113. Esthetics: 

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 Rapid Search Terms
root preparation and conditioning tetracycline root conditioning
root coverage on restored surfaces Emdogain for root coverage
using microscope in perio plastic surgery limiting factors for root coverage
root coverage on non-carious cervical lesions  soft tissue augmentation not associated with root coverage
subepithelial connective tissue graft (Langer) roll technique
factors affecting height of papilla surgery to regenerate papillas

 

 

 

 

 

Root Preparation

What is root preparation and what are the different categories? What materials are traditionally used for this? Does this work the same for animal studies and human studies? When is root preparation warranted?

  1. Zucchelli G et al: Hand and ultrasonic instrumentation in combination with root –coverage surgery: A comparative controlled randomized clinical trial. J Periodontol 2009 Apr; 80(4):577-85

  2. Bertrand PM, Dunlap RM: Coverage of deep, wide gingival clefts with free gingival autografts: root planing with and without citric acid demineralization. Int J Perio Restor Dent 8(1):65-67, 1988.

  3. Bouchard P1, Nilveus R, Etienne D. Clinical evaluation of tetracycline HCl conditioning in the treatment of gingival recessions. A comparative study. J Periodontol. 1997 Mar;68(3):262-9.

  4. Cheng YF, Chen JW, Lin SJ, Lu HK. Is coronally positioned flap procedure adjunct with enamel matrix derivative or root conditioning a relevant predictor for achieving root coverage? A systemic review. J Periodontal Res. 2007 Oct;42(5):474-85.

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)?

  1. Lucchesi JA, et al. Coronally positioned flap for treatment of restored root surfaces: a 6-month clinical evaluation. J Periodontol. 2007 Apr;78(4):615-23.

  2. 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

How would a microscope possibly improve perio plastic surgery? What kind of instruments are needed to facilitate this smaller, more delicate procedure?

  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.

What are some limiting factors for root coverage? What should you discuss with a patient before attempting root coverage? Are there things the patient can do to possibly improve the outcome? Are there any complications you might want to be aware of when doing root coverage?

  1. Gray JL. When not to perform root coverage procedures. J Periodontol 71:1048-1050,2000.

  2. Esteibar JR, et al. Complete root coverage of Miller Class III recessions. Int J Periodontics Restorative Dent. 2011 Jul-Aug;31(4):e1-7.

  3. Chambrone et al: The influence of tobacco smoking on the outcomes achieved by root-coverage procedures: A systematic review. J Am Dent Assoc. 2009; Mar; 140(3):294-306

  4. Erley K et al: Gingival recession treatment with connective tissue grafts in smokers and non-smokers. J Periodontol 2006;Jul; 77(7):1148-55

  5. Silva C et al: Coronally positioned flap for root coverage: Poorer outcomes in smokers J Periodontol 2006 Jan; 77(1)81-7

  6. Silva CO, de Lima AF, Sallum AW, Tatakis DN. Coronally positioned flap for root coverage in smokers and non-smokers: stability of outcomes between 6 months and 2 years. J Periodontol. Sep;78(9):1702-7. 2007

  7. Vastardis S., Yukna R.: Gingival/soft tissue abscess following subepithelial connective tissue graft for root coverage: Report of three cases. J Periodontol 2003 Nov; 74(11):1676-81

When would soft tissue augmentation be warranted other than for root coverage? How stable is this procedure over time? What are the differences in harvest and site prep from root coverage or increasing keratinized tissue?

  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 Periodontivcs 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.

What are some classifications for papilla height/contour? What anatomic features are we concerned with when trying to predict papilla height? How might this affect our treatment plans? What are some techniques to try to reconstruct the papilla? How predictable is this?

  1. Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 69:1124-1126, 1998.

  2. Jemt, T. Regeneration of gingival papillae after single-implant treatment. International

Journal of Periodontics and Restorative Dentistry 1997 (17) , 326 –333.

  1. 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.

  2. Takei H, Yamada H, Hua T. Maxillary anterior esthetics: Preservation of the interdental papilla. Dent. Clin. North Am. 33(2): 1989

  3. Azzi R, Etienne D, Carranza F. Surgical reconstruction of the interdental papilla. Int J Perio Rest Dent 18:466-473, 1998.

  4. 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.

  5. 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

How is management of the papilla around implants different than around teeth? How might this affect the prosthetic treatment plan?

  1. 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)

  2. Tarnow, D et al: The effect of inter-implant distance on the height of inter-implant bone crest. J Periodonto 71:546-549, 2000 (from LR 161)

  3. Tarnow D et al: Vertical Distance from the Crest of Bone to the Height of the Interproximal Papilla. J Periodntol 2004; 75:1242-1246 (from 161)

  4. Zetu, L., Wang. H-L: Management of inter-dental / inter –implant papilla. J Clin Peridotnol 2005; 32:831-839 (from LR 161)

  5. Chow YC, Wang HL. Factors and techniques influencing peri-implant papillae. Implant Dent. 2010 Jun;19(3):208-19. (saved on T drive)

 

What is root preparation and conditioning and what are the different categories? What materials are traditionally used for this? Does this work the same for animal studies and human studies? When is root preparation warranted?

 

Zucchelli 2009         ARTICLE

P: To compare the effectiveness, in terms of root coverage, of hand and ultrasonic root instrumentation in combination with a coronally advanced flap (CAF) for the treatment of isolated-type recession defects.

M+M: Randomized controlled split-mouth clinical study. 11 subjects (18-40 years old). Study inclusion criteria: Miller Class I isolated recession defects (greater than or equal to 3mm in depth) of similar depth in the contralateral quadrant of the upper jaw; presence of identifiable CEJ; greater than or equal to 1 mm KG apical to the root exposure; periodontally and systemically healthy; no contraindications for periodontal surgery and not taking medications known to interfere with periodontal tissue health or healing; and no periodontal surgery on the involved sites. Subjects smoking >10 cigarettes/day were excluded. Immediately prior to surgery, bilateral defects were randomly assigned by coin toss, to the test group- ultrasonic piezoelectric and the control group- curette root instrumentation. All recessions were treated with a CAF surgical technique using trapezoidal incision. Sutures were placed and post op instructions were given. Post-op after 6 months.

R: Root coverage: 95.4% in the control group and 84.2% in the test group, and complete root coverage: 82% in the control group and 55% in the test group- with no NSSD between the two groups. CAL gains were clinically significant in both groups (3.36 +/- 0.92 mm in the control group and 2.90 +/-0.70 mm in the test group). The increase in KG was SS in both groups (0.55 +/- 0.52 mm in the control group and 0.36 +/- 0.67 mm in the test group), but no NSSD between them.

BL: Hand and ultrasonic root instrumentation, in combination with CAF, for the treatment of the isolated-type of recession defect were equally effective in terms of root coverage and CAL gain. More expanded and longer-terms studies are required to confirm such results and to evaluate the efficacy of ultrasonic treatment for demineralized/softened root surfaces.

 

Bertrand 1988         ARTICLE

P: To evaluate the effect of citric acid in the treatment of deep, wide clefts with FGGs biometrically and with intrapatient controls.

M+M: 8 pts (all male, 20-56 yrs old), healthy, non-smokers with 0 pairs of adjacent or bilateral deep, wide clefts. Underwent initial therapy: SRP and OHI. Cleft measured pre-op and 3 months post-op w/ Detch probe to the 0.1 mm. Vertical dimension was from CEJ to FGM, and horizontal was width at CEJ.

2 groups (experimental and control): both treated with root planning w/ hand curettes, experimental treated w/ cotton pellets soaked in citric acid for 5 minutes, then recipient bed prepared creating butt joints and PTF reflected, 3-5mm apical, foil template prepared, thick FGG (2mm or thicker) excised from palate by sharp dissection, margins trimmed to be butt joints, and graft sutured to recipient site. Donor site treated with pressure , packed with Gelfoam, and covered by palatal stent. Nine days after surgery dressing and sutures removed.

R: NSSD for mean cleft coverage b/w control and experimental groups.

Range of coverage for control sites: 39% - 94%; Mean percentage of coverage: 66%

Range of coverage for experimental sites: 53% - 94%; Mean percentage of coverage: 74%

Mean overall coverage: 70%

BL: FGG to cover deep, wide clefts success did not depend on application of citric acid.

 

Bouchard 1997         ARTICLE     tetracycline root conditioning

BG: TTC have been found to be effective against a wide range of perio pathogens, potentially inhibit CT breakdown by inhibiting neutrophil collagenase, inhibit bone resorption in vitro at concentrations which are compatible with clinical situations, and increase collagen formation in osteoblasts, and enhance perio regeneration.

P: To determine the clinical effect of topical applications of TTC-HCL versus citric acid (CA) in root conditioning as an adjunct to the modified subepithelial graft procedure for root coverage.

M&M: All pts had a MOL of at least 80%. 30 class I and II recs in non-molar tth in 30pts were tx with a modified CT graft procedure (CT graft covered completely with CAF. 15 recs in the test goup were treated with TTC (50 mg/ml: capsule with 250mg powder dissolved in 5mL syringe filled with sterile water) for 5 minutes, and the control group received CA for 3 minutes. No systemic antibiotics given to either group. Clinical parameters were measured at baseline and 6 months. Smokers were included and present in both groups. Pts that smoked > 10 cigs/day were excluded from the study.

R: All pts had an uneventful healing period. NSSD between groups. Mean RC was 79% for test and 84% for the CA group. In the test group, 6/15 recs had complete RC vs 8/15 in the control. The gingiva thickened in all cases.

BL: TTC and CA have similar effects for RC performed with CT grafts.

Cr: It would be nice to have a group without any root conditioning to verify if the treatments are actually effective, although a study comparing CA vs no CA with the same procedure was recently performed (at this point in time).

 

Cheng 2007         ARTICLE            Emdogain for root coverage

Purpose: To assess the efficacy of EMD and root conditioning on the root coverage with coronally advanced flap .

Materials and methods: Meta-analysis, studies by the end of October 2005. Inclusion criteria: studies in English, done in human subjects, Miller Class I and II recessions more than 2mm, treatment with coronally positioned flap (CPF), coronally positioned flap + chemical root surface conditioning or coronally positioned flap and EMD, randomized controlled trial, controlled clinical trial or case series report with at least 6- to 12-month interval between the initial and final measurements and baseline and final measurements of buccal recession depth.

Histological studies, studies with insufficient data or semilunar coronally positioned flap were excluded.

The quality of the studies was assessed by two reviewers based on the adequacy of the method of randomization, existence of blinding of the examiners for the variable type of treatment and the existence and treatment of lost cases.

Results: 7 studies were included for CPF and 11 for CPF. Of those 3 studies used tetracycline for root conditioning and 1 study used EDTA.

Clinical attachment level: At 6 months the gains in CAL were 2.42±0.70mm in the CPF group and 2.22±0.36 in the CPF +root conditioning and 4.01±0.77mm in the CPF +EMD group. At 12 months the mean gain were 1.69±0.15mm, 3.10±0.00mm and 3.61±0.50mm respectively. CPF +EMD showed SSD results in 6 and 12 months than the other two groups. At 12 months differences were statistically significant among all groups. At 6 months differences between CPF and CPF+ root conditioning groups were not SSD.

Keratinized tissue: At 6 months the gains in keratinized tissue were -0.04±0.37mm in the CPF group, 0.14±0.47mm in the CPF + root conditioning group and 0.59±0.29mm in the CPF + EMD group. At 12 months the gains were 0.10±0.41mm, 0.30±0.00mm and 0.61±0.14mm. CPF + EMD showed better results that were SSD in both 6 and 12 months. NSSD between CPF and CPF + root conditioning.

Probing depth: PDs at 6 and 12 months were less than 2mm. 1.04±0.38mm in the CPF group, 1.09±0.14mm in CPF + root conditioning and 1.16±0.15mm in the CPF + EMD. At 12 months the mean values for the groups were 0.98±0.02mm1.4±0.00mm and 1.41±0.33mm.

Gingival recession depth: CPF + EMD decreased from 3.910.35mm to 0.62±0.36mm at 6 months and 0.72±0.40mm at 12 months. In the CPF recession depth decreased from 3.36±0.36mm to 0.8±0.42mm at 6 months and 1.37±0.04mm at 12 months. In the CPF + root conditioning recession depth decreased from 3.62±0.29mm to 1.17±0.25mm at 6 months and to 1mm at 12 months. All differences were SSD except the difference between CPF and CPF and root conditioning at 6 months.

Root coverage percentage: The CPF and CPF + root conditioning resulted in root coverage percentage ranging from 55-75%. The CPF + EMD technique resulted in 71.7-95.1% root coverage.

Conclusion: Root coverage manipulated by the coronally positioned flap with or without root conditioning was unpredictable. Results can be modified by adding EMD to increase significantly the clinical outcomes of gingival recession.

 

 

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)?

Lucchesi 2007             ARTICLE

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.

Materials and methods:

Results:

Conclusion:

 

Santamaria 2008             ARTICLE

P: To evaluate the treatment of recession associated with non-carious cervical lesions by a CPF or in combination with a RMGI.

M&M: 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.

R: 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.

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

How would a microscope possibly improve perio plastic surgery? What kind of instruments are needed to facilitate this smaller, more delicate procedure?

 

Francetti 2005             ARTICLE

P: to verify whether the use of a surgical microscope in the surgical treatment of gingival 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

M: 24 cases of gingival recession were treated. criteria were: 1) buccal recession 2-5mm in the esthetic area. 2) no loss of interdental bone or soft tissue (Miller class I and II), 3) 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 variables 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. the following treatment were preformed: 6 CAF + CTG/ 1 CAF + GTR/ 4 CAF + CTG + EMP, and 1 semilunar flap.

Control group- conventional instruments were used w/o surgical microscope. 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 mouths 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) , focussing on esthetic parameters (scarring, gingival margin, and papillae appearance).

R: All parameters were improved from baseline to 12 mouths in both groups, except NSD in PD. Outcome of the test group showed major improvement over the control, but NSD could be detected. 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 1)high concurrence among examiners, 2)significantly better scarring and marginal profile in the test group, and 3) NSD in papillae appearance. 

C: 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 database are needed.

D: Traditional surgery should be limited to areas of less esthetic importance, such as the mandibular anterior or posterior region.

Cr: Failures are completely unrelated to either the surgeon’s ability or techniques used. the failures may simply be related to the pt’s lack of compliance post-op or other unpredictable events, irrespective of the use of the microscope.

 

Bittencourt 2012             ARTICLE

P: To compare root coverage (RC), post-op morbidity, and esthetic outcomes of the SCTG technique with or wo the use of a microscope.

M&M: Split mouth study with 24 pts (13 males and 11 females) with bilateral Miller class recession I and II, >2mm in canines or premolars. Initial therapy with plaque control and non-traumatic brushing techniques were given. Treatment method was randomly designated to receive tx with SCTG with (test group) or wo microscope (control group). Periodontal clinical parameters were evaluated by a calibrated examiner at baseline, 6 and 12 months. Surgeries were performed by one clinician, the only difference in the technique between the groups was the use of the microscope. Duration of the surgery was recorded. Post-op morbidity was evaluated by an analog visual scale. Pt satisfaction was evaluated with a questionnaire.

R: Average RC after 12 months for test group: 98% control group: 88.3%. Complete RC test group: 87.5% control group: 58.3%. For all parameters except recession height, there was an improvement in the final examination but wo difference bw tx. Patient satisfaction test group: 100% control group: 79.1%. Post op morbidity: No difference bw groups. Duration test group: 60 min control group: 54 min.

C: The use of the microscope showed additional clinical benefits in the tx of recessions.

What are some limiting factors for root coverage? What should you discuss with a patient before attempting root coverage? Are there things the patient can do to possibly improve the outcome? Are there any complications you might want to be aware of when doing root coverage?

 

Gray 2000             ARTICLE

P: To review the risk factors and other considerations that may influence a clinician’s decision not to perform a root coverage procedure in patients with good health.

D: First step is to identify risk factors. Risk factors that cannot be modified or corrected are contraindications. The following are risk factors:

Loss of interproximal bone: Miller Class III and IV defects.

Tobacco use: Smoking is a risk factor that may contribute to the failure of all mucogingival surgical procedures. Smoking contributes to periodontal destruction and impedes healing after surgery. A patient who smokes and has had an undesirable outcome is a poor candidate for further procedures. Each clinician must decide whether or how to treat patients who smoke. Smokeless tobacco is also a risk factor for recession.

Oral hygiene: Improper oral hygiene technique cause much of the recession that requires surgical correction. Unless patients can be successfully re-educated, attempts at root coverage may be unsuccessful. This includes improper tooth pick use and fingernail biting. It should be noted that some areas of recession are difficult to clean, and root coverage is sometimes a valid indication for root coverage procedures.

Anatomic features: May contribute to recession, especially when alveolar bone is thin. Often occurs in prominent or malpositioned teeth. Other factors are shallow vestibules and effects of orthodontics/orthagnathic surgery.

Indications vs. Contraindications: Three indications are inadequate gingival width, esthetic concerns, and root hypersensitivity. Contraindications include 1) limitations due to esthetics and anatomy (high smile lines), 2) cervical restorations, and 3) patient expectations.

BL: Not all sites and not all patients are suitable candidates for surgery. Careful patient interviews and examinations are necessary to determine who is unsuitable for treatment.

 

Esteibar 2011             ARTICLE

P: To assess factors that are involved in complete root coverage (CRC) in class III Miller recessions.

M&M: Retrospective study. 121 Class III recessions in 50 patients that were treated for periodontal disease. Non -smokers were included. Pre-sx variables: tooth undergoing treatment, sex, age, interproximal bone loss, recession width and depth, integrity of interproximal soft tissue. Surgical variables: surgical technique used and graft thickness. Post-sx variable: creeping attachment. All recessions were treated with free gingival grafts (FGG), or subepithelial connective tissue graft (SCTG) or connective tissue double pedicle technique. All patients followed the same post-surgical medical care, amoxicillin 500mg, ibuprofen, 0.12% CHX for 6 weeks after the procedure, evaluation was performed at weeks 1, 2,4, 8 and 12 post-surgery.

R: 47.11% of Class III recessions obtained complete root coverage. Τhe Langer technique was the most frequently used procedure out of the three employed. Νo differences in the final result were observed among the procedures. With regard to creeping attachment hardly any differences were observed between the group that attained CRC (35%) and the one that did not (33%). In cases where the integrity of the interproximal soft tissue was preserved, a graft of more than 2 mm in thickness was used, recession width was 3 mm or less, and bone loss, as measured on the radiograph, was not above 3 mm, the success rate was 100%. Αll cases treated under these circumstances achieved CRC.

CON: Complete root coverage is possible in some Class III recessions.

 

Chambrone 2009                 ARTICLE

P: To evaluate the effect of tobacco smoking on clinical outcomes achieved by periodontal plastic surgery

procedures in the treatment of recession-type defects. Systematic review asking the question: “Does tobacco smoking influence the outcome measures achieved by root coverage procedures?”

M+M: Medline, EMBASE, and Cochrane Central Register of Controlled Trials were searched for RCT’s, controlled clinical trials, and case series that involved at least 6 months follow-up. They looked for studies that compared outcome measures achieved by smokers and nonsmokers after they went periodontal plastic surgery procedures for treatment of gingival recession. Inclusion criteria: Miller class I or II recession, recorded smokers vs non-smokers, 18 years or older, at least smoked 10 cigs/day. Outcome measures: change in recession, CAL, KT, % of sites having complete root coverage, and mean root coverage.

R: 632 studies were identified in initial search, only 7 studies included. Subepithelial CTG provided SS more root coverage and clinical attachment gain for nonsmokers than for smokers. Nonsmokers exhibited more sites with complete root coverage than smokers. NSSD with regard to CPFs in non-smokers vs smokers.

BL: Smoking negatively influences the treatment of gingival recession.

CR: In M+M authors mention ADM, FGG, and GTR. Reasons for exclusion were given (articles didn't meet search criteria) , but would have been nice to have it in the review.

 

Erley 2006             ARTICLE

P: To determine whether cigarette smoking affects wound healing of subepithelial connective tissue grafts (CTG).

M+M: 17 healthy patients (16 M, 1 F; 27-45 years old) with a total of 22 recession defects, Miller Class I or II of 2 mm or more on non-molar teeth. Pts classified as smokers if they had10 or more cigarettes per day. OHI given to all pts and surgery not performed until MOL of 80%. Clinical paramaters (recession, KG, relative attachment level, PD, BOP, and PI) were documented at baseline and 3 and 6 months post-op using a stent. Cotinine concentration in saliva was also recorded to confirm patient’s self reported smoking history and help quantify cigarette consumption by pt. All patients received CAF with a CTG with a procedure similar to the classic Langer technique, except that a FTF elevated and the epithelium from the donor tissue was removed. All surgeries completed by same operator. Statistical analysis completed.

R: SSD in recession depth between the two groups. At 6 months post-op, smokers group healed with was 1.0 mm recession depth, while non-smokers had a recession depth of 0.2 mm. Percentage of coverage was 98.3% for non-smokers versus 82.3% for smokers. 80% of non-smokers had complete root coverage vs 25% of smokers. This was also related to Cotinine levels. No difference in KT increase.


BL: Smoking has a significant negative effect on root coverage procedures using CAF+CTG. Smokers need to consider stopping or reducing smoking for best results with CTG.

Cr: no intraexaminer calibration performed

 

Silva 2006             ARTICLE

Purpose: To evaluate the effect of smoking on CPF outcomes in the treatment of Miller Class I gingival recession defects.

Materials and methods: 20 healthy subjects (11 males and 9 females, average age 34.5 years). 10 were smokers (smoking at least 10 cigarettes/day for at least 5 years prior to the beginning of the study) and 10 were non smokers. Smokers with lesser tobacco exposure or former smokers were excluded. Participants had one Class I Miller defect on upper canine or premolar, 2-3mm in depth. Periodontally and systemically they were healthy and they had no occlusal interferences.

Initial therapy was performed one month prior to the beginning of the study. At baseline and throughout the study bleeding and plaque index were used to monitor oral hygiene and gingival health. Standardized measurements for PD, CAL, recession depth (RD), keratinized tissue (KT) were recorded at baseline and 6months post-op, to the nearest 0.2mm. Prior to flap elevations exposed roots were instrumented and conditioned with TTC. Trapezoidal full thickness coronally and partial thickness apically flap was elevated, advanced coronally and sutured, after papillae were de-epithelialized.

Results:

Conclusion: CPF provided benefits for both groups. However cigarette smoking negatively impacted residual recession, % root coverage and frequency of complete root coverage.

 

Silva 2007                   NO ARTICLE

Purpose: To evaluate the influence of cigarette smoking on the long-term outcomes of coronally positioned flaps (CPF) in the tx of Miller class I gingival recessions.

Materials and methods:

Results:

BL: The 2-year stability of CPF is less than desirable, especially in smokers.

 

Vastardis 2003                 ARTICLE

P: To report 3 cases of complications after the use of a SCTG to cover recessions that occurred following the initial healing phase.

D:

All pts received a coronally positioned flap with SCTG graft.

The clinical outcome of the root coverage procedure was not affected by these infections.

The authors contribute the etiology of the cysts being from suture material left behind or epithelium that was not adequately removed from the graft.

Case 1: Seven weeks after the SCTG graft, the pt came for a maintenance appt and reported minimal swelling in the area of the graft. A sinus tract was identified. A gutta-percha point was inserted in the tract and did not lead to the apices of the teeth, which were tested and were vital. The tract was curetted with HI and the granulation tissue was removed. Three weeks later, the area completely healed and no recurrence of the abscess has been noted for 9 months.

Case 2: One week after the graft was placed (dressing was used) the sutures were removed and #5 had an area of the flap with a perforation. Antibiotics were not prescribed after the sx. When the pt came for the second post-op visit one week later, they reported that the area felt “strange.” There was a diffuse swelling with purulence under the flap that was red and sensitive to the touch. The teeth did not have any periapical pathology. Amoxicillin 500mg t.i.d. x 7 days was given to the pt. One week later she was symptom free and the treated area was healing normally.

Case 3: The grafting was performed and no Abx was given and Coe-Pak was placed.

One week after sx the healing was WNL. One month later, a swelling was noticed in the mucosa apical to tooth #12. Adjacent teeth tested vital and there was no periapical pathology. The area was drained with a single incision in the mucosa and curetted. Minimal suppuration was seen, but a caseous material was noted, which was hypothesized to be remaining polyglactin 910 suture. The area was left unsutured to drain. The pt was given amoxicillin 500mg t.i.d. x 7 days. The pt has been followed for 6 months and there has been no recurrence of the abscess. The area is symptom free and healing well.

BL: These abscesses do not affect the over-all outcome of root coverage if they are treated in a conventional manner.

 

 

When would soft tissue augmentation be warranted other than for root coverage? How stable is this procedure over time? What are the differences in harvest and site prep from root coverage or increasing keratinized tissue?

 

Seibert 1983                 ARTICLE

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

M&M:

Classification:

Class I: Buccolingual 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 buccolingual dimension

Class III: Combination buccolingual and apico-coronal loss of tissue resulting in loss of normal height and width

 

Seibert-2 1983                 ARTICLE

P: 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 pts, 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: B-L and Apico-Coronal dimensions of the onlay graft have to be planned in relationship to: 1- Length on 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 defect is too large, multiple stage procedure is needed. A-C dimension in a mod 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 lat border may be either beveled or 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 M-D margins are prepared thin. In the apical margin of the recipient site, a deep undercut is usually found. Pre-surgical palpation of 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 pt.

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. 1st stage: onlay graft from palate to bulk the area. 2nd stage: partial thickness graft with pigmented gingival tissue.

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

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

 

Seibert 1987                 ARTICLE

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

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


Siebert 1996                 ARTICLE

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

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 info 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 in an effort 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 in an attempt 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.

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.



Langer 1980                 ARTICLE

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

D: 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.
Postop observation: 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.

 

Langer 1982                 NO ARTICLE                  

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 recommeneded 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.

 

Orth 1996                 ARTICLE

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. 

 

Harris 2003                 ARTICLE

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

Materials and methods:

Results:

BL: an acellular dermal matrix seems to be a good substitute for a connective tissue graft when attempting soft tissue ridge augmentation.


Abrams 1980                 NO ARTICLE

P: To present a technique for ridge augmentation using a connective tissue pedicle graft in correction of the collapsed ridge for fixed prosthodontics

Description: 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 elevate 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.

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

 

Scharf and Tarnow 1992             ARTICLE            roll technique

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

M+M:

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). The incisions are placed 2mm from the sulcus to preserve the papillae and attachment.

A shallow incision is made along the crest of the ridge to join the vertical incision together.

A pedicle of epithelium and connective tissue (at least 0.6mm thick) is reflected toward the palate to expose the underlying donor CT.

Another horizontal incision is made along the apical crest of the CT pedicle.

CT pedicle is reflected towards the buccal aspect to expose the alveolar bone of the palate.

A tunnel is made underneath the buccal periosteum to accommodate the donor tissue.

CT is then rolled to the buccal aspect and secured between the periosteum and the bone with sutures.

The epithelial pedicle is replaced on the palate to cover the denuded donor site. Periodontal dressing is placed if required.


                      

 


3 Advantages:


Siebert 2000                 NO ARTICLE

Purpose: Described the different procedure for ridge augmentation which includes soft tissue aug procedure and osseous ridge aug procedure.

Discussion:

Soft tissue procedure:

Pouch procedure: mostly treats to augment buccolingual deformity. Although a limited amount of apico-coronal aug can be obtained. This procedure designed to receive CT removed from palate/tuberosity area or to receive implant of synthetic bone substitute like beta-tricalcium phosphate or resorbable HA. PTF begin with palatal site of the crest and extend apically on to the facial side of the ridge and it will be a FTF on facially, 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 roll tecq, 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 close. A pie shape free graft is removed from palate/tuberosity area and inserted like a wedge into the opening of the pouch. The epi surface of the wedge positioned at the level of surrounding epi surface. If aug is necessary in an apicoronal 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 use 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, tx planning for osseous aug for localized ridge defect can be dividing into 2 subdivisions. One focused on long established ridge resorption and the other address the reconstruction of ext site defects.

Augmentation of deficient ridge: GTR is predictable tecq 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 of 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 2nd 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.

 

Allen 1988                 ARTICLE

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.

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 procedure 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.

 

Akcali 2014                 ARTICLE

P: 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.

M&M: 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.

R: 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.

CON: 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.

 

 

What are some classifications for papilla height/contour? What anatomic features are we concerned with when trying to predict papilla height? How might this affect our treatment plans? What are some techniques to try to reconstruct the papilla? How predictable is this?

 

Nordland and Tarnow 1998                 ARTICLE

P: 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 poit 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.




 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jemt 1997                 ARTICLE

P: To propose a classification 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: 58% of single-implant crowns may have an increase in papillae height from the time of implant placement.

 

Tarnow 1992                 ARTICLE

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.

Materials and methods: 288 interproximal sites. 99 anterior, 99 premolars, 90 molars in 30 patients were randomly selected for examination. Pts underwent thorough SRP 2-8 weeks before the measurements to reduce edema and inflammation. Standardized periodontal probe with Williams markings was used. 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 remeasured when the flaps were reflected.

Results/BL:

When the distance was 3, 4, 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.

Takei 1989                 NO ARTICLE

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

Discussion

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

 

Azzi 1998                 ARTICLE

P: To describe a technique to surgically reconstruct the interdental papilla using buccal and palatal split-thickness flaps and a CTG.

Technique: Pts should quit smoking 1 week prior to surgery and 2-3 weeks after surgery in order to not delay healing. Pts should also undergo SRP and OHI prior to surgery. An intrasulcular incision is made around neck of tooth. Another incision is 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 bucall part of the flap is dissected past the MGJ leaving periosteum and thin layer of CT on the bone. CTG is harvested from the retromolar/tuberosity region. Distal wedge of tissue is harvested. 2 parallel incisions that extend to the MGJ are made behind the distal tooth, with a 3rd 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. 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, pt instructed to rinse w/ CHX. Dressing and sutures removed 1 wk.

D: The blood supply to the CT is a key element of this technique. PD at the sides of the reconstructed papillae are 3-5mm in the clinical cases that were described. If OH is adequate a healthy state of the tissues will persist without clinically significant inflammation. This technique provides a solution to a frequent clinical problem.

 

Blatz 1999                 ARTICLE

P: 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

Biology of the periimplant mucosa

Reconstruction of the lost interdental papilla

Nonsurgical papilla creation

Surgical papilla reconstruction

Prosthetic solutions:

 

McGuire 2007                  ARTICLE

P: To evaluate the efficacy and safety of using autologous fibroblast injections following a minimally invasive papilla priming procedure to augment open interproximal spaces.

M: 20 patients with open interproximal spaces, 2 sites per patient selected, randomized to receive autologous fibroblast injections (taken from 3mm punch biopsy of KG of tuberosity area was sent to lab) or placebo (cell culture media), 1 week after priming (controlled surgical insult). Repeated injections at 7-14 after 1st injection and 7-14 days after 2nd injection. Imaging, measurements of papilla to contact distance, and diagnostic models were used. Papillary height was measured at 4 month post op.

R: Efficacy analysis showed NSSD (due lack of insufficient clinical experience with this tx). Papillary height at 2 months showed better results in test group but NSSD. Patients and clinicians were asked to assess results using a visual analogue scale and both reported better results with test vs placebo. Material was safe.

BL: This is an early phase study, suggesting that injection of cultured and expanded autologous fibroblasts is safe, and may be efficacious for treatment of papillary insufficiency.

 

 

How is management of the papilla around implants different than around teeth? How might this affect the prosthetic treatment plan?

 

Salama 2003                 ARTICLE

P: A review and follow up to the 1998 article

D: 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 cornonal interproximal bone height (IHB) for all tooth replacement permutations.



BL: 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 effected and differ significantly by the various possible combinations of tooth, implant, and Pontic which may border a specific interproximal site.

 

Tarnow 2000                 ARTICLE

B: 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.

P: 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.


M&M: 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.

R: 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.

BL: 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 apart.

 

Tarnow 2003                     ARTICLE

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

M+M: 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

R: 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%).

BL: 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

 

Zetu 2005         ARTICLE

Review Article

P: 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.

Anatomy of the interdental-inter-implant papilla: interdentally, the gingiva that occupies the space coronal to the alveolar crest is known as interdental ginigva. In the incisor area, it ahs 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 brader 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. A class I papillary loss was defined 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), A class II papillary loss involves the presence of the tip of the papilla at or apical to the interproximal CEJ but coronal to the facial CEJ, while a class III has a papilla at or below the level of the facial CEJ (Nordland & Tarnow 1998). Jemt (1997) classification is also described.

Soft –tissue manipulation for preservation of the papillary height: Various soft tissue sx 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 remain to be determined.

Restorative Attempt to Correct the Aesthetic Challenge: the restorative dentist may fabricate an immediate tooth replacement using an ocate pontic bonded to the adjacent teeth. The ovate pontic allows for natural-appearing emergence profile and an ease for OH (Spear 1999). The pontic should extend initially 2.5mm below the free gingical 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.

BL: Review article in which authors present an esthetic triangle to address the foundations that are essential for maintaining/creating papilla.


 

Chow 2010                 ARTICLE

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

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 at12 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 have been described. 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 techniques can also be used. 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.


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