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A
pproximately 80% of the
population display part
of their gingivae when
smiling and this is even
more so with females. With
tooth loss, we see osseous resorption in
an apico-palatal direction, i.e. vertical and
horizontal resorption and concomitant
with this, the loss of three-dimensional
If the option
soft tissue volume. The alveolar crest or
for prosthetic ridge effectively moves lingually towards
gingival the palate with a narrowing or short-
replacement is ening of the perimeter of the dental arch,
planned from resulting in reduced mesio-distal space
available for any future restoration.
the beginning
As American prosthodontist, Dr Peter
of treatment, Whorle states, tissue is the issue, but
in other words, bone sets the tone. In other words, when
using a proactive the bone goes, the soft tissue follows! The
approach, the restorative dentist and ceramist are then
at a crossroads as to whether they com-
aesthetic results
promise lip support and the aesthetics of
are generally the case by modifying the tooth alignment Figures 1-2. Patient referred following implant failure and
significantly and anatomy to compensate for the defi- implant re-placement with an Astra implant at 11 and 21
better... ciencies, or look to undertake osseous and with a temporary crown in situ at initial consultation. Patient
gingival grafting in an attempt to recreate understandably unhappy with appearance, especially missing
the ideal hard and soft tissue anatomy for mesial papilla of 12 and to lesser extent, mesial papilla of 11
a more ideal restoration. and long tooth.
Figures 3-4. Significant loss of labial volume of hard and soft tissue around implant at 11, both vertically and horizontally. Negative
space issues caused by missing papillae mesial and distal to tooth 11.
The overall aesthetics of the gingival zontal soft tissue deficiency resulting in a Traditional surgical
apron around teeth is critical to the aes- long tooth and over-contoured cervical approaches for hard and soft
thetic outcome of any tooth replacement emergence. The zenith position of the gin- tissue replacement
implant therapy. Many researchers such gival margin is also distorted. However,
as Frauhoffer have evaluated the impact
of the soft tissue parameters on the overall
aesthetic result of implant restorations and
with loss of interproximal bone on one or
both approximating teeth and hence loss
of interdental papillae, this can be then
W hilst implant dentistry has indeed
evolved from implant placement
being based upon where the bone is
several have proposed assessment criteria seen as a combination defect involving to being restoratively driven, whereby
based upon multiple determinants such papilla deficiency as well as a vertical and the clinician establishes the ideal three-
as papilla height; papilla volume; zenith horizontal defect. dimensional anatomy of the definitive
position; gingival colour; gingival height; The even greater challenge for aes- restoration prior to implant placement,
horizontal deficiency; etc (with a score out thetic prosthodontic implant rehabilitation this requires, in the majority of cases, site
of 14 based upon seven criteria), whilst occurs in the multiple tooth loss situation, development by way of both bone and soft
others have advocated a combination score especially those lacking symmetry across tissue augmentation.
of both pink aesthetics and white aesthetics the arch such as the missing maxillary Unfortunately, the surgical proce-
(PES/WES; the highest possible combined central and lateral incisor and possibly dures required for this, which are often
score is 20.) In the overall context, gin- canine teeth. In this situation, with a multiple, require significant experience
gival aesthetics are just as important as the smile display exposing the gingival mar- and education, a high skill level and a
tooth replacement aesthetics! gins of the anterior maxillary teeth, there compliant and committed patient. And,
Whilst in the single tooth situation, often can then be made a direct comparison despite the best of intentions, the reality
the interproximal bone on the approxi- with the corresponding contralateral is that many can still fall short in devel-
mating teeth is maintained to support and side gingival-tooth relationship, thus oping an ideal site, especially with regard
maintain the papillae, the aesthetic defect highlighting the gingival deficiency in to vertical augmentation and papillary
is then seen more as a vertical and hori- three dimensions. replacement/development.
Figure 7. Final preparation for ceramic veneers on 22 and 12 Figure 8. Cementation of ceramic IPS e.max veneers on 12 and
and crown on 21 with fixture level impression at 11. 22 with Variolink Veneer (Ivoclar Vivadent). Final try-in of IPS
e.max crown on 21 and screw-retained implant crown on 11.
The compromised result is evidenced time and morbidity. Whilst horizontal cases, apart from selected single tooth ver-
with gingival deficiency both vertically augmentation alone is quite predictable, tical deficiencies, the results are generally
and horizontally and negative space issues vertical augmentation is much more diffi- disappointing. More often than not, pros-
with regard to papilla loss. So despite cult and less predictable and mostly, these thetic gingival replacement is required.
great efforts from both a surgical and challenging cases require both vertical Further, and even more relevant, is that
prosthodontic perspective and indeed the and horizontal augmentation. the attempted augmentation procedures, in
patient with regard to pain, discomfort In multiple implant cases or mul- falling short, even by just a small amount,
and time, the end result can often be very tiple tooth replacement cases, where the actually complicates the aesthetic out-
disappointing. In most cases, prosthetic replacement of the interdental papilla is come in that it places the transition zone
gingival replacement is not considered in required, despite the best of techniques, of the prosthetic gingival replacement in
the initial diagnosis and this solution is the papilla is missing, or at best, short and the visible aesthetic display. Whereas, if
more often seen as last resort. snubbed, and in medium to high scallop pre-planned, the transition zone would
We must also appreciate that many biotype cases, prosthetic papilla replace- more likely be outside the aesthetic
patients may not wish to undergo multiple ment will still be required to achieve display and hidden by the lips or more
surgical procedures... whether that be based acceptable aesthetics. Hence, the results easily managed.
upon patient psychology, time, cost, age or are still unpredictable and generally dis- The difficulty, indeed the challenge, is
medical contraindication, etc. Multiple sur- appointing, especially with the degree to appreciate and predetermine what cases
gical procedures including both bone (such of vertical augmentation achievable can be successfully and predictably sur-
as block, particulate, GBR, distraction and certainly in attempting to recreate gically augmented and which cases are
osteogenesis, BMPs, and/or orthodontic missing papillae. Often, multiple surgical better prosthetically augmented. Obvi-
extrusion) and soft tissue grafting (such procedures are undertaken in an attempt ously, this will be a significant variable
as connective tissue, allografts, etc) are to achieve the natural gingival three- based upon clinical surgical skills as well
required with associated increased costs, dimensional architecture and in most as patient preference. Indeed, it is sadly
Figure 9. Bonded IPS e.max crown on 21 and screw-retained Figure 10. Tissue bed ready for receipt of hybrid prosthesis.
IPS e.max implant crown at 11 with ceramic flange prior to
hybrid technique.
Figure 11. Initial AnaxGum hybrid composite resin veneer/ Figure 12. Hybrid resin/ceramic flange after initial maturing.
ceramic build prior to trimming.
far too common in aesthetic zone cases for Despite developments in pink ceramics, must walk a very fine line; having estab-
patients to go through multiple surgical there are obviously significant limitations lished good shade matching with the
procedures over an extended time period, in the colour matching and characterisa- white or tooth ceramics, he/she then
only to end up with a compromised aes- tion of pink porcelains for prosthetic pink has to try and achieve some semblance
thetic result or, alternatively, requiring augmentation. Issues such as restrictions of gingival matching with the pink por-
the use of prosthetic gingival replace- in colour matching due to limited ceramic celain with minimal firings and without
ment. No doubt perseverance with this gingival hues, the shrinkage that occurs compromising or destroying the white
approach has been in reaction to generally during firing, the number of firing cycles porcelain aesthetics.
disappointing ceramic gingival prosthetic required (and therefore its potential delete- Also, another complicating factor is the
replacement, especially in the transition rious effects on the white ceramics) and shrinkage that occurs on the firings of the
zone from prosthetic to natural gingivae. the difficulties in handling these materials gingival ceramic replacement, especially
especially in thin cross sections. This has in thin cross sections, and hence, it is often
Prosthetic pink led to the majority of cases having less than difficult, if not impossible, to achieve a
ceramic replacement ideal aesthetic outcomes, especially at the good seal to the underlying host tissue
interface between the prosthetic replace- bed following the completion of the white
Figures 13-14. Completed case following refinement and integration of ceramic/hybrid soft
tissue augmentation. A very happy patient indeed!