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A Procedure for Esthetic-Perio-Prosth Treatment Planning

Author: Dr. Masayuki Okawa AMED Member

Article published in the journal AMED Vision News | vol 4 issue 2

«Both dental and gingival esthetics act together to provide a smile with harmony and balance. A defect in the surrounding tissue cannot be compensated by the quality of the dental restoration and vice versa.»

These words are quoted from a book written by Dr. Pascal Magne in 2002, and I share a strong sympathy with it. Whenever I am challenged by complex aesthetic treatment, I always keep these words in mind. As many have realized recently, microscopes enable us to obtain higher accuracy and predictability in restoration; however, restoration work without any orthodontic treatment or periodontal management is not capable of reconstructing missing papilla or moving teeth dramatically. It is important to work with an Orthodontist who shares a belief in the guidelines of aesthetic restoration diagnosis and a Periodontist who has skills in high quality diagnosis and periodontal microsurgery technique. An Inter-disciplinary approach is necessary when patient satisfaction is our goal. This would enable us to manage much higher level of aesthetic treatments.

With this approach in mind, two problems with gingival discrepancies exist which create a negative impression of dental aesthetics: gummy smile, and missing papilla. These problems require an inter-disciplinary diagnosis and management by three dental specialists such as a Prosthodontist, a Periodontist and an Orthodontist. The key to achieve the most successful aesthetic outcome is to find out the cause of these problems and select the necessary approaches from a Prosthodontic, a Periodontic, an Orthodontic or an inter-disciplinary point of view.

«Gummy Smile»

Some people show more than 2mm of gingiva when smiling, this is called «Gummy Smile». This condition does not lead to disease, but for some people, this is enough to for them to become unhappy.

There are potentially three major causes for «Gummy Smile»:

  • The first is excessive maxillary growth and maxillary teeth over-eruption. As you know, teeth keep erupting until they touch opposing teeth. This process is called active eruption. Following this process, marginal gingiva moves apical to CEJ area. This process is called passive eruption.
  • The second cause is delayed apical migration of the gingival margin over the maxillary anterior teeth.
  • The third cause is tooth mal-position. In this situation, gingival surgery is not a proper approach. The ideal treatment will be intrusion of teeth and marginal gingiva to the desired position.

Dr. Kokich says that to diagnose a «Gummy Smile» patient, we must make sure that the source of the problem is either from anterior teeth or both anterior and posterior teeth. If all maxillary teeth have over erupted, treatment requires orthgnathic surgery. We would need to measure and justify the current crown length. If the teeth have been abraded, these teeth may be extruded, and an incisal restoration may be necessary. The important thing is pocket probing. If the sulcular depth is 3 to 4mm, the patient could benefit from gingival ectomy. The type of gingival surgery depends on the relationship between the alveolar crest and the CEJ. To determine the bone level, we have to push the probe past the sulcus, through the epithelial attachment and the connective tissue, and stop at the bone level. If CEJ is 2mm away from alveolar crest, gingivectomy is the proper procedure. If it is under 0.5mm, osseous re-contouring is necessary. To have bone re-contouring, the crown/root ratio must be well considered.

I would like to highlight the inter-disciplinary case (1)

The patient’s chief complaint was gummy smile. She also requested Porcelain Laminate Veneer restoration on her 4 anterior teeth to improve her teeth shape and color just like her sister who had PLV in my clinic.

Her right central incisal had a short crown length of less than 9mm. With crevicular probing under local anesthesia, we found out that her alveolar crest was very close to her CEJ. She had a wide width between her free gingival margin (FGM) and mucogingival junction (MGJ).

Case 1: before treatment Case 1: exam 1

We analyzed the case as type 1B altered passive eruption of Dr. Coslet’s classifcation and selected both gingivectomy and alveolectomy. Examining her from occlusal point of view, her crowded lower anterior teeth provided poor anterior guidance and wore out her maxilla anterior teeth. I reached the conclusion that stabilizing her anterior guidance would eventually stabilize her occlusion and prevent any further invention. She agreed to take Orthodontic treatment on her lower anterior teeth.

After the orthodontic treatment, under the magnifed view, and using the surgical guide made from the mock-up model, I applied both gingivectomy and alveoectomy, trimming and reconstructing the marginal line of her alveolar bone. After it healed, she took vital tooth bleaching to a desired shade.

Case 1: exam 2 Case 1: after treatment

These are the central and lateral views of her Post-Op. There was a dramatic increase in her aesthetic outcome by moving her gingival margin apically, relining her gingival scallop and brightening her teeth color. She no longer complains about her worn out teeth and has been very happy with her aesthetic outcome without removing tooth structure. She not only improved her «gummy smile», but also gained stable anterior guidance. This brought her both high aesthetic outcome and ideal occlusal functions.

Missing Papilla

Inter-disciplinary treatment helps us provide treatment for our patients with minimal intervention and optimal results. Some patients, however, have missing papillae problems. The first diagnosis should take place for the missing papilla to find out the cause of the defect. The cause of the defect is either from disease or from the high contact point of two central incisals.

One of the reasons for the missing papilla comes from diverging roots (both roots of the teeth are not in parallel). The triangular tooth shape can cause a high contact point, which makes a black triangle space. When the Orthodontic treatment is involved, we must carefully examine teeth proportion, and determine whether we need to re-shape teeth or pursue restoration; Furthermore, we should determine the bone loss caused by severe periodontal disease or destruction which would result in the lack of papillae.

The inter-disciplinary case (2)

A Japanese patient living in Boston at that time, complained about missing papilla between upper two central incisals. Before the treatment, her smile appeared unnatural because of her upper lip covering the missing papilla. Her papilla between the left and right upper central incisal was seriously missing. Moreover, her history told us that she had had a trauma on her upper anterior and had broken two central incisals. Unfortunately, her right central incisal became non-vital and the crack line went down to sub-gingival area. She had visited a specialist in Boston and had papilla reconstruction twice, but had lost it shortly after.

Case 2: before treatment

I worked on this case with Dr. M.Suzuki and we diagnosed and considered her treatment plan together. This case also required Orthodontic treatment.

First, Dr. Suzuki applied a connective tissue graft to increase her soft tissue at the missing papilla area. The reason we choose periodontal treatment first is very simple: to harmonize thickness of her gingival for good blood circulation.

Case 2: after ortho

After it healed, the Orthodontist extruded her right central incisal slowly. However, before Orthodontic treatment, it was very important for me to decide the tooth width and length from the diagnosis wax-up.

Case 2: after prep Case 2: after treatment

To conclude, inter-disciplinary diagnosis and treatment planning corroborated with microscopic restorative treatment, Periodontal microsurgery, and Orthodontic treatment solve complex aesthetics and provide a higher level of satisfaction for patients. It is also true that Inter-disciplinal treatment under a magnifed view helps us provide our patients minimal invasive treatments with the optimal results.

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