Change Agents

It seems that the older we get, the less the laws of gravity apply to various parts of our bodies — including our gums. Our upper gumlines seem to recede ever upward, while our lower gumlines start to drop like the stock market on Black Monday. It’s as if our gums are trying to escape our teeth.

But gingival recession isn’t the only periodontal woe to befall humankind. At the other end of the spectrum is the gummy smile. Some of us are simply born with too much gum tissue or a lip line that reveals too much of it. And let’s be honest — few of us can pull off a pink smile.

Fortunately, treatments to improve the esthetics of patients experiencing these conditions have been constantly improving, since the 1950s, when the term “mucogingival surgery” was coined. The kinds of procedures encompassed by this treatment protocol under its more current heading of “periodontal plastic surgery” include crown-lengthening gingivectomies and crown-shortening bone and soft-tissue grafting.

In their early days, the primary goal of these procedures was oral health — with little regard for esthetics. Today, though these surgeries may provide therapeutic and restorative benefits, many are performed solely for improved esthetics — as a change agent for a beautiful smile.

ESTHETIC CONSIDERATIONS

Obviously, if periodontal plastic surgery is desired for esthetic reasons, it must be because a certain desired look is lacking. Fortunately, digital programs are now available that can assist clinicians in identifying the looks their patients covet. But, typical parameters used to determine whether a smile is attractive involve symmetry and balance — and a little objectivity mixed with subjectivity.

“Gingival contouring is both a science and an art,” explains Los Angeles-based periodontist Joan Otomo-Corgel, DDS, a past president of the American Academy of Periodontology (AAP). “Creating symmetry varies from patient to patient, and the underlying alveolar bone, gingiva, and periodontal ligament need thorough evaluation prior to ‘sculpting.’”

But, Otomo-Corgel adds, “Beauty is in the eye of the beholder, and clinicians need to understand their patients’ concerns, and why the procedure is being performed — in addition to biologic principles.”

Good esthetic planning considers all facial attributes, including the positioning of eyes, cheeks and lips. Additionally, how much gum tissue, including the papilla, is visible in relation to the lip line plays a role in esthetics. And just as color and characterizations must be built into dental restorations, the same is true with soft-tissue restorations.

AAP president-elect Steven R. Daniel, DDS, — who operates a periodontal and implant practice in Murfreesboro, Tennessee — says that, for him, taking in the big picture is important in this line of work. “Although I do not think of myself as an artist, being able to step back and look at the smile as a whole and not just one tooth at a time is essential to producing a result that maximizes esthetics and creates what we consider to be a pleasing smile.”


POINT OF SALE | THE LONG AND SHORT OF IT

  • Esthetics procedures will never go out of style.
  • Sales opportunities are bound to grow in connection to crown shortening, as more practices make use of grafting materials and armamentariums.
  • Both crown lengthening and crown shortening procedures can be used for therapeutic, restorative and esthetic reasons.

CROWN SHORTENING

Gingival recession is actually not a direct result of aging, though it is most often seen in older adults. It can be brought on over the years by numerous factors, which can range from periodontal disease to bruxism. When gums recede, the gumline is often left with uneven margins. Recession also exposes dentin and roots, making teeth appear extra long. Gum recession is not only unsightly, but it exposes vulnerable roots to the ravages of root caries; can result in tooth sensitivity; and can hasten bone degeneration.

Through gingival grafting, these issues can be corrected. Gum grafts rely on tissue taken from one of three sources: tissue may be harvested from the patient (autograft); from a cadaver (allograft); or from an animal source (xenograft). Some clinicians swear by the use of anything but an autograft to eliminate the need for a surgical site where the tissue is harvested. Others, however, feel that using the patient’s own tissue offers the best chance for success.

“I believe that autografts are the standard of care,” says Fairfield, Connecticut-based periodontist Michael Sonick, DMD, an international lecturer, author, and guest lecturer for the International Dental Program at New York University School of Dentistry in New York City. “Tissue taken from the hard palate typically offers the best results, although there is a limit as to how many teeth can be accommodated with that tissue.” 

Grafting involves placing donor tissue, usually from the hard palate, over the area of recession, and suturing it into place. Autograft techniques commonly employed in this procedure include the free gingival graft, subepithelial connective tissue graft, and the pedicle graft.

The pedicle graft involves the use of tissue adjacent to the area of recession. But instead of removing the tissue for replacement, one edge is left attached, where it continues to be nourished by blood. The resulting flap is then merely positioned to cover the area of recession and stitched into place.

Both the free graft and subepithelial connective tissue graft techniques commonly utilize autografts taken from the hard palate. The difference is that in the latter method, the graft is taken from underneath the epithelium. This tissue is then sutured under a second flap above the area of recession, over which it is repositioned. Although this technique requires the creation of two flaps, and the extra healing that entails, it is reportedly a much more esthetic method. This is because the graft tissue is hidden under native tissue for a nearly imperceptible repair. The free graft, on the other hand, results in a rather mismatched patch, as the hard palate — which is whiter in color than gum tissue — is simply sutured to the recessed area.

Daniel notes that scores of grafting techniques have seen the light of day through the years. “Among these is the increasing use of dermal substitutes, which reduce the need to use autografts and attendant flap creation,” he says, adding, “Additional techniques, such as tunneling, have been developed and introduced, which allow this procedure to be performed in as minimally invasive a way as possible.”

Sonick also mentions the tunnel, or pinhole, technique, though he cautions that it can be somewhat technique sensitive. It involves the creation of a passageway through the gingiva that spans across the tops of multiple teeth. Into this tunnel, subepithelial connective tissue grafts can be placed. The advantage over the flap is that tissue is not completely disconnected, so papillae can remain in place, tissue can remain vascularized, and multiple areas can be simultaneously treated.

According to Boston-based periodontist and AAP president Terrence J. Griffin, DMD,  “New incision designs and suture materials have made root coverage and gingival augmentation much more predictable.” And, like Daniel, he says, “New donor materials are revolutionizing grafting procedures by producing better esthetics, less pain, and less postoperative sequalae.”

CROWN LENGTHENING

Aside from genetics, excessive maxillary gingival display can also result from orthodontic issues, periodontal disease, hyperactive or short upper lips, skeletal or jaw abnormalities, or problems surrounding tooth eruption. Sometimes, the teeth themselves are simply too short due to trauma or wear.

As Sonick explains it, the lip line, while smiling or simply at rest, is a measure used to determine what is “normal.” Says Sonick, “A gingival display of more than 2 mm above a tooth margin when smiling is widely considered to be too much.” In fact, Sonick points to one study in which both orthodontists and laypeople considered 3 mm of gingival display above the tooth margin as unattractive.2

The periodontist’s answer to the “gummy smile” is esthetic crown lengthening. But this is not simply a matter of performing a gingivectomy.  In fact, says Otomo-Corgel, “Crown lengthening, if done precisely, may be one of the more complicated periodontal surgeries provided to our patients.”

Crown lengthening, which may also be used to expedite therapeutic and restorative procedures, as well as to enhance esthetics, removes excess gingival tissue and, sometimes, bone tissue. “In my experience this procedure has two components: reshaping of the soft tissue (gums) and alteration of the supporting bone,” says Daniel. “This is most often done with standard surgical instruments to gently reflect the tissue so that the bone can be evaluated. The contour and volume of the bone is adjusted, often with rotary instruments, so that adequate space is created for the soft tissue attachment of the gum to the root of the tooth. The length of the gum is adjusted and the tissue repositioned with small sutures.”

Daniel says that under certain circumstances this procedure can be successfully accomplished without elevating a flap. “Some doctors use a hard tissue laser to remove the excess bone followed by a recontouring of the gum,” he explains, adding, “This is a more technique-sensitive approach and can be used only if the bone to be removed is thin. The use of cone beam computed tomography imaging can allow the doctor to evaluate bone thickness prior to surgery to help decide if this approach is appropriate.”

Sonick says that he’s developed a two-stage technique to address both bone and tissue. “In the first stage,” he says, “I cut a flap and remove bone. Then I reposition the flap and allow the area to heal. Then I come back in with a laser for soft-tissue contouring. It’s a more precise way of performing this procedure, as swelling is no longer a complication.”

Griffin and others stress that gumline sculpting is based on scientific principles involved with the establishment of biologic width. This is the distance between the height of the gingiva and the crestal height of the alveolar bone, and normally measures approximately 3 mm. Griffin says, in certain cases, the tissue will rebound (fail to stay in place) if adequate biologic width is not established. “If the bone is too close to the cemento-enamel junction, the tissue will drift down to re-establish at a level 3 mm over the bone,” he explains. “You have to properly diagnose initially whether the problem is soft tissue or soft tissue and bone as well before the surgical procedure begins. Sometimes, the surgery involves treating the soft tissue or the bone and, at other times, both.”


GROWING TISSUES

ERSTUDIOSTOK/ISTOCK/GETTY IMAGES PLUS

Guided tissue regeneration is a strategy that some clinicians are using for augmentation of both soft and hard tissues. In this technique, biocompatible barriers are placed, often in conjunction with grafted tissues  or growth factors, to encourage predictable tissue regeneration, while helping to eliminate proliferation of pathogens. Commercially available barriers, typically made of materials such as collagen, are resorbable, so that it is not necessary to remove them. Instead, they can be left in place to guide tissues to regenerate, replacing lost tissue.

Growth factors are derived from patient blood draws, in which plasma is separated from red blood cells through centrifuging. The platelet-poor plasma is then pipetted off and set aside to find the platelet-rich plasma (PRP) that is located just above the white blood cells. This PRP concentrates the platelets, in which the growth factors in the blood are stored. The PRP can then be used with a membrane to help regenerate bone and soft tissue. Terrence J. Griffin, DMD, a Boston-based periodontist and president of the American Academy of Periodontology, has used this method as a way to avoid having to remove palatal tissue. Using platelet-rich protein derived from the patient, on a collagen sponge contained in a collagen membrane, he’s found that growth of not only naturally occurring gum tissue but also growth of new bone is stimulated.

Says Griffin, “Procedures like gingivectomy and osseous recontouring were primarily resective in the past, and they are now being replaced with reparative or regenerative procedures.”


ARMAMENTARIUM

Instrument selection for these types of surgeries, of course, depends on clinician preference, and can vary widely. While many clinicians still wield traditional scalpels for cutting tissue during periodontal plastic surgeries, many are starting to rely more on microsurgical instruments. Sonick, for example, utilizes a microsurgery blade for connective tissue grafting, along with elevators for gentle reflection. In fact, he sees microsurgical instruments and the use of magnification as critical to ensuring optimal success.

Daniel is also a proponent of microsurgical instruments, saying their use, along with biologic materials used in grafting, helps to speed healing of the soft tissues.

In addition to standard surgical tools such as suture materials, mirrors, scalpels, files and curets, some manufacturers may offer specialty instruments, such as premarked gauges, to help determine bone location and facilitate measurements of tooth proportions for crown lengthening procedures. For crown shortening, instruments designed for bone grafting and placement are available, as well as grafting materials themselves.

THEPALMER/VETTA/GETTY IMAGES PLUS

Electrosurgery units, lasers, burs and handpieces are commonly used in such procedures. Although, according to Griffin, some periodontists still prefer to use a series of chisels for bone removal and sculpting.

But these experts emphasize the importance of interprofessional communication, training and practice when undertaking these procedures. “The latest techniques have focused on minimally invasive procedures, microsurgical instrumentation, and alternatives to autogenous grafts,” says Otomo-Corgel. “However, techniques and technology should be applied with sound biologic principles and predictable outcomes that stand the test of time. The clinician should have the training to understand which techniques are applicable to individual situations and goals.”

After all, says Griffin, “The primary benefit of these procedures is to have a happy patient: one who is satisfied with the short- and long-term results of the surgery, and who can enjoy the symmetry of a nice smile bordered by healthy tissue.”

And with practiced change agents, well acquainted with the ups and downs of periodontal plastic surgery, the dream of an ideal smile can easily become a reality for many.

Featured photo by VIKAVALTER/VETTA/GETTY IMAGES PLUS

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REFERENCES

  1. Kranz R, Gwosdow A. Recovering from recession — with far less pain. Massachusetts Society for Medical Research. Available at: whatayear.org/05_10.php. Accessed May 3, 2017.
  2. Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons to altered dental esthetics: asymmetric and symmetric situations. Am J Orthod Dentofacial Orthop. 2006;130:141—151.

From MENTOR. June 2017;8(6):32-36.

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