COSMETIC & RESTORATIVE CARE |
COVER STORY
JADA Continuing Education
Achieving gingival esthetics
MICHAEL S. REDDY, D.M.D., D.M.Sc.
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ABSTRACT
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Introduction. Dentists traditionally have thought of periodontal treatment as a means of saving the teeth while leaving the patient with an esthetic problem. This no longer is true. The goal of this article is to show how esthetic crown-lengthening procedures, papillary regeneration and root coverage may enhance the overall esthetic results of periodontal treatment.
Methods and Results. Esthetic crown lengthening aims not only to provide biological width for the healthy restoration of teeth, but also to permit esthetic gingival and prosthetic contours. Papillary regeneration aims to fill the dark spaces that may occur interproximally with the progression of periodontitis or as a result of tooth alignment. Finally, root coverage procedures now can provide predictable results with the application of connective-tissue periodontal grafts and plastic surgery techniques. This article presents a case report for each type of procedure, each of which resulted in improved esthetics and cosmetic appearance.
Clinical Implications. Periodontal treatment now is part of the solution for certain esthetic problems. While technically demanding, these procedures, in the hands of an appropriately trained and experienced clinician, can improve the overall results of patient treatment.
The realm of periodontics once was the elimination of periodontal pockets through the surgical excision of inflamed tissue. The use of apically positioned flaps, osseous surgery and gingivectomy achieved the important goals of pocket elimination and the stabilization of periodontal disease progression. A common side effect of the resective approach to periodontics was the creation of recession and the potential for a compromised esthetic outcome. An unesthetic result was so typical that the use of the words "periodontics" and "esthetics" in juxtaposition in the same sentence was considered an oxymoron of the highest caliber.
Periodontal treatment now is part of the solution for certain esthetic problems.
Today, the shift in the clinical paradigm of periodontal treatment has created an environment in which esthetic periodontal procedures are, in many practices, as common as resective therapy once was. The importance of gingival esthetics to an overall esthetically pleasing smile has been realized by esthetic and prosthodontic practitioners for some time. Even the popular media have noticed the trend toward the recognition of gingival esthetics and the marketing of gingival health and contours as a product benefit. Katherine Stroup, a Newsweek writer referring to an advertisement for a new toothpaste that used a supermodel as a spokesperson, recently quipped that "in the entire sordid history of male-female interaction, not a single prospective suitor has uttered the phrase, ‘Hey, check out the gums on that one,’ but ad execs hope that’s about to change."1 While Ms. Stroup may not recognize the esthetic features of proportional gingival contours, certainly Dr. P.D. Miller, the godfather of periodontal plastic surgery, likely would have a differing opinion.2
The common gingival esthetic problems that can be encountered as part of the prosthetic solution to cosmetic cases include excessive gingival display,3–7 uneven gingival contours,8–10 the loss of papillae11–13 and exposure of root surfaces.14,15 Periodontal solutions to these esthetic challenges often are best addressed by starting with the analysis of the patient’s smile line. The clinician should analyze the smile line by observing the patient at a normal speaking distance.16 Dentists frequently make the error, when addressing an esthetic complaint or planning restoration of the esthetic zone, of focusing on the patient’s teeth rather than the patient’s smile.17
Following are reports of cases of each of the common gingival esthetic problems and the treatment undertaken to correct them, all of which began with an analysis of the patient’s smile line.
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EXCESSIVE GINGIVAL DISPLAY
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The patient shown in Figure 1
had a typical esthetic complaint: she was unhappy with the appearance of her teeth. Her dental history showed that composite veneers had been bonded to the labial surface of her maxillary incisors (teeth nos. 7–10) twice previously and that she had wanted to have porcelain veneers to improve the esthetic appeal of her appearance. By focusing on the teeth, the dentist could have identified the primary esthetic problem as either the chipped and uneven incisal edges of the central incisors or the lack of translucency of the composite bonding. If, however, the dentist analyzed the patient’s smile line in addition to a problem-based focus that centered on the teeth, he or she could identify a potential esthetic limitation that was not addressed on either of the two occasions on which the composite veneers were placed.
A patient’s smile line is determined by the position of the lips during a natural unforced smile.
Figure 2 is a photograph of the same patient’s smile line taken during normal conversation. This image allows the clinician to quickly identify the esthetic problem of excessive gingival display.
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Figure 2. A photograph of the patient depicted in Figure 1 with a view of the smile line that readily illustrates the patient’s excessive gingival display.
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A patient’s smile line is determined by the position of the lips during a natural unforced smile. The upper lip determines the length of the maxillary incisor, as well as the vertical position of the gingival margins during a smile. In general, women tend to show slightly more gingiva than men, and a slight show of gingiva often is considered to be a feminine trait.18 However, the woman shown in Figure 2 displays an exaggerated amount of gingiva. The lower lip determines the length of the incisal edge of the maxillary incisors. In addition, the lower lip’s position during a smile determines the curvature of the incisal plane. The treatment plan for this patient included esthetic crown lengthening to reduce the amount of gingival display and raising the height of the anterior teeth, along with reducing the incisal length of the incisors to follow the contours of the lower lip.
Figure 3 illustrates the sequence of the esthetic crown-lengthening procedure. The dentist mapped out the initial surgical incision by measuring the length of the maxillary teeth and using a periodontal probe to create a bleeding point at the height of contour before making the incision (Figure 3A). The height of the gingival contour is not a symmetrical arch on the maxillary central incisors; it actually is at the distal one-third of the tooth on the incisors and follows the natural distal inclination of the roots of the incisors. The height of contour on the canine is at the midpoint of the tooth; however, it appears more distal when viewed from the anterior because the canine turns the corner of the arch (Figure 4). After the initial incision, the dentist removed the collar of gingiva and instrumented the roots. He then reflected the flap and performed osseous recontouring to establish an appropriate biological width for the connective tissue attached to the root, the junctional epithelial attachment and a gingival sulcus (Figure 3B). The amount of crown lengthening—illustrated with a periodontal probe in Figure 3C with the mucoperiosteal flap elevated and again in Figure 3D with the flap positioned before suturing—demonstrates that the space created for the biological width of soft-tissue attachment above the level of alveolar bone required ideal health and a lack of inflammation.
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Figure 3. The surgical sequence of esthetic crown lengthening. A. Initial incision establishing the gingival height of contour. B. Osseous recontouring to establish clinical crown extension. C. View of a periodontal probe showing the extent of crown lengthening from the original restoration margin to the level of the alveolar bone. D. View of the periodontal probe with the mucogingival flap in position, demonstrating the 3-millimeter subgingival space for the biological width.
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Figure 4. A diagram of the anterior six teeth indicating the height of gingival contour in relation to the midline of the teeth.
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The incision and the suturing of the flap included the first premolars in the esthetic crown lengthening. The treatment plan did not include veneers for the first premolars, but those teeth were included in the crown lengthening to prevent an esthetic asymmetry in the anterior teeth. The first premolars are considered anterior teeth in gingival esthetic cases, much as they often are considered esthetic teeth in denture setups.
The porcelain veneers were placed six weeks after the esthetic crown lengthening (Figure 5). An image of the patient’s smile line at the placement of the veneers (Figure 6) demonstrates that the contours of the gingival margins and the length and incisal plane of the teeth are closer to ideal.
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Figure 5. Anterior cheek-retracted view of the patient depicted in Figure 1 after the initial placement of anterior veneers.
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Figure 6. Smile line view similar to that of the patient depicted in Figure 2, demonstrating improved gingival esthetics.
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UNEVEN GINGIVAL CONTOURS
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Creating gingival symmetry and establishing an appropriate height at the distal one-third of incisors and the midline of canines and premolars also can be used to change the aspect ratio of teeth for an improved esthetic appearance. The tooth’s aspect ratio, or height-to-width contour, generally is considered to be optimal when the tooth is 75 percent as wide as it is tall.19 The patient depicted in Figure 7 had a generally esthetically pleasing smile. Her esthetic concern was that she preferred the shape of the right central incisor to that of the left. She felt the left central incisor (tooth no. 9) was wider than the right central incisor. The patient’s goal was to improve her smile by having porcelain veneers (in a light shade) laminated to teeth nos. 6 through 11. Examination of the patient’s smile line indicated that the left central incisor was approximately 9 millimeters wide and approximately 9 mm in length, which gave it a square aspect ratio.
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Figure 7. Smile line view of a patient with gingival asymmetry resulting in an altered aspect ratio between the central incisors.
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A common question concerning esthetic crown lengthening is whether it is necessary to recontour the alveolar bone through osseous surgery.
The patient’s treatment plan was designed to achieve gingival symmetry before the fabrication of the veneers. Figure 8 demonstrates the sequence of the esthetic crown-lengthening procedure. The dentist first established the height of contour of tooth no. 9 by creating an aspect ratio of 75 percent. Next, the dentist created a height of contour of 12 mm from the incisal edge to match the aspect ratio with the 9-mm width of the tooth (Figure 8A). He then matched the other central incisor’s height of contour to that of its partner. Next, he established the height of the lateral incisors, which generally are 1 mm shorter at the gingival margin than are the central incisors. Likewise, the length of the lateral incisors generally is 1 mm short of the incisal plane. The dentist modified the canines’ height of contour next, establishing their gingival margins at the same length as those of the central incisors. Although the canines are the same length as the central incisors, they appear higher because they follow the smile line as it turns up at the corners during a natural smile. Finally, the first premolars were included in the crown lengthening procedure as esthetic teeth. On reflecting the flaps for osseous recon-touring to create a biological width dimension, the dentist found that the left central incisor was, in fact, physically wider, as the patient had indicated (Figure 8B). However, the contouring of the gingiva, once sutured in place, serves to minimize the perception of the anatomical difference in tooth width (Figure 8C).
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Figure 8. The esthetic crown lengthening surgical sequence. A. The initial incision to establish a more ideal aspect ratio of the teeth by altering the gingival margin height. B. A view after osseous surgery, showing the tooth width discrepancy between the central incisors. C. Suturing and final positioning of the gingival margin. D. The initial healing at one week.
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The initial healing at seven days (Figure 8D) showed an improved gingival symmetry. The patient also perceived that the teeth were whiter. In actuality, the shade of the teeth had not changed at all, but the patient’s smile appeared brighter because more enamel was exposed to reflect light back at the observer. The esthetics of the initial healing already enhanced the gingival contour that followed the smile line established by the lip position (Figure 9).
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Figure 9. Smile line view of the initial healing of the patient depicted in Figure 8 with improved maxillary anterior tooth length, matching aspect ratios and vertical gingival position.
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A common question concerning esthetic crown lengthening is whether it is necessary to recon-tour the alveolar bone through osseous surgery. It is not necessary in every case, provided that there is space to establish connective-tissue attachment and junctional epithelium. The mean distance of the connective attachment (1.07 mm) and junction epithelium (0.97 mm) were measured from human autopsy specimens to determine the 2.04-mm dimension often referred to as the biological width.20 The depth of the sulcus (0.69 mm) may be added to this dimension to arrive at an indication of whether bony recontouring is indicated. Of course, the guideline measurements of biological width, just like the guidelines for tooth aspect ratios, may not be generalizable to every clinical situation. A restoration with a finish line that impinges on the biological width may not be evident initially. The most common symptom is unresolved interproximal inflammation occurring months after the restoration has been placed. This chronic inflammatory state is especially evident when anterior teeth are prepared and the contour of the cementoenamel junctions are not followed at the interproximal regions.
Figure 10 shows a patient with impingement of the central incisors’ crown margins on the attachment to the teeth. This patient’s subsequent inflammatory response was severe. In addition, the patient had large overcontoured crowns adjacent to small lateral incisors and canines. The lateral incisors had received bonded composite veneers at the time of the crown placement. The initial incisions encompassed the eight anterior teeth from premolar to premolar (Figure 11A) and revealed that the crown margins were within 0.5 mm of the alveolar bone. Osseous recontouring created a 3-mm distance between the crown margins and the alveolar crest (Figure 11B). With the flap reflected, it was evident that the lateral incisor composite veneers extended apically more than 3 mm above the cementoenamel junction.
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Figure 10. Anterior view of a patient with anterior crowns impinging on the biological width, resulting in chronic inflammation.
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Figure 11. The surgical sequence of the crown lengthening. A. The initial incision to excise inflammatory tissue and increase the gingival height at the lateral incisors, canines and premolars. B. Osseous recontouring to establish a biological width between the crown margins and the alveolar bone. C. Initial healing after crown lengthening; note the decrease in inflammation.
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The initial healing at one week (Figure 11C) demonstrated improved gingival contours and decreased gingival inflammation in response to achieving an appropriate biological width. The final restoration, after three years of service, showed improved periodontal health and more ideal gingival esthetics (Figure 12).
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Figure 12. A photo of the patient depicted in Figure 11, three years after undergoing crown lengthening and receiving new ceramic crowns and veneers, illustrating no return of the inflammation.
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LOSS OF PAPILLAE AND EXPOSURE OF ROOT SURFACES
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In addition to the gingival esthetic problems of excessive gingival display and uneven gingival contours, there are esthetic challenges that arise from an insufficient amount of gingiva, such as in the cases of loss of papilla and exposed root surfaces. In some cases, a combination of esthetic crown lengthening and root coverage grafting must be used to optimize the correction of a gingival asymmetry.
The esthetic enhancement and reconstruction of a papilla may be among the most challenging gingival esthetic procedures.12 The patient shown in Figure 13 had orthodontic treatment that involved the extraction of a supernumerary tooth. The mesiodens was located between the central incisors. After the dentist extracted and moved teeth to level and align them, it was apparent that no papilla was present between the central incisors.
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Figure 13. An orthodontic patient who had a supernumerary tooth at the midline and loss of the midline papilla after its extraction.
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To correct the problem, the dentist positioned a subepithelial connective-tissue graft at the inter-proximal area by means of a periodontal plastic surgical procedure. Figure 14 illustrates the sequence of gaining access through the vertical incision for the connective-tissue wedge graft. The dentist made a vertical incision above the mucogingival line at the interproximal aspect of teeth nos. 8 and 9 and made an intersulcular releasing incision (Figure 14A). He elevated the mucoperiosteal flap from the mucogingival line to the crest of the interproximal space by working through the vertical incision with a microelevator (Figure14B). He then obtained a wedge-shaped connective-tissue graft from the maxillary tuberosity area with a parallel split-thickness distal wedge incision. After reflecting the flaps, he removed the dense connective-tissue graft from the retromolar area and closed the flaps with simple interrupted sutures. He removed the epithelial surface from the connective-tissue wedge before positioning it at the recipient bed. To position the graft, he guided it into place through the vertical releasing incision with the aid of a positioning suture and then sutured it in place (Figure 14C).
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Figure 14. An abbreviated surgical sequence of the papilla reconstruction. A. A vertical access incision above the mucogingival line to allow tunneling access to the interproximal area. B. Elevation of the papilla from the internal aspect with a microelevator. C. Suturing after the positioning of a wedge-shaped subepithelial connective-tissue graft at the midline.
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The use of the vertical access incision over the alveolar bone is minimally invasive and limits the interruption of the blood supply to the graft, which is nourished from both the bone and internal surface of the flap. A view of the patient further along in orthodontic treatment (Figure 15) demonstrates the improved contour of the midline papilla after six months. The dentist can eliminate the remaining space between the teeth by adjusting the contact point of the central incisors from an incisal edge to a contact along the incisal one-third of the mesial surfaces of the teeth.
The loss of papilla is a common esthetic problem in implant dentistry.21–23 The papilla associated with long-standing tooth loss or the long-term use of a temporary partial denture often is reduced to the height of the residual ridge. The same surgical approach applies to the implant situation. The patient whose case is depicted in Figure 16 had a congenitally missing lateral incisor before the implant placement. The limited mesial-distal ridge length further limited the space for papillae. A simple vertical access incision in this case was used to graft both the mesial and distal papillae (Figure 16A). The dentist harvested the subepithelial connective-tissue graft from the retromolar area as previously described and guided it into place with a positioning suture that extended from the height of contour of the existing papilla out through the access incision (Figure 16B). The suture passed through the apex of the connective-tissue pyramid to aid in the positioning of the graft. The suture continued back through the access incision and out through the height of contour of the papilla (Figure 16C). The dentist then tied the positioning suture and sutured the graft further using a sling suture around the adjacent tooth. He used the same vertical incision to position a second graft on the mesial surface of the implant. The initial healing with a temporary crown in place exhibited a more natural-looking gingival contour (Figure 16D).
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Figure 16. The surgical sequence of a wedge-shaped connective-tissue graft used to regenerate papilla on the mesial and distal aspects of an implant. A. A single vertical access incision used to graft both interproximal surfaces of the implant. B. A guiding suture is passed from the height of contour of the papilla out through the access and attached to the connective-tissue graft. C. The suture is extended from the graft back through the height of contour and tied in place. D. Initial healing of the papilla with a temporary crown in place.
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Perspective is an important aspect of esthetics that is determined by a comparative process. The gingival margin’s position and contours can alter the perspective of the length of teeth in comparison with one another.19 Ideally, when teeth are viewed from a distance, they appear to be the same length or to have only a small gradation in dimension. One esthetic perspective problem frequently seen is that of long canines, either alone or in combination with short lateral incisors and premolars. The patient whose case appears in Figure 17 had an esthetic complaint of a very long canine, which had been restored as part of an anterior fixed partial denture. The patient had a relatively high smile line and displayed a lot of tooth when smiling and laughing. The patient had gingival recession, and the crown margin on the canine had been extended to the gingival margin, resulting in a canine with a clinical crown of 16 mm in length.
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Figure 17. The surgical sequence of subepithelial connective-tissue root coverage being applied to an existing fixed partial denture. A. A handpiece being used to cut back the crown and polish the finish line out of the root surface. B. The initial incision in preparation for coronal positioning. C. After suturing the connective-tissue graft over the root of the canine, the dentist positioned the flap coronally. D. A photo taken after long-term healing (three years), illustrating better perspective between the teeth.
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The restoring dentist had an understanding of gradation and perspective. To compensate for the length of the canine, the dentist ridge-lapped the premolar pontics 4 to 5 mm over the facial surface. This resulted in teeth with a long and narrow perspective. The dentist’s treatment plan involved restoring the gingival contour with a root-coverage procedure at the canine and then refabricating the maxillary prosthesis. The dentist resected the crown margin on the canine and polished the original finish line out of the root surface (Figure 17A). He prepared the initial incision for the mucoperiosteal flap with a submarginal butt joint incision on the adjacent teeth and a vertical releasing incision at the distal aspect of the central incisor and the mesial aspect of the molar to establish a broad base for the flap (Figure 17B). To position the flap coronally, he made a periosteal releasing incision on the interior aspect of the base of the flap. He removed the epithelium from the adjacent papillae that were to be overlaid by the coronally positioned flap. The dentist then harvested the subepithelial connective-tissue graft from the palate, positioned it over the canine root and adjacent bone surfaces and sutured it in place. He positioned the flap apically by means of suspension sutures placed in interproximal grooves that he prepared at the incisal contact areas of the existing bridge (Figure 17C). Three years after restoration, the patient had stable gingival margins and an improved aspect ratio on the canine that was in reasonable perspective to the adjacent restorations (Figure 17D).
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CONCLUSION
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The typical gingival esthetic problems of excessive gingival display, asymmetry in gingival contours, exposed root surfaces and loss of papillae can limit the success of cosmetic and prosthodontic treatment. In many cases, the combination of periodontal esthetic surgery with other restorative procedures can create a synergistic esthetic result that could not have been obtained with either treatment alone. Esthetic periodontics has become commonplace and can obtain predictable results. Case selection and careful interdisciplinary treatment planning can largely determine the predictability of the procedures. However, the biological healing of even the best surgical efforts sometimes can need revision even if the gingival margin was perfectly contoured at the time of suturing. The need for revision should be anticipated and planned for at the start of any treatment that involves gingival esthetics.
The key to achieving pleasing gingival esthetics is to start with a careful examination of the smile line at a normal speaking distance. The subtle influence of the gingiva can serve to outline the teeth in addition to indicating the oral health of the patient. The evaluation of periodontal esthetic procedures has been driven largely by patients’ increased awareness of and desire for esthetically pleasing smiles. Today more than ever, patients are demanding a youthful, attractive smile that includes healthy gingiva with ideal contours and texture.
Comprehensive esthetic treatment should take into consideration the esthetic principles from a gingival perspective. The periodontal surgical techniques outlined in this article can significantly enhance the esthetic outcomes of restorative treatment and the patient’s overall appearance. These procedures, in the hands of an appropriately trained and experienced clinician, offer predictable treatment in the management of esthetic problems.
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FOOTNOTES
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Dr. Reddy is a professor, University of Alabama at Birmingham School of Dentistry, Department of Periodontology, 1919 7th Ave. S, Birmingham, Ala. 35294, e-mail "mreddy{at}uab.edu". Address reprint requests to Dr. Reddy.
The author wishes to thank Dr. S. Jean O’Neal for her excellent prosthodontic contribution to the clinical cases, without which the outcomes would not have been possible.
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ABSTRACT
EXCESSIVE GINGIVAL DISPLAY
