Esthetic re-creation of soft tissue ar chitecture in

replacing missing maxillary anterior teeth

Eugene Joffe, DDS, PhD, FAGD

Replacing missing maxillary anterior teeth while pr oviding an adequate esthetic can Recreation of smile esthetics is an important
present a considerable challeng e. A substantial ef fort is directed to ward achieving a factor in restorative procedures, especially
better tooth-to-soft tissue relationship, r egardless of whether the restorati ve modali- when tooth replacement and oral recon-
ties are implants, naturally supported fixed bridges, or removable partial dentures . struction are a concern. Smile esthetics are
The interdental papilla is critical to the esthetically pleasant ar chitecture and con - particularly important when dealing with
tributes to successful harmonious restoration, especially in patients with a high smile . the maxillary anterior region. A relationship
There are se veral techniques for restoring the indental papilla. The best result comes between any kind of replacement and the
from careful planning and good communication with the patient. surrounding soft tissue contributes signifi-
cantly to clinical success. Esthetically, the
Received: Mar ch 20, 2002 Last r evisions: June 21, 2002 Accepted: August 7, 2002 tooth is inseparable from the architecture of

Case report No. 1

A 33-year-old man had a con-
genitally missing tooth No. 6.
The retained ankylosed primary
tooth No. C became loose and
needed to be replaced. The p ri-
mary tooth’s position was such
that the gingival contour height
was much lower than that of the
adjacent teeth and was not sym- Fig. 1. The retained primary tooth No. C, asym- Fig. 2. Surgically positioned gingiva line
metrical with permanent tooth metrical with the gingiva line of the left side. following extraction.
No. 11 on the left side (Fig . 1).
The impression was taken prior
to the extraction and the desirable
height of gingival contour for tooth
No. 6 was created on the model by
using the bur. The missing tooth
was sculpted on the model and the
template was produced in a vacu-
um former. Fig. 3. Temporary acrylic Fig. 4. Healing three months after Fig. 5. The newly formed
The ex tracti on was per- bridge with rounded, bullet- surgery, showing the reshaping of dentogingival contours,
formed, with minimal trauma shaped pontic inserted after gingival architecture. including the overall
to the buccal cortical plate. The insertion. symmetry and papillae.
future socket was established
surgically with a proper gingival height using a large round was not prepared during the surgery to be sufficiently large,
diamond bur (Fig. 2). it is important to allow the tissue around the pontic to heal
Teeth No. 5 and 7 were prepared with a full circumferen- and to avoid any unnecessary pressure on the tissues, which
tial shoulder for placement of a Targis/Vectris fixed partial could result in damaged and inflamed tissues that probably
bridge (Ivoclar, Amhers t ,N Y; 800/533-6825). Using the pre- will not heal at all.
vious template, the transitional acrylic bridge was made di- Three months later, once the recreation of the architecture
rectly. The length and shape of the pontic in the gingival was determined to be satisfactory (Fig. 4), the three-unit fixed
area received special attention. The rounded, bullet-shaped bridge was produced and bonded in place using One-Step and
pontic was well-polished when it contacted the alveolar Duo-Link luting cements (Bisco, Schaumburg, IL; 800/247-
ridge (Fig. 3). Adjustments were made to the provisional 3368). The newly formed dentogingival contours included the
pontic during the healing period to achieve the best con- overall symmetry and papillae formation and produced a
tours for the artificial socket and papillae. If the pontic bed good perception of a natural esthetic (Fig. 5).

316 General Dentistry www.agd.org

gingival tissues. For that reason, much
clinical research is directed toward sav-
ing, recreating, and improving gingival
soft tissues contours and papilla.1-5 Many
clinical approaches reflect such esthetic
concepts as smile line, gingival contour,
symmetry, and “golden” proportions.6,7
Smile composition reflects individuali-
ty and influences social perception and im-
age.8 Statistically, 10.57% of the popula-
tion has what is described as a high smile or
gummy smile. This type of smile uncovers
the maxillary gum tissue to various degrees
of width. The same research indicates that
68.94% have a “medium” type of smile,
where the upper lip border corresponds to
the cervical gum line, while 20.48% have a
“low” smile that covers the maxillary teeth
to a different degree.9 Many clinical re-
search efforts are based on these and other
esthetic principles in the pursuit of better
complete denture esthetics.10,11
A significant amount of dental and
soft tissue esthetics research relates to the
restoration of the maxilla anterior region,
utilizing different types of implants and
fixed partial dentures with pontic.7,12-19
For partial removable dentures de-
signed to replace missing maxillary anteri-
or teeth,esthetic considerations are associ-
ated largely with a choice of retaining
devices. However, while the complex rela-
tion of the denture teeth and dentogingi-
val complex is especially important for
people with a high smile, it rarely is a part
of clinical research.20,21
The following cases reflect different
clinical approaches for regaining the den-
togingival esthetic.

Case report No. 2

A 68-year-old man lost his fixed ante-
rior maxillary bridge (Fig. 6). For fi-
nancial reasons, the patient preferred
to replace the bridge with a removable
partial denture. He had a high smile
and utilizing a conventional partial
would either expose the acrylic of the Fig. 6. A 68-year-old man, following detach- Fig. 7. The artificial sockets with the pro-
anterior flange, reveal the “false” teeth, ment of a fixed anterior maxillary bridg e. jected papillae on the working model.
or force the dentist to reshape the
teeth traditionally by “scooping” in-
side to grind them to the ridge. None
of these results would produce the de-
sired natural appearance.
To recreate the dentogingival archi-
tecture and to satisfy the patient’s de-
sire for “natural-looking” teeth, the
dentist obtained the final impression Fig. 8. The teeth are set up according to the Fig. 9. A transmucosal alveoloplasty was
and mounted the models in the articu- design of the processed removable partial performed based on the positions of teeth
lator according to the previously estab- denture. on the partial denture.
lished centric relation position. Using
a laboratory bur, the artificial sockets
with projected papillae were created
on the maxillary working model. This
design represented the desirable den-
togingival architecture, including the
prominence of future dental papillae
for the finished case, while allowing
room to adapt and position artificial Fig. 10. The removable partial denture, 24 Fig. 11. The anterior area, one week after
teeth on the ridge (Fig. 7). hours after insertion. the initial insertion.
The removable partial denture
was produced with the teeth set up according to the designed structed not to remove it for the next 24 hours (Fig. 10). Once
model’s preparations (Fig. 8). Because of the design’s relative it was removed, a regimen was prescribed involving regular
simplicity, the denture was processed without a clinical trial. hygenic care and cleaning the denture and teeth.
At the time of insertion,the remaining roots were removed The reshaping of the alveolar ridge started and became no-
with minimum damage to the facial cortical plate. For future ticeable in the week following the procedure. The reshaping in
contacts between artificial teeth and the alveolar ridge, an the anterior area progressed, outlining the favorable architec-
alveoloplasty was performed to create sufficient depression in ture previously designed for this area (Fig. 11). The recreation
the underlying bone (Fig. 9). This procedure allowed the ridge of a stable and more natural-looking dentogingival complex
to resemble the working model and was performed directly was completed within two months, resulting in a more satis-
through the attached mucous membrane without flap eleva- factory esthetic appearance for the soft tissues surrounding
tion. The partial denture was inserted and the patient was in- the artificial teeth.

July-August 2003 317

 Case report No. 3
A 48-year-old woman had lost all of her natural maxillary teeth ex-
cept for No. 5,6,and 16. The missing teeth were replaced with a re-
movable partial denture. The patient was not satisfied with her
high smile, large alveolar edentulous ridge,and small denture teeth
(Fig. 12 and 13).
The alveolar ridge was flat and no longer reflected the normal
architecture based on the relationship of teeth and surrounding
tissue. The edentulous alveolar ridge was smooth, with no in-
terdental papillae. In addition, the replacement teeth were too
small and the gingival contour height in the arc of teeth No. 5
and 6 was too low (Fig. 14). The conventional setup of the teeth
would change their shape when adjusting to the ridge and would
not produce the esthetic results this patient desired.

Fig. 12. A 48-year-old woman whose high Fig. 13. The intraoral appearance of the pa- Fig. 14. Edentulous alveolar ridge that no
smile line exposes a considerable amount of tient in Fig. 12. longer reflects the normal architecture.
soft tissue.

Fig. 15. A transitional denture model for Fig. 16. Comparing the discrepancy between Fig. 17. A self-cured acrylic is applied to
the patient in Fig. 12. the desirable position and the existing position convert the existing denture into a transi-
of the teeth in relation to the alveolar ridge. tional appliance.

Fig. 18. The denture seen in Figure 17, now

a converted transitional partial denture. Fig. 19. Crown lengthening surgery per- Fig. 20. A transmucosal alveoplasty in
formed on teeth No. 5 and 6 to elevate the edentulous area, performed at the same
position of the smile line. time as the crown-lengthening surgery.

Fig. 22. Four weeks after surgery, the pa-

Fig. 21. Following surgery, the provisional tient’s dental architecture shows insufficient Fig. 23. The adjusted model, with deeper
partial denture is inserted. development. sockets.

Fig. 24. Two months after surgery, the patient Fig. 25. Position of the artificial teeth in the
shows a more realistic alveolar architecture, setup phase. Fig. 26. Intraoral view of finished partial
with deep sockets and well-projected papillae. dentures.

318 General Dentistry www.agd.org

 This case presented a considerable challenge be-
cause so many teeth needed to be replaced. It was not
feasible to produce the case without any clinical trial.
It was clear that many esthetic parameters would re-
quire correction. Because this case required a differ-
ent management approach, the denture bed would be
created first.
An impression of the existing denture was taken and
the model was sketched and carved for the desired
changes, including the position of the papillae (Fig. 15
and 16). The self-cured acrylic was added to the exist-
ing denture teeth, more or less reflecting both the ex-
pected position and the size of the teeth (Fig. 17 and 18).
To gain the anticipated position of the gingival line
of contours, the crown lengthening procedure was
performed on teeth No. 5 and 6 (Fig. 19). The surgery
was performed simultaneously in all areas where teeth
were to be restored. The sockets were formed by sink-
ing the sterile bur directly through the mucous mem-
brane, reaching the underlying bone. No suturing or
flap elevation was utilized (Fig. 20 and 21). The
changed maxillary partial was readjusted and the pa-
tient was instructed not to remove it for the next 24
hours. Healing was uneventful.
Four weeks after surgery, it was determined that the
alveoloplasty was not adequate for creating an accept-
able architecture. The depth of the formed sockets was
insufficient and the patient revealed more posterior
teeth while smiling, a possibility that had not been tak-
en into account during the planning phase (Fig. 22).
Corrections were made on a new model, taking the
previous design’s inadequacies into consideration.
The existing sockets were deepened and additional
sockets were cut on the model in the premolar areas to
achieve a more comprehensive esthetic (Fig. 23).
After the model was readjusted, more aggressive
surgery was performed on the edentulous alveolar
ridge to achieve the desirable results. This time, the
cuts were made not only through the mucous mem-
brane but deep through the bone as well. Once again,
the bleeding stopped and healing was uneventful, with
no dressing or suturing required. The readjusted den-
ture in the front applied sufficient pressure. The pa-
tient was instructed to keep the partial in her mouth
for 24 hours; after that time, regular hygiene was rec-
ommended. Two months after surgery, the alveolar ar-
chitecture looked much better, with deep sockets and
nicely projected papillae (Fig. 24).
The patient’s pre-existing teeth were kept well-pol-
ished and ridge contacts were adjusted as needed. Af-
ter the denture bed was developed, the new removable
partial denture was produced in the usual manner
with the metal frame and the teeth were set up accord-
ing to the newly formed sockets and papillae (Fig. 25).
The designed denture bed has eliminated guesswork
from the set up phase, allowing the necessary trial
phase and offering better control of esthetics to pro-
vide a more natural look (Fig. 26).
Summary
Different clinical situations require specific approaches for a satisfying dento-
alveolar esthetic. It is only natural to seek the best possible outcome when
restoring a patient’s missing teeth. The clinical cases presented here offer so-
lutions that may be implemented in everyday practice. The designed denture
bed technique can be used in many situations involving removable partial
dentures or complete maxillary dentures with compromised esthetics. The
designed denture bed also may be used in cases involving other types of den-
tal reconstructions,including implants, during the provisional healing period.
Author information
Dr. Joffe is in private practice in Jackson Heights, New York.
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