Interdental papillae and problems with them. What is an interdental papilla A papilla has become inflamed behind the front teeth
The main beautiful smile is, of course, the condition of the teeth. Their color, shape, size, bite. However, the condition of the gums is also important. The gums are the frame of your teeth and how neat, healthy this frame will be, the overall impression of your smile will depend.
Inflammation of the gum papilla
One of the common problems is inflammation of the gingival papilla. The gingival papilla is the part of the gum that is between the teeth.
With various diseases of the gums and teeth, in the case of inaccurate restorations, the gingival papillae become inflamed, hurt, change color, lose their shape, may partially or completely disappear, leaving rather unaesthetic gaps. Inflammation of the papilla may indicate a more serious dental problem.
Causes
Among the common causes of inflammation of the gums and gingival papillae:
- poor oral hygiene;
- gum injury;
- malocclusion;
- hormonal disorders.
The inflammation itself, for the time being, may not cause inconvenience, so patients often postpone a visit to the doctor or, worse, begin to self-medicate. Self-medication lubricates the symptoms, the disease progresses imperceptibly.
Chronic inflammation of the gingival mucosa can lead to the growth of papilla tissues. This phenomenon causes pain when eating, brushing your teeth. In some cases, the tissue grows so much that it covers the crowns of the teeth, forming gingival bays, where food debris, plaque and a huge amount of microbes accumulate.
If left untreated, the affected area begins to overgrow with gum, forming a large, loose part of the gum with high sensitivity. The affected area causes discomfort, pain when brushing your teeth and eating.
Treatment
The solution to the problem in most cases is the coagulation of the gingival papilla, i.e. cauterization. The procedure is carried out using an electrocoagulator, which is safe for the surrounding teeth. Discomfort may persist for 1-2 days after the procedure.
It is necessary to take as seriously as possible any, even seemingly insignificant, problem with the gums, because they can lead to larger and more complex troubles. Do not self-medicate, if there is any suspicion of gum disease, consult a doctor.
Doctor of Dentistry, Private Practice (Periodontology and Orthopedic Dentistry) (Leon, Spain)
Doctor of Dentistry, Private Practice (Periodontology) (Pontevedra, Spain); Associate Professor at the University of Santiago de Compostela
In order for the restoration to look natural, and the restored teeth to perform their function correctly, it is necessary to take into account the structure of the gums, the appearance of the lips and the face of the patient as a whole. Mucogingival surgery exists to treat gum recession.
Interdental papilla This is the area of the gum between two adjacent teeth. It not only performs the function of a biological barrier that protects the structures of the periodontium, but also plays a significant role in the formation of the aesthetic appearance. The absence of interdental papillae can lead to problems with pronunciation, as well as the retention of food residues in the interdental spaces.
With the loss of the interdental gingival papilla, its regeneration is quite difficult. Only a few such cases are known in dental practice. At the same time, none of the reports contains information on methods that allow the restoration of the gingival papilla. This report describes the surgical method for reconstructing the mucosa and papilla in the pontic pontic region in the presence of bone deficiency.
Surgical technique
A 45-year-old female patient came to the clinic for the treatment of periodontal pathology. She complained about the mobility of the two upper central incisors. The patient wanted to restore her appearance, as well as eliminate periodontal pathology. The central incisors had 3rd degree mobility, the depth of the pockets during probing was 10 mm and 8 mm. In the area of the right lateral incisor, a periodontal pocket 10 mm deep was also found in combination with a vertical bone defect, which indicated a deficiency of bone tissue under the gingival papilla (Fig. 1 a, b) .
Rice. 1a. Recession found on the vestibular side of teeth 11 and 12
Rice. 1b. Recession found on the vestibular side of teeth 11 and 12
A pocket 7 mm deep was also found in the region of 22 teeth.
When collecting anamnesis, no allergies, concomitant diseases or bad habits were revealed. The patient was assigned class 1 on the ASA scale. A few weeks before surgery, the patient was trained in oral hygiene, in addition, subgingival deposits were removed and the root surfaces were cleaned. After the removal of granulation tissue in the area of the gingival papilla in the region of the 12th tooth, a soft tissue recession to a height of 3 mm was found. In accordance with Miller's classification, she was assigned class III. On the vestibular side, in the area of teeth 11 and 12, soft tissue recession to a height of 2 mm was also found (Fig. 2) .
Rice. 2. Vertical defect and class III mobility of teeth 11 and 21
Due to bone loss around the two central incisors, a decision was made to remove them (Fig. 3) .
Rice. 3 a - d. The first large connective tissue graft was used in the area of the intermediate part of the bridge to protect the interincisal papilla. We made sure that the temporary prosthesis does not exert excessive pressure on the graft
When smiling, the patient's gums were partially exposed (no more than a third of the length of the coronal part). At the same time, the color of the gingival mucosa was heterogeneous. Photographs, x-rays, alginate impressions and masticography were taken. Based on the digital analysis of photographs, diagnostic models were made, which were then placed in the articulator. The patient was then offered treatment options. A tooth-supported bridge is the most relevant option for replacing missing teeth, especially as an alternative to complex vertical guided bone regeneration, which would require frequent examinations and strict adherence by the patient. The use of such a prosthesis is less risky than the installation of an implant-retained prosthesis, if bone and soft tissues are not present in sufficient quantities. The patient had a high socio-cultural level and aesthetic preferences. Taking into account other personal factors, in particular the patient's place of residence, we were forced to choose the fastest, most effective and reliable solution. During the first three visits to the hygienist, the patient cried. Given her emotional instability, we abandoned a comprehensive therapeutic approach to reduce the risk of psychological trauma and possible failure. After the existing problem was explained to the patient, she agreed to the removal of two central incisors, the correction of the gums in the area of the intermediate part of the bridge, as well as the gingival papilla using several connective tissue grafts. On the same day, after appropriate preparation of the canines and lateral incisors, a temporary fixed prosthesis was placed. The neck of tooth 12 was prepared appropriately for possible future soft tissue reconstruction. Endodontic treatment of the lateral incisors was required. Silicone impressions were made to create a second, more accurate, long-lasting temporary prosthesis, and to re-evaluate this clinical case from a biological, functional, and aesthetic point of view. Four weeks later, soft tissue recession was detected due to bone resorption from the vestibular side of the alveolar process of the upper jaw.
First, a large connective tissue graft was used (Fig. 4).
Rice. 4 a - d. After the second stage of surgery, the volume of tissue in the region of the right central incisor and the papilla between it and the lateral incisor was increased.
With the help of several soft tissue incisions, a tunnel was formed in the area of the intermediate part of the bridge prosthesis (Fig. 4) . A 6-0 nylon suture was used to fix the graft. We made sure that the temporary prosthesis does not exert excessive pressure on the graft (Fig. 4) . Then they took a break for 4 months. At the end of the period, an increase in the volume of soft tissues was revealed, which still remained insufficient (Fig. 5).
Rice. 5 a - d. The connective tissue graft was placed using a tunnel approach after frenectomy.
We needed more tissue in the region of the right central incisor and papilla between teeth 11 and 12. The depth of the pocket during probing is 7 mm (Fig. 5) . Considering the loss of 3–4 mm of papilla tissue, we can conclude that probing depth was likely to be 10 mm with a 5 mm bone defect at the level of the papilla. After that, they started the second phase of the surgical intervention (Fig. 5) . The preoperative condition of the interdental papilla was determined using the Norland and Tarnow classification. The interdental papilla, vestibular and palatal gingiva were anesthetized with local anesthesia using 1 capsule of Ultracaine® (articaine HCl/epinephrine, 40/0.005 mg/mL) and 1:100,000 epinephrine solution. For better visualization of the surgical field, a surgical dissecting loupe was used. First, a semicircular incision was made at the mucogingival junction to reposition the frenulum of the lip (Figure 6).
Rice. 6 a - d. A diamond cutter was used to remove part of the transplanted epithelium.
The second incision was made with a microscalpel from the lost gingival papilla along the gingival sulcus around the neck of the lateral incisor. The blade was turned towards the bone. The incision was made through the entire thickness of the gingival tissues and provided access for the mini-curette. The third incision was made along the apical border of the semicircular incision directly in the direction of the bone (Fig. 6). As a result, a gingival-papillary complex was formed. Its mobility was necessary to create a free space under the papilla and install a connective tissue graft. In addition, some mobility of the tissues of the palate was also provided. The resulting flap was fixed coronally with a sulcus-guided curette and a small periotome. The amount of donor tissue needed was determined by preoperative assessment of gingival and incisor heights compared to the proposed new papilla site. A section of connective tissue of significant size and thickness with a section of epithelium 2 mm wide was taken from the palate of the patient (Fig. 5). A section of the epithelium was taken to obtain a denser and fibrous connective tissue, as well as to better fill the space under the coronally fixed tissue flap. The use of a large volume of tissue increased the chances of successful graft engraftment, since the graft was fed from a larger area due to blood perfusion. An area of epithelium was placed on the buccal side of the coronally fixed tissue flap, but was not covered by it (Fig. 6), since the epithelium is more dense than the connective tissue, and therefore better suited as a base for the relocated flap. The connective tissue part of the graft was placed in the gingival sulcus of the lost gingival papilla to prevent movement of the tissue flap and retraction of the papilla (Fig. 6) . A 6-0 nylon suture (interrupted suture) was used to fix the graft in position and stabilize the wound. This microsurgical approach was made possible by the use of the Zeiss optical microscope. The palate wound was closed with a continuous suture. The patient was prescribed amoxicillin (500 mg, three times a day, 10 days), as well as an alcohol-free mouthwash with chlorhexidine (twice a day, 3 weeks). Cells of the keratinizing epithelium and food debris could be removed from the wound surface with a cotton swab soaked in chlorhexidine gluconate. The sutures were removed after 4 weeks. The patient was also prohibited from using mechanical means to clean the teeth in the area of the wound for 4 weeks. An earlier examination of the patient was not possible due to the remoteness of her place of residence. The postoperative period passed without complications. The third stage of surgical intervention took place before the installation of a permanent prosthesis. A part of the transplanted epithelium was removed using a diamond cutter (Fig. 7).
Rice. 7 a - c. Transformation of the intermediate part of the bridge after the first and second operations
The probing of the area between the intermediate part of the bridge and the lateral incisors was not carried out for 6 months. As a result of probing, a gingival pocket with a depth of 5 mm was found in the region of the lateral incisor, which was only 1 mm higher than the depth of the gingival pocket in the region of tooth 22.
results
The patient's condition was assessed 3 months after the first surgical procedure. Only horizontal tissue growth was achieved in the region of the intermediate part of the bridge (Fig. 8) .
Rice. 8 a, b. After the second stage of surgical intervention, the edge of the soft tissue of the gingival papilla was 3-4 mm closer to the incisors than before the operation, while there was no bleeding, and probing did not give negative results.
The probing depth in the region of the lateral incisor before the second operation was 7 mm. The right lateral incisor showed a recession 3 mm in diameter (Miller class III). After the second stage of surgical intervention, the edge of the gingival papilla was 3-4 mm closer to the incisors than before the operation. The probing depth decreased by 4-5 mm. A 2-year follow-up showed that the clinical results recorded 3 months after the operation had improved. In particular, there was no black triangle between the artificial crowns of the lateral and central incisors (Fig. 9 a, b).
Rice. 9 a. When checked two years later, no black triangle was found between the lateral and central incisors.
Rice. 9 b. When checked two years later, no black triangle was found between the lateral and central incisors.
There was no retraction or compression of the papilla tissue, and the probing depth did not increase. The radiographic study showed an improvement in the underlying bone (Fig. 10) .
Rice. 10 a - d. Radiographic examination showed a significant improvement in the underlying bone, although no bone graft was used.
The depth of the gingival sulcus of the papilla is greater than on the opposite side, there is no bleeding, and probing does not give negative results. The success of the procedure depended on the following factors:
- The space between the bone and the coronally fixed papilla was filled with a connective tissue graft.
- The connective tissue was well stabilized with a suture.
conclusions
In clinical cases that represent not only a medical but also an aesthetic problem, reconstructive surgery can mask tissue loss, but the patient rarely achieves an ideal appearance. To improve the results of such an intervention, periodontal plastic procedures can be used. It is recommended to use optics and microsurgical instruments. This allows the surgeon to improve visibility, avoid unnecessary incisions, and increase the chances of a favorable outcome.
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Gingivitis- this is an inflammation of the mucous membranes of the gums, which can be infectious and non-infectious, acute or chronic.
With gingivitis the gum is involved in the process without a circular ligament between the attached gum and the neck of the tooth. With the involvement of such a connection between the gum and the tooth, periodontitis develops, the outcome of which may be tooth loss.
Types and forms of gingivitis (classification)
According to the flow, they distinguish:1. Acute gingivitis- has a pronounced course, with proper treatment and elimination of the causes of development, the gum is completely restored, recovery occurs. Transition to a chronic form is possible. Most often, this form of gingivitis affects children, adolescents and young people.
2. Chronic gingivitis- the symptoms of the disease are often erased, patients sometimes get used to them. In a chronic course, periods of exacerbations and remissions are noted. Over time, irreversible changes form in the gums, it is possible to form pockets between the tooth and the gum and expose the tooth root.
According to the prevalence of the process, gingivitis is:
1. Local or focal gingivitis- the gum is affected in the area of one or more teeth and interdental spaces.
2. Generalized or widespread gingivitis- gums are affected throughout the jaw, more often both upper and lower. Generalized gingivitis is an occasion to think about the presence of more serious diseases in the body, resulting in problems with the gums, for example, diabetes mellitus, immunodeficiencies, including AIDS, digestive diseases.
Types of gingivitis depending on the form of gum inflammation:
1. Catarrhal gingivitis- This is the most common form of gum disease, it can occur acutely and chronically. Catarrhal gingivitis is characterized by serous inflammation, manifested by swelling, pain, redness and mucus discharge from the inflamed mucous membranes of the gums.
2. Ulcerative gingivitis (Vincent necrotizing ulcerative gingivitis)- this form of gingivitis is less common, usually the outcome of catarrhal inflammation. Associated with the activity of bacteria that destroy the tissues of the mucous membrane with the formation of ulcers and pus.
3. Hypertrophic (hyperplastic) gingivitis- always has a chronic course. This form usually occurs as a result of a prolonged inflammatory process in the gums. It is characterized by the growth of tissue of the mucous membrane of the gums (the medical term is proliferation).
There are two forms of hypertrophic gingivitis:
- edematous form - in the tissues of the mucous membranes of the gums, pronounced edema, increased blood circulation, that is, a chronic inflammatory process is observed. This form is partially reversible, that is, with proper treatment, it is possible to achieve a reduction in the growth of the gums.
- Fibrous form - connective (scar) tissue grows in the mucous membrane, while there are no signs of inflammation, this is the outcome of a chronic process and, unfortunately, irreversible. This is a visible cosmetic defect and discomfort when eating solid food.
Separately, we can also distinguish such forms of gingivitis:
1. Gingivitis of pregnancy- This is a fairly common phenomenon that a woman encounters in an interesting position. Usually it is hypertrophic gingivitis, its edematous form. The development of such gingivitis is associated with hormonal changes in the body of the expectant mother.
2. Adolescent Gingivitis- oddly enough, it is adolescent children and young people who are the most frequent patients diagnosed with gingivitis (8 out of 10 visitors to dental clinics complaining of gum problems). In most cases, this contingent is diagnosed with acute catarrhal gingivitis, so to speak, a "mild degree" of the disease, but in the presence of hormonal disruptions, the development of a chronic hypertrophic form of the disease is possible.
3. Herpetic gingivitis- inflammation of the gums caused by the herpes simplex virus. This is in most cases acute necrotizing ulcerative gingivitis against the background of chronic herpetic infection. Herpetic ulcers are usually located not only on the gums, but also on the mucous membranes of the entire oral cavity. Usually such gingivitis indicates problems with the immune system.
4. Desquamative gingivitis. With this form of gingivitis, partial rejection of the surface epithelium of the gingival mucosa occurs. First, red spots appear that form blisters, after they are opened, painful ulcers appear. The peculiarity of this gingivitis is that the causes are unknown, it is always a generalized and chronic process with an undulating course.
Causes of Gingivitis
There are a lot of reasons for the development of gum disease, and each of us faces them in everyday life. There are two groups of causes that lead to gingivitis. Firstly, these are internal causes, that is, those processes that normally or pathologically occur in the body and act on the gums. Secondly, these are external factors that injure, irritate and inflame the gums. The main cause of gingivitis is dental disease, infections and poor oral care. The remaining factors in most cases are a predisposing ground for gum disease, although they can also act as separate causes.
External causes of gingivitis
1. Infections and disorders hygiene oral cavity- pathogenic bacteria settle on the teeth, mucous membranes of the gums and oral cavity, can cause inflammation. Infections get through food, the remains of which remain in the oral cavity, dirty hands, toys, nipples, kitchen utensils, using dirty toothbrushes. Gingivitis can also be caused by so-called "childhood infections", that is, chicken pox, measles, rubella, scarlet fever and others.
2. Tartar - plaque on the teeth, which is impregnated with calcium salts and hardens, has a color from yellow to brown. Such a plaque eventually forms in almost every person, it is difficult to remove it at home. The dentist is better at this task. Tartar is often deposited in the gum crevices, pushing the gum back, injuring it. In addition, plaque is a good environment for the development of various bacteria in it. As a result, gingivitis is inevitable.
3. Caries always a source of chronic infection.
4. Visiting the dentist may result in gingivitis. This is an incorrect filling, tooth extraction, trauma to the mucous membrane during dental treatment, prosthetics, the use of caps for bite correction, and so on.
5. Dental implant rejection.
6. Physical stimuli: high and low temperatures, trauma from solid food or various objects, rough brushing of teeth, as well as the effects of radiation.
7. Chemical irritants. Alcohol, the use of low-quality toothpaste, rinse and other "dental chemicals", love for sweets, vinegar, spices, accidents of swallowing various solutions lead to chemical burns. The burn damages the mucous membrane, prepares the ground for the attachment of bacteria.
8. Smoking- combined action on the oral mucosa. Cigarette smoke is a chemical and physical irritant. In addition, smoking reduces local and general immunity, accelerates the deposition of tartar, acts on the nervous system, which contributes to impaired salivation. Smoking is one of the reasons for the development of atrophic gingivitis.
Photo: smoker's teeth.
9. Breathing through the mouth and snoring - at the same time, the mucous membranes of the mouth dry out, which contributes to the growth of bacteria.
10. habits Foods also contribute to gum disease. This is a love of sweet, spicy, sour and salty, the predominance of soft food in food, the lack of raw plant foods in the menu. All this irritates and injures the mucous membranes of the oral cavity.
Internal causes of gingivitis
| Cause of gingivitis | A form of gingivitis that can develop | How does gingivitis develop? |
| Teething | Acute catarrhal gingivitis | A growing tooth always injures the gum from the inside. Most often, children suffer both with the growth of milk teeth, and when they change to permanent ones. Adults encounter this problem with the growth of the so-called "wisdom teeth" or 3 molars (eights). |
| Malocclusion and other anomalies of jaw development | Chronic catarrhal gingivitis, Less often ulcerative and hypertrophic form. | Incorrectly positioned teeth during chewing periodically or permanently injure the gums and other mucous membranes of the oral cavity. |
Immune disorders:
| Chronic gingivitis, generalized forms. | Reduced general or local (in the oral cavity) immunity cannot fight various bacteria, viruses and fungi, as a result, any physical or mechanical irritation of the gums leads to the development of gingivitis. |
| Vitamin deficiency- avitaminosis and hypovitaminosis | Catarrhal and ulcerative gingivitis can occur acutely and chronically. | The most classic manifestation of gingivitis is scurvy, a vitamin C deficiency found in cold countries and deserts. A lack of vitamin C leads to a violation of the formation of collagen - the building material of connective tissue, which is present in absolutely all organs and tissues. Also, a deficiency of vitamins A, E, group B predisposes to gingivitis. |
| Digestive disorders and worm infestations | Chronic gingivitis | When the digestive system is disturbed, various conditions occur:
|
Hormonal disorders:
| Any form of chronic gingivitis often develops into generalized forms. Hormonal disorders are the most common cause of hypertrophic gingivitis. | Hormonal problems lead to metabolic disorders. Collagen metabolism suffers - as a result, a faster transition of chronic gingivitis into a hypertrophic form. In addition, due to a violation of protein metabolism, immunity and resistance to many infections suffer. |
Taking certain medications to a greater extent, these are hormones (hormonal contraceptives, steroids), as well as anticonvulsants.
Body intoxication due to drug use, poisoning with salts of heavy metals, severe infectious pathologies, tuberculosis, liver or kidney diseases.
Etiology of gingivitis
Gingivitis can be caused by various infections, both those that are normally found in the oral cavity, and pathogens that come from outside. The most common cause of gingivitis are staphylococci, streptococci, E. coli, fungi of the genus Candida, herpesvirus. Infections such as tuberculosis and syphilis can also lead to gingivitis.Symptoms
The first signs of gingivitis
First sign of gingivitis – This bleeding gums. The intensity of bleeding depends on the severity of the inflammatory process. Bleeding usually results from brushing your teeth, as well as eating solid foods (such as an apple). But in severe processes, blood can appear without much irritation of the gums, especially after sleep.Main symptoms
- Bleeding gums;
- soreness in the gums, which increases with eating, especially when eating irritating foods, such as hot or cold, sweet, spicy or salty;
- itching, swelling and redness of the gums in a limited area or throughout the mucosa of one or both jaws;
- bad breath;
- the presence of ulcers, abscesses, vesicles;
- increase or decrease in gums in volume;
- fever and other symptoms of intoxication - weakness, poor appetite, up to refusal to eat, feeling unwell and so on.
Symptoms of gingivitis depending on the type
| Type of gingivitis | Patient complaints | Changes during the examination of the gums, photo |
| Acute catarrhal gingivitis |
| The gum bleeds when pressed on it, swollen, bright red, loose, and the interdental papillae are enlarged. It is possible to identify single small ulcers. On the teeth in most cases there is plaque and tartar.  |
| Chronic catarrhal gingivitis |
| The gum bleeds, has a bluish tint, its thickening is noted, the gums resemble a roller above or below the tooth (due to swelling). Deposits of tartar are detected, the teeth do not stagger. |
| Ulcerative necrotizing gingivitis |
|
Materials and methods
Investigated subjects
0 - no papilla;
4 - hyperplasia of the papilla.
measurements
surgical procedure
Photo 1c. Palatal incision.
Photo 1d. Interlingual curette.
results
Discussion
Conclusion
Restoration of lost teeth with the help of orthopedic structures based on dental implants is a very common dental practice in our time. However, aspects of the osseointegration of the supports, as well as the restoration of the corresponding aesthetic parameters in the area of single and partial adentia, differ markedly.
An important aspect of rehabilitation remains the restoration of an adequate soft tissue contour and architectonics of the interdental papilla, both of which are extremely important components of an optimal smile profile. The absence of an interdental papilla compromises not only the appearance of the patient, but also provokes the occurrence of phonetic problems, as well as food getting stuck in the problem area.
Earlier studies have already proven the role of the distance from the tip of the interdental septum to the contact point between adjacent teeth as a factor influencing the amount of papilla restoration, at the same time, this parameter is variable for the papilla between adjacent natural teeth, between the implant and the own tooth, and also in the area of the overhanging part of the prosthesis. In cases where this distance between adjacent teeth is less than 5 mm, the papilla has the ability to completely fill the interdental space, while in the area between the implants, the average height of the soft tissues, as a rule, does not exceed 3.4 mm, as a result of which, in the area of implantation, deficiency of the height of the interdental papilla, which is critical in the rehabilitation of a patient with adentia in the anterior area.
There are many different approaches to repair the interdental papilla, however, often due to compromised blood supply conditions and scar tissue formation, most of the known surgical techniques are not predictive enough. Villareal in 2010 described a predictable approach to papilla regeneration using careful sequential soft tissue manipulations involving gentle incisions and minimal flap separation. The main principle of the author's approach was to maintain adequate blood supply and the existing quality of the mucosa. That is why, during this approach, it was recommended to abandon the suturing of the intervention area, since this can cause additional trauma or inflammation, which, ultimately, will negatively affect the final result of the treatment.
The purpose of this article is to present a series of clinical cases in which the restoration of the interdental papillae in the area of implantation was performed using a modified surgical technique.
Materials and methods
The clinical data used in this study were taken from the database of the Department of Periodontology and Implantology, Kriser Dental Center at New York University. Data certification was carried out in the quality control department of the same university. The study was conducted in accordance with the Health Insurance and Identity Sharing of Participating Parties Act and was approved by the University Committee for the Control of Research Conducted with Human Subjects.
Investigated subjects
The study included ten clinical cases of restoration of the edentulous region of the central region of the upper jaw using dental implants. The retrospective portion of the study analyzed patients with existing provisional restorations who had previously undergone an interdental papilla augmentation procedure between August 2011 and August 2012. The study group included 3 men and 7 women, whose average age was 45 years. During the study, the areas of the interdental papilla between two adjacent implants, between the implant and own tooth, as well as in the area of the intermediate part of the prosthesis in the area between the 13th and 23rd teeth were analyzed.
The inclusion criteria for the study group were as follows:
- The presence of an implant supporting a provisional restoration.
- No interdental papilla (0 or 1 according to Jemt classification).
- The absence of a papilla in the anterior part of the upper jaw between two adjacent implants, the implant and the tooth, in the area of the intermediate part of the prosthesis.
To assess the severity of the interproximal papilla, the Jemt classification was used:
0 - no papilla;
1 - the presence of a papilla only half of its normal height;
2 - the presence of more than half the height of the papilla;
3 - the presence of a papilla of normal size;
4 - hyperplasia of the papilla.
The exclusion criteria from the study group were as follows:
- The state of pregnancy or lactating women.
- Active form of periodontal disease in the area of remaining natural teeth.
- The presence of systemic diseases or medications that can affect the healing process of tissues around dental implants.
- Lack of motivation for long-term maintenance therapy.
measurements
Immediately after fixation of the provisional restorations, the distance from the contact areas of the suprastructures to the papillary region of the gums was measured using a North Carolina periodontal probe (Hu-Friedy). After that, the results were interpreted in accordance with the Jemt classification. In order to improve the accuracy of the final results, the measurements were carried out independently by two different investigators, but in no case did the opinions of the experts differ, and the condition of all papillae was rated as 0 or 1, according to the Jemt classification. During follow-up visits, measurements and classification of papillae were carried out according to the same scheme.
surgical procedure
Patients received 2 g of amoxicillin orally one hour before the intervention, or 600 mg for those allergic to penicillins. After local anesthesia with lidocaine with epinephrine at a concentration of 1: 100,000 (Henry Schein), the provisional constructs were removed in order to visualize the area of the interdental papilla. Before surgery, patients underwent a procedure for expanding the interdental space to provide sufficient volume for future soft tissues (photo 1a).
Photo 1a. Clinical view of a provisional restoration with a missing papilla in the area of the implant in place of the 12th tooth and the pontic in the area of the 11th tooth after augmentation.
Prior to modification of the provisional constructs, each of the papillae was assessed according to the Jemt classification. After removal of temporary restorations from the side of the vestibular mucosa, apical to the papillary region, an oblique incision was made through the entire thickness of the soft tissues (photo 1b).
Photo 1b. Oblique incision of the mucosa from the vestibular side.
A similar incision was also made on the palatal side (Figure 1c).
Photo 1c. Palatal incision.
The oblique direction of the incisions, as well as the formation of those at some distance from the existing papilla, was argued for the purpose of maintaining an adequate level of blood supply in the recipient site. Using the interlingual (TLC) (Ebina), modified and double-angled (Fig. 1d) curette, it was possible to provide tunneling access beyond the apical region of the papilla without additional soft tissue injury.
Photo 1d. Interlingual curette.
First, the working part of the instrument was placed in the region of the vestibular incision, after which the periosteum was carefully separated in order to form a subperiosteal tunnel to the alveolar ridge located apically to the existing interdental papilla (photo 2).
Photo 2a-2c. Separation of the periosteum using an interlingual curette.
At the same time, tissue separation was carried out so carefully that the area of the incision area was preserved in its original state. A similar manipulation was performed on the palatal side, which further helped to connect the two tunnel accesses.
The subepithelial connective tissue graft was taken from the palate after anesthesia. The procedure was carried out according to the techniques of Langer-Calagna, as well as Hurzeler-Weng. The wound area was sutured with 4/0 chromium-plated catgut sutures (Ethicon). Two sutures were placed on the mesial and distal sides of the graft itself to facilitate its further positioning and stabilization in the defect area (Figure 3).
Photo 3. Stabilization suture on a connective tissue graft.
The graft was initially placed in the recipient area through the vestibular incision, after which it was displaced up to the region of the palatine tunnel (Figure 4).
Photo 4. View of the graft placement in the area of the defect.
After reaching the optimal position of the graft, it was fixed in the region of the previously formed vestibular and palatine incisions using catgut sutures (photo 5).
Photo 5a-5b. Schematic representation of the augmentation procedure.
In the postoperative period, patients were prescribed amoxicillin 500 mg or clindamycin 150 mg three to four times a day for 1 week, ibuprofen was prescribed as painkillers (600 mg every 4-6 hours). Patients were also advised to use 0.12% chlorhexidine solution as a mouth rinse twice a day, starting 24 hours after surgery for the next 2 weeks, as well as a soft diet for the period of wound healing. Cleaning the intervention area with a brush or dental floss was prohibited, for this purpose it was recommended to use 0.9% saline 5 to 6 times a day, or the same chlorhexidine twice a day. Repeated examinations were carried out 7 and 14 days after the iatrogenic intervention (photo 6).
Photo 6. View 7-14 days after augmentation.
3 months after augmentation, the final prosthetic restorations were fixed (photos 7a-7d), while the design of those in the mucosal area exactly matched the contour of the previously fitted provisional restorations.
Photo 7a. Clinical view before fixation of the final prosthesis.
Photo 7b. Clinical view with final prosthesis in place.
Photo 7c. Clinical view of the final supraconstruction.
Photo 7d. X-ray of the implantation area at the site of the 12th tooth and the intermediate part in the area of the 11th tooth.
In some areas where the interdental papilla was not completely restored, a slight lengthening of the contact points was performed directly on the final supraconstructions. For the purpose of monitoring, all patients returned to the dentist every 3 months after fixation of the final restorations. Measurement of papilla height, as well as assessment of their parameters, according to the Jemt classification, during repeated examinations was carried out by two independent researchers. In one clinical case, a 55-year-old woman presented to the dentist for a "black space between implants" (Figure 8a).
Photo 8a. Papilla deficiency between implants.
In the area of adentia, in place of the left central and lateral incisors, she had two infraconstructions splinted by restorations. The papilla present was class 0 according to the Jemt classification. Restoration of the papilla was carried out according to the method described above. One year later, the black space area was completely filled with gingival soft tissue (Jemt 3), after which the patient received a new prosthetic restoration (photos 8b and 8c).
Photo 8b. View after 12 months: the new papilla filled the area of the defect.
Photo 8c. X-ray of the implantation area to control the bone tissue between the titanium supports.
results
The median follow-up in a series of 10 cases was 16.3 months (range 11 to 30 months), with a papillary improvement of 0.8 to 2.4 (range 0 to 3) based on the Jemt classification. ). At the same time, in 2 clinical cases, augmentation was performed in the region of the central incisors, and in 8 cases, between the central and lateral incisors. In only one patient, the papilla was restored between the implant and own tooth, while in 5 patients it was between two implants, and in 4 patients it was in the area of the pontic. During the study, zirconium abutments were used in 2 cases, and titanium abutments in 8 cases. Only in one clinical case, we failed to improve the initial soft tissue parameters.
Discussion
In order to restore the area of the interdental papilla, several clinical approaches have been proposed at once. For example, Palacci and colleagues used a full-tissue flap that was separated from the buccal and palatal sides and rotated 90 degrees to fill the space above the dental implants. Adriaenssens proposed the so-called "palatal sliding flap" method for restoring the papilla between the implant and the natural tooth in the anterior region of the maxilla. This approach consisted of moving the palatal mucosa in the vestibular direction. Nemcovsky and colleagues proposed using a U-notch to implement a similar approach. Arnoux developed several augmentation methods at once to restore aesthetic parameters around a single tooth, but later agreed that the proposed approaches are not predictive enough due to impaired blood supply and the presence of scar tissue.
Chao developed a needle-hole augmentation technique to restore the soft tissue covering of the root area. This approach did not require releasing incisions, acute dissection, or even suturing. The Chao procedure is very similar to the technique described in this article, with the difference that the first method involves only a vestibular incision and either a bioresorbable membrane (Bio-Gide, Geistlich) or a cell-free skin matrix (Alloderm, BioHorizons). The peculiarity is that the Chao technique is also aimed at restoring the coverage of the recession area, and not the reconstruction of the interdental papilla.
This article presents a modified approach to interdental papilla repair that provides predictive soft tissue regeneration outcomes. According to the results obtained, it was possible to achieve an improvement in the papilla area from 0.8 to 2.4, according to the Jemt classification. Based on this, this method can be recommended for the restoration of the papilla in the area between adjacent implants, between the implant and the tooth, as well as in the areas of the intermediate part of the prosthetic superstructure. At the same time, analyzing the results of treatment, it was also possible to conclude that the restoration of the papilla in the area between the implant and the tooth is more predictable than in the area between two implants. Based on the experience of the authors of the article, this is the first case of describing a technique for restoring the interdental papilla, which is quite predictable in the long term.
To provide adequate access and accurate formation of the muco-periosteal tunnel, the use of specific dental instruments is required. Thus, the use of an anatomically shaped interlingual (TLC) curette significantly reduces the risk of soft tissue perforation, and also increases the predictability of the performed manipulation (photos 1d and 2). At the same time, complete restoration of the papillae was achieved in 6 out of 10 clinical cases, and only in 3 cases did the doctor have to slightly lengthen the contact point in the area of the final restorations. But this did not affect the patient satisfaction rate with the results of the treatment. In one clinical case, we were unable to restore the soft tissues in the proper volume, which is why this patient underwent a second surgical intervention and is currently at the stage of wound healing.
Further clinical studies are required to confirm the stability of the results provided by this technique of soft tissue reconstruction, however, even based on the data obtained, it can be concluded that this technique is very predictable and effective for restoring soft tissues in the aesthetic zone.
Conclusion
Given the limitations of this study, a mean Jemt papilla improvement score of 1.6 (range 0.8 to 2.4) was found to be acceptable for soft tissue repair between two adjacent implants, between an implant and its own. tooth, as well as in the area of the intermediate part of the supraconstruction. Predictable treatment results are ensured by a precisely planned incision, an atraumatic approach and the provision of postoperative support at home. Further clinical studies are required to confirm the effectiveness of the proposed method.
Common problem: Loss of papillae and black triangles.
Loss of gingival papillae, especially in the anterior maxilla, is a major aesthetic problem and can cause significant psychological discomfort in patients with a high smile line.
The World Health Organization defines health as physical and psychological well-being. Therefore, dentists should strive to improve the appearance of the patient when restoring teeth (bridges, veneers, composite restorations) and correcting the gums. In other words, the goal of dental care is to ensure the physical and psychological well-being of the patient by optimizing the aesthetics of the teeth and gums.
With the prevalence of interdental papilla loss and associated aesthetic defects, there is a need to address this problem (Figures 4-3a and 4-3b).
Effective solution: Biological width measurement with bone probing.
In 1961, Gargiulo et al/ published the results of measurements of the depth of the periodontal sulcus, epithelial and connective tissue attachment, i.e. biological width (Fig. 4-hc). It is known that violation of the biological width leads to the development of gingivitis and periodontitis, even with careful oral hygiene (Fig. 4-3d). Tarnow et al. found an inverse relationship between the probability of filling the interdental space with the gingival papilla and the distance between the interdental contact and the alveolar ridge (Fig. 4-3e).
In the past, dentists paid attention to the location of the contact point solely for reasons of preventing food from entering the
Rice. 4-For. A forced smile does not bring satisfaction to the patient. There are "black triangles" between the teeth
Rice. 4-3b. patient smile line
Rice. 4-3d. The biological width was not taken into account during the treatment, which led to the development of gingivitis, despite careful hygiene
Rice. 4-Ze. The probability of filling the interdental space with the gingival papilla depending on the distance between the contact point and the edge of the bone (Tarnow et al.
interdental space and, taking into account this circumstance, prosthetics were performed, including the anterior group of teeth (Fig. 4-3f and 4-He). The coronal margin of interdental contact is predetermined by aesthetic criteria, while the apical margin depends on the distance to the alveolar bone (Fig. 4-3h).
In an article devoted to the features of the dentogingival complex, Kois
described the use of periodontal parameters in the planning of orthopedic treatment and the method for determining the contour of the edge of the alveolar ridge. It was this author who first demonstrated the feasibility of bone probing before prosthetics.
After local anesthesia has been administered, the periodontal probe is inserted until contact with the bone (Fig. 4-3i.
Rice. 4-3f. Symmetrical arrangement of contact points in the anterior part of the upper dentition.
and 4-3j), the obtained values are documented in the patient's chart (Fig. 4-3k). In the future, this data can be used in the creation of composite restorations, orthodontic tooth movement and the manufacture of prostheses, such as veneers and crowns (Fig. 4-31 and 4-3r).
Without a thorough analysis of the parameters of the gingival complex, it is impossible to achieve predictable regeneration of the gingival papillae (Fig. 4-3p).
The application of the method described above and the use of the obtained data during prosthetics allow us to obtain a satisfactory result (Fig. 4-3o).
Rice. 4-Zd. Wax-up of the upper anterior teeth (Kubein-Meesenberg et al.
). Localization of contact points is determined using interproximal cones
Rice. 4-3h. The relationship between the apical border of the interdental contact point and the level of the alveolar ridge (Tarnow et al.
Rice. 4-3j. Bone probing
Rice. 4-3i. Measurement of the size of the papilla and the distance between the bone level and the contact point
Rice. 4-Zk. Documentation of indicators in a special form
