Placing dental implants and/or natural tooth restorations in the aesthetic zone: achieving proper gingival contours.

A key goal of aesthetic/cosmetic dentistry is the fabrication of maintain-able, aesthetic, and functional pros-theses that preserve the health of the teeth and soft tissues. 1,2 Advances in restorative dentistry have significantly improved the clinician's ability to deliver predictable treatment. When implants are indicated, osseoin-tegration is an added factor that is essential for success. 3 It is universally accepted that implant dentistry is a restorative-driven treatment with a surgical component. 4 Whether implants and/or natural tooth-supported restorations are to be placed in the aesthetic zone, the following factors must be considered in order to achieve the desired result: • diagnosis of smile design • site development, including soft-and hard-tissue grafting to correct unaesthetic or functionally compromising anatomic abnormalities • proper biologic width • gingival contours • the removal of excessive alveolar bone and gingival tissue for the correction of a " gummy " smile. All of these factors need to be considered during treatment planning and addressed prior to placement of dental implants 5 or natural tooth-supported restorations. 6 Crown lengthening, 7 when indicated, is critical to the success of creating a smile that is harmoniously balanced with the surrounding facial features. 8 Patients who clinically display too much gingival tissue and short clinical crowns require a fully developed diagnosis and treatment plan to provide a predictable aesthetic outcome. 9 This is imperative with the utilization of dental implant restorations. 10 If a patient has altered passive eruption (APE) of the maxillary anterior teeth, but has completed facial growth, 11 then the gingival levels must first be corrected with either a gingivectomy or aesthetic crown-lengthening procedure before the placement of dental implants. This ensures that the gingival margin of the maxillary anterior teeth will be at the correct height after restoration of the implant, and over the long term. 12 This article discusses the principles and clinical techniques used to achieve correct positioning of gingival margin when restoring implants and/or natural teeth in the maxil-lary anterior region. The focus is on optimal aesthetics and long-term tissue health. Biological width is the measurement between the crestal bone and the inferior aspect of the periodontal sulcus, which on average is 2.04 mm and comprises the epithelial attachment (~0.97 mm) and connective tissue (~1.07 mm). This translates to at least 3 mm between the most apical extension of the restorative margin and the crest of the alveolar bone. 13 This allows sufficient space …