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Dental Tribune U.S. Edition | February 2012 XXXXXXX ” See EMERGENCY page A4 Ad Dental Tribune U.S. Edition | November 2012A4 achieve this symmetry and health. Sev- eral have been mentioned and described in this series. It must be stressed that it is the final goal that we should keep domi- nant in our sights — more so than any particular technique being used. The nu- merous techniques simply represent the various the paths to get there. When we do not have enough keratin- ized gingiva, we can try to increase it. When we have too much (hyperplasia), we can remove it. If the color is not the desired color, we can change it. There are many techniques available to achieve the desired goal. The question of how much vertical kera- tinized attached gingiva is necessary has been discussed for years. The amount, if adequate, should be symmetrical to allow emphasis of the smile of the teeth, color and form that we wish to emphasize. But too often overlooked is the horizontal aspect of the keratinized background. It should be symmetrical in width and height to provide a background that not only demonstrates health but enables our esthetic goal to be achieved — and main- tained. This case presentation will emphasize and demonstrate a team effort, in which I use several cosmetic periodontal surgical techniques, the skills of a very talented restorative dentist to visualize and then attain the patient’s esthetic desires — as well as the patient herself, who is now able to maintain a healthy, attractive smile. Case presentation Mrs. S, a 62-year-old female, was referred to my office by an excellent cosmetic re- storative dentist. (He has been awarded a fellowship in the International Academy for Dental Facial Esthetics.) Because of his exposure to different directives of treat- ment, including periodontal background options and the required cosmetic peri- odontal surgical techniques that would be necessary, he referred Mrs. S to my of- fice. Mrs. S is a positive, cooperative, strong- ly opinionated woman. At her initial visit, she presented (Fig. 1) with a myriad of goals, all boiling down to the fact that she desired a bright, glowing smile. She em- phatically did not wish to treat to cover her anterior maxillary centrals. She liked the length of her centrals. Her strongest desires were to correct the unevenness and the mélange of different colors ap- pearing when she smiled. Obvious were the crowns with their exposed dark ap- pearing margins, as well as the darker col- oring of her natural teeth. Through consultation, Mrs. S and I for- mulated a treatment plan: Initial peri- odontal therapy consisted of nonsurgical therapy, including scaling, curettage and oral hygiene instruction. The next step was replacing the exist- ing crown with physiological provision- als. Periodontal surgical techniques fol- lowed. Using the upper-right (UR) area as an example, we noted the uneven level of attached gingiva as well as periodon- tal pockets. I surgically manipulated the amount of keritenized gingiva and its placement vertically, in order to preserve the size of the zone of attached gingival needed to ensure harmonious blending with the rest of the tissue mesiodistally. The crown lengthening was basic, but the size — vertically and horizontally of the desired colored attached gingiva — was paramount to the final result (Figs. 4 and 5). Letting the healing take its normal course with patience was next. However, we reinforced the need for constant oral hygiene — with supervised check-ups. When the proper healing was complet- ed, the area was re-prepped and the pro- visionals were extended on the recently clinically exposed roots towards the gin- gival. This technique was done on all of her posterior sections. It was paramount to emphasize the preservation of the verti- cal and horizontal size of the attached gingiva, not only to create a healthy back- ground for the desired smile — but to en- sure a symmetrical, cosmetically appeal- ing background. Teeth may not be even, but the illusion of a smooth, glowing smile can still be portrayed. Success depends on the team- work put into place by knowledgeable colleagues and the esthetic experiences they bring — blended with the patient’s cooperation. The final restorations were completed with full-coverage crowns on the poste- riors. The anteriors were restored using porcelain laminates. The vertical dimension, enhanced by a smooth, linear appearance and aided by the symmetrical background achieved through cosmetic periodontal surgery, enables the smile to be maintained and turned this patient’s mouth into a glow- ing smile. The author wishes to acknowledge the imaginative cosmetic and restorative den- tistry seen in this case by Jerry Herman, DDS, New York, N.Y. Editorial Note: Part 1 appeared in Dental Tribune U.S., Vol. 4, No. 13 & 14, and Part 2 in Vol. 6, No. 17. “ SYMMETRY, page A3 DAvID L. HoExtEr, DMD, FICD, FACD is director of the Inter- national Academy for Dental Facial Es- thetics, and a clinical professor in peri- odontics at Temple University, Philadel- phia. He is a diplo- mate of implantolo- gy in the International Congress of Oral Implantologists as well as the American Society of Osseointegration, and a diplomate of the American Board of Aesthetic Dentistry. Hoexter lectures throughout the world and has pub- lished nationally and internationally. He has been awarded 11 fellowships, including FACD, FICD and Pierre Fauchard. He maintains a prac- tice at 654 Madison Ave., New York City, limited to periodontics, implantology and esthetic sur- gery. He can be reached at (212) 355-0004 or drdavidlh@gmail.com. CLINICAL