In spite of the recent developments in periodontal and peri-implant surgical regenerative procedures, completely and predictably reestablishing the hard and soft tissue contours is still a challenge in cases with three-dimensional (3D) ridge deficiencies (Figs 1 and 2).
This article presents a reliable and consistent alter- native to prosthetically restore cases with an uncertain surgical outcome or for those patients who do not want to undergo regenerative surgical procedures (Figs 3 to 14). The innovative hybrid prosthetic gingival restoration (Figs 6 to 9) makes it possible to pre- dictably achieve an excellent match between the pros- thetic and natural gingiva. Understanding the indications and procedures involved with this tech- nique requires a paradigm shift for the whole interdis- ciplinary team, but with considerable benefits to the patient.
Surgical procedures to reestablish the 3D architec- ture of hard and soft tissue ridge deformities have been developed and performed successfully through- out the last 15 years. In some cases, however, even after several state-of-the-art regenerative procedures such as bone grafting, soft tissue grafting, and orthodontic relocation, the results are still unpredictable, with compromised esthetic and functional results.
The biggest challenge in alveolar ridge augmenta- tion is the vertical aspect of the defect (Figs 15 to 21), including papillae and gingival margin levels, which are the most esthetically important areas of the gingiva. Tjan et al showed that approximately 80% of the population display part of their gingiva when smiling, which means that the vast majority of patients requiring tissue reconstruction will expose their gingival and ridge deficiencies. This informa- tion, in addition to the fact that patients are becom- ing more and more esthetically demanding, creates an explosive combination, since all available surgical procedures are often insufficient to reestablish ideal esthetics.
The prosthetic gingival restoration in implant ther- apy can be an esthetic and functional alternative for reconstructing ridge deformities. When designed from the outset—rather than being used as a last re- sort—it can dictate all adjunctive procedures neces- sary to achieve superior results.
TREATMENT PLANNING
When properly indicated, the prosthetic gingival restoration can predictably reestablish the esthetics of the missing soft tissue, reproducing the shape, color, and texture of the patient’s natural gingival.
Teamwork and an interdisciplinary treatment plan are paramount to the diagnosis, execution, and long- term success of this restoration. After identifying the patient’s needs and expectations, the implantologist, periodontist, prosthodontist, and dental technician must recognize all obstacles to attaining the ideal pink and white esthetic results, and should discuss the technical and biologic limitations of each specialist’s role. All diagnostic data must be clearly communi- cated to the patient. Because many of these patients have already undergone unsuccessful regenerative procedures, they should be aware of the possibility of a compromised final outcome.
The prosthetic gingival restoration is a consistent alternative to restore the patient’s dentogingival complex.
Advantages:
• Improves the predictability of pink and white es- thetic restorations.
• Reduces the need for and complexity of technique- sensitive surgical procedures.
• Is not dependent on the patient’s previous treat- ments and restorations. [Au: Correct?]
• Improves intraoral comfort and air sealing during speech because of the smooth, uniform, and cleans- able interface of the prosthetic gingiva with the re- maining tissues.
• Simplifies technical and clinical procedures, thus de- creasing cost and time.
• Makes it possible to compensate for inadequate maxillomandibular relationships.
Disdvantages:
• Requires proper patient education during treatment planning; otherwise, the patient may get frustrated when comparing the prosthetic gingival restoration to a removable partial denture.
• Requires an individualized maintenance program to ensure long-term success and patient discipline to accomplish rigorous hygiene procedures. This disad- vantage can be minimized when the implants, grafts, tissue conditioning, and restoration design are planned specifically for this technique.
IMPLANT PLACEMENT: DENTOGINGIVAL DIAGNOSTIC WAX-UP
The dentogingival diagnostic wax-up (Fig 22) will pro- duce an ideal esthetic restoration and will be the ulti- mate guide for the surgical (Figs 23 and 24), restora- tive, and laboratory procedures. The dental technician must have a deep understanding of the 3D tooth and implant positioning, gingival esthetics, and soft tissue management to design and execute an adequate dentogingival wax-up and restorations with harmony, balance, and continuity of form between the natural and prosthetic gingiva.
The biggest challenge in alveolar ridge augmenta- tion is the vertical aspect of the defect (Figs 15 to 21), including papillae and gingival margin levels, which are the most esthetically important areas of the gingiva. Tjan et al showed that approximately 80% of the population display part of their gingiva when smiling, which means that the vast majority of patients requiring tissue reconstruction will expose their gingival and ridge deficiencies. This informa- tion, in addition to the fact that patients are becom- ing more and more esthetically demanding, creates an explosive combination, since all available surgical procedures are often insufficient to reestablish ideal esthetics.
The prosthetic gingival restoration in implant ther- apy can be an esthetic and functional alternative for reconstructing ridge deformities. When designed from the outset—rather than being used as a last re- sort—it can dictate all adjunctive procedures neces- sary to achieve superior results.
TREATMENT PLANNING
When properly indicated, the prosthetic gingival restoration can predictably reestablish the esthetics of the missing soft tissue, reproducing the shape, color, and texture of the patient’s natural gingival.
Teamwork and an interdisciplinary treatment plan are paramount to the diagnosis, execution, and long- term success of this restoration. After identifying the patient’s needs and expectations, the implantologist, periodontist, prosthodontist, and dental technician must recognize all obstacles to attaining the ideal pink and white esthetic results, and should discuss the technical and biologic limitations of each specialist’s role. All diagnostic data must be clearly communi- cated to the patient. Because many of these patients have already undergone unsuccessful regenerative procedures, they should be aware of the possibility of a compromised final outcome.
The prosthetic gingival restoration is a consistent alternative to restore the patient’s dentogingival complex.
Advantages:
• Improves the predictability of pink and white es- thetic restorations.
• Reduces the need for and complexity of technique- sensitive surgical procedures.
• Is not dependent on the patient’s previous treat- ments and restorations. [Au: Correct?]
• Improves intraoral comfort and air sealing during speech because of the smooth, uniform, and cleans- able interface of the prosthetic gingiva with the re- maining tissues.
• Simplifies technical and clinical procedures, thus de- creasing cost and time.
• Makes it possible to compensate for inadequate maxillomandibular relationships.
Disdvantages:
• Requires proper patient education during treatment planning; otherwise, the patient may get frustrated when comparing the prosthetic gingival restoration to a removable partial denture.
• Requires an individualized maintenance program to ensure long-term success and patient discipline to accomplish rigorous hygiene procedures. This disad- vantage can be minimized when the implants, grafts, tissue conditioning, and restoration design are planned specifically for this technique.
IMPLANT PLACEMENT: DENTOGINGIVAL DIAGNOSTIC WAX-UP
The dentogingival diagnostic wax-up (Fig 22) will pro- duce an ideal esthetic restoration and will be the ulti- mate guide for the surgical (Figs 23 and 24), restora- tive, and laboratory procedures. The dental technician must have a deep understanding of the 3D tooth and implant positioning, gingival esthetics, and soft tissue management to design and execute an adequate dentogingival wax-up and restorations with harmony, balance, and continuity of form between the natural and prosthetic gingiva.
During this stage, the dental team will analyze the 3D volume of tissue loss, implant position, and gingival interfaces, based on the Quadrant’s Concept (Figs 25 to 29), to minimize the visibility of this junction, restore the asymmetry of the gingival architecture, and replace papillae form.This wax-up will generate a multifunctional guide with three important roles:
1. Radiographic guide that will allow the team to visu- alize the 3D volume of tissue loss in the computed tomography images.
2. Surgical guide for implant placement in prosthetic gingival restoration cases, dictating the number, location, axis and, most importantly, the depth of the implants (Figs 30 to 39).
3. Surgical guide for hard and soft tissue recontouring to minimize the visibility of the junction between natural and prosthetic gingiva and to maximize comfort and hygiene procedures.
SOFT TISSUE CONDITIONING
The soft tissue design under the artificial gingiva is key for the biologic, functional, and esthetic success of this restoration and differs completely from that of a conventional implant restoration. The need for soft tis- sue conditioning should be planned on the wax-up, developed during the surgical and provisional phase, and refined when seating the final prosthesis, depending on the extension of the area to be conditioned (Figs 40 to 44).
The alveolar ridge must be flat to generate an es- thetic and cleansable interface between prosthetic and natural gingiva. The lingual aspect of the pros- thetic gingival restoration should resemble the natural palatal contours to achieve comfort during mastica- tion and proper phonetics, avoid food entrapment, and promote air sealing.
MATERIAL SELECTION
The materials available for the prosthetic gingiva are ceramics, composite resin, and acrylic resin. Each has its own advantages, disadvantages, and indications.
For cemented fixed partial restorations, ceramics are usually the material of choice to reproduce pink and white esthetics. Due to the fact that ceramic is a delicate and challenging material to handle, with is- sues such as baking shrinkage, number of bakes, color matching, and moisture control, the final pink esthetic outcome may be compromised by an easily noticeable interface between the prosthetic and natural gingiva.
To overcome these limitations, a hybrid technique was developed to make the prosthetic gingiva restoration more attractive and predictable.30 The hy- brid technique is defined by a screw-retained implant partial denture with the white esthetics and the back- ground of the pink esthetics developed in ceramic and the final overlay of the pink contours developed in composite resin, directly in the mouth. Various kits of pink composite resins designed for this technique with different colors and stains allow for a customized restoration.
This hybrid technique offers some remarkable advantages (Figs 45 to 91):
• Preservation of the optical and physical properties of the porcelain by decreasing the number of ceramic bakes.
• More predictability and greater control of pink es- thetic factors such as shape, color, and texture.
• Possibility of repair, addition, recontouring, and un- complicated maintenance, even after years of use, without having to refire the ceramic.
1. Radiographic guide that will allow the team to visu- alize the 3D volume of tissue loss in the computed tomography images.
2. Surgical guide for implant placement in prosthetic gingival restoration cases, dictating the number, location, axis and, most importantly, the depth of the implants (Figs 30 to 39).
3. Surgical guide for hard and soft tissue recontouring to minimize the visibility of the junction between natural and prosthetic gingiva and to maximize comfort and hygiene procedures.
SOFT TISSUE CONDITIONING
The soft tissue design under the artificial gingiva is key for the biologic, functional, and esthetic success of this restoration and differs completely from that of a conventional implant restoration. The need for soft tis- sue conditioning should be planned on the wax-up, developed during the surgical and provisional phase, and refined when seating the final prosthesis, depending on the extension of the area to be conditioned (Figs 40 to 44).
The alveolar ridge must be flat to generate an es- thetic and cleansable interface between prosthetic and natural gingiva. The lingual aspect of the pros- thetic gingival restoration should resemble the natural palatal contours to achieve comfort during mastica- tion and proper phonetics, avoid food entrapment, and promote air sealing.
MATERIAL SELECTION
The materials available for the prosthetic gingiva are ceramics, composite resin, and acrylic resin. Each has its own advantages, disadvantages, and indications.
For cemented fixed partial restorations, ceramics are usually the material of choice to reproduce pink and white esthetics. Due to the fact that ceramic is a delicate and challenging material to handle, with is- sues such as baking shrinkage, number of bakes, color matching, and moisture control, the final pink esthetic outcome may be compromised by an easily noticeable interface between the prosthetic and natural gingiva.
To overcome these limitations, a hybrid technique was developed to make the prosthetic gingiva restoration more attractive and predictable.30 The hy- brid technique is defined by a screw-retained implant partial denture with the white esthetics and the back- ground of the pink esthetics developed in ceramic and the final overlay of the pink contours developed in composite resin, directly in the mouth. Various kits of pink composite resins designed for this technique with different colors and stains allow for a customized restoration.
This hybrid technique offers some remarkable advantages (Figs 45 to 91):
• Preservation of the optical and physical properties of the porcelain by decreasing the number of ceramic bakes.
• More predictability and greater control of pink es- thetic factors such as shape, color, and texture.
• Possibility of repair, addition, recontouring, and un- complicated maintenance, even after years of use, without having to refire the ceramic.
SEATING AND HYGIENE
During the seating process a transitory blenching may be observed. The intensity will vary depending on the extension of the tissue conditioning required, the de- sign of the pontics, and the gingival biotype. The pressure between the natural and prosthetic gingiva should be checked with dental floss. Flossing in this area should have the same intensity of pressure as ex- ists with ideal interproximal contact between adjacent natural dentition. Excess pressure should be reduced by reshaping the soft tissue with diamond burs or a diode laser, or by recontouring the prosthetic gingiva with specific burs and wheels. The main goal is to create a comfortable, healthy, and cleansable interface while maintaining high esthetics.
The hygiene and maintenance procedures should be carefully discussed with the patient. Follow-up ap- pointments should be scheduled initially 3 months after insertion and then can be moved up to every 6 months to 1 year, depending on the patient’s risk assessment.
Probing the bone level of the adjacent natural teeth is highly recommended before seating the prosthesis for further comparison during the follow-up appointments (Fig 92 and 93). During these sessions, the restoration should be removed to check the health of the soft tissue and to probe the adjacent teeth. If the situation of the soft tissues is not ideal, new hygiene education should be given, followed by reshaping of the prosthesis, if necessary, to allow ideal hygiene pro- cedures (Figs 94 to 101). When properly planned and executed, the hybrid prosthetic gingival restoration offers predictable func- tional and esthetic results (Figs 102 and 103).
CONCLUSION
The prosthetic regeneration of pink esthetics is a reliable and consistent alternative to resolve cases with an uncertain surgical outcome or for patients who do not want to undergo regenerative surgical procedures. When this type of restoration is planned from the be- ginning of treatment, the appropriate surgical, restorative, and technical procedures can be executed to maximize the biological, functional and esthetic results and surpass the patient’s expectations.
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