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TOPICS OF INTEREST

The Esthetic Width in Fixed Prosthodontics


Pascal Magne, Dr Med Dent,' Michel MagneJ2and Urs Belser, Dr Med Den$

With the evolution of adhesive dentistry and the increasing use of porcelain veneers, single-unit
crowns generally are restricted t o the replacement of pre-existing full-coverage crowns and the
restoration of nonvital and/or severely damaged teeth. Porcelain-fused-to-metal restorations are
still widely used t o generate single-unit crowns and fixed partial dentures. Collarless metal-ceramic
restorations represent the most successful evolution among efforts t o meet maximum esthetic
requirements using porcelain-fused-to-metal restorations. Extended metal frameworks and opaque
aluminous ceramic cores are associated with unpleasant optical effects in the soft tissues
surrounding such restorations. This problem is particularly evident in the presence of the upper lip,
which can generate an "umbrella effect" characterized by gray marginal gingivae and dark
interdental papillae. Based on the concept of the biologic width, a systematic approach is proposed
for the elaboration of an "esthetic width," including: 1) positioning of preparation margins; 2)
reduction of the metal framework; and (cl appropriate marginal design of porcelain-fused-to-metal
restorations. Strategic features of pontics and a specific interdental design are suggested to
compensate for deficient anatomical features of the soft tissue and the edentulous ridge.
J Prosthod 1999;8:706-178.Copyright o 1999 by The American College of Prosthodontists.

INDEX WORDS: esthetics, porcelain-fused-to-metal, porcelain shoulder, framework design,


pontics, interdental design

F ORTHE RESTORATION of single vital teeth, a


contemporary approach generally includes adhe-
sively luted porcelain veneers.1-3Techniques for bond-
ics, and longcvity arc critical. Most important, the
definitive tooth-restoration complex seeks to ap-
proach the natural tooth condition from esthctic,
ing ceramic facings have been in use for more than 15 functional, and biomechanical perspectives.' 1-14 As
years, and numcrous clinical evaluation^^-^ have re- the indications for porcclain laminates continue to be
ported excellent performance in terms of fracture expanded,15-17the use of traditional cemented full-
rates, microleakagc, debonding, and soft tissue re- coverage crowns tends to be limited to two specific
sponse when such restorations are compared with situations: 1) restoration of severcly damaged teelh;
traditional complete-coverage restorations.'0 The and 2) replacement of existing fdlcoveragc rcstora-
combination of ceramics and composite luting mate- tions (Figs 1A-lC, 2A-2B). The quest for the ideal
rials permits optimal integration of the materials' system continues, with allccramic restorations com-
physical, biological, and esthetic properties. Among pcting with traditional metal ccramics. The success
these, adhesive properties, tissue prcscrvation, esthet- and integration of extended prosthetic rehabilita-
tions, however, is not simply a matter of' technical
' V i ~ t i n gAssobate Profpccor, LtfinrinnecotaDental Research Cenbr ,fur choicc (porcelain-fused-to-metal vcrsus allceramic).
Biomatwials and Biomrchaniw, Brpadmen t OJ Oral Science, School qf It is also related to the diagnostic and provisional
Dentis+, Un:niiwri@ 4iLfinnccota,MinneaFolis, Lcturer, Departmerd restoration phases,'"'" the importance or which is
ofProsthodontics and Uepadrnrnt fr Preoention and Therupeutics School cf often ovcrshadowed by the development of new
Dental Medicine, Uniuersih of Genxiia,Switzerland
2Ceramist,@a1 Design Center,Montreux, Suttz~iland.
ceramic systems.
3PrOJessm and Chairman, Department of Pmsthodontics, School uf Fixed partial dentures also may be fabrkated
Dental Medicine, brn:nizIersi@of Geneoa, Switzerland. using either ceramic or metal-ceramic tcchnologies.
AcceptedApnl15, 1999. Metal-ceramics remain the esthetic standard [or
Su@rted b thr Suiii Foundationfori~~edical-Biolo~~ul~~ur~ts and in
part !p the ;2r[irirumta Dental Rerearch Center ,boy Biomaterials and
fixed partial denture applications. The tcchnical
Bwmechanics (lo lh..&lop). aspects of metal-ceramic fixed partial dentures have
Corr@on.&nc~ to: Pucal M q n e , Dr. A M Ik.tit., 0 been significantlyimproved (eg,refinement of frame-
Gni.oelEcole de A&feVaineDenfaire, Dioision & Prot&.x corljmnte @ work design, interdental morphology, and an cx-
occlusodontir, 19, rue Basthilemy-Menn, CH-I211 (;mice 4, Suitzrland.
tendcd porcelain margin combined with lranslucent
E-mail. P a , c c a l , M q n e ( ~ m e & ~ ~ ~ . u n i ~ e . ~ t i
Cofysight 0 1999 b The AnieJican Colhge ofProsthohntists luting agents). Novel approaches have been devel-
I ~.59-~41Xl99l0802-000~$5.00/0 oped for framework fabrication such as capillary

106 Journal ofPosthodontiw; VXS. A6 2 (June), 1999:bl)106-118


June 1595, Volume 8, Xumber 2 107

pontics and associated ridge crests. Key aspects of


this integration are presented in the following sec-
tions. The importance of metal framework design in
light of biological considerations is discussed. Strate-
gic features of pontics and specific interdental de-
signs are suggcsted that will compensate for deficient
anatomical characteristics of soft tissues and edcntu-
lous ridges.

Biological Framework Design


The morphology and dimension of supracrestal peri-
odontal tissues undoubtedly represent the most im-
portant parameters to be taken into consideration in
designing a fixed prosthesis. This fact has been
widely acccpted since the definition of the “biological
width”. This original concept initially addressed the
length of the dentogingival unit.25 Respect for the
biologic width and proper placement of preparation
margins not only contribute to optimization of gingi-
val health,26,’7but also enhance the esthetic design of
the prosthesis. The rational use of these principles

Figure 1. The patient exhibits peg-shaped maxillar) lat-


eral incisors and a resin crown on the right maxillary
central incisor (-4). The existing crown was replaced by a
porcelain-fused-to-metal crown with an advanced de-
sign-an extended porcelain margin and reduced metal
framework, providing the niargin of the restoration with
maximum light transmission (B).The crown, as well as the
two porcelain laminates on the lateral incisors, were luted
with a composite resin (C).

technology and composite metals (platinum filler


and high-gold-contcnt matrix) .24
When properly constructed, metal-ceramic rcsto- Figure 2. Despite a supragingival margin, the periodontal
tissues are inflamed around this resin crown on the left
can be used a variety Of cenlr;tl irlcisor (A), Peri&rltal health and esthetics were
Furthermore, estheticall!; Pleasing results can be restored following improved oral hygiene and the place-
obtained with proper integration of metal-ceramic ment of a PFM crownmith an intrasulcular margin (B).
108 Esthetic Width in Fixed Prmthodantia a Ma~qne,Ma~qm,and Belser

Figure 4. A similar distance (respecting the biologic


width) should be reproduced when reducing a metal
framework for the placcrnent of porcelain margins.

leads to the introduction of the concept of the


“esthetic width.”

The Esthetic Width


Understanding the concept of esthetic width requires
consideration of the tooth preparation itself and, in
particular, placement of preparation margins.28329
The biologic width, which describes the location and
dimension of the connective tissue attachment, should
first be respectcd when placing the retraction cord.
The exposed surface of the deflection cord will serve
as a reference to the bur for the margin placement
(Fig 3A-3C). In this context, pressure and trauma
should bc minimized during cord placement.’0 The
combined use of a spatula and a periodontal probe
(bimanual insertion technique) may facilitate this
step by better distributing forces during insertion
(Fig. 3B). Respect for the biologic width upon place-
ment of the finish line aids in the fabrication of a
restoration that will favor periodontal health.
Well-adapted and well-contoured provisional res-
torations are key elements in this process, permitting
the conditioning of the edentulous ridges and the
surrounding abutmcnt teeth. While palatal and fa-
cial contours must be consistent with the emergence
profile of the abutment tooth, proximal contours

Figure 3. The placement of retraction cord should not


damage the connective tissue attachment (A).Traumatic
forces can be avoided by using a bimanual insertion
technique: the cord is stabilized with a periodontal probe
on the site of insertion, while a spatula is used to position
the cord in the sulcus (B).The related placement of the
margin is made accordingly, the tip of the bur being guided
by the surface of the cord (C).
June 1999, Volume 8, Number 2 109

Figure 5. The presence or


the lips, especially the upper
lip, is detcrminant in the distri-
bution of light into the adja-
cent soft tissues.

Figure 6. This precxisting metal-ceramic fixed partial den-


ture prcsents an extended metal framework on abutment
tooth ‘3, but no metal is exposed on the margin (A). The
interaction of the lip with thc cervical arca gives rise to very
dark marginal soft tissues that simulate cervical metal
exposure (B).Interdental papillae are extremely sensitive to
this “umbrella efkct” of the lip as illustrated in another case
of six preexisting maxillary porcelain-fused-to-metal crowns
((7.
110 Esthetic Width in Fixed Prosthodontics a Magne, Mape, and Beker

often must be modified to compensate for thc flattcn-


ing of thc interdental papillae (see Interdcntal De-
sign). .& the supracrestal connective tissue attach-
ment is respected during tooth preparation, so should
the esthctic width be respcctcd when designing the
prosthetic framework (Fig 4); a distinct space is
necessary between the coronal border of the gingiva
and the cervical margin of thc framework to provide
adequate room for the application of specific shoul-
der porcelain^.^^ Collarless metal-ceramic crowns
have been shown to resist the same axial prcssurcs as
those restorations with complete metal s ~ p p o r t , ~ ~ > ~ ~
In addition, the optical consequences of extended
metal lrameworks are considerable, resulting in lack
of brightness in the area of the marginal soft tissues
even in the presence of vital abutrncnts (ic, the
“umbrella effect” discussed below).

The Umbreh Efect


A careful analysis of clinically relevant optical phe-
nomena should always include the effects produced
by the lips, particularly the upper lip (Fig 5), because
this featurc will significantly influence the interac-
Figure 7. The presence of an old resin crown luted with tion of light with the teeth and their supporting
an opaque cement also creates an “umbrella effect” around tissues ( ~6 and i 7).~When~ the lips are retracted (as
tooth 9 (A).After the replacement of Class 111 composite
restorations on teeth 7 and 8, good illumination of the
is the case during intraoral photography), the apical
tissues around tooth 9 was provided by placing a porcelain- extension ofthe kamework generally will not have a
fused-to-metal crown with porcelain margins (B). strong impact on the optical behavior or the crown,

Figure 8. In the presence of


a high lip line or during intra-
oral photography with re-
tracted lips, the light pen-
etrates directly to the soft
tissues, regardless of the ex-
tension of the framework. No
shadow arc evident in the
soft tissues (see also Fig. 6A).

Figure 9. The “umbrella ef-


fect” is produced by the ab-
sence ofindirect light penetra-
tion into the soft tissues (dotted
lines). Either an extended
metal framework or an opaquc
ceramic core may causc this
phenomenon.
June 1999, Volume 8, Number 2 111

Figure 10. Indirect light-


transmission phenomena can
occur whcn thc natural root is
usrd as a guide for light redis-
trihution. Reduced metal
frameworks and extended por-
celain margins are imperative
to permit transillumination of
the gingiva.

because the light can be directly distributed into the nation of the gingiva, which may otherwise bc totally
tissues (Figs GA, 8). When the upper lip is in its lacking in thrcc common situations: 1) in the pres-
normal position, however, the difference becomes ence of apically overextended frameworks (Fig 9); 2)
significant, because direct penetration of light into when using insufIiciently translucent restorations or
the surrounding periodontal tissues is prevented opaque cements (Fig. 7A); and 3) in the presencc of
(Figs 6B, GC, 9). In contrast, an adequately reduced cast dowel-andcore restorations or endosseous, root-
framcwork docs not demonstrate the socallcd "urn- form implants and rclatcd abutmcnts. The root
brella effect,'' even in the presence of the lip, because portion of a natural tooth is a very luminescent area.
indirect penetration of light is permitted by the por- The fluorescence of the radicular dentin contributes
celain shoulder (Figs 7B, 10).This allows transillumi- to the brightness of the root and the illumination of

Figure 11. These six anterior InCeram crowns (tccth


6-1 1) allow acceptable illuminalion of the soft tissues when Figure 12. Porcelain laminate veneers were placed on
considercd in an intraoral view with retracted lips (-4). teeth 8 through 11 (il). 'The periodontal tissues appcar
Nevcrthcless, gray papillae are obsrwed in the presencc of healthy and naturally illuminated cven in thc prcsence of
the uppcr lip (B). the lips (B).
112 Exthetic Width in Fixed Prosthodontics Magne, Magne, and BeLw

Figure 13. Preparation of a master cast with accurate soft tissue reproduction (modified according to Geller): single dies
are equipped with metal pins and trimmed conically to simulate the coronal portion of the root (A). Individual dies are
repositioned in the impression and stabilized with a pin stuck in the impression material; thc axial surface of the stone is
coated with a thin layer ofwax (B).The base is poured in two increments to allow the elimination of additional stabilization
pins. The resultant cast exhibits removable dies and an intact stone gingiva (C). The direction the upper lip is projected on
the metal framework (red line) using the hard stone gingiva as a guide (black line) (0).
The framework is reduced to the level
of the projectrd gingiva and coated with gold film to enhance the color of the metal before porcclain application (E).The
first bake is made for the porcelain shoulder and the opaque porcelain (F).
June 1999, Volume 8, Number 2 113

periodontal tissues. The use of fluorescent porcelain 13F). However, this cast should not be considered to
margins is imperative to simulate this phenomenon. be a precise duplicate of the dental arch and should
Extended cast dowel-and-core restorations present not be uscd for adjustments of occlusion. Instead,
significant challenges to luminosity, because porce- occlusal adjustments should be made using a nonseg-
lain margins can never fully compensate for the mented cast that represents the most accurate refer-
resulting lack of light penetration at the root level. ence for intertooth relationships. Surface finishing
One might assume that full-coverageceramic crowns procedures should be accomplished after the try-in.
would permit the optimal distribution of light. This is Finishing procedures include glazing and final corrcc-
certainly true for ceramic systems inwhich the core is tion of thc porcelain margin on an intact die using
not fabricated from an opaque ceramic. However, the porcelain-wax t e ~ h n i q u e . It
~ ~is) ~important
~ to
clinicians should remain observant when placing note that try-in procedures and occlusal adjustments
InCeram crowns. The nontransparent and nonfluo- are complicated by the presence of a porcelain
rescent reinforccd alumina framework3' must be shoulder, which remains extremely fragile as long as
extendcd to the margin for mechanical purposes. the restoration is not definitively cemented. During
Consequently, in terms of optical effect, InCeram try-in, careful control of occlusion using articulating
units may resemble metal-ceramic units with overex- paper can be accomplished intraorally. However,
tended metal frameworks (Fig 1 1A-1 IB). The areaof extraoral grinding and reshaping is recommended to
the interdental papilla is very sensitive to thc umbrella avoid cracking of the ceramic margin. In fact, while
effect, because adjacent teeth prevent the penetration the crown is seated intraorally on its abutment (not
of light into the interdental tissues (Figs 6C, 11B). cemented), vibrations generated from rotary instru-
Similar effects can be seen with porcelain-fused-to- mentation can create marginal microfracture of the
metal and InCeram crowns (Figs 6C, 11s).ln light of ceramic shoulder.
these considerations, one may easily recognize that
bonded porcelain laminates exhibit excellent optical Modified Pontic & s i p
behavior and promote a more natural appearance of
the marginal soft tissues (Fig 1ZL4-12B). All the foregoing statements apply when considering
fixed partial dentures in the esthetic zone (Fig 14).
As far as specific requirements for pontics are con-
cerned, the ideal crest would provide an adequate
TechnicalApplication of the Esthetic Width geometry for an ovate design (Fig. 15A).This may be
The first requirement in the application of the obtained if the clinician can successfully influence the
esthetic width is the most accurate possible reproduc- external soft tissue healing pattern of the fresh
tion in the final impressions of the surrounding soft extraction site by means of appropriately designed
tissues. As is the case when placing finish lines, a
miiiimally traumatic retraction method is essential.
Polyvinylsiloxane impression materials are recom-
mended because they provide accuracy for multiple
pours.?' The optimal use of final impressions requires
3 or 4 consecutive pours, including the fabrication of'
an additional master cast that accurately reproduces
the soft tissues, as advocated by Geller. To create this
cast, individual dies should be trimmed (Fig 13A) and
carefully repositioned in the impression (Fig 13B).
The subsequent pour of the cast base should result in
a cast with gingival contours recorded in stone (Fig
13C). The framework may be objectively reduced
using the hard stone gingiva as a reference, together
with the approximately estimated direction of the
Figure 14. The framework is similarly reduced at the
upper lip (Fig 13D-13E). The same cast should be
level of the abutments and under the pontics to allow thc
used during the ceramic layering process, beginning same ceramic stratification. The final case is shown in Fig
with the placement of the porcelain shoulder (Fig 16A-16C.
Figure 15. The ovatc pontic requires a concave morphology of the bone crest (A). The prcsencc o f a collapsed ridgc is not
coinpatiblc with an ovate pontic design because ofthe bone proximity (B).A sanitary politic form is most compatible with
function and hygiene. Ilowcver, when placed on a convcx crest, it will gcncratc the undesirable result ofwide space between
gingiva and tooth in the palatal aspect of the prosthesis (C). A ridge-lap pontic is easily placed on a coiivex crest, a slight
prcssurc being rnaintaincd only at the facial levcl ofthe contact with the gingiva (0)(see also Fig 16.4-16CJ.

provisional restorations. Nevertheless, the resulting hygiene method using floss (Superfloss, Oral-B, Bel-
clinical situation frequently features a collapsed and mont, CA) and a soft filament bnish in a “cross-
convex ridge (Fig 15B) that prevents selection of an movement” (Fig 17). This technique may be easily
ovate pontic unless corrective surgical procedures are applied in anterior areas ofthe mouth.
performed.38 To avoid the problem of proximity
between thc bone crest and the pontic uithout
resorting to corrective surgery, the design of the Interdental Design
pontic must be modified. Crcation of a classical The interdental morphology of a restoration providcs
sanitary pontic (Fig 15C) is recornmcnded for poste- an additional parameter that can be easily controlled
rior segments. In anterior rcgions, only a ridge-lap by thc operator and will significantly enhance the
pontic with a delicate and selective pressure distrib- esthetic outcome of treatment. When the soft tissue
uted on the f,i ,I aspect of the crest will provide the architecture or a patient is compared with an intact
patient with optimal comfort as well as esthetically dentition, it becomes apparcnt that the interdental
pleasing results with minimal surgical intervention papillae of the prosthodontics patient are flattened,
(Figs 15D, 1GA-1GC). This design requires a specific leading to unsightly black interdental triangles (Fig
Figure 16. The provisional prosthcsis was used to model
the facial side of the crest in this case of thin soft tissues
combined to a convex morphology (A). The contour of the
soft tissues is matchcd by thc contour of final prosthesis as
illustrated by the partial inscrtion of the latter (B).The
postoperative view shows the satisfactory integration or the
modified politic dcspite minimal surgical procedures (C).

18). This problem has captured the interest of bone is certainly a major prerequisite for thc long-
numerous periodontists arid led to the development term success of such procedures. However, these
of various sophisticated preprosthetic surgical proce- situations may also be allcviatcd using the rational,
d ~ r e s . 3It~appears that the presence of interdental nonsurgical approach described below.

Figure 17. Hygicnc under a ridge-lap pontic can be ineficient and painful if floss (black and dotted lines) is stretched and
moved laterally within the available space (translational movement [A]). The floss is best guided to the bottom of the
concavity when first pullcd niesio-palatally and disto-facially (then pulled disto-palatally and mesio-facially), defining the
socallcd “cross-movement” (B).
116 Esthetic Width in Fixed Prosthodontics Maene, Magne. and Belser

Figure 18. A natural and in-


tact periodontium can be eas-
ily distinguished from a “pros-
the t ic” periodon t iu m because
of the unavoidable flattening
o f the papillae.

Figure 19. Adjacent porcelain-fused-to-metal crowns show the interdental mini-wings compensating for h e deGcienl
volume of the papillae (A). Local extension of ceramic is made with a porcelain ofhigher chroma to prevent the appearance
of a bulky tooth (B).The shape of the anatomic crown is unchanged, but the proximal contact point is replaced by a
proximal contact line extending from the incisal edge to the papilla (C).
June 1999, Volume 8, Number 2 117
~

The Concept of Interdental “Mini-wings” ing the need for surgical intervention, In the interden-
td zone, the concept of interdental mini-wings repre-
Prosthetic tceth may reasonably compensatc for
sents a simple answer to the problematic soft tissue
deficiencics in the soft tissues at the interdental Icvel.
architecture of prosthetic cases (flattening of papil-
However, the natural convex proximal surface of the
lac and black interdental triangles).
tooth must be modified. To accomplish this, slight
interdental extension is made, still respecting the
emergence profile of the crown (Fig 19A). The Acknowledgment
interdental contact point becomes an interdental The authors express their gratitude to M’illi Gcller, CUT,
contact line (Fig 19B). O n thc mastcr cast, small Oral Design Center, Zurich, Switzcrland, for his inesti-
black triangles may still be visible, but the intraoral mable contribution in oral esthetics, and Carol Rose
try-in often will reveal intimate contact between such (Division of Oral Pathology, Department of Oral Science,
crowns and the associated interdental papillae (Fig University of Minnesota) for help in revising the English
19c).Hcre again, the spccial master cast (ie, soft draft.
tissue cast), which provides the ceramist with the
complete morphology of the gingiva in stone, is References
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