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Hyaluronic acid (HyA) is a naturally occurring glycosaminoglycan with notable anti-inflammatory, antimicrobial, and regenerative effects. In periodontology, its applications have extended across a spectrum of soft tissue-related procedures, including post-extraction socket healing, interdental papilla reconstruction, root coverage, keratinized gingiva (KG) augmentation, and periodontal therapy. Despite its growing application in clinical practice, the use of HyA in periodontal soft tissue management lacks standardized protocols and long-term clinical validation. This review aims to synthesize recent evidence and address this gap by categorizing current applications and evaluating their specific outcomes. A narrative review was conducted by searching PubMed (Medline) for relevant studies published between January 1, 2014, and February 28, 2025. The search followed the PCC framework and was complemented by manual exploration through Google Scholar. The PRISMA statement 2020 was followed to select the included studies. A total of 104 records were identified through electronic and manual searches. After removing one duplicate, 103 records were screened. Following title and abstract screening, 22 articles were assessed for full-text eligibility. Of these, one article could not be retrieved, and two were excluded, resulting in 19 studies being included in the final review. Included studies were thematically categorized into five clinical applications: post-extraction healing, interdental papilla regeneration, root coverage procedures, keratinized gingiva augmentation, and periodontal therapy. Across these contexts, HyA demonstrated varying degrees of clinical benefit, particularly in enhancing early healing and esthetic outcomes. HyA represents a biologically active adjunct in periodontal soft tissue management, with context-specific benefits. Standardization of protocols and long-term trials is necessary to define their optimal clinical use.  

Objectives To assess treatment options for the reconstruction of the lost interdental papilla and to evaluate evidence for their efficacy. Methods An electronic search (Medline, Embase and the Cochrane Library Database and OpenGray) and a hand search were carried out to identify all types of studies investigating interdental papilla reconstruction (except for reviews) with a minimum of 3 months follow-up. Results Forty-five studies were included in the study including 7 RCTs, 2 cohort studies, 19 case series and 17 case reports. Fifteen studies reported on the use of hyaluronic acid, 6 studies on platelet-rich fibrin, 16 studies on soft tissue grafting, 4 studies on orthodontics and 4 on additional modalities. The most common outcome measures were black triangle dimensions and papillary fill percentage. Meta-analysis was not possible due to the high heterogeneity of the studies. Conclusion There are various options for interdental papilla reconstruction of which hyaluronic acid injections, PRF, surgical grafting and orthodontics seem to improve outcomes at a minimum 3 months. The use of soft tissue grafting with sub-epithelial connective tissue graft seems to be associated with the most robust evidence for the longer-term reduction of ‘black triangles’. There is insufficient evidence to make recommendations to clinicians. Further research is needed in the form of well conducted RCTs with longer follow ups and patient reported outcome measures. Clinical relevance Patients frequently complain about the appearance of black triangles and their management options seem unclear. This systematic review provides insight into the available reconstructive options.

Formation of black triangles due to the loss of interdental papilla is one of the utmost perplexing esthetic problems of the periodontium. Many surgical and nonsurgical treatment options have been researched upon to obtain complete papillary fill, but minimally invasive procedures have always been the choice of treatment both for the operator as well as the patient. This article describes the use of injectable platelet-rich fibrin (i-PRF) as a novel nonsurgical technique for the reconstruction of deficient interdental papilla. This is probably the first article that describes the use of i-PRF for the nonsurgical treatment of black triangles. Six sites with the presence of deficient interdental papilla in four patients were selected for this case series. After completion and reevaluation of scaling and root planing, autologous i-PRF was injected at the base of the interdental papilla using the insulin syringe. Photographs obtained before the treatment and at 1, 3, and 6 months after the intervention were assessed by Image J software along with clinical measurements. The use of novel nonsurgical injectable PRF technique allows clinician to successfully treat deficient interdental papilla.

In the anterior area of the mouth, the interdental papilla is important for dental hygiene and appearance. When it disappears, unpleasant “black triangles” form, which affects patients’ self-confidence in their smiles and makes oral hygiene more difficult. The loss of interdental papilla is caused by several variables such as tooth shape, periodontal disease, and aging. Although surgical treatments have been utilized to restore or retain missing papilla, their predictability remains unknown. In response, researchers have investigated non-invasive procedures, such as the use of fillers such as hyaluronic acid (HA). Owing to its capacity to increase tissue volume and bind water, HA, a naturally occurring polysaccharide with special rheological qualities, has become a popular choice for use as a dermal filler. It shows promise when used to cure interdental papilla loss; the effects usually last for six–12 months. This review article explores the development and history of papilla rebuilding methods, emphasizing hyaluronic acid as a cutting-edge and successful method for regaining both periodontal health and aesthetics.

Background and Objectives: The key factor that enables osteoblastic activity and the formation of new bone, as well as gingiva, during orthodontic tooth extrusion (OE) is the periodontal ligament. The reaction of periodontal tissues associated with changes in the gingiva is a part of orthodontic tooth displacement. The aim of this study was to examine the effect of OE on the width of the zone of the keratinized and attached gingiva, the position of the mucogingival junction, and the height of the interdental papillae in the region where the OE was performed as well as in the adjacent region. Materials and Methods: This research included 28 adult patients (both orthodontically treated and untreated). The treated group included 15 patients, in whom orthodontic extrusion of the upper or lower frontal teeth was indicated and performed. The untreated group included 13 patients, with no previous or undergoing orthodontic treatment. Patients with periodontal disease and periodontal pockets in the frontal region and patients allergic to iodine were excluded from the study. Gingivomorphometric measurements were performed on two occasions in three groups of teeth (24 extruded and 30 agonist teeth in the treated patients; 66 teeth in the untreated patients). Statistical analysis of the obtained data was performed using the software package SPSS version 26.0. Results: Orthodontic extrusion induced changes in the position of the mucogingival line and an increase in the width of the keratinized gingiva. There were no statistically significant effects on the depth of the gingival sulcus, the attached gingiva width, or the height of the interdental papillae. Conclusions: Orthodontic tooth extrusion has an effect on the periodontium in the observed region. Vertical orthodontic force, directed towards the coronal plane, affects the surrounding soft oral tissues.

Background and Aim: Reconstruction of interdental papillae (IDP) is among the most difficult periodontal therapy. Papillary recession is multifactorial, and several surgical, nonsurgical, and minimally invasive techniques have been suggested. The purpose of this study was to evaluate the clinical application of injectable hyaluronic acid (HA) gel for the reconstruction of IDP in Nordland and Tarnow's Class I and II papillary recession cases. Materials and Methods: In the present in vivo clinical trial, 7 patients (2 males, 5 females) with 25 defects were selected. A volume of 0.2 ml HA gel was injected at the respective areas and massaged for 2-3 min. Photographs were obtained, and the assessment of the data was performed clinically (CP-GM, interproximal width [IPW]) and by Image analysis software (black triangle height [BTH], black triangle width [BTW]). Comparison of mean values was performed using the analysis of variance, followed by Post hoc Bonferroni test. Value of P ≤ 0.05 was considered statistically significant. Results: Application of HA gel for the reconstruction of IDP was successful in 6 months. CP-GM, BTH, IPW, and BTW showed a statistically significant difference from baseline to 3 and 6 months interval (P = 0.01). Post hoc Bonferroni test for CP-GM, BTH, BTW, and IPW revealed a statistically significant difference from baseline to 3 months (P ≤ 0.05) and 6 months (P ≤ 0.05) and a nonsignificant difference at 3-6 months (P ≥ 0.05). Conclusion: Injectable HA gel is a promising minimally invasive therapy for enhancing papillary esthetics.

Objective: To evaluate the effectiveness of I-PRF in the reconstruction of recessed interdental papillae after three injections spaced two weeks apart. Materials and methods: The study included 8 participants aged 20–35 years. Periapical radiographs were taken and entered into ImageJ software to measure the distance between the apex of the alveolar process and the contact area. Cases were included when the distance was 5 mm or less. The following indices and parameters were evaluated: plaque index (PI), gingival inflammation index (GI), gingival bleeding index (GB), height of papillary deficiency (HPD), measure of change in the height of papillary deficiency (MHPD), and percentage of change in the height of papillary deficiency (PHPD). Autologous PRF was obtained and immediately centrifuged. The I-PRF was injected at the interdental papilla base. Patients were followed up three months post-treatment. Results: The mean papillary dimensions after three months (5.43 ± 0.99) were lower than the baseline mean (5.55 ± 1.05), with no significant difference ( P  = 0.171). No significant differences were observed between genders in the parameters ( P > 0.05): HPD, MHPD, and PHPD. Although the mean HPD in males after three months (5.88 ± 0.83) was lower than at baseline (6.00 ± 0.76), and a similar trend was observed in females after three months (5.13 ± 1.00) compared to baseline (5.25 ± 1.14), independent t-tests revealed no significant differences between genders. Improvements in PI and GI were noted after three months. Conclusion: Within the limits of this study, the I-PRF injection technique was ineffective in managing recessed interdental papillae three months post-treatment.

Background: The regeneration and maintenance of the interdental papilla presents a great challenge to the clinician while smile designing. Proportions of papilla height (PH), crestal PH (CPH), and proximal contact areas (PCA) are more stable parameters. Aim: The purpose of the present study was to evaluate and correlate the papilla proportion (PP), crestal PP (CPP), and PCA proportion (PCAP) in periodontally healthy males and females. Materials and Methods: One hundred and twenty patients in an age group of 20-40 years, divided equally based on gender, were assessed for PH, CPH, and PCA of maxillary anterior teeth. The findings were recorded on study models and radiographs to obtain the PP, CPP, and PCAP on the mesial and distal aspects of respective tooth. Statistical Analysis: The overall comparison of parameters was performed using paired t-test. Results: The mean mesial PP (43.51% ± 3.10% for male and 45.23% ± 2.23% for female) and CPP values (48.36% ± 3.35% for male and 51.16% ± 2.96% for female) were found to be greater of each tooth type and were more pronounced for females. The PCAP values were greater for distal aspects (36.76% ± 7.00% for males and 33.30% ± 6.93% for females). Conclusion: The results of the study indicate that PP and CPP are more pronounced in females, while the PCAP is more marked in males. Furthermore, it appears that the PP and CPP are inversely related to the PCAP in both males and females.

Objective: Development of classification system for interdental papilla recession that encompasses the morphology, etiology and treatment options. Methods: Literature search for the existing classification systems on papillary recession was performed. Two classification systems including the widely accepted Norland and Tarnow classification and the classification given by Chang et al., were included in the preparation of the proposed classification. The etiologies of papillary recession and treatment options for the same were identified after extensive literature search and were also included in the classification. Content validity was tested using the Content Validity Index (CVI). Results and Conclusion: A valid classification system encompassing the different morphological, etiological and treatment aspects of Papilla recession was developed. The proposed classification would serve to identify the treatment options for gingival papillary recession after considering the various aspects of the cause of recession. Clinical significance: This classification system would enable a clinician derive an appropriate treatment option with predictable treatment outcomes for gingival papillary recession with ease.

Background: The aim of the present narrative review is to synthesize the available scientific evidence on the minimally invasive surgical techniques for periodontal regeneration preserving the entire papilla without dissection. Surgical treatment of intrabony defects may result in compromising the integrity of the interdental tissues and subsequent papilla loss. Therefore, it is indicated to investigate the approaches avoiding papillary incision over the osseous defect, thus optimizing wound healing conditions. Methods: Authors performed a search of literature via electronic databases such as PubMed, Web of Science, Cochrane, and Scopus, and extended by manual searching with a stop date of February 2025. Based on inclusion criteria only randomized clinical trials (RCT), cohort studies, case–control studies, and case series were included, and 106 records were initially identified. Various aspects of described novel approaches preserving the entire papilla were finally discussed. Results: A total of 12 studies were evaluated. There is a significant lack of randomized controlled clinical trials on minimally invasive techniques without incision in the papilla. However, numerous modifications of existing techniques have emerged, mainly in the form of case series and case reports with short-term data. Among them, some authors stated that the entire papilla preservation approaches may facilitate early soft tissue healing, reduce papilla trauma and the risk of gingival recession, minimize procedure time, improve flap stability, and alleviate discomfort and side effects, while others reported similar outcomes to conventional approaches and emphasize the need for further comparative clinical trials. Conclusions: Preserving papilla integrity and the soft tissue profile is essential for minimizing complications, especially in the esthetic zone. Within the limitations of this narrative review, presented findings emphasize the effectiveness of entire papilla preservation techniques in preventing post-surgery tissue loss compared to conventional incisions and flaps. Randomized controlled trials with longer follow-up periods and larger sample sizes are necessary to validate the efficacy of these approaches in comparison to established papilla preservation techniques.