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129 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 JULY 2007 • DENTISTRY TODAY 130 PERIODONTICS Placing Dental Implants... continued from page 129 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 continued on page 132 132 PERIODONTICS Placing Dental Implants... continued from page 130 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 134 134 PERIODONTICS Placing Dental Implants... continued from page 133 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 References 1. Niessen L. Customers for life: marketing oral health care to older adults. J Calif Dent Assoc. 1999;27:724-727. 2. Goldstein RE. Change Your Smile. 3rd ed. Chicago, Ill: Quintessence; 1997. 3. Francischone CE, Vasconcelos LW, Branemark PI. Osseointegration and Esthetics in Single Tooth Rehabilitation. Chicago, Ill: Quintessence; 2000. 4. Salama MA, Salama H, Garber DA. Guidelines for aesthetic restorative options and implant site enhancement: the utilization of orthodontic extrusion. Pract Proced Aesthet Dent. 2002; 14:125-130. 5. Kois JC. Altering gingival levels: the restorative connection, part I: biologic variables. J Esthet Dent. 1994;6:3-9. 6. Chiche G. A six-step approach to demystifying esthetics. Presented at: American Academy of Esthetic Dentistry 21st Annual Meeting; August 8, 1996; Philadelphia, Pa. 7. Morley J. A multidisciplinary approach to complex aesthetic restoration with diagnostic planning. Pract Periodontics Aesthet Dent. 2000;12:575-577. BUY DIRECT CALL 800-423-5657 or circle 80 on card 8. Levine RA, Randel H. Multidisciplinary approach to solving cosmetic dilemmas in the esthetic zone. Contemp Esthet Restor Pract. 2001;5:62-67. 9. Chiche G, Kovich V, Caudill R. Diagnosis and treatment planning of esthetic problems. In: Pinault A, Chiche G. Esthetics of Anterior Fixed Prosthodontics. Chicago, Ill: Quintessence;1994:Chapter 2. 10. Kokich VG. Maxillary lateral incisor implants: the orthodontic perspective. Adv Esthet Interdisc Dent. 2006;2: 32-39. 11. Kokich VG. Managing orthodonticrestorative treatment for the adolescent patient. In: McNamara JA Jr, ed. Orthodontics and Dentofacial Orthopedics. Ann Arbor, Mich: Needham Press. 2001:395-422. 12. Rufenacht CR. Structural esthetic rules. In: Fundamentals of Esthetics. Chicago, Ill: Quintessence; 1992:134. 13. Carranza FA, Newman MG. Clinical Periodontology. 8th ed. Philadelphia, Pa: WB Saunders; 1996:720-722. 14. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol. 1961;32:261-267. 15. Goldstein RE. Esthetics in Dentistry. Philadelphia, Pa: Lippincott; 1976: 425-455. 16. Smukler H, Chaibi M. Periodontal and dental considerations in clinical crown extension: a rational basis for treatment. Int J Periodontics Restorative Dent. 1997;17:464-477. 17. Weinman JP, Sicher H. Bone and Bones: Fundamentals of Bone Biology. 2nd ed. St Louis, Mo: CV Mosby; 1955. 18. Hermann JS, Cochran DL, Nummikoski PV, et al. Crestal bone changes around titanium implants. A radiographic evaluation of unloaded nonsubmerged and submerged implants in the canine mandible. J Periodontol. 1997;68:1117-1130. 19. Saadoun AP, Le Gall MG, Touati B. Current trends in implantology: part II-treatment planning, aesthetic considerations, and tissue regneration. Pract Proced Aesthet Dent. 2004;16: 707-714. 20. Levine RA, McGuire M. The diagnosis and treatment of the gummy smile. Compend Contin Educ Dent. 1997; 18:757-764. 21. Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification of delayed passive eruption of the dentogingival junction in the adult. Alpha Omegan. 1997;70:24-28. 22. Robbins JW. Esthetic gingival recontouring: caveat emptor. Contemp Esthet Restor Pract. 2002;6:66-74. 23. Dolt AH III, Robbins JW. Altered passive eruption: an etiology of short clinical crowns. Quintessence Int. 1997; 28:363-372. 24. Rosenberg ES, Cho SC, Garber DA. Crown lengthening revisited. Compend Contin Educ Dent. 1999;20: 527-538. 25. Garnick JJ, Silverstein LH. Periodontal probing: what does it mean? In: Clark’s Clinical Dentistry. Vol 3. Philadelphia, Pa: Lippincott; 1997:1-15. 26. Ten Cate AR. The development of the periodontium. In: Melcher AR, Bowen WH, eds. Biology of the Periodontium. New York, NY: Academic Press; 1969. 27. Spear FA. The esthetic management of multiple missing anterior teeth. Inside Dentistry. 2007;3:72-76. 28. Silverstein LH, Garnick JJ, Szikman M, et al. Medication-induced gingival enlargement: a clinical review. Gen Dent. 1997;371-376. 29. Amstad-Jossi M, Schroeder HE. Agerelated alterations of periodontal structures around the cemento-enamel junction and of the gingival connective tissue composition in germ-free rats. J Periodontal Res. 1978;13:76-90. 30. Magne P, Magne M, Belser U. Natural and restorative oral esthetics. Part I: rationale and basic strategies for successful esthetic rehabilitations. J Esthet Dent. 1993;5:161-173. 31. Silverstein LH, Koch JP, Lefkove MD, et al. Nifedipine-induced gingival enlargement around dental implants: a clinical report. J Oral Implantol. 1995;21:116-120. 135 PERIODONTICS 32. Kokich VG, Kokich VO. Interrelationship of orthodontics with periodontics and restorative dentistry. In: Nanda R, ed. Biomechanics and Esthetic Strategies in Clinical Orthodontics. St Louis, Mo: Elsevier; 2005:348-373. 33. Goldstein RE. Esthetics in Dentistry. Hamilton, Ontario, Canada: BC Decker; 2002(2):703-775. 34. Studer S, Zellweger U, Scharer P. The aesthetic guidelines of the mucogingival complex for fixed prosthodontics. Pract Periodontics Aesthet Dent. 1996;8:333-341. 35. Silverstein LH, Meffert RM, Jeffcoat M, et al. Clinicians guide to peri-implantology. In: Clark’s Clinical Dentistry. Vol 5. St Louis, Mo: Mosby YearBook; 1998:chap 62A. 36. Levine RA, Katz D. Developing a team approach to complex aesthetics: treatment considerations. Pract Proced Aesthet Dent. 2003;15:301-306. 37. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Carol Stream, Ill: Quintessence; 1994. 38. Singer BA. Principles of esthetics. Curr Opin Cosmet Dent. 1994;6-12. 39. Sterrett JD, Oliver T, Robinson F, et al. Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man. J Clin Periodontol. 1999;26:153-157. 40. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc. 2006;137:160-169. 41. Ahmad I. Geometric considerations in anterior dental aesthetics: restorative principles. Pract Periodontics Aesthet Dent. 1998;10:813-822. 42. Chalifoux PR. Checklist to aesthetic dentistry. Pract Periodontics Aesthet Dent. 1990;2:9-12. 43. Spear F. Construction and use of a surgical guide for anterior periodontal surgery. Contemp Esthet Restor Pract. April 1999;12-20. 44. Garnick JJ, Silverstein LH. Periodontal probing: probe tip diameter. J Periodontol. 2000;71:96-103. 45. Singer BA. Fundamentals of esthetics. In: Aschheim KW, Dale BG, eds. Esthetic Dentistry: A Clinical Approach to Techniques and Materials. Philadelphia, Pa: Lea & Febiger; 1993:5-13. 46. van der Geld PA, van Waas MA. The smile line: a literature search [in Dutch]. Ned Tijdschr Tandheelkd. 2003;110:350-354. 47. Kois JC. Predictable single-tooth periimplant esthetics: five diagnostic keys. Compend Contin Educ Dent. 2004;25:895-900. 48. Kan JY, Rungcharassaeng K, Umezu K, et al. Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans. J Periodontol. 2003;74:557-562. 49. Silness J. Periodontal conditions in patients treated with dental bridges. 3. The relationship between the location of the crown margin and the periodontal condition. J Periodontal Res. 1970;5:225-229. 50. Wolffe GN, van der Weijden FA, Spanauf AJ, et al. Lengthening clinical crowns: a solution for specific periodontal, restorative, and esthetic problems. Quintessence Int. 1994;25: 81-88. 51. Hornbrook DS. Cementation of allceramic veneers using the “tack and wave” technique. Contemp Esthet Restor Pract. 2002;6:36-48. 52. Rufenacht CR. Principles of Esthetic Integration. Carol Stream, Ill: Quintessence; 2000:73-97. 53. Gottlieb B, Orban B. Active and passive continuous eruption of the teeth. J Dent Res. 1933;13:214. 54. Gillen RJ, Schwartz RS, Hilton TJ, et al. An analysis of selected normative tooth proportions. Int J Prosthodont. 1994;7:410-417. 55. Becker W, Ochsenbein C, Becker BE. Crown lengthening: the periodontalrestorative connection. Compend Contin Educ Dent. 1998;19:239-246. 56. Kokich VG. Esthetics and anterior tooth position: an orthodontic perspective. Part 1: crown length. J Esthet Dent. 1993;5:19-23. 57. Kokich VG, Kokich VO. Orthodontic therapy for the periodontal-restorative patient. In: Rose LF, Mealey BL, Genco RJ, Cohen DW, eds. Periodontics: Medicine, Surgery, and Implants. 2nd rev ed. St Louis, Mo: Mosby; 2004:718-744. 58. Spear FM. Maintenance of the interdental papilla following anterior tooth removal. Pract Periodontics Aesthet Dent. 1999;11:21-28. 59. Kokich VG, Spear F. Guidelines for treating the orthodontic-restorative patient. Semin Orthod Dentofacial Orthop. 1999;3:3-20. 60. Koyuturk AE, Malkoc S. Orthodontic extrusion of subgingivally fractured incisor before restoration. A case report: 3-years follow-up. Dent Traumatol. 2005;21:174-178. 61. Salama H, Salama M, Kelly J. The orthodontic-periodontal connection in implant site development. Pract Periodontics Aesthet Dent. 1996; 8:923-932. 62. Silverstein LH, Kurtzman D, Cohen R, et al. Adjunctive Orchestrated Orthodontic Therapy: an emerging trend in cosmetic dentistry. Alpha Omegan. 2001;94:27-33. 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