ImPlant DenTIsTRY2 INSIDE DENTISTRY—APRIL 2007

The key to contemporary restor-ative dentistry is the fabrication of healthy,maintainable, esthetic, and functional pro-stheses. The true success of any restorationis reliant on the creation of an “illusion ofreality,”1 regardless of the restorative mo-dality used (eg, porcelain laminate veneers,crowns, and/or implant-supported pros-theses).2 Developments and advances tothe restorative armamentarium have sig-nificantly improved the clinician’s abilityto deliver predictable and reliable treat-ments. Osseointegration is one of the es-sential components of implant therapy.3

It is universally accepted that implant den-tistry is a restorative-driven treatment witha surgical component. 4

Mastering esthetics in the smile zonewith the use of implant-supported restora-tions should involve:

• proper diagnosis of smile design; gin-gival contours;

• the existence of proper biologic width;• proper decision making on site

development;• soft and hard tissue grafting to correct

unesthetic or functionally compro-mised anatomic abnormalities; and

• the removal of excessive gingival andalveolar bone for the correction of“gummy” smiles.

All of these factors need to be consider-ed during the treatment sequencing pro-cess and performed before placement ofdental implants5 or the restoration of na-tural tooth-supported restorations.6-8

These aforementioned procedures arethe blueprint to establishing a proper gin-gival smile line with correct biologic width.Crown lengthening is critical to the suc-cess of creating a smile that is harmoni-ously balanced with its surrounding facialfeatures.9-12 Consequently, patients whoclinically display too much gingiva and

short teeth require a thorough diagnosisand treatment plan to provide a predictableesthetic outcome.13-15 This is especially im-perative with the use of dental implantrestorations according to these authors andadvocated by Vincent Kokich, DDS.5 If apatient has altered passive eruption(APE) of the maxillary anterior teeth, ei-ther secondary to orthodontic treatmentor without orthodontic therapy but withcompleted facial growth,16,17 then thesurgeon must first correct the gingivallevels with either a gingivectomy oresthetic crown-lengthening procedurebefore the placement of dental implantsto ensure that the eventual gingival mar-gins of the maxillary anterior teeth willbe at their correct level relative to theadjacent anterior teeth, not only afterrestoration of the implant, but also overthe long term.18

Biological width dictates that there beat least 3 mm between the most apicalextension of the restorative margin andthe alveolar bone crest.19 This allows suf-ficient room for the supracrestal collagenfibers that are part of the periodontal sup-port mechanism, as well as providing agingival crevice of 2 mm to 3 mm.20,21 Ifthis guideline is followed, the restorativemargin should be positioned approxi-mately midway between the gingival tis-sue margin and the depth of the sulcus.22

Failure to allow sufficient space betweenthe crown margin, be it on a natural toothor an implant, and the alveolar crest heightresults in the finished restoration beingpositioned too deep in the periodontaltissues, which can result in increased in-flammation and possible periodontalpocket formation.23

In a situation where no periodontal dis-ease exists, the osseous structure roughlyfollows the scalloped parabolic contourof the cemento-enamel junction (CEJ),from facial to interproximal at an aver-

age distance of 2 mm to 3 mm.24,25 Inaddition, the average interproximal boneheight is 3 mm coronal to the facial crestof bone (COB).26 Because the soft tissuetopography is usually determined by theunderlying hard tissue, this osseous “scal-lop” usually results in a gingival scallop of3 mm.27 Examination of the periapicalradiographs or periodontal vertical bitewings will allow the clinician to ascertainthe position of the alveolar bone relativeto the CEJ of the teeth28 to determinewhether the COB is 2 mm to 3 mm api-cal to the CEJ, allowing for biologicwidth.29-31

However, in a clinical scenario wherethe COB is coronal to the CEJ, a condi-tion results in APE.32-34 In this situation,the gingival margin will usually be locat-ed, on average, 3 mm coronal to the levelof the COB, being more coronal on thebody of the tooth and creating the appear-ance of a short clinical crown.35,36 Thesevisual findings are coupled with the clin-ical information obtained by “bone sound-ing.” Bone sounding involves using aperiodontal probe to locate the CEJ anddetermine whether it can be felt withinthe gingival sulcus or only when the probepenetrates through the base of the sul-cus.37 Additionally, the periodontal probeis also used to feel for the COB. This valueis expressed as a numerical distance in mil-limeters, revealing the distance betweenthe COB and CEJ to ascertain whetherthere is sufficient biologic width.38 Nor-mally, the COB is 2 mm to 3 mm apicalto the CEJ in a normal, non-diseasedhuman periodontium.39

In addition to the gingival margin onthe facial aspect of the teeth, in a non-diseased dentition the interproximalpapilla between teeth with no bone lossdue to periodontal disease is approxi-mately 4.5 mm coronal to the interprox-imal COB. The mid-direct facial is about

1.5 mm more coronal to the COB. Thisadditional 1.5 mm, with the 3-mm aver-age osseous scallop from the CEJ, resultsin the tip of the papilla being an averageof 4.5 mm coronal to the facial free gingivalmargin, where there is a “normal” per-iodontium, with no loss of bone or per-iodontal attachment due to periodontaldisease.40

However, if the alveolar bone was sit-uated in any other position other thannormal, which is 2 mm to 3 mm apicalfrom the CEJ, then these aforementionedvalues would not be the same and clini-cally relevant when used as a referencefor the depth of a dental implant plat-form to allow for a proper emergenceprofile, according to the authors.

If implants are to replace missing teeth,then APE should be corrected before im-plant placement. In addition, if the pa-tient has APE of the maxillary anteriorsegment, whether secondary to:

• orthodontic tooth movement;41

• a coronal gingival complex resultingfrom tissue hypertrophy secondary toplaque-induced inflammation;42

• medications such as calcium channelblocking agents, anticonvulsants, andimmunosuppressant drugs;43

• deep decay causing short clinicalcrowns;44

• traumatic injury;44

• incisal attrition;45 or• tooth eruption and the patient has com-

pleted facial growth,46

then the surgeon should first correct theaberrant gingival margins with an esthe-tic gingivectomy procedure, or the gingi-val margins and alveolar crest levels mustbe altered with an esthetic crown-length-ening procedure47 before the placementof the dental implant. These procedurescan be accomplished at a separate surgi-cal visit or at the time of dental implantplacement but should be performed im-mediately before the preparation of theimplant osteotomy, according to the au-thors and others.48,49 This will ensurethat the eventual gingival margin overthe dental implant will be at its correctlevel relative to the adjacent anterior teeth,according to the authors.

Dental Implants:Mastering Esthetics in the Smile ZoneLee H. Silverstein, DDS; Gregori M. Kurtzman, DDS; David Kurtzman, DDS; and Peter C. Shatz, DDS

“...advances to the restorative armamentariumhave significantly improved the clinician’s ability to

deliver predictable and reliable treatments.”

insideImPlant DenTIsTRY

Gregori M. Kurtzman, DDSPrivate Practice

Silver Spring, Maryland

David Kurtzman, DDSGeneral Private Practice

Hospital-Based Practice Treating Special

Needs Patients

Marietta, Georgia

Peter C. Shatz, DDSAssistant Clinical Professor of Periodontics

Medical College of Georgia

Augusta, Georgia

Private Practice, Marietta, Georgia

Lee H. Silverstein, DDS, MSAssociate Clinical Professor of Periodontics

Medical College of Georgia

Augusta, Georgia

Private Practice, Marietta, Georgia

INSIDE DENTISTRY—APRIL 2007

3

CLINICAL GUIDELINESThere are anatomic principles that act asparameters when practitioners performesthetic gingival recontouring. A usefulguide can be fabricated by the laboratoryby modifying the mounted diagnostic castsso that the waxed modification reflectsthe ideal tooth anatomy desired in the fi-nal prosthesis, based on the guidelines pre-viously published by Chiche and Pinault.50

These guidelines suggest that the averagelength for esthetically pleasing maxillarycentral incisors is 10 mm to 12 mm.51

These guidelines for the length of the cen-tral incisors, along with the recommend-ed width-to-length ratio of 75% to 80%,52

should be kept in mind when recontour-ing the gingival tissues so as not to leavethe teeth too long or too short.53

Once the central incisor proportions areachieved, practitioners should focus onthe zenith or height of contour of the gin-gival margin on the centrals.54 The prop-er placement of the gingival zenith shouldbe at the peak of the parabolic curvatureof the gingival margin, which for the cen-tral incisors, cuspids, and bicuspids shouldspecifically be located slightly distal tothe middle of the long axis on these teeth.This gives the centrals, cuspids, and bi-cuspids the subtle distal root inclinationthat is paramount for the scaffold of abeautiful smile. The zenith for the lateralincisors is located at the midline of the longaxis of the tooth. Furthermore, the heightof the gingival crest for the lateral incisorsshould be 1 mm shorter than the gingivalmargins of the adjacent teeth. Addition-ally, the gingival tissues should be man-ipulated to have a resulting “knife-edge”gingival margin.55

Subsequent to the collection of the pa-tient’s clinical data, which will reveal thepresence of short clinical crowns and cre-stal bone levels approximating the CEJ, adiagnosis of APE can be made through themaxillary arch. The practitioner can thenfabricate an esthetic guide that can beplaced over the patient’s existing teeth toallow both the practitioner and patient tovisualize what the smile will look like withthe gingiva in a modified, more estheticposition.56

The repositioning of the gum line andcrestal alveolar bone can be accomplishedafter the administration of local anesthe-tic. A periodontal probe is placed into thesulcus, attempting to locate the CEJ, butsometimes the CEJ cannot be discerned.In a case where the location of the CEJ isnot clearly located, a periodontal probeshould be passed through the periodon-tal attachment until the crest of alveolarbone is felt. Coupled with current peri-apical radiographs, the location of thecrest of bone relative to the CEJ shouldbe discernible.57

Periodontal, esthetic, and surgicalcrown-lengthening is then accomplishedto correct the altered passive eruption.The laboratory-fabricated composite gin-gival esthetic guide can be used not onlyto position the alveolar crest 3 mm apical

to the CEJ,58 but also to provide a blue-print for attaining horizontal gingivalsymmetry and height. The guide will alsoensure proper interproximal scallopingbased on the desired results. The newlyestablished gingival margin will be de-termined by the patient’s lip line whilesmiling,59 the desired length of anteriorteeth relative to the existing level of alve-olar bone,60 and healthy interdental pap-illary tissue occupying the interdentalspaces.61

Subsequent to scalloping the gingivaltissues, an inverse beveled incision is made,connecting the sulci of the maxillary af-fected teeth. The surgical incision cantransverse the base of the papillary tissueor it can follow the topography of the in-terdental papilla. For esthetic success atthis critical phase of the crown-lengthen-ing process, it is important not to elevatethe papilla, which usually will cause aloss of interproximal tissue height andmay result in “black triangles.”

A full-thickness mucoperiosteal flapis then elevated with a periosteal elevator,and osseous resective techniques are per-formed with a surgical-length. No. 8 rounddiamond bur and periodontal hand chis-els to reshape the patient’s osseous bonemargins. The surgical flap can then bepositioned to the prearranged height de-termined by the esthetic surgical guide.The flaps are sutured using a 3/8 reversecutting suture needle with a 4-0 threadsize of polyglycolic acid (PGA), using asling-suture technique. Suture removal isperformed 10 days after surgery and thepatient is instructed on the oral hygieneregimen to be used. This includes brush-ing with a soft-bristled toothbrush in acircular motion, and cleaning interden-tally with either dental tape or floss.

After 10 weeks of postoperative heal-ing, the cosmetic rehabilitation begins withthe removal of the existing crowns. Theteeth can be prepared with burs using theesthetic guide as the blueprint for toothreduction. The restorations to be placedare ceramic crowns. These preparationsare either placed at the free gingival mar-gin or slightly subgingival on the facialaspect. Care should be taken not to vio-late the biologic width during the toothpreparation.62

Provisional restorations can be madeby placing them in a vacuum-formed ma-trix made on the modified model, fromwhich the esthetic surgical guide was fab-ricated, and then placed intraorally. Afterthe appropriate time, approximately 60 to90 seconds, the provisionals are removedand trimmed. The provisionals are bond-ed in place by spot-etching the prepara-tions and using a luting material.

The occlusion should then be checkedin the centric, protrusive, and lateral ex-cursive positions63 and adjusted as need-ed. The patient should return to the office10 days after insertion of the provisionalrestorations and provide input aboutwhat he/she likes and dislikes estheticallyabout the provisionals, and any changes

that are desired. Subsequent to the re-contouring of these provisional restora-tions to meet the patient’s expectations andgain the patient’s approval, impressionsare taken and a putty matrix of the ante-rior segment is made to ensure the labo-ratory placed the incisal edges correctly.

Final impressions are obtained 6 to 8weeks later64 by first placing a retractioncord, using a two-cord method with a wo-ven cord, taking care not to injure the gin-gival tissues. Full-mouth impressions aretaken with a vinyl polysiloxane facebowtransfer, and open-bite centric relationrecords are obtained using registrationmaterial mounted in a semi-adjustablearticulator. The case can be completed us-ing full feldspathic porcelain crowns onteeth Nos. 6 through 11. Excess cement isremoved with an explorer and periodon-tal scaler. The previously fabricated puttyfacial index should be placed to see if thereare any discrepancies, and any noted dis-crepancies should be modified.

The end result should be a healthy peri-odontal response and symmetry of thesmile, which illustrates a completed healthyesthetic functional prosthetic result. Thecentral incisors should demonstrate mid-line symmetry, as well as the correct 75%to 80% width-to-length ratio. In addi-tion, the incisal smile line should followthe curvature of the lower lip. The newlyestablished periodontal smile line shouldshow a reduction of the gummy smile andmake the smile more esthetically appeal-ing and harmonious with surroundingfacial features.65

Gingival levels should be assessed rel-ative to the projected incisal edge position.The projected incisal edge position shouldbe assessed relative to the position of thegingival levels. A predictable mode of de-termining the proper gingival positionsis to determine the desired tooth size rel-ative to the projected incisal edge posi-tion. The practitioner should rememberthat the incisal edge should not be posi-tioned using the relative position of thegingival margin to create the propertooth size. This is because the gingivalmargin can move with eruption or reces-sion.66 Therefore, the proper gingivalmargin positions should be determinedby establishing the correct width-to-lengthratio of the maxillary anterior teeth.67

This can be accomplished by determin-ing the desired amount of gingival dis-play and creating symmetry between theteeth throughout the maxillary arch.68

In other words, if the existing positionof the gingival margins creates the pres-ence of a short clinical crown relative to theprojected incisal edge position, then thegingival margins should be moved api-cally. This can be accomplished by per-forming esthetic crown lengthening,estheticgingivectomy, orthodontic intrusion, and/or prosthetic rehabilitation.69 The pro-cedure that is chosen to reposition thegum line is dependent upon several clin-ical factors, such as the location of the CEJrelative to the COB, the crown-to-root

ratio and the shape of the root(s), the a-mount of existing tooth structure, andthe sulcus/pocket depth. It is also para-mount when establishing the proper po-sition of the maxillary anterior teeth foran optimal cosmetic outcome to assessthe levels of the interdental papillary tis-sues and their position relative to thecrown length of the maxillary incisors.

One published article70 demonstratedthat if the interdental contact is shorterthan the interproximal papilla, then thiscould be an indication that there is clini-cally significant incisor abrasion. Thisscenario may cause shorter crowns whichshortens the contact between the centralincisors. However, if the interdental con-tact point is longer than the papilla, thenthe gingival margin contour would beflat and usually located coronal to the CEJ,analogous to the clinical presentation ofAPE.71 The correction of this conditionwould be accomplished by performingesthetic crown lengthening72 and or orth-odontic therapy to either extrude73 orintrude74 the affected teeth.

CONCLUSIONFigures 1 through 9 illustrate the conceptspresented in this article. Patients whoclinically display too much gingiva andshort teeth require a thorough diagnosisand treatment plan to provide a pre-dictable esthetic outcome. This is espe-cially imperative with the use of implantrestorations because, according to theseauthors, if a patient has APE of the max-illary anterior teeth, either secondary toorthodontic treatment or without orth-odontic therapy but has completed facialgrowth, then the surgeon must first cor-rect the gingival levels with either a gin-givectomy or esthetic crown-lengtheningprocedure before the placement of den-tal implants. This will ensure that the even-tual gingival margins of the maxillaryanterior teeth will be at their correct lev-el relative to the adjacent anterior teeth,not only after restoration of the implant,but also for a favorable long-term im-plant and/or natural tooth restoration.75

It is essential that there be at least 3 mmbetween the most apical extension of therestorative margin and the alveolar bonecrest. This allows sufficient room for thesupracrestal collagen fibers that are partof the periodontal support mechanism,as well as providing a gingival crevice of2 mm to 3 mm.

Essentially, the guideline of 3 mm onthe facial from the COB to the gingivalmargin and 4 mm to 5 mm from the in-terproximal COB to the tip of the papillafor proper implant placement to allowfor proper restorative contours would beirrelevant and erroneous if the perio-dontium and its hard and soft tissueswere not located where they should be ina normal situation, with no bone and orattachment loss.Also, if the gingival marginis not located at the CEJ and the under-lying bone is not 2 mm to 3 mm apical tothe CEJ and after its parabolic contours,

ImPlant DenTIsTRY

4 INSIDE DENTISTRY—APRIL 2007

then the value of 3 mm on the facial and4 mm to 5 mm on the interproximal areaguideline for proper implant placementshould not be used.

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4 INSIDE DENTISTRY—APRIL 2007

Figure 1 Illustration of an implant placed with-out diagnosis or correction of altered passiveeruption.

Figure 2 Clinical photograph of an implantplaced without correction of altered passiveeruption 5 weeks postoperatively.

ImPlant DenTIsTRY

Figure 4 A transitional single-tooth removableappliance in place. The patient was referred toevaluate excess hyperplastic tissue on adjacentteeth and the implant because the teeth looked“short.” Note the dark gray collar of the implantshowing through the soft tissue.

Figure 3 Diagrammatic representation of clini-cal case showing the COB on crown of tooth in-stead of being located 2 mm to 3 mm apical tothe CEJ. Note that the gumline is several millime-ters coronal to the position of the bone crest.

Figure 5 Intraoral view with the transitionalappliance removed. Note the inflammation andgrayish color where the implant collar is showingthrough the gingival tissue. Also note the alteredpassive eruption on adjacent teeth that was notcorrected before placement of this dental implant.

Figure 6 This illustration shows that if tissuewere to be removed then several threads of theimplant would be exposed.According to the implantsurgeon, 3 mm on the facial from the facial crestof the bone to the gumline and 4 mm interproxi-mally from the COB to the tip of the papilla wasused here, but because altered passive eruptionwas not corrected first, these “guidelines” werenot relevant and should not have been used forthis implant placement.

Figure 7 Diagram of the COB at the CEJ. Thiscase should have had a crown-lengthening pro-cedure to relocate the COB 2 mm to 3 mm api-cal to the CEJ following the contour of the tooth’sCEJ to reestablish proper biologic width.

Figure 8 Diagram showing the implant placedafter crown lengthening was performed immedi-ately before placement of the implant. Once theCOB was properly located apical to the CEJ in aparabolic fashion, the “guideline” of 3 mm on thefacial from the COB on the direct facial to the gin-gival margin will allow for a proper emergence pro-file of the future implant-supported restoration.

Figure 9 Note the interproximal bone hasbeen relocated 2 mm to 3 mm apical to the CEJin preparation for implant placement, and nowthe guideline of 4 mm interproximally from theCOB to the tip of interdental papilla can be usedto allow for a proper emergence profile of thefuture implant-supported crown.

ImPlant DenTIsTRYINSIDE DENTISTRY—APRIL 2007 5

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