In 1992, Tarnow, Magner and Fletcher published a classic paper on a study “to determine whether the distance from the base of the contact area to the crest of bone could be correlated with the presence or absence of the interproximal papilla in humans. The results showed that when the measurement from the contact point to the crest of bone was 5mm or less, the papilla was present almost 100 percent of the time.”1 The purpose of this paper is to illustrate a simple clinical technique to apply their findings.
In order to enhance the predictability of papilla position, certain assumptions should be made, pre-operatively: The dentogingival complex should be optimum health.2 Adjacent restorations and provisional crowns should have smooth margins with ideal emergence profiles. Careful tissue management and tissue retraction should be utilized.3 Adequate time should elapse post periodontal surgery to permit complete tissue maturation.
The clinical technique involves the following procedures:
Determine clinically the final incisal edge and positions and shape whether natural teeth or provisional crowns are involved.4 Take full maxillary and mandibular impressions and pour the teeth and gingival areas in diestone. Vaseline the incisal and occlusal surfaces of the cast of the arch to be prepared. Place a wafer of light cure tray material (Denplus photobase, Montreal, Canada) on the arch to be prepared, covering all of the occlusal and incisal surfaces. Trim the wafer back so that the edges are flush with the facial-incisal and occlusal surfaces on the cast. Place the cast with wafer attached face down on a Teflon pad and level the wafer. Notch all facial interproximal-incisal or occlusal areas with a number seven wax spatula. Re-check the cast with wafer on the Teflon pad for distortion. Light cure the wafer, remove any undercuts, and check accuracy of fit. This wafer now becomes the reference template for interproximal measurements.
At the appointment when final tooth preparation and impressions have been completed, the template can be utilized. The template is simply placed on the occlusal surfaces using non-prepared incisal or occlusal areas as reference. Measurements can now be taken from the occlusal-interproximal notched area sounded to interproximal alveolar bone using a William’s periodontal probe. One might ask why not measure from the margin of the preparation interproximally. However, this measurement maynot represent the middle of the interproximal bone and therefore, mid-interproximal measurement with the template is more accurate. These measurements are recorded and sent to the dental laboratory along with the template. An explanation to the laboratory is in order to indicate that each measurement less 5mm should locate the gingival portion of the interproximal contact. The template can also serve to confirm the accuracy of positioning the provisional crown, chairside at the preparation appointment.
This technique, however, does not provide a guide as to the shape of the interproximal contacts. The provisional crowns should provide guidance as to shape. The shape of the interproximal contact can influence the volume of interproximal tissue and its relationship to the contact.
This template would also be useful to assess and monitor papilla height and labial marginal tissue position in the esthetic zone when restoring implants.
Figure number one diagrammatically illustrates the measurement process. Figure two illustrates a clinical case with four heavily restored anteriors. Figures three, four and five show the template on the models and in place clinically. Figure six illustrates the clinical measurement; figure seven the die model and figure eight the reference from the template to contact position. Figure nine shows a full arch view of template in place and figure ten reveals the clinical result with good interproximal papilla placement relative to the contacts.
In conclusion, this paper has illustrated a simple method of predicting the position of the interproximal papilla when performing fixed prothodontics.
All Laboratory work performed by Burlington Dental Studio, Burlington, ON.
Dr. John F. Pepper completed Level VI at the Pandey Institute and carries on private practice in Dundas, ON.
Oral Health welcomes this original article.
REFERENCES
1.Tarnow, D.P., Magner, AW., and Fletcher, P. The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the Interproximal Dental Papilla. J. Periodontology, Dec. 1992 p.995.
2.Donovan, T.E. and Cho, G.C. Predictable Aesthetics with Metal-Ceramic and All Ceramic Crowns: The Critical Importance of Periodontology 2000, Vol. 27, 2001, 121-130.
3.Kois, J. The Restorative-Periodontal Interface: Biological Parameters. J. Periodontology. Vol. 11 1996 pp 29-38.
4.Dawson, P.E. Evaluation, Diagnosis and Treatment of Occlusal Problems 2 d Ed. Mosby, 1989 pp 321, 322.
