Smile esthetics: the influence of posterior maxillary gingival margin position

Purpose: Successful replacement of posterior teeth using contemporary prosthodontic techniques in esthetically demanding cases relies upon visual replication of the natural posterior dentition and surrounding gingival architecture. There is currently little in the way of guidance for creating ideal or acceptable gingival relationships for posterior teeth. Materials and Methods: A cross‐sectional study was conducted comparing perceptions of four groups of individuals to six digitally manipulated images with various posterior teeth gingival margin position configurations. A total of 120 volunteers aged 12 years to 80 years, comprising 30 patients diagnosed with hypodontia, 30 patients diagnosed with periodontal disease, 30 patients without either condition, and 30 qualified dentists were recruited from the Eastman Dental Institute & Hospital, London. A ranked order of preference for each set was obtained, and this was repeated after a minimum time interval of 10 minutes. Results: Posterior gingival margin configurations from 0 mm to 2 mm (measured at the first premolar) were deemed most esthetic by the majority of the patient groups; dentists had a strong preference for the 1 mm configuration. Dentists appeared to be more perceptive to the alterations in gingival positions. Conclusions: Posterior gingival margin configurations where the first premolar margins were 1 mm lower than the canine margins were deemed the most esthetically pleasing; however, it is likely that a range of acceptability of 1 mm deviations from this ideal exists.     

Effect of posterior gingival smile on the perception of smile esthetics

Objectives: To evaluate and compare the influence of posterior gummy smile on the perception of smile esthetics by orthodontists, general-dentists and laypersons. Study Design: A frontal photograph of a smile with normal gum exposure was chosen and manipulated digitally using Adobe Photoshop C3 to generate three further images with posterior gum exposure of 4, 6 and 8mm. These four images were assessed by the three evaluator groups: orthodontists (n=40), general-dentists (n=40) and laypersons (n=40). Both orthodontists and dentists had at least ten years professional experience and laypersons were aged between 40-50 years. The proportion of men to women was 20:20 in each group. Evaluators awarded a score to the smile esthetics of each image: 1=acceptable, 2=moderately acceptable, 3=unacceptable. Afterwards, each evaluator placed the four images in order of esthetic preference. Results: No significant differences (p>0.05) were detected between the three evaluator groups for the photo without posterior gummy smile. The perception of smile esthetics for a the 4mm posterior gummy smile (median for orthodontists=2, general-dentists= 1, laypersons=1), the 6mm (median for orthodontists=2, general-dentists=1, laypersons=1) and the 8mm (median for orthodontists=3, general-dentists=2, laypersons=2) was significantly different between orthodontists and the other two evaluator groups (p<0.0017).The three evaluator groups coincided in placing the image with the 6mm gum exposure in first place in order of esthetic preference. Conclusions: Posterior gummy smile influences the perception of smile esthetics more negatively among orthodontists than the rest of the groups. Key words:Aesthetics, gummy smile back, orthodontists, dentists, laypersons.     

Achieving ideal esthetics in osseointegrated prostheses. 1. Multiple units.

This article describes two new abutments that are intended to enhance the esthetics and function of the implant prosthesis while keeping it in harmony with the periodontium. Part 1 discusses the EsthetiCone, designed for use with multiple-unit restorations, which allows subgingival placement of porcelain for maximal esthetics. Unlike traditional abutments, the EsthetiCone is placed 4 to 6 weeks after the fixture is uncovered. Therefore, the size and type of abutment are chosen by the restorative dentist, rather than by the surgeon. Guidelines for abutment selection and placement are provided in this paper.     

Achieving ideal esthetics in osseointegrated prostheses. Part II. The single unit.

There are several advantages to the CeraOne single-tooth abutment. It seats directly onto the fixture, forming a nonrotating joint. A new type of gold alloy screw that can be tightened to 32 N/cm is used. In addition, the restoration is constructed on a prefabricated ceramic cap onto which porcelain is directly baked. A case report illustrates the technique and the highly esthetic results of such single-tooth replacement.     

Achieving and maintaining periodontal health and esthetics following the extraction of a central incisor

Both cases presented here involved an anterior extraction. Such cases can be very frustrating for both dentist and patient but success can be attained through good communication, attention to all details, and expert periodontic and laboratory support.     

Predictable periimplant gingival esthetics: use of the natural tooth as a provisional following implant placement

Maintaining the interdental papilla and bone height following implant placement has been a challenge for the restorative dentist. Bone resorption following anterior tooth extraction is common and often compromises the esthetics of the final restoration. The tissue must be maintained during the surgical and healing phases to achieve an esthetic outcome. Using the patient's natural tooth as a provisional can help maintain the volume and support the papilla. This article describes a technique to achieve maximum esthetics and preservation of tissue following tooth extraction and implant placement.

CLINICAL SIGNIFICANCE

By using the patient's extracted natural tooth, the tissue should maintain itself with minimal recession. This will allow for a more esthetic outcome.     

Subperiosteal connective tissue grafts for pocket reduction and preservation of gingival esthetics: a case report

BACKGROUND: Clinical studies and recent histological evidence following mucogingival surgery for the treatment of gingival recession have documented that when closely adapted to a previously exposed root surface, connective tissue is capable of forming a new attachment. Despite these findings, no clinical tests have been conducted to examine the ability of connective tissue to reduce probing depth (PD) and increase clinical attachment levels (CAL) when it is implanted into periodontal osseous defects. The purpose of this paper is to report the clinical results on a patient following 2 subperiosteal connective tissue grafts. METHODS: Subperiosteal connective tissue grafts were placed in 2 sites of periodontal bone loss and deep pocketing in one patient. Following flap reflection and root preparation, a connective tissue graft 1.5 to 2.0 mm in thickness was draped and sutured over each osseous defect and then completely covered by the external flap. RESULTS: Ten months following subperiosteal connective tissue grafting, tooth #7 had 4 mm of CAL gain. Tooth #10 had 3 mm of CAL gain 8 months postoperatively. Both teeth had 1 mm gain in gingival recession. Both teeth probed 3 mm postoperatively. CONCLUSIONS: When connective tissue was grafted into 2 periodontal osseous defects, there were significant reductions in probing depth and gains in CAL. There was minimal postoperative gingival recession. The new clinical attachment gain remained stable for 8 to 10 months following subperiosteal connective tissue grafting.     

Gingival esthetics

Achieving the most desirable gingival appearance enhances the esthetic result achieved with fixed prosthodontic restorations and is most often realized when gingival health is optimized before treatment and gingival trauma is minimized during treatment. Methods of optimizing gingival appearance by avoiding soft tissue contact are discussed as are factors considered important to maintaining good gingival appearance when subgingival margins are necessary.     

Influence of sex on the perception of oral and smile esthetics with different gingival display and incisal plane inclination

This study was designed to determine the esthetic perception of men and women to variations in upper and lower gingival display at smile and speech and to incisal plane tilting. Composed photographs of smile and speech with varying amounts of gingival exposure of the upper and lower teeth and gingiva at smile and at speech and with varying degrees of incisal plane tilting were rated for attractiveness by two groups of lay people. The images were presented as male or female images. A total of 300 questionnaires, including 7500 images, were evaluated by 100 subjects. The results showed that images were scored as less attractive as the amount of upper and lower gingival display was increased during smile and speech. The amount of gingival exposure graded in the esthetic range was up to one mm for the upper incisors and zero mm for the lower incisors. Incisal plane tilting was graded as unesthetic when above two degrees of deviation from the horizontal. Male and female evaluators scored images differently with upper gingival exposure. Female evaluators gave statistically significant higher scores than male evaluators to upper gingival exposure images at smile and speech of both males and females, suggesting that females are more tolerant of upper gingival exposure. Images were scored differently when presented as male or female images. Female images were scored lower by both male and female evaluators, suggesting that additional efforts should be taken in female patients to achieve an esthetic result.