Loss of interproximal papillae: opinions?

I agree with your decision to perform orthodontic extrusion to level the bone. However, be careful when you use the term "rapid" orthodontic extrusion. Sometimes you can actually extract the tooth using excessive force rather than remodel the alveolus. Once you have performed this preliminary step, assuming the facial plate is intact, why would you graft the site? What you will end up with is total remodeling of the dentoalveolar complex and lose the new papillae you worked so hard to recreate. This calls for extraction, immediate implant placement, and immediate provisionalization (out of function). The provisional will maintain the directional gingival fibers that are critical for aesthetic gingival anatomy and preserve the underlying bone. I would add L-PRF to the surgery to get rapid epithelialization and an actual increase in gingival biotype. RJM

If you want to fix this the four anterior teeth will need to be addressed. There are no papilla since there is significant perio bone loss. Orthodonticaly extruding the already elongated crown of #9 will just extract it. Placing an immediate implant in inadequate bone will just exacerbate the problem. Look at the bone architecture if the four anterior teeth remove and graft #9 and temp #8. The papilla can be regenerated after the bone base is restored nd the crowns are properly contoured. You are trying to fix poor prostodontics and it can't be done piecemeal.I would also graft the mesial of #10 and do a guided tissue procedure. The patient already has a thick "biotype" of gingiva and square teeth which is favorable. The periodontal bone loss and poor crowns needs to be addressed.Provisionals don't maintain fibers, the supporting bone is needed. The laterals may need veneers or crowns to match. Get some experienced help with this so you don't make it worse, stick to the fundamentals good implant site preparation in the esthetic region. Looks like the crooked post in #9 may have lead to a fracture. Pretty substandard work you are correcting, charge appropriately . Good luck thnk fo reading.

What about a hyaluronic acid injection?

CRS has said you need to hopefully restore the interproximal bone between the central and lateral which can be done but is challenging and then be careful to get a lower good contact point when making the final crowns . With time papilla formation may result. This case is all about poor dentistry leading to bigger issues . How would I treat the case , well for the last 10 years we have done things a little differently ( no membrane , no autogenous bone ) with routine long term success. So we would remove the tooth and temporise with a cantilever bridge off the other central and leave to heal for 3 weeks . The raise a site specific flap retaining the adjacent papillae and currette the site aggressively . The Implant ( 3.5 or 4 ) is then placed as this could possibly be the best graft material as it is semi-conductive and will stabalise the particulate graft material further , plus you will need it there to attach the abutment later . The depth of placement is dependant on the type of Implant but not too deep as we need to build the bone up and the Implant helps. The graft with a fully bio-aborbable material that can set and is thus stable and soft tissue cell occlusive for the first few weeks and then available to vascular ingrowth for improved angiogenesis. Suture with 5.0 vicryl and load early at 10 weeks only temporising once and using all ceramic crowns . Work with the bodies healing timing ad nprotocol for optimal bone true living bone formation ( no HA ). Just the way we do it regularly. Peter

Hello everebody, From what I see there is no papilla due to the bone loss not only between 9 and 10 but also between 8 and 9. The problem is bigger between 9 and 10 because #9 migrated outward due to bone loss and occlusion problem. Because of the migration you will not find the buccal plate. No matter what you do you will not get the papilla back. The best thing to do in my opinion is extract the tooth very gently (never raise a flap in cases like this, the tissue will collapse), and make a bridge. Thanks for reading. Edoardo Calvi

This is a simple case to treat. Just do a bridge. The result with a graft to plump up the pontic area and gain some reattachment to the lateral could fix the black space with a better probability than with an implant. The patient would be quite disappointed if after a year or so of ortho, and grafting, and implant healing a good aesthic result was not achieved. Both teeth ajacent to the space need coverage anyway. The crown on the central needs to be replaced and the lateral is off colour. Unless the patient refuses a bridge ( which would be needed as a temp while graft healing prior to implant placement) it could even be tried as a reversable option for treatment planning. Committing to an implant solution early on may result an aesthic problem that could have no fix for the patient.

The labial frena may be an issue. This is a case for a periodontist and orthodontist. Then one can place implants and restore.

Hi CRS , thanks yes fortunately get to do a bit of interesting complex aesthetic cases , using lip surgery, ortho etc. Here as well you would obviously benefit from a lab wax up prior to start to aid with the aesthetics ( or Esthetics ). Have done many similar cases one of which is written up in the EDI journal Issue 3/ 2011 vOL 7 pages 74 to 81. The photograhs are taken with a short maybe 45 mm lens which ha sdistorted the image thus hard to truely evaluate . Peter

I have enjoyed lurking on this site for some time and am generally impressed with the professional and courteous and informative nature of the discussion. But my question is why do you all have only one 'right' treatment plan? I see at least three different options described above which could, in the hands of trained practitioners, result in satisfactory or great outcomes. How come you all just think there is only one way--the way you want to do it? This is a great interdisciplinary case for ortho, perio and restorative dentists to figure out and present the options to the patient. Just use two if you think three is a delema but a sure way to get into trouble with patients is 'my way or the highway'. Give them a choice and then they own the treatment. I personally like the extrusion approach. The major caveat the ortho must be aware of is the direction of the extrusion. If left with this flare, it will not work. Also the conical nature of the tooth will affect how the aproximal bone is formed. But I would never present that treatment to my referring dentist's patient without consulting the referring dentist and the orthodontist and providing the patient with the three-unit FPD option. Keep up the professional and colleagious (is that a word?) comments.

Dear David on the contrary this site shows the variation of protocols adopted in treatment options . It allows practitioners to say what they would do through their own personal long term experience. The fixed concepts are the ones rightly taught at the Dental schools . Is there concensus in Dentistry , rarely thankfully as to progress we need to learn sometimes through mistakes . Whilst the extrusion is a good concept , time and inconvenience due to the number of visits ( hence cost factors ) come into play in the real world of daily practice . I agree totally on your comments . Peter