Jan Lindhe. Clinical Periodontology

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MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 625

Fig. 27-65. Forced tooth eruption (slow method) used to level gingival margins, treat recession on a single tooth and

create esthetic harmony. (a-b) Recession on the left central incisor exposed the root surface darkened from root ca

nal

treatment. The uneven gingival margins and dark root surface detracted from an otherwise attractive smile. (c)

nitol wire with an offset bracket was used to slowly extrude the incisor. (d) Occlusal adjustment was done on the

lingual side of the crown to create room for the tooth to erupt. This view, at 1 month in tooth movement, shows the

gingival tissues moving with the root of the tooth. (e) Sufficient eruption had occurred by 3 months to level the gin

gival margins. The orthodontic brackets were used for temporary stabilization and a new crown was prepared. (f)

The new crown masked the show-through of the dark root. The even gingival margins and beautiful crown created

esthetic harmony. Courtesy of Dr J. Ingber, Philadelphia, PA.

Forced tooth

eruption

Orthodontic tooth movement can be used to erupt

teeth

in adults (Reitan 1967, Ingber 1974, 1976, Potash

nick

& Rosenberg 1982). If moderate eruptive forces

are

used, the entire attachment apparatus will move in

unison with the tooth. The tooth must be extruded

distance equal to or slightly longer than the portion

sound tooth structure that will be exposed in the

subsequent surgical treatment. After the tooth has

reached the intended position and has been stabilized,

full thickness flap is elevated and bone recontouring

performed to expose sound root structure. For es

thetic

reasons it is important that the bone and soft

tissue

levels at adjacent teeth remain unchanged.

Forced tooth eruption can also be used to level and

align gingival margins and the crowns of teeth to

obtain

esthetic harmony. Instead of using surgical

procedures

to apically position the gingival margins

626 • CHAPTER 27

Fig. 27-66. Slow tooth eruption procedure used to level cemento-enamel junctions and angular bone crests. (a) Pre

treatment radiograph. (b) A nitol wire was used to erupt the molar. (c) The crown was shortened over a period of 4

months by selective grinding. (d) Radiograph taken 8 months after the start of treatment. The angular bone defects

were leveled. Courtesy of Dr J. Seibert, US.

Fig. 27-67a-b. Rapid tooth eruption procedure in conjunction with fiberotomy procedure. (a) Buccal view, the frac

ture

on the first premolar extended subgingivally. (b) Soft tooth structure was excavated and a twisted wire with an

occlusal hook was temporarily cemented in the root canal. A bar was placed into the amalgam restoration on the

premolar and bonded to the lingual surface of the canine.

of unaffected normal teeth to the level of a tooth with

recession or orthodontic malalignment, the tooth that

malpositioned or has sustained recession is erupted

the level of the normally positioned teeth. The entire

attachment apparatus and dentogingival junction will

follow the root of the tooth as it is moved coronally

(Fig.

27-65).

Indication:

Crown lengthening at sites where removal

attachment and bone from adjacent teeth must be

avoided. The forced eruption technique can also be

used as a means of reducing pocket depth at sites with

angular bony defects (Brown 1973, Ingber 1974, 1976).

The angular bony defect at the problem tooth can be

reduced while the attachment level at the adjacent

tooth

surface remains unchanged (Fig. 27-66).

Contraindication:

The forced eruption technique re-

quires

the use of fixed orthodontic appliances. Thus, in patients

who have only a few teeth remaining, an alternative

approach for crown lengthening has to be

selected.

Technique:

Orthodontic brackets are bonded to the pro-

MUCOGINGIVAL THERAPY - PERIODONTAL PLASTIC SURGERY • 627

Fig. 27-67c-h. (c-d) Sulcular fiber resection was performed at the mesial half of the tooth to the level of the bone

crest. The distal half remained as a control surface. The fiber resection was repeated once a week during the 3-week

eruption phase. (e) The tooth was stabilized for 6 weeks, and at that time a full-thickness flap was raised. The bone

crest had a "positive

angulation at the distal surface and remained unchanged at the

test

mesial surface. Osse-

ous

resection was used to level the bony septum on the distal surface. (f) Ample crown lengthening was obtained

and

the gingival margins healed to their former shape and location. (g) Pretreatment radiograph enlarged to show the

normal shape of the crests of the interdental septae. (h) Enlargement of the posteruption radiograph (3 weeks of

rapid eruption and 6 weeks of stabilization) to show the "positive" angular crest on the "control

distal side and

the unchanged crest on the mesial "test" side. Courtesy of Dr R. Pontoriero, Milan, Italy

blem tooth and to adjacent teeth and are combined problem tooth. A power elastic is tied from the bracket

with

an arch wire. Another type of mechanical system to the arch wire (or the bar), which pulls to tooth can be utilized

by placing a heavy gauge bar or wire coronally. If most of the crown structure is lost, root

in grooves prepared in

the adjacent teeth and over the canal therapy is required. A post placed in the root

628 •

CHAPTER

Fig. 27-68. Ectopic tooth eruption. The permanent tooth

is erupting close to the mucogingival junction.

canal is fitted with a power elastic, which is also joined

with the arch wire. The direction of the tooth move-

ment must be carefully checked to ensure that the

problem tooth is not tilted or moved toward the adja-

cent tooth surfaces.

Forced tooth eruption with fiberotomy

If fiberotomy is performed during the forced tooth

eruption procedure the crestal bone and the gingival

margin are retained at their pretreatment locations,

and the tooth-gingiva interface at adjacent teeth is

unaltered. Fiberotomy is performed by the use of a

scalpel at 7 to 10-day intervals during the forced erup

tion to sever the supracrestal connective tissue fibers,

thereby preventing the crestal bone from following the

root in coronal direction. In the case presented in Fig.

27-67, fiberotomy was performed only at the mesial

half of the root. Radiographs obtained after 9 weeks

demonstrate that crestal bone migration has occurred

at the distal but not at the mesial surface of the erupted

tooth (Pontoriero et al. 1987).

Indication:

Crown lengthening at sites where it is im-

portant to maintain unchanged the location of the

gingival margin at adjacent teeth.

Contraindication:

Fiberotomy should not be used at

teeth associated with angular bone defects.

Fig. 27-69a-c.

Ectopically erupting tooth – double pedicle

graft.

Schematic drawings illustrating the surgical tech

nique (see text for explanation).

Technique:

Similar to the technique described for the

forced tooth eruption procedure. Fiberotomy is per-

formed once every 7-10 days during the phase of

forced tooth eruption.

Ectopic tooth eruption

Surgical intervention is often indicated for teeth erupt

ing ectopically, i.e. having an eruption position facial

to the alveolar ridge (Fig. 27-68). To create a satisfac

tory width of the gingiva for the permanent tooth, the

tissue entrapped between the erupting tooth and the

deciduous tooth is usually utilized as donor tissue

(

Agudio et al. 1985, Pini Prato et al. 2000b).

Three different techniques have been described for

the interceptive mucogingival treatment of buccally

erupting teeth, depending on the distance from the

donor site (entrapped gingiva) to the recipient site

MUCOGINGIVAL THERAPY - PERIODONTAL PLASTIC SURGERY • 629

Fig. 27-70a-c.

Ectopically erupting tooth — apically posi-

tioned flap.

Schematic drawings illustrating the surgical

technique (see text for explanation).

(area located facially-apically to the erupting perma-

nent tooth) (Agudio et al. 1985, Pini Prato et al. 2000b):

Double pedicle graft (Fig. 27-69):

This flap procedure is

indicated when the permanent tooth erupts within the

zone of keratinized tissue but close to the mucogingi-

val junction. An intrasulcular incision is performed at

the deciduous tooth and extended laterally to the

gingival crevice of the adjacent teeth and apically to

the erupting permanent tooth. By mobilization of the

flap apical to the mucogingival line, the entrapped

gingiva can be elevated and transposed for position-

ing apically to the erupting tooth. Sutures may be

placed to secure the position of the gingival tissue

facial to the erupting tooth.

Apically positioned flap (Fig. 27-7W:

When the perma-

nent tooth is erupting apical to the mucogingival junc

tion, vertical releasing incisions have to be placed to

allow for apical positioning of the keratinized tissue.

Fig. 27-71a-c.

Ectopically erupting tooth — free gingival

graft.

Schematic drawings illustrating the surgical tech

nique (see text for explanation).

Two lateral releasing incisions are made and extended

apically beyond the mucogingival junction. An in-

trasulcular incision is performed at the deciduous

tooth and a partial thickness flap is elevated beyond

the ectopically erupting tooth. The mobilized gingival

flap is moved apical to the erupting tooth and secured

in position by sutures.

Free gingival graft (Fig. 27-71):

If the tooth is erupting

within the alveolar mucosa distant to the mucogingi-

val junction, a free gingival graft procedure may be

selected. The entrapped gingiva is removed by a split

incision and used as an epithelialized connective tis-

sue graft. The free gingival graft is placed at a pre-

pared recipient site facial/apical of the erupting tooth.

Careful suturing is performed to secure a close adap-

tation of the graft to the underlying connective tissue

bed.

All the described procedures have been proven to

be effective in establishing a facial zone of gingiva

630 • CHAPTER

Fig. 27-72. (a) A central incisor that cannot be maintained because of root fracture which also caused pronounced

periodontal destruction. (b) Immediately following tooth extraction, an ovate pontic was inserted to support the fa

cial and proximal soft tissues. (c-d) Radiographic and clinical view of the area 6 weeks after tooth extraction. (e)

Fol

low-up 1 year after the placement of permanent prosthetic recontruction (single implant).

following the alignment of teeth erupting in an ectopic

position (Pino Prato et al. 2000b,c).

THE DEFORMED EDENTULOUS

RIDGE

A partially edentulous ridge may retain the general

shape of the alveolar process. Such a ridge is tradition-

ally refered to as a normal ridge. Even though this

normal ridge has retained the buccolingual and api-

cocoronal dimensions of the alveolar process, it is not

normal in many other respects; the eminences that

existed in the bone over the roots are no longer present

and the interdental papillae are missing.

The smooth contours of the normal ridge create

problems for the restorative dentist. In a fixed bridge

the pontics (1) frequently give the impression that they

rest on the top of the ridge rather than emerge from

within the alveolar process, (2) lack a root eminence,

and (3) lack marginal gingivae and interdental papil-

lae. Dark triangles, which almost always interfere

with

dentofacial esthetics, are present in the embra

sure

area between the pontics and between the abutments

and the pontics. In other words, in the presence

of a

normal ridge it may be difficult or impossible to

produce a fixed prosthesis which truly restores the

esthetics and function of the natural dentition.

Prevention of soft tissue collapse following

tooth extraction

Following extraction of a tooth, the topography of the

surrounding soft and hard tissues will be altered. The

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 631

Fig. 27-73. (a) A 26-year-old female patient who had a trauma against the maxillary central incisors. Due to root

fracture and endodontic complications both central incisors had to be extracted. (b) A Rochette bridge with ovate

pontics was fabricated as a temporary replacement for the incisors. (c) Clinical view of the front tooth region

weeks after tooth extraction and placement of the resin bonded temporary bridge.

soft tissue margin will collapse and the height of the

adjacent papillae will be reduced. This soft tissue

collapse may be prevented by immediate post-extrac-

tion placement of an ovate pontic to support the soft

tissues. Fig. 27-72 illustrates such a situation where a

central incisor had to be extracted due to root fracture.

With the immediate placement of the pontic the facial

soft tissue margin and the papillae were maintained

almost unchanged following the healing of the extrac-

tion site. Also, in situations where several adjacent

teeth have to be extracted, insertion of ovate pontics

may facilitate the preservation of the outline of the soft

tissue ridge (Fig. 27-73).

Prevention of ridge collapse due to alveolar bone

resorption following tooth extractions must also be

considered. Borghetti & Laborde (1996) recommended

means for prevention of bone ridge collapse after

tooth extraction in any case of:

fracture of the vestibular osseous plate during

tooth extraction or due to trauma

resorption of the vestibular osseous plate

presence of a thin vestibular bone plate.

Among procedures proposed for prevention of ridge

collapse in conjunction with tooth extractions are (1)

flap elevation for complete soft tissue closure of the

extraction sites (Borghetti & Glise 2000), (2) placement

of connective tissue grafts over the extraction sites

(

Nevins & Mellonig 1998), (3) placement of bone grafts

(

Becker et al. 1994), and (4) utilization of barrier mem

branes (Lekovic et al. 1997). Procedures for preserva-

tion of the bone dimensions following tooth extraction

are discussed in Chapter 28.

Correction of ridge defects by the use of soft

tissue grafts

A deformed ridge may result from tooth extractions,

advanced periodontal disease, abscess formations,

etc. The deformity that exists in the ridge is directly

related to the volume of root structure and associated

bone that is missing or has been destroyed. According

to Seibert (1983), ridge defects can be divided into

three classes:

Class I: Loss of buccolingual width but normal apico-

coronal height

Class II: Loss of apicocoronal height but normal buc-

colingual width

Class III: A combination of loss of both height and

width of the ridge.

Ridge augmentation procedures should be preceded

by a careful surgical-prosthetic treatment planning by

joint consultations involving the surgeon and the re-

storative dentist in order to attain an optimal esthetic

result. The following factors should be determined

prior to the initiation of therapy:

•

Volume of tissue required to eliminate the ridge

deformity

•

Type of graft procedure to be used

•

Timing of various treatment procedures

632 • CHAPTER 27

Fig. 27-74. Sequence of steps in the

"roll

flap

procedure".

(a) Cross section of the residual edentulous ridge prior to

treatment. (b) The removal of the epithelium. (c) The elevation of the pedicle. (d) The pouch is created. (e) Sutures

are placed at the mucogingival junction to catch the tip of the pedicle flap and pull it into place in the pouch. (f)

The flap is secured. A convexity in the ridge was created.

•

Design of the provisional restoration

•

Potential problems with tissue discolorations and

matching tissue color.

Ideally, a provisional restoration should be made prior

to surgery. The shape of the teeth in the provisional

restoration, the axial inclination and emergence pro-

file of the teeth and the embrasure form should be an

exact prototype of the final prosthesis that is to be

constructed. It is the task of the clinician performing

the surgery to augment the tissues to meet the provi-

sional prosthesis in the most exact manner possible. If

a gingival flange of pink-colored acrylic is used

around

single or multiple pontics on a temporary

removable

partial denture, the flange must be cut

away in order

to avoid pressure on the graft and give

the tissues

room to swell during the immediate post-

surgical phase

of healing. The soft tissue at the surgi

cally treated

recipient site for a graft will undergo

considerable

swelling during the early phase of heal

ing and the

tissues will conform to the tissue-facing surfaces of

the bridge or partial denture. The prosthe

sis is thus

used to help in shaping the outline of the

augmented

ridge to the desired form. The location and

shape of

interproximal embrasure areas in the provi

sional

bridge will determine where the "papillae"

created in

the ridge will be located.

Surgical procedures for ridge augmentation

Numerous

surgical graft and implant procedures with

the

attempt to reconstruct a partially edentulous ridge

ridge defect have been described in the literature

over the years. The procedures may be grouped ac-

cording to the means used for ridge augmentation as

(1) soft tissue augmentation procedures and (2) hard

tissue augmentation procedures. In this chapter only

soft tissue augmentation procedures will be ad-

dressed, while hard tissue augmentation procedures

are covered in Chapter 28. To illustrate various ap-

proaches for utilization of soft tissues for ridge aug-

mentation, the following procedures will be dis-

cussed:

Pedicle graft procedure

•

Roll flap procedure

Free graft procedures

•

Pouch graft procedure

•

Interpositional graft procedure

•

Onlay graft procedure

Studer et al. (1997) proposed the use of the pedicle

graft procedure for correction of a single-tooth ridge

defect with minor horizontal and vertical loss,

whereas

in cases of larger defects submerged free

connective

tissue graft procedures should be selected.

The onlay

full thickness graft procedure is indicated

for ridge

augmentation primarily in the presence of

additional

mucogingival problems such as insuffi

cient gingival

width, high frenum, gingival scarring,

or tattoo.

These recommendations were based on

short-term

evaluation of the obtained volumetric in-

crease of the

edentulous ridge following various aug

mentation

procedures, which demonstrated superior

results

with the use of submerged connective tissue

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY •

Fig.

27-75. "Roll flap procc(IlIre" .

(a) Pretreatment view of a Class I ridge defect in the area of the right lateral

incisor.

Note the marked concavity in the ridge. (b) This view shows the surgical site 1 week after surgery and

prior to the

removal of the sutures. (c) The tissue surface of the pontic was relined with autopolymerizing resin. (

d) Final pros

thesis in place. Note the illusion of a root eminence and a free gingival margin apical to the lateral

incisor pontic

tooth. Courtesy of Dr L. Abrams, Philadelphia, PA.

grafts compared to the use of full-thickness grafts (

Studer et al.

2000).

The "roll flap procedure"

Surgical concept:

The "roll flap procedure" (Abrams

1980) involves the preparation of a de-epithelialized

connective tissue pedicle graft, which is subsequently

placed in a subepithelial pouch (Fig.

27-74).

This pro-

cedure is used in the treatment of small to moderate

Class I ridge defects, primarily in cases with a single-

tooth space. The technique enables the surgeon to

augment tissue apically and labially to the cervical

area of a pontic and to give the recipient site the

appearance of a normal tooth-gingiva interface.

Hence, a buccolingual ridge concavity can be con-

verted into a ridge convexity resembling the eminence

produced by the roots of the adjacent teeth (Fig.

27-75).

Technique (Fig. 27-74):

A rectangular pedicle of connec

tive tissue is prepared on the palatal side of the defect.

The length of the pedicle must match the amount of

apicocoronal augmentation that is planned. This, in

turn, is related to the amount of root eminence that

exists on either side of the defect. If a two or three-

tooth pontic space is treated with the "roll technique",

two or three separate pedicles are raised. Each of these

pedicles will form a new "root-cervical margin".

The epithelium on the palatal surface of the donor

site is first removed. A maximum amount of suprape-

riosteal connective tissue is raised from the palate

using sharp dissection. The void that is produced at

the donor site will gradually fill in with granulation

tissue. Caution must be exercised in dissecting the

pedicle flap so that tissue perforation is avoided when

the plane of dissection approaches the facial (labial)

surface. A pouch is made in the supraperiosteal con-

nective tissue at the facial (labial) surface of the ridge.

In order to preserve as much connective tissue and

blood supply as possible at the recipient site, the

dissection must be made as close as possible to the

periosteum of the facial bone.

The pedicle is tucked into the pouch as a try-in

procedure. Adjustment of pedicle size should now be

made. Once the pedicle fits as desired, it is made ready

for the stabilizing suture. The suturing scheme is illus

trated in Fig. 27-74. The suture must be positioned

close to the mucobuccal fold. This enables the surgeon

to pull the pedicle to the apical portion of the pouch.

The suture should not be tightly tied, since it only

serves as a positioning and stabilizing device. The use

of a resorbable suture material is recommended.

Adjustment of pontic contours:

Measures used to adapt

the tissue surface of the pontic to the contour of the

634 • CHAPTER 27

Fig.

27-76.

Sequence of steps in

the

"pouch

graft procedure"

utiliz-

ing a free graft of connective tis-

sue (CT) to expand the ridge. (A)

Cross-section of the residual eden

tulous ridge prior to treatment.

(

B) The horizontal incision to cre-

ate the pouch is made well to the

palatal side of the defect. The inci

sion is started partial-thickness to

leave CT to suture to when the

flap is closed. The dissection is

made supraperiosteal on the la-

bial side of the ridge to (1) ensure

an adequate blood supply within

the pedicle and

(2)

permit the flap

to expand labially or labially and

coronally free of tension. (C-D)

The CT graft can be placed as

shown for maximal buccolingual

augmentation. (E-F) If vertical

augmentation is desired, the CT

implant can be placed closer to

the crest of the ridge. As is shown

in D and F, the more the flap is

stretched or expanded to gain aug

mentation, the more difficult it is

to gain primary flap closure.

surgically treated ridge are common to all soft tissue

ridge augmentation procedures in patients with fixed

bridgework. A light contact is maintained between the

pedicle graft and the tissue surface of the pontics. The

postoperative swelling will cause the tissue to con-

form to the shape of the pontic. This enables the

clinician to shape the soft tissue into a form that is

intended for the augmented site. Autopolymerizing

resin is added to the tissue surface of the pontics and

is allowed to cure until the resin reaches a dough-like

state. The bridge is then seated and pressed into the

grafted site. When the resin has set to a firm consis-

tency, the bridge is removed and placed in hot water

to complete the process of polymerization (Fig.

27-75).

The tissue surface of the pontics and the embrasure

areas are then carved to the shape that is intended for

the final bridge. The surface of the pontic is polished

and the bridge put in place using an appropriate

temporary cement.

Postoperative care:

A periodontal dressing is placed

over

the donor site. No dressing should be placed over

the

facial (labial) surface of the grafted area where

swelling will occur. The dressing at the donor site

should be changed at weekly intervals and main-

tained until wound healing has progressed to a point

where the tissue is no longer tender to touch.

Pouch graft procedures

Surgical concept:

A subepithelial pouch is prepared in

the area of the ridge deformity, into which a free graft

of connective tissue is placed and molded to create the

desired contour of the ridge. The entrance incision and

the plane of dissection may be made in different ways

(

Kaldahl et al.

1982,

Seibert

1983,

Allen et al.

1985,

Miller

1986,

Cohen

1994):

•

Coronal-apically: the horizontal incision is made on

the palatal or lingual side of the defect and the plane

of dissection carried in an apical direction (Fig.

27-

76)

•

Apical-coronally: the horizontal incision is made

high in the vestibule near the mucobuccal fold and

the plane of dissection is carried coronally to the

crest of the ridge

•

Laterally: one or two vertical entrance incisions are

started from either side of the defect (Fig.

27-77).

The

plane of dissection is made laterally across the span

of the deformity.

Indication:

The technique is used to correct Class I

defects. Patients with large volume defects may have

thin palatal tissues which are insufficient to provide

the volume of the donor tissue necessary to fill the

deformity. In such cases, various procedures for hard

tissue augmentation may be selected (see Chapter

28).