Esthetic Re-creation Of Soft Tissue

Esthetic re-creation of soft tissue ar chitecture in replacing missing maxillary anterior teeth Eugene Joffe, DDS, PhD, FAGD

Replacing missing maxillary anterior teeth while pr oviding an adequate esthetic can present a considerable challeng e. A substantial ef fort is directed to ward achieving a better tooth-to-soft tissue relationship, r egardless of whether the restorati ve modalities are implants, naturally supported fixed bridges, or removable partial dentures . The interdental papilla is critical to the esthetically pleasant ar chitecture and con tributes to successful harmonious restoration, especially in patients with a high smile . There are se veral techniques for restoring the indental papilla. The best result comes from careful planning and good communication with the patient. Received: Mar ch 20, 2002

Last r evisions: June 21, 2002

Accepted: August 7, 2002

Recreation of smile esthetics is an important factor in restorative procedures, especially when tooth replacement and oral reconstruction are a concern. Smile esthetics are particularly important when dealing with the maxillary anterior region. A relationship between any kind of replacement and the surrounding soft tissue contributes significantly to clinical success. Esthetically, the tooth is inseparable from the architecture of

Case report No. 1 A 33-year-old man had a congenitally missing tooth No. 6. The retained ankylosed primary tooth No. C became loose and needed to be replaced. The p rimary tooth’s position was such that the gingival contour height was much lower than that of the adjacent teeth and was not symFig. 1. The retained primary tooth No. C, asymFig. 2. Surgically positioned gingiva line metrical with permanent tooth metrical with the gingiva line of the left side. following extraction. No. 11 on the left side (Fig . 1). The impression was taken prior to the extraction and the desirable height of gingival contour for tooth No. 6 was created on the model by using the bur. The missing tooth was sculpted on the model and the template was produced in a vacuum former. Fig. 3. Temporary acrylic Fig. 4. Healing three months after Fig. 5. The newly formed The ex tracti on was perbridge with rounded, bulletsurgery, showing the reshaping of dentogingival contours, formed, with minimal trauma shaped pontic inserted after gingival architecture. including the overall to the buccal cortical plate. The insertion. symmetry and papillae. future socket was established surgically with a proper gingival height using a large round was not prepared during the surgery to be sufficiently large, it is important to allow the tissue around the pontic to heal diamond bur (Fig. 2). Teeth No. 5 and 7 were prepared with a full circumferen- and to avoid any unnecessary pressure on the tissues, which tial shoulder for placement of a Targis/Vectris fixed partial could result in damaged and inflamed tissues that probably bridge (Ivoclar, Amhers t ,N Y; 800/533-6825). Using the pre- will not heal at all. Three months later, once the recreation of the architecture vious template, the transitional acrylic bridge was made directly. The length and shape of the pontic in the gingival was determined to be satisfactory (Fig. 4), the three-unit fixed area received special attention. The rounded, bullet-shaped bridge was produced and bonded in place using One-Step and pontic was well-polished when it contacted the alveolar Duo-Link luting cements (Bisco, Schaumburg, IL; 800/247ridge (Fig. 3). Adjustments were made to the provisional 3368). The newly formed dentogingival contours included the pontic during the healing period to achieve the best con- overall symmetry and papillae formation and produced a tours for the artificial socket and papillae. If the pontic bed good perception of a natural esthetic (Fig. 5).

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gingival tissues. For that reason, much clinical research is directed toward saving, recreating, and improving gingival soft tissues contours and papilla.1-5 Many clinical approaches reflect such esthetic concepts as smile line, gingival contour, symmetry, and “golden” proportions.6,7 Smile composition reflects individuality and influences social perception and image.8 Statistically, 10.57% of the population has what is described as a high smile or gummy smile. This type of smile uncovers the maxillary gum tissue to various degrees

of width. The same research indicates that 68.94% have a “medium” type of smile, where the upper lip border corresponds to the cervical gum line, while 20.48% have a “low” smile that covers the maxillary teeth to a different degree.9 Many clinical research efforts are based on these and other esthetic principles in the pursuit of better complete denture esthetics.10,11 A significant amount of dental and soft tissue esthetics research relates to the restoration of the maxilla anterior region, utilizing different types of implants and

fixed partial dentures with pontic.7,12-19 For partial removable dentures designed to replace missing maxillary anterior teeth,esthetic considerations are associated largely with a choice of retaining devices. However, while the complex relation of the denture teeth and dentogingival complex is especially important for people with a high smile, it rarely is a part of clinical research.20,21 The following cases reflect different clinical approaches for regaining the dentogingival esthetic.

Case report No. 2 A 68-year-old man lost his fixed anterior maxillary bridge (Fig. 6). For financial reasons, the patient preferred to replace the bridge with a removable partial denture. He had a high smile and utilizing a conventional partial would either expose the acrylic of the Fig. 6. A 68-year-old man, following detachFig. 7. The artificial sockets with the proanterior flange, reveal the “false” teeth, ment of a fixed anterior maxillary bridg e. jected papillae on the working model. or force the dentist to reshape the teeth traditionally by “scooping” inside to grind them to the ridge. None of these results would produce the desired natural appearance. To recreate the dentogingival architecture and to satisfy the patient’s desire for “natural-looking” teeth, the dentist obtained the final impression Fig. 9. A transmucosal alveoloplasty was Fig. 8. The teeth are set up according to the and mounted the models in the articuperformed based on the positions of teeth design of the processed removable partial lator according to the previously estabon the partial denture. denture. lished centric relation position. Using a laboratory bur, the artificial sockets with projected papillae were created on the maxillary working model. This design represented the desirable dentogingival architecture, including the prominence of future dental papillae for the finished case, while allowing room to adapt and position artificial Fig. 10. The removable partial denture, 24 Fig. 11. The anterior area, one week after teeth on the ridge (Fig. 7). hours after insertion. the initial insertion. The removable partial denture was produced with the teeth set up according to the designed structed not to remove it for the next 24 hours (Fig. 10). Once model’s preparations (Fig. 8). Because of the design’s relative it was removed, a regimen was prescribed involving regular hygenic care and cleaning the denture and teeth. simplicity, the denture was processed without a clinical trial. The reshaping of the alveolar ridge started and became noAt the time of insertion,the remaining roots were removed with minimum damage to the facial cortical plate. For future ticeable in the week following the procedure. The reshaping in contacts between artificial teeth and the alveolar ridge, an the anterior area progressed, outlining the favorable architecalveoloplasty was performed to create sufficient depression in ture previously designed for this area (Fig. 11). The recreation the underlying bone (Fig. 9). This procedure allowed the ridge of a stable and more natural-looking dentogingival complex to resemble the working model and was performed directly was completed within two months, resulting in a more satisthrough the attached mucous membrane without flap eleva- factory esthetic appearance for the soft tissues surrounding tion. The partial denture was inserted and the patient was in- the artificial teeth.

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Case report No. 3 A 48-year-old woman had lost all of her natural maxillary teeth except for No. 5,6,and 16. The missing teeth were replaced with a removable partial denture. The patient was not satisfied with her high smile, large alveolar edentulous ridge,and small denture teeth (Fig. 12 and 13). The alveolar ridge was flat and no longer reflected the normal

architecture based on the relationship of teeth and surrounding tissue. The edentulous alveolar ridge was smooth, with no interdental papillae. In addition, the replacement teeth were too small and the gingival contour height in the arc of teeth No. 5 and 6 was too low (Fig. 14). The conventional setup of the teeth would change their shape when adjusting to the ridge and would not produce the esthetic results this patient desired.

Fig. 12. A 48-year-old woman whose high smile line exposes a considerable amount of soft tissue.

Fig. 13. The intraoral appearance of the patient in Fig. 12.

Fig. 14. Edentulous alveolar ridge that no longer reflects the normal architecture.

Fig. 15. A transitional denture model for the patient in Fig. 12.

Fig. 16. Comparing the discrepancy between the desirable position and the existing position of the teeth in relation to the alveolar ridge.

Fig. 17. A self-cured acrylic is applied to convert the existing denture into a transitional appliance.

Fig. 19. Crown lengthening surgery performed on teeth No. 5 and 6 to elevate the position of the smile line.

Fig. 20. A transmucosal alveoplasty in edentulous area, performed at the same time as the crown-lengthening surgery.

Fig. 22. Four weeks after surgery, the patient’s dental architecture shows insufficient development.

Fig. 23. The adjusted model, with deeper sockets.

Fig. 18. The denture seen in Figure 17, now a converted transitional partial denture.

Fig. 21. Following surgery, the provisional partial denture is inserted.

Fig. 24. Two months after surgery, the patient shows a more realistic alveolar architecture, with deep sockets and well-projected papillae.

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Fig. 25. Position of the artificial teeth in the setup phase.

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Fig. 26. Intraoral view of finished partial dentures.

This case presented a considerable challenge because so many teeth needed to be replaced. It was not feasible to produce the case without any clinical trial. It was clear that many esthetic parameters would require correction. Because this case required a different management approach, the denture bed would be created first. An impression of the existing denture was taken and the model was sketched and carved for the desired changes, including the position of the papillae (Fig. 15 and 16). The self-cured acrylic was added to the existing denture teeth, more or less reflecting both the expected position and the size of the teeth (Fig. 17 and 18). To gain the anticipated position of the gingival line of contours, the crown lengthening procedure was performed on teeth No. 5 and 6 (Fig. 19). The surgery was performed simultaneously in all areas where teeth were to be restored. The sockets were formed by sinking the sterile bur directly through the mucous membrane, reaching the underlying bone. No suturing or flap elevation was utilized (Fig. 20 and 21). The changed maxillary partial was readjusted and the patient was instructed not to remove it for the next 24 hours. Healing was uneventful. Four weeks after surgery, it was determined that the alveoloplasty was not adequate for creating an acceptable architecture. The depth of the formed sockets was insufficient and the patient revealed more posterior teeth while smiling, a possibility that had not been taken into account during the planning phase (Fig. 22). Corrections were made on a new model, taking the previous design’s inadequacies into consideration. The existing sockets were deepened and additional sockets were cut on the model in the premolar areas to achieve a more comprehensive esthetic (Fig. 23). After the model was readjusted, more aggressive surgery was performed on the edentulous alveolar ridge to achieve the desirable results. This time, the cuts were made not only through the mucous membrane but deep through the bone as well. Once again, the bleeding stopped and healing was uneventful, with no dressing or suturing required. The readjusted denture in the front applied sufficient pressure. The patient was instructed to keep the partial in her mouth for 24 hours; after that time, regular hygiene was recommended. Two months after surgery, the alveolar architecture looked much better, with deep sockets and nicely projected papillae (Fig. 24). The patient’s pre-existing teeth were kept well-polished and ridge contacts were adjusted as needed. After the denture bed was developed, the new removable partial denture was produced in the usual manner with the metal frame and the teeth were set up according to the newly formed sockets and papillae (Fig. 25). The designed denture bed has eliminated guesswork from the set up phase, allowing the necessary trial phase and offering better control of esthetics to provide a more natural look (Fig. 26).

Summary Different clinical situations require specific approaches for a satisfying dentoalveolar esthetic. It is only natural to seek the best possible outcome when restoring a patient’s missing teeth. The clinical cases presented here offer solutions that may be implemented in everyday practice. The designed denture bed technique can be used in many situations involving removable partial dentures or complete maxillary dentures with compromised esthetics. The designed denture bed also may be used in cases involving other types of dental reconstructions,including implants, during the provisional healing period. Author information Dr. Joffe is in private practice in Jackson Heights, New York. References 1. Bichacho N. Cervical contouring concepts: Enhancing the dentogingival complex. Pract Periodontics Aesthet Dent 1996;8:241-254. 2. Bichacho N. Papilla regeneration by noninvasive prosthodontic treatment: Segmental proximal restorations. Pract Periodontics Aesthet Dent 1998;10:75-78. 3. Shapiro A. Regeneration of interdental papillae using periodontal curettage. Int J Periodontal Restor Dent 1985;5:26-33. 4. Wagman SS. The role of coronal contour in gingival health. J Prosthet Dent 1977; 37:280-287. 5. Goodacre CJ. Gingival esthetics. J Prosthet Dent 1990;64:1-12. 6. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent 1978;40:244252. 7. Studer S, Zellweger U, Scharer P. The aesthetic guidelines of the mucogingival complex for fixed prosthodontics. Pract Periodontics Aesth Dent 1996;8:333-341. 8. Cipra DL, Wall JG. Esthetics in fixed and removable prosthodontics: The composition of a smile. J Tenn Dent Assoc 1991;71:24-29. 9. Tjan AHL, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent 1984;51:24-28. 10. Brunton PA, McCord JF. Guidelines to lip position in the construction of complete dentures. Quintessence Int 1994;25:121-124. 11. Murrell GA. Esthetics and the edentulous patient. J Am Dent Assoc 1988;117:57E63E. 12. Daftary F, Bahat O. Prosthetically formulated natural aesthetics in implant prostheses. Pract Periodontics Aesthet Dent 1994;6:73-80. 13. Bichacho N,Landsberg CJ. A modified surgical/prosthetic approach for an optimal single implant-supported crown. Part II: The cervical countouring concept. Pract Periodontics Aesthet Dent 1995;6:35-41. 14. Garber DA, Rosenberg ES. The edentulous ridge in fixed prosthodontics. Compend Contin Educ Dent 1981;2:212-223. 15. Stein RS. Pontic-residual ridge relationship: A research report. J Prosthet Dent 1966;16:251-285. 16. Spear FM. Maintenance of the interdental papilla following anterior tooth removal. Pract Periodontics Aesthet Dent 1999;11:21-28. 17. Petrungaro PS, Smilanich MD, Windmiller NW. The formation of proper interdental architecture for single-tooth implants. Contemp Esthet Restor Pract 1999;3:1422. 18. Petrungaro PS. Forming interdental bone contours and tissue emergence profiles. Contemp Esthet Restor Pract 2000;4:20-29. 19. Petrungaro PS, Maragos C, Matheson O. Using the Master Diagnostic Model to enhance restorative success in implant treatment. Compend Contin Educ Dent 2000;21:33-46. 20. Chiche G, Clark J. Improved esthetics for anterior removable partial dentures: A case report. Quintessence Int 1989;20:789-792. 21. Appelbaum M. Controlling esthetics in removable partial dentures. NY State Dent J 1984;50:158-159. Reprints of this article are available in quantities of 1,000 or more. E-mail your request to Jo-Ellyn Posselt at [email protected].

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