Eric Van Dooren | Florin Cofar

Victor Clavijo | Gustavo Giordani | Venceslav Stankov

Interdisciplinary Esthetic Dentistry

– complications
Retreatments
The and maintenance
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IV
V
 – basics Planning and execution – Volume 1

Contents
Interactive videos ................................ IV

Suggested reading ....................... 1 239

Esthetic analysis
Conventional smile design
1 Prosthetically guided healing
Simultaneous white
and pink reshaping
2
Esthetic analysis
The digital paradigm shift
3 Boosting the biotype
4
5
Nonsurgical soft tissue management
Reshaping 3D root configuration
Working with dark substrates
Surgical and prosthetic
considerations
6
Interactive videos
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videos available for free
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Crown lengthening
7 Sequencing gingival
recession covering
8
– synergies Optimising complex cases – Volume 2

9
Orthodontics considerations

– complications Retreatments and maintenance – Volume 3

10 11 12 13
The central-lateral
Delaying implant ................... 857 incisor dilemma ..................... 893 Full arch .....................................967 Retreatment 1 ....................... 1 015

14 15 16 17 18 Vertical maxillary Vertical maxillary

Connective tissue growth growth and implant The pink gingival
Retreatment 2 ....... 1 069 hyperplasia ................ 1 131 in young adults ........ 1 151 removal ....................... 1 171 restoration................ 1 207
 Step one
10
Observe
Backgrounds Smile
≥ 22-year-old male Cases of ankylosis have many characteristics
in common with the long-term outcome in cases
≥ Dental trauma 10 years ago
of implant placement in young adults
with avulsion of the left central incisor
with craniofacial growth:
≥ shorter crown (incisal edge);

Complaint ≥ higher gingival margins than the adjacent teeth;

≥ thinner soft tissue around the ankylosed tooth;
≥ Unesthetic appearance

“
≥ buccal position of the ankylosed tooth
of the left central incisor compared to the adjacent teeth;
Due to the process
≥ open contact points (more in the posterior teeth).
of continuous vertical
Face
maxillary growth,
≥ Low smile line
Radiologic findings
teeth and bone continue ≥ Infra-position of his left central incisor ≥ Even if there is a severely resorbed and short root,
the tooth is still very stable.
to grow whereas an
ankylosed tooth or implant
stays in place together
863
with the surrounding
dentogingival complex.
”
864
 10
Step one
Start with the end
result in mind
In cases with vertical gingival defects, If we think in terms of the blood supply
the most difficult part is to address the vertical for the connective tissue graft, we need to be
component during the grafting procedure, realistic in terms of our expectations.
in this case the grafting of the left central This is exactly why, when having a vertical
incisor, to create harmony in the gingival defect, we always first evaluate the neighboring
levels. In general, the rule is that we can graft teeth. In this case, crown lengthening of the
and gain vertically as much as half of the right central and right lateral incisor would
height of the shortest papilla, in this case, allow us to compensate for the amount
the distal papilla of the left central incisor. of connective tissue grafting that is needed.

865
 Periodontal evaluation

“ Precise probing
and periodontal
evaluation of the
cementoenamel junction
and bone will give the
clinician an idea of how
much they can crown-
lengthen the teeth
and if flapless surgery
is an option.
”

866
10

867
 Crown lengthening

868
 10
Connective tissue graft

869
 Step two
Building the project
As the left central incisor is labially positioned, ≥ to verify that the planned augmentation
simulation of the correct tooth form and is realistic and technically feasible;
position is only possible after reduction of
≥ to reduce the existing tooth and make
the tooth on the plaster model. The tooth and
a wax-up of a tooth with a correct form,
gingival volume are reduced because of this
position, and especially a correct emergence
buccal position. It is important to simulate on
profile of 10–15 degrees. Visualization
the model the desired gingival augmentation
of the emergence angle is only possible
in pink wax for two reasons:
with the correct gingival profile in place.

870
“ The evaluation of this emergence profile is extremely
important because the emergence profile of the future tooth
will guide the healing of the graft.
”
10

871
872
“ The three-dimensional
(3D) root configuration
Step three
10
can easily be modified to fit
the needs of the surgery
Preparations
and the optimal prosthetic

”
After crown lengthening of the right central compensate for the buccal version
configuration.
and lateral incisors, a symmetrical preparation of the tooth and to reduce the pressure
was performed on the left central incisor. on the marginal gingiva in preparation for
Care was taken to have a correct zenith surgery. Because of the reduced retention,
position and to open space between the left but also because of the small amount of
lateral central and lateral incisors. enamel remaining after removal of the old
The opening of the distal space allows the composite, a slight extra incisal anchorage
coronal migration of the distal papilla. was performed. Retraction cords were only
The buccal surface was reduced from the needed for an accurate impression
new preparation outline into the sulcus to in the papillae areas.

873
 Laboratory work

874
“ Special attention is paid to the emergence profile
of the tooth. The removable pink wax-up allows us to
visualize the root coverage procedure on the model
10
and facilitates the evaluation of the wax-up.
”

875
 Laboratory work
It is always possible to slightly reconfigure of preparation and the impression between the coping and plaster die exactly where the space
the root profiles on the working model and roots of the lateral and central incisors. As the was needed. Because the solid model does
implement these when trying in the second position of the ankylosed tooth was distalized not allow us to copy the recontouring done
bake of the crown before the final glazing. compared to the ideal wax-up, the technician on the individual die, the e.max crown
In this specific case, for example, insufficient simulated the ideal root recontouring on the will have a step between the coping
space was provided for the papilla at the time model, removing the volume of the e.max and the original preparation.

876
 10

“ Because the solid model does not allow us to

copy the recontouring done on the individual die,
the e.max crown will have a step between
877
the coping and the original preparation.
”
878
10

879
880
“
10
While securing the non-glazed
crown in position, the interdental
root profile is reshaped with
a diamond burr. Space is created
for gaining adequate papillary
volume and height. In this specific
case and for educational purposes,
a new model was made after root
reshaping. It clearly shows the
difference after the interdental root
recontouring procedure.
”

881
882
 Step four
10
Final
prosthetic
Try-in
rehabilitation
After final glazing of the crown to obtain the
optimal color, texture, and form, the pressed
and layered e.max crown is cemented
with dual-curing cement. After cementation,
the zone apical to the cementation line
will be conditioned with a round burr.

883

After cementation and rootplasty

 “ It is important to create a concavity with a round burr
apically to the cemented crown. This will allow for symmetry
in thickness of the grafted area, removal of the enamel,
and will provide a receptor bed for the graft.
”

884
10

885
886
 11
The central-lateral
incisor dilemma
893
894
 11
Introduction

T
he simultaneous replacement of lateral and central incisors with dental implants
can be a source of concern for obvious reasons. Despite improvements in design,
connections, and surface treatment, bone remodeling should always be expected
after placement of an implant. When replacing two adjacent teeth with implants,
this physiologic remodeling can result in unesthetic clinical results.
The clinician will almost always be faced with the difficult choice of placing one
or two implants. Decision-making in this specific clinical situation is multifactorial,
but the available mesiodistal space between implants and the tooth form
are probably the most important factors.

895
 Tips and tricks One or two implants?
This choice is often a choice between theorical potential and pragmatic benefit.
If all conditions are optimal, two implants will be better than one. If any condition is not optimal, one implant will be better than two.
Keep in mind that conditions can be optimized. Orthodontics can be used to optimize prosthetic space.
Guided bone regeneration (GBR) can be used to optimize biologic space. Theoretically, not having a connector can mean improved
esthetics and cleanability. However this is only true under optimal conditions.

Prosthetic and biologic space

Limited Optimal

896
One implant Two implants
 11
Limited space

897

Optimal space
898
 11
Clinical situation 1
T
his 46-year-old female patient was referred for replacement of both
lateral incisors and right central incisor. All three teeth had recurrent
endodontic lesions associated with pain in the region of the apices.
Besides this main complaint, the black triangles between the anterior teeth,
probably caused by the old apicectomy, and the color of the soft tissue
around the right central and left lateral incisors were worrying the patient.

899
900
Step one
11
Record
Cone beam computed tomography (CBCT) ≥ simulate implant placement and eventually
is essential for a proper diagnosis and to plan relate it to the prosthetic design in any
the guided surgery in this case because implant planning software.

it allows to: For example, in this clinical case,

≥ visualize the three-dimensional (3D) it was very obvious, when looking
bone configuration and extent at the CBCT section of the lateral incisor,
of the endodontic lesions; that immediate implant placement (IIP) would
not be possible without GBR and raising a flap,
≥ measure bone height and thickness;
thus making the treatment more complicated
≥ measure the available bone apical and probably less predictable when it comes
to the roots and the endodontic lesion to the final esthetic result, especially
for implant stabilization; in the inter-implant area.
≥ measure the distance between
the existing roots and the available
mesiodistal space;
≥ evaluate soft tissue. To evaluate the soft
tissue, the authors recommend placing
a cotton roll or a retractor between
the teeth and the lip. This will separate 901
the lip mucosa form the gingiva;
902
Step two
11
The ideal
provisional
design
Before extraction, it is important to use
the chamfer preparation on the natural
tooth as a reference for the gingival form of
the provisional bridge for both central and
lateral incisors. The prosthetic soft tissue
support should not be different for an implant
restoration or a crown on a natural tooth.
The transmucosal design of the implant
restoration should ideally be a copy of the root
in the first 1.5 mm. In order not to lose
this important 3D reference after extraction
and subsequent gingival collapse,
a Duralay jig on both neighboring 903
teeth was made.
 Step two

Atraumatic extraction
This procedure should follow these guidelines:

≥ Use a periotome for the initial section

of the periodontal fibers and gently initiate
the luxation.
≥ Push the tooth in the alveolus first
when engaging with forceps; it will cause
rupture of the periodontal fibers and edema,
which will facilitate the extraction.
≥ Use forceps to gently turn the tooth.
Care must be taken to preserve the buccal
bone and interdental bony septum.
≥ After extraction, a sharp curette should be
used to clean the alveolus and remove
all remnants of the endodontic lesion.
≥ Probe and map the buccal bone levels;
this is important at this stage.

904 ≥ Use a round diamond burr or scalpel to

remove the sulcular epithelium.