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Papilla and pontic area regeneration in patient with gingival smile: A clinical
case

Article  in  Journal of Clinical and Experimental Dentistry · May 2018

DOI: 10.4317/jced.54859

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 J Clin Exp Dent-AHEAD OF PRINT Gingival smile

�� Journal section: Esthetic Dentistry doi:10.4317/jced.54859

Publication Types: Case Report http://dx.doi.org/10.4317/jced.54546
��
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�� Papilla and pontic area regeneration in patient
��
�� with gingival smile: A clinical case
��
��
�� Ramón Gómez-Meda 1, Carlos Torres-Sanchez 2, Santiago Mareque-Bueno 3, Juan Zufía-González 4, Daniel
�� Torres-Lagares 5, José-Luis Gutierrez-Pérez 6
��
��
�� 1
DDS, MS, Private practice in Periodontics and prosthodontics, Ponferrada, León, Spain
�� 2
DDS, MS, PhD, Associate Research, Oral Surgery and Prosthodontics Department, Dentistry Faculty, University of Seville,
�� Seville, Spain
�� 3
DDS MS, Private practice in Periodontics. Pontevedra, España. Profesor Santiago de Compostela University
�� 4
DDS, Private practice in Periodontics and prosthodontics, Madrid
��
5
DDS, MS, PhD,Master Chief of Oral Surgery, Dentistry Department, University of Seville, Seville, Spain
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DMD, PhD, Master Chief of Oral Surgery, Dentistry Department, University of Seville, Seville, Spain
��
��
�� Correspondence:
�� Oral Surgery Department
�� Faculty of Dentistry
University of Seville
�� Seville, Spain
�� C/Avicena S/N. C.P. 41009
[email protected] Please cite this article in press as: Gómez-Meda R, Torres-Sanchez C,
��
Mareque-Bueno S, Zufía-González J, Torres-Lagares D, Gutierrez-Pérez
�� JL. Papilla and pontic area regeneration in patient with gingival smile: A
�� clinical case. J Clin Exp Dent. (2018), doi:10.4317/jced.54859
Received: 24/03/2018
�� Accepted: 11/04/2018
��
��
��
��
�� Abstract
�� Purpose: Connective tissue grafts are widely documented as a predictable technique for treating Miller Class I and
�� II recessions, as well as procedures in which soft tissue augmentation is required for aesthetic reasons. This article
�� aims to explore the resolution of a clinical case with this type of problem.
�� Clinical case: This case describes a technique for reconstructing a pontic area and adjacent papilla by means of
�� two consecutive connective tissue grafts. The first graft served to increase the amount of tissue in the horizontal
�� direction, and the second promoted vertical reconstruction of the defect.
�� Results and Conclusion: In cases with aesthetic requirements, restorative intervention may be able to mask tissue
�� loss, but it can hardly achieve optimal aesthetic results. Periodontal plastic surgery techniques can be used to achie-
�� ve that ideal result. The clinician must diagnose conditions in order to select correct treatment regimen for each
�� individual case.
��
�� Key words: Papilla, gingival smile, pontic, restorative dentistry.
��
��
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Introduction riodontal structures, but it also plays an important role in
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To achieve an aesthetic and harmonious smile, it is neces- aesthetics. Furthermore, its absence may lead to phonetic
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sary to balance prosthetic restoration with gingival archi- difficulties or food impaction (5). A lost dental papilla is di-
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tecture and the patient’s lips and face. Several mucogingi- fficult to regenerate. Very few cases have been identified in
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val techniques have been proposed for covering gingival the literature (6-8), and there are no studies demonstrating a
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recessions (1-4). The interdental papilla protects the pe- predictable technique for papilla reconstruction (9).
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 J Clin Exp Dent-AHEAD OF PRINT Gingival smile

�� The success of rehabilitation therapy relies on more Case Report

�� than just dental and functional restoration. Patients hope -Clinical and soft tissue parameters
�� that prosthetic rehabilitation will create a harmonious, A 45-year-old non-smoker patient with periodontal
�� aesthetic smile with balanced mouth tissues. Therefore, defects around the upper incisors. The central incisors
�� dental aesthetics should be complemented with aesthetic presented mobility type III and a probing depth of 10
�� soft tissues, which are an important topic of study nowa- mm and 8 mm circumferentially. The right lateral incisor
�� days (10). also had a 10-mm probing depth at the mesial level, in-
�� Since Allen (11) described the foundations of soft tissue dicating bone loss under the papilla (Fig. 1a). It also had
�� grafts for root coverage and their rational bases, these a 7-mm probing depth in the left lateral medial area. The
�� techniques have been used for covering implant reces- patient’s medical history was not relevant: non-smoker,
�� sions (12), as well as in the augmentation of soft tissues without allergies or chronic and/or repetitive patholo-
�� in aesthetic areas (6). gies. Some weeks prior to surgery, the patient was ins-
�� The use of these techniques as part of bone regenera- tructed in oral hygiene techniques and was subjected to
�� tion is justified when an increase in bone availability is another in-root scaling and root planing. At the time of
�� needed for non-aesthetic reasons, as such aesthetic re- diagnostic evaluation, the patient had a Miller Class III
�� quirements can be properly achieved using soft tissue recession with loss of papilla between the right incisors;
�� grafts (10). there was also a 2-mm recession in the vestibular area
�� The present case involves a surgical technique for the of both (Fig. 1a). Removal of the two central incisors
�� reconstruction of a pontic space with a bone defect and was inevitable due to the surrounding attachment loss
�� the adjacent missing papilla. (Fig. 1b).
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Fig. 1: a) Initial situation of patient with a Miller Class III recession with loss
�� of papilla between the right incisors. b) Bone support around central incisors.
�� c, d, e, f) A first large connective tissue graft was positioned in the pontic
�� area. g, h, i, j) After the first intervention, the tissue volume had increased, but
�� it was clearly insufficient. Another connective tissue graft was carried out to
compensate for this.
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�� E2
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 J Clin Exp Dent-AHEAD OF PRINT Gingival smile

�� The patient’s smile showed gingival exposure, without and Tarnow’s table (9). The interdental papilla, vesti-
�� harmony in the pink area. Photographic and radiogra- bular gingiva, mucosa and palatine gingiva were anes-
�� phic records, impressions, and a facebow were all taken. thetized using Articaine HC1 / epinephrine 40 / 0.005
�� The photographs were digitally analyzed, after which mg / ml with epinephrine 1: 100,000 (Ultracain) (8,9).
�� the models were mounted in an articulator and waxed A surgical dissection microscope was used to better vi-
�� following the digital analysis. The treatment alternatives sualize the surgical area. The first incision was of partial
�� and their determinants were presented and explained to thickness with a semilunar shape, made from the muco-
�� the patient, and her choice was to undergo correction of gingival junction to reposition the large labial frenulum
�� the pontic area and try to correct the papilla defect throu- (Fig. 2a-2d) (3). The second incision was made using a
�� gh several connective tissue grafts. The tooth was not microscalpel of the lost papilla around the neck of the
�� initially extracted for implant placement due to existing lateral incisor. The blade was directed toward the bone
�� periodontal disease, which mobilizes teeth as a result of to separate the connective tissue from the root surfa-
�� lack of support. Therefore, therapy with a fixed prosthe- ce. This incision enabled the preservation of the entire
�� sis was chosen to provide better retention of the final height and thickness of the gingival component, and it
�� result of orthodontic and periodontal treatment. In this allowed access under the vestibular gingiva using minia-
�� context, alveolar preservation (reduced by loss of su- ture curettes. Surgical enlargement was used to preserve
�� pport) is not necessary, as no implants were going to be the integrity of the papilla (3,13).
�� placed. Under favorable conditions, a soft tissue graft is The third incision was made at the apical edge with par-
�� more predictable than a bone graft in obtaining proper tial thickness in a semilunar shape and directed straight
�� results, and the former should therefore be chosen when to the bone (Fig. 2e-2h). This incision released the gingi-
�� bone augmentation is not necessary (10). val-papillary set. The mobility of this dento-papillary set
�� -Surgical procedure was essential in enabling the creation of space under the
�� Local anesthesia was administered using one carpule papilla, necessary to receive a connective tissue graft.
�� of articaine HC1 / epinephrine 40 / 0.005 mg / ml with Mobility of palatal tissue was also achieved at the same
�� epinephrine 1: 100,000 (Ultracain). The central incisors time. The flap was positioned coronally using a curette
�� were extracted. The canines and lateral incisors were under the groove and a small periosteotome under the
�� prepared, and a provisional fixed prosthesis was placed. pontic area (13). The amount of donor tissue required
�� Margin preparation of the lateral incisors was located was determined using the initial gingival-incisal pre-sur-
�� supragingivally in mesial, given planned future recons- gical height, which was compared with the final desired
�� truction of the soft tissue. A canal root treatment was re- papilla level (2,14).
�� quired in the lateral incisors. Silicone impressions were A long, thick graft with a 2-mm layer of epithelium was
�� also taken to manufacture a second, more durable and removed from the palate (Fig. 1g-1j). This epithelial la-
�� precise temporary prosthesis. yer served to obtain denser fibrous connective tissue and
�� The collapse of the soft tissues due to processes of ves- to better maintain the space under the coronally positio-
�� tibular reabsorption was very evident. A first large con- ned flap. The use of a large mass of connective tissue
�� nective tissue graft was positioned in the pontic area means that the graft’s chances of survival may increase
�� (Fig. 1c-1f). The bases for the selection of this treatment due to greater surface area available for nutrition throu-
�� option are described above. Incisions of partial thickness gh blood perfusion. The epithelial layer was oriented
�� were made at the level of the concavities, preserving the towards the buccal groove of the coronally positioned
�� papilla area tissue and consequently creating a tunnel flap, and it was not coated with the flap (Fig. 2e-2h) (11).
�� between the two pontic areas. A 6/0 nylon suture was The reason for this was that the epithelium is denser than
�� used to stabilize the graft without completely covering the connective tissue and is therefore more adequate for
�� it. The temporary bridge did not place too much pressure supporting the repositioned flap. The connective tissue
�� on the graft (Fig.1c-1f) (1-4). Four months were alloca- portion of the graft was placed in the furcation of the lost
�� ted in order to achieve mature tissue. The tissue volume papilla to prevent the collapse of the flap and subsequent
�� increased during this time but was still clearly insuffi- retraction of the papilla (Fig. 2e-2h). A continuous nylon
�� cient (Fig. 1g-1j). More tissue was missing in the right 6/0 suture was used to stabilize the graft at the desired
�� central incisor and distal papilla area. The bone probing position, providing excellent wound stability. A micro-
�� depth was 7 mm (Fig. 1g-1j); given a loss of 3 or 4 mm surgical approach was taken using the Zeiss Omni Pico
�� of papilla, there would therefore be a hypothetical pro- microscope. The wound in the palatal area was closed
�� bing depth of 10 mm and a 5-mm defect in the papilla with a continuous suture (7,8).
�� area, which was rectified using another connective tissue The patient was prescribed 500 mg of amoxicillin, to be
�� graft. taken every eight hours for ten days, and the patient was
�� The second surgery was performed (Fig. 1g-1j). The ini- instructed to perform chlorhexidine rinses without alco-
�� tial preoperative situation was classified using Nordland hol twice a day for three weeks and to use a cotton bud
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 J Clin Exp Dent-AHEAD OF PRINT Gingival smile

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�� Fig. 2: a) Situation after the first surgery. b, c, d) Intrasulcular incision in the
�� second surgery. Incision over the frenulum. Incision making the vestibular
�� tunel. e, f, g, h) Second connective tissue graft.
��
��
�� soaked in chlorhexidine gluconate to remove any pee- no bone grafting having been done (Fig. 3h-3k).
�� ling epithelial cells or food debris in the intervened area -Follow-up
�� (11). The sutures were removed four weeks after surgery The patient was evaluated three months after the first
�� as the patient lived far from the practice and could not surgery. A horizontal increase had been achieved in the
�� travel before; under normal circumstances, the sutures pontic area (Fig. 3h-3k). The probe depth was 7 mm in
�� could have been removed two weeks after surgery. The the lateral incisor mesial area before the second surgery.
�� patient was told not to use any mechanical plaque con- There was a recession of 3 mm and a Miller Class III re-
�� trol instruments in the intervened area for four weeks cession in the right lateral incisor mesial area. After the
�� after surgery. Controls had previously been performed second surgery, the papilla’s soft tissue margin was 3–4
�� every week. The patient healed successfully and with mm more incisal than before the surgery (Fig. 3l-3ll).
�� no complications. The situation of the soft tissues at the This represented an improvement in the periodontal
�� level of the pontic area was very significantly improved junction of approximately 4 mm. Three years later, the
�� (Fig. 3a-3c). The third surgical phase was performed be- clinical results recorded within three months of surgery
�� fore the final prostheses were placed. A diamond burn had not only been maintained but had actually impro-
�� was used to remove part of the grafted epithelium (Fig. ved, as there was no “black triangle” in the lateral and
�� 3d-3g). The interdental area between the pontic area and central incisor area (Fig. 3h-3ll). There had been no con-
�� the lateral incisors was not probed until six months later. traction or retraction of the papilla, and the probe depth
�� A depth probe of 5 mm was recorded in the lateral inci- had not increased. Radiographic records showed that the
�� sor medial area, just 1-mm more than in the distal area, underlying bone increased considerably (Fig. 3h-3k).
�� with no signs of swelling or bleeding. A significant im- The aesthetic aspect of the smile had also been substan-
�� provement was observed in the underlying bone despite tially improved (Fig. 3m).
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 J Clin Exp Dent-AHEAD OF PRINT Gingival smile

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Fig. 3: a, b, c) Improved soft tissue volume. d, e, f, g) The third surgical phase
�� was performed before the final prostheses were placed. A diamond burn was
�� used to remove part of the grafted epithelium. h, i, j, k) A significant improve-
�� ment in the underlying bone was observed, despite no bone grafting having
�� been carried out. l, ll) After the second surgery, the soft tissue margin of the
papilla was 3–4 mm more incisal than before the surgery. This represented an
�� improvement of approximately 4 mm in the periodontal junction. Three years
�� later, the clinical results recorded within three months of surgery had not only
�� been maintained but had in fact improved, as there was no “black triangle” in
�� the lateral and central incisor area. m) Final situation after three years.
��
��
�� Discussion defects, oral sites other than those involving maxillary
�� This case report showed a predictable soft tissue aug- canine and premolar teeth, and Miller Class III and IV
�� mentation procedure in the tooth-supported fixed rehabi- defects (3,15).
�� litation of an aesthetic area using a subepithelial connec- While more clinical trials are needed, this case report
�� tive tissue graft. Alternatives to subepithelial connective showed that fixed prostheses using teeth as abutment
�� tissue grafts are supported by evidence of varying stren- remain a valid option for replacing lost dental pieces,
�� gth (15). Additional research is needed on the treatment especially as an alternative to complex vertical bone re-
�� outcomes for specific oral sites. generation surgeries; these techniques require a greater
�� This procedure can be carried out using other perio- number of follow-up appointments and therefore greater
�� dontal plastic surgery techniques, and acellular dermal patient cooperation (13). The fixed prosthesis is thus a
�� matrix grafts or enamel matrix derivatives may improve less risky option than implants when the patient lacks
�� the obtained results when used in conjunction with these the necessary amount of soft and hard tissues. Although
�� techniques (1). More clinical trials are necessary to as- periodontal factors do not usually have a direct effect on
�� sess the treatment outcomes for multiple-tooth recession the survival rate of a fixed prosthesis, harmony between
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 J Clin Exp Dent-AHEAD OF PRINT Gingival smile

�� the prosthesis and the periodontium is critical to aesthe- advanced flap or via a tunneling technique: a randomized controlled
tics; otherwise, the longevity of the prosthesis and the clinical trial. Clin Oral Investig 2016;20:2191-202.
�� 5. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from
�� periodontium will be compromised (3,4). the contact point to the crest of bone on the presence or absence of the
�� This case report showed that prosthetic design, the num- interproximal dental papilla. J Periodontol 1992 Dec;63:995-6.
�� ber and quality of the abutment teeth, preparation of the 6. Ahmedbeyli C, Ipçi ŞD, Cakar G, Kuru BE, Yılmaz S. Clinical eva-
pontic area, the given occlusion, and the material used luation of coronally advanced flap with or without acellular dermal
�� matrix graft on complete defect coverage for the treatment of mul-
�� must all be considered when planning prosthodontic tiple gingival recessions with thin tissue biotype. J Clin Periodontol
�� treatments (13). The location of the preparation margin 2014;41:303-10.
�� and the contour and emergence profile of the prosthesis 7. Wang HL, Romanos GE, Geurs NC, Sullivan A, Suárez-López Del
will influence the response of the gingival tissues to the AF, Eber RM. Comparison of two differently processed acellular der-
�� mal matrix products for root coverage procedures: a prospective, ran-
�� prosthesis. Pontic design and cleansability also contri- domized multicenter study. J Periodontal 2014;85:1693-701.
�� bute to the response of the gingival tissues, as well as 8. Pini Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Interden-
�� to their clinical and aesthetic outcome. Even an optimal tal papilla management: a review and classification of the therapeutic
pontic design will not prevent inflammation of the mu- approaches. Int J Periodontics Restorative Dent 2004 Jun;24:246-55.
�� 9. Nordland WP, Tarnow DP. A classification system for loss of papi-
�� cosa adjacent to the pontic area if pontic hygiene is not llary height. J Periodontol 1998;69:1124-6.
�� maintained by removing plaque. Case selection and the 10. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation
�� patients’ ability to maintain adequate oral hygiene are procedures or mucogingival defects in esthetic sites. Int J Oral Maxi-
therefore essential to the longevity of prostheses, and re- llofac Implants 2014;29 Suppl:155-85.
�� 11. Allen AL. Use of the supraperiosteal envelope in soft tissue graf-
�� gular follow-up appointments provide an opportunity for ting for root coverage. I. Rationale and technique. Int J Periodontics
�� early detection and treatment of failures (5,9,13). Also Restorative Dent 1994;14:216-27.
�� important to consider are sociocultural and aesthetic ex- 12. Hidaka T, Ueno D. Mucosal dehiscence coverage for dental im-
pectations, as well as personal factors such as emotional plant using split pouch technique: a two-stage approach. J Periodontal
�� Implant Sci 2012;42:105-9
�� resistance, which can reduce the risk of psychological 13. Abduo J, Lyons KM. Interdisciplinary interface between fixed
�� trauma and possible failure. prosthodontics and periodontics. Periodontol 2000 2017; 74:40–62.
�� Within the inherent limitations of this case report, it can 14. Graziani F, Gennai S, Roldán S, Discepoli N, Buti J, Madianos P,
be suggested that: 1) In cases with aesthetic require- Herrera D. Efficacy of periodontal plastic procedures in the treatment
�� of multiple gingival recessions. J Clin Periodontol 2014;41 Suppl
�� ments, restorative intervention can mask tissue loss, but 15:S63-76.
�� it can hardly achieve optimal aesthetic results. Periodon- 15. Tatakis DN, Chambrone L, Allen EP, Langer B, McGuire MK,
�� tal plastic surgery techniques can be used to achieve that Richardson CR, Zabalegui I, Zadeh HH. Periodontal soft tissue root
ideal result. The clinician must diagnose all conditions coverage procedures: a consensus report from the AAP Regeneration
�� Workshop. J Periodontol 2015;86:(2 Suppl):S52-5.
�� in order to correctly select the best treatment for each in-
�� dividually case. 2) A close interdisciplinary relationship Conflict of interest
�� between periodontics and prosthodontics is therefore ne- The authors have declared that no conflict of interest exist.
�� cessary to avoid unsatisfactory treatment outcomes that
�� require extensive and expensive retreatment. 3) Surgical
�� magnification and microsurgery instruments are advisa-
�� ble in order to give the clinician a better view of the area,
�� avoid unnecessary incisions of discharge, and increase
�� the predictability of the process.
��
�� References
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des-Dias SB, Jardini MAN, Tatakis DN. Connective tissue graft
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