Building on the concepts of the first two articles; we can sometimes manipulate the biology to improve on previous dentistry. Periodontics in combination with orthodontics and restorative dentistry can help us improve both the existing biology and the esthetics. Modification of the finishing line involves removal of the restoration, removal of the finish line and repreparing the finish line coronally followed by a connective tissue graft (CTG).
Modifying the finishing line of a restoration is not a new concept. This technique is similar to root coverage procedures where cervical restorations are removed, the root surface and prominence is reduced and connective tissue overlaid to cover the root, references.1,2 The most critical factor is the depth of the finish line. The heavier the finish line the more difficult it will be to smooth away the finish line and reprepare it coronally. In this first case the previous resins were removed and the cervical area grafted prior to implant placement and restorative treatment. Careful planning allowed for properly proportioned teeth and the necessary soft tissue to match (Figs. 1A-I).
In next case there was previous recession in the cuspid (missing lateral and first bicuspid) and second bicuspid. Previous finish lines were carried up to existing free gingival margin with compromised esthetics. Removal of the finish line and soft tissue grafts improved the esthetics without compromising the biology. Simply grafting over the old restoration would not work since the existing restoration would prevent attachment of the new tissue. Thus the old restorations were removed, the margins were moved coronally and the old finish lines smoothed away. Provisional restorations were placed to a more ideal position before surgery (Figs. 2A-E). After an appropriate healing time the case was completed. This case could also have been managed very predictably with orthodontics via forced eruption, but the patient declined this approach.
In both cases the concepts followed were those described by Salama and Garber.3 These were very different situations in that these tissues were augmented. This type of correction will not happen spontaneously.
Planning for the soft tissue requires as much or more thought than planning for the restorations and preventing a problem is always easier than trying to correct it after the fact.
In our final case we will use many of these concepts to rehabilitate a young patient with many congenitally missing permanent teeth. After consultation with the orthodontist, a treatment plan involving orthodontics, sinus graft surgery and the placements of multiple implants to close spaces and replace the congenitally missing teeth was presented to the patient. The surgical positioning of the implants followed the concepts laid out in Gargiulo,4 Vacek5 and Salama/ Garber’s works.3 See progress of treatment planning details demonstrating orthodontic needs, surgical requirements and prosthodontics needs (Figs. 3A-R).
In conclusion you can predictably restore teeth, conventionally or with implants and have the confidence to create exquisite esthetics if you follow the guidelines as set out in these three articles, “The management of the dental gingival implant complex.”OH
A special thank you to Dr. Angelos Metaxas for the splendid orthodontic treatment and to Dr. Rory Hunter for providing the excellent restorations in the last case. All treatment presented in this article was completed by Dr. D. Belcastro. Dr. Belcastro is a contributing consultant for esthetics to Oral Health Journal.
Oral Health welcomes this original article.
REFERENCES: PART THREE
1.sLanger and Langer Subepithelial connective tissue graft tech. for root coverage. J. Perio. 1985; 56:715-720.Reference for conventional and restoration removal CTG’s.
2.Miller PD et al Surgical advances in the coverage of exposed roots. In: Williams RC et al, Current Opinions in Perio. Vol. 3. London: Rapid Science Publishers, 1996: 103-108.
3.Salama and Garber, Practical Periodontics Aesthetic Dentistry 1998: 10: 1131-1141.
4.Dimensions and relations of the dentogingival junction in humans. Gargiulo, Wentz, Orban, J. periodontal 1961; 32: 261-267
5.Vacek J.S. et al, Intl Journal of Prosthodontics and Restorative Dentistry, Vol. 14, #2, 1994
