Ttie Internotional Journal of Periodontics & Restorative Denfistry

395

Reconstruction of the Lost

Interproximal Papilla-
Presentation of Surgical and
Nonsurgical Approaches

Markus B. Blotz, DMD' In recent years clinicions' and

Markus B. HQrzeier. DMD. PiiD' dentists' esthetic demands in
Jörg R. Strub, DMD, PhD"' dentistry have increased rapidly
driven by an enhanced aware-
ness of beouty and esthetics.^ The
uitimate goai in modern restora-
Modern esthetic dentistry involves not only the restoration of lost teeth and
tive dentistry is to ochieve "white"
their ossocioted hard tissues, but increasingly the management and recon-
and "pink" esthetics in the esthet-
struction of the encasing gingivo with adequate surgiooi techniques. The
ically important zones. "White
loss of interproximai dentoi papitiae may cause functionoi, phonetic, ond
devastating esthetic probiems. Compiete and predictable restoration of
esthetics" are the natural denti-
lost interdentai papillae remains one of the biggest challenges in periodon- tion or ttie restorotion of dental
tal reconstructive surgery. On reviewing the literature, pubiications involving hard tissues with suitoble materi-
surgical ond nonsurglca! techniques for papiila reconstruction are basicaliy ols. With today's advances in
case presentations. Very iittie scientific data concerning long-term success material science and the skiils ot
ond predictability of specific techniques has been published so for Starting dental technicians, the imitotion
with facts dbout the anatomy ond morphoiogy of the interdentoi tissues, of the natural tooth's tunction
this artide gives an overview of surgical and nonsurgicai techniques to and appearance hos reached o
restore iost interproximoi dentai papiiloe. (Int J Periodontics iiestorafive very high level.^'' " Pink esthetics"
Dent 1999; 19:395-400.) refer to the surrounding hard and
sofi" tissues, which can enhance
or diminish the esthetic result.
'Assistant Professor. Department of Prosthodontics, University ot
Restorotion and mainte-
Freiburg, Germony. nance ot those tissues with ade-
"Associate Professor. Department ot iîestorative Dentistry and quate surgicai ond prosthetic
Periodontics, University of Freiburg, Germany; Visiting Assistant techniques are o real challenge
Professor, Department of Stomatology, Houston, Texas, and
Privóte Proctice. Munich, Germany.
in modern esthetic dentistry. ^"-'^
•'Professor, Chairman, and Dean, Department of Prosthodontics, Mucogingival surgery covers only
University of Freiburg, Germany. a smoli range of daily periodontal
probiems: the shollow vestibule,
Reprint requests: Dr Markus B. B\otz. Assistont Professor.
Department af Prosthodontics, University of Freiburg,
fhe aberrant frenuium, and iim-
Hugstetterstrasse 55, D-79106 Freiburg, Germany. ited width of attached gingivo.''^

Volume 19, Number4.

396
Mcdern periodontal plastic
surgery includes a much broader
range of treatment modali-
ties, ' ^' ' ^ Treatment of marginal tis-
sue recession, excessive gingivai
display, deficient ridges, ridge col-
iapse, and esthetic defects
around teeth and implants are
some of the probiems that have
to be solved today One of the
most chalienging ond ieast pre-
dictable probiems is the recon-
struction of the icst interproximai
papiiia. The ioss of papillae may
cause functional and, especioily
in the maxiiiary onterior region,
phonetic and severe esthetic
probiems. In the past, the refor-
mation of lost papillae was seen
as a positive side effecf fhaf
occurred coincidenfally foiiow-
ing plastic periodontai surgery
The interdenfai papula, as a struc-
ture with minor blood supply was
left more or less untouched by
clinicians. In the past, severol case
presentotions have been pub-
lished showing different surgical
ond prosthetic techniques to
rebuild lost papillae. But no long-
term results are available tc rec-
ommend any particular tech-
nique over anotherfor correcting
iosf interdentol tissues completeiy
and predictabiy
Knowiedge of the anatomy
and morphology of the inter-
proximai tissues is mandatory to
understand and develop surgi-
cal approaches and treatment
patterns and tc allow the rec-
ommendation of a certain aug-
mentation technique. This arti-
cle gives an overview of the
The internationai Journai of Periodontics & Restorotive Dentistry
anatomic and morphologic
aspects of the interproximai
papiilo and presents severoi
techniques to restore the lost
interproximai papiiia between
teeth and implants and in the
pontic area.
Anatomy and morphology
of the interdental gingival
papilla
The fundamenfal task of gingi-
vai fissues is the protection of
underlying anatomic structures
from mechanicai and biologic
influences. The fact that teeth
penetrate the oral mucosa
mokes special constructions
necessary to provide protection
at the point of weakness, the
dentogingival junction.
Gingiva can be detined os
fhe tissue extending externaiiy
from the gingival margin and the
tip ot the interdental papilla to
the mucogingivai junction, which
separates the oiveolor mucosa
from the attached gingiva (Fig
1 ). it aiso includes the internal gin-
givoi connective tissue and den-
toaiveolar fibers.'''•^° Structuraiiy
gingiva consists of epithelia (junc-
tionoi and orai) and a coilage-
nous iamino prcpria containing
moinly fibers, vesseis, and nerves.
The gingivai orol epitheiium is ker-
atinized. The junctionai epithe-
lium, with its attachment to the
enamel located internally, ex-
tends apicolly from fhe gingival
margin and, under clinically nor-
mal conditions, forms a shaliow
suicus. Coilagen fiber bundles of
the gingivoi lomino proprio, the
so-called supragingival fiber
apparatus, have been ciassified
according to their main oriento-
tlon.'^-^° The main task cf den-
fogingivGi, dentoperiosteal, aive-
oiogingivai, ond periosteogingivai
tiber groups is the attachment of
gingiva ta the tooth and to bony
structures (Fig 2). Fibers of fhe cir-
cular, semicircular, fransgingivol,
infercircuiar, intergingivai, and
tronsseptai bundles oonnect
teeth to one onother, Interpa-
piiiary tibers fix the vestibular
papiiia to the oral papilla, "-^^ The
architecture of this apparatus
provides stabiiity and protection
for the teeth, fhe surrounding tis-
sues, and their very sensitive inter-
focial structures.
it is on interesting facf fhat
the junctionai epitheiium con,
after removal, regenerate com-
pletely ^"-^^ Its celluiar turnover
rate is extraardinariiy high. The
junctionai epithelium surrounds
fhe erupted tooth like a collar,
foiiows the cementoenamei
junction, and is about 2 mm high
and up to 100 |jm thick. Under
clinically healthy or slightly
intlamed conditions o gingival
suicus of between 0.2 and 0,7
mm in depth develops.^'' The
base of fhe suicus is formed by
the free surface of the junctionai
epitheiium,^' Interproximai fused
junctionai epithelia of adjacent
teeth form the interdentai col
(discussed below).
The posterior and anterior
superior aiveoiar and the major
 397

attached gingiva
unction
alveolar mucosa
Fig 1 Gingiva n the tissue extending exieinaiiy from the gin- Fig 2 Left, dentogingival. denfoperiosteal. oiveologingival. and
giva! margin and fhe lip of the interdental papilla to fhe periosteogingivat fiber groups provide affachmenf of gingiva
mucogingival juncfion. to fhe footh ond to bony structures. Righf fhe gingivoi vascutar-
ization is derived from branches originating in the inferdental
septa, fhe periodontai ligament, ond the oral mucosa.

polatine arteries secure primary
blood suppiy in the maxiiia, and
the inferior aiveoiar, buccai, sub-
iinguai, and mentai arteries sup-
piy the mandibie. The gingivai
vasoularization derives from
branches originating in the inter-
dentai septa, the periodontai iig-
omenf, and the oral mucosa^^
(Fig 2), Within the gingivai iamina
propria, terminai blood vesseis
form 2 networks: one is situated
below the oral gingival epithe-
iium and inciudes the gingivai
margin, and the other stretches
along ttie junotionai epifheiium
and is aiso fermed the gingivai
piexus,^^ The gingivai piexus, rich
in anastomoses, extends from ttie
ooronal to the apical termina-
tion of the junctionai epithe-
The morphoiogy of the inter-
dental gingiva is determined by
the adjacent teeth and underly-
ing bone crest. If 2 adjacent
teeth have contact and if the
interdentai papiiia is defined os
the gingivai tissue extending from
the incisai tip of the papilla to a
line fangentiai to the gingivoi
margins of those teeth, a heolthy
papula reaches about half way
fo the incisai edge,^^ Normaily
fhe papillary area shows a high
degree ot stippling,^•^°
Untii 1959 the inferdentai
papilla was believed to have
pyramidai contours with one
peak, Cohen^' was the tirst to
describe fhe papilla wifh 2 peaks,
vestibuiary and iingually, vj'ith a
concave crest shaping the so-
caiied col,^'"^ This crest, which
relates to the position and exten-
sion of the contoct area of the
odjocent teeth, is usuolly nonker-
atinized or porakeratinized ond
covered with stratified squamous
epitheiium,^^'^The degree of ker-
atinizotion of fhe coi area can be
modified with fhe use of inter-
proximai sfimuiation^'-^ and inter-
proximai hygiene,^'-^ Holmes^^
showed in a ciinicai study that an
excised Interdentai papiiia does
not regenerate completely to its
originai outiine and height. This is
contrary to a study pubiished by
Kahi and Zander^' on monkeys.
The vestibulor peak of the inter-
dental papiiia extends more
ooronally than fhe lingual one.
The distance between those
peaks ronges between 2 and ó
mm and the depth of the coi

Vaiume 19, Number 4,1999

398

Fig 3 Right, connective ooiiagenous fibers of fhe mucosa

arcund Impiants stretch paratiel to the implant surface. Left,
because af the iaok of periodontal ligaments, blood supply of
the periimpiant muoosa is only provided by branches tram the
bone and the orai soft tissue.

ranges between 0,3 and 1.5
mm.''^ Both parameters increase
from anterior to posterior re-
gions.''^ interpapillary fibers
connect both peaks. Like the
vestibular and oral ports, the inter-
proximal gingiva normally ex-
tends about 2 mm coronal to the
cementoenamel junction, parai-
lel to the crest of the alveoiar
bone.'^ An interdental papillo is
deemed present when it fliis the
interdental space up to the con-
tact point. The contact point,
which is the result of the emer-
gence profile and the line angle
form, is iocated between the
maxiiiary centrai incisors in the in-
cisai third of the labiai aspect,
between the central and the lat-
eral incisor in the middle, and
between the Idteral incisor and
the canine in the apical third.'^
This means that the most visibie
papllia—the one iocated be-
tween the maxillary central in-
cisors—fills up more space than
others; its absence couses more
obvious esthetic probiems and it
is therefore the most difficult fo re-
build. According to the definitions
mentioned above, the interden-
tal papula is always deemed miss-
ing in cases of diastemato or non-
contact of adjacent teeth, in
those cases, the interproximal gin-
gival tissue oiso shows a higher
degree of keratinization.
To determine whether the dis-
tance from the base of the con-
tact area to the crest of bone
couid be correiated with the
presence or absence of the infer-
praximdl papilla, Tarnow et al''^
examined 288 interproximal sites
in humans. The results of this pio-
neering study showed that when
the meosurement from the con-
tact point to the crest of bone
was 5 mm or less, the papilla was
present almost 100% of the time.
When the distance was ó mm the
papilia was still present in 5ó%, but
when the distance was 7 mm or
more the papilla was only pre-
sent 27% of the time or iess.
Bialagv cf the periimpiant
mucosa
Most surgical papiiia reconstruc-
tion techniques developed to
treat interdentai gingivo can be
modified to handle the soft tissues
surrounding impiants, although
significant differences between
those tissues must be considered,
At first sight, gingiva and peri-
impiant mucosa show strong sim-
iiarities ciinicaily and histoiogi-
cally,''^""^ Because of the iack of
cement-like structures on the
implant surface, connective col-
iogenous fibers of the mucosa
around implants are oriented dif-
ferently than those of the gingi-
val fiber apparatus, in tact, they
stretch parailei to the impiont sur-
foce, originafing in the orestal
bone (Fig 3), Also, the junctionai

The Internationai Journai of Periodontics S Restorative Dentistry


epithelium is langer—about dou-
ble the size of that in healthy gin-
giva.''^ Another important differ-
ence, which concerns the blood
supply is caused by the absence
of the periodontal ligament and
branches originating there™ (Fig
3). Because of its high amount of
collagen and low number of
fibroblasts, the periimplant
mucosa can aiso be defined ds
a scar-iike tissue.^'
Reconstruction of the lost
interdental papula
Most of the reconstructive tech-
niques to rebuiid lost interdental
papiiiae focus on the maxillary
anterior region, where esthetic
defects appeor interproximally as
"black triangies."These are unac-
ceptabieforboth the patient and
the clinician. Phonetic problems
and tcod impaction are other dis-
odvantages. Causes for interden-
tal tissue ioss are, for example,
common periodontal diseases,
tootti extraction, excessive surgi-
cal periodontal treatment, and
localized progressive gingival and
periodontal diseases.
To avoid interpraximal de-
fects in the estheticaily important
zone, care shauld be taken when
periodontal therapy is performed
to eliminate inflammatory pro-
cesses. This is also valid for non-
surgical procedures such as scal-
ing and root planing, if surgical
treatment is necessary, ade-
quate flap designs are required
to prevent extreme tissue loss
and maintain natural gingival
contours.^^"^'' Numerous tech-
niques have been published
using flap designs that ieave
interdentai papillae connected
to both the palatal and the labial
flap or retained on one of the
flops, or that totally preserve the
Takei and coworkers^^-^' rec-
ommended the papiiia preser-
vation fiap technique that pre-
serves the papiiia compieteiy but
ailows good access for root plan-
ing or bone-graft augmentation
of osseous defects. A modified
version of this surgical approach
was described by Corteilini et ai.'''
Nansurgical papilla creation
If an interdental papilla is absent
because of a diastema, ortho-
dontic closure is the treatment of
choice. "Creeping" papille for-
mation has been described by
closing the interdental space and
creating a contact area."^' in cer-
tain cases this formation can also
be achieved with appropriate
restorative techniques and alter-
ation of the mesial contours of
the adjacent teeth.
Distally anguiated roots of
centrai incisors in contact may
be another indication for ortho-
dontic treatment. By reposition-
ing these roots and reshaping the
mesial contours of the teeth, the
contact point can be located
more apically and the embra-
sure reduced, changing the inter-
dental papilla in a positi '^
399
In various case reports ingber
and coworkers*^"** showed
tremendous achievements in the
management of gingival defor-
mities by using forced eruption.
Ingber described forced erup-
tion as an orthodontic process: a
tooth is moved coronally through
opplication ot a gentle and con-
tinuous force using orthodontic
appliances.The effects are alter-
ations within the supporting
structures, causing changes in
the bone level and the soft tissue
contours and thereby creating
new papillde, ideally
A noninvasive treatment tc
recreate papiiiae destroyed after
acute necrotizing uioerative gin-
givitis was presented by Shapiro,'^^
Periodicaily repeated scaling,
root planing, and curettage dur-
ing 3 months induced prolifera-
tion of gingivai tissue caused by
inflammatory hyperplasia. About
9 months after initiai treatment,
regeneration of the interdental
papilla was observed. Some
papillae showed complete re-
generation, whiie others did not
respond to the periodic curet-
tage, making more invasive tech-
niques unavoidabie.
Recently Jemt*^ observed tis-
sue reaction similar to Shapiro's
findings around impiants. In a
piiot study of retrospective mate-
riai, the size of interproximal den-
tal papillae adjacent tc single-
implant restorations was followed
for 1 to 3 years.** The results indi-
cated that papulae regenerate
to some extent without any clin-
ical manipulation. At the time of
Volume 19, Number 4,1999
400
foliaw-up, 58% of the tested papil-
lae had recovered completeiy
Jemt explains this spontaneous
recovery as maturation and reor-
ganization of previously inflomed
hyperpiastic tissue ooused by
plaque accumulation. This inter-
esting finding raises the question
of Vi/hether the fundamental
demand of a cerfoin distance
from the bone orest to the inter-
proximai contact point to atfirm
the presence of a papilia—
shown by Tarnow et al''^—is aiso
vaiid tor the periimplont soft fissue
that resembles scar tissue more
than healthy gingiva.
Another attempt to regain
iost papiiiae secureiy but nonin-
vasiveiy is the local eniorgement
of the interdental soft tissue. This
might be possibie by injection or
implantotion ot materiais used in
modern plastic surgery.
Surgical papitia reconstruction
As expiained above, the inter-
dental papilia is G small area with
minor blood supply This seems to
be the major limiting tactor in all
surgical reconstructive and aug-
mentation techniques. Most sur-
gicai methods pubiished involve
gingivai grafting, but show only
iimited success because of insuf-
ticieht biood suppiy.
In a case report. Beagle^'
described a technique using a
pedicie tlap between the 2 cen-
trai incisors without any graft.
Basically he combined the roli
technique reported by Abrams™
The internationai Journai of Periodontics & Restorative Dentistry
with Evian et ai's papiiia preser-
votion technique.^ First, a portiai-
thiokness fiap was dissected ond
iabially elevated. Then, the thus-
eiongated papiiia was toided on
itseit, resembling the roil tech-
nique for ridge augmentation,
Adequate sutures were used to
bind this "papilla" together and
position it between the 2 incisors.
A periodontai dressing tor further
support was applied from the
paiatal aspect oniy
Techniques using pedicle
fiaps show cieariy better resuits
than techniques with tree gingi-
vai grafts because sufficient
biood suppiy is provided from the
base ot the pedicle,'^ Further
treotmenf deveiopments include
subepifheiiol connective tissue
grafts to provide greoter support
of displaced gingivoi fissue
flaps.'2.73
In 199Ó, Han and Jakefi'' de-
scribed a newly deveioped tech-
nique whereby the Interdental
papilla was displaced coronally
and a subepitheiiai connective
tissue graft packed underneath,
Their technique is based on a flap
design reported previously by
Tarnow'": the semiiunar coronaily
repositioned flap, A crescent-
shoped incision was made parai-
lel to the tree gingivai margin of
the faciai tissue and the dissected
tiap was positioned coronaily ta
cover a denuded root thot was
caused by gingivai recession. In
their modification for gingivai
papilla reconstruction, they rec-
ommended placing the semilu-
nar incision in the interdentai
region to aliow restoration of o
lost interproximoi papiiia by ploc-
ing a groft beiow the defioient
area. According to the authors,
this procedure might have to be
repeated a second or third time
after 2 to 3 months of heaiing,
depending on the extent of pap-
iilory loss. This technique was
appiied in a patient who pre-
sented with an endosseous im-
plant in the region ot the maxiliary
right centrai incisor (Fig 4a), Both
the mesial and the distal popil-
loe were obsent. After insertion ot
a provisional restoration, a slight
improvement of the interdental
situation was recognizabie (Fig
4b), The proposed semilunar and
intrasuicular incisions were per-
tormed to free the connective tis-
sues from the root surfaces. This
gingival-papillary unit could be
displaced coronaily. A subep-
itheiiai connective tissue graft of
appropriate size was removed
from the palate (Fig 4c) and
packed into the dead space cre-
ated by the displacement. The
gain in interdentai tissue was obvi-
ous directly after wound closure
(Fig 4d) ond also after healing
periods of 3 (Fig 4e) and 4 months
CFig4f).
Tarnow et ai"^ showed that
the presenoe ot the papula is
dependent on the distance
between the bone crest and the
contoct point of 2 adjacent teeth
ond should ideaily be about 5
mm. This leads to the cohcluslon
that guided regeneration ot the
underlying bone results in com-
piete reconstruction of a lost

Fig 4a Potient presents with an endos-
seous implant In the reglen cf the maxit-
Icry right central inciser. Both the meaal
and the distal papillae are absent
Fig4d Semilunar and intrasulcuiar inci-
sions are performed, the gingival-papii-
lary unit is displaced coranally, and the
graft is stuffed into the space created
underneath. Frontal view of fhe situa-
tion directly after wound closure.
interproximai papilla. In fact,
guided bone regeneration in
interdentai areas is a major prob-
iem. One reason may be the fact
that with bone regenerotive
techniques and materiais primary
and secure wound ciosure is nec-
essary, but is hampered by the
deficiency of tissue in fhe papilla
region. Reduced biood supply
and frogilify of this tissue add to
the difñcuifies. New methods and
advanced flap designs have
Fig 4b Slight improvement of the inter-
dentai situation IS achieved by the
ihsertioh of o provisional restoration.
Fig 4e Close-up view of the clinicai sit-
uation after a heoting period of 3
months after removing the temporary
restoration.
been proposed to solve this prob-
iem.
The combinoticn of a new
flap design an the faciol aspect of
ffie defect, described by Hürzeier
and Weng,''^ and the coronaiiy
positioned polatal sliding flop
on the lingual aspect, published
by Tinti and Parma-Benfenati,'*
might be an answer to hondie the
delicate interdentai tissue and
cover augmentation materials
completeiy and securely, if
401
fig 4c Subepitheiial oonnective tissue
graft of appropriate size is removed
trom the palate.
Fig 4f Froniai titiv oí !ne final situation
A months postoperative. The right cen-
tral incisor hos been restored with an
Implant-supported PFM crown.
indicated, an infracresfai and
supraorestai bone defect might
befilledwith bone grafting mate-
rial and covered with o bioresorb-
abie barrier membranefixedwith
bioresorbabie pins,The use ot bio-
resorbabie devices eiiminates the
need for a second surgical pro-
cedure for removai of the barrier
membrane. AttenA'ard the flaps
shouid be readapted coronaiiy
without any tension. The 2 flap
designs mentioned obcve allow
Voiume 19, Number 4,1999
402
suturing of fhe inferproximai area
in 3 different iayers,'^The deepest
iayer needs to be sutured v^/ith a
bioresorbabie suture materiai,The
other iayers shouid be sutured
with a nonresorbabie material to
avoid odditionai Inflammatory
reaction of the tissue. When sutur-
ing in 3 or 4 iayers it is mandatory
to use microsurgicai suturing tech-
niques. The use of # 4-0 or 5-0
sutures would add too much
suture materiai to the interproxi-
moi area and couid cause necro-
sis of the papillae. Therefore, # 7-0
or 8-0 sutures should be used to
readapt the buccal and linguai
flaps in a more coronai posifion.
With the combination of ad-
vanced techniques, the probiem
in reconstructing the interproxi-
mai area seems to be mare re-
lated to the barrier technology
than to soft fissue managemenf.
New flap designs, surgical ap-
proaches, and suture materials
aliaw interproximai tissues to be
kept closely adapted in the inter-
proximai areas postoperatively
In cases of severe periodontai
breakdown wifh great tissue loss
The internationai Journal of Periodontics & Restorative Dentistry
and gingivai margins afthe same
level inferdenfaliy as oraiiy and
vesfibulary, the apioaiiy reposi-
tioned flap''™ may be a possi-
bility to create an estheticaiiy
aoceptabie gingivai contourThe
crestai bone has to be recon-
toured through osteopiasty foi-
iowing its noturai morphoiogy.
Because of fhe iengfhening of
fhe ciinicai crown fhaf accom-
ponies this technique, it might be
necessary to shorten the incisai
edges of the affected teeth.
Papiiiae will not regeneróte, but
the esthetic appearance might
be ciearly enhonced.
Prosthetic soluiions
The presence of an interdental
papiiia depends on the distance
between the crest of bone ond
the interproximai contoct point,
aiiowing it to fiii interdentai
spaces with soft tissue by alter-
ing the mesiai contours of the ad-
jacent teeth and positioning the
contact point more apicaiiy, in a
ciinicai case where a mesiai
Fig 5a (ieft) Mesiai diostema and short
clinical crowns compromise the
patient's esthetic oppearonce.
Fig 5b (righf) Interproximal space is
dosed by recontouring the shape and
outlines of the ceramometal crowns on
the maxillary canines and incisors. The
frontal view dernonstrates a natural gin-
gival contour and interdental popillae.
diastema and short ciinicai
crowns were compromising the
patient's esthetic appearance,
this treatment pattern was foi-
iowed (Fig 5a), The maxiiiary
canines and incisors were pros-
theticaiiy restored using poroe-
iain-fused-fo-mefai (PFM) crowns.
By reconfouring the shope and
outlines of the prosthetic restora-
tions, the interproximai spaces
were closed and a natural gingi-
vai contour, inciuding interdentai
popiiiae, was achieved (Fig 5b),
The interdentai tissue can
aiso be conditioned with the use
cf provisionai crowns prior fo fhe
definitive restoration, refined suo-
cessiveiy to induoe creeping
papiiia formation, if aii other pro-
cedures are contraindicated or
faii, prosthetic soiufions have fo
be considered as the iast possi-
biiity to rebuiid iost interdental
papiiiae, interdentai spaces can
befiiied using pink-coiored resin
orporoeiain,'^
Figure 6 demonstrates a case
in which a patient was provided
with a PFM fixed partiai denture
from fhe maxiilary right lateral

Fig 6 Prosthetic solution ta hide soft
and hard tissue defects añer providing
the patient with a PFM ñxed partial den-
ture from fhe maxillary right lateral incisor
to the left canine. Interdentai spaces in
the pontic area are filled with pink-coi-
cred porcelain, giving the impression of
healthy interproximai papulae.
incisor to ttie leff canine.The miss-
ing papillae in the pontic area
were imitated with pink-colored
porcelain. Dental technicians'
skills and knowiedge are chai-
lenged in cases like this. Different
shades of pink ceramic moterials
are mandotary to achieve
esthetically satisfying results. Very
often, however, esfhetics and oral
hygiene are compromised by
fhese prosfhetic solutions, in
severe cases, ttie use of a remov-
able gingival mask might be the
last opportunity to hide severe tis-
sue defects.
Fig 7a Lateral view shows fhe situd'ori
after insertion afon imptant-supporfed
PFM fixed partiai denture to restore the
missing maxillary incisors. A severe soft
and hard tissue defect is abvious.
A 2ó-year-oid female patient
who lost ail maxiiiary incisors and
their associated hard and soft tis-
sues in a car accidenf received 3
impiants in the edentuious area
and was referred to the authors'
department for further treatment.
The disadvantages in this case
were the unfavorabie implant
position—too far palatal—and
the fact that the alveolar defect
had not been augmented previ-
ousiy with bone or soft tissue
grafts, An implant-supported PFM
fixed partiai denfure was manu-
factured. The missing hard and
403
Fig 7b Missing hora and soft tissues are
restored by a removable precision
attachment-retained ocrylic gingival
veneer Laterai view after insertion of fhe
individuaiiy colored gingival epithesis.
soft tissues were restored by a
removable, precision attach-
ment-retained acrylic gingival
veneer. A metai tramework of
high-noble gold alloy was used to
support the individudily colored
pink resin. Figure 7a shows the ciin-
icol situotion offer insertion of the
finoi PFM prosthesis, The severe
alveoiar defect is obvious. The sit-
uation after insertion of the gingi-
val epithesis is shown in Fig 7b.The
integrated precision attochment
offers good refention, yet allows
easy removai of fhe gingival
veneer for oral hygiene,
Voiume 19, Number 4,1999
404
Conciusion
Rebuilding of pink esthetics, the
frame-like gingival and peri-
implant tissues, beccmes more of
an issue in modern esthetic den-
tistry, parallel to patients' and
clinicians' enhanced esthetic
awareness and dental techni-
cians' skills. The absence of the
interproximal papiiiae may
cause devastating esthetic, func-
tional, and phanetic problems.
Anatomic and morphologic
characteristics ot the interprcxi-
mal gingival and periimplant tis-
sues are very well known and sci-
entifically documented. The
interdental papilla could be
defined as a very small and frag-
ile tissue with minor blood supply
that demands sensitive handling.
Clinicians from different disci-
plines including periodontics,
orthodontics, and periodontal
plastic surgery have described
various treatment plans and
techniques to restore the defi-
cient papilla, but none of them
seems to be sufficient to regain
the lost interproximal tissue com-
pletely and predictably. Most of
the articles published to date are
case presentatians containing
no scientific data about long-
term results with specific tech-
niques. A lot mere scientific
research and reliable data are
needed ta recommend certain
techniques far use in private
practice on a regular basis,
it seems that future surgical
methods have to involve modern
bone augmentation techniques
The International Journal of Periodontics S Restorative Dentistry
to be more successful, based on
the fact that the gingival contour
fellows the crestal bone end thet
the presence of the interpreximal
papilla is dependent on the dis-
tance between the bone crest
and the interdental contact
point. However, it has not yet
been preven hew valid these
facts are for the scer-like soft tissue
surrounding implant-supported
restorations. At this point, the pre-
dictabie restoration of the lost
interdental papiiia remains an
unsolved problem.
Ac knowledgments
The authors wish to thank Drs C.Gernharcft,
F. But2, and A Lennon for their contribution
to this article.
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