Biologic Esthetics by Gingival Framework Design:

Part 2. Gingival Esthetics Evaluation Criteria

Yuji Tsuzuki, RDT1

T
here are three fundamental components to pre- general manner. In this article, specific techniques to
senting a beautiful and healthy dentition. The achieve this goal are presented.
first is tooth morphology, the second is gingival
architecture, and the third is the relationship of the lip
to all other components. All of these components will
create a positive or negative impression depending on GINGIVAL ESTHETICS EVALUATION
color, morphology, and tooth alignment. CRITERIA
Acquiring and maintaining gingival health and oral
esthetics is the goal when planning definitive restora- It is necessary to pay attention to the gingival frame-
tions. There are several factors to consider when evalu- work1 and to understand the balance between the cor-
ating gingival health, such as the marginal periodontal onal structure and gingiva (Fig 1). Generally, healthy
condition and tooth alignment. In part 1 of this article, gingiva has its own features, which vary according to
the importance of paying attention to the periodontal the tooth shape (square, triangle, or ovoid). More-
condition and constructing a healthy gingival architec- over, the horizontal alignment of the cementoenamel
ture during prosthesis fabrication was discussed in a junction (CEJ), cervical bone crest, and free gingival
margin usually appear to be similar to the overlying
gingiva2 (Fig 2). Left-right symmetry is one of the most
important factors for a beautiful smile line. To acquire
this symmetry, there should be ideal occlusion and the
teeth should be in an ideal three-dimensional position.
1
Dental Technician, Kyoto, Japan. When patients display this ideal oral environment, it
is unlikely that they will need major prosthetic work
Correspondence to: Yuji Tsuzuki, Ray Dental Labor, Elitz Yamashina
Building 3F, 18-8 Takehanatakenokaidocho Yamashina-ku, Kyoto unless they experience an accident or trauma. Usually
City, Kyoto, Japan. Email: ray710@camel.plala.or.jp patients who require major prosthetic treatment have

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 TSUZUKI

Fig 1  Gingival framework and incisal frame-

work formed by the dentition. Right-left
symmetry and continuity toward the posterior
teeth determine the esthetic factor of the
dentition.

Gingival framework
Incisal framework

A: Interdental papilla
B: Interdental bone crest
C: Free gingival margin
E D: CEJ
D E: Cervical bone crest

C
B

Fig 2  Vertical anatomical index of the anterior teeth, gingiva, and alveolar bone. Generally, a healthy periodontium has its
own features that vary according to the tooth shape (square, triangle, ovoid) and that are usually similar to the underlying
horizontal alignment of CEJ, cervical bone crest, and free gingival margin. The gingival framework is maintained by the ver-
tical relationship among CEJ, cervical bone crest, and free gingival margin.3 (Modified from Obama4 with permission.)

a preexisting intraoral condition such as tooth mal­ tal to have interdental papillae as a landmark for indi-
alignment. Therefore, it is very important to evaluate cation of a healthy periodontal condition. Adequate
the esthetics of the gingiva at the treatment-planning composition of the dentogingival complex7 (tooth,
stage. Otherwise, the treatment options will be limited gingiva, and alveolar bone) (Fig 4) is required for the
to prosthetics. interdental papilla to fill the interproximal space be-
low the contact point. Two-dimensional (mesiodistal,
horizontal, vertical) consideration of the esthetic area
Two-Dimensional Considerations is performed based on five evaluation criteria (Fig 5). It
is generally considered that a dentition with triangular-
Evaluation items of gingival health and esthetics have shaped teeth creates a more pleasing impression than
been enumerated by Fürhauser et al in the concept one with square-shaped teeth in terms of the balance
he named the “pink esthetic score”5 (Fig 3). It is vi- of esthetics of the mouth.

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 Biologic Esthetics by Gingival Framework Design: Part 2

Fig 3  For calculation of the pink esthetic score, there are

five esthetic evaluation items for a single implant-supported Pink esthetic score
restoration replacing one missing anterior tooth5: (1) mesial
and distal interdental papillae, (2) soft tissue level and
contour, (3) alveolar process, (4) gingival texture, and (5) 4
gingival color. A solely prosthetic approach is limited for 3 5
the fulfillment of all esthetic requirements. Surgical man-
agement of hard and soft tissue is required. (Reprinted from 2 2
Honda et al6 [modified from Fürhauser et al5] with permis-
sion.)
1
1

Fig 4  Anatomical composition of the

tooth/gingiva/alveolar bone dentogin-
gival complex advocated by Kois.7 In gen-
eral, the distance from the highest to the
lowest point of the gingival margin is 5.5
mm; for alveolar bone, 3.5 mm. Hence, BC CT(1.0 mm)
the distance from alveolar bone crest to
gingival margin is 3.0 mm at midfacial 3.5 mm 3.0 mm JE(1.0 mm)
CEJ
and 4.5 to 5.0 mm at the interdental pa-
pilla. (Reprinted from Obama4 [modified S(1.0 mm)
from Elian et al8] with permission.) 4.5~ 5.5 mm
FGM 5.0 mm
3.0 mm

2 5
3

1 Gingival zenith point

2 Interdental papilla
3 Proximal contact position
4 Incisal edge position
5 Interdental triangle zone

Fig 5  Esthetic evaluation criteria at the dentition level including coronal structures and gingiva. Right-left symmetry and
regularity is evaluated two-dimensionally. As long as healthy periodontium and proper tooth positions are maintained, the
level of the interdental papillae and proximal contact areas are parallel. The shape of the gingival zenith point and triangle
zone changes dramatically according to the shape of the tooth and interdental distance.9 The existing condition of the inter-
dental papillae is determined by these factors.

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Fig 6  Classification of defect patterns

Class I of the alveolar ridge by Seibert and
Cohen.10 Soft tissue or hard tissue
grafting is sometimes suggested by
the technician at the diagnosis and
treatment-planning stage in the pres-
ence of such defects. The prosthetic
approach may differ according to the
Labiolingual resorption condition of the alveolar ridge. It is
important to evaluate the condition
thoroughly. (Reprinted from Obama4
[modified from Seibert and Cohen10]
with permission.)
Class II

Vertical resorption Maintained labiolingual

width

Class III

Vertical resorption Labiolingual resorption

Three-Dimensional Considerations and Cohen10 classified alveolar ridge defects (Fig 6),
and soft tissue or hard tissue grafting is sometimes
The volume of the alveolar ridge is composed of hard suggested by the technician according to this classifi-
tissue (alveolar bone), including teeth, and soft tissue cation and diagnosis.
(gingiva). There is much individual variation. Three- Cases 1 and 2 illustrate the use of surgical interven-
dimensional (vertical and horizontal) consideration of tion to improve the prosthetic outcome. In Case 1 (Fig
the alveolar ridge is required in fixed or implant pros- 7), treatment of the patient’s maxillary right anterior
thetic cases. The prosthetic result may often be com- dentition included ridge augmentation with a con-
promised without surgical reconstruction of hard and nective tissue graft. In Case 2 (Fig 8), horizontal and
soft tissues in patients with a defective alveolar ridge. vertical ridge augmentation improved the treatment
Moreover, prosthetic treatment is often compromised outcome of the patient, who presented with a root
and limited without orthodontic and surgical treat- fracture of the maxillary left central incisor.
ment to improve three-dimensional esthetics. Seibert

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 Biologic Esthetics by Gingival Framework Design: Part 2

CASE 1 Improvement of the Prosthetic Condition by Surgical Treatment

7a 7b 7c 7d

7e 7f 7g 7h

Figs 7a to 7h  The patient, a female in her 20s, complained of dissatisfaction with the esthetics of her fixed partial
denture. Ridge augmentation was performed in the defective edentulous area of the maxillary right lateral incisor us-
ing a connective tissue graft from the palate. The presence of a defect at the pontic site in fixed prosthetic treatment
affects not only the alignment but also the shape of the whole prosthesis. Surgical intervention dramatically improved
the prosthetic condition and the treatment result. (Courtesy of Dr Hiroyuki Takino, Takino Dental Clinic, Japan.)

CASE 2 Improvement of the Prosthetic Condition by Surgical Treatment

8a 8b 8c 8d

8e 8f 8g 8h

Figs 8a to 8h  The patient, a male in his 20s, presented with a root fracture of the maxillary left central incisor. A
surgical approach to improve soft and hard tissue defects is inevitable in fixed implant prosthodontics. It improves the
treatment result dramatically. The prosthetic condition of this patient was improved by horizontal and vertical ridge
augmentation to restore the alveolar ridge defect. (Courtesy of Dr Kotaro Nakata, Nakata Dental Clinic, Japan.)

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 TSUZUKI

Table 1 Classification of Various Prosthetic Conditions Considering the Gingival Framework

Type 1: Symmetric

Treatment area does not require particular morphologic consideration of marginal

gingiva. There is adequate symmetric marginal gingiva.

Type 2: Alternative

Esthetic disharmony exists at hard and soft tissue level. Adequate improvement
can be expected using a surgical and prosthetic approach.

Type 3: Compromised

Orthodontic treatment is indicated to improve tooth position. The result will be

compromised if prosthodontic treatment is performed alone.

Type 4: Creative

Symmetric edentulous area allows some leeway of the gingival framework design.

CLASSIFICATION OF PROSTHETIC prosthetic condition according to the gingival frame-

work is shown in Table 1.
CONDITION Three of these classifications are illustrated with
clinical cases. Case 3 (Fig 9) is a type 2 alternative
For prosthodontic treatment in esthetic areas, it is case. The patient’s gingival level was improved by
necessary to clearly identify the prosthetic condition prosthetic treatment. Case 4 (Fig 10) is an example of
before setting the appropriate treatment goal by first a type 3 compromised case. In Case 5 (Fig 11), a type
considering the periodontal health as well as recon- 4 creative case, the gingival contours are the result of
struction of teeth. The author’s classification of the an implant-supported fixed prosthesis.

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 Biologic Esthetics by Gingival Framework Design: Part 2

CASE 3 Type 2 (Alternative)—Improvement of the Gingival Level by

Prosthetic Treatment

9a 9b 9c

9d 9e 9f

Figs 9a and 9b  The patient wanted to improve the esthetics of her anterior teeth. Orthodontic treatment was
indicated but was not accepted by the patient. Both central incisors are discolored due to previously placed restora-
tions. The maxillary lateral incisors are peg-shaped. The long axes of these teeth are not in harmony. In particular, the
gingival level of the right lateral incisor created disharmony of the gingival framework. Provisional restorations were
fabricated from the diagnostic wax-up to rearrange the balance of the dentition (technique previously described by
Sulikowski and Yoshida11).
Figs 9c and 9d  Final restorations on and off of the master cast (IPS e.max Press, Ivoclar Vivadent). The tooth long
axes were balanced, and the gingival framework was controlled by the subgingival contours of the restoration.
Fig 9e  The gingival levels were altered by the provisional restorations.
Fig 9f  Long axes, size, and proportion of teeth are improved and harmonized. Acceptable esthetics was achieved by
prosthetic treatment alone in this patient. (Courtesy of Kubota Dental Clinic, Japan.)

CASE 4 Type 3 (Compromised)—Prosthetic Result Not Optimal Without

Orthodontics

10a 10b 10c 10d

Figs 10a and 10b  The patient wanted to improve the esthetics of the anterior teeth because of their malalignment.
Orthodontic treatment was indicated and recommended, but the patient refused it. The patient was treated using a
prosthetic approach alone. As a result, the maxillary right central incisor underwent root canal therapy, and adjacent
teeth were reshaped.
Figs 10c and 10d  Posttreatment photographs. The marginal gingiva is harmonized. Although the patient is satisfied
with the result, this is not an optimal solution to the chief complaint because the tooth positions were not changed
(all-ceramic crown, IPS e.max Press).

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CASE 5 Type 4 (Creative)—Gingival Design by Implant-Supported Prosthesis

Figs 11a and 11b  Implant treatment

was indicated for this patient who
had fractured anterior teeth. After
extraction and socket preservation,
the pontic area was designed and
contoured by the provisional restora-
tion in consideration of the balance
of the gingival framework of the six
anterior teeth.

11a 11b

Figs 11c and 11d  A custom im-

pression coping was fabricated to
transfer the information of reshaped
gingiva in the pontic area. Guided
surgery was used to place two im-
plants while maintaining parallelism.

11c 11d

Figs 11e and 11f  Custom impres-

sion coping. The tissue surface of the
implant and pontic area was repro-
duced with acrylic resin. A plastic bar
was used between the two implants
to maintain strength.

11e 11f

Figs 11g and 11h  The cast was

sculpted into the contours of the
definitive tissue surface of the
restoration by grinding. Zirconium
abutments were chosen.

11g 11h

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 Biologic Esthetics by Gingival Framework Design: Part 2

Figs 11i to 11m  Completed supra-

structure of the implant prosthesis.
The gingival framework of the six
anterior restorations is well balanced
(IPS e.max Zirpress, Ivoclar Vivadent).

11i

11j 11k

11l 11m

Fig 11n  Final prosthesis in place.

A favorable gingival framework has
been established after well-planned
surgical and prosthetic treatment
including implant positioning.

11n

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CASE 6 Prosthetic Treatment with Asymmetric Tooth Positions

Fig 12a  The maxillary left central

incisor crown of the patient, a male
in his 50s, is esthetically deficient and
has a defective marginal fit.
Fig 12b  Posttreatment photograph
of the all-ceramic crown (IPS e.max
Press). Color is reproduced well.

12a 12b

Figs 12c and 12d  Consideration

was given to the shape and tooth
alignment to harmonize with rest
of the dentition under the limited
prosthetic condition caused by asym-
metric tooth positioning and gingival
levels. (Courtesy of Takino Dental
Clinic, Japan.)

12c 12d

Right Left

3
2 5
Fig 13  Some balance must be created and
maintained in the dentition even when perfect
1 symmetry is not required. Factors that influence
the esthetic result of the restored dentition are
enumerated and explained.

Central incisor is the starting point of the dentition. Alignment condition is determined by the size of
1: Tooth align-
teeth and alveolar ridge. Shape and alignment of the central incisor influences the impression of the
ment
mouth, which represents the personality. Acceptable symmetry of the two central incisors is inevitable.

2: Mesial line Mesial line angle produces regularity of the dentition, which continues toward posterior teeth. Some
angle irregularity is allowed according to the existing dentition and the prosthetic condition.

Distal outline produces the contour of the dentition. Harmonized outline of each tooth produces regular-
3: Distal outline
ity of the dentition.

Gingival level affects length of the clinical crown. Symmetry and continuity is required. In this case, gin-
4: Gingival level gival level was controlled by subgingival contouring considering the symmetry and continuity toward the
canine area (high-low-high gingival level relationship).

5: Incisal edge Incisal edge level affects length of the clinical crown as well as the gingival level. In this case, it was
level designed slightly longer to compensate for the incline of the facial cusp line.

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 Biologic Esthetics by Gingival Framework Design: Part 2

Table 2 E
 valuation of Coronal-Gingival Balance Before and After Treatment Based on the
Relationship Between Interdental Papillae and Gingival Zenith Points
Gingival zenith
point and
interdental
papilla

Regular type Irregular type Flat type

Evaluation of Good symmetry of gingival frame- Asymmetric gingival framework and Symmetry of gingival framework
coronal-gingival work and interdental papillae. Tooth irregular undulation exists. Tooth exists to an extent, but undulation is
balance position and periodontium are positions and periodontium are flat due to recession of interdental
within normal limits. Well-balanced unfavorable. Unbalanced coronal- papillae. This condition is often found
coronal-gingival relationship. gingival relationship. with fixed partial denture or implant
cases.

Prosthetic If gingival consideration is not Set position of finish line of the Recession of interdental papillae
approach required, supragingival prosthetic prosthesis must be carefully con- results in black triangles, which must
approach is possible. The dentition sidered. Analysis of axial surfaces be eliminated using half pontics or
can be restored using the anatomi- including subgingival contours the long proximal contact technique.
cal crown shape of the natural teeth. using the provisional restoration is These modifications of the proximal
required. area tend to result in deviation from
the natural anatomical tooth shape.

Form
arrangement
Natural Artificial

SOLUTIONS FOR OTHER CASES production of a natural-looking prosthesis that will be

in harmony with its surrounding environment (Fig 13).
Some cases do not fit easily into the classifications
described in Table 1. Creativity as well as some com-
promise considering tooth positions is required to har-
monize the total esthetics, as in Case 6 (Fig 12). CORONAL-GINGIVAL BALANCE
Symmetry and balance of the crown and gingiva can
Natural Beauty from Asymmetry be evaluated simply by connecting the interdental pa-
pillae and gingival zenith points. This relationship can
Perfect right-left symmetry does not exist in nature, be classified into three types: regular, irregular, and
nor does it exist in the mouth. This subtle asymmetry flat. In dentitions with irregular or flat types, prosthetic
produces natural beauty. treatment may require a special arrangement (such as
Perfect symmetry is “imaginary beauty,” which is half pontics or long proximal contacts to close the in-
created by human desire. Reasonable symmetry pro- terproximal space; consideration of the axial surface
duces a more natural, dynamic look (eg, Case 6) than including subgingival contour) in addition to restoring
perfect, artificial symmetry. Delicate consideration of the natural anatomical shape (Table 2).
the dentition, including the periodontium, leads to the

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 TSUZUKI

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