The periodontal restorative interface: esthetic considerations

Esthetic considerations are a significant contributing factor in the management of prosthodontic cases and an interdisciplinary approach is often necessary to achieve an optimal result. The visible soft‐tissue architecture plays a key role in developing an esthetic smile. Furthermore, an understanding of the relationship between the restorative margin and the gingiva is important for long‐term stability of the result. The gingival architecture and gingival health are important for ensuring optimal esthetics following prosthodontic work and close attention to both soft and hard tissues around the teeth, before, during and after restorative procedures, will greatly improve the likelihood of a successful outcome. Moreover, knowing the options available in periodontal plastic surgery is important in esthetic dentistry today. The relevant literature related to restorative and surgical procedures when performing esthetic dentistry are reviewed in this article, and different approaches are illustrated with appropriate cases to explain the treatment approach that was utilized to improve the esthetic appearance of the case.     

美学区牙冠延长术联合树脂修复改善露龈笑并关闭牙间隙的初步探索

上颌前牙美学区作为微笑过程关注的重点，区域内任何粉白美学的缺陷都可能损害整体的微笑美学，对于高位笑线伴有被动萌出不足的患者，微笑时显露牙龈过多是常见的美学问题之一。而美学区牙冠延长术通过对牙周软硬组织的切除和成形，可有效重建协调、美观的龈缘位置和曲线，增加被动萌出不足的临床冠高度，同时改善牙冠宽长比等相关白色美学缺陷。文章完整展示了1例针对因被动萌出不足所致露龈笑且存在上中切牙牙间隙的美学治疗过程，包括美学分析、治疗计划的制定、临床实施过程和随访效果观察，详细介绍了美学区牙冠延长术的手术过程，并采用美学树脂直接修复关闭窄牙间隙，为此类患者的临床诊治积累经验。     

Closure of Diastema and Gingival Recontouring Using Direct Adhesive Restorations: A Case Report

One of the challenges in clinical esthetic dentistry is closing anterior diastemas without creating "black triangles" between the teeth. The success of a restorative treatment in anterior teeth depends on the esthetic integration between soft tissues and hard tissues. The conditioning of the interdental papilla is a simple, direct, predictable, and low-cost alternative. This paper reports a case on diastema closure in anterior teeth that was successfully treated using gingival recontouring and composite resin restorations.

CLINICAL SIGNIFICANCE

The closure of diastemas in anterior teeth using direct adhesive restorations and gingival recontouring is a viable option for the clinician because it restores esthetic harmony between soft and hard tissues.     

Prosthodontic management of ridge deficiencies

The treatment goals in prosthodontics and dental laboratory technology are to provide patients with long-term predictable and esthetic outcomes. The periodontal tissues define the framework that will maintain ridge height, thickness, color, texture, and gingival-tooth frame. The loss of teeth, residual ridge resorption and the loss of gingival tissues continue to affect long-term and esthetic treatment outcomes. Prosthodontic treatment requires consideration of the potential negative tissue effect that time and normal biologic change might have on the completed prosthetic design. This article describes alternative restorative solutions for clinical conditions that have traditionally been managed by surgery, removable prosthodontics, or esthetically compromised fixed restorations. Different clinical conditions for tooth-retained and implant-retained fixed partial dentures as well as the laboratory technology describing construction of these different restorations will be discussed.     

Orthodontic treatment of a congenitally missing maxillary lateral incisor

Clinicians agree that, regardless of gender or race, tooth agenesis has become more prominent in recent societies. The congenital absence of one or more maxillary lateral incisors poses a challenge to effective treatment planning for the restorative dentist. However, the one-sided orthodontic approach of just moving canines mesially to eliminate restorative procedures leads to compromise. Adult patients presenting with malocclusions, missing lateral incisors, or anterior crowding but who fail to get proper orthodontic treatment, requesting instead esthetic solutions that do not establish a stable occlusion, proper alignment, and proper axial inclination of the teeth will have compromised esthetic and periodontal results. An evaluation of anterior smile esthetics must include both static and dynamic evaluations of frontal and profile views to optimize both dental and facial appearance. This article presents how orthodontics is combined with other specialties in treating a congenitally missing lateral incisor. One case is used to illustrate how orthodontic treatment is progressed in collaboration with other specialists. CLINICAL SIGNIFICANCE: Patients with missing teeth, crowding, midline deviation, unesthetic gingival contours, or other restorative needs may require the interaction between various specialists. For the successful treatment of orthodontic-restorative patients, an interdisciplinary team effort is vital.     

Smile design for the adolescent patient--interdisciplinary management of anterior tooth size discrepancies

Adolescent patients often seek orthodontic treatment to correct spacing of the maxillary anterior teeth. If the spacing is caused by a tooth size discrepancy that affects one or more anterior teeth, an interdisciplinary treatment plan involving orthodontic, restorative, and periodontal treatment is recommended to achieve a harmonious esthetic result. This article describes a clinical approach for treatment of these complex cases, focusing on the importance of tooth form, gingival esthetics, and treatment sequencing.     

An Impression Technique for Preserving Interdental Papillae

An esthetic revolution is occurring in dental profession. The esthetic treatment enhances appearance, improve smiles, restore function and raise self esteem. This is now well known that both teeth and gums make good smile and good facial esthetic. Sometimes while doing treatment in esthetic zone, impression procedure can cause strangulation of interdental papilla, causing loss of papillae. This article therefore describes a new impression technique that involves the matrix impression system and "every other tooth" technique.     

The role of cosmetic dentistry in restoring a youthful appearance.

BACKGROUND: Dentistry is faced with a population that is getting older and keeping more of its natural teeth. Smiles show physical and esthetic signs of aging. Advances in the area of cosmetic dentistry now offer the dental profession new opportunities in conservative and esthetic restorative procedures that have the potential to reverse the signs of dental aging, thereby making patients appear younger. CASE DESCRIPTION: The physical and esthetic attributes of an aged dentition are identifiable. Tooth wear over time alters the appearance of the teeth and smile in a way that is perceptible to dentists and laypeople. Bonding and adhesive ceramic restorative procedures have the potential of reversing the esthetic manifestations of the aging process for teeth. Specific diagnostic tools, including a composite resin mock-up and construction of an incisal putty matrix, allow for previsualization of possible treatment outcomes and allow clinicians to resolve occlusal as well as esthetic treatment concerns before initiating actual treatment. CLINICAL IMPLICATIONS: The ability to make patients look younger through cosmetic enhancement of teeth and smiles has tremendous implications for the future practice of dentistry. Dentists who have the training and skills to meet the increasing demand for esthetic procedures by patients seeking to restore a youthful appearance may find an expanded role within their practices for this type of treatment.     

Functional and esthetic rehabilitation with in-ceram alumina and zirconia system: a multidisciplinary approach

The development of all-ceramic systems following metalceramics restorations allowed simulation of natural dentition due to favorable esthetics and resistance. In-Ceram is an alternative when esthetics is primordial as well as resistance required in rehabilitation. However, an ideal smile is associated to not only shape, color, texture and translucency but also harmony with gingival tissue. So, the aim of this study is to report a clinical case based on periodontal and fixed partial dentures principles to perform periodontal plastic surgery followed by esthetic rehabilitation. A female patient, 40-year-old, presented complaint about dental esthetics. After clinical and radiographic exams, metal-ceramics crowns (teeth 11, 12, 13, 21, 22 and 23) were considered unsatisfactory due to marginal leakage, color change in gingival tissue associated to metallic margin, and gummy smile. So, a crown lengthening surgery of anterior teeth was performed followed by rehabilitation of superior teeth with In- Ceram single crowns. CLINICAL SIGNIFICANCE: The interaction between periodontics and fixed prosthodontic area is the key of an adequated treatment planning which involves gingival smile to provide function and an esthetic condition in association with an esthetic, resistant and predictable material.     

Crown lengthening in the esthetic zone

Crown lengthening in the esthetic zone is a prosthodontically designed and surgically executed procedure that must only be considered after careful restorative and surgical treatment planning, including a detailed smile analysis, clinical and radiographic evaluation of the quality of soft and hard tissues, and selection of the appropriate approach for each individual case. The presented techniques are modifications of the original conventional surgical approach, where longer healing periods may have been required and loss of papilla height or fullness is of concern. Recognition of the advantages and disadvantages of each technique should increase predictability and success in interdisciplinary smile enhancement therapy.     

Use of mucogingival surgical procedures to enhance esthetics

The procedures outlined herein deal primarily with improving esthetics. The importance of esthetics in periodontics is most apparent in patients with a high lip line. Current mucogingival procedures provide the surgeon with the capability to have a major role in the total treatment of complex restorative cases. Periodontal considerations must be included as an integral part of esthetic dentistry. A complete examination of the patient must include a thorough periodontal evaluation. In addition to the usual detection of periodontal pockets and inflammation indicative of periodontal disease, the examination should include a thorough mucogingival evaluation for detection of the following: (1) inadequate keratinized gingiva; (2) gingival recession; (3) excessive gingival display; (4) insufficient clinical crown length; (5) asymmetric gingival margins; (6) flat marginal contour; (7) improper gingival margin relationships; (8) lack of harmony of gingival margins with the lip line; and (9) alveolar ridge deficiencies. Mucogingival surgical procedures should be performed after control of all etiologic factors and in concert with the restorative therapy so that the surgery can produce the most desirable esthetic result. It must be understood that the location and contour of the gingival margin and its relationship to adjacent margins are as important to the final esthetic result as the location, form, and relationship of the incisal margins of the anterior teeth. Attention to the total dental display as framed by the smile, with appropriate mucogingival analysis and treatment, is necessary to achieve the most satisfying esthetic results.     

Implant replacement of the maxillary central incisor utilizing a modified ceramic abutment (Thommen SPI ART) and ceramic restoration

The prosthetic restoration of a missing anterior tooth with a dental implant is a challenge. Treatment coordination with a multidisciplinary team is critical in the successful outcome of this type of patient treatment. Newer surgical treatment modalities in the management of hard and soft tissues are becoming common, with very good predictability and long-term stability. Additionally, the use of advanced dental technology and materials such as sintered zirconium allows the restorative practitioner the opportunity to fabricate an esthetic, precise-fitting, biocompatible, and strong definitive prosthesis for the patient, with good longevity. CLINICAL SIGNIFICANCE: The use of an all-ceramic abutment and restoration is described, along with the "soft tissue sculpting" procedure through the use of a custom provisional restoration. The relative ease and convenience of the procedure is also illustrated.     

Enameloplasty and esthetic finishing in orthodontics-identification and treatment of microesthetic features in orthodontics part 1

Interdisciplinary treatment also has expanded to include not only soft tissue assessment of the periodontal components of the dentition and smile, but of the face as well. The next level of esthetic enhancement certainly will include facial proportionality as a key component in our patient evaluation. This paper expands the diagnostic vision of the dentist to include facial proportions and relationships of hard and soft tissues to improve diagnosis and treatment of dental and facial esthetics.     

Esthetic Rehabilitation of Retained Primary Teeth—A Conservative Approach

With the advancement in ceramic restorations bonded to tooth structure, the treatment has become a feasible and conservative option to restore teeth with alteration in shape when owing to high demand in esthetics, with or without minimum tooth preparation. This article describes a report of a 32‐year‐old woman who was dissatisfied with her smile. The patient reported that she still had deciduous teeth, and that the maxillary lateral incisors had been restored with direct resin composite to correct the teeth shape. After discussing the restorative possibilities, a decision was made to place all‐ceramic crowns (lithium disilicate glass‐ceramic) with minimal tooth preparation, which figures as a conservative full‐coverage approach. An esthetic outcome resembling a natural‐looking smile resulted in the patient's satisfaction. Bonding of all‐ceramic crowns onto minimally prepared deciduous teeth figures as a conservative treatment in case of partial anodontia, which decreases the chance of root resorption induced by trauma and benefits from good adhesion to enamel.     

Esthetic considerations in removable prosthodontics

Patients requiring extensive replacement of teeth with removable prostheses are indeed esthetic orphans in many contemporary dental practices. Although the advent of successful osseointegration has dramatically reduced the need for removable prostheses, there are still many patients who for health, anatomic, psychological, or financial reasons are not candidates for implants. These patients deserve the same level of esthetic restorative dentistry as those who are restored with fixed prostheses. Clearly, the restorative dentist has the greatest flexibility from an esthetic standpoint with complete dentures. Soft and hard tissues can be replaced with contemporary characterized denture-base materials, and a truly infinite variety of tooth forms, shades, and arrangements can be used to meet the expectations of the most demanding patient. For partially edentulous patients, the major problem is designing a removable partial denture that avoids the unsightly display associated with conventional clasp assemblies. There are strategies available to accomplish this effectively while establishing an environment for optimal periodontal health, and to minimize destructive stresses on the abutment teeth.
CLINICAL SIGNIFICANCE
This article discusses the procedures essential for providing an upscale, quality esthetic service with removable prostheses. Effective strategies to eliminate unsightly clasp assemblies with removable partial dentures are described.     

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目前牙齿美学修复是口腔临床中的热点。在对前牙美学缺陷患者的修复治疗中,最重要的是要检查获取患者全部相关的牙齿美学信息,分析患者美学缺陷中的问题,最后做出正确的美学修复设计。本文讨论有关前牙美学修复中前牙美学分析和美学设计中常用的方法、4个重要的美学参数以及露龈笑的病因和治疗。     

Simulated shape design. Helping patients decide their esthetic ideal

BACKGROUND: Esthetic care is changing dentistry from a need-based to a want-based practice. Patients are asking for esthetic treatment, and clinicians are retooling their practices to satisfy this need. One important part of providing esthetic dentistry is ensuring that the patient is as well-informed as possible about treatment outcomes. DESCRIPTION OF TECHNIQUE: This article describes a tool dentists can use to show patients potential tooth sizes, shapes and arrangements before carrying out treatment. Simulated shape design, or SSD, is a reversible method of demonstrating potential esthetic outcomes that involves creating trial restoration shapes and placing them over a patient's teeth. SSD is a simple technique that any dentist can perform. In essence, the technician makes new tooth shapes in wax, the dentist places these in the patient's mouth and the patient evaluates them. The dentist then makes modifications in the SSD, which he or she reports to the technician. CLINICAL IMPLICATIONS: With the decisions of shape, arrangement and size made at chairside, the whole flow of esthetic treatment can be handled smoothly. Preparations can be cut more accurately to better support the restorative material; decisions can be made to open or not open the contacts; and shapes can be agreed on in the earliest stage of evaluation, then duplicated faithfully in the provisional and final restorations. There are no surprises for the patient, the dentist or the technician. Both the esthetic (smile design) and functional elements (anterior guidance) of the restoration can be checked with SSD. SSD could become the standard in determining whether or not to proceed with esthetic treatment.     

四维微笑设计辅助非对称面型前牙超薄瓷贴面修复前牙区散在间隙1例及文献复习

目的探讨以四维微笑设计为主导、以面部流线为参考体系的全程数字化设计在前牙美学修复中的应用效果。方法对1例前牙区散在间隙患者进行四维微笑设计,辅助行超薄瓷贴面数字化美学修复。通过口内和面部扫描获得患者数字化信息,进行四维微笑设计和预测,进行2次美学预告,医患共同确定治疗方案后,进行微创基牙预备,制作超薄瓷贴面,就位后粘接。术后观察美观度、边缘密合度,于修复完成后1年复查。结果超薄瓷贴面边缘密合,颜色过渡自然,红白美学效果好,微笑时面部协调,1年后随访,颜面整体美学佳,基牙、牙周组织健康,患者满意。文献复习结果表明,时序性面部扫描与口内扫描数据拟合可以准确地进行四维微笑美学预测,模拟动态微笑及发音过程的真实状态,结合面部流线,为非对称面型患者设计出自然协调的个性化微笑;然而对于咬合改变、咬合不稳定或颞下颌关节紊乱患者,需增加电子面弓、锥形束CT等数据拟合,更加准确地模拟患者术后的下颌运动。结论以四维微笑设计为主导、以面部流线为参考体系的全程数字化设计,辅助非对称面型前牙超薄瓷贴面的修复前牙散在间隙的效果良好,患者术后微笑协调美观,符合预期效果;患者参与度、满意度高,值得临床推广。     

Macroesthetic elements of smile design

BACKGROUND: Clinicians' expanding use of cosmetic restorative procedures has generated greater interest in the determination of esthetic guidelines and standards. The overall esthetic impact of a smile can be divided into four specific areas: gingival esthetics, facial esthetics, microesthetics and macroesthetics. In this article, the authors focus on the principles of macroesthetics, which represents the relationships and ratios of relating multiple teeth to each other, to soft tissue and to facial characteristics. CASE DESCRIPTION: The authors categorize macroesthetic criteria based on two reference points: the facial midline and the amount and position of tooth reveal. The facial midline is a critical reference position for determining multiple design criteria. The amount and position of tooth reveal in various views and lip configurations also provide valuable guidelines in determining esthetic tooth positions and relationships. CLINICAL IMPLICATIONS: Esthetics is an inherently subjective discipline. By understanding and applying simple esthetic rules, tools and strategies, dentists have a basis for evaluating natural dentitions and the results of cosmetic restorative procedures. Macroesthetic components of teeth and their relationship to each other can be influenced to produce more natural and esthetically pleasing restorative care.     

Crown lengthening surgery--indications and techniques

Crown lengthening is a surgical procedure aimed at removal of periodontal tissue to increase the clinical crown height. As a restorative dentist using this technique of crown lengthening, one needs to have an understanding of biological width, indications, technique, as well as some possible limitations.The authors aim to discuss these concepts in order that the restorative dentist can use crown lengthening as part of an overall treatment plan in a controlled and predictable manner, taking into account biological factors. Clinical Relevance: Today's restorative dentist faces an apparent increase in patients exhibiting toothwear that may result in shortened teeth, making crowning these teeth problematic. In addition, it is evident that patients are becoming more aware of the importance of a pleasing smile. This article discusses crown lengthening as one way in which the restorative dentist can address both clinical demands.