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Dental Tribune U.S. Edition

Clinical DENTAL TRIBUNE | November 20116A of attached gingival were unevenly distributed in the same quadrant, the reddish blue alveolar mucosa would be out of place and draw negative attention. In contrast, if the attached gingiva locally encroaches on the alve- olar mucosa, a color reversal would occur, resulting in a large, uneven pink zone against an uneven reddish- blue background. In the past, oversized free gingival grafts have frequently been used to replace absent or inadequate zones of attached gingival. Those large donor grafts were protective but had an unaesthetic appearance; an encroach- ment of colors into the alveolar muco- sa would usually occur. Even though this pink invasion was subtler com- pared with the reddish-blue of the alveolar mucosa invading the gingival, it nevertheless broke the background symmetrical illusion. As a further example, overgrowth of tissue, i.e., fibrous hyperplasia, chang- es the shape of the tissue, thereby par- tially covering the tooth and changing the appearance of its size. If covered by hyperplastic keratinized gingiva, the tooth appears smaller, especially when compared with the adjacent tooth. This overgrowth may be of develop- mental, iatrogenic or systemic origins. The result is unaesthetic. These can and should be corrected, which will be discussed in future parts of this series. When referring to cosmetic illusion using gingival colors, it is important to reflect on examples of nonsymmetri- cal color breaks of the gingiva. They represent an unhealthy situation and are an eyesore because they disrupt esthetics. In a case of inflammation, perma- nent pathology may occur, resulting in irreversible unaesthetic root exposure (recession). A vertical reddish color at the gingival margin may warn that pathology is starting. Several techniques are reported to correct recession, but in reality, the result is not predictable for restored health. Therefore, it is predictably easier and aesthetically more achiev- able to treat the inflammation earlier. Without a healthy zone of attached gingiva, a crown’s margin will become exposed, thus exhibiting an unattract- ive contrasting color. It might be the underlying metal margin of the crown or the yellow color of the recessed tooth’s root. Without a healthy zone, a lami- nate’s margin will probably collect plaque and lead to inflammation and bleeding gingiva. As mentioned previ- ously, this can draw negative attention and most likely lead to recession and an irregular gingival pattern variations Part two of this series discusses and illustrates cosmetic periodontal surgery, utilizing various gingival graft techniques to correct defects, obtain health, and produce symmetrically appearing color, hues and form. This type of surgery is an ideal tool for making happy patients who smile with brilliant confidence. Case presentation A young woman was referred to my office with exposed, unsightly longer- looking teeth. They appeared longer due to her receding “gums.” Although the patient had a low caries rate and a good oral hygiene technique, she had been told by a previous dentist that she had weak and ugly gums. She noted that her gums bled periodically when brushing, and complained about their unattractive appearance, which made her stiffen her lower lip when smiling. She was intelligent and self-conscious- ly aware of her problem. She desired to have the recession stopped and the aesthetics to smile with confidence. Examination revealed that the lower right cuspid had recession (Fig. 1), showing an exposed buccal root. There was an absence of attached gingival, leaving the area surrounded by alveolar mucosa. Therefore, the tooth was surrounded by reddish tis- sue, which made the root more visibly unattractive. The contrast of deep red color surrounding an exposed root was accentuated when the lip was retracted, showing a frenum pull. This made it difficult for her to keep the area free of plaque. In contrast, adja- cent teeth had pink attached gingiva. The surgical technique chosen to correct this defect, restore her health, and enhance her aesthetics was a variation of the lateral oblique pedicle graft technique. Case No. 1: Treatment The LR Nos. 28, 27 and 26 area was anesthetized using lidocaine 1:100,000. The local anesthetic was infiltrated locally both buccal and lingual. A No. 15 blade was used to incise an outline, which included all the interproximal keratinized tissue of Nos. 28 and 27 as well as the buccal of No. 28. The poor, small buccal zone of tissue was removed from the No. 27 buccal area. The recipient site was then pre- pared. The tooth was lightly scaled. A periodontal elevator (Hoexter elevator by Hu-friedy) was utilized to reflect the tissue. The incision also included into the alveolar mucosal area, allowing ease of mobility. The graft flap was rotated so the largest portion of the keratinized area could be employed to cover the recessed area and the newly exposed recipient buccal blood supply of No. 27. To stabilize the graft in our desired position, a sling-type suturing technique was utilized. The area was covered with a periodontal dressing (Coe Pak). Tetracycline 250 mg was prescribed qid for seven days. An anal- gesic was also prescribed. The results present an obviously healthy and restored symmetrical, pink zone of attached gingival and continuity with the adjacent area. The recession was gone, the length and width of the attached gingival was symmetrically blended with the adja- cent area, and the frenum-pull was corrected. Figure 2, taken 15 years postoperatively, attests to the durabil- ity of the results using this technique. The result enabled the patient to smile with confidence, without hesi- tation; she no longer had the reflex- ive action of holding her lip back. The procedures also permitted her to maintain good oral hygiene, made her feel that she was keeping her teeth (recession indicates age to some), and achieved a maintainable, normal color balance, which collectively created an aesthetically pleasing appearance. Case No. 2 Predictability of results of root reces- sion coverage has been improved in recent years with the utilization of Guided Tissue Regeneration (GTR). This case demonstrates another gingival graft technique: the coronal repositioned gingival graft. It uses guided tissue regeneration using an acellular collagen membrane, which adds to the predictability of acquiring a blood supply. The resultant zone of attached gingival and root cover- age blend aesthetically into the back- ground with a symmetrical width and lateral flow of healthy, pink keratin- ized tissue. Viewing the initial appearance of #11, it displays the longer-appearing cuspid with recession (Fig. 3), which makes it stand out and causes the area to be unattractive and noticeable. Figures 4a and b show the acellular membrane placed over the exposed buccal root of No. 11, after the buccal flap is reflected. The tissue is sutured with a continuous suture covering the exposed root in the desired final posi- tion and the acellular membrane (Fig. 5). Figure 6 shows the healed area four months later. The recession is now reclaimed by a healthy attached gingival zone. The acellular colla- gen preferred in this technique in my office is supplied by CK Dental. The results allow a symmetrical appear- ing zone of pink, keratinized tissue to blend in the area. The cuspid is no longer “long in the tooth.” The linear, even shape of the teeth is aesthetically pleasing. The overall result is easily maintained by the background of cor- rect color, texture, and symmetrical zone of appearance and health. Now the restoring of the #10 incisal edge will have options toward the desired appearance. Summary Fortunately, in these particular cases, the patients’ dental awareness made it possible for them to request correction of their oral health and aesthetics. These illustrations demonstrate the aesthetic awareness and desires of today’s society. Practitioners must be able to recognize and work toward these goals. By creatively using varia- tions of techniques to achieve such results, the art of dentistry is recov- ered. Achieving health is primary, but providing a maintainable, healthy and pleasing appearance is also signifi- cantly desirable and important. DT Editorial Note: Part 1 appeared in Dental Tribune U.S., Vol. 4, No. 13 & 14 f DT page 5A About the author Dr. David L. Hoexter is direc- tor of the International Academy for Dental Facial Esthetics, and a clinical professor in periodon- tics at Temple University, Phila- delphia. He is a diplomate of implantology in the International Congress of Oral Implantologists as well as the American Society of Osseointegration, and a dip- lomate of the American Board of Aesthetic Dentistry. Hoexter lectures throughout the world and has published nationally and internationally. He has been awarded 11 fellowships, including FACD, FICD and Pierre Fauchard. He maintains a practice at 654 Madison Ave., New York City, limited to periodontics, implantology and esthetic surgery. He can be reached at (212) 355-0004 or drdavidlh@aol.com. Fig. 3 Fig. 4a Fig. 4b Fig. 5 Fig. 6