Tissue sculpturing: An alternative method for improving esthetics of anterior

fixed prosthodontics
Letícia Borges Jacques, DDS, MSD,a Aloísio Borges Coelho, DDS, MSD,a Henrique Hollweg, DDS,
MSD,a and Paulo César Rodrigues Conti, DDS, PhDb
Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil
Esthetics associated with health of surrounding tissues in fixed prosthodontics is arduous, especially
when treating the maxillary anterior region. An unfavorable relationship between residual ridge,
pontic, and gingival papilla commonly compromises the final result. Alternative procedures based on
biologic procedures can be developed to improve relationships and provide esthetic and functionally
acceptable fixed partial dentures. This article describes a technique for the improvement of esthetics
with conditioning of the tissue beneath the pontics, by displacing tissue with a treatment restoration.
Lateral displacement of tissue under gradual, controlled pressure enhances the interdental papilla,
which improves esthetics. The role of plaque control is also discussed in this article. (J Prosthet Dent
1999;81:630-3.)

T he shape of a pontic should be designed to meet

functional demands, promote access, and ensure
esthetics, with the goal of maintaining the health of the
adjacent tissue. For this reason, a convex tissue surface
is indicated for pontics of posterior or anterior fixed
partial dentures (FPDs). However, the convex shape of
the residual ridge often does not allow the dentist to
construct a satisfactory, well-shaped pontic. Alteration
of the shape of a residual ridge by surgical intervention
or gradual pressure has been a valuable management
strategy to improve tissue contour. Nevertheless, a dis-
cussion is indicated to improve esthetics that influence
the health of gingival tissue.1-3 In the past, some
believed that a pressure over the residual ridge resulted
in an inflammatory process. For many years, slight pres-
sure for development of more appropriate ridge anato- Fig. 1. Frontal view of provisional restoration, with initial
my was contraindicated. pontic position located buccally.
Recently published data have shown that a well-con-
trolled hyperpressure applied with a convex and highly
polished pontic, associated with rigid plaque control, PROCEDURE
resulted in only a thinning of the epithelium and
shortening of rete pegs, without inflammation.4,5 1. Fabricate a provisional FPD with slight pontic con-
Researchers have stressed that when a patient does not tact beneath the residual ridge (Fig. 1).
floss beneath the pontics, an inflammatory process will 2. Apply gradual, gentle compression over the soft
follow hyperpressure. This procedure can improve tissue by adding acrylic resin over the pontic sur-
esthetics by developing the shape and height of the face toward the ridge. The amount of acrylic resin
pontics without interfering with tissue health. A close added should not exceed 1 mm to avoid excessive
relationship between pontic and surrounding tissues pressure. The provisional restoration should be
after electrosurgery is also indicated for the improve- inserted only after final curing of acrylic resin to
ment of esthetics.6-9 evaluate hyperpressure. (The pressure should be
This article described a technique for the manage- capable of producing a tissue ischemia without
ment of the residual ridge and improving esthetics with interfering with the fit of the provisional restora-
use of provisional restorations. tion.)
3. Develop a convex shape for the pontic both buc-
colingually and mesiodistally. (This shape allowed
aPostgraduate Student, Department of Prosthodontics. easy, accessible flossing, which is critical for long-
bClinical Professor, Department of Prosthodontics. term treatment outcomes [Figs. 2 and 3].)

630 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 81 NUMBER 5

JACQUES ET AL
Fig. 2. Lateral view of pontic before adding acrylic resin.
Concave aspect of lingual surface prevents proper hygiene.
4. Highly polish all surfaces, especially the surface
contacting the ridge.
5. Cement the provisional restoration and instruct
the patient in the cleaning techniques and their
importance. It is important to stress to the patient
the importance of tissue conditioning success.
Compliance of the patient can be emphasized by
explaining the goals and possible failures of this
procedure.
6. Recall the patient in 1 week to evaluate accommo-
dation of the tissue beneath the pontic.
7. Remove the provisional restoration during this
visit and add a new layer of acrylic resin to contin-
ue the tissue conditioning. The amount of resin to
be added is judged through an analysis of the
shape of tissue and esthetics (Fig. 4). After adding
the acrylic resin, polish and recement the provi-
sional restoration.
8. Repeat this procedure every week until final
esthetic conditioning. (An improvement in emer-
gence profile of the pontic and the appearance of
an extruded pontic from the gingival tissue can be
achieved at this time [Figs. 5 and 6]. The dentist
must be aware of the limit of tissue resilience,
which should be closely monitored. Strength and
MAY 1999
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Convex aspect of pontic which, associated with high-
ly polished surfaces, makes flossing easier.
direction of pressure are determined by esthetics.
The limit for pressuring illustrated here is the level
of gingival apex, which is displaced to distal and
slightly inferior to the apex of the central incisor.)
9. Make a standard impression after completion of
conditioning to provide a master cast with a
removable artificial gingiva. Transfer the tissue
shape to the cast. (This will allow the dental tech-
nician to fabricate a pontic with identical final char-
acteristics [Figs. 7 and 8].)
DISCUSSION
The advantages of pontic hyperpressure have not
been acknowledged,1-3,10 based on the assumption that
an inflammatory response will consistently follow this
procedure. However, for most of these studies, only the
relationship between mechanical stimulation (hyper-
pressure), type of denture material, and inflammation
are recorded. Perhaps the most important etiologic
factor, namely, presence of plaque, was not fully
considered.
Conversely, Tripodakis and Constantinides 4
discussed the importance and clinical usefulness of
pressuring tissue to improve esthetics. They stated that
the pontic width was primarily determined by occlusal
631
THE JOURNAL OF PROSTHETIC DENTISTRY JACQUES ET AL

Fig. 4. Frontal view after 3 weeks shows tissue health, Fig. 6. Provisional restoration in position after 5 weeks.
plaque absence, and remodeling of soft tissue.

Fig. 5. Tissue conditioning completed after 5 weeks shows Fig. 7. Frontal view of master cast with removable gingiva,
distally displaced apex and papilla formation. which transfer information to technician.

requirements, and its length was essential for esthetics

to reproduce the natural facial contour. However, this
configuration is difficult to achieve because of the tis-
sue contour underneath that can result in a short, con-
cave pontic. These features have compromised not only
esthetics, but also elimination of dental plaque. There-
fore a gradual, controlled hyperpressure can transform
an unfavorable tissue configuration. This allowed a
more natural, functional FPD. There is also a possibili-
ty of closing undesirable “black holes” through papilla
“formation” by pressuring tissue.
A minimum thickness of 3 to 5 mm of soft tissue is
Fig. 8. Frontal view of final restoration shows healthy and
required to improve final outcome. This measurement
esthetic characteristics.
is recorded from the gingival crest to the alveolar ridge.
Optimal results are realized when pressure is applied to
thick tissues, although caution is needed regarding its Nevertheless, when compared with electrosurgery,
resilience. Specific tissue dilation can also be accom- this technique has some advantages. For example, tis-
plished with eletrosurgery,6-9 when removing soft tis- sue sculpturing is a nonsurgical, minimally invasive and
sue to create pontic sites. safe procedure; the patient is not exposed to complica-

632 VOLUME 81 NUMBER 5

JACQUES ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

tions of surgery. In addition, there is no tissue removal.
Interdental papilla was enhanced or sculptured by the
lateral displacement of the tissue over a residual ridge.
The result of compressing is the accommodation of tis-
sue. Hyperpressure is considered a reversible procedure
and allows a meticulous follow up of pressure, patient
compliance, and eventual tissue dilation. Limited
adjustments of appropriate pressure can be controlled
by removal of acrylic resin, improved polishing, and
plaque control, which enhance predictability of this
procedure. Electrosurgery oftentimes requires a heal-
ing period, whereas specific hyperpressure has been an
immediate response. Similar hyperpressure procedures
have been used for tissue conditioning before implant
placement.10,11 Both techniques are based on the appli-
cation of controlled pressure for obtaining desirable
anatomic changes.
One contraindication or disadvantage of this proce-
dure has been the detection of residual ridge deformi-
ties types I, II, and III, according to Seibert.13-14 Soft
tissue grafts are indicated for these patients, before con-
ditioning tissue.13,14
SUMMARY
This article described a method for improvement of
esthetic and soft tissue health by exerting pressure on
tissue with provisional restorations. The importance of
patient compliance and plaque control is essential. The
advantages and sequence of procedures for achieving
best results were emphasized.
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Reprint requests to:
DR LETÍCIA BORGES JACQUES
FACULDADE DE ODONTOLOGIA DE BAURU
DEPARTAMENTO DE PRÓTESE
VILA UNIVERSITÁRIA
AL. OCTÁVIO PINHEIRO BRIZOLLA, 9-75
BAURU — SAO PAULO CEP 17043-101
BRAZIL
FAX: (14)-2341830
E-MAIL: jacques@techno.com.br
Copyright © 1999 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/99/$8.00 + 0. 10/1/97149

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