THE AmEricAn
JOUrnAL OF
V O L U m E 1 n U m B E r 1
F A L L 2 0 1 1
T H E A m E r ic A n J O U r n A L O F E S T H E T ic D E n T iS T r Y Fa ll • 2 0 11 (1 – 8 4 ) V OL U m E 1 • N u m b e r 1
Volume 1 • Number 1 • Fall 2011 ISSN 2162-2833 (print) ISSN 2162-2841 (online)
DENTISTRY
The American Journal ofReaders are invited to submit personal photographs for consideration for use in the journal. The number of photos may vary in each issue, but we hope the images will provide an interesting break between the outstanding papers within. This is an opportunity for you, the reader, to share with your colleagues some of the images you are proud of, that may otherwise never see the light of day. For this inaugural issue, we present images from Antelope Canyon, a slot canyon in northern Arizona, photo-graphed by Richard J. Simonsen (http://www.richardsimonsen.com). At certain times of the year and day, the sun may shine through from the slot above that communicates to the surface. Such canyons can be dangerous, as they fill with rainwater quickly in the event of a thunderstorm upstream, sometimes trapping those who choose to ignore nature’s warnings. It is the effect of the running water over millions of years that makes the unique patterns on the walls of the soft sandstone rock walls.
5
Editorial:
Welcome aboard!
Richard J. Simonsen
10
Minimally Invasive Restorative
Treatment of Hypoplastic Enamel
in Anterior Teeth
Jussara Karina Bernardon Renata Gondo
Luiz Narciso Baratieri
26
The Gray Zone Around Dental
Implants: Keys to Esthetic Success
Iñaki Gamborena Markus B. Blatz
48
Determining the Influence of
Flowable Composite Resin
Application on Cuspal Deflection
Using a Computerized Modification
of the Strain Gauge Method
Hamdi H. Hamama Nadia M. Zaghloul Ossama B. Abouelatta Abeer E. El-Embaby
60
All-Ceramic Crowns and
Extended Veneers in Anterior
Dentition: A Case Report with
Critical Discussion
Júnio S. Almeida e Silva Juliana Nunes Rolla Daniel Edelhoff Élito Araujo
Luiz Narciso Baratieri
7
8
Guidelines for Authors
ISSN 2162-2833 (print) ISSN 2162-2841 (online)
DENTISTRY
The American Journal of Editor-in-ChiEf Richard J. Simonsen, DDS, MSProfessor, Faculty of Dentistry Health Sciences Center Kuwait University
PO Box 24923, Safat 13110, Kuwait [email protected] Editorial Board Joel H. Berg, DDS, MS Markus B. Blatz, DMD, PhD Jeff Brucia, DDS John R. Calamia, DMD
Alexander Carroll, DDS, MBA David Chambers, EdM, MBA, PhD Gordon J. Christensen, DDS, MSD, PhD Theodore P. Croll, DDS
Alessandro Devigus, Dr Med Dent Sillas Duarte Jr, DDS, MS, PhD Newton Fahl Jr, DDS, MS Jack L. Ferracane, PhD Ronald E. Goldstein, DDS Laura C. Kottemann, DMD Gerard Kugel, DMD, MS, PhD Tyler Lasseigne, DDS
Pascal Magne, Dr Med Dent, PhD Tidu Mankoo, BDS Assad F. Mora, DDS, MSD Marc L. Nevins, DMD, MMSc Vijay Parashar, DDS, MS André V. Ritter, DDS, MS Richard D. Roblee, DDS, MS David D. Rolf II, DMD, MS Leo E. Rouse, DDS Frank Spear, DDS, MSD Douglas A. Terry, DDS Gwenlynn Werner, DMD David Winkler, DDS Publisher H. W. Haase
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Editorial
5 VOLUME 1 • NUMBER 1 • FALL 2011
i
am very pleased to welcome you to a new additionto Quintessence Publishing Company’s stable of fine journals and books in dentistry. this is the first issue of
The American Journal of Esthetic Dentistry, a journal
dedicated to promoting the highest clinical standards of esthetic dentistry based on an evidence base and on a minimally invasive approach. We wish to share with our readers the research advances and clinical accomplish-ments of the profession over the past several decades.
With our outstanding editorial board and many others who will aid in the re-view of papers and ideas for the journal, we pledge to provide you with the high-est standard of peer-reviewed informa-tion in the form of papers submitted by you, the reader, and fellow dedicated members of our profession.
the theme of “esthetic dentistry” is a broad one. one could argue that almost all phases of clinical dentistry involve— directly or indirectly—esthetics, and we will publish papers in most areas of clinical interest to the general dentist, who is faced with the enormous task of keeping up with new developments in all fields of the profession. You can ex-pect many papers of the quality you see here in this issue from around the globe, and also you can expect excit-ing new developments in terms of be-ing able to review your journal and read the papers online with your iPad or similar instrument in months to come.
Future editorials will discuss themes and trends in our profession that i hope will be of interest to a wide group of
readers. i may take a certain position on an issue in order to stimulate con-versation and responses such that a broad perspective of opinions can be aired. it will be my job as your editor to try to stimulate such debates and com-mentary, such as, for example, around the current overtreatment problems in the cosmetic dentistry arena. i also welcome guest editorials from those of you who may wish to tackle a particular subject of interest to the profession. an active and robust “letters to the Editor” section is on my list of goals for devel-opment as time goes on. i hope that you will feel free to communicate with me on any ideas or constructive criti-cism you may have.
Please enjoy the first issue of The
American Journal of Esthetic Dentistry !
richard J. Simonsen, ddS, MS Editor-in-Chief
DENTISTRY
The American Journal of
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Journals:
1. Al-Johany, SS, Alqahtani AS, Alqahtani FY, Alzahrani AH. Evaluation of different esthetic smile criteria. Int J Prosthodont 2011;24:64–70.
Books:
1. Gürel G. Porcelain laminate veneers: Predictable tooth preparation for complex cases. In: Romano R (ed). The Art of Treatment Planning: Dental and Medical Approaches to the Face and Smile. Chicago: Quintessence, 2010:249–263.
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10
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Minimally Invasive Restorative
Treatment of Hypoplastic
Enamel in Anterior Teeth
Jussara Karina Bernardon, DDS, MS, PhD Clinical Professor, Department of Operative Dentistry,
Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Renata Gondo, DDS, MS, PhD
Clinical Professor, Department of Operative Dentistry,
Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Luiz Narciso Baratieri, DDS, MS, PhD Professor, Department of Operative Dentistry,
Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Hypoplastic enamel can compromise the smile by altering the mor-phology and natural translucency of the teeth. To avoid performing iatrogenic procedures, etiologic knowledge of the enamel deficiency is essential to indicate the most appropriate treatment approach. In the case of white stains involving the enamel and dentin, a no-table treatment option is a direct restoration with composite resin, which has excellent optical properties to reproduce the natural tooth structure and appropriate mechanical properties to ensure treatment longevity. In this article, a clinical case of a patient who reported dissatisfaction with her smile esthetics, prompted by the presence of hypoplastic enamel staining at the central and lateral incisors, is presented. Treatment consisted of composite resin
restorations with the natural stratification technique. The final esthetic result proved the possibility of obtaining natural-looking restorations, while en-suring the esthetic and functional satisfaction of both the patient and clinician. (Am J Esthet Dent
2011;1:10–24.)
Correspondence to: Dr Jussara Bernardon
Armaro Antônio Viera 2489, apto 403, Itacorubi, Florianópolis, Santa Catarina, Brazil. Fax: 55 048 38799226. Email: [email protected]
VOLUME 1 • NUMBER 1 • FALL 2011 VOLUME 1 • NUMBER 1 • FALL 2011 Fig 1 Proximal view of the anterior teeth. Note the change in color and presence of white spots.
BERNARDON ET AL
12
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
S
everal factors maycompro-mise the esthetics of the smile, including hypoplastic enamel, which may affect the morphology, texture, and color of the tooth surface, the result of an incomplete or defective fortion of the enamel organic ma-trix. The intensity and duration of stimulation on ameloblasts reflect the extent and location of enamel defects.1 Lesions may
be triggered by hereditary or environmental factors. With he-reditary factors, generally only the enamel of primary and per-manent teeth is affected.2
Hy-poplastic enamel resulting from environmental factors, however, can be caused by a variety of influences, including nutritional deficiencies, rashes (eg, mea-sles, chickenpox, scarlet fe-ver), syphilis, hypocalcemia, systemic disorders, ingestion of chemicals (eg, fluoride), trauma, infections of the primary denti-tion, or by idiopathic causes.2,3
Environmental factors usually af-fect only one arch and can alter both the enamel and dentin.4
Therefore, depending on the etiology, stains resulting from hypoplastic enamel may have systemic features, affecting a group of teeth, or be localized, with asymmetric distribution and isolated to specific teeth.5
These spots compromise smile esthetics because they have an opaque, rough, and ir-regular appearance, compared
to the natural shine and trans-lucency of enamel. This opacity prevents light transmission in the specific region of the lesion, providing a distinct difference between it and the surrounding enamel. Several types of treat-ments may be recommended according to severity, and the least invasive technique should always take precedence. There-fore, the etiologic diagnosis is of paramount importance and aims to prevent unnecessary treat-ment of the hypoplastic teeth. For mild (smooth, light) and su-perficial lesions, tooth bleaching can be performed, with or with-out abrasion of the enamel. This is a minimally invasive technique and is limited to the enamel of the affected area.6 In the case
of moderate or severe stains with dentin involvement, the preferred treatment is a direct or indirect restorative procedure. With the ongoing development of composite resins, which pre-sent a wide range of available colors and excellent mechani-cal properties, it has been pos-sible to perform more esthetic, predictable, and conservative restorations.7 The use of
com-posite resin has the advantage of minimal reduction of the tooth structure and the completion of the procedure in a single ap-pointment.8
BERNARDON ET AL
CLINICAL CASE
The chief complaint of the patient was esthetic dissatisfaction from discolora-tion of the teeth and the presence of white spots on the incisors (Figs 1 and 2). After taking the case history with a clinical examination, it was determined that the teeth were naturally dark and that the white spots were hypoplastic
enamel areas at the incisal and middle thirds of the maxillary and mandibular incisors, without functional involvement (Figs 3 and 4). The patient underwent radiographic examination, and no peri-odontal or periapical changes were evident. The affected teeth yielded a positive response to the vitality test.
An additional recommended base-line examination is transillumination,
13 VOLUME 1 • NUMBER 1 • FALL 2011 VOLUME 1 • NUMBER 1 • FALL 2011 Fig 2 Initial appearance of the
patient. At conversation distance, the spots, while clearly visible, can be left untreated if they do not bother the patient. However, in this case, the patient was concerned about the appearance of her teeth.
BERNARDON ET AL
14
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY which involves the use of a transillumi-nator positioned along the palatal sur-face of the tooth being assessed (Figs 5a to 5c). This technique allows analy-sis of the transmission of light through the hypoplastic defects, identification of the thickness of the affected areas, and verification of the degree of compro-mised enamel (and dentin, if affected). Thus, transillumination is effective in
de-termining the treatment approach: the less the light propagation through the affected areas, the greater the depth of the stain. If the dentin is involved, the most common treatment approach is a direct restoration with composite resin and limited preparation of the compro-mised surface.
Initially, because of tooth discolora-tion, the patient was asked to perform Fig 3 Preoperative labial view demonstrating yellow coloration of the teeth
and the presence of white spots at the incisal and middle thirds of the maxillary central incisors and incisal third of the left lateral incisor.
Fig 4 Occlusal view of the maxillary incisors. Note the change in morphology
BERNARDON ET AL
15 VOLUME 1 • NUMBER 1 • FALL 2011 a supervised home whitening or
bleach-ing regimen with 10% carbamide peroxide gel for 4 weeks (2 hours/day) (Fig 6). Home bleaching is a relatively simple, conservative, and effective treatment,9,10 with satisfactory results
obtained in a short time period.11
Bleaching, associated with restorative treatment, is a common approach that aims to establish a more homogenous
condition in terms of saturation and brightness of the teeth to be restored.12
The restoration was performed 14 days after completion of the bleaching pro-cess to ensure that the adhesive proce-dure and color selection were carried out properly.13
A microhybrid composite resin sys-tem (Opallis, FGM) with the appropri-ate mechanical properties to ensure Figs 5a to 5c Using a transilluminator placed on the palatal surface of the involved incisors, it was
possible to visualize the stain depth and relate this to the depth of the hypocalcified area.
Fig 6 Frontal view after home bleaching with 10% carbamide peroxide gel for 4 weeks (2 hours/
day). Note that the stains remained visible, confirming the need for restorative intervention.
BERNARDON ET AL
16
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
strength and maintenance of polishing and surface brightness and sufficient optical properties to mimic the features found in natural teeth was selected for the restorative procedure.14 A resin
system with both enamel and dentin shades is recommended because the natural tooth overlaps these structures in different thicknesses, which creates the polychromatic effect seen on natu-ral teeth.15 The selected system
pre-sented several hues and saturations for enamel and dentin beyond the transparent resins, which reproduce different degrees of translucency, opal-escence, and fluorescence.
When selecting the color for the res-toration, the teeth should be clean and moist so that the natural translucency is preserved.15 Color scales are
essen-tial, and it is of paramount importance that they be of the same manufacturer as the resin system selected to avoid potential discrepancies between the
chemistry of the different brands avail-able. This is because the enamel and dentin shade guides vary in saturation and translucency depending on the system used. The color scale should be positioned as closely as possible to the tooth. The color selection for den-tin should be performed at the cervical third of the affected tooth, where the dentin is thicker and more saturated, and enamel color selection should occur at the middle third. The system used had separate scales for enamel and dentin, which is an advantage be-cause it allowed for an individual evalu-ation of the structures. In addition, each tab had a different thickness, and it was possible to predict the shade of the final restoration by altering the thickness of the tab selected (Fig 7). By placing the enamel shade tab on top of the dentin shade tab, it was possible to predict how the resins would interact in the future restoration (Fig 8). The operative Fig 7 (left) Choice of color using the color scale positioned on the facial surface of the affected
tooth. The enamel and dentin colors were selected separately.
Fig 8 (right) By placing the dentin shade guide against the enamel shade guide, the final shade can
BERNARDON ET AL
17 VOLUME 1 • NUMBER 1 • FALL 2011 field was isolated to ensure a clean and
suitable environment for the bonding procedures.
The cavity preparation should be restricted to removing the hypoplastic enamel using diamond points com-patible to the size of the lesion under constant irrigation to avoid heating of the structure (Fig 9). The entire depth of the hypoplastic enamel should be removed. Otherwise, the resulting dif-ference in opacity between natural and affected tooth structure can negatively affect the outcome of the restoration (Figs 10 and 11).
There is no need to bevel the cavo-superficial angle, preserving as much healthy tooth structure as possible (Fig 12). The absence of preparations en-sures a reversible treatment without compromising esthetics or the adhe-sive bond. After the preparation was complete, conditioning was performed with 37% orthophosphoric acid for 15 seconds on the dentin and 30 seconds on enamel (Fig 13), followed by appli-cation of the adhesive system, accord-ing to the manufacturer’s instructions (Fig 14).
Fig 11 After preparation,
the white spot was still evident, which called for its removal with a diamond bur of smaller diameter.
Fig 12 Final aspect of the
hydrated cavity preparation, which was restricted to removal of the white spot.
Fig 9 After rubber dam was
used to isolate the affected teeth, the white spot was re-moved using diamond burs.
Fig 10 Occlusal view of the
preparation. Note the remaining white spot that could compro-mise the restorative outcome if not removed.
Fig 13 Etching of the hard
tissue with 37% orthophosphoric acid (15 seconds for dentin, 30 seconds for enamel).
Fig 14 Application of the
ad-hesive system according to the manufacturer’s instructions.
BERNARDON ET AL
18
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY The restorative procedure was per-formed using the stratification tech-nique, based on the techniques of building ceramics. This new trend is also referred to as the anatomical tech-nique.16,17 In this technique, layers of
selected materials are used to repro-duce the enamel and dentin structures while also respecting their thickness and anatomical contour.
The artificial dentin reconstruction was performed using the dentin resin DA1 (Opallis). This resin was applied covering the deepest portion of the cav-ity to sculpt the shape of the mamelons (Figs 15 and 16). Dentin mamelons can have various shapes and determine the translucent halo characteristics of the tooth (Fig 17). Each layer was photopolymerized for 40 seconds. To complete the artificial dentin, a resin for bleached teeth was applied at the tip of the mamelons (D-Bleach, Opallis). In a natural tooth, dentin presents as an intense and very reflective opaque white color on the tip of the mamelons. However, when light penetrates the dentin through the enamel, it results in Fig 15 Composite resin was
placed in the preparation to reproduce the dentin layer.
Fig 16 Mamelons must be
defined when applying the composite resin.
Fig 17 Frontal aspect after
placing the second dentin resin layer for bleached teeth. Note the design of the mamelons.
an “orange” appearance. This is the counter-opalescence feature of dentin. To reproduce this effect, an opalescent and highly translucent resin (T-Blue, Opallis) was placed on the tips of the mamelons and between the dentin and incisal edge of the tooth (Fig 18).
Then, artificial enamel was recon-structed using a single enamel resin layer (E-Bleach) (Fig 19). In the stratifi-cation technique, it is important to con-sider that the artificial enamel thickness should correspond to one third of that of natural enamel18 to avoid value
reduc-tion of the restorareduc-tion. This means that a thicker layer of artificial enamel results in a gray and more monochromatic res-toration.14 This is because the
refrac-tory index of the natural tooth structure is different from that of the composite resin.14 The enamel surface was
final-ized at this time, avoiding use of dia-mond points (Fig 20).
The same procedures were per-formed for the maxillary right central (Figs 21 to 24) and left lateral inci-sors (Figs 25 to 28). After complete polymerization and at a later session,
BERNARDON ET AL
19 VOLUME 1 • NUMBER 1 • FALL 2011 Fig 18 A highly translucent
resin was placed on the opal-escent areas of the incisal third region of the tooth.
Fig 19 Positioning of the final
enamel composite resin layer. Care was taken to cover all preparation margins.
Fig 20 Proximal view of the
vertical development and lobes shaped in the definitive restora-tion.
Fig 24 Final aspect of the
restoration of the maxillary right central incisor.
Fig 23 Incremental
tech-nique for resin application: DA1, D-bleach H, T-Blue, and Bleach (Opallis).
Fig 27 (left) Mamelon design
using dentin resin (DA1 and D- Bleach, Opallis).
Fig 28 (right) Final aspect of
restoration. Note the contrast between the restoration and the natural tooth, which is dehy-drated as a result of absolute isolation.
Fig 21 Removal of the white
spots on the right central inci-sor with a diamond bur.
Fig 25 Removal of the
hypo-plastic enamel on the left lateral incisor.
Fig 22 After hydration, the
preparation was completed with removal of the white spot.
Fig 26 Final aspect of the
hy-drated cavity preparation, which was restricted to removing only the hypoplastic white spot.
BERNARDON ET AL
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THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY the surface of the restoration was tex-tured, and finishing and polishing were completed (Figs 29 to 32). Surface tex-turing is indispensable in ensuring a natural-looking restoration because
an irregular surface provides light dis-persion. Lobules and development grooves (vertical texture), horizontal grooves, and perikymata should be reproduced using extra-fine diamond
Fig 30 Vertical development and
the edges were completed with an oval format extra-fine diamond bur.
Fig 32 The restoration was
pol-ished to make the surface bright and smooth.
Fig 29 A surface enhancer was used to identify the
differ-ent reflection areas of the teeth.
Fig 31 Note the similarity in morphology between the
BERNARDON ET AL
21 VOLUME 1 • NUMBER 1 • FALL 2011 burs. Finishing was completed using
flexible disks and rubber tips. Polish-ing with felt disks and polishPolish-ing pastes ensures surface brightness and de-creases plaque retention. The final
result showed that composite resin provides a suitable material to produce esthetic effects similar to that of the natural tooth structure (Figs 33 to 39). Figs 33a to 33c A transilluminator was again used to visualize the similarity in light transmission
between tooth and restoration (compare to Figs 5a to 5c).
Fig 34 Final aspect of restorations, frontal view. Fig 35 (right) Final aspect of restorations, palatal
view.
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THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Figs 36 to 38 Final smile after bleaching and
restora-tive treatment. Note the correct merging of the dental substrate with the composite resin and reproduction of the optical aspects in the incisal third region.
BERNARDON ET AL
23 VOLUME 1 • NUMBER 1 • FALL 2011 Fig 39 The patient was satisfied with the end result. Note the naturalness and harmony of the smile
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THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
CONCLUSIONS AND
GUIDELINES FOR
PRACTITIONERS
In cases of hypoplastic enamel, a correct diagnosis is indispensable for an appro-priate treatment prognosis. In lesions with dentin involvement, direct compos-ite resin restorations promote satisfacto-ry results with conservation of a healthy dental structure, excellent mechanical
properties, and reproduction of the nat-ural tooth color and characteristics.19
Proper color selection is not enough; satisfactory resin system selection and proper realization of the stratification technique must also be accomplished. Following this protocol is critical to the quality of treatment received.
This article is based on a chapter in the book Clinical
Vision: Cases and Solutions by Dr Baratieri and was
originally written in Portuguese.
REFERENCES
1. Elcock C, Smith RN, Simpson J, Abdellatif A, Bäckman B, Brook AH. Comparison of methods for measurement of hypoplastic lesions. Eur J Oral Sci 2006;114(suppl 1): 365–369.
2. Clarkson J. Review of terminol-ogy, classifications, and indices of developmental defects of enamel. Adv Dent Res 1989;3:104–109. 3. Ribas AO, Czlusniak GD.
Anomalias do esmalte dental: Etiologia, diagnostico e tratamento. Biol Health Sci 2004;10:23–26.
4. Bendo CB, Scarpelli AC, Novaes JB Jr, Valle MPP, Paiva SM, Pordeus IA. Enamel hypoplasia in permanent incisors: A six-month follow-up. RGO 2007;55:107–112. 5. Sensi lG, Marson FC, Strassle
H, Duarte SJ. Recuperação Cosmética de Deformidades Dentais. Pro-odont Estética, ed 2. Porto Alegre: Artmed, 2008: 156–178.
6. Croll TP. Enamel Microabrasion. Chicago: Quintessence, 1991. 7. Simonsen RJ. Developmental
defect restorations. In: Simonsen RJ. Clinical Applica-tions of the Acid Etch Tech-nique. Chicago: Quintessence, 1978:63–70.
8. Machado FC, Ribeiro RA. Defeito de esmalte e cárie dentária em crianças prematu-ras e/ou de baixo peso ao nascimento. Pesq Bras Odontoped Clin Integr 2004; 4:243–247.
9. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 1989;20: 173–176.
10. Leonard RH Jr, Bentley C, Eagle JC, Garland GE, Knight MC, Phillips C. Nightguard vital bleaching: A long-term study on efficacy, shade retention, side effects and patients’ perceptions. J Esthet Restor Dent 2001;13:357–369. 11. Joiner A. The bleaching of
teeth: A review of the literature. J Dent 2006;34:412–419. 12. Hirata R. Tips: Dicas em
Odontologia Estética. São Paulo: Artes Médicas, 2011:576. 13. McGuckin RS, Thurmond BA,
Osovitz S. Enamel shear bond strengths after vital bleaching. Am J Dent 1992;5:216–222 14. Baratieri LN, Belli R. Resinas
compositas. In: Baratieri LN. Clinical Solutions—Fundamen-tals and Techniques. Flori-anópolis: Editora Ponto, 2008:131–142.
15. Baratieri LN, Belli R. Colo: Fundamentos básicos. In: Baratieri LN. Clinical Solu-tions—Fundamentals and Techniques. Florianópolis: Editora Ponto, 2008:21–55. 16. Ardu S, Krejci I. Biomimetic
direct composite stratification technique for the restoration of anterior teeth. Quintessence Int 2006;37:167–174 [erratum 2006;37:408].
17. Vanini L. Light and color in anterior composite restora-tions. Pract Periodontics Aesthet Dent 1996;8:673–682. 18. Vanini L, Mangani F,
Klimovs-kaia O. Colour in dentistry. In: Vanini L, Mangani F, Klimovs-kaia O. Conservative Restora-tion for Anterior Teeth. Viterbo, Italy: ACME, 2005:97–200. 19. Bernardon JK, Gondo R.
Restorative treatment of hypoplastic stains in anterior teeth. In: Baratieri LN. Clinical Vision: Cases and Solutions. Florianópolis: Editora Ponto, 2010:62–101.
26
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
The Gray Zone
Around Dental Implants:
Keys to Esthetic Success
Iñaki Gamborena, DMD, MSD, FID
Private Practice, San Sebastian, Spain; Clinical Assistant Professor,
Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.
Markus B. Blatz, DMD, PhD
Professor and Chairman, Department of Preventive and Restorative
Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.
Correspondence to: Dr Iñaki Gamborena
Resurecccion mª de Azkue, 6 20018 San Sebastian, Spain.
VOLUME 1 • NUMBER 1 • FALL 2011 VOLUME 1 • NUMBER 1 • FALL 2011 Single-implant restorations in the anterior maxilla have become a routine
treat-ment option. While customized tooth-colored prosthetic components show great-ly improved clinical outcomes, esthetic success relies not ongreat-ly on the restorative result, but also on the condition of the soft tissues. A common esthetic shortcom-ing is the grayish appearance of the peri-implant soft tissues, which are difficult to manipulate around dental implants. The parameters and clinical guidelines that should be used to influence esthetic success and avoid the gray zone around implant restorations can be categorized into five key factors: (1) optimal three-dimensional implant placement for functional and esthetic long-term implant success; (2) maximized soft tissue thickness to conceal the implant-restorative interface; (3) proper abutment selection to improve biocompatibility, tissue stabil-ity, color, translucency, and fluorescence; (4) careful crown restoration to imitate the natural teeth; and (5) awareness of the lip line, which may greatly influence the final outcome. Mimicking the inherent optical properties, especially fluorescence, of natural teeth with implant components and crown materials is fundamental for ideal restorative and soft tissue esthetics. (Am J Esthet Dent 2011;1:26–46.)
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T
he esthetic success of a dental restoration is judged by its inte-gration with the surrounding dentition in respect to position, angulation, di-mensions, proportions, shape, surface morphology, and shade.1–3 Othercru-cial esthetic parameters that are often overlooked include the morphology, texture, and ultimately the color of the surrounding gingiva.3,4 The soft tissue
is the natural frame of the teeth and any dental restoration and is, therefore, a fundamental parameter for esthetic success.1,3,5 This aspect is often
ne-glected because successful soft tissue outcomes—including handling, manip-ulation, and healing—are very demand-ing, time intensive, and unpredictable.5
Magne et al6 described a prevalence
of grayish soft tissue discolorations around tooth-supported full-coverage porcelain-fused-to-metal and even all-ceramic restorations. Interestingly, oth-er poth-erioral facial parametoth-ers such as position of the upper lip and height of the smile line7–9 also seem to influence
the degree of gingiva discoloration. The authors note that “this problem is particularly evident in the presence of the upper lip, which can generate an ‘umbrella effect’ characterized by gray marginal gingivae and dark interdental papillae.”6
This umbrella effect is magnified with dental implant restorations in the an-terior maxilla because the supporting hard and soft tissues are often com-promised even before restorative treat-ment and are influenced by the color and design of the implant, its prosthetic components, and the definitive resto-ration.10–17 Therefore, ideal periodontal
and restorative esthetic success with maxillary anterior implant-supported restorations presents a great challenge for the entire dental team and depends on a variety of parameters.10–14
The parameters and clinical guide-lines that should be used to influence esthetic success and avoid the gray zone around implant restorations can be categorized into five key factors: (1) optimal three-dimensional (3D) implant placement for functional and esthetic long-term implant success; (2) maxi-mized soft tissue thickness to conceal the implant-prosthetic component inter-face; (3) proper abutment selection to improve biocompatibility, tissue stabil-ity, and color to provide a perfect blend with surrounding tissues and teeth; (4) careful crown restoration to imitate the natural teeth; and (5) awareness of the lip line, which may greatly influence the final outcome.
3D IMPLANT PLACEMENT
The fundamental factor for long-term functional and esthetic success as well as soft tissue color and stability is opti-mal 3D implant placement.18 A simple
but essential guideline is to position the implant as close as possible to where the natural tooth was or ideally would be.10 If a line is drawn at the center of
the implant along its long axis and ex-tending through the tooth restoration, it should run through the center of the incisal edge of the prospective tooth (Fig 1). The greater the 3D mismatch between the crown and implant body, the poorer and less stable the final
GAMBORENA ANd BLAtz
29 VOLUME 1 • NUMBER 1 • FALL 2011 outcome will be. The incisal edge is
also the target for the angulation of the implant. An implant that is angu-lated too far to the buccal aspect will result in greater tissue recession under functional load. Conversely, a palatally placed implant leads to a more ex-treme emergence profile, resulting in increased bone resorption and thinning of the tissues. Both situations will lead to an intensified grayish appearance of the soft tissues at the gingival margin.
The third dimension is determined by the depth of the implant in respect to the marginal bone and soft tissue. An implant placed at the proper depth allows for the development of an ideal emergence profile and a soft tissue col-lar void of a gray zone. It is impossible to create a proper emergence profile when the implant is placed too shal-low, while an implant placed too deep is difficult to manage clinically and in-creases the possibility of peri-implant infection, inflammation, and bone loss.
A surgical guide fabricated from the diagnostic wax-up/setup is an indis-pensible tool to ensure proper 3D im-plant placement. The anticipated incisal edge position of the final tooth restora-tion determines the posirestora-tion, angularestora-tion, and depth of the implant in all three di-mensions, which directly influence the position, height, and thickness of the surrounding hard and soft tissues.10,12
SOFT TISSUE THICkNESS
Even in cases where ideal implant placement was achieved, the esthetic outcome may become compromised over time due to resorption of the mar-ginal bone and soft tissues.5,19
Fig 1 (right) Maxillary anterior implants should
be positioned and angulated so that a virtual line through the center of the implant along its long axis would run through the center of the incisal edge of the prospective crown.
GAMBORENA ANd BLAtz
30
THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY Case 1 (Figs 2 to 6) illustrates a situa-tion where a single implant was placed immediately after extraction of the maxillary right central incisor without any hard or soft tissue augmentation. A modified metal abutment was fabricat-ed, and the definitive restoration was
inserted (Figs 2 and 3). A follow-up photograph taken several years post-operatively reveals a grayish appear-ance of the soft tissue surrounding the implant restoration (Fig 4). This discol-oration becomes increasingly evident 11 years after completion as a result of Figs 2a and 2b A modified metal abutment was used after
im-mediate implant placement at the maxillary right central incisor site without bone or soft tissue augmentation.
Fig 3 Postoperative situation
showing the implant-supported crown.
Fig 4 (above left) Follow-up view after several years reveals a
grayish appearance of the soft tissues.
Fig 5 (above right) Follow-up view after 11 years showing soft
tis-sue discoloration due to the metal abutment.
Fig 6 (left) Periapical radiograph after 11 years reveals loss of
buccal bone.
GAMBORENA ANd BLAtz
31 VOLUME 1 • NUMBER 1 • FALL 2011 the resorption of the buccal bone and
surrounding soft tissues, revealing the unfavorable gray color of the metal im-plant abutment (Figs 5 and 6).
To avoid this result, it is advisable to maximize tissue thickness in every case and for both delayed and imme-diate implant placement.19–22 In fact,
the mucosal characteristics of the peri-implant tissues necessitate connective tissue grafting for long-term esthetic success.21 With clear surgical
objec-tives, a modern approach should al-ways include the most conservative procedure that satisfies the esthetic and functional requirements. For ex-ample, if a bone graft is unnecessary, stage-one surgery should always be performed with a minimal flap incision, such as a split-thickness flap or even no flap, to avoid unnecessary exposure of the underlying bone. Several authors have indicated that flapless surgical implant placement using computer- assisted surgical guides minimizes bone resorption, preserves soft tissue architecture, and improves the healing process.23 While some of these results
still need to be verified in long-term clin-ical trials, the positive effects of flapless implant placement on patient comfort due to the minimally invasive nature of the procedure are clearly evident.23
The key components of this surgical process are maintenance of the inter-proximal bone, minimal bone exposure only on the implant site, precise coro-nal graft suturing central to the implant axis, and tension-free flap closure and adaptation.
The design of the healing abutment, which can be placed during or after
connective tissue grafting, is another critical issue. Connective tissue grafts (CTGs) are placed around implants to enhance gingival margin stability and create a more fibrous and less mobile tissue complex.19–22 In dentistry today,
the clinician’s search for soft tissue abundance in the early stages of im-plant treatment means creating a large amount of soft tissue during or soon af-ter implant placement and manipulat-ing these tissues durmanipulat-ing the prosthetic phase. This is a shift from traditional ap-proaches in which multiple subsequent soft tissue grafts are performed until the desired thickness was achieved. Multiple surgical interventions, how-ever, are less predictable because the scarring and compromised blood supply make every subsequent graft-ing attempt more challenggraft-ing. For ideal prosthetic soft tissue manipula-tion, the healing abutment should be significantly narrower than the tooth to be replaced. At first, the tissue will not have the same scalloped architecture as found around natural teeth. How-ever, when the provisional restoration is placed, its subgingival contour and shape will determine the position and scallop of the soft tissue margin.10,13 It
also seems advantageous to connect the definitive abutment as early as pos-sible and not to remove it after that time.
Thicker peri-implant soft tissue masks the implant-abutment-restoration interface and provides a better color match between the soft tissues around the implant and those around the neigh-boring teeth.15–17 Some basic
guide-lines for tissue thickness and abutment selection are as follows:
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THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
• A soft tissue thickness greater than 3 mm allows for the use of titanium or zirconia abutments without negative esthetic implications.
• A thin soft tissue of less than 2 to 3 mm requires either a CTG or zirco-nia abutment.
• A dentin-colored abutment is always preferred.
In Case 2 (Figs 7 to 13), a colored in-stead of a white zirconia abutment was placed due to the presence of less than 1 mm of labial soft tissue. This approach,
along with the adequate soft tissue sup-port and contour, provided a satisfying outcome.
ABUtMENt sELEctiON
In an evaluation of the soft tissue around single-tooth implant crowns, Fürhauser et al24 showed that the color of the
peri-implant soft tissue matched that of the reference tooth in no more than one-third of cases. Another study found that all-ceramic implant abutment and crown Case 2
Fig 7 Thin peri-implant soft
tissue of only 1 mm was evident on the buccal aspect.
Fig 8 A custom-colored
zirconia abutment (Procera, No-bel Biocare) was fabricated to optimize the esthetic outcome.
Fig 9 Colored zirconia
abut-ment and alumina crown (Procera Crown Alumina, Nobel Biocare).
Fig 10 Intraoral occlusal view
showing the soft tissue support.
Fig 11 Postoperative
buc-cal view. The tooth-colored abutment and all-ceramic crown blend favorably with the adjacent teeth and surrounding soft tissue despite the compro-mised soft tissue thickness.
Fig 12 Postoperative
peri-apical radiograph.
Fig 13 (left) Occlusal view of
the definitive implant-supported restoration.
GAMBORENA ANd BLAtz
33 VOLUME 1 • NUMBER 1 • FALL 2011 materials provide a better soft tissue
color match with neighboring teeth than do conventional metal-alloy compo-nents.16 zirconia has been shown to be
the preferred implant abutment material due to its high strength13,25,26 and
ex-cellent biocompatibility.27–29 The
short-comings of zirconia include its higher cost and unfavorable optical properties in regard to color and fluorescence.30
Case 3 (Figs 14 to 55) includes all previously described factors and treat-ment parameters. The missing maxillary left central incisor was replaced with a Case 3
Fig 14 Preoperative
periapi-cal radiograph of the missing maxillary left central incisor.
Fig 15 Preoperative intraoral situation.
Fig 17 Intraoral view of the
edentu-lous ridge topography.
Fig 18 Virtual
implant placement for guided surgery.
Fig 16 Lateral
tomogram showing the extent of the ridge defect.
dental implant (Figs 14 to 18). Ideal 3D implant placement was planned on the computer and transferred via guided surgery. During stage-one surgery, the implant (3.5 × 13 mm, NobelAc-tive, Nobel Biocare) was inserted, and a CTG harvested from the maxillary tuberosity was placed to increase tis-sue thickness (Figs 19 to 23). Figure 24 shows the augmented edentulous ridge 6 months postoperatively. Next, a zirconia abutment was connected to the implant, and a provisional restora-tion was fabricated, relined in the oral
33 VOLUME 1 • NUMBER 1 • FALL 2011
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cavity, and cemented (Figs 25 to 29). The different lighting conditions (natu-ral and ultraviolet [UV] light) shown in
Figs 30 to 33 reveal the optical short-comings of these materials, especially the lack of natural fluorescence. Figure Fig 19 Implant placement (3.5 × 13 mm,
NobelActive, Nobel Biocare).
Fig 20 A subepithelial CTG was harvested
from the maxillary tuberosity to augment the deficient ridge.
Fig 21 After placement of the CTG, the flaps
were adapted without tension and sutured with thin suture material to limit trauma.
Fig 22 Labial view of the adapted flap after
suturing.
Fig 23 Intraoral situation 1 week
postopera-tively.
Fig 24 Postoperative situation after 6 months
reveals improved ridge morphology.
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35 VOLUME 1 • NUMBER 1 • FALL 2011 34 shows the detailed optical
charac-teristics of natural enamel and dentin under different light sources.
Fluorescence is a crucial property for natural esthetics.30–32 Colorants
and fluorescent modifiers that can be
applied to zirconia abutments even af-ter milling and finishing have recently been developed.30 The abutment or
framework is dipped into a fluores-cent coloring liquid before sintering to infiltrate the zirconia (Colour Liquid Case 3 Continued
Fig 25 Definitive zirconia abutment and
provi-sional restoration.
Fig 26 (right) Insertion of the colored zirconia
abutment.
Fig 27 (above left) Try-in of the provisional crown.
Fig 28 (above right) Precision of fit was verified extraorally. Fig 29 (right) Periapical radiograph used to verify fit.
GAMBORENA ANd BLAtz
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THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY Fluoreszenz, zirkonzahn). the abut-ment is blow dried after the dipping process to remove the excess and then placed under a drying lamp to prevent damage to the heating elements of the sinter furnace.
In addition to the regular zirconia, a more translucent zirconia (Prettau zirconia “translucent,” zirkonzahn) along with 16 coloring liquids (zirkon-zahn) are available. Figures 35 to 37 illustrate the infiltration process and its Fig 32 Optical properties of the zirconia
abut-ment under natural light.
Fig 33 Optical properties of the zirconia
abut-ment under UV light reveals a lack of fluores-cence.
Fig 34 Color
charac-teristics of natural enamel and dentin: (a) The three basic color zones; (b) areas of brightness/value;
(c) enamel characteristics
under a polarizing filter;
(d) color characteristics
of dentin; (e) degrees of dentin fluorescence under UV light.
Fig 31 Optical properties of the provisional
crown under UV light. Note the lack of fluores-cence.
Fig 30 Optical properties of the provisional
crown under natural light.
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37 VOLUME 1 • NUMBER 1 • FALL 2011 effect on the optical appearance under
different light sources. Three different abutments were fabricated: translucent zirconia with and without fluorescence and conventional zirconia with fluores-cence. Figures 38 to 40 show the
pa-tient’s favorable soft tissue thickness and the clinical try-in of the three differ-ent abutmdiffer-ents under regular and UV light. Interestingly, the translucent abut-ment provided the best match in natu-ral light but the worst under UV light. Fig 35 Three different abutments were
fab-ricated with conventional zirconia, a more translucent zirconia (Prettau zirconia “translu-cent”), and fluorescent colorants (Colour Liquid Fluoreszenz): colored translucent zirconia with fluorescence (transl + fluoresc) and without fluo-rescence (translucent), and conventional zirconia with fluorescence (zr + fluoresc). Natural light reveals the chroma characteristics.
Fig 36 Fabrication of a fluorescent abutment:
(a) Provisional composite abutment; (b)
duplicat-ed zirconia abutment before the sinter process;
(c) dipping of the zirconia abutment into
fluo-rescent colorants before sintering; (d) definitive abutment after sintering.
Fig 37 The three different abutments under UV
light. Conventional colored zirconia and fluoresc-ing liquid (zr + fluoresc) reveal the most favora-ble effect.
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The most favorable fluorescent effect was achieved with colored convention-al zirconia and fluorescing liquid.
In summary, the selection of zirconia implant abutments should be based on the following factors:
• 3D implant position: The screw-access opening in the abutment should not compromise mechani-cal strength, and the circumferential thickness should be at least 0.8 mm. • Soft tissue thickness: A minimum of
3 mm is ideal.
• Interocclusal space: Sufficient abut-ment height is required for ideal strength and resistance.
• Implant abutment color: The order of priority should be fluorescence/
value, translucency, and shade (chroma and hue).
• Color of the intended crown restora-tion (alumina versus zirconia).
For optimal stability and fit of the coping, the preparation margin of the implant abutment is generally a circum-ferential chamfer or rounded shoulder. On the labial aspect, the margin is typi-cally placed deeper than on the palatal aspect, but should not extend more than 1 mm subgingivally to avoid difficulties during cement removal. The abutment should support approximately 90% of the total surrounding soft tissue con-tour, with the crown supporting no more than 10%.30
Fig 38 (above left) Intraoral try-in of the three
abutments under natural light.
Fig 39 (above right) Ideal soft tissue thickness
(> 3 mm).
Fig 40 (left) Intraoral try-in of the three
abut-ments under UV light.
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39 VOLUME 1 • NUMBER 1 • FALL 2011 The provisional restoration generally
remains in place for 4 to 6 weeks until the position of the tissue is stable. A final impression of the abutment should then be made to transfer this informa-tion to the laboratory for fabricainforma-tion of the definitive restoration.
CROWN RESTORATION
The definitive crown material is se-lected based on its core structure to enhance the optical characteristics of the intended restoration. The coping is chosen by its ability either to mask underlying structures or to complement the underlying abutment color. zirconia is increasingly used as a coping ma-terial due to its versatility in respect to strength, thickness, color, and translu-cency, but especially due to its inherent brightness and options for fluorescence through infiltration.13–17,30 It seems only
logical that when a fluorescent abut-ment is used, the material selected for the definitive crown should also offer a certain degree of fluorescence to match the adjacent natural dentition.30–32 It is
important to evaluate the optical prop-erties of the coping in relation to the remaining natural dentition under differ-ent light sources. UV light reveals the dramatic effects of fluorescence, which provides the vitality and brightness ex-hibited by natural teeth.
Fluorescence is an inherent property of natural teeth31,32 but is rarely found
in “esthetic” dental materials.33–40 In
natural teeth, the root and coronal den-tin show the highest degree of fluores-cence, especially in the gingival third,
while enamel has low fluorescent prop-erties.30–32 Ceramic coping materials
such as alumina37 and zirconia39 do
not provide natural fluorescence and, therefore, are treated with fluorescent modifiers and/or veneered with fluores-cent dentin stains, liners, and shoulder porcelains.30,37,39 As in natural teeth,
the fluorescent effect is most prominent in the gingival third of the restoration. Therefore, natural fluorescence does not only influence the optical effects of the restoration itself, but also greatly in-fluences the color and appearance of the surrounding soft tissues.30
Figures 41 to 55 show the selection of the definitive coping material and the final outcome of Case 3. Figures 41 and 42 reveal the influence of fluorescent stains on the value and chroma of alu-mina and zirconia copings under natu-ral and UV light. The impact of using a fluorescent (Fig 43) versus a nonfluo-rescent coping (Fig 44) is quite obvious on the stone cast (Figs 45 and 46) and even more so in the oral cavity (Figs 47 to 55). The definitive implant-supported crown shows optical and fluorescent properties that ideally match the exist-ing natural dentition under various light sources.
LIP LINE
A high lip line or “smile line” that reveals all anterior teeth and large amounts of gingival tissue7,8 is a great challenge
for the dental team since it is impossible to hide the implant-restorative interface. A high smile line may be due to vertical maxillary excess or a hypermobile lip.
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THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY It is a common rule that, besides be-ing symmetric, the most cervical aspect of the gingival margins of the central in-cisors should be at the same level as the
canines, while the margins of the lateral incisors should be approximately 1 mm below an imaginary line drawn from the canine-centrals-canine.1 It seems
Fig 43 Definitive fluorescent abutment on the
stone cast demonstrating ideal fluorescence under UV light.
Fig 44 Nonfluorescent coping on the cast
under UV light.
Fig 45 Fluorescent coping on the cast under
UV light.
Fig 46 Definitive crown showing fluorescent
properties under UV light.
Fig 41 The influence of fluorescent stains on
the value and chroma of alumina and zirconia copings under natural light: (a and c) without fluorescence; (b and d) with fluorescence.
Fig 42 Fluorescent properties of alumina and
zirconia copings under UV light: (a and c) without fluorescence; (b and d) with fluorescence.
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41 VOLUME 1 • NUMBER 1 • FALL 2011 advisable for central incisor implant
restorations to initially place the gingi-val margin slightly more incisally. This slight “overcompensation” will prove
extremely helpful to counterbalance tissue recession typically seen over time. The CTG now becomes an essen-tial aspect for functional and esthetic Case 3 Continued
Fig 48 Intraoral try-in under UV light
demon-strates ideal blending of the fluorescent properties of the definitive crown with the adjacent teeth.
Fig 49 Definitive implant restoration.
Fig 51 (right) The definitive abutment and
res-toration provide the same degree of fluorescence as a natural tooth.
Fig 47 Intraoral try-in of definitive crown under
natural light shows an excellent blend with the shade of the adjacent teeth.
Fig 50 Postoperative occlusal view showing
