Achieving natural aesthetics on anterior teeth is one of the most challenging tasks with regards to providing treatment with dental implants. The technicians can provide the most beautiful ceramic work however, if the gum contour does not match the adjacent teeth then the overall aesthetic appearance is significantly compromised.
The art of gum shaping is a critical part of implant treatment in the aesthetic zone (smile area) of the mouth. There are many ways to provide this treatment and I will briefly describe one of the techniques we use at our clinic.
Why provide gum shaping?
In most cases, the healing abutment around implant are a circular shape. Teeth in the anterior aesthetic zone have a more conical and varied anatomy. This anatomical shape determines the shape of the gingival margins and interdental papilla (pink gum triangles between the teeth). If a permanent implant crown is made using a single impression of the gums following removal of the healing abutment then the shape of the future tooth will be determined by the cylindrical shape of both the implant and the healing abutment. In many cases this is not going to enable the provision of an aesthetic tooth replacement to match the adjacent teeth. In the picture below you can see how missing out on the gum shaping process can result in an asymmetrical tooth when compared to the adjacent tooth.
Gum shaping around dental implants
The gum (soft tissues) around the implant needs to be carefully manipulated to provide a similar contour to that seen on the adjacent central incisor in this example. Rather than simply accepting a compromised result, we provide our patients with a prototype implant restoration which is made out of PMMA. This looks and feel almost as good as the final tooth which is great for patients as it means they are able to have a replacement tooth very early on in their overall treatment process.
The PMMA prototype can be altered to have composite added to it. The composite is carefully placed onto the relevant part of the apical third of the restoration. This will allow for the careful manipulation of the crown morphology that is in direct contact with the soft tissues. If a small amount of composite is added to the middle of the crown (see image below) this will create blanching of the soft tissues in this area. Over 7-10 days, this will result in the redistribution of the gum so that an apical zenith is created in the area where the composite was added and the gum will have been pushed into the interproximal spaces to reduce any black triangular spaces.
In the picture above, composite has been added over 3 appointments to slowly develop a similar gum contour to the adjacent tooth. The ‘before’ image shows how the tooth appeared more square and shorter in the absence of gum shaping. Therefore, regardless of how good the ceramic work is, the tooth would never look symmetrical if it was left like this.
In this case we repeated the process for a total of 4 times to create a similar gingival contour to the adjacent tooth. Once we were satisfied with the gun shaping, the final ceramic restoration was made to fit the new gum contour and replace the PMMA prototype. :
The final outcome shows as a gum contour which is very close to the natural adjacent tooth. The shade of the final tooth was lightened to be more in line with the natural teeth. However, I include this preliminary picture to demonstrate that gum shaping can make teeth look more natural than ceramic work does on it’s own. The final picture is shown below:
The following examples demonstrate what a difference adding this stage to aesthetic implant treatment can make:
Implant dentistry in the aesthetic zone must take soft tissue management into consideration. The aesthetic appearance of the final tooth is critical when determining the success of the treatment. For predictable and consistent outcomes, we believe it is imperative that implant surgeons provide gum contouring as part of their aesthetic implant treatment.
I hope this blog gives an easy to understand insight into this procedure. Please feel free to contact me for any queries or for information on further training in this field.
Thank you for reading
Mohsin Patel BDS MJDF RCS (Eng)