Model-Guided Soft Tissue Augmentation

Eric Van Dooren, DDS1

Cristiano Soares, CDT2
Nitzan Bichacho, DMD3
Gustavo Giordani, DDS4
Victor Clavijo, DDS, MSc, PhD5
Leonardo Bocabella, CDT6

T CASE REPORT
he main challenge in modern esthetic dentistry
is to simplify procedures while improving their
predictability. Many articles and case reports A 50-year-old female patient presented with an old,
show excellent esthetic results, but often the treat- deficient three-unit ceramometal fixed prosthesis (Fig
ment modalities are difficult to understand and follow. 1). At clinical evaluation, both the maxillary left cen-
This article presents a case report to describe a new tral incisor and canine teeth were vital, no periodontal
technique for optimizing and simplifying the fabrica- pockets were detectable, and the patient’s oral hy-
tion of a three-unit fixed prosthesis with predictable giene was acceptable. The patient wished to have the
soft tissue augmentation for a pontic site. The “realis- existing prosthesis replaced without the use of dental
tic” model-based soft tissue augmentation predictably implants. As the patient’s lifestyle involved extensive
guides the surgical and prosthetic procedures. travel, she declined orthodontics and preferred treat-
ment that would require a minimal number of appoint-
ments.
Without proper diagnosis and treatment planning,
the esthetic results for this or any patient might be
1
Private Practice Limited to Periodontics, Fixed Prosthdontics, and
Implants, Antwerp, Belgium; Visiting Professor, University of Liege, disappointing and unacceptable for both dentist and
Belgium, and University of Marseille, France. patient. Therefore, clinical/photographic documenta-
2
Dental Technician, Campinas, Brazil.
tion is mandatory. A proper sequence of intraoral and
3
Professor and Head, R.E. Goldstein Center for Aesthetic Dentistry
and Clinical Research, Department of Prosthodontics, Faculty of smile photographs are the minimal prerequisites for
Dentistry, Hebrew University–Hadassah, Jerusalem, Israel. proper digital and clinical treatment planning (Fig 2).
4
Oral and Maxillofacial Surgeon, São Paulo, Brazil. Additionally, photographs and a video of the full face
5
Private Practice, São Paulo, Brazil.
need to be taken to relate the teeth to the face (Fig 3).
6
Dental Technician, Campinas, Brazil.
Although a digital smile design or semi-mathematical
Correspondence to: Dr Eric Van Dooren, Tavernierkaai 2, 2000 approach (with ideal/golden proportions) of the future
Antwerp, Belgium. Email: vandoorendent@[Link] restoration can be planned on the computer screen, a

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 VAN DOOREN ET AL

CASE REPORT

2 3

4a

Fig 1 Deficient three-unit ceramo-

metal fixed prosthesis in situ.
Fig 2 Preoperative full face
photograph.
Fig 3 Sequence of preoperative
smile photographs.
Fig 4a Simplified digital planning.
Fig 4b Digital smile design
planning.
4b

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 Model-Guided Soft Tissue Augmentation

5 6 7

Figs 5 to 9 Initial wax-up and

prosthetic design.

8 9

simplified digital approach will assist considerably in 7. Surgical procedure and placement of the definitive
analyzing the limitations of the case. In fact, this pre- restoration
treatment analysis is of primary importance in order to 8. Healing and maturation of the surgical site around
avoid future disappointing results. Drawing simple lines the restoration margins and outlines
can provide valuable information regarding papilla
heights, eventual midline shift, and gingival/incisal
levels (Fig 4). Initial Wax-up
The treatment plan in this case was to replace the
three-unit ceramometal prosthesis with an all-ceramic In the model-guided soft tissue augmentation proto-
restoration and to perform soft tissue augmentation, col, the first step is a precise silicone impression (vinyl
with a connective tissue graft, of the pontic recipient polysiloxane or polyether) and fabrication of two ac-
site. However, the sequence and the timing of the sur- curate plaster casts. Alginate impressions are not pre-
gical and prosthetic treatments of the case are com- cise enough for this procedure. The soft tissue con-
pletely different from conventional soft tissue augmen- tour, gingival margin, root contour, and tooth form
tation treatment sequences. should be clearly visible on all teeth.
The sequence for model-guided soft tissue aug- On the first model, the dental technician defines
mentation is simple and straightforward: and sculpts final teeth forms in harmony with the con-
tralateral side. In the present case, the teeth forms
1. Initial wax-up or prosthetic design were sculpted with a bur and a subtle wax-up opti-
2. Removal of the old restoration and intraoral mock- mized the forms. At this stage, the main objective is
up, followed by a provisional prosthesis for esthetic to create harmony in the prosthetic forms between the
and functional evaluation left and right sides (Figs 5 to 7).
3. Final preparation of teeth and final impression Because of the significant labial inclination of the
4. “Realistic” model-based wax-up and “soft tissue maxillary left central incisor (crown and root), the tech-
augmentation” on the final model nician altered the marginal gingival soft tissue thick-
5. Development of the ideal 3D pontic recipient site ness on the model. This can be seen by looking at the
on the model models from different angles. A “perfect asymmetry”
6. Fabrication of the final ideal restoration in design was achieved (Figs 8 and 9).

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Fig 10 Initial preparations.

Fig 11 Supragingival
preparation of the maxil-
lary left lateral incisor.
10 11

12 13

14

Fig 12 Provisional prosthesis in situ for functional and esthetic evaluation.

Fig 13 Retraction cord in place for final impression.
Fig 14 Optical impression and CAD/CAM designing.

Prosthesis Removal and Provisional preparation level was related to the marginal soft tis-
sue level of the contralateral side (Figs 10 and 11).
Fabrication
When measuring the thickness of the provisional re-
A silicone key was fabricated from the original wax-up tainers, it became evident that endodontic treatment
to be used to evaluate esthetics and function with a of the maxillary right central incisor was necessary to
mock-up and later with a provisional restoration. The create enough space for the final restorative material.
patient’s prosthesis was removed and care was taken This was necessary because the patient had declined
to make initial supragingival preparations. The new orthodontic movement of the tooth. As the buccal

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 Model-Guided Soft Tissue Augmentation

15 16

Fig 15 Original stone

cast.
Figs 16 and 17 Real-
istic wax-up and soft
tissue augmentation.
Fig 18 Working model
after duplication.
17 18

contour of the tooth was altered on the original model Soft Tissue Augmentation on the Final
by the dental technician, the buccal contour was also
Model
flattened clinically by using a bur from the new supra-
gingval outline up to the intracrevicular level (Fig 12). Two casts were poured, and on one of thm the dental
technician made a realistic soft tissue wax-up in order
to obtain the ideal 3D pontic recipient site. It is im-
Final Preparation of Teeth and portant for the dental technician to compare the wax-
Final Impression up and the soft tissue contour and volume with the
contralateral side and to try to simulate a “realistic”
One week after teeth preparation, and with optimal soft tissue augmentation (Figs 15 to 18). This analysis
soft tissue conditions, final impressions were made. A should be done together with the dentist.
double retraction cord technique was used to ensure The wax-up model was duplicated to provide a
optimal precision and soft tissue conditioning (Fig 13). working model with the same soft tissue dimensions.
To prevent possible entrapment of thin remnants of An ideal wax-up for the three-unit prosthesis was fab-
the impression material in the sulci, the traditional im- ricated. Buccal and occlusal silicone indices were used
pression technique was used (Impregum/Permadyn, to copy as much as possible the original model, for
3M ESPE, St Paul, Minnesota, USA); however, optical which the overall design, tooth forms, and incisal edge
impressions, CAD/CAM design, and 3D printing of position approved by the patient at the initial evalua-
models will become the standard in the near future tion served as guidelines, but this time the focus was
(Fig 14). to get the ideal 3D relation of the pontic to the model-

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 VAN DOOREN ET AL

19

20 21 22

Figs 19 and 20 Ideal 3D relation of the pontic to the model.

Fig 21 Relation of pontic before model-based augmentation.
Fig 22 Relation of pontic after model-based augmentation.

based augmented area (Figs 19 and 20). Placing the used when working with implant prosthetics and soft
wax-up on the model before and after model-based tissue conditioning.
augmentation and duplication clearly demonstrates Once the blue line, and thus the most buccal posi-
the difference in 3D pontic position and soft tissue tion of the pontic, was defined on the model, the full
contours (Figs 21 and 22). pontic contour was designed with a black pencil and
refined with a round diamond bur (Figs 26 to 28). Now
that the ideal contour, position, and form of the pontic
Ideal 3D Pontic Recipient Site on the Final were defined, the definitive ceramic restoration could
Model be fabricated.

Once the wax-up was fabricated on the working mod-

el, an optimal pontic recipient site was created. To vis- Fabrication of the Definitive Restoration
ualize the ideal buccal contour on the model before
carving the model with a bur, a buccal silicone index A definitive three-unit [Link] Press prosthesis (Ivoclar,
was made. In this index, the line that expressed the Schaan, Liechtenstein) was fabricated, respecting the
transition between ideal pontic position (wax-up) and ideal soft tissue position and contour. Care was taken
ideal but realistic model-augmented soft tissue volume to relate the framework design to the final tooth forms
was colored with a blue pencil and pressed against the and to optimize the support for the veneering porce-
model (Figs 23 and 24). The blue line on the model lain. The size of the connectors was important to mini-
represented the ideal emergence line for the pontic mize postoperative porcelain chipping and framework
as well as the point were the pontic would support the fractures (Figs 29 to 31).
soft tissue in an ideal way after the surgical soft tissue The framework was layered with [Link] Ceram
augmentation (Fig 25). The same concept should be porcelain, with attention placed on creating optical

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 Model-Guided Soft Tissue Augmentation

Figs 23 to 25 Application of blue pencil to

define the ideal buccal emergence line.

23 24 25

26 27 28

Fig 26 Designing the full-contour pontic design.

Fig 27 Refining the pontic design with a diamond bur.
Fig 28 Ideal 3D pontic design.

29 30 31

Figs 29 and 30 Relating the framework design to the final tooth form.
Fig 31 Three-unit [Link] Press framework.

illusion effects by optimizing the line angle position, face were obtained using disks and burs (Figs 33 to
form, surface texture, space distribution, and light re- 35). From a prosthetic point of view, the most difficult
flection (Fig 32). As an alternative, one could choose a part of this case was to match a unilateral defect and a
monolithic framework, with only buccal layering, or a three-unit prosthesis to the contralateral side consist-
zirconia framework. The optical properties of the sur- ing of single natural teeth with optimal contours.

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32 33

34 35

Fig 32 Layering with [Link] Ceram porcelain.

Fig 33 Defining embrasure size.
Fig 34 Optimizing line angle position and light reflection.
Fig 35 Final three-unit prosthesis.

Connective Tissue Grafting and Prosthesis When cementing the prosthesis, care was taken to
ensure that the buccal-gingival aspect of the pontic
Cementation
would produce the proper prosthetic support to the
incision line and the grafted area. Retraction cords
A connective tissue graft was harvested from the tuber- were placed before cementation to protect the sulci of
osity region. The graft was reshaped to fit the pouch, the abutment teeth.
and the de-epithelialized tissue was removed (Fig 36). The three-unit prosthesis was adhesively cemented
An ophthalmological surgical blade was used to make with a dual-cure composite cement (Variolink 2, Ivo-
a semilunar crestal incision, and a split-thickness pouch clar) and all excess cement was removed (Fig 40).
was made as a recipient site for the graft (Fig 37). The sutures were removed after 1 week (Fig 41),
The incision was planned to be a copy of the blue and the patient was given proper hygiene instructions.
line on the model and should become the gingival Healing was uneventful, and the esthetic outcome and
ledge to be supported by the gingival aspect of the gingival adaptation clearly improved in time. After 1
pontic design. The graft was sutured with two sutures year, papilla heights improved, gingival stippling im-
(Seralene 6/0, American Dental Systems, Vaterstetten, proved, and the prosthetic soft tissue support was op-
Germany) (Figs 38 and 39). timal (Figs 42 and 43).

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36 37

38 39

40 41

Fig 36 Connective tissue graft harvested from the tuberosity region.

Fig 37 Semilunar crestal incision.
Fig 38 Suturing the graft.
Fig 39 Ensuring proper prosthetic support for the graft.
Fig 40 Clinical situation after cementation.
Fig 41 One-week postoperative photograph.

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Fig 42 One-year postoperative photograph.

Fig 43 Maturation and stippling of the grafted site.

42 43

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