Treating the Gingival Architecture Key to Smile Makeover Success

Fig 1. Preoperative full-face smile. The patient had ceramic veneers on the maxillary right canine, right lateral incisor, and right central incisor. A full ceramic crown was on the left central incisor, and a two-unit cantilever bridge with a pontic replaced her left lateral incisor with a full abutment crown on her left canine.

Fig 2. Preoperative close-up view of the patient’s smile. Note the asymmetry between the central incisors, dark shade, and over-contoured restorations. The patient had an asymmetric smile with the upper lip being higher on the right side and the gingiva appearing excessive and asymmetric.

Fig 3. The pontic was on top of the tissue rather than appearing as emerging from the tissue. The connector between the lateral incisor and canine was long and provided no room for the papilla.

Fig 4. After a smile design evaluation, gingival sculpting was performed with the Gemini EVO Laser to improve gingival symmetry. Based on available free gingiva and biologic width considerations, 1.5 mm of gingiva was removed from the maxillary right canine, right lateral, and right central, and 1 mm of gingiva was removed from the left central. This made the height of the gingiva on the canines and centrals approximately equal and the height of the gingiva of the laterals 0.5 mm lower than the height of the centrals and canines. The gingival zenith was now positioned just distal to the midline on the canines and centrals, and on the midline on the lateral.

Fig 5. To develop the left lateral incisor pontic site, a split-thickness crescent-shaped incision was made with the Gemini EVO Laser, and the tissue was folded under. A two-unit cantilever provisional bridge was fabricated from a provisional composite (Inspire™, Clinician’s Choice) and finished with a provisional resin glaze (Glisten™, Clinician’s Choice), with the tissue side of the pontic being convex and holding the folded tissue in place for healing. This will heal with a concavity to give the final pontic the appearance of emerging from the tissue rather than sitting on top of it. Provisionals were also fabricated for the maxillary right canine, right lateral incisor, right central incisor, and left central incisor and cemented with temporary veneer cement (ClearTemp™ LC, Ultradent).

Fig 6. At 4 days postoperative from the gingival sculpting and pontic site development surgery, healing of the gingiva was evident on the right canine, right lateral incisor, right central incisor, and left central incisor. The pontic site, although still inflamed, was beginning to nestle around the provisional pontic.

Fig 7. At 4 weeks postoperative, in addition to the tissue being well healed, the pontic site had well-developed rolled tissue and emergence.

Fig 8. The pontic site now had a concavity to allow the pontic of the left lateral incisor to appear to emerge from the tissue like a natural tooth rather than appear to be resting on the tissue.

Fig 9. Occlusal view of the pontic site.

Fig 10. Layered lithium-disilicate veneers (e.max®, Ivoclar) were used for the maxillary right canine, right lateral incisor, and right central incisor, and a layered lithium-disilicate crown (e.max) for the maxillary left central incisor. A layered lithium-disilicate bridge (e.max) was fabricated for the maxillary left lateral incisor and left canine. The veneers were cemented with PANAVIA™ Veneer LC (Kuraray). The bridge was cemented with PANAVIA™ V5 (Kuraray).

Fig 11. Postoperative close-up view of the patient’s smile, demonstrating improved harmony with symmetric gingival show, a natural pontic emergence on the bridge, and proportional teeth.

Fig 12. Postoperative full-face smile.