21-1_Elias

70 The Journal of Cosmetic Dentistry Spring 2005 Volume 21 Number 1

Edentulous areas in the anterior region often appear to be underdeveloped, to create an ovate pontic. There is no cervical bulge, because there is no root (Figs 1 & 2). This article presents the general dentist with an alternative to connective tissue grafting in developing an ovate pontic site, when esthetics are a driving concern and there is a high lip line.

The patient was a healthy 35-year-old female. Appearance was her primary concern. She did not like her smile (she was particularly unhappy with the appearance of #7 and #10) and believed that her false teeth looked false; she wanted her six front teeth to look real and pretty.

She was periodontally stable and medium-risk, with cuspids having high gingival attachment. Biomechanically she was medium-risk, with some old restorations and congenitally missing laterals with Maryland bridges that were more than 18 years old. The patient stated that they had come off several times at very inopportune moments.

Functionally, the patient showed no signs of wear, movement, or breakage. Dentofacially, she was high-risk, showing a full smile dentally and gingivally.

Development of a Simplied Esthetic Edentulous Horizontal Ridge Site

CLINICAL TIP ELIAS

Dr. Elias is a 1979 graduate of the Uni-versity of MissouriKansas City School of Dentistry, and has maintained a re-storative cosmetic practice in Indepen-dence, Missouri, for 26 years.

Dr. Elias, who became Accredited by the AACD in 1989, served for six years on the AACDs Board of Directors. He also is a member of the American Dental As-sociation, the American Society of Den-tal Esthetics, and the American Equili-bration Society; and of the Phi Kappa Phi and Omicron Kappa Upsilon honor societies. Dr. Elias and his wife, Sharon, have four children and two grandsons.

byJames D. Elias, D.D.S.

Volume 21 Number 1 Spring 2005 The Journal of Cosmetic Dentistry 71

Total DGCOsseous Crest/Free Gingival Margin (FGM) Relationship

Normal crest 85% facially = 3 mm

High crest 2% facially < 3 mm

Low crest 13% facially > 3 mm

Total DGCClinical Guidelines

Osseous Crest/FGM Relationship1,2

Normal crest (range 35 mm) Interproximally 4.5 mm (mean)

High crest Interproximally < 3 mm

Low crest Interproximally > 5 mm

CRITERIA FOR CASE SELECTION

STABLE AND SUFFICIENT UNDERLYING BONE

This was determined by x-ray (Fig 3) and by sounding to bone, which was accomplished with the following steps:

administering local anesthetic

probing the sulcus (feeling resis-tance)

keeping the probe against the root surface

pushing hard to the osseous crest

probing the edentulous area.

These steps help to ensure a pre-dictable result, as we do not want to risk raising a ap only to nd a bone defect that could cause further tissue loss.

RIDGE TYPE

We wanted a rounded to at ridge, which would allow us to elevate the tissue more than 3 mm from the bone (Figs 4 & 5). Using the total dentogingival complex (DGC [see

above chart]) can simplify periodon-tal procedures and enhance our abil-ity to provide intracrevicular margin location. An understanding of the biologic variables will provide a more enlightened clinical approach. Remember that tissue follows bone.

TISSUE TYPE

The more thick and plump the tissue, the better the results versus a thin, poorly vascularized area. Verti-cal height of the tissue will be deter-mined by the height of the interden-tal papillae next to the edentulous area (Fig 2).

TECHNIQUEBeginning with the end in mind,

the objective is to devise an ovate pontic site and create the illusion of a tooth growing out of a socket with a cervical bulge and interdental pa-pillae (Fig 6).

INCISION

Use a straight scalpel blade di-rected in the long axis of both abut-ment teeth. Begin the incision to the

bone lingual to the incisive papilla and make a slight elliptical incision toward the buccal for gingival con-tour, then back lingual to the inci-sive papillae of the adjacent teeth (Figs 4 & 5).

ELEVATION

With a periosteal elevator, gen-tly elevate the tissue away from the bone on the ridge and buccal plate. In essence, we are creating an extrac-tion site (Fig 5).

PONTIC CREATION

Figures 7 and 8 show provision-als with bullet-shaped ovate pon-tics, which serve as a matrix around which the tissue could form and heal. Prior to beginning the proce-dure, a mock-up and then a study model for a suck-down stint and a provisional shell can be created. We can reline and begin adding and shaping the gingival of the pontic to be more root-like, creating a matrix for the tissue (Fig 9). If necessary, a hole can be drilled in the provision-al and a suture can be placed to pull

CLINICAL TIP ELIAS


CLINICAL TIP ELIAS

Figure 1: Patients smile and lip position. Figure 2: Undeveloped ridge with Maryland bridges removed.

Figure 3: X-rays of before and after treatment.


CLINICAL TIP ELIAS

Figure 4: Scalpel position and elevation.

Figure 5: Incisal shot of ovate wound creation.

Figure 6: Creation of interdental papillae and cervical bulge.

Figure 8: Gingival view, bullet-shaped ovate pontic.

Figure 7: Provisionals with bullet-shaped ovate pontic, which serve as a matrix.

Figure 9: Provisionals seated, pushing tissue to the buccal and creating a cervical bulge.


CLINICAL TIP ELIAS

Figure 11: Pink porcelain used on pontic area to maintain tooth length.

Figure 13: After smile.Figure 12: After, smile retracted.

the tissue up and allow it to heal (Fig 10). The goal is to place the pontic no closer than 2 mm from the bone and to not push the buc-cal tissue further away than 3 mm from the bone. Granulation and tis-sue formation in the voids are to be expected (Fig 6).

We could have irrigated with chlorhexidine, but that would have caused staining. Instead, we placed tetracycline and hydrocortisone in the wound prior to temporary place-ment.

HEALING AND HOME CAREThe patient was scheduled to re-

turn one week later so that we could to work on incisal edge, function, and guidance.

We allowed 612 weeks for heal-ing. This time period during healing is excellent for perfecting the incisal edge position, functional guidance, and esthetic parameters. We then re-moved the provisionals, took master impressions, and reseated the provi-sionals. It is important not to allow more than ve minutes without sup-

porting the pontic site, as it will col-lapse.

The precise information on ex-act incisal edge position, lingual guidance, shades, shapes, and tooth lengths was then given to the labora-tory. The goal was for each lateral to be the same length (9.0 mm was de-termined to be the ideal length, but an additional 2.5 mm was needed to ll the pontic site). We had our lab-oratory make the additional 2.5 mm in pink porcelain (Fig 11). Therefore, even if there is any shrinkage, there will still be a 9.0 mm pontic visible

Figure 10: Suture tissue to provisionals to hold tissue from slumping.


CLINICAL TIP ELIAS

Figure 15: Full-face view after treatment.

Figure 14: Full-face view before treatment.

from an arms length away. The new bridge was then created and seated.

Home care for this procedure con-sists of a modied bass technique, brushing from the gums down to-ward the teeth and pontic; light oral irrigation; and ossing. It was impor-tant for the patient to realize that we had intentionally created a wound and that she had to treat it with care, always brushing downward toward the toothnever up and down or cross-ways.

SUMMARY The goal of the procedure is to

achieve horizontal symmetry of the gingival tissue (i.e., facial levels of the cuspids and centrals should be the same, and the laterals should be 1.01.5 mm more coronal).

When performed in accordance with the previously discussed crite-ria, this simplied esthetic edentu-lous ridge site development allows the general dentist to be in control

from start to nish. It is possible to create a cervical bulge horizontally and develop an ovate pontic that would make Mother Nature proud (Figs 12 & 13). Our patient came in thinking she wanted her six front teeth enhanced, but she left wanting 10. We both are better off (Figs 14 & 15).

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Acknowledgments

Special thanks to my staff and dental mentors: Dr. John Kois, Dr. Peter Daw-son and the Pankey Institute, Dr. Frank Spears, Dr. John Derango, Dr. Jack Tur-bill, and Dr. Bill Blatchford.

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References1. Tarnow DP, et al. Reforming the interprox-

imal papilla. J Periodontal 63:995996, 1992.

2. Kois JC. Altering gingival levels: the restor-ative connection. Part I: biologic variables. J Esthet Dent 6(1):39, 1994.

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