Periadantalagy2000, Printed in Denmark

Val. 11, 1996, 18-28 All rights reserved

Copyright

@ Munksgaard

1996 2000

PERIODONTOLOGY ISSNO906-6713

DAVID A. GARBER & MAURICE

A. SALAMA

Until recently, dentists' and the public's concept of dental aesthetics was necessarily limited to alterations of the teeth themselves. Dentists concerned themselves with changing the position, the shape and the color of the teeth -basically restoring missing units or enhancing those already present. For the most part the dentist was forced to accept the pre-existing relationship between the three components of the smile; the teeth, the gingival scaffold and the lips. Interestingly, the restorative dentist's concept of aesthetics varied considerably from that practiced by removable prosthodontists where, in the full denture set-up, they could not only select the most desirable shape and color of denture tooth concomitant with the patient's facial features but could position them in the optimal relationship with regards to the upper lip, the lower lip and the commissures of the mouth -thereby creating the desired ideal smile. The three basic tenets germaine to optimal aesthetics in removable prosthetics were not really a part of the restorative dentist's rules, as any changes in the pre-existing lip-tooth-gingival relationships were thought to necessitate longterm orthodontic therapy, often in combination with orthognathic surgery or aggressive periodontal procedures. Today much of this has changed; with the advent of soft tissue periodontal plastic procedures designed to enhance dentofacial harmony following the same basic tenets as those of the removable prosthodontist. The domain of periodontics has changed from being strictly a health service to one where smile enhancement has been brought to the forefront of treatment planning. The essentials of a smile involve the relationships between the three primary components:

.the teeth .lip framework .the gingival scaffold.

The teeth
The dentist is concerned with the color, the position, and the shape or silhouette form of teeth. The advent of adhesive dentistry has allowed literally an instantaneous change in the color, the shape and the position of teeth via bonding techniques such as porcelain laminate veneers and direct composite bonding.

The gingival

scaffold

The primary objective of periodontal therapy is to restore and maintain the health and integrity of the attachment apparatus. From an aesthetic perspective this is often not enough. An irregular gingival arrangement, despite being healthy, may strike a discordant note, and it may become desirable to establish a certain harmony and continuity of form to the free gingival margin. In its broadest sense, this would require that the gingival architecture for the two central incisors mimic one another. For the lateral incisors, one would like to see these gingival margins somewhat more incisally placed and, for the most part, bilaterally symmetrical. The cus-

I Table 1. Methods harmony

Surgery Additive

of developing

gingival

Orthodontics
gingival techniques

Resective gingival techniques

Extrusion Intrusion

pids, in turn, would have the free gingival margin at the same level of the centrallncisors and match ing one another. Extending distally, the tissues on the premolars would be somewhat coronally positioned (1,9). Periodontic plastic procedures, such as the basic gingivectomy, soft tissue grafting or the apically positioned flap, may be used to change the silhouette form of teeth and their relative proportion.

To develop this symmetry, both surgical and orthodontic procedures might be used (Table I).

Surgical

techniques

Additive techniques for augmenting gingiva have evolved from the early free gingival grafts through the many different forms of contiguous grafting. This would include pedicle grafts, connective tis-

Fig. 2. Postoperative view following semilunar graft displaying optimally developed gingival symmetry Fig. 3. Postorthodontic case showing excessivedisplay of gingival tissue below the inferior border of the upper lip. This is a caseof altered passive eruption, which should be differentiated from vertical maxillary excess.The short, rather squat teeth and hyperplastic tissue usually indicate an altered passive eruption case. Compare this with the postoperative result in Fig. 5 where the gingiva line falls just below the inferior border of the upper lip. Fig. 4. Periodontal probing showing the amount of tissue readily removed without compromising the biological width. A basic gingivectomy/gingivoplasty is therefore the procedure of choice. Fig. I. Preoperative view showing gingival recession of the maxillary left central incisor. This is the only apically notated gingival margin showing an overall lack of harmony. Fig. 5. The case following a gingivectomy showing normally proportioned teeth with a decreasein the amount of gingival display just below the border of the upper lip.

19

Garber

& Salama

sue grafting, semilunar techniques, coronally positioned grafts and guided tissue regeneration (Fig. 1, 2) (2, 3, 5, 7, 8, 10, 11, 13, 14). Resective techniques involve both the basic gingivectomy with or without gingivoplasty, as well as the full flap procedure incorporating osseous removal for crown lengthening of one or more teeth (Fig. 3-5). Orthodontic techniques The great advantage in moving teeth orthodontically is that the entire attachment apparatus, incorporating the osseous structure, periodontalligaments and the soft tissue components, moves together with the tooth. This means that, in health, during an extrusive movement, the free gingival margin will move coronally at the same distance as the incisal edge moves (Fig. 6) .Concomitantly, the osseouslevel will move an identical distance in the same direction. From an aesthetic perspective, this means that any intrusive or extrusive tooth movement can be used to develop symmetry of the gingival margin in a nonsurgical mode (Fig. 7-9). This is particularly useful when any form of restoration is necessary,as a surgical procedure invariably exposes root structure, where the mesiodistal dimension of the tooth is now considerably narrower (Fig. 10). In attempting to restore this, it becomes necessary to prepare the tooth and the tissue in such a way that an emergence profile can be developed from deep within the sulcus to avoid lateral horizontal extensions from the preparation line on the narrower root surface to the desired wider form of the restoration. If there is a dramatic diminution of the mesiodistal width of the root at the original gingival level versus the desired level, then orthodontics may be the treatment of choice.

The medium lipline in western culture is deemed to be the most attractive. When the patient smiles, a nominal exposure of 1 to 3 mm of gingiva from the most apical extent of the free gingival margin to the inferior border of the upper lip is exposed. Thus the teeth in their entirety are on display as well as the interdental gingival tissue and the border of free gingiva around the cervical area of the tooth.

The geometry

of harmony

Within the confines of th~ lipline, the remaining two components of the smile need to be arranged in such a way as to develop a c~rtain continuity of form, harmony and balance (Fig. 11). Classically, the prosthodontist would like to set up a denture so that the level of the gingival margins of the maxillary teeth parallel the form of the upper lip. The incisal edges of these maxillary teeth tend to follow the form of the lower lip. In a transverse dimension, the teeth should extend progressively posteriorly and laterally to fill the vestibule extending to the corners of the smile. In the composition of a beautiful smile, the form, balance, symmetry and relationship of the elements make it attractive or unattractive. An expanse of soft tissue should not be considered to be unaesthetic per se,but the way this soft tissue is arranged relative to the teeth and lips is of aesthetic concern. Continuity of linear horizontal form between the gingival expanse, the teeth and the upper lip is critical. Any asymmetry in this parallelism disturbs the sense of balance in the composition, disturbing the flow and results in an unaesthetic smile (Fig. 12). By this definition, a high lipline in itself may not be unaesthetic if these basic rules are followed. However, in today's mass media-influenced culture, many people consider eventhe slightest excessive display of gingival tissue -the "gummy smile" -unattractive. The gummy smile or high lipline case with an expanse of soft tissue can result from two basic problems:
.altered .vertical passive eruption maxillary excess.

The lips
The lips form the frame of a smile and as such, define the aesthetic zone. Liplines have classically been defined as being high, medium or low (6). In the typical low lipline, only a portion of the teeth are exposed below the inferior border of the upper lip. The high lipline shows a large expanse of gingiva extending from the inferior border of the upper lip to the free-gingival margin.

The definitive diagnosis of the problem determines the treatment. One of the clinical criteria in determining which of these two factors is responsible for a" gummy

20

Principles of aesthetic diagnosis

Fig. 6. Orthodontic clinical eruption sequence showing how movement of the left central incisor in an incisal direction results in a concomitant change in the level of the free gingival margin aswell as the osseouscrest Fig. 7. Preoperative smile showing compensatory overeruption of the maxillary central incisors as a result of a long-term anterior bruxing pattern. Note the unaesthetic change in gingival line as compared with the drape of the upper lip Fig. 8. Orthodontic appliance is in position showing the use of an intrusive archwire. The stainless steel archwire in a passive position lays in the manllary anterior vestibule. When ligated to the central incisor brackets, it exerts an intrusive force. Fig. 9. Postorthodontic result showing alignment of the gingiva on the two central incisors without harming the adjacent teeth. No surgery was performed in this situation. Compare with Fig. 7. Fig 10. Computer simulation showing restorative differential in preparation of caseswhere the gingival harmony is restored with orthodontic intrusion versus surgical crown lengthening

21

Garber & Salama

Fig. II. Computer simulation showing a smile with the various components in harmony. The incisal edgeline follows the form of the lower lip -while the line joining the tops of the free gingival margins form the upper lip. The teeth bilaterally extend to fill the vestibules to the commissures of the lips. Fig. 12.A preoperative maxillary anterior reconstruction in place showing the lack of harmony between the various components of the smile, the teeth, the lips, and the gingiva. The gingival line is diametrically opposed before the maxillary arch. Note the harmony developedin the postoperative case between the lips, the teeth, and the gingival scaffold. Fig. 13.Preoperativeview showing rather short, squat teeth in which the height is inadequate relative to the width. Periodontal bone-soundingvia the sulcus indicates that there is

a large dimension between the free gingival margin and the cementoenamel junction, as well as spacebetween cementoenamel junction and the osseouscrest for insertion of the biological width. The green line on the teeth is indicative of the preoperative level of the free gingival margin. Fig. 14. A gingivectomy was performed to elevate the level of the free gingival margin -developing a more proportion ate form for the teeth, aswell as removing an excessive display of gingiva below the inferior border of the upper lip. Fig. 15. Postoperative healing of the gingivectomy as well as orthodontic repositioning of the right central incisor without closing the diastema provides for bonding in equal amounts between the two central incisor without closing the diastema. Fig. 16. Preoperative view of smile showing short nonproportionate teeth as well as an excessive display of gingiva.

22

Principles of aesthetic diagnosis

smile " relates to the basic shape of the teeth. If the teeth appear to be somewhat short and squat meaning that the vertical dimension appears to be too short as compared with the horizontal dimension, the gummy smile is probably due to altered passive eruption. If, however, the silhouette form of the tooth appears to be normal and an expanse of tissue is exposed below the inferior border of the upper lip, this is probably due to an overgrowth of the maxilla in a vertical dimension or a vertical maxillary excess. In many situations, the gummy smile may be a combination of these two factors.

The

gummy .

smile

altered

passive

eruptIon
Altered passive eruption is an aberration in normal development where a large portion of the anatomic crown remains covered by the gingiva. This complicates developing dentofacial harmony for two dominant reasons: .The tissue being positioned coronally on the teeth results in a silhouette form that is unattractive. There is only a nominal degree of scallop to the free gingival margin, resulting in a tooth shape that is somewhat square instead of a more attractive elliptical or ovoid form. .The excess soft tissue tends to be displayed below the inferior border of the upper lip, complicating the desired relationship in that it makes a potentially medium lipline into a high lip line. Altered passive eruption has been classified into two distinct types (4). In type I, there is typically an excessive amount of gingiva, as measured from the free gingival margin to the mucogingival junction. In type II, there is a normal dimension of gingiva when measured from the free gingival margin to the mucogingival junction. Although these might appear to be clinically similar in that there is tissue extended over the coronal portion of the tooth, therapeutically the diagnosis between the two types is essential to determine the appropriate treatment modality. Type I can be further subdivided on an anatomical histological basis into sub-categories A and B. This subclassification depends on the relationship of the osseous crest to the

cementoenamel junction of the tooth. In subcategory A, the dimension between the level of the cementoenamel junction and the osseous crest is greater than 1 mm, which is sufficient for the insertion of the connective tissue fibrous attachment component of the biological width. In subcategory B, detected by the process of bone sounding via the sulcus, the osseous crest occurs in close proximity to the cementoenamel junction, thereby diminishing the space for the insertion of the connective tissue of the biological width. The biological width, which comprises the junction epithelium, the connective tissue fibrous attachment and the sulcus, is co~sidered to be an inviolate parameter. This implies that the biological width should not be impinged upon by restorative endeavors. Based on early necropsy studies, the average dimensions of the biological width were considered to be approximately 2.7 mm -about 1 mm for the junctional epithelium, 1 mm for the connective tissue attachment and 1 mm for the sulcus. In clinical practice, we have found this to be a more varied dimension often exceeding the 3 mm average. Treatment of type I -altered passive eruption The typical case of altered passive eruption type I A exhibits short, square-Iooking teeth and an expanse of gingiva below the inferior border of the upper lip. A needle probing of the osseous crest through the gingival sulcus detects a distance between the cementoenamel junction and the osseous crest that is sufficient to maintain the biological width (Fig. 13). A gingivectomy using scalpel, electrosurgery or carbon dioxide laser will readily remove this tissue. The tissue should be removed cervically in order not to compromise the interdental papillae. This procedure will result in a revised silhouette form for the tooth (Fig. 14) that is more elliptical and attractive and will resolve the unwarranted excessivedisplay of gingiva apparent during smiling (Fig. 15). Altered passive eruption -type I-B Diagnosis is confusing in this subcategory, as the clinical appearance is similar, with an excessive amount of gingiva from the free gingival margin to the mucogingival junction readily shown during smiling (Fig. 16). On bone sounding via the sulcus, it would appear that the osseous crest is at the

23

Garber & Salama

Fig. 17. The bone-sounding process viewed by making a submarginal incision, leaving the free gingival margin in place while elevating mucoperiosteal full-thickness flaps. With a probe in place, the dimension from the free gingival margin to the cementoenamel junction and level of the osseouscrest is evident. Fig. 18.The osseoushas been redevelopedapically with the form following and paralleling the rise and fall of the cementoenamel junctions typical of this genetic phenotype. Fig. 19. The flaps coapted and sutured in position just incisal to the cementoenamel junction Fig. 20. Following initial healing of the flap procedure, a gingivectomy/gingivoplasty is performed as part of the two-stage procedure using electrosurgery to fine-tune the harmony of the free gingival margin, ensuring the pres-

ence of interdental papillae and realigning the gingival margin optimally, not with the cementoenamel junction, but with the drape of the upper lip. Fig. 21. Postoperative early healing of the case following the second stage of electrosurgery. Compare with Fig. 16 and note the more proportionate teeth as well as the diminished amount of gingival display. Fig. 22. Lateral oblique view of a patient with vertical maxillary excessin combination with altered passiveeruption. The green line on the gingiva indicates the extent of the required gingivectomy to develop gingival harmony as well as optimal tooth proportion. The black lines on the incisal edgesdenote the tooth structure to be removed in cosmetic contouring to develop ideal embrasure form and incisal edgeline.

24

Principles of aesthetic diagnosis

The sounding with a probe tends to identify the more incisally positioned outer cortical plate. The proximity of the osseous crest to the cementoenamel junction requires surgical relocation of the soft tissue apically via reduction of the osseous crest (Fig. 18, 19) (1, 5) to allow for insertion of these fibers in a more coronal position followed by a concomitant apical positioning of the junctional epithelium and the sulcus. This ultimately results in the free gingival margin being positioned right at the cementoenamel junction. The surgical procedure, however, may require modification depending on the relative position of the upper lip to the cementoenameljunction (Fig. 20, 21). Altered passive eruption -type II In altered passive eruption type II, the pathognomonic short teeth are clinically evident, but the zone of masticatory mucosa is not excessive as in type I. This then requires reduction apically of the entire dentogingival complex, with or without osseous reduction, to aesthetically solve the aesthetic problem.

same level as the cementoenamel junction. This would seem to be contrary to the concept of the biological width, as the connective tissu~ fibrous at tachment cannot insert into the enamel and yet must be present (Fig. 17).Clinical and histological necropsy observations suggest that, in altered passive eruption type I- B, there is an added dimension buccolingually to the osseous form. This extra thickness to the osseous structure allows for an apical angulation of the bone crest from the gingi val aspect of the periodontal ligament side. Although periodontal connective tissue fibers normally run horizontally across the osseous crest extending from the cementum to the gingiva, in this form of altered passive eruption, the fibers run apically' parallel to this angular crest, allowing for insertion of the connective tissue fibers just apical to the cementoenamel junction in the cementum.

The gummy smile maxillary excess

-vertical

The gummy smile frequently results from a skeletal dysplasia (Fig. 22)I such as a hyperplastic growth of the maxillary skeletal base. This results in the teeth being positioned farther away from the skeletal maxillary base and a display of gingiva below the inferior border of the upper lip. Diagnosis in the high lipline case involving a vertical maxillary excessrequires ruling out the casesdue to a superim-

Table 3. Treatment of the gummy smile: altered passive eruption or vertical maxillary excess
Condition Altered passive eruption type I-B Treatment options Flap with osseous resection

Vertical maxillary

excess -degree

Periodontics Orthognathic

and restorative surgery

dentistry

Garber & Salama

26

Principles of aesthetic diagnosis

Fig. 23. The gingivectomy is performed with the CO2laser on the upper right side, but contrasted to the left side. This is done prior to any orthognathic surgery to give the surgeon a more precise guideline as to the degreeof impaction required during his procedures. Fig. 24. The patient following the orthognathic procedures. This depicts the patient with lips at rest showing a nominal amount of incisal edge as well as a full smile. The degreeof vertical translation of the lip between the rest and full smile is the required dimension of a tooth to eliminate any show of gingiva. This, however,may result in an excessively long tooth. The lip at rest is the limitation to vertical impaction for the orthognathic surgeon, as any further impaction will result in no show of incisal edge at rest and a more aged appearance for the patient. Here, following orthognathic procedures, there is still a show of gingiva below the inferior border of the lip in full smile view. Fig. 25. To eliminate this postorthognathic surgery show of tissue, the patient elected to have further periodontal surgery to lengthen the teeth -eliminating the gingiva. The green dot on the teeth is indicative of the cementoenamel junction to which the original gingivectomy was done. Now the osseousstructures redeveloped in a more apical level and the flap repositioned further apically to display more tooth structure. Fig. 26. Postoperative early healing showing the relocated gingiva line following bleaching of these teeth and cosmetic contouring of the incisal edgesabove the mandibular teeth. Fig. 27. A preoperative view of the completion of the orthodontic phase prior to orthognathic surgery. Fig. 28. The postoperative view following gingivectomy, orthognathic procedure, surgical crown lengthening, bleaching, and cosmetic contouring 5 years following completion of the case. Fig. 29. The implant site optimally developed showing a continuity of form of the free gingival margin, aswell as the three-dimensional reconstruction of the papillae and root eminence. Fig. 30. Postoperativeview of the lateral incisor and restoration in place. Note harmony with the rest of the natural teeth, but supported by the soft tissue reconstruction to make it indistinguishable from the adjacent dentition.

Table 4. Desirable traits of an attractive smile

Teeth

color position silhouette

shape

Gingiva

Lips

define the aesthetic zone three forms ofliplines: high, medium, and low the geometry of harmony gingival line follows upper lip contour incisal edge line follows lower lip form

position of altered passive eruption in combination with maxillary hyperplasia. These combined cases should first be treated for any altered relationship between gingiva and cementoenamel junction (Fig. 21). This results in the development of a more aesthetic tooth silhouette form and allows for more accurate diagnosis. Orthognatic procedures can take place to reposition the maxilla. The combined casesrequire for optimal treatment a multidisciplinary approach to treatment planning involving an orthodontist, a periodontist, an orthognathic surgeon and a restorative dentist.

The classification of vertical maxillary excess (Tables 2, 3) was developed to help determine the most appropriate treatment modality. The diagnosis relative to the degree of severity is predicated upon first treating the altered gingival display (removing the altered passive eruption component) and to develop a normal tooth form (crown form). Degrees of severity I, II and III are then determined by the amount of remaining gingiva displayed. The treatment modalities range from orthodontic intrusion alone through complex treatments involving orthognathic surgery, orthodontics, restorative components and periodontal plastic procedures. In vertical maxillary excess cases degrees II and III involving orthognathic surgery, the treatment planning relates to developing the relationship between the incisal edge and the lip at' rest. In some combination cases,the vertical translation of the lip from rest to its position at maximal smile may, in fact, exceed the normal length of a tooth crown. As such, patients must decide whether to accept a nominal display of gingiva below the upper lip and normal crown dimensions or to prefer an increased length of the crowns and no display of gingiva. It is critical in these casesto treat to the position of the lip at rest, as otherwise the surgeon may overimpact the maxilla, burying the incisal edge beyond the vermilion border of the lip -resulting in a dramatically aged appearance. In combination cases,the diagnostic procedural treatment is as follows:

27

Garber

& Salama

.First create an attractive silhouette form for the teeth developing normal anatomical form. This will remove any altered passive eruption component from the case,leaving only the vertical maxillary excess or skeletal dysplasia evident. It also gives the surgeon a definitive guideline as to the potential lip-to-tooth relationships and the amount of impaction necessary (Fig. 23). .The orthognathic procedure is limited by the incisal edge to lip at rest position. A minimum of 2.0 mm of the incisal edge of the teeth should be showh at rest; that is, the maxilla is not to be impacted beyond this level (Fig. 24). .Following orthognathic impaction, any remaining gingival display may be removed as determined by the patient's subjective needs by using a periodontal flap with osseousresection accomplished in a two-stage approach. The flap should first be replaced and sutured at its original position, and following initial healing, sculpted with electrosurgery to develop optimal silhouette tooth form, thereby retaining the interdental papillae (Fig. 25-28) . Diagnosis for total dentofacial aesthetics today involves a comprehensive knowledge of the desired smile composition as determined by its three basic elements: the teeth themselves, the gingival scaffold and the lip framework. Developing these relationships about the three basic tenets of a beautiful smile incorporates:
.adhesive dentistry .a multidisciplinary .implants.

Summary
As the public becomes increasingly concerned with looking younger and healthy, aesthetic considerations will become increasingly more relevant in dental treatment planning. As such, dentists must define the basic tenets of an aesthetic smile extending that vision beyond simply "pretty teeth " to a concept whereby total dentofacial harmony is developed. Aesthetics is not simply a matter for restorative dentists -it uses restorative dentistry as one of the disciplines, but it is about beauty. The same rules that apply for a denture are therefore pertinent for crown and bridge and/ or implants and must be applied in all aesthetic endeavors.

References
1. Allen E~ Use ofmucogingival surgical procedures to enhance esthetics. Dent Clin North Am 1988: 32: 307-330. 2. Eernimoulin I~ Luscher E, Muhlemann HR. Coronally repositioned periodontal flap. Clinical evaluation after one year. I Clin Periodontol1975: 2: 1-13. 3. Cohen D, Ross S. The double papillae flap in periodontal therapy. I Periodontol1968: 39: 65-70. 4. Coslet IG, Vanarsdall RL, Weisgold A. Diagnosis and classification of delayed passive eruption of the dentogingival junction in the adult. Alpha Omegan 1977: 70 (3): 24-28. 5. Garber DA, Rosenberg ES. The edentulous ridge in fIXed prosthodontics. Compendium 1981: 2: 212-224. 6. Goldstein RE. Esthetics in dentistry. Philadelphia: I.E. Lippincott Co., 1976. 7. Gottlow I, Nyman S, KarringT, Lindhe I. Treatment oflocalized gingival recessions with coronally displaced flaps and citric acid. An experimental study in the dog. I Clin Periodontol1986: 13: 57-63. 8. Langer E, Calagna L. The subepithelial connective tissue graft. I Prosthet Dent 1980: 44: 363-367. 9. Lombardi RE. The principles of visual perception and their clinical application to denture esthetics. I Prosthet Dent 1973:29:358-382. 10. Nabers CL. Free gingival grafts. Periodontics 1966: 4: 243-245. 11. Pennel EM, Higgison ID, Towner TD, King KG, Fritz ED, Salder IF. Oblique rotated flap. I Periodontol 1965: 36: 305-309. 12. Seibert IS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. II. Prosthetic/periodontal interrelationships. Compendium 1983: 4: 549-562. 13. Sullivan HC, Atkins IH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics 1968: 6: 121-129. 14. Sullivan HC, Atkins IH. Free autogenous gingival grafts. III. Utilization of grafts in the treatment of gingival recession. Periodontics 1968: 6: 152-160.

integrated approach

When implants form part of the treatment plan, the basic tenets relevant for removable prosthodontics and conventional restorative work remain identical. The high lip line is thus the most difficult for clinicians to deal with, because it exposes to the onlooker any restorative work. In any implant case,the basic arrangement of the various components of the smile -the teeth, the lips, and the gingival scaffold -must first be made harmonious prior to developing the individual implant receptor sites with the identical configuration to conventional teeth; that is, an interdental papilla on each side with a rise and fall to the free gingival margin in between and the illusion of a root eminence -all in harmony with the contralateral teeth (Fig. 29, 30) (Table 4).

28