114. Esthetics: 4. pontic sites, papillas, non carious cervical lesions and esthetic crown lengthening

Rapid Search Terms:

Non-carious cervical lesions, restorations and root coverage
Microsurgery in soft tissue augmentation
Pontic site development / Soft tissue ridge augmentation
Papillae Characteristics around implants and teeth
Esthetic Crown Lengthening
Altered passive eruption
Vertical maxillary excess

Study Questions:

How is root coverage affected by non-carious cervical lesions?
How is root coverage affected by existing restorations?
What might you need to do with an existing restoration?
What should you discuss with your restoring dentist (if the restoration has not been placed yet)?
What are some classifications for papilla height/contour?
What anatomic features are we concerned with when trying to predict papilla height?
How might those factors affect our treatment plans?
What are some techniques to try to reconstruct the papilla? How predictable is this?
How is management of the papilla around implants different than around teeth?
How might papillary reconstruction affect the prosthetic treatment plan?
How does esthetic crown lengthening differ from functional crown lengthening?
What treatment parameters must be considered prior to surgery?
What is vertical maxillary excess? Are there different degrees?
What is altered passive eruption? Are there different types?
What information about the final restoration is needed to correctly plan?
Are there differences if restorations are involved? When is periodontal treatment not enough?

References:

(References without links have not been added yet)

Non-carious cervical lesions, Restorations and root coverage
1. Santamaria M et al. Coronally positioned flap plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesions: A randomized controlled clinical trial. J Periodontol 2008 Apr; 79(4):621-8
2. Santamaria MP1, da Silva Feitosa D, Casati MZ, Nociti FH Jr, Sallum AW, Sallum EA. Randomized controlled clinical trial evaluating connective tissue graft plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesion: 2-year follow-up. J Periodontol. 2013 Sep; 84(9):e1-8.
3. Zucchelli G1, Gori G, Mele M, Stefanini M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Non-carious cervical lesions associated with gingival recessions: a decision-making process. J Periodontol. 2011 Dec; 82(12):1713-24.
4. Lucchesi JA, Santos VR, Amaral CM, Peruzzo DC, Duarte PM. Coronally positioned flap for treatment of restored root surfaces: a 6-month clinical evaluation. J Periodontol. Apr; 78(4):615-23. 2007
Microsurgery in soft tissue augmentation
1. Francetti L eta L. Microsurgical treatment of gingival recession: A controlled clinical study. Int J Periodontics Restorative Dent. 2005 Apr; 25(2):181-8
2. Bittencourt S, et al. Surgical microscope may enhance root coverage with subepithelial connective tissue graft: a randomized-controlled clinical trial. J Periodontol. 2012 Jun;83(6):721-30
Pontic site development / Soft tissue ridge augmentation
1. Seibert JS: Reconstruction of deformed partially edentulous ridges, using full thickness onlay grafts: Part I. Technique and wound healing. Compend Cont Educ Dent 4:437 -453, 1983
2. Seibert JS: Reconstruction of deformed partially edentulous ridges, using full thickness onlay grafts: Part II. Prosthetic/periodontal interrelationships. Compend Cont Educ Dent 4: 549 – 562, 1983
3. Seibert J, Cohen D. Periodontal considerations in preparation for fixed and removable prosthodontics. Dent Clin North Am 1987;31(3):529-555
4. Seibert JS, Louis JV. Soft tissue ridge augmentation utilizing a combination onlay-interpositional graft procedure – A case report. Int J Perio Rest Dent 16:311-321,1996
5. Langer B, Calgna L. The subepithelial connective tissue graft. J Prosthet Dent 1980; 44(4):363-367
6. Langer B, Calagna L. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent 1982; 2 (2): 23-30
7. Orth C. A modification of the connective tissue graft procedure for the treatment of type II and type III ridge deformities. Int J Periodontics Restorative Dent 1996; 16(3):267-278
8. Harris R. Soft tissue ridge augmentation with an acellular dermal matrix. Int J Periodontics Restorative Dent 2003; 23(1):87-92
9. Abrams L. Augmentation of the deformed edentulous ridge for fixed prosthesis. Compend Contin Educ Dent 1980; 1 (3):205 – 214
10. Scharf D. Tarnow: Modified roll technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent 1992; 12(5):415-425
11. Seibert J., Salama H. Alveolar ridge preservation and reconstruction. Periodontl 2000; 1996; 11:69-84
12. Allen EP. Use of mucogingival surgical procedures to enhance esthetics. Dent Clin North Am 1988:32(2):307-330
13. Akcali A, et al. Soft tissue augmentation of ridge defects in the maxillary anterior area using two different methods: a randomized controlled clinical trial. Clin Oral Implants Res. 2014 Apr 10.
14. Gluckman H., Salama M. The Pontic-Shield: Partial Extraction Therapy for Ridge Preservation and Pontic Site Development Int J Periodontics Restorative Dent May-Jun 2016; 36(3):417-23.
Papillae Characteristics around implants and teeth
1. Jemt, T. Regeneration of gingival papillae after single-implant treatment. International Journal of Periodontics and Restorative Dentistry 1997 (17) , 326 –333
2. Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 69:1124-1126, 1998.
3. Takei H, Yamada H, Hua T. Maxillary anterior esthetics: Preservation of the interdental papilla. Dent. Clin. North Am. 33(2): 1989
4. Tarnow DP et al. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992 Dec; 63(12):995-6.
5. Azzi R, Etienne D, Carranza F. Surgical reconstruction of the interdental papilla. Int J Perio Rest Dent 18:466-473, 1998.
6. Blatz MB, Hürzeler MB, Strub JR. Reconstruction of the lost interproximal papilla–presentation of surgical and nonsurgical approaches. Int J Periodontics Restorative Dent. Aug; 19(4):395-406. 1999 Review.
7. Tarnow, D et al: The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontal 71:546-549, 2000 (from LR 161)
8. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol. 2001 Oct; 72(10):1364-71.
9. Salama H, Salama MA, et al. The Interproximal height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement. 2003 update of 1998 Pract Periodontics Aesthet Dent (saved on T drive)
10. Kan JY1, Rungcharassaeng K. Interimplant papilla preservation in the esthetic zone: a report of six consecutive cases. Int J Periodontics Restorative Dent. 2003 Jun; 23(3):249-59.
11. Tarnow D et al: Vertical Distance from the Crest of Bone to the Height of the Interproximal Papilla. J Periodontal 2004; 75:1242-1246 (from 161)
12. Pini Prato GP1, Rotundo R, Cortellini P, Tinti C, Azzi R. Interdental papilla management: a review and classification of the therapeutic approaches. Int J Periodontics Restorative Dent. 2004 Jun; 24(3):246-55.
13. Zetu, L., Wang. H-L: Management of inter-dental / inter –implant papilla. J Clin Peridotnol 2005; 32:831-839 (from LR 161)
14. McGuire MK, Scheyer ET. A randomized, double-blind, placebo-controlled study to determine the safety and efficacy of cultured and expanded autologous fibroblast injections for the treatment of interdental papillary insufficiency associated with the papilla priming procedure. J Periodontol. Jan; 78(1):4-17. 2007
15. Chow ; YC, Wang HL. Factors and techniques influencing peri-implant papillae. Implant Dent. 2010 Jun; 19(3):208-19. (saved on T drive)
16. Becker W, Gabitov I, Stepanov M, Kois J, Smidt A, Becker BE. Minimally invasive treatment for papillae deficiencies in the esthetic zone: a pilot study. Clin Implant Dent Relat Res. 2010 Mar; 12(1):1-8.
17. Froum S, Lagoudis M, Rojas GM, Suzuki T, Cho SC. New Surgical Protocol to Create Interimplant Papilla: The Preliminary Results of a Case Series. Int J Periodontics Restorative Dent. 2016 Mar-Apr; 36(2):161-8
18. Goiato MC, de Medeiros RA2, da Silva EVF2, Dos Santos DM2. Evaluation of the papilla level adjacent to implants placed in fresh, healing or healed sites: A systematic review. Int J Oral Maxillofac Surg. 2017 May 15
Esthetic Crown Lengthening
1. Garber DA1, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000. 1996 Jun; 11:18-28
2. Magne P, Gallucci GO, Belser UC. Anatomic crown width/length ratios of unworn and worn maxillary teeth in white subjects. J Prosthet Dent. 2003 May; 89(5):453-61.
3. Silberberg N, Goldstein M, Smidt A. Excessive gingival display–etiology, diagnosis, and treatment modalities. Quintessence Int. 2009 Nov-Dec; 40(10):809-18.
4. Chu SJ1, Tan JH, Stappert CF, Tarnow DP. Gingival zenith positions and levels of the maxillary anterior dentition. J Esthet Restor Dent. 2009; 21(2):113-20.
5. Deas DE1, Moritz AJ, McDonnell HT, Powell CA, Mealey BL. Osseous surgery for crown lengthening: a 6-month clinical study. J Periodontol. 2004 Sep;75(9):1288-94.
6. Lanning SK, Waldrop TC, Gunsolley JC, Maynard JG. Surgical crown lengthening: evaluation of the biological width. J Periodontol. 2003 Apr;74(4):468-74.
7. Brägger U, Lauchenauer D, Lang NP. Surgical lengthening of the clinical crown. J Clin Periodontol. 1992 Jan;19(1):58-63
8. Fletcher P. Biologic rationale of esthetic crown lengthening using innovative proportion gauges. Int J Periodontics Restorative Dent. 2011 Sep-Oct;31(5):523-32
9. Batista EL Jr1, Moreira CC, Batista FC, de Oliveira RR, Pereira KK. Altered passive eruption diagnosis and treatment: a cone beam computed tomography-based reappraisal of the condition. J Clin Periodontol. 2012 Nov; 39(11):1089-96.
10. Schmidt JC1, Sahrmann P, Weiger R, Schmidlin PR, Walter C. Biologic width dimensions–a systematic review. J Clin Periodontol. 2013 May; 40(5):493-504.
11. Deas DE, Mackey SA, Sagun RS Jr, Hancock RH, Gruwell SF, Campbell CM. Crown lengthening in the maxillary anterior region: a 6-month prospective clinical study. Int J Periodontics Restorative Dent. 2014 May-Jun; 34(3):365-73
12. Tawfik O et al. Lip Repositioning With or Without Myotomy: A Randomized Clinical Trial J Periodontol 2018 Jul; 89(7):815-823.
13. Dym,H, Diagnosis and Treatment Approaches to a “Gummy Smile” Dent Clin North Am 2020 Apr;64(2):341-349.

Abstracts:

Non-carious cervical lesions, Restorations and root coverage

Topic: Non-carious cervical lesions, Restorations and root coverage

Authors: Santamaria M et al

Title: Coronally positioned flap plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesions: A randomized controlled clinical trial.

Source: J Periodontol 2008 Apr; 79(4):621-8

Type: Clinical

Keywords: Cemento-enamel junction; gingival recession/surgery; glass ionomer cement; randomized controlled clinical trials; surgical flap; tooth abrasion.

Purpose: To evaluate the treatment of recession associated with non-carious cervical lesions by a CPF or in combination with a resin-modified glass ionomer (RMGI).

Method: 19 patients with bilateral class I buccal recessions associated with non-carious cervical lesions were selected. Recession defects were randomly selected to receive either a CPF or a CPF with a RMGI. BOP, PD, Recession, CAL, non-carious lesion height, and dentin sensitivity were measured at baseline, 45 days and 2,3,6 months postop.

Results: Both groups showed SS gains in CAL and soft tissue coverage. The difference between the groups were NSSD for BOP, PD, CAL and keratinized thickness at 6 months. The % of original lesion coverage was 56% for the CPF plus RMGI and 59% for CPF alone (NSSD). The estimated root coverage for CPF plus RMGI was 88%, and for CPF was 97%. There was a more decrease in sensitivity with the CPF plus RMGI group compared to CPF.

Conclusion: Both procedures produced similar results at 6 months. There was a more reduction in sensitivity when a RMGI was used.

Topic: Connective tissue grafting

Authors: Santamaria MP1, da Silva Feitosa D, Casati MZ, Nociti FH Jr, Sallum AW, Sallum EA. Title: Randomized controlled clinical trial evaluating connective tissue graft plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesion: 2-year follow-up.

Source: DL J Periodontol. 2013 Sep; 84(9):e1-8.

Type: RCT

Keywords: Dental esthetics; dental restoration; permanent; gingival recession; glass ionomer cements; tooth abrasion; tooth cervix

Purpose: To evaluate 2-year term results of gingival recession associated with non-carious cervical lesions (NCCLs) treated by connective tissue graft (CTG) alone or in combination with a resin-modified glass ionomer restoration (CTG+GI).

Methods and Materials: Thirty-six patients with Miller Class I buccal recession defects associated with NCCLs. The defects were randomly assigned to receive either CTG or CTG+GI. BOP, PD, recession level (measured as the distance from the gingival margin to the incisal border of the tooth), clinical attachment level, and cervical lesion height coverage were measured at baseline, 6 months, 1 year, and 2 years after treatment. The depth of the NCCL was measured as the distance between the pulpal wall and coronal margin of the NCCL using an endodontic spreader perpendicular to a midpoint location of the lesion.

Results: Both groups showed statistically significant gains in CAL and soft-tissue coverage. The differences between groups were not statistically significant in BOP, PD, recession level, or CAL after 2 years. Cervical lesion height coverage was 79.31% +/- 18.51% for CTG and 71.95% +/- 13.25% for CTG+GI. Estimated root coverage was 91.56% +/- 11.74% for CTG and 93.29% +/- 7.97% for CTG+GI.

Conclusions: Within the limits of the present study, it can be concluded that both procedures provide comparable soft tissue coverage with and without the presence of resin-modified glass ionomer

Topic: Root Coverage

Authors: Zucchelli G et al

Title: Non-carious cervical lesions associated with gingival recessions: a decision-making process.

Source: J Periodontol. 2011 Dec; 82(12):1713-24.

Type: Clinical Study

Keywords: Cemento-enamel junction; gingival recession; surgery

Background: A method to predetermine the maximum root coverage level (MRC) was recently demonstrated to be reliable in predicting the position of the soft tissue margin after root coverage surgery.

Purpose: To suggest a decision-making process for treating non-carious cervical lesions (NCCLs) associated with gingival recessions based upon the topographic relationship between the MRC and NCCL and to assess patient and independent-periodontist esthetic evaluations.

Methods: Five treatments were performed in 94 patients with NCCLs associated with a single gingival recession:

1) coronally advanced flap (CAF);

2) bilaminar procedure;

3) coronal odontoplasty plus restoration plus root odontoplasty plus CAF;

4) restoration plus CAF; and

5) restorative therapy.

Clinical and esthetic evaluations made by the patient and an independent periodontist were done 1 year after treatments.

Results: The satisfaction of the patient and periodontist with esthetics was very high in all NCCL treatments and Miller Class gingival recessions. The patient satisfaction and evaluation of root coverage and the periodontist evaluation of root coverage were statistically correlated with color-match evaluations and not with the amount of root coverage clinically achieved in each patient.

For Periodontist, root coverage evals- VAS > 80

1) coronally advanced flap (CAF); 14/15 =93%

2) bilaminar procedure; 16/18 -88%

3) coronal odontoplasty plus restoration plus root odontoplasty plus CAF; 22/27 = 82%

4) restoration plus CAF; 14/19 = 74%

5) restorative therapy. 9/15 = 60%

Conclusion: The proposed approaches provided good esthetic appearance and correct emergence profile for the great majority of NCCLs associated with gingival recessions.

Topic: non-carious cervical lesions

Authors: Lucchesi JA, Santos VR, Amaral CM, Peruzzo DC, Duarte PM.

Title: Coronally positioned flap for treatment of restored root surfaces: a 6-month clinical evaluation.

Source: J Periodontol. Apr; 78(4):615-23. 2007

Type: clinical

Keywords: Flap; glass ionomer; resin.

Purpose: To evaluate clinically the treatment of gingival recession associated with non-carious cervical lesions “NCCL” (abrasion, abfraction or erosion) by resin modified glass ionomer cement or microfilled resin composite (MCR) plus coronally positioned flap at 6 months following surgery.

Methods: 59 healthy patients= 39 patients miller class 1 + NCCL , 20 patients miller class 1 + no NCCL

- - 3 groups:

o Group 1(control): root exposure without NCCL treated with a CPF,

o Groups 2: root exposure with NCCL treated with RMGI (resin modified glass ionomer) plus a CPF

o Group 3: root exposure with NCCL treated with MRC (microfilled resin composite) restoration plus CPF.

- - PI, BOP, PD, recession reduction, CAL, keratinized tissue height, keratinized tissue thickness, percentage of root coverage, percentage of restored root coverage were all measured at baseline, 3 and 6 months. Acrylic stents were made to take the measurements.

Results: Mean root coverage at 6 months was 80.83% for group 1, 71.99% for group 2 and 74.18% for group 3. No SSD between any of the groups at any time.

Conclusion: All treatments showed root coverage improvement without damage to the periodontal tissue, supporting the use of CPF for treatment of root surfaces restored with RMGI or MRC as being effective over a 6-month period.

Microsurgery in soft tissue augmentation

Topic: Soft tissue augmentation

Author: Francetti L eta L

Title: Microsurgical treatment of gingival recession: A controlled clinical study

Source: J Periodontics Restorative Dent. 2005 Apr; 25(2):181-8

Type: Randomized controlled clinical trial

Keywords: Gingival recession; microsurgical techniques; clinical study

Purpose: to verify whether the use of a surgical microscope in the treatment of gingival recession could improve the outcome in terms of root coverage and final tissue appearance in esthetic area compared with traditional periodontal surgery

Methods:

- - 24 cases of gingival recession were treated.
  - Criteria: 1) Buccal recession (2-5mm) in the esthetic area. 2) No loss of interdental bone or soft tissue (Miller class I and II). 3) Good plaque control.
  - 12 procedures were performed with the aid of a surgical microscope (test group), whereas the other 12 pts were treated without the microscope (control group).
  - 2 weeks after OHI phase, the following variables were measured: recession depth (REC), PD, CAL, and KG at baseline and 12 months following surgery. Pictures were taken pre and 12 months post-op.
  - Test group– minimally invasive surgical technique with a surgical stereomicroscope and microsurgical instruments.

o The following treatment were preformed: 6 CAF + CTG/ 1 CAF + GTR/ 4 CAF + CTG + EMD, and 1 semilunar flap.

- - Control group- conventional instruments were used w/o surgical microscope.

o The following treatment were preformed: 9 CAF + CTG, 1 CAF + GTR and 2 CAF.

- - Post-op: 7 and 15 days, then 1, 4, 7, 10, and at 12 months REC, PD, CAL, KG were measured.
  - 3 examiners separately evaluated pre and post-op pictures of the final cases on a scale from 1-3 (1=unsatisfactory, 2=good, 3=excellent), focusing on esthetic parameters (scarring, gingival margin, and papillae appearance).

Results:

- - All parameters were improved from baseline to 12 mouths in both groups, except NSSD in PD.
  - Mean defect coverage at 12 months was 86% (test) and 78% (control), NSSD (P=.330) mainly because of the low number of cases.
  - Complete coverage was 58.3% (test) and 33.4% (control), with a residual recession ranging between 0 and 1 mm.
  - Qualitative esthetic evaluation showed

o 1) High concurrence among examiners

o 2) Significantly better scarring and marginal profile in the test group

o 3) NSSD in papillae appearance.

Conclusion: Pt who underwent microsurgery had better results in terms of both success and predictability compared to those treated by conventional surgery. Further investigations with a larger sample size are needed. Traditional surgery should be limited to areas of less esthetic importance, such as the mandibular anterior or posterior region.

The difference between groups for residual recession was less than 1 mm and was deemed not to be statistically significant.

Topic: Microsurgery in soft tissue augmentation

Author: Bittencourt S, et al.

Title: Surgical microscope may enhance root coverage with subepithelial connective tissue graft: a randomized-controlled clinical trial.

Source: J Periodontol. 2012 Jun;83(6):721-30

Type: Clinical trial

Keywords: Clinical trial, connective tissue, gingival recession, microscopy, split-mouth design, surgical flap

Purpose: To compare root coverage, postoperative morbidity, and esthetic outcomes of the subepithelial connective tissue graft (SCTG) technique with or without the use of a surgical microscope in the treatment of Miller Class I and II gingival recessions.

Methods: 24 patients were included in this split mouth study with bilateral Miller Class I and II recessions in maxillary canines or premolars, probing depths of <3 mm without bleeding on probing, tooth vitality, and absence of caries/restorations in the areas to be treated. Initial therapy was completed and clinical parameters (recession height, distance from CEJ to the gingival margin, recession width, probing depth, clinical attachment level, thickness of keratinized tissue) taken at baseline, 6, and 12 months post-surgery. Thickness of keratinized tissue was measured 2 mm apical to the gingival margin before surgery and after surgery. During the surgical treatment, two treatment groups were used: test group, where SCTG was performed with a microscope at x8 and x12 magnification and control group, in which SCTG was performed without any type of magnification. At 6 months, a questionnaire was given to patients to record the procedures relative to esthetics, root sensitivity before and after surgery, and the postoperative period.

Results: Healing was uneventful in all patients. At 12 months, root coverage was 98% for the test group and 88.3% for the control group. Complete root coverage was 87.5% in the test group and 58.3% in the control group at 12 months. The mean time spent in surgery was 60 minutes for the test procedure and 54 minutes in the control group. Post-operative pain was similar between groups. 100% of patients were satisfied with the esthetics from the test group, while only 79.1% in the control group were satisfied. Three patients in the control group continued to complain about hypersensitivity, whereas none in the test group had any hypersensitivity.

Conclusion: Both approaches are capable of producing root coverage; however, the use of the surgical microscope is associated with additional clinical benefits in the treatment of teeth with gingival recessions.

Pontic site development / Soft tissue ridge augmentation

Topic: Onlay graft
Author: Seibert JS
Title: Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part 1: technique and wound healing
Source: Compendium of Continuing Education 1983; 4(5): 437-453
Type: Discussion
Keywords: ridge defect, surgical techniques, wound healing, edentulous ridge, reconstruction, onlay graft

Purpose: To describe the principles, surgical techniques, wound healing, and prosthetic procedures involved in reconstructing deformed edentulous ridges with full thickness onlay grafts.

Discussion:

Ridge Classification:

- - Class I: Bucco-lingual loss of tissue with normal ridge height in an apico-coronal dimension
  - Class II: Apico-coronal loss of tissue with normal ridge width in a bucco-lingual dimension
  - Class III: Bucco-lingual and apico-coronal loss of tissue resulting in loss of normal height and width

Rationale for Full Thickness Onlay Graft:

- - Very predictable for augmenting the zone of attached gingiva.
  - For class 1 ridges, standard graft procedures call for preparing the recipient site down to the periosteum and removal of any “loose” tissue.
  - For class 2 or 3 ridges, modifications are needed to preserve connective tissue.
  - The conventional FGG measures 0.75 – 1.25mm thick. Nutrients are diffused by plasma leaking into the area from damaged and undamaged capillaries at the periostium/deep CT interface.
  - Full thickness onlay grafts utilize the full thickness of the palate including the fat and glandular submucosal tissue contained in the deep connective tissue.
  - Full thickness grafts include the submucosa and does not block the vascularization of the graft.
  - Thick grafts have: greater primary contraction, less secondary contraction, the best resistance to functional stress, are less assured to “take.” The authors noted very little shrinkage of the grafts (primary or secondary).

Preparation of Recipient Site:
·         When preparing the recipient site, it is important to preserve the lamina propria over the defect.
·         #15 Blade is used to remove the epithelium, extending 1mm deep.
·         Extreme caution is advised when the recipient sites are over anatomic bony defects such as a cleft palate case or maxillary sinus.
·         After harvesting the graft, a final step is used to increase vascularity of the recipient site: a series of parallel cuts is made deep into the exposed lamina propria (perpendicular to the ridge) of the defect area to atraumatically injure the larger blood vessels and promote them to send capillary shoots into the graft more rapidly.

Preparation of the Graft/Donor Site

- - The gingival zone and tuberosity of the palate are used most often. The authors found that tissue higher in the palate was more piable and useful for onlay grafts.
  - Care must be taken to avoid the greater palatine artery.
  - The authors recommend storing the graft in moist gauze and immediately treating the donor wound to form a stable clot and reduce hemorrhage.

Placement of the Graft and Provisionals

- - It is advisable for the surgical assistant to hold the graft in place while the surgeon sutures it into place. The sutures should not be placed too close to the borders of the graft and a deep “bite” should be taken into the underlying CT to avoid the sutures pulling out during the healing process.
  - The pontic teeth of the provisional bridge must be ground so that they make only light contact with the surface of the graft. Pressure from the pontic teeth or flange may inhibit revascularization of the graft.

Healing

- - The palate takes about 2 weeks to heal when a partial thickness graft is harvested (it takes about 4-5 weeks with the full-thickness graft).
  - Patients are instructed to not brush the site for a week and (if applicable) to not remove their RDP’s for 24 hours after the procedure. If a second stage augmentation procedure is necessary, it is scheduled approximately 6 weeks after the initial procedure.

Topic: Full thickness grafts and edentulous ridges ps2id id=’Seibert2′ target=”/]
Author: Seibert J.S.
Title: Reconstruction of Deformed, Partially Edentulous Ridges, Using Full Thickness Onlay Grafts. Part II. Prosthetic/Periodontal interrelationships
Source: Compend Cont Educ Dent 4: 549 – 562, 1983
Type: Book Chapter

Purpose: To describe prosthetic and periodontal interrelationships involved in reconstructing deformed partially edentulous ridges with full thickness onlay grafts.
Discussion: Objectives of the prosthodontist or generalist must be clearly defined and communicated to the periodontist.

Pros and Perio factors:

- 1. Lip line: Resting lip line, lip line during speech, high smile lip line.
  2. Type and extend of deformity.
  3. Arch form.
  4. Tooth form: Size and length of teeth.
  5. Teeth position: Protruding contour of the teeth, midline of teeth, “root eminence”.
  6. Relationship of the pontics to the abutment teeth and gingiva: Axial position of the pontics, embrasures, emergence form and profile from the gingiva (modified ridge-lap, ovate pontic design), color of the gingiva, surface characteristics (like scars and clefts).

Ovate pontics are recommended in high smile patients, but sufficient B-L ridge thickness should be achieved. The “socket” is made into the healed graft site and must be place midway b/w the labial and lingual ridge surface, and midway b/w the adjacent papillae. If the ridge is not sufficiently wide in B-L dimension, a modified “socket” can be made from the labial surface only. If the healed ridge is too thin B-L and a large pontic is needed, the thin remaining labial and palatal wall of the gingiva may slough, atrophy or recede, recreating a defect in the ridge. If ovate pontics are to be used, the required labial bulk must be planned. After some healing has occurred, electrosurgery, gingivectomy- gingivoplasty can be used to create a better illusion of harmony or accentuate the receptacle area for the pontics. The contour of the healing tissue and the provisional prosthesis can be seen 10w after the onlay procedure. Tissue is generally stable at 3 months and final prosthesis can be made.

Graft dimensions: Buccal-Lingual and Apico-Coronal dimensions of the onlay graft have to be planned in relationship to: Length of the pontic, embrasure space, arch contour, vestibular form, axial angulation of the abutment and pontic teeth. If sufficient bulk of tissue can be removed, it may be possible to reconstruct with only one procedure. If the defect is too large, multiple stage procedure is needed. Apico-Coronal dimension in a moderate to large volume ridge defects are the hardest to treat. Onlay graft is the first step treating large class II and III defects, and it can be repeated as necessary.

Ridge and gingival contouring: in order to mimic the natural look, it is necessary to over-bulk the central area of the implant site in an effort to create a convex labial surface and stimulate root eminence and interdental groove in the periphery of the graft site. The mesial and lateral border may be either beveled or a butt joint, depending on the contour of the defect. It has to be thinned in the papillary area adjacent to teeth to blend the edges in it. Usually Mesial-Distal margins are prepared thin. In the apical margin of the recipient site, a deep undercut is usually found. Pre-surgical palpation of the area is important. The graft should be tapered to a thinner apical margin to duplicate adjacent mucogingival contour. If left too prominent it will create a vestibular fornix that is annoying to the patient.

Color matching: Full thickness graft taken from the palate, appear to match the color of adjacent gingival tissues better than thinner partial gingival graft taken from the tuberosity/gingiva zone. Exception: dark pigmented gingival tissues. In this case two-stage procedure may be needed. 1^st stage: onlay graft from palate to bulk the area. 2^nd stage: partial thickness graft with pigmented gingival tissue.

Scars: Scars can be dissected and covered with onlay graft.

Clefts: Can be de-epithelized and covered with an onlay graft.

Topic: Pontic site development / Soft tissue ridge augmentation
Authors: Seibert J, Cohen D.
Title: Periodontal considerations in preparation for fixed and removable prosthodontics.
Source: Dent Clin North Am 1987; 31(3):529-555.
Type: discussion
Keywords: edentulous ridge; gingival graft; ridge defect

Purpose: This article covers options to solve the problem of having favorable periodontal support with poor or deformed edentulous ridges.

Discussion: After extraction, normal bony prominences are remodeled, the papillae are gone and the marginal gingival loses its scallop. This leads to prosthetic work that has enlarged pontics and black triangles in esthetic areas, which can contribute to problems with phonetics and spraying saliva during speech.

- - Different etiologies: congenital, trauma, perio disease, cancer etc.
  - Ridge defect classification: Class I B-L loss, no vertical component, Class II Apico-coronal loss, no BL component and Class III: both B-L and apico-coronal loss (Class II and III prob need 2 stage approach to graft and implant)
  - Old prosthodontic methods to correct: blended pontic (too long), pink porcelain flange to disguise extent of defect, Andrews bar (hybrid bar b/w 2 PFMs on either side of edentulous space). Pontic design in the anterior is generally compromised in some way in the ability to clean it for esthetics. There are advantages and disadvantages of modified ridge lap and ovate pontics.
  - A knife-edged ridge: Usually narrow zone of masticatory mucosa, common in mandible. Possibly need FGG to correct.
  - Things that should be discussed b/w restoring dentist and surgeon: ridge deformity, how it will be corrected, location of the donor site, number of procedures required to reconstruct the ridge, the provisional design, the final pontic design, the need for surgical stent and esthetic considerations.

Often, if a pt has a deformity in their ridge, the tissue will be thin and often has scar tissue within. This can potentially compromise the blood supply to this area. If a graft is done in an area like this, the defect could be worsened, or a new defect can be created at the donor site, so planning ahead is crucial. Ridge undercuts should be addressed, either with osseous re-contouring (but should try to preserve bony support) or grafting apical to defects to fill in the concavity and leave the bony rim. If there is a deficiency of vestibular depth, this should be corrected with grafting as well.

- - “Roll procedure” de-epithelialized CT pedicle graft. Abrams technique. De-epithelialize adjacent area then split thickness and roll towards buccal, tuck into created pouch and suture. Good for small to moderately large Class I ridge defects. Depends on thickness of palatal CT. This technique does not gain ridge height and cannot be used to change the color or surface characteristics of the existing ridge. The temp pontic is seated with light positive pressure against the tissue surface to start training the tissue.
  - Pouch procedure: Different pouches can be made depending on the entrance incision and plane of dissection. Free graft placed in the pouch. Can incise from coronal aspect and pouch apically, incise from apical entrance at depth of vestibule then dissect in coronal direction. Incise from a lateral aspect, which can also form a tunnel. Can use with a combination of bone grafts, and can correct all sizes of class I defects.
  - Wedge and inlay-onlay graft: Essentially a CT graft with a coronally positioned flap. Leave a band of epithelium at the most buccal aspect and suture into place. If need augmentation in a coronal dimension, can leave a part of the wedge exposed and above the level of the surrounding tissue. Can correct Class I defects a small to moderate Class II defects.
  - Onlay graft procedure: Thick FGG using full thickness grafts from the palate. The amount of apicocoronal augmentation that can be obtained is directly related to the thickness of the graft that is used and the amount of connective tissue that takes. The procedure can be repeated at two month intervals to build ridge height. Indicated for situations when you need to gain ridge height. They can also be used to add bulk to class III ridge defects.
  - Free graft procedures of masticatory mucosa in preparation for removable prosthesis: Used to correct mucogingival problems in the thin and knife-edged atrophic edentulous ridge, elimination of undercut areas in the edentulous ridge, and vestibular extension procedures. Unwanted alveolar tissues and muscle tissues are removed from the area covered by denture base and masticatory muscosa is grafted into the space vacated by the former tissues. Thicker donor tissue is best and rugae from the anterior palatal region can be used.

BL: It is possible to use the above techniques to reconstruct ridge deformities

Topic: Pontic site development / Soft tissue ridge augmentation
Authors: Seibert JS, Louis JV
Title: Soft tissue ridge augmentation utilizing a combination onlay-interpositional graft procedure – A case report.
Source: Int J Perio Rest Dent 16:311-321,1996
Type: Clinical

Purpose: To address a major problem in soft tissue ridge augmentation: the esthetic reconstruction of severe Class III (combination buccolingual and apicocoronai) ridge deformities.
Discussion:

Connective tissue graft: common problem to connective tissue graft procedures is the inability to harvest a sufficient volume of donor tissue to reconstruct the ridge to its former dimensions. Strips of thin to medium thickness of connective tissue can be layered or “sandwiched” together to gain a sufficient bulk of donor material. It is not infrequent that both sides of the palate must be utilized to gain sufficient donor material.

Interpositional grafts: differ from subepithelial connective tissue grafts in that they are more like a “wedge” of tissue that is inserted into a pouch created within the deformed ridge. The epithelial surface of the donor tissue is left exposed and positioned at the level or above the surface level of the surrounding tissues. Interpositional grafts receive their new blood supply from the connective tissue bed surrounding their entire periphery. The connective tissue surface area available to participate in revascularization is less than half available in SCTG, but considerably more than that available in onlay types of grafts. Utilized mainly for buccolingual augmentations. If they are positioned a few millimeters above the surface of the surrounding tissue, augmentation can also be gained in the vertical plane.

Onlay grafts: were designed primarily to gain apicocoronal ridge augmentation, to smooth out deeply fissured ridges or soft tissue clefts, to reconstruct papillae adjacent to abutment teeth, and to mask tissue discolorotion such as amalgam tattoos. A greater volume of donor connective tissue can be harvested from the palate in comparison to a connective tissue graft, since there is no need to create an access flap. However, this creates a larger open wound that takes longer to fill with granulation tissue and causes patients greater discomfort. Submerged connective tissue grafts can gain a new blood supply from all surfaces, onlay grafts can revascularize only along the undersurface and butt-joint margins around their periphery. If onlay grafts are made too thick to maximize vertical augmentation, the external surface of the grafted connective tissue, along with the epithelium and basement membrane, may slough.

The combination onlay- interpositional graft procedure was developed to incorporate the best features of the onlay graft with these of interpositional and SCTG procedures.

Desirable features are:

- 1. The submerged connective tissue section of the interpositional graft aids in the revascularization of the onlay section of the graft
  2. A smaller postoperative open wound in the palate donor site
  3. More rapid healing in the palate donor site with less patient discomfort
  4. Greater to control the degree of buccolingual and apicocoronal augmentation within a single procedure
  5. Vestibular depth is not decreased and the mucogingivai junction is not moved coronally, eliminating the need for follow-up corrective procedures.

Conclusion: A case report of a 16 year- old male with ridge deficiency at the site of upper later incisor treated with onlay- interpositional graft is presented.

Topic: Connective tissue grafting
Authors:Langer B, Calgna L.
Title: The subepithelial connective tissue graft.
Source: Prosthet Dent 1980; 44(4):363-367
Type: Classic
Keywords: Connective tissue, pontic site development, esthetics, soft tissue

Purpose: To describe the use of subepithelial CT graft to augment concavities and irregularities in edentulous ridges in aesthetic areas.

Discussion:

- - Donor site: A horizontal internal bevel incision using a No. 15 surgical blade is made on the palate 1 mm apical to the free gingival margin of the posterior teeth. Vertical incisions are made at either end of the horizontal incision to allow for the reflection of a split-thickness flap. The length of the horizontal incision is dependent upon the dimension of the concavity to be filled. The split-thickness flap is reflected away from the underlying connective tissue base. This tissue is dissected away from the underlying bone and will be used as the donor material. The marginal gingiva is left untouched. The split-thickness flap is then replaced over bone to the marginal gingiva completely covering the denuded bone. The CT is stored briefly in a moist, sterile gauze pad for future use.
  - Recipient bed: In the pontic region, a split thickness flap is elevated proximal to the adjacent abutment teeth. Periosteum and connective tissue are allowed to remain over the alveolar ridge which will become a source of blood supply to help nourish the autogenous connective tissue graft. The donor CT is placed between the elevated split-thickness flap and the alveolar ridge. The flap is then sutured over the donor tissue to immobilize it in the desired position. And will serve as an additional source of blood supply to nourish the CTG.

Following the surgical graft procedure, the temporary prosthesis is modified, if necessary, to conform to the augmented ridge and temporarily cemented, a periodontal dressing is placed. The dressing and sutures are removed after 1 week and the region is either left uncovered or redressed for an additional week. Healing is usually uneventful. Secondary procedures to either add more tissue or reduce irregularities by gingivoplasty may be required to further enhance cosmetics. 
Observations: Performed for 30 patients, after 2 year, none of the grafts failed or receded from their postoperative healed position. It was observed that the augmented ridge became dimensionally stable approximately 2 months after the graft procedure.
BL: This technique can augment concavities and irregularities in edentulous sites where cosmetics are important with good degrees of predictability

Topic: Subepithelial connective tissue graft
Authors: Langer B, Calagna L
Title: The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics.
Source: Int J Periodontics Restorative Dent 1982; 2 (2): 23-30
Type: Review
Keywords: subepithelial connective tissue graft, donor site

P: To describe the subepithelial connective tissue graft to enhance anterior cosmetics in areas with anatomical defects.

Tech:

2 Techniques ot harvest tissue: Donor site

- 1. With existing pockets, harvesting of donor material of palatal pockets from an internally beveled flap. The collar of CT comprising the pocket wall and remaining on the bone after reflection of the internally beveled flap is used as the donor material. Epithelium, which is part of the marginal gingiva and pocket lining, is removed. CT from other sources such as a distal wedge or lingual flap may be used.
  2. If pocket elimination is not indicated, a horizontal incision is made 4-5mm apical to the FGM and an internally beveled flap is elevated, leaving a layer of CT on the bone. A 2nd parallel incision is then made 1-2mm more coronal from the original one and at least 1 mm from the FGM. This latter incision is beveled apically towards the bone. The CT lying over the bone and beneath the first flap is carefully peeled away and removed (donor tissue).

Recipient Site: Partial thickness flap is elevated to the mucobuccal fold in the recipient area. In most cases, a horizontal incision is made over the crest of the edentulous alveolar ridge connecting two vertical oblique incisions. The flap is incised leaving CT covering the alveolar bone. This will provide a double source of vascular supply to the donor CT. The CT is slid between the recipient flap, placed, and sutured. Overbuilding is recommended in edentulous ridges. Papillae are created by inducing slight pressure of the pontic into the newly augmented site 6-8 weeks POT. This procedure can be repeated several times until the desired result is attained.

BL: A classic article describing the subepithelial connective tissue graft with 4 case reports shown. Technique can be used for correction of uneven gingival margins and edentulous alveolar ridge depressions.

Topic: soft tissue augmentation
Authors: Orth C
Title: A modification of the connective tissue graft procedure for the treatment of type II and type III ridge deformities.
Source: Int J Periodontics Restorative Dent 1996; 16(3):267-278
Type: technique description

Keywords: gingival recession, connective tissue graft, modification, ridge deformities

Purpose: To describe a modification of the connective tissue graft technique for localized ridge augmentation (Seibert* type II and III).

Technique:

Recipient site: Partial thickness pedicle flap is elevated on the buccal. In most cases horizontal incision is made slightly facial to the alveolar crest and then one or two vertical releasing incisions to facilitate flap mobility. The region of interdental papillae may or may not be included. Flap is extended into the mucobuccal fold. The epithelium covering the ridge is then removed to expose the bleeding connective tissue. Removal of epithelium should extend as palatally as possible.

Donor site: Palatal tissue in the molar/premolar area is more desirable. The measurements from the recipient site are used to outline the graft to be harvested. Harvesting starts with a horizontal incision 3-4mm from the gingival margin. Incision is extended apically to the underlying bone in butt-joint fashion. Two vertical incisions are made at the periphery of the horizontal incision extending to the midline of the palate and to the underling bone. The length of the incisions depends on the buccolingual dimensions of the recipient site (usually 6-8mm). A second horizontal incision that continues apically and obliquely until it meets the underlying bone, on average 5-7mm from the palatal surface. During each step effort is made to remove as much palatal tissue as possible. The final graft will resemble a thick FGG with an accompanying connective tissue tail. Graft is adapted and secured with interrupted or a continuous mattress sutures. It’s better to secure the palatal aspect first. The provisional fixed partial denture is adjusted assuming light contact with the surface of the graft. Surgical sites should be inspected 1-2 weeks post-op.

Two case reports where the author used this technique are presented. In the second one this procedure was repeated 3 times in order to have the desirable results, because of the size of the initial defect.
Conclusion: This technique can be used to reconstruct large edentulous ridge concavities, irregularities, and deformities of Type II and III defects. This procedure is a useful adjunct for correcting esthetic and functional problems.

*Seibert Classification for ridge deformity: (1983)

- - Class I: buccolingual loss of tissue with normal Apicocoronal ridge height
  - Class II: Apicocoronal loss of tissue with normal buccolingual ridge width
  - Class III: combination-type defects (loss of both height and width)

Topic: Soft tissue augmentation
Author: Harris R
Title: Soft tissue ridge augmentation with an acellular dermal matrix.
Source: Int J Periodontics Restorative Dent 2003; 23(1):87-92
Type: Prospective study
Keywords: Acellular dermal matrix; soft tissue augmentation; fixed partial denture; clinical

Purpose: To evaluate the use of ADM as a replacement for a CTG to augment edentulous ridge

Methods:

- - 5 pts with deformed edentulous ridges included that would undergo FPD.

o 3 cases with ridge deformity in a single central incisor

o 2 cases with ridge deformity in both central incisors

- - Partial thickness flap was reflected with sharp dissection in the area of the deformed edentulous ridge. Vertical incisions were placed.
  - ADM was hydrated in two saline washes. ADM was secured into the defect with 5-0 sutures.
  - In cases treated, there were up to 8 layers of ADM sutured into the defect.
  - Primary closure was obtained in all cases. No dressings were used. Provisional restorations were relieved so that no pressure was applied to the grafted area.
  - Patients received routine postoperative care. Final evaluation of the results was done at 3 to 12 months (Avg follow up was 6.2 months).
  - Punch biopsy was taken for histologic evaluation.

Results:

- - Histologic evaluation showed that ADM incorporated showing 3-4 layers of tissue with elastin.
  - Since elastin is not generally seen in the gingiva, it can be assumed that these are the areas where ADM incorporated into the result.
  - Unknown how long elastin will be present
  - 1 case had ADM exposure, which required additional grafting with FGG.

Discussion: Major shortcoming of this study was that it was not blinded in any way. Long-term stability of the augmentation also needs to be evaluated. It is unclear if this type of augmentation would be successful in the vertical dimension, in this study; all of the defects were horizontal defects.
Bottom Line: An acellular dermal matrix seems to be a good substitute for a connective tissue graft when attempting soft tissue ridge augmentation.

Topic: Pontic site development/soft tissue ridge augmentation
Author: Abrams L
Title: Augmentation of the deformed edentulous ridge for fixed prosthesis
Source: Compend Contin Educ Dent 1980; 1 (3):205 – 214
Type: Report
Keywords: Ridge augmentation, edentulous ridge, fixed prosthesis

Purpose: To discuss resolving the problem caused by residual edentulous ridges that are deformed by tissue loss or collapse, creating difficulty in foxed prosthodontics with esthetic pontic replacement.

Discussion: Indications: when the soft tissue defect interferes with esthetics, function, comfort or ability to be cleansed.
Contraindications: insufficient soft tissue, knife-edge ridge, or where the residual ridge defect does not interfere with the lip line esthetic pattern

The procedure begins with a non–epinephrine anesthetic to ensure generous bleeding at the tissue site. The first step is to remove the surface epithelium by a scalpel or a rotary diamond. The presence of bleeding in the entire area indicates complete epithelial removal. The proximal marginal periodontium of the adjacent teeth must be preserved intact. At this time, an epinephrine-containing anesthetic is used for hemostatic control. A triangular flap is elevated from the palate within the de-epithelialized zone (full or partial thickness), a pouch is created by blunt dissection labial to the alveolar bone, and the flap is inverted and guided into place by a retaining suture at the area of the mucogingival junction. The area from which the flap has been removed is then sutured and packed with periodontal dressing. Dressing and sutures are removed after 8-10 days.

Topic: Modified roll technique
Author: Scharf DR, Tarnow DP
Title: Modified roll technique for localized alveolar ridge augmentation
Source: Int J of Perio and Rest Dent 1992; 12(5): 414 – 425
Type: Discussion
Keywords: Abram’s roll technique, modification, ridge augmentation, ridge deficiency

Purpose: To report on a modification of Abram’s roll technique for localized alveolar ridge augmentation.

Technique:

- 1. Define and reflect the epithelial pedicle
    1. Two full thickness vertical releasing incisions are made from the crest of the ridge towards the palate (made parallel in order to maximize the blood supply).
    2. The incisions are placed 2mm from the sulcus to preserve the papillae and attachment.
    3. A shallow incision is made along the crest of the ridge to join the vertical incision together.
    4. A pedicle of epithelium and connective tissue (at least 0.6mm thick) is reflected toward the palate to expose the underlying donor CT.
  2. Develop the connective tissue pedicle
    1. Another horizontal incision is made along the apical crest of the CT pedicle.
    2. CT pedicle is reflected towards the buccal aspect to expose the alveolar bone of the palate.
  3. Position the pedicle
    1. A tunnel is made underneath the buccal periosteum to accommodate the donor tissue.
    2. CT is then rolled to the buccal aspect and secured between the periosteum and the bone with sutures.
    3. The epithelial pedicle is replaced on the palate to cover the denuded donor site. Periodontal dressing is placed if required.

Advantages: Compared to Abram’s original technique this offers 3 advantages: 1) maximized the amount of CT that can be rolled to the buccal, 2) it minimizes the amount of exposed CT or bone, and 3) it minimizes post-op discomfort.

Topic: Alevolar ridge preservation
Author: Seibert J.S., Salama H.
Title: Alveolar ridge preservation and reconstruction
Source: Periodontology 2000; 1996; 11:69-84
Type: Review

Purpose: Described the different procedures for ridge augmentation, which includes soft tissue augmentation procedures, and osseous ridge augmentation procedures.

Soft tissue procedures:

Pouch procedure: mostly treats to augment buccolingual deformity. Although a limited amount of apico-coronal augmentation can be obtained. This procedure designed to receive connective tissue removed from palate/tuberosity area or to receive implant of synthetic bone substitute like beta-tricalcium phosphate or resorbable HA. Partial thickness flap begins with a palatal site of the crest and extend apically on to the facial side of the ridge and it will be a full thickness flap on the facial, then CT placed into the pouch to obtain the desired amount of thickness buccolingually. CT graft, bone graft or synthetic bone graft can be used. In the roll technique, a deepithelized pedicle of CT can be raised from palatal side, reflected to the crest of the ridge and then tucked back upon itself into a pouch, which is created under the soft tissue of the defect. Good technique for treating areas with pigmentations. For CT graft a supraperiosteal plane of dissection is recommended and for bone graft a dissection under the periosteum instead.

Interpositional (wedge and inlay) graft procedure: the opening if the pouch is not closed. A pie shape free graft is removed from palate/tuberosity area and inserted like a wedge into the opening of the pouch. The epithelial surface of the wedge is positioned at the level of surrounding epithelial surface. If augmentation is necessary in an apico-coronal direction, then part of the wedge can be positioned above the level of the surrounding tissue.

Onlay graft: This is a “thick free gingival graft “which is used to augment in apicocoronal direction to gain ridge height. The procedure can be repeated as necessary at 2 month intervals to build ridge height. Contraindicated when blood supply and capillary proliferation can’t be expected.

Osseous ridge augmentation:

In implant therapy, treatment planning for osseous augmentation for localized ridge defect can be dividing into 2 subdivisions. One focused on long established ridge resorption and the other address the reconstruction of extraction site defects.

Augmentation of deficient ridge: GTR is a predictable technique that can be used separately in a staged approach to first augment the ridge or in conjunction with implant placement where primary stability of the implant is achievable. Important factor for GTR is graft stabilization, flap management (tension free flap closure, no membrane exposure). According to Busar, decortication of the bone may enhance the procedure.

Three-dimensional reconstruction of the post maxilla: The procedure is “internal ridge augmentation” in the form of sinus elevation process.

Extraction site development: Immediate /early implant placement is recommended for 4 wall socket environment. When primary stability is not achievable for implant placement with the compromised socket structure, staged approach of implant placement should be considered. Under specific criteria, tooth extrusion (hopeless teeth with a third of their attachment) with orthodontics can be effective to improve the soft and hard tissue architecture.

Soft tissue enhancement in implants: depending on the need, it may be before, during or after placement. For severe soft tissue deficiencies and one stage implant placement: before or during implant placement. Onlay and CT graft are the most used. For two-stage implants: At the 2^nd stage with a palatal incision to have more KG in the flap (flap is buccally rotated). Roll techniques and subconnective tissue graft is also used in conjunction with the buccally rotated flap.

Topic: Pontic site development / Soft tissue ridge augmentation
Authors: Allen EP.
Title: Use of mucogingival surgical procedures to enhance esthetics.
Source: Dent Clin North Am 1988:32(2):307-330.
Type: discussion
Rating: good

Keywords: mucogingival; esthetics; gingival margin; asymmetry

Purpose: This article refers to the use of mucogingival surgical procedures to enhance esthetics. In addition to providing esthetic surgical therapy when treating periodontitis, the periodontist can utilize mucogingival surgical techniques to improve esthetics in patients with problems other than periodontitis. Such problems usually involving the maxillary anterior region include: 1) excessive gingival display with insufficient clinical crown length, 2) asymmetry of gingival margins, 3) improper relationship of gingival margins, 4) flat marginal contour, 5) localized marginal tissue recession and 6) localized alveolar ridge deficiency.

Discussion:

- - Excessive gingival display: It is a condition characterized by excessive exposure of maxillary gingiva during smiling, commonly called “gummy smile” or high lip line. This condition is primarily caused by a skeletal deformity in which there is a vertical maxillary excess, a soft tissue deformity in which there is a shorter upper lip, or a combination of these two deformities. Another cause of excessive gingival display is insufficient crown length. Improved esthetics is attained by gingival contouring to expose more clinical crown. Gingival contouring may be accomplished by gingivectomy/gingivoplasty or by flap procedures, depending upon the amount of soft tissue reduction needed, the amount of keratinized gingiva and the need for osseous reduction. The clinical examination should include determination of clinical crown length, anatomic crown length, keratinized gingiva height, and location of alveolar crest.
  - Gingival asymmetry: Symmetry of the gingival margins is an important aspect of anterior periodontal esthetics. Ideally the position of the gingival margin of an anterior tooth matches that of its contralateral mate. Asymmetry is easily corrected by excision of excessive gingiva or by a localized apically positioned flap procedure.
  - Improper relationship of gingival margins: An example of this kind of problem is a case of cuspid transportation in which the cuspids occupy the position of congenitally missing lateral incisors. The gingival margin of the canine is positioned more apical than that of its adjacent central incisor and premolar. Corrective procedures in such situations are often limited to reshaping of the cuspid to more closely resemble a lateral incisor. In patients with high lip line the position of the gingival margins is very important. Correction of the gingival margin position may be accomplished by contouring of the gingival margins of the adjacent teeth in most cases. If reduction of soft tissue is contraindicated, extrusion of the cuspids will position their marginal tissues more coronal with respect to the adjacent teeth.
  - Flat marginal contour: A flat margin may occur when interdental papillae are blunted or lost. Gingival contouring may help reduce the undesirable esthetic impact of this defect. Placement of full coverage restorations following gingival contouring can produce dramatic esthetic improvement.
  - Localized marginal tissue recession: Gingival asymmetry may be also due to localized marginal recession. When localized marginal recession is an esthetic problem, it can be effectively treated except in cases of loss of interdental bone and soft tissue height. As a first step in treatment, the etiologic factors of recession must be controlled (OH techniques, occlusal factors) and then the recession corrected if required by esthetics. Successful predictable treatment of gingival recession with coronally positioned flap requires 3-5mm of KG with a minimal thickness of 1.5mm. The color and the morphology of the positioned tissue blend s with adjacent tissue so that it is difficult to detect the healed surgical site. These factors provide an important advantage for this procedure over free gingival grafts when esthetics is of primary concern.
  - Localized alveolar ridge deficiency: Localized alveolar ridge deficiency due to excessive bone loss pose difficult restorative problems, both functionally and esthetically. When this deficiency occurs in the maxillary anterior area in a patient with high lip line, it presents a serious challenge to the restorative dentist. A number of techniques have been reported for rebuilding this type of deficiency. These include soft tissue grafting, de-epithelialized connective tissue pedicle or roll technique (Abrams), full –thickness onlay grafting technique (Siebert), palatal pedicle flap technique (Allen). Most of these procedures are technique sensitive and require careful communication between the surgeon and the restorative dentist.

BL: Attention to the total dental display as framed by the smile, with appropriate mucogingival analysis and treatment, is necessary to achieve the most satisfying esthetic results.

Topic: Pontic site development / Soft tissue ridge augmentation
Authors: Akcali A, et al
Title: Soft tissue augmentation of ridge defects in the maxillary anterior area using two different methods: a randomized controlled clinical trial
Source: Clin Oral Implants Res. 2014 Apr 10.
Type: Clinical
Rating: Good
Keywords: ridge defect, soft tissue augmentation, subepithelial connective tissue graft, volumetric measurement

Purpose: To test whether or not vascularized interpositional periosteal-connective tissue grafts (VIP-CTG) are as successful as free subepithelial connective tissue grafts (CTG) in augmenting volume defects of the alveolar ridge in the maxillary anterior area and in maintaining the volume augmented.

Method: 20 systemically and periodontally healthy non- smoker patients with single tooth gaps in the maxillary anterior area presenting Seibert Class I ridge defects were included in the study. The healing period after the tooth extraction had to be at least 3 months prior to the surgical procedures. Baseline clinical periodontal measurements were recorded (plaque, BOP, PD, CAL). Impressions were taken. Models were cast and used as the baseline reference for volumetric measurements. 1, 3 and 6 months after the surgical volume augmentation procedure, clinical periodontal measurements were recorded, impressions were retaken and models were cast. To evaluate the volumetric changes of soft tissues between baseline and 6 months, all the stone models were digitized using a lab- based optical scanner. Digital cast models representing the different time points during the treatment were superimposed. Visual analogue scale (VAS) was used to evaluate the pain level during the 1st week of postoperative healing period.

Subjects were assigned equally to one of two treatment groups: In the test group, a modified VIP-CTG was performed. In the control group, a free subepithelial CTG, harvested from the palate was used .

In both groups, incisions were placed over the crest of the ridge reaching to alveolar bone. Papillae were included in the incision line only when there was a loss of papillary height. A deep supraperiosteal soft tissue pouch was prepared by sharp dissection extending apically to the mucogingival line and to the neighboring teeth mesio-distally in both groups. In the control group, the pouch was extended 2 mm to the palatal aspect of the defect area. Subsequently, a free subepithelial connective tissue graft (thickness 1-1.5mm) was harvested using the trap door approach. The graft was inserted into the pouch that was previously prepared at the recipient site and secured with two non-resorbable sutures at the labial and the palatal aspect. The flap margins at the crest were adapted using single interrupted sutures.

In the test group, a pediculated subepithelial connective tissue graft was performed. Same thickness as the free CTG. The graft was undermined, then mobilized and rotated into the pouch at the recipient site.

Results: Volume gain after surgery, expressed as a distance in labial direction was documented in both groups.

1 month after surgery, a gain of 1.21 mm was recorded in the test group and 1 mm in the control group. At 3 months, the soft tissue volume change (t0–t3) was similar in both groups, 1.26 mm in the test group and 1.18 mm in the control group. At 6 months, the volumetric gain compared to baseline (t0–t6) was significantly higher in the pedicle group (1.18 mm) compared to the free connective tissue group (0.63 mm) range 0.28–1.22). At 6 months, the control group had lost almost half of the volume gain recorded at 1 month. No statistically significant differences were observed between the pediculated and free connective tissue graft group at 1 and 3 months (t0–t1 and t0–t3).The mean shrinkage in soft tissue volume between baseline and 6 months was statisti- cally higher for the control group (47%) compared with the test group (6.4%).

Pain levels showed no statistically significant differences between the study groups at any time point.

Conclusion: Both soft tissue augmentation techniques were effective in increasing the volume of defective alveolar ridges in the anterior maxilla. However, possibly due to better bood perfusion, the pediculated connective tissue resulted in less shrinkage of the graft during the 6-month healing period. No difference was observed in postoperative pain.

Topic: Pontic shield

Author: Gluckman H., Salama M.

Title: The Pontic-Shield: Partial Extraction Therapy for Ridge Preservation and Pontic Site Development

Source: Int J Periodontics Restorative Dent May-Jun 2016; 36(3):417-23.

DOI: 10.11607/prd.2651

Type: Case Report

Purpose: Case series of sites treated with pontic-shield technique

Methods: 10 adults, non-smokers or apical pathology Sites healed for 90 days

Socket-shield technique- Teeth sectioned along long axes as apical as possible. Buccal/facial half of tooth remain intact and undamaged.Palatal section extracted. Remaining root is reduced coronally to 1mm above alveolar crest and thinned concaved.

Modified Pontic-shield technique- Sites grafted with xenograft bone and closure achieved with buccal flap advancement and CTG inserted into buccal and palatal pouches ( 2 sockets) and cytoplast membrane (1 sockets) and socket seal (3 sockets).

Results:

Case report 1

Failing 5 unit FPD, implants planned for sites 7,9,11
Pontic shield planned for sites 8,10
Sockets filled with xenograft and sealed with CTG
Absence of Buccal collapse evident

Case report 2-

Similar to case 1, a xenograft was used to fill pontic socket however a FGG of 2-3mm was used to seal socket.
Healing was prolonged in comparison to other cases.

Case Report 3

Pontic site was grafted with xenograft and sealed with rotated palatal flap.

Results: noticeable ridge preservation quantified by subjective observation was achieved in all cases at the 12- and 18-month.

Conclusion: Case series shows clinical results and technique of the use of a pontic-shield technique to prevent buccal collapse after extraction.

Papillae Characteristics around implants and teeth

Topic: Connective tissue grafting
Authors: Jemt et al
Title: Regeneration of gingival papillae after single-implant treatment.
Source: DL International Journal of Periodontics and Restorative Dentistry 1997 (17) , 326 –333
Type: Restrospective study
Keywords: papilla, regeneration, soft tissue, esthetics

P: To propose an index to clinically evaluate the degree of recession and regeneration of papillae adjacent to single-implant restorations, and to test this proposed index in a pilot study.

M&M: Retrospective study. 21 pts with single implant restorations that had photographs taken at the time of insertion, as well as 1-3 years later after prosthesis placement were included. Central incisors, lateral incisors, canines and premolars were included. Two crowns were in the mandible and the rest in the maxilla. The index designated 5 different levels indicating the amount of papilla present. The assessment was measured form a reference line through the highest gingival curvatures of the crown restoration on the buccal side and the adjacent permanent tooth. The distance form this line to the contact point of the natural tooth/crown was also assessed. Discoloration of the soft tissue above the restoration and visible titanium margins were identified as present or not present. Signs of severe inflammation or fistulas were also noted.
Assessments of papillae contour were determined for the 25 crowns on 3 separate occasions with a time interval of 11 days. The mean difference between the two registrations was 0.11. All implants were placed in a healed ridge.

R: The index scores ranged from 0-3 at placement and 1-4 at the follow-up appointment. Mean index of papilla at mesial and distal at time of crown placement was 1.44 and 1.52 respectively. The values at the follow-up were 2.48 and 2.46 for mesial and distal respectively. 10% of the papilla were class 3 at the time of crown insertion, while 58% had recovered at the follow-up. When photographs were compared simultaneously, the size of the papilla was considered to have increased in 40 sites in the follow-up pictures, while the remaining 10 remained the same size. Some buccal recession was noted, but no metal was visible.
BL: This study shows that one to three years after placement, 58% of single-implant crowns may have an increase in papillae height from the time of implant placement through spontaneous regeneration.

Topic: Classification of papillary height
Authors: Nordland WP, Tarnow DP.
Title: A classification system for loss of papillary height.
Source: J Periodontol 69:1124-1126, 1998.
Type: Review
Keywords: Dental, papilla/anatomy and histology

Purpose: Present a classification system for loss of papillary height.
Normal: Interdental papilla fills the embrasure space to the apical extent of the contact point.
Class I: The tip of the interdental papilla lies b/w the interdental contact point and the most coronal extent of the interproximal CEJ (space present but interproximal CEJ is not visible).
Class II: The tip of the papilla lies at or apical to the interproximal CEJ but coronal to the apical extent of the facial CEJ (so interproximal CEJ visible).
Class III: The tip of the papilla lies level with or apical to the facial extent of the facial CEJ.

The authors suggest that a more precise description of the “black triangle” may be used by incorporation of mm increments of papilla loss.

Topic: papillae preservation
Authors: Takei H, Yamada H, Hua T.
Title: Maxillary anterior esthetics: Preservation of the interdental papilla.
Source: Dent. Clin. North Am. 33(2): 1989
Type: discussion article

Keywords: interdental papilla, papilla preservation, periodontal disease

Purpose: To discuss the esthetic considerations in the periodontal treatment of maxillary anterior teeth emphasizing in papilla preservation.

Discussion

The author feels one can best maintain an acceptable gingival contour by treating the maxillary anterior area non-surgically. Anterior teeth have favorable anatomy for maintaining good oral hygiene and for scaling/root planning so non-surgical approach seems reasonable.
· Moreover, even with the conservative incision, surgical approach can result in extensive shrinkage and loss of interdental papilla.
· If pockets are deep and necessitate surgical approach, the author recommends the papilla preservation flap on palatal side. The papilla is pushed facially to allow access to the root surfaces and any infrabony defects that may be present. No attempt is made to thin the undersurface of the papilla. Sulcular incision could be used with caution in case of inadequate interdental space for papilla preservation flap, in those cases, the incisions should be as close to the teeth as possible.

Conclusion: 1^st choice for periodontal treatment in maxillary anterior segment is SRP; 2^nd is papilla preservation technique, and 3^rd is the surgical, conventional flap.

Topic: Interdental papilla
Author: Tarnow DP et al
Title: The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla
Source: J Periodontol. 1992 Dec; 63(12):995-6
Type: Clinical study
Keywords: Papilla, interproximal; gingiva/anatomy and histology

Purpose: To determine whether the distance between the contact point and the crest of bone correlated with the presence or absence of interdental papilla in humans.

Methods:

288 interproximal sites (99 anterior, 99 premolars, 90 molars) in 30 patients were randomly selected for examination.
Pts underwent SRP 2-8 weeks before the measurements were taken to reduce edema and inflammation.
A standardized periodontal probe with Williams’s markings was used.
The presence or absence of the interproximal papilla was determined visually prior to probing. If there was no visible space apical to the contact point the papilla was deemed to be present.
At the time of the surgery the probe was inserted vertically at the facial aspect of the contact point until the bone crest was sounded.
To verify the sounded measurements, 38 of the 288 sites were re-measured when the flaps were reflected and were found to be accurate to the nearest millimeter.

Results:

When the distance from contact point to crest of bone was 3, 4, or 5mm: papilla was present almost 100% of the times.
When it was 7, 8, 9 or 10mm, the papilla was missing most of the time.
At 6mm it was present a little bit more than half of the time.
The majority of areas examined were between 5-7mm in distance.
History of periodontal surgery did not show any definitive trend.

Bottom Line: When the contact point to the crest of bone was 5mm or less, the interproximal papilla is present almost 100% of the time. When the distance from the contact point to the crest of bone was greater than 6mm, the interproximal papilla was almost never present.

Topic: Papillae characteristics around implants and teeth
Author: Azzi R, Etienne D, Carranza F
Title: Surgical reconstruction of the interdental papilla
Source: Int J Perio Rest Dent 18:466-473, 1998.
Type: Case report
Purpose: To describe a technique for surgically reconstructing the interdental papilla using buccal and palatal split-thickness flaps and a connective tissue graft.

Discussion: Patients should quit smoking 1 week prior to surgery and 2-3 weeks after surgery in order to not delay healing. Patients should also undergo phase I treatment prior to surgery. An intrasulcular incision is made, followed by another incision made buccally across the interdental papilla at the level of the CEJ, leaving the existing papilla attached to the palatal flap. An envelope-type split thickness flap is then elevated buccally and palatally. The buccal part of the flap is dissected past the mucogingival junction (MGJ), leaving periosteum and a thin layer of connective tissue (CT) on the bone. CTG is harvested from the retromolar/tuberosity region. A distal wedge of tissue is harvested. 2 parallel incisions that extend to the MGJ are made behind the distal tooth, with a third incision at the distal end of the parallel incisions. The incision is made straight down for the first 1mm and then continued apically as an inverse bevel incision toward the bone. A flap is then reflected and the underlying tissue is removed to the bone. Graft is obtained, and it has a trapezoidal shape. The graft is shaped to fit under the flaps. The epithelial segment is left in place and the flaps cover the CT portion. The area is covered with dressing. Patients were instructed to rinse w/ CHX. Dressing and sutures removed after 1 week.

Conclusions: The blood supply to the CT is a key element of this technique. Probing depths at the sides of the reconstructed papillae were 3-5mm in the clinical cases recorded. If oral hygiene is adequate, a healthy state of the tissues will persist without clinically significant inflammation.

Topic: Papilla reconstruction
Author: Blatz MB, Hurzeler MB, Strub JR
Title: Reconstruction of the lost interproximal papilla: Presentation of surgical and nonsurgical approaches
Source: Int J of Perio and Rest Dent 1999; 19(4): 395-406
Type: Discussion
Keywords: Dental papillae, reconstruction, surgical techniques, esthetic dentistry

Purpose: An overview of the anatomic and morphologic aspects of the inter proximal papilla and presents several techniques to restore the lost inter proximal papilla between teeth and implants and in the pontic area.

Anatomy and morphology of the interdental gingival papilla:

Anatomy

Gingiva: the tissue extending externally from the gingival margin and the tip of the interdental papilla to the MGJ, which separates the alveolar mucosa from the attached gingiva. It also includes the internal gingival connective tissue and dentoalveolar fibers.
Dentogingival, dentoperiosteal, alveologingival, and periosteogingival fiber groups provide attachment of gingiva to the tooth and to bony structure.
Under clinically healthy conditions a gingival sulcus of 0.2-0.7mm exists
The gingival vascularization derives from branches originating in the interdental septa, PDL, and the oral mucosa.

Morphology

Papilla morphology is determined by the adjacent teeth and underlying bone crest.
Cohen was the first to describe the papilla with 2 peaks vestibulary and lingually with a concave crest shaping called col.
An interdental papilla is deemed present when it fills the interdental space up to the contact point. The contact point is the result of the emergence profile and the line angle form, its location varies with tooth form: between the max central incisors (incisal third) , between central to lateral incisors(middle), and between lateral and canine (apical third).
The most visible papilla is located between the 2 central incisors (fills up more space), its absence causes esthetic problems and therefore the most difficult to restore.
Tarnow et al showed that the presence of the papilla is dependent on the distance between the bone crest and the contact point of 2 adjacent teeth. When the measurement from the contact point to the crest of bone was 5mm or less, the papilla was present 100% of the time. When 6mm the papilla was still present 56%, but if the distance is 7mm or more the papilla was only present 27% of the time.

Biology of the peri-implant mucosa:

Connective collagenous fibers stretch parallel to the implant surface, originating in the crystal bone. The junctional epithelium is typically twice the length on an implant compared to that of a tooth.
Because of the lack of the PDL, blood supply of the peri-implant mucosa is only provided by branches from the bone and the oral soft tissue. Because of its high amount of collagen and low number of fibroblasts, the peri-implant mucosa can be defined as a scar-like tissue.

Reconstruction of the lost interdental papilla:

Nonsurgical papilla creation

If papilla is lacking due to a diastema, orthodontic closure is the treatment of choice. This forms a papilla by “creeping” papilla formation as the contact between the teeth is achieved.
Distally angulated roots can result in poor papilla fill. Orthodontic treatment to upright the roots along with recontouring the contacts of adjacent teeth to reduce the embrasure space leads to papilla fill.
Ingber et al described orthodontic forced eruption in order to change the bone level thereby creating more ideal soft tissue contours and creating new papillae.
Shapiro described a process of repeated SRP and curettage during 3 months to induce proliferation of gingival tissue caused by inflammatory hyperplasia. Some papilla showed complete regeneration.
Local enlargement of tissue can potentially be achieved be injection or implantation of materials used in modern plastic surgery.

Surgical papilla reconstruction

Surgical reconstruction is difficult and limited by the small area of the papilla with minor blood supply.
Beagle described a technique using a pedicle flap between 2 central incisors without any graft (Roll technique by Abrams + papilla preservation tech by Evian) . Achieved better results than FFG because sufficient blood supply.
Han and Takei performed a technique where the interdental papilla was displaced coronally + sub epithelial CTG (modification of Tarnow’s semilunar coronally repositioned flap). For patients who presented with an endosseous implant in the region of the maxillary right central incisor this procedure maybe repeated 2-3 times after 2-3 months of healing.
Tinti and Parma-Benfenati describe a combination new flap design on the facial aspect by Huzeler and Wang + coronally positioned palatal sliding flap on the lingual aspect. This technique may allow for better handling of the papilla while adding graft material.
Infracrestal and supracrestal bone defect might be filled with Bone grafting materials and covered with a bioresorbable barrier membrane fixed with bioresorbable pins. Then, re-adapt the flap coronally without any tension.

Prosthetic solutions:

For poorly positioned and contoured teeth, restorations can be utilized to recontour the contact and embrasure areas which can develop soft tissue profiles. This can be achieved through modification of provisionals over time.
Alternatively, hard and soft tissue defects can be disguised with the use of pink acrylic/porcelain in the deficient areas.

Topic: Inter-implant Distance
Author: Tarnow D.P., Cho S.C., Wallace S.S.
Title: The effect of Inter-Implant Distance on the Height of Inter-Implant Bone Crest
Source: J Periodontal 71:546-549, 2000
Type: Radiographic Study

Background: once 2-stage implants are uncovered, an implant-abutment interface is established and apical bone resorption of 1.5-2 mm is evidenced apical to the newly established implant-abutment interface.

Purpose: To evaluate the lateral dimension of bone loss at the implant-abutment interface and to determine if this lateral dimension has an effect on the height of the crestal bone between adjacent implants separated by different distances.

Materials: 36 patients. Radiographic measurements taken minimum 1 and maximum 3 years after implant uncovery. All radiographs were taken with a parallel technique utilizing a customized XCP bite block as a positioning index for consistency. Radiographs were scanned, imaged, and magnified for measurement. The lateral distances from the crest of the interimplant bone to the implants were recorded (A and B). The radiographs were divided into 2 groups: inter-implant distance was 3mm or less and those greater than 3 mm.

Results: Lateral distance from the implant to crest of ridge was 1.34 mm for A and 1.40 mm for B. Crestal bone loss for implants with a 3 mm or less distance between them was 1.04 mm and for implants with >3 mm apart was 0.45 mm.

Conclusion: There is a lateral component to the bone loss after abutment connection of 2 stage implant and that there is greater inter-implant crestal bone loss if the 2 implants are not spaced more than 3 mm

Topic: Papillae Characteristics around implants and teeth
Authors: Choquet V, Hermans M., Adriaenssens P., Daelemans P., Tarnow DP, Malevez C.
Title: Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region.
Source: J Periodontol. 2001 Oct; 72(10): 1364-71.
Type: retrospective study
Keywords: Dental papilla/ anatomy and physiology; dental implants, single tooth; oral surgery/methods

Purpose: To determine whether the distance from the base of the contact point to the crest of the bone would correlate with the presence or absence of interproximal papillae adjacent to single tooth implants and whether the surgical technique at uncover influences the outcome.

Methods: A clinical and radiographic retrospective evaluation of 26 patients with 27 implants and the papilla level around single implants and adjacent teeth was performed in the anterior maxilla. 6 months after implant placement, 17 implants were uncovered with standard technique and 10 implants uncovered with papilla generating technique. 52 papilla were evaluated clinically and radiographically. Presence or absence of papilla was evaluated as well as the following variables:

Influence of 2 different surgical uncover techniques
Vertical relation between papilla height and crest of bone between implant and adjacent teeth
Vertical relation between papilla level and contact point between the crowns of teeth and implant
Distance from contact point to crest of bone

Results: When the distance from contact point to crest of bone was <5mm the papilla was present almost 100% of the time. If the distance was >6mm, papilla present 50% of time or less. The average distance between the crest of bone and most coronal papilla was 3.85 mm. The papilla generating uncover technique increased papilla to 4.01 mm compared to conventional uncover at about 3.77mm.

BL: There is a strong correlation of the bone crest and the presence or absence of papillae between implants and adjacent teeth. The results also show a positive influence for the modified surgical technique to generate more papillae.

Topic: Papillae Characteristics around implants and teeth
Authors: Salama H, Salama MA, et al.
Title: The Interproximal height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement
Source: 2003 update of 1998 Pract Periodontics Aesthet Dent
Type: Review

Purpose: A review and follow up to the 1998 article

Discussion: The 1998 article illustrated deficiencies in the regeneration of interproximal papillae. In this review, new measurements were taken from the most coronal peak of bone and its overlying tissue dimension. New data shows the existence of a “predictably achievable papilla height,” is defined as the maintainable papilla length in the maxillary anterior sextant as measured from the most coronal interproximal bone height (IHB) for all tooth replacement permutations.

Conclusion: New data shows that predictable soft tissue vertical dimensions in the optimized maxillary anterior interproximal site cannot be represented by one measurement or number. The dimensions are affected and differ significantly by the various possible combinations of tooth, implant, and Pontic which may border a specific interproximal site.

Topic: Connective tissue grafting
Authors: Kan JY, Rungcharassaeng K.
Title: Interimplant papilla preservation in the esthetic zone: a report of six consecutive cases.
Source: Int J Periodontics Restorative Dent. 2003 Jun; 23(3):249-59.
Type: Case series
Keywords: papilla, estehtics, immediate placement, soft tissue

Purpose: To explore the concept of preserving existing osseous and gingival architecture by alternating immediate implant placement and provisionalization (aka “interimplant papilla preservation technique”) in a long spanning restored ridge.

Materials and Methods:The study subjects included patients with impending loss of multiple adjacent teeth in the anterior maxilla (canine to canine) for whom implants had been determined as the treatment of choice.

Interimplant papilla preservation following removal of multiple anterior adjacent teeth was determined

by three factors:

Timing: The papilla must be maintained at the time of tooth removal.
Spacing: An interimplant distance of at least 3 mm must be established.
Sequence: The failing teeth are to be replaced alternately to ensure periimplant tissue stability.

The final three dimensional implant position and angulation were achieved as follows:

Apicocoronally: The implant neck was placed approximately 3 mm apical to the zenith of the predetermined facial free gingival margin of the final restoration.
Mesiodistally: The implant was placed at the center of the predetermined mesiodistal width of the final restoration, with a minimum distance of 2.0 mm from the root of the adjacent tooth.
Labiopalatally: The implant was placed slightly lingual to the predetermined buccolingual width of the final restoration and along the palatal wall of the extraction socket for stability. The implant emerged slightly labial to the predetermined incisal edge of the final restoration to avoid perforation of the labial bone.

Each patient was evaluated every 3 months during the first year and every 6 months thereafter. Sequential periapical radiographs were made every 6 months to evaluate periimplant marginal bone changes. The marginal bone level was measured in relation to the implant radiographic reference point at the mesial and distal aspects of the implant neck. The interimplant papilla was assessed using the papilla index score (PIS) before the implant treatment and 6 months after the final implant restorations were in place. The PIS was defined as: 0 = no papilla; 1 = less than half the height of the papilla; 2 = at least half of the height of the papilla but not all the way to the contact point; 3 = papilla fills the entire proximal space; and 4 =hyperplastic papilla.

Results: All 14 implants placed in six consecutive patients maintained osseointegration after a mean functioning time of 22.6 months (range 12 to 34 months). No marginal bone changes greater than 1 mm were observed at the mesial and distal aspects of any implant. All eight interimplant papillae had been maintained with a mean PIS of 3, compared to the
mean pretreatment PIS of 2.75. Less than 1 mm of gingival recession was noted in the facial aspect of all implants. All patients were satisfied with the final esthetic outcome, and none reported any noticeable changes in the gingival level or architecture.

Conclusioins: Strategic timing and pre-surgical planning is critical in ultimate esthetic outcome.

Topic: Interproximal papilla
Authors: Tarnow D et al
Title: Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants.
Source: J Periodontol. 2003 Dec;74(12):1785-8.
Type: Clinical Study
Keywords: dental esthetics, dental implantation, dental papilla/anatomy and histology; soft tissue /anatomy and histology

Purpose: To measure the average height of tissue from the crest of the bone to the tip of the papilla between two adjacent implants.

Methods: Pts from 5 private dental offices who had implants placed adjacent to each other and who had a fixed prosthesis in place for at least 2 months were included. Anterior and posterior implanted sites were included, implants were placed in regenerated as well as in natural bone with the implant abutment interface located at or coronal to the alveolar crest, one and two-stage implants were included. A total of 136 inter-implant papillary heights were examined in 33 patients. After administration of appropriate local anesthesia, a standardized periodontal probe was placed vertically from the height of the papilla to the crest of bone. The measurements were rounded off to the nearest millimeter

Results: The mean height of papillary tissue between two adjacent implants was 3.4 mm, with a range of 1-7mm. The most frequently probed heights were 2mm (16.9%), 3mm (35.3%), and 4mm (37.5%).

Bottom line: 2mm to 4mm (average 3.4 mm ) of soft tissue height can be expected to cover the inter-implant crest of bone. In esthetic zone, need to proceed cautiously when placing two implants adjacent to each other

Topic: papilla

Authors: Pini Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R.
Title: Interdental papilla management: a review and classification of the therapeutic approaches.
Source: Int J Periodontics Restorative Dent. 2004 Jun; 24(3):246-55.
Type: review

Keywords: interdental papilla management, black triangles, classification, periodontal therapy, review

Purpose: Several surgical and non-surgical techniques have been proposed to treat soft tissue deformities and manage the interproximal space. This review categorizes the various approaches in different clinical situations.

Discussion:

Classification:

There are several classifications for the loss of papilla height.

Norland and Tarnow classification:

– Normal: interdental papilla fills the embrasure to the apical extent of the contact

– Class I: the tip of the papilla lies between the contact and the most coronal extent of the proximal CEJ

– Class II: the tip of the papilla lies at or apical to the interproximal CEJ but coronal the apical extent of the facial CEJ.

– Class III: the tip of the papilla lies level with or apical to the facial CEJ.

Nonsurgical approaches:

Correction of traumatic oral hygiene procedures.

Restorative/prosthodontic restorations: correction of the abnormal tooth shape, locating the contact point more apically. Orthodontic approach: closing diastema with moving the teeth bodily, results in creeping of the interdental papilla between two adjacent teeth. Repeated curettage of the papilla: this instrumentation may induce a proliferative hyperplastic inflammatory reaction of the papilla.

Surgical approaches:

Papilla recontouring: gingivectomy in cases of gingival hyperplasia

Papilla preservation: can prevent or reduce apical displacement of the papilla.

Papilla reconstruction: some techniques have been proposed to reconstruct the interdental tissue. Beagle et al in 1992 described a technique combining a pedicle flap with papilla preservation. A palatal split-thickness flap is dissected and labially elevated. The flap is folded on itself and sutured to create the new papilla. Han and Takei proposed used semi-lunar incision placed in the alveolar mucosa of the interdental area, elevating a split-thickness flap and the coronal displacement of the gingivopapillary unit.

Some authors have proposed using a palatal and labial split-thickness flap with a CT graft for reconstruction of the papilla.

Some attempts have been proposed to recreate the scalloped positive architecture of the soft tissue around implants. One novel technique consists of buccal dislodgement of a full-thickness flap raised from a site slightly more palatal to the implant. New suturing approach, ramp mattress suture, provides a coronal pulling traction. After 4 to 5 weeks, a vestibular scalloped gingivectomy is performed in correspondence to the vestibular surface of the abutments to create a positive architecture of the gingival margin.

Conclusion: Although more and more sophisticated approaches showing good results have been proposed to restore the lost papilla, the predictability of various procedures has not been completely documented, and no data on the long-term stability are available.

Topic: Interdental papilla
Author: Zetu, L., Wang. H-L
Title: Management of inter-dental / inter –implant papilla
Source: J Clin Peridontol 2005; 32:831-839
Type: Review
Keywords: Bone grafts; dental implants; esthetic; guided bone regeneration; interdental/inter-implant papillae; monocortical bone graft; papillae; soft-tissue grafts

Purpose: To evaluate factors that influence interdental and inter-implant papillae, and discuss and compare existing techniques that are currently available and to present the approach that the authors developed that could help clinicians to manage and recreate the interproximal papillae.

Discussion:

Anatomy of the interdental-inter-implant papilla:

Interdentally, the gingiva that occupies the space coronal to the alveolar crest is known as interdental gingiva.
In the incisor area, it has a pyramidal shape with the tip located immediately beneath the contact point; it is narrower and referred to as a dental papilla.
In the posterior region, it is broader and was formerly described as having a concave col or bridge shape (Cohen 1959). Moreover, the col is a valley-like depression, which connects the buccal and lingual papilla and takes the form of the interproximal contact.

Factors influencing the presence of papilla:

The foundation for the gingival support is the underlying contour of the osseous crest. Presence of adjacent tooth attachment and the volume of the gingival embrasure influence the papillary existence.
Tarnow (1992) examined the existence of interdental papillae in humans. He found that when the distance from the contact point to the alveolar bone was less or equal to 5mm, the papilla was present 98% of the time; while at 6mm it dropped to 56% present, and at 7mm it was only present 27%. Hence, it was concluded that the vertical height from the base of the contact to the crest of the bone is a key-determining factor in maintaining the papilla.
Norland and Tarnow (1998) Papillary loss classification
- Class I: when the tip of the papilla was found between the contact point and the interproximal CEJ (with no visual appearance of the inter-proximal CEJ)
- Class II: when the tip of the papilla is at or apical to the interproximal CEJ but coronal to the facial CEJ
- Class III: when the tip of the papilla is at or below the level of the facial CEJ

Bone Support for Preservation of the Papillary Height

Bone loss may lead to compromised dental placement and aesthetic problems in the interdental papillary area.
Ridge preservation is an important technique to help prevent major bone loss in the horizontal direction following tooth extraction, and actually leads to a gain in vertical height.
GBR or bone augmentation to create bone volume that is needed for supporting the papilla appearance has also been recommended. These techniques include GBR to augment horizontal and minimal vertical bone height (Wang and Al-Shammari 2002), onlay grafting (Cordara et al. 2002) and combinations of soft- and hard-tissue grafting (Nemcovsky and Artzi 1999)

Soft –tissue manipulation for preservation of the papillary height:

Various soft tissue surgical procedures have been introduced in an attempt to recreate the papilla such as techniques from Azzi (1998, 2001), Takei (1985-papilla preservation technique), Beagle (1992-papilla reconstruction technique using palatal split-thickness flap), Tinti (2002-ramping technique, in chich healing abutments are used to “tent up” a FTF flap with a modified vertical mattress suture), Misch (2004: split-finger technique to preserve/promote papillae formation. Predictability of these techniques remains to be determined.

Restorative Attempt to Correct the Aesthetic Challenge:

The restorative dentist may fabricate an immediate tooth replacement using an ovate pontic bonded to the adjacent teeth. The ovate pontic allows for natural-appearing emergence profile and allows easy access for OH (Spear 1999).
The pontic should extend initially 2.5mm below the free gingival margin. This will allow the pontic to be situated within 1mm of the facial and interproximal bone and will give support to the surrounding facial gingiva and interdental papilla.
After a 4-wk healing period, the height of the pontic should be adjusted to extend approximately 1.5mm below the tissue (Spear 1999).
Unfortunately, that are some situations when all methods of hard and soft tissue augmentation techniques fail. When this occurs, prosthetic techniques must be used to imitate the papilla (pink composites, pink acrylic/porcelain).
Alteration of the contact point will aid in simulating a papilla. However, no presently available spectrum of ceramic shades exists to guarantee an aesthetically satisfactory gingival contour.

Topic: Papillae characteristics around implants and teeth
Author: McGuire MK, Scheyer ET
Title: A randomized, double-blind, placebo-controlled study to determine the safety and efficacy of cultured and expanded autologous fibroblast injections for the treatment of interdental papillary insufficiency associated with the papilla priming procedure
Source: J Periodontol. Jan; 78(1):4-17. 2007
Type: Clinical study
Keywords: Cell transplantation, fibroblasts, tissue engineering

Purpose: To test the hypothesis that cell transplantation, locally delivered with injections of autologous fibroblasts, results in expansion of interdental gingival soft tissue volumes in subjects with papillary insufficiencies.

Methods: 20 patients with open interproximal spaces, with at least 2 sites per patient were selected for this study. Subjects were randomly selected to receive autologous fibroblast injections taken from a 3mm punch biopsy of KG from the tuberosity area or placebo (cell culture media) 5-7 days after priming the papilla through controlled surgical insult. Priming was used to induce a transient, acute inflammatory response in the papilla, temporarily increasing the volume of tissue to allow a larger injection of cell suspension. Repeated injections were done at 7-14 days after the first injection and 7-14 days after second injection. Photographs, measurements of papilla to contact distance, and diagnostic models were used. Papillary height was measured at 4 months after the procedure.

Results: The primary efficacy analysis was the difference, from baseline to 4 months, in the percentage change of the distance from the tip of the papilla to the base of the contact area in the primary treatment areas. The results of this analysis failed to show a treatment effect. Papillary height at 2 months showed better results in test group, but results were not statistically significant. Patients and clinicians were asked to assess results using a visual analogue scale and both reported better results with test over placebo. The material was determined to be safe.

Discussion: The results of this study suggest that injection of cultured autologous fibroblasts is safe, and may be efficacious, for the treatment of papillary insufficiency based on VAS assessments by patients and investigators. However, endpoints failed to show evidence of treatment effect when considering distance from the tip of the interproximal papilla to the base of the contact area, measurements from the dental arch molds or the digital photographs, distance from the tip of the papilla or the base of the contact area to the alveolar crest, and width of the interproximal spaces.

Topic: Peri-implant papilla
Author: Chow YC, Wang HL
Title: Factors and techniques influencing peri-implant papilla
Source: Implant Dent 2010; 19(3): 208-219
Type: Review
Keywords: implant, papilla, esthetics, interproximal soft tissue

Purpose: To review the potential clinical factors that may influence the appearance of peri-implant papilla and discuss the current techniques of peri-implant papilla enhancement.

Methods: MEDLINE search was performed to identify articles related to implant esthetics and papillae.

Discussion:
Potential clinical factors

Dental papilla enhancement techniques:

Hard tissue management is essential in implant dentistry, since controlling and conserving the hard tissue height can help in achieving papillary height.
Therefore ridge preservation at the time of tooth extraction is critical to prevent the loss of underlying bone. Tooth should be extracted with the minimal possible trauma.
Immediate implant placement may allow preservation of the bone and surrounding tissues.
Kan’s study showed bone loss of less than 0.3mm at 12 months when implants were immediately placed and provisionalized. Midfacial, mesial and distal gingival levels lost an average of 0.55mm, 053mm and 0.39mm.
If multiple adjacent teeth are going to be extracted alternate removal of teeth can be performed, and the remaining teeth will support the interproximal tissues from one side and also can be used as guides for implant placement.
Flapless implant placement will also provide esthetic soft tissues profile around single – tooth implant restorations regardless of the loading protocol.
Flap design should be as limited as possible and minimize the risk of papilla loss.

Surgical reconstruction of deficient dental/periimplant papillae

Palacci developed a technique at stage 2 uncover for multiple implants. After the flap is elevated a semilunar incision is made in relation to each implant to create a pedicle. The pedicle is then rotated 90 degree towards the mesial aspect of the abutment and stabilized with interrupted suture.
Connective tissue grafts can also be used. None of these procedures provide evidence of predictability and few demonstrate long-term stability.

Non-surgical reconstruction techniques

Restoratively the shape and length of the crown can be changed and the contact point can be used more apically.
The use of ovate pontic can help in molding the papillary height and gingival embrasure form.
When teeth are indicated for extraction, forced orthodontic extrusion should be considered to enhance hard and soft tissue profiles.
McGuire and Scheyer introduced innovative papilla priming procedure, in an attempt to enhance papillary form. The deficient sites received autologous fibroblast injections but the treatment effect was stable at 2 months and disappeared at 4 months.

Conclusion: Crestal bone level seems to be the primary factor for the presence of peri-implant papilla. Interproximal distance may also affect the existence of the papilla.

Topic: Treatment of root surface for root coverage treatment.
Author: Becker W., Gabitov I., Stepanov M., Kois J., Smidt A., Becker B.E.
Title: Minimally invasive treatment for papillae deficiencies in the esthetic zone: a pilot study
Source: Clin Implant Dent Relat Res. 2010 Mar; 12(1):1-8.
Type: Pilot Study

Purpose: To evaluate a new method for reducing or eliminating small papillary deficiencies.

Methods: Eleven patients, seven females and four males with an average age of 55 years old with 14 treated sites where included in the study. 2 of the patients required treatment for more than one site. The treated sites had deficient papillae adjacent to teeth or implants. Less than 0.2ml was injected 2-3mm apical to the papilla, patients were seen three weeks after the initial treatment and photographed, and if the dark space remained another injection was applied. The process was repeated up to 3 times. Then the patients were followed up from 6 to 25 months after the initial application. The photographs were submitted to an outside consultant for determination of measurement changes between initial and final treatments.

Results: A total of 14 dark spaces were treated (4 teeth, 10 implants). An outside consultant applied a unique method and reproducible mathematical formula for evaluating small, dark spaces between teeth or dental implants. Each site was individually evaluated for percentage change between initial and final applications. The method measures changes in dark spaces from clinical photographs. Two implant sites and one site adjacent to a tooth had 100% improvement between treatment intervals. Seven sites had from 94 to 97% improvement, three sites improved from 76 to 88%, and one site adjacent to an implant had improved 57%. Eight sites required two papilla injections and six required three treatments.

Conclusion: The use of an injectable hyaluronic gel to enhance papillary esthetics after implant treatment should be evaluated in a controlled clinical study. The results of this pilot study are promising.

Topic: Papillae Characteristics around implants and teeth
Authors: Froum S., Lagoudis M., Rojas GM., Suzuki T., Cho SC.
Title: New surgical protocol to create interimplant papilla: The preliminary results of a case series.
Source: Int J Periodontics Restorative Dent. 2016 Mar-Apr; 36(2):161-8.
Type: case series
Keywords: interimplant papilla, regeneration

Purpose: To discuss a new surgical technique to regenerate the papilla adjacent to multiple or single implants using novel instrument and a new incision design

Methods: 10 patients with maxillary anterior implant-supported provisional restorations and missing interproximal papillae (score O to 1) received a subepithelial CTG. The recipient site was prepared with an oblique buccal incision apical to the mucogingival junction and the defective papilla, a and an oblique palatal incision followed by a buccolingual tunneling performed with the translingual curette. The CTG was inserted into the recipient site through the buccal incision and pulled under the papillae through the lingual incision and positioned over the interproximal papilla area. The 10 sites were treated and evaluated pre and postoperatively with the papilla score based on the Jemt classification.

Results: An average improvement in papilla index score from .8 to 2.4 was found after an average of 16.3 months follow-up. In only one case was no improvement observed.

BL: This case series demonstrated that interimplant papilla regeneration can be successful over a period of 11 to 30 months postloading. Long-term prospective studies on tissue stability and esthetic outcomes are needed.

Topic: Papillae Characteristics around implants and teeth
Authors: Goiato MC, de Medeiros RA, da Silva EVF, Dos Santos DM
Title: Evaluation of the papilla level adjacent to implants placed in fresh, healing or healed sites: A systematic review
Source: Int J Oral Maxillofac Surg. 2017 May 15
Type: Systematic Review
Keywords: dental implants; dental papillae; single-tooth implants.

Purpose: To perform a systematic review of the literature regarding the formation or recession of papilla adjacent to implants placed in fresh, healing or healed sites.

Method: An electronic search was performed by two independent reviewers who applied the inclusion and exclusion criteria on the PubMed/MEDLINE, Scopus, and Embase databases from January 2005 up to February 2016.

Results: The initial screening yielded 1,065 articles, from which 15 were selected for a systematic review after applying the inclusion and exclusion criteria. Nine studies compared fresh and healed sites, four studies compared healing and healed sites, one study compared fresh and healing sites, and one study analyzed all three sites. The majority of studies identified by this systematic review showed no difference between groups after the longer follow-up period.

Conclusion: The sites where the implants were placed did not have a long-term influence on papilla formation or recession.

Esthetic Crown Lengthening

Topic: Diagnosis
Authors: Garber D, Salama MA
Title: The aesthetic smile: diagnosis and treatment.
Source: Periodontol 2000. 1996 Jun; 11:18-28.
Type: Discussion
Rating: Good
Keywords: Dental esthetics; dental restoration; permanent; gingival recession; glass ionomer cements; tooth abrasion; tooth cervix

Discussion:

In the composition of a beautiful smile, the form, balance, symmetry and relationship of the elements make it attractive or unattractive. The essentials of a smile involve the relationships between the three primary components:

1) The teeth

The dentist is concerned with the color, the position, and the shape or silhouette form of teeth. The advent of adhesive dentistry has allowed literally an instantaneous change in the color, the shape and the position of teeth via bonding techniques such as porcelain laminate veneers and direct composite bonding.

2) Lip framework

The lips form the frame of a smile and as such, define the aesthetic zone. Liplines have classically been defined as being high, medium or low.

o Low lipline: only a portion of the teeth are exposed below the inferior border of the upper lip.

o High lipline: shows a large expanse of gingiva extending from the inferior border of the upper lip to the free-gingival margin.

3) The gingival scaffold.

Periodontic plastic procedures, such as the basic gingivectomy, soft tissue grafting or the apically positioned flap, may be used to change the silhouette form of teeth and their relative proportion

The Gummy Smile

Altered passive eruption:

Altered passive eruption is an aberration in normal development where a large portion of the anatomic crown remains covered by the gingiva. This complicates developing dentofacial harmony for

two dominant reasons:

1) The tissue being positioned coronally on the teeth results in a silhouette form that is unattractive. There is only a nominal degree of scallop to the free gingival margin, resulting in a tooth shape that is somewhat square instead of a more attractive elliptical or ovoid form.

2) The excess soft tissue tends to be displayed below the inferior border of the upper lip, complicating the desired relationship in that it makes a potentially medium lipline into a high lipline.
Altered passive eruption has been classified into two distinct types:

Type I, there is typically an excessive amount of gingiva, as measured from the free gingival

margin to the mucogingival junction. Typical cases exhibit short, square-looing teeth and an expanse of gingiva below the inferior border of the upper lip

- Type A: dimensions between the level of the CEJ and osseous crest is > 1mm which is sufficient for the insertion of CT component of biologic width
- Type B: detected by bone sounding, osseous crest occurs in close proximity to the CEJ, thereby diminishing the space for insertion of CT of the biologic width
Type II: there is a normal dimension of gingiva when measured from the free gingival margin to

the mucogingival junction. Although these might appear to be clinically similar in that there is tissue extended over the coronal portion of the tooth, therapeutically the diagnosis between the two

types is essential to determine the appropriate treatment modality

Topic: Anatomic crown width/length
Authors: Magne P, Gallucci GO, Belser UC
Title: Anatomic crown width/length ratios of unworn and worn maxillary teeth in white subjects.
Source: J Prosthet Dent. 2003 May; 89(5):453-61.
Type: Retrospective study
Rating: Good
Keywords: crown width/length ratios, dimension, incisal wear

Background: Dimensions of teeth have been available for a century. Some significant and clinically relevant aspects of dental esthetics, however, such as the crown width/length ratios, have not been presented in tooth morphology sources until recently.

Purpose: To analyze the anatomic crowns of 4 tooth groups (central incisors, lateral incisors, canines, and first premolars) of the maxillary dentition with respect to width, length and width/length ratios and determine how these parameters are influenced by the incisal edge wear.

Methods: Standardized digital images of 146 extracted human maxillary anterior teeth from white subjects (44 central incisors, 41 lateral incisors, 38 canines, 23 first premolars) were used to measure the widest mesiodistal portion “W” (in millimeters) and the longest inciso-cervical/occluso-cervical distance “L” (in millimeters). The width/length ratio “R” (%) was calculated for each tooth. A 1-way analysis of variance was used to compare the mean values of W, L, and R for the different groups (“unworn” and “worn” subgroups, except for premolars). Multiple least significant difference range tests (confidence level 95%) were then applied to determine which means differed statistically from others.

Results: There was no influence of the incisal wear on the average value of W (width) within the same tooth group. The widest crowns were those of central incisors (9.10 to 9.24 mm) canines (7.90 to 8.06 mm) lateral incisors (7.07 to 7.38 mm). Premolars (7.84 mm) had similar width as canines and worn lateral incisors. The L-value was logically influenced by incisal wear (worn teeth were shorter than unworn teeth) except for lateral incisors. The longest crowns were those of unworn central incisors (11.69 mm) unworn canines (10.83 mm) and worn central incisors (10.67 mm) worn canines (9.90), worn and unworn lateral incisors (9.34 to 9.55mm), and premolars (9.33 mm). Width/length ratios also showed significant differences. The highest values were found for worn central incisors (87%) and premolars (84%). The latter were also similar to worn canines (81%), which constituted a homogeneous group with worn lateral incisors (79%) and unworn central incisors (78%). The lowest ratios were found for unworn canines and unworn lateral incisors (both showing 73%).

Conclusions: Along with other specific and objective parameters related to dental esthetics, average values for W (mesiodistal crown dimension), L (incisocervical crown dimension), and R (width/length ratio) given in this study for white subjects may serve as guidelines for treatment planning in restorative dentistry and periodontal surgery

Topic: excessive gingival display
Authors: Silberberg N, Goldstein M, Smidt A.
Title: Excessive gingival display– etiology, diagnosis, and treatment modalities
Source: Quintessence Int. 2009 Nov-Dec; 40(10):809-18.
Type: review

Rating: good

Keywords: altered passive eruption, diagnosis, etiology, excessive gingival display, gummy smile, vertical maxillary excess (VME)

Purpose: to discuss the various aspects of excessive gingival display and its etiology and topresent the current solutions that exist in the literature.

Discussion:

Diagnosis:

– Facial examination:

o Facial symmetry and proportions in both frontal and lateral views

o Upper lip length at rest: is measured form the subnasale to the lower border of the upper lip. The average lip length is 20 to 24 mm in young adults and tends to increase with age

o Display of maxillary central incisors at rest: average display is 3 to 4 mm in young women and 2 mm in young men and tends to decrease with age.

o Amount of gingival exposure during rest, speech, smile, and laughter: during extensive smile, the upper lip should rest at the level of the midfacial gingival margins of the maxillary anterior teeth.

o Smile line: high smile line: reveals the entire crown of the tooth and abundant amount of gingiva. In average smile line: 75% to 100% of the crowns is revealed with the IP gingiva. A low smile line when less than 75% of the crowns is revealed.

o Gingival margin outline: The outline of the gingival margins should be parallel to both the incisal edges and the curvature of the lower lip. The gingival margins of the maxillary central incisors and the canines should be symmetric and in a more apical position than those of the lateral incisors.

– Intraoral examinations:

o Occlusal plane: The occlusal plane should closely coincide with the imaginary line connecting the commissures of the lips and two-thirds the height of the retromolar pad

o Harmony of the dental arches

o Anatomy, proportion, and color of the teeth

o Periodontal examination: The periodontal biotype may influence the reaction of the gingival tissues to periodontal therapy and surgery. There are 3 periodontal biotypes: thin and scalloped, normal, and thick and flat.This information has a crucial influence on the strategies and decisions.

Etiology of excessive gingival display and treatment modalities:

– Altered/delayed passive eruption: Passive eruption is a normal condition in which the gingival margins recede apically to the level of the CEJ after the tooth has erupted completely. In cases in which the gingival margins fail to recede to the level of the CEJ, the condition is named altered passive eruption. Because the gingival tissues are positioned coronal to the CEJ, the teeth appear short and square. The incidence in general population is about 12%.

A classification for altered passive eruption was suggested by Coslet et al:

Type 1A—excessive amount of keratinized gingiva with normal alveolar crest–to–CEJ relationship
Type 1B—excessive amount of keratinized gingiva with osseous crest at the CEJ level
Type 2A—normal amount of keratinized gingiva with normal alveolar crest–to–CEJ relationship
Type 2B—normal amount of keratinized gingiva with osseous crest at the CEJ level

– Anterior dentoalveolar extrusion: Overeruption of the maxillary incisors with their dentogingival complex leads to a more coronal position of the gingival margins and excessive gingival display. Treatment of this condition may include orthodontic intrusion of the involved teeth moving the gingival margin apically, surgical periodontal correction with or without adjunctive restorative therapy, or an interdisciplinary comprehensive treatment plan

– Vertical maxillary excess (VME): this involves an overgrowth of the maxilla in the vertical dimension.

– Short upper lip: when the upper lip is less than 15 mm, measured from subnasale to lower border of the upper lip.

– Hyperactive upper lip: increased activity of the elevator muscles of the upper lip during smile.

– Asymmetric upper lip

Treatment considerations:

Gingivectomy is indicated when there is excess keratinized soft tissue and the bone level is appropriate. Careful evaluation must take place before surgery so that adequate keratinized gingival tissues will remain after surgery. This procedure applies to cases of gingival overgrowth and altered passive eruption type 1A.

Apically positioned flap without osseous resection is recommended for cases in which the bone level is appropriate but gingivectomy will leave less than 3 mm of keratinized gingival tissues. This is performed in cases of altered passive eruption type 2A.
Apically positioned flap with osseous resection is recommended for all other cases where osseous resection is required. The osseous resection should bring the bone crest 2.5 to 3.0 mm away apically from the CEJ or from the definite location of the finishing line of the final restoration to achieve a physiologic biologic width.

Restorative therapy should be planned in cases of excessive gingival display in the following situations: (1) short clinical crowns due to loss of tooth structure (ie, tooth wear);

(2) existing faulty restoration or following an esthetic complaint by the patient; and

(3) exposed roots as a consequence of periodontal therapy causing teeth hypersensitivity and impaired esthetics.

Conclusion: In general, cases of excessive gingival display may have more than one etiology and should therefore be diagnosed carefully, and an interdisciplinary treatment should be considered. It is of high importance to involve the patient throughout the process of diagnosing and treatment planning. An informed patient is a key factor to treatment success and personal satisfaction.

Topic: Esthetic crown lengthening
Author: Chu SJ, Tan JH, Stappert CF, Tarnow DP
Title: Gingival zenith positions and levels of the maxillary anterior dentition
Source: J Esthet Restor Dent. 2009; 21(2):113-20
Type: Clinical study
Rating: Good
Keywords: gingival zenith position; free gingival margin

Background: The gingival zenith position (GZP) is defined as the most apical point of the gingival marginal scallop. The location of the gingival zenith in a medial-lateral position relative to the vertical tooth axis of the maxillary anterior teeth remains to be clearly defined.

Purpose: To determine the GZP from the vertical bisected midline along the long axis of each individual maxillary anterior tooth; and the Gingival zenith level (GZL) of the lateral incisors in an apical-coronal direction relative to the gingival line joining the tangents of the GZP of the adjacent central incisor and canine.

Methods:

20 patients (13f, 7m) with healthy gingival tissue (6 thick and 14 thin biotypes) were studied.
Alginate impressions were taken of the study group.
A digital caliper with an LED display used to measure the 240 sites of the maxillary teeth from canine to canine.

Results:

100% of central incisors displayed a distal GZP from the Vertical bisected midline (VBM)
65% of lateral incisors displayed a distal GZP from the VBM
35% of lateral incisors displayed a centralized GZP
All but one canine showed a centralized GZP
The mean GZL of the lateral incisors relative to the central incisor and canine was approximately 1mm (range 0 to 1.8mm).

Bottom Line: The mean location of the GZP from the VBM of the clinical crown of central incisors, lateral incisors and canines was 1mm, 0.4mm distally and 0mm. The GZL of the lateral incisor in relation to the canine and central incisor was approximately 1mm. These reference points could be used in conjunction with other subjective and objective esthetic parameters during diagnosis, treatment planning and in reconstructing a natural smile.

Topic: Esthetic crown lengthening
Author: Deas DE, Moritz AJ, McDonnell HT, Powell CA, Mealey BL
Title: Osseous surgery for crown lengthening: a 6-month clinical study
Source: J Periodontol. 2004 Sep;75(9):1288-94
Type: Clinical study
Rating: Good

Keywords: Alveolar bone, follow-up studies, surgical flaps, tooth/anatomy and histology, tooth crown/surgery

Purpose: To investigate the immediate increase in crown height following surgery, monitor the established crown height over time, determine how much supporting bone is removed during crown lengthening surgery, and investigate how the position of the flap margin relative to the alveolar crest at surgical closure relates to the stability of surgically created crown height.

Methods: 25 periodontally healthy patients requiring crown lengthening of 43 teeth participated in the study. Phase I therapy was completed if indicated. Alginate impressions were taken and customized probing stents were used for clinical measurements. 3 guidelines were given to each surgeon: 1) place the alveolar crest at least 3mm from the anticipated crown margin, 2) leave at least 9mm of clinical crown height coronal to the osseous crest 3) place the flap margin either at or apical to the anticipated restorative margin following suturing. During surgery, intrasulcular and/or internally beveled incisions, efull thickness flaps, flap thinning, osteoplasty and ostectomy were performed. All root surfaces were scaled and root planed, after which flaps were sutured and pressure was applied for 3 minutes. All sites on teeth targeted for crown lengthening were labeled treated sites (TT), and interproximal sites on neighboring teeth were labeled as follows: adjacent (AA) if they shared a proximal surface with a treated tooth and non-adjacent (AN) if they were on the opposite site, away from the treated tooth. Baseline clinical indices were recorded at eight sites on each molar and six sites on each premolar (PI, BOP, PD, distance from stent to the gingival margin, relative attachment level from the base of sulcus to the stent). Surgical measurements at the same sites included the distance from stent to the alveolar bone both before and after osseous surgery and the distance of from flap margin to alveolar bone after suturing. Clinical measurements were repeated at 1, 3, and 6 months after surgery.
Results: There was no significant difference between the percentage of treated sites with plaque and BOP at any time point. The decrease in PD was statistically significant from baseline to 1, 3, and 6 months for all three groups (TT, AA, AN). Attachment loss was noted for all three groups and was significant for each group compared to baseline. At TT sites, the mean increase in crown length following surgery was 2.27mm. This crown height was reduced to 1.91mm by 1 month, 1.69mm by 3 months and 1.57mm to 6 months. At each time point there was a significant increase in crown height compared to baseline but there was a trend toward reduced crown height over time. The same trend was noticed in adjacent and non-adjacent sites. The mean osseous reduction at treated, adjacent and non-adjacent sites was 1.13mm, 0.78mm and 0.065mm, respectively. When tissue rebound following surgery (6 months) was evaluated, it was noted that the closer the flap margin was sutured to alveolar crest, the greater the tissue rebound during the post- surgical period. The rebound averaged 1.33 mm when the flap was sutured 1mm or less from the alveolar crest, whereas it was -0.16 mm when the flap was sutured 4mm or more from the alveolar crest.

Discussion: The data presented suggest that there is significant marginal soft tissue rebound following crown-lengthening surgery that has not fully stabilized by 6 months. Coronal rebound appears to be related to the position of the flap relative to the alveolar crest at suturing. Clinicians should establish proper crown height during surgery without overreliance on flap placement at the osseous crest to gain necessary crown length.

Topic: biologic width and crown lengthening
Author: Lanning SK, Waldrop TC, Gunsolley JC, Maynard JG
Title: Surgical crown lengthening: evaluation of the biological width
Source: J Periodontol 2003; 74(4): 468-474
Type: Clinical study
Reviewer: Mary Elizabeth Bush
Rating: Good
Keywords: biologic width, crown lengthening, surgical, periodontium/anatomy and physiology, surgical flaps
Purpose: To evaluate the positional changes of the periodontal tissues, particularly the biologic width, following surgical crown lengthening over a 6-month healing period.

Methods: 23 periodontal healthy patients requiring surgical crown lengthening were included in the study. Prior to surgery, patients underwent prophylaxis and oral hygiene instruction. Acrylic stents were fabricated to standardize probe placement. Clinical parameters including plaque index (PI), gingival index (GI), pocket depth (PD), free gingival margin (FGM), attachment level (AL), and Bone level (BL) were observed prior to surgery, and at 3 and 6 months after. Measurements were taken at treated sites, and adjacent non-adjacent sites. Biologic width was calculated through probing and bone sounding. At the time of surgery, the level of the osseous crest was lowered based on the needed biologic width, positive architecture was maintained with adjacent teeth.

Results: 18 patients completed the study. No complications were observed with surgery or prosthetic treatment. 98% of the study teeth were restored with a fixed restoration by 6 months. At all sites there was a significant difference in the apical location of the free gingival margin but this did not vary from 3 to 6 months. For treated sites, there was significantly more attachment loss at 3 and 6 months compared to adjacent and non-adjacent sites. The biologic width at adjacent and non-adjacent sites was smaller at 3 and 6 months compared to baseline. The biologic width of treated sites at 6 months was no significant different from baseline.

Conclusion: Surgical crown lengthening is effective for the placement of prosthetic margins and maintenance of biologic width around a tooth. The biologic width at all treated sites was reestablished to its original dimension by 6 months. Additionally, the location of the free gingival margin was stable from 3 to 6 months.

Topic: Crown Lengthening
Author: Brägger U, Lauchenauer D, Lang NP
Title: Surgical lengthening of the clinical crown.
Source: J Clin Periodontol. 1992 Jan;19(1):58-63
Type: clinical
Rating: Good

Purpose: To assess the changes in the periodontal tissue levels as an intermediate result of the surgical crown lengthening procedure over a 6-month healing period

Methods: 25 patients ranging from 20 to 81 years of age were included in the study. A total of 85 teeth (43 experimental and 42 control teeth) were evaluated after 6 weeks and 6 months. All patients were subjected to initial periodontal therapy including OHI and scaling/root planing and removal of marginal irritants. The following clinical parameters were assessed at 6 sites (MB, B, DB, DL,L,ML) on each test tooth: Plaque index (PI), Gingival index (GI), distance from reference mark on the splint to the free gingival margin (FGM), distance from a reference mark on the splint to the alveolar bone (BL), distance from the reference mark on the splint to the probeable base of the pocket (AL). n order to standardize localization and direction of the probing procedures, grooves were drilled in a prefabricated hot-cured acrylic splint. By subtracting FGM from AL the probing pocket depths (PD) were calculated. During surgery, the alveolar crest was reduced, thereby creating a distance of 3 mm to the future reconstruction margin.

Results: At 68 sites, 1mm of crestal alveolar bone was removed during the procedure, at 43 sites 2mm, and at 9 sites 3-4mm.

The results of this study demonstrated that once defined by surgery the mean changes of the level of the FGM were minimal and were comparable to the shifts in the FGM level occurring at the control teeth.

Conclusion: It may be concluded, that creating a distance of 3 mm from the alveolar crestal bone level to the future reconstruction margin during surgical lengthening of the clinical crown leads to stable periodontal tissue levels over a period of 6 months.

Topic: Esthetic Crown Lengthening
Authors: Fletcher P.
Title: Biologic rationale of esthetics crown lengthening using innovative proportion gauges.
Source: Int J Periodontics Restorative Dent. 2011 Sept-Oct; 31(5): 523-32.
Type: case report
Rating: good
Keywords: crown lengthening; biologic width; tooth proportion relationship; esthetics

Background: The goals of clinical crown lengthening include providing adequate tooth structure for placement of restorative margin and establish a healthy dentogingival complex for subsequent fabrication of a well-fitting, esthetically pleasing definitive restoration.

Biologic width: average measurement of 2.73mm (.97mm epithelial attachment, 1.07mm connective tissue, and .69mm for sulcus depth).

The consensus of opinion is that atleast 2mm of exposed tooth structure is needed for crown retention in addition to .97mm of junctional epithelial length and 1.07mm connective tissue barrier, which makes the ideal length atleast 4.0mm of superosseous tooth structure available for placement of restorative crown and establishment of an attached apparatus.

Purpose: to present a biologically based, step-by-step approach to periodontal esthetic crown lengthening using a series of color-coded measurement gauges.

Case 1: 29 y/o male dissatisfied with appearance of smile and was determined after periodontal exam that clinical crown lengthening was indicated with esthetic restorations of 4 maxillary incisors. Chu Aesthetic Gauges were used as guides to establish the correct occlusogingival (length) of the tooth as a function of its width and the correct papilla position as a function of its length. The gauge also determines the correct biologic length of each crown as a function of the clinical length.

T-bar proportion gauge placed on incisal edge and the length is determined based on width using the horizontal and vertical markings. The colored markings on the arms correspond to each other (the markings on the vertical arm are 3mm longer than the horizontal arm). This marking indicates location of bone crest midfacially relative to gingival margin. The addition 3mm provides adequate tooth structure for the biologic width.
Bleeding points established at zenith of desired clinical crown length and the Periogauge tip replaced Proportion Gauge. A gingivectomy was performed to desired color markings of short arm of Periogauge. The bone was recontoured on the direct facial to the appropriate markings on the long arm of Periogauge. Interproximal papilla will reform if the distance from the base of the contact to the crest of bone is 5mm or less.
The Papilla Tip Gauge longer arm measures the height of the interproximal bone crest to incisal edge. The corresponding color codes on the shorter papilla arm are 4mm coronal. This is a visual for the surgeon to see where the papilla should end in relation to the interproximal bone crest.
Length of papilla has been found to be about 40-50% of the length of the tooth, so it should only be shortened .4 to .5 mm for every 1.0mm that is disproportionate to the length of the clinical crown

Results: Healing was uneventful with soft tissue healing completed after 8 weeks, while osseous remodeling continues for over one year. Definitive restoration can be placed after 8-12 weeks of healing.

BL: This type of objective measuring device is a valuable aid in assuring sufficient tooth structure is exposed, as well as in establishing a clinical crown with an ideal width to length proportional relationship.

Topic: Esthetic Crown Lengthening
Authors: Batista EL Jr, Moreira CC, Batista FC, de Oliveira RR, Pereira KK
Title: Altered passive eruption diagnosis and treatment: a cone beam computed tomography-based reappraisal of the condition.
Source: J Clin Periodontol. 2012 Nov; 39(11):1089-96
Rating: Good
Keywords: altered passive eruption; computed tomography; cone beam; crown; aesthetic; lengthening; surgeries; tooth eruption

Purpose: To characterize anatomical features of altered passive eruption (APE)- affected teeth using cone beam computed tomography (CBCT) and to present a novel combined surgical approach to its correction.

Method: Eighty-four teeth from 14 subjects affected by APE were subjected to CBCT. Periodontal variables were recorded before surgery, and anatomical variables were measured on CBCTs. Clinical crown length was measured on study casts. Surgical treatment was carried out based on the lengths of the anatomical crowns transferred to a surgical guide that served as a reference for the incisions. The mean distance between the CEJ and the bone crest was on average <1 mm, facial bone thickness was ³1 mm and soft tissue thickness was >1 mm for every tooth analysed; no association between the soft and the hard tissue thicknesses was observed.

Conclusion: The CBCT can be used in the diagnosis and treatment planning of APE cases. Anatomically, the APE cases described often presented a thick facial bone plate.

Topic: Connective tissue grafting
Authors: Schmidt JC, Sahrmann P, Weiger R, Schmidlin PR, Walter C.
Title: Biologic width dimensions–a systematic review.
Source: J Clin Periodontol. 2013 May; 40(5):493-504.
Type: Classic
Rating: Good

Keywords: biologic width, junctional epithelium, connective tissue attachment, crown margins, crown lengthening

Purpose: To evaluate the dimensions of the biologic width in humans.

Materials and Methods: A systematic literature search was performed for publications published by 28 September 2012 using five different electronic databases; this search was complemented by a manual search. Two reviewers conducted the study selection, data collection, and validity assessment. From 615 titles identified by the search strategy, 14 publications were included and six were suitable for meta-analyses.

Results: Included studies were published from the years 1924 to 2012. They differed with regard to measurements of the biologic width. Mean values of the biologic width obtained from two meta-analyses ranged from 2.15 to 2.30 mm, but large intra- and inter-individual variances (ranges: 0.2 – 6.73 mm) were observed. The mean dimensions of the junctional epithelium ranged from 0.57 mm (Subject sample range: 0.1 +/-1.4 mm) to 1.14 +/-0.49 mm (Subject sample range: 0.32 +/-3.27 mm). The mean dimensions of connective tissue attachments ranged from 0.77 +/-0.29 mm (Subject sample range: 0.29 +/-1.84 mm) to 1.10 +/-0.13 mm. The tooth type and site, the presence of a restoration and periodontal diseases/surgery affected the dimensions of the biologic width. Pronounced heterogeneity among studies regarding methods and outcome measures exists.

Conclusions: No universal dimension of the biologic width appears to exist. Establishment of periodontal health is suggested prior to the assessment of the biologic width within reconstructive dentistry. A “magic number” for the biologic width as a treatment objective cannot be recommended, as the use of mean values could mask the actual clinical situation.

Topic: Crown lengthening
Authors: Deas DE, Mackey SA, Sagun RS Jr, Hancock RH, Gruwell SF, Campbell CM.
Title: Crown lengthening in the maxillary anterior region: a 6-month prospective clinical study.
Source: Int J Periodontics Restorative Dent. 2014 May-Jun; 34(3):365-73
Type: Prospective clinical study
Rating: Good
Keywords: osseous parameters, crown lengthening, tissue rebound

Purpose: To assess osseous parameters and stability of maxillary anterior teeth following crown lengthening surgery.

Methods: Thirty-six patients requiring facial crown lengthening of 277 maxillary anterior and first premolar teeth were included. Presurgical and intraoperative clinical measurements were recorded at baseline and 1, 3, and 6 months post-surgery at midfacial, mesiofacial, and distofacial line angles.

Results: The data presented here suggest that when crown lengthening anterior maxillary teeth, the distance between the desired gingival margin and alveolar crest is usually insufficient to allow for biologic width. In addition, there is significant tissue rebound that may stabilize by 6 months. Tissue rebound appears related to flap position relative to the alveolar crest at suturing. These findings suggest that clinicians should establish proper anterior crown length with osseous resection.

Discussion: Overall, 15% of midfacial sites were within 2 mm of the postsurgical alveolar crest after suturing; these sites rebounded coronally by a mean of 0.9 ± 1.4 mm by 6 months. At the 53% of sites which were sutured with margins 3 mm from the alveolar crest, the tissue rebound was 0.1 ± 1.1 mm, and at the 33% of sites sutured > 4 mm from the alveolar crest, the tissue rebound was –0.2 ± 1.0 mm. These findings reflect the tendency of the healing periodontium to reform that dimension referred to as biologic width and suggest that a postsurgical gingival margin position less than 3 mm from bone may result in significant marginal soft tissue rebound.

Topic: Lip Repositioning

Author: Tawfik O.

Title: Lip Repositioning with or without myotomy: a randomized clinical trial

Source: J. Perio 2018 Jul; 89 (7): 815-823

DOI: 10.1002/JPER.17-0598

Type: RCT

Keywords: esthetics, dental; gingiva; lip; smiling

Purpose: assess the technique of lip repositioning and compare it to muscle severance as a variation to the technique – in terms of outcome, stability of the result and its application with different etiologies.

Materials/Methods:

Measurements of gingival display at maximum smile and relaxed smile were recorded to diagnosis VME.
In group 1 participants were treated by surgical lip repositioning with myotomy
In group 2 participants were treated by surgical lip repositioning without myotomy

Surgical procedure:

Modification of Rubenstein and Kostianovsky, and Rosenblatt and Simon.

Like Rosenblatt and Simon, the lower incision was kept at the MGJ

Like Rubenstein and Kostianovsk, the upper incision was kept at double the gingival display.

A single partial thickness incision.

- The lower incision always coincided with the MGJ line to avoid any loss in attached gingiva and the incision was deep enough to remove the epithelium but keep the under-lying CT intact.
- The upper incisions was determined by the preoperative measurement of the amount of excess gingival display (where the distance between the two incisions was double the gingival display).

The incision lines were extended horizontally to the mesial line angle of MX 1^stmolar on each side

- creating an elliptical outline to consistently decrease both the anterior and posterior gingival display

The strip of outlined mucosa was removed leaving behind a bed of CT.
For group 1, an additional step was performed.

- Muscle severance was completed by blunt dissection of the muscle attachment above the level of the coronal incision.
- The muscle fibers were pushed upwards with a periosteal elevator leaving the underlying periosteum intact.
- The displaced muscle fibers were then trimmed near the upper incision line to eliminate any remaining pull.
- Continuous sutures were used throughout the periosteum to create a physical barrier and prevent the muscles from reattaching at the same points of insertion.

The area of the frenum was always approximated first to ensure symmetry and accurate midline replacement then sutures at the canine and molars bilaterally.
Complete closure was achieved by multiple interrupted sutures between the initial key suture placement areas

Results:

Repositioning with myotomy, had a mean gingival display of 3.00mm at 3 months, 3.42mm at 6 months, and 3.57 mm at 12 months (the baseline gingival display 6.29mm)

Indicate a relatively stable result

Classical lip repositioning had a mean measured gingival display of 1.65mm at 3 months, 2.21mm at 6 months, and 2.73 mm at 12 months (the baseline gingival display 4.31mm)

Decline in the results over time.

Lip length was recorded as two separate readings, philtrum length and vermillion border length.

Patients in the myotomy group showed a mean increase in philtrum length of 1.78mm

Patients in the traditional group showed a mean increase in philtrum length of 1.77mm

The change with myotomy was SS when compared to the baseline; with the classical technique, NSSD

Vermillion border readings for the myotomy group was 1.55mm and classical techniques showed a mean increase of 1.23 mm

The rate of decline in the myotomy group, was less than that when compared to the classical technique

more post-operative swelling for myotomy group, but higher patient esthetic satisfaction

Conclusion:

lip repositioning with or without myotomy is a predictable technique for the reduction of excessive gingival display, with a high level of patient satisfaction. Myotomy showed a more stable result over time.

Dym H, Diagnosis and Treatment Approaches to a “Gummy Smile” Dent Clin North Am 2020 Apr;64(2):341-349.

Topic: Gingival Excess

Author: Dym, H

Title: Diagnosis and Treatment Approaches to a “Gummy Smile”

Source: Dent Clin North Am 2020 Apr;64(2):341-349.

DOI: 10.1016/j.cden.2019.12.003

Type: Review

Keywords: altered passive eruption, excessive gingival display, gummy smile, lip repositioning, vertical maxillary excess

Purpose: Review the etiology, diagnosis and surgical approaches in treating the gummy smile.

Discussion:

Causes of Excessive Gingival Display:

Short lip length
Hypermobile/hyperactive lip activity
Normal movement from rest 6-8mm and up to 10mm for hypermobile lip
Short Clinical Crown
Dentoalveolar extrusion
Altered passive eruption
Vertical Maxillary Excess
Gingival Hyperplasia

Assessing the gummy smile:

Medical History
Facial analysis- facial thirds from front or lateral views
Middle third increase- vertical maxillary excess
Lip analysis: static vs dynamic
Average 20-22mm
Rest position analysis
Dental analysis: crown length and incisal margin
Periodontal examination

Altered Passive Eruption:

Active phase of eruption involves movement of tooth out of alveolar bone and into occlusion.
Passive eruption is exposure of the crown as a result of apical migration of the gingival tissues

Altered passive eruption is the failure of dental/gingival complex to migrate apically past stage 2

Must rule out hypermobile lip, if this is the case then lip repositioning surgery or Botox is an option.

Key element to diagnose is location of CEJ in the sulcus.

Surgical Options:

Lip repositioning

Causes of Relapse:

Not following “twice gingival display” rule during incision
Cutting in the keratinizied attached gingiva
Performing procedure with limited amount of KG
Incising deep into connective tissue and muscle fibers
Cases with high muscle pull

Botox:

Derived from Clostridium botulinum that inhibits presynaptic acetylcholine release at the neruomuscular junction.
Can be viable treatment option to counteract hypermobility by injecting levator labii superioris and levator labii superioris alaque nasi bilaterally
3 sites of injections: 2mm lateral to alar-facial groove, 2mm lateral to first injection, and 2mm inferior between first 2 sites
4-6 units are used per side

Examination steps when “gummy smile” is present

Check bottom of nose to vermilliion boarder of upper lip.
Distance should be 20-22mm in females and 22-24mm in males
Locate CEJ and perform bone sounding

Classification (Coslet)

Type I- gingival margin coronal to CEJ

MGJ apical to alveolar crest

Noticeably wider band of KG (as described by Bowers)

Type II- gingival margin coronal to CEJ

MGJ at the level of the alveolar crest

Normal band of KG (as described by Bowers)

Subgroups A and B exist for both types

A-Alveolar crest 1.5 – 2mm from CEJ

B-Alveolar crest at or coronal to CEJ

Treatment based on classifications:

I A – Gingivectomy

I B – Gingivectomy, full thickness flap(replaced) w/ osseous

II A- Apically positioned flap

IIB – Apically positioned flap w/ osseous

Active eruption– occlusal movement of the tooth until it contacts opposing dentition. It can continue with occlusal wear.

Passive eruption– apical migration of the gingiva

Average tooth length (Wheelers)

Central -10.5mm
Lateral-9mm
Canine 10mm

Ideal length to width ratio: width is .75 % of the length

114. Esthetics: 4. pontic sites, papillas, non carious cervical lesions and esthetic crown lengthening

Rapid Search Terms:

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References:

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