Improving Aesthetics: Harmonizing the White and Pink

INTRODUCTION
Frequently, when treating the aesthetic concerns of the patient, practitioners focus on the teeth (the white) and ignore the gingiva (the pink). Yet, both these aspects need to be addressed to provide the best aesthetic outcome and to correct what is either naturally present or the result of wear and tear over the years. It is not unusual to restore the anterior maxillary teeth with direct resin veneers, porcelain veneers, or full-coverage crowns, and end up with a patient who may not be completely satisfied with the result. This is often on a subconscious level, and the patient and practitioner cannot pinpoint what doesn’t look “right.”
The best analogy to explain this: even the most beautiful picture needs a frame to do it justice. If we took the Mona Lisa and placed it in a cheap plastic frame from a local thrift store, would it look as beautiful as if it were framed in an expensive and elegant frame? When restoring the maxillary anterior teeth, we need to regard the gingival tissue as the frame for the teeth to be restored. Adjusting the gingival margins to make the central incisors appear even, to get the zeniths of the anterior teeth in harmony, and to correct any slant to the gingival planes should all be considered before proceeding with the restoration of the teeth. It is not uncommon for the gingival margins of the central incisors to have one more coronal than the other. Another common problem is the gingival margin of the lateral incisors being positioned more apical than the central incisors and canines. This can result during eruption of the teeth, either from passive eruption of the central incisors or a more apical eruption of the lateral incisors, or a combination of these processes.

Evaluating the Gingival Aspects
In the healthy gingiva, with the absence of periodontal disease, the osseous structure follows the scalloped parabolic contour of the cemento-enamel junction (CEJ); from facial to interproximal at an average distance of 2.0 to 3.0 mm.¹ Additionally, the interproximal bone height is on average 3.0 mm coronal to the facial crest of bone.² As the soft-tissue topography is typically determined by the underlying hard tissue, the osseous “scallop” results in a gingival scallop of 3.0 mm.³ Examination of the periapical or vertical bite-wing radiographs will permit the clinician to determine the position of the alveolar bone relative to the CEJ of the teeth to determine whether the crestal bone is 2.0 to 3.0 mm apical to the CEJ, thus allowing for biologic width.^1,2
Clinically, when the crestal bone is positioned coronal to the CEJ, a condition results in a phenomenon referred to as altered passive eruption.⁴ In this situation, the gingival margin will usually be located 3.0 mm coronal to the level of the crest of bone, and this more coronal positioning on the tooth creates the appearance of a short clinical crown.⁵ These visual findings are confirmed with clinical information obtained by “bone sounding.” Bone sounding involves using a periodontal probe to locate the CEJ, and determining whether it can be felt within the gingival sulcus or only when the probe penetrates through the base of the sulcus.⁶ The periodontal probe is also used to feel for the crest of bone. Normally, the crest of bone is located 2.0 to 3.0 mm apical to the CEJ.⁷ When considering the display of the gingival margin on the facial aspect of the teeth (in a healthy periodontium with no bone loss), the interproximal papilla will appear between teeth approximately 4.5 mm coronal to the interproximal crest of bone.⁸ Clinical display of excessive gingiva with short teeth, where the width of the tooth equals the length, requires a thorough diagnosis and consideration in the treatment plan to provide a predictable aesthetic outcome.^9-11 Excessive display of gingiva can affect the overall aesthetics of the smile, becoming the focus instead of the frame of the smile. This can be the result of passive eruption of the gingival complex as the teeth erupt.^12,13
Delayed or altered passive eruption exists when the gingival complex remains positioned coronal to the CEJ, with the attachment on the enamel instead of the cementum of the root, giving the appearance of short clinical crowns.¹⁴ Passive eruption is a common occurrence, and is often not recognized or treated. When the patient presents with passive eruption of the maxillary anterior teeth and facial development is complete, then the gingival levels will require correction before restorative treatment is initiated, or the final aesthetic result can be compromised.^1,15 This will ensure that the gingival margins of the maxillary anterior teeth will be at their correct level, and aesthetics can be maximized following restoration.² Probing of the facial sulcus will help determine where the crestal bone lies in relation to the gingival margin, and will identify those cases of true passive eruption; from cases where an osseous component needs to be corrected to gain more length in the apical direction.

Evaluating the Incisal Edge
The incisal edge position may also contribute to the length-to-width proportion issues due to incisal wear. Some patients may present with incisal wear in combination with passive eruption, resulting from continuing eruption as the teeth wear incisally and continue to erupt to maintain occlusal contact. This is evident whenever no wear is observed posteriorly and wear is observed anteriorly, and the anterior teeth are in contact when in maximum occlusion; this results in a flattening of the occlusal plane and an aged smile. The practitioner will need to decide if the anterior teeth need to be lengthened in an incisal direction in relation to the occlusal plane to provide optimal aesthetics with a more youthful smile.

Correcting the Aesthetics
Once the central incisor proportions are determined, the practitioner should focus on the height of contour of the gingival margin (zenith) on the central incisors.¹⁶ The proper placement of the gingival zenith on the central incisors is to have it positioned slightly distal to the middle of the long axis of the tooth. This also holds true for the canine and premolar teeth as well. This provides the central incisors, canines, and premolars with a subtle distal root inclination which is associated with a beautiful smile. On the other hand, the lateral incisor has its zenith at the midline of the long axis of the tooth. Additionally, the height of the gingival crest for the lateral incisor should be positioned ideally 1.0 mm more coronal than the gingival margins of the central incisor and canine.
The resulting healed and healthy gingival margins should have a “knife-edge” gingival margin.¹⁷ The gingival tissue can be corrected by a variety of methods, including: a scalpel, periodontal knifes (Orban/Kirkland [Hu-Friedy]), monopolar electrosurgery, bipolar electrosurgery, and lasers (diode and CO2). Hemorrhage control during surgery, when a correction of the gingival tissue is done with a scalpel or periodontal knives, is a challenge associated with these techniques; this can create aesthetic issues with immediate-placed direct or indirect restorations such as discoloration at the margins. Frequently, this necessitates performing surgery and allowing a short healing period before the restorations can be performed directly. Monopolar electrosurgery also has its negatives due to the high wattage used to cut the tissue with lateral heat generation resulting at the incision. Monopolar electrosurgery requires a dry field during treatment, and this may increase tissue inflammation during the initial healing period and subsequent tissue shrinkage. “Charring” of the tissue margins at surgery has also been reported with monopolar electrosurgery and may be a result of the need for operating in a dry field. This may cause the gingival margin to move apically as healing occurs, compromising the final aesthetics. Bipolar electrosurgery uses less wattage and has been used extensively in neurosurgery with no reported tissue shrinkage or marginal charring. Lasers are showing increased frequency of use and also have reported stable gingival margins with a lack of shrinkage upon healing.
With regard to the case to be discussed in this article, we will concentrate on the bipolar electrosurgery approach. Bipolar electrosurgery was developed to overcome the obstacles associated with monopolar electrosurgery. The technology used today in dentistry is a crossover from neurosurgery, where delicate incisions are required in wet fields with no lateral heat generation. The bipolar electrosurgery technology used in the course of treatment described below (Bident Bipolar Intraoral Surgical Unit [Synergetics]) transfers those neurosurgical requirements to the dental environment, allowing intraoral soft-tissue surgery in wet fields with char-free, nonbleeding incision margins. This permits placement of immediate composite resin restorations without contamination of the resin by hematologic byproducts, thus eliminating discoloration of the resin due to hemorrhage.^18-22

CASE REPORT
A female patient, in her late 40s, presented complaining about a gummy smile, wear of the front teeth, a tilted appearance to the occlusal plane, and thin lips (Figure 1). Further examination revealed that passive eruption was present; the crestal bone was positioned apical to the gingival margin, yet the attachment of the sulcus was coronal to the CEJ. A wide band of keratinized attached gingiva was present, and the gingival tissues demonstrated no inflammation or bleeding upon probing. The incisal wear had resulted in a prematurely aged smile with a flattening of the occlusal plane (Figure 2). Moderate incisal wear was found on the anterior maxillary teeth, minor lower anterior incisor wear, and no evidence of posterior wear. In maximum occlusion, the patient demonstrated occlusal contact of the anterior teeth with adequate anterior guidance. The patient indicated a history of grinding her teeth (Figure 3).

Figure 1. Patient as she presented with the complaint of thin lips, display of too much gingiva, and worn maxillary anterior teeth.	Figure 2. Maxillary anterior teeth due to incisal wear present with width equaling the length, presenting an aged smile. Note the wide band of attached gingiva.
Figure 3. Moderate wear is evident on the incisal edges of the maxillary anterior teeth with no wear noted posteriorly.	Figure 4. The Chu proportions instrument (Hu-Friedy) is utilized to demonstrate the proper length with regard to the width of the central incisor as it presents prior to treatment.

Impressions were taken and study models fabricated. Analysis of the length-to-width ratios using the Chu proportion instruments (Hu-Friedy) demonstrated that, with the established width present due to intimate proximal contact between the teeth, significant length had been lost. The Chu proportion instrument allows the length-to-width ratio of an ideal relationship to be quickly determined. The color marks allow the practitioner to quickly determine which length matches the width. In this patient’s case, as observed on the right central incisor (with a width measured to the outer edge of the red lines on the horizontal bar), the length should ideally be positioned on the outer edge of the red line on the vertical bar when the stop is positioned on the incisal edge (Figure 4). Preoperatively, we can observe and note that the length ends at the outer edge of the blue line on the vertical bar would result in a square-looking tooth.
The position of the maxillary premolars, with a lingually-based position, gave the smile a narrow look that resulted in “dark corridors” affecting the overall smile. After discussion with the patient, we arrived at a treatment plan consisting of a correction of the gingival margins by moving them in an apical direction to eliminate the “gummy” appearance. This would be followed by direct resin veneers of the maxillary teeth (from first molar to first molar) in order to build out the buccal corridor, giving the patient a wider smile. In addition, the incisal edges of the maxillary anterior teeth would be lengthened to restore the lost incisal length and to provide a more youthful smile with a correction of the occlusal plane.
In cases like these, the incisal edge can be lengthened, but the position of the lower lips must be taken into consideration so that the new edge position of the maxillary anteriors is not contacting or dragging on the lower lip when smiling or talking. With this in mind, the incisal edge of the central incisors in this case could be lengthened incisally 2.0 mm. Since the patient had adequate anterior guidance, we would use the established guidance with respect to the direct resin veneers planned. The composite resin would be added in a buccal and incisal direction with no extension onto the lingual surface; this would be done so that, during protrusion, the lower incisal edges would slide over the natural tooth surfaces and continue onto the resin with no interferences. The author prefers using composite (versus wax) for “waxing” the cast, as the composite can be molded and shaped until the desired contours are established, and then light-cured. Use of actual wax requires repeated heating during the process and results in a weaker mock-up that can break during the lab aspects of treatment. Additionally, if a vacuform stent is to be fabricated, the heated sheet material will destroy the wax on the cast but will have no effect on cured resin.

An adhesive was applied to the cast and light-cured to facilitate adhesion of the composite that would be applied during the mock-up. Composite was added to the incisal edges of the central incisors to gain 2.0 mm additional length, and then light-cured. Next, utilizing the Chu proportion instrument, a mark was made on the cast, measuring from the new incisal edge position on the central incisors to the outer edge of the red line on the vertical bar. Additional composite was then placed on the central incisors to shape them to a final contour, building out the buccal to overcome the flat facial plane present. Next, composite was placed onto the lateral incisal edges, extending them to end 1.0 mm shorter than the incisal edges of the centrals, and then light-cured. Again, the Chu proportion instrument was used to set the gingival position based on the measured width present and a mock-up composite veneer was placed on the lateral incisors. This was repeated with the canines, restoring the flattened incisal edge resulting from the wear. Composite was then placed on the premolars and first molar bilaterally, building them buccally but not extending the cusp tips in the occlusal direction. This resulted in a broader smile with a more rounded facial plane (Figures 5 and 6). Anterior guidance was respected and the mock-up allowed this to be followed with the longer incisal edge position (Figure 7). The Chu proportion instrument was utilized to verify that the new lengths were in proportion with the established widths (Figure 8).

Figure 5. Comparison of the before and after wax-up showing the buccal view with teeth lengthened both incisally and gingivally.	Figure 6. Comparison of the before and after wax-up showing the lateral view with teeth lengthened both incisally and gingivally.
Figure 7. Comparison of the before and after wax-up showing the maintenance of the patient’s anterior guidance.	Figure 8. Chu proportion instrument utilized to verify the length was in proportion to the established width on the finalized mock-up on the cast.
Figure 9. A vinyl polysiloxane (VPS) putty stent (Correct Quick [Pentron Clinical]) of the wax-up with the lower cast articulated into the putty.	Figure 10. Following setting of the VPS putty stent, the material is cut back to the incisal edge of the teeth to be lengthened incisally.
Figure 11. The VPS stent on the unaltered model demonstrating where the incisal edges will be positioned with direct bonding.	Figure 12. The Chu proportions instrument used to determine the new zenith on the central incisor and a mark is made in the tissue with the handpiece for the Bident Bipolar Intraoral Surgical Unit (Synergetics).

A vinyl polysiloxane (VPS) putty (Correct Quick [Pentron Clinical]) was mixed and placed onto the maxillary cast and extended to cover the entire lingual aspect of all the maxillary teeth and over the buccal/facial aspects. The lower cast was hand-articulated into the VPS putty before setting, and then allowed to set (Figure 9). The author prefers to have the lower cast articulate into the VPS putty so that the final stent has a position for the patient to occlude into, allowing the patient to stabilize the stent intraorally during treatment; this is more comfortable for the patient than remaining open during this phase of treatment. After setting, the stent was trimmed with a scalpel removing VPS putty on the anterior teeth facially to within 1.0 mm of the incisal edge (Figure 10). Placement of the altered VPS stent onto the original cast without the mock-up demonstrated where the new facial surface and incisal edge position would be with respect to the pretreatment position (Figure 11).
Local anesthetic (Septocaine [Septodont]) was infiltrated into the buccal vestibule from the first premolar to first premolar on the maxillary arch. The Chu proportion instrument was positioned on the current incisal edge and the handpiece for the Bident Bipolar Intraoral Surgical Unit was utilized to make a mark where the new zenith would be established for the anterior teeth (Figure 12). The bipolar electrosurgery unit was then used to remove a crescent-shaped piece of gingival tissue at each anterior tooth sparing the papilla interproximally; not altering the papilla avoids the iatrogenic development of black triangles, resulting in a more natural- looking “frame” for the new veneers being placed. By using the bipolar electrosurgery technology, the tissue suffered no tissue shrinkage, and coagulation was maximized so that bleeding did not discolor the direct resins that would be placed immediately follow the gingival recontouring (Figure 13).
Next, the direct composite resin veneering technique was initiated. The teeth to be veneered were acid-etched for 30 seconds using a 37% phosphoric acid gel (Pentron Clinical). Following rinsing and drying, multiple coats of a fifth-generation total-etch adhesive (Bond1 [Pentron Clinical]) was applied to the teeth and then light-cured for 20 seconds per tooth. Next, the VPS stent was inserted intraorally, and the patient was asked to occlude into the stent to verify fit (Figure 14). The stent was then removed and a translucent incisal nanocomposite (Artiste Super Clear [Pentron Clinical]) was placed into the stent at the incisal positions of the anterior teeth (Figure 15). The stent was then reinserted and the patient was asked to occlude into the stent. The stent applies pressure to the composite on the lingual aspect, assuring intimate contact with the lingual tooth surfaces. A TD8X (Miltex) flat-bladed composite instrument was then utilized to adapt the resin to the stent and incisal edge of the tooth (Figure 16), and then light-cured for 40 seconds per tooth (Figure 17). The stent was removed and additional light-curing was performed from the lingual for 40 seconds per tooth. An interproximal diamond saw blade (Cerisaw [DenMat]) was then utilized to break the contacts, allowing placement of a matrix during finalization of the direct resin veneers (Figure 18). Starting with the central incisors, a piece of stainless steel matrix (DenMat) was placed between the 2 central incisors to establish a straight midline in the final direct resin veneers. A thin Teflon tape (Plumber’s Tape [Home Depot]) was placed between the central and lateral incisors bilaterally, and then adapted over the lateral incisor facial surface. The benefits of using this Teflon tape are that it readily adapts to the tooth’s surface; has no memory, so it will not push the composite placed against it in a direction not desired; is very thin so does not have the potential of creating an open contact; and its slippery surface allows removal without binding on the adjacent teeth after treatment is completed.

Figure 13. The gingival tissue has been trimmed to a more apical level with the Bident Bipolar Intraoral Surgical Unit, providing better length to width proportions.	Figure 14. Intraoral try-in of the VPS stent with the patient occluding into the stent to stabilize it and increase patient comfort during the treatment.
Figure 15. Artiste nanocomposite in a translucent enamel shade nanocomposite (Artiste Super Clear [Pentron Clinical]) is placed into the VPS stent where the teeth will be lengthened incisally.	Figure 16. After placement of the VPS stent with composite at the incisals intraorally, an instrument is utilized to adapt it to the teeth incisally and to the stent.
Figure 17. The incisal composite is light-cured with the VPS stent intraorally.	Figure 18. The lengthened incisal edges following removal of the VPS stent intraorally.
Figure 19. Immediately following completion of the direct resin veneers demonstrating more natural and youthful aesthetics than prior to treatment.	Figure 20. Demonstrating the ideal length to width proportions of the completed direct resin veneers with the Chu proportion instrument.

Next, Artiste nanocomposite (in dentin shade B2) was adapted over the gingival half of the tooth, tapering it from the gingival margin to midtooth and creating mammelons, then light-cured for 40 seconds. Next, the nanocomposite (in enamel shade B) was placed; overlapping the dentin composite by a few millimeters, and extending the material to the new incisal edge position established by the translucent Artiste Super Clear resin that was previously placed; this material was then light-cured for 40 seconds. Next, the metal matrix at the midline was removed, and then the previously placed Plumber’s Tape was flipped to adapt it to the facial surface of the newly established central incisors. An additional piece of Plumber’s Tape was placed between the lateral incisors and canines and adapted to the facial surfaces of the canines. Again, the process of applying dentin and enamel composite resin was performed (as previously described) on the central incisors and on the lateral incisors. This process was repeated moving posteriorly (on the canines, the first premolars, the second premolars, and finally on the first molars), until all of the direct veneers were completed (Figure 19). The Chu proportion instrument was then used once again to verify that the length-to-width proportions of the final veneers were acceptable (Figure 20). Finishing carbides (Brasseler USA) were utilized to finalize the shape and contour of the direct composite resin veneers. This was followed by use of finishing diamonds (Brasseler USA) to create a preliminary polished surface. Next, further polishing was performed with polishing disks (Fini [Pentron Clinical]) in a slow-speed handpiece; starting with medium (blue); proceeding to fine (red); and finishing with extra fine (white), using light pressure with each disk. Final polishing was performed with a felt cup (Brasseler USA) on a mandrel in a slow-speed handpiece with Fini diamond polishing paste; moderate pressure was used to create a high polish.

Figure 22. The patient’s new smile one week postgingival recontouring and with direct resin veneers.

Figure 23. Deep brow lines, crow’s feet, and a deep chin crease, causing a prematurely-aged appearance.

Figure 24. Prominent nasolabial folds and smokers’ lines with thin lips, causing a prematurely-aged appearance.

Figure 25. Botox utilized in the upper facial area and dermafill in the lower facial area to help create a more youthful appearance and accent the dental treatment.

Figure 26. Comparison of the before treatment and after dental treatment and aesthetic augmentation with Botox and dermafill, creating a more youthful appearance and bringing out the patient’s natural beauty.

The gingival recontouring and direct composite resin veneers helped to improve or correct the “gummy” smile, balanced the occlusal plane to correct the tip to the right, and replaced length to the worn incisal edges (Figure 21). The patient was checked at one week following treatment to confirm that the anterior guidance had not changed, and that no functional interferences existed on the extended incisal edges. The gingival tissue was healing well and minimal inflammation was noted (Figure 22). Had a monopolar electrosurgical unit been used to recontour the tissue, moderate marginal inflammation would still have been noted at this point in time following treatment. In addition, based on the author’s clinical experience, the patient would have also had postoperative discomfort at the one-week checkup.

Completing the Final “Framework”
In the author’s opinion, aesthetic improvement need not stop at the teeth and lips in the modern dental practice. We need to also evaluate and potentially correct the soft tissue of the face to help maximize the aesthetic result and achieve a more harmonious appearance. So, despite the significant improvement noted in this patient’s aesthetics from the restorative work, we have to ask, “How could the aesthetic result for this patient be further improved?” and “How can the ‘frame’ be improved to maximize her aesthetics?”
The patient presented with normal signs of the aging process, resulting from decreased elasticity of the skin (accentuating creases and wrinkles) due to the loss of hyaluronic acid within the skin and underlying tissue. Examination noted deep brow lines in the forehead, prominent Procerus muscles with the establishment of “11”s between the eyebrows, “crow’s feet” at the lateral boarders of the eyes, deep nasolabial folds, thin lips (especially the upper lip), “smokers’ lines” around the lips, and a deep horizontal chin crease. The combined result created a more aged appearance for the patient (Figures 23 and 24). Botox (Allergan) has been utilized to relax the muscles causing the creases and will typically be confined to the upper face where muscle overactivity can accentuate the creases making them more noticeable aesthetically. With aging, the body loses hyaluronic acid and the result is deepening of folds and creation of fine vertical lines around the lips. Dermafills assist in replacing the lost hyaluronic acid, plumping the area to soften the appearance and restore a more youthful look. Typically, dermafills are utilized in the lower face for aesthetic treatment (Figure 25).
Botox was injected to eliminate the forehead creases and crow’s feet, plus it softened the area between the eyebrows. A dermafill (Restylane [Medicis]) was applied to fill in the nasolabial folds and to help eliminate the horizontal chin crease. Additionally, it was placed to fill in the smokers’ lines and to plump the upper and lower lips, providing a more youthful appearance and giving the patient fuller lips. In addition, it turned the corners of the mouth upward to eliminate a frowned look. The final result of the gingival recontouring, direct resin veneers, and the facial treatments using Botox/dermafill helped this patient “turn back the clock” and achieve her desired aesthetic outcome (Figure 26).

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Dr. Kurtzman is in private general practice in Silver Spring, Md, and a former assistant clinical professor at University of Maryland. He has earned Fellowships in the AGD, American Association of Implant Prosthetics, American College of Dentists, International Congress of Oral Implantologists (ICOI), Pierre Fauchard, Academy of Dentistry International; masterships in the AGD and ICOI; and Diplomate status in the ICOI and American Dental Implant Association. He has lectured internationally on the topics of restorative dentistry, endodontics and implant surgery and prosthetics, removable and fixed prosthetics, and periodontics, and has more than 250 published articles. Dr. Kurtzman has been honored to be named one of the Leaders in Continuing Education by Dentistry Today annually since 2006. He can be reached at drimplants@aol.com or by visiting the Web site maryland-implants.com.

Disclosure: Dr. Kurtzman reports no disclosures.