Clinical Evaluation of the Use of Surgical Tube Technique Versus Hyaluronic Acid Gel Injection in Reconstruction of the Interproximal Papilla in Patients With Class II Papillary Deficiency
Phase: NA
Conditions: the Clinical Effect of Surgical Tube Technique in Reconstruction of the Interproximal Papilla
Sponsor: waleed mohammad sabry

 
1 
 
 Clinical Evaluation of the Use of Surgical Tube Technique versus 
Hyaluronic Acid Gel Injection in Reconstruction of the Interproximal 
Papilla in Patients with Class II Papillary Deficiency  
(Randomized Clinical Trial) 
 
 
 التأثير االكلينيكي لل
نبوب الجراحي مقارنة 
 بحقن حمض الهيالورونيك في اعاده بناء الحليمه البينيه في حاالت العيوب اللثويه المستوي
الثاني 
 ( التجارب السريرية العشوائية) 
 
 
Protocol submitted to  
Faculty of Dentistry, Cairo University 
for partial fulfillment of the requirements for the PhD Degree in 
periodontology 
By 
Waleed Mohammad Sabry 
B.D.S Faculty of Dentistry 
 Misr International University,2012 
Master degree in Periodontology 
 Ain Shams University,2020 
 
2020 
 
 
 
Supervisors’ signature 
Head of department’s signature 
1- 
 
 
2- 
 
 
3- 
 
 
 
 
Date 
 
 
 
Code:  

 
2 
 
 
 
 
Protocol checklist 
Section and topic 
Item no. 
Checked item 
Reported 
on page No. 
Reviewer’s 
check 
I. Administrative information 
1 
Title 
  
 
2 
Protocol registration 
 
 
3 
Protocol version 
 
 
4 
Funding 
 
 
5 
Roles and responsibilities 
 
 
 
II. Introduction 
 
 
 
A) Background and Rationale 
6 a 
Research question  
 
 
Statement of the problem 
 
 
Rationale for carrying out the trial 
 
 
Review of literature 
 
 
6 b 
Choice of comparators 
 
 
B) Objectives 
7 
Aim of the study  
 
 
Hypothesis 
 
 
C) Trial design 
8 
Trial design 
 
 
 
III. Methods 
 
 
 
A) Participants, interventions 
& outcomes 
9 
Study setting 
 
 
10 
Eligibility criteria 
 
 
11 
Interventions 
 
 
12 
Outcomes 
 
 
13 
Participant timeline 
 
 
14 
Sample size 
 
 
15 
Recruitment 
 
 
B) Assignment of interventions 
16 
Allocation 
 
 
16 a 
Random sequence generation 
(Randomization) 
 
 
16 b 
Allocation concealment 
mechanism 
 
 
16 c 
Implementation 
 
 
17 
Blinding (masking) 
 
 
C) Data collection, 
management, and analysis 
18 
Data collection methods 
 
 
19 
Data management 
 
 
20 
Statistical methods 
 
 
D) Monitoring 
21 
Data monitoring 
 
 
22 
Harms 
 
 
23 
Auditing 
 
 

 
3 
 
 
 
 
 
 
 
 
 
 
IV. Ethics and dissemination 
24 
Research ethics approval 
 
 
25 
Protocol amendments 
 
 
26 
Informed Consent  
 
 
27 
Confidentiality 
 
 
28 
Declaration of interests 
 
 
29 
Access to data 
 
 
30 
Ancillary and post-trial care 
 
 
31 
Dissemination policy 
 
 
 
V. Appendices 
 
32 
Informed consent materials 
 
 
 
33 
Biological specimens 
 
 
 
VI. Statement of originality 
34 
Statement of originality 
 
 
VII. References 
 
 
 
 
 
 
Evidence based committee (Reviewers) 
 
Name 
Signature 
Date 
1. 
 
 
 
2. 
 
 
 
 
Research plan committee 
 
Name 
Signature 
Date 
1.  
 
 
 
2.  
 
 
 

 
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I. Administrative information: 
1. Title  
 The clinical effect of surgical Tube technique versus Hyaluronic Acid gel injection in 
reconstruction of the interproximal papilla in patients with class II papillary defect. (Randomized 
clinical Trial). 
2. Protocol Registration  
3. Protocol version  
   First version. 
4. Funding  
   Self-funding. 
5. Roles and responsibilities 
Main supervisor 
     Dr. Ahmed Mohamed El Barbary 
    Associate Professor of Oral Medicine and Periodontology-Faculty of Dentistry- 
Cairo University.  
 
      Dr. Osama Gouda 
    Associate Professor of Oral Medicine and Periodontology-Faculty of Dentistry- 
Badr University. 
 
• Initiation of the study. 
• Generation of random sequence numbers and implementation of randomization. 
• Supervision of surgical procedures. 
• Revision of protocol and final thesis. 
CO-supervisor 
     Dr. Marwa Mostafa 
    Lecturer of Oral Medicine and Periodontology-Faculty of Dentistry- Cairo University. 
• Revision of final thesis. 
• Supervision of surgical procedures. 
• Recording clinical outcomes at baseline and different observation periods. 
 
  Main investigator 
 Waleed Sabry 
• Recruitment and allocation of patients. 

 
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• Preparation and follow-up of patients. 
• Surgical treatment of patients. 
• Preparation of protocol and thesis. 
 
Trial responsibility: 
 
  Department of  Oral Medicine and Periodontology, Faculty of Dentistry, Cairo University 
Committees: 
• Research plan committee 
• Oral Medicine and Periodontology department council 
• Evidence based dentistry committee 
• Ethics committee 
• Faculty Council 
 
II. Introduction: 
 
A. Background and rationale: 
6. Research question:  
In papilla class II defect will tube technique correct the papillary loss to fulfill complete gain in 
papillary height and embrasure fill compared to Hyaluronic acid injection? 
 
 
              The full occupation of the interdental papilla at the entire embrasure space apical to the 
interdental contact point/area., especially anteriorly, has been one of the most important aspects in 
increasing public demands for esthetics. Added to the esthetically unaccepted black triangle, loss 
of interdental papilla results in food impaction and plaque accumulation. Thus, negatively affects 
the integrity of the periodontal tissue health (Burke etal 1994). 
 
  
Knowing that the interdental space is surrounded by avascular root surfaces on either side, 
the feeding source of blood supply comes from the gingivo-papillary unit and the crest of the 
alveolar bone. Any tear or excess trauma to this narrow band of papillary tissue results in 
compromised vascularity which leads to necrosis. This gives attention for the urgency of 

 
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maintaining papillary integrity during all dental procedures and lessening traumatization to 
consider preventing its loss ( Zucchelli  2008). 
 
 
Several attempts for augmentation and rebuilding techniques aiming at reconstructing the 
defective papilla encountered major limiting factor pointing at the minor blood supply feeding the 
small fragile interdental papilla (Georgieva, etal. 2017;Alahmari 2018; Thomas etal. 2000).  
 
 
The injection of hyaluronic acid gel have been considered of the latest conventional non 
invasive techniques for treatment of deficient  papilla to escape drawbacks of surgeries however  
still entails unpredicted complete gingival papilla improvement owing to the relative compact 
nature of the gingiva which is  influenced by the gingival biotype that could hinder  the positive 
outcomes on favor of  thick biotype that could help to enrich the effect of  hyaluronic acid thru 
accelerating the thick connective tissue related abundance of gingival fibroblast proliferation, 
promoting the generation of collagen fibers (Becker etal. 2010). 
 
 
Karring etal 1974 tested papillary tissue augmentation through influencing connective 
tissue cell proliferation, providing clot stability, protecting the reconstructed site during wound 
healing. He reported that sub-epithelial connective tissue possess the genetically determined factor 
to induce changes in the differentiation of the nature of the epithelium developing at a region. Sub-
epithelial connective tissue graft has been successfully used for the double blood supply it 
provides, closer color blend of graft to the adjacent tissue and absence of keloid healing.  
 
 
However, because of the low blood supply and the anatomic restriction of the recipient 
gingival papilla, the result is unpredictable unless successful surgical attempt aiming for clot 
stability influenced by the defect related flap design, to avoid early wound failure and exposure of 
the treated area occurred (Langer etal. 1985; Han & Takei 2000).                                                       
 
 
Many surgical approaches using traditional periodontal plastic and augmentation 
procedures have been proposed to overcome the problem of the low blood supply. However, Due 
to the number and location of incisions, which can disrupt the blood supply, techniques with new 
flap designs were found to be invasive with limited success and long-term stability needed for 
complete healing (Carranza & Zogbi  2011; Singh etal 2013). 
 
 A new surgical technique called Tube technique has been developed for protection of the 

 
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wound without disturbing the blood supply of the graft by precise flap design allowing 
containment of the graft within a rich vascular enclosed bed, thereby predictably offering reliable 
and satisfactory results (Hooshang etal 2020). 
 
 
Our randomized clinical trial target is comparing between the clinical efficacy of surgical 
Tube technique and Hyaluronic Acid gel injection in reconstruction of the interproximal papilla in 
patients with class II papillary defect. 
Statement of the problem:  
 
Restoring defective interdental papilla partially or totally in structure and function creates a 
challenge in dental field owing to the small working space and limited blood supply to the area. 
This led to the innovation of different techniques for treatment of defective interdental papilla that 
aimed at papillary tissue augmentation reported to be attained through influencing connective 
tissue cell proliferation, providing clot stability, protecting the reconstructed site during wound 
healing (Nordland, 2018;Singh etal. 2013) 
 
 
Among these techniques is the injection of hyaluronic acid gel have been considered of the 
latest non-invasive technique to escape drawbacks of surgeries. Though proved to have some 
positive results in the literature however still entails unpredicted complete gingival papilla 
improvement because of the diverse injection methods, cycles, dosage, and the course of treatment 
that needs further optimization, in addition to the lack of unified patient inclusion criteria, 
especially the gingival biotype ( Langer etal. 1985;Han & Takei  2000).  
 
 
Several surgical techniques designed to host the richest effective known sub-epithelial 
connective tissue graft had failed to allow maximum benefit of the graft due to the disadvantages 
from the number and location of incisions of their flap design, which possibly disrupt the blood 
supply needed added to unconsidered flap thickness, and flap retraction that impacted the success 
of soft tissue grafting (Singh etal 2013;Al-Zarea  etal. 2015). 
 
 
Surgical Tube technique has recently been developed optimizing flap thickness, flap 
retraction and tension to escape disturbance of the blood supply of the graft by its use of apical 
incisions and containment of the graft within a rich vascular enclosed bed, thereby offering an 
attempt to guarantee integrity of soft tissue with no disruption of blood supply (Hooshang etal 
2020). 
 

 
8 
Rationale for conducting the research: 
1. Complete Regeneration of the defective interdental papilla has been evasive in the 
literature. Many Attempts failed to fully restore the integrity of interdental papilla that 
protects the periodontal structure aiming at longstanding survival of interdental tissue 
facing negative destructive factors, and following current directions of dentistry to esthetic 
purposes(Sharma etal. 2010;Singh etal 2013). 
 
2. Most of the literature is limited towards case reports, providing no evidence of 
predictability and few demonstrate long term stability. No controlled clinical trial has 
addressed the issue of restoring deficient interproximal spaces (Carnio  2004). 
 
3.  Nonsurgical  techniques are currently considered superior to conventional surgeries 
regarding decreasing the surgical trauma, improving the clot stability, reducing patient 
discomfort postoperatively as well as minimizing surgical chair time (Cortellini 2001) 
Based on theses principles, nonsurgical injection of hyaluronic acid seemed to overcome 
the major limiting factor in most surgical techniques regarding the limited blood supply and 
the small working space.  
 
4. Supported by a recent study conducted by Georgieva etal. 2017, who reported  an increase 
in the height of the gingival papilla and  reduction of the area of the black triangle  that 
were significant between baseline and 3 or 6 months in a group with thick gingival biotype  
after injection with hyaluronic acid, Yet maximum papillary full gain effect is limited to 
other factors. 
 
5. Least traumatic surgical attempts were presented aiming at full papilla reconstruction and 
are  based on Sub-epithelial connective tissue graft  for the beneficial genetically 
determinant factors it possess  guiding gingival tissue for regeneration yet was lacking flap 
design precision to provide wound stability to fulfill full gain  benefit (Carranza & Zogbi 
2011). 
 
6. Based on principles needed to preserve connective tissue graft, a case report has tested a 
novel technique {Tube} for treating interproximal recession and reconstructing the 
interproximal papilla, resulted in uneventful healing  at both the donor and recipient sites in 

 
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both cases. With a net gain of 5 mm measured one year post-surgically (Hooshang etal 
2020). 
 
 
 
 
Review of literature:  
  
The interdental papilla is the gingival portion that fills the proximal area under the contact 
between two adjacent teeth, where it  is defined as gingival tissues extending from incisal tip of the 
papilla to a line tangential to the adjacent margins of the adjacent teeth. Anatomically, it is small 
and delicate with a diminutive blood supply, it is almost the most important esthetic part during 
smiling. (Csiszar etal.2007).  
 
Nordland & Tarnow 1998 classified papillary loss according to system which utilizes 3 
identifiable anatomical landmarks: the interdental contact point, the facial apical extent of the 
cemento-enamel junction (CEJ) and the interproximal coronal extent of the CEJ. Normal 
Interdental papilla fills embrasure space to the apical extent of the interdental contact point/area. 
Class I which the tip of the interdental papilla lies between the interdental contact point and the 
most coronal extent of the interproximal CEJ (space present but interproximal CEJ is not visible). 
Class II which the tip of the interdental papilla lies at or apical to the interproximal CEJ but coronal 
to the apical extent of the facial CEJ (interproximal CEJ visible). Class III which the tip of the 
interdental papilla lies level with or apical to the facial CEJ. 
 
 
The absence of interdental papilla contributes to chronic retention of food debris leading to 
subsequent affection of periodontal health and esthetically unaccepted black triangle(Lee 
etal.2016).The etiological pyramid of the black space has been proposed by Sharma and Park in 
2010. To be influenced by the initial position of the teeth (diastema), the length of gingival niche 
area, triangular shaped crown, divergent roots and periodontal bone loss. Also tooth brush trauma 
and decreased keratinization due to ageing has also been implicated as a causative factor of 
interdental papilla loss. 
 
 
Reconstruction of papillary insufficiency is one of the most difficult and challenging 
periodontal treatments. This is because the interdental papilla is a small, fragile area with minor 

 
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blood supply which seems to be the major limiting factor in all surgical and augmentation 
techniques (Singh etal. 2013;Al-Zarea  etal. 2015). 
 
 
The injection of biocompatible hyaluronic acid gel (HA) have been considered conventional 
non-invasive techniques for treatment of deficient papilla. Hyaluronic acid (0.1) mm It is an 
essential glycosaminoglycan of the extracellular matrix of the periodontal tissues, and the majority 
of cells can produce it during several phases of their cell cycle. It is involved in tissue repair and 
wound healing by stimulating cell proliferation, migration and interaction with several growth 
factors. Furthermore, HA has a crucial role in space-filling owing to its hygroscopic nature. 
Moreover, it regulates osmotic pressure and enhances tissue lubrication and resiliency, which helps 
in maintaining the structural and homeostatic integrity of tissues ( Ascher etal. 2011).  
 
  
However, hyaluronic acid gel injection still entails unpredicted complete gingival papilla 
improvement owing to the relative compact nature of the gingiva and influence of the gingival 
biotype that could hinder the positive outcomes on favor of thick biotype that could help to enrich 
the effect of hyaluronic acid through accelerating the thick connective tissue related abundance of 
gingival fibroblast proliferation, promoting the generation of collagen fibers. Limited studies have 
utilized HA gels for papillary reconstruction but still lacking a high degree of evidence and 
predictability (Becker etal. 2010; Mansouri etal. 2013) 
 
 
Several conventional surgical approaches using traditional periodontal plastic and 
augmentation procedures aiming for complete papilla fill to overcome this problem. However, flap 
design were found to be invasive with increased patient morbidity, limited success, long-term 
stability and unpredictability due to small working spaces and limited blood supply. (Georgieva, 
etal. 2017;Alahmari 2018). 
 
 
Most of the surgical approaches targeting papilla reconstruction were based on Sub-
epithelial connective tissue graft (Beagles etal 1996). Han & Takei 1996 used semilunar coronally 
repositioned papilla based on the use of free connective tissue graft. He concluded that subsequent 
second- and possibly third-stage surgery should reconstruct more of the papilla which is considered 
one of the disadvantages of this flap design. So Pellegrine 1996 modified this technique by folding 
the CTG to provide adequate thickness of the attached gingiva. 
 
 
Modified Beagle’s technique and Beagle’s surgical technique were unpredictable due to 

 
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small working spaces and limited blood supply to the area in addition to the vertical releasing 
incisions that could further jeopardize vascular supply and leave unpleasant scarring after healing 
(Beagles 1996;Chaulkar  2020). 
  
 
 
Han and Tackei technique made a trial to modify the flap design by semilunar coronally 
repositioned papilla that enabled to preserve the interdental papilla blood supply and improving the 
gingival biotype from 0.75 mm to 2 mm, One year post-operative view showing 80% papillary fill 
(Jangid etal.2016).  
 
These subepithelial conventional techniques were unpredictable due to small working spaces and 
limited blood supply to the area. Disadvantages of these techniques were mostly due to the number 
and location of incisions, which could have  disrupted the blood supply needed for complete 
healing(Azzi etal. 2001). 
 
 
Microsurgical techniques had been introduced and enhance the visual accuracy by means of 
illumination and magnification. Literature on periodontal microsurgery showed improved surgical 
outcome when used for root coverage procedure and regenerative therapy. (Wachtel etal. 2003; 
Francetti. etal.2005). By the aid of subepithelial connective tissue, the microsurgical technique 
found to maintain the reconstructed papilla remained stable and without any clinical signs of 
inflammation for 4 years after surgical procedure, but the long-term survivability and the technique 
sensitivity involved in the surgery are to be considered ( Nordland 2008). 
 
 
Recent clinical study assessed the efficacy of microsurgical reconstruction of lost interdental 
papillam and  was based on single surgical intervention, with the aid of connective tissue graft 
which is proved useful in Correction of papillary loss, but the Maximum gain with single 
procedure was found to be limited. Other limitations of the study were being due to smaller sample 
size and short period of follow up and were recorded for long term clinical and histological follow 
up studies are necessary before its predictability (Singh etal. 2018). 
 
  
Tube technique is recently introduced by Hooshang etal. 2020 on the track of surgical 
techniques to overcome disadvantages of the other techniques. The innovated flap design of tube 
technique does not disturb the blood supply of the graft by its use of apical incisions and 
containment of the graft within a rich vascular enclosed bed, thereby offering reliable and 

 
12 
satisfactory results. Integrity of the soft tissue is key to the successful outcome of this technique. 
The tube grafting technique requires technical precision. It is sensitive to any surgical trauma and 
tension, especially when the recipient site tissue is delicate.  
 
 
 
Thus, the present randomized clinical trial is to compare the  clinical effect of surgical Tube 
technique versus Hyaluronic Acid Gel injection in Reconstruction of the interproximal papilla  in 
patients with class II papillary defect. 
  
Comparator: [Standard of care] Hyaluronic Acid injection 
It is a minimally invasive non-surgical injection of  hyaluronic acid that observed to 
overcome the major limiting factor in most surgical techniques regarding the limited blood 
supply and the small working space. Supported by a recent study conducted by Jinng etal. 
2019, who reported significant  increase in the height of the gingival papilla and  reduction 
of the area of the black triangle between baseline and 3 or 6 months in a group with thick 
gingival biotype  after injection with hyaluronic acid, that was adding possible maximum 
effect with minimal postoperative hazards. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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II.B. Objectives of the study: 
7. Aim of the study 
The aim of this randomized clinical trial is to compare the clinical effect of surgical Tube 
technique versus Hyaluronic Acid gel injection in reconstruction of the interproximal papilla in 
patients with class II papillary defect.  
Picots: 
P: Population: patients with class II papillary defect. 
I: Intervention: Tube technique hosting sub-epithelial connective tissue graft. 
C: Control:  Hyaluronic acid injection.  
Primary outcome: interdental papilla loss (Decrease of black triangle ) (mm2) 
Secondary outcome: assessment of gain in papillary height , radiographic distance between (CP-
BC), assessment of CAL.  PD reduction, amount of gingival recession.  
T: Time frame: 6 months. 
S: Study design: Randomized clinical trial. 
 
Hypothesis:  
Null hypothesis: There is no difference in the gain in papillary height comparing hyaluronic acid 
injection versus Tube technique in patients with class II papillary defect. 
 
8.Trial design 
 
The study is designed as a superiority, 2 arm parallel groups, randomized clinical trial with 
allocation ratio 1:1. 
 
 
 
 
 
 
 
 
 
 

 
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III. Methods 
A) Participants, interventions and outcomes 
9. Study settings: 
This study will be carried out on patients enrolled from the outpatient and postgraduate clinics of 
Oral Medicine and Periodontology department, Faculty of Dentistry, Cairo University. 
 
10. Eligibility criteria: 
Inclusion Criteria:  
● Highly motivated patients with papillary deficiency types II, according to Nordland 
and Tarnow 1998 classification will be selected, having at least one deficient papilla in 
the anterior region. 
                     ● Distance between the contact point and inter-proximal bone crest (CP-BC) of ≤ 7  
mm and probing depth of ≤ 4 mm at the deficient papillary site (Abdelraouf etal. 2019). 
  ● Patients with full mouth plaque index (PI) and gingival index (GI) scores should be 
between 0-1.  
                    ● Healthy patients free of any medical condition.              
 
Exclusion criteria: 
 
● Patients with medical conditions that may affect periodontal healing or regeneration.  
● Patients with a history of allergic reactions, pregnant or breastfeeding females, 
smokers and alcoholics. 
● Patients with current or previous drugs intake that may predispose to gingival 
enlargement. 
● Patients under orthodontic treatment or had orthodontic treatment in the past six 
months.  
● Carious teeth, proximal restorations or fixed prosthesis. 
● Patients with a history of traumatic oral hygiene measures or periodontal surgeries 
over the last six months at the area of interest or having any scar tissue. 
● Poor oral hygiene patients. 
11. Interventions 

 
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11a-General operative procedure 
• The patients who fulfil the inclusion criteria will be enrolled. 
• The nature of the study will be explained to each patient as well as the importance of 
compliance with pre- and post-operative instructions and follow-up visits. 
• Each patient will be asked to sign an informed consent (appendix 1) 
• After enrolment, periodontal examination and full periodontal charts will be recorded for 
each patient including Papilla Class I1, CP-BC plaque Index (Leary et al., 1967), gingival 
bleeding Index (Ainamo & Bay, 1975), probing depth (PD), clinical attachment level 
(CAL) and gingival recession. 
Radiographic Evaluation 
            Standardized digital periapical radiographs will be obtained preoperatively and at follow-up  
using the long cone paralleling technique. All radiographs will be obtained using the same 
equipment, film exposure and development conditions. 
 
Pre-surgical therapy 
• All patient will receive strict oral hygiene instructions full mouth supra and sub-gingival 
debridement using hand instruments and ultrasonic scalers under local anesthesia. 
• Four to six weeks following pre-surgical therapy, a periodontal re-evaluation will be 
performed to confirm the suitability of the chosen sites for this periodontal surgical study. 
• The clinical and radiographic parameters will be recorded at baseline 
 
The patients will be randomly assigned into two groups: A total of 36 sites (18 site per group) 
Group A (Intervention): Patients will receive Tube technique. 
Group B (Control): Patients will receive Hyaluronic acid. 
 
Surgical Procedures 
Group A (Intervention): Patients will receive Tube technique (Hooshang etal. 2020). 
1) Using a #15 blade, a semilunar incision is placed on the buccal aspect at the level of the 
mucogingival junction and a full-thickness flap was elevated. The flap is extended mesio-distally 
by an additional 4 to 5 mm than needed for the graft. This extension allowed the buccal flap to be 
freely moved into the recession area. 
 
2) Another semilunar incision will be placed on the palatal aspect, such that the zenith of the 

 
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incision is located proximal to the alveolar crest.  
 
3) An excavator (smaller than the width of the defect; evaluated pre-surgically on a study model) is 
used to carefully reflect the papilla away from the alveolar bone and root surfaces on the buccal 
aspect to access the interproximal region to prepare the bed for the graft. The excavator is used to 
do the same on the palatal aspect. The amount of reflection should yield a very relaxed papilla flap 
that permits placement of the papilla at the new coronal position without tension.  
 
4) The recipient site at this time should resemble a “tube” with two openings; one on the buccal 
aspect at the mucogingival junction and one on the palatal aspect.  
 
5) To harvest the graft, the incision is made parallel to and 2 mm away from the gingival margin. A 
thin flap containing the keratinized tissue is separated, then the second incision is made parallel to 
the gingival margin, but perpendicular to the alveolar bone. With a sharp periosteal elevator, the 
graft is raised with the periosteum and released at its anterior and posterior ends, and then from its 
base .The harvested graft should be larger than the side of interproximal defect in both cases: each 
graft will be 12 to 15 mm long, 5 mm wide, and 2 mm thick. A 4.0 chromic gut suture is used to 
pass the eye (swage) of the needle into the tube from the palate toward the buccal. The suture 
needle then engaged one end of the graft. An additional separate second suture is placed on the 
other end of the CT graft. One suture end (eye first) is passed through the tube toward the palatal 
side  
 
6) The connective tissue graft is carefully slipped through the buccal aspect of the tube into the 
prepared interproximal bed towards the palate by means of the suture with the assistance of a 
periosteal elevator as needed. The thickest part of the graft is placed in the interproximal area.  
 
7) The connective graft is sutured under the flaps onto the buccal and palatal tissues and the buccal 
and palatal flaps are sutured over the top of the graft.  
 
8) The size of the needle does not matter for this procedure; we use 4-0 silk with an FS2 cutting 
needle and a 4-0 chromic gut suture with a C-6 (FS-2) cutting needle.  
 
9) Using the index finger and thumb the graft will be squeezed from both ends inward for at least 4 
to 5 minutes to further stabilize the graft into position. Both patients are instructed to avoid 

 
17 
brushing or flossing the recipient as well as donor site. They are also asked to avoid hot, chewy, 
sticky foods. They were advised to ice the wound to reduce post-surgical swelling.  
 
Group B (Control): Patients will receive Hyaluronic acid (HA) (0.1) mm (Abdelraouf etal. 2019) 
The product used in this trial is Restylane Lidocaine (Restylane-Lidocaine cross-linked Hyaluronic 
Acid Filler, Galderma S.A, Sweden). Restylane was the first FDA-approved HA filler in 2003. 
Restylane is a non-animal stabilised cross-linked HA filler with an HA concentration of 20 mg/ml. 
The longevity of Restylane filler in tissues is approximately 6 months. Restylane-Lidocaine (FDA 
approved in 2012) is a newer product of Restylane with 0.3% lidocaine incorporated into the 
syringe itself. 
-Stent will be performed and re evaluation  
-After 4 weeks, re-evaluation is performed, and the degree of papillary deficiency according to 
Nordland and Tarnow 1998 classification as well as plaque and gingival indices will be assessed 
for eligibility. Alginate impression is taken for the involved arch/arches for the construction of 
study casts and fabrication of customized stents. Only patients with deficient papilla sites fulfilling 
the inclusion criteria are recalled, scheduled for the 1st injection after 1 week and will sign the 
informed consent. 
 After 1 week 3 injection will be given at each papilla site  
-In the injection phase, 3 injections are given at each papilla site: at baseline, 3- and 6-weeks 
intervals. At the first injection visit, before attempting to inject, clinical measurement of the height 
of the black triangle is done by measuring the distance between the deficient papilla tip and contact 
area (PT-CP distance) to the nearest 0.5 mm (baseline). This will be done using a graduated 
periodontal probe and the fabricated customized stent for proper and standardized positioning of 
the probe at each measurement interval 
 
- Hyaluronic acid and saline are pre-loaded in insulin plastic syringes before injection for patient 
blinding. The needle is inserted 2-3 mm apical to the tip of the interdental papilla and directed 
coronally with an angulation of 45° to the long axis of the tooth, and the bevel directed apically. 
Then, the papilla is lightly moulded in an incisal direction for 1 minute using gauze. 
 
-In the follow-up phase, patients are recalled after 3,6months the first injection where clinical re-
measurement of the black triangles and standardized digital clinical photographs will be retaken. 
 
Postoperative care:  

 
18 
-Patient self-care instructions (Heitz et al. 2004): 
- 
Avoid any hard brushing and trauma to the surgical site for two weeks. 
- 
Maintain a soft diet to avoid trauma to the surgical site. 
- 
After 24 hours patients can use warm saline rinses daily 
- 
Sutures will be removed fourteen days after the surgery. 
- 
Plaque control will be maintained by chlorohexidine mouth rinse after the surgery. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12. Outcomes: 

 
19 
 
Outcomes  Outcome name  
Measuring device  
Measuring units  
1ry 
outcome 
interdental 
papilla 
loss 
(Decrease of black triangle 
area ) (mm2) 
Photoshop CS5. 
mm 
2nd 
outcomes  
Gain in papillary height 
 
Change in the distance (CP-
BC) 
 
                CAL 
 
Pocket depth (PD) 
 
Gingival 
recession 
(GR) 
 
Gingival bleeding 
 
Plaque index 
 
Post-surgical patient      
Satisfaction and post-
injection 
UNC Periodontal Probe 
 
 
Digital periapical radiograph 
(linear measurement) 
 
UNC Periodontal Probe 
 
UNC Periodontal probe 
 
UNC Periodontal probe 
 
 
UNC Periodontal probe 
 
 
UNC Periodontal probe 
  
Post-surgical 
patient 
satisfaction 
questionnaire 
(PSPSQ) (Kiyak, Hohl, West, 
& McNeill, 1984)  
 
mm 
 
 
mm 
 
 
mm 
 
mm 
 
mm 
 
Gingival 
bleeding score 
 
Plaque 
Index 
score 
 
(1-7) point scale 
 
 
 
 
 
 

 
20 
-Digital clinical photographs: (SABT) mm (Abdelraouf etal. 2019) 
Clinical photographs will be obtained with the same digital camera (Nikon D5100 DSLR) mounted 
on a ring flashlight, using the same lens (Sigma Macro 105mm F2.8 EX) and the same focal 
length. The photographs are taken under the same lightning conditions and camera settings. The 
patients are sitting in an upright position, looking straight ahead. The Frankfort plane of the patient 
as well as the camera lens is positioned parallel to the ground. The photographs will be captured 
perpendicular to the teeth adjacent to the deficient papilla. Strict care is taken to ensure that the 
same up-down and right-left shooting positions are reproduced at different time intervals. 
 
-The surface area of the black triangle (SABT) is assessed using standardized digital clinical 
photographs analyzed by an image analysis program (Photoshop Cs 5, Adobe Systems, San Jose, 
CA, USA). The surface area of the black triangle was assessed from the photographs taken at 
baseline (before injection), 3 and 6 months from the first injection. 
- 10 mm William's graduated periodontal probe was used as a scale for calibration. 
 
Papilla Presence Index (PPI): ( Cardaropoli etal. 2004) 
-PPI (1): is reported when papilla is completely present and coronally extends to the contact point 
to completely fill the inter-proximal embrasure which this papilla is at the same level as the 
adjacent papillae. 
-PPI (2): describes a papilla that is no longer completely present and lies apical to the contact point 
which this papilla is not at the same level as the adjacent papillae and the embrasure is no longer 
completely filled but the interproximal cemento-enamel junction is still not visible. 
-PPI (3): refers to the situation in which the papilla is moved more apical and the cemento-enamel 
junction becomes visible. 
-PPI (4): describes when the papilla lies apical to both the incisal cemento-enamel junction and 
buccal cemento-enamel junction which interproximal soft tissue recession is present together with 
buccal gingival recession and patients esthetics is dramatically compromised. 
 
Clinical attachment level (CAL): 
CAL will be determined by measuring the distance from the cemento-enamel junction to the base 
of the pocket using a UNC 15 periodontal probe. 
 
 
 

 
21 
Probing depth (PD): 
Probing depth will be measured from the gingival margin to the base of the periodontal pocket 
using a UNC 15 periodontal probe. 
 
Gingival recession (GR): 
Gingival recession will be measured using UNC periodontal probe from the cemento-enamel 
junction till the gingival margin (Miller, 1985). 
 
Gingival Bleeding score: 
- 
Gingival bleeding score will be performed through gentle probing of the orifice of the 
gingival crevice from all four surfaces of all teeth using UNC Periodontal probe.  
- 
Recorded as (+) if bleeding is present or (-) if bleeding is absent.  
- 
If bleeding occurs within 10 seconds a positive finding is recorded and the number of 
positive sites is recorded and then expressed as a percentage of the number of sites 
examined (Ainamo & Bay, 1975). 
 
Patient Satisfaction: 
- 
Three questionnaires will be asked to determine patients’ satisfaction with the outcome 
of surgery 
1. Considering this was an elective operation, how likely would you be to recommend it 
to others? 
2. If you had to make the decision again, how likely would you be to undergo this 
surgery’? 
3. Considering everything, how satisfied are you with the outcome of your surgery 
- 
These questions could all be answered by the patient using a 7-point response scale 
where: Very Satisfied = 7; Not At All Satisfied = 1. (Kiyak et al., 1984). 
 
 
 
 
 
 
 
 

 
22 
13. Participant timeline 
13. 
Participant 
timelineTime 
point 
T0 T1 
 
T2 
(Surgical 
phase- 8 
weeks) 
T3 
Starting 
from T2 
till 
7th 
day 
 
T4 
3- 
months 
post-
surgical 
T5 
6-
months 
post-
surgical 
1-  
Enrollment 
X 
 
 
 
 
 
 
Eligibility 
screen 
X 
 
 
 
 
 
 
Informed 
consent 
X 
 
 
 
 
 
 
Initial 
phase 
(Oral hygiene 
measures) 
 
standardized 
periapical 
radiograph  
study casts 
 
 
 
 
 
 
 
X 
X 
 
 
 
 
 
 
 
 
 
X 
 
 Allocation 
 
 
X 
 
 
 
Intervention 
Injection 
 
Surgical 
tube 
technique 
 
 
   
      X 
 
 
 
 
Post-operative 
Care 
 
 
 
X 
 
 
 
Papillary 
height , CAL, 
PD, 
GR 
measurements 
 
X 
X 
 
X 
X 
 

 
23 
 
 
14. Sample size: 
 
This power analysis used interdental papilla loss after six months as the primary outcome. Based 
upon the results of Awartani FA and Tatakis DN (2016), the mean and standard deviation (SD) for 
control group were 0.71 (0.74) mm2. The minimal clinically significant difference was 1 
mm2according to expert opinion. Using alpha (α) level of (5%), β level of 0.8 (Power = 80%); the 
effect size for independent samples t-test (d) was 1.32 and the minimum estimated sample size was 
10 sites per group. Sample size was increased to 12 sites per group to compensate for a drop-out 
rate of 20% after six months. Sample size calculation was performed using PS Power and Sample 
Size Calculations Version 3. 
 
15. Recruitment strategy 
 
• The main investigator will be responsible for recruitment of patients. 
• Patients will be selected from the outpatient clinic of the Oral Medicine and Periodontology 
Department, Faculty of Dentistry - Cairo University. 
• Screening of patients will continue until the target sample is achieved. 
• Identifying and recruiting potential subjects will be achieved through patient database. 
 
1. One year. 
2. Candidate self-funding 
 
B) Assignment of interventions 
16. Allocation 
16a. Randomization 
The patients will be randomly allocated to either the intervention group or the control group 
using computer generated random numbers that will be performed by the supervisor. The 
patients will be allocated in a ratio of 1:1. 
SABT 
Patient 
Satisfaction 
 
 
X 
 
 
X 
 

 
24 
 
16b. Allocation concealment mechanism 
     The two groups will be equally prepared for both surgical procedures. Then the decision of 
which group will receive Hyaluronic acid injection and which will Tube Technique will be taken 
according to the randomized numbers placed in opaque sealed envelopes. The number will be 
picked by the supervisor. 
 
16c. Implementation
The supervisor will be responsible for generation of allocation sequence as will as assign the 
patients to the 2 intervention groups. The main investigator will be responsible for patient 
enrollment. 
 
 
 
17. Masking/blinding: 
Due to the type of intervention only the outcome assessor and the statistician will be blinded.
 
Single blinded: 
- 
Blinding of the participants is not applicable. 
- 
Blinding of the operator is not applicable. 
- 
Outcome assessor (primary and secondary outcomes) and biostatistician will be blinded. 
 
 
Key elements of Random Sequence Generation in protocol are: 
1-Method of random sequence generation (computerized random number generator). 
2- Allocation ratio (1:1, 2:1). 
3- Type of randomization: simple, blocked, stratified. 
 
c) Data collection, management, and analysis: 
 
18. Data collection methods 
 
- All the data of the patients included in the study will be recorded from them or extracted from the 
patient’s periodontal chart.  

 
25 
- Telephone numbers of all patients included in the study will be recorded as a part of the 
written consent.  
 - All patients will receive a phone call at the time of the pre-determined follow up dates.  
  
19. Data management: 
   Excel sheet program will be used though a computer system to manage the data with a secured 
password.  
 
20. Statistical methods: 
• 
The outcome used (State 1ry or 2ry): interdental papilla loss area (mm2) 
• 
Values used for outcome (e.g. mean difference, percentage, proportion..... etc ): mean and 
standard deviation 
• 
Entry 1: (mean difference between 2 groups, mean and standard deviation of group 1, 
proportion 1 or estimated prevalence):  
Minimal clinically significant difference = 1 mm2 according to expert opinion 
• 
Entry 2: (standard deviation of control group, mean and standard deviation of group 2, 
proportion 2 or clinically important difference):  
Mean of the control group = 0.71 
SD of control group = 0.74 
• 
Alpha level of significance: 0.05 
• 
Effect size used in calculation: d = 1.32 
• 
Power of the study: 0.8 
• 
Statistical test used: Independent samples t-test 
• 
The calculated sample size: 10 sites per group. 
• 
Increased number for anticipated missing data: Sample size will be increased to 12 sites per 
group to compensate for a drop-out rate of 20% after six months. 
D) Data monitoring: 
21. Monitoring 
No formal data monitoring committee will be needed since it is a study with known minimal risks. 
22. Harms 
Postoperative pain and/or swelling will be managed through analgesics. 
 
23. Audit 
Auditing of the study design will be done by the evidence-based committee – Faculty 

 
26 
Dentistry – Cairo University.  
 
IV. Ethics and dissemination 
 
24. Research ethics approval 
This protocol and the template informed consent form will be reviewed by the Ethics 
Committee of Scientific Research -Faculty of Dentistry- Cairo University.  
 
25. Protocol amendments 
Any modifications to the protocol which may have an impact on the conduct of the 
study, potential benefit of the patient or may affect patient safety, including changes of 
study objectives, study design, sample sizes, study procedures, or significant 
administrative aspects will require a formal amendment to the protocol. Such 
amendment will be agreed upon by the Council of Oral Medicine and Periodontology 
Department and the Faculty of Dentistry, Cairo University.  
 
26. Informed consent 
Researcher will introduce the trial to patients and provide full explanation of its aim and 
benefits in layman language. Patients will then be able to have an informed discussion 
with the researcher. Researcher will obtain written consent from patients willing to 
participate in the trial. All consent forms will be translated into Arabic.  
 
27. Confidentiality 
All study-related information will be stored securely. All participant information will be 
stored in locked file cabinets in areas with limited access. All reports, data collection, 
process, and administrative forms will be identified by a coded ID [identification] 
number only to maintain participant confidentiality. All records that contain names or 
other personal identifiers will be stored separately from study records identified by code 
number. All local databases will be secured with password-protected access systems.  
 
 
 
28. Declaration of interest 
If there will be any conflict of interest it will be declared.  
  
29. Access to data 
The principal investigator and the supervisors will have access to the data sets. All data 
sets will be password protected. To ensure confidentiality, data dispersed to project team 
members will be blinded of any identifying participant information.  
 

 
27 
30. Post-trial care 
All patients will be followed up for six months after the clinical trial is over.  
 
31. Dissemination policy 
- Study results will be published as partial fulfillment of the requirements for Doctorate’s 
degree in Periodontology. - Topics suggested for presentation or publication will be 
circulated by the authors.  
 
32. Informed consent 
VI. Statement of originality 
 
To the best of our knowledge, no randomized clinical trial has been published that involve 
comparing the clinical effect of surgical tube technique to hyaluronic acid gel injection in 
reconstruction of the tnterproximal papilla in patients with class II papillary defect. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
VII. References 
- 
Alahmari F. Reconstruction of Lost Interdental Papilla: A Review of Nonsurgical 
Approaches. J Dent Medical Sciences. 2018; 17:59-65. 

 
28 
- 
Al-Zarea BK, Sghaireen MG, Alomari WM, Bheran H, Taher I. Black Triangles Causes 
and Management: A Review of Literature. British Journal of Applied Science & 
Technology. 2015; 6:1-7. 
- 
Ascher B, Bayerl C, Brun P, Kestermont P, Rzany B, Poncet M, Guennoun M, Podda M. 
Efficacy and safety of a new hyaluronic acid dermal filler in the treatment of severe 
nasolabial lines 6-month interim results of a randomized, evaluator-blinded, intra-
individual comparison study. Journal of Cosmetic Dermatology. 2011; 10:94-98. 
- 
Azzi R, Daniel E, Takei HH, Carranza FA. Root coverage and papilla reconstruction 
using autogenous osseous and connective tissue graft. Int J Periodontics Restorative Dent 
21.2001; 141-147. 
- 
Azzi R, Etienne D, Carranza F. Surgical reconstruction of the interdental papilla. Int J 
Periodontics Restorative Dent.1998;18: 467-73. 
- 
 B. Langer, L. Langer, Subepithelial connective graft technique for root coverage, J 
Periodontol. 56. 1985 715–720.  
- 
Becker W, Gabitov I, Stepanov M, et al: Minimally invasive treatment for papillae 
deficiencies in the esthetic zone: A pilot study. Clin Implant Dent Relat Res 12:1, 2010 
- 
Burke S, Burch JG, Tetz JA: Incidence and size of pretreatment overlap and 
posttreatment gingival embrasure space between maxillary central incisors. Am J Orthod 
Dentofacial Orthop 105:506, 1994 
- 
Carranza N, Zogbi C. Reconstruction of the interdental papilla with an underlying 
subepithelial connective tissue graft: Technical considerations and case reports. Int J 
Periodontics Restorative Dent 2011; 31:e45‑50. 
- 
Cortellini P, Tonetti MS (2001) Microsurgical approach to periodontal regeneration. 
Initial evaluation in a case cohort. J Periodontol 72:559-569. 
- 
Csiszar A, Wiebe C, Larjava H, Hakkinen L. Distinctive molecular composition of 
human gingival interdental papilla. J Periodontol. 2007; 78:304-314.  
- 
D. Cardaropoli, R. Stefania, G. Correnti, The Papilla presence index (PPI): a new system to 
assess interproximal papillary levels, Int. J. Periodontics Restor. Dent. 24 (2004) 488–492. 
- 
Ena Sharman, Anuj Sharma, Kamaljit Singh:The role of subepithelial connective tissue 
graft for reconstruction of interdental papilla: Clinical study, 2017. 
- 
Francetti L, del Fabbro M, Calace S, Testori T, Weinstein RL (2005) Microsurgical 
treatment of gingival recession. Int J Periodontics Restorative Dent 25: 181- 188. 
- 
Georgieva I, Peev S, Gerova T, Mitteva M, Bazitova- Zlazitova- Zlateva M. Interdental 

 
29 
papillae height assessment in the aesthetic zone of the maxilla Scripta Scientifica 
Medicinae Dentalis. 2017; 3:11-16. 
- 
Georgieva I, Peev S, Gerova T, Mitteva M,Bazitova- Zlazitova- Zlateva M. Interdental 
papillae height assessment in the aesthetic zone of the maxilla Scripta Scientifica 
Medicinae Dentalis. 2017; 3:11-16. 
- 
Heitz, F., Heitz-Mayfield, L. J. and Lang, N. P. (2004) 'Effects of post-surgical 
cleansing protocols on early plaque control in periodontal and/or periimplant wound 
healing', J Clin  PERIODONTOL, 31(11),PP. 1012-8. 
- 
Hooshang Kashani, Manali V. Vora, Ryutaro Kuraji, Hanna Brody and Yvonne L. Kapila: 
Rebuilding the Interproximal Papilla: Description of “Tube” Technique and Two Case 
Reports, Clin Adv Periodontics 2020;0:1–5. 
- 
J. Carnio, Surgical reconstruction of interdental papilla using an interposed subepithelial 
connective tissue graft: a case report, Int. J. Periodontics Restor. Dent. 24 (2004) 31–37. 
- 
 J.L. Wennstorm, G. Zucchelli, G.P. Pini Prato, Mucogingival therapy- periodontal plastic 
surgery, in: J. Lindhe, N.P. Lang, T. Karring (Eds.), Clinical Periodontology and Implant 
Dentistry, 5th ed., Blackwell Munksgaard, 2008, pp. 955–1028. 
- 
J.R.Beagle,Surgical 
reconstruction 
of 
the 
interdental 
papilla: 
case 
report,Int.J.PeriodonticsRestor.Dent.12(1992) 145–151. 
- 
Kritika Jangid1, Julie Thomas1, Sheeja Varghese1 and Nadathur Jayakumar1: Aesthetic 
Papillary Reconstruction – A Case Report of a New Technique Using Connective Tissue 
Graft, British Journal of Medicine & Medical Research 11(1): 1-5, 2016, Article 
no.BJMMR.20069 ISSN: 2231-0614 
- 
Lee W, Kim H, Yu S, Kim B. Six Month Clinical Evaluation of Interdental Papilla 
Reconstruction with Injectable Hyaluronic Acid Gel Using an Image Analysis System. 
Journal of Esthetic and Restorative Dentistry. 2016; 28:221-230. 
- 
Mansouri SS, Ghasemi M, Salmani Z, Shams N. Clinical Application of Hyaluronic Acid 
Gel for Reconstruction of Interdental Papilla at the Esthetic zone. Journal Of Islamic Dental 
Association Of Iran. 2013; 25:152-157. 
- 
Minimally invasive treatment for papillae deficiencies in the esthetic zone: a pilot study. 
Clin Implant Dent Relat Res. 2010; 12:1-8. 
- 
Pellegrine AA, Okajima LS, Henriques PSG, Ferraz AP, Giannini M.Reconstrucao da 
papilla interdental – umaabordagem cirurgica/ restauradora. Rev Assoc Paul Cir Dent. 
2006;60:148-54. 
- 
 Sara Amr Abdelraouf, Omnia Aboul Dahab, Ahmed Elbarbary, Amany Mohy El-Din, 

 
30 
Basma Mostafa: Assessment of Hyaluronic Acid Gel Injection in the Reconstruction of 
Interdental Papilla: A Randomized Clinical Trial, Journal of Medical Sciences. 2019 Jun 
15; 7(11):1834-1840. 
- 
Sharma AA, Park JH. Esthetic considerations in interdental papilla:Remediation and 
regeneration. J Esthet Restor Dent. 2010;22:18-30. 
- 
 Singh VP, Uppoor AS, Nayak DG, Shah D. Black triangle dilemma and its management in 
esthetic dentistry. Dent Res J (Isfahan) 2013;10:296‑301. 
- 
T. Karring, N.R. Lang, H. Loe, The role of gingival connective tissue in determining 
epithelial differentiation, J. Period- ontol. Res. 10 (1974) 1–11. 
- 
 T.J. Han, H.H. Takei, Progress in gingival papilla reconstruc- tion, Periodontology 1996 
(11) (2000) 65–68. 
- 
Thomas AH, Henry HT (1996) Progress in gingival papilla reconstruction. Periodontol 
2000 11: 65-68. 
- 
Wachtel H, Schenk G, Bohm S, Weng D, Zuhr O, et al. (2003) Microsurgical access flap 
and enamel matrixderivative for the treatment of periodontal intrabony defects: a controlled 
clinical study. J Clin Periodontol 30: 496-504.