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CAM techniques help in the rebuilding of ideal marginal gingiva contours of anterior maxillary teeth
ORIGINAL CONTRIBUTIONS
CAD/CAM techniques help in the rebuilding of ideal marginal gingiva contours of anterior maxillary teeth A case report Jiayue Yin, MSD; Dan Liu, MSD; Yuehua Huang, BDS; Lin Wu, DDS, PhD; Xiaolin Tang, DDS, PhD
T
he contour of the marginal gingiva, referred to as “pink esthetics,” plays an important role in promoting a good appearance in the esthetic zone. Clinicians primarily use crown-lengthening surgery (CLS) to obtain enough biological width and to rebuild the contour of the marginal gingiva.1 According to the principle of “biological width,”2 the location of the alveolar bone is what determines the location of the marginal gingiva. Therefore, it is necessary to locate accurately not only the position of the marginal gingiva but also the alveolar bone position. Traditionally, periodontists have performed CLS by means of relying on what they could see with the naked eye; however, dentists may find it difficult to trim the marginal gingiva and the underlying alveolar bone precisely using this method. Thus, a precise template is a useful tool for this type of surgery. Dentists often make handmade surgery templates3,4; however, because they make the templates by means of using the naked eye, they cannot avoid making deviations in their templates. The 3-dimensional (3D)–printing technique is based on computer-aided design (CAD) and rapid prototyping (RP) technologies. In 2016, investigators reported that using the 3D-printing technique helped physicians improve the accuracy of their medical practice.5,6 Dental clinicians have not used 3D-printing
ABSTRACT Background and Overview. “Pink esthetics,” which are considered to be as important as “white esthetics,” have attracted increasing attention. To date, clinicians rarely have applied computer-aided design and computeraided manufacturing (CAD/CAM) techniques in the rebuilding of the contour of the marginal gingiva in the esthetic zone. Case Description. In this case report, the authors describe a female patient who had gingival inflammation and an asymmetrical contour of the marginal gingiva of the anterior maxillary teeth because previously placed ceramic crowns violated the biological width. The authors used a 3dimensional–printing surgery template to guide precise crown-lengthening surgery to expose subgingival shoulders and to obtain an ideal marginal gingival contour. Then the authors used interim CAD/CAM crowns to induce the growth of the interdental papilla by 0.5 to 1.5 millimeters. Finally, the patient had a symmetrical and well-balanced contour of the marginal gingiva. In addition, the authors reduced the patient’s “black triangle” areas to the greatest possible extent. Conclusions and Practical Implications. This case report illustrates that CAD/CAM products, including 3-dimensional–printing surgery templates and CAD/CAM interim crowns, are helpful in shaping and rebuilding the ideal contour of the marginal gingiva in the esthetic zone, such as the anterior maxillary teeth. Key Words. CAD/CAM; esthetics; crown lengthening; gingiva. JADA 2017:-(-):--http://dx.doi.org/10.1016/j.adaj.2017.03.003
Copyright ª 2017 American Dental Association. All rights reserved.
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Figure 1. Photo of inflamed gingiva on the patient’s anterior maxillary teeth at the first visit.
techniques widely in CLS. In a previously published study,7 we established a method to make a 3D-printing template to guide clinicians in cutting the gingiva and trimming the alveolar bone. We found that using a 3D-printing template could help clinicians obtain an ideal contour for the marginal gingiva. The “black triangle” or “open gingival embrasures” is a kind of esthetic defect that can occur at the interproximal area owing to interdental papilla loss. Interdental papilla will fill completely the interproximal area (100%) if the distance between the top of alveolar bone and proximal contact is 5 millimeters or less.8 On the basis of this theory, prosthodontists have tried to use interim crowns to induce the growth of interdental papilla to fill the triangle areas.9 However, handmade interim crowns that have a rough cervical margin may not only do harm to the health of the gingival tissue but also may influence the contour of the marginal gingiva. In comparison with handmade crowns, crowns made by means of CAD and computer-aided manufacturing (CAD/CAM), which have a smooth cervical margin and precise cervical contour, will keep the gingiva free of inflammation and help shape precisely the contour of the marginal gingiva. In this report, we describe the case of a female patient who had gingival inflammation and an asymmetrical contour of the marginal gingiva of the anterior maxillary teeth because the ceramic crowns had violated the biological width. To assist in the successful rebuilding of the patient’s marginal gingiva, we made a 3D-printing template and interim crowns by using CAD/CAM strategies. In our case report, we describe the fully digitized technique that we used to rebuild the contour of the marginal gingiva in the esthetic zone. CASE REPORT
The ethics committee of the Hospital of Stomatology, China Medical University, Shenyang, Liaoning Province,
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China (2013 Ethics Check No. 12), approved this case report. A 30-year-old female patient had red, swollen labial gingiva of the anterior maxillary teeth (nos. 11, 21, and 22); she reported that, 10 years previously, a clinician had treated these teeth by placing ceramic crowns. The patient was not a smoker and was in good physical condition. After the clinician had placed the ceramic crowns, the patient repeatedly experienced inflamed gingival tissue, and the tissue had been inflamed severely during the previous 2 years. At the first visit, we recorded the patient’s periodontal condition (Figure 1 and eFigure 1, available online at the end of this article) and performed a periodontal examination (eFigure 2, available online at the end of this article) by means of using the Florida Probe System (Florida Probe). We found that the labial subgingival shoulders were approximately 3.0 to 4.0 mm under the gingival margins, whereas the lingual shoulders were above the gingival margins. The splint restoration of the anterior teeth made it difficult for the patient to clean the interdental zone. The radiograph obtained of the anterior maxillary teeth indicated gross open margins of the restoration, which may have retained more dental plaque and contributed to the inflamed gingiva (eFigure 3, available online at the end of this article). In addition, the radiograph indicated that the endodontic therapy had failed (eFigure 3, available online at the end of this article). Treatment process. We obtained informed consent from the patient before beginning therapy. The treatment procedures were as follows: - We removed the fixed denture of the anterior maxillary teeth and performed initial full-mouth periodontal therapy. We carefully performed supragingival and subgingival scaling with ultrasonic instruments (Piezon Master 700, Electro Medical Systems) and Gracey curettes (Hu-Friedy) to remove the dental plaque and the calculus. At the same time, we debrided some of the granulation tissue of the inflamed gingiva. We also irrigated the gingival pockets with a 3% hydrogen peroxide solution to remove the residual calculus and soft tissue. Finally, we put an iodine glycerol agent into the pockets to inhibit the bacteria growth. We also provided the patient with instruction related to careful oral hygiene to teach her how to brush her teeth and use dental flosses and interdental brushes. - We performed endodontic therapy on teeth nos. 11, 21, and 22 (eFigure 3, available online at the end of this article).
ABBREVIATION KEY. 3D: Three-dimensional. C: Labial central sites. CAD: Computer-aided design. CAM: Computeraided manufacturing. CLS: Crown-lengthening surgery. D: Labial distal sites. L: Lingual sites. M: Labial mesial sites. RP: Rapid prototyping.
ORIGINAL CONTRIBUTIONS
TABLE 1 One month after the initial periodontal Distances between the gingival shoulders and the therapy, we found that corresponding gingival margin sites 1 month after the initial the subgingival shoulders were located from periodontal therapy. 1.0 mm to 2.5 mm VARIABLE TOOTH NO. under the gingival 11 21 22 margin (Table 1). We Site D* C† M‡ L§ D C M L D C M L performed gingivo¶ 1.5 1.0 1.5 0.5 1.5 1.5 2.5 1.0 1.5 1.5 1.5 1.0 Distance, millimeters plasty combined with * D: Labial distal sites. CLS, as guided by † C: Labial central sites. means of using a ‡ M: Labial mesial sites. § L: Lingual sites. 3D-printing template, ¶ Positive values indicate subgingival shoulders; negative values indicate supragingival shoulders. to obtain an esthetic contour of the marTABLE 2 ginal gingiva and to expose the subgingival Distances between the gingival shoulders and the shoulders. During the corresponding crests of the alveolar bones, as measured surgery, we found that during surgery. the distances between the labial gingival VARIABLE TOOTH NO. shoulders and the 11 21 22 crests of alveolar bone Site M‡ L§ D C M L D C M L D* C† were from 0.5 to 2.5 Distance, millimeters 2.5 1.5 2.5 3.5 2.5 2.5 0.5 4.0 1.5 2.5 2.5 4.0 mm (Table 2), which * D: Labial distal sites. suggested that the † C: Labial central sites. previously placed ‡ M: Labial mesial sites. § L: Lingual sites. crowns had violated the biological width to a severe degree. - One month after the surgery, we restored the CAD/ CAM interim crowns to induce interdental papilla and to shape the contour of the marginal gingiva. - Five months after the gingiva induction, we placed permanent zirconia ceramic crowns. Preparation of the 3D-printing template. One month after the initial therapy, we used the 3D-printing technique to obtain the precise surgery template. We used the following procedure: - Before surgery, we took digital photos of the patient’s Figure 2. The 3-dimensional–printing template, designed by means of dentition and face while she was smiling. We recorded using Geomagic Studio 11.0 software (Geomagic Studio, Software the distances between the gingival shoulders and the Informer) for the crown-lengthening surgery. gingival margins. We prepared the alginate impression of the dentition and the plaster molds. - We obtained point cloud data related to the plaster - We determined the template area (eFigure 4, available molds by means of using a laser scanner (D700, 3Shape). online at the end of this article). - We designed the gingival curves by means of using - We transferred the data to the rapid prototyping reverse engineering software Geomagic Studio 11.0 machine (Objet 350 Connex1, Stratasys) to print the (Geomagic Studio, Software Informer) (Figure 2, template. The template thickness was 1.0 mm. eFigure 4, available online at the end of this article). To CLS guided with the 3D-printing template. Before do this, we set up the coordinate system and the occlusal we performed the CLS, we rinsed the 3D-printing template in a povidone-iodine solution for 10 minutes plane, designed the mark points of the final gingival curve, constructed the 3D gingival margin curve, tuned and then washed the template with normal saline. We the mark points, and made horizontal flips of the performed the surgery by means of using the standard procedure. During the surgery, we put the template on gingival curve to obtain the symmetrical curve of the contralateral counterpart tooth. the teeth to guide the gingivectomy and ostectomy -
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Figure 3. The 3-dimensional–printing template guided the authors during the crown-lengthening surgery as they trimmed both the gingiva and the alveolar bone.
Interdental papilla induction with interim CAD/ CAM crowns. We designed the interim crowns (PMMA DISK, Yamahachi Dental) and made them by means of using a CAD/CAM (inLab, Sirona) system. We placed the crowns 1 month after we completed the CLS. We set the contact points according to the Tarnow principle,8 between the teeth and within 5 mm above the crest of interdental alveolar bone (Figure 5 and eFigure 6, available online at the end of this article). Five months after the induction of the crowns, we noted that the zenith location of the interdental papilla between the incisors was displaced coronally by 0.5 to 1.0 mm (Table 3). The interdental triangles between the incisors disappeared after the induction (Figure 6 and eFigure 6, available online at the end of this article). Five months after the gingiva induction, we placed the permanent zirconia-based crown (Zenostar, Wieland Dental) (Figure 7 and eFigure 7, available online at the end of this article). Seven months after we placed the crowns, we noted that the marginal gingiva was in good condition and that the black triangles had disappeared completely (Figure 8 and eFigure 7, available online at the end of this article). DISCUSSION
Figure 4. Appearance of the marginal gingiva of the anterior maxillary teeth 1 month after crown-lengthening surgery.
Figure 5. Interim computer-aided design and computer-aided manufacturing crowns placed to induce and shape the interdental papilla.
(Figure 3 and eFigure 5, available online at the end of this article). One month after the CLS, we noted that the patient’s gingiva had no inflammation. In addition, we noted that the contour of the marginal gingiva was symmetrical and well-balanced (Figure 4).
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Precise therapy using mainly computer-assisted techniques is replacing the traditional style of therapy, which relied on surgery by hand and observation with the naked eye. In the past, dentists prepared handmade surgery templates composed of various materials.3,4,10-12 In our case study, we described our use of a 3D-printing template on the basis of CAD and RP technology. We used Geomagic Studio software to design the marginal gingiva contour. The clinical outcome of our patient’s case was satisfactory. Geomagic Studio is a reverseengineering software that has been used frequently in oral clinical practice.13,14 The software can generate accurate digital models according to point cloud data from 3D objects. We used the software to modify quickly and preview the contour of the marginal gingiva. Then we transferred the data to the 3D printer to obtain accurate surgical templates. Compared with handmade templates, we found that 3D-printed templates have more advantages; the most beneficial advantage is that 3D-printing templates are more accurate and symmetrical. We also found it easier to design and modify the gingival curve by means of using computer software. Finally, 3D-printing templates are thinner and more uniform. In conclusion, 3D-printing templates can help dentists perform precise surgery and help patients obtain a more symmetrical and wellbalanced gingival margin. The formation of a black triangle, which results from the loss of the interdental papilla, is an important factor
ORIGINAL CONTRIBUTIONS
TABLE 3
Distance of the coronal displacement of the zenith of the interdental papilla, as measured 5 months after placement of an interim computer-aided design and computer-aided manufacturing crown restoration. VARIABLE
TOOTH NO. 11
12
21
Site
D*
M†
D
M
D
M
Distance, millimeters
0.5
1.0
1.0
1.5
1.5
0.5
* D: Labial distal sites. † M: Labial mesial sites.
Figure 6. Three months after the gingival induction by the interim computer-aided design and computer-aided manufacturing crowns, the black triangles could not be seen.
Figure 7. Five months after the gingiva induction, permanent zirconia ceramic crowns were placed.
that affects the esthetic appearance of the anterior maxillary teeth.15 Factors contributing to the formation of black triangles include periodontal biotypes,16 distances between the roots,17 locations of contact points, periodontitis, and periodontal therapy such as CLS. There are 2 ways to correct black triangles: surgical methods and nonsurgical methods. Surgical methods include a coronally repositioned flap combined with subepithelial
Figure 8. Seven months after placement of the final restoration, no black triangles could be seen.
connective tissue graft18,19 or a free gingival flap graft.20 Nonsurgical methods include rebuilding of the interdental papilla by means of placing interim crowns9,21 or orthodontic treatment.21 In our patient, we used interim CAD/CAM crowns to rebuild interdental papilla, and we designed the distances from the contact points to the alveolar bone crests to be less than 5 mm on the basis of the results of the study by Tarnow and colleagues8 in 1992. Using CAD/CAM interim crowns has 2 advantages. First, because they are designed and produced by computer software, the edges of the CAD/CAM crowns can be thinner and smoother than those of handmade crowns. Therefore, the interim CAD/CAM crowns are less likely to retain bacterial plaque. Second, the contour of the cervical line designed by computer software can be more accurate, which can guide the growth of interdental papilla more precisely. In this case, we placed interim CAD/CAM crowns to induce and shape the marginal gingiva contour. Consequently, we noted that the interdental papilla was displaced coronally by 0.5 to 1.5 mm and had a symmetrical and well-balanced appearance. In conclusion, the use of an interim CAD/CAM crown can reduce black triangles effectively, shape the marginal gingiva curve accurately, and maintain the patient’s periodontal health. For this patient, our approach to provide thorough initial periodontal therapy greatly improved the patient’s
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gingival color, shape, and texture; the periodontal therapy we provided also eliminated the gingival inflammation. We have noted that, with this basis of healthy gingiva, the patient’s marginal gingiva position has remained stable. Investigators have reported that initial periodontal therapy induces the recovery of interdental papilla.22 Therefore, the initial periodontal therapy is essential and important for both the healthy and esthetic appearance of the gingival tissue. In the case of this patient, the periodontists (X.T.) provided thorough initial periodontal therapy and performed precise CLS, and the prosthodontists (J.Y.) completed the interim and final crown restoration. The results of our case indicate that close interdisciplinary cooperation is necessary for a good clinical outcome. We noted a minor defect. After we placed the final restoration, we saw that the zenith of the left central incisor was a little higher than the right central incisor. We think that this minor defect may have occurred as a result of the complicated gingival healing process. According to the results of previously published studies, the location of the gingival margin after periodontal surgery can be influenced by many factors, including gingiva thickness or periodontal biotype23 as well as different biological width.24 In the future, we will consider all these possible factors and try to improve the symmetry of the gingival curve in clinical practice. In addition, we believe that clinicians should study more cases like the one we present to continue to improve treatment outcomes and gain more experience in the design and manufacture of surgical templates. CONCLUSIONS
The use of 3D-printing templates can guide clinicians as they perform precise CLS. Interim CAD/CAM crowns can be used to induce the growth of interdental papilla and maintain healthy gingiva. The results of our case report illustrate that it can be helpful for clinicians to use CAD/ CAM techniques for patients whose treatment requires rebuilding of an ideal contour of the marginal gingiva in the esthetic zone, such as in the anterior maxillary teeth. n SUPPLEMENTAL DATA
Supplemental data related to this article can be found at http://dx.doi.org/10.1016/j.adaj.2017.03.003. Dr. Yin is a prosthodontist, Department of Prosthodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Liu is an MSD candidate, Department of Periodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Huang is an MSD candidate, Department of Periodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Wu is a professor and a prosthodontist, Department of Prosthodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Tang is a professor and a periodontist, Department of Periodontics, School of Stomatology, China Medical University, 117 Nanjingbeijie, Heping District, Shenyang, Liaoning Province 110002, China, e-mail xltang@cmu. edu.cn. Address correspondence to Dr. Tang.
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Disclosure. None of the authors reported any disclosures. This study was supported by grants from the Clinical New Technique Program of the School of Stomatology, China Medical University (2009-2), Shenyang, Liaoning Province, China. Drs. Yin and Liu contributed equally to this article. 1. Hempton TJ, Dominici JT. Contemporary crown-lengthening therapy: a review. JADA. 2010;141(6):647-655. 2. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol. 1961;32(3):261-267. 3. Malik K, Tabiat-Pour S. The use of a diagnostic wax set-up in aesthetic cases involving crown lengthening: a case report. Dent Update. 2010;37(5): 303-304, 306-307. 4. Frizzera F, Pigossi SC, Tonetto MR, Kabbach W, Marcantonio E Jr. Predictable interproximal tissue removal with a surgical stent. J Prosthet Dent. 2014;112(4):727-730. 5. Chana-Rodriguez F, Mananes RP, Rojo-Manaute J, Gil P, MartinezGomiz JM, Vaquero-Martin J. 3D surgical printing and pre contoured plates for acetabular fractures. Injury. 2016;47(11):2507-2511. 6. Giannopoulos AA, Mitsouras D, Yoo SJ, Liu PP, Chatzizisis YS, Rybicki FJ. Applications of 3D printing in cardiovascular diseases. Nat Rev Cardiol. 2016;13(12):701-718. 7. Zhao YB, Wu L, Tang XL, Guo C. Computer aided design and computer aided manufacture of template for crown lengthening [in Chinese]. Shanghai Kou Qiang Yi Xue. 2013;22(4):443-447. 8. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-996. 9. Le D, Hu WJ, Zhang H. Combined crown lengthening surgery with restorative therapy for inducing papilla growth: a case report [in Chinese]. Beijing Da Xue Xue Bao. 2013;45(2):312-315. 10. Borges I Jr, Ribas TR, Duarte PM. Guided esthetic crown lengthening: case reports. Gen Dent. 2009;57(6):666-671. 11. Scutella F, Landi L, Stellino G, Morgano SM. Surgical template for crown lengthening: a clinical report. J Prosthet Dent. 1999;82(3):253-256. 12. Walker M, Hansen P. Template for surgical crown lengthening: fabrication technique. J Prosthodont. 1998;7(4):265-267. 13. Franco A, Willems G, Couto Souza PH, Coucke W, Thevissen P. Three-dimensional validation of the impact of the quantity of teeth or tooth parts on the morphological difference between twin dentitions. J Forensic Odontostomatol. 2016;1(34):27-37. 14. Yan R, Luo D, Qin X, Li R, Rong Q, Hu M. Digital modeling for the individual mandibular 3D mesh scaffold based on 3D printing technology [in Chinese]. Zhonghua Kou Qiang Yi Xue Za Zhi. 2016;51(5):280-285. 15. Singh VP, Uppoor AS, Nayak DG, Shah D. Black triangle dilemma and its management in esthetic dentistry. Dent Res J (Isfahan). 2013;10(3):296-301. 16. Ahmad I. Anterior dental aesthetics: gingival perspective. Br Dent J. 2005;199(4):195-202. 17. Tal H. Relationship between the interproximal distance of roots and the prevalence of intrabony pockets. J Periodontol. 1984;55(10):604-607. 18. Azzi R, Takei HH, Etienne D, Carranza FA. Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts. Int J Periodontics Restorative Dent. 2001;21(2):141-147. 19. Kaushik A, Pk P, Jhamb K, et al. Clinical evaluation of papilla reconstruction using subepithelial connective tissue graft. J Clin Diagn Res. 2014;8(9):ZC77-ZC81. 20. Rebaudi A, Massei G, Trisi P, Calvari F. A new technique for bone augmentation and papilla reconstruction with autogenous free gingivalbone grafts. Int J Periodontics Restorative Dent. 2007;27(5):429-439. 21. Sato S, Nomura N, Kawashima H, Ito K. Creation of a nonsurgical papilla in orthodontic treatment with severe periodontal disease: a case report. Quintessence Int. 2007;38(4):e218-e221. 22. Yanagishita Y, Yoshino K, Taniguchi Y, Yoda Y, Matsukubo T. Nonsurgical recovery of interdental papillae under supportive periodontal therapy. Bull Tokyo Dent Coll. 2012;53(3):141-146. 23. Pontoriero R, Carnevale G. Surgical crown lengthening: a 12-month clinical wound healing study. J Periodontol. 2001;72(7):841-848. 24. Rasouli Ghahroudi AA, Khorsand A, Yaghobee S, Haghighati F. Is biologic width of anterior and posterior teeth similar? Acta Med Iran. 2014; 52(9):697-702.
ORIGINAL CONTRIBUTIONS
eFigure 1. Photos of the anterior maxillary teeth before the initial periodontal therapy. A. Before the ceramic crowns were removed. B. After the crowns were removed (labial side). C. After the ceramic crowns were removed (incisal side).
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eFigure 2. Periodontal charts created by using the Florida Probe System (Florida Probe). A. At first visit. B. One month after the initial periodontal therapy. C. One week after the permanent crowns were placed. D. Seven months after the crowns were placed. GM: Gingiva margin.
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eFigure 2. Continued
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eFigure 2. Continued
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eFigure 2. Continued
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eFigure 3. Radiographs of the endodontic therapy. A. At first visit. B. Immediately after endodontic therapy.
eFigure 4. Images of the 3-dimensional–printing template designed for the crown-lengthening surgery. A. Designing the gingival margin contour. B. Outlining the template area (labial side). C. Outlining the template area (incisal side). D. Completed template.
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eFigure 5. Photos indicating how the 3-dimensional (3D)–printing template helped the clinicians guide the crown-lengthening surgery to trim both the gingiva and the alveolar bone. A. Labial appearance of the anterior teeth before surgery. B. Preview of the 3D-printing template. C. Surgery being performed with the guidance of the 3D-printing template. D. Final suturing.
eFigure 6. Photos of the interdental papilla induced with interim computer-aided design and computer-aided manufacturing crowns. A. Appearance of the anterior maxillary teeth 1 month after surgery. B. Interim computer-aided design and computer-aided manufacturing crowns, as prepared to induce and shape interdental papilla. C. Appearance of the anterior maxillary teeth after the temporary crowns were placed immediately. D. Three months after the placement of the temporary crowns.
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eFigure 7. Photos indicating the appearance of the gingiva after the final restoration. A. Immediately after the permanent crowns were placed. B. Seven months after the final restorations were placed (labial side). C. Seven months after the final restorations were placed (lingual side). D. Seven months after the final restorations were placed (smile view).
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CAD/CAM techniques help in the rebuilding of ideal marginal gingiva contours of anterior maxillary teeth A case report Jiayue Yin, MSD; Dan Liu, MSD; Yuehua Huang, BDS; Lin Wu, DDS, PhD; Xiaolin Tang, DDS, PhD
T
he contour of the marginal gingiva, referred to as “pink esthetics,” plays an important role in promoting a good appearance in the esthetic zone. Clinicians primarily use crown-lengthening surgery (CLS) to obtain enough biological width and to rebuild the contour of the marginal gingiva.1 According to the principle of “biological width,”2 the location of the alveolar bone is what determines the location of the marginal gingiva. Therefore, it is necessary to locate accurately not only the position of the marginal gingiva but also the alveolar bone position. Traditionally, periodontists have performed CLS by means of relying on what they could see with the naked eye; however, dentists may find it difficult to trim the marginal gingiva and the underlying alveolar bone precisely using this method. Thus, a precise template is a useful tool for this type of surgery. Dentists often make handmade surgery templates3,4; however, because they make the templates by means of using the naked eye, they cannot avoid making deviations in their templates. The 3-dimensional (3D)–printing technique is based on computer-aided design (CAD) and rapid prototyping (RP) technologies. In 2016, investigators reported that using the 3D-printing technique helped physicians improve the accuracy of their medical practice.5,6 Dental clinicians have not used 3D-printing
ABSTRACT Background and Overview. “Pink esthetics,” which are considered to be as important as “white esthetics,” have attracted increasing attention. To date, clinicians rarely have applied computer-aided design and computeraided manufacturing (CAD/CAM) techniques in the rebuilding of the contour of the marginal gingiva in the esthetic zone. Case Description. In this case report, the authors describe a female patient who had gingival inflammation and an asymmetrical contour of the marginal gingiva of the anterior maxillary teeth because previously placed ceramic crowns violated the biological width. The authors used a 3dimensional–printing surgery template to guide precise crown-lengthening surgery to expose subgingival shoulders and to obtain an ideal marginal gingival contour. Then the authors used interim CAD/CAM crowns to induce the growth of the interdental papilla by 0.5 to 1.5 millimeters. Finally, the patient had a symmetrical and well-balanced contour of the marginal gingiva. In addition, the authors reduced the patient’s “black triangle” areas to the greatest possible extent. Conclusions and Practical Implications. This case report illustrates that CAD/CAM products, including 3-dimensional–printing surgery templates and CAD/CAM interim crowns, are helpful in shaping and rebuilding the ideal contour of the marginal gingiva in the esthetic zone, such as the anterior maxillary teeth. Key Words. CAD/CAM; esthetics; crown lengthening; gingiva. JADA 2017:-(-):--http://dx.doi.org/10.1016/j.adaj.2017.03.003
Copyright ª 2017 American Dental Association. All rights reserved.
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Figure 1. Photo of inflamed gingiva on the patient’s anterior maxillary teeth at the first visit.
techniques widely in CLS. In a previously published study,7 we established a method to make a 3D-printing template to guide clinicians in cutting the gingiva and trimming the alveolar bone. We found that using a 3D-printing template could help clinicians obtain an ideal contour for the marginal gingiva. The “black triangle” or “open gingival embrasures” is a kind of esthetic defect that can occur at the interproximal area owing to interdental papilla loss. Interdental papilla will fill completely the interproximal area (100%) if the distance between the top of alveolar bone and proximal contact is 5 millimeters or less.8 On the basis of this theory, prosthodontists have tried to use interim crowns to induce the growth of interdental papilla to fill the triangle areas.9 However, handmade interim crowns that have a rough cervical margin may not only do harm to the health of the gingival tissue but also may influence the contour of the marginal gingiva. In comparison with handmade crowns, crowns made by means of CAD and computer-aided manufacturing (CAD/CAM), which have a smooth cervical margin and precise cervical contour, will keep the gingiva free of inflammation and help shape precisely the contour of the marginal gingiva. In this report, we describe the case of a female patient who had gingival inflammation and an asymmetrical contour of the marginal gingiva of the anterior maxillary teeth because the ceramic crowns had violated the biological width. To assist in the successful rebuilding of the patient’s marginal gingiva, we made a 3D-printing template and interim crowns by using CAD/CAM strategies. In our case report, we describe the fully digitized technique that we used to rebuild the contour of the marginal gingiva in the esthetic zone. CASE REPORT
The ethics committee of the Hospital of Stomatology, China Medical University, Shenyang, Liaoning Province,
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China (2013 Ethics Check No. 12), approved this case report. A 30-year-old female patient had red, swollen labial gingiva of the anterior maxillary teeth (nos. 11, 21, and 22); she reported that, 10 years previously, a clinician had treated these teeth by placing ceramic crowns. The patient was not a smoker and was in good physical condition. After the clinician had placed the ceramic crowns, the patient repeatedly experienced inflamed gingival tissue, and the tissue had been inflamed severely during the previous 2 years. At the first visit, we recorded the patient’s periodontal condition (Figure 1 and eFigure 1, available online at the end of this article) and performed a periodontal examination (eFigure 2, available online at the end of this article) by means of using the Florida Probe System (Florida Probe). We found that the labial subgingival shoulders were approximately 3.0 to 4.0 mm under the gingival margins, whereas the lingual shoulders were above the gingival margins. The splint restoration of the anterior teeth made it difficult for the patient to clean the interdental zone. The radiograph obtained of the anterior maxillary teeth indicated gross open margins of the restoration, which may have retained more dental plaque and contributed to the inflamed gingiva (eFigure 3, available online at the end of this article). In addition, the radiograph indicated that the endodontic therapy had failed (eFigure 3, available online at the end of this article). Treatment process. We obtained informed consent from the patient before beginning therapy. The treatment procedures were as follows: - We removed the fixed denture of the anterior maxillary teeth and performed initial full-mouth periodontal therapy. We carefully performed supragingival and subgingival scaling with ultrasonic instruments (Piezon Master 700, Electro Medical Systems) and Gracey curettes (Hu-Friedy) to remove the dental plaque and the calculus. At the same time, we debrided some of the granulation tissue of the inflamed gingiva. We also irrigated the gingival pockets with a 3% hydrogen peroxide solution to remove the residual calculus and soft tissue. Finally, we put an iodine glycerol agent into the pockets to inhibit the bacteria growth. We also provided the patient with instruction related to careful oral hygiene to teach her how to brush her teeth and use dental flosses and interdental brushes. - We performed endodontic therapy on teeth nos. 11, 21, and 22 (eFigure 3, available online at the end of this article).
ABBREVIATION KEY. 3D: Three-dimensional. C: Labial central sites. CAD: Computer-aided design. CAM: Computeraided manufacturing. CLS: Crown-lengthening surgery. D: Labial distal sites. L: Lingual sites. M: Labial mesial sites. RP: Rapid prototyping.
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TABLE 1 One month after the initial periodontal Distances between the gingival shoulders and the therapy, we found that corresponding gingival margin sites 1 month after the initial the subgingival shoulders were located from periodontal therapy. 1.0 mm to 2.5 mm VARIABLE TOOTH NO. under the gingival 11 21 22 margin (Table 1). We Site D* C† M‡ L§ D C M L D C M L performed gingivo¶ 1.5 1.0 1.5 0.5 1.5 1.5 2.5 1.0 1.5 1.5 1.5 1.0 Distance, millimeters plasty combined with * D: Labial distal sites. CLS, as guided by † C: Labial central sites. means of using a ‡ M: Labial mesial sites. § L: Lingual sites. 3D-printing template, ¶ Positive values indicate subgingival shoulders; negative values indicate supragingival shoulders. to obtain an esthetic contour of the marTABLE 2 ginal gingiva and to expose the subgingival Distances between the gingival shoulders and the shoulders. During the corresponding crests of the alveolar bones, as measured surgery, we found that during surgery. the distances between the labial gingival VARIABLE TOOTH NO. shoulders and the 11 21 22 crests of alveolar bone Site M‡ L§ D C M L D C M L D* C† were from 0.5 to 2.5 Distance, millimeters 2.5 1.5 2.5 3.5 2.5 2.5 0.5 4.0 1.5 2.5 2.5 4.0 mm (Table 2), which * D: Labial distal sites. suggested that the † C: Labial central sites. previously placed ‡ M: Labial mesial sites. § L: Lingual sites. crowns had violated the biological width to a severe degree. - One month after the surgery, we restored the CAD/ CAM interim crowns to induce interdental papilla and to shape the contour of the marginal gingiva. - Five months after the gingiva induction, we placed permanent zirconia ceramic crowns. Preparation of the 3D-printing template. One month after the initial therapy, we used the 3D-printing technique to obtain the precise surgery template. We used the following procedure: - Before surgery, we took digital photos of the patient’s Figure 2. The 3-dimensional–printing template, designed by means of dentition and face while she was smiling. We recorded using Geomagic Studio 11.0 software (Geomagic Studio, Software the distances between the gingival shoulders and the Informer) for the crown-lengthening surgery. gingival margins. We prepared the alginate impression of the dentition and the plaster molds. - We obtained point cloud data related to the plaster - We determined the template area (eFigure 4, available molds by means of using a laser scanner (D700, 3Shape). online at the end of this article). - We designed the gingival curves by means of using - We transferred the data to the rapid prototyping reverse engineering software Geomagic Studio 11.0 machine (Objet 350 Connex1, Stratasys) to print the (Geomagic Studio, Software Informer) (Figure 2, template. The template thickness was 1.0 mm. eFigure 4, available online at the end of this article). To CLS guided with the 3D-printing template. Before do this, we set up the coordinate system and the occlusal we performed the CLS, we rinsed the 3D-printing template in a povidone-iodine solution for 10 minutes plane, designed the mark points of the final gingival curve, constructed the 3D gingival margin curve, tuned and then washed the template with normal saline. We the mark points, and made horizontal flips of the performed the surgery by means of using the standard procedure. During the surgery, we put the template on gingival curve to obtain the symmetrical curve of the contralateral counterpart tooth. the teeth to guide the gingivectomy and ostectomy -
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Figure 3. The 3-dimensional–printing template guided the authors during the crown-lengthening surgery as they trimmed both the gingiva and the alveolar bone.
Interdental papilla induction with interim CAD/ CAM crowns. We designed the interim crowns (PMMA DISK, Yamahachi Dental) and made them by means of using a CAD/CAM (inLab, Sirona) system. We placed the crowns 1 month after we completed the CLS. We set the contact points according to the Tarnow principle,8 between the teeth and within 5 mm above the crest of interdental alveolar bone (Figure 5 and eFigure 6, available online at the end of this article). Five months after the induction of the crowns, we noted that the zenith location of the interdental papilla between the incisors was displaced coronally by 0.5 to 1.0 mm (Table 3). The interdental triangles between the incisors disappeared after the induction (Figure 6 and eFigure 6, available online at the end of this article). Five months after the gingiva induction, we placed the permanent zirconia-based crown (Zenostar, Wieland Dental) (Figure 7 and eFigure 7, available online at the end of this article). Seven months after we placed the crowns, we noted that the marginal gingiva was in good condition and that the black triangles had disappeared completely (Figure 8 and eFigure 7, available online at the end of this article). DISCUSSION
Figure 4. Appearance of the marginal gingiva of the anterior maxillary teeth 1 month after crown-lengthening surgery.
Figure 5. Interim computer-aided design and computer-aided manufacturing crowns placed to induce and shape the interdental papilla.
(Figure 3 and eFigure 5, available online at the end of this article). One month after the CLS, we noted that the patient’s gingiva had no inflammation. In addition, we noted that the contour of the marginal gingiva was symmetrical and well-balanced (Figure 4).
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Precise therapy using mainly computer-assisted techniques is replacing the traditional style of therapy, which relied on surgery by hand and observation with the naked eye. In the past, dentists prepared handmade surgery templates composed of various materials.3,4,10-12 In our case study, we described our use of a 3D-printing template on the basis of CAD and RP technology. We used Geomagic Studio software to design the marginal gingiva contour. The clinical outcome of our patient’s case was satisfactory. Geomagic Studio is a reverseengineering software that has been used frequently in oral clinical practice.13,14 The software can generate accurate digital models according to point cloud data from 3D objects. We used the software to modify quickly and preview the contour of the marginal gingiva. Then we transferred the data to the 3D printer to obtain accurate surgical templates. Compared with handmade templates, we found that 3D-printed templates have more advantages; the most beneficial advantage is that 3D-printing templates are more accurate and symmetrical. We also found it easier to design and modify the gingival curve by means of using computer software. Finally, 3D-printing templates are thinner and more uniform. In conclusion, 3D-printing templates can help dentists perform precise surgery and help patients obtain a more symmetrical and wellbalanced gingival margin. The formation of a black triangle, which results from the loss of the interdental papilla, is an important factor
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TABLE 3
Distance of the coronal displacement of the zenith of the interdental papilla, as measured 5 months after placement of an interim computer-aided design and computer-aided manufacturing crown restoration. VARIABLE
TOOTH NO. 11
12
21
Site
D*
M†
D
M
D
M
Distance, millimeters
0.5
1.0
1.0
1.5
1.5
0.5
* D: Labial distal sites. † M: Labial mesial sites.
Figure 6. Three months after the gingival induction by the interim computer-aided design and computer-aided manufacturing crowns, the black triangles could not be seen.
Figure 7. Five months after the gingiva induction, permanent zirconia ceramic crowns were placed.
that affects the esthetic appearance of the anterior maxillary teeth.15 Factors contributing to the formation of black triangles include periodontal biotypes,16 distances between the roots,17 locations of contact points, periodontitis, and periodontal therapy such as CLS. There are 2 ways to correct black triangles: surgical methods and nonsurgical methods. Surgical methods include a coronally repositioned flap combined with subepithelial
Figure 8. Seven months after placement of the final restoration, no black triangles could be seen.
connective tissue graft18,19 or a free gingival flap graft.20 Nonsurgical methods include rebuilding of the interdental papilla by means of placing interim crowns9,21 or orthodontic treatment.21 In our patient, we used interim CAD/CAM crowns to rebuild interdental papilla, and we designed the distances from the contact points to the alveolar bone crests to be less than 5 mm on the basis of the results of the study by Tarnow and colleagues8 in 1992. Using CAD/CAM interim crowns has 2 advantages. First, because they are designed and produced by computer software, the edges of the CAD/CAM crowns can be thinner and smoother than those of handmade crowns. Therefore, the interim CAD/CAM crowns are less likely to retain bacterial plaque. Second, the contour of the cervical line designed by computer software can be more accurate, which can guide the growth of interdental papilla more precisely. In this case, we placed interim CAD/CAM crowns to induce and shape the marginal gingiva contour. Consequently, we noted that the interdental papilla was displaced coronally by 0.5 to 1.5 mm and had a symmetrical and well-balanced appearance. In conclusion, the use of an interim CAD/CAM crown can reduce black triangles effectively, shape the marginal gingiva curve accurately, and maintain the patient’s periodontal health. For this patient, our approach to provide thorough initial periodontal therapy greatly improved the patient’s
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gingival color, shape, and texture; the periodontal therapy we provided also eliminated the gingival inflammation. We have noted that, with this basis of healthy gingiva, the patient’s marginal gingiva position has remained stable. Investigators have reported that initial periodontal therapy induces the recovery of interdental papilla.22 Therefore, the initial periodontal therapy is essential and important for both the healthy and esthetic appearance of the gingival tissue. In the case of this patient, the periodontists (X.T.) provided thorough initial periodontal therapy and performed precise CLS, and the prosthodontists (J.Y.) completed the interim and final crown restoration. The results of our case indicate that close interdisciplinary cooperation is necessary for a good clinical outcome. We noted a minor defect. After we placed the final restoration, we saw that the zenith of the left central incisor was a little higher than the right central incisor. We think that this minor defect may have occurred as a result of the complicated gingival healing process. According to the results of previously published studies, the location of the gingival margin after periodontal surgery can be influenced by many factors, including gingiva thickness or periodontal biotype23 as well as different biological width.24 In the future, we will consider all these possible factors and try to improve the symmetry of the gingival curve in clinical practice. In addition, we believe that clinicians should study more cases like the one we present to continue to improve treatment outcomes and gain more experience in the design and manufacture of surgical templates. CONCLUSIONS
The use of 3D-printing templates can guide clinicians as they perform precise CLS. Interim CAD/CAM crowns can be used to induce the growth of interdental papilla and maintain healthy gingiva. The results of our case report illustrate that it can be helpful for clinicians to use CAD/ CAM techniques for patients whose treatment requires rebuilding of an ideal contour of the marginal gingiva in the esthetic zone, such as in the anterior maxillary teeth. n SUPPLEMENTAL DATA
Supplemental data related to this article can be found at http://dx.doi.org/10.1016/j.adaj.2017.03.003. Dr. Yin is a prosthodontist, Department of Prosthodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Liu is an MSD candidate, Department of Periodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Huang is an MSD candidate, Department of Periodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Wu is a professor and a prosthodontist, Department of Prosthodontics, School of Stomatology, China Medical University, Shenyang, Liaoning Province, China. Dr. Tang is a professor and a periodontist, Department of Periodontics, School of Stomatology, China Medical University, 117 Nanjingbeijie, Heping District, Shenyang, Liaoning Province 110002, China, e-mail xltang@cmu. edu.cn. Address correspondence to Dr. Tang.
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Disclosure. None of the authors reported any disclosures. This study was supported by grants from the Clinical New Technique Program of the School of Stomatology, China Medical University (2009-2), Shenyang, Liaoning Province, China. Drs. Yin and Liu contributed equally to this article. 1. Hempton TJ, Dominici JT. Contemporary crown-lengthening therapy: a review. JADA. 2010;141(6):647-655. 2. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol. 1961;32(3):261-267. 3. Malik K, Tabiat-Pour S. The use of a diagnostic wax set-up in aesthetic cases involving crown lengthening: a case report. Dent Update. 2010;37(5): 303-304, 306-307. 4. Frizzera F, Pigossi SC, Tonetto MR, Kabbach W, Marcantonio E Jr. Predictable interproximal tissue removal with a surgical stent. J Prosthet Dent. 2014;112(4):727-730. 5. Chana-Rodriguez F, Mananes RP, Rojo-Manaute J, Gil P, MartinezGomiz JM, Vaquero-Martin J. 3D surgical printing and pre contoured plates for acetabular fractures. Injury. 2016;47(11):2507-2511. 6. Giannopoulos AA, Mitsouras D, Yoo SJ, Liu PP, Chatzizisis YS, Rybicki FJ. Applications of 3D printing in cardiovascular diseases. Nat Rev Cardiol. 2016;13(12):701-718. 7. Zhao YB, Wu L, Tang XL, Guo C. Computer aided design and computer aided manufacture of template for crown lengthening [in Chinese]. Shanghai Kou Qiang Yi Xue. 2013;22(4):443-447. 8. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-996. 9. Le D, Hu WJ, Zhang H. Combined crown lengthening surgery with restorative therapy for inducing papilla growth: a case report [in Chinese]. Beijing Da Xue Xue Bao. 2013;45(2):312-315. 10. Borges I Jr, Ribas TR, Duarte PM. Guided esthetic crown lengthening: case reports. Gen Dent. 2009;57(6):666-671. 11. Scutella F, Landi L, Stellino G, Morgano SM. Surgical template for crown lengthening: a clinical report. J Prosthet Dent. 1999;82(3):253-256. 12. Walker M, Hansen P. Template for surgical crown lengthening: fabrication technique. J Prosthodont. 1998;7(4):265-267. 13. Franco A, Willems G, Couto Souza PH, Coucke W, Thevissen P. Three-dimensional validation of the impact of the quantity of teeth or tooth parts on the morphological difference between twin dentitions. J Forensic Odontostomatol. 2016;1(34):27-37. 14. Yan R, Luo D, Qin X, Li R, Rong Q, Hu M. Digital modeling for the individual mandibular 3D mesh scaffold based on 3D printing technology [in Chinese]. Zhonghua Kou Qiang Yi Xue Za Zhi. 2016;51(5):280-285. 15. Singh VP, Uppoor AS, Nayak DG, Shah D. Black triangle dilemma and its management in esthetic dentistry. Dent Res J (Isfahan). 2013;10(3):296-301. 16. Ahmad I. Anterior dental aesthetics: gingival perspective. Br Dent J. 2005;199(4):195-202. 17. Tal H. Relationship between the interproximal distance of roots and the prevalence of intrabony pockets. J Periodontol. 1984;55(10):604-607. 18. Azzi R, Takei HH, Etienne D, Carranza FA. Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts. Int J Periodontics Restorative Dent. 2001;21(2):141-147. 19. Kaushik A, Pk P, Jhamb K, et al. Clinical evaluation of papilla reconstruction using subepithelial connective tissue graft. J Clin Diagn Res. 2014;8(9):ZC77-ZC81. 20. Rebaudi A, Massei G, Trisi P, Calvari F. A new technique for bone augmentation and papilla reconstruction with autogenous free gingivalbone grafts. Int J Periodontics Restorative Dent. 2007;27(5):429-439. 21. Sato S, Nomura N, Kawashima H, Ito K. Creation of a nonsurgical papilla in orthodontic treatment with severe periodontal disease: a case report. Quintessence Int. 2007;38(4):e218-e221. 22. Yanagishita Y, Yoshino K, Taniguchi Y, Yoda Y, Matsukubo T. Nonsurgical recovery of interdental papillae under supportive periodontal therapy. Bull Tokyo Dent Coll. 2012;53(3):141-146. 23. Pontoriero R, Carnevale G. Surgical crown lengthening: a 12-month clinical wound healing study. J Periodontol. 2001;72(7):841-848. 24. Rasouli Ghahroudi AA, Khorsand A, Yaghobee S, Haghighati F. Is biologic width of anterior and posterior teeth similar? Acta Med Iran. 2014; 52(9):697-702.
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eFigure 1. Photos of the anterior maxillary teeth before the initial periodontal therapy. A. Before the ceramic crowns were removed. B. After the crowns were removed (labial side). C. After the ceramic crowns were removed (incisal side).
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eFigure 2. Periodontal charts created by using the Florida Probe System (Florida Probe). A. At first visit. B. One month after the initial periodontal therapy. C. One week after the permanent crowns were placed. D. Seven months after the crowns were placed. GM: Gingiva margin.
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eFigure 2. Continued
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eFigure 2. Continued
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eFigure 2. Continued
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eFigure 3. Radiographs of the endodontic therapy. A. At first visit. B. Immediately after endodontic therapy.
eFigure 4. Images of the 3-dimensional–printing template designed for the crown-lengthening surgery. A. Designing the gingival margin contour. B. Outlining the template area (labial side). C. Outlining the template area (incisal side). D. Completed template.
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eFigure 5. Photos indicating how the 3-dimensional (3D)–printing template helped the clinicians guide the crown-lengthening surgery to trim both the gingiva and the alveolar bone. A. Labial appearance of the anterior teeth before surgery. B. Preview of the 3D-printing template. C. Surgery being performed with the guidance of the 3D-printing template. D. Final suturing.
eFigure 6. Photos of the interdental papilla induced with interim computer-aided design and computer-aided manufacturing crowns. A. Appearance of the anterior maxillary teeth 1 month after surgery. B. Interim computer-aided design and computer-aided manufacturing crowns, as prepared to induce and shape interdental papilla. C. Appearance of the anterior maxillary teeth after the temporary crowns were placed immediately. D. Three months after the placement of the temporary crowns.
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eFigure 7. Photos indicating the appearance of the gingiva after the final restoration. A. Immediately after the permanent crowns were placed. B. Seven months after the final restorations were placed (labial side). C. Seven months after the final restorations were placed (lingual side). D. Seven months after the final restorations were placed (smile view).
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