correct use of artiﬁ cial gum for implant-assisted prosthesis · making prosthetic considerations...

Methodology

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Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)

F : Troiano M, Sanchez P, Benincasa M, Cagnone G. Correct use of arti icial gum for implant-assisted prosthesis. Annals of Oral & Maxillofacial Surgery 2013 Jun 01;1(2):19.

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AbstractIntroduction

The general practitioner and dental technician should attempt to prosthet-ically restore the area that cannot be surgically reconstructed. Regardless of technician’s endeavours to meet aesthetics and functionality criteria, inal restoration can be viewed as a

failure, since it departs from previ-ously set goals and ultimately disap-points the patient1. This article dis-cusses the correct use of arti icial gum for implant-assisted prosthesis.Methodology

Treating the anterior segment of both jaws in complex clinical cases is always dif icult, even with clear diagnostic parameters and in spite of following a sensible treatment plan. Completing a bone and soft-tissue graft and conditioning them in a sec-ond-stage surgery do not guarantee success in treatment: in some cases, it is necessary to resort to use of pros-thetic devices, such as arti icial gum. Discussion

Clinical success with the use of pink gum restoration depends on the pre-cise planning of prosthetic surgical steps.Conclusion

The use of arti icial gum is a new way for dental professionals (surgeons, prostheticians and dental techni-cians) to assess a case and devise a treatment.

IntroductionGeneral practitioners and dental tech-nicians should attempt to prostheti-cally restore the area that cannot be surgically reconstructed. Regardless of technician’s endeavours to meet

aesthetics and functionality criteria, inal restoration can be viewed as a

failure, since it departs from previ-ously set goals and ultimately dis-appoints the patient1. This is not a technical failure, but a diagnostic one. Furthermore, the biologic response of tissue to surgical procedure, a fun-damental aspect of treatment, is not fully taken into consideration.

Thus, and bearing in mind that it is a costly and lengthy treatment, regen-erative surgery is not always the best option from a biological standpoint. Consequently, depending on the case, treatment plan should include use of arti icial gum in prosthetic recon-struction from the very beginning2. This aim of this study is to discuss the correct use of arti icial gum in implant-assisted prosthesis.

MethodologyTo reach an accurate diagnosis and develop an appropriate treatment plan using arti icial gum for recon-structive purposes, it is necessary to take the following steps:

• Perform a clinical examination• Take impressions that will serve as

study models• Keep a record of occlusions• Take photographs (Figures 1 and 2)

• Intra-oral • White: teeth• Pink: gum

• Extra-oral• Front and pro ile

• Consider the possibility of using arti icial gum

• Do a diagnostic wax-up.

Diagnostic wax-up is a critical tool for determining the best approach to treatment as well as for detecting the limitations of applying surgical or prosthetic procedures. This tech-nique can also:

• provide the general practitioner with relevant information to take accurate X-rays and come up with viable surgical guides

• serve as a mould for manufacturing a temporary restoration device

• allow for a dental position and tooth-axis alignment that enable continuity between the arti icial gum and the remainder of patient’s own gum and ridge

• determine the design of the frame in which to place the material to create arti icial gum, making it possible to distinguish the cervical ceramic of the tooth from the pink gum.

• Thus, wax-up method should attempt to achieve ideal dental proportion and position without relying on the current position of alveolar ridge. By positioning the teeth correctly, achieving an appropriate distance to the soft tissue and following the design of papillae, the specialist will obtain a 3D image showing how much bone tissue is missing and pro-viding a guideline for the general practitioner as to which surgical techniques might be appropriate, their potential success rate and the appropriate size and placement of arti icial gum. It will also help in deciding which treatment would yield the best aesthetic results (Figure 3).

However, this will only be possi-ble if we manage to avoid the most common mistakes in prosthetic restoration:

• Noticeable interface between the arti icial and the natural gum in the aesthetic zone (Figure 4)

• Bad implant position for creating an emergency pro ile that the arti i-cial gum needs, given that this type

Correct use of artifi cial gum for implant-assisted prosthesisM Troiano*, P Sanchez, M Benincasa, G Cagnone

*Corresponding authorEmail: [email protected]

Bvrd Oroño 267, Rosario (2000), Argentina

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Methodology

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of clinical case requires implants to be placed 3 or 4 mm more apically in order to solve the problem

• Impossibility of placing a lingual screw to achieve a screw-retained

restoration: this limits recoverabil-ity and disassembly of distance-control devices

• Placement of more implants than necessary due to a diagnostic error,

making it impossible to restore all of them

• Bone crest anatomy makes it impossible to place the arti icial gum.

A CT and a radiographic guide on the basis of the diagnostic wax-up are fundamental tools of the ield, which, coupled with 3D dental

imaging software, help to establish appropriate implant number and position3 .

Arch position and number of implants, implant angle and depth are critical to establish the right approach to successful gingival pros-thetic restoration.

The lower the number of implants, the easier it is to restore the arch. This means fewer posts and more pontics. As long biomechanics are not jeopardized, limiting the number of implants gives the lab technician lee-way to shape the anatomy of arti icial gum, therefore optimizing patient hygiene.

Placing the implants far away from the midline and the anterior segment, which can be restored with pontics, is good for aesthetics and phonation, since it can create a ‘prosthetic premaxilla’ meeting the patient’s needs.

Implant angle must be duly planned to facilitate lingual screw

A B

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Figure 2: Preoperative photos : A to F.

A B

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Figure 1: Facial appearance: A to F.

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access for a screw-retained pros-thesis. The screw-retained prosthe-sis will facilitate emergency pro ile monitoring; the aesthetic material can be placed closer to the implant collar, thus allowing the dental tech-nician to shape the pro ile in the transmucosal area during the pro-cess of prosthesis manufacturing and testing. Using a more conven-tional, cement-retained prosthe-sis would be more complex, since it relies on posts, thus limiting the space available to modify the arti-icial gum–natural gum interface4.

Another good reason for choos-ing a screw-retained prosthesis is

maintenance, since it is easier to reach for hygiene and repair pur-poses, which is sometimes neces-sary. The restoration’s recoverabil-ity allows the general practitioner and the dental technician to take it out and repair it as necessary.

Implant depth is a critical factor for achieving functional and aes-thetic restoration. In conventional implant restoration, the implant must be placed 2 or 3 mm api-cally, towards the cervical edge of the crown. For an arti icial gingival reconstruction, the implant must be placed 3 mm beyond the tip of arti-icial gum.

The greater the loss of horizontal tissue, the deeper the surgeon will have to drive in the implant to achieve a harmonious gingival pro ile, creat-ing a 30° to 40° arti icial gum angle in relation to the occlusal plane, which will prevent food from getting caught in the area and allow good upper-lip mobility.

Important factors:

• Surgical aesthetics of hard and soft tissue in the implant area

• Dental aesthetics: it determines the location of dental restoration and use of arti icial gum

• Facial aesthetics: face of the patient must be taken into account when making prosthetic considerations (Figures 5 to 9).

DiscussionClinical success with the use of pink gum restoration depends on the pre-cise planning of prosthetic surgical steps.

Surgical considerations

The surgical placement of implant must be accurate. Surgical guide will provide the implant axis and place-ment depth. From a surgical point of view, it is preferable to drive the implant deeper into the bone, ena-bling the use of a lingual screw and a greater number of pontics (following biomechanical principles), instead of using multiple adjacent posts. This

A B

C D E

Figure 4: Prosthetics design: A to E.

A B C

Figure 3: Radiology. Dimensional reconstruction: A to C.

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surgical perspective breaks with tradition.

Accordingly, ridge restoration should be carried out more horizon-tally than vertically. In contrast with most implants, which seek to recreate vertical inter-proximal support for the papilla, bone reduction or remod-elling is often necessary when work-ing with arti icial gum, in order to

create a lat ridge between implants5. This will help to link patient’s ridge with pontics in a functional and aesthetic manner, which again is a departure from traditional surgical methods in favour of this prosthetic technique.

Prosthetic considerations

The dental ceramist must under-stand the basic clinical principles of implant-assisted prosthesis, the components that make up a bal-anced smile, the alveolar bone resorption classification and the aesthetic principles behind a pink contour, colour and tex-ture. It is important that he/she searches for anatomical references. Morphological research through photographs, old casts, the patient’s teeth and the contour of the gum in

the adjacent areas may follow simi-lar dental-gingival standards nec-essary to make the most accurate prosthetic choice possible.

Consequently, dental-casting tech-nique is highly important in this case because it is meant to provide an accurate reproduction of the soft tis-sue, which will support the arti icial gum and the pontic6. If the temporary restoration involves tissue condition-ing, the copy of the abutment pro ile must be perfect.

Temporary tooth/gum

Temporary restoration represents an important step in planning an artificial gum procedure. It gives the dental professional a second chance to test the design (the diag-nostic wax-up being the first)—under ideal circumstances, in any

A B C

Figure 6: Prosthetic design: A to C

A B C

Figure 7: Vestibular view: A to C

Figure 8: Screw structure sealing with resin pink (Sinfony 3M ESPE).

A B

Figure 5: Maxilla implants abutments installation: A and B.

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case. Soft-tissue conditioning and remodelling must be carried out at this stage.

Temporary teeth or gum are essential for treatment. They serve to test the union between the natural gum and the arti icial gum, checking the interface to guarantee that the tip of the gum does not show dur-ing full smile. Phonation must be tested after completing temporary restoration.

It is important to solve hygiene and maintenance concerns with the temporary teeth or gum already in position.

Emergency profiles are key to artificial gum restoration, which is substantially different from tra-ditional restoration. Technicians must create an artificial gum that reproduces the characteristics of the missing tissue and improves aesthetics.

The aim is to create a buccal con-tour in which the arti icial gum looks like the patient’s own gum before the loss of teeth. The arti icial gum should rise from the implant and form an acute angle after crossing the trans-mucosal area. This will help breach the gap between natural and arti icial soft tissue.

There are three arti icial gingi-val restoration (papilla) designs to choose from:

• The papilla may be fully arti icial when completely missing between two crowns

• It may be partly natural and partly artificial if the papilla next to the crown is slightly atrophied.

In this case, the restoration pro-file must be proportional in order for the prosthetic restoration’s artificial papilla and the natu-ral papilla of the toothed area to share the inter-proximal space, so as to match colour and shape, which is clinically and practically difficult.

To have enough space for hygiene purposes in a partially edentulous patient, it is necessary to take special care when creating

• the irst arti icial gum interface: check the transition from natural to arti icial gum

• the second ceramic interface, which involves the con iguration of the tooth axis (before the pink gum is inished), dental anatomy, ver-tical dimension and interdental space

• the third ceramic interface, which involves checking the pink gum material, tooth–gum connection and papilla location

Final arti icial gum touch-ups are done directly on the patient

(Figure 10). By using a thin diamond bur, the edge of the arti icial gum can be trimmed to have it match the patient’s own gum, if the shape and sulcus of the latter area is greater (twice as much). The surface in con-tact with the gum must be shiny, smooth and concavity free. A lat or oval surface is recommended for areas in contact with natural tissue.

There is a choice of two materials and three techniques for creating the arti icial gum:

Composite

There are a number of reasons for selecting this material:

• It preserves the physical proper-ties of the porcelain fused to metal restoration

• The pink aesthetic shade, shape and texture can be controlled

• It facilitates maintenance and repair

• Foreseeable results• Composite gum manufactur-

ing enables to carry out any type of prosthesis repair, or even to replace the prosthesis, without affecting the ceramic crowns,

A B C

Figure 9: Vestibular view: A to C

A B

Figure 10: Postoperative facial aspects: A and B

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which is one of the main reasons for deciding on a screw-retained prosthesis.

Ceramic

• This restoration cannot be screw-retained due to anatomical and angle dif iculties; therefore, it needs to be cement-retained

• When only a small amount of gum is required, such as part of a papilla, it is easy to add pink ceramic while working on the crowns

• When a large amount of arti icial gum is necessary in order for the transition line to be outside of the aesthetic zone, it is advisable to use ceramic.

Hybrid• The pink core is done in ceramic

and a composite overlap preserves the aesthetic aspect, giving maxi-mum interface control (Figure 7, and Figures 11 to 14).

The soft-tissue interface and the mesostructure are done in pink ceramic, facilitating sub-gingival biocompatibility. Pink composite is only used supra-gingivally, so that is matches the aesthetic interface7,8.

ConclusionTo restore aesthetic defects in the anterior segment of the jaw is one of the greatest challenges in restorative dentistry today.

The use of arti icial gum represents a new way for dental professionals

(surgeons, prostheticians and den-tal technicians) to assess a case and devise a treatment. To apply these techniques, it is essential to reach an accurate diagnosis and to plan treat-ment in advance, given that implants must be suitable for this restoration

system. Patient should know that restoration will be supported by three main posts before beginning treatment and that the procedure involves less surgical steps and risks, since vertical bone growth is not its goal. This method is aimed at gaining

A B C

Figure 13: Prosthetic installation. Occlusal view: A to C.

A B

Figure 12: Final restoration: ceramic and hybrid prosthetics over ive implants: A and B.

A B

C D

Figure 11: Final restoration: ceramic and hybrid prosthetic over ive implants: A to D (MR 31 osseotite).

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greater aesthetic control and limiting the number of surgical steps.

References1. Cronin RJ, Wardle WL. Loss of anterior interdental tissue: periodontal and pros-thodontic solutions. J Prosthet Dent. 1983 Oct;50(4):505–9.

2. Coachman C, Salama M, Garber D, Calamita M, Salama H, Cabral G. Prosthetic gingival reconstruction in the ixed partial restoration: Part 1: introduction to arti-icial gingiva as an alternative therapy.

Int J Periodontics Restorative Dent. 2009 Oct;29(5):471–7.3. Goodacre CJ. Gingival esthetics. J Prosthet Dent. 1990 Jul;64(1):1–12.

4. Priest GF, Lindke L. Gingival-colored porcelain for implant-supported pros-theses in the aesthetic zone. Pract Periodontics Aesthet Dent. 1998 Nov–Dec;10(9):1231–42.5. Engquist B, Astrand P, Anzen B, Dalhgren S, Engquist E, Feldmann H, et al. Simpli ied methods of implant treatment in the edentulous lower jaw: a 3-year follow-up report of a con-trolled prospective study of one-stage versus two-stage surgery and early loading. Clin Implant Dent Relat Res. 2005;7(2):95–104.6. Wol inger GJ, Balshi TJ, Rangert B. Immediate functional loading of Bränemark system implants in edentu-lous mandibles: clinical simpli ied proto-cols. Int J Oral Maxillofac Implants. 2003 Mar–Apr;18(2):250–7. 7. Duncan JD, Swift E Jr. Use of tissue-tinted porcelain to restore soft-tissue defects. J Prosthodont. 1994 Jun;3(2):59–61.8. Rosa DM, Souza Neto J. Odontologia esté-tica e a Prótese ixa dentogengival—considerações cirúrgicas e protéticas—casos clínicos e laboratoriais: uma alternativa entre as soluções estéticas. Rev Reg Aracatuba Assoc Paul Cir Dent. 1999;53(4):291–6. Italian.

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Figure 14: Occlusion and distoclusion: A to D.

correct use of artiﬁ cial gum for implant-assisted prosthesis · making prosthetic considerations...

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