prosthetic gingival reconstrution

The International Journal of Periodontics & Restorative Dentistry

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Prosthetic gingival restorations havehistorically been underutilized in par-tially edentulous patients. The initialattempts were aimed solely at maskingthe patient’s existing tissue loss withoutshowcasing the artificial gingiva of therestoration, owing to the obvious es-thetic limitations of the prosthetic workexecuted. As was highlighted in thefirst two parts of this article series, whencomprehensively understood and cor-rectly planned, artificial gingival restora-tions can predictably reestablish har-monious anatomy to the lost gingivaltissue, reproducing the color, contour,and texture of the patient’s gumline.1–8

The planning must be carried out by allmembers of the reconstructive team,including the surgeon, prosthodontist,and ceramist. Ideally, all team membersinvolved in the process must under-stand the clinical and technical stepsnecessary to correctly reestablishesthetics and function in the patient’sexisting defect environment. Thisallows for equal participation in thedecision-making process and providesthe patient with all relevant treatmentalternatives. Prosthetic gingival restora-tion requires additional theoretical andtechnical development on the part of

Prosthetic Gingival Reconstruction inFixed Partial Restorations. Part 3:Laboratory Procedures and Maintenance

Christian Coachman, DDS, CDT*Maurice Salama, DMD**David Garber, DMD***Marcelo Calamita, DDS****Henry Salama, DMD**Guilherme Cabral, DDS, CDT*

Part 1 of the present series presented a rationale for including prosthetic gingivain the planning of a fixed restoration to ensure an esthetic result for patients withsevere horizontal and vertical ridge deficiencies. The second part focused on thediagnostic and treatment planning aspects of the use of artificial gingiva. Thisthird and final installment in the series focuses on the laboratory and clinical pro-cedures involved in fabricating a prosthesis with artificial gingiva and providesinformation on proper maintenance of these restorations. (Int J PeriodonticsRestorative Dent 2010;30:19–29.)

*Ceramist, Team Atlanta Lab, Atlanta, Georgia.**Clinical Assistant Professor of Periodontics, University of Pennsylvania, Philadelphia,

Pennsylvania; Medical College of Georgia, Atlanta, Georgia; Private Practice, Atlanta,Georgia.

***Clinical Assistant Professor of Periodontics, University of Pennsylvania, Philadelphia,Pennsylvania; Private Practice, Atlanta, Georgia.

****Associate Professor of Removable Prosthodontics, Guaralhos University of São Paulo,São Paulo, Brazil; Private Practice, São Paulo, Brazil.

Correspondence to: Dr Maurice Salama, 600 Galleria Parkway, Suite 800, Atlanta, GA30339; fax: 404-261-4946; email: [email protected].

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Volume 30, Number 1, 2010


the treatment team, so that these res-torations display harmony, balance,and continuity of form between thenatural and artificial gingivae.9–12 Theintegration of the color of natural tissueand artificial tissue must be planned soas to minimize the visibility of this junc-tion, restore the dimensions of the gin-gival architecture, and replace papillaform.3,10,12 The tissue loss that occursin patients in whom prosthetic gingivais indicated usually makes it very diffi-cult to create an adequate dentalarrangement and provide suitableanatomy of each tooth without usingartificial gingivae.13

The ceramist must understand thebasic clinical principles of surgery andimplant dentistry, the components ofa smile, the classifications of alveolarosseous resorption, and the principlesof pink esthetics, such as contour,color, and texture. A training in three-dimensional visualizations and thesearch for lost anatomic references isparamount. Morphologic research ofphotos or old models, as well as of theexisting teeth and gingival contours ofadjacent areas that may have a similarstandard of dental-gingival esthetics,is also required to try to determine asaccurately as possible the theoretical“original position of the teeth andridge.”9 This represents the union of theprinciples of a conventional fixed par-tial denture with the those of a denturethat incorporates artificial gingiva.14

Clinical and laboratory procedures

Part 2 of this series discussed the sur-gical planning and the ideal three-

dimensional implant positioning for aprosthetic gingival restoration. The pres-ent article will discuss the prostheticprocedures that are needed to achieveideal esthetic and functional propertiesin a prosthetic gingival restoration.

Exposure and implant impression

These procedures are identical tothose for a conventional screw-retained implant restoration. The clin-ician must ensure that the impressionprecisely reproduces the soft tissuethat will receive the artificial gingivaand pontic. If tissue conditioning willbe performed with the provisionalrestoration, this profile must also becaptured by the impression.

Dental-gingival provisional

Provisionals are an important step inthe process of planning a pink porce-lain restoration.15 This represents thesecond opportunity for the technicianto test the restoration design (the firstchance was the diagnostic wax-up).Ideally, gum conditioning and reshap-ing should be done during this phase,and any needed modifications shouldbe communicated to the surgeon.

The provisional plays several rolesin the treatment process (Figs 1 to 4).It is used to test the junction betweenthe natural and artificial gingivae, toensure that the gingival interface ishidden beyond the lip perimeter dur-ing maximum smile. Phonetics aretested with the provisional in place.The provisional will confirm the accu-racy of the planned grafts and implant

placement and can be used as a blue-print for the definitive restoration. Thedentist and patient can test hygieneprocedures with the provisional inplace to determine the ease of main-tenance. The dentist can also use thisopportunity to show the patient howthis kind of restoration behaves andobtain patient approval before thedefinitive restoration is fabricated.Finally, the provisional can be used tocondition the gingival tissue.

Gingival conditioningThe plan for conditioning of the artificialgingiva begins at the diagnostic wax-upstage. It is begun at the moment ofseating the provisional and the gingivalprofile can be refined when seating thedefinitive restoration, depending onthe size of the necessary modifications.The gum conditioning procedures per-formed before the final impression willbe reproduced on the working soft tis-sue model. If necessary, before fabri-cating the definitive restoration, thetechnician (with approval from theimplant team) can reshape the soft tis-sue on the working model, trimming itso that the denture will have an idealprofile. This of course requires the den-tist to reproduce this reshaping of thegingiva at the time of the final try-in ofthe denture.

The ridge under the pontics shouldbe flat to allow a smooth transition be-tween the natural and artificial gingivaeand permit ideal hygiene in this area. Aconcave ridge for ovate pontics is notrecommended because the intent insuch patients is to create an illusion ofcontinuity. An ovate pontic is thereforemade to create the illusion of the crownemerging from inside the gum.

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After the final adjustments aremade to the pink ceramic in the mouth,the clinician can analyze the need forsmall modifications of the natural gumwith diamond burs or a laser. At thispoint the dentist should also check thehygiene spots again, making sure thatnothing needs to be changed (Fig 5).

reproduces the characteristics of thelost tissue and hides the unestheticaspects of the patient’s mouth.

The goal is to produce a naturalbuccal contour that shifts, if possible,the transition of the gum apically anddevelops the profile of the artificial gumto resemble its appearance before the

Artificial gingiva emergenceprofile

The emergence profile is very impor-tant in an artificial gingival restorationbecause it differs substantially fromconventional restorations. The techni-cian must create artificial gingiva that

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Fig 1 (left) A silicone index is made overthe diagnostic wax-up to generate the“white” aspect of the provisional restoration.

Fig 2 (right) The provisional is placed intoposition and adjusted to the ideal shapebefore the “pink” is added. Then the gingivalcomposite is added, reproducing the shape,shade, and texture of the missing tissue.

Figs 3 (left) and 4 (right) The gingivalcomposite is refined, polished, and glazedin the lab. Then the provisional is screwedback into position to serve as a “test drive”for the definitive restoration.

Fig 5 Drawings highlighting the importance of gum conditioning and the pontic shape in esthetics and hygiene. (left) Nonhygienic ridge-lappontic. The shape of the ridge generates a concave surface under the pontic. The floss is not able to touch the entire surface underneath thepontic. (center) Nonesthetic pontic. The illusion created by the ovate pontic is not the one desired in artificial gingiva restorations. (right)Hygienic and esthetic pontic. The flat shape of the ridge is a cleansable surface and produces an esthetic horizontal interface between naturaland artificial gingivae.


patient lost teeth (Fig 6). The artificialgum should emerge from the implantand create a sharp angle after crossingover the transmucosal area. This sharpangle will help blend the gap betweenthe artificial and natiral gingivae. Afteremerging from the sulcus, the artificialgum profile will move directly towardthe artificial marginal gingiva andceramic crown.

Planning the artificial papillae

Artificial gingival restorations can havedifferent kinds of papilla design. Thesevariations should be planned initiallywith the diagnostic wax-up and shouldbe further evaluated with the provi-sional. The papilla can be totally arti-ficial when there is an absoluteabsence of a papilla between twocrowns. It can be half natural and halfartificial, when the papilla beside acrown is slightly resorbed. In this case,

the emergence profile of the restora-tion should be aimed at providingsome pressure on the natural papilla,to push it toward the incisal, and atsharing the interproximal space withthe artificial papilla and restoring theideal volume of an esthetic papilla.Sometimes there is a need to fabricatea “floating” papilla. This is an artificialpapilla that overlaps an adjacent nat-ural tooth. These situations are moredelicate to try in and adjust, as spacefor flossing must be retained but thegap must be obscured to create theillusion of a natural gingival margin.

Abutments and framework

It is preferable to plan artificial gingivalrestoration cases as screw-retained.Intermediate angled abutments canbe used that allow the framework to bescrewed on over them (eg, Multiunit,Nobel Biocare) if the implant positions

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Fig 6 A seamless transition between artifi-cial and natural gingivae is the goal to gen-erate an esthetic and comfortable situationfor the patient. The transition below theupper lip is important for support.


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are unsuitable for a screw-retainedrestoration over straight abutments.Whenever possible, it is easier to godirectly over the head of the implant,which means having a narrower metalcollar on the cervical area.

The fabrication will be executedon a working soft tissue model withartificial gingiva (rigid modifiable gin-gival mask). The framework is typi-cally metal, but recent advancementsin zirconia make this material anotherpossibility.16

The connectors should be posi-tioned more apically than usual, ie,shifted from the contact area towardthe height of the papilla, such that theinterproximal spaces are opened upfor the development of correct ana-tomy and ceramic light transmissionand shape (Fig 7). Otherwise, theframework should follow all the prin-ciples of a conventional fixed partialdenture.

perform this over the definitive frame-work; this will highlight any remainingdeficiencies (Fig 8).

Ideally, the laboratory technicianwill have performed at least one eval-uation of the patient before fabricatingthe definitive ceramics. At the firstdiagnostic wax-up, the provisionalrestoration or wax-up is placed overthe framework. After this evaluation, inthe mouth or with digital photographs,the technician will have mentally devel-oped an ideal design as he or shebuilds the ceramics. It is advisable atthis stage to take some pictures for adynamic evaluation of the patient smilewith the prototype in place.

Ceramic buildup and try-in

On the day the ceramist is finishingthe ceramic buildup, a long appoint-ment is typically required so that a fewtry-ins can be done at specific stages.

Second diagnostic wax-up andtry-in (over the framework)

This try-in enables the ceramist to visu-alize the planned restoration design invivo. Verification of the generalesthetic guidelines, the transition zonebetween the natural and artificial gin-givae, labial support, the lip closurepath, maxillomandibular relationships,vertical dimension, phonetics, andaccess for hygiene is done. After thisstep is accomplished, the ceramicbuildup will be much more pre-dictable.

This is the last chance to test thedesign and converse with the patientbefore proceeding to the definitiveceramic buildup. With this procedure,the clinician can test and explain to thepatient that muscular repositioningmay demand a period of neuromus-cular adaptation, in proportion to thevolume of bone loss and its capacityfor adaptation. It is very effective to

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Fig 7 (left) Indexes are made over themodel of the provisional to guide fabrica-tion of the framework.

Fig 8 (right) The framework with the waxcrowns in position is placed in the mouth.Following the level of the natural papillaeon the distal of the canines, the tips of thepapillae are placed in wax. The harmony ofthe shapes among natural gingiva, artificialgingiva, and the lips is checked.


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The first try-in would be after the firstceramic bake (Fig 9), when the midline,overjet, overbite, and the basic toothshades can be checked. The secondstage would be after the final bake ofthe crowns but before the gingivaeare added (Fig 10); tooth anatomy, ver-tical dimension, and interdental spaceare checked, as these are very impor-tant to enable the correct buildup ofthe papillae (Fig 11). The third stage ofverification is done after the artificialgingivae are added. The dentistshould check the overall esthetic lookand perform occlusal and interproxi-mal adjustments. The relationshipbetween the natural and artificial gin-givae can be adjusted, and estheticsand hygiene are always kept in mind.

The final touchup of the artificialgingiva is done with the denture inposition in the mouth. With a fine dia-mond bur, the margin of the artificialgingiva should be trimmed to blend itwith the natural gingiva, with the shape

and grooves of the natural tissue dupli-cated. The surface in contact with thegingiva should be highly glazed, pol-ished, and free of concavities. A flat orovoid surface is recommended for allareas in contact with the natural tissue.

The artificial gingiva

The authors suggest currently that thegingival aspect of the restoration isbest constructed with composite resinwhen possible (Figs 12 to 14). Thismaterial is the ideal choice for manyreasons: (1) it preserves the physicalproperties of the porcelain-fused-to-metal restoration; (2) the shape, shade,and texture of the pink esthetic factorscan be controlled; (3) repair and main-tenance are facilitated; and (4) theresults are predictable. Fabricating thegingiva with composite is also one ofthe main reasons for the denture to beplanned as screw retained; any kind of

repair or even a complete replacementcan be done in the future without inter-fering with the ceramic crowns.

In some situations, creation of theartificial gingiva with pink ceramics maybe recommended:

• The restoration could not beplanned as screw retained becauseof anatomical issues and angula-tion, so it needs to be permanentlycemented.

• Restorations are planned over nat-ural tooth abutments that will bepermanently cemented.

• When the total amount of artificialgingiva required is very small, forexample, a part of a papilla, it is sim-ply easier to add the pink ceramicwhile building up the crowns.

• When the amount of artificial gingivarequired is very large, taking thetransition line to areas outside theesthetic zone, ceramic is recom-mended.

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Figs 9 (left) and 10 (right) Again, the silicone index is used to guide the ceramic buildup.The crowns are given their final shapes before the gingival material is added.

Fig 11 The prosthesis is placed in themouth to check the esthetics of the crowns.Shape and shade need to be completelyfinished before the composite gingiva isadded. The denture should be glazed first,prepared for bonding, and placed in themouth before the gingival composite isapplied directly.


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The hybrid ceramic/compositeartificial gingivaA hybrid artificial gingiva is the processof choice today, with the main core ofthe pink in ceramic and an overlay incomposite resin to facilitate optimalpredictable esthetics with maximumcontrol. This also allows the dentist todevelop the submergence profile anddirect soft tissue interface in pinkceramics, facilitating a more biocom-patible subgingival environment. Thepink composite is then only placedsupragingivally, to blend into theesthetic interface. Using the same prin-ciple, a clinician can execute a pinkrestoration with ceramics and anyneeded future repairs can be donewith pink composite, so that ceramiccrowns do not need to be baked againafter being in the mouth. This helpspreserve the esthetic and physicalproperties of the porcelain. Obviously,this is only possible with screw-retainedrestorations.

Preparing the ceramic denture forpink composite resinThe denture needs to be prepared bythe technician to receive the compos-ite gingiva (Figs 12 and 13). This prepa-ration consists of:

• Mechanical retention • Waxing up the surface of the den-

ture that will not be covered bycomposite gingiva

• Sandblasting the surface that willreceive the composite

• Acid etching• Application of the bonding agent• Silanization• Application of a thin coat of compos-

ite resin (flowable pink composite)

After these steps are accom-plished, the denture is ready to beplaced in the mouth so that the remain-ing gingival material can be added (Fig14). The fact that one can execute thisprocedure in the mouth makes the

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Figs 12 and 13 The denture is prepared to receive the gingival composite. Areas ofmechanical retention are created, and the areas that will not receive composite are protect-ed to allow sandblasting, etching, and silanization before the first layer of pink composite isapplied.

Fig 14 The morphology of the gingiva iscompleted intraorally. Then the denture isremoved to refine its shape, remove anyexcesses and concavities under it, and pol-ish and glaze the composite.


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Fig 15a The pontic is in position over theridge before the gingiva is added.

Fig 15b The gingiva is added intraorally. Fig 15c The denture is removed from themouth, revealing a concavity under thepontic.

Figs 15d (left) and 15e (right) The edgeof the gingiva toward the ridge is removed,but not beyond 45 degrees, so as to avoidcreating an unattractive and uncomfortablesituation for the lips or a food trap.

Fig 15 Steps involved in shaping the composite resin gingiva intraorally.

Figs 15f (left) and 15g (right) The final stepis to remove any remaining concavity byadding more material under the denture tocreate a flat and hygienic surface. This addi-tion will also create some pressure on theridge at insertion, helping with esthetics atthe transition interface and with phonetics.


esthetic result much easier and morepredictable, in comparison with ceram-ics, which is entirely done in the lab.

The artificial gingiva should fill in allthe empty spaces along the ridge, thedenture, and adjacent teeth. This willprevent food impaction and help withhygiene.

After the full contour of the artifi-cial gingiva is finished in the mouth, thedentist should unscrew the restorationand proceed to finishing the compos-ite resin in the laboratory. This requiresremoving any excess off the margins,eliminating concavities, and polishingand glazing the composite (Fig 15).

At this point it is important todetermine whether the patient will beable to perform the hygiene proce-dures without assistance. If he or shecannot, changes should be made tofacilitate patient hygiene. This issue isalways a challenge because hygieneand esthetics can sometimes conflictwith each other.17

Shaping the composite resin gingiva directly in the mouthFigure 15 details the process of addingand shaping the definitive compositeresin gingiva intraorally.

Seating and hygienic orientation

After all adjustments are made andfinal polishing is accomplished, therestoration is ready to be seated (Fig16). This procedure will be the same asany conventional screw-retained den-ture. The blanching of the recipienttissue “interface” that occurs may bemore intense, as the area under pres-sure is larger. At this stage, it is vital toreinforce, step by step, the importanceof hygiene procedures to the patient(Fig 17) and schedule a check-upappointment in about 1 month.

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Fig 16 The surface underneath the pros-thesis must allow for thorough hygiene. Thisis only possible if the floss can touch theentire surface between the artificial and nat-ural gingiva. The patient must also be ableto pass the floss threader between all theabutments.

Fig 17 After the patient uses the flossthreader, the floss should slide from oneside of the prosthesis to the other, foldingaround the abutments and adjacent teeth.Superfloss is recommended for this proce-dure. The pressure between the natural andartificial gingivae must be similar to a con-tact point between teeth, ie, the floss cango through but with some resistance.


Maintenance

The size and design of the artificialgingiva are limited mostly by the fac-tor of maintenance. Maintenance iscrucial for the long-term success ofsuch restorations. It is mandatory toinclude artificial gingiva from thebeginning of treatment planning,including the surgical approach, ridgeshape, and implants, to ensure an idealesthetic and healthy restoration (Fig 18).Although these implant-supportedrestorations are designed to enablepatients to perform perfect mainte-nance, it is strongly recommendedthat the denture be screw-retained,so that it may be unscrewed periodi-cally to verify the health of the tissuesinvolved. Furthermore, this alsoenables the practitioner to repair, pol-ish, reshape, or add to the artificialgingiva if necessary.

Conclusion

Restoring a defective environmentinside the esthetic zone will always bechallenging. This three-part series hashighlighted a new focus for the implantteam—interface development—whichinvolves the alternative of including

artificial gingiva as a predictable treat-ment option for fixed partial restora-tions in patients with severe ridgedefects. The use of this solution in-volves a new paradigm in thinking forthe entire implant team. Diagnosisand treatment planning for artificialgingiva from inception are mostimportant for the successful outcomeof this technique and may allow theteam to plan a less invasive estheticapproach in any patient, decreasingthe number of clinical procedures andthe time required for vertical ridgeaugmentation. The most challengingaspect of surgery is minimized, makingesthetic outcomes more predictable.Each member of the team plays animportant role.

The technician must have a greaterunderstanding of both the surgical andclinical procedures involved to be anactive participant on the treatmentplanning team. Training to reproducenot only the teeth but also gingivalesthetics and anatomy is paramount.Currently, with the commercially avail-able materials (ceramics and compos-ite resin) it is possible to reproducenature when a restoration is properlydesigned, allowing correct mainte-nance and long-term predictable func-tion to the implant restoration.

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Fig 18 The denture is placed into positionafter again checking the hygiene proceduresand performing the final glaze of the com-posite gingiva. Note the facial esthetics andnatural lip support of the artificial gingivalrestoration.


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