Papilla esthetics is critical in achieving the final outcome we hope for in clinical procedures. It also occurs to many clinicians as mysterious and unpredictable, on the other hand there are often promises of closing a black triangle with surgery that push the envelope of what we know is biologically possible. Our ability to predictable expect the papilla to fill the interdental space is dependent on the architecture of the space. The form of the two adjacent structures, teeth or implants, the distance between these structures and the position of the osseous crest are the primary factors. If we know these details than how much tissue we can expect in the embrasure is quite predictable, although it may not be enough to close a black triangle.
It is common to desire to close a black triangle between two adjacent natural teeth. How about the situation where we cement final anterior restorations and have a black triangle. Will it fill in, was it from splinted provisionals and we should reassure the patient and wait, or not put in the final restorations. In the clinical scenario where we have two adjacent natural teeth(Class I papilla) there are limiting horizontal and vertical criteria. Horizontally to have a papilla the two teeth can not be closer together than 1mm ( Tal). In the vertical dimension we will have complete papilla fill 90% of the time when the distance from the tip of the osseous crest to the contact is 4.5mm or less ( Tarnow, Van Der Velden).
We have two options for when the distance is greater than 4.5mm. One is to reposition the osseous crest using orthodontic extrusion prior to restorative. Another alternative is to lengthen the contact area. Ideally we like the distance from the base of the contact to the incisal edge to represent 50% of the tooth length. If this becomes too large it can decrease the overall esthetics, but we do have the option to vary it when needed.
When seating final restorations if you sound to bone and the distance is correct, place the restorations and be patient. Recent studies show that it may tale as much as eighteen months, but the papilla will fill the space if the parameters are correct biologically.
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