Restorative Dentistry and Papilla Reconstruction in Reduced Periodontium

Esthetics has become a major concern in periodontal plastic surgery and in restorative therapy. The reconstruction, in patients with a high lip line smile, of the lost interdental papilla in the esthetic zone, due to loss of periodontal support, periodontal disease or surgical pocket elimination in the esthetic zone is one of the most difficult goals for the practitioner. Restoring teeth in the presence of a normal periodontium is relatively simple with today’s knowledge of restorative materials together with the collaboration of skilled and talented dental technicians. Optimal esthetic results can be achieved where the restoration appearance is comparable to that of natural teeth. The literature on papilla reconstruction is limited to case reports (Azzi et al, 1998; Azzi and Etienne, 1998; Azzi et al, 1999; Azzi et al, 2001; Azzi et al, 2002; Beagle, 1992; Han and Takei, 1996; Shapiro, 1985) but very few papers describe reconstruction in a reduced periodontium. Previous studies reported that the alveolar bone crest acts as a scaffold to support the overlying gingival tissues (Sanavi et al, 1998). The bone anatomy follows the configuration of the cementoenamel junction in the interproximal region. This creates a pyramidal form in the interproximal region that enables the dental papilla to fill the interproximal space. Thus, to a certain degree, it is the scalloped shape of the bone that establishes the papillary form. According to Becker and colleagues (1997), the scalloped osseous anatomy in the maxillary anterior region, averages 3 mm in height from facial to interproximal, with a range of 2.1–4.1 mm. On the buccal aspect, the dentogingival complex unit measures 3 mm above the osseous crest. This comprises the connective tissue attachment (1 mm mean height), the epithelial attachment (1 mm mean height) and the sulcus (average depth 1 mm). For the interproximal gingiva, the height is comprised between 4.5–5 mm (Kois, 1994). This may be explained by the increased sulcus depth (normally between 1.5 mm and 2.5 mm) while the biologic width (epithelial attachment plus connective tissue attachment) remains constant circumferentially within a variation of 0.5 mm (Gargiulo et al, 1961; Vacek et al, 1994). The long-term stability of the papilla depends on the anatomic environment. The level of the interdental gingiva relies on an appropriate support from the underlying bone; the presence of a complete papilla is observed when the distance is Restorative Dentistry and Papilla Reconstruction in Reduced Periodontium