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Interdental Papillae Reconstruction
Ceramic veneers with gingiva-shaded porcelain to replace lost interdental papillae
By Adam J. Mieleszko, CDT, and Stephen J. Chu, DMD, MSD, CDT
While not a new concept, the use of gingiva-shaded pink-colored restorative materials for cosmetic replacement of hard and soft tissues with implant-supported reconstructions is a potentially effective esthetic solution. In 1990, Grunder and Strub discussed and offered a comprehensive prosthodontic approach to treatment alternatives to the conventional Brånemark hybrid acrylic rehabilitation.1 Problems associated with the use of acrylic teeth and gingival replacement materials were color stability and wear resistance over time.2 The use of metal-ceramics in implant reconstructions ensured increased color stability and wear resistance.
Malament and Neeser applied these concepts to not only full-arch fixed dental prostheses, but also smaller dental segments.3 They presented innovative concepts in framework design to manage prosthetic gingiva adaptation and control in color consistency. As materials for gingiva replacement improved, Coachman et al published a three-part series of articles on this subject matter and discussed using a combination of different materials, such as ceramics and composites, in a layered, or “hybrid,” design to achieve the desired esthetic outcome.4-6 Composite material was used because such systems offer a greater array of colors to match the gingiva.
That series of articles clearly outlined the problems associated with esthetic and functional outcomes if pink materials were not used in the definitive reconstruction. These problems included decreased intra-arch distance with resultant narrower teeth, increased intra-arch length and longer teeth, a reverse smile line, rectangular tooth forms, inverted tooth axes, and lack of support of the upper lip.
To achieve excellent esthetic results, the restorative units must be splinted to allow the anatomy of the interdental papillae to be recreated not only in color, but also in form and texture. The remaining question, then, is whether adequate esthetic outcomes using gingiva-shaded materials and techniques can be accomplished with non-splinted single units in combination with implants and teeth, with an absence of interdental papillae. Vertical, rather than horizontal, lines would be created between the pink veneer and crown restorations, presenting challenges in masking to create the illusion of restorative and esthetic unity.
The following report describes the case of a patient who requested individual crowns and veneers after multiple surgical interventions to replace a failing implant tooth No. 9 and address the resultant recession around the adjacent restored teeth. Restorative papillae reconstruction was required.
A 43-year-old Caucasian woman presented with missing interproximal papillae after surgical recession in an effort to replace a failing implant tooth No. 9 (Figure 1). The patient had a high interdental smile line, revealing the lack of papillae display on the left side of her mouth versus the right side, which had a normal papillae display (Figure 2). The lack of interdental papillae display was the patient’s chief concern.
Orthodontic forced eruption was initially considered to correct the vertical position of the lost papillae between teeth Nos. 9 through 11. However, this approach was abandoned after noting and evaluating the diminished root length, which was due to external root resorption after years of orthodontic therapy for the patient as an adolescent (Figure 3). Despite the crown-to-root ratio being less favorable after implant surgery, the teeth were stable (non-mobile) and functional.
Considering that the patient had multiple surgical interventions to replace the failing implant tooth No. 9, the final treatment plan included the following: replace the existing veneer restorations of teeth Nos. 6 through 8; replace the single implant crown tooth No. 9; provide pink veneers on teeth Nos. 10 and 11; and place a no-preparation veneer on tooth No. 12. Study casts were made for a diagnostic wax-up to be fabricated, restoring the proper individual tooth proportion, form, and gingival architecture (Figure 4). The existing veneers on teeth Nos. 6 through 8, 10, and 11 were removed with high-speed rotary instrumentation, and provisional restorations were fabricated employing pink acrylic where required on teeth Nos. 9 through 11. Ceramic extrinsic colorants or stains were mixed with unfilled light-cured resin and applied to the surface of the acrylic and bisacryl restorations with a sable brush (Figure 5).
At the final impression stage of treatment, the final tooth, stump, and gingival shades were taken, respectively (Figure 6). Tooth shade was taken using the VITA 3D-Master® shade guide (Vita, vitanorthamerica.com). A custom ceramic gold-alloy abutment was fabricated for implant No. 9 on the master die cast (Figure 7). A metal-ceramic coping was made for the implant abutment, and opacious dentin was layered not only on the coping but also on the veneer restorations Nos. 10 and 11. A silicone matrix was used to verify equal layering of the veneering enamel ceramics. The enamel ceramics were layered evenly, as were the gingiva-shaded materials, on the veneer preparations and the metal-ceramic frameworks (Figure 8). The final build-up of the single-unit restorations before glazing, polishing, and devesting from the refractory cast is seen in Figure 9.
Though they had a visual appearance of being one distinct contiguous unit, the pink veneers were separate, single-unit restorations. Because the metal-ceramic crown on implant No. 9 was separated from the single pink veneers Nos. 10 and 11, the ceramics needed to be segregated using the beveled slip-joint technique.7 This was to ensure that the flat plane approximating porcelain surfaces would not be visible from the frontal perspective, provided the flat planes could be created at an off-angle axis to the line of vision. Carpenters refer to this as a miter, or beveled, joint.
As seen in Figure 10 through Figure 12, the beveled slip-joint concept and the effect of the restorations on the master cast are evident. From the direct labial view (Figure 11), the connector areas are visible even though they are separate and can allow floss to pass through the flat-plane surfaces. However, from the indirect frontal view (Figure 12), the flat-plane surfaces are less obvious.
The final restorations were polished and fitted on the master cast. The final single metal-ceramic crown, on which the color of the high-noble alloy was changed to a light-yellow shade through gold plating (Figure 13), and pink gingiva-shaded veneers Nos. 10 and 11 (Figure 14) were etched and ready to be luted. A light-cured luting resin cement and total-etch technique were used to bond the pink veneers into place. After light-curing, the excess resin cement was removed and contact areas cleaned with floss tape (Figure 15).
Figure 16 shows the final intraoral view of the restorations in maximum intercuspal position. The esthetic integration of the all-ceramic veneers, metal-ceramic implant crown, and pink ceramic veneers was evident in the patient’s smile (Figure 17). From the extra-oral front-view perspective, the restorations blended well with the pink ceramics, and the vertical discrepancies of the contact areas were unnoticeable as single-unit restorations. These restorations could be easily cleaned and maintained individually, yet they provide the visual appearance of splinted units. The patient was extremely pleased with the outcome both esthetically and functionally.
The use of gingiva-shaded porcelain to cosmetically replace lost interproximal papillae is a restorative treatment alternative to forced orthodontic eruption therapy. This case report showed how pink ceramics, with single-unit restorations, can be created employing the beveled slip-joint technique. This design for gingiva-shaded porcelain veneers allows adjacent implants and teeth to be cosmetically restored while enabling oral hygiene through flossing of individual restorations.
The authors thank Mitchell Bloom, DMD, from New York University College of Dentistry, for the surgical correction of implant No. 9 documented in this report.
1. Grunder U, Strub JR. Implant-supported suprastructure design. Int J Periodontics Restorative Dent. 1990;10(1);19-39.
2. Malament KA, Neeser S. Prosthodontic management of ridge deficiencies. Dent Clin North Am. 2004;48(3):735-744.
3. Coachman C, Salama MA, Garber DA, et al. Prosthetic gingival reconstruction in a fixed partial restoration. Part 1: Introduction to artificial gingiva as an alternative therapy. Int J Periodontics Restorative Dent. 2009;29(5):471-477.
4. Salama MA, Coachman C, Garber DA, et al. Prosthetic gingival reconstruction in a fixed partial restoration. Part 2: Diagnosis and treatment planning. Int J Periodontics Restorative Dent. 2009;29(6):573-581.
5. Coachman C, Salama MA, Garber DA, et al. Prosthetic gingival reconstruction in a fixed partial restoration. Part 3: Laboratory procedures and maintenance. Int J Periodontics Restorative Dent. 2010;30(1):19-29.
6. Chu SJ, Paravina RD, Sailer I, Mieleszko AJ. Color in Dentistry: A Clinical Guide to Predictable Esthetics. Carol Stream, IL: Quintessence Publishing; 2017.
This article was double-blind peer reviewed by members of IDT’s Editorial Advisory Board
About the Authors
Adam J. Mieleszko, CDT
Synergistic Dentistry of New York
New York, NY
Stephen J. Chu, DMD, MSD, CDT
Adjunct Clinical Professor New York University College of Dentistry
New York, NY
Disclosure: The authors have no disclosures to report.