Red Esthetics










Chapter
11
Red
Esthetics
Daniele
Rondoni
Ferran Piug
Jordi
Manauta
Anna
Salat
Interview
with
Galip
Gurel

''
Ernest
Hemingway

366
Dr Galip Gurel graduated from the University of Istanbul Dental
School
in
1981 and continued his postgraduate education at the
University of Kentucky, Department of Prosthodontics, and at
Yeditepe University in Istanbul. Dr Gurel is the founder and the
honorary president of the Turkish Academy of Aesthetic Dentistry.
He
has been named President of the European Academy
of
Esthetic
Dentistry for 2011 and 2012. Dr Gurel
is
also a member of the
American Society for Dental Aesthetics and
an
honorary diplomate
of the American Board of Aesthetic Dentistry.
He
is
the editor-in-
chief of the Turkish edition of Quintessence International and on
the editorial boards of the Journal
of
Cosmetic Dentistry, Practical
Procedures
& Aesthetic Dentistry, and European Journal
of
Esthetic
Dentistry.
Dr Gurel has lectured
on
dental esthetics all over the world and
is a visiting professor at New
York
University (USA), University
of
Marseille Dental School (France), and Istanbul Yeditepe University
(Turkey).
He
is
the author of
The
Science and
Art
of
Porcelain
Laminate Veneers (Quintessence Publishing, 2003), which has been
translated into
10
different languages.
He
has practiced in his own
clinic in Istanbul, specializing
in
esthetic dentistry, since 1984. A
renowned sportsman, Dr Gurel has been the captain of the Turkish
National Water Polo
Team
110 times, a world champion
in
the
Camel Trophy race, and a
participant
in
the Paris-Dakar
Rally.

Q:
In
which method do you think gingival restoration
materials
are
more difficult to
use,
in
the stratification
technique or
in
the correct application
in
the mouth?
A:
As
you
know,
we
are using the "pink solution"
in
esthetic
cases when
we
have
deficient soft tissue that cannot
be
regenerated with a series of surgical approaches or for
restoration of mismanaged soft tissues
and/
or
misplaced
implants.
When
such compromised gingivae must
be
replaced with
a restorative
material, unfortunately most of the time this
missing area is
filled with white esthetics through the use
of
extremely long crowns. This solution ruins the crown
proportions and creates a huge esthetic deficiency.
The
ideal solution for restoring this type of case is
to
build up
the area with
ideal contour and length and to restore the
missing
part
with pink materials.
In
some cases this pink region has been restored with
pink
porcelain, which provided adequate results but
could not simulate the natural color blend with the soft
tissues.
Lately
we
have
seen
that
restoring that area
with a pink composite resin provides the most
natural-
looking estheti<; results.
In
its simple form, rebuilding the
deficient area with pink composite is
no
different than
building up a composite over the tooth surface. Just
as
we
layer different Values and Hues of composite that
we
place
on
the teeth to
mimic
the tooth color and create
the most
natural effect,
we
do exactly the same for the
pink areas.
The
buildup of the pink is also performed directly in
the mouth after the main
Hue
is chosen.
The
details
are incorporated with stains and colors to match the
restoration
color with the individual gingival color
specifically
for each patient.
In
the beginning, handling
the pink composite feels strange;
however,
after a few
restorations
have
been completed,
it
feels
as
comfortable
as
placing tooth-colored coi:nposite over the natural teeth.
389

/
,•
398
Normal gingiva
is
characterized clinically by its pink color,
firm
consistency, scalloped margins,
firm
interdental papillae
that
fill the space below the contact areas , and absence of bleeding
on
gentle probing. Special conditions occur, especially in
complicated
implant
cases,
that
require a material
that
can
imitate
perfectly the lost natural tissue.
Red Esthetics
Today,
esthetics does not only
have
to
be
white;
an
increased
knowledge of anatomy and evolution of materials
have
given
us
the ability to_ solve complicated esthetic problems affecting
soft tissues.
We
all know
we
can produce a
mimetic
pink
esthetic restoration with ceramics and
acrylic resins.
Now,
however,
we
have to consider the composite evolution. The
properties found
in
the new-generation materials
have
been
proven to
be
ideal for more and more prosthetic applications.

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Chapter 11 Red Esthetics Daniele Rondoni Ferran Piug • Jordi Manauta • Anna Salat Interview with Galip Gurel '' Ernest Hemingway 366 Dr Galip Gurel graduated from the University of Istanbul Dental School in 1981 and continued his postgraduate education at the University of Kentucky, Department of Prosthodontics, and at Yeditepe University in Istanbul. Dr Gurel is the founder and the honorary president of the Turkish Academy of Aesthetic Dentistry. He has been named President of the European Academy of Esthetic Dentistry for 2011 and 2012. Dr Gurel is also a member of the American Society for Dental Aesthetics and an honorary diplomate of the American Board of Aesthetic Dentistry. He is the editor-in-chief of the Turkish edition of Quintessence International and on the editorial boards of the Journal of Cosmetic Dentistry, Practical Procedures & Aesthetic Dentistry, and European Journal of Esthetic Dentistry. Dr Gurel has lectured on dental esthetics all over the world and is a visiting professor at New York University (USA), University of Marseille Dental School (France), and Istanbul Yeditepe University (Turkey). He is the author of The Science and Art of Porcelain Laminate Veneers (Quintessence Publishing, 2003), which has been translated into 10 different languages. He has practiced in his own clinic in Istanbul, specializing in esthetic dentistry, since 1984. A renowned sportsman, Dr Gurel has been the captain of the Turkish National Water Polo Team 110 times, a world champion in the Camel Trophy race, and a participant in the Paris-Dakar Rally. Q: In which method do you think gingival restoration materials are more difficult to use, in the stratification technique or in the correct application in the mouth? A: As you know, we are using the "pink solution" in esthetic cases when we have deficient soft tissue that cannot be regenerated with a series of surgical approaches or for restoration of mismanaged soft tissues and/ or misplaced implants. When such compromised gingivae must be replaced with a restorative material, unfortunately most of the time this missing area is filled with white esthetics through the use of extremely long crowns. This solution ruins the crown proportions and creates a huge esthetic deficiency. The ideal solution for restoring this type of case is to build up the area with ideal contour and length and to restore the missing part with pink materials. In some cases this pink region has been restored with pink porcelain, which provided adequate results but could not simulate the natural color blend with the soft tissues. Lately we have seen that restoring that area with a pink composite resin provides the most natural-looking estheti<; results. In its simple form, rebuilding the deficient area with pink composite is no different than building up a composite over the tooth surface. Just as we layer different Values and Hues of composite that we place on the teeth to mimic the tooth color and create the most natural effect, we do exactly the same for the pink areas. The buildup of the pink is also performed directly in the mouth after the main Hue is chosen. The details are incorporated with stains and colors to match the restoration color with the individual gingival color specifically for each patient. In the beginning, handling the pink composite feels strange; however, after a few restorations have been completed, it feels as comfortable as placing tooth-colored coi:nposite over the natural teeth. 389 / ,• 398 Normal gingiva is characterized clinically by its pink color, firm consistency, scalloped margins, firm interdental papillae that fill the space below the contact areas , and absence of bleeding on gentle probing. Special conditions occur, especially in complicated implant cases, that require a material that can imitate perfectly the lost natural tissue. Red Esthetics Today, esthetics does not only have to be white; an increased knowledge of anatomy and evolution of materials have given us the ability to_ solve complicated esthetic problems affecting soft tissues. We all know we can produce a mimetic pink esthetic restoration with ceramics and acrylic resins. Now, however, we have to consider the composite evolution. The properties found in the new-generation materials have been proven to be ideal for more and more prosthetic applications. Composite resin materials can be used both in the clinic and in the laboratory. We can take advantage of this possibility by beginning the work in the laboratory, creating the gingival color base, and finalizing the work at chairside, where the clinician can apply the pink masses directly in patients. This possibility allows us to achieve natural, mimetic results. We know that composite finishing and polishing are quickly accomplished, which together with the reparability of composites, represent the main advantages of these kinds of materials. Forth is reason, we have to consider composite a very important material for prosthetic strategies. / Observing nature closely, we can notice different chromatic features in the anatomy of pink areas, and each detail corresponds to a natural feature. It is important for us to have a complete materials system that can imitate all of the natural optical effects and at the same time is simple, so we can achieve excellent results in a few steps: This is a highly transparent pink mass that reproduces the cervical area where gingiva covers dental tissue. In combination with white or red stain, TPT can reproduce the frenulum, whose coloring has a high contrast with other gingival colors. · tn · This is a light pink transparent mass that reproduces the tight apical root area, where the gingiva is more tense and white and acquires the typical light color reflected by the underlying bone. • Dark pink (TPD): This is a violet-pink transparent mass used to reproduce the less tense gingival area, which is less adherent to the bone. Because the blood flow in this area is higher, the color tends to a bluish Hue. Dark pink can be used in combination with blue and red stains to imitate the natural gingival color of these intense areas. • Pink-orange (TP): This opaque and chromatic mass can be used to create the first composite layer and areas close to the gingival margin. It can be applied as well in combination with blue stain to reproduce the apophysis. •White stain (SW): This stain increases opacity and re-creates the typical coloring of ischemic gingiva or the apophysis. • Red stain (SR): This stain increases the chromaticity of pink composite, imitating the blood flow and more evident blood vessels. When mixed with masses, SR imitates tissues with heavy blood flow as happens in the presence of gingivitis. •Blue stain (SBL): This stain increases the effect of the small vessels and fornix, when used in deep layers. When mixed with composite, SBL imitates melanotic features and blue gingiva. • Brown stains (SBR and SBR2): These stains increase the Chroma to simulate melanotic features, heavy blood flow, and deep areas. It is important to have stains available to reproduce individual effects. They can be mixed with the composite masses or used directly under the pink composite resin masses. 392 H c 39'1 Normal Gingiva 1 An acrylic resin model with a bone shape will be the basis for stratification of the soft tis-sue thickness. All materials that will act as a base should be sandblasted. A correct bonding agent and a light-curing adhesive are applied to the sandblasted sur-face and polymerized for 1 minute. If the area is large, polymerization time must be increased. Margin stratification begins. In this case, TPL is used to develop a light ridge. On the root surface, TP is placed as an opaque layer to develop the bone structure. SW will be used to create some white charac-terizations to make the gingiva appear more tight in these areas. A layer of TPT is placed as a final layer to create an impression of natural depth. Technician: Daniele Rondoni, Savona, Italy. For the deep gingiva , TPD is used to enhance Chroma. It is possible to develop some blue character-izations for the areas of low blood flow. In the final step, the frenulum is created using a mixture of TPT and red and white stains. 395 I 396 Melanotic (Pigmented) Gingiva 1 An acrylic resin model with a bone shape will be the basis for stratification of the soft tis-sue thickness. All materials that will act as a base should be sandblasted. A correct bonding agent and a light-curing adhesive are applied to the sandblasted sur-face and polymerized for 1 minute. If the area is large, polymerization time must be increased. A layer of TPD is placed to develop a dark gingival ridge. / Blue stain is placed alo·ng the tooth and root contours to develop some strong melanotic effects. The TP must be overlapped slightly over the layer of stain to hide some of the strong blue color and give a precise shape. A mixture of TPD with red and blue stains is placed to develop the frenulum . Technician: Daniele Rondoni, Savona, Italy. For the deep gingiva, TP is used to create an opaque base. It is placed as a roll and then extended with a brush. A small amount of TPD mixed with red stain is used to build the gingival margin. A final layer of TPT is placed to mask the ef· fects to the desired level. 397 Swollen Gingiva 395 1 An acrylic resin model with a bone shape will be the basis for stratification of the soft tis-sue thickness. All materials that will act as a base should be sandblasted. A correct bonding agent and a light-curing adhesive are applied to the sandblasted sur-face and polymerized for 1 minute. If the area is large, polymerization time must be increased. An incomplete mixture of TPL and SR is placed to create the effect of bleeding gin-giva. On the root surface and the bone, the blood A mixture of TPD and SW is used for the fren-vessels are characterized with SBL and SR. ulum to enhance the ischemic effect. SW is used to create some ischemic features. A layer of TPT is placed to hide the blue and red effects slightly. A final layer of TPD is placed to opacify the features as much as needed to hide the un-derlying layers (right side). Technician: Daniele Rondoni, Savona, Italy. In addition, a thin layer of TPT is applied to hide the white spots near the margin. If it is desirable to show the effects more clearly, TPL is used for the final layer instead (left side). 399 Pink Ceramics The frame wax-up must be prepared very pre-cisely according to the final shape desired. 3 The dentinal body and the incisal edge are prep a red first. 2 Once the metal frame is completed, a thin, opaque layer is placed and fired in the oven. This body will act as a frame for further and more delicate layering. To achieve a natural gingiva, we need to heed a few requirements, all of them necessary to enhance our techniques: •We should choose from a narrow selection of materials. The range must extend from intense reds to softer pinks. •We must master the internal staining technique to achieve complex features in very small spaces. These techniques can greatly facilitate this work. •To enhance the texture while modeling ceramics, we cut a brush in half to enable us to reproduce the "orange peel" effect of the attached gingiva. / Then the pink ceramics are stratified in a way very similar to that used for composite resins. The final dental layers are carried out with the desired effects. Low-speed green stones and diamond burs are used to define the final shape and pre-pare the teeth for the final glazing. After the second firing, the outcome can be assessed, and correction masses can be added, as necessary, in order to proceed to the finishing stage. After glazing and firing, mechanical polish-ing is still needed. Noritake pink ceramic shade guide with all the ·colors available for gingival stratification. 481 Young gingival tissues To create the appe-arance of younger gingival tissues, we use softer pink shades and more intense texture. In this case, we have reproduced blood vessels with an internal stain. Ceramist: Ferran Puig, Mollerussa, Lerida, Spain. Adult gingival tissues In these gingivae we have applied various types of pink tones to achieve a more intense red. The texture must be softer because of erosion and tissue relaxation. 1 Elderly gingival tissues A very soft texture and a wider range of Hues (red and brown) characterize this case. To achieve these colors, we must make adjustments with internal stains. Conclusions 1. Oral soft tissues have an enormous color range; their primary colors are red, white, blue, and brown. 2. The transparency and opacity of pink materials play a fundamental role in integration of restorations. 3. Mixture of pink masses with primary stains (blue, red, white, and brown) allows the creation of any color. 4. Underlying effects play a fundamental role in the natural appearance of the soft tissues. Mixing masses, making a custom shade guide, and taking note of the mixing ratio will allow us to repeat restorations with a reliable method. I Alani A, Maglad A, Nohl F. The prosthetic management of gingival aesthetics. Br Dent J 2011;210:63-69. Barzilay I, Irene T. Gingival prostheses-A review. J Can Dent Assoc 2003;69:74-78. Coachman C, Van Dooren E, Gurel G, Calamita MA, Calgaro M, de Souza Neto J. Minimally invasive reconstruction in implant therapy. The prosthetic gingival restoration. Quintessence Dent Technol 2010;33:61-75. Coachman C, Salama M, Garber D, Calamita M, Salama H, Cabral G. Prosthetic gingival reconstruction in a fixed partial restoration. 1. Introduction to artificial gingiva as an alternative therapy. Int J Periodontics Restorative Dent 2009;29:471-477. Coachman C, Salama M, Garber D, Calamita M, Salama H, Cabral G. Prosthetic gingival reconstruction in fixed partial restorations. 3. Laboratory procedures and maintenance. Int J Periodontics Restorative Dent 2010;30:19-29. Kim TH, Cascione D, Knezevic A, Nowzari H. Restoration using gingiva·colored ceramic and a ridge lap pontic with circumferential pressure: A clinical report. J Prosthet Dent 2010;104:71-76. Polack MA, Mahn DH. The aesthetic replacement of mandibular incisors using an implant-supported fixed partial denture with gingival-colored ceramics. Pract Proced Aesthet Dent 2007; 19:597-603. Rondoni D. lmportanza e fondamenti della morfologia nel restauro estetico dentale. Dent Labor 201'0; 16:27-38. Salama M, Coachman C, Garber D, Calamita M, Salama H, Cabral G. Prosthetic gingival reconstruction in the fixed partial restoration. 2. Diagnosis and treatment planning. Int J Periodontics Restorative Dent 2009;29:573-581. Small BW. The use of pink porcelain for gingival defects in restorative dentistry: A case report. Gen Dent 2010;58:285-287.

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