The presence of isolated periodontal defects is one of the most challenging esthetic issues encountered by the restorative dentist. The typical presentation is a patient with an esthetically pleasing smile with one area of significant interproximal tissue loss. The patient in the picture is an example; she has already been to two different periodontists and underwent two separate surgeries trying to graft the defect between her central and lateral incisor with bone and gingiva.
We know biologically that the papilla height is determined by the location of the bone, and that there is a predictable amount of tissue above the crest of bone in the average patient. It is critical to understand the bone to tissue relationships for different treatment options before commencing any further treatment on this patient.
Tooth to tooth: Even though there is bone loss, patients who have adjacent natural teeth have on average 4.5mm of tissue above the interproximal bone. This is true for this patient as well, which means she has had about 5mm of bone loss between the central and lateral. As the bone was lost, the papilla migrated apically maintaining this 4.5mm distance.
Tooth to implant: It is tempting when we see problems like this to immediately think about extraction, but you have to consider the outcome of each option prior to tooth removal. If you take out the lateral and replace it with an implant the papilla level will be determined by the bone on the adjacent remaining teeth. You will still get 4.5mm of tissue above the bone. Since the bone on the distal of the central is the same height as the lateral this means you will have a defect as bad or worse than what is currently there.
Implant to implant: Since both the central and lateral are the problem we might consider removing both teeth and placing two adjacent implants. Research tells us that when we place adjacent implants the interproximal papilla will end up 3 to 3.5mm above the crest of bone. This means that the result will be worse than where she is now. Of course bone grafting could be done at the time of extraction, hopefully moving the bone coronally prior to implant placement. This could improve the final result, but the question will be how many millimeters vertically the grafting can move the bone.
Pontic to pontic: Another alternative for her treatment is to remove the central and lateral and not place implants. Instead connective tissue grafting can be done followed by a fixed bridge from the right canine to the left central incisor. Connective tissue grafting has been shown to achieve significant tissue heights of 6 to 9mm above the underlying bone, and be very stable. Of course now the patient will have a fixed bridge rather then implants which bring some different risks with it, but this may be the most predictable result esthetically.
Ultimately this patient was treated without extraction. Instead orthodontic eruption was done to move the bone and gingiva coronally on both the central and lateral, followed by restoration of the lateral incisor.