Inverted T-Shape Connective Tissue Graft for Interdental Papilla Reconstruction: A Clinical Case Series

Abstract

Objective: To evaluate the clinical application and outcomes of the inverted T-shape connective tissue graft (IT-CTG) technique for reconstructing deficient interdental papillae in cases of advanced gingival recession, focusing on both quantitative and qualitative results in a consecutive case series.

Clinical considerations: The IT-CTG technique was performed using a remotely mucoperiosteal tunnel approach, with the donor graft harvested in an inverted T configuration from the palate. Patient selection included five individuals with RT2 or RT3 recession and papilla loss in the esthetic zone, following defined inclusion and exclusion criteria. All surgical steps were standardized, including graft shape, the use of thin suture material, and a consistent postoperative care protocol. Quantitative outcomes such as papilla height gain and Jemt's papilla index improvement were assessed at 3, 6, and 12 months. Among five treated sites, complete papilla fill (Jemt index score 2) was achieved in two sites (both RT3 cases; 40%) after restorative procedures had been performed, and partial fill (Jemt index score 1-2, corresponding to 50%-75% improvement) was observed in the remaining three sites (RT2 cases; 60%). The mean Jemt's papilla index improved from a baseline of 0.2 to 1.8 in the final follow-up. Acceptable esthetic outcomes and minimal morbidity were consistently noted across all patients. The addition of restorative procedures is expected to further enhance papilla fill and support creeping attachment over time.

Conclusions: The inverted T-shape connective tissue graft technique achieved acceptable papilla reconstruction, satisfactory esthetic outcomes, and minimal complications in this case series. While the results are promising, further controlled studies with larger sample sizes and longer follow-up are necessary to confirm the efficacy and broader applicability of this approach.

Clinical significance: Loss of interdental papilla in advanced gingival recession presents a significant esthetic and functional challenge, often resulting in compromised smile esthetics and patient dissatisfaction. The IT-CTG technique offers an innovative surgical solution for interdental papilla reconstruction, especially in cases where traditional approaches may be limited by poor vascularity and difficult access. By employing enhanced vascularization and a remotely tunneled approach, IT-CTG may improve esthetic outcomes and restore papillary architecture in the anterior esthetic zone. This technique is particularly beneficial in cases of RT2 and RT3 recession with papilla loss, where achieving optimal fill in a single procedure is challenging. Integration of IT-CTG into clinical practice expands the treatment options for clinicians managing complex mucogingival defects, though careful case selection and adjunctive restorative procedures may be required to support complete papilla regeneration and long-term stability.

Keywords: case study; connective tissue; esthetics‐dental; gingival recession.