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16 Dental Tribune Middle East & Africa Edition | January-February 2016 aesthetics The flawless reconstruction of gingival tissue requires sound teamwork as well as excellent materials and exceptional skill. Layering with the light-curing laboratory composite SR Nexco takes this procedure to a new level. > Page 18 A good option for the lifelike recreation of gingival tissue By Dr. Patrice Margossian, Marseille, & Pierre Andrieu, France C areful planning is indis- pensable in the treat- ment of an edentulous jaw with implant-supported restorations. The axes and positions of the implants must correspond to the given biolog- ical, mechanical and esthetic conditions. In situations where severe bone recession has oc- curred, the work of the dental team will involve not only the reconstruction of dental but also of gingival tissue. The dentogingival complex must primarily fulfil two aspects: function (chewing and speak- ing) and esthetics (alignment of the teeth and gums and lip support). Clinical case presentation When the 37-year-old female patient presented to our prac- tice her teeth and the related bone structure were in very poor condition (Figs 1 and 2). Numerous teeth were missing in both the upper and lower jaw. Furthermore, the upper jaw showed considerable bone and gingival resorption. The patient wished to have fixed teeth again and regain an at- tractive appearance. Due to the extensive damage that had occurred, the complete res- toration of both jaws with im- plants was indicated. Surgical phase As a result of sufficient bone structure in the lower jaw, this part of the mouth could be restored at once with four im- mediately loadable implants. During the reconstructive phase, the upper jaw had to be treated with a provisional removable denture due to the atrophied jaw ridge. The tooth extractions in the upper and lower jaw took place during one day. At the same time, the four lower jaw implants were inserted and loaded. An imme- diate denture was placed in the upper jaw. During the osseointegration period of the mandibular im- plants, the bones in the upper jaw were reconstructed. The maxillary sinus and the jaw ridge were augmented in one appointment. At the next ap- pointment, ten implants were placed according to the treat- ment plan. Six months after this intervention, the implants were exposed. As a result of a well-planned soft tissue man- agement strategy, firm kera- tinized tissue had formed in adequate form. The perma- nent restorations for the upper and lower jaw were fabricated two months later (Figs. 3 and 4). Prosthetic phase The determination of the oc- clusal plane and the ideal inci- Fig. 1: Initial portrait of the patient Fig. 3: After bone augmentation measures had tak- en place, ten implants were inserted. The picture shows the situation prior to the prosthetic phase. Figs 5a and b: Recording of the esthetic facial axes with the Ditramax system Fig. 6: The denture was set up with pre-fabricated teeth (SR Phonares II). Fig. 9: Application of the colour saturated intensive Gingiva materials (SR Nexco® Paste Intensive Gingiva) Fig. 7: Try-in of the CAD/CAM-fabricated titanium framework in the upper jaw Fig. 10: The application of various translucent materials impart- ed the prosthetic gingiva with the desired depth effects. Fig. 8: The ground down composite resin areas were conditioned for receiving the light-curing laboratory composite SR Nexco. Fig. 11: Lifelike, vital, esthetic – the white and pink esthetics have been optimally imitated. Fig. 4: Four implants were inserted in the lower jaw. Bone augmentation measures were not necessary in this case. Fig. 2: Extremely poor oral condi- tion: The teeth could not be rescued. The jaw ridge in the upper jaw was considerably atrophied. “When the upper and lower jaw have to be restored, it is important to start with the upper jaw. Alterna- tively, both jaws can be restored simultaneously.”