Gingival perspectives of esthetics/cosmetic dentistry courses

GINGIVAL PERSPECTIVES
OF ESTHETICS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTSCONTENTS
INTRODUCTION
ANATOMY OF DENTOGINGIVAL COMPLEX
TISSUE HEIRARCHY
OSSEOUS CREST CONSIDERATIONS
PERIODONTAL BIOTYPE & BIOFORM
TOOTH MORPHOLOGY
CONTACT POINTS
TOOTH POSITION (GINGIVAL PROGRESSION)
EXTRA-ORAL SKELETAL AND SOFT TISSUE
LANDMARKS
REVIEW OF LITERATURE
CONCLUSION

INTRODUCTIONINTRODUCTION
Beauty is in the eye of the beholder. Perception of
beauty is in the brain. An organized and systematic
approach is required to evaluate, diagnose, and resolve
esthetic problems predictably
The gingival perspective of esthetics is concerned with
the soft tissue envelope surrounding the teeth.

ANATOMY OF THE DENTOGINGIVALANATOMY OF THE DENTOGINGIVAL
COMPLEXCOMPLEX
The dentogingival complex is composed of three
entities:
1. The supra-crestal connective tissue
attachment,
2. Epithelial (or junctional epithelium)
attachment and
3. The sulcus.

THE GINGIVA IS DIVIDED ANATOMICALLY INTO
MARGINAL,
ATTACHED,
INTERDENTAL
AREAS.
GINGIVA
Muco-gingival junction
Periodontal
ligament
FREE
GINGIVA
TOOTH
Crest of
Alveolar
bone
Muco-gingival junction
ATTACHED
GINGIVA
Alveolar mucosa
lies outsidealveolar bone

Marginal Gingiva
The marginal or unattached gingiva is the
terminal edge or border of the gingiva
surrounding the teeth in collar like fashion.
In about 50% of cases, it is demarcated from
the adjacent, attached gingiva by a shallow
linear depression, the free gingival groove.

Gingival SulcusGingival Sulcus
The gingival sulcus is the shallow crevice or span around the tooth
bounded by the surface of the tooth on one side and the epithelium
lining the free margin of the gingiva on the other. It is V shaped
and barely permits the entrance of a periodontal probe.
In clinically healthy gingiva in humans, a sulcus of some depth can
be found. The depth of this sulcus, determined in histological
sections, has been reported as 1.8 mm, with variations from 0 to 6
mm; other studies have reported 1.5 mm and 0.69 mm, respectively.

Attached Gingiva
The attached gingiva is continuous with the
marginal gingiva. It is firm, resilient, and
tightly bound to the underlying periosteum of
alveolar bone.
The facial aspect of the attached gingiva
extends to the relatively loose and movable
alveolar mucosa, from which it is demarcated by
the mucogingival junction.

The width of the attached gingiva is another
important clinical parameter.
It is the distance between the mucogingival
junction and the projection on the external
surface of the bottom of the gingival sulcus or
the periodontal pocket.

Interdental GingivaInterdental Gingiva
The interdental gingiva occupies the gingival
embrasure, which is the interproximal space beneath
the area of tooth contact.
The interdental gingiva can be pyramidal or have a
“col” shape.
In the former, the tip of one papilla is located
immediately beneath the contact point; the latter
presents a valley like depression that connects a facial
and lingual papilla and conforms to the shape of the
interproximal contact.

Gingival EpitheliumGingival Epithelium
The principal cell type of the gingival epithelium, as
well as of other stratified squamous epithelia, is the
kerotinocyte. Other cells found in the epithelium are
the clear cells or nonkeratinocytes, which include the
Langerhans cells, Merkel cells, and melanocytes.
The main function of the gingival epithelium is to
protect the deep structures while allowing a selective
interchange with the oral environment. This is
achieved by proliferation and differentiation of the
keratinocyte.

OSSEOUS CRESTOSSEOUS CREST
The quoted measurement of 2.04 mm for the biologic
width assumes that the osseous crest is normal,
prevalent in 85% of the population, with a sulcus depth
of 1 mm, yielding 3 mm for the entire dentogingival
complex.
The importance of the latter is that if crowns are
necessary, meticulous care should be taken to ensure
that this equilibrium is maintained (3 mm), and not
violated by any clinical procedure

GINGIVA: RolesGINGIVA: Roles
Connects soft tissue to hard, while it establishes a seal
around the tooth.
Provides sensation for control of biting & chewing
Controls oral microbes
Protects the PDL & alveolar bone
Adapts to changing oral conditions & eruption
Attaches firmly to the bone supporting the tooth
Joins with the adjacent alveolar mucosa

PERIODONTAL BIOTYPE ANDPERIODONTAL BIOTYPE AND
BIOFORMBIOFORM
The human tissue biotype is classified as thin, normal
or thick.
Thin periodontal biotypes are friable, escalating the
risk of recession following crown preparation and
periodontal or implant surgery.
This is particularly significant for full coverage crowns
for the following reasons.

Firstly, the thin gingival margins allow
visibility of’ a metal substructure (either
porcelain fused to a metal crown or implant
abutment), thereby compromising aesthetics in
the anterior regions of the mouth.
Secondly, due to the thin fragility of the thin
tissue, delicate management is essential for
avoiding recession and hence visibility of
subgingivally placed crown margins at the
restoration / tooth interface.

Conversely a thick biotype is fibrotic and resilient,
making it resistant to surgical procedures with a
tendency for pocket formation (as opposed to
recession).
Therefore, a thick biotype is more conducive for
implant placement, resulting in favorable aesthetic
outcomes

Periodontal bioformsPeriodontal bioforms
Are categorized into three basic gingival scaIIop
morphologies, high, normal and flat.
HIGH, NORMAL FLAT.

GINGIVAL MARGINGINGIVAL MARGIN
OUTLINEOUTLINE
PARALLELISM
In an ideal smile, the outline
of the gingival margins should
be parallel to both the incisal
curve and to the curvature of
the lower lip.

SYMMETRYSYMMETRY

GINGIVAL ZENITHGINGIVAL ZENITH
The zenithzenith is the most apical point of the gingival
outline

PAPILLAE
The papilla between the two central incisors appears
longer than that of adjacent teeth in relation to the
position of the interproximal contact areas.

Emergence profileEmergence profile
Stein and Kuwata: Described the part of the axial
contour that extends from the base of the gingival
sulcus past the free margin of the gingiva as the
emergence profile.
Failure to maintain proper emergence profile may be a
result of relying on the theory of food deflection when
developing crown contours, or it may be a result of
failure to remove adequate tooth structure during
tooth preparation.

In either case, if the restorative margin is extended
subgingivally, the over-bulked contours change the
emergence profile of the tooth.
This will create a protected area that encourages
plaque accumulation and is more difficult to clean.

TOOTH MORPHOLOGYTOOTH MORPHOLOGY
Tooth morphology determines two aspects of gingival
undulations.
Firstly : the basic tooth forms (determine the degree of gingival
scallop)
#circular
Shallow
#square
#triangular Pronounced
( Predisposes to the so called ‘black
triangles’)www.indiandentalacademy.com

Secondly, the convex acuity of a tooth
circumference influences the coronal /
apical position of the FGM. Put succinctly,
convex tooth morphology yields a more
apical location of the FGM, while a
concave shape leads to a coronal position of
the FGM.
The biological relationship of tooth
morphology to FGM locations can be
exploited to manipulate the soft tissue
around prostheses that are aesthetically
sensitive.

CONTACT POINTSCONTACT POINTS
The contact points of the maxillary teeth are relevant
for ensuring optimal ‘pink aesthetics’ for patients with
a high smile line (or visible cervical margins).
The i study by Tarnow, which produced the ‘5 mm
rule’. states that when the distance from the contact
point to the interproximal osseous crest is 5 mm or less,
there is complete fill of the gingival embrasures with
an interdental papilla.

For every 1 mm above 5 mm, the chance of complete
fill is progressively reduced by 50%.
For square-shaped teeth with wide contact points, the
chances of ‘black triangles’ is minimal compared with
triangular teeth having narrow, more incisally
positioned contact points.
The existence of the interdental papilla is dependent on
the presence or absence of teeth. No teeth, no papillae;
a scenario, which is evident in edentulous ridges where
papillae are absent

For example, if a lateral incisor is extracted, the
interproximal papilla between the central incisor and
canine will disappear, and the FGM of the lateral
incisor will reestablish itself to 3 mm from the
underlying osseous crest.
This is identical to the unsupported dentogingival
complex on the midfacial aspect of natural teeth. The
latter is also true for diastema, where an interdental
papilla is absent.

Furthermore, the degree of interproximal fill is also
dependant on the periodontal biotype. A thick
periodontal biotype encourages interdental fill, while a
thinner tissue type creates un-aesthetic hollow gingival
embrasures.
This problem is compounded when an implant is placed
next to a natural tooth. It is the interproximal bone of
the adjacent natural tooth that determines the
presence, or absence of a papilla, not the bone
surrounding the implant fixture.

For thick biotypes, the papilla may be
established to normal dimensions of’ 5 mm, but
for thin biotypes, it is difficult to recreate a
papilla longer than 4 mm from the osseous crest.
Finally, the 5 mm rule is only applicable for
adjacent natural teeth or implants bounded by
natural dentition.

Due to the flat fixture platforms, adjacent
implants lack the interproximal osseous peak
present between natural teeth.
The recently introduced scalloped plat form
fixtures (Nobel Perfect, Nobel Biocare,
Sweden), may help to redress this issue with an
endeavour to mimic natural root morphology.

TOOTH POSITION ANDTOOTH POSITION AND
GINGIVAL PROGRESSIONGINGIVAL PROGRESSION
The intra-arch tooth position is assessed in three
planes: vertical (apical—coronal), sagittal (facial—
lingual) and horizontal ( mesial - distal).
In the vertical plane, the cervical portion of the tooth
can be apical, coronal or in line with the FGM. An
example of a coronally positioned FGM occurs in cases
of altered passive eruption, where the FGM fails to
migrate apically to assume its relative position to the
CEJ.

In the sagittal plane, a facially placed tooth
will have an apically located FGM with a thin
underlying buccal plate & vice versa.
Horizontal: imbrications in the horizontal
plane result in crowding, due to limited arch
space for wide teeth. These teeth have close root
proximity with thin interproximal bone.

Buccally placed lateral incisor causing
apically positioned FGM

The opposite is the case for diastema with thick
interproximal bone and blunted papillae.
One of the most significant features of gingival
aesthetics is Contour progression from the
incisors to canine.

GINGIVAL AESTHETIC LINEGINGIVAL AESTHETIC LINE
( GAL( GAL )
The gingival aesthetic line (GAL) is a
classification for creating pleasing gingival level
transition between the maxillary anterior teeth.
GAL is defined as a line joining the tangents of
the zeniths of the FGM s of the central incisor
and canine.

The GAL angle is that formed at the intersection of
this line to the maxillary dental midline.

four classes of GAL
Assuming a normal w/l ratio, anatomy,
position and alignment of the anterior dental
segment, four classes of GAL are described:
Class I:Class I:
Class II:Class II:
Class III:Class III:GAL
Class IV:Class IV:

Class I:Class I: The GAL angle is between 450 and
900 and the lateral incisor is touching or below (1- 2
mm) the GAL-

Class II: The GAL angle is between 450 and 900
but the lateral incisor is above(1-2mm) the GAL and
its mesial part overlaps the distal aspect of the central
incisor

Class III: the GAL is 900, and the canine,
lateral and central incisors all lie below the GAL-

Class IV: The gingival contour cannot be
assigned to any of the above 3 classes. The GAL angle
can be acute or obtuse.
In a single mouth, the right and left sides can display
different GAL classes.
The aim of the clinician is to restore the gingival
contour to a GAL Class I, 11 or Ill to achieve aesthetic
appraisal.

EXTRA ORAL ANATOMYEXTRA ORAL ANATOMY
Extra—oral anatomy is genetically determined,
consisting of the skeletal and soft tissue land— marks,
the perio-oral skeletal and soft tissue form of the lower
third of the face should harmonize with the dentition.
During a relaxed ideal smile, the upper lip exposes the
cervical aspects of the maxillary anterior teeth.

The gingival margins of the maxillary central
Incisors should be symmetrical and at the same
height. Up to 3 mm of gingival exposure above
the cervical margins of the maxillary teeth is
aesthetically acceptable.
Beyond 3 mm results in a ‘gummy smile’
requiring correction by orthodontic or surgical
intervention to avoid visual tension.

Treatment modalities depend on the type of pathosis,
1. Hyper plastic gingivae require gingivectomy or crown
lengthening;
2. Recession can be corrected using orthodontics or cosmetic
periodontal plastic surgery using tissue grafts or guided tissue
regeneration membranes;
3. Over eruption by orthodontic intrusion;
4. Deficient pontic sites by ridge augmentation procedures and
5. Skeletal abnormalities by orthognathic surgery.
E.g.

Esthetic periodontal defects and its
correction
May include :
1. Violations of biologic width
2.    Gingival asymmetries
3.    Excessively gingival display
4.    Localized gingival recessions
5.    Deficient pontic areas
6.    Abnormal frena.
7.    Excessive gingival pigmentation
8.    Inadequate interproximal papilla

1.Violations of biologic width1.Violations of biologic width
Restorations which are over extended in the cervical
region should be carefully removed and proper cleaning
of the teeth is recommended with excavation of deep
carious lesions in the cervical region.
Provisional restorations should then be fabricated
with proper contouring in the cervical region. The
pockets should be probed and isolated areas of
excessive bone loss should be marked and regenerative
procedures instituted.

Surgical technique for establishing proper biologic
width involves recontouring the osseous crest so that a
minimum of 3 mm of the flap can be placed coronal to
the position of the recontoured osseous crest. This will
take into consideration the average biologic width of
2mm.
In accidental tooth fractures or any other clinical
situations where the restorative margins may violate
the biologic width, bone removal in the adjacent teeth
might be necessary to get desired esthetic result

2.Gingival asymmetries2.Gingival asymmetries
Whenever the facial gingiva of the anterior
teeth does not follow a symmetrical pattern,
crown length discrepancies are perceived; some
teeth appear longer while others appear shorter.
Correcting these discrepancies to an esthetic
gingival pattern becomes the main goal of the
esthetic or restorative dentist.

The possible causes of gingival
asymmetries are :
1. Gingival hyperplasia
2.     Altered passive eruption
3.     Tooth or teeth malpositioning
4.      Over zealous tooth brushing
5.      Periodontal disease

Esthetic crown lengthening
When a disparity in the clinical crown length
exits between contra lateral teeth resulting in a
left/right side height discrepancy, esthetic
surgical correction can be provided to enhance
the cosmetic result before restorative measures.

Functional crown lengthening
In such cases ‘esthetic crown lengthening’ may
be carried out by performing gingivectomy and
or osseous resection only on the facial aspect,
for better esthetics.
Root exposure is often a common
complications and intentional root canal or post
surgical treatment with veneers or crowns may
be required

Excessive gingival display (gummy
smile)
A gingival display of more than 3mm in active
or moderate smile may be termed “gummy”.
Excessive gingival display or gummy smile can
be caused by any of three factors.

The causes include:
1.         Maxillary over growth
2.         Tooth malposition
3.         Delayed apical migration of the gingival
margin or altered passive eruption.
Crown lengthening procedures can correct the
latter two defects. Usually a surgical and
orthodontic correction may be needed in these
cases

Excessive gingival pigmentation
Skin tone, texture and color differ in races, and
different regions the color of the human gingiva
also differs, usually pink with certain areas
showing a diffuse pigmentation.
Gingival pigmentation is due to the deposition
of melanin pigments in the basal layer of the
mucosa. In mammals it is brown, black or blue
black.

The saturation of these pigments causes an
unesthetic dark or gingival display.
In people with fair skin and high lip lines. The
pigmentation usually occurs in diffuse patches;
some times a continuous area is seen.

The surgery can be performed under local
anesthesia with the following techniques.
1. Gingivo-abrasion technique
2. Split thickness epithelial excision
3. Combination technique which involves
gingivo-abrasion and split thickness epithelial
excision.

Gingivo-abrasion technique
A medium grit foot ball
shaped diamond bur is used at
high speeds on the epithelium
to denude it.
Care should be taken not to
abrade the periosteum.
A periodontal pack is the
placed over the denuded
epithelium.

Split thickness epithelial excision
technique
A split thickness island of epithelium is
removed on the attached part of the mucosa.
A periodontal pack is then placed and left
for a week.

Combination technique
In cases where pigments are present very
close to the marginal gingiva and where the
gingival pattern as areas of depression and
elevations on the facial aspect, a combination
technique is advised.
Gingivo-abrasion is used near the marginal
gingiva and areas where a split excision of
difficult.

Open inter proximal spaces
Open inter-proximal space may be caused due to
diverging roots, abnormal clinical crown shape and
absence of inter proximal papilla.
The first two can be corrected orthodontically and by
the reshaping of the clinical crown respectively. While
the last is the most difficult to manage.
Because currently there are no predictable methods to
regenerate the inter proximal papilla.

Review of literature
David J. Clark, DDS and Jihyon Kim,; Optimizing Gingival
Esthetics A Microscopic Perspective
CONCLUSION
Reasonable restorative outcomes can be achieved with amalgam
and gold with low or no magnification. In contrast, tooth
colored materials require much higher levels magnification for
consistent success. Common clinical magnification simply has
not kept pace with dramatic changes in restorative materials
and patient expectations. In spite of other advances in
dentistry, marginal integrity, emergence profile, and resistance
to micro leakage have all taken a giant step backward.

MICHAEL S. REDDY, D.M.D., D.M.Sc Achieving gingival
esthetics; JADA, Vol. 134, March 2003
The typical gingival esthetic problems of excessive gingival
display, asymmetry in gingival contours, exposed root surfaces
and loss of papillae can limit the success of cosmetic and
prosthodontic treatment.
In many cases, the combination of periodontal esthetic surgery
with other restorative procedures can create a synergistic
esthetic result that could not have been obtained with either
treatment alone

Anterior Esthetic Gingival Depigmentationand Crown
Lengthening: Report of a Case; The Journal of Contemporary Dental Practice,
Volume 6, No. 3, August 15, 2005
Conclusion
Excessive gingival display and gingival hyper pigmentation are
major concerns for a large number of patients. Although several
techniques are currently in use, the scalpel technique is still the
most widely employed.
Lasers and cryosurgery may offer less postoperative pain.
Additionally, a surgical soft tissue grafting for depigmentation
may ensure less chance for recurrence over a five year follow up.
the external bevel gingivectomy combined with the
depigmentation procedure described above offers practical
technique to dramatically improve patient esthetics.

CONCLUSIONCONCLUSION
Tooth color is obviously essential in the final result, but
esthetic treatment planning should never be devised
around shading improvements alone.
Failure to take account of the soft tissue considerations
will negate all the other aspects of treatment, resulting
in ultimate esthetic failure. Rather than an
afterthought, the gingival viewpoint, at the outset,
should be an integral part of any esthetic treatment
planning, ensuring health, approval and longevity of the
final result

REFERENCES
1. GERARD CHICHE & ALAIN PINAULT
– Esthetics of fixed prosthodontics.
2. CLAUDE R. RUFENACHT, fundamentals
of esthetics
3. CHICHE, esthetics of anterior fixed
prosthodotics.
4. GARDIN, Porcelain laminate veneers
5. SOLOMON EGR: Esthetic consideration of
smile; IPS; 1999: 10(3&4); 41-47

6. GOLDSTEIN, RE: Change your Smile, ed 3
Chicago, Quintessence, 1997
7. British Dental Journal 2005; 199: 195-202.
8. Dental clinics of North America – 1998 – Achieving
optimal gingival esthetics around restored natural
teeth & implants
9. David J. Clark, DDS and Jihyon Kim,; Optimizing
Gingival Esthetics
A Microscopic Perspective

10. Anterior Esthetic Gingival Depigmentationand
Crown Lengthening: Report of a Case; the Journal
of Contemporary Dental Practice, Volume 6, No. 3,
August 15, 2005
11. 11.Rosa DS, Aranha AC, Eduardo Cde P, Aoki A
Esthetic treatment of gingival melanin hyper
pigmentation with Er:YAG laser: short-term clinical
observations and patient follow-up. . J Periodontol.
2007 Oct; 78(10):2018-25.

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