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Correction of gingival cants in combination with smile line cants is difficult.  It is even more difficult when crown lengthening is required necessitating a staged approach to heal and accurately predicting tissue heights to correct the patient’s condition.  It is even more difficult when the patient desires both final restorations and crown lengthening to be completed at the same appointment due to time restraints.

The patient above presented with an old Cerec anterior reconstruction featuring a myriad of disharmonies and cants, and desired a replacement with better symmetry and a more natural appearance.  The patient desired both gingivoosseous recontouring (open flap) as well as final porcelain restorations to be completed without the staged approach allowing evaluation of soft tissue margins before prepping final marginal levels for porcelain.
What happens now if the patient feels a suture end at the end of her appointment at home and decides to TEAR OUT her midline papilla?  It is disconcerting, at best.  According to Tarnow et al, interdental papillae height is determined by crestal height.  He found that nearly 100% of cases showed full papillae regeneration when the contact point was 5mm or less from the bony crest.  Kois teaches that a 4mm distance from crest to contact will allow for a definitive papilla fill 100% of the time.  Indeed, it is known that the interdental papillae are the only part of the human body that is capable of fully regenerating after being resected.
Tarnow DP, Magner AW, 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 Periodontol. 1992 Dec;63(12):995-6. doi: 10.1902/jop.1992.63.12.995. PMID: 1474471.
In this case, you will see a photograph of the patient upon dismissal from the preparation/crown lengthening appointment with papillae intact.  You will see a post-cementation photo, a 4 week post-operative, 8 week post-operative and 24 week post-operative review.  What is interesting is that papillae regeneration really does occur – is it perfect?  Not yet, possibly still maturing.
What is also interesting is that the “cramped papillae” from the pre-operative situation were able to recover better on the side with the crown lengthening relative to the “untouched” right hand side.
Thanks as always to Shin for your artistry.
#IPSemax #TSE #CrownLengthening #PapillaeTrauma #PapillaeRegeneration