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2 INSIDE DENTISTRY—OCTOBER 2008 “...artificial gingiva restorations can reduce inside RestoraTIve DenTIsTRY the necessity of technique-sensitive surgical procedures...” Prosthetic Gingival Reconstruction Christian Coachman, DDS, CDT Ceramist Team Atlanta Lab in the Fixed Partial Restoration Atlanta, Georgia Christian Coachman, DDS, CDT; David Garber, DMD; Maurice Salama, DMD; Henry Salama, DMD; David Garber, DMD Guilherme Cabral, DDS, CDT; and Marcelo Calamita, DDS Clinical Assistant Professor in the Departments of Periodontics and Oral Alternatives to restore defective sively understood and correctly planned, (Figure 2). She presented with misalign- Rehabilitation and deficient edentulous spans should artificial gingival restorations can reestab- ment of the incisal edges and papillae on Medical College of Georgia include prosthetic gingival restoration as lish predictably harmonious anatomy to tooth No. 9 and an altered free gingival School of Dentistry an integral part of an overall esthetic recon- the lost gingival tissue, reproducing the margin level (Figure 3). It was suspected Augusta, Georgia structive option in the decision-making color, contour, and texture of the patient’s that her condition may have been caused by process. To reestablish natural crown ratios gum line.2-9 a late growth spurt of the maxillary com- Department of Prosthodontics and natural gingival profiles in complex Prosthetic gingival restoration requires plex or eruption of the adjacent teeth. Louisiana State University cases, artificial gingiva restorations can additional theoretic and technical devel- The possible treatment options includ- New Orleans, Louisiana reduce the necessity of technique-sensitive opment of the technician so that he or ed: (1) remove the implant, perform bone surgical procedures that depend on the she can execute these restorations with har- and soft-tissue grafts, then place a new Private Practice individual pattern of biologic repair, there- mony, balance, and continuity of form implant; (2) perform distraction osteog- Atlanta, Georgia by simplifying and reducing the time and between the patient’s gum and artificial enesis on tooth No. 9; or (3) not perform cost of treatment. gum.4,5,9,10 The integration of the color surgery and instead provide an artificial Aiming to fabricate proportional tooth of natural and artificial tissue must be gingival restoration. Maurice Salama, DMD form and an ideal anatomy without arti- planned to minimize the visibility of this The patient was dental-phobic and Clinical Assistant Professor Periodontics ficial gingiva, the implant team may junction, restore the asymmetry of the traumatized by previous dental experi- University of Pennsylvania undertake bone and gingival grafting to gingival architecture, and replace papilla ences and so declined any further surgical Philadelphia, Pennsylvania try to return vertical volume to the ridge. form.4,10-13 intervention. She wanted only a simple In many instances, even when the surgi- The tissue loss that occurs in cases in reshaping of tooth No. 8 to try to match Medical College of Georgia cal procedures are essentially successful, which prosthetic gingiva is indicated usual- tooth No. 9, which was shorter. She was Augusta, Georgia they may not completely resolve the esthet- ly makes it very difficult to create an ade- educated that this plan would not suffice ic dilemma. Even when the height of the quate tooth arrangement and the correct because the differential in length was too Private Practice ridge is recovered, it can still be very diffi- application of the individual anatomy of great and that the final result would not be Atlanta, Georgia cult to reestablish optimal papilla form.1 each tooth without using artificial gum.1 in esthetic harmony. An alternative plan Historically, prosthetic gingival restora- was presented to the patient, which was tion has been underused in partially eden- CASE PRESENTATION noninvasive and used artificial gingiva. Henry Salama, DMD tulous cases. Initial attempts were aimed Because the defect was just beyond Clinical Assistant Professor Periodontics solely at masking the patient’s existing tis- History the esthetic zone (ie, the interface between University of Pennsylvania sue loss without showcasing the artificial The patient presented having had, 10 years artificial and natural gingiva was beyond Philadelphia, Pennsylvania gingiva of the restoration because of the prior, osseous and soft-tissue grafts, fol- the lip perimeter when smiling), the pink obvious esthetic limitations of the pros- lowed by implant placement (Figure 1) composite should be done directly in the Private Practice thetic work executed. When comprehen- with an alumina crown on tooth No. 9 mouth, facilitating a better match of color, Atlanta, Georgia Guilherme Cabral, DDS, CDT Ceramist Team Atlanta Lab Atlanta, Georgia São Paulo, Brazil Figure 1 Initial placement of ceramic-metal Figure 2 Placement of an all-ceramic crown Figure 3 Patient presentation 10 years after the Marcelo Calamita, DDS augmented abutment after repeated osseous showing resultant alteration in tooth form caused entail grafts and implant placement. The patient Associate Professor of Removable and connective-tissue grafts of the upper left by loss of the papillae, ie, long restorative con- presented with a relative change in the position of Prosthodontics central incisors. Clinical photograph from 10 tact point between centrals. Clinical photograph tooth No. 9. This probably was caused by either a Guaralhos University of São Paulo years ago. from 10 years ago. late growth spurt where the maxillary bone and São Paulo, Brazil teeth moved incisally while the implant crown stayed in the same position or eruption of the Private Practice teeth adjacent to tooth No. 9. Notice the decrease in papillae height and the apical position of the gingival margin on tooth No. 9. These factors mod- ified the esthetics of the restoration dramatically. RestoraTIve INSIDE DENTISTRY—OCTOBER 2008 3 Figure 4 Preoperative study model showed all Figure 5 The diagnostic wax-up restoring the in- Figure 6 The original restoration was tapped Figure 7 A full-contour wax-up of the crown was of the esthetic factors. cisal and coronal harmony to tooth No. 9 and rede- out and removed. developed over the working model to guide in the veloping the laboratory soft-tissue profiles in pink design of the final abutment, coping, and restoration. composite (wax also can be used) on the model’s restorative gingival interface, ie, the mesial and distal papillae and new level to the free gingival margin. Figure 8 Pink composite was added to the Figure 9 This pink composite was readily Figure 10 A zirconium abutment and crown Figure 11 The ceramic buildup with the pink wax-up, simulating the optimal form of the soft- removable so that it could be used as a guide to coping were fabricated. model composite in position. tissue profiles and relocating the restorative gin- the ceramic buildup. gival interface coronally. Figure 12 The completed composite ceramic Figure 13 The ceramic crown with pink gingival Figure 14 The subgingival contours of the zir- Figure 15 The zirconium abutment was crown surrounded by the simulated restorative simulation removed the deficiency of soft-tissue, conium abutment were overlaid with pink ceramic. screwed into position intraorally. gingival interface. resulting in an untoward esthetic “black triangle” and altering the gingival height. Figure 16 The two-piece abutment and crown Figure 17 Pink composite was directly bonded Figure 18 After removal from the mouth, the pink Figure 19 Occlusal view showing the redevel- in position. Note that the margin of the crown intraorally to the abutment, with the crown in augmented abutment was finished chairside by re- oped gingival profiles recouping the tissue loss. was supragingivally positioned just apical to the position to develop a perfect interface between moving the excess flash and sharp concavities and level of the adjacent incisor and slightly apical to the pink gingival composite, the crown, and the polishing the composite. (Finishing can also be per- the level of the potential composite gingival level. compromised site. formed in the dental laboratory.) shape, and texture between natural and the tissue health if the excess cement should be used to allow for easy of the crown). Two options to deliver pink artificial gingiva. cannot be removed. retrievability and refinishing, with no gingival esthetics were available: The basic requirements for placing 2. The restoration must be retrievable cement line below the gingiva. pink gingival composite restorations because pink gingival composite may 1. Conventional abutment and a ce- over implants include: not have the same longevity as ceram- In this case, the implant was placed 10 mented crown with pink gingiva ics and could require replacement or years prior on an angulation that did not incorporated on the crown. This 1. No cement line can be placed below refinishing in 5 to 15 years. allow for screw retention of the restora- would create the negative factor of the gingiva, which will compromise 3. Screw retention of the restoration tion (the screw exited on the buccal surface having the actual cement line well RestoraTIve 4 INSIDE DENTISTRY—OCTOBER 2008 Figure 20 through 22 The restoration was designed to allow the patient to be able to remove plaque and debris accumulating at the soft tissue–restora- Figure 23 The “pink” abutment, finished, was tive interface. Floss must pass readily through the contacts and over the flat or convex apical areas to be able to clean the convex restorative surfaces and torqued to 32 Ncm. Notice the blend between passively contact the surface of the remaining soft tissues of the site. Maintenance is key for long-term successful pink restorations. natural tissue and artificial composite gingiva. through Figure 22). It is essential to ensure that the patient will be able execute all of these hygiene procedures before final torquing of the “pink” abutment into position (Figure 23). After the abutment was in position, the crown was placed with retrievable cement (Figure 24 through Figure 28). A follow-up appointment was scheduled for 1 month posttreatment to check the health of the Figure 24 The crown was cemented in position Figure 25 The crown was placed secondarily over the abutment and restorative gingival profile. with a retrievable cement to provide for access to gingiva and efficiency of the hygiene pro- the abutment screw if necessary. cedures executed by the patient. CONCLUSION Restoring a defective environment inside the esthetic zone will always be challeng- ing. This article has highlighted a new focus for the implant team called “inter- face development” which involves the alter- native of a composite artificial gingival restorative as a predictable treatment option for fixed partial restorations in these complex esthetic cases. Understanding and deploying this solution involves a Figure 26 and 27 The final re-treatment results, with restored harmony to the smile line and soft-tis- Figure 28 Intraoral lateral view of the final sue profiles. restorations—ceramic abutment, composite gin- new paradigm in thinking for the entire gival restoration, and all-ceramic crown. implant team. The technician should have a wider understanding of both the surgical and below the level of the gingival margin. wax-up to reproduce the missing soft tis- of flowable pink composite. The abutment clinical procedures to be an active partic- 2. Separate the gingival from the crown sue (Figure 5). This pink gingival com- was then placed in the mouth (Figure 15). ipant on the treatment planning team. and add it to a screw-retained abut- posite mask was removable. The wax-up The glazed crown was placed into posi- Training to reproduce not only the teeth ment, and then cement the crown provided an exact simulation of where to tion on the abutment so that the direct but also gingival esthetics and anatomy over it. This would bring the cement position the ideal crown margin and bonding of the gingival composite could are paramount. Currently, with the qual- line coronally toward the gingival restorative gingival interface on the be done instantly (Figure 16). ity of the available materials (ceramics margin so as not to compromise the abutment to develop a finish line barely A direct composite technique was exe- and composite resin) it is possible to mimic soft tissue. subgingival relative to the artificial com- cuted by adding small increments of pink the esthetics of nature, matching teeth and posite gingiva but supragingival relative composite to the abutment, trying to gingiva, while allowing for correct main- After choosing the second option, the to the remaining natural tissue (Figure 6 match the color, shape, and form of the tenance and long-term life expectancy of abutment was prepared and designed to through Figure 9). natural gingiva (Figure 17). After the pink the implant bridge. receive the pink gingival composite. The The abutment and coping were fabri- composite was completed, the crown was supragingival form of the abutment was cated in zirconium (Procera ® , Nobel removed, and then the abutment with the REFERENCES visualized in an ideal situation to mini- Biocare USA LLC, Yorba Linda, CA), and pink composite attached was unscrewed. 1. Costello FW. Real teeth wear pink. Dent Today. mize the adjacent crestal gingiva. When the buildup was made with Nobel Rondo™ Outside of the mouth, extra pink com- 1995;14(4):52-55. the abutment was placed in the mouth, Ceramics (Nobel Biocare USA LLC) posite was added to fill in undercuts and 2. Rosa DM, Souza Neto J. Odontologia esté- the finish line of the crown and the restora- (Figure 10 through Figure 14). The chal- voids. 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