The periodontal restorative interface: esthetic considerations

Influence of crown-lengthening surgery on teeth rehabilitated with ceramic single crowns: A 12-month prospective clinical study

OBJECTIVE

To compare the clinical periodontal parameters of teeth restored with a single ceramic crown, with and without crown lengthening procedure.

METHODS

This prospective, longitudinal, controlled, and single-blinded clinical trial involved 22 patients with a total of forty-one teeth with ceramic crowns. The teeth were divided into two groups: test (n = 21), comprising teeth rehabilitated post crown-lengthening surgery, and control (n = 20), comprising teeth rehabilitated without crown-lengthening surgery. Plaque index (PI), gingival index (GI), probing depth (PD), bleeding on probing (BoP), and clinical attachment level (CAL) were compared between groups (surgically treated and non-surgically treated) and within each group for each type of site (treated -tt; adjacent - ad; and nonadjacent - nad). Additionally, gingival phenotype (GP), gingival recession (GR), and keratinized tissue width (KTW) were also assessed post- restoration. Statistical analyses used a significance level set at 5 %.

RESULTS

PI, GI, and BoP were reduced, but no statistically significant differences were observed within each group or between groups for most follow-up periods. CAL of the TT sites was consistently higher in the test group, and PD was also higher in the test group (p < 0.05), except at T3. adPD, nadPD, adCAL, and nadCAL demonstrated no significant differences between groups and periods. A significant association was identified between GP and the occurrence of GR, with the thick-flat phenotype demonstrating less association with GR, regardless of whether crown lengthening was performed or not.

CONCLUSION

Crown-lengthening surgery in rehabilitated teeth does not significantly affect PI and GI after 12 months. Although crown-lengthening surgery affected PD and CAL in TT sites, it did not affect adjacent and non-adjacent sites.

CLINICAL RELEVANCE

These findings emphasize the importance of considering individual patient factors and the potential impact on periodontal tissues when planning crown-lengthening surgery. Clinicians must have a comprehensive understanding of the dynamics of the periodontal tissues involved in restorative treatments to optimize the procedure, increase success rates, and minimize potential complications.

The use of hyaluronic acid injection for treatment of black triangle and reconstruction of lost interdental papilla in anterior teeth: a systematic review

OBJECTIVE

Non-surgical therapeutics to reconstruct lost interdental papilla are evolving; these include hyaluronic acid injection. The aim of this systematic review is to evaluate the efficacy, safety, and long-term outcomes of hyaluronic acid injection in the treatment of black triangles and reconstruction of lost interdental papilla in anterior teeth.

MATERIALS AND METHODS

The protocol was registered in PROSPERO (CRD42023446875) and in accordance with the Cochrane Handbook of Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 'PRISMA'. The search involved four databases, PubMed/MEDLINE, The Cochrane Library, Google Scholar, and ProQuest for ''grey literature' with additional manual search for studies published up to May 2024. Human clinical studies of a prospective nature (randomised clinical trials and prospective cohort studies) were included. Exclusion criteria were case reports, case series, review articles, letter to editor, personal opinion, and animal studies. Furthermore, studies which utilised hyaluronic acid injection in conjunction with other therapeutic material, tissue graft, or any surgical procedure were also excluded. The data were extracted independently by the two authors and incorporated after consensus. The risk of bias was assessed using the RoB2: the revised Cochrane risk of bias tool for randomised clinical trials and the Newcastle Ottawa scale for prospective cohort studies.

RESULTS

24 studies, 15 prospective clinical studies and nine randomised clinical trials, were included with a total of 898 interdental papillae injected with hyaluronic acid. The studies showed promising outcomes in the reconstruction of lost interdental papilla with minimal adverse reactions. Risk of bias assessment among prospective clinical studies revealed 13 good quality studies with only two poor studies while the randomised clinical trials consisted of three with low, one with some concern, and five studies with high risk of bias. However, due to the high heterogeneity, a meta-analysis was not feasible.  Conclusion: Hyaluronic acid injection is an effective minimally invasive approach in treating black triangles and reconstructing lost interdental papilla in the anterior teeth. Further long-term well-designed randomised clinical trials employing standardised procedures are essential to validate this treatment and provide better quality of evidence.

Assessment of the correlation between supracrestal gingival tissue dimensions and other periodontal phenotypes components via the digital registration method: a cross‑sectional study in a Chinese population

BACKGROUND

Supracrestal gingival tissue dimensions (SGTDs) has been considered to be an essential element of periodontal phenotype (PP) components. This study aimed to explore the relationship between SGTDs and other PP components by digital superposition method that integrated cone beam computed tomography (CBCT) with intraoral scanning.

METHODS

This cross-sectional study was conducted at the Stomatology Hospital of Fujian Medical University. Participants were recruited based on the inclusion and exclusion criteria. The data obtained from the digital scanner (TRIOS 3, 3Shape, Denmark) and CBCT images were imported into the TRIOS software (Implant Studio, 3Shape, Denmark) for computing relevant parameters. The significant level was set at 0.05.

RESULTS

A total of 83 participants with 498 maxillary anterior teeth were finally included. The mean values of supracrestal gingival height (SGH) and the distance from the cementoenamel junction (CEJ) to the crest of the alveolar ridge (CEJ-ABC) on the buccal site were significantly higher than palatal SGH (SGH-p) and palatal CEJ-ABC (CEJ-ABC-p). Men exhibited taller CEJ-ABC and SGH-p than women. Additionally, tooth type was significantly associated with the SGH, SGH-p and CEJ-ABC-p. Taller SGH was associated with wider crown, smaller papilla height (PH), flatter gingival margin, thicker bone thickness (BT) and gingival thickness (GT) at CEJ, the alveolar bone crest (ABC), and 2 mm apical to the ABC. Smaller SGH-p displayed thicker BT and GT at CEJ, the ABC, and 2 and 4 mm apical to the ABC. Higher CEJ-ABC showed lower interproximal bone height, smaller PH, flatter gingival margin, thinner GT and BT at CEJ, and 2 mm apical to the ABC. Smaller CEJ-ABC-p displayed thicker BT at CEJ and 2 and 4 mm apical to the ABC. On the buccal, thicker GT was correlated with thicker BT at 2 and 4 mm below the ABC.

CONCLUSION

SGTDs exhibited a correlation with other PP components, especially crown shape, gingival margin and interdental PH. The relationship between SGTDs and gingival and bone phenotypes depended on the apico-coronal level evaluated.

TRIAL REGISTRATION

This study was approved by the Biomedical Research Ethics Committee of Stomatology Hospital of Fujian Medical University (approval no. 2023-24).

Biological shaping as a conservative alternative for crown lengthening: A review

OBJECTIVES

The perio-restorative approach to maintaining supracrestal tissue attachment (STA; formerly known as biologic width) is a fundamental goal in modern dentistry. This article aims to review the clinical impact of biologic shaping (BS) as an innovative alternative to traditional crown lengthening procedures, reflecting over two decades of clinical experience.

MATERIAL AND METHODS

As a review paper, it is crucial to highlight that BS stands as a unique approach designed to optimize STA while emphasizing minimal to no removal of supporting bone. The review spans over two decades, consistently demonstrating clinical efficacy and predictability. Remarkably, BS focuses on addressing issues such as root concavities, developmental grooves, irregularities, furcation lips, and CEJ offering a remarkable level of clinical precision.

RESULTS

The reviewed literature underscores that BS has consistently achieved substantial clinical success in fulfilling its objectives. This method presents a biologically sound alternative to traditional crown lengthening, placing a strong emphasis on the preservation of essential bone tissue and the establishment of durable STA.

CONCLUSIONS

The results suggest that BS is a logical and biologically driven approach for maintaining STA, making it a promising alternative to traditional crown lengthening. The method offers a predictable and reproducible way to preserve bone tissue while achieving durable STA. This innovation holds great promise in the field of periodontal and restorative dentistry.

Is 1:1000 adrenaline as a topical haemostat an effective alternative to control bleeding in dentistry and oral surgery?

Minor oral surgery can give rise to bleeding intra- and post-operatively. This can be minimal in most patients; however, it can be more problematic in patients with impaired clotting disorders, liver disease, or taking any form of anticoagulation therapy. Haemostatic agents are available to overcome such bleeding risks. The topical application of 1:1000 adrenaline used in medicine can be considered for use in dentistry. Adrenaline is widely used within medicine, surgery and dentistry. Examples include its use in local anaesthetic agents, in the management of anaphylaxis and as part of the cardiopulmonary resuscitation algorithm. 1:1000 adrenaline used topically for ear, nose and throat surgeries has shown improved visual fields during surgery with better surgical outcomes. It is relatively safe, but in patients with cardiovascular comorbidities, it should be practised with caution. This has precipitated the idea for its use within oral surgical procedures, including canine exposures, third molar surgery, root displacement into the antrum and periapical surgery. The haemostatic effect of 1:1000 adrenaline as an alternative should be considered in operative dentistry and oral surgery to aid in haemostasis and improve intra-operative visualisation, reducing the risk of iatrogenic damage and bleeding, thereby improving treatment outcomes.

Contemporary concepts on periodontal complications from prosthetic and restorative therapies

The clinical outcome of every prosthetic and restorative procedure depends on the maintenance of a healthy periodontium. It is, therefore, important that the prosthodontist and restorative dentist cause no harm or permanent damage to the underlying hard and soft tissues when performing clinical procedures necessary to carry out the planned treatment. Several factors involved in these procedures have been described to have an impact on gingival health. For the present article, a selection of four of these factors are presented with the goal of evaluating the current trends and their influence on periodontal structures: (1) tooth preparation configuration and apical extension, (2) gingival tissue sulcular expansion/retraction, (3) prosthetic contours, and (4) prosthesis marginal adaptation and the consequences of excess cement remnants. Based on the available scientific evidence and clinical experience, recommendations for the practitioner are given.

Digitally Guided Workflow for the Esthetic and Prosthetic Oral Rehabilitation of a Patient with Excessive Gingival Display: A Case Report

This report describes the esthetic and prosthetic oral rehabilitation of a patient with excessive gingival display using a digital guided workflow. As per this digital workflow, the patient’s photographs, three-dimensional radiographic images, and a diagnostic digital intraoral scan were obtained. Preoperative digital case planning and designing were followed by the fabrication of surgical guides, printed casts, and matrices to accurately execute surgical esthetic crown lengthening and reproduce the digital design in the subsequent prosthetic rehabilitation.

Hyaluronic acid injection to restore the lost interproximal papilla: a systematic review

OBJECTIVES

To assess the efficacy and safety of hyaluronic acid (HA) injections to restore the lost interproximal papilla.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed/MEDLINE, Scopus and Cochrane electronic databases with no time restriction up to September 2021. Any clinical study evaluating HA injection into the interproximal papilla loss Class I and II according to Norland & Tarnow, were included based on the following PICO questions (1) Are HA injections effective for the reconstruction of the interproximal papilla loss? (2) What are the side/adverse effects of using HA for the reconstruction of interproximal papilla loss? The risk of bias assessment was performed using the Cochrane Collaboration's the Newcastle Ottawa and Joanna Briggs institute tools.

RESULTS

A total of 1497 titles were retrieved. From these, eleven were included and underwent full data extraction. However, due to heterogeneity in the data among the included articles, a meta-analysis could not be performed. Three articles reported no-differences in term of papilla tip to contact point distance or the papilla fill reduction. Finally, five studies showed a reduction in the black triangle with a percentage range between 19 and 47%.

CONCLUSION

The non-surgical use of HA injection seems to have a positive effect on the re-establishment of interproximal papilla lost. However post-operative complications might develop.

Periodontal outcomes of anterior fixed partial dentures on teeth treated with the biologically oriented preparation technique: A 6-year prospective clinical trial

STATEMENT OF PROBLEM

One of the most frequent complications in participants with fixed partial dentures (FPDs) is the apical migration of the gingival margin, which may be associated with factors such as fit, gingival margin location, or tooth preparation type. The prevalence of the complication in participants restored with FPDs prepared by using the biologically oriented preparation technique (BOPT) is unclear.

PURPOSE

The purpose of this prospective clinical trial was to evaluate the clinical and biologic outcomes of FPDs on teeth prepared by using the BOPT, over a 6-year follow-up period.

MATERIAL AND METHODS

Tooth-supported zirconia FPDs in the anterior region prepared by using the BOPT were evaluated. Each participant was monitored annually for 6 years by evaluating plaque index, probing depth, vestibular gingival thickness, and gingival margin stability. Biologic and/or mechanical complications were also recorded. Patient satisfaction was measured by using a visual analog scale (VAS).

RESULTS

A total of 25 FPDs supported by 70 teeth in 24 participants were analyzed. Low plaque index values and stable probing depths were observed, whereas the gingival index was 0 for most of the teeth. Teeth treated by using the BOPT presented significant increase in gingival thickness, and the gingival margin was found to be stable in 100% of the treatments. FPD survival was 100%.

CONCLUSION

Tooth supporting FPDs prepared by using the BOPT presented good periodontal health and gingival margin stability, without recession and with a 100% survival rate during a 6-year follow-up.

Surgical guides for esthetic crown lengthening procedures: Periodontal and prosthetic aspects

BACKGROUND

In patients with gingival exposure on smiling due to altered passive eruption, esthetic crown lengthening is often indicated. Meticulous planning and surgical precision are key for successful outcomes. Surgical guides are helpful tools that are seldomly reported on in the literature related to esthetic crown lengthening procedures.

TYPES OF STUDIES REVIEWED

The authors searched the literature for articles that described the planning, tools, and execution related to esthetic crown lengthening procedures.

RESULTS

Several techniques have been reported to guide the esthetic crown lengthening procedure, ranging from direct bone level measurement to 3-dimensional printed surgical guides.

PRACTICAL IMPLICATIONS

This review serves the clinician as an aid in the decision-making process for esthetic crown lengthening procedures and available surgical guide options, including computer-based guides.

Periodontal Behavior and Patient Satisfaction of Anterior Teeth Restored with Single Zirconia Crowns Using a Biologically Oriented Preparation Technique: A 6-Year Prospective Clinical Study

Objectives. The aim of this study was to analyze the behavior of the periodontal tissues around teeth in the anterior region when restored with zirconia single crowns, using a biologically oriented preparation technique (BOPT), over a 6-year follow-up. Methods. The study investigated tooth-supported single crowns in the anterior region that were fabricated with a zirconia core and feldspathic ceramic covering, in 34 patients. Follow-up analysis took place annually for 6 years, assessing periodontal responses by evaluating the following variables: plaque index (PI); probing depth (PD); gingival index (GI); gingival thickness adjacent to the restoration; and stability of the gingival margin (MS). Any (biological and mechanical) complications were also recorded, as well as the patients’ satisfaction with the treatment. Results. After 6 years’ follow-up, a low mean plaque index was obtained, probing depth was stable, and gingival thickness and margin stability had increased. Complications (biological and mechanical) did not present a statistically significant incidence and a crown survival rate of 97.2% was achieved. Patients’ satisfaction obtained a mean VAS score of 9.04 under 10. Conclusion. Teeth that are prepared with BOPT in the anterior region present good periodontal behavior around the restored teeth, particularly in terms of the stability of the gingival margin and increased gingival thickness. Single crowns prepared with BOPT obtain an excellent clinical survival rate, as well as a high score in patients’ satisfaction after 6 years.

Synergetic effect of growth factor and topography on fibroblast proliferation

An innovative basic fibroblast growth factor (bFGF)-loaded polycaprolactone (PCL) fibrous membrane with highly aligned structure is developed for guided tissue regeneration (GTR). The aligned membrane is fabricated by electrospinning. In order to make efficient use of bFGF, PCL electrospun fibrous membrane is firstly surface-coated by self-polymerization of dopamine, and followed by immobilization of heparin via covalent conjugation to the polydopamine (PDA) layer. Subsequently, bFGF is loaded by binding to heparin. The loading yield of bFGF on heparin-immobilized PDA-coated PCL membrane significantly increases to around 7 times as compared with that of pure PCL membrane. NIH-3T3 cells show an enhanced proliferation and exhibit a stretched morphology aligned along the direction of the fibers on the aligned membranes. However, aligned bFGF-loaded PCL membrane exhibit a similar morphology but a highest cell density prolonged till 9 days. The synergetic effect of growth factor and topography would effectively regulate cell proliferation.

Clinical behavior of posterior fixed partial dentures with a biologically oriented preparation technique: A 5-year randomized controlled clinical trial

STATEMENT OF PROBLEM

Evidence of the behavior of the periodontal tissues around anterior teeth restored with the biologically oriented preparation technique (BOPT) is available. However, outcomes of this technique in posterior teeth restored with fixed partial dentures (FPDs) are lacking.

PURPOSE

The purpose of this randomized controlled clinical trial was to evaluate the clinical, mechanical, and biological behavior of posterior 3-unit FPDs placed on teeth prepared with BOPT.

MATERIAL AND METHODS

Forty participants received a 3-unit zirconia FPD in the posterior region of the mandible or maxilla. Twenty FPDs were placed on teeth prepared with BOPT (study group) and 20 on teeth with a horizontal chamfer finishing line (control group). Follow-up examinations were performed 1, 3, and 5 years after treatment to evaluate periodontal responses around the prepared teeth by means of the following parameters: plaque index, gingival index, probing depth, and marginal stability (MS). Mechanical behavior was also assessed, as were any complications.

RESULTS

After the 5-year follow-up, 57.9% of the control group and 35% of the BOPT group presented a plaque index of 1. The gingival index was 1 in 68.4% of the control group and 30% of the BOPT group after the follow-up period. In the analysis of probing depth, 26.3% of teeth in the control group had pockets of more than 3 mm in depth, whereas the BOPT group had only 10%. Marginal stability appeared in 100% of the BOPT group, whereas only 10.5% of the control group exhibited gingival stability. Complications during the follow-up period were similar, 20% in the control group and 15% in the BOPT group.

CONCLUSIONS

Posterior FPDs prepared by using BOPT had a good clinical response over a 5-year follow-up, with a low gingival index, a small increase in pocket depth, and a 100% marginal stability of the surrounding tissues. High survival rates after 5 years indicated that the technique produced predictable outcomes.

A randomized controlled clinical trial comparing the use of displacement cords and aluminum chloride paste

OBJECTIVES

This clinical study measured the change in opening and height of the displaced gingiva using paste and cord retraction materials for definitive impression making of natural teeth and assessed if they were comparable and clinically acceptable.

METHODS

Impressions of 4 maxilla premolars from 10 participants were taken using a split-mouth protocol. All participants were free of periodontal disease, had a thick biotype, a minimal of 3 mm height of keratinized gingival tissue and gingival sulci depths of 2 mm. The bleeding index (BI), gingival index (GI) plaque index (PI), sulcular depth, level of attachment and tooth sensitivity were recorded at baseline, just after retraction, at 24 hours and at 2 weeks. Impressions were poured in stone and then after initial analysis were cross-sectioned to allow measurements of the gingival height change and gap size to be recorded.

RESULTS

The paste produced a slightly smaller gap compared to the cord (0.041 mm less, P = .014) whilst the mean displacement for the cord was 0.282 mm and paste was 0.241 mm respectively. Gingival height with the paste was 0.047 mm lower than that achieved by the cord (P = .208).

CONCLUSIONS

Cord and paste retraction produced comparable clinically acceptable gingival gaps, with the cord producing statistically larger gap size.

CLINICAL SIGNIFICANCE

The cord and paste retraction materials produced comparable clinically acceptable gingival retraction.

Effect of A-PRF Application on Palatal Wound Healing after Free Gingival Graft Harvesting: A Prospective Randomized Study

Objective  The aim of this study was to investigate the healing effect of advanced platelet-rich fibrin (A-PRF) clot membranes in palatal wounds, resulting from free gingival graft (FGG) harvesting, on the reepithelization rate and on the pain experience after surgery.

Materials and Methods  Twenty-five patients requiring FGG have participated in this prospective cohort study. After FGG harvesting, the test group ( n = 14) received A-PRF clot membranes at the palatal wound and the control group ( n = 11) received a gelatin sponge. Epithelialization rate of the palatal wound, wound healing area, correspondent percentage of reduction, and postsurgical pain experience were assessed at 2, 7, 14, 30, and 90 days.

Results  A-PRF group had higher palatal wound reduction than the control group, at 7, 14, and 30 days of follow-up. The highest difference between the groups was attained at 30 days (91.5% for A-PRF vs. 59.0% control group). At 14 days, a significant difference in the proportion of patients showing total epithelization was found: 64.3% for A-PRF versus 9.1% for the control group. At 90 days, both groups showed total recovery. The control group experienced higher pain level and discomfort until the 14th day, being notably higher on the second day.

Conclusion  The results suggest that A-PRF membranes haste the healing process, and promote greater reduction along the recovery period and less painful postoperative period.

Does Surgical Crown Lengthening Procedure Produce Stable Clinical Outcomes for Restorative Treatment? A Meta-Analysis

PURPOSE

The present systematic review was designed to assess whether surgical crown lengthening (SCL) procedure produces stable clinical outcomes for restorative treatment.

METHODS

Based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a specific PICO question was constructed: "Does the SCL procedure produce stable clinical outcomes for restorative treatment?" Electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Oral Health Group Trials Register) were searched up to December 2017. The risk of bias was assessed based on the revised recommendations of the Consolidated Standards of Reporting Trials (CONSORT) statement. Forest plots were computed reporting weighted mean difference (WMD) of outcomes and 95% confidence intervals (CI) for crown length (CL), position of gingival margin (PGM), biological width (BW), and bone level changes.

RESULTS

Five studies were included. The risk of bias was considered high in all studies. A high degree of heterogeneity was noticed for CL, PGM, and BW. The overall mean difference for CL (WMD = -1.84, 95% CI = -0.103 to 2.05, p = 0.076), PGM (WMD = 0.87, 95% CI = 0.12 to 1.62, p = 0.02), and BW (WMD = -0.11, 95% CI = -2.21 to 1.99, p = 0.91) were not significant at follow-up. The overall mean difference for bone level changes was significant (WMD = 1.64, 95% CI = 1.26 to 2.03, p < 0.001) at follow-up.

CONCLUSION

It remains debatable whether SCL produces gingival rebound, or re-establishes BW and changes in clinical attachment level; however, further studies with low risk of bias randomized CCTs and long-term follow-up are recommended to reliably assess the restorative outcomes of SCL.

Periodontitis: facts, fallacies and the future

This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.

Multidisciplinary full-mouth rehabilitation with soft tissue regeneration in the esthetic zone

OBJECTIVE

Oral rehabilitation often requires a multidisciplinary approach including restorative dentistry, prosthodontics, and periodontology to fulfill high esthetic and functional demands, frequently combined with changes in the vertical dimension. The presence of gingival recessions can be associated with numerous factors, such as brushing or preparation trauma and persistent inflammation of the gingiva due to inadequate marginal fit of restorations. Because gingival recessions can cause major esthetic and functional problems, obtaining stability of the gingival tissue around prosthetic restorations is of essential concern. Modifications of the occlusal vertical dimension require sufficient experience of the whole dental team. Especially in patients with functional problems and craniomandibular dysfunction, a newly defined occlusal position should be adequately tested and possibly adjusted.

CLINICAL CONSIDERATIONS

This case report presents a complete prosthetic rehabilitation combined with a periodontal surgical approach for a patient with gingival recessions and functional/esthetic related problems. The vertical dimension was carefully defined through long-term polymethyl methacrylate provisionals as a communication tool between all parts involved. All-ceramic crowns were inserted after periodontal healing as definitive rehabilitation.

CONCLUSIONS

Complex rehabilitation in patients with high esthetic demands including soft tissue corrections requires a multidisciplinary team approach that consists of periodontal surgeon, dentist and dental technician.