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Sample Copy. Not For Distribution.

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Perio-Esthetics and Implant Prosthodontics in Anterior

Rehabilitation


ii

Publishing-in-support-of,

EDUCREATION PUBLISHING

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Website: www.educreation.in _____________________________________________________________________________

© Copyright, 2018, Abhinav Gupta

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Printed in India


iii

Perio-Esthetics and Implant

Prosthodontics in Anterior Rehabilitation

By

Abhinav Gupta

EDUCREATION PUBLISHING (Since 2011)

www.educreation.in


iv


v

About The Author

Dr. Abhinav Gupta

Dr. Abhinav Gupta M.D.S. has completed his post-graduation in Prosthodontics

from M.A.H.E university, Manipal, India. He is currently working as Associate

Professor (Prosthodontics and Oral Implantology) in Aligarh Muslim University, India. He has also worked in his various capacities in Oral Implantology at Maulana Azad

Institute of Dental Sciences, Dr.R.M.L. hospital and Safderjung hospital, New Delhi.

His focus of interest is Dental Implants, Maxillofacial Prosthesis and Smile

Makeovers. He is a member of German society of Oral Implant ology (DGOI), and Indian implant societies (AOI, ISOI). He has numerous research papers to his credit.

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About The Book

Esthetics is the prime concern in today's dental care both for the patient and the treatment provider. Esthetic dentistry is just not limited to color matching

restorations but soft tissue considerations like position of the lips, color and contour

of gingiva around teeth also play a very important role in overall esthetic appearance

of face. Providing an esthetic restoration in the anterior region of the mouth has been the basis of peri-implant esthetics. Perio esthetics or Periodontal plastic

surgeries in its broad term covers various procedures either around natural teeth or

dental implant fixtures in the esthetic zone. This may range from crown lengthening

procedures, coverage of denuded root surfaces, ridge augmentation, periodontal prosthetic corrections and cosmetic surgical corrections around dental implants.

Prosthetics also plays an equal important role in implant esthetics. Various prosthetic

parameters like 3 D implant placement, implant abutment interface,

provisionalisation during interim period, choice of abutment material, digital dentistry

etc. are important factors at the pinnacle of successful outcome. This book is a comprehensive overview of clinical techniques related to Periodontal esthetics and

Implant Esthetics

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Content List

S. No. Chapters Page No.

I Aesthetic periodontal therapy : Introduction 1

II Aesthetic crown lengthening 2

Introduction 2

Procedures for esthetic evaluation 2

Surgical procedures for crown lengthening. 13

III Decision making in root coverage in aesthetic areas 19

Introduction 19

Classifi cation of gingival recession. 21

Decision making in root coverage 22

Root coverage techniques. 24

Choice of technique 39

Healing events affecting aesthetic outcome 44

Aesthetic evaluation of out come. 46

IV Surgical treatment planning for the single-unit

implant in aesthetic areas:

48

Introduction 48

Pretreatment considerations 49

Healed site classi fication for implant

placement.

52

Immediate implant placement into extraction site, treatment rationale, surgical procedures.

56

Surgical procedures for implant placement. 59

V Prosthetic Management of Implants in the Esthetic

Zone

61

VI Bibliography 73


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Perio-Esthetics and Implant Prosthodontics in Anterior Rehabilitation

1

I. Aesthetic Periodontal Therapy ________________________________________________________________________

INTRODUCTION:

Aesthetics is a fundamental consideration of contemporary clinical dentistry. Aesthetic considerations have influenced the management of dental maladies in

varying degrees of many years. Patient awareness and expectations have increased

recently to the point that less than optimal aesthetics are no longer an acceptable

outcome.

The evolution of restorative materials as well as a better understanding of tissue

biology and wound healing have been combined to provide the optimal aesthetic

result. Certain parameters have been offered to define the aesthetic characteristics

of teeth and their investing tissues.

Aesthetics is an inseperable part of todays periodontal treatment, however

consistency of results reliability of treatment modalities and long-term prognosis

require scientific approaches to therapeutic procedures. Establishing a complete and

accurate diagnosis is an essential prerequisite to effective aesthetic therapy.

Aesthetic periodontal therapy encompasses a much broader range of treatment

modalities and addresses treatment of gingival recession, excessive gingival display,

deficient ridges, loss of interdental papillae drug-induced gingival enlargements and

soft tissue management around aesthetic restorations. It also deals with procedures

for placement and management of implant restorations in aesthetic areas.

An attempt is made to discuss, the procedures for aesthetic crown lengthening,

decision making and procedures for root coverage, and the surgical treatment

planning of implant placement for a single tooth restorations in aesthetic areas.

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Abhinav Gupta

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II. Aesthetic Crown Lengthening ________________________________________________________________________

INTRODUCTION:

The most commonly encountered gingival abnormalities that have the potential to

affect aesthetic appearance of maxillary anterior tooth, include Gingival asymmetry,

Excessive gingival display, Flat gingival marginal contour, Open interproximal space, Gingival recession. One of the most common causes for excessive gingival display is

delayed apical migration of the gingival margin (or) what is called „altered passive

eruption‟.

Previously, many authors proposed surgical procedures to treat excessive gingival display, gingival asymmetry and flat gingival margin contours. (6,7,144)

In 1993, Allen E.P proposed surgical crown lengthening procedures mainly for

two purposes, one for function (i,e to provide tooth length for caries removal,

restoration of the tooth without violating the biologic width and for restoration retention), and other purpose was for aesthetics (i.e for aesthetic enhancement in

patients with excessive gingival display). Surgical crown lengthening procedure was

one of the most under used procedures in surgical periodontics. Surgical crown

lengthening procedure must be planned based on diagnosis and the principles of

wound healing. (6)

This section is primarily concerned with aesthetic crown lengthening, i.e to treat

excessive gingival display coupled with insufficient crown length, gingival

asymmetry, or flat gingival marginal contours.

PROCEDURES FOR AESTHETIC EVALUATION:

Prior to developing a suitable treatment plan, it is essential to establish a complete

and accurate assessment of conditions with which the patient presents.

First, it is important to determine the chief complaint or the patient‟s reasons for seeking treatment.

Next, the medical status of the patient must be reviewed and vital signs recorded.

Following thorough review of the patient‟s medical status, the clinical

examination is conducted. This should begin with extraoral conditions with attention to facial symmetry, face height, lip length and thickness, profile and smile line.

When any significant discrepancies exist in one or more extraoral parameters, it

may be unrealistic to expect intraoral procedures alone to provide a satisfactory

result. In these cases Orthognathic and/or plastic surgery procedures may need to

be modified. (144).

Next a thorough intraoral examination is conducted combining clinical and

radiographic observations.

The pretreatment esthetic evaluation should enable to deal more effectively with

the patient‟s needs and concerns, provide for realistic expectations regarding treatment outcomes, define surgical requirements and define the responsibilities of

participating therapists. (144).



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1. Horizontal and Vertical Reference Lines of the Face:

Most clinicians have tendency to focus solely on the defect, but when evaluating

esthetic problems, the clinician needs to widen his or her focus, studying first the proportions of the face, how these proportions relate to the smile and how the lip

line relates to the teeth and the mucogingival complex. The perioesthetic defect

should then be evaluated.

In an esthetic analysis of the dentogingival complex the midline of the face, the

position of the incisal edges and the gingival line are important landmarks. The gingival line defined as a tangent running through the gingival height of

contour of the maxillary central incisors and canines, ideally should be parallel to

the bipupillary line and the incisal edges. Additionally the papillae between the

maxillary central incisors should coincide with the midline of the face. (Fig. 1 & 2)

Figure 1. Facial proportions : horizontal and vertical reference lines.The bipupillary

line and midline of the face are frequently used in esthetic evaluations.

Figure 2. The dentomucogingival complex: horizontal and vertical reference lines.

The gingival line (2) should be parallel to the incisal edges (3) and the papilla

between the maxillary central incisors should coincide with the midline of the face (1).


Abhinav Gupta

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2. Lip Line:

After evaluating the facial proportions, the clinician should classify the lip line (smile

line) according to its position in relation to the gingival line. The lip line, assessed when the patient is full smile, can be classified as high (excessive gingival display),

medium (vermillion border of maxillary lip at or near the gingival line), and low

(maxillary lip covering a portion of the maxillary teeth.

A medium lip line relationship is generally considered ideal and most clinical

guidelines assume a medium lip line.

Although the classification is rather simple, the determination may be difficult

because some patients may hide their natural lip line in an effort to cover an esthetic

concern.

3. Position and Shape of the Gingival Margins:

In an ideal relationship the position of the gingival margin is dictated by the vertical

limits of the full smile, the gingival margins of the maxillary central incisors and

canines positioned at the vermilion border of maxillary lip. The gingival margin of the lateral incisors is usually located 1 to 2mm more incisally or at the same height as

the central incisors and canines. The height of contour of the gingival margin is at

the distal line angle of maxillary central incisors and canines and in the center

mesiodistally of the maxillary lateral incisor (Fig.3). The degree of scallop of the gingival margin depends on the periodontal morphotype (or) periodontal biotypes.

Two different periodontal biotypes have been described in relation to the morphology

of the interdental papilla and the osseous architecture : the thin scalloped

periodontium and the thick flat periodontium. Thick morphotyes have flat gingival

contours and thin morphotypes have scallop gingival contours. The gingival height of contour of the premolars and molars assumes a gradually more occlusal position as it

moves posteriorly. The horizontal limits as well as the vertical limits (lip line) of the

smile should be evaluated. Most patients show the maxillary gingiva or teeth or both

upto the first molar in full smile. To provide for the proper depth and harmony of the smile, the gingival display should be consistent and proportional from tooth to tooth

from the maxillary first molar to the first molar.

Figure 3. Gingival height of contour. The height of contour of the gingival margin

of the maxillary central incisors and canines is at the distal line angle and in the

center, mesiodistally, of the maxillary lateral incisor.

4. Gingival Margin Discrepancies:

Two treatment options available for resolving gingival margin discrepancies are

orthodontic repositioning and surgical correction and the clinician must determine

which treatment option is appropriate. First, the sulcus depth of the teeth in question is evaluated. (Fig. 4A) If the tooth with a more coronal gingival margin has



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a sulcus depth of 3 to 4mm with the CEJ at its base, then surgical crown lengthening

may be indicated. If the sulcus depth is minimal, orthodontic intrusion of the shorter

tooth is indicated to reposition the gingival margin.

Next the clinician evaluates the relationship of the gingival margins of the

central incisors to the gingival margins of the lateral incisors. (Fig.4B) If the shorter

central incisors gingival margin is at the same level or apical to the lateral incisor‟s

gingival margins, the appropriate treatment may be extrusion of the longer central

incisor. An evaluation of the incisal edges of the teeth in question may also help the clinician determine proper treatment. If one tooth is wider labiolingually, that may

indicate that it has been abraded and allowed to supraerupt. (Fig.4C) The proper

treatment is intrusion of the abraded tooth and restoration of the incisal edge.

If a mis diagnosis occurs and the clinician attempts to correct the gingival discrepancy with surgical crown lengthening rather than orthodontic repositioning.

The root surface and CEJ are exposed. This can cause an esthetic dilemma even if

the tooth is restored. (144)

Figure 4. A. To determine proper treatment for a gingival margin discrepancy, probe

the sulcus of the shorter tooth. In this case, there is very little probing depth, which would mean that any surgical crown lengthening would result in exposure of the CEJ

and root surface. B. Evaluate the position of the gingival margins of the central

incisors to the lateral incisors. In this case, orthodontic extrusion of the longer

central incisor would create unesthetic tooth lengths and gingival contours. The

correct treatment would be orthodontic intrusion of the shorter central incisor, aligning its gingival margin with the longer central incisor and then restoring its

incisal edge. C. Evaluate the incisal edges. If one is wider, it may have been

abraded and allowed to supererupt.

5. Excessive Gingival Display:

Excessive gingival display or a gummy smile can be a significant

esthetic dilemma for many patients. Excessive gi ngival display can be

caused by any of three factors and because each is treated differently, correct diagnosis is crucial (124).

First, maxillary overgrowth may cause excessive gingival display

and to diagnose skeletal deformities, the clinician must eval uate the

proportions of the face. The ideal ly proportioned face is divided into three equal parts from the hairline to the eye brow, from the eyebrow to

the base of the nose, and from the base of the nose to the chin. (Fig.

5)


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