Prosthodontics

A review of esthetic pontic design optionsDaniel Edelhoff, Dr med dentVHubertus Spiekermann, Prof Dr med Dr med denlVMuratYildirim, Dr med dent'

Advances in the field of restorative materials allow a lost tooth to be replaced by artificial tooth structurethat is virtually indiscernible (rom the original. However, in fixed partial dentures the standards for the pon-tic area and the adjacent soft fissue in the maxillary anterior region have increased in partioular. The pontiodesign in this region is primarily influenced by esthetic and phonetic considerations. Local defects of thealveolar ridge often complioafe restorative measures. Treatment methods proposed to solve this probleminvolve modification of the pontic design and prefreatment of the recipient site for the pontic. This article re-views the different clinioal and technical options that are available for designing esthetic and funcfionalpontics for the anterior region. (Quintessence ini 2002:33:736-746)

Key words: all-ceramic gingival mask, gingival shade guide, ponfio design, ridge preservation, soft tissueconditioning

The restoration of anterior edentulous areas withBxed partial dentures (FPDs) presents a particularchallenge for the clinician. Because of their ease of useand favorable long-term results,' conventional FPDsrepresent the most popular treatmetit measure today. 'In these restorations, the pontic must fulfill the eomplexroles of replacitig the function of the lost tooth, achiev-ing an esthetic appearanee, enabling adequate oral hy-giene, and preventing tissue irritation. In addition, thepontic must meet certain structural requirements to en-sure the mechanical stability of the restoration.-*

Numerous proposals for selection of pontics, someof which involve contradictory design options, havebeen presented in the past. In most cases, the rceom-mended pontic designs are based on empirically devel-oped opinions.'-'Although pontics in the posterior re-gion are primarily designed to satisfy functional andhygiene requirements, those in the anterior regionmust fulfill certain esthetic criteria.

'Associate ProfessOi, Department o( Prostiiodontics, Sctiool of Dentistry,University of Aactien, Aachen, Germany.

'Professor and Chairman, Department of Prosthodontics, School ofDentistry, University of Aaciien, Aachen, Germany

Reprint requests; Dr Daniel Edelhoff, Associate Professor, Department ofProsthodontics, School of Dentistry, Medical Center, University of Aaciien,52074 Aachen, Germany E-mail' dedeilioff@ijkaachen.de

This article has been translated from "sthetische Gestaltung desBriJckenzwischengliedes." Die Quintessenz 2[)[)[1;51:233-245.

The extraction of a tooth in the anterior regionoften involves simultaneous local alveolar ridge defi-ciencies.'"" In the past, primarily prosthodontie meth-ods were used to eompensate for these defects.'^ As aresuh of the recent advances in periodontology andthe requirements of modern implantology, a numberof techniques have been developed to preserve thealveolar ridge and surgically rebuild defective sites.''-'*Today, these techniques are also used in crown-and-bridge prostheties for ridge preservation before' ' " ordirectly after extraction,^'-^^ as well as for buccalcrown-lengthening procedures and ridge augmenta-tion procedures, - ^ leading to an increased frequencyof satisfying ridge contours.

In addition, the basal contour of the pontic in par-ticular has been modified to enhance esthetics andfunction in the anterior area.''''^ Long-term provi-sional restorations arc an integral part of this stage ofthe treatment.'^

In situations where surgical pretreatment is unde-sired or contraindicated, various prosthodontie tech-niques are available to compensate for lost papillae oralveolar ridge defects, sueh as adjustment of the con-tact point,^' reduction of the embrasure space to cre-ate a papillary illusion, and use of pink ceramics.' "''"

The purpose of this article is to provide a review ofthe clinical and technical options that are available forfabricating esthetic pontics and to illustrate the practi-cal procedures.

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PONTIC DESIGN OPTIONS

A large number of studies have been publisbed in den-tal literature on the subject of tbe ideal pontic design.The terminology used in this field is not always stan-dardized- The designs range from conical pontlcs,which are placed directly in the extraction socket,-" topontics that require large ''-''- or very smalH^ receptorsites, to hygienic (sanitary) pontics, which do notcome in contact with the soft tissue at all.'

The majority of researchers studying pontic designassumed that inftammation of the alveolar mucosaunder pontics is caused by the accumulation of plaqueon tbe basal surface of the pontic.''-+^ As a result,glazed ceramics were believed to be the material ofchoice for pontics,-" ' * because of their low rate ofplaque accumulation. Podshadley^ and Stein,-* how-ever, refuted this assumption in independent studies;they did not find any histologie differences in the softtissue reactions to pontics fabricated of gold alloys,resin, glazed ceramics, or unglazed ceramics.

Stein-i also demonstrated that the shape of thepontic and the orai hygiene measures of the patient,rather than the material itself, represent the most sig-nificant factors to be considered in the prevention ofinflammation. To preserve the health of the soft tissue,therefore, a number of autbors have advocated the useof pontics with a well-polished and smooth, convexstirface that makes pressure-free-' or minimum-pres-sure" contact with the alveoiar ridge in a smallarea. ""

In a retrospective study of partially edentulous pa-tients, 91% of the edentulous anterior sections of thejaw exhibited alveolar defects of various extents.'" Asuitable classification for alveolar ridge defects wasprovided by Seibert" (Table 1)- The combined defect(Class III) occurs most often.'""

In a survey conducted among patients witb FPDsin the maxillary anterior region, 20% of the respon-dents were dissatisfied with the appearance of theirdenture, and 40% complained about entrapment offood particles." On the whole, pafients with horizon-tal defects (Class I) reported greater subjective satis-faction with their restorations than did those patientswhose ridge defect included a vertical component(Classes 11 and III).

Frequently, the contour of the alveolar ridge rsorp-tion requires that a pontic with an unsuitable concavebasal configuration be used in tbe area that comes incontact with the alveolar mucosa.-"* The convex basalsurface should enable tbe dental floss to make contactwith all the surfaces. This type of pontic design, how-ever, cannot always be used without allowing for someesthetic (high smile line), phonetic, or functional(trapping of food particles) restrictions.

TABLE 1 Classification and incidence of maxillaryanterior ridge defects*

Ciass Definition

No delectsHorizontal loss ot tissue withnormai vertical ridge height ^Vertical loss ot tissue withnormai horizontal ridge heightCombination ot Class I and II:loss ot normal height and width=

'Classilicafmn ot anterior ridge defects, as described by Seibert.'" andthe incidence of Ihese defecls in the anterior rnaiilla. as reported byAbfams eta^'and Hawkins etal."

Conical pontic

In a study by Reichenbacb,-" tbe conical pontic wasused to prevent the extraction site from collapsingafter the removal of a tooth and to imitate the naturalemergence profile of the tooth (Fig 1). After extendedperiods of service, however, the adjacent soft tissuetended to become inflamed, and the alveolar bone re-sorbed.^''" Based on tbe information available today,these reactions probably occurred because tbe ponticdid not allow adequate oral hygiene. This method isstill used in a modified application, the immediatepontic technique,^'^^ to maintain the topography ofthe alveolar ridge after the extraction of a tooth.

Hygienic pontic

The hygienic pontic fitlfills the prerequisites for main-taining a healthy periodontium, because it does notcome in contact with the underlying soft tissue andprovides easy access for oral hygiene aids to clean theabutment teetb.^ The gap between tbe pontic and tbealveolar ridge, bowever, is large enougb to trap foodparticles and to allow the tongue to enter. Because offunctional and, above all, the esthetic and phoneticdrawbacks, this type of pontic sbould be used only inthe posterior region of the mandible.

Saddie pontic

The saddle-shaped ponfiC^ achieves highly esthetic re-sults, if the alveolar ridges are free of defects. Theemergence profile, which is very similar to that of thenatural tootb, ensures that no palatal gap forms,which could cause phonetic problems (Fig 2).Trapping of food particles is not expected, because thepontic seamlessly adapts itself to the alveolar ridge.Today, however, it is generally agreed that tbis tech-nique should not be used, because tbe large concave

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Fig 1 Conical pontio. The conical pontic is Fig 2 Saddie pontic. The esthetics, tune- Fig 3 Ridge iap pontic. This type of ponticplaced in the extraction site. This type of tion, and phonetics achieved with this typepontic is no ionger used, because it proved ol pontic are highiy satisfactory. The risk thattoo difficult to clean Furtheimore, rsorption tood particies wiil become trapped is mini-ot the alveciar bone occurred too frequentiy. mai. Nevertheiess, hygiene procedures are

iimited by the concave design of the pontic.

achieves the same esthetic resuits but iseasier to ciean (see Fig 2). The formation ofa paiatai gap, however, may result in pho-netic probiems and increased food im-pact ion.

contact area witb tbe alveolar ridge prevents tbe re-moval of adberent plaque," ^ In clinical recalls, cbangesin tbe soft tissue-" and severe inflammation, includingulcration,'" were associated with 85% of the saddle-shaped pontics.

Ridge iap pontic

A reduction of the surface area (ridge lap pontic) doesnot significantly improve hygiene underneath the pon-tic, because the basal contour remains concave,"*' un-suitable to provide a tight contact to the dental floss(Fig 3).

Modified ridge lap pontic

The modified ridge lap pontic is the most popular typeof pontic (Fig 4), The convex basal surface, whichrests on a small area of the alveolar ridge, fulfills therecommendations made in the dental literature withregard to hygiene procedures and prevention of irrita-tion of the underlying soft tissue,'' '*^ Frequently, how-ever, the contour of the alveolar ridge requires that acompromise be made in the design to prevent the im-pairment of esthetics, function, or phonetics,^^ In par-ticular, the vertical loss of dimension of the ridge, oc-curring in the majority of the patients, can causedifticulties in this respect. If this vertical loss of dimen-

sion is compensated for by tbe restoration, the ponticslook unnaturally long (long pontic design) and can heassociated with functional problems: Because of thelack of interdental gingiva, open interproximal spacesappear, increasing the exchange of saliva and air andpresenting a higher risk of food impaction,*"

Ovate pontic

In contrast to the classic requirements for pontics,which suggest the importance of pressure-free contactover a small area,*' the ovate pontic cornes in contactwith a larger area of the underlying soft tissue'''" andapplies light pressure (Fig 5), This design has beenfound to produce bighly esthetic results following suit-able pretreatment of tbe alveolar ridge.

Because this design produces an emergence profilethat looks very similar to that of the natural tooth, itfulfills ideally the esthetic and functional requirementsof a pontic for the anterior region. This type of ponticdesign, however, requires an adequate amount of softtissue, which has to be sculpted accordingly. Varioustechniques are available for this purpose, ranging fromcontrolled regeneration directly after the extraction ofthe tooth (immediate pontic technique) - ^ to plasticsurgery (gingival grafting), '" which is accompaniedhy tissue conditioning in the course of the subsequentprosthodontic treatment,'^

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Fig 4 Modified ridge iap pontic The mosthygienic pontic form lor the anterior region.In certain applioations, the design ol thebase has some limitations, resuiting in es-thetic and tunctionai shoricomings.

Fig 5 Ouate pontic Because ot its particu-lar interaction with the soft tissue, this poniioproduces outstarrding results with regard toesthetics, funotion. and phonetics. The riskot food impact ion is minimal.

Figs 6a and 6b Ouate pontic The ponticappears to emerge trom the gingiva like anaturai tooth.

Tbe large pontic-ridge contact site requires tbat thepatient be particularly well motivated to conduct oralhygiene procedures.""' The patient's compliance, there-fore, must be evaluated during the pretreatment phase.If all the mentioned prerequisites are fulfilled, thispontic design is capable of satisfying the highest of es-thetic standards- It is particularly suitable for patientswith a high smile line (Figs 6a and 6b). Hygiene proce-dures are easy to perform because of the convexity ofthe base (Fig 7).

TREATMENT PLANNING

Before beginning treatment, study casts are fabricatedand radiographs are taken of the abutment teeth and

Fig 7 Ovale pontic. The ovate pontic aliows thorough piaque re-movai because of the convex shape

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Fig e Soft tissue conditioning. Foiiowing a 6-weeK healingpfiase, the soft tissue can be contoured by relining the base of theiong-term provisionai restoration.

Fig 9 Soft tissue ccnditioning. Soft tissue situation after 6 rrionthsof controlled pressure applied by the long-lerm provisionalrestoration. The vertical shaping of the pseudopapiliae has beensuccessfuliy completed

the edentulous parts of the arch. This information willhelp to evaluate the quality of the abutments and to an-alyze the positional relationship of the pontic to thealveolar ridge, the abutment teeth, and the gingiva, aswell as to assess the size of the edentulous space. Thecementoenamel unctions of the abutment teeth orthose of the adjacent teeth are used as a vertical refer-ence point. For esthetic and functional reasons, the newtooth should be harmoniously integrated into the row ofteeth both horizontally (lip support) and vertically.*'*

The following aspects of the dentition should beclinically evaluated: the line, color, and texture of thegingiva; the lip line in repose and during speaking;and the height of the smile line. The position of the lipline has a significant influence on the selection of thedesign of the pontic. If the contact area with the alve-olar ridge is visible when the patient speaks or smiles,special esthetic considerations must be observed.

To achieve esthetically pleasing results, the tooth tobe restored sbould emerge from the soft tissue of thealveolar ridge at the same level as the cementoenameljunction of the adjacent teeth. The surgical treatmentrequired to generate this emergence profile is deter-mined by the type of alveolar ridge defect."" The classi-flcation proposed by Seibert" sbould be used for tbispurpose (see Table 1).

The ideas and expectations of the patient shouldbe given special attention during the planning phase.

PROSTHETIC SOFTTISSUE CONDITIONING

Generally, the residual ridge soft tissue that is to bethe recipient site for the ovate poritic has to be shaped

by gingivoplastic or prostbodontic site-conditioningmeasures. In this treatment phase, relineable long-term provisional restorations play an important role indetertnining the contact area of the pontic and in re-modeling the soft tissue recipient site. In three-unitFPDs, the pontic should be in tbe middle between thetwo adjoining papillae. Careful planning is necessaryfor the preparation of several adjacent pontic sites(middle line). If tbe alveolar ridge is narrow, the con-tact area can be moved labially.

For further shaping of the soft tissue, the basal sur-face of the long-term provisional pontic is slightlyroughened with diamonds or by air abrasion.Subsequently, a ligbt-curing, low-viscosity resin compos-ite is used to build the pontic up in small increments(Fig 8).

Tbe FPD is tried in to evaluate whether the residualridge soft tissue must be additionally reshaped withlarge, coarse-grit diamond balls (Fig 9). The pontic-sidcd crown area can also be built up in a convexshape (half-pontic design) to support the interproximalsoft tissue. The correct amount of pressure is applied tothe newly developed tissue if the blood circulation re-turns to normal" in the anemic zone after 5 minutes oftry-in under pressure (biting on cotton rolls). Finally,the built-up base is polisbed and the provisionalrestorations are placed with a temporary cement.

The aforementioned measures are repeated at inter-vals of 2 weeks until the soft tissue contour has devel-oped satisfactorily and pseudopapillae have formed(Fig 9). The long-term provisional restoration shouldbe used for a time period of at least 6 to 12 months.After this time, the fine adjustment phase, in whichthe functional and esthetic aspects of the restoration

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Fig 10 Fabrication of the ovate pontic Thebase of the framework is built up with self-curing resin during tbe try-in procedure, ac-cording to the guidelines established duringsoft tissue conditioning by the long-termpro^'isionalrestoration.

Fig 11 Fabrication of tiie ovate pontic.Final relining is carried out with a medium-viscosity polyether for the correct transfer ofthe soft tissue situation to the master cast.

Fig 12 Section ot a prefabricated gingival shade guide iormetal-ceramio veneering materials.

Fig 13 Local alveolar lidge defects masked with pink ceramicveneering materials piacecf en the pontics of an anterior FPD.

are worked out with the patient, should come to anend. Furthermore, the condition of the soft tissueshould be stable (see Fig 9). An anatomic elastic im-pression of the clinically proven provisional restora-tions provides the dental technician with importantinformation about the design of the permanentrestoration.

Because the newly created pseudopapillae tend tocoUapse when the provisional restoration is removed,information about the condition of the soft tissue ofthe pontic site cannot be properly transferred whenimpressions are taken of the abutment teeth. This in-formation, therefore, is gained when the bridge frame-work is tried in. For this purpose, the basal area of theFPD framework is built up with a self-euring acrylicresin, as described for the modification of long-term

provisional restorations (Fig 10), ^ Finally, this area isrelined with a medium-viscosity polyether (Fig 11). Totransfer the soft tissue situation to the master cast, theplaster is removed in this area and replaced with atooth-colored silicone material.'"

GINGIVA-COLORED CERAMICS

if augmentative measures are contraindicated or unde-sirable, small alveolar deficiencies and missing papillaecan be reconstructed by restorative measures," First,the exact shade of the gingiva has to be established.This ean be accomplished with special gingival shadeguides that are supplied with the different commer-cially available pink veneering materials (Figs 12 and

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Fig 14 Aii-ceramic gingival masks. The masks are made ot apressed glass-ceramic, which is subsequenliy customized withstaining materials.

Fig 15 Ail-ceramic gingivai masks. Finai situation after the adhe-sive placement ol the gingivai masi

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Figs 16a and 16b Lateral view of two permanently piaced ail-ceramic anterior FPDs in the maxilla(lett central inoisor to lett canine and right canine to right central incisoi). The contour ot the pontiosreplacing the lett and right lateral inoisors is oval (ovate pontic design).

Certain guidelines for this technique have to becarefully followed, including the use of a long-termprovisional, which has to be modified several timesduring tbe first montbs after tootb removal," Besidescase reports, very few scientific data are available sofar to indicate tbe long-term stability of tbe precondi-tioned soft tissues.

When conventional tecbniques were used for tootbremoval, 91% of tbe edentulous anterior sections oftbe jaw exhibited alveolar defects of various extents,'"In recent years, plastic surgical methods for the aug-mentation of local alveolar defects have greatly im-proved the chances for outstanding esthetics of ante-rior fixed partial dentures.-'"

When surgical approaches are used to develop therecipient site of the ovate pontic, primary and sec-ondary shrinkage of the grafts is an important issue.Depending on the thickness of the graft, volumetricshrinkage ranging from 25% (thick) to 450/0 (very thin)has been reported.''' Mormann et a l" stated tbatsbrinkage was completed in 28 days; Seibert" foundthat the greatest amount of shrinkage appeared to takeplace within 6 weeks after the surgical procedure.

As an integral part of the treatment, the ridge con-tour achieved by tbese tecbniques bas to be remodeledas a recipient site for an ovate pontic, A suitably con-cave ridge contour is usually generated by tbe applica-tion of mild pressure to the soft tissue by a relineable,long-term provisional prostbesis as described earlier.Apart from numerous case descriptions, very few sci-entific data have been publisbed about tbe long-termbebavior of augmented ridge sections and their rela-tionship with the restoration.

In contrast to traditional guidelines, extended con-tact of the basal pontic contour with the soft tissue isestablished to create a suitable emergence profile. Theapplication of pressure to the soft tissue has to be ad-justed carefully to avoid any unfavorable biologic re-

Fig 17 Orai hygiene procedures con-ducted on an ovale pontic.

sponse, Cavazos'" reported that mild pressure appliedto the residual ridge tissue, created by an 0,25-mmovercontour of the pontic, would not aftect the biologicresponse, altbougb an overcontour of 1,00 mm resultedin increased infiammation of tbe residual ridge,

Tripodakis and Constantinides'"' found that hyper-pressure of the pontic causes morphologic modifica-tions of the underlying soft tissue, resulting in a his-tologically thinner epithehal layer and shorter retepegs. However, no signs of infiamtnation were foundwhen the patients flossed underneath the convexpontic. Instructing patients in the correct use of oralhygiene procedures is therefore an integral partof the treatment (Fig 17). If these measures areneglected, inflammation of the soft tissue of the resid-ual ridee is i

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The morphologie relationship hetween the soft tis-sue and the underlying bone contour is an importantprerequisite for a stable long-term result, Tarnow etaP' showed that the presenee of the interproximalpapilla is closely related to the distance between theerest of bone and the contact points of two adjacentteeth. At the maximum, this distance ideally should be5 mm. These findings confirm the hypothesis that theunderlying bone contour supports the soft tissue con-tour, Jemt ^ observed, in a retrospeetive study of sin-gle-tooth implants, that the majority of the papillae re-covered spontaneously during the 1- to 3-year clinicalfollowup by the effect of maturation.

Because no reliable seientifie data are available sofar, long-term provisional restorations should be em-ployed for at least 6 to 12 months to ensure soft tissuestability and to increase the predictability for the finalrestoration.

If augmentative measures are contraindieated orundesired, prosthodontic solutions should he used tocompensate for the alveolar ridge defieieney. Thesemeasures compensate for the ridge defcet with tooth-colored pontics, resuiting often in an unfavorably longpontic design.-"* Better esthetics are aehieved if the de-fect is covered with pink ceramic masks or a remov-able flexible gingival prosthesis made of silicone mate-rial. The latter option, however, inereases the risk ofplaque accumulation and the silicone prosthesis has tobe replaced on a regular basis, because the material isaltered by the oral environment. Some patients feeldiscomfort associated with gingival prosthesis, becauseof an unfavorable foreign body sensation.

Because the described method entails more exten-sive treatment than that required for the plaeement ofconventional fixed partial dentures, excellent patientcompliance is needed throughout the treatment andpostpiacement periods. The ideas and expectations ofthe patient should be given special attention duringthe planning phase and throughout the treatmentprocedure.

Further clinical studies are needed to focus on thelong-term prognosis of the alveolar ridge preservationtechniques, as well as on the long-term stability ofridge augmentations and their relationships with therestoration.

CONCLUSION

The following conelusions can be drawn for estheticpontie design in the anterior region:

1. Procedures for the preservation of the alveolarridge contour as well as for the augmentation ofridge defects are a promising alternative to the

purely prosthodontic solutions. An integral part ofthis treatment is the use of a relineable long-term-provisional prosthesis.

2. Surgical proeedures are particularly suitable for pa-tients with a high smile line and a defect with a ver-tical component. They can be combined with surgi-eal implant measures, if implant-supported FPDsare planned.

3. The presence or development of an adequateamount of soft tissue allows the use of an ovatepontie. Because of its partieular interaction with themucous membrane, outstanding esthetic and func-tional improvements are achieved.

4. The extensive treatment procedure requires closecollaboration witb tbe patient. The compliance ofthe patient includes meticulous hygiene proceduresin the postplacement period,

5. A lack of oral hygiene measures and inadequate hy-pe rpressure will inevitably lead to inflammation un-derneath the pontic.

6. If augmentative measures are contraindieated orundesired, prosthodontic solutions should be usedto compensate for the alveolar ridge deficiency.These measures usually involve the use of pink ce-ramics.

ACKNOWLEDGMENTS

The aulhor.i would like to thank Mr Andreas Rubben, CDT, and MrVolker Weber. MDT, Aachen, Germany, for the prosthdornic work.

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746

Mastering DentalPhotograptiyWolfgang Bengel

Images are funda-mentei in the day-to-day practice of den-tistry. They serve asdocumentation o den-tal procedures and asforensic evidence, andthey play an essentialrole in dentist-patientcommunication, pro-viding the basis forpatients' expectationsfor treatment. How-ever, many dentists,daunted by modern

photographic technology, do not realize thefull potential of imagery in their practices.

This book, written by an experienced dentist andleader of numerous photographic seminars, offerspractical insights, instructions, and tips that will en-able any dental practitioner to achieve excellence indental photography. In more than 500 photos, thebook provides examples of high-quality results andthe steps needed to achieve them. Covered topicsinclude conventional and digital photography; tech-niques for various forms of clinical photography;production of slide series; and archiving,

270 pp; 516 illus (471 color); ISBN 3-87652-383-4;US $98

Contents Fundamentals of Photography Camera Systems Appropriate for Dental Photography Perioral and Intraoral Photography Portrait and Profile Photography Photographing Objects for Dentistry and Dental

Technology Photography of Dental Casts Print Reproduction Reproduction of Radiographs Slide Reproduction Making Presentation Slides Storing and Archiving Your Photographs Digital Photography Intraoral Video Systems: Selection and Lise Legal Considerations

To OrderCall toll free 800-621-0387

or Fax 30-682-3288Website www.quintpub.cam

E-mail service@quinfbook.com

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