J Clin Periodontol 2005; 32: 831–839 doi: 10.1111/j.1600-051X.2005.00748.x Copyright r Blackwell Munksgaard 2005

Laura Zetu1n and Hom-Lay Wang2 Management of inter-dental/ 1Private practice, Jackson; 2Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University of Michigan, Ann Arbor, inter-implant papilla MI, USA

Zetu L, Wang H-L. Management of inter-dental/inter-implant papilla. J Clin Periodontol 2005; 32: 831–839. doi: 10.1111/j.1600-051X.2005.00748.x. r Blackwell Munksgaard, 2005.

Abstract Objectives: The aims of this paper are to review and compare existing techniques for creation of interdental/interimplant papillae, to address factors that may influence its appearance and to present an approach that authors developed that could help clinicians to manage and recreate the interproximal papillae. Methods: Papers related to interdental and interimplant papillae published over the last 30 years were selected and analyzed. Results: Thorough treatment planning is essential for maintenance of the height of the interproximal papillae following tooth removal. The key for achieving an esthetically pleasing outcome is the clinicians’ ability of properly managing/creating interdental/ interimplant papillae. Bone support is the foundation for any soft tissue existence, techniques such as socket augmentation, orthodontic extrusion, guided bone regeneration, onlay graft and distraction osteogenesis are often used for this purpose. Soft tissue grafts as well as esthetic mimic restorations can also be used to enhance the Key words: bone grafts; dental implants; esthetic outcomes. esthetic; guided bone regeneration; inter- dental/inter-implant papillae; monocortical Conclusions: An esthetic triangle is developed to address the foundations that are bone graft; papillae; soft-tissue grafts essential for maintaining/creating papilla. These include adequate bone volume, proper soft tissue thickness as well as esthetic appearing restorations. Accepted for publication 17 November 2004

Inter-dental papilla is the gingival por- became a viable solution to fixed or compare techniques that are currently tion, which occupies the space between removable prosthodontics (Bra˚nemark available and to present the approach two adjacent teeth. Morphologically, the et al. 1977, Adell et al. 1981, Esposito that the authors developed that could papillae had been described first in 1959 & Worthington 2003). Better under- help clinicians to manage/regenerate the by Cohen (1959). Before this time, inter- standing of the osseointegration process inter-proximal papillae. dental papilla was considered as a gingi- makes implant rehabilitation no longer a val trait having a pyramidal shape and vehicle to restore lost masticatory and functioning as a deflection of the inter- phonetic function, but it has become a proximal food debris. Now it is clear that multi-million industry driven by the bone Anatomy of the Inter-dental/Inter- the physiology of the papilla is more augmentation, soft-tissue management implant Papilla complex. It not only acts as a biological and aesthetic restoration. Patients have In order to understand the factors barrier in protecting the periodontal come to expect aesthetically pleasing involved in maintaining the dental papil- structures, but also plays a critical role restorative treatments and have ques- la, a systematic review of the anatomy in the aesthetics. Hence, it is very impor- tioned the disappearance of inter-implant is to be included. Gingiva is that part of tant to respect papillary integrity during papillae (so-called ‘‘black triangles dis- the mucosa that has an intimate rap- all dental procedures and to minimize as ease’’). Therefore, many soft- and hard- port with the dental elements, the inter- much as possible its disappearance. tissue management techniques were dental space and the alveolar bone. Over the past 30 years, replacing developed to overcome this problem. Topographically, the gingiva has been missing teeth with dental implants Numerous studies have attempted to divided into three classic categories: free, determine the condition in which papilla attached and inter-dental gingiva. In fact, nFormerly, Resident, Department of Perio- would appear and ways to regenerate it. this subdivision is not needed since dontics/Prevention/Geriatrics, School of Dentis- The aims of this review are to evaluate we describe gingiva as an anatomical try, University of Michigan, Ann Arbor, the factors that influence inter-dental/ and functional complex with a different MI, USA. inter-implant papillae, to discuss and shape and topography resulting from the 831 832 Zetu & Wang tissue adaptation around teeth (Schroeder not entirely explain the presence of the between the locations (mesial, distal, & Listgarten 1997). Inter-dentally, the papilla (Spear 1999). Following this con- facial and lingual) for connective tissue gingiva that occupies the space coronal cept, it became evident that the soft tissue or epithelial attachment (Vacek et al. to the alveolar crest is known as inter- may play a crucial role in establishing the 1994) (Table 1). Thus, the mere existence dental gingiva. In the incisor area, it has a entire height of papilla. From the concept of a constant value of 2 mm of gingival pyramidal shape with the tip located of biologic width, which, in natural teeth, tissue above the alveolar crest fails to immediately beneath the contact point, defines the distance between the most explain by itself the 5 mm height (Tar- it is narrower and it is referred to as a extent of the gingival sulcus and the crest now et al. 1992, Salama et al. 1998) of dental papilla. In the posterior region, it of the alveolar bone (Gargiulo et al. the gingival scallop found in the case of is broader and was formerly described as 1961), we learn that this space is occu- the inter-dental papilla. However, Becker having a concave col or bridge shape pied by gingival fibres, hemidesmosomes et al. (1997) measured the mean (Cohen 1959). Moreover, the col is a and connective tissue in direct contact height from the alveolar crest to the valley-like depression, which connects with the tooth structure. This creates a inter-proximal bone and found that there the buccal and lingual papilla and takes natural seal around teeth protecting them is a statistically significant difference the form of the inter-proximal contact. from microbial invasion and traumatic between individuals regarding the anato- The borders of dental papilla are super- insult. When comparing the depth of the mical gingival scalloped contours (Beck- iorly the base of the contact point dentogingival tissues between different er et al. 1997). The authors emphasized between two adjoining teeth, inferiorly tooth surfaces, Vacek et al. (1994) found the concept that a more pronounced the alveolar crest and lateral borders that there were no significant differences gingival scallop had a higher level of delineated by the concave mesial and distal marginal gingiva of adjacent teeth (Fig. 1a and b). The inter-dental gingiva is attached to the tooth by connective tissue and junctional epithelium (JE) (Gargiulo et al. 1961) and it is lined in a coronal position by sulcular epithelium (Scrhoeder & Listgarten 1997).

Factors Influencing the Presence of Papilla Availability of underlying osseous support The foundation for the gingival support is the underlying contour of the osseous crest. Ochsenbein (1986) described the position of the inter-dental bone in rela- tion to the radicular bone, which was named ‘‘positive architecture’’. This term refers to the situations in which the osseous crest follows the shape of the cementoenamel junctions (CEJs), has a scalloped contour and the position of the inter-proximal bone is more coronal than the radicular bone. In the posterior areas, the inter-dental bone forms a tent- shaped ‘‘col’’ that is relatively flat bucco- lingually, while the anterior inter-dental bone has a pyramidal shape (Ochsenbein Fig. 1. (a) Inter-dental/Inter-implant papillae; (b) inter-proximal view of inter-dental papilla 1986). Gargiulo et al. (1961) measured in natural tooth; (c) inter-proximal view of inter-dental papilla in implant. the distance from the CEJ to the alveolar bone and they found that an average of 2 mm comprised this distance (Gargiulo Table 1. Biologic width around natural teeth and dental implants et al. 1961). When the authors looked at the differences of the osseous scallop Teeth Implants, Cochran (1997) from the facial to the inter-proximal, a Gargiulo et al. Vacek et al. range of 1.01–3.10 mm was described (1961) (1994) (Gargiulo et al. 1961). Therefore, it was hypothesized that the existence of this Sulcus depth (mm) 0.69 1.34 0.16 discrepancy of approximately 1.5 mm in Junctional epithelium (mm) 0.97 1. 14 1.88 bone height can be an important predictor Connective tissue (mm) 1.07 0.77 1.05 BW (mm) 2.04 1.91 3.08 for papillary appearance although it can- Management of inter-dental/inter-implant papilla 833 the inter-dental bone when compared dental papilla (Tal 1984, Heins & Wie- extraction or osseous intervention is to with a flatter gingival scallop (4.1 versus der 1986). Teeth with root proximity be performed. Therefore, the inter-prox- 2.1 mm). The concept of biological width (less than 0.5 mm inter-dental distance) imal area poses more challenges if has been applied to dental implants as possess very thin bone (Heins & Wieder this evaluation will not be performed well, with an epithelial attachment of 1986). In return, thin cancellous bone prior to any interventional treatment approximately 2 mm (Cochran 1997) has a greater risk for resorption, decreas- (Kois 2001). (Table 1). However, since most of the ing the inter-proximal bone height and Replacing missing teeth with dental dental implants have a flat platform at the implicitly the papillary disappearance. implants recently has become a suitable top, the implant is almost always posi- Tal (1984) studied the inter-proximal treatment option for the partially eden- tioned below the inter-implant bone crest distance of roots and the prevalence of tulous patient. Techniques used in the (Fig. 1c). The location of the implant infrabony defects. The author reported development of implant recipient site platform inter-dentally places the inter- that only when the distance between have been developed, with an important proximal biologic width subcrestally, roots was X3.1 mm, two separate emphasize on the hard and soft tissues which differs from the one in natural infrabony defects were noted (Table 2). (Spear et al. 1997), ideally resulting in teeth, which always forms supracrestally. Therefore, it was speculated that for peri-implant tissues that are more resis- Therefore, the inter-implant tissue lacks each individual root it would take at tant to mechanical forces while provid- the crestal support which exists between least 1.5 mm horizontal bone compo- ing an aesthetic pleasing outcome. an implant and a natural tooth or two nent to be lost in order to develop a Similar to natural teeth, resorption of adjacent implants. vertical defect. This finding correlates the inter-implant bone results in loss of Thus, it became obvious that other with Waerhaug’s opinion that there is a inter-implant papillae. Difficulty key factors, besides the bone level, may relatively consistent radius of destruc- remains when trying to maintain or be involved in the papillary presence/ tion (1.78 mm) initiated by the advan- create the papilla between two adjacent absence. It was emphasized that the cing plaque front, which predisposes implants. Choquet & Hermans (2001) presence of adjacent tooth attachment narrow areas of bone to horizontal investigated the presence or absence of and the volume of the gingival embra- bone loss and wider regions to vertical the inter-proximal papillae adjacent to sure influence the papillary existence bone resorption (Waerhaug 1979a). single-tooth implants to determine if (Spear 1999, Kois 2001). Tarnow et al. Hence, it is easy to maintain inter-prox- there is a correlation between the dis- (1992) examined the existence of inter- imal bone height to facilitate the foun- tance from the base of the contact point dental papillae in humans. The authors dation of papillae. This implies that a to the alveolar crest. When the distance found that when the distance from the minimal of 3 mm inter-dental distance between the contact point and crest of contact point to the alveolar bone was may be needed in maintaining papillae. the bone was less than 5 mm the papilla less or equal to 5 mm, the papilla was It was also suggested, that when root was present in 100% of the times. present in 98% of the times, while at proximity is present, parallelism of the However, the occurrence of the papilla 6 mm it dropped to 56% and at 7 mm it roots using orthodontic methods might had a frequency below 50% when the was only present 27% of the times. be beneficial to support the inter-prox- distance was more than 5 mm. It has Hence, the authors concluded that the imal gingival architecture (Salama & been suggested in the literature (Adell vertical height from the base of the Salama 1993). et al. 1986) that a minimum of 1.25– contact to the crest of the bone is a Concluding, the presence or absence 1.5 mm of clearance has to be main- key determining factor in maintaining of the papilla is influenced by more than tained between the implant fixture and the papillary between teeth. one factor (e.g. crestal alveolar bone adjacent teeth for proper osseointegra- When assessing the form and volume height, dimension of the inter-proximal tion and decreased risk of damaging the of the gingival embrasure occupied by space both horizontally and vertically, adjacent teeth. This is based primarily the inter-proximal papilla, a certain lat- size and shape of the contact area) on the periodontal ligament width of eral bone distance has to exist between (Table 2). This calls for a judicious adjacent teeth, although it failed to con- the roots of two adjacent teeth in order evaluation of the distance from the sider other important aspects such as to maintain the integrity status of the FGM to the osseous crest before any maintaining the integrity of the papilla (Saadoun et al. 1999). A direct relation- ship has been demonstrated to exist Table 2. Factors which influence presence/absence of the inter-dental/inter-implant papilla between the existence of a minimum Crestal alveolar bone height mesiodistal distance of 3 mm of bone Vertical: 1.0–3.0 mm (Gargiulo et al. 1961) between implants and maintenance of 2.1–4.1 mm (Becker et al. (1997) the adequate papilla (Tarnow et al. Horizontal: 3.0 mm (Tal 1984) 1992). The amount of crestal bone loss Dimension of interproximal space (distance from contact point to the alveolar crest) was 1.04 mm when the inter-implant Natural tooth: 5 mm (Tarnow et al. 1992) o distance is less than 3 mm, while only Single implant: o5 mm (Choquet & Hermans 2001) Two implants: o3.5 mm (Tarnow et al. 2003) 0.45 mm bone loss was noted in the area Soft tissue appearance (e.g., scallop; thick or thin biotype) with a distance of more than 3 mm Flat is better than pronounced and high scallop (Salama et al. 1995, Kois 2001) (Tarnow et al. 2000). The range and Thick biotype is better than thin biotype (Kois 2001) average of tissue height were evaluated Minimal buccal plate thickness between two adjacent implants by Tar- 41.8 mm in anterior implant (Spray et al. 2000) now et al. (2003). Mean height of tissue Contact areas (e,g., triangular versus square) was found to be 3.4 mm between two Square is better than triangular (Kois 2001) adjacent implants with a wide range of 834 Zetu & Wang variations from 1 to 7 mm. The most gorized as flat, scalloped and pro- the facial plate thickness at which frequently probed heights were 2 mm in nounced according to the osseous chances of bone gain or bone loss are 16.9% of the cases, 3 mm 35.3% of the anatomy (Becker et al. 1997). Teeth minimal. The largest chances for bone cases and 4 mm in 37.5% of the cases. with a free gingival margin located resorption were observed when the According to the authors, a limitation more apical than ideal and a flat gingival facial thickness was less than 1.4 mm, exists when formation of the inter- scallop may present a compromised while the possibility of bone gain was implant papilla is expected. This implies situation after tooth extraction. Accord- seen at a 2 mm thickness. This is why that a rigorous treatment plan is critical ing to Salama & Salama (1993) these the authors concluded that 2 mm is a in the anterior area where aesthetics is a teeth may benefit from ‘‘orthodontic critical thickness for the integrity of major concern. extrusion’’ when the supporting inter- facial plate after stage 2. proximal bone follows the extruded tooth and provides support for the papil- Soft-tissue assessment la regeneration (Salama et al. 1995). The The key to an aesthetically pleasant opposite situation when there is moder- Inter-dental Space Concerns: a Tooth smile is proper management of the soft ate coronal gingival overgrowth and a or a Tissue Problem? tissues around natural teeth or implants. pronounced scallop may be beneficial Gingival tissues have been designed to Aesthetic soft-tissue contours are for the aesthetic purposes of papillary provide a framework for the body described by a harmoniously scalloped conservation. Kois (2001) described the defense against the disease. For this gingival line, the avoidance of an abrupt gingival biotype as being thick or thin. reason, it is advocated that the dental change in clinical crown length between A thick gingival biotype implies more papilla can provide a seal to withstand adjacent teeth, a convex buccal mucosa fibrotic tissue, more vascularization and the microbial invasion and its loss may of sufficient thickness and distinct papil- thicker underlying hard tissue which in promote food impaction or aesthetic la (Ono et al. 1998). The shape or the turn is more resistant to recession and deformities. True loss of a previously contour of the gingiva is highly variable often results in pocket formation in the existing inter-dental papilla can be and depends on the location and size of presence of the bacterial insult. Thin accounted for in the periodontal disease the inter-proximal contact area, volume gingival tissue has less underlying oss- process. Periodontitis is defined as an of this space, size and shape of the eous support and less blood supply, inflammatory disease of the supporting present teeth in the arch. Bergstrom which predisposes to recession after tissues of teeth and it is caused by the (1984) investigated the topographical tooth extraction (Kois 2001). Highly microorganisms which have the ability features within the maxillary papillary scalloped cases with a friable gingiva to invade and colonize the periodontal gingiva between the lateral and central require careful, atraumatic tooth extrac- tissues. Thus, the first step in creat- incisors in healthy young adults. The tion and flapless implant placement, ing a harmonious relationship between author described the length of the papil- which is advantageous because it mini- tooth and gingival tissue is the elimina- la from its base to the contact point in mizes bone loss and gingival recession tion of marginal inflammation of the relation to the length of the crown of the (Garber et al. 2001). This approach, periodontal tissues. Reddened, inflamed central incisor. The authors found a ratio however, is quite challenging because inter-dental tissue draws the attention of 0.5 indicating that a healthy papilla of lack of visibility and the possible of the observer because of the contrast reaches halfway to the incisal edge of existence of a thin labial plate of bone. with the tooth colour and adjoining the maxillary incisor. When the surface It requires careful planning and flawless tissue. Rolled gingival margins encou- area of the papilla was measured in surgical execution. As a compromised rage more rapid growth of plaque and relation to the labial surface area of the solution, it may be optimal to extract the disappearance of the healthy triangular lateral incisor, the ratio was close to hopeless tooth, perform hard- and soft- look of the papilla. Similar to the natural 0.25, indicating that the papillary sur- tissue grafting and place the implant 3–6 counterpart, soft-tissue changes in face under healthy conditions amounts months later. implants play an important role in asses- to about 1/4 of the labial surface of the Maintaining facial bone is equally sing the success rate in the aesthetic lateral incisor crown (Bergstrom 1984). important as well, in order to prevent area. Cochran et al. (2002) reported When the tooth shape is taken into future dehiscences and implicit reces- that soft-tissue changes (e.g., recession) consideration, square-shaped teeth may sion around implants. Teeth positioned of approximately 1 mm take place in the have a more favourable aesthetic out- too far facially often result in thin or no first year after the restorative therapy is come than ovoid or triangular-shaped buccal bone, which will create a col- performed on a one-stage implant. This teeth because of a longer inter-proximal lapse in the gingival architecture after has to be taken into consideration when contact and implicitly a less amount of tooth extraction. According to Salama implant treatment planning in the aes- papilla to fill in the space (Kois 2001). A et al. (1996) these teeth are not good thetic region is performed and maybe a triangular/taper shape has the inter- candidates for orthodontic extrusion longer term provisional restoration proximal contact area positioned more since there is no existent facial bone. should be kept in place to help obtaining incisally, so higher risk of inter-proxi- Opposite to this, teeth located too far better esthetics in the anterior aesthetic mal recession exists, which can create labially have the advantage of a thicker zone (Cochran et al. 2002). the presence of inter-proximal black bone and implicitly less resorption after In cases of gingival overgrowth the triangles (Kois 2001). extraction. Spray et al. (2000) examined gingiva covers the enamel and the sulcus The existing position of the inter- the relationship between the amount of depth will increase, thereby facilitating dental gingiva illustrates the level at vertical bone loss and facial bone thick- bacteria accumulation and decreasing the which the gingiva is attached to the ness. The authors proposed the term of cleansing ability or plaque removal. Oss- tooth. Gingival scallop has been cate- ‘‘critical bone thickness’’ representing eous resective procedures have been Management of inter-dental/inter-implant papilla 835 developed to reshape the dentoalveolar inter-dental/inter-implant papillary loss degree of recession and regeneration of architecture to create a more favourable or regeneration, several classification the papillary contour around single environment for periodontal mainte- systems have been proposed. Nordland implant restorations has been devel- nance and health (Oschenbein 1986). & Tarnow (1998) developed a classifi- oped by Jemt (1997). The index system In aesthetic crown-lengthening surgery, cation system for the loss of papillary designates five different levels of the patient biotypes (Pontoriero & Carnevale height, which used as reference points amount of papillary presence, which is 2001) can play an important role in the the facial and inter-proximal CEJs of measured from a reference line that amount of rebound healing of the newly natural teeth and the inter-dental con- passes through the highest gingival established gingival margin. Individual tact point (Nordland & Tarnow 1998). curvature of the implant restoration on variation in gingival thickness will mod- A class I papillary loss was defined the facial side and the adjacent perma- ify final tissue healing levels post-opera- when the tip of the papilla was found nent tooth (Jemt 1997). An index score tively. ‘‘Thick’’ tissue biotypes have the between the contact point and the inter- 0 had been assigned when papilla was greatest chance to rebound in a coronal proximal CEJ (with no visual appear- absent. Index score 1 was assessed direction (Pontoriero & Carnevale 2001). ance of the inter-proximal CEJ). A when less than half of the papillary Frustrating to patients and dentists class II papillary loss involves the height was present. Index score 2 alike is the presence of spaces produced presence of the tip of the papilla at means that at least half of the height by the loss of inter-dental papillae to or apical to the inter-proximal CEJ of the papilla is present but does not periodontal disease and surgical ther- but coronal to the facial CEJ while a reach the contact point. Index score 3 apy. The loss of inter-dental papilla class III has papilla disappearance at was designated when the papilla filled can create phonetic problems, as well or below the level of the facial CEJ the entire proximal space and an index as cosmetic deficiencies (the black tri- (Nordland & Tarnow 1998). This clas- score 4 was given if the papillae were angles disease). A papillary deficiency sification may be of importance for hyperplastic and overfilled the restora- could result from surgical excision, trau- clinicians when trying to evaluate the tion (Jemt 1997). matic tooth extraction, apically posi- success of different treatment modal- Unfortunately, there are situations tioned flap and many others (Table 3). ities existent to enhance soft-tissue when ideal aesthetics cannot be achieved Identifying the aetiology of the ‘‘black aesthetics. Similar to the natural coun- with any of the treatments mentioned triangle disease’’ may involve more terpart, an index system to assess the above. In this situation, the patient than one approach. First, it is advisable to evaluate the papilla height and com- pare it with the adjacent papilla. If there are no discrepancies in the vertical dimension, then the problem is most likely the tooth shape or the angulation of the tooth root (Kokich 1996). A divergence of the roots means in most of the cases an increase in the gingival embrasure volume, which can pose a problem in future aesthetic reconstruc- tion of the papilla. Decreasing the gin- gival embrasure is best achieved with restorative or orthodontic treatment. Orthodontic treatment in conjunction with tooth stripping can be performed to reduce the volume of the gingival embrasure. Lack of advanced understanding of the process of papillary loss (Table 3) has made surgical intervention, ortho- dontics or restorative treatment options more challenging especially in cases where soft tissue is the problem. In order to assess progressive degrees of

Table 3. Causes of papillary loss Absolute causes Periodontal disease Osseous surgery Traumatic tooth extraction Relative causes Gingival biotype (e.g., thin versus thick) Increase in gingival embrasure because of root divergence Fig. 2. Aesthetic triangle as a reference guide for treatment planning of aesthetic problems. 836 Zetu & Wang should be informed and a compromised Table 4. Tissue height needed from the contact point to the crestal bone level in order to maintain solution should be recommended. papillae in different clinical situations Aesthetic triangle to facilitate papil- lae existence was developed by the Contact point-alveolar bone crest 100% papillae appearance (mm) Author authors to manage aesthetic problems Inter-dental papillae 45 Tarnow et al. (1992) around natural teeth and dental implants o4.5 Kois (2001) (Fig. 2). The base of the triangle is the Implant–tooth papillae o4.5 Salama et al. (1998, 2002), hard-tissue assessment and implicates Salama (2001) the foundation for the adjacent tissue Implant–implant o3.5 Tarnow et al. (2003) (papillae) height, since bone dictates the Implant–pontic o5.5 Salama et al. (2004) soft-tissue expression. The second layer Tooth–pontic o6.5 Salama et al. (2004) Pontic–pontic 6 Salama et al. (2004) of the aesthetic triangle contains the o soft-tissue assessment by ways of exam- ining the tissue thickness, symmetry to determine if soft-tissue grafts or ovate (Iasella et al. 2003). Controlling and anterior segment has made surgical pontic site development is needed. conserving the hard-tissue height by intervention of papillary reconstruction Finally, the tip of the triangle will means of socket augmentation can help a viable alternative at the time of comprise existing restorative procedures in achieving better soft-tissue aesthetics implant placement. Restricting flap ele- to correct aesthetic problems (pink por- (papillary presence). vation can minimize the amount of bone celain, veneers, etc,). Preservation of the papillary height resorption (Wilderman et al. 1970), thus can be achieved via forced orthodontic helping in the preservation of the inter- extrusion, which is aimed at increasing dental papilla. Jemt (1997) using a pro- the vertical osseous dimension at the posed index score (described above) Bone Support for Preservation of the inter-proximal sites while preserving reported that 58% of the papillae Papillary Height adjacent soft-tissue (papilla) height. Sal- adjacent to single-implant restorations ama & Salama (1993) recommended the regenerated to some extent after 1–3 As previously discussed, bone loss may slow eruption technique to advance the years without any clinical manipulation lead to compromised dental implant periodontal attachment apparatus includ- of the soft tissues. The author speculated placement and aesthetic problems in ing the alveolar bone more coronally for that these changes may be in part the inter-dental papillary area. A ridge the correction of hard- and soft-tissue because of plaque accumulation in the deficiency will necessitate the over- discrepancies. One potential drawback inter-proximal areas, which may stimu- building of prosthetic tooth structure, of using this method is the possibility late the hyperplastic, inflamed tissues to prosthetic gingiva, or acceptance of a of losing the level of the proximal alveo- mature and be recognized as papillae. black triangle (Kois 1998). Conse- lar bone support, since orthodontic extru- Various soft-tissue surgical proce- quently, phonetics can be affected sion tends to level the bone and even dures have been introduced in an where the space allows passage for the create the inverse architecture. attempt to re-create the papillae (Aubert air or saliva. Guided bone regeneration (GBR) or et al. 1994, Azzi et al. 1998, 2001). Socket augmentation (i.e., ridge pre- bone augmentation to create bone vol- Takei et al. (1985) described the ‘‘papil- servation technique) has been developed ume that is needed for supporting the la preservation technique’’ in an attempt when a tooth is extracted atraumatically papilla appearance has also been recom- to correct the deficient inter-proximal and the space is maintained by means mended. These techniques include but papillae contours between multiple teeth of a bone substitute with or without a are not limited to GBR to augment and it is primarily used as an aestheti- membrane. These modern techniques horizontal and minimal vertical bone cally driven procedure. Different tech- focus on rebuilding the alveolar ridge height (Wang & Al-Shammari 2002), niques for papilla preservation have while maintaining the soft-tissue sur- onlay grafting (Cordaro et al. 2002), been described, most of them emphasiz- roundings. Iasella et al. (2003) evaluated distraction osteogenesis (McAllister & ing limiting the vertical releasing inci- the horizontal and vertical bone resorp- Gaffaney 2003) and combinations of sions in the papillary area (Nemcovsky tion in 24 patients randomly selected to soft- and hard-tissue grafting (Nemcov- & Artzi 1999). A papillary reconstruc- receive either extraction alone or ridge sky & Artzi 1999). Table 4 lists minimal tion technique using a palatal split thick- preservation using tetracycline hydrated distances needed from the contact point ness flap has also been proposed by freeze-dried bone allograft (FDBA) and to the alveolar crestal bone level in order Beagle (1992). The tissues obtained a collagen membrane. Both groups lost to maintain papillae among all clinical from the area lingual to the papilla are ridge width, although an improvement situations. folded coronally to fill the inter-proxi- was seen in the ridge preservation mal space. Other variations may include group. Most of the resorption occurred the ‘‘T’’ shape incision and the double from the buccal and in maxillary sites. finger incision. Tinti & Benfenati (2002) Regarding the vertical changes, the Soft-tissue Manipulation for described a ‘‘ramping suture’’ technique ridge preservation group gained an aver- Preservation of the Papillary Height in which the healing abutments are used age height of 1.3 mm of bone, compared During the past years, maintenance of to ‘‘tent up’’ a full-thickness flap with a with the extraction alone group, which the inter-dental papilla following tooth modified vertical mattress suture. lost an average of 0.9 mm of bone extraction has gained more attention. Recently, Misch et al. (2004) introduced height, differences being statistically Advanced understanding of the anatomy the split-finger flap technique to pre- significant of 2.2 mm between groups and disease progression in the maxillary serve/promote papillae formation. The Management of inter-dental/inter-implant papilla 837 rationale for this technique is that unlike 4-week healing period, the height of contours and try to reconstruct the other techniques, the papilla is formed the pontic should be adjusted to extend inter-dental papillae, although to date with tissue from both the facial and approximately 1.5 mm below the tissue no effort has been made to organize palatal aspects, which further enhances (Spear 1999). Occasionally, there can be this body of literature into a coherent papillary support and appearance. A a soft-tissue residual deficiency even treatment approach. It is quite evident sulcular incision is made 2–3 mm to after the meticulous attention to delicate that little scientific literature exists in the palatal side with a loop design extraction, bone grafting and immediate this area and there is a strong need for adjacent to the implant location. The placement of an ovate pontic. further research in establishing the long- incisions are then joined facially with a term success of the papillary regenera- semicircular incision at the preplanned tion techniques. free tissue margin of the implant crown. The facial ‘‘fingers’’ are elevated to the Restorative Attempt to Correct the Aesthetic Challenge desired inter-implant height for papillae. Conclusions The middle ‘‘palatal finger’’ is then split Jemt (1999) proposed a technique of and is reflected to the respective mesial preserving the inter-dental papillae by Thorough treatment planning is essen- and distal sides. The soft-tissue main- means of placing a provisional tempor- tial for maintenance of the height of the tains its elevated position with a permu- ary crown at the time of second-stage inter-proximal papillae following tooth cosal extension or a final prosthetic surgery. The provisional crowns were removal. Once the potential problems abutment that is extended through the used to guide the soft tissue into the are known, additional procedures can be soft tissue. A modified vertical mattress inter-dental space faster than healing performed or anticipated. It has been suture is used to suture each papilla. abutments alone (Jemt 1999). Jemt & proven that by maintaining or trying to Procedures such as this may help reduce Lekhom (2003) compared the inter- correct the height of bone in the inter- the problem of the ‘‘black triangle’’, in proximal tissue volume around the proximal area, an aesthetic reconstruc- the open anterior inter-proximal space, implant-supported single crowns in tion of the papilla can be achieved. however, their predictability remains to function for 2 years versus papillary Periodontal plastic procedures can be be determined. volume around implants which were used to enhance the ultimate outcome. Soft-tissue grafting procedures have placed in grafted bone. The authors In aesthetically compromised cases, been successfully used to augment tis- reported that a significant buccal and restorative intervention can mask the sues around teeth as well as implants. inter-proximal resorption of the bone loss of tissues but rarely can they Partial reconstruction of the inter-dental graft was seen 2 years after the implant achieve ideal aesthetics. Implementing papillae by means of plastic procedures placement, which may have a negative all these techniques into clinical practice in combination with subepithelial con- impact on the aesthetic outcome in the may alleviate the challenge which lays nective tissue grafts has been described inter-proximal area. However, the inter- upon the dental practitioners in dealing (Nemcovsky 2001). Unfortunately, these dental papillae were reported to have with inter-dental/implant papilla appear- ance. An aesthetic triangle is developed are limited procedures since they do not increased significantly (po0.05) in address the reason why the papillae volume during the first year, almost to address the foundations that are disappear. completely filling up the embrasure essential for maintaining/creating papil- Since soft-tissue collapse can occur areas after 2 years of crown placement. la. These include adequate bone volume, following bone resorption, additional The author’s conclusion was that the proper soft-tissue thickness as well as steps to the above mentioned procedures placement of the abutment cylinder aesthetic appearing restorations. can be taken to maintain the tissues and the crown seemed to play a more height. For example, papilla preserva- important role for re-establishing the tion can be initiated prior to tooth inter-proximal tissue volume at the Acknowledgements extraction with inter-disciplinary treat- implant-supported single crowns. This study was partially supported by ment planning. An immediate tooth Unfortunately, there are some situa- the University of Michigan, Periodontal replacement using an ovate pontic tions when all methods of hard and soft- Graduate Student Research Fund. The bonded to the adjacent teeth may help tissue augmentation fail. In this case, authors do not have any financial inter- in moulding the papillary height and compromised aesthetics by means of ests, either directly or indirectly, in the ginigival embrasure form (Spear 1999). prosthetic techniques can be utilized to products listed in the study. Ideally, the restorative dentist will fab- create the illusion of papillae. Alteration ricate an immediate tooth replacement in the position of the contact point or the using an ovate pontic bonded to the volume of the inter-proximal space with References adjacent teeth. 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