Loss of anterior interdental tissue: Periodontal and

prosthodontic solutions
R. J. Cronin, D.D.S., M.S.,* and W. L. Wardle, D.D.S.**
U.S. Air Force Hospital Davis-Monthan, Davis-Monthan Air Force Base, Tucson, Ariz.
T he restoration of anterior teeth with an undesirable
display of interproximal embrasure has always been a
problem for prosthodontists. The loss of anterior inter-
dental tissue occurs as the result of traumatic injury,
periodontal surgery, surgical extraction, congenital
defects, other oral surgical procedures, and improper
toothbrushing. The lack of sufficient edentulous ridge
contour in an anteroposterior and coronal direction to
support fixed prosthodontics requires imaginative
prosthodontics a.nd/or preprosthodontic periodontal
surgery.
PROSTHODONTIC CONSIDERATIONS
The restoration of anterior embrasures with general-
ized alveolar and gingival loss has usually been accom-
plished with rernovable prostheses. Several authors
have suggested the use of a simply constructed labial
acrylic resin periodontal veneer prosthesis. They
improve esthetics and phonetics, elevate patient self-
esteem, and have a stabilizing effect on mobile teeth.
However, gingival prostheses are contraindicated in
patients with poor oral hygiene because increase in
cervical caries and gingival inflammation have been
reported.4
The esthetic m.anagement of localized lost anterior
maxillary interdental tissue is demanding. A localized
pocket elimination procedure, a small traumatic or
surgical defect, or a cleft palate closure can create an
esthetic problem. Acceptable esthetic results have been
reported with the use of a removable palatal prosthesis
with a pin-retained acrylic resin papilla. Fixed-
removable prostheses such as the Andrews bridge
and/or Ackerman bar attachments have been used.
The views expressed herein are those of the authors and do not
necessarily reflect the views of the U.S. Air Force or the
Department t)f Defense.
*Colonel, USAF (DC); Director of Dental Resident Training; Chief
of Fixed Prosthodontics.
**Colonel, USAF (DC), Ret.; formerly, Director of Professional
Services and Chief of Periodontics.
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Loss of a central and lateral incisor with
resultant loss of interpontic soft tissue contour.
Gingivally extended pontics and fixed partial dentures
with labial veneers have also been designed. These
treatment methods improve esthetics but have function-
al and cosmetic disadvantages.6-7
PERIODONTAL CONSIDERATIONS
The residual ridge left by a single tooth extraction is
usually restored with a single pontic form. However,
multiple anterior pontics and the loss of interpontic
papilla complicate restorative procedures (Fig. 1)
Surgical correction of this type of soft tissue defect is
recommended as the treatment of choice prior to a fixed
partial denture.
Surgical approaches using a connective tissue auto-
graft to solve this problem have been reported in the
literature., A surgical approach combining a subepi-
thelial connective tissue autograft and a free gingival
graft has been devised by the authors to improve
interpontic papilla form prior to the use of fixed
prosthodontics.
PREPROSTHODONTIC
SURGICAL APPROACH
The preprosthodontic surgical procedure is normally
performed approximately 2 months after extractions.
505
CRONIN AND WARDLE
Fig. 2. Pieces of deepithelialized connective tissue
autograft material prepared for use in defective
ridge.
Fig. 5. Flap sutured in an exaggerated coronal posi-
tion and placement of free gingival graft to cover
denuded bone that was result of flap displacement.
Fig. 3. Recipient site surgical incisions. One horizon-
tal and two vertical incisions connect at mucogingival
junction.
Fig. 4. Flap reflection with connective tissue auto- Fig. 7. Esthetic result after cementation of a four-unit
graft placed under full-thickness flap. fixed partial denture.
This allows sufficient time for healing of the extraction
sites and edentulous ridges. A treatment partial den-
ture should be fabricated for the patients comfort and
appearance. The subepithelial connective tissue-free
gingival autograft ridge augmentation procedure is
described below.
Fig. 6. Final healing with resultant improved ridge
contour.
Donor site. A typical free gingival graft is outlined
with a No. 15 surgical blade in the palatal tissue
adjacent to the gingival margin of the first and second
premolar and first molar. The amount of donor tissue
required should be estimated prior to surgical interven-
tion. As the tissue is reflected, the anterior third of the
506
OCTOBER 1983 VOLUME 50 NUMBER 4
LOSS OF ANTERIOR INTERDENTAL TISSUE
Fig. 8. Acute loss of midbne interdental papilla Fig. 9. Custom-made gingival porcelain shade guide.
incision about 1.25 mm thick is progressively increased
distally to around 2.5 mm. The entire strip of epitheli-
urn and underlying connective tissue is removed.
The thicker distal two thirds of the graft is now
stripped of its epithelium with a No. 15 surgical blade
and the entire donor material divided into three sec-
tions. The deepithelialized portions provide bulk to the
defective ridge, and the epithelialized portion is used as
a free gingival graft (Fig. 2). These pieces are placed in
saline solution until the recipient site is prepared.
Recipient site. Vertical incisions are made on the
labial aspect of the ridge adjacent to the abutment
teeth. Care should be taken not to involve the soft tissue
around these teeth in an effort to preserve the adjacent
papilla form. An exception is made if the abutment
teeth are periodontally involved. The vertical incisions
are extended across the ridge several millimeters into
the palate side. A horizontal releasing incision is made
in the vestibule at the mucogingival junction. This
incision connects the two vertical incisions (Fig. 3).
A full-thicknes,s flap is reflected. The portions of
deepithelialized connective tissue are placed under the
labial flap (Fig. 4.). The connective tissue bulk should
be sufficient for suturing of the flap in an exaggerated
coronal position to compensate for some shrinkage
during healing. A free gingival graft composed of the
remaining third of the donor material with epithelium
intact is placed apically to the displaced flap to cover
the denuded bone (Fig. 5).O-13
A periodontal dressing is placed over the surgical site
and is removed with the sutures after 1 week. The
surgical site is allowed to heal for 1 month. The need
for soft tissue plastic surgery with a coarse diamond
wheel to smooth the ridge surface is also assessed after
1 month. Healing is usually uneventful, and 2 months
postoperatively a fixed partial denture can be fabri-
cated (Figs. 6 and 7).
PROSTHODONTIC APPROACH
Preprosthodontic periodontal surgery is the treat-
ment of choice to prepare the interdental tissue for a
fixed prosthesis. The surgical approach can be contra-
indicated for a variety of reasons, that is, medical
history and/or insufficient underlying interdental bone
support in the defect. It is difficult to build interdental
papilla in spaces of bone loss and to increase tissue
height in narrow spaces with restricted blood supply
(Fig. 8). When surgery has been contraindicated, a
porcelain papilla attached to a fixed prosthesis has been
successfully used.
The fabrication of porcelain gingival tissue is infre-
quently attempted because the red hues are difficult to
develop. Special characterizations in dental porcelain
are achieved by using surface colorants and internal
modifiers obtained from milled metallic oxides. The
red colorants are relatively unstable hues and tend to
break down at fusing temperatures. Most red colorants
are actually pinkish forms of a low-Chroma and
high-Value red.14 The use of a custom-made porcelain
gingival shade guide made from various combinations
of available opaques, internal modifiers, and surface
colorants is recommended (Fig. 9). Researchers have
noted the vast range of tones and colors in gingival
tissue, ranging from a pale pink to a deep bluish
purple.15 McLean has discussed the difficulty of
altering porcelain shades by the use of highly reflective
surface stains. Accurate gingival shade matching is
achieved by a combination of colorants.
The papilla can be added between retainer and
pontic as suggested by Eissmann et al. or between
pontics as described by Goldstein.* When there is no
missing tooth in the defect, a cantilevered porcelain
papilla is suggested.
The teeth are prepared for complete coverage with
margin placement influenced by the contour of the
THE JOURNAL OF PROSTHETIC DENTISTRY
507
CRONIN AND WARDLE
Fig. 13. Incisal view of tissue adaptation.
Fig. 11. Removable die master cast.
Fig. 12. Solid master cast used for papillary ad-
aptation.
adjacent defect. The porcelain interdental papilla is
fabricated on a custom-made frame. The frame is
waxed to conform to the defect and allows a uniform
thickness of porcelain on the coronal and papillary
portions (Fig. 10). The porcelain is normally applied
on the coronal portion. A dual master cast system is
used: a removable die master cast for marginal accura-
Fig. 14. Before (top) and after (bottom) treatment photo-
graphs demonstrating esthetic improvement.
cy (Fig. 11) and a solid master cast for papilla
adaptation (Fig. 12). Appropriate opaque internal
modifiers and surface colorants are selected for the
porcelain papilla by referring to a custom-made shade
guide. The crowns are adjusted for internal fit and
gingival contact (Fig. 13). Surface texturing and mini-
mal surface colorant correction is performed prior to
final glazing and cementation (Fig. 14).
This technique and similar procedures are consid-
ered hygienic compromises. Careful attention to the
508 OCTOBER 1983 VOLUME 50 NUMBER 4
LOSS OF ANTERIOR INTERDENTAL TISSUE
maintenance of a convex gingival form for the prostho-
dontic papilla is critical. Fixed prosthodontics is indi-
cated for the comfort of the patient and the stability of
the remaining tissues. The cantilever pontic design
encourages thorough cleansing because it provides easy
interdental acce:ss for dental floss.
SUMMARY
The restoration of anterior spaces with a loss of
interdental tissue has been reviewed. A surgical tech-
nique combining a subepithelial connective tissue auto-
graft and a free gingival graft has been described. This
preprosthodontic surgical approach is recommended as
the treatment of choice. When surgery is contraindi-
cated, the use of a cantilevered porcelain papilla is
suggested.
REFERENCES
1. Risch, J. R., White, J. G., and Swenson, H. M.: The esthetic
labial gingival prosthesis. Dent Lab Rev 56:32, 1981.
2. LEstrange, P. R., and Strahan, J. D.: The wearing of acrylic
periodontal veneers. Br Dent J 128:193, 1970.
3. Renggli, H. H[., and Curilovic, Z.: The gingival prosthesis.
Quintessence Int 2:65, 1971.
4. Baumhammers, A.: Prosthetic gingiva for restoring esthetics
following periodontal surgery. Dent Digest 75:58, 1969.
5. Williams, D. I,.: Prosthesis for a lost gingival papilla. Dent
Surv 53~36, 1977.
6. Kantorowicz, C. F.: Bridge work for cleft palate patients. Br
Dent J 145:335, 1978.
7. Benington, I. C., Watson, I. B., Jenkins, W. M., and Allan,
8.
9.
10.
11.
12.
13.
14.
15
16.
17.
18.
G. R. J.: Restorative treatment of the cleft palate patient. Br
Dent J 146115, 1979.
Meltzer, J, A.: Edentulous area tissue graft correction of an
esthetic defect. A case report. J Periodontol 50:320, 1979.
Langer, B., and Calagna, L.: The subepithelial connective
tissue graft. J PROS.I.HET DENT 44:363, 1980.
Sullivan, H. C., and Atkins, J. N.: Free autogenous gingival
grafts. I: Principles of successful grafting. Periodontics 6:121,
1968.
Dordeck, B., <&let, J. C., and Seibert, J.: Clinical evaluation
of free autogenous gingival grafts placed on alveolar bone. J
Periodontol 47:559, 1976.
James, W., and MrFall, W.: Placement of free gingival grafts
on denuded alveolar bone. Part I: Clinical evaluations. J
Periodontol 49:283, 1978.
James, W.. %lcFall, W., and Burkes, E.: Placement of free
gingival grafts on denuded alveolar bone. Part II: Microscopic
observations. J Periodontol 49:291, 1978.
Preston, J. D., and Bergen, S. F.: Color Science and Dental
Art. St. Louis, 1980, The C. V. Mosby Co., p 47.
Wright, S. hl.: Prosthetic reproduction of gingival pigmenta-
tion. Br Dent J 136:367, 1974.
McLean, J. W.: The Science and Art of Dental Ceramics:
Bridge Design and Laboratory Procedures in Dental Ceramics.
Chicago, 1980, Quintessence Publishing Co., Inc., voi 2,
p 308.
Eissmann, H. F., Rudd, K. D., and hlorrow, R. M.: Dental
Laboratory Procedures: Fixed Partial Dentures. St. Louis,
1980, The C. V. hlosby Co.. vol 2, p 302.
Goldstein, R. E.: Esthetics in Dentistry. Philadelphia, 1976,
J. B. Lippincott Co., p 452.
Krprmi reyurt 10:
DR. WILLIAM I>. WARDLE
MEDICAL SQUARE, STE. 1X
1610 N. TLKa0N BLVD.
Tucsos. AZ 85716
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