In a previous article, “Esthetic Management of a Flat Periodontium Through Orthodontic Extrusion”, I discussed the use of orthodontic extrusion to manage papilla position in patients with a flat periodontium. Orthodontic extrusion is the approach that achieves the most esthetic result; however, there are some patients who are unwilling to go through orthodontics to achieve the most ideal result.

Take for instance, the patient in the photograph; she has had interproximal bone loss across the anterior causing the papilla to move in an apical direction. She also has had some recession, so her old crown margins are visible. The challenge is that in a normal situation the papilla between the centrals is 5-6mm from the incisal edges, and the tip of the papilla is 4.5-5mm above the facial gingival margins, the total length of the centrals averaging 10.5 to 11mm.

Her presenting situation has the papilla 9mm from the incisal edges, and the tip of the papilla 1.5mm above the gingival margins, creating an overall tooth length of 10.5-11mm. I presented this patient the ideal option of orthodontic extrusion to erupt the four anterior teeth, equilibrating the incisal edges as the teeth erupted until the distance from the incisal edges to the tip of the papilla was 5-6 mm. At this point the teeth would appear too short and facial only crown lengthening could be performed to re-establish a normal tooth length and papilla height, giving her a more esthetic smile. She was not interested in that option at all.

Since she would not consider orthodontics the papilla position is not going to be changed. And since the incisal edge position is correct for her smile and smile line, it cannot be changed. This means she will end up with a 9mm distance from the incisal edges to the tip of the papilla, which will create a very long contact and rectangular looking teeth.

What can be changed is the facial gingival margin position. Facial crown lengthening can improve the height of the papilla, but also will make the teeth longer. Since her centrals are already 10.5-11mm long, 1.5mm of facial crown lengthening is all I could do to prevent the teeth from looking overly long. Following the facial crown lengthening they ended up being about 12 – 12.5mm. This made the papilla look more esthetic but it was not a pretty result overall.

What I was trying to do was make the papilla taller since the contact length can't be changed without the teeth being extruded orthodontically. In an ideal world, the ratio of contact length to papilla height should be even, but in her case she had an extremely long contact and a very short papilla. Since she was not attuned to wearing braces, I came up with a solution that didn't necessarily deliver a perfect result, but her smile was much more attractive than what she came to me with.

However, what I hope you are seeing in these before and after photos is that patients with a flat periodontium need to go through orthodontic extrusion unless you and your patient are willing to accept very “rectangular” teeth as a final result.