simultaneous white and pink approach

Simultaneous white and pink approach

Plastic Periodontal concepts have evolved significantly in the last 10 years to follow the trend of minimally invasive approach and reduce the morbidity of the surgery. At the same time, we can observe another trend of shrinkage in the number of appointments for the patient.
The main question is here to understand if it is better for the quality of the final result to combine both trends.
The aim of this article is to present contemporary concept, but which are related to solid old scientific data (Landsberg, Bichacho 1993 cervical contouring concept) where the pink part is performed simultaneously with the prosthetic procedure in order to improve the final outcome and use the final prosthetic design as a healing reference for the connective tissue graft. This approach is highly inspired by implant strategy in the anterior zone where the implant abutment design drives the healing of the gum and the graft around. (learned from Eric Van Dooren).

Old PFM bridge

Fig.1

A 55 years old female patient consults for changing this old PFM bridge.

intraoral view shows buccal concavity around the 2 missing laterals incisors

Fig.2

Xray shows no chronical infections on the non-vital teeth. The first treatment plan proposed was a full mouth rehabilitation due to the wear process but the patient didn’t approve for financial reasons. The second treatment plan was an upper arch rehabilitation in order to have the freedom to rise the VDO and create space to improve the esthetic outcome.
A six-element bridge from 13 to 23 and crown on 24,25,14,15 and table top on 16,17, 26, 27 are planned. Esthetically, the flat cervical area of 21 has to be improved with a small gingivectomy. Émergence profile of 22 and 12 should be designed ideally as if the pink volume would be perfect.

Fig.3

On the occlusal view, the two concavity front missing laterals are easily visible and should be improved with plastic surgery.

Fig.4

wax up with the new design where cervical areas are aligned and corrected.

Fig.5

Old restorations are removed and new prep design and gum correction are performed.

Fig.6

The impression is made with wash technique using light body and putty in two steps (Honigum Mixtar Heavy, Honigum light DMG Hamburg).

Fig.7

In order to produce in fast way temporaries according to the esthetic project a silicon key made from the wax-up (Honigum putty soft and Honigum light DMG Hamburg). This key is prepared in the cervical area in order to let the resin excess be visible and removed easily to have a perfect temporary in 5 min.

Fig.8

The resin used here is a new generation of temporary material in order to get the best esthetic. This new resin is stronger than all other syringeable material and suitable for abrasion and bruxism. It can be also useful for semi-permanent restoration in case of a long testing period while the vertical dimension is raised in a significant way (more than 5 mm in the anterior area). (LuxaCrown DMG Hamburg).

Fig.9

After three months with a very simple polishing step, the optical and due to the physical stability surface texture is quite very acceptable. Also, biofilm and plaque sticking are prevented thanks to this easy, fast, and simple polishing step. Due to the lack of volume, both lateral are too bulky in the cervical area to balance it. But this defect will be corrected on the day of the placement of the ceramic restoration.

Fig.10

After the removal of temporaries, we can note healthy and keratinized gum which will facilitate the good prognosis of the connective tissue graft.

Fig.11

Following the Zucchelli technic, the connective tissue is taken from palatal gum around 6 and 7, and the epithelium is removed from the surface. Then the piece is split into two-part one thicker than the other one to be customized according to the buccal defect.
Only a simple crystal incision for each side is made to avoid flap. The connective tissue is placed slightly under the gum in the room prepared previously with a microsurgery instrument.
Once both sides are blown, the restoration is tested, checked to be sure that the ideal emergence profile of both laterals is compressing and penetrating inside the gingiva.
Once the insertion is validated, the ceramic bridge is cemented with a modified glass ionomer resin cement.

Fig.12

After cementation of ceramic restoration suspended stitches are made to create coronal traction of the connective tissue and the superficial envelope.

Fig.13

Directly after surgery the blowing effect of the connective tissue is visualized and shows a significant improvement. Then the ideal design planned on the model in the lab can fit with the clinical situation. Again the pink healing will be driven by the white design. This is why we believe that the simultaneous step of plastic surgery with the placement of final restoration is a plus in contemporary treatment planning.

Fig.14

Spécial acknowledgment for my Ceramist: Wilfrid Pertot (Marseille).

Fig.15

Profile view with ideal emergence profile. Soft tissue healing was driven by the ceramic ridge design.

Fig.16

Profile view with ideal emergence profile on the other side with same pink and white integration.

Fig.17

Occlusal view with the ideal convexity for both level white and pink.

Conclusions

As presented in this article the mock-up is the key element of every single esthetic treatment.
We can see many advantages from the mock-up technic
1- visualization of the final outcome (esthetically and functionally)
2- a guide for the facial or occlusal reduction for veneer prep
3- fast and simple temporaries

BIBLIOGRAPHY

Koubi S, Gurel G, Margossian P, Massihi R, Tassery H.
A Simplified Approach for Restoration of Worn Dentition Using the Full Mock-up Concept: Clinical Case Reports.
Int J Periodontics Restorative Dent. 2018 Mar/Apr;38(2):189-197.
Gurel G.
Predictable, precise, and repeatable tooth preparation for porcelain laminate veneers.
PractProcedAesthet Dent. 2003; 15(1): 17-24
Magne P, Magne M.
Use of ad- ditive wax-up and direct intraoral mock-up for enamel preservation with porcelain laminate veneers.
Eur J Esthet Dent. 2008 ; 1(1): 10-19.
Vailati F, Belser U
Classification and treatment of anterior maxillary dentition affected by dental erosion:
the ACE classification
Int J Periodontics Restorative Dent. 2010 Dec;30(6):559-71.S Koubi,/ G Gurel