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Esthetic Gingival Restoration – Oral Health Group


Esthetic Dilemma of the Gingival Margin
The info is unambiguous; each porcelain and composite resin are biocompatible with the gingiva and nicely tolerated.1-3 The caveat is that composite tends to trigger tissue irritation if it comes into intimate contact with the gingiva.4-6 This in the end causes unesthetic gingival recession. Porcelain is much less problematic, however plaque build-up on the margin, reacting to the skinny layer of resin cement, results in the same free gingival irritation and, ultimately, recession.7,8

Even cautious subgingival margin placement will all too usually, inside a brief span of three–5 years, attributable to ageing, gingival irritation, or lack of house upkeep on the affected person’s half, result in unesthetic recession and full seen publicity of the darker dentinal tissue.9,10 Thus, the restorative conclusion is to find composite resins supragingivally,3,11 with the composite moderately away (0.25-0.50mm) from periodontal constructions and thereby unlikely to trigger tissue irritation.

With at the moment obtainable adhesives and restoratives, it is a relatively simple process.12-19 Later era adhesives bond equally nicely, and predictably, to each enamel and dentin.14,15 Considerably, seventh and eighth era adhesives have related bonding strengths to each enamel and dentin, eliminating the potential stresses brought on by unequal polymerization contraction.17-19 It’s clinically attainable to create a steady lasting restoration by means of the dentino-enamel junction (DEJ), overlaying as a lot of the enamel and the dentin as necessitated by decay or abfraction (or each).

The esthetic predicament shortly turns into evident, nevertheless. Dental restorative supplies are designed to match the shade of the enamel portion of the tooth. Whereas some producers provide “dentin” shades, these hues usually don’t carefully match the darker coloration of uncovered dentin, notably in endodontically handled tooth. A considerable enhance within the obvious size of a tooth, particularly within the anterior labial area, detracts from the esthetic smile. A typical central incisor measures roughly 10.5mm cervico-incisally (CI).20

To revive a Class V decay or abfraction, or maybe a small gingival recession, an enamel-colored resin is positioned on the labial DEJ. Rising the maxillary central incisor’s vertical side (Fig. 1) by a mere 3mm provides 30% to the obvious vertical dimension, considerably altering the cervico-incisal to mesio-distal (CI:MD) ratio, completely upsetting the esthetic parameters of the smile. (Fig. 2) In conditions the place there may be even reasonable (not even contemplating in depth) recession, the visible imbalance is even additional impaired. The CI:MD ratio affect is even larger on maxillary laterals and mandibular incisors (common 9.0mm CI). Maxillary and mandibular cuspids (common 10-11mm CI) are sometimes the tooth most affected by gingival recession, and are additionally extremely seen each anteriorly and laterally.

Fig. 1

Normal length maxillary central incisors – expected appearance.

Regular size maxillary central incisors – anticipated look.

Fig. 2

Maxillary incisors apparent length increased by 30% - very unnatural and unesthetic.




Maxillary incisors obvious size elevated by 30% – very unnatural and unesthetic.

People who’ve gingival recession, abfraction and/or decay are inclined to look older than they are surely (lengthy within the tooth). Masking the darker root dentin with an enamel-shaded resin merely makes their tooth extra seen, seemingly longer, and correspondingly much less esthetic.

The practitioner’s dilemma is how you can clear up this downside virtually, esthetically, and with minimal invasiveness. The restoration should be useful, changing lacking dental constructions to pure dimensions and contours. The restoration ought to restore misplaced enamel with enamel-shaded composite resin, and receded gingiva with gingival-shaded composite resin. By creating a synthetic enamel-gingival junction in composite restorative materials, the affected person’s esthetics and smile will be restored.

Fixing the Gingival Esthetic Dilemma
Beautifil II Gingiva (Shofu USA, San Marcos CA) has been particularly designed for the re-balancing of pink aesthetics within the cervical areas of the dentition. (Fig. 3) Beautifil II Gingiva is indicated for wedge-shaped defects, cervical decay, the esthetic rectification of gingival recession, shielding uncovered cervical areas and splinting of cellular tooth. The resin materials is obtainable in 5 tones (darkish pink, gentle pink, brown, orange and violet) (Fig. 4) which will be layered and/or blended to realize customized shades that permit the therapy of sufferers with numerous hues of gingival pigmentation, based on their scientific wants. (Fig. 5)

Fig. 3

 Beautifil II Gingiva Shades (Shofu USA, San Marcos CA).

Beautifil II Gingiva Shades (Shofu USA, San Marcos CA).

Fig. 4

. The resin material is available in 5 shades (dark pink, light pink, brown, orange and violet).

The resin materials is obtainable in 5 shades (darkish pink, gentle pink, brown, orange and violet).

Fig. 5

Resins layered and/or blended to achieve custom gingival shades.

Resins layered and/or blended to realize customized gingival shades.

Beautifil II is a extremely esthetic, fluoride-releasing composite resin materials indicated for all courses of restorations. Quite a few research over the previous 20 years have proven no secondary caries, no failures, no post-operative sensitivity and a excessive retention of each shade match and floor luster. The fabric relies on Shofu’s proprietary Giomer know-how. (Fig. 6) The numerous benefit of the Giomer class of resins is that they not solely launch fluoride to guard the tooth on the restorative margin, however that their fluoride content material will be recharged by toothpastes, fluoride rinses and varnishes. Thus, the Giomer’s fluoride releasing capability doesn’t lower over time.

Fig. 6

Giomers continue to release fluoride because their fluoride content can be recharged with fluoride toothpastes, rinses and varnishes.

Giomers proceed to launch fluoride as a result of their fluoride content material will be recharged with fluoride toothpastes, rinses and varnishes.

One other necessary consideration is that the gingival margin of the restorative materials (whether or not pink or enamel in shade) should be stored supragingival and barely away from the free gingival margin.3,4,6 Whereas a really slim band of darker root construction could also be seen in direction of the apex, the restoration’s enamel (coronal) and pink gingival (radicular) coloration will focus consideration away from this space. With gingivally blended restorations, the skilled can ship each esthetic and supragingival margins throughout the identical restoration. A supragingival margin facilitates prepared entry and efficient house upkeep for the affected person.

It’s crucial {that a} restoration that’s so near the free gingival margin be positioned underneath situations managed for moisture and bleeding. Rubber dam placement is impractical (goal space is positioned apically) and retraction twine might bodily or chemically compromise the working space. Ideally, the affected person’s oral hygiene creates a wholesome gingival microenvironment, with minimal pocketing and no bleeding on probing. Generally, nevertheless, the practitioner should modify the precise state of affairs to extend the probability of scientific success. The best and finest method for predictable tissue sculpting is using the diode laser.21,23 Using low energy (1.0-1.5 watts), the dentist can produce an excellent, dry, clear, and blood-free working space in lower than a minute.

Medical Instances

Seen Recession and Decay
Remarkably, the affected person’s chief concern was the gingival recession on the left maxillary lateral, not the mesial caries. (Fig. 8) Thankfully, the affected person’s oral hygiene was comparatively good, and restoring the MLB decay was simple (BeautiBond (Fig. 7) and Beautifil Move Plus X, each from Shofu USA, San Marcos CA). The steps for the esthetic rectification of the buccal recession are:

  1. Gently micro-abrade the receded space and the apical enamel to take away meals particles and plaque. The nozzle of the abrader needs to be angled incisally to forestall gingival irritation and bleeding. Rinse completely and frivolously air dry, leaving the floor barely moist (though the diploma of moistness isn’t important).
  2. Apply BeautiBond, a seventh era dental adhesive, and go away for 10 seconds. Totally air dry the adhesive (very important). Gentle treatment.
  3. Choose the suitable Beautifil II Gingiva shade (Gentle Pink and Violet for this affected person) and apply to the receded space to revive the buccal dimension and contour of the unique mushy tissue. Gentle treatment. You will need to go away a small (0.25-0.50mm) hole between the apical margin of the restorative and the free gingival margin. (Fig. 9) This house prevents gingival irritation, is definitely maintainable by the affected person, and is mostly not seen even with close-up pictures. (All images
    executed with the Shofu EyeSpecial digicam, (Fig. 10) Shofu USA, San Marcos CA.)

Fig. 7

BeautiBond 7th generation dental adhesive.

BeautiBond seventh era dental adhesive.

Fig. 8

Maxillary left lateral with decay and recession.

Maxillary left lateral with decay and recession.

Fig. 9

 Maxillary left lateral with mesial restoration and gingival restorative rectification.

Maxillary left lateral with mesial restoration and gingival restorative rectification.

Fig. 10

EyeSpecial Dental Camera (Shofu USA, San Marcos CA).

EyeSpecial Dental Digicam (Shofu USA, San Marcos CA).

Mandibular Anteriors Recession
That is probably the most generally encountered recession within the oral cavity. The mandibular anteriors are small, shut collectively, and never successfully cleaned by the tongue and the decrease lip. (Fig. 11) As a result of gravity, meals particles and plaque are inclined to accumulate labially and interproximally. (Fig. 12) On this case, the key wrongdoer for the recession is the frenum that pulls the hooked up gingiva apically. The preliminary course of is a diode laser frenectomy to get rid of the muscular forces.21-23 The steps for the esthetic rectification of the buccal recession are:

  1. Gently micro-abrade, in an incisal route, the receded areas and the enamel nearest to the DEJ to take away meals particles and plaque. Rinse completely and frivolously air dry, leaving the floor barely moist.
  2. Apply BeautiBond and go away for 10 seconds. Totally air dry the adhesive. Gentle treatment.
  3. Choose the suitable Beautifil II Gingiva shade (Gentle Pink on this case) and apply to the receded space to revive the buccal dimension and contour of the unique mushy tissue. Gentle treatment. Depart a small (0.25-0.50mm) hole between the apical margin of the restorative and the free gingival margin. (Fig. 13) This process restores the anticipated gingival peak, and contributes to creating the affected person’s smile look youthful.

Fig. 11

Mandibular anteriors with labial gingival recession.

Mandibular anteriors with labial gingival recession.

Fig. 12

Mandibular anteriors close-up.

Mandibular anteriors close-up.

Fig. 13

Mandibular anteriors with gingival restorative rectification.

Mandibular anteriors with gingival restorative rectification.

Conclusion
Beautifil II Gingiva allows the practitioner to beat the gingival esthetic dilemma. The esthetic gingival restoration method is predictable and may usually be achieved with out the necessity for native anesthetic or discomfort to the affected person. These restorations are completely useful and substitute each exhausting and mushy lacking dental constructions to pure dimensions and contours with minimal invasiveness. The restoration of the coronal anatomy with tooth-colored composite resins is nicely established; the event of a synthetic enamel-gingival junction and the reconfiguration of lacking gingival constructions with composite resins is a novel answer that restores the affected person’s smile and facial esthetics.

Oral Well being welcomes this unique article.

References

  1. Freedman G: Ultraconservative Porcelain Veneers, Esthet Dent Replace 2:224-228, 1997.
  2. Freedman G: Ultraconservative Rehabilitation, Esthet Dent Replace 5:80-85, 1991.
  3. Freedman G, Fugazzotto PA, Greggs TR: Aesthetic Supragingival Margins, Pract Periodontics Aesthet Dent 2:35-38, 1990.
  4. Newcomb GM: The Relationship Between the Location of Subgingival Crown Margins and Gingival Irritation, J Periodontol 45:151, 1974.
  5. Renggli H, Regolati B: Gingival Irritation and Plaque Accumulation by Properly Tailored Supragingival and Subgingival Proximal Restorations, Helv Odont Acta L6:99, 1972.
  6. Waerhau SJ: Histologic Concerns which Govern the place the Margins of Restorations Needs to be Situated in Relation to the Gingiva, Dent Clin North Am 4:161, 1960.
  7. Berman M: The Full Protection Restoration and the Gingival Sulcus, J Prosthet Dent 29:1301, 1973.
  8. Marcum O: The Impact of Crown Margin Depth upon Gingival Tissues, J Prosthet Dent 17:479, 1967.
  9. Freedman GA, McLaughlin G: The Shade Atlas of Porcelain Laminate Veneers, St Louis, Ishiyaku EuroAmerica, 1990.
  10. Freedman G: Modern Esthetic Dentistry, Elsevier Publishing, 2011 Chap 23; 551.
  11. Freedman G, Klaiman HF, Serota KT, et al: EndoEsthetics: Half II. Castable Ceramic Submit and Core Restorations. Ont Dent 70:21-24, 1993.
  12. Albers HF: Dentin-resin bonding. Adept Report 1990; 1:33-34.
  13. Munksgaard EC, Asmussen E. Dentin-polymer Bond promoted by Gluma and numerous resins. J Dent Res 1985; 64:1409-1411.
  14. Barkmeier WW, Erickson RL: Shear bond energy of composite to enamel and dentin utilizing Scotchbond multi-purpose. Am J Dent 1994; 7:175-179.
  15. Swift EJ, Triolo PT: Bond strengths of Scotchbond multi-purpose to moist dentin and enamel. Am J Dent 1992; 5:318-320.
  16. Gwinnett AJ: Moist versus dry dentin; its impact on shear bond energy. Am J Dent 1992; 5:127129.
  17. Freedman G, Leinfelder Ok: Seventh Technology Adhesive Techniques. Dentistry 2003; January:15–18.
  18. Freedman G: seventh era Adhesive Techniques. Dental Asia (English) 2019; March-April:50-53.
  19. Freedman G: Adhesion: Previous, Current, and Future. Oral Well being 2019: July 109:7 8-14,82.
  20. Wheeler RC: A Textbook of Dental Anatomy and Physiology. W.B. Saunders 1965: 6:126.
  21. Goldstep F: Smooth Tissue Diode Laser: The place Have You Been All My Life?. Oral Well being 2009: 99:7;34-38.
  22. Goldstep F: Diode Lasers for Periodontal Therapy: The Story So Far. Oral Well being 2009: 99:12;44-46.
  23. Goldstep F: Diode Lasers: The Smooth Tissue Handpiece. Dental Asia 2011: Jan-Feb; 28-32.

In regards to the Creator

Dr. George Freedman is a founder and past president, American Academy of Cosmetic Dentistry; co-founder, Canadian Academy for Esthetic Dentistry; and Diplomate, American Board of Aesthetic Dentistry. Author or co-author of 12 textbooks, including "Contemporary Esthetic Dentistry" (Elsevier), and more than 700 articles, he is a REALITY Team Member. An internationally recognized lecturer on esthetics, technology, and dental materials, he was awarded NYU College of Dentistry's Irwin Smigel Prize in Aesthetic Dentistry. A McGill graduate, Dr. Freedman is a Regent and Fellow of the IADFE and maintains a private practice limited to Esthetic Dentistry in Toronto.Dr. George Freedman is co-founder and previous president, American Academy of Beauty Dentistry; co-founder, Canadian AED; Regent and Fellow, Worldwide Academy for Dental Facial Esthetics, and Diplomate and Chair, American Board of Aesthetic Dentistry. Adjunct Professor, Dental Drugs, Western College, Pomona CA and Professor/Program Director, BPP College, London, UK, MClinDent Programme, Restorative and Beauty Dentistry.

Dr. Paiman Lalla, graduate of College of The West Indies, acquired his AEGD (Lutheran Medical Heart) and Fellowships within the Worldwide Congress of Oral Implantology and American Academy of Implant Prosthodontics. He practises in Trinidad & Tobago and serves on the Medical Panel, Ministry of Nationwide Safety.


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