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Test 91.1
PERIODONTICS
Placing Dental Implants and/or Natural Tooth
Restorations in the Aesthetic Zone
Achieving Proper Gingival Contours
key goal of aesthetic/cosmetic dentistry is the fabrication of maintainable, aesthetic, and functional prostheses that preserve the health of the teeth
and soft tissues.1,2 Advances in restorative
dentistry have significantly improved the
clinician’s ability to deliver predictable treatment. When implants are indicated, osseointegration is an added factor that is essential
for success.3 It is universally accepted that
implant dentistry is a restorative-driven
treatment with a surgical component.4
Whether implants and/or natural toothsupported restorations are to be placed in
the aesthetic zone, the following factors must
be considered in order to achieve the desired result:
• diagnosis of smile design
• site development, including soft- and
hard-tissue grafting to correct unaesthetic
or functionally compromising anatomic
abnormalities
• proper biologic width
• gingival contours
• the removal of excessive alveolar bone
and gingival tissue for the correction of a
“gummy” smile.
All of these factors need to be considered
during treatment planning and addressed
prior to placement of dental implants5 or natural tooth-supported restorations.6 Crown
lengthening,7 when indicated, is critical to the
success of creating a smile that is harmoniously balanced with the surrounding facial
features.8 Patients who clinically display too
much gingival tissue and short clinical
crowns require a fully developed diagnosis
and treatment plan to provide a predictable
aesthetic outcome.9 This is imperative with the
utilization of dental implant restorations.10
If a patient has altered passive eruption
(APE) of the maxillary anterior teeth, but has
completed facial growth,11 then the gingival
levels must first be corrected with either a
gingivectomy or aesthetic crown-lengthening
procedure before the placement of dental
implants. This ensures that the gingival margin of the maxillary anterior teeth will be at
the correct height after restoration of the
implant, and over the long term.12
This article discusses the principles and
clinical techniques used to achieve correct
A
Lee H.
Silverstein, DDS,
MS
Gregori M.
Kurtzman, DDS
David Kurtzman,
DDS
Peter C. Shatz,
DDS
Richard
Szikman, DDS
Figure 1. Position of the implant platform if positioned
at the free gingival margin (FGM) when APE is present,
placing it too coronal for proper aesthetic development
of the restoration.
Figure 2. APE, illustrating position of implant if the softtissue correction is not accomplished either before or at
implant placement.
Figure 3. Position of the implant platform when placed
at the CEJ of the adjacent teeth compromises the aesthetic result, as emergence profile of the implant
restoration does not have a natural appearance.
Figure 4. Position of the implant platform when placed
apical to the adjacent CEJ allows for proper emergence
profile of the implant restoration.
positioning of gingival margin when restoring
implants and/or natural teeth in the maxillary anterior region. The focus is on optimal
aesthetics and long-term tissue health.
the restorative margin should be positioned
approximately midway between the gingival
margin and the depth of the sulcus.15 Failure
to allow sufficient space between the crown
margin (natural tooth or implant) and the
crest of the alveolus can result in increased
inflammation and possible periodontal
pocket formation.16
In the absence of periodontal disease, the
osseous crest roughly follows the scalloped
parabolic contour of the cemento-enamel
junction (CEJ) and is 2 to 3 mm apical to the
CEJ.17 In addition, the average interproximal
bone height is 3 mm coronal to the facial
height of bone.18 Since the soft-tissue topography is usually determined by the underly-
BIOLOGICAL PRINCIPLES
Biological width is the measurement between
the crestal bone and the inferior aspect of the
periodontal sulcus, which on average is 2.04
mm and comprises the epithelial attachment
(~0.97 mm) and connective tissue (~1.07 mm).
This translates to at least 3 mm between the
most apical extension of the restorative margin and the crest of the alveolar bone.13 This
allows sufficient space for the supracrestal
collagen fibers, and allows a gingival crevice
of 2 to 3 mm.14 If this guide is followed, then
continued on page 130
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PERIODONTICS
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Figure 5. Bilateral retained maxillary deciduous cuspids and anterior altered
passive eruption (APE).
Figure 6. Gingival recontouring in the maxillary anterior region to place the
gingival margin at the CEJ.
Figure 7. Suturing of the implant sites following extraction of the deciduous
cuspids, relocation of the crestal and interdental bone so it is 2 mm apical
to the CEJ of the adjacent teeth, and then placement of dental implants.
Figure 8. Four weeks after surgery, demonstrating gingival margins of the
anterior teeth at their proper position.
DENTISTRY TODAY • JULY 2007
ing hard tissue, this osseous
“scallop” usually results in a
gingival scallop of 3 mm.19
Examination of periapical
or vertical bite-wing radiographs will allow the clinician to ascertain the position
of the alveolar bone relative
to the CEJ 20 to determine
whether the crest of bone
(COB) is the needed 2 to 3 mm
from the CEJ, allowing for biologic width.21
However, occasionally the
COB is coronal to the CEJ, a
condition that is referred to
as altered passive eruption
(Figure 1).22 Since the gingival margin will be coronal to
the level of the COB, the
result is the appearance of a
short clinical crown23 (Figure
2). Should the soft tissue be
corrected after implant placement, aesthetic issues may
arise in restoring the implant, as its platform lies
coronal to the CEJ of the adjacent teeth (Figure 3). These
visual findings should be coupled with the information
obtained by “bone sounding.”
Bone sounding requires anesthesia and involves the use of
a periodontal probe to locate
the CEJ and determine
whether it can be felt within
the gingival sulcus or only
when the probe penetrates
through the base of the sulcus.24 The periodontal probe
is also used to feel for the
alveolar crest. This value is
expressed in millimeters, revealing the distance between
the osseous crest and CEJ to
ascertain whether there is
sufficient biologic width.25 As
noted, this distance is 2 to 3
mm in nondiseased human
periodontium.26 In addition
to the gingival margin on the
facial aspect of the teeth, in a
dentition free of disease and
with no bone or attachment
loss the tip of the interproximal papillae are approximately 4.5 mm coronal to the
interproximal COB. The zenith of the facial gingival
margin is approximately 1.5
mm more coronal to the COB.
This osseous scallop from the
CEJ results in the tip of the
papilla being on average 4.5
mm coronal to the free gingival margin.27
However, if the alveolar
bone is not in the “normal”
position (2 to 3 mm apical to
the CEJ), these aforementioned values would need to
be adjusted. When patients
are to have dental implants to
replace missing teeth, any
APE should be corrected prior
to implant placement. In
addition, the gingiva may be
coronally positioned secondary to the following:
• plaque-induced inflammation28
• incisal attrition 29
• gingival hyperplasia resulting from the use of medications such as calcium
channel blocking agents, anticonvulsants, and immunosuppressive agents30
• orthodontic tooth movement31
• deep decay causing
short clinical crowns32
• traumatic injury33
• tooth eruption after the
patient has completed facial
growth.34
In such cases the surgeon
should first correct the coronally positioned gingival
margins with a gingivectomy
procedure, or the gingival
margins and alveolar crest
levels must be altered with
a crown-lengthening procedure35 prior to the placement of the dental implant.
These procedures can be
accomplished at a separate
surgical visit or at the time of
dental implant placement,
but should be performed prior
to the preparation of the implant osteotomy.36 This will
ensure that the eventual gingival margin over the dental
implant will be at its correct
level relative to the adjacent
anterior teeth (Figure 4).
CLINICAL TREATMENT
GUIDELINES AND
PROCEDURES
Anatomic considerations serve
as important parameters
when performing aesthetic
gingival recontouring. The
laboratory can fabricate a
useful guide in the form of a
wax-up. The mounted diagnostic casts are modified in
wax so that ideal tooth anatomy as desired in the final
prosthesis is created. Guidelines published by Chiche and
Pinault should be followed.37
These guidelines suggest that
the average length for aesthetically pleasing maxillary
central incisors is 10 to 12
mm, 38 and the width-tolength ratio is 75% to 80%.39
These guidelines should be
kept in mind when recontouring the gingival tissues so as
not to leave the teeth too long
or too short.40
After proportions are
achieved on the central incisors, practitioners should focus on the height of contour of
the gingival margin of these
teeth.41 The proper placement of the peak of the parabolic curve of the gingival
margin for the central incisors, cuspids, and bicuspids
should be located slightly distal to the middle of the long
axis of these teeth. This gives
these teeth the subtle distal
root inclination that is important for an aesthetically pleasing smile. The zenith
for the lateral incisors is
located at the midline of the
long axis of the tooth. Furthermore, the height of the
gingival crest for these teeth
should be 1 mm shorter than
the gingival margins of the
adjacent teeth. For all teeth the
gingival tissues should ideally
have a “knife-edge” margin.42
The presence of short clinical crowns and crestal bone
levels approximating the CEJ
indicates a diagnosis of APE.
The practitioner can then fabricate an aesthetic guide that
can be placed over the patient’s existing teeth to allow
both the practitioner and
patient to visualize what the
smile would look like with the
gingiva in a modified, more
aesthetic position.43
The repositioning of the
gingival margin and crestal
alveolar bone requires the administration of local anesthesia. A periodontal probe is
placed into the sulcus, attempting to locate the CEJ,
but sometimes the CEJ cannot be discerned. In a case
where the location of the CEJ
is not clearly identified, a
periodontal probe should be
passed through the periodontal attachment until the crest
of alveolar bone is contacted.
Coupled with current periapical radiographs, locating
the crest should help identify
the CEJ.44
Surgical crown lengthening is then accomplished to
correct the APE. The laboratory-fabricated gingival aesthetic guide can be used not
only to position the alveolar
crest 3 mm apical to the
CEJ,45 but also to provide a
blueprint for attaining horizontal gingival symmetry and
height. The guide will also
ensure proper interproximal
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PERIODONTICS
Placing Dental Implants...
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Figure 9. Uncovering implants and placement of healing abutments (4 mm).
scalloping. The newly established gingival margin will be
determined by the patient’s
lip line while smiling,46 the
desired length of anterior
teeth relative to the existing
level of alveolar bone,47 and
healthy interdental tissue.48
Scalloping the gingival
tissues is accomplished with
a 15c surgical blade. An
inverse beveled incision is
made, connecting the sulci of
the affected maxillary teeth.
The surgical incision can
transverse the base of the
papillary tissue or can follow
the topography of the interdental papilla. For aesthetic
success at this critical phase
of crown lengthening, it is
important not to elevate the
papilla, which usually will
result in loss of interproximal
tissue height.
A full-thickness mucoperiosteal flap is then elevated
with a periosteal elevator (ie,
Woodson No. 2 elevator), and
osseous resection is performed with a surgical length
No. 8 round diamond bur (No.
5801 [Brasseler]) and periodontal hand chisels (Kirkland 15/16 [Hu-Friedy]).
The surgical flap can then
be positioned to the prearranged height determined
by the aesthetic surgical
guide. The flaps are sutured
using a 3/8 reverse cutting
suture needle (Hu-Friedy)
with a 4-0 thread of polyglycolic acid, using a sling suture
technique. Suture removal is
performed 10 days following
surgery, and the patient is
instructed in the oral hygiene
regimen to be used. This includes brushing with a softbristled toothbrush in a circular motion and cleaning interdentally with either dental tape or floss. Additionally, Stim-U-Dents (Johnson
& Johnson) can be used to
maintain the apically repositioned gingiva while removing bacterial plaque.
Ten weeks should be allowed for postoperative healing before beginning either
implant placement (if required) or preparation of nat-
ural teeth for restorations.
By using a gingivectomy or
crown-lengthening procedure
to properly establish the gingival smile line prior to implant placement or natural
tooth preparation, a proper
prosthetic emergence profile
can be established with a
well-constructed provisional
restoration. This is true if the
abutments are supported by
implants or natural teeth.
When the restorative phase
of treatment begins, the teeth
can be prepared with burs
such as the KS burs (Brasseler),
using the aesthetic guide as a
blueprint for tooth reduction.
For full-coverage restorations, ceramic crowns provide
excellent aesthetics. Preparations for these crowns are
either placed at the free gingival margin or slightly subgingival on the facial aspect.
Care should be taken not to
violate the biologic width during tooth preparation.49
Provisional restorations can
be made by placing Luxatemp
(Zenith/DMG) in a vacuumformed matrix that was fabricated on the modified model
from which the aesthetic surgical guide was fabricated.
After approximately 60 to 90
seconds, the provisionals are
removed and trimmed. The
provisionals are bonded in
place by spot etching the
preparations and using Tetric Flow (Ivoclar Vivadent) as
the luting material.
The occlusion should then
be checked in centric, protrusive, and lateral excursive
positions50 and adjusted as
needed. The patient returns
to the office 10 days after
insertion of the provisional
restorations and provides
input about the aesthetics.
Subsequent to recontouring
the provisional restorations
to meet the patient’s expectations, impressions are taken
and a putty matrix of the
anterior segment is made to
ensure that the laboratory
has correctly placed the
incisal edges.
Final impressions are
obtained 6 to 8 weeks later51
using a 2-cord method with a
woven retraction cord such as
Ultrapak (Ultradent Products). Care is taken so the
gingival tissues are not injured. Full-mouth impressions are taken with vinyl
polysiloxane (Take 1 [Kerr]),
and face-bow transfer and
open bite centric relation
records are obtained using
LuxaBite registration material (Zenith/DMG). The models
are mounted in a semiadjustable articulator such as
the Stratos 200 articulator
(Ivoclar Vivadent). The case
can be completed using full
feldspathic porcelain crowns
(Colorlogic [DENTSPLY Ceramco]), which are bonded
with both OptiBond Solo Plus
(Kerr) and Variolink II (Ivoclar Vivadent). Excess cement
is removed with an explorer
and periodontal scaler. The
previously fabricated putty
facial index should be placed
to see if there are any discrepancies. Such discrepancies are modified.
CLINICAL EXAMPLE
A clinical case is described in
Figures 5 to 10. In this case, 2
implants replaced 2 retained
deciduous cuspids that were
extracted after gingival recontouring was accomplished. As
shown, the result of these procedures is a healthy periodontium, and the symmetry of the
smile illustrates a completed
healthy, aesthetic, and functional restorative result. The
FREEinfo, circle 78 on card
133
PERIODONTICS
The gingival margin
should be assessed
relative to the projected incisal edge position. A predictable
method for determining the proper gingival position is to
determine the desired
tooth size relative to
the projected incisal
edge position.
location of the CEJ relative to
the COB, the crown-to-root
ratio and the shape of the
root(s), the amount of existing
tooth structure, and the sulcus/pocket depth.
It is also paramount when
establishing the proper position of the maxillary anterior
teeth for an optimal cosmetic
outcome to assess the level of
the interdental papillae and
their position relative to the
crown length of the maxillary
incisors. It has been demonstrated58 that if the height
between the interdental
papilla base and the contact
central incisors demonstrate
midline symmetry as well as
the correct 75% to 80% widthto-length ratio. In addition, the
incisal smile line follows the
curvature of the lower lip.52
The newly established smile
line is more aesthetically appealing and harmonious with
surrounding facial features.53
DISCUSSION
The gingival margin should
be assessed relative to the
projected incisal edge position. A predictable method for
determining the proper gingival position is to determine
the desired tooth size relative
to the projected incisal edge
position. The practitioner
should remember that the
incisal edge should not be
positioned using the location
of the gingival margin to create the proper tooth size. This
is because the gingival margin can move with eruption or
recession.54 Therefore, the
proper position of the gingival
margin should be determined
by establishing the correct
width-to-length ratio of the
maxillary anterior teeth,55
using the width-to-length
ratio as previously published
by Sterrett et al.39 In general,
the amount of gingival display must create symmetry
among the teeth throughout
the maxillary arch.56
If the existing position of
the gingival margin creates a
short clinical crown relative
to the incisal edge, then the
gingival margins should be
moved apically. This can be
accomplished by performing
crown lengthening, gingivectomy, orthodontic intrusion,
and/or prosthetic rehabilitation.57 The procedure that is
chosen depends upon several
clinical factors, such as the
TO ORDER CALL 800-528-8537 or circle 79 on card
point is greater than the distance between the contact
point and the incisal edge,
then there is an indication
that there has been significontinued on page 134
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Figure 10. Completed smile 2 years after restoration of the maxillary
implants.
cant occlusal abrasion. This
scenario may cause shorter
crowns, which shortens the
contact between the central
incisors. However, if the interdental contact point is longer
than the papilla, then the
contour of the gingival margin would be flat and usually
located coronal to the CEJ,
analogous to the clinical presentation of APE.59 Correction
would be accomplished by per-
forming crown lengthening60
and/or orthodontic therapy to
either intrude61 or extrude62
the affected teeth.
CONCLUSION
For patients who display too
much gingiva and short teeth,
a thorough diagnosis and
treatment plan are needed to
provide a predictable aesthetic outcome. This is especially
important when utilizing den-
tal implant restorations. If a
patient has altered passive
eruption of the maxillary
anterior teeth either secondary to orthodontic treatment
or in the absence of orthodontic therapy, and the patient
has completed facial growth,
then the surgeon must first
correct the gingival level
with either a gingivectomy
or crown-lengthening procedure before the placement of
dental implants. This will
ensure that the gingival margin of the maxillary anterior
teeth will be at its correct
level relative to the adjacent
anterior teeth, not only after
restoration of the implant,
but for the long term. It is
essential that there be at
least 3 mm between the
most apical extension of the
restorative margin and the
alveolar bone crest. This
allows sufficient room for
insertion of the supracrestal
collagen fibers, as well as
provides a gingival crevice of
2 to 3 mm.
For proper implant placement that allows for a proper
restorative result, the guideline of 3 mm on the facial
aspect from the osseous crest
to the gingival margin, and 4
to 5 mm from the interproximal COB to the tip of the
papilla, is appropriate when
there is no bone and/or attachment loss. Further, if the
gingival margin is not located at the CEJ and the underlying bone is not 2 to 3 mm
apical to the CEJ with its
parabolic contours, then the
distances of 3 mm on the
facial and 4 to 5 mm on the
interproximal area should
not be used. F
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Acknowledgment
Illustrations accompanying
this article were created by
David Kurtzman, DDS.
Dr. Silverstein is an associate clinical professor of periodontics at the
Medical College of Georgia in
Augusta. He has published more
than 100 scientific articles and has
written 8 textbook chapters. He is on
the contributing editorial boards of
Practical Periodontics and Aesthetic
Dentistry, Dentistry Today, Collaborative Dental Techniques, Inside
Dentistry, Functional Esthetics and
Restorative Dentistry, and General
Dentistry. He is the author of
Principles of Dental Suturing: A
Complete Guide to Surgical Closure
and has just completed a new textbook, Principles of Soft Tissue
Surgery: A Complete Step by Step
Procedural Guide. Dr Silverstein
maintains a private practice at
Kennestone Periodontics in Marietta,
Ga. He can be reached at (770) 9525432 or [email protected].
Dr. G. Kurtzman is in private general
practice in Silver Spring, Md. He has
lectured both nationally and internationally on the topics of restorative
dentistry, endodontics, and dental
implant surgery and prosthetics. He
can be reached at dr_kurtzman@
maryland-implants.com.
Dr. D. Kurtzman is in private general
practice in Marietta, Ga. He is an
accomplished illustrator and can be
contacted at [email protected].
Dr. Shatz is assistant clinical professor of periodontics at the Medical
College of Georgia in Augusta and is
in private practice in Marietta, Ga. He
can be reached at [email protected].
Continuing Education
Test No. 91.1
T
o submit Continuing Education answers, use the answer sheet on page 128. On the
answer sheet, identify the article (this one is Test 91.1), place an X in the box corresponding to the answer you believe is correct, detach the answer sheet from the
magazine, and mail to Dentistry Today Department of Continuing Education.
The following 8 questions were derived from the article Placing Dental Implants and/or
Natural Tooth Restorations in the Aesthetic Zone: Achieving Proper Gingival Contours by Lee H.
Silverstein, DDS, MS, et al on pages 129 through 135.
Learning Objectives
After reading this article, the individual will learn:
• aesthetic concerns prior to placing implants or natural tooth-supported
restorations, and
• treatment guidelines and procedures for achieving aesthetic and biologically healthy
gingival contours when placing implants or natural tooth-supported restorations.
1. Biological width dictates that at least
____ mm be present between the restoration margin and the crestal bone.
a.
b.
c.
d.
2
3
4
5
2. The interproximal papillae between teeth
with a healthy periodontium and no bone
loss are approximately ____ mm coronal
to the interproximal crest of bone.
a.
b.
c.
d.
4
4.5
5
5.5
3. Altered passive eruption when present
on teeth adjacent to an implant site
should be corrected ____.
a.
b.
c.
d.
before implant placement
after implant placement
at implant uncovery
following restoration of the implant
4. The recommended width-to-length ratio
of maxillary central incisors is ____.
a.
b.
c.
d.
60%
70%
75%
90%
5. When evaluating altered passive eruption during the clinical examination,
determination of where the gingival
margin should be located is made by ___.
a. probing into the sulcus to determine where
the crestal bone is located
b. identification on periapical radiographs
c. an arbitrary determination based on
aesthetics
d. both a and b
6. A stent based upon a diagnostic wax-up
does which of the following?
a. assists in guiding the periodontal surgery
b. assists in temporization fabrication of
the case
c. acts as a blueprint in treatment planning
d. all of the above
7. To avoid the creation of “black triangles”
during periodontal surgery, ____.
a.
b.
c.
d.
flap design should split the papilla
flap design should include the papilla
flap design should not include the papilla
both a and b
8. A predictable method of determining the
proper gingival position is to determine
the desired tooth size relative to ____.
Dr. Szikman is in private practice in
Marietta, Ga, practicing cosmetic
and implant dentistry at the Szikman
Dental Group. He can be reached at
[email protected].
a. the projected incisal edge position
b. width-to-length ratio of the teeth on a
mock-up model
c. width-to-length ratio of the teeth on a study
model
d. both a and b
Continuing our “Journey of Excellence”
JULY 2007 • DENTISTRY TODAY