PERIODONTICS - Dental XP Dental Implants.pdfmost apical extension of the restorative mar-gin and the crest of the alveolar bone.13 This allows sufficient space for the supracrestal

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Test 91.1

Akey goal of aesthetic/cosmetic den-tistry is the fabrication of maintain-able, aesthetic, and functional pros-

theses that preserve the health of the teethand soft tissues.1,2 Advances in restorativedentistry have significantly improved theclinician’s ability to deliver predictable treat-ment. When implants are indicated, osseoin-tegration is an added factor that is essentialfor success.3 It is universally accepted thatimplant dentistry is a restorative-driventreatment with a surgical component.4

Whether implants and/or natural tooth-supported restorations are to be placed in the aesthetic zone, the following factors mustbe considered in order to achieve the de-sired result:

• diagnosis of smile design• site development, including soft- and

hard-tissue grafting to correct unaesthetic or functionally compromising anatomicabnormalities

• 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 consideredduring treatment planning and addressedprior to placement of dental implants5 or nat-ural tooth-supported restorations.6 Crownlengthening,7 when indicated, is critical to thesuccess of creating a smile that is harmo-niously balanced with the surrounding facialfeatures.8 Patients who clinically display toomuch gingival tissue and short clinicalcrowns require a fully developed diagnosisand treatment plan to provide a predictableaesthetic outcome.9 This is imperative with theutilization of dental implant restorations.10

If a patient has altered passive eruption(APE) of the maxillary anterior teeth, but hascompleted facial growth,11 then the gingivallevels must first be corrected with either agingivectomy or aesthetic crown-lengtheningprocedure before the placement of dentalimplants. This ensures that the gingival mar-gin of the maxillary anterior teeth will be atthe correct height after restoration of theimplant, and over the long term.12

This article discusses the principles andclinical techniques used to achieve correct

positioning of gingival margin when restoringimplants and/or natural teeth in the maxil-lary anterior region. The focus is on optimalaesthetics and long-term tissue health.

BIOLOGICAL PRINCIPLESBiological width is the measurement betweenthe crestal bone and the inferior aspect of theperiodontal sulcus, which on average is 2.04mm and comprises the epithelial attachment(~0.97 mm) and connective tissue (~1.07 mm).This translates to at least 3 mm between themost apical extension of the restorative mar-gin and the crest of the alveolar bone.13 Thisallows sufficient space for the supracrestalcollagen fibers, and allows a gingival creviceof 2 to 3 mm.14 If this guide is followed, then

the restorative margin should be positionedapproximately midway between the gingivalmargin and the depth of the sulcus.15 Failureto allow sufficient space between the crownmargin (natural tooth or implant) and thecrest of the alveolus can result in increasedinflammation and possible periodontal pocket formation.16

In the absence of periodontal disease, theosseous crest roughly follows the scallopedparabolic contour of the cemento-enameljunction (CEJ) and is 2 to 3 mm apical to theCEJ.17 In addition, the average interproximalbone height is 3 mm coronal to the facialheight of bone.18 Since the soft-tissue topog-raphy is usually determined by the underly-

Placing Dental Implants and/or Natural ToothRestorations in the Aesthetic ZoneAchieving Proper Gingival Contours

Lee H.Silverstein, DDS,MS

Figure 2. APE, illustrating position of implant if the soft-tissue correction is not accomplished either before or atimplant placement.

Figure 1. Position of the implant platform if positionedat the free gingival margin (FGM) when APE is present,placing it too coronal for proper aesthetic developmentof the restoration.

Figure 4. Position of the implant platform when placedapical to the adjacent CEJ allows for proper emergenceprofile of the implant restoration.

Figure 3. Position of the implant platform when placedat the CEJ of the adjacent teeth compromises the aes-thetic result, as emergence profile of the implantrestoration does not have a natural appearance.

Gregori M.Kurtzman, DDS

David Kurtzman,DDS

Peter C. Shatz,DDS

RichardSzikman, DDS

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PERIODONTICS130

ing hard tissue, this osseous“scallop” usually results in agingival scallop of 3 mm.19

Examination of periapicalor vertical bite-wing radi-ographs will allow the clini-cian to ascertain the positionof the alveolar bone relativeto the CEJ20 to determinewhether the crest of bone(COB) is the needed 2 to 3 mmfrom the CEJ, allowing for bio-logic width.21

However, occasionally theCOB is coronal to the CEJ, acondition that is referred toas altered passive eruption(Figure 1).22 Since the gingi-val margin will be coronal tothe level of the COB, theresult is the appearance of ashort clinical crown23 (Figure2). Should the soft tissue becorrected after implant place-ment, aesthetic issues mayarise in restoring the im-plant, as its platform liescoronal to the CEJ of the ad-jacent teeth (Figure 3). Thesevisual findings should be cou-pled with the informationobtained by “bone sounding.”Bone sounding requires anes-thesia and involves the use ofa periodontal probe to locatethe CEJ and determinewhether it can be felt withinthe gingival sulcus or onlywhen the probe penetratesthrough the base of the sul-cus.24 The periodontal probeis also used to feel for thealveolar crest. This value isexpressed in millimeters, re-vealing the distance betweenthe osseous crest and CEJ toascertain whether there issufficient biologic width.25 Asnoted, this distance is 2 to 3mm in nondiseased humanperiodontium.26 In additionto the gingival margin on thefacial aspect of the teeth, in adentition free of disease andwith no bone or attachmentloss the tip of the interproxi-mal papillae are approxi-mately 4.5 mm coronal to theinterproximal COB. The ze-nith of the facial gingivalmargin is approximately 1.5mm more coronal to the COB.This osseous scallop from theCEJ results in the tip of thepapilla being on average 4.5mm coronal to the free gingi-val margin.27

However, if the alveolarbone is not in the “normal”position (2 to 3 mm apical tothe CEJ), these aforemen-tioned values would need tobe adjusted. When patients

are to have dental implants toreplace missing teeth, anyAPE should be corrected priorto implant placement. Inaddition, the gingiva may becoronally positioned second-ary to the following:

• plaque-induced in-flammation28

• incisal attrition29

• gingival hyperplasia re-sulting from the use of med-ications such as calciumchannel blocking agents, anti-convulsants, and immunosup-pressive agents30

• orthodontic tooth move-ment31

• deep decay causingshort clinical crowns32

• traumatic injury33

• tooth eruption after thepatient has completed facialgrowth.34

In such cases the surgeonshould first correct the coro-nally positioned gingivalmargins with a gingivectomyprocedure, or the gingivalmargins and alveolar crestlevels must be altered with a crown-lengthening pro-cedure35 prior to the place-ment of the dental implant.These procedures can beaccomplished at a separatesurgical visit or at the time ofdental implant placement,but should be performed priorto the preparation of the im-plant osteotomy.36 This willensure that the eventual gin-gival margin over the dentalimplant will be at its correctlevel relative to the adjacentanterior teeth (Figure 4).

CLINICAL TREATMENTGUIDELINES AND

PROCEDURESAnatomic considerations serveas important parameterswhen performing aestheticgingival recontouring. Thelaboratory can fabricate auseful guide in the form of awax-up. The mounted diag-nostic casts are modified inwax so that ideal tooth anato-my as desired in the finalprosthesis is created. Guide-lines published by Chiche andPinault should be followed.37

These guidelines suggest thatthe average length for aes-thetically pleasing maxillarycentral incisors is 10 to 12mm,38 and the width-to-length ratio is 75% to 80%.39

These guidelines should bekept in mind when recontour-ing the gingival tissues so asnot to leave the teeth too long

or too short.40

After proportions areachieved on the central inci-sors, practitioners should fo-cus on the height of contour ofthe gingival margin of theseteeth.41 The proper place-ment of the peak of the para-bolic curve of the gingivalmargin for the central inci-sors, cuspids, and bicuspidsshould be located slightly dis-tal to the middle of the longaxis of these teeth. This givesthese teeth the subtle distalroot inclination that is im-portant for an aesthetical-ly pleasing smile. The zenithfor the lateral incisors islocated at the midline of thelong axis of the tooth. Fur-thermore, the height of thegingival crest for these teethshould be 1 mm shorter thanthe gingival margins of theadjacent teeth. For all teeth thegingival tissues should ideallyhave a “knife-edge” margin.42

The presence of short clin-ical crowns and crestal bonelevels approximating the CEJindicates a diagnosis of APE.The practitioner can then fab-ricate an aesthetic guide thatcan be placed over the pa-tient’s existing teeth to allowboth the practitioner andpatient to visualize what thesmile would look like with thegingiva in a modified, moreaesthetic position.43

The repositioning of thegingival margin and crestalalveolar bone requires the ad-ministration of local anesthe-sia. A periodontal probe isplaced into the sulcus, at-tempting to locate the CEJ,but sometimes the CEJ can-not be discerned. In a casewhere the location of the CEJis not clearly identified, aperiodontal probe should bepassed through the periodon-tal attachment until the crestof alveolar bone is contacted.Coupled with current peri-apical radiographs, locatingthe crest should help identifythe CEJ.44

Surgical crown lengthen-ing is then accomplished tocorrect the APE. The labora-tory-fabricated gingival aes-thetic guide can be used notonly to position the alveolarcrest 3 mm apical to theCEJ,45 but also to provide ablueprint for attaining hori-zontal gingival symmetry andheight. The guide will alsoensure proper interproximal

Figure 5. Bilateral retained maxillary deciduous cuspids and anterior alteredpassive eruption (APE).

Figure 6. Gingival recontouring in the maxillary anterior region to place thegingival margin at the CEJ.

Figure 7. Suturing of the implant sites following extraction of the deciduouscuspids, relocation of the crestal and interdental bone so it is 2 mm apicalto the CEJ of the adjacent teeth, and then placement of dental implants.

Figure 8. Four weeks after surgery, demonstrating gingival margins of theanterior teeth at their proper position.

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DENTISTRY TODAY • JULY 2007

scalloping. The newly estab-lished gingival margin will bedetermined by the patient’slip line while smiling,46 thedesired length of anteriorteeth relative to the existinglevel of alveolar bone,47 andhealthy interdental tissue.48

Scalloping the gingivaltissues is accomplished witha 15c surgical blade. Aninverse beveled incision ismade, connecting the sulci ofthe affected maxillary teeth.

The surgical incision cantransverse the base of thepapillary tissue or can followthe topography of the inter-dental papilla. For aestheticsuccess at this critical phaseof crown lengthening, it isimportant not to elevate thepapilla, which usually willresult in loss of interproximaltissue height.

A full-thickness mucoper-iosteal flap is then elevatedwith a periosteal elevator (ie,

Woodson No. 2 elevator), andosseous resection is per-formed with a surgical lengthNo. 8 round diamond bur (No.5801 [Brasseler]) and peri-odontal hand chisels (Kirk-land 15/16 [Hu-Friedy]).

The surgical flap can thenbe positioned to the pre-arranged height determinedby the aesthetic surgicalguide. The flaps are suturedusing a 3/8 reverse cuttingsuture needle (Hu-Friedy)with a 4-0 thread of polygly-colic acid, using a sling suturetechnique. Suture removal isperformed 10 days followingsurgery, and the patient isinstructed in the oral hygieneregimen to be used. This in-cludes brushing with a soft-bristled toothbrush in a circu-lar motion and cleaning in-terdentally with either den-tal tape or floss. Additional-ly, Stim-U-Dents (Johnson& Johnson) can be used tomaintain the apically reposi-tioned gingiva while remov-ing bacterial plaque.

Ten weeks should be al-lowed for postoperative heal-ing before beginning eitherimplant placement (if re-quired) or preparation of nat-

ural teeth for restorations.By using a gingivectomy orcrown-lengthening procedureto properly establish the gin-gival smile line prior to im-plant placement or naturaltooth preparation, a properprosthetic emergence profilecan be established with awell-constructed provisionalrestoration. This is true if theabutments are supported byimplants or natural teeth.

When the restorative phaseof treatment begins, the teethcan be prepared with burssuch as the KS burs (Brasseler),using the aesthetic guide as ablueprint for tooth reduction.For full-coverage restora-tions, ceramic crowns provideexcellent aesthetics. Prepara-tions for these crowns areeither placed at the free gingi-val margin or slightly subgin-gival on the facial aspect.Care should be taken not toviolate the biologic width dur-ing tooth preparation.49

Provisional restorations canbe made by placing Luxatemp(Zenith/DMG) in a vacuum-formed matrix that was fabri-cated on the modified modelfrom which the aesthetic sur-gical guide was fabricated.

After approximately 60 to 90seconds, the provisionals areremoved and trimmed. Theprovisionals are bonded inplace by spot etching thepreparations and using Tet-ric Flow (Ivoclar Vivadent) asthe luting material.

The occlusion should thenbe checked in centric, protru-sive, and lateral excursivepositions50 and adjusted asneeded. The patient returnsto the office 10 days afterinsertion of the provisionalrestorations and providesinput about the aesthetics.Subsequent to recontouringthe provisional restorationsto meet the patient’s expecta-tions, impressions are takenand a putty matrix of theanterior segment is made toensure that the laboratoryhas correctly placed theincisal edges.

Final impressions areobtained 6 to 8 weeks later51

using a 2-cord method with awoven retraction cord such asUltrapak (Ultradent Prod-ucts). Care is taken so thegingival tissues are not in-jured. Full-mouth impres-sions are taken with vinylpolysiloxane (Take 1 [Kerr]),and face-bow transfer andopen bite centric relationrecords are obtained usingLuxaBite registration materi-al (Zenith/DMG). The modelsare mounted in a semiad-justable articulator such asthe Stratos 200 articulator(Ivoclar Vivadent). The casecan be completed using fullfeldspathic porcelain crowns(Colorlogic [DENTSPLY Cer-amco]), which are bondedwith both OptiBond Solo Plus(Kerr) and Variolink II (Ivo-clar Vivadent). Excess cementis removed with an explorerand periodontal scaler. Thepreviously fabricated puttyfacial index should be placedto see if there are any dis-crepancies. Such discrepan-cies are modified.

CLINICAL EXAMPLEA clinical case is described inFigures 5 to 10. In this case, 2implants replaced 2 retaineddeciduous cuspids that wereextracted after gingival recon-touring was accomplished. Asshown, the result of these pro-cedures is a healthy periodon-tium, and the symmetry of thesmile illustrates a completedhealthy, aesthetic, and func-tional restorative result. The

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Figure 9. Uncovering implants and placement of healing abutments (4 mm).

central incisors demonstratemidline symmetry as well asthe correct 75% to 80% width-to-length ratio. In addition, theincisal smile line follows thecurvature of the lower lip.52

The newly established smileline is more aesthetically ap-pealing and harmonious withsurrounding facial features.53

DISCUSSIONThe gingival margin shouldbe assessed relative to theprojected incisal edge posi-tion. A predictable method fordetermining the proper gingi-val position is to determinethe desired tooth size relativeto the projected incisal edgeposition. The practitionershould remember that theincisal edge should not bepositioned using the locationof the gingival margin to cre-ate the proper tooth size. Thisis because the gingival mar-gin can move with eruption orrecession.54 Therefore, theproper position of the gingivalmargin should be determinedby establishing the correctwidth-to-length ratio of themaxillary anterior teeth,55

using the width-to-lengthratio as previously publishedby Sterrett et al.39 In general,the amount of gingival dis-play must create symmetryamong the teeth throughoutthe maxillary arch.56

If the existing position ofthe gingival margin creates ashort clinical crown relativeto the incisal edge, then thegingival margins should bemoved apically. This can beaccomplished by performingcrown lengthening, gingivec-tomy, orthodontic intrusion,and/or prosthetic rehabilita-tion.57 The procedure that ischosen depends upon severalclinical factors, such as the

location of the CEJ relative tothe COB, the crown-to-rootratio and the shape of theroot(s), the amount of existingtooth structure, and the sul-cus/pocket depth.

It is also paramount whenestablishing the proper posi-tion of the maxillary anteriorteeth for an optimal cosmeticoutcome to assess the level ofthe interdental papillae and

their position relative to thecrown length of the maxillaryincisors. It has been demon-strated58 that if the heightbetween the interdentalpapilla base and the contact

point is greater than the dis-tance between the contactpoint and the incisal edge,then there is an indicationthat there has been signifi-

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133

The gingival marginshould be assessedrelative to the project-ed incisal edge posi-tion. A predictablemethod for determin-ing the proper gingi-val position is todetermine the desiredtooth size relative tothe projected incisaledge position.

cant occlusal abrasion. Thisscenario may cause shortercrowns, which shortens thecontact between the centralincisors. However, if the inter-dental contact point is longerthan the papilla, then thecontour of the gingival mar-gin would be flat and usuallylocated coronal to the CEJ,analogous to the clinical pres-entation of APE.59 Correctionwould be accomplished by per-

forming crown lengthening60

and/or orthodontic therapy toeither intrude61 or extrude62

the affected teeth.

CONCLUSIONFor patients who display toomuch gingiva and short teeth,a thorough diagnosis andtreatment plan are needed toprovide a predictable aesthet-ic outcome. This is especiallyimportant when utilizing den-

tal implant restorations. If apatient has altered passiveeruption of the maxillaryanterior teeth either second-ary to orthodontic treatmentor in the absence of orthodon-tic therapy, and the patienthas completed facial growth,then the surgeon must firstcorrect the gingival levelwith either a gingivectomyor crown-lengthening proce-dure before the placement ofdental implants. This willensure that the gingival mar-gin of the maxillary anteriorteeth will be at its correctlevel relative to the adjacentanterior teeth, not only afterrestoration of the implant,but for the long term. It isessential that there be atleast 3 mm between themost apical extension of therestorative margin and thealveolar bone crest. Thisallows sufficient room forinsertion of the supracrestalcollagen fibers, as well asprovides a gingival crevice of2 to 3 mm.

For proper implant place-ment that allows for a properrestorative result, the guide-line of 3 mm on the facialaspect from the osseous crest

to the gingival margin, and 4to 5 mm from the interproxi-mal COB to the tip of thepapilla, is appropriate whenthere is no bone and/or at-tachment loss. Further, if thegingival margin is not locat-ed at the CEJ and the under-lying bone is not 2 to 3 mmapical to the CEJ with itsparabolic contours, then thedistances of 3 mm on thefacial and 4 to 5 mm on theinterproximal area shouldnot be used. F

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Figure 10. Completed smile 2 years after restoration of the maxillaryimplants.

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62. Silverstein LH, Kurtzman D, Cohen R,et al. Adjunctive OrchestratedOrthodontic Therapy: an emergingtrend in cosmetic dentistry. AlphaOmegan. 2001;94:27-33.

Acknowledgment Illustrations accompanyingthis article were created byDavid Kurtzman, DDS.

Dr. Silverstein is an associate clini-cal professor of periodontics at theMedical College of Georgia inAugusta. He has published morethan 100 scientific articles and haswritten 8 textbook chapters. He is onthe contributing editorial boards ofPractical Periodontics and AestheticDentistry, Dentistry Today, Collabo-rative Dental Techniques, InsideDentistry, Functional Esthetics andRestorative Dentistry, and GeneralDentistry. He is the author ofPrinciples of Dental Suturing: AComplete Guide to Surgical Closureand has just completed a new text-book, Principles of Soft TissueSurgery: A Complete Step by StepProcedural Guide. Dr Silversteinmaintains a private practice atKennestone Periodontics in Marietta,Ga. He can be reached at (770) 952-5432 or [email protected].

Dr. G. Kurtzman is in private generalpractice in Silver Spring, Md. He haslectured both nationally and interna-tionally on the topics of restorativedentistry, endodontics, and dentalimplant surgery and prosthetics. Hecan be reached at [email protected].

Dr. D. Kurtzman is in private generalpractice in Marietta, Ga. He is anaccomplished illustrator and can becontacted at [email protected].

Dr. Shatz is assistant clinical profes-sor of periodontics at the MedicalCollege of Georgia in Augusta and isin private practice in Marietta, Ga. Hecan be reached at [email protected].

Dr. Szikman is in private practice inMarietta, Ga, practicing cosmeticand implant dentistry at the SzikmanDental Group. He can be reached [email protected].

PERIODONTICS135

JULY 2007 • DENTISTRY TODAY

135

Continuing EducationTest No. 91.1

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.

Continuing our “Journey of Excellence”

T o submit Continuing Education answers, use the answer sheet on page 128. On theanswer sheet, identify the article (this one is Test 91.1), place an X in the box corre-sponding 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.

1. Biological width dictates that at least____ mm be present between the resto-ration margin and the crestal bone.

a. 2b. 3 c. 4d. 5

2. The interproximal papillae between teethwith a healthy periodontium and no bone loss are approximately ____ mm coronalto the interproximal crest of bone.

a. 4b. 4.5c. 5d. 5.5

3. Altered passive eruption when present on teeth adjacent to an implant site should be corrected ____.

a. before implant placement b. after implant placementc. at implant uncoveryd. following restoration of the implant

4. The recommended width-to-length ratio of maxillary central incisors is ____.

a. 60%b. 70%c. 75% d. 90%

5. When evaluating altered passive erup-tion 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 radiographsc. an arbitrary determination based on

aesthetics d. both a and b

6. A stent based upon a diagnostic wax-updoes which of the following?

a. assists in guiding the periodontal surgeryb. assists in temporization fabrication of

the casec. acts as a blueprint in treatment planningd. all of the above

7. To avoid the creation of “black triangles”during periodontal surgery, ____.

a. flap design should split the papillab. flap design should include the papillac. flap design should not include the papilla d. both a and b

8. A predictable method of determining theproper gingival position is to determine the desired tooth size relative to ____.

a. the projected incisal edge positionb. width-to-length ratio of the teeth on a

mock-up modelc. width-to-length ratio of the teeth on a study

modeld. both a and b