the international journal of periodontics & restorative ... · development of the biologic...

The International Journal of Periodontics & Restorative Dentistry

© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Volume 36, Number 1, 2016

83

©2016 by Quintessence Publishing Co Inc.

1 Lecturer, Steinbeis Institute University, Berlin, Germany; Private Practice, Rome.2 Private Practice, Rome.3 Founder and Director, Kois Center, Seattle, Washington, USA. Correspondence to: Dr Piero Simeone, via Antonio Bertolini 1/E, cap 00199 Rome, Italy. Fax: +39 06 80692066. Email: [email protected]

Managing Severe Periodontal Esthetic Challenges: The Restorative-Surgical Connection

When treating patients with severe periodontal disease, dentists often face the difficult dilemma of how to effectively treat the disease while satisfying patient esthetic demands.1 Care must be taken to evaluate the patient’s periodontal anatomy and the position of the planned prosthetic margin to ensure proper development of the biologic architecture. The treatment goals for this patient included exposure of adequate tooth structure for the placement of a restorative margin, establishment of a healthy dentogingival complex, and the subsequent fabrication of a well-fitting, esthetically pleasing definitive restoration.2 This article presents a case where careful communication between the restorative dentist, the periodontal surgeon, and the laboratory technician resulted in a predictable esthetic and restorative outcome while improving the periodontal health of the patient. Key to this collaboration was the use of a structured treatment-planning protocol and the fabrication of a realistic cast, which represented the three-dimensional anterior soft tissue architecture as it was present in the patient’s mouth. Int J Periodontics Restorative Dent 2016;36:83–93. doi: 10.11607/prd.2618

When treating patients with severe periodontal disease, dentists often face the difficult dilemma of effec-tively treating the disease while sat-isfying patients’ esthetic demands. Correct clinical crown length is de-termined by the amount of tooth display necessary for esthetics, and must follow proportion guidelines for pleasing tooth shapes.3 Surgi-cal crown lengthening may be nec-essary to expose adequate sound tooth structure when extensive car-ies, crown fracture, faulty preexist-ing margins, or failed restorations require the placement of a restora-tion margin where biologic width violation would be a risk.4,5 Peri-odontal surgery may also be nec-essary to correct excessive gingival display or to reposition the dento-gingival complex as an adjunct to esthetic restorative procedures, or as needed for periodontal health reasons.6 The proper occlusogin-gival position of the interproximal papilla is critical to achieve esthetic success and prevent black holes in the interproximal gingival region.7 In this case, repositioning the peri-odontal tissues was necessary to correct the compromised dentogin-gival complex and reestablish more esthetically pleasing proportions of the dentition in the face.

Although numerous techniques and technologies are available to in-crease the quality and predictability

Piero Simeone, DDS, MSc, CDT1

Giuseppe Leofreddi, DDS2

John C. Kois, DMD, MSD3



84

of dental treatment, this case was managed with the use of a struc-tured treatment planning approach and a stone cast that accurately rep-resented the preoperative soft tis-sue contours, to determine clinical end points before any treatment.

The clinical team, composed of a restorative dentist, a peri-odontal surgeon, and a laboratory technician, created four diagnos-tic parameters for prosthetically

guided surgery in a patient with ex-tensive periodontal disease to de-crease periodontal pocket depths and reduce excess tissue display in a nonesthetic gummy smile.

Case Presentation

A 58-year-old woman presented with a noncontributory (ASA 1) medical history and generalized ad-

vanced periodontal disease (AAP Type IV). Probing depths rang-ing from 3 to 7 mm were present on teeth 13 to 23 with no mobility (Table 1); the patient exhibited no additional shared risk factors (Fig 1). The loss of supporting periodontal architecture also resulted in com-promised esthetics. Unfortunately, the high lip dynamics contributed to a gingival tissue display (gummy smile) that was no longer estheti-cally pleasing (Fig 2).6 Most obvious were the asymmetric gingival levels with a generalized facial recession of 2 mm and the interproximal loss of the dental papilla (black holes) (Fig 3).

Table 1 Periodontal probing scores for teeth 13 to 23

Tooth 13 12 11 21 22 23

Lingual 4 3 5 6 3 6 7 3 7 4 3 5 6 2 5 3 2 3

Facial 3 2 4 5 3 6 6 4 7 4 3 4 5 3 4 3 2 3

Fig 1 Initial full-mouth radiograph.

Fig 3 Intraoral view showing the loss of interdental papilla, gingival asymmetry, and root exposure.

Fig 2 Patient showing a gummy smile and unesthetic loss of inter-dental papilla (black holes).



85

Clinical examination and planning strategy

Diagnostic approach

As the etiology of the open gingival embrasures included bone loss and tooth morphology, the treatment re-quired an interdisciplinary diagnos-tic approach including periodontal, restorative, and orthodontic evalu-ations. A careful radiographic ex-amination provided important information to the clinical team and included the use of radiopaque markers to quantify interdental soft tissue loss.8 The resulting informa-tion was used to fabricate a realistic

cast that accurately represented the preoperative hard and soft tissue positions. This cast contained the morphologic information for peri-odontal-restorative simulation.9 The aim of this approach was to provide a three-dimensional previsualization of the final esthetic outcome that would result from the surgical and restorative laboratory procedures.

Diagnostic findings

The cephalometric analysis indi-cated that this patient had a skel-etal Class II relationship combined with significant anterior vertical

overlap. It was also determined that the deep bite was caused primarily by the maxillary tooth position and the relationship of the maxillary in-cisal edge to the lips. The vertical dimension of occlusion was within the normal range (Fig 4).10

Periapical radiographs indicated that the root inclination and posi-tion were in the normal range. Ra-diopaque markers, made by mixing eugenol cement and amalgam pow-der, were applied between teeth in the black holes to radiographi-cally show the tip of the papilla, the amount of interdental papilla loss relative to the osseous crest, and the interdental contact point position

Fig 4a (left) Cephalometric analysis was focused on the upper maxilla and the anterior teeth position relative to the lip line. The lower occlusal plane was in the norm, and the upper incisal edge was below the lower lip line.

Fig 4b (below) Clinical view showing the amount of the deep bite (lower blue line). The upper blue line reflects the position of the lower lip line at rest position. These two parameters were measured and confirmed in the cephalometric analysis.



86

(Fig 5). This approach was useful in determining the new central incisal edge position, interdental contact areas, and teeth sizes in relation to the bone crest and lip lines.11

Treatment planning and therapeutic sequence

After full mouth scaling and root planing, all second molars were re-moved since they presented severe loss of attachment, Class III mobility, and furcation involvement. In accor-dance with the patient, the decision was made to surgically correct the furcation area of the mandibular left first molar to make it accessible for the hygiene procedures. After this preliminary phase, surgical pocket

elimination of the maxillary anterior area was carried out. Four months after the extractions, implants were placed in the maxillary left and man-dibular right posterior regions.

Three months later, provision-als were screwed to the fixtures to serve as anchorage for the orth-odontic treatment of the maxillary first premolar, which needed to be moved mesially to better manage the area between the canine and first premolar.

From a restorative point of view, the case was split into two phases: first, the implant impressions were taken, and then, when the esthetic and functional try-in of the poste-rior areas was ready, the anterior teeth were prepared to receive ve-neers. At this point, a final impres-

sion of the maxillary anterior teeth was made, picking up the posterior bisque bake to finalize the case.

Fabrication of the realistic cast for anterior evaluation

The realistic cast included the di-agnostic information necessary to redesign the new restorations after the periodontal surgical procedure. The diameters of the roots were replicated directly from the mesio-distal radiograph measurements, to allow a more appropriate form and profiles of the new restorations after the surgical exposure of the roots to avoid an unsatisfactory fi-nal esthetic result. In other words, the bone position, gingival amount,

Fig 5a The black holes were fully filled with eugenol cement mixed with amalgam powder to visualize the tip of the soft tissues relative to the bony crest.

Fig 5b Periapical radiographs clearly showing the markers, providing an easy way to atraumatically measure the distance between the tip of the papilla and the bone with a probe.



87

and radicular anatomy were repro-duced in an artificial manner by means of probing and radiograph-ic examinations with radiopaque markers (Figs 6 and 7).

Comprehensive presurgical planning

Reducing the periodontal pocket depth represented an opportunity to reestablish a new, healthy den-togingival complex in relation to a more appropriate anterior display.

Based on the diagnostic find-ings and clinical considerations, the treatment proposed was to move the entire dentogingival complex in an apical direction to compen-sate for the elongated black holes that would be present after pocket elimination surgery. This would also correct the gummy smile and elimi-nate the periodontal pockets, while shortening the incisal edge posi-tion would reduce the deep bite.

With this periodontal-restorative approach, the initial step was to re-define the upper incisal edge posi-tion of the new restorations relative to the lips at rest and the upper smile line.

Four distinct diagnostic param-eters were assessed to determine the altered position of the entire dentogingival complex:

1. The location of the ideal incisal edge position in the face

2. Requirements for visual harmony with the posterior maxillary occlusal plane

3. The amount of tooth display due to lip dynamics

4. The position, symmetry, and scallop of the gingival architecture

These four parameters were repre-sented on the realistic cast together with radiographic measurements to previsualize the final result in com-bination with the correction of the gingival pockets.

After the surgical pocket elimi-nation, the embrasures were in fact compensated for by the shortened overbite of the new restorations. The realistic cast was a useful ad-

junct to visualize the root position and anatomy relative to new gingi-val architecture in order to complete the diagnostic wax-up in combina-tion with the surgical pocket elimi-nation (Fig 8).

Restorative planning

Kois stated, “The most critical re-lationship for biologic health when the clinician is placing a restoration at or below the free gingival margin is the margin location relative to the

Fig 7a The cast demonstrated the gingival height recorded in the radiograph mea-surements as shown in Fig 5b. The cast also shows the bone in a realistic position.

Fig 7b The gingival architecture reflects the clinical reality: the artificial gum reflects the actual clinical coverage of the cervical portion of the root as made from radiograph measurements. This type of cast is essential to previsualize the esthetic effect of surgery to better program the final restorations.

Fig 6a Cast showing gingival architecture without teeth and roots. Bone is not visualized.

Fig 6b The cervical third of the roots was reproduced from the radiograph measure-ments (using the mesiodistal diameter) and had the same dimensions on the realistic cast as in the radiographs.



88

bony crest.”5 The distance from the free gingival margin to the osseous crest on the facial aspect is normally 3 mm based on the most coronal position of the bone, line angle to line angle.12 The height of the inter-dental papillae can also be predict-ed to be 4 mm incisal to the osseous crest between anterior teeth with normal root proximity, assuming the interproximal distance is ≤ 2 mm at the osseous crest.13–16 Keeping these parameters in mind, the decision about where to place the restor-

ative margin must be made. Ideally, the margin should be placed at the free gingival crest or slightly supra-gingival. If an intracrevicular margin is required for esthetic reasons, it should be placed approximately 0.5 to 1 mm apical to the free gingival margin to avoid detrimental effects to the attachment apparatus.

Prior to beginning any restor-ative treatment, the clinician must take into account these biologic parameters when deciding on both design and material selection for

the final restoration. To minimize the tooth preparation and not increase biomechanical risks for structural compromise and pulpal health, ve-neers were chosen as a conservative approach.

Clinical procedures: Surgical periodontal

A submarginal incision was carried out according to the pocket depth previously measured and trans-

Fig 8a This realistic cast exactly mimicked the three-dimensional gingival architecture and crown-root anatomy. The image shows a replica of the soft and hard tissues.

Fig 8c Surgical simulation of the gingival pocket elimination and root anatomy exposure on the realistic cast. The remaining gingival thickness is 3 mm buccal-palatal and 5 mm interproximal from the bone (stone). This approach allows the clinicians to visualize the esthetic result of the surgery to better plan the restorations.

Fig 8b The dotted line marked the incision for the new gingival symmetry relative to the clinical probings and new smile line for surgical simulation.

Fig 8d Planning of new restorations as a consequence of the surgi-cal intervention. Based on the clinical and radiographic analysis, the dental display was moved apically to compensate for the surgi-cal pocket elimination. This is a useful tool to discuss the therapy plan with the patients before any treatment. Veneers were planned to preserve the dental structure with minimally invasive treatment.



89

ferred to the buccal gingiva, and a full thickness flap was elevated to expose the alveolar bone (Figs 9a and 9b). Once the secondary flap

was removed, the maxillary left central incisor was lengthened, giv-ing particular care to remodel the peak of bone on the mesial aspect

of that tooth (Fig 9c). The mock-up made on the realistic cast was used in this phase to check the new pros-thetic margin location relative to

Fig 9a A submarginal incision was made according to the pocket depth.

Fig 9b The flap was raised to expose the bone structure.

Fig 9c An osteoplasty was performed to level and align the scallops according to the new smile line. The maxillary first pre-molar was also included in the treatment for esthetic reasons.

Fig 9d The mock-up was used to check the new prosthetic margin location relative to the bone and the new incisal edge position.

Fig 9e Connective tissue suture.

Fig 9f Clinical view 2 months postoperative. Fig 9g Clinical view 18 months postoperative. This extended postoperative follow-up was strategically planned with the patient because of postsurgical healing and orthodontic therapy on the posteriors. The anterior surgical pocket elimination was planned as the first step after professional hygiene and extraction of the molars.



90

the bone and the new incisal edge position (Fig 9d). The roots were scaled and the flap was then placed at the predetermined gingival mar-gin level based on the information derived from the working cast, with respect to the biologic width and the esthetic upper lip smile line. The full thickness flap was sutured in that position, and the sutures were removed 10 days postopera-tive (Fig 9e).

The surgical procedure facilitat-ed the reestablishment of the new dentogingival complex at a more apical position to simultaneously re-

duce the periodontal pocket depth and the excessive gingival display (Figs 9f and 9g).12, 17–25

Clinical procedures: Restorative

Lithium disilicate material was cho-sen to restore the maxillary anterior teeth, the maxillary posterior seg-ment was restored with the Zirconia framework on implant abutments, and metal-ceramic was chosen for the mandibular right molar for me-chanical reasons.26

The incisal margins of the lon-gest teeth (12 and 22) were first reduced to the predetermined in-cisal length while accommodating pulpal chamber preservation (Fig 10). The contact points were pre-pared to enable the technician to easily close the cervical area with porcelain as planned on the realis-tic cast. To be more conservative, the preparations were strategically planned for the buccal application of veneers.

The remaining tooth structure was reduced using the same ap-proach, thus removing tooth struc-

Fig 11 Preparations ready for impressioning with retraction cord in the crevicular sulcus. Horizontal positioning of the veneers was planned to preserve lingual tooth structure.

Fig 10 Leveling phase of the upper incisal edge: (left) the black marker was recorded from the lower lip position and (right) replaced in the wax-up.



91

Fig 13 Veneers completed and ready for cementation. The cervical area was built with monolithic ceramic while the remainder of the restorations had porcelain veneered on the core.

Fig 12 Final impression for anterior veneers. The posterior crowns were incorporated into the silicone. Note the gentle finish line sliding in the displaced crevicular area. The cervical preparation area was on the radicular portion, as previously planned on the realistic cast.

ture in the least invasive and most controlled manner (Fig 11). Final impressions were made and all in-formation was transferred to the laboratory to realize the posterior segments for the occlusal and es-thetic try-in. At this point, the teeth were prepared for the veneers and

a pickup impression was carried out to finalize the anterior restorations together with the posterior areas (Fig 12).

The veneers were fabricated using lithium disilicate material fol-lowing the manufacturer’s recom-mendations (Fig 13). Each restoration

was assessed for proximal contacts, occlusal relationships, shade match-ing, and marginal adaptation and was then luted in place (Variolink Ve-neer, Ivoclar Vivadent). The soft tis-sues and restorations have remained stable for 5 years and reflect the periodontal-restorative treatment



92

previously planned on the realistic cast (Figs 14 and 15). In addition, the teeth were properly positioned in the lip frame to enhance the pa-tient’s smile (Fig 16).

Conclusions

This case demonstrated the im-portance of using a predetermined protocol and comprehensive diag-

nostic information to manage es-thetic compromises that resulted from advanced periodontal disease, while also improving the health of the dentogingival complex. The

Fig 14 (left) Final radiographs. (right) Radiographs at 5-year recall.

Fig 15 Clinical view of the final case 7 years after surgical peri-odontal treatment and 5 years after placement of the veneers. Soft tissues and restorations are stable and reflect the periodontal-restorative treatment previously planned on the realistic cast.

Fig 16 The final restorations are in harmony with the lip dynamics.



93

peridontal-restorative procedures implemented for this patient al-lowed the clinician to predictably accomplish the desired soft tissue remodeling while respecting the biologic width and the patient’s es-thetic expectations.

Acknowledgments

The authors reported no conflicts of interest related to this study.

References

1. Hu X, Nahles S, Nelson CA, Lin Y, Nelson K. Analysis of soft tissue display during enjoyment smiling: Part 1–Caucasians. Int J Periodontics Restorative Dent 2013; 33:e9–e15.

2. Simeone P, Pilloni A. Simulated crown lengthening procedure: A technical ap-proach for proper prosthetic design. Pract Proced Aesthet Dent 2003;15: 548–550.

3. Tjan AH, Miller GD, The JG. Some es-thetic factors in a smile. J Prosthet Dent 1984;51:24–28.

4. Kois JC. “The gingiva is red around my crowns”: A differential diagnosis. Dent Econ 1993;83:101–102.

5. Kois JC. The restorative-periodontal interface: Biological parameters. Peri-odontol 2000 1996;11:29–38.

6. Robbins JW. Differential diagnosis and treatment of excess gingival display. Pract Periodontics Aesthet Dent 1999; 11:265–272.

7. Gobbato L, Tsukiyama T, Levi PA Jr, Griffin TJ, Weisgold AS. Analysis of the shapes of maxillary central incisors in a Caucasian population. Int J Periodontics Restorative Dent 2012;32:69–78.

8. Martegani P, Silvestri M, Mascarello F, et al. Morphometric study of the interproxi-mal unit in the esthetic region to cor-relate anatomic variables affecting the aspect of soft tissue embrasure space. J Periodontol 2007;78:2260–2265.

9. Magne M, Bazos P, Magne P. The alveo-lar model. Quintessence of Dental Tech-nology 2009;32:39–46.

10. Slavicek R. Clinical and instrumental function analysis for diagnosis and treat-ment planning Part 5. Axiography. J. Clin Orthod 1988;22:656–667.

11. Chu SJ, Hochman MN, Fletcher P. A biometric approach to aesthetic crown lengthening: Part II—Interdental con-siderations. Pract Proced Aesthet Dent 2008;20:529–536.

12. Kois JC. Altering gingival levels: The re-storative connection part I: Biologic vari-ables. J Esthet Restor Dent 1994;6:3–7.

13. Chang LC. Effect of bone crest to con-tact point distance on central papilla height using embrasure morphologies. Quintessence Int 2009;40:507–513.

14. Chen MC, Liao YF, Chan CP, Ku YC, Pan WL, Tu YK. Factors influencing the pres-ence of interproximal dental papillae between maxillary anterior teeth. J Peri-odontol 2010;81:318–324.

15. van der Velden U. Regeneration of the in-terdental soft tissues following denuda-tion procedures. J Clin Periodontol 1982; 9:455–459.

16. Cho HS, Jang HS, Kim DK, et al. The ef-fects of interproximal distance between roots on the existence of interdental papillae according to the distance from the contact point to the alveolar crest. J Periodontol 2006;77:1651–1657.

17. Gargiulo AW, Wentz FM, Orban B. Di-mensions and relations of the dentogin-gival junction in humans. J Periodontol 1961;32:261–267.

18. Vacek JS, Gher ME, Assad DA, Richard-son AC, Giambarresi LI. The dimensions of the human dentogingival junction. Int J Periodontics Restorative Dent 1994; 14:154–165.

19. Perez JR, Smukler H, Nunn ME. Clinical dimensions of the supraosseous gingi-vae in healthy periodontium. J Periodon-tol 2008;79:2267–2272.

20. Perez JR, Smukler H, Nunn ME. Clinical evaluation of the supraosseous gingi-vae before and after crown lengthening. J Periodontol 2007;78:1023–1030.

21. Wise MD. Stability of gingival crest after surgery and before anterior crown place-ment. J Prosthet Dent 1985;53:20–23.

22. Pontoriero R, Carnevale G. Surgical crown lengthening: A 12 month clini-cal wound healing study. J Periodontol 2001;72:841–848.

23. Lanning SK, Waldrop TC, Gunsolley JC, Maynard JG. Surgical crown lengthen-ing: Evaluation of the biological width. J Periodontol 2003;74:468–474.

24. Ingber JS, Rose LF, Coslet JG. The “bio-logic width”: A concept in periodontics and restorative dentistry. Alpha Ome-gan 1977;70:62–65.

25. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the pres-ence or absence of the interproximal dental papilla. J Periodontol 1992;63: 995–996.

26. Simeone P, Gracis S. Eleven-year ret-rospective survival study of 275 ve-neered lithium disilicate single crowns. Int J Periodontics Restorative Dent 2015; 35:685–694.


the international journal of periodontics & restorative ... · development of the biologic...

Documents