What is an interdental papilla? Regeneration of the gingival papilla and mucous membrane in the area of the intermediate part of the bridge

Doctor of Dentistry, private practice (periodontics and prosthetic 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, appearance lips and the patient's face as a whole. Mucogingival surgery is available to treat gum recession.

Interdental gingival papilla- This is the area of gum between two adjacent teeth. It not only serves as a biological barrier that protects periodontal structures, but also plays a significant role in the formation of the aesthetic appearance. The absence of interdental gingival papillae can lead to problems with pronunciation, as well as the retention of food debris in the interdental spaces.

If the interdental gingival papilla is lost, its regeneration is quite difficult. IN dental practice Only a few such cases are known. However, none of the reports contain information about methods that can restore the gingival papilla. This report describes surgical method restoration of the mucous membrane and gingival papilla in the area of the intermediate part of the bridge in the presence of deficiency bone tissue.

Surgical technique

The patient, 45 years old, came to the clinic for treatment of periodontal pathology. She complained about the mobility of the two upper central incisors. The patient wanted to restore her appearance and also eliminate periodontal pathology. The central incisors had mobility of the 3rd degree, the depth of the pockets during probing was 10 mm and 8 mm. In the area of the right lateral incisor, a periodontal pocket with a depth of 10 mm 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 labial side of teeth 11 and 12

Rice. 1b. Recession found on the labial side of teeth 11 and 12

A 7 mm deep pocket was also found in the area of tooth 22.

When collecting anamnesis, no allergies were detected, concomitant diseases or bad habits. The patient was classified as ASA class 1. Several weeks before surgery, the patient was taught oral hygiene, in addition, subgingival deposits were removed and root surfaces were cleaned. After removal of granulation tissue in the area of the gingival papilla in the area of the 12th tooth, soft tissue recession to a height of 3 mm was discovered. In accordance with Miller's classification, she was assigned class III. WITH vestibular side in the area of teeth 11 and 12, soft tissue recession was also detected to a height of 2 mm (Fig. 2).

Rice. 2. Vertical defect and class III mobility of teeth 11 and 21

Due to the loss of bone around the two central incisors, the 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 gingival papilla. We made sure that the temporary prosthesis does not put undue 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 gum mucosa was heterogeneous. Photographs, x-rays were taken, alginate impressions were taken and masticography was performed. Based digital analysis From the photographs, diagnostic models were made, which were then placed in the articulator. The patient was then given treatment options. A tooth-supported bridge represents the most current option for replacing missing teeth, especially as an alternative to complex vertical alignment bone regeneration, which would require frequent examinations and strict adherence to the patient's regimen. The use of such a prosthesis is less risky than installing a prosthesis with fixation on implants, if the bone and soft fabrics not present in sufficient quantity. The patient had a high sociocultural level and aesthetic preferences. Considering others personal factors, in particular the patient’s place of residence, we were forced to choose the fastest, most effective and reliable solution. During her 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 remove two central incisors, correct 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 installed. The neck of tooth 12 was prepared accordingly, taking into account the likely future soft tissue reconstruction. Endodontic treatment of the lateral incisors was required. Silicone impressions were made to create a second, more precise temporary prosthesis designed to long term operation, as well as for re-evaluation of a given clinical case from a biological, functional and aesthetic point of view. Four weeks later, soft tissue recession was detected due to bone resorption on the vestibular side alveolar process 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 area of the right central incisor and the papilla between it and the lateral incisor was increased

Using several soft tissue incisions, a tunnel was created in the area of the pontic pontic (Fig. 4). Nylon was used to fix the graft. suture material 6-0. We ensured that the temporary prosthesis did not place undue pressure on the graft (Fig. 4). Then we 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 installed using a tunnel approach after frenectomy

We needed more tissue in the area of the right central incisor and the gingival papilla between teeth 11 and 12. The depth of the pocket during probing is 7 mm (Fig. 5). Given the loss of 3-4 mm of papilla tissue, we can conclude that the probable probing depth was 10 mm with a 5 mm bone defect at the level of the papilla. After this, the second phase of surgery began (Fig. 5). The preoperative status of the interdental gingival papilla was determined using the Norland and Tarnow classification. The interdental gingival papilla, the gums on the vestibular and palatal sides were anesthetized using 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 labial frenulum (Fig. 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 gum tissue and provided access for a 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 free space under the gingival papilla and install a connective tissue graft. In addition, some mobility of the palate tissue was also ensured. The resulting flap was fixed coronally using a curette directed along the gingival sulcus and a small periotome. The amount of donor tissue required was determined during a preoperative assessment of gingival and incisal height in comparison with the expected new location of the gingival papilla. A section of connective tissue of significant size and thickness with a section of epithelium 2 mm wide was taken from the patient’s palate (Fig. 5). An area of epithelium was taken to obtain denser and more 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 engraftment of the graft, since the graft was nourished by blood perfusion larger area. An area of epithelium was placed on the buccal side of the coronally fixed flap of tissue, but was not covered by it (Fig. 6), since the epithelium is denser than connective tissue, and was therefore better suited as a base for a repositioned flap. The connective tissue portion 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 secure the graft in position and stabilize the wound. This microsurgical approach was made possible by using optical microscope Zeiss. The wound on the palate is closed with a continuous suture. The patient is prescribed amoxicillin (500 mg, three times a day, 10 days), as well as an alcohol-free mouthwash with chlorhexidine (twice a day, 3 weeks). Keratinizing epithelial cells and food debris could be removed from the wound surface using a cotton swab soaked in chlorhexidine gluconate. After 4 weeks, the stitches were removed. The patient was also prohibited from using mechanical means to clean teeth in the wound area for 4 weeks. An earlier examination of the patient was impossible due to the remoteness of her place of residence. The postoperative period passed without complications. The third stage of surgery took place before installation of the permanent prosthesis. Using a diamond cutter, part of the transplanted epithelium was removed (Fig. 7).

Rice. 7 a - c. Transformation of the intermediate part of the bridge after the first and second operations

The area between the pontic and the lateral incisors was not probed for 6 months. As a result of probing, a gingival pocket with a depth of 5 mm was discovered in the area of the lateral incisor, which was only 1 mm greater than the depth of the gingival pocket in the area 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 pontic pontic area (Fig. 8).

Rice. 8 a, b. After the second stage of surgical intervention, the edge of the soft tissue of the gingival papilla turned out to be 3-4 mm closer to the incisors than before the operation, while there was no bleeding, and probing did not give negative results

The depth of probing in the area of the lateral incisor before the second operation was 7 mm. A recession of 3 mm in diameter was found in the area of the right lateral incisor (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 depth during probing decreased by 4-5 mm. An examination carried out after 2 years showed that the clinical results recorded 3 months after surgery had improved. In particular, there was no black triangle between the artificial crowns of the lateral and central incisor (Fig. 9 a, b).

Rice. 9 a. When checked after two years, no black triangle was found between the lateral and central incisors

Rice. 9 b. When checked after two years, no black triangle was found between the lateral and central incisors

There was no retraction or compression of the papillary tissue, and the probing depth did not increase. Radiographic examination showed improvement in the condition of the underlying bone (Fig. 10).

Rice. 10 a - d. Radiographic examination showed significant improvement in the condition of the underlying bone, although no bone graft was used

The depth of the gingival groove 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 gingival papilla was filled with a connective tissue graft.
The connective tissue was well stabilized by the suture.

conclusions

In clinical cases that represent not only medical, but also aesthetic problem, reconstructive surgery can disguise tissue loss, but the patient rarely achieves an ideal appearance. To improve the results of such intervention, periodontal plastic procedures can be used. The use of optics and microsurgical instruments is recommended. This allows the surgeon to improve visibility, avoid unnecessary incisions and increase the chances of favorable outcome treatment.

The health and beauty of your teeth depends on the health of your gums. The gap between the teeth is filled by the gingival papilla. This is a sensitive and vulnerable part of the soft tissue. Domestic injuries, improper hygiene oral cavity, dental diseases can lead to inflammation and excessive growth of gingival papillae.

You can get rid of gum problems using cauterization. The procedure has a scary name for the average person. In fact, everything goes quickly and painlessly, thanks to modern technologies and drugs.

Features of gums between teeth

The areas of gum that fill the spaces between the surfaces of dental crowns are called gingival or interdental papillae. Interdental papillae protect periodontal structures. Incorrect formation or absence of structures leads to problems:

violation of correct pronunciation;
retention of food debris in the interdental space;
aesthetic inconveniences.

Gingival papillae cover the spaces between teeth

Gingival papillae are a very sensitive and vulnerable part of the soft tissue. They are easily damaged by mechanical impact, violations of oral hygiene rules.

The health of teeth and gums depends on the condition of the interdental spaces. Therefore, you need to carefully monitor them and seek help from a specialist at the first symptoms of disturbances.

Inflammation of interdental papillae

Inflammation of the gingival papilla can occur due to a number of reasons. The first symptom of the disorder is bleeding and redness of the gum surface.

Causes of inflammation of the interdental papillae:

Household injuries (using a toothpick, dental floss, too hard Toothbrush, solid food).
Injuries during therapeutic treatment teeth, stone cleaning.
Diseases of teeth and gums.
Malocclusion.
Hormonal disorders.

Constant violation of the integrity of the papilla tissue leads to bleeding and the entry of foreign microorganisms into the wound.

Inflammation of the gingival papillae - gingivitis

The process of inflammation of the papillae on the gums is characterized by regular bleeding (usually observed after brushing teeth or eating), increased sensitivity. The damage will begin to heal after the natural completion of the inflammatory process. But if it grows excessively, the surface of the nipple will increase in size. The overgrown area of the gum will become even more sensitive and vulnerable, new inflammation and bleeding cannot be avoided. Self-medication in a situation with inflammation of gum areas should not be practiced, otherwise it will be more difficult for the doctor to understand the causes of the disorder.

Gingival recession with enlarged papillae

How to treat inflammation of the gingival papillae

You should contact your dentist if you experience regular gum bleeding; this will save you from many troubles. Even a small problem with gum health cannot be ignored and left to chance.

When the gingival papilla grows, a coagulation procedure is performed. Gums are cauterized electric shock. The procedure is carried out very carefully, under local anesthesia. The patient does not feel pain, but discomfort may be observed after the procedure.

Coagulation in dental practice

Coagulation (diathermocoagulation) is one of the methods of surgical dentistry, used for the treatment and plastic surgery of soft tissues. Practice received wide use. Today there is equipment that allows many operations to be performed using electrode excision.

Coagulation in dentistry is cauterization. The operating instrument is heated by electricity. The therapeutic effect of diathermocoagulation of the gums is ensured by high-frequency alternating current. The current voltage is low, but the power is 2A.

If the operation is successful, the affected area becomes white. The effect is primarily aimed at blood vessels. AC current affects inner surface vascular wall, promotes blood clotting. Due to this, damaged blood vessels are quickly closed, and bleeding gums are eliminated.

Coagulation of the gingival papilla allows you to quickly and reliably disinfect the wound, stop the development of the inflammatory process, and stop bleeding. Using this method, you can return an overgrown nipple to its former healthy appearance.

When is coagulation used in dentistry?

Coagulation is a serious surgical method. Its use in practice requires certain qualifications. The procedure can be carried out after an accurate diagnosis has been made.

Indications for the use of diathermocoagulation:

Chronic pulpitis, pulp polyp.
Periodontal inflammation (the contents of the tooth root canals are disinfected by cauterization).
Removal benign neoplasms oral mucosa (papillomas, hemangiomas, fibromas).
Gingivitis, cutting off of overgrown gum nipples.

Using coagulation, the contents of periodontal pockets are disinfected. If enlarged blood vessels are visible in the mouth, they can also be removed using an electric current.

When should coagulation not be used?

The use of coagulation is contraindicated in the following cases:

treatment of baby teeth;
individual intolerance to the effects of electric current;
narrowing or enlargement of the root canal of the tooth;
unformed root tips.

The coagulation procedure is contraindicated for people with heart and vascular diseases.

A qualified specialist will definitely ask the patient questions about his state of health. You need to tell everything, indicate if you are allergic to anesthesia, and inform about taking medications.

Set for electrocoagulation procedure

How is coagulation of the gingival papilla performed?

Coagulation of the gums can be carried out using different techniques, methods and instruments.

There are several ways to carry out the coagulation procedure in dentistry:

Action with a heated tool. An outdated technique, rarely used today.
Cauterization with an electrocoagulator. All modern clinics equipped with these devices.
Laser action. The most secure and soft method treatment.

The choice of method depends on the equipment of the clinic and the characteristics of the disease. Each technique has its own advantages and disadvantages.

Heated tool

The tools for cauterizing the gums are a spatula, a dental trowel, or a plugger. Today the method is outdated.

Treatment of the gums with a heated instrument allows you to remove small areas of tissue. Using technology, they stop bleeding and cauterize wounds.

Gums immediately after coagulation

When performing the procedure, it is important to ensure complete sterility of the instrument.

Electrocoagulator

An electrocoagulator is a special device that operates at high frequency current. The main part of the tool is the loop. It is heated by electricity and cauterizes the desired area of the gum or oral mucosa. Dental electrocoagulators are either stationary or portable. You can adjust the power of the device and select different operating modes.

The device operates silently. Its effect on humans is painless (the procedure is performed under anesthesia) and safe.

Laser

Laser therapy is widely used not only in cosmetology, but also in dentistry. This is the most advanced technology for removing overgrown gums. The radiation acts quickly, reliably and painlessly.

Main advantages laser therapy– after the procedure there are no traces or wounds on the gums, the sore spot is completely disinfected. You cannot get an infection during laser treatment, even if you really want to.

Laser plastic surgery of gingival papillae

If you have a choice about which method to use, it is better to give preference to laser.

Electrocoagulation technologies

Coagulation of the gums with the help of devices can be carried out using two different technologies. They differ in the depth of the influence of current on a person.

Electrocoagulation technologies:

Bipolar. Electricity is passed only through the desired area (through the gum). The current short circuit occurs at a short distance. With the help of bipolar technology, you can only get rid of small tumors on the gums. An end plate is not required when using the technique.
Monopolar. Electricity passes through the entire human body. With the help of technology, you can get rid of serious and deep-seated gum problems. To close the electrical circuit, the patient must wear a return plate.

Dentists prefer monopolar technology. It is more versatile and reliable. Monopolar electrocoagulation should not be used for people with heart and vascular diseases, intolerance to the effects of current, or for pregnant women at any stage.

Healthy gums, without growths, neoplasms and inflammation - the basis beautiful smile. If the gums become inflamed, the interdental papillae turn red and begin to bleed, this is a reason to consult a dentist. Overgrown gingival nipples can be removed using the electrocoagulation method. The procedure should only be entrusted to a qualified specialist.

The invention relates to the field of medicine and is intended for use in the restoration and formation of interdental gingival papillae. Temporary crowns are made for adjacent implants from a transparent bioinert material with transparent hollow molds located between them that fit tightly to the gums. The mold is pre-equipped with micro-holes for connecting a source to them low blood pressure at 0.6-0.7 atmospheres. Every 3-4 days, connect a source of reduced pressure for 10-15 minutes. 15-20 mg of non-resorbable biositall is gradually injected into the protopapilla formed on the surface of the periosteum of the edge of the alveolar ridge, in the form of a hemorrhagic blister, using a syringe with a curved needle. Then, one 20-minute session of phonophoresis with 10% Solcoseryl gel is performed daily on this area of acceleration for regeneration for 7-12 days. The method makes it possible to accelerate the growth of the mass of interdental gingival papillae and provide the desired, expected cosmetic and functional result.

The proposed invention relates to medicine, namely dentistry, and can be used to restore, increase, and form interdental gingival papillae.

It is known that to form the contour of the gums, a gum former is installed on the implant. It is installed temporarily while the soft tissue of the gums is healing. This formation of gums is necessary because... The contours of the soft tissues of the gums in the period after installation of the implant, as a rule, change significantly and this causes difficulties in installing the abutment - the supporting and connecting element between the implant and the oral cavity. (John A. Hobken, Roger M. Watson, Lloyd Dos. Dos. Sizn, Guide to Implantology, M., Medpress-inform, 2007, p. 22).

Disadvantages: the former has an additional width relative to the abutment, which causes the formation of a “ridge” around the implant outside of it, there are no conditions for creating papillae between the teeth, which entails an unsatisfactory aesthetic condition, inadequate adherence of soft tissues in the interdental spaces and is fraught with retention of residues in them food, poor oral hygiene, inflammatory processes due to poor hygiene.

This method is accepted as the closest analogue.

The applicants have not identified information about the methods of formation of gingival papillae.

Objectives: ensuring high-quality and reliable formation of interdental gingival papillae, improving the aesthetics of the implantation zone, reducing the risk of complications after prosthetics, increasing the level of oral hygiene.

A significant novelty of the method is that temporary crowns are made together with transparent hollow molds located between them, which fit tightly to the gums after they are placed and have holes for connecting to them every 3-4 days for 10-15 minutes a source of reduced pressure at 0. 6-0.7 atmospheres until a protopapilla forms on the surface of the periosteum of the edge of the alveolar ridge in the form of a hemorrhagic blister, into which 15-20 mg of non-resorbable biositall is injected using a syringe with a curved needle, and then applied to this area daily, once for 7-12 days for a 20-minute session of phonophoresis with 10% Solcoseryl gel.

The technical result of the proposed method during testing was an accelerated increase in the mass of interdental gingival papillae. The procedure purposefully provides the desired, expected cosmetic and functional result. The height of the formed papillae reaches short term 2.0-2.5 mm and tightly closes the interdental spaces, corresponds to the normal anatomical relationship, they fit well to the gums and the coronal part of the implants.

The method is carried out as follows.

For adjacent implants (tooth and implant), temporary crowns are made from a transparent bioinert material together with transparent hollow molds located between them, tightly adjacent to the gums after they are put in place. The mold is pre-equipped with micro-holes for connecting to them a source of reduced pressure of 0.6-0.7 atmospheres.

Every 3-4 days, connect a source of reduced pressure for 10-15 minutes. Visual inspection shows how a protopapilla forms in the form of a hemorrhagic blister on the surface of the periosteum of the edge of the alveolar ridge. 15-20 mg of non-resorbable biositall is gradually injected into this blister using a syringe with a curved needle, and then one 20-minute session of phonophoresis with 10% Solcoseryl gel is carried out on this area of acceleration for regeneration every day for 7-12 days.

When testing the method on 56 patients, no complications were identified, reliable results were obtained, the formation of gingival papillae was obtained within 15-17 days.

Example. Patient K., 51 years old, medical history 1443, applied for continued sanitation of the oral cavity and restoration of dentition defects in the upper jaw. Reconstruction using implants has been proposed. Upon examination after installation of the implants, it was revealed that the height of the interdental gingival papillae is insufficient and does not meet aesthetic requirements. To resolve the issue, a model of the prosthetic bed was first made, temporary crowns were made of bioinert transparent material on the heads of the implants, and at the same time, closed cavities isolated from the crowns were made for the formation of interdental gingival papillae. The cavities are equipped with holes for connecting a source of reduced pressure. The implants are inserted into prepared prosthetic beds. Every 3-4 days, a pressure of 0.6-0.7 atmospheres was connected to the mold-cavities for 10-15 minutes. Gradually, a hemorrhagic blister formed on the surface of the periosteum, into which 15-20 mg of biositall was injected from a syringe with a curved needle, after which 20-minute phonophoresis sessions were performed with 10% Solcoseryl gel. A total of 7 procedures were performed to form gingival papillae. On examination: hyperemia, no inflammation. The height of the papillae is 2.0-2.5 mm, the tissue is homogeneous, tightly adjacent to the gum and the coronal part of the implant.

A method of forming an interdental gingival papilla, including the introduction of implants into the alveolar ridge, characterized in that temporary crowns are made together with transparent hollow molds located between them, tightly fitting to the gums after they are placed and having holes for connection to them every 3-4 days. 10-15 minutes of a source of reduced pressure of 0.6-0.7 atmospheres until a protopapilla forms on the surface of the periosteum of the edge of the alveolar ridge in the form of a hemorrhagic blister, into which 15-20 mg of non-resorbable biositall is injected using a syringe with a curved needle, and then onto this area is carried out daily, once for 7-12 days, with a 20-minute session of phonophoresis with 10% Solcoseryl gel.

Similar patents:

The invention relates to medicine, namely dentistry, and is intended for prosthetics lower jaw with complete absence of teeth in patients with unfavorable clinical conditions prosthetic bed.

If you want to improve the appearance of your smile, if you don’t like something about it, but you cannot accurately and correctly formulate what exactly, if you want to talk with your dentist about the aesthetics of your smile in the same language, then the following note is just right for you.

Nature (or God... depending on your views on life) has made us different. And our originality and uniqueness have its own charm. But what to do when this uniqueness goes too far beyond our ideas of beauty? How to formulate your claims to nature (and perhaps to the previous intervention of dentists)? To assess the aesthetic component of our face, lips, teeth - everything what gives birth to a beautiful harmonious smile It turns out there are a lot of parameters. This is what dentists use (at least should use) when planning changes in your appearance. Because the various nuances very, very much, but I don’t have the task of making each of you expert in the field of aesthetic dentistry, then we will focus on the ten simplest and most important.

1. Parallelism of horizontal landmarks.

One of the most important signs a harmonious smile is the parallelism of imaginary lines: the interpupillary line (in the figure there is a blue line connecting the right and left pupil of the eye) and the line of the lips (in the figure there is a red line drawn between the corners of the mouth).

Both of these lines should also be parallel to the lines connecting the edges of the central incisors (green) and the incisal cusps of the canines (blue)

2. Smile line.

The smile line runs along the cutting edges of the front upper teeth (shown in the photo with a solid line) and should ideally follow the curve of the upper edge of the lower lip (shown in the photo with a dotted line), i.e. be convex.

3. Gum level.

A smile looks more attractive and aesthetically pleasing, in which the line connecting the necks of the teeth (shown by a dotted line) repeats the line of the upper lip, and the level of the gum exposed when smiling is symmetrical on the right and left. At the same time, with a maximally open smile, only the gum “triangles” between the teeth and a small strip of gum above them (no more than 2-3 mm wide) should be noticeable.

Thus, the gums around the upper teeth, upper and lower lips form a kind of frame for your smile. If the “picture” is not visible behind the frame, then such a smile will not look attractive.

Excessive visualization of the gums (the so-called “gummy smile”) is most often eliminated with the help of surgery, orthodontic treatment, as well as cosmetic interventions (for example, Botox injections into the upper lip, upper lip augmentation, etc.).

4. Vertical symmetry and midline.

A line passing through the center of the face should pass exactly between the central incisors of the upper jaw. The discrepancy between these lines causes a feeling of disharmony even with a quick glance at your smile from the outside. In this case, it is not at all necessary that it also passes between the central lower incisors. Firstly, complete coincidence rarely occurs, and secondly, this in no way affects aesthetic perception of your smile when looking at it from the outside.

5. "Golden proportion".

The principle of the golden proportion in relation to the smile in aesthetic dentistry is that when viewed from the front, strictly in the center, the ratio of the visible width of the front teeth should be approximately the following - 0.6 (width of the canine): 1 (width of the lateral incisor): 1.6 (width of the central incisor).

As can be seen in the photo, the width of the visible part of the remaining teeth (4s, 5s) should consistently decrease, creating a sense of perspective.

6. Tooth proportions.

The central incisors of the upper jaw always attract special attention, because... best visible when talking and smiling. Therefore, it is very important that their proportions are correct. Teeth look most harmonious having a tooth width to length ratio of approximately 0.7-0.8: 1

At the same time, in at different ages this ratio may change. Due to the physiological wear of teeth in more mature age this ratio tends to be 1:1. Therefore, if you want to “rejuvenate” your smile, you usually need to increase the length of the tooth.

7. Interincisal angles.

Interincisal angles are the spaces between the cutting edges of the anterior group of teeth.

With the harmonious construction of teeth, these angles should gradually increase from the center to the periphery: from a small closed angle between the central incisors, to a more direct and even open angle between the 2nd and 3rd teeth.

Tooth wear leads to a decrease or complete absence interincisal angles, which makes the patient look older when he smiles.

At the same time, “female” teeth are characterized by rounded corners of the incisors, while “male” teeth are characterized by straighter ones.

8. Zenith of the gingival contour.

The zenith of the gum is its most concave part around the neck of the tooth (indicated by dots in the photo).

Zenith level approx. different teeth in the smile zone should be on at different levels. For the central incisors and canines - approximately at the same level (or slightly higher for the canines), for the lateral incisors - slightly lower than both (as shown by the lines in the photo). At the same time, it is equally important that the zeniths on symmetrical teeth are at the same level. This is especially important to consider if this area becomes noticeable when smiling. When even with the most open smile the gums are not exposed, then there is no serious need to set the zeniths perfectly symmetrically.

In this case, it attracts too much attention low level The zenith is on tooth 12, it is significantly lower than the symmetrical tooth 22. There is also a slight difference in the position of the zeniths on the central incisors (teeth 11 and 21). As a result of treatment, these shortcomings were eliminated, as can be seen in the first photo.

9. Position of cutting edges.

The cutting edges of the central group of teeth are also located at different levels. For the central incisors and canines - approximately at the same level, for the lateral incisors - slightly higher (as marked by lines in the photo).

Again, due to the wear of teeth with age, the cutting edges of the teeth become at the same level, the line connecting them takes on a straight rather than convex appearance, and sometimes (with increased pathological abrasion) – even concave. Therefore, to make a smile more “youthful,” you need to return the relationship of the cutting edges to a harmonious one.

It can also be noted that the dominance of the central incisors over the lateral incisors and canines also gives the smile a more youthful appearance.

The dominance of the canines, their sharp, prominent cutting cusps, make the smile more aggressive. This effect is based on the fact that in nature, long, sharp, well-developed fangs are characteristic of predators, whose entire philosophy of existence is based on aggression towards their prey.

10. Interdental gingival papillae.

The gingival papilla is the part of the gum that fills the interdental space (marked with lines in the photo).

The location and appearance of the papillae is determined by the underlying bone, which has exactly the same contour. At the most optimal option the apices of the gingival papillae are located as in the photo (marked with dots) - between the central incisors the gingival papilla is longest, and gradually its length decreases towards the periphery. Moreover, they should all have a healthy appearance - a triangular shape with a sharp apex, pink color, no swelling.

At various diseases periodontal disease, as well as with incorrectly performed restorations, the gingival papilla can become inflamed, acquiring a darker (or even bluish) color, losing its pointed shape, or may even disappear completely. At the same time, unaesthetic black spaces form between the teeth.

This is what the main one looks like, but not yet full list those parameters that need to be assessed and taken into account when planning and creating perfect smile. What he does aesthetic dentistry. Now you can evaluate for yourself how close your smile is to ideal. And I hope that this note will help you better understand what exactly you would like to change and improve. After all, this will greatly facilitate mutual understanding between you and your dentist.

Materials and methods

Subjects studied

0 – absence of papilla;

4 – papillary hyperplasia.

Measurements

Surgical procedure

Photo 1c. Palatal incision.

Photo 1d. Interlingual curette.

results

Discussion

Conclusion

Restoring lost teeth using orthopedic structures supported by dental implants is very common nowadays dental practice. However, aspects of osseointegration of supports, as well as the restoration of corresponding aesthetic parameters in the area of single and partial edentia, differ markedly.

An important aspect of rehabilitation remains the restoration of an adequate soft tissue contour and the architectonics of the interdental papilla, as extremely important components of the optimal smile profile. The absence of an interdental papilla compromises not only the patient’s appearance, but also provokes phonetic problems, as well as food getting stuck in the problem area.

In more early studies The role of the distance from the top of the interdental septum to the contact point between adjacent teeth has already been proven as a factor influencing the volume of restoration of the papilla, at the same time this parameter is variable for the papilla between adjacent natural teeth, between the implant and the natural tooth, as well as in the area of the overhanging tooth. parts 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 implantation area often occurs deficiency in the height of the interdental papilla, which is critical in the rehabilitation of a patient with adentia in the frontal area.

There are many different approaches to restore the interdental papilla, however, often due to compromised blood supply conditions and the formation of scar tissue, most known surgical technicians are insufficiently predicted. Villareal in 2010 described a predictable approach to papillary regeneration using careful sequential soft tissue manipulation, including gentle incision 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. This is why this approach recommended against suturing the intervention area, as this may cause additional trauma or inflammation, which ultimately will negatively affect the final result of treatment.

The purpose of this article is to present a series of clinical cases in which restoration of interdental papillae in the implantation area was performed using a modified surgical technique.

Materials and methods

Clinical data used in this study were obtained from the database of the Department of Periodontology and Implantology at New York University Kriser Dental Center. Data certification was carried out by the quality assurance department of the same university. The study was conducted in accordance with the Health Insurance and Identity Sharing Act and was approved by the University's Human Subjects Research Review Board.

Subjects studied

The study included ten clinical cases of restoration of the edentulous area of the central part of the upper jaw using dental implants. In the retrospective portion of the study, patients with existing restorations who had previously undergone interdental papilla augmentation between August 2011 and August 2012 were analyzed. The study group included 3 men and 7 women, average age which amounted to 45 years. During the study, the areas of the interdental papilla between two adjacent implants, between the implant and the natural 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 the provisional restoration.
Absence of interdental papilla (0 or 1 according to Jemt classification).
Absence of a papilla in the anterior part of the upper jaw between two adjacent implants, an implant and a 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 – absence of papilla;
1 – the presence of a papilla of only half its normal height;
2 – presence of more than half the height of the papilla;
3 – presence of a papilla of normal size;
4 – papillary hyperplasia.

The exclusion criteria from the study group were as follows:

State of pregnancy or lactating women.
Active periodontal disease in the area of remaining natural teeth.
Availability systemic diseases or reception medicines, which can affect the healing process of tissue around dental implants.
Lack of motivation to carry out long-term maintenance therapy.

Measurements

Immediately after fixation of the provisional restorations, the distance from the contact areas of the superstructures to the papillary region of the gums was measured using a North Carolina periodontal probe (Hu-Friedy). After this, the results were interpreted in accordance with the Jemt classification. To improve the accuracy of the final results, measurements were carried out independently by two different examiners, but in no case did expert opinion differ and all papillae were scored 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

One hour before the intervention, patients took 2 g of amoxicillin orally, or 600 mg if allergic to penicillins. After local anesthesia with lidocaine with adrenaline at a concentration of 1: 100,000 (Henry Schein), the provisional structures were removed in order to visualize the area of the interdental papilla. Before surgical intervention Patients underwent a procedure to expand the interdental space to provide sufficient volume for future soft tissue (Figure 1a).

Photo 1a. Clinical appearance provisional restoration with a missing papilla in the implant area at the site of the 12th tooth and an intermediate part in the area of the 11th tooth after augmentation.

Before modification of the provisional structures, each of the papillae was assessed according to the Jemt classification. After removing the temporary restorations from the vestibular mucosa apical to the papillary region, an oblique incision was made through the full thickness of the soft tissue (Figure 1b).

Photo 1b. An oblique incision of the mucosa from the vestibular side.

A similar incision was made on the palatal side (Figure 1c).

Photo 1c. Palatal incision.

The oblique direction of the incisions, as well as the formation of such at a certain distance from the existing papilla, was reasoned with the goal of maintaining an adequate level of blood supply in the recipient area. Using the interlingual (TLC) (Ebina), modified and double-angled (Figure 1d) curette, it was possible to provide tunnel access apical to the papilla without additional soft tissue trauma.

Photo 1d. Interlingual curette.

First, the working part of the instrument was placed in the area of the vestibular incision, after which the periosteum was carefully separated to form a subperiosteal tunnel to the alveolar ridge, located apical to the existing interdental papilla (photo 2).

Photo 2a-2c. Separation of the periosteum using an interlingual curette.

In this case, 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 later helped to connect the two tunnel approaches.

The subepithelial connective tissue graft was collected from the palate after anesthesia. The procedure was carried out using Langer-Calagna and Hurzeler-Weng techniques. The wound area was sutured using 4/0 chrome 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 able to be moved up to the palatal tunnel area (photo 4).

Photo 4. View of graft placement in the defect area.

After achieving the optimal position of the graft, it was fixed in the area of the previously formed vestibular and palatal incisions using catgut sutures (photo 5).

Photo 5a-5b. Schematic representation of the augmentation procedure.

IN postoperative period Patients were prescribed 500 mg amoxicillin or 150 mg clindamycin three to four times daily for 1 week and ibuprofen (600 mg every 4 to 6 hours) for pain relief. Patients were also advised to use 0.12% chlorhexidine solution as a mouth rinse twice daily, starting 24 hours after surgery for the next 2 weeks, as well as a bland diet while the wound healed. 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. Repeat examinations were carried out 7 and 14 days after the iatrogenic intervention (Figure 6).

Photo 6. View 7-14 days after augmentation.

3 months after augmentation, the final prosthetic restorations were fixed (photos 7a-7d), and the design of those in the mucosal area exactly matched the contour of the previously fitted provisional structures.

Photo 7a. Clinical appearance before fixation of the final prosthesis.

Photo 7b. Clinical view with the final prosthesis in place.

Photo 7c. Clinical appearance of the final superconstruction.

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 it was not possible to completely restore the interdental papilla, a slight lengthening of the contact points was carried out directly on the final superstructures. For monitoring purposes, all patients re-visited the dentist every 3 months after fixation final designs. The measurement of the height of the papillae, as well as the assessment of their parameters, according to the Jemt classification, was carried out during repeated examinations by two independent researchers. In one case report, a 55-year-old woman sought dental attention due to the presence of a “black space between implants” (Figure 8a).

Photo 8a. Papilla deficiency between installed implants.

In the edentulous area, in place of the left central and lateral incisors, she had two infrastructures installed, splinted through restorations. The papilla present was classified as class 0 according to the Jemt classification. Restoration of the papilla was carried out according to the method described above. After one year, the black space area was completely filled with soft gingival tissue (Jemt 3), after which the patient received a new prosthetic restoration (Figure 8b and 8c).

Photo 8b. View after 12 months: the new papilla has filled the defect area.

Photo 8c. X-ray of the implantation area to control the bone tissue between the titanium supports.

results

The mean follow-up period in the 10 case series was 16.3 months (range 11 to 30 months), with Jemt classification achieving papillary improvement of 0.8 to 2.4 (range 0 to 3) ). Moreover, in 2 clinical cases, augmentation was carried out in the area 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 the natural tooth, while in 5 patients it was restored between two implants, and in 4 patients it was restored in the area of the intermediate part of the prosthesis. During the study, zirconium abutments were used in 2 cases, and titanium abutments in 8 cases. Only in one clinical case we were unable to improve the initial soft tissue parameters.

Discussion

In order to restore the area of the interdental papilla, several clinical approaches have been proposed. For example, Palacci et al used a full-tissue flap that was separated from the buccal and palatal sides and rotated 90 degrees to fill the space over dental implants. Adriaenssens proposed the so-called “palatal sliding flap” method to restore the papilla between the installed implant and the natural tooth in the anterior region of the upper jaw. This approach consisted of moving the palatal mucosa in a vestibular direction. Nemcovsky et al suggested using a U-shaped incision to implement a similar approach. Arnoux developed several augmentation methods to restore aesthetic parameters around a single tooth, but later agreed that the proposed approaches were not sufficiently predictive 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 tooth root area. This approach did not require any release incisions, sharp dissection, or even suturing. The Chao procedure is very similar to the technique described in this article, with the difference that the first one involves only a vestibular incision and the use of a bioresorbable membrane (Bio-Gide, Geistlich) or acellular dermal matrix (Alloderm, BioHorizons). Another peculiarity is that the Chao technique is also aimed at restoring the coverage of the recession area, and not reconstructing the interdental papilla.

This article presents a modified approach to interdental papilla restoration that provides predictable soft tissue regeneration results. According to the results obtained, it was possible to achieve an improvement in the papillary 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, and also in areas of the intermediate part of the prosthetic superstructure. At the same time, analyzing the results of treatment, it was also possible to come to the conclusion that 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 adequately provide access and accurately form the mucoperiosteal tunnel, the use of specific dental instruments. Thus, the use of an anatomically shaped interlingual curette (TLC) significantly reduces the risk of soft tissue perforation, and also increases the predictability of the manipulation performed (photos 1d and 2). Wherein full recovery papillae were achieved in 6 out of 10 clinical cases, and only in 3 cases the doctor had to slightly lengthen the point of contact in the area of the final restorations. But this did not in any way affect the rate of patient satisfaction with the results of the treatment. In one clinical case, we were unable to restore soft tissue in the proper volume, which is why this patient underwent repeated surgical intervention and at this time he is in the wound healing stage.

Further studies are required to confirm the stability of the results achieved by this soft tissue reconstruction technique. clinical trials, however, even based on the data obtained, it can be summarized that this technique is very predictable and effective for restoring soft tissue in the aesthetic zone.

Conclusion

Given the limitations of this study, the average Jemt papillary improvement score of 1.6 (range 0.8 to 2.4) was found to be acceptable for soft tissue restoration between two adjacent implants and between an implant and its own. tooth, as well as in the area of the intermediate part of the superstructure. The predicted treatment result is ensured by a precisely planned incision, an atraumatic approach and the provision of postoperative support at home. To confirm the effectiveness of the proposed technique, subsequent clinical studies are required.