The 24th CE Leader of the Year
The 24th CE Leader of the Year
The aesthetic dilemma of the gingival margin
The data is clear: both porcelain and composite resin are biocompatible and well tolerated at the gingival margin. 1-3 One of the main reasons for concern is that if the composite material directly hits the gums, it will cause tissue irritation. 4-6 This may eventually lead to gum recession which is rather unsightly. Porcelain is less challenging, but the accumulation of plaque on the edges, usually irritated by a thin layer of exposed resin cement, can cause similar irritation of free gums and eventually cause gum recession. 7,8
Even a skilled subgingival margin placement, usually within 3 to 5 years, whether due to aging, gum irritation, or improper home maintenance by the patient, will result in unsightly decline and highly visible exposure of the dark dentin surface. 9,10 The best repair method is to position the edge of the composite material on the gums. 3,11 Keep the resin material reasonably away from the soft periodontal structure (0.25 to 0.5 mm), thereby reducing the possibility of tissue irritation.
Today's adhesives and repair agents make this a fairly simple task. 12-19 The bonding of next-generation adhesives to enamel and dentin is predictable and relatively the same. 14,15 Generally speaking, seventh- and eighth-generation adhesives exhibit similar adhesion to tooth enamel and dentin, eliminating the stress caused by unequal polymerization shrinkage. 17-19 Therefore, it is clinically realistic to place a continuous restoration through the dentin-enamel junction (DEJ) to cover as much enamel and dentin as possible due to decay. Abstraction, or aesthetics.
However, a major aesthetic dilemma soon appeared. Most dental restoration materials are standardized to enamel shades. Although there are some "dentin" shades available, they are usually not close to the darker color that exposes the dentin, especially in endodontic treated teeth.
When level V decay, shedding, or small gum receding is restored, the glaze resin will adhere to the DEJ of the lips. A typical central incisor is approximately 10.5 mm cervical incisor (CI). 20 Any significant increase in the apparent length of the teeth, especially in the front lip area, will destroy the beauty of the smile. Increasing the vertical and horizontal CI of the maxillary central incisor by 3 mm (Figure 1) and the apparent vertical dimension increased by 30%, significantly changing the CI:MD ratio. This disturbs the aesthetic parameters of the smile (Figure 2).
For patients with moderate decline, the visual difference is further strengthened. The CI:MD ratio of maxillary lateral incisors and mandibular incisors (average 9.0 mm CI) was more significant. The upper and lower canines (clinically longer, with a CI of 10 to 11 mm) are usually the teeth most prone to gum recession and the most obvious teeth, whether they are anterior or lateral teeth.
Patients with receded gums, shedding, and/or decayed gums often look older than they really are. Unfortunately, hiding the deeper roots with enamel resin only makes these teeth more visible. It seems longer; therefore, less attractive.
Practitioners must solve these problems effectively, aesthetically, and with minimal intrusiveness. The ideal treatment is functional, restoring missing enamel and dentin to its natural size and contour. The missing enamel is replaced by enamel shadow composite resin. Retracted gums are replaced by gum shadow compound resin. Their interface is the artificial enamel-gingival junction in the composite material, which restores the beauty of the patient's smile.
Solve the problem of gum aesthetics
Beautifil II Gingiva (Shofu Dental) aims to rebalance the pink beauty of the neck area (Figure 3). Indications for the use of Beautifil II Gingiva include wedge-shaped defects, cervical decay, aesthetic correction of gingival recession, splints for protecting the exposed cervical area and moving teeth. There are 5 shades of gum resin (dark pink, light pink, brown, orange, and purple) (Figure 4), which can be layered and/or mixed to create custom shades for various gum pigmentation according to specific clinical needs ( Figure 5).
Beautifil II composite resin is very beautiful, can release fluoride, and is suitable for all types of restorations. Many studies published in the past 20 years show that there is no failure, no secondary caries, no postoperative sensitivity, and high retention of color stability and surface gloss. The chemical process is based on Shofu's proprietary Giomer technology (Figure 6). Giomer resins have a significant advantage: they release fluoride and protect the tooth structure at the edge of the restoration. Their fluoride content can be replenished with toothpaste, fluoride mouthwash and varnish.
Therefore, the release capacity of Giomer fluoride will not decrease over time.
The restorative gingival margin (whether pink or enamel) must be on the gum and slightly away from the free gingival margin. 3,4,6 Although a very narrow dark dentin band can be seen at the root tip, the coronal enamel and pink gum staining of the restoration diverts attention from this area. Gum hybrid restorations allow professionals to provide both aesthetics and supragingival margins in the same restoration. The supragingival margin also helps patients perform effective home maintenance.
Restorations that are very close to the edges of free gums require effective moisture and bleeding control. The rubber dam technique is not practical in the apical work area. The tow rope may physically or chemically damage the repair material. For conscientious patients, good oral hygiene produces a healthy gum microenvironment: the smallest periodontal pocket and no bleeding during probing. However, for most patients, doctors must correct the gum status to increase the likelihood of clinical success. The most predictable tissue carving technique is the diode laser. 21-23 With low power (1 to 1.5 W), an ideal, dry, clean and blood-free work area can be achieved in less than a minute.
Case 1: Obvious recession and recession
The patient's main complaint was gingival recession on the outside of the left upper jaw, rather than mesial caries (Figure 7). Because the patient's home care is effective, it is very simple to use Shofu Dental's BeautiBond (Figure 8a) and Beautifil Flow Plus X for MLB repair. The steps for aesthetic restoration of buccal recession gums are:
This kind of recession is often encountered. The lower front teeth are small and tightly located, making it difficult to clean with the tongue and lower lip (Figure 11). Gravity and an upright position can cause food debris and dental plaque to accumulate on the lips and between the neighbors (Figure 12). For this patient, the possible cause of gingival recession is the frenulum attached to the apical gums. The initial treatment is diode laser frenectomy to eliminate muscle traction. 21-23 The steps of gingival aesthetic restoration for receded cheeks are:
Effective, long-term home maintenance must include procedures that the patient is familiar with and easy to implement. Tooth brushing is effective and widely used. Dental flossing between teeth is not so important. Although string dental floss is well documented and encouraged, patient resistance to the process and inconsistent household use limit its benefits. Water Flosser (Water Pik) facilitates the cleaning process between teeth and has been shown to improve results. 24 There are many models to choose from, including Sonic Fusion (Water Pik), which can use water floss and sonic brushing at the same time (Figures 14 and 15).
Beautifil II Gingiva provides practitioners with a solution to the dilemma of gum aesthetics. The aesthetic restoration of the gums is predictable and is usually done without local anesthesia or patient discomfort. These restorations are fully functional and can restore the structure of hard and soft teeth to their natural size and contour with minimal invasiveness. The restoration of coronal anatomy with tooth-colored composite resin is well-documented and quite routine; the development of artificial enamel-gingival junctions and the technology of reconfiguring the missing gingival structure with composite resin is a novel solution that can restore the patient’s Smile and facial beauty.
1. Freedman G. Ultra conservative porcelain veneer. Esthet Dent is updated. 1997; 2: 224-228.
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3. Freedman G, Fugazzotto PA, Greggs TR. Aesthetic upper gingival margin. Practice periodontal disease aesthetic dent. 1990; 2:35-38.
4. General Manager of Newcomb. The relationship between the position of the subgingival crown and gingival inflammation. J periodontitis. 1947; 45:151.
5. Renggli H, Regolati B. Gingival inflammation and plaque accumulation produced by well-adapted supragingival and subgingival proximal restorations. Journal of Helv Odont. 1972; L6:99.
6. Wallhow SJ. Histological considerations that determine the position of the prosthesis edge relative to the gums. Dent Clin North America 1960; 4:161.
7. Berman M. completely covers the restoration and gingival sulcus. J Dents of the prosthesis. 1973;29:1301.
8. Marcum O. The effect of crown edge depth on gingival tissue. J Dents of the prosthesis. 1967; 17:479.
9. Freedman G, McLaughlin G. Color Atlas of Porcelain Laminates. Ishiyaku EuroAmerica, Inc.; 1990.
10. Freedman G. Chapter 23: Cement. In: Contemporary Aesthetic Dentistry. Elsevier Publishing; 2011:551.
11. Freedman G, Klaiman HF, Serota KT, etc. Inner Aesthetics: Part Two. Pouring ceramic post and core restorations. Dent. 1993; 70:21-24.
12. Albers HF. Dentin-resin bonding. Expert report. 1990; 1:33-34.
13. Dentin-polymer bonding promoted by Munksgaard EC, Asmussen E. Gluma and various resins. J Dent research. 1985; 64: 1409-1411.
14. Buckmeier WW, Erickson RL. The shear bond strength of Scotchbond multi-purpose composite to enamel and dentin. I’m J Dent. 1994; 7: 175-179.
15. Swift EJ, Triolo PT. Scotchbond is versatile for bonding strength to wet dentin and enamel. I’m J Dent. 1992; 5: 318-320.
16. Gwinnett AJ. Moist dentin and dry dentin; its effect on shear bond strength. I’m J Dent. 1992; 5: 127129.
17. Freedman G, Leinfelder K. The seventh generation adhesive system. Dentistry. 2003; 1:15-18.
18. Freedman G. 7th generation adhesive system. Asian Dentistry (English). 2019; 2:50-53.
19. Freedman G. Adhesion: Past, present and future. Oral health. 2019;109:7-14,82.
20. Wheeler RC. Textbook of Dental Anatomy and Physiology. WB Sanders; 1965.
21. Goldstep F. Soft Tissue Diode Laser: Where have I been in this life? Oral health. 2009;99:7;34-38.
22. Goldstep F. Diode laser for periodontal treatment: the story so far. Oral health. 2009;99:12,44-46.
23. Goldstep F. Diode laser: soft tissue mobile phone. Asian Dentistry (English). 2011; 1:28-32.
24. Rosema NA, Hennequin-Hoenderdos NL, Berchier CE, etc. The effect of different interdental cleaning devices on gum bleeding. J Int Acad Journal of Periodontology. 2011;13(1):2-10.
Dr. Freedman is the co-founder and past chairman of the American Academy of Aesthetic Dentistry, the co-founder of the Canadian Academy of Aesthetic Dentistry, a director and researcher of the International College of Dental Facial Aesthetics (IADFE), and the diplomat and chairman of the American Board of Aesthetic Dentistry. He is an adjunct professor of dental medicine at the University of Western Pomona, California, and a professor and project director of the MClinDent project in Prosthetic and Aesthetic Dentistry at BPP University in London. Dr. Freedman is the author of 14 textbooks, more than 900 dental articles and numerous webinars. You can contact him at freedman@epdot.com.
Disclosure: Dr. Friedman advises more than 50 companies.
Dr. Lalla graduated from the University of the West Indies and worked in dentistry in Trinidad and Tobago, with a special focus on cosmetic and implant dentistry. After receiving AEGD at the Lutheran Medical Center, he won scholarships from the International Conference on Dental Implantology, the American Society of Implant Prosthetics, and IADFE. His contact information is tropicaldental@yahoo.com.
Disclosure: Dr. Lalla's report did not disclose.
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