ORIGINAL CONTRIBUTIONS
CAD/CAM techniques help in the
rebuilding of ideal marginal gingiva
contours of anterior maxillary teeth
A case report
Jiayue Yin, MSD; Dan Liu, MSD; Yuehua Huang, BDS;
Lin Wu, DDS, PhD; Xiaolin Tang, DDS, PhD
T
he contour of the marginal gingiva, referred to as
“pink esthetics,” plays an important role
in promoting a good appearance in the esthetic
zone. Clinicians primarily use crown-lengthening
surgery (CLS) to obtain enough biological width and to
rebuild the contour of the marginal gingiva.1 According
to the principle of “biological width,”2 the location of the
alveolar bone is what determines the location of the
marginal gingiva.
Therefore, it is neces-
sary to locate accu-
rately not only the
position of the marginal gingiva but also the alveolar
bone position. Traditionally, periodontists have per-
formed CLS by means of relying on what they could see
with the naked eye; however, dentists may find it difficult
to trim the marginal gingiva and the underlying alveolar
bone precisely using this method. Thus, a precise tem-
plate is a useful tool for this type of surgery. Dentists
often make handmade surgery templates3,4; however,
because they make the templates by means of using the
naked eye, they cannot avoid making deviations in their
templates. The 3-dimensional (3D)–printing technique is
based on computer-aided design (CAD) and rapid pro-
totyping (RP) technologies. In 2016, investigators re-
ported that using the 3D-printing technique helped
physicians improve the accuracy of their medical
practice.5,6 Dental clinicians have not used 3D-printing
Copyright ª 2017 American Dental Association. All rights reserved.
ABSTRACT
Background and Overview. “Pink esthetics,” which
are considered to be as important as “white esthetics,”
have attracted increasing attention. To date, clinicians
rarely have applied computer-aided design and computer-
aided manufacturing (CAD/CAM) techniques in the
rebuilding of the contour of the marginal gingiva in the
esthetic zone.
Case Description. In this case report, the authors
describe a female patient who had gingival inflammation
and an asymmetrical contour of the marginal gingiva of the
anterior maxillary teeth because previously placed ceramic
crowns violated the biological width. The authors used a 3-
dimensional–printing surgery template to guide precise
crown-lengthening surgery to expose subgingival shoul-
ders and to obtain an ideal marginal gingival contour. Then
the authors used interim CAD/CAM crowns to induce the
growth of the interdental papilla by 0.5 to 1.5 millimeters.
Finally, the patient had a symmetrical and well-balanced
contour of the marginal gingiva. In addition, the authors
reduced the patient’s “black triangle” areas to the greatest
possible extent.
Conclusions and Practical Implications. This case
report illustrates that CAD/CAM products, including
3-dimensional–printing surgery templates and CAD/CAM
interim crowns, are helpful in shaping and rebuilding the
ideal contour of the marginal gingiva in the esthetic zone,
such as the anterior maxillary teeth.
Key Words. CAD/CAM; esthetics; crown lengthening;
gingiva.
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 ORIGINAL CONTRIBUTIONS
Figure 1. Photo of inflamed gingiva on the patient’s anterior maxillary
teeth at the first visit.
techniques widely in CLS. In a previously published
study,7 we established a method to make a 3D-printing
template to guide clinicians in cutting the gingiva
and trimming the alveolar bone. We found that using a
3D-printing template could help clinicians obtain an
ideal contour for the marginal gingiva.
The “black triangle” or “open gingival embrasures” is
a kind of esthetic defect that can occur at the inter-
proximal area owing to interdental papilla loss. Inter-
dental papilla will fill completely the interproximal area
(100%) if the distance between the top of alveolar bone
and proximal contact is 5 millimeters or less.8 On the
basis of this theory, prosthodontists have tried to use
interim crowns to induce the growth of interdental
papilla to fill the triangle areas.9 However, handmade
interim crowns that have a rough cervical margin may
not only do harm to the health of the gingival tissue but
also may influence the contour of the marginal gingiva.
In comparison with handmade crowns, crowns made by
means of CAD and computer-aided manufacturing
(CAD/CAM), which have a smooth cervical margin and
precise cervical contour, will keep the gingiva free of
inflammation and help shape precisely the contour of the
marginal gingiva.
In this report, we describe the case of a female patient
who had gingival inflammation and an asymmetrical
contour of the marginal gingiva of the anterior maxillary
teeth because the ceramic crowns had violated the bio-
logical width. To assist in the successful rebuilding of the
patient’s marginal gingiva, we made a 3D-printing tem-
plate and interim crowns by using CAD/CAM strategies.
In our case report, we describe the fully digitized tech-
nique that we used to rebuild the contour of the marginal
gingiva in the esthetic zone.
CASE REPORT
The ethics committee of the Hospital of Stomatology,
China Medical University, Shenyang, Liaoning Province,
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China (2013 Ethics Check No. 12), approved this case
report.
A 30-year-old female patient had red, swollen labial
gingiva of the anterior maxillary teeth (nos. 11, 21, and
22); she reported that, 10 years previously, a clinician had
treated these teeth by placing ceramic crowns. The
patient was not a smoker and was in good physical
condition. After the clinician had placed the ceramic
crowns, the patient repeatedly experienced inflamed
gingival tissue, and the tissue had been inflamed severely
during the previous 2 years. At the first visit, we recorded
the patient’s periodontal condition (Figure 1 and
eFigure 1, available online at the end of this article) and
performed a periodontal examination (eFigure 2, avail-
able online at the end of this article) by means of using
the Florida Probe System (Florida Probe). We found that
the labial subgingival shoulders were approximately 3.0
to 4.0 mm under the gingival margins, whereas the
lingual shoulders were above the gingival margins. The
splint restoration of the anterior teeth made it difficult
for the patient to clean the interdental zone. The radio-
graph obtained of the anterior maxillary teeth indicated
gross open margins of the restoration, which may have
retained more dental plaque and contributed to the
inflamed gingiva (eFigure 3, available online at the end of
this article). In addition, the radiograph indicated that
the endodontic therapy had failed (eFigure 3, available
online at the end of this article).
Treatment process. We obtained informed consent
from the patient before beginning therapy. The treat-
ment procedures were as follows:
- We removed the fixed denture of the anterior
maxillary teeth and performed initial full-mouth peri-
odontal therapy. We carefully performed supragingival
and subgingival scaling with ultrasonic instruments
(Piezon Master 700, Electro Medical Systems) and
Gracey curettes (Hu-Friedy) to remove the dental plaque
and the calculus. At the same time, we debrided some of
the granulation tissue of the inflamed gingiva. We also
irrigated the gingival pockets with a 3% hydrogen
peroxide solution to remove the residual calculus and
soft tissue. Finally, we put an iodine glycerol agent into
the pockets to inhibit the bacteria growth. We also
provided the patient with instruction related to careful
oral hygiene to teach her how to brush her teeth and use
dental flosses and interdental brushes.
- We performed endodontic therapy on teeth nos. 11,
21, and 22 (eFigure 3, available online at the end of this
article).
ABBREVIATION KEY. 3D: Three-dimensional. C: Labial
central sites. CAD: Computer-aided design. CAM: Computer-
aided manufacturing. CLS: Crown-lengthening surgery.
D: Labial distal sites. L: Lingual sites. M: Labial mesial sites.
RP: Rapid prototyping.
 ORIGINAL CONTRIBUTIONS

- One month after TABLE 1

the initial periodontal Distances between the gingival shoulders and the
therapy, we found that
the subgingival shoul- corresponding gingival margin sites 1 month after the initial
ders were located from periodontal therapy.
1.0 mm to 2.5 mm VARIABLE TOOTH NO.
under the gingival
11 21 22
margin (Table 1). We
Site D* C† M‡ L§ D C M L D C M L
performed gingivo-
¶
plasty combined with Distance, millimeters 1.5 1.0 1.5 0.5 1.5 1.5 2.5 1.0 1.5 1.5 1.5 1.0
CLS, as guided by * D: Labial distal sites.
† C: Labial central sites.
means of using a ‡ M: Labial mesial sites.
3D-printing template, § L: Lingual sites.
¶ Positive values indicate subgingival shoulders; negative values indicate supragingival shoulders.
to obtain an esthetic
contour of the mar-
ginal gingiva and to TABLE 2
expose the subgingival Distances between the gingival shoulders and the
shoulders. During the corresponding crests of the alveolar bones, as measured
surgery, we found that
the distances between during surgery.
the labial gingival VARIABLE TOOTH NO.
shoulders and the 11 21 22
crests of alveolar bone Site D* C† M‡ L§ D C M L D C M L
were from 0.5 to 2.5
Distance, millimeters 2.5 1.5 2.5 3.5 2.5 2.5 0.5 4.0 1.5 2.5 2.5 4.0
mm (Table 2), which
* D: Labial distal sites.
suggested that the † C: Labial central sites.
previously placed ‡ M: Labial mesial sites.
crowns had violated § L: Lingual sites.
the biological width to
a severe degree.
- One month after the surgery, we restored the CAD/

CAM interim crowns to induce interdental papilla and to

shape the contour of the marginal gingiva.
- Five months after the gingiva induction, we placed

permanent zirconia ceramic crowns.

Preparation of the 3D-printing template. One
month after the initial therapy, we used the 3D-printing
technique to obtain the precise surgery template. We
used the following procedure:
- Before surgery, we took digital photos of the patient’s

dentition and face while she was smiling. We recorded
the distances between the gingival shoulders and the
gingival margins. We prepared the alginate impression of
the dentition and the plaster molds.
- We obtained point cloud data related to the plaster
Figure 2. The 3-dimensional–printing template, designed by means of
using Geomagic Studio 11.0 software (Geomagic Studio, Software
Informer) for the crown-lengthening surgery.
- We determined the template area (eFigure 4, available

molds by means of using a laser scanner (D700, 3Shape). online at the end of this article).
- We designed the gingival curves by means of using - We transferred the data to the rapid prototyping

reverse engineering software Geomagic Studio 11.0 machine (Objet 350 Connex1, Stratasys) to print the
(Geomagic Studio, Software Informer) (Figure 2, template. The template thickness was 1.0 mm.
eFigure 4, available online at the end of this article). To CLS guided with the 3D-printing template. Before
do this, we set up the coordinate system and the occlusal we performed the CLS, we rinsed the 3D-printing
plane, designed the mark points of the final gingival template in a povidone-iodine solution for 10 minutes
curve, constructed the 3D gingival margin curve, tuned and then washed the template with normal saline. We
the mark points, and made horizontal flips of the performed the surgery by means of using the standard
gingival curve to obtain the symmetrical curve of the procedure. During the surgery, we put the template on
contralateral counterpart tooth. the teeth to guide the gingivectomy and ostectomy

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Figure 3. The 3-dimensional–printing template guided the authors dur-
ing the crown-lengthening surgery as they trimmed both the gingiva and
the alveolar bone.
Figure 4. Appearance of the marginal gingiva of the anterior maxillary
teeth 1 month after crown-lengthening surgery.
Figure 5. Interim computer-aided design and computer-aided
manufacturing crowns placed to induce and shape the interdental papilla.
(Figure 3 and eFigure 5, available online at the end of
this article). One month after the CLS, we noted that
the patient’s gingiva had no inflammation. In addition,
we noted that the contour of the marginal gingiva was
symmetrical and well-balanced (Figure 4).
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Interdental papilla induction with interim CAD/
CAM crowns. We designed the interim crowns (PMMA
DISK, Yamahachi Dental) and made them by means of
using a CAD/CAM (inLab, Sirona) system. We placed
the crowns 1 month after we completed the CLS. We set
the contact points according to the Tarnow principle,8
between the teeth and within 5 mm above the crest of
interdental alveolar bone (Figure 5 and eFigure 6, avail-
able online at the end of this article). Five months after
the induction of the crowns, we noted that the zenith
location of the interdental papilla between the incisors
was displaced coronally by 0.5 to 1.0 mm (Table 3). The
interdental triangles between the incisors disappeared
after the induction (Figure 6 and eFigure 6, available
online at the end of this article).
Five months after the gingiva induction, we placed the
permanent zirconia-based crown (Zenostar, Wieland
Dental) (Figure 7 and eFigure 7, available online at the
end of this article). Seven months after we placed the
crowns, we noted that the marginal gingiva was in good
condition and that the black triangles had disappeared
completely (Figure 8 and eFigure 7, available online at
the end of this article).
DISCUSSION
Precise therapy using mainly computer-assisted tech-
niques is replacing the traditional style of therapy, which
relied on surgery by hand and observation with the
naked eye.
In the past, dentists prepared handmade surgery
templates composed of various materials.3,4,10-12 In our
case study, we described our use of a 3D-printing
template on the basis of CAD and RP technology. We
used Geomagic Studio software to design the marginal
gingiva contour. The clinical outcome of our patient’s
case was satisfactory. Geomagic Studio is a reverse-
engineering software that has been used frequently in
oral clinical practice.13,14 The software can generate ac-
curate digital models according to point cloud data
from 3D objects. We used the software to modify
quickly and preview the contour of the marginal
gingiva. Then we transferred the data to the 3D printer
to obtain accurate surgical templates. Compared with
handmade templates, we found that 3D-printed tem-
plates have more advantages; the most beneficial
advantage is that 3D-printing templates are more ac-
curate and symmetrical. We also found it easier to
design and modify the gingival curve by means of using
computer software. Finally, 3D-printing templates are
thinner and more uniform. In conclusion, 3D-printing
templates can help dentists perform precise surgery and
help patients obtain a more symmetrical and well-
balanced gingival margin.
The formation of a black triangle, which results from
the loss of the interdental papilla, is an important factor
 ORIGINAL CONTRIBUTIONS

TABLE 3
Distance of the coronal displacement of the zenith of the interdental papilla, as
measured 5 months after placement of an interim computer-aided design and
computer-aided manufacturing crown restoration.
VARIABLE TOOTH NO.
11 12 21
Site D* M† D M D M
Distance, millimeters 0.5 1.0 1.0 1.5 1.5 0.5
* D: Labial distal sites.
† M: Labial mesial sites.

Figure 6. Three months after the gingival induction by the interim Figure 8. Seven months after placement of the final restoration, no
computer-aided design and computer-aided manufacturing crowns, the black triangles could be seen.
black triangles could not be seen.

connective tissue graft18,19 or a free gingival flap graft.20

Figure 7. Five months after the gingiva induction, permanent zirconia
ceramic crowns were placed.
that affects the esthetic appearance of the anterior
maxillary teeth.15 Factors contributing to the formation of
black triangles include periodontal biotypes,16 distances
between the roots,17 locations of contact points, peri-
odontitis, and periodontal therapy such as CLS. There are
2 ways to correct black triangles: surgical methods and
nonsurgical methods. Surgical methods include a coro-
nally repositioned flap combined with subepithelial
Nonsurgical methods include rebuilding of the interdental
papilla by means of placing interim crowns9,21 or
orthodontic treatment.21 In our patient, we used interim
CAD/CAM crowns to rebuild interdental papilla, and we
designed the distances from the contact points to the
alveolar bone crests to be less than 5 mm on the basis of
the results of the study by Tarnow and colleagues8 in 1992.
Using CAD/CAM interim crowns has 2 advantages. First,
because they are designed and produced by computer
software, the edges of the CAD/CAM crowns can be
thinner and smoother than those of handmade crowns.
Therefore, the interim CAD/CAM crowns are less likely to
retain bacterial plaque. Second, the contour of the cervical
line designed by computer software can be more accurate,
which can guide the growth of interdental papilla more
precisely. In this case, we placed interim CAD/CAM
crowns to induce and shape the marginal gingiva contour.
Consequently, we noted that the interdental papilla was
displaced coronally by 0.5 to 1.5 mm and had a symmetrical
and well-balanced appearance. In conclusion, the use of an
interim CAD/CAM crown can reduce black triangles
effectively, shape the marginal gingiva curve accurately,
and maintain the patient’s periodontal health.
For this patient, our approach to provide thorough
initial periodontal therapy greatly improved the patient’s

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 ORIGINAL CONTRIBUTIONS
gingival color, shape, and texture; the periodontal ther-
apy we provided also eliminated the gingival inflamma-
tion. We have noted that, with this basis of healthy
gingiva, the patient’s marginal gingiva position has
remained stable. Investigators have reported that initial
periodontal therapy induces the recovery of interdental
papilla.22 Therefore, the initial periodontal therapy is
essential and important for both the healthy and esthetic
appearance of the gingival tissue.
In the case of this patient, the periodontists (X.T.)
provided thorough initial periodontal therapy and per-
formed precise CLS, and the prosthodontists (J.Y.)
completed the interim and final crown restoration. The
results of our case indicate that close interdisciplinary
cooperation is necessary for a good clinical outcome.
We noted a minor defect. After we placed the final
restoration, we saw that the zenith of the left central
incisor was a little higher than the right central incisor.
We think that this minor defect may have occurred as
a result of the complicated gingival healing process.
According to the results of previously published studies,
the location of the gingival margin after periodontal
surgery can be influenced by many factors, including
gingiva thickness or periodontal biotype23 as well as
different biological width.24 In the future, we will
consider all these possible factors and try to improve the
symmetry of the gingival curve in clinical practice. In
addition, we believe that clinicians should study more
cases like the one we present to continue to improve
treatment outcomes and gain more experience in the
design and manufacture of surgical templates.
CONCLUSIONS
The use of 3D-printing templates can guide clinicians as
they perform precise CLS. Interim CAD/CAM crowns can
be used to induce the growth of interdental papilla and
maintain healthy gingiva. The results of our case report
illustrate that it can be helpful for clinicians to use CAD/
CAM techniques for patients whose treatment requires
rebuilding of an ideal contour of the marginal gingiva in
the esthetic zone, such as in the anterior maxillary teeth. n
SUPPLEMENTAL DATA
Supplemental data related to this article can be found at
http://dx.doi.org/10.1016/j.adaj.2017.03.003.
Dr. Yin is a prosthodontist, Department of Prosthodontics, School of Sto-
matology, China Medical University, Shenyang, Liaoning Province, China.
Dr. Liu is an MSD candidate, Department of Periodontics, School of Sto-
matology, China Medical University, Shenyang, Liaoning Province, China.
Dr. Huang is an MSD candidate, Department of Periodontics, School of
Stomatology, China Medical University, Shenyang, Liaoning Province, China.
Dr. Wu is a professor and a prosthodontist, Department of Prosthodon-
tics, School of Stomatology, China Medical University, Shenyang, Liaoning
Province, China.
Dr. Tang is a professor and a periodontist, Department of Periodontics,
School of Stomatology, China Medical University, 117 Nanjingbeijie, Heping
District, Shenyang, Liaoning Province 110002, China, e-mail xltang@cmu.
edu.cn. Address correspondence to Dr. Tang.
6 JADA ( )
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Disclosure. None of the authors reported any disclosures.
This study was supported by grants from the Clinical New Technique
Program of the School of Stomatology, China Medical University (2009-2),
Shenyang, Liaoning Province, China.
Drs. Yin and Liu contributed equally to this article.
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eFigure 1. Photos of the anterior maxillary teeth before the initial periodontal therapy. A. Before the ceramic crowns were removed. B. After the
crowns were removed (labial side). C. After the ceramic crowns were removed (incisal side).

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eFigure 2. Periodontal charts created by using the Florida Probe System (Florida Probe). A. At first visit. B. One month after the initial periodontal
therapy. C. One week after the permanent crowns were placed. D. Seven months after the crowns were placed. GM: Gingiva margin.

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eFigure 2. Continued

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eFigure 2. Continued

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eFigure 2. Continued

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eFigure 3. Radiographs of the endodontic therapy. A. At first visit. B. Immediately after endodontic therapy.

eFigure 4. Images of the 3-dimensional–printing template designed for the crown-lengthening surgery. A. Designing the gingival margin contour.
B. Outlining the template area (labial side). C. Outlining the template area (incisal side). D. Completed template.

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eFigure 5. Photos indicating how the 3-dimensional (3D)–printing template helped the clinicians guide the crown-lengthening surgery to trim both
the gingiva and the alveolar bone. A. Labial appearance of the anterior teeth before surgery. B. Preview of the 3D-printing template. C. Surgery being
performed with the guidance of the 3D-printing template. D. Final suturing.

eFigure 6. Photos of the interdental papilla induced with interim computer-aided design and computer-aided manufacturing crowns. A. Appearance
of the anterior maxillary teeth 1 month after surgery. B. Interim computer-aided design and computer-aided manufacturing crowns, as prepared to
induce and shape interdental papilla. C. Appearance of the anterior maxillary teeth after the temporary crowns were placed immediately. D. Three
months after the placement of the temporary crowns.

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eFigure 7. Photos indicating the appearance of the gingiva after the final restoration. A. Immediately after the permanent crowns were placed.
B. Seven months after the final restorations were placed (labial side). C. Seven months after the final restorations were placed (lingual side). D. Seven
months after the final restorations were placed (smile view).

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