Esthetics in dentistry involves many aspects: mor- phological and optical aspects, functional aspects in relation to shape and how they affect esthetics, and biological integration. In QDT 2014, I briefly presented some morphological and optical factors and how they af- fect the final appearance of teeth and restorations.
The present article analyzes biological aspects regarding the relation between the tooth’s cervical emergence profile and gingival soft tissue, and how they influence the final esthetic outcome of our restorations. These are concepts that should be applied during laboratory procedures in order to create restorations that respect and preserve bio- logical structures as well as reduce damage to them.
Observation of the cervical third of the natural tooth helps us understand the emergence profile, which develops from the cementoenamel junction. The marginal gingiva and papillae form and levels reveal the effect of the emergence profile on the shape and stability of the soft tissue. We also can understand the relation, the balance, and the harmony that exist between the tooth and gingiva.
We can distinguish between:
• Subgingival emergence profile, which is responsible for support and stability of soft tissue.
• Supragingival emergence profile, which is responsible for protection of soft tissue.
We know that hard tissue supports soft tissue. By way of the tooth anatomy of the emergence profile in the cervi- cal third, we can design and drive the gingiva where and how we want—naturally—in relation to the quantity and quality of soft tissue, reaching harmony and stability. Only in this way can esthetics and a natural appearance be guaranteed.
Pink and white esthetics should blend well together, and the former should support the latter in perfect balance. It is important not to allow our fantasy and imagination to change what already exists. We should simply try to emu- late what nature offers us today, no more.
Materials and technology are just tools. Digital systems, in particular, when used without knowledge, experience, ability, and sensibility, can become dangerous to the biolo- gy and therefore to the patient. In all cases, first we need to use our head, our hands, and our heart
EMERGENCE PROFILE IN WAX-UP
In these wax copings we can see how the emergence pro- file changes from the distal to the mesial of the tooth in order to create a natural form and level of the gingival con- tours and papillae, as well as establish the correct position of the gingival zenith. The anatomy of the restoration in these areas will determine the final appearance of the dentogingival esthetics. Overcontour produces apicalization, while undercontour produces coronalization of marginal gingiva. Working with this concept, we can shape the soft tissue around the res- toration as it occurs in nature. In the same way, transitional lines and interproximal morphology affect the form, dimen- sion, and level of the papillae
There are three labial contour situations:
1. Undercontoured: The marginal gingiva is not protected, due to chemical or mechanical action, from mechanical stimulation of food during eating or brushing during hy- giene.
2. Overcontoured: The marginal gingiva is hyper-protected, because of the lack of stimulation and automatic clean- ing, causing accumulation of residual food and bacterial plaque.
3. Normal contour: The marginal gingiva is protected and stimulated correctly. This is the situation that needs to be reproduced in our restorations
Correct and precise reproduction of artificial gingiva is important in order to have a reference for fabricating appropriate subgingival and supragingival emergence profiles of our restorations. Then by fitting restorations on a solid cast, the cervical anatomy can be verified and optimized.
MARGINAL CLOSURE
Marginal precision in the preparation finish line is also im- portant in order to (1) protect the dental structure, (2) avoid creating horizontal overcontours with consequent apical- ization of the gingiva, and (3) reduce the quantity of cement exposed toward the soft tissue. A large marginal gap means large cement exposure, which is not healthy for the gingiva, especially when the marginal closure of restora- tions is located subgingival or interproximal and cement exposed cannot be polished well.
We should obtain and maintain the marginal precision during all subsequent laboratory and clinical steps. It is possible to extend our precision even further using mag- nification systems. With magnification we enter another world—we can see what previously was hidden—and this requires us to change our working protocols completely. Clearly, time and patience are needed to master new and continually evolving methods and applications
CASE IN POINT
This is a typical case in which acid action has caused un- dercontoured labial profiles that are no longer able to pro- tect the marginal gingiva from mechanical stimulation. By restoring the anterior segment with six veneers (e.max
Press and e.max Ceram, Ivoclar Vivadent), reshaping the axial labial contours, and with the correct emergence pro- file in the cervical third, the health and appearance of the marginal gingiva were transformed completely, harmoniz- ing the esthetics of the hard and soft tissues
One year after cementation, the improved condition and appearance of the gingiva are evident. Of course, the shape of the teeth was optimized by the six veneers, but the soft tissue contributes to the overall esthetics. Function, incisal edge position, and color in all its dimensions are also important factors that balance and harmonize the restorations with the lips, face, and emotion of the patient.
CONCLUSION
Dental esthetics always must be supported by gingival es- thetics, and vice versa. Any tooth defect or gingival defect compromises the final appearance of the smile.
The morphology of the cervical third greatly influences the gingival design. Only through knowledge, experience, and constant practice can we improve our confidence to perceive and reproduce correct emergence profiles.
The marginal precision of restorations is also responsi- ble for the health and stability of the soft tissue. It is funda- mental to develop clinical and technical work protocols that are adequate to reproduce precision and, above all, to maintain it from the impression, during the laboratory pro- cedures, and to the final cementation of restorations. Scientific and dental technology knowledge, accompa- nied by strong teamwork, are other factors essential for successful dental restorations.
Observation of the cervical third of the natural tooth helps us understand the emergence profile, which develops from the cementoenamel junction. The marginal gingiva and papillae form and levels reveal the effect of the emergence profile on the shape and stability of the soft tissue. We also can understand the relation, the balance, and the harmony that exist between the tooth and gingiva.
We can distinguish between:
• Subgingival emergence profile, which is responsible for support and stability of soft tissue.
• Supragingival emergence profile, which is responsible for protection of soft tissue.
We know that hard tissue supports soft tissue. By way of the tooth anatomy of the emergence profile in the cervi- cal third, we can design and drive the gingiva where and how we want—naturally—in relation to the quantity and quality of soft tissue, reaching harmony and stability. Only in this way can esthetics and a natural appearance be guaranteed.
Pink and white esthetics should blend well together, and the former should support the latter in perfect balance. It is important not to allow our fantasy and imagination to change what already exists. We should simply try to emu- late what nature offers us today, no more.
Materials and technology are just tools. Digital systems, in particular, when used without knowledge, experience, ability, and sensibility, can become dangerous to the biolo- gy and therefore to the patient. In all cases, first we need to use our head, our hands, and our heart
EMERGENCE PROFILE IN WAX-UP
In these wax copings we can see how the emergence pro- file changes from the distal to the mesial of the tooth in order to create a natural form and level of the gingival con- tours and papillae, as well as establish the correct position of the gingival zenith. The anatomy of the restoration in these areas will determine the final appearance of the dentogingival esthetics. Overcontour produces apicalization, while undercontour produces coronalization of marginal gingiva. Working with this concept, we can shape the soft tissue around the res- toration as it occurs in nature. In the same way, transitional lines and interproximal morphology affect the form, dimen- sion, and level of the papillae
There are three labial contour situations:
1. Undercontoured: The marginal gingiva is not protected, due to chemical or mechanical action, from mechanical stimulation of food during eating or brushing during hy- giene.
2. Overcontoured: The marginal gingiva is hyper-protected, because of the lack of stimulation and automatic clean- ing, causing accumulation of residual food and bacterial plaque.
3. Normal contour: The marginal gingiva is protected and stimulated correctly. This is the situation that needs to be reproduced in our restorations
Correct and precise reproduction of artificial gingiva is important in order to have a reference for fabricating appropriate subgingival and supragingival emergence profiles of our restorations. Then by fitting restorations on a solid cast, the cervical anatomy can be verified and optimized.
MARGINAL CLOSURE
Marginal precision in the preparation finish line is also im- portant in order to (1) protect the dental structure, (2) avoid creating horizontal overcontours with consequent apical- ization of the gingiva, and (3) reduce the quantity of cement exposed toward the soft tissue. A large marginal gap means large cement exposure, which is not healthy for the gingiva, especially when the marginal closure of restora- tions is located subgingival or interproximal and cement exposed cannot be polished well.
We should obtain and maintain the marginal precision during all subsequent laboratory and clinical steps. It is possible to extend our precision even further using mag- nification systems. With magnification we enter another world—we can see what previously was hidden—and this requires us to change our working protocols completely. Clearly, time and patience are needed to master new and continually evolving methods and applications
CASE IN POINT
This is a typical case in which acid action has caused un- dercontoured labial profiles that are no longer able to pro- tect the marginal gingiva from mechanical stimulation. By restoring the anterior segment with six veneers (e.max
Press and e.max Ceram, Ivoclar Vivadent), reshaping the axial labial contours, and with the correct emergence pro- file in the cervical third, the health and appearance of the marginal gingiva were transformed completely, harmoniz- ing the esthetics of the hard and soft tissues
One year after cementation, the improved condition and appearance of the gingiva are evident. Of course, the shape of the teeth was optimized by the six veneers, but the soft tissue contributes to the overall esthetics. Function, incisal edge position, and color in all its dimensions are also important factors that balance and harmonize the restorations with the lips, face, and emotion of the patient.
CONCLUSION
Dental esthetics always must be supported by gingival es- thetics, and vice versa. Any tooth defect or gingival defect compromises the final appearance of the smile.
The morphology of the cervical third greatly influences the gingival design. Only through knowledge, experience, and constant practice can we improve our confidence to perceive and reproduce correct emergence profiles.
The marginal precision of restorations is also responsi- ble for the health and stability of the soft tissue. It is funda- mental to develop clinical and technical work protocols that are adequate to reproduce precision and, above all, to maintain it from the impression, during the laboratory pro- cedures, and to the final cementation of restorations. Scientific and dental technology knowledge, accompa- nied by strong teamwork, are other factors essential for successful dental restorations.
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