Home Orthopedics After the removal of two central teeth, a papilla was formed. Inflammation of the gingival papilla

Orthopedics

After the removal of two central teeth, a papilla was formed. Inflammation of the gingival papilla

Basic beautiful smile is, of course, the condition of the teeth. Their color, shape, size, bite. However, the condition of the gums is also important. Gums are the frame of your teeth, and the overall impression of your smile will depend on how neat and healthy this frame is.

Inflammation of the gingival papilla

One of the common problems is inflammation of the gingival papilla. The gingival papilla is the part of the gum that is located between the teeth.

At various diseases gums and teeth, in case of carelessly performed restorations, gingival papillae they become inflamed, painful, change color, lose shape, and may partially or completely disappear, leaving rather unesthetic gaps. Inflammation of the gingival papilla may indicate the presence of more serious dental problems.

Causes

Among the common causes of inflammation of the gums and gingival papillae:

poor oral hygiene;
gum injury;
malocclusion;
hormonal disorders.

The inflammation itself, for the time being, may not cause inconvenience, so patients often postpone a visit to the doctor or, worse, begin to self-medicate. Self-medication alleviates symptoms, and the disease progresses unnoticed.

Chronic inflammation of the gum mucosa can lead to the proliferation of papillary tissue. This phenomenon causes pain when eating and brushing teeth. In some cases, the tissue grows so much that it covers the crowns of the teeth, forming gum bays where food debris, plaque and great amount microbes

If left untreated, the affected area begins to become overgrown with gum, forming a large, unattached portion of the gum with high sensitivity. The affected area causes discomfort and pain when brushing teeth and eating.

Treatment

The solution to the problem in most cases is coagulation of the gingival papilla, i.e. cauterization. The procedure is carried out using an electrocoagulator, which is safe for surrounding teeth. Discomfort may persist for 1-2 days after the procedure.

It is necessary to take any, even seemingly minor, problem with your gums as seriously as possible, because they can lead to larger and more complex problems. Do not self-medicate; if you suspect gum disease, consult a doctor.

Materials and methods

Subjects studied

0 – absence of papilla;

4 – papillary hyperplasia.

Measurements

Surgical procedure

Photo 1c. Palatal incision.

Photo 1d. Interlingual curette.

results

Discussion

Conclusion

Restoring lost teeth using orthopedic structures supported by dental implants is a very common dental practice nowadays. However, aspects of osseointegration of supports, as well as the restoration of corresponding aesthetic parameters in the area of single and partial edentia, differ markedly.

An important aspect of rehabilitation remains the restoration of an adequate contour of soft tissues and the architectonics of the interdental papilla, as extremely important components optimal profile smiles. The absence of an interdental papilla compromises not only appearance patient, but also provokes the occurrence of phonetic problems, as well as food getting stuck in the problem area.

Earlier studies have already proven the role of the distance from the apex of the interdental septum to the contact point between adjacent teeth as a factor influencing the amount of restoration of the papilla, at the same time, this parameter is variable for the papilla between adjacent natural teeth, between the implant and the own tooth, and also in the area of the overhanging part of the prosthesis. In cases where given distance between adjacent teeth is less than 5 mm, the papilla has the ability to completely fill the interdental space, while in the area between the implants the average height of the soft tissues, as a rule, does not exceed 3.4 mm, as a result of which a deficiency in the height of the interdental papilla often occurs in the implantation area, which is critical in the rehabilitation of a patient with adentia in the frontal area.

There are many different approaches to restore the interdental papilla, but often due to compromised blood supply conditions and the formation of scar tissue, most known surgical techniques are not sufficiently predictive. Villareal in 2010 described a predictable approach to papillary regeneration using careful sequential soft tissue manipulation, including gentle incision and minimal flap separation. The main principle of the author's approach was to maintain adequate blood supply and the existing quality of the mucosa. This is why this approach recommended against suturing the intervention area, as this may cause additional trauma or inflammation, which ultimately will negatively affect the final result of treatment.

The purpose of this article is to present a series of clinical cases in which restoration of interdental papillae in the implantation area was performed using a modified surgical technique.

Materials and methods

Clinical data used in this study were obtained from the database of the Department of Periodontology and Implantology at New York University Kriser Dental Center. Data certification was carried out by the quality assurance department of the same university. The study was conducted in accordance with the Law on health insurance and sharing the identities of the parties involved, and has been approved by the University's Human Subjects Research Review Committee.

Subjects studied

The study included ten clinical cases of restoration of the edentulous area of the central part of the upper jaw using dental implants. In the retrospective portion of the study, patients with existing restorations who had previously undergone interdental papilla augmentation between August 2011 and August 2012 were analyzed. The study group included 3 men and 7 women, average age which amounted to 45 years. During the study, the areas of the interdental papilla between two adjacent implants, between the implant and the natural tooth, as well as in the area of the intermediate part of the prosthesis in the area between the 13th and 23rd teeth were analyzed.

The inclusion criteria for the study group were as follows:

The presence of an implant supporting the provisional restoration.
Absence of interdental papilla (0 or 1 according to Jemt classification).
Absence of a papilla in the anterior part of the upper jaw between two adjacent implants, an implant and a tooth, in the area of the intermediate part of the prosthesis.

To assess the severity of the interproximal papilla, the Jemt classification was used:

0 – absence of papilla;
1 – the presence of a papilla of only half its normal height;
2 – presence of more than half the height of the papilla;
3 – presence of a papilla of normal size;
4 – papillary hyperplasia.

The exclusion criteria from the study group were as follows:

State of pregnancy or lactating women.
Active periodontal disease in the area of remaining natural teeth.
Availability systemic diseases or reception medicines, which can affect the healing process of tissue around dental implants.
Lack of motivation to carry out long-term maintenance therapy.

Measurements

Immediately after fixation of the provisional restorations, the distance from the contact areas of the superstructures to the papillary region of the gums was measured using a North Carolina periodontal probe (Hu-Friedy). After this, the results were interpreted in accordance with the Jemt classification. To improve the accuracy of the final results, measurements were carried out independently by two different examiners, but in no case did expert opinion differ and all papillae were scored as 0 or 1 according to the Jemt classification. During follow-up visits, measurements and classification of papillae were carried out according to the same scheme.

Surgical procedure

One hour before the intervention, patients took 2 g of amoxicillin orally, or 600 mg if allergic to penicillins. After local anesthesia lidocaine with adrenaline at a concentration of 1: 100,000 (Henry Schein), provisional structures were removed in order to visualize the area of the interdental papilla. Before surgical intervention patients underwent a procedure to expand the interdental space to ensure sufficient volume for future soft fabrics(photo 1a).

Photo 1a. Clinical appearance provisional restoration with a missing papilla in the implant area at the site of the 12th tooth and an intermediate part in the area of the 11th tooth after augmentation.

Before modification of the provisional structures, each of the papillae was assessed according to the Jemt classification. After removing the temporary restorations from the vestibular mucosa apical to the papillary region, an oblique incision was made through the full thickness of the soft tissue (Figure 1b).

Photo 1b. An oblique incision of the mucosa from the vestibular side.

A similar incision was made on the palatal side (Figure 1c).

Photo 1c. Palatal incision.

The oblique direction of the incisions, as well as the formation of such at a certain distance from the existing papilla, was reasoned with the goal of maintaining an adequate level of blood supply in the recipient area. Using the interlingual (TLC) (Ebina), modified and double-angled (Figure 1d) curette, it was possible to provide tunnel access apical to the papilla without additional soft tissue trauma.

Photo 1d. Interlingual curette.

First, the working part of the instrument was placed in the area of the vestibular incision, after which the periosteum was carefully separated to form a subperiosteal tunnel to the alveolar ridge, located apical to the existing interdental papilla (photo 2).

Photo 2a-2c. Separation of the periosteum using an interlingual curette.

In this case, tissue separation was carried out so carefully that the area of the incision area was preserved in its original state. A similar manipulation was performed on the palatal side, which later helped to connect the two tunnel approaches.

The subepithelial connective tissue graft was collected from the palate after anesthesia. The procedure was carried out using Langer-Calagna and Hurzeler-Weng techniques. The wound area was sutured using 4/0 chrome catgut sutures (Ethicon). Two sutures were placed on the mesial and distal sides of the graft itself to facilitate its further positioning and stabilization in the defect area (Figure 3).

Photo 3. Stabilization suture on a connective tissue graft.

The graft was initially placed in the recipient area through the vestibular incision, after which it was able to be moved up to the palatal tunnel area (photo 4).

Photo 4. View of graft placement in the defect area.

After achieving the optimal position of the graft, it was fixed in the area of the previously formed vestibular and palatal incisions using catgut sutures (photo 5).

Photo 5a-5b. Schematic representation of the augmentation procedure.

IN postoperative period Patients were prescribed 500 mg amoxicillin or 150 mg clindamycin three to four times daily for 1 week and ibuprofen (600 mg every 4 to 6 hours) for pain relief. Patients were also recommended to use 0.12% chlorhexidine solution as mouth rinse twice a day, starting 24 hours after surgery for the next 2 weeks, as well as a soft diet for the period of wound healing. Cleaning the intervention area with a brush or dental floss was prohibited; for this purpose, it was recommended to use 0.9% saline solution 5 to 6 times a day, or the same chlorhexidine twice a day. Repeat examinations were carried out 7 and 14 days after the iatrogenic intervention (Figure 6).

Photo 6. View 7-14 days after augmentation.

3 months after augmentation, the final prosthetic restorations were fixed (photos 7a-7d), and the design of those in the mucosal area exactly matched the contour of the previously fitted provisional structures.

Photo 7a. Clinical appearance before fixation of the final prosthesis.

Photo 7b. Clinical view with the final prosthesis in place.

Photo 7c. Clinical appearance of the final superconstruction.

Photo 7d. X-ray of the implantation area at the site of the 12th tooth and the intermediate part in the area of the 11th tooth.

In some areas where it was not possible to completely restore the interdental papilla, a slight lengthening of the contact points was carried out directly on the final superstructures. For monitoring purposes, all patients re-visited the dentist every 3 months after fixation of the final restorations. The measurement of the height of the papillae, as well as the assessment of their parameters, according to the Jemt classification, was carried out during repeated examinations by two independent researchers. In one case report, a 55-year-old woman sought dental attention due to the presence of a “black space between implants” (Figure 8a).

Photo 8a. Papilla deficiency between installed implants.

In the edentulous area, in place of the left central and lateral incisors, she had two infrastructures installed, splinted through restorations. The papilla present was classified as class 0 according to the Jemt classification. Restoration of the papilla was carried out according to the method described above. After one year, the black space area was completely filled with soft gingival tissue (Jemt 3), after which the patient received a new prosthetic restoration (Figure 8b and 8c).

Photo 8b. View after 12 months: the new papilla has filled the defect area.

Photo 8c. X-ray of the implantation area for control bone tissue between titanium supports.

results

The mean follow-up period in the 10 case series was 16.3 months (range 11 to 30 months), with Jemt classification achieving papillary improvement of 0.8 to 2.4 (range 0 to 3) ). Moreover, in 2 clinical cases, augmentation was carried out in the area of the central incisors, and in 8 cases - between the central and lateral incisors. In only one patient the papilla was restored between the implant and the natural tooth, while in 5 patients it was restored between two implants, and in 4 patients it was restored in the area of the intermediate part of the prosthesis. During the study, zirconium abutments were used in 2 cases, and titanium abutments in 8 cases. Only in one clinical case we were unable to improve the initial soft tissue parameters.

Discussion

In order to restore the area of the interdental papilla, several clinical approaches have been proposed. For example, Palacci et al used a full-tissue flap that was separated from the buccal and palatal sides and rotated 90 degrees to fill the space over dental implants. Adriaenssens proposed the so-called “palatal sliding flap” method to restore the papilla between the installed implant and the natural tooth in the anterior region of the upper jaw. This approach consisted of moving the palatal mucosa in a vestibular direction. Nemcovsky et al suggested using a U-shaped incision to implement a similar approach. Arnoux developed several augmentation methods to restore aesthetic parameters around a single tooth, but later agreed that the proposed approaches were not sufficiently predictive due to impaired blood supply and the presence of scar tissue.

Chao developed a needle hole augmentation technique to restore the soft tissue covering of the tooth root area. This approach did not require any release incisions, sharp dissection, or even suturing. The Chao procedure is very similar to the technique described in this article, with the difference that the first one involves only a vestibular incision and the use of a bioresorbable membrane (Bio-Gide, Geistlich) or acellular dermal matrix (Alloderm, BioHorizons). Another peculiarity is that the Chao technique is also aimed at restoring the coverage of the recession area, and not reconstructing the interdental papilla.

This article presents a modified approach to interdental papilla restoration that provides predictable soft tissue regeneration results. According to the results obtained, it was possible to achieve an improvement in the papillary area from 0.8 to 2.4, according to the Jemt classification. Based on this, this method can be recommended for the restoration of the papilla in the area between adjacent implants, between the implant and the tooth, and also in areas of the intermediate part of the prosthetic superstructure. At the same time, analyzing the results of treatment, it was also possible to come to the conclusion that restoration of the papilla in the area between the implant and the tooth is more predictable than in the area between two implants. Based on the experience of the authors of the article, this is the first case of describing a technique for restoring the interdental papilla, which is quite predictable in the long term.

To adequately provide access and accurately form the mucoperiosteal tunnel, the use of specific dental instruments is required. Thus, the use of an anatomically shaped interlingual curette (TLC) significantly reduces the risk of soft tissue perforation, and also increases the predictability of the manipulation performed (photos 1d and 2). Wherein full recovery papillae were achieved in 6 out of 10 clinical cases, and only in 3 cases the doctor had to slightly lengthen the point of contact in the area of the final restorations. But this did not in any way affect the rate of patient satisfaction with the results of the treatment. In one clinical case, we were unable to restore soft tissue in the proper volume, which is why this patient underwent repeated surgical intervention and in given time he is in the wound healing stage.

Further studies are required to confirm the stability of the results achieved by this soft tissue reconstruction technique. clinical trials, however, even based on the data obtained, it can be summarized that this technique is very predictable and effective for restoring soft tissue in the aesthetic zone.

Conclusion

Given the limitations of this study, it was possible to determine that average The papilla improvement according to the Jemt classification is 1.6 (range 0.8 to 2.4), and is acceptable for soft tissue restoration between two adjacent implants, between an implant and an intrinsic tooth, and in the pontic area of a superstructure. The predicted treatment result is ensured by a precisely planned incision, an atraumatic approach and the provision of postoperative support at home. To confirm the effectiveness of the proposed technique, subsequent clinical studies are required.

Gingivitis, periodontitis - behind these incomprehensible names lies a dangerous disease for teeth associated with inflammation of the gums, which, if left untreated, can lead to tooth loss.

What are the causes of this disease and how to deal with it correctly?

Today, more than half of humanity suffers from inflammation of the gums, and the reasons for this are very different - from poor lifestyle to poor heredity or disruption of the body due to hormonal changes.

In this case, inflammatory processes can differ in the nature of their course and treatment methods. In order to correctly decide on therapy and know what to do, you should familiarize yourself with all the possible nuances.

Causes of the inflammatory process

The reasons for the development of inflammatory processes in the gums can be both external and internal. They also differ in the scale of impact. It is the correctly identified cause of inflammation that becomes the key to effective treatment.

General factors

Gum problems can result from:

smoking;
lack of minerals and vitamins in the body;
diseases of the gastrointestinal tract and cardiovascular system;
diabetes mellitus;
hormonal imbalances;
infectious processes;
taking certain medications (for example, antidepressants, birth control, or nasal drops may have a negative effect);
reduced immunity.

Local factors

These include:

teething;
injury, heat or chemical burns gums;
development of dental calculus;
poor oral hygiene, accumulation of toxin-producing microorganisms;
improper prosthetics or filling, in which the gum is injured by the overhanging edge of the crown or filling (inflammation localized within one or two teeth occurs).

The photo shows examples of gum inflammation

Gingivitis - we will survive this trouble

The listed factors quite often lead to the development of such dangerous inflammatory processes in the gums as gingivitis and periodontitis. In this case, a generalized nature of inflammation is observed, implying damage to the entire oral cavity.

This form of inflammation occurs most often. The disease can be provoked by both general and local factors.

This type of inflammatory process is characterized by following symptoms:

slight swelling, bleeding and redness of the gums;
change acute form gingival papillae to dome-shaped;
appearance unpleasant odor and taste, itching sensation;
soreness of the gums upon contact with food;
fever, general weakness;
formation of abundant plaque (at the initial stage).

A mild form of the disease (only the gingival papillae are affected) can be replaced by moderate and severe forms with damage to the free part of the gums and their entire space, respectively.

The photo shows a chronic process, the cure of which will require an integrated approach.

Ulcerative gingivitis

In this case, inflammatory processes affect the mucous membranes of the gums, provoking the development of tissue necrosis near the gingival margin and inflammation of regional lymph nodes.

The most likely cause of this process, along with hypothermia, infectious diseases and reduced immunity is poor oral hygiene.

Symptoms characteristic of catarrhal gingivitis include:

the presence of dirty gray plaque at the top of the gingival papillae, the removal of which leads to bleeding gums;
temperature rise with increased heart rate, pale skin and loss of appetite.

When this form of the disease develops, it is extremely important to start treatment in a timely manner.

The photo shows a severe form of the disease with purulent inflammation, which requires antibacterial and surgical treatment.

Hypertrophic gingivitis

A feature of this form is the reactive proliferation of connective fibrous tissue and epithelial basal cells, caused by chronic inflammation mucous membranes of the gums. Most often, such violations are caused by changes in work endocrine system, lack of vitamins and metabolic disorders.

The following symptoms of the disease appear:

thickening of the epithelium (if untreated, keratinization is possible);
a significant increase in gum size, a change in its color to dark red (granulating course of hypertrophic gingivitis);
severe compaction of gum tissue, the appearance painful sensations upon palpation (fibrous development).

Inflammatory processes in the oral area

In addition to generalized inflammation of the entire gingival surface, local processes are possible in certain areas due to the development of periodontitis, injury to the gums by the crown, and the eruption of wisdom teeth.

Also, inflammatory processes in the gums of pregnant women stand apart. We will talk about these situations.

Periodontitis

Fistula with periodontitis

A characteristic feature of periodontitis is the formation of a cyst at the apex of the root of the affected tooth in the form of a pus-filled sac, which causes swelling, swelling and soreness of the gums.

In this case, the swelling is fickle, appearing and disappearing.

The cause of the development of the disorder is advanced caries that has developed into pulpitis, or poor-quality filling of root canals during the treatment of pulpitis or at the stage of preparation for prosthetics.

It is periodontitis that makes it possible to make a final diagnosis and establish X-ray, compared by the doctor with the results of a visual examination. In this situation, the image clearly shows a change in the bone tissue in the area of the tooth root and poor quality of the filling.

Inflammatory process during pregnancy

Changes in the condition of the gums with the development of bleeding and swelling are very often observed during pregnancy.

The provoking factor, dentists call - change hormonal levels women, which, with deterioration of oral hygiene, leads to the development of gum inflammation.

You need to be especially attentive to the condition of the oral cavity in the second and third trimesters (the hypertrophic process shown in the photo is typical for these periods).

With absence timely treatment inflammation can progress rapidly, not only aggravating general state expectant mother, but also causing premature birth and the birth of underweight babies.

Prosthetics and installation of crowns

Incorrect prosthetics with the installation of crowns or dentures with overhanging edges causes permanent injury to the gums, which ultimately develops a large-scale inflammatory process.

In such a situation, a periodontal pocket of sufficiently deep depth can form in the interdental space, in which inflammation develops.

Negative effects of wisdom teeth

Cutting figure eights is one of the likely causes of inflammation of the gums, which swell and become painful in the tooth area.

The presence of slight swelling is considered normal, but if the inflammation becomes widespread, you should immediately consult a doctor due to the risk of wound infection.

Most a common option inflammation of the gums during the eruption of wisdom teeth is pericoronitis, associated with the entry of food particles under the gingival hood covering the molar and the development of pathogenic microorganisms there.

In this case, not only the gums around the tooth can become inflamed, but also neighboring tissues, which can lead to a purulent abscess.

You can cope with the disease only with the participation of a specialist who will prescribe appropriate therapy using antiseptic solutions for washing, rinsing or, if necessary, excise the hood that creates trouble or completely remove the wisdom tooth.

An integrated approach to treatment

It is necessary to begin treatment of the inflammatory process from the moment the first symptoms are detected. Therapy aimed at eliminating inflammation is quite multifaceted, so you can choose the most suitable method of treatment.

Consultation and initial examination of a specialist

First of all, the dentist visually assesses the condition of the oral cavity and the degree of the inflammatory process.

One of the first measures for such complaints is a complete sanitation of the mouth, which, as a rule, is followed by the removal of deposits on the teeth using a special ultrasonic device.

Sanitation of the oral cavity through the treatment of teeth affected by caries can eliminate the acute inflammatory process (in particular, alleviate the condition of necrotizing ulcerative gingivitis). Also, this measure is necessary to reduce the risk of re-development of inflammation.

Removing plaque from teeth makes it possible to eliminate one of the main causes of inflammation - exposure to pathogenic microorganisms.

After ultrasonic cleaning, the teeth are polished, creating a smooth surface on which plaque will not collect. If the gums are very inflamed and bleeding, polishing is carried out when the process becomes less acute.

Anti-inflammatory therapy

Anti-inflammatory treatment of gum inflammation is carried out using various medicines: antiseptic solutions for rinsing from a syringe, therapeutic periodontal dressings and applications.

Depending on the cause of the inflammatory process, the following treatment methods are used:

If you want to antibacterial therapy, then the drugs are selected from the group of macrolides (Sumamed, Azithromycin), cephalosporins (Ephodox, Cefazolin) and penicillins (Augmentin, Amoxiclav).

If hypertrophic gingivitis develops, surgical intervention may be required at the discretion of the dentist.

Antibiotics (in tablet form) are prescribed to all patients with necrotizing ulcerative gingivitis and for persistent acute gingivitis. The most commonly used medications are: Clindamycin, Ofloxacin, Augmentin, Azithromycin, Lincomycin.

The course of antibiotic therapy is chosen by the doctor individually.

Treatment regimen for gum inflammation at home

In addition to antibiotics, to relieve inflammation, irrigation of the oral cavity with Proposol aerosol and lubrication of the affected areas with dental ointments, such as Metrogyl or Solcoseryl, can be prescribed. The use of drugs in gel form is preferable, as its base promotes absorption active substance in the gum.

To boost immunity, your doctor may prescribe vitamins - ascorbic acid or ascorutin. If desired, they can be replaced with rosehip infusion.

Tactics for action at home for inflammation and soreness of the gums are presented in the diagram.

Treatment of inflammation caused by injury

If the cause of the inflammatory process is injury to the gums by the overhanging edge of the filling, first of all, the offending area is cut down or the filling material is completely replaced.

If prosthetics fail, drug therapy similar to the treatment of gingivitis may first be prescribed, after which, depending on the result, the need to replace the crowns for a complete cure is considered.

Features of choosing toothpaste and brush

Gum inflammation requires integrated approach to treatment, therefore, along with correctly selected drug therapy, you need to carefully consider the choice of toothbrush and toothpaste.

The paste should contain:

anti-inflammatory components(extracts of ginseng, sage, chamomile, calendula, St. John's wort, cloves);
antibacterial substances(having an effect on gram-negative and gram-positive bacteria - triclosan, used in conjunction with a copolymer that prolongs the action of the component);
regenerating gum tissue products ( oil solutions vitamins A and E, carotoline, some enzymes).

It should be noted that toothpastes with antibacterial components are not intended for daily use due to the negative impact on the oral microflora in case of long-term use. Such pastes can be used for no longer than 3 weeks, after which it is necessary to take a 5-6 week break.

The only option that is suitable for daily use and has not only a therapeutic, but also a preventive effect, are toothpastes with a natural component such as tea tree oil.

A brush suitable for cleaning an inflamed oral cavity should be soft enough so that the mucous membrane and gums do not experience excessive pressure. You can use the brush for no longer than one month.

Preventive actions

Inflammation of the gums, especially in acute stage, requires long and complex treatment, so you should remember preventive measures, which will significantly reduce the risk of developing such a disease and not postpone a visit to the doctor if alarming symptoms appear.

Concept awareness biological width– a sign of the evolution of the orthopedist. At every seminar, at every meeting, doctors are tormented by the same questions - “how to sharpen correctly? up to the gum or below? where should I hide the edge of the crown?” The answer to these interrelated questions is given by knowledge of the sizes and types of tissues surrounding the tooth or implant.

Schematically shows the main components that form biological width

Biowidth is formed by connective tissue attachment ( otherwise called "circular ligament"), epithelial attachment ( actually the “bottom” of the periodontal groove) and thickness of the mucous membrane ( which forms the dental-gingival groove or groove). The total biological width is 3 mm.

If you prepare a tooth to the gingival contour and carry out standard retraction with a thread, you will notice a certain reserve of subgingival space, which is mistakenly used by orthopedists to place the edge of the preparation. The error becomes noticeable already when taking an impression - the corrective mass does not get into the space behind the shoulder - there is simply no room for it. Therefore, during retraction, the visually identifiable shoulder may undergo rigorous polishing and leveling.

If you fold back the flap and check the value of the biological width, it will be equal to 3 mm.

So, there are 3 main types of observed preparation levels:

gingival level (allowing high-quality polishing of the ledge to facilitate the preparation of the edge of the restoration, taking an impression and performing fixation according to any protocol)
subgingival level (those “half a millimeter under the gum”, which make it difficult to remove the impression, and therefore the “readability” of the impression by a dental technician, make it difficult to fix using the adhesive protocol due to injury to the gums by the rubber dam clamp)
deep subgingival level (actual preparation error or work dictated by circumstances of non-contact with the patient)

At the gingival level of preparation, manual polishing of the shoulder or polishing of the connection line between the root and the crown becomes possible.

The interproximal area of preparation is also regulated during preparation by the values of biological width to create adequate interdental papillae that are not inflamed when wearing an indirect restoration. Providing a “bypass” of the gingival papilla can be done by installing a wedge at the time of tooth preparation. When preparing a tooth, the position of the contact point must be taken into account and indicated to the dental technician. In fact, if we have a distance from the preparation line to the bone part of 3 mm, then according to the Tarnow relationship, the contact point should be located within 1.5-2.5 mm from the ledge line.

Otherwise, the gingival papilla will not occupy the entire contact point, forming a “black triangle”, so disliked by orthopedists. By adjusting the position of the contact point to the dental technician, we protect ourselves from problems with the papillae in 100% of cases.

However, the health of the gingival papilla is primarily based on the fact that it must be supported by the root of the tooth, and not by the crown. In this photo, a metal-free crown is installed on a tooth, with the help of which we determined the distance from the ledge line to the bone part by folding back the flap. The absence of immersion “by half a millimeter” does not in any way affect the aesthetic appearance of the crown.

Many doctors appeal to the fact that their patients cannot afford metal-free crowns and they are “forced” to work with standard metal-ceramic crowns. Taking this into account and in order to “hide the transition of the edge of the crown into the tooth,” they prepare below the gingival contour. Since the postulates of biological width work not only on cosmetic types of crowns, but on all types in general, the placement of the ledge level will be the same.

In order for the work to look aesthetically pleasing, the exact edge of the preparation line is important - the rest can be decided.

Even without a ceramic shoulder...

Metal-ceramic crowns in the anterior segment on the day of installation. The gingival contour looks good even after controlled cleaning of the post-marginal area from cement residues.

Biological width should also be a leading factor when planning orthopedic work.

When correcting the zenith level, the ledge preparation line is formed by retreating 3 mm from the new (corrected) level of the alveolar part.

During surgical lengthening, it is very convenient to mark the preparation line.

And carry out the final preparation 8 weeks after surgery.

Removing the behind-the-stage zone – required condition quality work. If, after retraction, we still immerse the line of the ledge into the vacated space, the behind-the-ledge zone in the impression will be imprinted to a lesser extent. Therefore, after retraction, polishing is strict.

The retraction area and the penetration of the base and corrective mass into this area are clearly visible on the underlay.

The epithelial attachment and thickness of the mucous membrane precisely regulates the position of the ledge line for each specific tooth being prepared. Therefore, a periodontal probe is an integral attribute of the work of not only a periodontist, but also a good orthopedist.

The quality of the imprinted post-abrasive zone allows the dental technician to solve the problem of the aesthetic appearance of the crown edge as efficiently and beautifully as possible.

In addition to your own teeth, you need to maintain the proportions of the biological width and around the implants. There is a significant difference between these two types of meanings. First of all, it is worth considering that the collagen fibers that form the connective tissue attachment to your own tooth have a transverse direction, and in the tissues surrounding the neck of the implant or abutment, it is strictly longitudinal. Therefore, the difference in values is 1 mm. The biological width of the implant is 4 mm.

A standard healing abutment with a height of 7 mm is installed.

Emergency profile

A small disadvantage of A-silicones will be demonstrated here. The fact is that when working with implants, polyester impression compounds are preferable - they have greater fluidity and do not displace the gingival profile apically. A-silicones (and even more so C-silicones) imperceptibly deform the gingival contour, the consequences of which you will see further.

The biological width of the tissues surrounding the implant is 4 mm.

Individual zirconia abutment with a neck height of 4 mm.

Standard metal-ceramic crown without any shoulder.

Abutment installed

A metal-ceramic crown was installed. The “revenge of A-silicone” is clearly visible here. More elastic than polyester, A-silicone causes creasing of the thin edge of the gum. Therefore, when working with A-silicone, indicate to the dental technician the necessary adjustment for the placement of the abutment shoulder: for a thick biotype, 0.5 mm, and for a thin biotype, 1 mm.

Common problem: Loss of gingival papillae and the appearance of “black triangles”.

Loss of gingival papillae, especially in the anterior maxilla, is a serious aesthetic problem and can cause significant psychological discomfort in patients with a high smile line.

The World Health Organization defines health as physical and psychological well-being. Therefore, dentists should strive to improve the patient’s appearance when restoring teeth (bridges, veneers, composite restorations) and gum correction. In other words, the goal dental care is to ensure the physical and psychological well-being of the patient by optimizing the aesthetics of teeth and gums.

Due to the prevalence of loss of interdental papillae and the aesthetic defects associated with this condition, there is a need to solve this problem (Fig. 4-3a and 4-3b).

Effective solution: Measuring biological width using bone probing.

In 1961, Gargiulo et al published the results of measurements of the depth of the periodontal sulcus, epithelial and connective tissue attachment, i.e. biological width (Fig. 4-3c). It is known that violation of the biological width leads to the development of gingivitis and periodontitis, even with careful oral hygiene (Fig. 4-3d). Tarnow et al." revealed an inverse relationship between the probability of filling the interdental space with the gingival papilla and the distance between the interdental contact and the alveolar ridge (Fig. 4-3).

In the past, dentists paid attention to the location of the contact point solely for reasons of preventing food from entering the

Rice. 4-Pros. A forced smile does not bring satisfaction to the patient. There are “black triangles” between the teeth

Rice. 4-ЗБ. Patient's smile line

Rice. 4-3d. When carrying out treatment, the biological width was not taken into account, which led to the development of gingivitis, despite careful hygiene

Rice. 4-Ze. The probability of the gingival papilla filling the interdental space depending on the distance between the contact point and the bone edge (Tarnow et al.

interdental space and, taking this circumstance into account, prosthetics were performed, including the anterior group of teeth (Fig. 4-3f and 4-H). The coronal boundary of the interdental contact is determined by aesthetic criteria, and the apical boundary depends on the distance to the alveolar bone (Fig. 4-3h).

In an article devoted to the features of the dentogingival complex, Kois

described the use of periodontal parameters in prosthetic treatment planning and a method for determining the contour of the alveolar ridge margin. It was this author who first demonstrated the feasibility of probing the bone before prosthetics.

After local anesthesia has been administered, the periodontal probe is inserted until it makes contact with the bone (Fig. 4-3i.

Rice. 4-3f. Symmetrical arrangement of contact points in the anterior part of the upper dentition.

and 4-3j), the obtained values are documented in the patient’s chart (Fig. 4-3k). In the future, these data can be used to create a composite restoration, orthodontic movement of teeth and the manufacture of prosthetics, such as veneers and crowns (Fig. 4-31 and 4-3).

Without a thorough analysis of the parameters of the dentogingival complex, it is impossible to achieve predictable regeneration of the gingival papillae (Fig. 4-3p).

The application of the technique described above and the use of the obtained data when performing prosthetics allows us to obtain a satisfactory result (Fig. 4-3).

Rice. 4-Zd. Wax-up of upper anterior teeth (Kubein-Meesenberg et al.

). Localization of contact points is determined using interproximal cones