to plaque in this region increase the chances of failure of surgical techniques.  Also most of the surgical techniques provide no evidence of predictability and long-term stability.
Tissue engineering techniques are being worked on in almost all medical departments for the sole purpose of regeneration. The basic ingredients for successful tissue regeneration include components of the tissue engineering triad, which include the cells which will create a new tissue, the scaffold (collagen, bone, mineral etc.) which will hold the cells in place and signals (growth factors, morphogens) which will instruct the cells to form the tissue of desired type  [Figure 1].
Autologous cultured fibroblasts have been used successfully in dermatology for soft tissue augmentation in the treatment of acne and scars. , In a previous study McGuire MK has reported safety and efficacy in periodontal applications of human Fibroblast-derived dermal substitute in comparison to gingival autograft.  Yamada et al. has reported that cultured gingival fibroblast seeded onto type I or III collagen sponge may provide a new tool for treatment of gingival recession. 
Studies have demonstrated that the gingival fibroblast has considerable phenotypic heterogeneity and theoretically could contribute to periodontal regeneration by providing a source of undifferentiated mesenchymal cells, which under appropriate stimulation, could differentiate toward fibroblastic, cementoblastic, and osteoblastic phenotypes. ,
Here a case in which tissue engineered fibroblast cells have been used for the purpose of regeneration on lost interdental papillary height.
| Case Report|| |
A 24-year-old male reported to the Postgraduate Department of Periodontology, C.S.M.S.S. Dental College, Aurangabad, with the complaint of an unesthetic black triangle between maxillary left central and lateral incisor [Figure 2]. He also complained of food lodgment in the same region.
|Figure 2: Baseline photograph - class I Tarnow's papillary recession seen between the left central and lateral incisors|
Click here to view
On examination Tarnow's class I papillary recession was noted between 21 and 22.  On the first day the patient underwent oral prophylaxis and a pair of alginate impressions were recorded. An acrylic stent was prepared over the incisal edges of 21 and 22 for standardization of measurements. The distance between the tip of papilla (P) and a fixed point on the stent (S) PS 1 was measured to be 5 mm with William's graduated probe at baseline [Figure 3].
|Figure 3: Baseline photograph. Distance between the tip of the papilla (P) to a fixed point on the stent (S) PS1 measured with a William's graduated probe - 5 mm|
Click here to view
Tissue culture procedure
One week after the initial visit 3 mm gingival punch biopsy was taken from the attached gingiva between 26 and 27. The tissue was placed in a sterile vial containing sterile phosphate-buffered saline and immediately transferred to the laboratory $ . Tissue was cultured for the growth of fibroblasts in Dulbecco's modified Eagle's medium (DMEM) incubated at 37° C in an atmosphere of 10% CO 2 . ,
After the growth of a sufficient number of cells seen under the phase-contrast microscope [Figure 4] and counting them on a hemocytometer (≥10 6 cells/ml), cells from the medium were removed and washed by centrifugation and a cell suspension was created [Figure 5]. The growth of a sufficient number of cells required 5 days.
|Figure 5: Fibroblast cell suspension seen under the phase contrast microscope|
Click here to view
Papilla priming procedure
On the day of gingival biopsy the receded papilla received a controlled surgical insult to induce inflammation into the papilla so that its volume increases and higher quantities of cell suspension could be injected into the selected papilla. 
Cell transplantation injections
The cell suspension created was transferred to the clinic in a glass vial containing sterile phosphate buffered saline. On the fifth day after PPP or after gingival biopsy culture, 0.3-0.4 ml of the suspension was injected into the selected papilla from the labial side with a syringe attached with a 30-gauge needle. The second set of injections was given in a similar manner into the palatal side of the papilla on the 10 th day after PPP or gingival biopsy. Excessive pressure during injection was avoided as it carries a risk of tissue ischemia.
| Results|| |
Subsequent clinical measurements were recorded on the 15 th day, 1 month and 2 months after the first set of injections. At baseline the distance between the tip of the papilla and the fixed point on the stent PS 1 was 5 mm. On the 15th day of the first set of injections the distance (PS 2 ) reduced to 4.5 mm [Figure 6]. At 1 month after the first injection the distance (PS 3 ) further reduced to 3.5 mm [Figure 7]. Finally complete fill of the black triangle, i.e., growth of the papilla till the base of the contact point was seen at the end of 8 weeks [Figure 8]. The distance at the end of 8 weeks/at 2 months from the fixed point on the stent to the tip of the papilla (PS 3 ) was measured to be 3 mm. [Table 1].
|Figure 6: At the end of 15 days the distance between the tip of the papilla (P) to a fixed point on the stent (S) PS2 - 4.5 mm|
Click here to view
|Figure 7: At the end of 1 month the distance between the tip of the papilla (P) to a fixed point on the stent (S) PS2 - 3.5 mm|
Click here to view
|Figure 8: Complete fill of the black triangle seen at the end of 2 months. PS3 - 3 mm|
Click here to view
|Table 1: Distance between the tip of papilla (P) to a fixed point on the stent (S)|
Click here to view
At the end of 8 weeks a 2 mm gain in the papillary gingival height was achieved through two subsequent injections of a suspension of autologous cultured and expanded fibroblasts. This gain completely filled the black triangle.
| Discussion|| |
Studies suggest that traditional surgical techniques for papilla regeneration require multiple repetitions to obtain optimal results, which tend to cause patient incompliance and inconvenience. ,, Also these techniques report to be technique sensitive and cost the patient with respect to time and money. In contrast the autologous fibroblast injection technique requires negligible surgical innervations for initial tissue harvest and provides long-term results without the need for additional harvest. The technique presented above is relatively painless. Fibroblasts extracted from the gingival biopsy were reimplanted by injections back into the receded papilla to expand the papillary tissue by the production of the patient's own collagen fibers.
Boss et al. evaluated the efficacy of autologous cultured fibroblasts effectively in plastic surgery to correct rhytids, acne, and scars.  The concept is to restore the population of fibroblasts that is reduced as a result of aging, photodamage or scarring. The idea to repopulate a specific area with cells to reproduce a specific function has been used with success in areas of myocardial infarction, where myoblastic cells are reintroduced in areas of infarction to restore the contractile function of heart. Clark et al. have evaluated the safety of dermal fillers injected for soft tissue augmentation.  Other autologous Injectable materials include suspension of intact of intact autologous collagen fibers derived from the patient's dermal layer. 
The primary objective of this case report was to evaluate the efficacy of cultured autologous fibroblast injections for regeneration of lost gingival tissues. McGuire et al through a controlled clinical trial proved that human fibroblast-derived dermal substitute was safe and capable of generating gingival keratinized tissue in areas of recession in almost a similar quantity to that of gingival autograft.  Jhaveri et al. in a case series quoted that acellular dermal matrix allograft seeded with autologous gingival fibroblasts by tissue-engineering technology may be explored as a substitute to a subgingival connective tissue graft for the treatment of Miller class I and II recession defects.  Yamada et al. concluded that cultured gingival fibroblast seeded onto type I or III collagen sponge may provide a new tool for treatment of gingival recession. 
Any clinician who administers local anesthesia encounters difficulty in inserting much volume into the papilla because of its dense and tightly bound connective tissue, so even injection of an adequate volume of cell suspension to reach therapeutic concentration into the papilla is difficult. Practitioners also know that surgically manipulated papilla are swollen 7-10 days postoperatively and gradually return to preoperative dimensions by 1 month.  Insertion of optimum amount of cell suspension could be capitalized on this edematous increase in tissue volume. This concept lays the basis for the papilla priming procedure.
In the above phase complete fill of the black triangle by regeneration of papilla was seen at the end of 2 months. The regeneration effect on the papilla became obvious at around 15 days after the first fibroblast injection. If this effect is not seen a third injection of the cell suspension may be tried 7-8 days after the second injection. Reports are present suggesting that the regenerated papilla tend reaching their original position 6-7 months following the initial treatment. , Further follow-up in needed to evaluate the long-term results.
| Conclusion|| |
Autologous cultured fibroblast injections are an efficient and safe treatment option for regeneration of lost interdental papillary height. This technique is better acceptable by patients and complications associated with surgical techniques to regenerate interdental papilla are avoided. The cultured substitute is immune stable but inflammatory response may be seen.
| References|| |
|1.||McGuire MK. Periodontal plastic surgery. Dent Clin North Am 1998;42:411-65. |
|2.||Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol 2000 1996;11:65-8. |
|3.||Blatz MB, Hurzeler MB, Strub JR. Reconstruction of the lost interproximal papilla - Presentation of surgical and non-surgical approaches. Int J Periodontics Restorative Dent 1999;19:395-406. |
|4.||Zachrisson BU. Interdental papilla reconstruction in adult orthodontics. World J Orthod 2004;5:67-73. |
|5.||Cardaropoli D, Re S, Corrente G, Abundo R. Reconstruction of the maxillary midline papilla following a combined orthodontic-periodontic treatment in adult periodontal patients. J Clin Periodontol 2004;31:79-84. |
|6.||Shapiro A. Regeneration of interdental papilla using periodic curettage. Int J Periodontics Restorative Dent 1985;5:26-33. |
|7.||Azzi R, Etienne D, Carranza F. Surgical reconstruction of the interdental papilla. Int J Periodontics Restorative Dent 1998;18:466-73. |
|8.||Azzi R, Takei HH, Etienne D, Carranza F. Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts. Int J Periodontics Restorative Dent 2001;21:141-7. |
|9.||Lanza RP, Langer L. Text book from Lanza and Langer, tissue engineering and transplant medicine. 2 nd ed. Worcester Massachusetts. |
|10.|| West TB, Alster TS. Autologous human collagen and dermal fibroblasts for soft tissue augmentation. Dermatol Surg 1998;24:510-2. |
|11.||Watson D, Keller GS, Lacombe V. Autologous fibroblasts for treatment of facial rhytids and dermal depressions. Arch Facial Plast Surg 1999;1:165-70. |
|12.||McGuire, Martha E. Evaluation of safety and efficacy of periodontal applications of a living human fibroblast derived dermal substitute. J Periodontol 2005;76:867-80. |
|13.||Yamada K, Yamaura J, Katoh M, Hata K, Okuda K, Yoshie H. Fabrication of cultured oral gingiva by tissue engineering techniques without materials of amimal origin. J Periodontol 2006;77:672-7. |
|14.||McCullouch CA, Bordin S. Role of fibroblasts in subpopulations in periodontal physiology and pathology. J Periodontal Res 1991;26:144-54. |
|15.||Otsuka K, Pitaru S, Overall CM, Aubin JE, Sodek J. Biochemical comparison of fibroblast populations from different periodontal tissues: Characterization of matrix protein and collagenolytic enzyme synthesis. Biochem Cell Biol 1988;66:167-76. |
|16.||Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 1998;69:1124-6. |
|17.||Melcher AH. Healing of wounds in the periodontium. In: Melcher HA, Bowen WH, editors. Biology of the Periodontium. London: Academic Press; 1969. p. 497-529. |
|18.||Clark DP, Hanke CW, Swanson NA. Dermal implants: Safety of products injected for soft tissue augmentation. J Am Acad Dermatol 1989;21:992-8. |
|19.||DeVore DP, Kelman CD, Fagien S, Casion P. Autologen: autologous, injectable dermal collagen. In: Bosnick S, ed. Principles and Practices of Ophthalmic Plastic and Reconstructive Surgery. Philadelphia: W.B. Saunders; 1996. p. 670-5. |
|20.||Jhaveri HM, Chavan MS, Tomar GB, Deshmukh VL, Wani MR, Miller PD Jr. Acellular Dermal Matrix Seeded With Autologous Gingival Fibroblasts for the Treatment of Gingival Recession: A Proof-of-Concept Study. J Periodontol 2010;81:616-25. |
|21.||Clark RA. Wound repair. Overview and general considerations. In: Clark RA, ediotr. The Molecular and Cellular Biology of Wound Repair. 2 nd ed. New York: Plenum Press; 1996. p.3-50. |
|22.||McGuire MK, Scheyer ET. A Randomized, Double-Blind, Placebo-Controlled Study to Determine the Safety and Efficacy of Cultured and Expanded Autologous Fibroblast Injections for the Treatment of Interdental Papillary Insufficiency Associated With the Papilla Priming Procedure. J Periodontol 2007;78:4-17. |
|23.||Boss WK, Usal H, Fodor PB, Chernoff G. Autologous cultured fibroblasts. A protein repair system. Ann Plast Surg 2000;44:536-42. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]