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    The Reconstruction of Pink and White Esthetics: Clinical

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    The Reconstruction of Pink and White Esthetics: Clinical

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    The Reconstruction of Pink and White Esthetics: Clinical

    Uploaded by

    Preventiva HRAC

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    © All Rights Reserved
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    of 4

    Clinical

    The reconstruction of pink and


    white esthetics
    Christian Coachman,1 Marcelo Calamita2

    Surgical procedures to re-establish the three dimensional then be used in the reconstruction of the gingiva in order
    architecture of hard and soft tissue ridge deformities have to ensure harmony, balance, and continuity of form
    been developed and performed successfully throughout between the patient’s natural gingiva and the prosthetic
    the past 15 years. In some cases, however, the results are gingiva.13,16,19-24 Usually, dentists and technicians are well
    still unpredictable and unsatisfactory in terms of esthetics versed when it comes to reconstructing the white
    and function, even if state-of-the-art regenerative component of a smile, the teeth. However, restoring
    procedures such as bone graft, soft tissue graft and challenging cases in the anterior area involves a more
    orthodontic relocation are employed (Figures 1 and 2). comprehensive approach and requires a deeper
    Creating a prosthetic gingiva can represent an esthetic understanding of the pink component of the smile, the
    and functional alternative for the predictable gingiva. The gingival architecture represents the frame for
    reconstruction of ridge deformities in fixed partial implant the teeth. If it is not restored correctly, either surgically or
    restorations,2,8,9-17 particularly in patients who do not want prosthetically, it will impair the final three dimensional
    to undergo any surgical procedure. By opting for such a esthetic outcome. Just as the astute technician learns how
    procedure from the very beginning, dental professionals to pay attention to the minute details of the tooth
    are in a position to choose a design and/or use adjunctive anatomy, shade variations and textures, he or she should
    measures that produce better results than if this do the same with regard to the various types or designs of
    procedure were to be used as the last resource or as a the gingiva. Gingival anatomy, shade and texture should
    form of repair. 2,10 -13,15,18-21 be analysed and learned to be restored in the best
    Teamwork and an interdisciplinary treatment plan are possible way. If the patient has a high lip line, this problem
    paramount for the long-term success of this kind of will be even more evident.
    restoration. The dental technician should have the skills to
    analyse the three-dimensional shape of the tooth, to Case presentation
    determine the correct position of the implant and to A 37-year-old male patient presented with a history of
    understand the principles of gingival esthetics and also tooth loss in regions 11 and 21. Of the implants placed in
    the need for soft tissue management. This knowledge can these regions, the implant in region 11 had failed (Figure
    2). The patient was very dissatisfied with the esthetics and
    phonetics of his anterior teeth, did not feel comfortable
    1 CDT, DDS (acting in the capacity of dental technician in the
    about smiling and had a low self-esteem. When he was
    present case)
    2 DDS, MSD, PhD, both São Paulo/Brazil informed about the different treatment options such as
    orthodontic relocation combined with hard and/or soft
    Corresponding author: Dr Christian Coachman tissue grafts, he chose the easiest and fastest option: the
    Well Clinic / Unitade São Paulo, R Bento de Andrade, 116
    São Paulo SP 04503-000, Brazil restoration of the dentogingival complex by means of the
    [email protected] pink hybrid technique. In region 11, a new implant was

    88 INTERNATIONAL DENTISTRY SA VOL. 12, NO. 3


    Coachman / Calamita

    Figure 1: Preoperative situation. Figure 2: Loss of the implant in region 11. Placement of a new
    implant.

    placed (NobelReplaceTM, Nobel Biocare, USA). After four


    months, a substructure made of yttriumtetragonal zirconia
    polycrystals (Y-TZP) was placed over the implants. Zirconia
    exhibits high biocompatibility and improved fracture
    toughness25-27 and is compatible with the veneering
    ceramic IPS e.max® Ceram (Ivoclar Vivadent, Liechtenstein).
    In regions 12 and 22, copings made of IPS e.max® Press
    lithium disilicate glass-ceramic, shade A1, were placed. The
    corresponding veneering ceramic – IPS e.max Ceram – is
    very versatile. It can be fired to both substrates, glass and Figure 3: Completed ceramic restoration: Single-tooth crowns (IPS
    e.max Press) and implant-retained restoration with ZrO2 framework.
    oxide ceramics (Figure 3).

    Dentogingival diagnostic wax-up guided


    treatment
    The dentogingival diagnostic wax-up allows the restoration interface between the prosthetic and natural gingiva.15,30
    to be created on the basis of white and pink esthetic The lingual aspect should provide comfort during
    principles. The wax-up is the ultimate guide for all the mastication, ensure optimum phonetics, avoid food
    surgical, restorative and laboratory procedures conducted. entrapment and promote air sealing.
    At this stage, the team will perform an analysis of the
    three-dimensional volume of the lost tissue and the Ceramic
    position of gingival interfaces, based on the Quadrants A strict digital photography protocol is paramount for the
    Concept18 in order to minimize the visibility of this junction, successful shade communication. Digital manipulation of
    restore the asymmetry of the gingival architecture, and the photos can help the visualization of the value, chroma
    replace the papilla.13,14,16,17,22,28 and internal characterizations (Figures 4 to 6). For this
    The need for soft tissue conditioning should be evaluated purpose, pre-op photos can be used, which then help in
    when the wax-up is created. Depending on the extension the selection of the ceramic powders. Furthermore, during
    of the area to be conditioned, the corresponding steps will the try-in of the crowns, they are used to check if the shade
    be carried out during the surgical and provisional phase needs to be adjusted.
    and refined when seating the final bridge.18,29 The ridge When utilizing the IPS e.max system, the practitioner
    should be flat to generate an esthetic and cleansable should understand all the options the system has to offer

    90 INTERNATIONAL DENTISTRY SA VOL. 12, NO. 3


    Coachman / Calamita

    Figures 4 to 6: Try-in. Digital modification of the photos in order to


    better visualize brightness, chroma, characterizations and surface
    structure

    in order to take advantage of the unique features that this


    system provides.

    Pink material selection


    The materials currently available for the reproduction of
    artificial gingiva are ceramics, acrylics and composite. Each
    one has its own advantages, disadvantages and specific
    indications.
    For fixed partial restorations, ceramics were usually the determine the pink esthetics, such as shape, colour and
    material of choice to reproduce not only the white esthetics texture.
    but also the pink esthetics.11-17 As ceramics are a very • Possibility of repair, re-contouring and uncomplicated
    delicate and challenging material to handle, particularly as maintenance, even after years of use, without having to
    far as shrinkage during firing, the number of firing cycles, re-fire the ceramic.
    colour matching and moisture control is concerned, the
    final appearance of pink porcelain bridges was usually Seating and hygiene orientation
    unsatisfactory. The esthetics were further compromised by During the seating process, transitory blanching of the
    the easily noticeable interface between the prosthetic and gingiva may occur. The intensity will vary depending on
    natural gingiva. the extension of the tissue conditioning required, the
    In an attempt to overcome these limitations, a hybrid design of the pontics and the biotype of the patient’s
    technique was developed in order to make the prosthetic gingiva and should be checked with dental floss. The
    gingival restoration more esthetic and predictable18,30 excess of pressure should be reduced by re-shaping the
    (Figures 7 to 9). The hybrid technique basically involves a soft tissue with diamond burs, electrosurgery or diode
    screw-retained partial implant bridge providing the white laser, or by re-contouring the prosthetic gingiva with
    esthetics and a gingival base made of ceramics, which is specific burs or wheels. The main goal is to create a
    covered with a composite overlay to create the final pink comfortable, healthy and cleansable interface while
    contours (using eg anaxGUM Pink Composite, Anaxdent, maintaining a high esthetic level.
    Germany). The composite is placed directly in the mouth The hygiene and maintenance procedures should be
    and finished chairside. carefully discussed with the patient as they are paramount
    The utilization of the hybrid technique presents some for the long-term success of the restoration. Follow-up
    remarkable advantages: appointments should be scheduled in advance. The first
    • Preservation of the optical and physical properties of the appointment should be scheduled within three months
    ceramic veneering material by decreasing the number of after insertion. Subsequently, patients can be placed on six
    ceramic bakes. months to one year recall cycles, depending on their risk
    • More predictability and control of the factors that assessment.

    92 INTERNATIONAL DENTISTRY SA VOL. 12, NO. 3


    Coachman / Calamita

    Figure 7: Implant restoration prior to … Figure 8: … and after the intraoral reconstruction of the gingival
    portion using composite.

    Conclusion
    In spite of all the recent developments in periodontal
    and peri-implant surgical regenerative procedures,
    comprehensively and esthetically re-establishing the hard
    and soft tissue contours still represents a challenge.
    The prosthetic restoration of the pink esthetics offers a
    reliable and consistent alternative to resolving cases with
    uncertain surgical outcome or cases in which patients do
    not want to undergo regenerative surgical procedures. The
    understanding of the indications and procedures involved
    in this technique requires a paradigm shift for the whole
    interdisciplinary team to maximize the biological, functional
    and esthetic results and to surpass the patients’
    expectations (Figures 10 and 11).
    Figure 9: Extraoral finishing of the gingival portion. The design of
    the restoration should ensure both ideal hygiene capabilities and an
    Reprinted with permission Reflect 01/10.
    esthetic appearance.

    Literature: A list of references is available on request.

    Figures 10 and 11: IPS e.max restoration completed with the pink hybrid technique.

    INTERNATIONAL DENTISTRY SA VOL. 12, NO. 3 93

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