Correcting Soft-Tissue Deficiencies Without Surgery
Inside Dentistry provides the latest in endodontics, implantology, periodontics, and more, with in-depth articles, expert videos, and top industry insights.
April 1, 2024
Volume 20, Issue 4, April 2024
Page(s): p. 38
Neville Hatfield, DMD
Most of us have seen cases involving prosthetics that incorporate pink porcelain to cover large defects in a patient's periodontium.1-3 Typically, these cases are extremely difficult to execute, and they often require specialized porcelain work from a master laboratory technician, which can be costly. In the world of everyday dentistry, clinicians have to work within the confines of their patients' budgets and wishes. For certain cases in which patients cannot afford ideal treatment or for which ideal treatment must be delayed, it would behoove clinicians to think beyond the scope of their regular armamentaria and use pink composite. Although pink composite is most often used to cover screw access holes in fixed, implant-supported full-arch prostheses or as a communication tool during the temporization phase of prosthetic work that will require pink porcelain,4,5 other cases in which it is commonly used include those involving areas of gingival recession with exposed root surfaces in the esthetic zone. Ideally, most of these cases should be referred to a periodontist for a surgical connective tissue graft procedure. However, the use of pink composite can provide an alternative esthetic solution that is more affordable and requires less time.
One such case just recently presented itself when an 84-year-old female patient asked in a recall examination about treatment to improve the esthetics of her front teeth. Her granddaughter was having an upcoming baby shower, and she was worried about looking her best for it. More ideal treatment options were discussed with the patient, but simply put, her wishes, budget, and time constraints did not allow for a more substantial intervention. As such, a treatment plan to improve the esthetics of her maxillary anterior teeth with tooth-colored and gingiva-shade composites was presented and accepted.
The patient's dentition exhibited significant marginal staining and decay, several areas of recurrent decay around previously placed restorations, and severe crowding and malrotation (Figure 1). Regarding the patient's maxillary anterior teeth, it was noted that her gingival zenith lines were uneven and set more apically on teeth Nos. 6, 7, 8, 9, and 11 than what would be typical for a healthy dentition. Tooth No. 10 would not be included in the restorative plan because its gingival zenith was within an acceptable range.
To begin, shade matching procedures were performed for both the tooth-colored composite (Figure 2) and the gingiva-shade composite (Figure 3). For the gingival composite, a test amount was placed, without etching or bonding, in a thickness anticipated to properly match the shade of the patient's gingiva and then light cured. Whether the shade appeared to be too low or too high in chroma (ie, "depth" of color) was indicative of whether material would need to be added or taken away for the final restoration. Once the appropriate shades were determined, all of the old restorations were removed from teeth Nos. 6, 7, 8, 9, and 11 along with any decay (Figure 4). A 38% phosphoric acid etchant was applied onto and just past the edges of the surfaces being restored for 15 seconds (Figure 5). The etchant was subsequently rinsed, and a bonding agent (BeautiBond®, Shofu) was scrubbed into the areas for 20 seconds per the manufacturer's directions. The bonding agent was then air thinned and light cured for 10 seconds per tooth.
After the chosen tooth-colored composite (Beautifil® II [A1], Shofu) was heated on a warmer, it was placed in increments onto the facial surfaces of teeth Nos. 6, 7, 8, and 9 (Figure 6). This composite was chosen because of its inclusion of Giomer Technology, a proprietary bioactive filler that releases six different beneficial ions, including fluoride, to help prevent plaque formation and recurrent decay. It also demonstrates excellent polishability, radiopacity, and a slight chameleon effect to help it blend in with existing tooth structure. Once placed, the composite was shaped into an emergence appropriate for each tooth and to accept pink composite (Figure 7).
Next, the gingiva-shade composite (Beautifil® II Gingiva [Light Pink], Shofu) was added and shaped to the appropriate buccal emergence in confluence with the natural soft tissue (Figure 8). This gingival composite was selected not only for its inclusion of Giomer Technology but also because its range of five different base shades can be combined to allow for 15 total gingival shade variations.
When using pink composites, it is important to create a margin that has a definitive "roll" at the end that is similar to how a natural gingival collar abuts the tooth in a healthy periodontium. Another important detail in the application of pink composite is determining how much depth to add to the preparation to allow for the appropriate thickness for the shade to blend in appropriately.
Most of the shaping and all of the polishing in this case was completed with a system of finishing and polishing disks (Super-Snap®, Shofu). By going through the progression of disks and finishing with a polishing paste (Direct Dia Paste, Shofu), an incredibly lifelike luster was achieved. The highly polished surfaces combined with the bioactivity of the selected composites will help to prevent the development of marginal staining and recurrent caries that is commonly seen with composite restorations.
After 3 days, the patient returned to the practice for evaluation. The soft tissue was remodeling but demonstrated postoperative petechial hemorrhage. The patient was taking a blood thinner, so she was at a higher risk of experiencing postoperative bleeding and prolonged healing. After continued gingival healing, the petechiae will disappear, and the color of the pink composite will blend better with that of the surrounding soft tissue.
In this case, gingiva-shade composite enabled a clinically acceptable treatment alternative to heavy prosthetic and periodontal work that resolved the patient's chief complaint while remaining within her financial and time constraints. Pink composite is a highly underutilized tool that should be a part of all clinicians' armamentaria.
Neville Hatfield, DMD
Private Practice
Mahwah, New Jersey
Shofu Dental
shofu.com
800-827-4638
