Advice for Complication in Creation and Maintenance of an Interproximal Papilla?

To achieve proper aeshetics in replacing unilateral central incisor and lateral incisor is indeed very challenging and demanding. You did not mention whether you had papilla before placement of implants or it was a flat edentulous ridge. Without first hand clinical observation,it is difficult to pinpoint cause or causes of your failure.But from your description,it sounds to be a multifactorial problem,which may include poor surgical technique like very thin flap,poor reflection of flap,poor tunneling, poor suturing, or defective contours or margins of provisionals or patient's mishandling of site post operatively. It also seems to me that possibly you might have tried to do too many things at a time. we know that once pappilla is lost,it is very difficult to recreate it. Best solution could be restorative not a surgical one in my poinion. 1, Bring down contact point between No.7 andNo.8. 2, Place porcelain laminates on no.9 and no.10 if possible to have bilateral symmetry.Good luck.

Whenever possible in this area I prefer to place a single implant and cantilever the lateral.. as it is much easier to get acceptable esthetics with an ovate pontic than to place two implants side by side. As a side note it is more economical as well. (not the main point here). The only place I would consider side by side is the two centrals...and only if they can be place 3mm apart and with good initial interradicular bone.

Jpdental has good advice.As Dr. Tarnow,Drs.Salams,Dr. Garber has shown that to fill papilla the distance required between contact point and crest is more in case of implant/pontic than implant/implant situations.And of course ovate pontic dose adds up in aesthetics. But here damage has been done. Now the question is how to reslove the problem? Surgically or restoratively? Dr. Callan, will you respond?

Ischemic necrosis is my guess with the information you supplied. There is not enough vascularity to initiate angiogenesis to the grafted tissue. Also, added pressure from the temporary crowns do not help the situation. It may be due to several factors, previous surgery, scarring and possibly surgical technique. You may try tissue expansion and grafting the space created with alloderm or connective tissue and repositioning the flap coronally.

Ischemic necrosis, previous state of tissue, too many things at a time...none of these are the reason for what you see. Simply put, as jp says, it is almost impossible to place two implants in the esthetic zone and have more than 3 mm of space (as Tarnow recommends). So, the lateral biologic width of one implant has violated the lateral biologic width of the adjacent one and the other way around. Then, the peak of crestal bone between the two implants is gone, (bone loss is compounded and more than 1 mm away from a line joining the top of the implants). There is a not so complex solution, but may be hard from a patient management's point of view at this point: Remove the restorations, make a temp supported by #8 and cantilever #7. Bury implant #7 (I guess you would tell patient that at least it will "hold the bone in the area supporting esthetics, soft tissue"), connective tissue graft #7 area and contour the pontic on #7 as an ovate pontic to make the gingiva adapt to that. Then, deliver a splinted restoration supported by #8 with #7 as an ovate pontic. It is the only way to solve this now, but it will likely look very good if everything is done carefully. For the future, cantilever the lateral incisor in the esthetic zone when having two adjacent missing teeth. Good luck.

I would do what Dr. P suggests, if you want a more esthetic result.

First of all,in all aesthetic zone situations it may not be possible to cantilever due to quality/quantity of bone,occlusion,parafunctional habits etc.Dr. E is aware of 3 mm rule.So he may have reasons to place two implants instead of one.So burrying one may not be a suitable solution in that case.We do not know.But it is an another solution. In any case .5 mm less than recomonded distance between two implants certainly can not play such havoc on soft tissues in 12 days. It takes some time for papilla loss between two implants and it happens gradually not so fast in less than 3 mm situation. In this case graft loss has to do something with poor blood supply(poor surgery) or defective contours or margins of provisionals or may be patient.

If your implants are in and integrated, it is possible to grow more tissue and bone back into the area, but it is a time consuming proposition. If you can find a successful restorative solution without further surgery, it might be best for the patient. The only procedure that I have developed to grow new bone and tissue between implants is as follows: Allow the area to heal for about 3 months before further surgery is attempted. The initial incision between Teeth Number 6 & 9 needs to be to the facial, far enough so the final midline suture is in the midline after grafting. Do a full thickness flap and release the periosteum high in the vestibular fornix. The mucosa needs to be able to stretch a full centimeter past the initial incision. Place a straight healing abutment on each of the implants, 3mm in height. I use grafton putty and flex as needed to overgraft the area, and use AlloDerm for increased thickness of mucosa in the desired area. Suture the mucosa over the graft material, AlloDerm, and the 3 mm healing abutments with primary closure and sutures without tension. (I find it helpful to use PRP to soak the AlloDerm and squirt into and under the graft material. The PRP aids in initial angiogenesis of the graft material, speeds up the soft tissue healing, and acts as a biological glue to hold the grafted area together, thus reducing post operative pain, and aid in healing). It is helpful to squeeze gently on the grafted site for a few minutes while initlal clotting takes place. This firms up the graft material and site, and gets rid of excess fluid in the grafted material. Upon completion, the area has to be temporized with nothing touching the grafted site. There will be a normal healing and dehiscence of the grafted area over the top of the 3 mm healing abutments. The remaining tissue and bone should be enough to allow an esthetic result with proper contours of the interdental papilla, if a long flat contact between 7 & 8 is utilized as needed.

Hi , I would use a narrow diameter abutment post and and then use a tunneling technique with Zircon crowns .It would definitely help. Dr.Ashish www.drashish.com

Satish Joshi, The cantilever the lateral is a good idea, but is too late now. The surgical trauma may have been too much. As you know I feel the bacterial problems are the main cause of post operative problems. Gatewood, Cobb, and Killoy did an article in 1993 in Clin Oral Implant Res. They show the problems on rough surfaces of implants and the microbial colonization on these surfaces. The NB groovey is very difficult the to keep clean. The host response in this case to periodontal pathogens may have been just too low. The # 1 cause cause of implant problems is "Bacterial". What to do now? send me some pics to evaluate (drdoncallan@aol.com) I do not know the answer without seeing the result.

Hi, As you know if you don't have enought bone between two imlants you have always papilla problebs.And the contact point and crestal bone distance is more than 5mm ıt means you have a problem.But even thought you can do something.After deepitelization(with Er-Yag laser or knife)of the papilla area than you can cover with a pedicle flap from palatal side and suture with 6/0 or 7/0 stitch.No periodontal dressing.I have several clinical expertise and quite succesfull..good luck

Dr.Callan, Thanks for your response. This is not my case and I do not know Dr.E. But He/she can send pics to you and you may be able to come up with your expert opinion. I totally agree with you that cantilevering lateral may not be a good solution now. Also before final treatment can be planned it is essential to study patient's info. 1,Patient had two soft tissue grafts already with disastrous results.What is the guarantee that third attempt will be successful? 2,As we know with each surgery tissues become more and more compromised (scarring),Vestibular depth becomes shallower with each coronally repositioned flap, if tunneling is not done and less and less keratinized tissues or tire patch look with every FGG requiring follow up plasty. 3,We know graft failures not only involes loss of grafted tissues but may end up in larger than original defects. Then why not to try restorative solution which can give a good results with long flat contact and contra lateral teeth restored with thin laminates to mimic same.

Thanks for all the comments. I realize that it is difficult to pinpoint what went wrong and what could be done at this point without looking at the clinical pictures. I will post these pics (surgical and complications) soon.

Dr. E, You never mentioned where the crestal bone is at between the two implants. Have you had a decrease in hight? If this is what happened then you will have a tough time getting the papilla to grow back- Tarnow says 3-3.5mm from the crest- that is it. You never answered whether the tissue thickness was adequate before surgery? was there a papilla? If the implant platforms were not placed at least 3mm below the intended hight of your free gingival margin- you will not get a papilla. Just because they were placed at the crest- that crestal level may not have been ideal for your restorations, and may have had to be modified. We must always remember that implant placement is prosthetically driven- not the other way around.

My opinion is that its all the sx trauma, too much too soon, and most of all maybe the compromised blood supply. Im always looking at where that supply is going to come from now when I am entering with the scalpel, whether its a bone graft or a ST graft. No blood, then problems are all but guarranteed. I want blood, I want to see things leaking before I close. If its a full flap, then Ill perf to get it if I dont see it. I would also think that a VIPCT would be something good here, and would like to know some thought processes from everyone along that line. Maybe even a pedicle. But Even with that, and from personal experience, the end of a VIPCT still has to be placed well into the buccal and covered with the buccal blood supply as well. Youre going to lose some of that distal-most portion because there isnt a return at the end until it gets a supply, either through the opposing flap, the periosteum or angiogenesis. And the other flap has a distal edge to it as well. I have also strangulated the supply with too many sutures or too much tension. I have seen some of my picture-perfect suturing just go through the tissue like a hot knife in butter from wound contraction and inadequate periosteal release, confirming one of my favorite quotes about surgeons whistling in the graveyard way too soon. Aint fun when its your graveyard and youre looking at things sloughing off everywhere and its your own halloween. Go to the cases here and look at one I posted. It was corrected but not without blood, sweat and time. Mostly blood!! (Its the blood). Also, look at the medical hx. That is huge. And take things in steps, dont do it all in a day. Sometimes we expect too much too soon. You can speed up biology just a little but you can surely slow it down almost completely, rapidly, and sometimes with very little effort. JM2C. Bill

The Bone height between the two implants has not been lost. The implants were placed 2-3 mm below the CEJ of the teeth on either side. The tissue thickness was there prior to the surgery, and the FGG that I placed above the incision line (above the MGJ after coronally positioning the Keratinzed tissue portion) healed uneventfully. At the time of surgery, closure of the flap, and suturing I did have alot of bleeding. This is what is puzzelling me, the only thing that was done differently this time, was the placement of the lab made temps by the GP. Looking at the post op pics, the sloughing of the tissue is at the direct buccal tissue where the temp would have blanched out the tissue. These temps were removed as soon as I saw the tissue sloughing, and now at 5 weeks post op, the buccal tissue looks perfect, no recession took place (fortunately), but the Papilla is not there. The bone was flat prior to placement of the 2 implants (the patient had exo and bone grafting to preserve bone and augement the ridge previously). I will update the progress of this case as the tissue matures more. maybe because the crestal bone height is there and by moving hte contact to follow Tarnow's rule I could get some papilla back. would you do Papilla regeneration following a different techenique? maybe Palaci's technique to rotate the Pedicle flaps from Palatal? Or treat the case restoratively at this point?

Wish that we have X-rays and picture to see....

A novel method proposed for interdental papilla creation and maintenance is a 'papillary implant'. A patent was recently granted for such a design. While the patent design called for a titanium implant, I think a better design would feature a papillary implant made out of zirconium which also osseointegrates [although not has well as titanium as demonstrated by lowers BIC values in studies], however how much mechanical torque can supporting a papilla be? Additionally the white colour would certainly result in more aesthetic outcome as opposed to the grey hue usually associated with titanium implant placement. No word on if/when this patent will be commercialized, but none the less an intriguing solution to this problem.

I'm interested to hear what people think about the literature being rewritten in regards to the 3mm rule. As we all know, the 3mm rule was conceived using implants with a potential flaw engineered in the design, specifically polished collar to first thread. Many speakers, and some soon to be released articles, indicate the 3mm rule may be antiquated since implants are now generally rough all the way up and have some magic fairy dust sprinkled on them. Even Tarnow has mentioned this in a lecture and I know others have as well. Personally, I try sticking to the 3mm rule but I have noticed 2mm can be adequate as well in the right situation with the right implant. As far as building a papilla in the esthetic zone, if you have the bone then the papilla will grow. It may take a few years but sometimes letting the body heal is the best remedy. Proper contouring and design of the crown is critical, as well as hygiene and occlusion, but the trend is the papilla will grow if you have the bone interproximally. It sounds like you followed all the steps one normally would in dealing with this case and you are just dealing with a patient with a less than ideal biotype. when you show your pics from the case you are sure to have people break down your decisions, which is what you are looking for. I look forward to learning from your case as well.

The shape and form of the papilla is a direly correlated to the level of the bone between the implants. since the tarnow low was not kept properlyand there is not sufficient distance between the implants, there is actualy no chance for surgical reconstruction of the papilla. the only solution for a case like this is a prosthetic one. I would recomend zirconia bridge combined with pink porcelain.

The bone provides support the soft tissue.We have to prevent marginal bone loss that caused by 1 .the micromovement between implant and abutment. 2.lack of platform switching 3.microgap 4.bone level

pojanart is 100% correct

put #7 to sleep and restore. ask lab to add wing to #7 crown which will be bonded to lingual of #6 to counter rotational forces

If all else fails which seems likely since the so called 3mm rule has been transgressed both vertically and horizontally. Try intentional gingival hyperplasia. Tell your patient not to clean the space between the centrals for 3 months. The plaque will cause a hyperplastic response of the interdental gingiva and a satisfactory pretender to the papilla ........often appears. Cheers.

Dear Dr. E, Patrick Pallaci technique is the best. but depends on the buccal bone too.

Why don't you guys comment on a similarly posted case with photographs in the "cases" section.