129 Test 91.1 PERIODONTICS

Placing Dental Implants and/or Natural Tooth Restorations in the Aesthetic Zone Achieving Proper Gingival Contours

key goal of aesthetic/cosmetic den- tistry is the fabrication of maintain- A able, aesthetic, and functional pros- theses that preserve the health of the teeth and soft tissues.1,2 Advances in restorative dentistry have significantly improved the clinician’s ability to deliver predictable treat- ment. When implants are indicated, osseoin- Lee H. tegration is an added factor that is essential Silverstein, DDS, for success.3 It is universally accepted that MS implant dentistry is a restorative-driven treatment with a surgical component.4 Whether implants and/or natural tooth- supported restorations are to be placed in Figure 1. Position of the implant platform if positioned Figure 2. APE, illustrating position of implant if the soft- the aesthetic zone, the following factors must at the free (FGM) when APE is present, tissue correction is not accomplished either before or at be considered in order to achieve the de- placing it too coronal for proper aesthetic development implant placement. of the restoration. sired result: • diagnosis of smile design • site development, including soft- and Gregori M. hard-tissue grafting to correct unaesthetic Kurtzman, DDS or functionally compromising anatomic David Kurtzman, abnormalities DDS • proper biologic width • gingival contours Peter C. Shatz, DDS • the removal of excessive alveolar bone and gingival tissue for the correction of a Richard “gummy” smile. Szikman, DDS All of these factors need to be considered during treatment planning and addressed prior to placement of dental implants5 or nat- ural tooth-supported restorations.6 Crown Figure 3. Position of the implant platform when placed Figure 4. Position of the implant platform when placed lengthening,7 when indicated, is critical to the at the CEJ of the adjacent teeth compromises the aes- apical to the adjacent CEJ allows for proper emergence success of creating a smile that is harmo- thetic result, as emergence profile of the implant profile of the implant restoration. restoration does not have a natural appearance. niously balanced with the surrounding facial features.8 Patients who clinically display too much gingival tissue and short clinical positioning of gingival margin when restoring the restorative margin should be positioned crowns require a fully developed diagnosis implants and/or natural teeth in the maxil- approximately midway between the gingival and treatment plan to provide a predictable lary anterior region. The focus is on optimal margin and the depth of the sulcus.15 Failure aesthetic outcome.9 This is imperative with the aesthetics and long-term tissue health. to allow sufficient space between the crown utilization of restorations.10 margin (natural tooth or implant) and the If a patient has altered passive eruption BIOLOGICAL PRINCIPLES crest of the alveolus can result in increased (APE) of the maxillary anterior teeth, but has Biological width is the measurement between inflammation and possible periodontal completed facial growth,11 then the gingival the crestal bone and the inferior aspect of the pocket formation.16 levels must first be corrected with either a periodontal sulcus, which on average is 2.04 In the absence of , the or aesthetic crown-lengthening mm and comprises the epithelial attachment osseous crest roughly follows the scalloped procedure before the placement of dental (~0.97 mm) and connective tissue (~1.07 mm). parabolic contour of the cemento-enamel implants. This ensures that the gingival mar- This translates to at least 3 mm between the junction (CEJ) and is 2 to 3 mm apical to the gin of the maxillary anterior teeth will be at most apical extension of the restorative mar- CEJ.17 In addition, the average interproximal the correct height after restoration of the gin and the crest of the alveolar bone.13 This bone height is 3 mm coronal to the facial implant, and over the long term.12 allows sufficient space for the supracrestal height of bone.18 Since the soft-tissue topog- This article discusses the principles and collagen fibers, and allows a gingival crevice raphy is usually determined by the underly- clinical techniques used to achieve correct of 2 to 3 mm.14 If this guide is followed, then continued on page 130

JULY 2007 ¥ DENTISTRY TODAY 130 PERIODONTICS

Placing Dental Implants... ing hard tissue, this osseous are to have dental implants to or too short.40 continued from page 129 “scallop” usually results in a replace missing teeth, any After proportions are gingival scallop of 3 mm.19 APE should be corrected prior achieved on the central inci- Examination of periapical to implant placement. In sors, practitioners should fo- or vertical bite-wing radi- addition, the gingiva may be cus on the height of contour of ographs will allow the clini- coronally positioned second- the gingival margin of these cian to ascertain the position ary to the following: teeth.41 The proper place- of the alveolar bone relative • plaque-induced in- ment of the peak of the para- to the CEJ20 to determine flammation28 bolic curve of the gingival whether the crest of bone • incisal attrition29 margin for the central inci- (COB) is the needed 2 to 3 mm • gingival hyperplasia re- sors, cuspids, and bicuspids from the CEJ, allowing for bio- sulting from the use of med- should be located slightly dis- logic width.21 ications such as calcium tal to the middle of the long However, occasionally the channel blocking agents, anti- axis of these teeth. This gives COB is coronal to the CEJ, a convulsants, and immunosup- these teeth the subtle distal condition that is referred to pressive agents30 root inclination that is im- as altered passive eruption • orthodontic tooth move- portant for an aesthetical- (Figure 1).22 Since the gingi- ment31 ly pleasing smile. The zenith val margin will be coronal to • deep decay causing for the lateral incisors is Figure 5. Bilateral retained maxillary deciduous cuspids and anterior altered the level of the COB, the short clinical crowns32 located at the midline of the passive eruption (APE). result is the appearance of a • traumatic injury33 long axis of the tooth. Fur- short clinical crown23 (Figure • tooth eruption after the thermore, the height of the 2). Should the soft tissue be patient has completed facial gingival crest for these teeth corrected after implant place- growth.34 should be 1 mm shorter than ment, aesthetic issues may In such cases the surgeon the gingival margins of the arise in restoring the im- should first correct the coro- adjacent teeth. For all teeth the plant, as its platform lies nally positioned gingival gingival tissues should ideally coronal to the CEJ of the ad- margins with a gingivectomy have a “knife-edge” margin.42 jacent teeth (Figure 3). These procedure, or the gingival The presence of short clin- visual findings should be cou- margins and alveolar crest ical crowns and crestal bone pled with the information levels must be altered with levels approximating the CEJ obtained by “bone sounding.” a crown-lengthening pro- indicates a diagnosis of APE. Bone sounding requires anes- cedure35 prior to the place- The practitioner can then fab- thesia and involves the use of ment of the dental implant. ricate an aesthetic guide that a to locate These procedures can be can be placed over the pa- Figure 6. Gingival recontouring in the maxillary anterior region to place the the CEJ and determine accomplished at a separate tient’s existing teeth to allow gingival margin at the CEJ. whether it can be felt within surgical visit or at the time of both the practitioner and the or only dental implant placement, patient to visualize what the when the probe penetrates but should be performed prior smile would look like with the through the base of the sul- to the preparation of the im- gingiva in a modified, more cus.24 The periodontal probe plant osteotomy.36 This will aesthetic position.43 is also used to feel for the ensure that the eventual gin- The repositioning of the alveolar crest. This value is gival margin over the dental gingival margin and crestal expressed in millimeters, re- implant will be at its correct alveolar bone requires the ad- vealing the distance between level relative to the adjacent ministration of local anesthe- the osseous crest and CEJ to anterior teeth (Figure 4). sia. A periodontal probe is ascertain whether there is placed into the sulcus, at- sufficient biologic width.25 As CLINICAL TREATMENT tempting to locate the CEJ, noted, this distance is 2 to 3 GUIDELINES AND but sometimes the CEJ can- mm in nondiseased human PROCEDURES not be discerned. In a case .26 In addition Anatomic considerations serve where the location of the CEJ to the gingival margin on the as important parameters is not clearly identified, a Figure 7. Suturing of the implant sites following extraction of the deciduous facial aspect of the teeth, in a when performing aesthetic periodontal probe should be cuspids, relocation of the crestal and interdental bone so it is 2 mm apical dentition free of disease and gingival recontouring. The passed through the periodon- to the CEJ of the adjacent teeth, and then placement of dental implants. with no bone or attachment laboratory can fabricate a tal attachment until the crest loss the tip of the interproxi- useful guide in the form of a of alveolar bone is contacted. mal papillae are approxi- wax-up. The mounted diag- Coupled with current peri- mately 4.5 mm coronal to the nostic casts are modified in apical radiographs, locating interproximal COB. The ze- wax so that ideal tooth anato- the crest should help identify nith of the facial gingival my as desired in the final the CEJ.44 margin is approximately 1.5 prosthesis is created. Guide- Surgical crown lengthen- mm more coronal to the COB. lines published by Chiche and ing is then accomplished to This osseous scallop from the Pinault should be followed.37 correct the APE. The labora- CEJ results in the tip of the These guidelines suggest that tory-fabricated gingival aes- papilla being on average 4.5 the average length for aes- thetic guide can be used not mm coronal to the free gingi- thetically pleasing maxillary only to position the alveolar val margin.27 central incisors is 10 to 12 crest 3 mm apical to the However, if the alveolar mm,38 and the width-to- CEJ,45 but also to provide a bone is not in the “normal” length ratio is 75% to 80%.39 blueprint for attaining hori- position (2 to 3 mm apical to These guidelines should be zontal gingival symmetry and the CEJ), these aforemen- kept in mind when recontour- height. The guide will also Figure 8. Four weeks after surgery, demonstrating gingival margins of the tioned values would need to ing the gingival tissues so as ensure proper interproximal anterior teeth at their proper position. be adjusted. When patients not to leave the teeth too long continued on page 132

DENTISTRY TODAY ¥ JULY 2007 132 PERIODONTICS

Placing Dental Implants... Woodson No. 2 elevator), and ural teeth for restorations. After approximately 60 to 90 continued from page 130 osseous resection is per- By using a gingivectomy or seconds, the provisionals are formed with a surgical length crown-lengthening procedure removed and trimmed. The No. 8 round diamond bur (No. to properly establish the gin- provisionals are bonded in 5801 [Brasseler]) and peri- gival smile line prior to im- place by spot etching the odontal hand chisels (Kirk- plant placement or natural preparations and using Tet- land 15/16 [Hu-Friedy]). tooth preparation, a proper ric Flow (Ivoclar Vivadent) as The surgical flap can then prosthetic emergence profile the luting material. be positioned to the pre- can be established with a The occlusion should then arranged height determined well-constructed provisional be checked in centric, protru- by the aesthetic surgical restoration. This is true if the sive, and lateral excursive guide. The flaps are sutured abutments are supported by positions50 and adjusted as using a 3/8 reverse cutting implants or natural teeth. needed. The patient returns suture needle (Hu-Friedy) When the restorative phase to the office 10 days after with a 4-0 thread of polygly- of treatment begins, the teeth insertion of the provisional colic acid, using a sling suture can be prepared with burs restorations and provides technique. Suture removal is such as the KS burs (Brasseler), input about the aesthetics. performed 10 days following using the aesthetic guide as a Subsequent to recontouring surgery, and the patient is blueprint for tooth reduction. the provisional restorations Figure 9. Uncovering implants and placement of healing abutments (4 mm). instructed in the For full-coverage restora- to meet the patient’s expecta- regimen to be used. This in- tions, ceramic crowns provide tions, impressions are taken cludes brushing with a soft- excellent aesthetics. Prepara- and a putty matrix of the scalloping. The newly estab- The surgical incision can bristled in a circu- tions for these crowns are anterior segment is made to lished gingival margin will be transverse the base of the lar motion and cleaning in- either placed at the free gingi- ensure that the laboratory determined by the patient’s papillary tissue or can follow terdentally with either den- val margin or slightly subgin- has correctly placed the lip line while smiling,46 the the topography of the inter- tal tape or floss. Additional- gival on the facial aspect. incisal edges. desired length of anterior dental papilla. For aesthetic ly, Stim-U-Dents (Johnson Care should be taken not to Final impressions are teeth relative to the existing success at this critical phase & Johnson) can be used to violate the biologic width dur- obtained 6 to 8 weeks later51 level of alveolar bone,47 and of , it is maintain the apically reposi- ing tooth preparation.49 using a 2-cord method with a healthy interdental tissue.48 important not to elevate the tioned gingiva while remov- Provisional restorations can woven retraction cord such as Scalloping the gingival papilla, which usually will ing bacterial plaque. be made by placing Luxatemp Ultrapak (Ultradent Prod- tissues is accomplished with result in loss of interproximal Ten weeks should be al- (Zenith/DMG) in a vacuum- ucts). Care is taken so the a 15c surgical blade. An tissue height. lowed for postoperative heal- formed matrix that was fabri- gingival tissues are not in- inverse beveled incision is A full-thickness mucoper- ing before beginning either cated on the modified model jured. Full-mouth impres- made, connecting the sulci of iosteal flap is then elevated implant placement (if re- from which the aesthetic sur- sions are taken with vinyl the affected maxillary teeth. with a periosteal elevator (ie, quired) or preparation of nat- gical guide was fabricated. polysiloxane (Take 1 [Kerr]), and face-bow transfer and open bite centric relation records are obtained using LuxaBite registration materi- al (Zenith/DMG). The models are mounted in a semiad- justable articulator such as the Stratos 200 articulator (Ivoclar Vivadent). The case can be completed using full feldspathic porcelain crowns (Colorlogic [DENTSPLY Cer- amco]), which are bonded with both OptiBond Solo Plus (Kerr) and Variolink II (Ivo- clar Vivadent). Excess cement is removed with an explorer and periodontal scaler. The previously fabricated putty facial index should be placed to see if there are any dis- crepancies. Such discrepan- cies are modified.

CLINICAL EXAMPLE A clinical case is described in Figures 5 to 10. In this case, 2 implants replaced 2 retained deciduous cuspids that were extracted after gingival recon- touring was accomplished. As shown, the result of these pro- cedures is a healthy periodon- tium, and the symmetry of the smile illustrates a completed healthy, aesthetic, and func- tional restorative result. The FREEinfo, circle 78 on card 133 PERIODONTICS

location of the CEJ relative to It is also paramount when their position relative to the point is greater than the dis- The gingival margin the COB, the crown-to-root establishing the proper posi- crown length of the maxillary tance between the contact ratio and the shape of the tion of the maxillary anterior incisors. It has been demon- point and the incisal edge, should be assessed root(s), the amount of existing teeth for an optimal cosmetic strated58 that if the height then there is an indication relative to the project- tooth structure, and the sul- outcome to assess the level of between the interdental that there has been signifi- ed incisal edge posi- cus/pocket depth. the interdental papillae and papilla base and the contact continued on page 134 tion. A predictable method for determin- ing the proper gingi- val position is to determine the desired tooth size relative to the projected incisal edge position. central incisors demonstrate midline symmetry as well as the correct 75% to 80% width- to-length ratio. In addition, the incisal smile line follows the curvature of the lower lip.52 The newly established smile line is more aesthetically ap- pealing and harmonious with surrounding facial features.53

DISCUSSION The gingival margin should be assessed relative to the projected incisal edge posi- tion. A predictable method for determining the proper gingi- val position is to determine the desired tooth size relative to the projected incisal edge position. The practitioner should remember that the incisal edge should not be positioned using the location of the gingival margin to cre- ate the proper tooth size. This is because the gingival mar- gin can move with eruption or recession.54 Therefore, the proper position of the gingival margin should be determined by establishing the correct width-to-length ratio of the maxillary anterior teeth,55 using the width-to-length ratio as previously published by Sterrett et al.39 In general, the amount of gingival dis- play must create symmetry among the teeth throughout the maxillary arch.56 If the existing position of the gingival margin creates a short clinical crown relative to the incisal edge, then the gingival margins should be moved apically. This can be accomplished by performing crown lengthening, gingivec- tomy, orthodontic intrusion, and/or prosthetic rehabilita- tion.57 The procedure that is chosen depends upon several clinical factors, such as the TO ORDER CALL 800-528-8537 or circle 79 on card 134 PERIODONTICS

Placing Dental Implants... tal implant restorations. If a to the gingival margin, and 4 8. Levine RA, Randel H. Multidisciplinary approach to solving cosmetic dilem- continued from page 133 patient has altered passive to 5 mm from the interproxi- mas in the esthetic zone. Contemp eruption of the maxillary mal COB to the tip of the Esthet Restor Pract. 2001;5:62-67. 9. Chiche G, Kovich V, Caudill R. anterior teeth either second- papilla, is appropriate when Diagnosis and treatment planning of ary to orthodontic treatment there is no bone and/or at- esthetic problems. In: Pinault A, or in the absence of orthodon- tachment loss. Further, if the Chiche G. Esthetics of Anterior Fixed Prosthodontics. Chicago, Ill: Quin- tic therapy, and the patient gingival margin is not locat- tessence;1994:Chapter 2. has completed facial growth, ed at the CEJ and the under- 10. Kokich VG. Maxillary lateral incisor implants: the orthodontic perspective. then the surgeon must first lying bone is not 2 to 3 mm Adv Esthet Interdisc Dent. 2006;2: correct the gingival level apical to the CEJ with its 32-39. 11. Kokich VG. Managing orthodontic- with either a gingivectomy parabolic contours, then the restorative treatment for the adoles- or crown-lengthening proce- distances of 3 mm on the cent patient. In: McNamara JA Jr, ed. Orthodontics and Dentofacial Ortho- dure before the placement of facial and 4 to 5 mm on the pedics. Ann Arbor, Mich: Needham dental implants. This will interproximal area should Press. 2001:395-422. ensure that the gingival mar- not be used. ! 12. Rufenacht CR. Structural esthetic rules. In: Fundamentals of Esthetics. gin of the maxillary anterior Chicago, Ill: Quintessence; 1992:134. teeth will be at its correct References 13. Carranza FA, Newman MG. Clinical 1. Niessen L. Customers for life: market- . 8th ed. Philadelphia, level relative to the adjacent ing oral health care to older adults. J Pa: WB Saunders; 1996:720-722. anterior teeth, not only after Calif Dent Assoc. 1999;27:724-727. 14. Gargiulo AW, Wentz FM, Orban B. restoration of the implant, 2. Goldstein RE. Change Your Smile. 3rd Dimensions and relations of the den- Figure 10. Completed smile 2 years after restoration of the maxillary ed. Chicago, Ill: Quintessence; 1997. togingival junction in humans. J implants. but for the long term. It is 3. Francischone CE, Vasconcelos LW, Periodontol. 1961;32:261-267. essential that there be at Branemark PI. Osseointegration and 15. Goldstein RE. Esthetics in Dentistry. Esthetics in Single Tooth Rehabil- Philadelphia, Pa: Lippincott; 1976: least 3 mm between the itation. Chicago, Ill: Quintessence; 425-455. cant occlusal abrasion. This forming crown lengthening60 most apical extension of the 2000. 16. Smukler H, Chaibi M. Periodontal and 4. Salama MA, Salama H, Garber DA. dental considerations in clinical crown scenario may cause shorter and/or orthodontic therapy to restorative margin and the Guidelines for aesthetic restorative extension: a rational basis for treat- crowns, which shortens the either intrude61 or extrude62 alveolar bone crest. This options and implant site enhancement: ment. Int J Periodontics Restorative contact between the central the affected teeth. allows sufficient room for the utilization of orthodontic extrusion. Dent. 1997;17:464-477. Pract Proced Aesthet Dent. 2002; 17. Weinman JP, Sicher H. Bone and incisors. However, if the inter- insertion of the supracrestal 14:125-130. Bones: Fundamentals of Bone Biology. dental contact point is longer CONCLUSION collagen fibers, as well as 5. Kois JC. Altering gingival levels: the 2nd ed. St Louis, Mo: CV Mosby; 1955. restorative connection, part I: biologic 18. Hermann JS, Cochran DL, Num- than the papilla, then the For patients who display too provides a gingival crevice of variables. J Esthet Dent. 1994;6:3-9. mikoski PV, et al. Crestal bone contour of the gingival mar- much gingiva and short teeth, 2 to 3 mm. 6. Chiche G. A six-step approach to changes around titanium implants. A demystifying esthetics. Presented at: radiographic evaluation of unloaded gin would be flat and usually a thorough diagnosis and For proper implant place- American Academy of Esthetic Den- nonsubmerged and submerged im- located coronal to the CEJ, treatment plan are needed to ment that allows for a proper tistry 21st Annual Meeting; August 8, plants in the canine mandible. J 1996; Philadelphia, Pa. Periodontol. 1997;68:1117-1130. analogous to the clinical pres- provide a predictable aesthet- restorative result, the guide- 7. Morley J. A multidisciplinary approach 19. Saadoun AP, Le Gall MG, Touati B. entation of APE.59 Correction ic outcome. This is especially line of 3 mm on the facial to complex aesthetic restoration with Current trends in implantology: part II- would be accomplished by per- important when utilizing den- aspect from the osseous crest diagnostic planning. Pract Periodon- -treatment planning, aesthetic consid- tics Aesthet Dent. 2000;12:575-577. erations, and tissue regneration. Pract Proced Aesthet Dent. 2004;16: 707-714. 20. Levine RA, McGuire M. The diagnosis and treatment of the gummy smile. Compend Contin Educ Dent. 1997; 18:757-764. 21. Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification of delayed passive eruption of the dentogingival junction in the adult. Alpha Omegan. 1997;70:24-28. 22. Robbins JW. Esthetic gingival recon- touring: caveat emptor. Contemp Esthet Restor Pract. 2002;6:66-74. 23. Dolt AH III, Robbins JW. Altered pas- sive eruption: an etiology of short clin- ical crowns. Quintessence Int. 1997; 28:363-372. 24. Rosenberg ES, Cho SC, Garber DA. Crown lengthening revisited. Com- pend Contin Educ Dent. 1999;20: 527-538. 25. Garnick JJ, Silverstein LH. Periodontal probing: what does it mean? In: Clark’s Clinical Dentistry. Vol 3. Philadelphia, Pa: Lippincott; 1997:1-15. 26. Ten Cate AR. The development of the periodontium. In: Melcher AR, Bowen WH, eds. Biology of the Periodontium. New York, NY: Academic Press; 1969. 27. Spear FA. The esthetic management of multiple missing anterior teeth. Inside Dentistry. 2007;3:72-76. 28. Silverstein LH, Garnick JJ, Szikman M, et al. Medication-induced : a clinical review. Gen Dent. 1997;371-376. 29. Amstad-Jossi M, Schroeder HE. Age- related alterations of periodontal struc- tures around the cemento-enamel junction and of the gingival connective tissue composition in germ-free rats. J Periodontal Res. 1978;13:76-90. 30. Magne P, Magne M, Belser U. Natural and restorative oral esthetics. Part I: rationale and basic strategies for suc- cessful esthetic rehabilitations. J Esthet Dent. 1993;5:161-173. 31. Silverstein LH, Koch JP, Lefkove MD, et al. Nifedipine-induced gingival enlargement around dental implants: a clinical report. J Oral Implantol. 1995;21:116-120. BUY DIRECT CALL 800-423-5657 or circle 80 on card 135 PERIODONTICS

32. Kokich VG, Kokich VO. Inter- 57. Kokich VG, Kokich VO. Orthodontic relationship of orthodontics with peri- therapy for the periodontal-restorative odontics and restorative dentistry. In: patient. In: Rose LF, Mealey BL, Nanda R, ed. Biomechanics and Genco RJ, Cohen DW, eds. Esthetic Strategies in Clinical Periodontics: Medicine, Surgery, and Continuing Education Orthodontics. St Louis, Mo: Elsevier; Implants. 2nd rev ed. St Louis, Mo: 2005:348-373. Mosby; 2004:718-744. 33. Goldstein RE. Esthetics in Dentistry. 58. Spear FM. Maintenance of the inter- Hamilton, Ontario, Canada: BC dental papilla following anterior tooth Decker; 2002(2):703-775. removal. Pract Periodontics Aesthet Test No. 91.1 34. Studer S, Zellweger U, Scharer P.The Dent. 1999;11:21-28. aesthetic guidelines of the mucogingi- 59. Kokich VG, Spear F. Guidelines for val complex for fixed prosthodontics. treating the orthodontic-restorative Pract Periodontics Aesthet Dent. patient. Semin Orthod Dentofacial 1996;8:333-341. Orthop. 1999;3:3-20. o submit Continuing Education answers, use the answer sheet on page 128. On the 35. Silverstein LH, Meffert RM, Jeffcoat M, 60. Koyuturk AE, Malkoc S. Orthodontic et al. Clinicians guide to peri-implantol- extrusion of subgingivally fractured answer sheet, identify the article (this one is Test 91.1), place an X in the box corre- ogy. In: Clark’s Clinical Dentistry. Vol 5. incisor before restoration. A case sponding to the answer you believe is correct, detach the answer sheet from the St Louis, Mo: Mosby YearBook; report: 3-years follow-up. Dent T magazine, and mail to Dentistry Today Department of Continuing Education. 1998:chap 62A. Traumatol. 2005;21:174-178. 36. Levine RA, Katz D. Developing a team 61. Salama H, Salama M, Kelly J. The approach to complex aesthetics: treat- orthodontic-periodontal connection in The following 8 questions were derived from the article Placing Dental Implants and/or ment considerations. Pract Proced implant site development. Pract Aesthet Dent. 2003;15:301-306. Periodontics Aesthet Dent. 1996; Natural Tooth Restorations in the Aesthetic Zone: Achieving Proper Gingival Contours by Lee H. 37. Chiche GJ, Pinault A. Esthetics of 8:923-932. Silverstein, DDS, MS, et al on pages 129 through 135. Anterior Fixed Prosthodontics. Carol 62. Silverstein LH, Kurtzman D, Cohen R, Stream, Ill: Quintessence; 1994. et al. Adjunctive Orchestrated 38. Singer BA. Principles of esthetics. Orthodontic Therapy: an emerging Curr Opin Cosmet Dent. 1994;6-12. trend in cosmetic dentistry. Alpha Learning Objectives 39. Sterrett JD, Oliver T, Robinson F, et al. Omegan. 2001;94:27-33. Width/length ratios of normal clinical crowns of the maxillary anterior denti- After reading this article, the individual will learn: tion in man. J Clin Periodontol. Acknowledgment 1999;26:153-157. Illustrations accompanying 40. Spear FM, Kokich VG, Mathews DP. ¥ aesthetic concerns prior to placing implants or natural tooth-supported this article were created by Interdisciplinary management of ante- restorations, and rior dental esthetics. J Am Dent Assoc. David Kurtzman, DDS. 2006;137:160-169. ¥ treatment guidelines and procedures for achieving aesthetic and biologically healthy 41. Ahmad I. Geometric considerations in gingival contours when placing implants or natural tooth-supported restorations. anterior dental aesthetics: restorative principles. Pract Periodontics Aesthet Dent. 1998;10:813-822. Dr. Silverstein is an associate clini- 42. Chalifoux PR. Checklist to aesthetic dentistry. Pract Periodontics Aesthet cal professor of periodontics at the Dent. 1990;2:9-12. Medical College of Georgia in 1. Biological width dictates that at least 5. When evaluating altered passive erup- 43. Spear F. Construction and use of a Augusta. He has published more ____ mm be present between the resto- tion during the clinical examination, surgical guide for anterior periodontal than 100 scientific articles and has surgery. Contemp Esthet Restor Pract. written 8 textbook chapters. He is on ration margin and the crestal bone. determination of where the gingival April 1999;12-20. the contributing editorial boards of a. 2 margin should be located is made by ___. 44. Garnick JJ, Silverstein LH. Periodontal Practical Periodontics and Aesthetic b.3 a. probing into the sulcus to determine where probing: probe tip diameter. J Dentistry, Dentistry Today, Collabo- Periodontol. 2000;71:96-103. c. 4 the crestal bone is located rative Dental Techniques, Inside 45. Singer BA. Fundamentals of esthetics. d. 5 b. identification on periapical radiographs In: Aschheim KW, Dale BG, eds. Dentistry, Functional Esthetics and Esthetic Dentistry: A Clinical Ap- Restorative Dentistry, and General c. an arbitrary determination based on proach to Techniques and Materials. Dentistry. He is the author of 2. The interproximal papillae between teeth aesthetics Philadelphia, Pa: Lea & Febiger; Principles of Dental Suturing: A with a healthy periodontium and no bone d. both a and b 1993:5-13. Complete Guide to Surgical Closure 46. van der Geld PA, van Waas MA. The and has just completed a new text- loss are approximately ____ mm coronal smile line: a literature search [in book, Principles of Soft Tissue to the interproximal crest of bone. 6. A stent based upon a diagnostic wax-up Dutch]. Ned Tijdschr Tandheelkd. 2003;110:350-354. Surgery: A Complete Step by Step a. 4 does which of the following? Procedural Guide. Dr Silverstein 47. Kois JC. Predictable single-tooth peri- b. 4.5 a. assists in guiding the periodontal surgery implant esthetics: five diagnostic keys. maintains a private practice at Compend Contin Educ Dent. Kennestone Periodontics in Marietta, c. 5 b. assists in temporization fabrication of 2004;25:895-900. Ga. He can be reached at (770) 952- d. 5.5 the case 48. Kan JY, Rungcharassaeng K, Umezu 5432 or [email protected]. K, et al. Dimensions of peri-implant c. acts as a blueprint in treatment planning mucosa: an evaluation of maxillary 3. Altered passive eruption when present d. all of the above Dr. G. Kurtzman is in private general anterior single implants in humans. J on teeth adjacent to an implant site Periodontol. 2003;74:557-562. practice in Silver Spring, Md. He has 49. Silness J. Periodontal conditions in lectured both nationally and interna- should be corrected ____. 7. To avoid the creation of “black triangles” patients treated with dental bridges. 3. tionally on the topics of restorative a. before implant placement during periodontal surgery, ____. The relationship between the location dentistry, endodontics, and dental b. after implant placement a. flap design should split the papilla of the crown margin and the periodon- implant surgery and prosthetics. He tal condition. J Periodontal Res. can be reached at dr_kurtzman@ c. at implant uncovery b. flap design should include the papilla 1970;5:225-229. maryland-implants.com. 50. Wolffe GN, van der Weijden FA, d. following restoration of the implant c. flap design should not include the papilla Spanauf AJ, et al. Lengthening clinical d. both a and b crowns: a solution for specific peri- Dr. D. Kurtzman is in private general 4. The recommended width-to-length ratio practice in Marietta, Ga. He is an odontal, restorative, and esthetic prob- 8. lems. Quintessence Int. 1994;25: accomplished illustrator and can be of maxillary central incisors is ____. A predictable method of determining the 81-88. contacted at [email protected]. a. 60% proper gingival position is to determine 51. Hornbrook DS. Cementation of all- b. 70% the desired tooth size relative to ____. ceramic veneers using the “tack and Dr. Shatz is assistant clinical profes- wave” technique. Contemp Esthet sor of periodontics at the Medical c. 75% a. the projected incisal edge position Restor Pract. 2002;6:36-48. d. 90% b. width-to-length ratio of the teeth on a 52. Rufenacht CR. Principles of Esthetic College of Georgia in Augusta and is Integration. Carol Stream, Ill: Quin- in private practice in Marietta, Ga. He mock-up model tessence; 2000:73-97. can be reached at kenperio@bell- c. width-to-length ratio of the teeth on a study 53. Gottlieb B, Orban B. Active and pas- south.net. sive continuous eruption of the teeth. J model Dent Res. 1933;13:214. Dr. Szikman is in private practice in d. both a and b 54. Gillen RJ, Schwartz RS, Hilton TJ, et Marietta, Ga, practicing cosmetic al. An analysis of selected normative and implant dentistry at the Szikman tooth proportions. Int J Prosthodont. 1994;7:410-417. Dental Group. He can be reached at 55. Becker W, Ochsenbein C, Becker BE. [email protected]. Crown lengthening: the periodontal- restorative connection. Compend Contin Educ Dent. 1998;19:239-246. 56. Kokich VG. Esthetics and anterior tooth position: an orthodontic perspec- tive. Part 1: crown length. J Esthet Continuing our “Journey of Excellence” Dent. 1993;5:19-23.

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