Hemolasertherapy - A Novel Approach to Reconstruct the Interdental Papilla: A Case Report

Introduction

Interdental papilla (IDP) is the part of gingiva that occupies the gingival embrasure area.¹ Black triangles manifest themselves when there is a loss of interdental papilla.² Complications like cosmetic deformities, phonetics and food lodgment may arise with these black triangles.³ There are several root causes for this condition, like periodontitis, abnormal tooth shape and contour, root angulation, bone height, diastema, etc.⁴ Clinicians have made constant efforts to treat this condition via non-surgical therapies like repeated curettage, restorative techniques, enamel reduction procedure and the injection of tissue volumizing agents (hyaluronic acid and botulinum toxin).² Surgical therapies that have been explained in literature for this cosmetic defect are Beagle’s technique, the modified Beagle technique, the envelop technique and semilunar coronally positioned technique.² However, due to inadequate blood supply, it is a tough task for the dentist to reconstruct the lost IDP in an esthetically challenging zone with least predictable outcomes.

Photobiomodulation (PBM) resolves inflammation and speeds up cellular regeneration.⁵ On application of low-level laser therapy (LLT), nitric oxide is released from cytochrome c, which in turn shoots up the level of Adenosine triphosphate (ATP), quickens electron transfer reactions and promotes nucleic acid and protein synthesis. Few authors have proposed that several molecular events are activated in the process like the release of low concentrations of reactive oxygen species (ROS) and cyclic Adenosine monophosphate (cAMP) which induce calcium influx into the cell. This affects the expression of transcription factors like NF-κβ. Overall, protein synthesis surges along with the induction of the anti-apoptotic pathway and the promotion of cell migration and proliferation. Another hypothesis suggests that stem cells and progenitor cells present in the blood exhibit enhanced mitogenic performance and neovascularization on administration of LLT.^6,7 In the present case scenario, it was anticipated that induced gingival bleeding would recruit mesenchymal cells from the blood into the interested site required for the proliferation process. Therefore, our goal was to evaluate the efficacy of hemolasertherapy in reconstructing the lost IDP.

Case Presentation

A 20-year-old female patient presented to the Department of Periodontology at our institution with the chief complaint of food lodgment in her lower front teeth region. The patient also complained of bleeding gums while brushing. No underlying medical condition or pathology was noted. On intra-oral examination, calculus deposits were noted with a shallow vestibule and inadequate attached gingiva with respect to 31 and 41 teeth. Also, loss of IDP was appreciated in between the mentioned teeth. Intra-oral periapical radiograph revealed no bone loss and consequently, the IDP loss was graded under category I (As per Tarnow’s classification) (Figure 1). The patient was diagnosed with chronic generalized gingivitis with localized periodontitis w.r.t 31 and 41. A comprehensive treatment plan was designed that included phase I therapy, Clark’s vestibuloplasty, followed by hemolasertherapy to build-up the lost IDP. The patient was explained about the condition and the required treatment. Written informed consent was obtained regarding the same.

After two weeks of phase I therapy, Clarks vestibuloplasty under local anesthesia was planned w.r.t 31, 32, 33, 41, 42, 43 teeth to increase the vestibular depth (Figure 2a). The patient was recalled after seven days for suture removal and was then scheduled for hemolasertherapy after one month.

On the day of therapy, the patient was explained again about the procedure. A pre-procedural mouth rinse with 0.2% chlorhexidine was advised. After administration of adequate local anesthesia (bilateral mental nerve block), the dimension of the papilla loss was measured with the help of a UNC-15 periodontal probe (Figure 2b). Clinical photographs were taken before the procedure. The area was thoroughly photobiomodulated prior to the therapy to improve local microcirculation. Around nine bleeding points were induced by a probe i.r.t 31 and 41 (Figure 2c).

The blood was allowed to flow into the sulcus. The procedure was carried out using a Sunny diode laser at a wavelength of 650 nm. A non-contact delivery approach in pulsed mode was adopted. A distance of 1 mm was maintained between the tip of the laser hand piece and the gingiva and each spot was biostimulated for 30 seconds (Figure 3). Two sessions in total were scheduled at an interval of seven days. After each session, the patient was advised to brush regularly but to avoid flossing to preserve the stimulated area. She was prescribed Chlorhexidine mouthwash for 14 days.

The patient was followed up for three months. Clinical examination revealed complete closure of black triangle (Figure 4). Thus the problem of black triangle was resolved in the area. The patient was satisfied with the therapy.

Discussion

Cohen was the first to describe the morphology of IDP. “Pink esthetics” refers to interdental papilla and gingiva that can augment or diminish esthetic outcomes. Reconstruction of IDP is challenging for the clinician and has least predictable outcome. Hence, for all the dental procedures, it is imperative to respect the papillary integrity

Hemolasertherapy is a non-surgical therapy used for papilla regeneration. One of the best advantages of this technique is that it is a minimally invasive modality.⁸ It is a comfortable and convenient approach from the patient’s perspective with minimal bleeding and pain, contrary to the complex mucogingival procedures performed for black triangles. Also, it is easier to motivate patients for such short-term therapies.

Akhil et al. published a case report of papilla regeneration using a fibre tip inserted 3-4 mm into the papilla. Here, they followed the contact mode of delivery. The authors used low-level diode laser therapy with an exposure time of 20 seconds. This resulted in complete regeneration of IDP.⁸

Fatima et al. in a report discussed papilla reconstruction using hemolasertherapy in three patients. Photobiomodulation by contact mode was carried out after creating bleeding points. Also, the patient’s blood samples were collected and checked for mesenchymal stem cells (MSC’s) activities by reverse transcription polymerase chain reaction. Expression of genes responsible for enhanced cellular activity was observed in the assay after the therapy.⁹

New arenas in the fields of biotechnology and laser therapy have widened the scope for regeneration. Studies have shown that emitted photons permit cellular and molecular events in target tissues, which could be a boost in regenerative therapy. PBM, by visible or near infra-red light (NIR) light, causes physical or biochemical changes within the cells. It appears that biostimulation is dependent upon factors such as output power, energy density, and also cell being irradiated. Low-level irradiation of MSCs can promote cell proliferation and enable repopulation at the injured site, neovascularization and modulation of immune responses.

To conclude, the simplicity of the procedure is the most striking feature. This technique focuses mainly on the patient’s comfort, besides being safe and convenient. However, the overall success depends on several aspects like the grade of IDP loss, bone height, distance between the two roots of teeth, patient’s oral hygiene, etc. Further studies should be carried out with a larger sample size and long-term follow-up plan to evaluate the success rate and the drawbacks of this therapy.

Conflict of interest

The authors do not report any conflict of interest amongst each other.