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Esthetics of Artificial Gingiva | Dentures | Dental Implant

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  20 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY Correspondence to: Dr Marie-Violaine Berteretche Faculté de Chirurgie Dentaire, 5 Rue Garancière, 75006 Paris, France. Fax: 00 33 1 57 27 87 01. Email: berteretche.mv@wanadoo.fr The Esthetics of Artificial Gingiva and Complete Dentures Marie-Violaine Berteretche,  DDS, PhD Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Denis Diderot University, Hôtel-Dieu Garancière Dental Hospital, Paris, France. Olivier Hüe,  DDS, PhD Professor, Department of Prosthodontics, Faculty of Dentistry, Aix-Marseille University, La Timone Hospital, Marseille, France. Patients’ esthetic demands are increasing daily and now extend to the artificial gingiva of removable dentures. This article proposes a systematic approach to analyze and reproduce the gingival char-acteristics. This three-step process involves the gingival display of the smile line, gingival pigmentation, and gingival morphology. Dif-ferent procedures using either polymethyl methacrylate resins and/ or composite resins can be used to reproduce the gingival features. These innovative techniques make it possible to produce highly es-thetic complete dentures for edentulous patients presenting with a “gummy” smile, and the results offer satisfactory long-term stability. (Am J Esthet Dent 2012;2:20–31.)  © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  T he need for highly esthetic restorations has become an increasing trend in contemporary odontology. 1  The facial appearance, smile, and teeth all play a role in dental esthetics and in defining and asserting an individual’s personality. 2  The face plays a key role in the psychol-ogy of self-identification and self-presentation. An individual will always scrutinize the face, lips, and teeth of his or her partner in conversation. Research shows that a good dental appearance is required in many social groupings. 3  Consequently, facial attractiveness is closely tied to the presence of an ideal smile as defined by prevailing criteria in west-ern culture. 4  A major esthetic factor in western society is the pressure to look younger. Recently, researchers have established a set of criteria to define the principles governing the ideal smile in a dentate patient, regardless of age. 5,6  These criteria concern the following factors: ã The face: reference lines, planes of symmetry, profile, facial propor-tions 7 ã The tooth-to-lip ratio: lip movement, tooth visibility at rest, curve of the incisal edges and lower lip 8,9   ã The tooth: form, dimensions, color, surface texture 10   ã The marginal gingiva: collar form and position, form of the gingival papillae 11,12 21 VOLUME 2 ã NUMBER 1 ã SPRING 2012 © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  BERTERETCHE AND HÜE 22 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY The technical-therapeutic approach-es employed in fixed prosthetics have focused on matching and reproducing these criteria with or without input from implant dentistry. While patient objec-tives concerning removable complete or partial dentures with or without im-plants have always focused on restor-ing dental function, there has been a shift toward esthetics as a major patient requirement in prosthetic success. However, restoring esthetics often proves incompatible with restoring func-tional stability in the oral environment. Stability hinges on a single straightfor-ward principle: mounting teeth on the ridge, which equates to ignoring a lack of support for the cheeks and lips. 13  This remains a respected principle and has ultimately created the “denture look.” However, the rule championed by Earl Pound in 1954 established that “the teeth will be set up back in the srci-nal position from which they came.” 14  Various esthetic concepts have been grafted onto this core rule, including the dentogenic concept, 15  golden or divine proportion, 16,17  and visual perception. 18  These appearance-based criteria for artificial teeth combined with the dental materials used create an arsenal that enables dentists to meet patients’ es-thetics expectations. The vast majority of dental patients are extremely con-cerned about the appearance of their future prosthesis and will idealize their prior smile and dentition. Most patients express a need for well-aligned white teeth and a concern about the percep-tion others will have of their prosthesis. Dental practitioners need to define their patient’s esthetic conceptions. To achieve this goal, they must account for criteria spanning from cultural es-thetics 19  to psychologic issues 20  and should involve the patient in the pro-cess 21  to perfectly align the dentist’s design with the patient’s perception. 22  Recently, gingival display has been increasingly recognized as an esthetic factor in both natural dentition and re-movable dentures. In natural dentition with fixed partial dentures, thickness and gingival pigmentation are ignored since they are patient-acquired and patient-specific. For removable den-tures, however, reproducing these dif-ferent characteristics is essential for restoring oral esthetics. Achieving proper gingival esthetics depends on three key factors: analy-sis of gum features, the materials em-ployed, and technical outcomes. The purpose of this article is to provide a systematic approach to the analysis and reproduction of gingival charac-teristics in complete denture wearers. ANALYSIS OF GINGIVAL CHARACTERISTICS Gingival display A hidden gingival margin was long considered the ideal clinical outcome. Currently, however, it is considered esthetically acceptable to show 2 to 3 mm of gingival display, although any-thing more remains unesthetic. 4  Some authors add that permanent visibility of the posterior teeth and gingival tis-sue is esthetically desirable. In dentate patients, the gingival display depends © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.  BERTERETCHE AND HÜE 23 VOLUME 2 ã NUMBER 1 ã SPRING 2012 on the smile line. A low smile line re-veals only the incisal edges, a midline smile line displays the teeth, and a high smile line involves gingival display. In young dentate patients, gingival dis-play can extend to the premolar teeth (45% of cases), especially in women. Gingival display then decreases sig-nificantly with age. 9  Gingival display is also directly correlated with ethnicity, proving extensive in African Americans but virtually nonexistent in Asian popu-lations. 3,4  This is tied to lip type. 8  The amplitude of upper lip elevation and its esthetic role are comparable between completely edentulous and dentate pa-tients. Through a clinical dental exami-nation, the dental technician can gain a clearer picture of the degree of labial involvement using a labiometer such as the Papillameter (Candulor USA) (Figs 1a and 1b). Fig 1b Labial analysis: (a)   lip position at rest; (b)   lip position when smiling; (c)   assessment of labial involvement. Fig 1a The Papillameter (Candulor USA). acb © 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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