Gingival Embrasure Research Articles

Multidisciplinary Consideration for Managing Gingival Black Triangles in Aesthetic Dentistry: A Review

The importance of aesthetics in modern dentistry is paramount. Aesthetics has its different values and perceptions, which may be different from the eyes of the patient and those of the clinician [1]. It is dependent on the socio-economic status and the upbringing and mentality of each individual person. Open gingival embrasures or black triangle cause complex functional and aesthetic problems. Management of such problems requires careful evaluation of the underlying causes. In today’s aesthetic environment where both the dentist and the patient are aware of aesthetic value, the real challenge was to reconstruct this lost papilla and moreover to obtain stable and sustainable results. asure area, root angulations, interproximal contact position, triangular-shaped crowns and aging. Treatment of black triangles often requires an interdisciplinary approach, involving of periodontal; orthodontic and restorative treatment. In this review, the authors highlighted the important etiological factors that predispose to the occurrence of the black triangles. In addition to the common biological factors, dimensional changes of papilla during orthodontic alignment, the relevant consequences of periodontal disease treatment and iatrogenic treatment mishaps such as poor veneers and crowns are factors have also been discussed as factors that may lead to black triangles.

A case report on the management of mandibular midline diastema by using laser as a treatment modality

A frenum is a fold of mucous membrane that connects the labial mucosa (lips) to the gingiva or that connects the tongue to the floor of the mouth and hence providing support to the lips and the tongue. The normal frenal attachment is at the level of mucogingival junction (mucosal) and hence maintaining a balance between the interproximal contacts of the anterior teeth of either maxilla or mandible. But if this frenal attachment is high or in other words if there is a an aberrant frenum, then this type of frenal attachment either results in spacing between the anterior teeth or in some cases can lead to the loss of gingival embrasure resulting in the creation of black triangle between the anterior teeth. Present case report is on a 38 years old female whose chief complaint was spacing between the mandibular central incisors and upon intraoral examination, it was noted that there was an aberrant frenum which has also resulted in loss of gingival embrasure between the mandibular anterior teeth and hence this aberrant frenum was treated by a process called frenectomy by using a thermal treatment modality called as Laser. Upon follow up after 1 week, there was a reduction in spacing between mandibular central incisors.

Impact of long contact areas for the management of varying levels of interdental papilla loss on the perception of smile esthetics between dentists and laypersons in asymmetric and symmetric situations.

To determine the effect of restorations with long contact areas for the management of interdental papilla deficiencies, in smile attractiveness among laypersons and dentists. A full-portrait image was used to create a set of digitally modified images, simulating the management of various levels of interdental papilla loss. In a total of 48 modified images, single as well as multiple loss of interdental papilla among the anterior teeth, treated with a single or multiple restorations were simulated for unilateral and bilateral situations. Through a digital monitor 160 laypeople and dentists were asked to assess the attractiveness of each displayed image utilizing a visual-analog-scale. Multiple Wilcoxon-signed-rank tests followed by Mann-Whitney U tests were performed considering a significance level of 0.05. The management of an open gingival embrasure due to interdental papilla loss, by simulating the restoration of both central incisors led to a significantly higher mean smile attractiveness compared to the restoration of a single central incisor. Among the investigated regions, the management of open gingival embrasure in the area of central incisors using a restorative approach was perceived as the least esthetic (p<0.05). Despite the restorative management of interdental papilla loss, with the establishment of longer contact areas for the reduction of open gingival embrasures, as the level of the interdental papilla loss is increased, facial esthetics are compromised. When a longer contact area is accomplished through a single restoration, asymmetry among the teeth can be induced, especially in the region of the central incisors.

Diastema Closure in Conservative Dentistry

Diastema, or gaps in the front teeth, is unsightly and can have a detrimental effect on an individual's self-confidence and ability to make professional connections in social and professional settings. Therefore, examining the patient's wants, desires, and aesthetic concerns is important to evaluate the treatment plan to get optimal results. Modern eons have seen an upsurge in the need for interdisciplinary relationship between orthodontics, restorative dentistry, and periodontology to achieve an effective treatment plan and consequence. The black triangle (gingival embrasure without papilla), which occurs when a diastema is closed directly, is a major issue in aesthetic dentistry. The black triangle will ruin the patients' smiles; therefore, it is best to avoid it. The composite mastic used to seal diastemas should have sufficient convexity in the gingivo-incisal direction to prevent this issue. Closing a diastema can be done in several ways, some of which take a long time or do not give a good contour.

Esthetic and periodontal management of missing lower anterior teeth

The issue of missing teeth in the lower esthetic zone can either be addressed by orthodontic space closure or opening with subsequent prosthodontic substitution. Space closure bears the risk of postreatment open gingival embrasures especially in older patients and suboptimal occlusal outcomes due to lack of intercanine and interincisal contact which may render space opening the preferred treatment. To date modern CAD/CAM technology for fabricating custommade zirconia resin-bonded devices in combination with connective soft tissue grafting offers a minimally invasive approach for achieving excellent esthetic and functional outcomes in patients for which space opening is the only treatment option.

The incidence and severity of open gingival embrasures in adults treated with clear aligners and fixed appliances: a retrospective cohort study

BackgroundTo evaluate the incidence and severity of open gingival embrasures (OGEs) in adult patients treated with clear aligners and fixed appliances.MethodsTwo hundred non-extraction adult subjects with less than 5 mm of crowding (mean age, 24.6 ± 3.8 years) were enrolled in this retrospective study. The subjects were divided into the clear aligner (n = 100) and fixed appliance group (n = 100). The intraoral photographs were utilized to determine the incidence of OGEs in the upper arch between maxillary central incisors, as well as the lower arch between mandibular central incisors. Crown overlap, crown shape, posttreatment root angulation, the distance from the interproximal contact point (ICP) to the alveolar bone crest (ABC) after treatment and interproximal enamel reduction (IPR) were determined in the two groups.ResultsThe incidence of OGEs between maxillary and mandibular central incisors after orthodontic treatment was 35.0% and 38.0% in the clear aligner group, respectively, significantly higher than that (18.0% and 24.0%) in the fixed appliance group (P < 0.05). The average area of an OGE after clear aligner treatment was larger both in the maxilla (0.16 ± 0.12mm2) and mandible (0.21 ± 0.24mm2) compared with that (0.05 ± 0.03mm2 and 0.05 ± 0.06mm2) after fixed appliance treatment (P < 0.05). No difference was found regarding pretreatment crown overlap, crown shape, treatment duration, posttreatment root angulation, amount and distribution of IPR and the distance from ICP to ABC.ConclusionsThe incidence and severity of OGEs were higher in adults treated with clear aligners. Clinicians should be aware of the risk of OGEs during treatment with clear aligners.

Keterkaitan antara Halitosis dengan Bakteri Penyebab Periodontitis

Halitosis, often known as foul breath, refers to an unpleasant odor that emanates from the mouth cavity when inhaling or talking. Halitosis can have a negative impact on a person's quality of life, including symptoms of depression or anxiety, low self-esteem, embarrassment, prejudice, and social isolation. Bad breath can be caused by both intra oral and extra oral factors. Bacterial growth in the oral cavity is excellent for the production of volatile sulfur compounds (VSC). The posterior dorsum of the tongue, gingival sulcus, periodontal pockets, and gingival embrasures are all places where bacterias can accumulate. Fusobacterium nucleatum, Prevotella intermedia, Porphyromonas gingivalis, and Treponema dentiocola are known to actively produce VSC through interactions with specific substrates such as cysteine, methionine, tryptophan, arginine, and lysine to produce hydrogen sulfide (H2S) and methylmercaptan (CH3SCH3). However, the presence of VSC does not indicate the presence of periodontitis, as any space in the oral cavity that can cause the retention of bacteria/biofilms can become a site for bacterial decomposition, thereby facilitating the growth of VSC. Tongue cleansing is proven to help reduce the formation of VSC.

Restoring black triangle with bioclear matrix versus conventional celluloid matrix method: a randomized clinical trial

BackgroundOpen gingival embrasures form complex aesthetic and functional problems. This clinical trial assessed the bioclear matrix using injection molding technique against conventional celluloid matrix technique in management of black triangle.MethodsA total of 26 participants were randomly divided into two groups (13 participants each) according to the technique used. In group (A) celluloid conventional matrix method was used, while in group (B) bioclear matrix with injection molding technique was used. The different outcomes (Esthetic evaluation, marginal integrity and patient satisfaction) were evaluated following the FDI criteria by two blinded examiners. The evaluation was done at (T0) (immediate after restoration); (T6) after 6 months; and (T12) after 12 months. Statistical analysis was done as categorical and ordinal data were presented as frequency and percentage values. Categorical data were compared using fisher’s exact test. Intergroup comparisons for ordinal data were analyzed utilizing the Mann–Whitney U test, while intragroup comparisons were analyzed using Friedman’s test followed by the Nemenyi post hoc test. The significance level was set at p ≤ 0.05 within all tests.ResultsRegarding radiographic marginal integrity and marginal adaptation, the bioclear matrix group revealed superior results when compared to celluloid matrix group with a significant difference between both groups at all intervals (p < 0.05); however no significant difference was detected at different intervals. While for proximal anatomical form and esthetic anatomical form, as well as phonetics and food impaction, all cases in both groups were successful with no statistical significant difference between groups. For the periodontal response, there was no significant difference between groups. However, there was a significant difference between scores measured at different intervals, with T0 being significantly different from other intervals (p < 0.001). Marginal staining revealed that there was no significant difference between groups. While, a significant difference between scores measured at different intervals.ConclusionsThe restorative management of the black triangle with both protocols was able to deliver superior aesthetic and good marginal adaptation; suitable biological properties; with adequate survival time. Both techniques were almost equally successful, however they are depending on the operator skills.Trial registrationThe clinical trial was registered in the (www.clinicaltrials.gov/) database in 23/07/2020; with the unique identification number NCT04482790.

Periodontally accelerated osteogenic orthodontics: A narrative review

The orthodontic patient has evolved in recent years, leaving an important place for adult patients. These patients most often require special management, they are demanding aesthetic orthodontic treatments, but also shorter. The acceleration of orthodontic movement has long been sought for its multiple potential contributions, including the reduction of treatment time, a reduction of side effects linked to the maintenance of orthodontic equipment in the oral cavity (such as bacterial plaque retention, root resorption, and the open spaces of the gingival embrasure), an improved tooth movement envelope, differential tooth movement, and improved stability after treatment. Numerous surgical techniques have been developed to speed up orthodontic movements. The aim of this study was to review the current literature regarding the periodontally accelerated osteogenic orthodontics technique.

Biomechanical factors in the open gingival embrasure region during the intrusion of mandibular incisors: A new model through finite element analysis.

Introduction: Open gingival embrasure (OGE) is a common complication in adults following clear aligner therapy and the influence of gingival or alveolar bone biotype on OGE is of great concern. Unfortunately, due to the limited number of patients with clearaligner therapy and the clinical methods to distinguish the gingival biotype of patients being invasive, it is difficult to carry out clinical studies on the gingival or alveolar bone biotype of the OGE. In the meanwhile, the detailed biomechanics of the occurrence of OGE remains unknown. The goal of this study was to establish a new model to simulate the virtual space region, namely, the OGE region, to investigate the relationship between alveolar bone biotype and the occurrence of OGE, and explore potential biomechanical factors related to OGE. Methods: The OGE region in the interproximal space was established using a filler with a very low modulus of elasticity (1 × 10-6MPa). To illustrate the biomechanics of OGE more exhaustively, a line was created at the top of the alveolar crest along the proximal tooth root. FEA was then used to analyze the biomechanics of the surrounding tissues, the OGE region and the line at the top of the alveolar crest along the proximal tooth root of the central incisor under two different labial bone thicknesses (thick and thin) with an axial inclination of 80°, 90° and 100°. Results: During intrusion of the incisors in clear aligner therapy, as inclination increased or bone tissue became thinner, the stress in the surrounding tissues [tooth root, alveolar crest, and periodontal ligament (PDL)] was greater. In the OGE region and interproximal alveolar crest, the strain increased with increasing inclination and labial bone thinning. The results from the line at the top of the alveolar crest along the proximal tooth root showed more detailed biomechanics: In all groups, stress and strain were focused on the mesial-labial alveolar crest. Interestingly, our results also demonstrated that when OGE occurs, other complications may arise, including root resorption and bone dehiscence.

IPR treatment and attachments design in clear aligner therapy and risk of open gingival embrasures in adults

BackgroundThe incidence of open gingival embrasures (OGE) in patients after fixed appliance treatment is relatively high, while there are no detailed reports on patients after clear aligner therapy. Also, no clinical studies with large sample size have investigated whether interproximal enamel reduction (IPR) can actually avoid OGE. The purpose of this study was to determine the prevalence of OGE in adults after clear aligner therapy and to investigate the risk of OGE associated with IPR treatment and attachment design, focusing on the amount and distribution in mandibular anterior teeth.MethodsPre-treatment and post-treatment intraoral frontal photographs of 225 non-extraction patients were evaluated retrospectively for the occurrence and severity of OGE. The amount of IPR and the number of attachments in the anterior teeth from subjects after screening were recorded according to the first version of clear aligner software (Clincheck, San Jose, USA) and clinical medical documents. Logistic regression analysis was performed to identify the factors contributing to OGE.ResultsThe incidence of OGE in non-extraction patients after clear therapy between maxillary and mandibular central incisors was 25.7% and 40.3%, respectively. IPR was not associated with the occurrence of OGE but was associated with severity (P < 0.05). The number of attachments in the anterior teeth or central incisors was significantly related to the incidence of OGE (P < 0.05) but was not associated with severity.ConclusionA high rate of OGE occurs after clear aligner therapy. Clinicians should be aware of the application of IPR and the design of attachments during clear aligner therapy.

Comparison between Subjective and Colorimetric Probe Technique in Grading Interdental Embrasure Spaces in Esthetic Zone

Background: An effective nonsurgical and surgical periodontal treatment cannot be accomplished by brushing alone as it does not detach the plaque interdentally. Interdental cleaning aids can remove this interdental plaque. This optimizes the plaque control. Selecting the right size of interdental brush fills the entire interdental space thereby cleaning all the areas of the embrasure. Aim: The aim of the study was to assess the grading of gingival embrasure by periodontists with subjective technique and calibrated interdental probe. Subjects and Methods: Ten healthy patients were selected for the study. Gingival embrasures of patients were assessed with discretion by six periodontists. Later, every periodontist was educated about the use of calibrated probes. After a specific time-lapse, all the periodontists have examined the same patients again with the calibrated interdental probe. The embrasures in the patients were examined from left to right in maxillary and mandibular single-rooted and bicuspid teeth. Statistical Analysis: The assessment of scores between calibrated and arbitrary techniques by a single doctor for each gingival embrasure in all the patients was calculated by the Wilcoxon matched pair test. Comparison between doctors with the mean error was calculated by the Kruskal–Wallis ANOVA. Results: Significant results were observed in grading gingival embrasures by individual periodontists for every tooth between calibrated and arbitrary techniques. Conclusions: Based on morphology and location of teeth the gingival embrasure space differs. Choosing an interdental aid subjectively, probably will not give an appropriate cleaning viability. To accomplish a legitimate cleaning viability, an appropriate size interdental brush ought to be chosen for a specific embrasure. Utilizing a calibrated interdental probe helps the clinician choose an appropriate interdental brush for a specific embrasure space.

Management of central diastema with high-frenulum labialis

Objective: To explain the management of the central diastema case in a patient with high- frenulum labialis. Methods: Using a conventional Orthodontic appliance MBT system. This method is selected to orthodontically corrected central diastema while eliminating deep bites and other existing malposition in this case. Results: Central diastema and deep bite corrected, as well as other malposition. However, the frenulum labialis which was planned to undergone frenectomy was postponed to avoid an open gingival embrasure (black triangle). Conclusion: Correction of central diastema done by using a conventional orthodontic appliance MBT system. However, the disposal of frenulum labialis should not always be done, because it should consider the possibility of the emergence of gingival embrasure (black triangle) after the Labialis frenulum was discarded.

ASSESSMENT OF MICRO ESTHETICS IN PATIENTS REPORTING FOR ORTHODONTIC TREATMENT

Background: Patients today seeking esthetic treatment are looking for enhancement of their appearance for improved quality of life. We advocate the use of the term “appearance” in conjunction with the term “esthetics'' because it involves a broader assessment of the patient other than the smile. So, in orthodontic diagnosis and treatment planning we have created an approach in evaluation divided into three divisions:1 Macro Esthetics—this includes the profile, vertical facial dimensions—in other words—the face. (2)Mini Esthetics—the smile attributes—buccal corridors, smile arc, incisor display, etc. (3) Micro esthetics—the teeth and their many attributes such as contacts and connectors, embrasures, gingival shape and contour.Aim: The aim of this is to the micro esthetics in patients reporting for orthodontic treatment in Saveetha Dental College.Material and Methods: This is a retrospective clinical study carried out at Saveetha Dental College, Chennai. This study involves the assessment of micro esthetics in patients reporting for orthodontics treatment. The data were taken over a period of 2 years from June 2019 to February 2021. The sample/data were retrieved based on micro esthetics , crown length and width ratio, gingival embrasures, midline, tooth shape.Results: According to the study 66% of the individuals had different crown length and crown width ratio and 34% of individuals had the same crown length and crown width ratio. Most of the patients had midline deviations.Conclusion: Within the limits of the study most of the patients have micro esthetic assessment after orthodontic treatment.

A survey of orthodontic clear aligner practices among orthodontists

The purpose of this cross-sectional study was to survey orthodontic clear aligner therapy (CAT) practices among orthodontists in Australia. A pilot-tested electronic questionnaire was distributed to 434 full members of the Australian Society of Orthodontists. Questions were related to demographics, use and choice of aligners, digital treatment planning, patient selection, treatment protocols, refinements/finishing, retention, and patient-reported aligner issues. Factors regarding the decision not to provide CAT were also surveyed. The response rate was 54.6%. Most orthodontists (93.13%) provided CAT, which made up 24.17% of their annual orthodontic caseload. The median percentage of initial digital treatment plans (DTP) approved without changes was 0, with 4-6 changes reported by 24.14%. Orthodontists reported a mean of 2.02 ± 1.76 refinements per patient. Orthodontists were least comfortable treating patients with bilateral crossbite (71.28%) and deep overbite (62.56%). DTP challenges regarding tooth attachments and tooth positions and issues regarding patient compliance with CAT wear protocols were commonly reported. More than 1 CAT system was used by most (63.92%), with in-house systems used by 21.63%. Orthodontists rarely or never (63.68%) performed premolar extraction treatment with CAT. Adjunctive interproximal reduction was reportedly mostly carried out to relieve crowding and reduce open gingival embrasures. The view that fixed appliances provide better outcomes was a major influence (71.43%) on the decision for those who did not provide any CAT. CAT practices among orthodontists varied. Further research is required to investigate the challenges in effective CAT provision highlighted in this survey.

Black Triangle and Vitiated Esthetic Vis-à-Vis Management: A Review

Along with functional periodontal health, esthetic demand is increasing among patients. Creating a perfect smile through periodontal plastic procedures or multidisciplinary approaches involving orthodontic, restorative, and prosthetic specialties is a real challenge in esthetic dentistry. “Black triangle” is one of the common causes that can compromise esthetic. Black triangle is open gingival embrasure cervical to interproximal contact. Its presence may also cause problem in phonetic and retention of food debris. This article discusses the definition, causes, classification, prevalence, and various approaches in handling the case of black triangle.

A NOVEL PERIODONTAL PLASTIC SURGICAL PROCEDURE FOR PAPILLA RECONSTRUCTION IN ANTERIOR AESTHETIC REGION WITH A VARIANT BEAGLE'S TECHNIQUE- A CASE REPORT

Black triangle, an open interproximal space between maxillary anterior teeth can create aesthetic concern among patients specially while smiling and during speech. There are several risk factors leading to the development of black triangle and the most common among them includes aging, periodontal disease, length of embrasure area, interproximal contact position, triangular- shaped crowns and root angulations. Various techniques like orthodontic correction, prosthetic veneers and various periodontal surgical methods have been used to cover these unesthetic open embrasures. Treating this black triangle can be best done by surgical techniques but it is challenging and very unpredictable. The purpose of this case report is to present a papilla regeneration technique with minimal surgical trauma in the reconstruction of papilla in the maxillary anterior region of a 36-year-old woman who presented with class II interdental papilla loss in 21 and 22 regions according to Nordland and Tarnow's classification. In the present study, a variant technique given by Beagle in 1992 was used to cover this open gingival embrasure. The technique uses a gingival flap from the labial aspect to close the open gingival embrasures thus improving the aesthetic as well as smile of the patient. The results obtained with this technique were satisfactory.

Use of a Rotational Flap with Soft Tissue Graft and Tunneling Technique for Ovate Pontic Site Development for a Highly Esthetic Outcome: A Case Report

The objective of therapy was to replace the missing teeth with a restoration that closely adhered to the natural teeth and soft tissue contour to provide an esthetic outcome. A 19-year-old male reported a failed fixed partial denture (FPD) in the maxillary left central incisor. The abutment extended to the maxillary right central incisor and the maxillary left lateral incisor. Radiographic examination revealed that the neighboring maxillary right central incisor abutment was nonrestorable. The treatment plan was the extraction of the maxillary right central incisor with socket preservation, modification of the pontic sites for placement of an ovate pontic for the replacement of the missing maxillary upper central incisors with an FPD with the maxillary lateral incisors serving as the abutment teeth. The pontic sites were corrected with a U-shaped flap extended 5 mm palatal from the mid-crestal line. The incision was avoided at the interdental papilla area. The facial flap was elevated. The facial soft tissue was vertically tunneled. The flap was flipped into the facial tunnel and stabilized with horizontal nylon matrix sutures. The surgical site was stabilized with a provisional FPD with an ovate pontic. The final restoration was a full zirconia facial veneered FPD. Surgical site showed significant healing with a natural emergence profile, and interdental papillae filling the gingival embrasure, showing no evidence of recession. At the 1-year follow-up, the gingival thickness improved and the pontic emergence profile was natural. A very stable result for soft tissue volume and interdental papillae were seen. According to the result obtained with rotational flap, it can be used for small anterior defects with promising results, without the need for bone graft procedures or additional tissue graft. With proper case selection, the use of a rotational flap with a tunnel technique and an ovate pontic in the anterior esthetic region is an alternative treatment option that can successfully restore masticatory and esthetic function.

Three-Dimensional Finite Element Analysis of Different Connector Designs for All-Ceramic Implant-Supported Fixed Dental Prostheses

All-ceramic fixed dental prostheses (FDPs) tend to fracture at the connector regions due to high stress concentration at these areas influenced by their design. This study was performed as an adjunct to an existing clinical study to evaluate the influence of the different radii of curvature of gingival embrasure on the stress distribution of a three-unit all-ceramic implanted supported FDP. Three three-dimensional (3D) models were created by scanning two titanium dental implants, their suitable zirconia abutments, and a patient-retrieved dental prosthesis using a micro-CT scanner. The radius of curvature of the gingival embrasure for the distal connector of the FDP was altered to measure 0.25 mm, 0.50 mm, and 0.75 mm. A finite element analysis (FEA) software (ABAQUS) was used to evaluate the impact of different connector designs on the distribution of stresses. Maximum Principal Stress data was collected from the individual components (veneer, framework, and abutments). The radius of curvature of gingival embrasure had a significant influence on the stress distribution at the assessed components. The tensile peak stresses at all structures were highest in the 0.25 mm model, while the 0.50 mm and 0.75 mm models presented similar values and more uniform stress distribution.

Potency of hyaluronic acid from eggshell–membrane for open gingival embrasure reconstruction following orthodontic tooth movement (a histomorphological study)

The aim of this research was to assess the effectiveness of eggshell-membrane (ESM)-containing hyaluronic acid (HA) in the treatment of open gingival embrasure (OGE) following orthodontic tooth movement (OTM).This study is an in vivo quasi experimental research. A total of 24 Cavia cobaya were equally divided into two groups, treatment (10% HA injection) and control (phosphate-buffered saline [PBS]). A separator was inserted between mandibular incisors to induce an OGE. A volume of 20 μl of either PBS (n = 12) or ESM extract (n = 12) was locally injected within the interdental papilla. Decapitation of animals was made on day 1, 4, and 7 postinjection. The staining was done using hemotoxylin and eosin to observe angiogenesis and Mallory to observe the collagen density. Fourier-transform infrared spectroscopy (FTIR) and thin-layer chromatography (TLC) analysis were performed to detect the amount of HA available in ESM. The results were then compared with independent t-tests and the Mann-Whitney test. The level of statistical significance was set at 0.05.The FTIR and TLC analysis showed that HA was successfully identified in the ESM samples. Local injection of 10% HA induced an increase of angiogenesis compared to the control group on day 1 and 4 postinjection (P < 0.05). Significant differences (P < 0.05) were also noted in the collagen density and the growth of interdental papilla on day 4 and 7 postinjection.ESM has the potential effect of regenerating the interdental papilla construction after OTM by increasing the collagen fiber density and inducing angiogenesis.