implant | EXCELLENCE

Gingival replacement in the

aesthetic zone with implant cases:
a last resort or a planned approach?
By David B. Dunn, BDS (Hons), FRACDS, FPFA

A
pproximately 80% of the
population display part
of their gingivae when
smiling and this is even
more so with females. With
tooth loss, we see osseous resorption in
an apico-palatal direction, i.e. vertical and
horizontal resorption and concomitant
with this, the loss of three-dimensional
If the option
soft tissue volume. The alveolar crest or
for prosthetic ridge effectively moves lingually towards
gingival the palate with a narrowing or short-
replacement is ening of the perimeter of the dental arch,
planned from resulting in reduced mesio-distal space
available for any future restoration.
the beginning
As American prosthodontist, Dr Peter
of treatment, Whorle states, tissue is the issue, but
in other words, bone sets the tone. In other words, when
using a proactive the bone goes, the soft tissue follows! The
approach, the restorative dentist and ceramist are then
at a crossroads as to whether they com-
aesthetic results
promise lip support and the aesthetics of
are generally the case by modifying the tooth alignment Figures 1-2. Patient referred following implant failure and
significantly and anatomy to compensate for the defi- implant re-placement with an Astra implant at 11 and 21
better... ciencies, or look to undertake osseous and with a temporary crown in situ at initial consultation. Patient
gingival grafting in an attempt to recreate understandably unhappy with appearance, especially missing
the ideal hard and soft tissue anatomy for mesial papilla of 12 and to lesser extent, mesial papilla of 11
a more ideal restoration. and long tooth.

122 Australasian Dental Practice March/April 2014

 implant | EXCELLENCE

Figures 3-4. Significant loss of labial volume of hard and soft tissue around implant at 11, both vertically and horizontally. Negative
space issues caused by missing papillae mesial and distal to tooth 11.

Figure 5. Pre-treatment comparison between left and right sides.

The overall aesthetics of the gingival
apron around teeth is critical to the aes-
thetic outcome of any tooth replacement
implant therapy. Many researchers such
as Frauhoffer have evaluated the impact
of the soft tissue parameters on the overall
aesthetic result of implant restorations and
several have proposed assessment criteria
based upon multiple determinants such
as papilla height; papilla volume; zenith
position; gingival colour; gingival height;
horizontal deficiency; etc (with a score out
of 14 based upon seven criteria), whilst
others have advocated a combination score
of both pink aesthetics and white aesthetics
(PES/WES; the highest possible combined
score is 20.) In the overall context, gin-
gival aesthetics are just as important as the
tooth replacement aesthetics!
Whilst in the single tooth situation, often
the interproximal bone on the approxi-
mating teeth is maintained to support and
maintain the papillae, the aesthetic defect
is then seen more as a vertical and hori-
zontal soft tissue deficiency resulting in a
long tooth and over-contoured cervical
emergence. The zenith position of the gin-
gival margin is also distorted. However,
with loss of interproximal bone on one or
both approximating teeth and hence loss
of interdental papillae, this can be then
seen as a combination defect involving
papilla deficiency as well as a vertical and
horizontal defect.
The even greater challenge for aes-
thetic prosthodontic implant rehabilitation
occurs in the multiple tooth loss situation,
especially those lacking symmetry across
the arch such as the missing maxillary
central and lateral incisor and possibly
canine teeth. In this situation, with a
smile display exposing the gingival mar-
gins of the anterior maxillary teeth, there
can then be made a direct comparison
with the corresponding contralateral
side gingival-tooth relationship, thus
highlighting the gingival deficiency in
three dimensions.
Traditional surgical
approaches for hard and soft
tissue replacement
W hilst implant dentistry has indeed
evolved from implant placement
being based upon where the bone is
to being restoratively driven, whereby
the clinician establishes the ideal three-
dimensional anatomy of the definitive
restoration prior to implant placement,
this requires, in the majority of cases, site
development by way of both bone and soft
tissue augmentation.
Unfortunately, the surgical proce-
dures required for this, which are often
multiple, require significant experience
and education, a high skill level and a
compliant and committed patient. And,
despite the best of intentions, the reality
is that many can still fall short in devel-
oping an ideal site, especially with regard
to vertical augmentation and papillary
replacement/development.

March/April 2014 Australasian Dental Practice 123

implant | EXCELLENCE

Figure 6. Initial DSD

analysis for pink
replacement and tooth
shape modifications.

Figure 7. Final preparation for ceramic veneers on 22 and 12 Figure 8. Cementation of ceramic IPS e.max veneers on 12 and
and crown on 21 with fixture level impression at 11. 22 with Variolink Veneer (Ivoclar Vivadent). Final try-in of IPS
e.max crown on 21 and screw-retained implant crown on 11.

The compromised result is evidenced
with gingival deficiency both vertically
and horizontally and negative space issues
with regard to papilla loss. So despite
great efforts from both a surgical and
prosthodontic perspective and indeed the
patient with regard to pain, discomfort
and time, the end result can often be very
disappointing. In most cases, prosthetic
gingival replacement is not considered in
the initial diagnosis and this solution is
more often seen as last resort.
We must also appreciate that many
patients may not wish to undergo multiple
surgical procedures... whether that be based
upon patient psychology, time, cost, age or
medical contraindication, etc. Multiple sur-
gical procedures including both bone (such
as block, particulate, GBR, distraction
osteogenesis, BMPs, and/or orthodontic
extrusion) and soft tissue grafting (such
as connective tissue, allografts, etc) are
required with associated increased costs,
time and morbidity. Whilst horizontal
augmentation alone is quite predictable,
vertical augmentation is much more diffi-
cult and less predictable and mostly, these
challenging cases require both vertical
and horizontal augmentation.
In multiple implant cases or mul-
tiple tooth replacement cases, where the
replacement of the interdental papilla is
required, despite the best of techniques,
the papilla is missing, or at best, short and
snubbed, and in medium to high scallop
biotype cases, prosthetic papilla replace-
ment will still be required to achieve
acceptable aesthetics. Hence, the results
are still unpredictable and generally dis-
appointing, especially with the degree
of vertical augmentation achievable
and certainly in attempting to recreate
missing papillae. Often, multiple surgical
procedures are undertaken in an attempt
to achieve the natural gingival three-
dimensional architecture and in most
cases, apart from selected single tooth ver-
tical deficiencies, the results are generally
disappointing. More often than not, pros-
thetic gingival replacement is required.
Further, and even more relevant, is that
the attempted augmentation procedures, in
falling short, even by just a small amount,
actually complicates the aesthetic out-
come in that it places the transition zone
of the prosthetic gingival replacement in
the visible aesthetic display. Whereas, if
pre-planned, the transition zone would
more likely be outside the aesthetic
display and hidden by the lips or more
easily managed.
The difficulty, indeed the challenge, is
to appreciate and predetermine what cases
can be successfully and predictably sur-
gically augmented and which cases are
better prosthetically augmented. Obvi-
ously, this will be a significant variable
based upon clinical surgical skills as well
as patient preference. Indeed, it is sadly

124 Australasian Dental Practice March/April 2014

implant | EXCELLENCE

Figure 9. Bonded IPS e.max crown on 21 and screw-retained Figure 10. Tissue bed ready for receipt of hybrid prosthesis.
IPS e.max implant crown at 11 with ceramic flange prior to
hybrid technique.

Figure 11. Initial AnaxGum hybrid composite resin veneer/ Figure 12. Hybrid resin/ceramic flange after initial maturing.
ceramic build prior to trimming.

far too common in aesthetic zone cases for
patients to go through multiple surgical
procedures over an extended time period,
only to end up with a compromised aes-
thetic result or, alternatively, requiring
the use of prosthetic gingival replace-
ment. No doubt perseverance with this
approach has been in reaction to generally
disappointing ceramic gingival prosthetic
replacement, especially in the transition
zone from prosthetic to natural gingivae.
Prosthetic pink
ceramic replacement
Despite developments in pink ceramics,
there are obviously significant limitations
in the colour matching and characterisa-
tion of pink porcelains for prosthetic pink
augmentation. Issues such as restrictions
in colour matching due to limited ceramic
gingival hues, the shrinkage that occurs
during firing, the number of firing cycles
required (and therefore its potential delete-
rious effects on the white ceramics) and
the difficulties in handling these materials
especially in thin cross sections. This has
led to the majority of cases having less than
ideal aesthetic outcomes, especially at the
interface between the prosthetic replace-
must walk a very fine line; having estab-
lished good shade matching with the
white or tooth ceramics, he/she then
has to try and achieve some semblance
of gingival matching with the pink por-
celain with minimal firings and without
compromising or destroying the white
porcelain aesthetics.
Also, another complicating factor is the
shrinkage that occurs on the firings of the
gingival ceramic replacement, especially
in thin cross sections, and hence, it is often
difficult, if not impossible, to achieve a
good seal to the underlying host tissue
bed following the completion of the white

W ith our advances in CAD/CAM

technologies and materials science
developments, along with highly artistic
ceramic skills, we have been able to create
very natural and lifelike ceramic tooth
replacements. Where gingival replace-
ment is needed, however, has been the
weak link and ultimately, the deciding
factor as to whether a restoration is aes-
thetically successful or otherwise.
ment and the natural surrounding gingivae.
There is a small range of pink ceramic
shades available, generally simple mono-
chromatic pink shade guides and yet natural
gingival shading and characterisation is
quite characterised and complex.
Further, the additional firings required
for the pink porcelain can unfortunately
cause deterioration in the white porcelain
aesthetics due to over firing. The ceramist
aesthetics. This requires multiple impres-
sion procedures with specific techniques
to improve this situation and multiple
ceramic additions and firings. Still how-
ever, this more often than not results in a
perceptible margin or step of the pink
ceramic flange to the surrounding gingival
tissues and hence negatively affects the
blend of the gingival replacement with the
surrounding tissues.

126 Australasian Dental Practice March/April 2014

implant | EXCELLENCE
Figures 13-14. Completed case following refinement and integration of ceramic/hybrid soft
tissue augmentation. A very happy patient indeed!
Hybrid ceramic/resin
prosthetic replacement
T his article will explore some of the
treatment planning considerations
in determining the need for prosthetic
gingival replacement and the latest tech-
niques utilising hybrid ceramic/composite
resin as against the conventional ceramic
replacement. This hybrid technique
has been developed by Drs Christian
Coachman and Eric van Dooren and
provides many advantages over the con-
ventional options in treatment of these
difficult cases.
This approach is appropriate for many
commonly seen clinical situations in
the aesthetic zone related to loss of gin-
gival papilla through to situations with
significant horizontal and vertical tissue
deficiencies, or loss of anterior seal with
concomitant saliva and air escape.
If the option for prosthetic gingival
replacement is planned from the begin-
ning of treatment, in other words, using
a proactive approach, the aesthetic results
are generally significantly better.
In addition, the ability for the patient to
maintain appropriate oral hygiene around
the prosthesis due to both implant posi-
tioning and the development of the soft
tissue bed to receive the hybrid pros-
thesis are also greatly improved.
128 Australasian Dental Practice March/April 2014
Hybrid implant
prosthesis technique
T he first step in the assessment and treat-
ment planning process is to identify,
pre-operatively, the real 3D deficiency in
both hard and soft tissue volume. This ide-
ally should be done initially with a digital
analysis utilising simple computer soft-
ware programs such as keynote and digital
images, to overlay the defect or area to
be restored with the idealised future restor-
ative tooth dimensions in three dimensions.
This then enables the visualisation of the
actual hard/soft tissue defect that needs
to be replaced to achieve ideal aesthetics.
Further, with the use of a calibrated digital
ruler, the dimension of this defect can be
measured and quantified.
The next step in the diagnostic process
is then to convert this digital design to a
diagnostic wax-up encompassing both the
white and pink aesthetic determinants.
This diagnostic wax up becomes the master
guide for all of the following procedures
from both a surgical, restorative and labo-
ratory perspective. Digital Smile Design
(DSD) is of great benefit in this process.
Preparation of the soft tissues is an
important part of the design process. More
often than not, this requires some removal
or re-shaping to provide a uniform, convex
and cleansable profile for the future
ceramic/hybrid gingival replacement.
Hence, this planning process is critical
prior to implant placement, otherwise,
the implant may be placed too superfi-
cially leading to an unfavourable ridge-lap
design, hence compromising oral hygiene.
Three-dimensional implant placement
is also critical to the success of this pro-
cedure. These restorations must also be
screw-retained to allow simple removal,
reassessment and maintenance.
Further, in consideration of the path of
insertion of the prosthetic replacement
flange, the restoration must be inserted
from the incisal and labial direction and
effectively rotate in onto the implant.
Hence, the preferred implant interface
ideally should be a hex. Some internal
connection type interfaces ( eg the conical
connection) can have a metal implant
interface insert that can separately connect
into the crown construction with a low hex.
Hence, in these situations, the implant
connector can be separately placed first
into the implant and then the prosthesis
rotated in and connected onto the insert in
a two-stage approach, just as if the implant
had a hex interface. Otherwise, the paral-
lelism and depth of the internal connection
precludes any labial insertion path and will
compromise the ability to create the appro-
priate gingival replacement morphology
and flange seating.
implant | EXCELLENCE
The use of new hybrid ceramic/
composite resin approaches to these chal-
lenging situations is in direct response
to the limited shade and characterisation
options with existing pink ceramics and
the difficulties with firing shrinkage in cre-
ating an imperceptible interface between
the host tissues and the prosthetic gingival
replacement. Resins offer improved aes-
thetic matching via a much wider range
of different hues, tints and viscosities plus
the ability to both maintain these restora-
tions through re-shading and resurfacing
the of composite structure, as well as
relining the flange/host tissue interface
if changes occur over time.
The first stage in this process, following
the appropriate diagnostics, implant
placement and provisionalisation, is to
undertake a custom impression procedure
with a customised impression coping to
accurately reproduce the emergence pro-
file of the implant and to critically record
the soft tissue bed for the gingival replace-
ment. The implant/s are generally placed
deeper in the alveolus due to the missing
hard tissue component and to avoid any
ridge lap type of relationship. Further,
the goal is still to have the prosthetic/host
tissue transition interface ideally below
the visible display in smiling.
At the technical level, the prosthesis
is completed with respect to the tooth
white aesthetics with a thin ceramic
pink flange appropriate to the needs of the
case, as determined by the initial design
and refinement of this design in the pro-
visional restoration(s). This pink ceramic
flange or substructure provides the sup-
port for the overlying composite and
provides a highly polished and convex
intaglio interface with the soft tissues. The
ceramist does not need to be overly con-
cerned with multiple firings in achieving
an aesthetic match... Indeed the hue of this
ceramic sub flange should be the darkest
hue of the surrounding gingival tissues to
which will be veneered the various hues,
tints and translucencies of the resin com-
ponent of the restoration.
The prosthesis and un-veneered ceramic
flange is designed to put some initial pres-
sure on the underlying soft tissues in the
flange extension area and is then inserted
and assessed for fit as well as the exten-
sion of the flange and transitions with the
underlying soft tissue bed. This restora-
tion is left for at least 2 weeks in situ for
the soft tissues to form around the flange
130 Australasian Dental Practice March/April 2014
and mature. The intaglio surface should
be smooth and convex to facilitate appro-
priate hygiene procedures and the patient
well-educated on hygiene procedures to
clean under this flange.
At a subsequent appointment, the res-
toration is then removed and prepared for
resin bonding. Some mechanical retention
areas are cut into the bonding surface of
the flange with a high speed small round
or inverted cone diamond and the surface
sand-blasted. The ceramic flange is then
etched with hydrofluoric acid (HF) for 40
seconds (dependent upon ceramic type
of the flange) and then steam cleaned. A
silane coupling agent is then applied in
multiple coats and warm air dried after one
minute. A light-cured bonding agent is then
applied and cured for 10 seconds. The pros-
thesis is then ready for the application of
the composites of varying hues, viscosities
and translucencies to achieve the desired
matching. This is done with the prosthesis
in the mouth and fully seated. This is a very
artistic procedure and requires some exper-
imentation and experience with the various
materials and their effects.
The author has tried many different
materials over time and has currently
found the AnaxDENT range of resin mate-
rials the most suitable for this technique.
AnaxGUM, consists of a co-ordi-
nated system of pastes (Gingival Paste)
and liquid modelling materials (Paints
and Flows) developed by Dr Christian
Coachman and the owner of AnaxDENT,
Mr Andreas Kopietz. This system has the
best range of materials specifically for this
task. The Australian and New Zealand
distributor of these products is Pacific
Dental Specialties.
The restoration is taken out and then
excess resin from the flange interface
removed. The restoration is then left for
another 1-2 weeks in situ before again
being removed, the margins refined by
cutting the resin flange margin at approxi-
mately 45 degrees to the soft tissue
interface to give a better soft tissue tran-
sition and then adding and reshaping to
this margin for improved lighting effects.
Undercuts and concavities in this flange
fitting surface must be filled with pink
composite to ensure good oral hygiene.
The hybrid flange is carefully polished
with brushes and polishing pastes (Pasta
Rossa, then Pasta Grigia 11) so as not to
eliminate the critical surface texture of the
flange. The restoration is then resin sealed.
This hybrid part of the restoration
will have an effective life-span of some
4 years when it may require some aes-
thetic maintenance. This can be achieved
very simply by roughening/sandblasting
the flange area and the repeating the
etching/silane and bonding steps. In this
way, a new restoration can essentially
be achieved as well as re-sealing of the
flange interface.
The restoration of these implant cases
with loss of hard and soft tissue volume
in the aesthetic zone has been a challenge
to our profession. Historically, this has
been handled with variable success
with either multiple surgical procedures in
an attempt to re-build the anatomy of the
site, or alternatively, with the prosthetic
replacement, most commonly by way of
pink ceramic.
Both approaches have met with less
than ideal results and more often than not,
the surgical approaches have still needed
some prosthetic replacement, whilst the
prosthetic solution has met with only
average aesthetic results at best and which
deteriorate over time.
This hybrid technique as described is
not a panacea for all ills and is ideally
a planned treatment approach rather than
a fall back solution when all else fails!
It also requires appropriate diagnostic
work-up, adherence to specific implant
placement protocols, soft tissue prepara-
tion and provisionalisation, great artistic
skill and experience at both the laboratory
and especially clinical level, to deliver
optimum results.
About the author
Dr David Dunn is the principal of the
Macquarie Street Centre for Implant and
Aesthetic Dentistry in Sydney, Australia.
He lectures locally and internation-
ally and along with courses for Nobel
Biocare and Ivoclar Vivadent, is part of
the faculty for the gIDE Master Clini-
cian Program in Implant Dentistry. He
presents Mentor programs for a range
of Aes-thetic, Implant and Fixed prostho-
dontics subjects including the treatment
of the edentulous arch utilizing a graft-
less approach. Should you be interested in
receiving further information regarding
upcoming programs or courses,
please refer to our website or contact
practicemanager@mscdental.com.au or
call (02) 9247-1394.