Alternatives to restore defectiveand deficient edentulous spans shouldinclude prosthetic gingival restoration asan integral part of an overall esthetic recon-structive option in the decision-makingprocess. To reestablish natural crown ratiosand natural gingival profiles in complexcases, artificial gingiva restorations canreduce the necessity of technique-sensitivesurgical procedures that depend on theindividual pattern of biologic repair, there-by simplifying and reducing the time andcost of treatment.

Aiming to fabricate proportional toothform and an ideal anatomy without arti-ficial gingiva, the implant team mayundertake bone and gingival grafting totry to return vertical volume to the ridge.In many instances, even when the surgi-cal procedures are essentially successful,they may not completely resolve the esthet-ic dilemma. Even when the height of theridge is recovered, it can still be very diffi-cult to reestablish optimal papilla form.1

Historically, prosthetic gingival restora-tion has been underused in partially eden-tulous cases. Initial attempts were aimedsolely at masking the patient’s existing tis-sue loss without showcasing the artificialgingiva of the restoration because of theobvious esthetic limitations of the pros-thetic work executed. When comprehen-

sively understood and correctly planned,artificial gingival restorations can reestab-lish predictably harmonious anatomy tothe lost gingival tissue, reproducing thecolor, contour, and texture of the patient’sgum line.2-9

Prosthetic gingival restoration requiresadditional theoretic and technical devel-opment of the technician so that he orshe can execute these restorations with har-mony, balance, and continuity of formbetween the patient’s gum and artificialgum.4,5,9,10 The integration of the colorof natural and artificial tissue must beplanned to minimize the visibility of thisjunction, restore the asymmetry of thegingival architecture, and replace papillaform.4,10-13

The tissue loss that occurs in cases inwhich prosthetic gingiva is indicated usual-ly makes it very difficult to create an ade-quate tooth arrangement and the correctapplication of the individual anatomy ofeach tooth without using artificial gum.1

CASE PRESENTATION

HistoryThe patient presented having had, 10 yearsprior, osseous and soft-tissue grafts, fol-lowed by implant placement (Figure 1)with an alumina crown on tooth No. 9

(Figure 2). She presented with misalign-ment of the incisal edges and papillae ontooth No. 9 and an altered free gingivalmargin level (Figure 3). It was suspectedthat her condition may have been caused bya late growth spurt of the maxillary com-plex or eruption of the adjacent teeth.

The possible treatment options includ-ed: (1) remove the implant, perform boneand soft-tissue grafts, then place a newimplant; (2) perform distraction osteog-enesis on tooth No. 9; or (3) not performsurgery and instead provide an artificialgingival restoration.

The patient was dental-phobic andtraumatized by previous dental experi-ences and so declined any further surgicalintervention. She wanted only a simplereshaping of tooth No. 8 to try to matchtooth No. 9, which was shorter. She waseducated that this plan would not sufficebecause the differential in length was toogreat and that the final result would not bein esthetic harmony. An alternative planwas presented to the patient, which wasnoninvasive and used artificial gingiva.

Because the defect was just beyondthe esthetic zone (ie, the interface betweenartificial and natural gingiva was beyondthe lip perimeter when smiling), the pinkcomposite should be done directly in themouth, facilitating a better match of color,

2 INSIDE DENTISTRY—OCTOBER 2008

Prosthetic Gingival Reconstruction in the Fixed Partial RestorationChristian Coachman, DDS, CDT; David Garber, DMD; Maurice Salama, DMD; Henry Salama, DMD;Guilherme Cabral, DDS, CDT; and Marcelo Calamita, DDS

“...artificial gingiva restorations can reduce the necessity of technique-sensitive

surgical procedures...”

insideRestoraTIveDenTIsTRY

Christian Coachman, DDS, CDTCeramist

Team Atlanta Lab

Atlanta, Georgia

David Garber, DMDClinical Assistant Professor in the

Departments of Periodontics and Oral

Rehabilitation

Medical College of Georgia

School of Dentistry

Augusta, Georgia

Department of Prosthodontics

Louisiana State University

New Orleans, Louisiana

Private Practice

Atlanta, Georgia

Maurice Salama, DMDClinical Assistant Professor Periodontics

University of Pennsylvania

Philadelphia, Pennsylvania

Medical College of Georgia

Augusta, Georgia

Private Practice

Atlanta, Georgia

Henry Salama, DMDClinical Assistant Professor Periodontics

University of Pennsylvania

Philadelphia, Pennsylvania

Private Practice

Atlanta, Georgia

Guilherme Cabral, DDS, CDTCeramist

Team Atlanta Lab

Atlanta, Georgia

São Paulo, Brazil

Marcelo Calamita, DDSAssociate Professor of Removable

Prosthodontics

Guaralhos University of São Paulo

São Paulo, Brazil

Private Practice

Figure 1 Initial placement of ceramic-metalaugmented abutment after repeated osseousand connective-tissue grafts of the upper leftcentral incisors. Clinical photograph from 10years ago.

Figure 3 Patient presentation 10 years after theentail grafts and implant placement. The patientpresented with a relative change in the position oftooth No. 9. This probably was caused by either alate growth spurt where the maxillary bone andteeth moved incisally while the implant crownstayed in the same position or eruption of theteeth adjacent to tooth No. 9. Notice the decreasein papillae height and the apical position of thegingival margin on tooth No. 9. These factors mod-ified the esthetics of the restoration dramatically.

Figure 2 Placement of an all-ceramic crownshowing resultant alteration in tooth form causedby loss of the papillae, ie, long restorative con-tact point between centrals. Clinical photographfrom 10 years ago.

shape, and texture between natural andartificial gingiva.

The basic requirements for placingpink gingival composite restorationsover implants include:

1. No cement line can be placed belowthe gingiva, which will compromise

the tissue health if the excess cementcannot be removed.

2. The restoration must be retrievablebecause pink gingival composite maynot have the same longevity as ceram-ics and could require replacement orrefinishing in 5 to 15 years.

3. Screw retention of the restoration

should be used to allow for easyretrievability and refinishing, with nocement line below the gingiva.

In this case, the implant was placed 10years prior on an angulation that did notallow for screw retention of the restora-tion (the screw exited on the buccal surface

of the crown). Two options to deliver pinkgingival esthetics were available:

1. Conventional abutment and a ce-mented crown with pink gingivaincorporated on the crown. Thiswould create the negative factor ofhaving the actual cement line well

INSIDE DENTISTRY—OCTOBER 2008 3

Figure 4 Preoperative study model showed allof the esthetic factors.

Figure 5 The diagnostic wax-up restoring the in-cisal and coronal harmony to tooth No. 9 and rede-veloping the laboratory soft-tissue profiles in pinkcomposite (wax also can be used) on the model’srestorative gingival interface, ie, the mesial and distalpapillae and new level to the free gingival margin.

Figure 7 A full-contour wax-up of the crown wasdeveloped over the working model to guide in thedesign of the final abutment, coping, and restoration.

Figure 6 The original restoration was tappedout and removed.

Figure 8 Pink composite was added to thewax-up, simulating the optimal form of the soft-tissue profiles and relocating the restorative gin-gival interface coronally.

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Figure 9 This pink composite was readilyremovable so that it could be used as a guide tothe ceramic buildup.

Figure 11 The ceramic buildup with the pinkmodel composite in position.

Figure 10 A zirconium abutment and crowncoping were fabricated.

Figure 12 The completed composite ceramiccrown surrounded by the simulated restorativegingival interface.

Figure 13 The ceramic crown with pink gingivalsimulation removed the deficiency of soft-tissue,resulting in an untoward esthetic “black triangle”and altering the gingival height.

Figure 15 The zirconium abutment wasscrewed into position intraorally.

Figure 14 The subgingival contours of the zir-conium abutment were overlaid with pink ceramic.

Figure 16 The two-piece abutment and crownin position. Note that the margin of the crownwas supragingivally positioned just apical to thelevel of the adjacent incisor and slightly apical tothe level of the potential composite gingival level.

Figure 17 Pink composite was directly bondedintraorally to the abutment, with the crown inposition to develop a perfect interface betweenthe pink gingival composite, the crown, and thecompromised site.

Figure 18 After removal from the mouth, the pinkaugmented abutment was finished chairside by re-moving the excess flash and sharp concavities andpolishing the composite. (Finishing can also be per-formed in the dental laboratory.)

Figure 19 Occlusal view showing the redevel-oped gingival profiles recouping the tissue loss.

below the level of the gingival margin.2. Separate the gingival from the crown

and add it to a screw-retained abut-ment, and then cement the crownover it. This would bring the cementline coronally toward the gingivalmargin so as not to compromise thesoft tissue.

After choosing the second option, theabutment was prepared and designed toreceive the pink gingival composite. Thesupragingival form of the abutment wasvisualized in an ideal situation to mini-mize the adjacent crestal gingiva. Whenthe abutment was placed in the mouth,the finish line of the crown and the restora-tive gingival interface would be completelysupragingival, leaving space beyond it tobond the pink composite apically to thelabial and interproximal aspects of theneck of the abutment.

To plan this precise position for thecrown margin on the abutment, a full-contour diagnostic wax-up to reproducethe ideal shape of the tooth was devel-oped (Figure 4). This left room apicallyfor the artificial gingiva to be developed.Pink composite was added over the crown

wax-up to reproduce the missing soft tis-sue (Figure 5). This pink gingival com-posite mask was removable. The wax-upprovided an exact simulation of where toposition the ideal crown margin andrestorative gingival interface on theabutment to develop a finish line barelysubgingival relative to the artificial com-posite gingiva but supragingival relativeto the remaining natural tissue (Figure 6through Figure 9).

The abutment and coping were fabri-cated in zirconium (Procera®, NobelBiocare USA LLC, Yorba Linda, CA), andthe buildup was made with Nobel Rondo™

Ceramics (Nobel Biocare USA LLC)(Figure 10 through Figure 14). The chal-lenge was matching the adjacent naturalteeth. After finishing the buildup, thecrown was tried in over the abutment,and then the shape and shade were com-pleted and the crown glazed.

The abutment was prepared to receivethe composite. A thin layer of pink ceram-ic was applied to the abutment as a bond-ing interface between the zirconium andthe composite. Then, the ceramic surface ofthe abutment was sandblasted, etched, andsilanated. Finally, it received a thin layer

of flowable pink composite. The abutmentwas then placed in the mouth (Figure 15).The glazed crown was placed into posi-tion on the abutment so that the directbonding of the gingival composite couldbe done instantly (Figure 16).

A direct composite technique was exe-cuted by adding small increments of pinkcomposite to the abutment, trying tomatch the color, shape, and form of thenatural gingiva (Figure 17). After the pinkcomposite was completed, the crown wasremoved, and then the abutment with thepink composite attached was unscrewed.

Outside of the mouth, extra pink com-posite was added to fill in undercuts andvoids. Using a thin diamond bur, the edgeswere shaped and flashed and the excesseswere removed. Polishing procedures wereperformed, followed by glazing of the pinkcomposite (Figure 18). The abutment wasthen tried in to check the subtle estheticnuances of the delicate interface betweenthe natural and artificial gingiva (Figure19). The ability to perform hygiene pro-cedures also was checked, making surethat floss could slide through the entireinterface between artificial gingiva, natu-ral gingiva, and adjacent teeth (Figure 20

through Figure 22). It is essential to ensurethat the patient will be able execute all ofthese hygiene procedures before finaltorquing of the “pink” abutment intoposition (Figure 23).

After the abutment was in position, thecrown was placed with retrievable cement(Figure 24 through Figure 28).A follow-upappointment was scheduled for 1 monthposttreatment to check the health of thegingiva and efficiency of the hygiene pro-cedures executed by the patient.

CONCLUSIONRestoring a defective environment insidethe esthetic zone will always be challeng-ing. This article has highlighted a newfocus for the implant team called “inter-face development”which involves the alter-native of a composite artificial gingivalrestorative as a predictable treatmentoption for fixed partial restorations in thesecomplex esthetic cases. Understandingand deploying this solution involves anew paradigm in thinking for the entireimplant team.

The technician should have a widerunderstanding of both the surgical andclinical procedures to be an active partic-ipant on the treatment planning team.Training to reproduce not only the teethbut also gingival esthetics and anatomyare paramount. Currently, with the qual-ity of the available materials (ceramicsand composite resin) it is possible to mimicthe esthetics of nature, matching teeth andgingiva, while allowing for correct main-tenance and long-term life expectancy ofthe implant bridge.

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Figure 20 through 22 The restoration was designed to allow the patient to be able to remove plaque and debris accumulating at the soft tissue–restora-tive interface. Floss must pass readily through the contacts and over the flat or convex apical areas to be able to clean the convex restorative surfaces andpassively contact the surface of the remaining soft tissues of the site. Maintenance is key for long-term successful pink restorations.

Figure 23 The “pink” abutment, finished, wastorqued to 32 Ncm. Notice the blend betweennatural tissue and artificial composite gingiva.

Figure 25 The crown was placed secondarilywith a retrievable cement to provide for access tothe abutment screw if necessary.

Figure 24 The crown was cemented in positionover the abutment and restorative gingival profile.

Figure 26 and 27 The final re-treatment results, with restored harmony to the smile line and soft-tis-sue profiles.

Figure 28 Intraoral lateral view of the finalrestorations—ceramic abutment, composite gin-gival restoration, and all-ceramic crown.

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