Jan Lindhe. Clinical Periodontology

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MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 615

Fig.

27-51.

Clinical photographs illustrating the treatment of an experimentally induced localized recession defect

in a dog with a coronally displaced flap. Presurgical appearance of the localized recession defect (a). The site fol

lowing flap closure of the defect (b) and after 3 months of healing (c).

attachment of the same height had formed in the soft

tissue covered portion of the defect, i.e. about 50% of

the successfully covered defect showed new connec-

tive tissue attachment.

Gottlow et al. (1986) examined the result of healing

following treatment of experimentally produced re-

cession type defects with a coronally advanced flap in

dogs (Fig. 27-51). The histologic analysis after 3

months of healing disclosed that on average 20% of

Fig.

27-52.

Microphotograph of the healing following a

coronally displaced flap in the dog as illustrated in Fig.

27-51. A

new connective tissue attachment is formed

and extends coronally from the apical border of the

notch prepared at the bottom of the bone dehiscence

(

) to the apical termination of the epithelium (aJE) lo

cated within the notch indicating the presurgical level

of the soft tissue margin (N

). B: alveolar bone crest.

the apicocoronal length of the original defect had been

exposed due to recession during healing (i.e. about

80% root coverage was achieved), 40% was covered

epithelium and 40% demonstrated new connective

tissue attachment (Fig. 27-52). Determining factors for

the type of healing result were the size and the shape

of the defect. The possibility of achieving a new con-

nective tissue attachment in the apical portion of the

defect seemed to be considerably better in narrow

616 • CHAPTER 27

recession defects than in wider ones, most likely be-

cause the periodontal ligament at the lateral parts of

the defect will serve as a source of granulation tissue

from which a new connective tissue attachment can

develop.

The healing following pedicle graft procedures has

also been histologically studied in monkeys (Caffesse

et al. 1984, Gottlow et al. 1990), and in these studies

38-44% of the successfully covered recession defects

demonstrated formation of new connective tissue at-

tachment. The study by Gottlow et al. (1990) also

showed that the use of a GTR membrane between the

root surface and the pedicle graft generated signifi-

cantly more new connective tissue attachment (79% of

the covered recession defect).

Some case reports with human block sections pro-

vide evidence that new connective tissue attachment

with cementum formation may be formed following

pedicle graft procedures. Histologic evaluation of two

teeth treated with a laterally positioned flap revealed

that connective tissue attachment was re-established

in the apical fourth of the successfully covered portion

of the root (Sugerman 1969). Cortellini et al. (1993)

examined histologically a tooth treated with the GTR

procedure and showed that connective tissue faced

74% of the length of the recession defect. New cemen

turn with inserting collagen fibers, i.e. new connective

tissue attachment, covered 48% of the distance be-

tween the apical border of the root instrumentation

and the soft tissue margin.

Healing of free soft tissue grafts

Survival of a free soft tissue graft placed over a de-

nuded root surface depends on diffusion of plasma

and subsequent revascularization from those parts of

the graft that are resting on the connective tissue bed

surrounding the dehiscence. The establishment of col

lateral circulation from adjacent vascular borders of

the bed allows the healing phenomenon of "bridging

(

Sullivan & Atkins 1968a,b). Hence, the amount of

tissue that can be maintained over the root surface is

limited by the size of the avascular area (Oliver et al.

1968, Sullivan & Atkins 1968). Other factors consid-

ered critical for the survival of the tissue graft placed

over the root surface are that a sufficient vascular bed

is prepared around the dehiscence and that a thick

graft is used (Miller 1985b).

Another healing phenomenon frequently observed

following free graft procedures is "creeping attach-

ment", i.e. a coronal migration of the soft tissue mar-

gin. This occurs as a consequence of tissue maturation

during a period of about 1 year post-treatment.

Histologic evaluations of the nature of the attach-

ment established to the root surface following the use

of free grafts for root coverage are few. Sugerman

(

1969) reported from a histologic evaluation of a hu-

man tooth treated with a free soft tissue graft that new

connective tissue attachment was found in the apical

fourth of the successfully covered recession defect.

Pasquinelli (1995) harvested a human block biopsy of

a premolar for histologic evaluation 42 weeks after

treatment of a narrow recession defect with root bio-

modification (tetracycline HC1) and an epithelialized

free soft tissue graft. The root coverage amounted to 5

mm, or 83% of the original recession. The epithelial

lining was found to terminate 2.6 mm below the gin-

gival margin, and the most coronally positioned new

cementum with inserting connective tissue fibers was

seen 3.4 mm apical to the gingival margin. No his-

tologic reference for the apical extension of the origi-

nal defect was available, but the author estimated,

based on extrapolations from pre-treatment probing

assessments, that 3.6 mm of new attachment had

formed, corresponding to 51% of the apicocoronal

height of the covered, previously detached root por-

tion.

On the other hand, Harris (1999) and Majzoub et al.

(2001), each reporting the histological outcome of free

connective tissue grafts in two cases, found only mini

mal amounts of new cementum formation in the most

apical part of the recession defect and that healing

resulted in a long junctional epithelium occupying the

interface between the covering soft tissue and the

root.

Thus, the limited histological information available

from humans on the healing of free soft tissue grafts

indicates that a healing pattern similar to the one

discussed above following pedicle graft procedures

may result, namely that connective tissue attachment

may be established in the most apical and lateral parts

of the recession defect, but that an epithelial attach-

ment is formed along the major portion of the root.

INTERDENTAL PAPILLA

RECONSTRUCTION

There may be several factors contributing to the loss

of papilla height and the establishment of "black tri-

angles" between teeth. The most common reason in

the adult individual is loss of periodontal support due

to plaque-associated lesions. However, abnormal

tooth shape, improper contours of prosthetic restora-

tions and traumatic oral hygiene procedures may also

negatively influence the outline of the interdental soft

tissues.

Nordland & Tarnow (1998) proposed a classifica-

tion system regarding the papillary height adjacent to

natural teeth, based on three anatomical landmarks:

the interdental contact point, the apical extent of the

facial cemento-enamel junction (CEJ), and the coronal

extent of the proximal CEJ (Fig. 27-53).

•

Normal:

the interdental papilla occupies the entire

embrasure space apical to the interdental contact

point/area.

•

Class I:

the tip of the interdental papilla is located

between the interdental contact point and the level

of the CEJ on the proximal surface of the tooth.

•

Class

II:

the tip of the interdental papilla is located

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 617

Fig. 27-53. Schematic drawing illustrating the classification system for papilla height (Nordland & Tarnow 1998),

at or apical to the level of the CEJ on the proximal

surface of the tooth but coronal to the level of the

CEJ mid-buccally.

• Class

III:

the tip of the interdental papilla is located

at or apical to the level of the CEJ mid-buccally.

In an observational study in humans, Tarnow et al.

(

1992) analyzed the correlation between the presence

of interproximal papillae and the vertical distance

between the contact point and the interproximal bone

crest. When the vertical distance from the contact

point to the crest of bone was 5 mm or less, the papilla

was present almost 100% of the time, whereas if the

distance was 6 mm or more most commonly only

partial papilla fill of the embrasure between the teeth

was found. Considering that a supracrestal connective

tissue attachment zone of approximately 1 mm is

normally found (Gargiulo 1961), the observation indi-

cates that the biological height of the interdental pa-

pilla may be limited to about 4 mm. This interpretation

is supported by the observation that in interdental

areas denuded following an apically repositioned flap

procedure, an up-growth of around 4 mm of soft tissue

had taken place 3 years after surgery (Van der Velden

1982). Hence, before attempts are made to surgically

reconstruct an interdental papilla, it is important to

carefully assess both (1) the vertical distance between

the bone crest and the apical point of the contact area

between the crowns, and (2) the soft tissue height in

the interdental area. If the distance bone crest-contact

point is 5 mm and the papilla height is less than 4

mm, surgical intervention for increasing the volume

of the papilla could be justified in order to solve the

problem of an interdental "black triangle". However,

the contact point is located > 5 mm from the bone

crest, because of loss of periodontal support and/or

an inappropriate interdental contact relationship be-

tween the crowns, means to apically lengthen the

contact area between the teeth should be selected

rather than a surgical attempt to improve the topog-

raphy of the papilla.

If loss of papilla height is caused by soft tissue

damage only from oral hygiene devices, the inter-

proximal hygiene procedures must be initially discon-

tinued to allow soft tissue recovery and then succes-

sively modified in order to eliminate/minimize the

traumatic injury to the papillae.

Surgical techniques

Several case reports have been published regarding

surgical techniques for reconstruction of deficient pa-

pillae (e.g. Beagle 1992, Han & Takei 1996, Azzi et al.

1998). However, the predictability of the various pro-

cedures has not been documented and no data are

available in the literature providing information on

the long-term stability of surgically regained interden

tal papillae.

Beagle (1992) described a pedicle graft procedure

utilizing the soft tissues palatal of the interdental area.

Technique

(Fig. 27-54):

A split-thickness flap is dis-

sected on the palatal aspect of the interdental area. The

flap is elevated labially, folded and sutured to create

the new papilla at the facial part of the indental area.

A periodontal dressing is applied on the palatal aspect

only, in order to support the papilla.

Facial CEJ

Interproximal CEJ

Interdental

contact point

Facial CEJ

Interproximal CEJ

Interdental

contact point

618 • CHAPTER 27

Fig. 27-54a-c.

Papilla reconstruction – pedicle graft technique.

Schematic drawings illustrating the surgical technique

(

see text for explanation).

Fig. 27-55.

Papilla reconstruction – the

semi-lunar coronally repositioned papilla" technique. (a-c)

Schematic drawings

illustrating the surgical technique (see text for explanation). (d-f) Reconstruction of papillae distal to the central

incisors with the use of the semi-lunar coronally repositioned papilla technique in a patient with a fixed bridge

reconstruction.

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 619

Fig. 27-56a-c.

Papilla reconstruction — "envelope" technique.

Schematic drawings illustrating the surgical

technique

(see text for explanation).

Han and Takei (1996) proposed an approach for

papilla reconstruction ("semi-lunar coronally reposi-

tioned papilla") based on the use of a free connective

tissue graft.

Technique (Fig. 27-55):

A semi-lunar incision is placed

in the alveolar mucosa facial to the interdental area

and a pouch-like preparation is performed into the

interdental area. Intrasulcular incisions are made

around the mesial and distal half of the two adjacent

teeth to free the connective tissue from the root sur-

faces to allow a coronal displacement of the gingival-

papillary unit. A connective tissue graft, taken from

the palate, is placed into the pouch to support the

coronally positioned interdental tissue.

Azzi et al. (1998) described a technique in which an

envelope-type flap was prepared for coverage of a

connective tissue graft.

Technique (Fig. 27-56):

An intrasulcular incision is

made at the tooth surfaces facing the interdental area

to be reconstructed. Subsequently, an incision is

placed across the facial aspect of the interdental area

and an envelope-type, split-thickness flap is elevated

into the proximal site as well as apically to a level

beyond the mucogingival line. A connective tissue

graft is harvested from the tuberosity area, trimmed

to adequate size and shape and placed under the flaps

in the interdental papilla area. The flaps are brought

together and sutured with the connective tissue graft

underneath.

CROWN LENGTHENING

PROCEDURES

Excessive gingival display

In most patients, the lower edge of the upper lip

assumes a "gum-wing" profile which limits the

amount of gingiva that is exposed when a person

smiles. Patients who have a high lip line expose a

broad zone of gingival tissue and may often express

concern about their "gummy smile" (Fig. 27-57a). The

form of the lips and the position of the lips during

speech and smiling cannot be easily changed, but the

dentist may, if necessary, modify/control the form of

the teeth and interdental papillae as well as the posi-

tion of the gingival margins and the incisal edges of

the teeth. In other words, it is possible by a combina-

tion of periodontal and prosthetic treatment measures

to improve dentofacial esthetics in this category of

patient.

As a base for treatment decisions, a careful analysis

of the dentofacial structures and how they may affect

esthetics should be performed and should include the

following features:

•

Facial symmetry

•

Interpupillary line — even or uneven

•

Smile line — low, median or high

•

Dental midline in relation to facial midline

•

Gingival display during speech and during broad,

relaxed smile

•

Harmony of gingival margins

•

Location of gingival margins in relation to the ce-

mento-enamel junctions

•

Tooth size and proportions/harmony

•

Incisal plane/occlusal plane.

If excessive gingival exposure is due to insufficient

length of the clinical crowns, a crown lengthening

procedure is indicated to reduce the amount of

gingiva exposed, which in turn will favorably alter the

shape and form of the anterior teeth. To select the

proper treatment approach for crown lengthening, an

analysis of the individual case with regard to crown-

root-alveolar bone relationships should also be in-

cluded.

In the young adult with an intact periodontium the

gingival margin normally resides about 1 mm coronal

to the cemento-enamel junction. However, some pa-

tients may have a height of free gingiva that is greater

than 1 mm, resulting in an unproportional appearance

620 • CHAPTER 27

Fig.

27-57.

Crown lengthening procedure. (a-b)

Pretreatment views. The clinical crowns are considerably shorter than

the anatomical crowns. The lateral incisors were congenitally missing and orthodontic treatment had been carried

out

to move the posterior teeth anteriorly. The canine teeth in the position of the lateral incisors added to the es

thetic

disharmony. (c) A gingivectomy was performed to expose the anatomical crowns of the teeth. (d) One month

post-

surgery. At this appointment, the canine and first premolar teeth were reshaped and bonded. (e) Tooth form

and

proportional balance were improved by bonding. (f) At 3 years post-treatment, the gingival tissues exhibited

rebound and retained the architectural form sculpted into the tissue at the time of the surgical procedure. Cour

tesy

of Dr J. Seibert, US.

of the clinical crown. If such a patient complains about

their "small front teeth" and the periodontium is of a

thin

biotype, full exposure of the anatomical crown

can be

accomplished by a gingivecomy/gingivo

plasty

procedure (Fig.

27-57).

An assessment should also be made regarding the

amount and pattern of pigmentation existing within

the

gingival tissues, and the patient's desire to maintain or

lessen the pigmentation contained within the

tissues.

The externally beveled path of incision that is

usually

employed in a gingivectomy procedure will

remove the pigmentation and produce pink gingival

tissue upon initial healing (Fig.

27-58).

The surgically

induced color change in the tissues comes about rap-

idly, and markedly affects esthetic values. For this

reason, an externally beveled gingivectomy proce

dure

should not be terminated at the midline in pa

tients that

have pigmented gingival tissues. It should be extended

across the midline to the premolar area to

avoid a color

mismatch in the esthetic zone of the

anterior teeth. The

color change may be permanent or

the pigmentation

may slowly return over a period of

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 621

Fig. 27-58. (a) Pretreatment view. The patient disliked her "small front teeth" and diastema. Radiographs and prob

ing indicated the gingival tissues were covering the cervical one third of the crowns. Crestal bone was thin and in

normal relationship to the cemento-enamel junctions. The patient preferred "pink gum

if she could possibly have

them. (b) A long externally beveled path of incision was used to accomplish the gingivectomy. (c) This view shows

the color changes and pleasing architecture produced in the anterior gingiva at 2 months post-surgery. The di-

astema was partially closed by direct bonding at this time. (d) Post-treatment view showing the enhancement of es

thetic values for the patient. Courtesy of Dr J. Seibert, US.

a year or more. Patients should be informed of the

changes in tissue color that will occur and should be

allowed to make a choice as to the color of the tissue

they will have postsurgically. If they wish to maintain

their pigmentation, an internally beveled path of inci-

sion (internal gingivectomy) should be employed

(Fig.

27-59).

If the periodontium is of the thick biotype and there

is a bony ledge at the osseous crest, an apically posi-

tioned flap procedure (see Chapter 25) should be per-

formed. This will allow for osseous recontouring (Fig.

27-60).

More extensive bone recontouring is required to

solve esthetic problems found in patients who do

indeed have short anatomical crowns in the anterior

section of the dentition. In this category of patients,

prosthetic measures must be used after resective peri-

odontal therapy to increase the apicocoronal dimen-

sion of the crowns (Fig. 27-61). Patients who are can-

didates for this kind of resective therapy can be di-

vided into two categories:

1. Subjects who have normal occlusal relationships

and incisal guidance. In this category the incisal

line

of the front teeth must remain unaltered but the

clinical crowns can be made longer by surgically

exposing root structure and by locating the cervical

margins of the restorations apical to the cemento-

enamel junction (Fig. 27-61).

2. Subjects who have abnormal occlusal relationships

with excessive interocclusal space in the posterior

dentition when the anterior teeth are in edge-to

edge

contact. In this category of patients the length of the

maxillary front teeth can be reduced without

inducing posterior occlusal interferences. In addi-

tion, the marginal gingiva can be resected or relo-

cated to an apical position before crown restora-

tions are made.

In some individuals having excessive display of

gingiva, the size and shape of the teeth and the loca-

tion of the gingival margins may be perfectly normal.

The excessive display of gingiva in these cases is often

caused by vertical maxillary excess and a long mid-

face

(Fig. 27-62). Periodontal crown lengthening pro

cedures

will not suffice to solve their problems, but

rather the

maxilla must be impacted by major maxil

lofacial

surgical procedure. The risk-benefits and cost ratios

must be thoroughly evaluated before recom-

622 • CHAPTER 27

Fig. 27-59. Pretreatment view. This patient disliked the looks of her "small front teeth

; she sought consultation to

have her teeth made longer by crowning them. Probing and radiographs revealed normal osseous morphology and

wide zone of attached gingiva that covered the cervical one third of the incisors. It was explained to the patient

that

a surgical solution was preferred to restorative procedures to make her teeth longer. The patient made a re-

quest

that the color of her gingival tissues remain unchanged. (b) An internally beveled path of incision was used

effect an "internal gingivectomy" to maintain the pigmentation in the tissues. This created mini flaps in the areas

the papillae. (c) 5-0 gut sutures were used to stabilize the papillae. (d) The crown lengthening that was achieved

with maintenance of color harmony can be seen in this view at 3 months post-surgery. Courtesy of Dr E. Saacks,

Pennsylvania, PA.

mending this type of surgical therapy to correct es-

thetic problems.

Exposure of sound tooth structure

Crown lengthening procedures may be required to

solve

problems such as (1) inadequate amount of tooth

structure for proper restorative therapy, (2) subgingi

val

location of fracture lines, and (3) subgingival loca

tion of

carious lesions.

The techniques used to accomplish crown length-

ening include (1) apically positioned flap procedure

including bone resection, and (2) forced tooth erup

tion

with or without fiberotomy.

Apically positioned flap with bone recontouring

The apically positioned flap technique with bone re-

contouring (resection) may be used to expose sound

tooth structure. As a general rule, at least 4 mm of

sound tooth structure must be exposed at time of

surgery. During healing the supracrestal soft tissues

will

proliferate coronally to cover 2-3 mm of the root

(Herrero

et al. 1995, Pontoriero & Carnevale 2001), thereby

leaving only 1-2 mm of supragingivally lo

cated sound

tooth structure. When this technique is

used for crown

lengthening it must also be realized

Fig. 27-61. Crown lengthening by surgical and prosthetic procedures. (a) Pretreatment view. The patient displayed

short front teeth" and a broad exposure of gum tissue. The full anatomical crown is exposed in this case and the

surgically induced recession will expose root structure. (b) The patient had an unusually wide zone of attached

gingiva. The gingival margins were positioned apically by making an internally beveled flap with a submarginal

entrance incision as outlined in red ink. The crest of the bone was reduced in height. (c) After the tissues had ma

tured following surgery, individual crowns were prepared for each of the anterior teeth. Crown lengthening was

achieved and the patient no longer exposed a broad expanse of gum tissue. Courtesy of Dr D. Garber, Atlanta, GA.

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 623

Fig.

27-60.

(a) Pretreatment view. The patient, a dentist, requested crown lengthening to lessen his "gummy smile

and give him a more masculine appearance. The patient had a wide zone of attached gingiva and thick crestal

bone.

Palpation indicated bony exostoses. (b) An apically positioned flap and osseous resective surgery, from sec

ond

premolar to second premolar, were used to lengthen the teeth. The surgery was confined to the labial surfaces.

This

view shows one half of the surgery completed. (c) Vertical mattress sutures were utilized to hold the flap api

cally. (d)

Three years post-treatment. Note that the gingival tissues retain the morphology created at the time of sur

gery.

Courtesy of Dr J. Seibert, US.

624 • CHAPTER 27

Fig. 27-62. This patient displays a large expanse of gin

gival tissue when smiling or speaking. The patient has

long mid-face and vertical maxillary excess. The gin-

gival margins reside 1 mm coronal to the cemento-

enamel junction and the anatomical and clinical

crowns are approximately equal.

Fig. 27-63. (a-b) Surgical resective therapy for crown lengthening cannot be confined to the tooth in need of treat-

ment. The principles of osseous resection require that bone be removed from the adjacent teeth to create a gradual

rise and fall in the profile of the osseous crest. This causes a loss of attachment apparatus and recession on the

adja

cent teeth as well.

Fig. 27-64. A deformity which interfered with dento-

facial esthetics was created at the right central incisor

by using a surgical crown lengthening procedure at

one

single tooth to expose sound tooth structure. The

soft

tissues cannot follow the abrupt and steep changes

the osseous profile. The crown preparation invaded the

zone of normal supracrestal connective tissue. This

created a chronic periodontal pocket and adversely af-

fected esthetics. Courtesy of Dr A. Winnick, Toronto,

Canada.

that gingival tissues have an inherent tendency to

bridge abrupt changes in the contour of the bone crest.

Thus, in order to retain the gingival margin at its new

and more apical position, bone recontouring must be

performed not only at the problem tooth but also at

the

adjacent teeth to gradually reduce the osseous

profile (

Fig. 27-63). Consequently, substantial

amounts of

attachment may have to be sacrificed

when crown

lengthening is accomplished with an

apically positioned

flap technique. It is also important to remember that, for

esthetic reasons, symmetry of

tooth length must be

maintained between the right

and left side of the dental

arch. This may, in some

situations, call for the inclusion of even more teeth in

the surgical procedure.

Indication:

Crown lengthening of multiple teeth in a

quadrant or sextant of the dentition.

Contraindication:

Surgical crown lengthening of single

teeth in the esthetic zone (Fig. 27-64).

Technique:

The apically positioned flap technique and

methods used for bone recontouring are discussed in

Chapter 25.