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Esthetic Dentistry

Restorative dentistry has developed significantly in the are of esthetics since the advent of acid-etch bonding. As bonding materials, laminates and porcelains continue to be refined dental esthetic consideration more and more often focus on the relationship of the gingival tissues to the teeth. In a recent interview, Dr. Gordon Christenson, restorative and clinical research dentist, noted fifty percent of his newly diagnosed esthetic cases are referred to the Periodontist for management of gingival esthetic factors. In this newsletter, gingival factors which may influence the results of your esthetic dentistry as well as some of the periodontal corrective measures which are available are discussed.

The first step in creating a harmonious relationship between tooth and gingival tissue is the elimination of marginal inflammation of the periodontal tissues. Reddened marginal tissue draws the attention of the casual observer due to the stark contrast with the tooth’s color and adjoining tissue. Edematous tissue produces a shadow effect on the gingival one-third of the tooth increasing the perception that the tooth is yellow or brown. Rolled gingival margins encourage more rapid growth of plaque in the "stagnation area", the triangular shaped depression between the bulky, inflamed gingival margin and the tooth’s gingival height of contour. A healthy, knife-edge gingival margin minimizes this stagnation area.

Thin, delicate gingival tissues are more demonstrative of the inflammatory response and undergo significant gingival recession after root preparation and restorative procedures if they are highly inflamed. Bluish hues in the marginal gingiva may represent subgingival calculus, vascular stagnation or the presence of restorative margins too deep or too wide within the sulcular area. Responsible efforts at plaque control by the patient are critical in the immediate and long term success of esthetic dentistry cases. In patients with pre-existing subgingival restorative margins and bluish tissue responses, adjustment of the gingival margin’s relationship to the restorative margin is required. Provisional restorations may be needed to maximize gingival esthetics and assess margin placement.

Color is readily recognized for its influence on appearance. To understand and assess other esthetic values, our profession has looked at those individuals considered most esthetically pleasing and extracted dental parameters that define the "ideal" smile. Although every smile is different, a recent article in the ADA journal by Dzierzak has summarized these parameters.

Esthetic Values:

  • Tooth color matches age and complexion
  • Tooth to face size ratio is acceptable
  • No visual defects catch the eye
  • Curvature of the maxillary incisal edges mimics lower lip line
  • If displaced, midlines are harmonious with each other
  • No gingival inflammation
  • Adequate attached gingiva
  • Harmony of cervical and interproximal gingival contours
  • Upper lip covers all but interproximal gingiva
  • No open cervical embrasures
It should be noted that these values are applicable to individual patients when the patient believes that esthetics is an issue. Any diagnosis and therapy begins then with questioning the patient about the personal impact of differences the dentist may note from his concept of an esthetic smile and the existing smile. To some patients, esthetics will not be an issue and to some it will. It should also be added that these societal esthetic values are often subconsciously applied by the patient and alter lip and jaw posture during smiles, as well as other facial expressions. A good example is the teenager with a retrognathic mandible who subconsciously protrudes the lower jaw to make the facial profile acceptable.

The position, contour, and bulk of the gingiva on the crown of the tooth determines the perception of tooth length and width. The esthetic value of the tooth’s length is, however, related not just to its physical length, but to the relationship of that length to the width, height, and shape of the face. The maxillary central incisor has been found to be one-fifteenth the width and height of the face. Multiple teeth shorter than this ratio may indicate the presence of altered passive eruption. Additional tooth exposure through periodontal surgery will have a marked impact on esthetics.

Assessment of the amount of gingiva which shows during the smile is an aid in determining if additional tooth length is desirable. Under normal circumstances, only the interdental papillae are exposed by the smile. The presence of lip insufficiency with normal tooth length should alert the practitioner to a possible skeletal discrepancy. Although gingival surgery might improve the esthetic value, orthodontic evaluation is indicated in this case. Contour in the interproximal region and bulk of tissue in a buccolingual direction impact esthetics. When the normal scalloped curvature of the interproximal region is interrupted by hyperplastic tissue, attention is drawn to the area just as enamel hypoplasia draws attention. Gingivoplasty is very effective at recreating harmonious curvature.

A single tooth with much less tooth length than adjoining teeth poses an esthetic value problem. Often such a tooth will be in linguoversion and shorter than the adjoining teeth. Such a tooth is a candidate for orthodontics. In short teeth with incisal heights compatible esthetically with the adjoining teeth, periodontal surgery will be more beneficial. In the case of a tooth which has supraerupted, the alveolar housing as well as the gingival tissue height will have to be reduced to produce esthetic gingival contours.

Uneven gingival recession also produces discrepancies in contour and poor esthetics. When the individual tooth exhibits recession, the amount of tooth structure exposed is out of proportion to the remaining teeth and the eye is drawn to the area. The ability to achieve an esthetic result rests upon root coverage of the affected tooth. Several surgical procedures are possible to correct this situation, but all are dependent on the amount of labial tooth malposition. The more the root surface is located to the facial of the facial bone the more difficult it is to achieve root coverage. If the root prominence can be mechanically reduced or reduced by tooth movement, the process of root coverage is enhanced.

Another evaluation of esthetics involves the assessment of the lower lip line and the incisal edges of the upper anterior teeth. The upper incisal edges should be parallel to this line which increases the sense of balance. All of us have seen the unesthetic appearance of a periodontally involved maxillary lateral incisor whose incisal edge hangs over the lower lip line. In a similar way, those individuals who show gingival tissue during a smile may have a gingival line which runs at an angle to the lower incisal edge line and reduces the esthetics of the smile. Gingival modification is a potential solution to this problem as well.

Frustrating to patients and dentists alike are the presence of spaces produced by the loss of interdental papillae to periodontal disease and surgical therapy. Our advancing understanding of the disease process has made surgical intervention less common in the maxillary anterior segment, reducing root exposure. In addition, approaches to anterior surgery have more and more emphasized the retention of the interdental papilla. Recently, Beagle described a technique for reconstruction of the maxillary midline papilla using a lingual approach, split thickness flap. The tissues obtained from the area lingual to the papilla are folded coronally to fill the interproximal space. Procedures such as this may help reduce the problem of the "black triangle", the open anterior interproximal space. At this time, anterior esthetic restorative dentistry remains the primary means of anterior interproximal space closure.

We would be happy to consult with you regarding gingival esthetics and its role in your restorative plan, both in the initial planning stages and in the provisional restorations phase.
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