C O S M E T I C S
Optimizing Gingival Esthetics:
A Microscopic Perspective
A
s patients become increasing-
ly aware of the esthetic po-
tential through cosmetic den-
tistry, there is an increasing
demand for smile makeovers with
porcelain. In our efforts to create
beautiful smiles, we tend to focus
on tooth color, shape, proportion
and alignment as we are bom-
barded with restorative choices.
However our efforts for an ideal
restorative outcome will fall short
if we are distracted from the larger
picture to focus on teeth and
somewhat neglect the impor-
tance of gingival health and con-
tour. The goal of modern esthet-
ic dentistry is to achieve both
“white” and “pink” esthetics.1
“White esthetics” refers to nat-
ural dentition or tooth colored
restorations. “Pink Esthetics”
refers to the surrounding soft
tissues (Figs. 1 & 2).
Every dentist has experienced
the disappointment of a cosmetic
case that starts out beautifully
then is marred by receding or
inflamed tissue. The question is
how do we increase our chances
for optimal tissue response and
long term health? Our focus in
this article for this broad ques-
tion will be our microscope cen-
tered approach for porcelain pre-
cision and the role of high level
magnification in assisting ideal
gingival esthetics.
116 oralhealth April 2005
David J. Clark, DDS and Jihyon Kim, DDS
HOW MUCH MAGNIFICATION IS
“ENOUGH MAGNIFICATION”?
Today most restorations are still
performed with little or no magni-
fication. However, critical analy-
sis of some esthetic compromises
will show progressive decline of
gingival color from ideal salmon
pink to bluish purple typical of
chronic mild inflammation. In our
practice we are surprised at the
number of patients who report to
us for re-treatment of cases be-
cause of mildly red or purple gin-
FIGURE 1—Microscope Enhanced Esthetic
Dentistry. Perfect gingival health and
esthetics become a reality with micro-
scopically adapted and highly polished
porcelain.
giva (Fig. 3). Such requests are
evidence that non-ideal tissue
responses impact patient accep-
tance of cases much more than
dentists would have thought. We
may be underestimating the im-
portance of “pink” esthetics to
overall treatment success.
Numerous studies have shown
that gingival and subgingival
marginal discrepancies greater
than 50 microns cause untoward
tissue response with increased
crevicular fluid flow, altered
bacterial flora, and poor esthet-
ics.2-5 Carr has demonstrated
that the unaided human eye
FIGURE 2—Equa-gingival finish line with
Microscope Assisted Precision. Pressed
ceramics by Peggy J. Parker C.D.T. of
DTI / Twin Lakes. Post-operative photo-
graph shows optimum tissue health. Such
esthetic results were rare until we incor-
porated microscopic visualization for
preparation, impression, temporization,
sculpting of finish lines, and seating.

FIGURE 3—Although the two porcelain
crowns on the central incisors violate the
Golden Rule of proportion, this patient
presented for re-treatment because of
poor gingival esthetics, not because of
porcelain esthetics. A very large percent
of esthetic treatments done with low or
no magnification create similar tissue
responses.
FIGURE 6—Shows a common occurrence
of incomplete merging of images. Both
images demonstrate the visual noise or
blurry periphery of loupes optics.
FIGURE 9—Unacceptable margin esthet-
ics. Dentists who experience these types
of postoperative results often became
gun-shy and either stop providing
esthetic treatment or start “ burying” fin-
ish lines deep in the sulcus. The better
solution is Microscope Assisted Pre-
cision in esthetics.
C O S M E T I C S
FIGURE 4—Oculars (loupes) rely on con-
vergent vision that essentially requires
an overlap of two images. This form of
magnification creates increasing prob-
lems and eye strain as power increases.
The clinical microscope utilizes a more
refined optical system.
FIGURE 7—Represents 24x Infinity Cor-
rected or parallel optics. There is no eye
strain and no visual noise. Loupes magni-
fication at 8x and above becomes excru-
ciating for most clinicians, the microscope
is a superior and healthier choice.
FIGURES 10A & B—Depict the pre and post-operative full view of the case shown at
high magnification in Figures 1 and 2.
FIGURE 5—Features 8x convergent mag-
nification with loupes and a representa-
tion of the two images that your brain
receives as you begin to focus.
FIGURE 8—Typical undulating CEJ con-
tour on a mandibular canine. There is a
stark difference in the appearance of
enamel and dentin at 10x magnifica-
tion that coupled with an appreciation
of dental anatomy, will guide more
appropriate margin placement.
April 2005 oralhealth 117

FIGURE 11—Depicted here is a co-obser-
vation tube allowing us to simultaneous-
ly view the nuances of a case. Involving
the ceramist more directly in patient
care leads to better communication of
information and a passionate commit-
ment of the technical team. We found
that monetary compensation was less
effective than pride in generating the
commitment required for microscope
enhanced dentistry.
FIGURE 14—Shows a different area of
the same tooth with a different set of
problems. The tooth has been sectioned
to highlight both a “sub” and “short”
porcelain margin. The finish line was
also placed on composite, not tooth
structure. This is a common problem. All
resin buildup materials (tooth colored or
not) in deep subgingival areas demand
extremely high levels of magnification
and illumination to prepare adequately.
cannot distinguish two discrete
lines closer than 200 microns.6
Not surprisingly many restora-
tive margins have average dis-
118 oralhealth April 2005
C O S M E T I C S
FIGURE 12—An extracted tooth is fea-
tured in figures 12-14. The tooth was
removed because of hopeless endo-
restorative failure after one year. In fig-
ure 12, magnification at 24x reveals
composite cement that was left near
crown margin. The discoloration creates
the illusion that the material is calculus,
not cement. The composite cement was
likely a different color one year earlier
(when the crown was seated by the pre-
vious dentist). The new composite
cements have more natural color,
increased translucency, and higher
bond strengths than previous cements.
This has generated a new problem of
widespread residual cement causing
poor tissue health and esthetics.
crepancies of 200 microns and
sadly we often see gross dis-
crepancies much greater in fail-
ing restorations.
Carr has also demonstrated
that 4x magnification is re-
quired for the human eye to dis-
tinguish two black lines 50
microns apart. However, 4x
loupes may not be sufficient in
consideration of three impor-
tant issues.
1) Less visual contrast is avail-
able to distinguish a tooth col-
ored restorative margin from a
FIGURE 13—Shows a “plus” margin in
profile. This very common situation will
nearly always result in extremely poor
gingival health and esthetics. Most clini-
cians and technicians are in absolute
disbelief that their porcelain contours
could look like this, but the reality is that
this problem is present on most porce-
lain restorations in select marginal
areas. High magnification and the
rolling profile technique for analysis
shed light on the dilemma.
tooth finish line than two
black lines separated by white.
Therefore 4x magnification
may be insufficient in porce-
lain or resin restorations. In
fact many clinicians who take
our microscope courses com-
ment that they need at least
10x magnification to discern
the marginal integrity of por-
celain laminates.
2) Magnification of 4x or greater
require better quality light be-
yond what can be provided by a
traditional operatory light. At
higher magnifications a micro-
scope makes more sense than
adding a headlamp to loupes
that have insufficient power.
3) Magnification needs can rou-
tinely escalate to 16x or 24x
 C O S M E T I C S

FIGURES 15A & B—Microscopic visualization affords the ability to achieve consistent
yet delicate tissue retraction. Heavy, aggressive retraction (A) can give way to a
more refined approach (B).

Table 1
Microscope protocol for porcelain margin evaluation
Sub Plus
Short Long
Under-Contoured Emergence Profile Rounded Emergence Profile
FIGURE 16—We utilize a brownie point
in a high-speed handpiece at 24x to
trim finish lines with less than 0.75 mm
Table 2 of apical impression profile. Other
Parameters to be combined with factors from Table 1 modalities can cause chunks of the mar-
to maximize the total potential for tissue health ginal stone to break away with the
excess stone.
1) Residual cement and calculus apical to finish lines
2) Root roughness from errant bur movements
skill and recognition enables us
3) Micro-roughness and porosities of porcelain
to readily identify the cemento-
4) Microleakage
enamel junction (CEJ), create
more appropriate finish lines for
when working with challenging Optics of a stereoscopic micro- the rigors of porcelain adapta-
circumstances such as posteri- scope (Figs. 4-7). When combined tion, and eliminate noxious tis-
or areas, difficult isolation, or with the shadowless coaxial light sue irritants.
indirect vision. source, they transform the clini-
cian’s potential for accuracy in One of the most common offens-
Thus in order to achieve mar- nearly every aspect in the differ- es to delicate gingival architecture
ginal precision with consistency ent disciplines in dentistry. is when the clinician fails to follow
in porcelain or resin restorations, the undulating contour (Fig. 8) of
magnification of 8x or higher is Most importantly, increasing the CEJ and instead creates a flat
recommended. Such magnifica- levels of magnification produce a margin from facial to lingual. This
tion and light requirements are squared, not linear relationship to is often exacerbated or initiated
difficult to attain with loupes and visual acuity. In other words, 10x by rubber dam placement, which
a separate light source. magnification allows the human flattens the papillae and leads to
retina to acquire 100 times more misinterpretation of the appropri-
FUNDAMENTALS OF information and 20x allows 400 ate placement for the interproxi-
CLINICAL MAGNIFICATION times the visual information. mal finish line.
The operating microscope offers
not just higher magnification PRINCIPLES OF TOOTH PREPARATION Thus begins a series of mis-
than oculars (loupes) but better AND PORCELAIN MARGINS FOR takes. The interproximal margin
magnification. Oculars have GINGIVAL ESTHETICS is cut too deep, followed by ag-
been very helpful and may The enormous advantage the gressive tissue retraction. When
always have a role in dentistry, operating microscope offers is two approximating teeth are pre-
but the optics is crude when com- ability for acute visual inspec- pared in this manner and the tis-
pared to the Infinity Corrected tion. This precision along with sue is subsequently retracted

April 2005 oralhealth 121


FIGURE 17—The rolling profile technique
for evaluation and sculpting of porce-
lain interfaces. Coaching our ceramists
to see and think in a three dimensional
microscopic way required more than a
quick phone call. Hands on teaching in
our office with microscopes and a video
feed to monitors have proven invalu-
able. In addition to the dramatic
improvement in the accuracy of the
ceramists work, we continue to do a
chairside microscopic analysis and
sculpting of porcelain before seating.
with cord, electrosurgery or abla-
tion, the papilla is often obliterat-
ed. The papilla sometimes returns
but sometimes not.
In a classic study, two interden-
tal papillae were excised from16
dental students.7 Of the 32 speci-
mens, 22 papillae did not return to
the original shape. This 69 percent
attrition rate should serve as a
wakeup call. The dreaded “black
triangle” usually ensues, which
can be both an esthetic and func-
tional nightmare. Exotic regenera-
tive techniques or bulky porcelain
contours are a poor substitute for
conservative tooth preparation
and delicate micro-manipulation
of tissues.
With the benefit of high-level
magnification, a series of delicate
and physiologically appropriate
steps can occur.
MICROSCOPE ASSISTED PRECISION
AND ENAMEL FINISH LINES
The fear of marginal esthetics
(Fig. 9) has driven clinicians to
“bury” their margins, creating a
122 oralhealth April 2005
C O S M E T I C S
FIGURES 18A, B & C—In (A) the porcelain laminate is not fully seated. Dehydration and
magnification (B) reveal residual luting composite that was used to retain the inter-
im laminates. After discovery and removal of the obstacle, full seating of the lami-
nate to within 25 microns is observed (C).
whole new set of problems,
which include pulpal, periodon-
tal and microleakage issues.
Whenever possible a porce-
lain-enamel marginal inter-
face is the goal in bonded
porcelain restoration (Figs. 1
& 2). This will place the finish
line either slightly supragingi-
val, equa-gingival or slightly
subgingival. In cases of gingival
recession, it is preferable to cover
exposed dentin with gingiva (in
lieu of porcelain or composite)
via procedures such as connec-
tive tissue grafts.
Periodontists using high-level
magnification have demonstrated
predictable and breathtaking root
coverage. Afterwards, a porcelain
margin can be placed on enamel,
nestled neatly near robust gingiva.
The Contact Lens Effect has
become a popular term. One
interpretation relates to the abili-
ty to create invisible porcelain
margins that need not be hidden.
We see that the optimal combina-
tion is 1) translucent porcelain, 2)
a translucent luting agent, and 3)
translucent tooth structure, pre-
ferably enamel. Once the finish
line for a porcelain laminate is
placed on dentin, the contact lens
effect loses some of its magic
because dentin is more opaque
than enamel.
Dentin margins pose other diffi-
culties as draw becomes more of a
problem, the pulp is further trau-
matized, and a strong enamel bond
is sacrificed for a tenuous dentin
bond. Maintaining a minimum of a
750 micron distance from the CEJ
during preparation requires high
levels of magnification.
MARGINAL PRECISION
OF PORCELAIN
Volumes of information are
bandied about when debating
which porcelain has the best mar-
ginal accuracy. In the end, most of
these arguments are moot be-
cause other factors create discrep-
ancies that are significantly more
critical. A poll done by CRA re-
vealed that 90 percent of impres-
sions received in U.S. laboratories
contained portions that did not
capture the finish lines. In these
cases we will see gross inaccura-
cies that will lead to micro leak-
age and poor tissue response.
Additionally, microscopic in-
spection reveals that many res-
torations are not fully seated dur-
ing cementation. The culprit is
often improper contacts, hardly a
microscopic issue, but floss alone
is not enough to make a proper
assessment. High magnification
provides complete visual informa-
tion required to trouble shoot all
causes of incomplete seating,
including a “lifting” contact. Once

Drs. Jihyon Kim and David Clark enjoying the ideal posture, perfect light, and com-
plete visual information that are all provided by the clinical microscope.
these factors are controlled, a
legitimate analysis of porcelain
margins can begin.
Once microscopic accuracy be-
comes a reality for both clinician
and ceramist, a constant dialogue
between the two parties is of para-
mount importance (Fig. 12).
Simply describing a porcelain lam-
inate margin as “poor” or “open” or
“bulky” is insufficient information
to help coach a ceramist who is
using microscopic visualization.
For example it is possible for a
porcelain margin to be “plus” and
yet have an overall under-con-
toured emergence profile.
Conversely, a porcelain crown
or veneer can possess a grossly
over-rounded emergence profile
and still be “sub” (Figs. 13-15).
Another critical problem is an
over-reliance on porcelain glaze to
create smoothness. This quick fix
creates the illusion that the sur-
face is smooth and glossy, but
high level magnification and
oblique lighting reveal the unac-
ceptable surface created with
glaze alone.
Upon microscopic inspection
124 oralhealth April 2005
C O S M E T I C S
and re-treatment, many failing
cases that were suspected to be
biologic width violations were
actually violation of factors in
Tables 1 and 2. Clinicians work-
ing with microscopic precision
report that fewer cases result in
tissue responses requiring crown
lengthening or periodontal sur-
gery. The biologic width for a
tooth is determined by individual
factors which cannot be predicted
or controlled. Individual biology
will determine how much tissue is
needed to protect crestal bone.
However working with microscop-
ic precision may enable us to en-
croach further into the gingival
sulcus and yet maintain optimum
tissue health.
INSPECTION OF FINISH LINES
One of the startling revelations
to come from high magnification
work is that finish lines prepared
at low magnification commonly
rest on calculus, composite or
heavy plaque. The resultant re-
sidual roughness and marginal
inaccuracy of porcelain will
result in compromised tissue
health. For tooth colored restora-
tions, we find 4x, 8x and 12x
power to be the workhorse opera-
tion steps of magnification. Brief
utilizations of 16x and 24x for
inspection are now considered
essential for a growing number
of clinicians for various nuances
of aesthetic dentistry.8,9
GINGIVAL RETRACTION...
LESS IS MORE
Microscopic visualization allows
an extremely delicate level of
treatment of hard and soft tissues.
Figures 16 and 17 demonstrate
two very different levels of retrac-
tion. Figure 16 shows a crisp fin-
ish line with over two millimeters
of apical impression profile
(impression of tooth surface apical
to finish line). This traditional
retraction protocol creates an eas-
ier environment for both impres-
sion taking and die trimming.
The problem is that gingiva
rarely returns to preoperative form.
With extreme magnification, a com-
pletely different approach and
mindset are possible. Figure 17
shows a crisp finish line with only
3/4mm of apical impression profile.
The finer apical profile requires:
1. Microscopically milled finish
lines;
2. Extremely high-level magnifi-
cation during retraction to pro-
vide the absolute minimum
level of tissue displacement;
3. Die trimming at extreme mag-
nification of 10x-20x (Fig. 18);
4. Case specific use of brownie
points for careful die trimming.
We spend significant time en-
gaged in delicate tissue retraction
at high magnification, and subse-
quently at the die trim in many
cases. The maintenance of intact
and unchanged papillae and at-
tachment levels is a worthwhile
goal. The additional time invested
by the clinician should be factored
into an appropriate fee for this
level of treatment. Another tangi-
ble benefit of microscope dentistry
 C O S M E T I C S

is reduced postoperative discomfort for patients.10
TECHNICIANS CAN BE THE MISSING LINK
Microscope dentists, enjoying newfound precision
with preparations and impressions, may well
become frustrated with ceramists whose work
becomes the weak link in precision. We tried many
labs and toiled with ceramists who, though they
had lab microscopes, were unwilling to treat our
cases with special care. Many labs have micro-
scopes with poor optics, dim light, filthy lenses,
and are in such a state of neglect that they are
nearly worthless.
One of the most challenging steps in the quest
for precision in porcelain is the visual challenge of
minimal contrast. In addition to the stark color
contrast it offers, gold casts a useful shadow when
viewed directly on the tooth or die. Unfortunately,
most technicians use the visual approach that
works well with gold when analyzing porcelain.
While gold may be analyzed by looking directly at
the margin/die interface, we have found that
porcelain must be evaluated in profile.
Together with our ceramists we have created a
protocol to consistently produce porcelain and
porcelain fused to metal restorations that hold up
to the scrutiny of 16x magnification. One compo-
nent of the system is the three die protocol that
gives us a virgin die for evaluation and final sculpt-
ing of the finish lines. In order to implement this
new protocol, Chuck Rickabaugh at Twin Lakes/
DTI actually created a lab within a lab. With the
right team, it can be done!
• The new super viscous cements are creating ever
widening marginal gaps as the crown or veneer
cannot be wrestled fully to place.
The concept is different with the microscope-cen-
tered approach taught at Precision Esthetics North-
west and Newport Coast Oral Facial Institute. No
gingival finishing burs are used. Instead with micro-
scope precision, the excess luting cement is ‘scis-
sored’ away cleanly as the ultra-precise laminate is
seated. A surgical #12 blade in a Hartzell round
scalpel handle cleaves away excess luting composite.
There is only one margin, a laboratory or chair side
pre-sculpted and pre-polished porcelain margin.
CHAIRSIDE MARGIN RECONTOURING
AND MICROSCOPE ENHANCED SEATING
The final leg of our quest for microscopically ideal
esthetics demands another step. While waiting for
anesthesia, we evaluate the three parameters of
marginal integrity. The marginal interface and
emergence angles are evaluated at 12x to 24x in pro-
file while slowly rolling the die and porcelain
restoration 360° forwards and backward. “Plus” mar-
gins and overly rounded emergence profiles are care-
fully and quickly sculpted with a Brasseler #0301

GINGIVAL PORCELAIN FINISHING BURS ARE

UNNECESSARY IN A MICROSCOPE-CENTERED APPROACH
Mainstream dentistry is moving toward the cre-
ation of two margins, a porcelain and a composite
margin. Porcelain that is several hundred microns
off in both horizontal and vertical axis are theoret-
ically sealed by the new super viscous composite
cements. Margins that are accessible are some-
times “dressed down” with finishing burs. These
protocols are the standard of care but when viewed
under the microscope we see the following:

• The high luster of porcelain cannot be fully re-

established near the sulcus with the ‘dressing
down’ of porcelain margins. Additionally the root
is often scarred and the gingiva mutilated,

• The cement margin is chalky and becomes even

coarser over time,

• The composite margins are prone to micro-

leakage,

April 2005 oralhealth 125


medium grit silicone polishing
wheel (Fig. 19).
If the integrity of a die is in ques-
tion, the patient is present for
verification. This versatile and in-
expensive wheel appears to “melt”
the porcelain away without the
chattering and potential micro-
fractures from burs. Incredibly, it
also leaves a very smooth finish.
Try-in, luting, and cement re-
moval under the microscope is a
joyful experience. The microscope
enables us to visualize problems
invisible under low or no magnifi-
cation (Figs. 20-22). Better yet, a
rich array of clues will lead to
solutions so that the case can pro-
ceed to success instead of starting
over or compromising the final
result.
CONCLUSION
Reasonable restorative outcomes
can be achieved with amalgam
and gold with low or no magnifi-
cation. In contrast, tooth colored
materials require much higher
levels of magnification for consis-
tent success. Common clinical
magnification simply has not kept
pace with dramatic changes in
restorative materials and patient
expectations. In spite of other
advances in dentistry, marginal
integrity, emergence profile, and
resistance to microleakage have
all taken a giant step backward.
Certainly, gifted clinicians ex-
126 oralhealth April 2005
C O S M E T I C S
ist who operate with little or no
magnification and do breathtak-
ing esthetic dentistry. The micro-
scope does not make one dentist
better than another. Nonethe-
less, many accomplished restora-
tive dentists have embraced the
use of the microscope because it
brings greater predictability and
joy to their dentistry. Excellence
in dentistry is a choice, and mag-
nification can be a powerful asset
in achieving it.
The testimony of doctors who
use the microscope daily in their
practices confirms its value. An
overwhelming majority affirm
that it has improved their clini-
cal skill. The microscope, with
instantaneous magnification
from 2.5x to 24x, no visual noise,
and shadowless coaxial light,
offers the best means for achiev-
ing complete visual information
in dentistry. It can nurture great
confidence, healthier posture,
and better and surer hands for
the clinician. In the end, the
excellent visual information the
microscope offers can help the
doctor to create more precise,
more healthful, and more esthet-
ically pleasing dentistry. OH
Dr. David Clark founded the Acad-
emy of Microscope Enhanced Dent-
istry, an international association
formed to advance the science and
practice of microendodontics, micro-
periodontics, microprosthodontics and
microdentistry. He is a course director
at the Newport Coast Oral Facial Ins-
titute in Newport Beach, CA. He is co-
director of Precision Aesthetics North-
west in Tacoma WA. Dr. Clark main-
tains a microscope-centered restora-
tive practice in Tacoma, Washington
USA.
Dr. Jihyon Kim is a 1999 graduate
of the University of Washington
School of Dentistry. She is one of the
founding members of the Academy of
Miroscope Enhanced Dentistry.
Oral Health welcomes this original
article.
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