The anterior “aesthetic zone” can have numerous challenging and fascinating dilemmas. Expectations from the patient, doctor, and laboratory technician need to be identified so that the parameters surrounding the final outcome of a beautiful natural smile are achieved.
One of the hardest aesthetic challenges that will test the patient, doctor, and lab technician is restoring the post-periodontal surgical patient. Loss of interproximal papilla can leave unattractive black gingival triangles and shovel shaped anterior incisors. Apical repositioning of the periodontium to reduce pathologic pocket depths results in long teeth exposing root surfaces to caries, bacteria, and overall sensitivity.
A 56 year old woman presented with the chief complaint of dissatisfaction with “black gaps and long teeth” after periodontal surgical therapy. The original diagnosis of generalized chronic perodontitis resulted in the loss of teeth 14 and 15. The patient was referred for aesthetic and restorative treatment planning.
Comprehensive evaluation of this case included a full series of radiographs, smile analysis (which involved gingival symmetry, arch form, tooth proportions, facial type, lip line, occlusion, and overall health), implant placement for missing teeth 14 and 15, full mouth study models, cosmetic wax-up models, photography and treatment planning with an understanding of all these dynamic factors.
The periodontal surgical phase of her treatment was completed along with the surgical placement of two 3i 4.0 x 11 mm implants in sites 14 and 15. Five months post-healing was complete and successful. No mobility was noted on any of the anterior teeth.
Smile analysis with the patient revealed her desires for a beautiful smile. Closing the black triangles was the number one objective. As seen in photos, there was a significant challenge with the length to width ratios due to the apical position of the gingival margin.
Evaluation of the patient at full smile revealed a low maxillary lip line which helped in establishing tooth length. However, gingival symmetry proved to be the challenge with the loss of interdentally papillary height. All in all, the total treatment of periodontal surgical therapy, implant placement in 14 and 15 and smile restoration would be the primary long-term outcome for the patient.
The patient’s preliminary evaluation, her desire for keeping her teeth, long term color stability, and the desire for an improved smile pointed to the choice of full and partial all-ceramic veneers.
Biologic width was examined due to the fact that the veneers would have to start sub-gingival to create the emergence profile needed for closing the black gingival triangles. In order to rehabilitate the interdental papillae, along with closing the interdental black spaces, interproximal margins of the restorations would need to be placed at a specific depth. The magic depth is the distance between the base of the sulcus and the crest of the bone. This is termed biologic width. The average distance of the biologic width around a tooth is approximately 2 mm, which is made up of 1 mm of epithelial adherence and 1 mm of connective tissue attachment. When the interdental papillae fills the gingival embrasures, 5 mm of soft tissue is present between the bone crest interproximally and the tip of the interdental papillae.
The first step in positioning the restoration margin sub-gingivally required the troughing of the gingival sulcus approximately 1 mm. The instrument of choice employed for this was the Smart US 20D CO2 Laser from Deka.(1) The high absorption rate in water at a depth of 1/10 mm guaranteed absolute safety to underlying or surrounding tissue structures. This laser offers the clinician numerous applications on soft tissue therapies—particularly the coagulation and bacteria reducing properties resulting in quicker healing recovery time with less swelling and pain.
Preparation of teeth 5 through 12 required gross reduction of coronal tooth structure with a Brasseler 1958 Carbide. Finesse preparation with a 5856-016 Brasseler(2) diamond was required to drop the interproximal margin 1 mm sub-gingival to create a 1 mm shoulder at a 90 to 110 degree angle to the axial wall. Incisal reduction of 2 mm was performed. No insertion of retraction cords was necessary due to margins at or slightly below the gingival crest.
Full arch border lock fitted trays by Schreinemakers(3) were selected. Impregnum garant quick soft light body injectable was used for syringing around the preps and Impregnum Penta Soft Quick(4) heavy body tray material. The impression material is truly hydrophobic in nature and does an excellent job in displacing tissue for amazing detail.
Bite registration was taken with Luxabite® by Zenith(5) using a horizontal non-bendable stick with the patient standing against a horizontal reference (symmetrigraf) background. The error that many clinicians make today is taking this horizontal reference with the interpapillary (eye) line. Reality is that people’s eyes are not level with a true horizontal line and therefore can result in an overall canted smile.
Facebow transfer with the Artex® system(6) was taken with the patient standing and aligned with the same background symmetrigraf.
Preparation for temporization involved cleansing the preps with consepsis, rinsing, lightly drying, then applying systemp desensitizer and lightly drying. Siltex putty(7) matrix custom form fabricated from the cosmetic lab wax-up was then injected with A1 Luxatemp by Zenith into the area of only the prepped teeth. This was inserted into the mouth and allowed two minutes set time. The flash acrylic was then carefully removed and the facial surfaces were polished and sealed with permaseal by Ultradent. This was a direct technique.
Make sure to vent the interproximal areas for the relief of pressure on the interproximal papillae. This will allow the tissue to creep into a wedge form thereby providing a papillary point. Instruct the patient to use a rotodent electric brush and oral rinses (hydrogen peroxide with water 50/50) for 30 seconds twice a day at home.
Selection of all ceramic systems for full coverage veneers/crowns must be made with the idea of high strength, great aesthetics, and long term stability. In general, the higher the glass content, the greater the optical properties. Combined with today’s successful adhesive cementation materials, bonding all-ceramic crowns to teeth is highly predictable and sustainable.
Elite® Finesse all-ceramic restorations were chosen to provide a consistent blackout of the interproximal spaces and for uniform color saturation.
The gingival emergence profile of the restorations is extremely important in guarding the periodontal complex and interproximal papillae.
The finesse restorations were bonded with 3M single bond adhesive and 3M relyx veneer translucent cement isolated with a rubber dam. Final cleanup and occlusal adjustments were completed.
As one can see, innovative thinking is the key to incorporating all the factors that go into accomplishing results that need multi-disciplinary clinical procedures. Yet, you the general practitioner are the one in charge of orchestrating treatment. That’s why you are called, “The General.”
James C. Downs received his D.M.D. degree from Tufts University School of Dental Medicine. He is an expert in comprehensive restorative treatment by completing numerous full-mouth reconstruction cases. He maintains an aesthetic, family-oriented practice in Denver, Colorado.