Managing Open Interdental Spaces with Indirect Veneer Restorations: Assessment and Identification of the Problem (Prologue)By Robert Winter on May 18, 2020 | comments
This is the prologue to Dr. Winter's five-part restorative series. Read Part 1, Part 2, Part 3, Part 4 and Part 5.
An open interdental space, whether it is a diastema or black triangle, can create esthetic concerns for the patient, establish a plaque accumulation area, or become a food trap. To resolve the concern or problem, a proper assessment of the clinical scenario is essential.
The open interdental space may be the result of a biologic problem including periodontal disease, or improper tooth position, angulation, or form.
If there is periodontal disease with interproximal horizontal bone loss but not loss of facial bone, the papilla may be apically positioned, which opens an interdental space. The gingival architecture will be flatter without the normal scallop because the papilla will move apically. The periodontal disease, or other underlying problems, must be treated before you can address the interdental space issue.
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If there is no periodontal disease and there is an open interdental space, you need to determine what is causing the problem.
First, you should assess the anatomic tooth and root form and their approximation, to determine any abnormality. If it is simply the tooth position, orthodontic treatment can be used to bodily bring the teeth together, eliminating the problem.
If the teeth have normal tooth form, the interdental contact will be established, and the papilla will fill in the gingival embrasure.
If the roots of the teeth are diverging, it will create greater distance between the teeth subgingivally even though the teeth have interdental contact. The papilla will typically be more blunted the wider this distance. The gingival attachment is maintained at 2.0 mm on the average; however, the sulcus depth becomes shallower. The most conservative treatment is to orthodontically move the roots into normal alignment. This decreases the volume of space between the teeth, and the papilla moves incisally, filling in the space if normal crown form exists. The sulcus depth should increase to a normal 2.5 mm interdentally.
If there is abnormal anatomic morphology of the tooth crown, the first treatment option is to reshape the crown with a reductive process. If the tooth is triangular or ovoid-shaped, there will be a short interdental contact. In this case, you can perform an enamelplasty on the interproximal surface to create a flatter surface. Once the flatter surface is established, orthodontic movement can bring the teeth together with a longer interdental contact, closing of the gingival embrasure.
The negative consequence of a reduction procedure is it will narrow the tooth and possibly negative impact on tooth proportion.
An alternative option to change tooth form is to use an additive process.
A direct composite restoration can be added to each of the interdental surfaces, or an indirect restoration can be done if there are additional changes required to comprehensively restore the tooth. This additive approach may close the interdental space, or there still may be a need for orthodontic movement.
My five-part series addresses the management of open interdental spaces with an indirect veneer restoration, assuming there is normal periodontal health and orthodontic treatment will not be performed.
Robert Winter, D.D.S., is a member of Spear Resident Faculty.