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Periodontics 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 gingival margin (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 dental implant 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 periodontal disease, the gingivectomy 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 periodontal probe 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 gingival sulcus 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 periodontium.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.
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