The interproximal zone and septum syndrome.

The interproximal zone and septum syndrome.

PLAN

Introduction

1. The interproximal zone
   1. Definition 
   2. Anatomy
      1. Dental elements
      2. Periodontal elements
   3. Physiological modification of the interproximal region
   4. Pathologies of the interproximal zone
2. Interdental symptom syndrome
   1. Definition
   2. Etiologies
   3. Symptomatology
   4. Differential diagnosis
   5. Positive diagnosis
   6. Evolution and complication
   7. Treatment
   8. Prognosis

Conclusion

The interproximal zone and septum syndrome.

Introduction 

The point of contact between two teeth is of paramount importance for the health of the tooth and the periodontium.

An absence or lack of contact leads to very harmful disorders.

1. The interproximal zone

1.1. Definition

The interproximal zone is an anatomical and functional unit delimited by two adjacent teeth in contact.

It includes dental and periodontal elements:

1. Marginal dimples and ridges, 

2. The proximal faces,

3. The interdental contact point or surface,

4. The gingival papilla and

5. The alveolar septum

1.2. Anatomy

It is important to have a good understanding of the anatomy of the constituent elements of this area in order to be able to restore it in good conditions later.

1. 2.1 Dental elements

• Marginal ridges:

• Are linear elevations of the occlusal surface of cuspid teeth and the lingual or palatal surface of incisors and canines
• They provide the junction between the vestibular and lingual cusp of multicuspid teeth and between the free edge and the cingulum of monocuspid teeth.
• The proximal faces:
• It is a convex surface which becomes concave towards the neck and ends in a straight part near the gum.
• The contact zone:

• An interproximal contact is a clash of adjacent teeth in the continuity of the dental arch.
• The point of contact:
• The interdental contact point is defined as the contact zone between the proximal faces of 2 adjacent teeth.
• It is located at the crossroads of 4 pyramidal volumes or embrasures: vestibular, palatine/lingual, occlusal, cervical.
• The area thus delimited around the point of contact is called the interproximal space.
• In the young; it is noticeably located

• At the level of the vestibular 1/3 in the Vestibulo Lingual direction and
• At the level of the 1/3 grinding of the dental crown including the cusps in the vertical direction (It is almost at the top of the proximal face).
• In adults; due to interproximal wear resulting from the mobility of the teeth during chewing, we speak of contact surface.

1.2.2 Periodontal elements

• The interproximal contact zone , between two convex surfaces, induces the formation of four pyramidal spaces called embrasures and we distinguish:

• The occlusal embrasure; located above the point of contact
• The cervical embrasure; located below the point of contact (serves as a housing for the interdental papilla)
• The vestibular embrasure; located vestibularly relative to the point of contact 
• The lingual embrasure; located lingually to the point of contact.
• The gingival papilla:

It is the portion of free gum that fills the interdental space of two adjacent teeth in contact.

In young subjects, the interproximal space is filled by the papilla, which is subdivided into 2 papillae, vestibular and lingual, separated by a depression ”the interdental neck”

With age, this papilla tends to gradually free up this space.

This area is particularly fragile because it is not very keratinized (not being subject to functional stimulation)

• The alveolar septum:

It is a spongy bone (fragility to all types of aggression) limited by two cortices (external and internal)

It serves as a support for the gingival papilla.

The food bolus is subjected to trituration by the antagonistic posterior teeth

Then it is oriented by the ridges:

– The greater part goes towards the inclined crushing slope of the ridge,

– And the weakest part, guided by the proximal slope, engages on either side of the point of contact

Food is thus rejected towards the vestibule or the lingual surface by the inclined planes of the gingival papilla. In this case there is no interdental food stagnation; therefore there is very little risk of proximal caries developing.

The interproximal zone and septum syndrome.

3. Physiological modification of the interproximal region

The dentition of an adolescent has punctiform contacts between each tooth.

In older people the following changes occur:

– Proximal and occlusal wear;

– Abrasion of the marginal ridges.

– The contact point becomes a contact surface ;

– Dental groove becomes a cleft

– The interproximal space increases in volume and the papilla tends to retract in the absence of inflammation.

– At the level of the fibro-mucosa and the alveolar bone, senescence results in a retraction exposing part of the root; the clinical crown lengthens while the clinical root decreases by the same amount, the interdental septa are decapitated, however the hermeticity of the desmodont is reserved.

Results :

• The bolus is still crushed but the flow is more vestibular than lingual because of the contact surface
• Food stagnation in the interdental space (promoted by concave areas and collapse of the papilla)
• Gum recession
• Appearance of caries and periodontal disease

4. Pathologies of the interproximal zone

As soon as the anatomical integrity is affected or if there are disharmonies in the relationship between the teeth, it quickly appears:

• Food retention, bacterial plaque
• Proximal caries
• Deepening of the gingival sulcus.
• Migration of the epithelial attachment.
• Destruction of the superficial fibers of the LAD.
• Bone resorption (periodontal pocket).

2. Interdental symptom syndrome 

2.1. Definition

• It is an inflammation of the tissues of the interdental space, first the gum, then if nothing is done, the alveolar bone, and which ends with the destruction of the bony septum and an infection with a small abscess located between the two teeth concerned.
• Septum syndrome is the consequence of a dysfunction of the interdental area which manifests itself by a more or less deep painful lesion.
• It is caused by food compaction, often aggravated by iatrogenic elimination maneuvers.

2.2. Etiologies

• Functional causes:

o Atypical swallowing with lingual interposition.

• Morphological causes:

o Shape anomalies,

o Dental malposition

o Infectious pathologies

• Occlusal causes:

o Plunging cusp: penetrates deeply between 2 teeth and creates a space

o Loss of mesiodistal wedging (uncompensated extraction, generalized microdontia)

• Iatrogenic causes:

o Defective restoration (overflowing amalgam, poorly adapted prosthesis, hook or attachment system of an auxiliary prosthesis, roughness of a restoration)

2.3. Symptomatology

• Clinical signs:
• Subjective:

1. Food compaction with a feeling of compression.

2. Pain caused especially during and after meals.

3. Pain caused by thermal variations.

4. Spontaneous pains can exist more or less intense, sometimes diffuse or even pulsating. These pains can be violent and difficult to localize, often confused with pulpitis pains.

• Goals :
• The inspection:

• Food stuffing.
• Hypertrophy of the papilla.
• Spontaneous and induced hemorrhage (calms DLR)

• Sensitivity to pressure and transverse percussion.
• Radiology (Retro alveolar or bite wing): May show:

• Interdental septum involvement +/- advanced depending on the stage of the lesion (horizontal, vertical, oblique)
• A desmodontal enlargement
• The presence or absence of proximal caries, overflowing fillings.

The interproximal zone and septum syndrome.

2.4. Differential diagnosis

Based on the following 3 tests:

• Periodontal probing,
• Vitality tests, and
• X-ray

It will be made with:

• Acute pulpitis
• Acute periapical reactions
• Alveolitis

2.5. Positive diagnosis

• Using a mouth spatula with which we apply simple pressure to the area which will trigger:

• A very sharp pain and
• Possible gum bleeding

2.6. Evolution and complications

– If no treatment is undertaken, the progression is towards damage to the epithelial attachment, then destruction of the connective tissue attachment, and finally lysis of the alveolar bone may appear:

• Complex periodontal disease with tooth mobility;
• Cementum caries;
• Periodontal abscess;
• Pulpit with retro;
• Intraosseous abscess.

2.7. Treatment

• Symptomatic TRT

• Cleaning the interdental space (clearing the proximal space of debris)
• Under anesthesia, curettage of the pocket and removal of papillary hypertrophy if it exists.

H2O2 hemostasis

• Touch with 10% Chromic acid, or failing that, Eugenol.
• General analgesic TRT if necessary

• The recommendation to use 0.2% chlorhexidine mouthwashes twice a day for a week
• Oral hygiene tips
• In the presence of significant papillary hypertrophy:

• Resection with a scalpel “papillectomy” and a protective cement is placed for a few days, this cement prevents the formation of a new floating papilla
• In case of a suprabony periodontal pocket:

Careful curettage of the pocket under local anesthesia , this curettage removes tartar, necrotic cement and granulation tissue

• Etiological TRT

• Eliminate all causes responsible for the passage of food, depending on the clinical case the practitioner can:
• Recreate an ideal contact point (recovery of a faulty restoration)
• Perform occlusal adjustments
• Modify the existing prosthesis
• Prophylactic TRT

Periodic consultation with the dentist to detect proximal caries + Regular monitoring of the periodontal condition.

Good hygiene.

The interproximal zone and septum syndrome.

2.8. Prognosis

• If the TRT is relatively rapid, tissue loss will be minimal.
• Some cases of Septum syndrome can be responsible for true bone necrosis which may require surgical TRT.

Conclusion

The interdental space, an important anatomical and functional entity of the dental arches, must be known and respected by practitioners in order to perform non-iatrogenic and physiological fillings.

Successful treatment requires careful and regular maintenance of the proximal areas by a patient who is aware of plaque control and rigorous brushing, as well as the passage of the silk thread which must not tear when passing the contact point.

The interproximal zone and septum syndrome.

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The interproximal zone and septum syndrome