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Steven E. Holbrook, DMD

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Clinical Articles

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Practice Management

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In part 1 of a series, Drs. Tony and Stuart Aherne discuss the importance of the papilla and demonstrate methods for preserving and recreating the papilla in challenging clinical situations

Contemporary periodontal treat-ment requires great consideration in order to achieve good esthetic results at the end of therapy. Hard and soft tissues need to be controlled in a careful way. Stability of the gingival margins, absence of pocket depth, functionality, and esthetic long-term results are keywords for treatment objectives (European Academy of Esthetic Dentistry [EAED] Active Members Meeting, 2010).

The location of the prosthetic finish line is a fundamental aspect of the esthetic outcome. A good long-term result will depend on many different variables, in particular:

• Periodontal biotype
• Position of the tooth
• Susceptibility to periodontal disease
• Control of inflammation
• Good oral health

The most demanding esthetic challenge is the recapture of papilla height around natural teeth and implants. Various surgical techniques have been proposed, but the results seem questionable and technique-sensitive. Surgical and prosthetic treatment modalities must complement one another to obtain the desired result. This will be achieved and maintained only with excellent oral hygiene and maintenance, in addition to supportive periodontal therapy and patient compliance.

Clinical implications
A contemporary clinical approach based upon the current literature should first of all tackle the major impact of oral hygiene in a stable perio-restorative situation. If case protocol allows more minimally invasive procedures without intimate contact of the gingival complex, this should be taken into account. New adhesive and ceramic techniques are the first choice in dental practice. Therefore, suitable materials with optimal biological response to plaque accumulation should be used in the interproximal papilla.
The interproximal papilla was first described by Cohen in 1959. He described it as the gingival portion that occupies the space between two adjacent teeth or adequate clinical restorations supported by natural teeth and implants or pontic designs. The interproximal papilla, playing a meaningful role for esthetics and phonetics, may accordingly appear in different dimensions. The foundation for the structured support is the underlying contour of the osseous crest. It became obvious that other key factors, besides the bone level, may be involved in the papillary presence/absence, like the presence of the adjoining tooth attachment and the volume of the gingival embrasure (Spear FM, 1999; Kois JC, Kan JY, 2001; Tarnow DP, Magner AW, Fletcher P, 1992). The vertical height from the base of the interproximal contact to the bone crest is one determining factor in maintaining a papilla. However, there are other factors in a three-dimensional space, such as form and volume of the embrasure, size, shape of the contact area, lateral bone dimension, root proximity and biotype, all of which can play a significant role (Tal H, 1984; Heins PJ, Wieder SM, 1986). As such, there are different options for therapeutic impact (Zetu L, Wang HL, 2005).

Proper soft tissue management is directed towards recreating the papillae (Aubert H et al, 1994; Azzi R, Etienne D, Carranza F, 1998; Azzi R, Takei HH, Etienne D, Carranza FA, 2001). Different techniques for papilla preservation have been described as having a beneficial impact on papilla reconstruction (Takei HH et al, 1985; Murphy KG, 1996; Cortellini P, Orato GP, Tonetti MS, 1995, 1999; Cortellini P, Tonetti MS, 2007, 2009). This is especially so in regard to implant uncovering techniques in combination with optional soft-tissue grafting where a large variety of techniques have been introduced in the recent past (Palacci P, 2001; Tinti T, Benfenati SP, 2002; Misch CE, Al-Shammari KF, Wang HL, 2004; Nemcovsky CE, 2001; Happe A, Körner G, Nolte A, 2010).
The predictability of all these techniques remains to be determined. Reconstructing a missing papilla is an inspiring and satisfying achievement in modern treatment concepts, but predictability is low, so efforts should first be focused on preservation and then reconstruction. Very promising approaches deriving from recent studies on papilla preservation are available (Takei HH et al, 1985; Murphy KG, 1996; Cortellini P, Orato GP, Tonetti MS, 1995, 1999; Cortellini P, Tonetti MS, 2007, 2009).

Case one
A 19-year-old woman with a congenitally missing right lateral incisor presented for treatment (Figure 1). There was sufficient space for implant placement because the patient had previously undergone orthodontic therapy. A 3.25 mm x 11.5 mm Biomet 3i™ NanoTite™ Certain® implant was placed (Figure 2). A hard-tissue augmentation was carried out using Endobon® and OsseoGuard® (Biomet 3i™), and the area was allowed to heal for 5 months. At stage II recovery, the implant was gradually uncovered by using progressively larger healing abutments so that the tissue was not expanded too rapidly (Figure 3). When there was sufficient emergence profile present from the healing abutment, a screw-retained provisional was placed using a temporary healing cylinder (Figure 4). This was left in place for 2 months, at which time an Atlantis™ zirconium abutment was fabricated together with a temporary crown to help custom guide the soft tissues (Figures 5 and 6). The temporary crown was left in place on top of the final abutment for an additional 5 months to give adequate time for the soft tissues to form a correct emergence profile and healthy papilla (Figure 7). Ultimately, an IPS e.max® pressed-ceramic restoration was placed (Figure 8) to the new form and shape, which was transferred from the impression to provide complete harmony to the final result (Figure 9).


Treatment methods
Success is clearly dependent on oral hygiene standards and surgical skills. The main goal is to reconstruct the bony support. Reconstruction of the base can be attained via guided tissue regeneration (GTR) procedures and/or bone augmentation, including bone grafting or distraction osteogenesis, and additional soft-tissue management.

Synergistic effects can be obtained by strategic selection of abutment types and restorative design of the adjacent surfaces.
Provisionalization is a key element in esthetically demanding situations in order to condition the interproximal papilla. The emergence profile that has been created should be cautiously transferred into the final restorative situation, taking into account the biologic width, the quantity and quality of the periodontal soft tissues, adequate time management, and material characteristics.


Case two
A 33-year-old woman presented because a black triangle had formed between her upper right central and the upper right lateral incisor. This was associated with poor crown margins and poor oral hygiene (Figure 10). X-rays were taken to determine the bone level (Figure 11). Shell temporary crowns were fabricated. After a maintenance program, the existing crowns were removed, the preparations were refined, and the bone level and periodontal situation were determined (Figure 12). Shell temporary crowns were relined and fitted. The contact area was apicalized to encourage papillary growth (Figure 13). The patient was put on a strict maintenance protocol, and ultimately papillary reformation became complete. Final NobelProcera™ crowns (Nobel Biocare™) were placed, which eliminated the black triangle and gave complete form and harmony on the left and right hand sides (Figures 14 and 15).

Management of the interproximal papilla is an extremely challenging and complex procedure. When successful, it provides profound esthetic benefits that are distinctly recognizable, especially in patients who have a high lip line. Tissues have to be handled with great care and manipulated gently. Surgical procedures should be minimally invasive when case protocol allows, and microsurgical concepts can be of great benefit. Provisionalization to custom guide the tissues is a mandatory aspect of treatment, as is stringent maintenance care.


Tony Aherne, BDS, NUI, DRD, RCS Ed, MDS, is a former secretary, treasurer, and executive council member of the European Academy of Aesthetic Dentistry. A founder of the Irish Academy of Aesthetic Dentistry, he has a practice in Cork specializing in implant dentistry and prosthodontics.

Stuart Aherne, BDS, is a graduate of the University of Wales College of Medicine and completed his vocational training in Cardiff. He is presently working as a partner in a private specialist prosthodontic and implant practice in Cork.


Aubert H, Bertrand G, Orlando S, et al (1994) Deep rotated connective tissue flap for the reconstruction of the interdental papilla. Minerva Stomatol 43(7-8):351-357.

Azzi R, Etienne D, Carranza F (1998) Surgical reconstruction of the interdental papilla. Int J Periodontics Restorative Dent 18(5):466-473.

Azzi R, Takei HH, Etienne D, et al (2001) Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts. Int J Periodontics Restorative Dent 21(2):141-147.

Cohen B (1959) Morphological factors in the pathogenesis of the periodontal disease. Brit Dent J 7:31-39.

Cortellini P, Prato GP, Tonetti M (1995) The modified papilla preservation. J Clin Periodontol 66:261.

Cortellini P, Prato GP, Tonetti MS (1999) The simplified papilla preservation flap. A novel surgical approach for the management of soft tissues in regenerative procedures. Int J Periodontics Restorative Dent 19(6):589-599.

Cortellini P, Tonetti MS (2007) A minimally invasive surgical technique with an enamel matrix derivative in the regenerative treatment of intra-bony defects: a novel approach to limit morbidity. J Clin Periodontol 34(1):87-93.

Cortellini P, Tonetti MS (2009) Improved wound stability with a modified minimally invasive surgical technique in the regenerative treatment of isolated interdental intra-bony defects. J Clin Periodontol 36(2):157-163.

EAED active members meeting (2010) Proceedings of the scientific session. Biological interfaces in aesthetic dentistry. Tremezzo (Como), Italy, 30 September-2 October 2010

Happe A, Körner G, Nolte A (2010) The keyhole access expansion technique for flapless implant stage two surgery: technical note. Int J Periodontics Restorative Dent 30(1):97-101.

Heins PJ, Wieder SM (1986) A histologic study of the width and nature of inter-radicular spaces in human adult pre-molars and molars. J Dent Res 65(6):948-951.

Kois JC, Kan JY (2001) Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales. Pract Proced Aesthet Dent 13(9):691-698, 700, 721-722.

Misch CE, Al‐Shammari KF, Wang HL (2004) Creation of inter-implant papillae through a split finger technique. Implant Dent 13(1):20-27.

Murphy KG (1996) Interproximal tissue maintenance in GTR procedures: description of a surgical technique and 1-year re-entry results. Int J Periodontics Restorative Dent 16(5):463-477.

Nemcovsky CE (2001) Interproximal papilla augmentation procedure: a novel surgical approach and clinical evaluation of 10 consecutive procedures. Int J Periodontics Restorative Dent 21(6):553-559.

Palacci P (2001) Esthetic implant dentistry: soft and hard tissue management. Quintessence Publishing, Chicago.

Spear FM (1999) Maintenance of the interdental papilla following anterior tooth removal. Pract Periodontics Aesthet Dent 11(1):21‐28.

Takei HH, Han TJ, Carranza FA Jr (1985) Flap technique for periodontal bone implants. Papilla preservation technique. J Periodontol 56(4): 204-210.

Tal H (1984) Relationship between the interproximal distance of roots and the prevalence of intrabony pockets. J Periodontol 55(10):604-607.

Tarnow DP, Magner AW, Fletcher P (1992) The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 63(12):995-996.

Tinti C, Benfenati SP (2002) The ramp mattress suture: a new suturing technique combined with a surgical procedure to obtain papillae between implants in the buccal area. Int J Periodontics Restorative Dent 22(1):63-69.

Zetu L, Wang HL (2005) Management of interdental/inter-implant papilla. J Clin Periodontol 32(7):831-839.




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