cosmetic dentistry_ beauty & science

would usually occur. Even though this pink invasion was subtler compared with the reddish-blue of the alveolar mucosa invading the gingival, it neverthe- less broke the illusion of a symmetrical background. As a further example, overgrowth of tissue, i.e. fibrous hyperplasia, changes the shape of the tissue, thereby partially covering the tooth and changing the appearance of its size. If covered by hyperplastic keratinised gingiva, the tooth appears smaller, espe- cially when compared with the adjacent tooth. This overgrowth may be of developmental, iatrogenic or systemic origins. The result is unaesthetic. These can and should be corrected, which will be discussed in future parts of this series. In referring to cosmetic illusion using gingival colours, it is important to reflect on examples of non-symmetrical colour breaks of the gingiva. They represent an unhealthy situation and are an eyesore because they disrupt aesthetics. In a case of inflammation, permanent pathology may occur, resulting in irreversible unaesthetic root exposure (recession). A vertical reddish colour at the gingivalmarginmaywarnthatpathologyisstarting. Several techniques are reported to correct re- cession,butinreality,theresultisnotpredictablefor restoredhealth.Therefore,itispredictablyeasierand aesthetically more achievable to treat the inflam- mation earlier. Without a healthy zone of attached gingiva, a crown’s margin will become exposed, thus exhibitinganunattractivecontrastingcolour.Itmight be the underlying metal margin of the crown or the yellow colour of the recessed tooth’s root. Without a healthy zone, a laminate’s margin will probably collect plaque and lead to inflammation and bleeding gingiva. As mentioned previously, this can draw negative attention and most likely lead to recession and irregular gingival pattern variations. Part II of this series discusses and illustrates cos- metic periodontal surgery, utilising various gingival graft techniques to correct defects, obtain health, andproducecolour,huesandformsthatappeartobe symmetric. Thistypeofsurgerymakesforhappypatientswho smile with brilliant confidence. _Case I Ayoungwomanwasreferredtomyofficewithex- posed,unsightlylonger-lookingteeth.Theyappeared longer owing 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 pe- riodicallywhenbrushing,and complained about their un- attractive appearance, which made her stiffen her lower lip when smiling. She was intel- ligent and self-conscious of her problem. She desired to have the recession stopped and the aesthetics to smile with confidence. Examinationrevealedthat the lower right cuspid had recession (Fig. 1), showing an exposed buccal root. There was an absence of attached gingival,leavingtheareasur- rounded by alveolar mucosa. Therefore, the tooth was sur- rounded by reddish tissue, which made the root more visibly unattractive. The con- trast of deep red colour sur- rounding an exposed root was accentuated when the lip was retracted, showing a frenum pull. This made it dif- ficult for her to keep the area free of plaque. In contrast, adjacent teeth had pink at- tached gingiva. The surgical technique chosen to correct this defect,restoreherhealthandenhanceheraesthetics was a variation of the lateral oblique pedicle graft technique. Treatment The #28, 27 and 26 area was anesthetised using 0.001 % lidocaine. The local anaesthetic was infil- tratedlocallybothbuccallyandlingually.A#15blade was used to incise an outline, which included all the interproximal keratinised tissue of teeth #28 and 27, as well as the buccal aspect of #28. The poor, small buccal zone of tissue was removed from the #27 buccal area. The recipient site was then prepared. The tooth waslightlyscaled.Aperiodontalelevator(Hoexterel- evator, Hu-Friedy) was utilised to reflect the tissue. The incision also included the alveolar mucosal area, allowing ease of mobility. The graft flap was rotated so the largest portion of the keratinised area could I 11 case report _ periodontal surgery I cosmeticdentistry 4_2011 Fig. 4a Fig. 4b Fig. 3