Journal of the California Dental Association

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Periodontal Considerations in Veneer Cases

David Peto

To cite this article: David Peto (2015) Periodontal Considerations in Veneer Cases, Journal of
the California Dental Association, 43:4, 193-198, DOI: 10.1080/19424396.2015.12222834
To link to this article: https://doi.org/10.1080/19424396.2015.12222834

Published online: 09 Mar 2023.

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periodontics
C D A J O U R N A L , V O L 4 3 , Nº 4

Periodontal
Considerations
in Veneer Cases
David Peto, DDS, MSD

A B S T R A C T Porcelain veneers are a minimally invasive technique to enhance

patients’ smiles. A crucial component in these cases is the supporting periodontal
apparatus and its interaction with the restorations. This article addresses basic
concepts such as biologic width, altered eruption patterns, appropriate gingival
contouring and smile design to give practitioners the tools to diagnose, evaluate and
treat cases successfully and predictably.

AUTHOR

T
David Peto, DDS, MSD,
oday’s patients are esthetically predictable and long-lasting results.
maintains a private practice driven. They are well informed This article will address concepts
limited to periodontics and very demanding when in smile design, as well as biologic
and implant dentistry in it comes to the results of width, altered eruption patterns and
Beverly Hills, Calif. He is a cosmetic dentistry. This appropriate gingival contouring to give
diplomate of the American
Board of Periodontology.
places an enormous responsibility the practitioner the tools to diagnose,
Conflict of Interest on the dentist and his or her team evaluate and treat veneer cases,
Disclosure: None reported. to diagnose, work up and treat these particularly for patients with gummy
cases. A very common treatment smiles, successfully and predictably. Most
option for the cosmetically driven important, it will highlight the value of
patient is the use of porcelain veneers. a team approach to patient care in order
Veneers are a minimally invasive to achieve ideal results for the patient.
technique to enhance patients’ smiles.
Far from being a simple treatment Principles of Smile Design
option, veneer cases can present Before beginning a discussion of the
many challenging issues. In order periodontal-restorative relationships, it
to achieve an excellent result, the is important to establish the ultimate
restorative doctor must address the esthetic end points that you are trying
tooth-related cosmetic concerns and to achieve. These principles are well
the soft tissue must exist in harmony known and have been described by
with the restorations. An understanding numerous authors.1-10 These ideas fall
of the relationship between the under the broad category of smile design.
periodontal tissues and restorations is The rationale behind smile design is to
essential in order to achieve esthetic, create a clinical situation where both
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C D A J O U R N A L , V O L 4 3 , Nº 4

the dental hard and soft tissues work from the frontal view. In addition, the utilizing the veneers to move the contact
harmoniously to create an ideal smile. central incisor is 2-3 mm wider than point more apically can help to improve
Dental midline: The dental midline the lateral and 1-1.5 mm wider than the the soft tissue fill in those sites.
should be perpendicular to the canine. Similarly, the canine is 1-1.5 mm Lip line: When smiling, the inferior
interpupillary line. The philtrum of the wider than the lateral incisor. Both the border of the upper lip should be level
lip is one of the most accurate anatomical central incisor and canine are longer than with or within 1-2 mm of the gingival
landmarks for the midline. The midline the lateral incisor by 1-1.5 mm. Maxillary margin. If there is excess gingival display,
should be parallel to the long axis of the premolars also play an important role in a gummy smile will result, compromising
face, perpendicular to the incisal plane filling up the buccal corridor, eliminating the esthetic outcome. Depending on
and should drop straight down from the darks space at the corner of the mouth the extent of gingival display, different
papilla between the central incisors. during smiling. The use of temporary treatment modalities exist to correct
Incisal lengths: When the mouth is crowns during the restorative phase is the problem. One such treatment — lip
relaxed, approximately 3.5 mm of the useful at this point in order to determine repositioning — is described below in
maxillary central incisors should be the ideal esthetics for each patient. the section on vertical maxillary excess.
visible. Appropriate tooth length is Patient-specific factors: Gender, age
also important for proper phonetics. and personality are crucial factors when
Tooth dimensions: The central considering smile rehabilitation. Tooth
Most authors recommend
incisors are the most prominent teeth dimension, shape, cusp anatomy and
in the mouth. Thus, proper restoration that proper harmony tooth shade are just a few elements
of these teeth is crucial in an esthetic be achieved by eye via that are impacted by these issues.
smile. The width-to-length ratio of proper adjustment of the
the centrals is typically 4:5. The shape Why Do Patients Want Veneers?
and location of the central incisors provisionals rather than strict If patients were satisfied with their
influences the appearance and placement adherence to a formula. smiles, they would not be pursuing
of the lateral incisors and canines. cosmetic dental treatment. In some
Various methods have been used to cases, patients are unsatisfied with
determine ideal proportions. The golden the shade of their teeth or are trying
proportion is perhaps the most well Zenith points: The zenith point to correct mild chipping and uneven
known. It is based on the mathematical is the most apical position of the incisal edges. For patients who have
ratio of 1.6:1:0.6, a ratio commonly found tooth margin where the gingiva is the excellent oral hygiene, stable occlusion
in nature. However, is it difficult to apply most scalloped. It is located distally and sufficient tooth structure, these
in practice, as patients have different arch to an imaginary vertical line drawn cases are fairly straightforward. The
forms, lip anatomy and facial proportions. through the center of the tooth. conscientious restorative doctor, working
In fact, strict adherence to this formula Interdental embrasures: In order to together with the laboratory, can achieve
could lead to esthetic failure.11 Other achieve maximal esthetics, soft tissue an excellent, long-lasting result.
models exist. Most authors recommend embrasures should be present between the In most cases, however, the esthetic
that proper harmony be achieved by eye teeth. Lack of gingiva in this area results deficiencies are more extensive. What this
via proper adjustment of the provisionals in the formation of a black triangle. This means is that when a patient presents for
rather than strict adherence to a formula. is frequently seen in patients who have veneers, there are numerous underlying
Bhuvaneswaran1 provides the a history of bone loss due to periodontal factors that make treatment more difficult.
following guidelines for tooth proportion: disease. If the contact point between teeth The restoring doctor must therefore
The central incisors should be 10-11 is greater than 5 mm from the crest of the carefully evaluate the patient and the
mm in length. Width is 75-80 percent of alveolar bone, black triangle formation type of case that is presented and develop
this value. Maxillary laterals are never is likely. However, if the contact point a thorough treatment plan to achieve
symmetrical and they influence gender is within 5 mm of the osseous crest, a the patient’s goal of a revitalized and
characterization. Only the mesial half of papilla will be present almost 100 percent beautiful smile. Often this will require the
the maxillary canines should be visible of the time.12 If bone loss has occurred, direct involvement of a periodontist. The
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following sections will detail diagnosis, In cases of extreme wear, a reduction in Altered Passive Eruption
surgical and restorative treatment planning, the VDO is likely.14 If there has been a loss Another common cause of short
and proper phasing of the esthetic veneer in the vertical dimension, more extensive clinical crowns is altered passive eruption
case, specifically in the challenging restorative work may need to be done. (APE). APE occurs when the marginal
situation of correcting a gummy smile. In these cases, full-mouth reconstruction gingiva is malpositioned on the anatomic
There are two main causes of gummy may be necessary to re-establish the VDO. crown. In such cases, the tissue does
smiles. The first is short clinical crowns (Guidelines for re-establishing the VDO not approximate the cemento-enamel
and the second is vertical maxillary are beyond the scope of this discussion.) junction (CEJ).15-17 During normal tooth
excess (VME). In some patients, Once the proper VDO has been eruption, the attached gingiva moves
both of these issues are present. established, patients with short clinical apically.18 This process usually continues
crowns should be seen by a periodontist into the early or mid 20s.19 In patients
Short Clinical Crowns so that he or she can partner with the with APE, the gingival margin fails to
One of the most common reasons restoring doctor. Using a team approach, migrate to the appropriate level. Coslet
that patients pursue veneer treatment the surgeon will be able to assess the case et al.20 divided patients into two main
is for the correction of short clinical types based on the relationship of the
crowns. Patients with short teeth are gingiva to the anatomic crown. These
often afraid to smile or even speak in classes were subdivided according to
public. Short teeth give the appearance
Clear communication the position of the osseous crest.
of age and wear and because of the during the restorative Type 1 is represented by the presence
drastic change in length-to-width ratio, planning stages enables of the gingival margin coronal to the
these teeth are very unesthetic. both the restoring doctor and CEJ. There is typically a wide band
Short clinical crowns may be the of keratinized tissue from the gingival
result of very different processes. A surgeon to develop the ideal margin to the mucogingival junction. The
main cause of short teeth is incisal wear, treatment plan for the patient. mucogingival junction is usually apical to
where normal-length teeth have been the alveolar crest. Type 2 is represented
reduced. A second reason for short by a normal width of keratinized gingiva
clinical crowns is altered passive eruption. from the margin to the mucogingival
While certain elements of treatment for and determine if surgical intervention junction. In this type, all of the gingiva
these conditions will overlap, there are is necessary in order for the dentist and is located on the clinical crown and the
important distinctions that emerge. patient to achieve the desired restorative mucogingival junction is located at the
outcome. In cases where the VDO did level of the CEJ. Both types are subdivided
Incisal Wear not change over time, crown lengthening into A and B. In subgroup A, the normal
The loss of tooth structure is a natural may be necessary in order to expose distance of 1.5-2.0 mm from CEJ to
consequence of age and wear. In cases sufficient tooth structure to restore the osseous crest is observed. In subgroup B,
of normal physiologic wear, the vertical case in the most ideal way. In cases where the alveolar crest is at the level of the CEJ.
dimension of occlusion (VDO) is not the patient’s bite had to be opened to Diagnosis of altered passive eruption
changed, largely due to dentoalveolar restore the VDO, there may be no need is accomplished via clinical and
compensation.13 In these cases, the for crown lengthening. If there is sufficient radiographic exam. Because the clinical
patient’s profile has not been affected since space for veneers of appropriate incisal crowns are short, excessive wear must be
the vertical dimension and freeway space length, crown lengthening may result in ruled out. This can be accomplished by
have been maintained. An easy way to teeth that appear too long because they checking for evidence of parafunction
determine if the VDO has been affected now need to meet the lower incisors (i.e., worn cusp tips, linea alba on
is by having the patient bring in old at a greater vertical dimension. Clear the cheeks indicating repeated cheek
photos and comparing the facial esthetics. communication during the restorative biting, trauma to the lateral borders of
If the VDO has been maintained, then planning stages enables both the restoring the tongue). If altered passive eruption
there will be no change in the distance doctor and surgeon to develop the is suspected, consultation with a
from the patient’s nose to chin. ideal treatment plan for the patient. periodontist is recommended in order to
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C D A J O U R N A L , V O L 4 3 , Nº 4

determine the proper surgical approach.

In order to determine the appropriate
FIGURE 1. Preoperative view. (Photo courtesy of FIGURE 2 . After gingivectomy. (Photo courtesy
treatment for altered passive eruption, the Robin Weltman, DDS, MS.) of Robin Weltman, DDS, MS.)
periodontist will perform bone sounding
in order to determine the position of
the CEJ relative to the osseous crest.
This is accomplished by anesthetizing
the patient and inserting the probe
under pressure until bone is reached.
In type 1A cases, the distance from
the CEJ to the osseous crest is normal. FIGURE 4 . After surgery and veneers. (Photo
courtesy of Robin Weltman, DDS, MS.)
In these cases, gingivectomy and
gingivoplasty are sufficient to resolve the FIGURE 3 . Preoperative view. (Photo courtesy of
excess gingival display. (FIGURES 1 and Robin Weltman, DDS, MS.)
2 . Note the appearance of Nos. 8 and
9 in FIGURE 1 . The teeth are short and positioned flap is utilized to maintain tissue attachment to the root surface
square and lack the appropriate length- the width of attached gingiva. In type of a tooth.21 The term was based on
to-width ratio. In addition, the gingival 2A cases, the flap is displaced and work done by Gargiulo et al.22 when
margins are level with No. 7 and No. 10, tissue is allowed to heal. No osseous measurements were taken on 30 autopsy
further compromising the smile esthetics. recontouring is necessary. In type 2B specimens. They determined that the
Following the gingivectomy in FIGURE cases, bone removal is necessary to junctional epithelial attachment to
2 , the appearance of Nos. 8 and 9 is establish normal dimensions from the the tooth measured 0.97 mm and the
more harmonious. The gingival margins CEJ to the crest and the flap is displaced connective tissue attachment measured
are at the appropriate heights, and the apically to preserve the attached tissue. 1.07 mm, resulting in a total attachment
length-to-width ratio is improved.) distance of 2.04 mm. In addition, the
In type 1B cases, there is insufficient Biology and Treatment Planning, sulcus above the junctional epithelium
space from the CEJ to the osseous crest Presurgical Steps, Surgery and measured 0.69 mm. In order to maintain
for the establishment of a proper biologic Healing periodontal health, it is recommended
width. In these cases, esthetic crown Once the etiology of the short that at least 3 mm of space exist from
lengthening via osseous resection is clinical crowns has been established, the the crest of the bone to the margin
necessary to achieve ideal results (FIGURES restorative and surgical team can devise of the restoration. This distance will
3 and 4 ). Note the short teeth at Nos. 8 a final treatment plan for the patient. account for the epithelial and connective
and 9, as well as the peg laterals at Nos. 7 In cases where crown lengthening is tissue attachment to the tooth, as well
and 10. In addition, the gingival margins necessary, there are repeatable steps that as the sulcus. Nevins and Skurow23
from Nos. 6-11 are uneven, making both the restoring dentist and surgeon recommend keeping margins within
the esthetic deficiency more acute. In can take to ensure a predictable and 0.5-1 mm of the sulcus in order to avoid
FIGURE 4 , crown lengthening has been esthetic outcome. Before discussing the impinging on the junctional epithelium.
performed and porcelain restorations have specific stages of surgery, a review of the It is important to keep in mind that
been placed. The tooth length-to-width biologic principles of the periodontal- these numbers are based on cadaver
ratios have dramatically improved. There restorative interface is important. studies. In a recent systematic review,
is an overall harmonious appearance Schmidt et al.24 noted that mean values
of the teeth in the smile. The tissue Biologic Width for biologic width obtained from two
margins are appropriately scalloped and One of the most important aspects in meta-analyses were 2.15 and 2.30 mm.
the periodontium is pink and healthy. the periodontal-restorative relationship However, large intra- and inter-individual
Treatment of type 2 cases requires is the biologic width. The biologic variances were observed (0.2-6.73 mm).
a different approach. Because there is width is the distance established by the As a result, 3 mm is generally acceptable,
minimal keratinized tissue, an apically junctional epithelium and connective although large discrepancies do exist.
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TABLE

Classification and Treatment Options

Degree Gingival and Treatment modalities
mucosal display
I 2–4 mm Orthodontic intrusion only
Orthodontics and periodontics temporary veneers also enable the surgeon
Periodontics and restorative therapy to ensure that a suitable biologic width
II 4–6 mm Periodontics and restorative therapy has been established. If the tissue is pink
Orthognathic surgery and healthy following surgery, then the
The choice depends on the remaining amount of root encased temporary veneers are not encroaching
in bone and crown-to-root ratio upon the biologic width. However, if the
III ≥8 mm Orthognathic surgery with or without adjunctive periodontal tissues appear red and inflamed more than
and restorative therapy complete dentofacial harmony two weeks post-surgery, there is a possibility
that inadequate osseous reduction was
performed. Veneer margins should be
Presurgical Steps of full thickness buccal/labial flaps to expose assessed to ensure a supragingival location,
Prior to commencing a case, a diagnostic the supporting alveolar bone. The CEJs of any excess cement should be removed
wax-up is essential. A wax-up of the the affected teeth are the coronal landmarks and proper oral hygiene must be reviewed
future veneers will enable the dentist to for the osseous reduction. This reduction to rule out potential contributing factors
visualize the desired outcome. The wax- is typically carried out with high-speed resulting in soft tissue inflammation.
up also gives the patient the opportunity handpieces under irrigation, and a new Because there is individual variability
to evaluate the number of teeth proposed osseous margin is created more apically to in the dimension of the biologic width, it is
for veneer treatment, the tooth shape the original level of the crest. Depending on recommended that restorative procedures
and position, as well as overall tooth the etiology of the short clinical crowns, soft be delayed at least six weeks until final
length. Once that patient approves the tissue removal may accompany the osseous impressions are taken. In many cases,
wax-up, a silicon impression can be used reduction. The flap is then repositioned and especially in cosmetic anterior cases, a
and temporary veneers can be fabricated. sutured in place. The patient is instructed longer healing period is recommended.
This will allow the patient to evaluate not to brush or floss the area for two Wise25 suggests 21 weeks for soft tissue
the appearance of the final veneers in the weeks, and an antibacterial rinse such as gingival margin stability. If a restoration
mouth, and to suggest changes before the chlorhexidine gluconate may be prescribed. is placed too early in the healing process,
final restorations are fabricated by the lab. As noted above, the generally accepted the gingival margin may migrate, resulting
Once the patient has approved the space between the crest and the CEJ is 3 mm in an unsatisfactory esthetic outcome.
final shapes of the veneers, the wax-up can to account for the biologic width. However, However, tissue rebound may occur if too
also be used as a surgical guide. A vacuum- due to individual variability, the surgeon will much time elapses prior to final restorations.
formed stent can be fabricated using the need to assess this for each patient. This can Because of the variability in patient
wax-up. This will provide the surgeon with be accomplished during surgery by additional healing, it is difficult to assign a strict rule
the proposed final tooth length. Once bone sounding of other teeth that are not for placement of final restorations. Both
the positions of the veneer margins are being treated. The distance from the gingival the restoring dentist and surgeon must
determined, the surgeon can then perform tissue to the underlying bone will give the monitor the patient’s healing. Once they
the necessary amount of bone and/or soft surgeon the patient-specific distance that feel that tissue stability has been achieved,
tissue removal in order to accommodate the exists between the osseous crest and the final restorations may be placed. As a rule,
desired restoration. A surgical guide prevents margin of the soft tissue. This distance can anywhere between three26 to six27 months
two potential problems: Too much bone then be recreated to ensure that when the may be considered adequate healing time
and soft tissue reduction will result in teeth new biologic width is established, it has the in cosmetic crown-lengthening cases.
that appear too long, and inadequate hard same dimensions as the presurgical value.
and soft tissue reduction will necessitate Vertical Maxillary Excess
further surgery to achieve the desired result. Healing Another common finding in patients
The temporization phase is important in with short clinical crowns and gummy
Surgery veneer cases. Firstly, patients can evaluate smiles is vertical maxillary excess (VME).
In cases of short clinical crowns due tooth appearance, as well as other important This frequently results from a skeletal
to excessive wear or due to APE, crown aspects such as vertical dimension and dysplasia resulting in teeth that are farther
lengthening is accomplished via reflection phonation. During the healing phase, the away from the maxillary base and a display
A P R I L 2 015 197
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C D A J O U R N A L , V O L 4 3 , Nº 4

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THE AUTHOR, David Peto, DDS, MSD, can be reached at dpeto@
weloveperio.com.
may need to be combined with lip 5. Mashid M, Khoshvaghti A, Varshosaz M, Vallaei N. Evaluation

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