Papilla regeneration advice

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Posted on By Howard Gluckman In Anterior/Esthetic

My dearest colleagues. This patient had a full flap raised on the implant and the adjacent tooth and has lost the entire papillae. Any advice on technique to attempt to treat. I have promised the patient nothing except that I will do the treatment for free. If I get a result he will pay me if not its all fair.
Comments welcome.


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18 Comments

How about a pedicled palatal connective tissue flap?


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Howie, somehow I think you already treated it successfully. How about VISTA with tuberosity, Emdogain on the root, your nice sutures?
Looking forward to see everything!
Best regards
Snjezana


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As snjezana said, I would use tuberosity graft, pushed through a small vertical incision apical to the papilla in the mucosa. Lift up papilla with tunnelling and papilla elevators. Bring graft in position with purse string sutures. Additional coronal positioning with slings and sutures tacked to crowns with composite. An apical mattress suture would also help to keep the graft coronally pushed into papillary region. And emdogain as well as previously suggested. Looking forward to your solution. Regards Naheed


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limited orthodontics to extrude #10 and increase the Interproximal Height of Bone (may need endo, crown) and create more papillae or IPR and bring the contacts closer.


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Orthodontic extrusion is a good idea, but in my experience the patients with aesthetic implant failure doesn't want RCT on the adjacent tooth. I have a recollection of 6 cases like this, all young people with tooth trauma, than RCT, than RCT revision, apicoectomy 2,3 and more times. They are afraid of an another failure.
But approximal contact should be stronger and heigher. And later surgical crown lengthening on #8.
Snjezana


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My thoughts on surgical technique here are similar to Snjezana and Naheed. CTG and tunneling basically. However, I'm not sure if any surgical option is predictable here. May improve gingival margin position over the implant, but not sure about papilla fill. Aside from extrusion, I have had success with bonding pink Gradia composite, if smile line does not show the transition zone.

As always I look forward to what you do here Howie :)

Ehab


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Howie, I don't have a different answer than what has already been proposed. But in running this through my mind, I'm thinking that the ridge defect is a Class 2 defect. The ridge could have been augmented with Khoury prior to implant placement. Probably the IHB on the mesial of #10/22 was compromised from the beginning and was at risk, but with Khoury, #9/21 would look better at the mid facial aspect. I've seen you do Khoury through one vertical and perhaps this could have been avoided with the Khoury technique from the mesial aspect. Somehow, I think this is still possible if only to correct the length of #9/21. Of course the implant would have to be removed. With ST grafting and an eventual platform switch implant you might be able to stretch the papilla. Wild thoughts? I know!!! Another option would be to sleep the implant and FPD bridge where you could graft and expect a 6 mm thickness of ST on the mesial of #10/22. If you shoot me down, do it quick. Thanks for your posts.


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I don't want to be the one who say that, but there is no predictable way to treat this papilla loss surgically alone. Any attempt to treat this case surgically alone will make it worst.
to have an esthetic smile, one should consider a more global treatment plan, from canine to canine (the smile line is not correct), with replacement of the prosthetic of number 9. the divergence between 9 and 10 does not help.
Tough case, good luck


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Howie tough case,

I would try the following

1. Replace abutment and implant crown with unercontoured abutment shoulder and temp crown
2. CTG vista
3. Re eval

Yiannis


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Hi Howie;
I think that we are fortunate that the crown on the lateral is under contoured which means that there is no support for a papilla. My gut also says that the crown on the left central is also misshapen but in order to correct this problem, you may have to treat the right central as well.
I am not sure that there is a surgical approach to create a new papilla. Extruding the lateral will help create the papilla in conjunction with the changing the crown.

This is a true challenge.
Regards,
gerald


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Prior to surgical correct, orthodontically move the root of #10 to the midline. This would correct the perceived angulation problem and decrease the volume of the papillae reconstruction. Spooled not take long to move #10
Good luck


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Howie,
Here is case I did about 7 years ago and has remained as seen here. (See Dental XP 5-11-13 "Filling a Black Hole").
Composite recontouring was done to further fill defect.
Certainly not perfect but concept is worth considering.
Pedicle flaps were developed from palate and facial side of defect. The palatal flap included the incisive papilla and was rotated into defect. The facial pedicle was advanced coronally and "sandwiched against palatal flap thus helping blood supply to margins. Perhaps a CTG pedicle from palate between these 2 flaps would improve blood supply?
Good Luck.
Photos copyright KozyDentalCare 2017


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See video 5-11-13 "Filling a Black Hole"


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thanks Paul a brilliant idea I think I will that. looks more predictable


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A CBCT would be in order to evaluate residual facial plate thickness/implant position. Prosthetically, there is a grossly overcontoured restoration... Also I suspect that the implant looks like it is placed too facial.

I would take advantage of mother nature's "free" connective tissue graft before you do anything surgically. Remove crown and abutment, place coverscrew, then allow for closure (put in essix/flipper/Maryland) (See Tarnow et al)

Does the design of the implant permit facial plasty of the titanium, to reduce contour, for more favorable soft tissue adaptation?

Interproximally bone is not terrible, a pedicle or zuchelli graft via VISTA covering 8-11 is worth a try.

Distal Zenith Gingival plasty/Crown lengthening of 8 may draw the eye away from 9, try adding a crown or veneer on 8. Final crown on 9 should include custom abutment with some form of platform switch/narrow emergence

First posted forum comment.

Just a few thoughts


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thanks for all the great feedback. Much appreciated


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KLS Martin
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