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Using Periodontal Plastic Surgery Techniques
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R T I C L E S
In the 1980s, mucogingival surgery evolved into periodontal plastic surgery with various reconstructive techniques designed to produce root coverage fo r marginal tissue recession, to augment deficient ridges, and to lengthen crowns in cases of excessive gingival display.
Using periodontal plastic surgery techniques Preston D. Miller, Jr., DDS
e r io d o n t a l s u r g e r y is g e n e r a lly p erceived as excisional in n a tu re with pocket elim ination being the trea tm e n t goal. Laymen are fam iliar with th e te rm “g in g iv e c to m y ” a n d en v isio n e lo n g a te d an d sensitive te e th follow ing periodontal surgery. T h e gingivectomy, however, is a d ated p r o c e d u r e . P e r io d o n ta l s u r g e r y h a s generally becom e less excisional and m ore re c o n s tru c tiv e . P reviously u n tr e a ta b le osseous defects now respond predictable e i th e r to b o n e g r a ftin g te c h n iq u e s o r g u id ed tissue reg en eratio n , and areas o f recession can be covered with soft tissue. Originally, perio d o n tal plastic surgery1 was referred to as mucogingival surgery.2
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Two p rocedures in mucogingival surgery were d eep en in g the vestibule an d frenal surgery. Currently, th ere is little n eed to d ee p en the vestibule (except occasionally in edentulous patients), and frenectom y is less fre q u e n tly p e r f o r m e d . C u rre n tly , p e rio d o n ta l plastic su rg e ry em p h asizes tr e a tin g m a rg in a l tissu e re c e ssio n an d augm enting ridges for im proved ap p ear ance. T hese latter two procedures, along with crown lengthening surgery to correct e x c e ssiv e g in g iv a l d is p la y ( “g u m m y sm ile”), are the subjects o f this paper. M arginal tissue recession M a rg in a l tis su e r e c e s s io n 3 is tr e a te d
su rg ic a lly e i th e r by u s in g m a s tic a to ry m u c o sa l g r a f ts fro m th e p a la te o r by m o v in g tissu e la te ra lly o r c o ro n a lly to cover th e recession. T he palatal autograft is o fte n r e f e r re d to as a “fre e g in g iv al ^ graft,” but this term is incorrect. “Free gingiva” is the unattached gingiva su rro u n d in g a tooth, an d this tissue is n o t used in grafting procedures. F u rth erm o re, ; the palatal tissue used for grafting is n o t g in g iv a b u t m a s tic a to ry m u c o sa ta k e n fro m th e h a rd p alate. C o h e n 4 classified so ft-tissu e g ra ftin g p r o c e d u re s u se d in p e rio d o n tic s as free soft a u to g ra fts an d c o n tig u o u s so ft-tissu e a u to g ra fts ; a n d contiguous grafts w ould include laterally p o sitio n e d flaps, o b liq u e ro ta te d flaps,
Fig 1 ■ Preoperative view o f maxillary canine o f
Fig 2 ■ Laterally positioned pedicle graft sutured
Fig 3 ■ One-year postoperative view with 5-mm
43-year-old male with 7-mm (Class III) recession.
in p o s itio n a ttem p tin g 5-m m r o o t c o v er a g e
root coverage with attachment.
(com plete root coverage is not obtainable because o f adjacent 3 mm recession on premolars).
JADA, Vol. 121, O cto b er 1990 ■ 485
A R T I C L E S
d o u b le p a p illa e fla p s , a n d c o r o n a lly positioned Haps. C o n tiguous soft tissue autografts were in tro d u ced by G rupe and W arren5 u n d er the term “lateral sliding flap” a procedure currently known as the laterally positioned ped icle graft (Fig 1-3). Gingiva fro m an adjacent tooth is freed by a horizontal and two vertical incisions an d tra n sfe rre d to the recipient tooth. This often resulted in recession o n th e d o n o r to o th , a n d th e p ro c e d u re was la te r m o d ifie d so th a t a “collar” o f gingiva rem ained on the do n o r to o th . T h e “la te r a l s lid in g f la p ” gave im petus to the oblique ro tated flap,1’ the d o u b le papillae flap,7 a n d th e coronally positioned flap.8-10 In all o f these, existing gingiva is moved or rotated to create m ore gingiva on a recipient tooth. B e rn im o u lin " in tr o d u c e d a tw o-step te c h n iq u e fo r c o ro n a lly p o s itio n in g a h ealed palatal autograft. A lthough still a viable technique, it is less frequently used. Root coverage with the palatal autograft as a s in g le p r o c e d u r e is g e n e r a lly b o th successful and predictable.1213 A thorough u nderstanding o f the class o f recession14 is necessary if m axim um root coverage is to be a tte m p te d . A lth o u g h c o m p le te ro o t coverage is anticipated in Class I and Class II recessions, only p a rtia l ro o t coverage can be achieved in Class III recession (Fig 1-3). Coronally positioning existing gingiva is used to treat areas o f m inim al recession. A reas w ith only 2 to 3 m m o f recession with attached gingiva may be overlooked. O ften the patient expresses a desire to “do s o m e th in g ” o n ly to h av e th e d e n t is t d isc o u ra g e th e p a tie n t from tre a tm e n t. Occasionally, these areas have superficial c a rie s , se n sitiv ity , o r y e llo w ish -b ro w n staining, which creates an esthetic concern for the patient. Allen an d M iller10 outlined th e criteria an d te c h n iq u e for coronally positioning existing gingiva (Fig 4-6). A contiguous autograft is the preferred tre a tm e n t fo r m arg in al tissue recession w h en th e re is a d e q u a te d o n o r gingiva. Only on e surgical site is involved. T here is n o p r o b le m w ith th e c o lo r m a tc h o f tissues. T h e p alata l a u to g ra ft, however, offers the m ost versatile surgical treatm ent for m arginal tissue recession because the palate offers adequate d o n o r tissue. O ne problem in using palatal tissue has b e e n th e c o lo r m a tc h o f tissu e s a f te r h e a lin g as palatal a u to g ra fts are w hiter and m ore opaque (Fig 7, 8) than gingival tissue. In addition, palatal autografts may be too thick after healing. O ften a slight d e r m a b r a s io n o f th e h e a le d g ra ft is n ecessary to p ro d u c e th e m o st esth etic 486 ■ JADA, Vol. 121, O cto b er 1990
Fig 4 ■ Preoperative view o f 23-year-old fem ale
Fig 5 ■ C oron ally p o s itio n e d fla p to cem en -
w ith h ig h s m ile lin e sh o w in g 3-m m (C la ss I)
toenam el ju nction to provide thicker gingiva. A
r e c e ssio n on m axillary cen tral in c iso r s. N o te
layer o f p alatal c o n n e c tiv e tis s u e w as p la c e d
gingiva to be positioned is quite thin.
beneath the flap.
F ig 6 ■ O n e-year p o s to p e r a tiv e view . N o te
Fig 7 ■ Preoperative view o f 16-year-old fem ale
thickness o f gingiva obtained by connective tissue
with 3-mm recession and no gingiva on mandibular
augmentation.
central incisors (Class II recession).
F ig 8 ■ O n e-y ea r p o s to p e r a tiv e view a fte r
Fig 9 ■ Preoperative view o f 55-year-old fem ale
placement o f a classic (epithelialized) free palatal
with 5-mm recession (Class I) on maxillary canine.
graft. Color match o f tissue and attachment have been achieved.
F ig 10 ■ O n e-year p o s to p e r a tiv e view a fte r
Fig 11 ■ A 28-year-old patient after orthodontic
p lacem ent o f a subepithelial con n ective tissue
therapy. The smile features an excessive display of
graft (Courtesy o f Dr. Laurleen Langer, New York).
gingiva with insufficient clinical crown length and asymmetry.
A R T I C L E S
Fi g 12 ■ S u rg ic a l e x p o s u r e o f th e fu ll a n a to m ic
F ig 13 ■ Six w eeks p o s to p e ra tiv e ly , a d ra m a tic a lly
c r o w n w a s a c c o m p l i s h e d b y i n t e r n a l b e v e le d
im p ro v e d a p p e a r a n c e is s e e n . L e n g th e n in g o f th e
e x c is io n o f a g in g iv a l c o l l a r f a c ia lly o n a ll s ix
t e e t h b y s u r g i c a l e x p o s u r e h a s r e s u l t e d in
a n te r io r te e th
r e d u c t i o n o f t h e e x c e s s i v e g in g i v a l d i s p la y ,
a n d th e le f t a n d rig h t f ir s t
p re m o la rs . T h e in te r d e n ta l p a p illa e w e re le f t
e lim in a tio n o f a s y m m e try , a n d a d e n t iti o n
in ta c t.
h a rm o n io u s w ith th e u p p e r lip (C o u rte sy o f Dr. E.
M in im a l
o d o n to p la s ty
re m o v e d
irre g u la ritie s o n th e in c isal ed g e s.
P a t A lien , D allas).
smoking d oes.12 This is expecially tru e for palatal autografts and, to a lesser ex ten t, fo r c o n tig u o u s g rafts. S m o k in g cau ses constricture o f capillaries with dim inished blood flow to the graft site th at results in p o o r o x y g e n a tio n o f tis su e s a n d s u b sequent sloughing o f the graft. If a p atien t stops sm oking im m ediately before surgery an d does n o t smoke for 1 week (p re fe ra b ly 2) afte r surgery, th e n healing an d graft success is com parable to th at o f the nonsm oker.12
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Crown lengthening O fte n a p a t i e n t ’s p r o b le m is e i t h e r “show ing to o m u ch g u m ” o r “too sh o rt te e th ”— excessive gingival display.16 T his p r o b le m m ay b e a p p r o a c h e d o r th odontically o r by a co m b in atio n o f orth o d o n tic tr e a t m e n t a n d o r th o g n a t h ic surgery, b u t sim ply rem oving gingiva via precisely p lan n ed incisions often produces a satisfactory e sth etic result. A lle n 16 has o u tlin ed th e surgical criteria to treat this p r o b le m . G in g iv a l f o rm a n d to o th anatom y m ust be com pletely u n d ersto o d to obtain the m axim um esthetic result (Fig
j ; ' | I ’ ! i '
11-13). F ig 14 ■ P re o p e r a tiv e view o f 48-year-old fe m a le
Fig 15 ■ P o s to p e ra tiv e view b e f o r e p la c e m e n t o f
w ith a la r g e C la ss I I I r id g e d e f e c t . P a ti e n t h a d
f ix e d p r o s th e s is . A n o n la y g r a f t , f o llo w e d b y a
w o r n a r e m o v a b le p a r t i a l d e n t u r e w ith a c ry lic
seco n d -stag e o n la y g r a f t, w as u s e d to a u g m e n t th e
fla n g e o f s im u la te d g in g iv a f o r 18 years.
rid g e to its a p p r o x im a te d im e n s io n s b e f o r e e x tra c tio n
(C o u rte s y
of
D r. J a y
S e ib e r t,
P h ila d e lp h ia ).
result. Langer an d L anger13 have attem pted to solve th e se e s th e tic p ro b le m s by u sin g palatal connective tissue autografts rath er than epithelialized palatal autografts (Fig 9, 10). A gain, p alata l tissue is u sed fo r g ra ftin g , b u t only th e u n d e rly in g c o n n e c tiv e tis su e is h a r v e s te d . As th e connective tissue graft is th in n e r than the classic e p ith e lia liz e d g ra ft a n d has n o e p ith e liu m , a b e t t e r c o lo r m a tc h is g en erally achieved w ith th e co n n ectiv e tissue graft. If thick connective tissue grafts are used, then the color m atch is similar to th a t o f th e classic e p ith e lia liz e d g raft, especially after long-term healing. T h e palatal au to g raft is n o t lim ited to root coverage procedures. It can be used to o b tain an increase w idth o f attach ed g in g iv a, c o n c o m ita n tly in c re a s in g th e v e s tib u la r d e p th a n d e lim in a tin g th e te n s io n fro m an a b n o r m a l f re n u lu m . P a la ta l a u to g r a f ts u se d f o r g in g iv a l augm entation are generally th in n e r than th o se u se d fo r r o o t c o v e ra g e , a n d th e surgical technique is quite different.
T he palatal autograft is especially useful w h e n fu ll c o v e ra g e r e s to r a tio n s are planned for teeth with a minimal am ount o r la c k o f a t ta c h e d g in g iv a . W ith o u t recession, the decision to graft should be based on several factors. These include the age o f th e p a tie n t, th e m a in te n a n c e of m arginal tissue w ithout inflam m ation, and the type of restorative dentistry planned. O bviously th e c o n tig u o u s au to g ra fts should be used w henever possible as only one surgical site is involved. To maximize th e use o f a d ja c e n t tissu e, th e o b liq u e rotated flap an d the double papillae flap w ere la te r d e v e lo p e d . N e it h e r is n o t c u r r e n tl y r e c o m m e n d e d , a n d if th e laterally p o sitio n ed p ed icle g raft o r the coronally positioned flap is n o t feasible, a palatal autograft (eith er epithelialized or c o n n e c tiv e tissu e) p ro b a b ly s h o u ld be selected. Smoking and grafts No postoperative factor precipitates failure in soft tissue graftin g to th e d eg ree that
Ridge augm entation Reconstruction o f a p ro p er ridge form to re c e iv e p o n tic s is a p la s tic s u r g e r y pro ced u re. T he anatom ical configuration o f th e d e f e c t o f te n d e t e r m in e s th e s e le c tio n a n d s e q u e n c e o f tr e a t m e n t procedures. S iebert17 placed ridge defects in t h r e e g e n e r a l c a te g o rie s : C lass I, b u cc o lin g u a l loss o f tissue w ith n o rm a l ridge h eig h t in a apicocoronal dim ension; Class II, ap ico co ro n al loss o f tissue with n o r m a l r id g e w id th in b u c c o lin g u a l d im e n s io n ; a n d C lass I II, c o m b in e d b u c c o lin g u a l a n d a p ic o c o ro n a l loss o f tissue resu ltin g in loss o f n o rm al h eig h t an d width. A lth o u g h a C lass I d e f e c t m ay b e co rrected in a single surgical p ro ce d u re , C lass II a n d III d e fe c ts o f te n r e q u ir e second-and third-stage au g m en tatio n s to regain norm al ridge form. Plastic surgeons plan a sequence o f p ro ced u res to reconstru ct stru ctu res— a co n cep t th at dentists te n d to h av e d iffic u lty a c c e p tin g . We expect to “get it rig h t” the first time, and repeating a surgery is often viewed only as correcting a surgical failure. Obviously this is n o t th e case in rid g e a u g m e n ta tio n surgery. T h e first p eriodontal surgical proced u re fo r rid g e a u g m e n ta tio n was th e de-epithelialized connective tissue pedicle graft JADA, Vol. 121, O cto b er 1990 ■ 487
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or “roll” technique described by A brams.1» In this technique, epithelium is rem oved palatal to the defect before elevating this tissue and “rolling” it facially. Il is still used to treat Class I defects. Various “p o u c h ” p ro cedures to receive e ith e r co n n e ctiv e tis su e 19-20 o r synthetic b o n e m a teria l such as h y d roxylapatite21 have also been used to correct Class I and small Class II defects. Severe Class II to III defects are the greatest challenge and best m anaged by the onlay graft, a thick palatal autograft, d escribed by S eib ert17 (Fig 14, 15). Severe Class II an d III defects often r e q u ir e m u ltip le g r a f tin g . If m u ltip le g rafting is req u ired , 2 m onths is need ed betw een p ro c e d u re s fo r healing, shrink age, and tissue m aturation.
th e d e n tis t to r e c o n s tr u c t b u t also to regenerate lost tissues. ----------------------- J'A D A ----------------------T h e a u t h o r th a n k s P eg g y S p e c k f o r h e r e d ito r ia l assistan c e, a n d D rs. E. P at A llen , L a u re e n L a n g er, a n d Jay S e ib e rt fo r c lin ic al p h o to s. D r. M ill e r is c l i n i c a l p r o f e s s o r , d e p a r t m e n t o f p e r io d o n to lo g y , U n iv e rs ity o f T e n n e s s e e , M e m p h is. A d d ress re q u e s ts fo r re p rin ts to Dr. M iller, 6268 P o p la r Ave, M e m p h is 38119. 1. M ill e r P D . R e g e n e r a t i v e a n d r e c o n s t r u c t i v e p e r i o d o n t a l p la s t ic s u r g e r y . D e n t C lin N o r t h A m 1988;32:287. 2. F rie d m a n N . M u c o g in g iv a l s u rg e ry . T e x D e n t J 1957;75:358. 3. M aynard JG , W ilson RD. A tta c h e d gingiva a n d its c lin ic al sig n ifican ce . In: P ric h a rd JF, ed . T h e d ia g n o sis a n d tr e a tm e n t o f p e rio d o n ta l d isea se in g e n e ra l d e n ta l p ra c tic e . P h ila d e lp h ia : S a u n d e rs; 1979:138.
Summary
In th e 1980s, m u c o g in g iv a l s u r g e r y evolved in to p e rio d o n ta l plastic surgery w ith v a r io u s te c h n iq u e s d e s ig n e d to p ro d u c e ro o t coverage in areas o f m ar g in al tissue recessio n , to au g m en t d efi c ie n t ridges, a n d to le n g th e n crowns in cases o f excessive gingival display. P eri o d o n tal plastic surgery n o t only enables
4 8 8 ■ JADA, Vol. 121, O ctob er 1990
4. C o h e n D W . P e r i o d o n t i c s : r e f l e c t i o n s a n d p ro je c tio n s. A lp h a O m e g a n 1969;62:173-9. 5. G r u p e H E , W a rre n RF. R e p a ir o f gingival d efec ts by a slid in g fla p o p e ra tio n . J P e rio d o n to l 1965;27:92. 6. P e n n e l B M , H ig g a s o n J D , T o w n e r J D , e t al. O b liq u e ro ta te d fla p . J P e rio d o n to l 1965;36:305. 7. C o h e n DW , R oss SE. T h e d o u b le p a p illa e re p o s itio n e d fla p in p rio d o n ta l therapy. J P e rio d o n to l 1968;39:65. 8. H a r v e y P M . S u r g i c a l r e c o n s t r u c t i o n o f t h e gingiva. P a rt II, P ro c e d u re s. NZ D e n t J 1970;66:42. 9. T a rn o w D P. S e m i lu n a r c o r o n a lly r e p o s it io n e d flap. J C lin P e rio d o n to l 1986;13:182. 10. A lle n EP, M ille r P D . C o r o n a l p o s iti o n in g o f
e x istin g gingiva: s h o rt te rm resu lts in th e tr e a tm e n t o f s h a llo w m a r g i n a l tis s u e r e c e s s i o n . J P e r i o d o n t o l 1989,66:316. 11. B e r n im o u lir . J .
C o ro n a lly
r e p o s itio n e d
p e r io d o n ta l fla p . C lin ica l e v a lu a tio n a fte r o n e year. J C lin P e rio d o n to l 1975;2:1. 12. M ille r P D . R o o t c o v e ra g e u s in g th e f r e e s o ft tissue a u to g r a f t follow ing c itric ac id a p p lic a tio n . P a rt III. A su ccessful a n d p re d ic ta b le p ro c e d u re in a re a s o f d e e p -w id e r e c e s s io n . I n t J P e r io d o n t ic s R e s to ra tiv e D e n t 1985;5:15. 13. H o lb ro o k T, O c h s e n b e in C. C o m p le te c o v e ra g e o f d e n u d e d r o o t su rface w ith a o n e stag e gingival g raft. I n t J P e rio d o n tic s R esto rativ e D e n t 1983;3:8. 14. M ille r P D . A c la s sific a tio n o f m a r g in a l tiss u e re c e ssio n . I n t J P e rio d o n tic s R estorative D e n t 1985;5:9. 15. L a n g e r B, L a n g e r L. S u b e p ith e lia l c o n n e c tiv e tissue g ra ft te c h n iq u e fo r r o o t co v erag e. J P e rio d o n to l 1985;56:715. 16. A lle n EP . U s e o f m u c o g i n g i v a l s u r g i c a l p ro c e d u re s to e n h a n c e esth etics. D e n t C lin N o rth Am 1988;32:307. 17. S e ib e r t JS . R e c o n s tr u c tio n o f d e f o r m e d , p a rtia lly e d e n tu lo u s rid g e s u sin g fu ll th ic k n e ss o n la y g ra fts: I. T e c h n iq u e a n d w o u n d h e a lin g . C o m p e n d C o n tin E d u c D e n t 1983;4:437. 18. A b r a m s L . A u g m e n t a t i o n o f t h e d e f o r m e d r e s id u a l e d e n tu lo u s rid g e f o r fix e d p r o s th e s is . C o m p e n d C o n tin E duc D e n t 1980; 1:205. 1 9 . L a n g e r B, C a l a g n a L. T h e s u b e p i t h e l i a l c o n n e c tiv e tissu e g raft. J P ro sth e t D e n t 1980;44:363. 20. M ille r PD. R idge a u g m e n ta tio n u n d e r ex istin g fix e d p ro sth e sis. J P e rio d o n to l 1986;57:742. 2 1 . A lle n EP, G a in z a C S , F a r t h e r i n g G G , e t a l. Im p ro v e d te c h n iq u e f o r localized rid g e a u g m e n ta tio n . A r e p o r t o f 21 cases. J P e rio d o n to l 1985;56:195.
R T I C L E S
In the 1980s, mucogingival surgery evolved into periodontal plastic surgery with various reconstructive techniques designed to produce root coverage fo r marginal tissue recession, to augment deficient ridges, and to lengthen crowns in cases of excessive gingival display.
Using periodontal plastic surgery techniques Preston D. Miller, Jr., DDS
e r io d o n t a l s u r g e r y is g e n e r a lly p erceived as excisional in n a tu re with pocket elim ination being the trea tm e n t goal. Laymen are fam iliar with th e te rm “g in g iv e c to m y ” a n d en v isio n e lo n g a te d an d sensitive te e th follow ing periodontal surgery. T h e gingivectomy, however, is a d ated p r o c e d u r e . P e r io d o n ta l s u r g e r y h a s generally becom e less excisional and m ore re c o n s tru c tiv e . P reviously u n tr e a ta b le osseous defects now respond predictable e i th e r to b o n e g r a ftin g te c h n iq u e s o r g u id ed tissue reg en eratio n , and areas o f recession can be covered with soft tissue. Originally, perio d o n tal plastic surgery1 was referred to as mucogingival surgery.2
P
Two p rocedures in mucogingival surgery were d eep en in g the vestibule an d frenal surgery. Currently, th ere is little n eed to d ee p en the vestibule (except occasionally in edentulous patients), and frenectom y is less fre q u e n tly p e r f o r m e d . C u rre n tly , p e rio d o n ta l plastic su rg e ry em p h asizes tr e a tin g m a rg in a l tissu e re c e ssio n an d augm enting ridges for im proved ap p ear ance. T hese latter two procedures, along with crown lengthening surgery to correct e x c e ssiv e g in g iv a l d is p la y ( “g u m m y sm ile”), are the subjects o f this paper. M arginal tissue recession M a rg in a l tis su e r e c e s s io n 3 is tr e a te d
su rg ic a lly e i th e r by u s in g m a s tic a to ry m u c o sa l g r a f ts fro m th e p a la te o r by m o v in g tissu e la te ra lly o r c o ro n a lly to cover th e recession. T he palatal autograft is o fte n r e f e r re d to as a “fre e g in g iv al ^ graft,” but this term is incorrect. “Free gingiva” is the unattached gingiva su rro u n d in g a tooth, an d this tissue is n o t used in grafting procedures. F u rth erm o re, ; the palatal tissue used for grafting is n o t g in g iv a b u t m a s tic a to ry m u c o sa ta k e n fro m th e h a rd p alate. C o h e n 4 classified so ft-tissu e g ra ftin g p r o c e d u re s u se d in p e rio d o n tic s as free soft a u to g ra fts an d c o n tig u o u s so ft-tissu e a u to g ra fts ; a n d contiguous grafts w ould include laterally p o sitio n e d flaps, o b liq u e ro ta te d flaps,
Fig 1 ■ Preoperative view o f maxillary canine o f
Fig 2 ■ Laterally positioned pedicle graft sutured
Fig 3 ■ One-year postoperative view with 5-mm
43-year-old male with 7-mm (Class III) recession.
in p o s itio n a ttem p tin g 5-m m r o o t c o v er a g e
root coverage with attachment.
(com plete root coverage is not obtainable because o f adjacent 3 mm recession on premolars).
JADA, Vol. 121, O cto b er 1990 ■ 485
A R T I C L E S
d o u b le p a p illa e fla p s , a n d c o r o n a lly positioned Haps. C o n tiguous soft tissue autografts were in tro d u ced by G rupe and W arren5 u n d er the term “lateral sliding flap” a procedure currently known as the laterally positioned ped icle graft (Fig 1-3). Gingiva fro m an adjacent tooth is freed by a horizontal and two vertical incisions an d tra n sfe rre d to the recipient tooth. This often resulted in recession o n th e d o n o r to o th , a n d th e p ro c e d u re was la te r m o d ifie d so th a t a “collar” o f gingiva rem ained on the do n o r to o th . T h e “la te r a l s lid in g f la p ” gave im petus to the oblique ro tated flap,1’ the d o u b le papillae flap,7 a n d th e coronally positioned flap.8-10 In all o f these, existing gingiva is moved or rotated to create m ore gingiva on a recipient tooth. B e rn im o u lin " in tr o d u c e d a tw o-step te c h n iq u e fo r c o ro n a lly p o s itio n in g a h ealed palatal autograft. A lthough still a viable technique, it is less frequently used. Root coverage with the palatal autograft as a s in g le p r o c e d u r e is g e n e r a lly b o th successful and predictable.1213 A thorough u nderstanding o f the class o f recession14 is necessary if m axim um root coverage is to be a tte m p te d . A lth o u g h c o m p le te ro o t coverage is anticipated in Class I and Class II recessions, only p a rtia l ro o t coverage can be achieved in Class III recession (Fig 1-3). Coronally positioning existing gingiva is used to treat areas o f m inim al recession. A reas w ith only 2 to 3 m m o f recession with attached gingiva may be overlooked. O ften the patient expresses a desire to “do s o m e th in g ” o n ly to h av e th e d e n t is t d isc o u ra g e th e p a tie n t from tre a tm e n t. Occasionally, these areas have superficial c a rie s , se n sitiv ity , o r y e llo w ish -b ro w n staining, which creates an esthetic concern for the patient. Allen an d M iller10 outlined th e criteria an d te c h n iq u e for coronally positioning existing gingiva (Fig 4-6). A contiguous autograft is the preferred tre a tm e n t fo r m arg in al tissue recession w h en th e re is a d e q u a te d o n o r gingiva. Only on e surgical site is involved. T here is n o p r o b le m w ith th e c o lo r m a tc h o f tissues. T h e p alata l a u to g ra ft, however, offers the m ost versatile surgical treatm ent for m arginal tissue recession because the palate offers adequate d o n o r tissue. O ne problem in using palatal tissue has b e e n th e c o lo r m a tc h o f tissu e s a f te r h e a lin g as palatal a u to g ra fts are w hiter and m ore opaque (Fig 7, 8) than gingival tissue. In addition, palatal autografts may be too thick after healing. O ften a slight d e r m a b r a s io n o f th e h e a le d g ra ft is n ecessary to p ro d u c e th e m o st esth etic 486 ■ JADA, Vol. 121, O cto b er 1990
Fig 4 ■ Preoperative view o f 23-year-old fem ale
Fig 5 ■ C oron ally p o s itio n e d fla p to cem en -
w ith h ig h s m ile lin e sh o w in g 3-m m (C la ss I)
toenam el ju nction to provide thicker gingiva. A
r e c e ssio n on m axillary cen tral in c iso r s. N o te
layer o f p alatal c o n n e c tiv e tis s u e w as p la c e d
gingiva to be positioned is quite thin.
beneath the flap.
F ig 6 ■ O n e-year p o s to p e r a tiv e view . N o te
Fig 7 ■ Preoperative view o f 16-year-old fem ale
thickness o f gingiva obtained by connective tissue
with 3-mm recession and no gingiva on mandibular
augmentation.
central incisors (Class II recession).
F ig 8 ■ O n e-y ea r p o s to p e r a tiv e view a fte r
Fig 9 ■ Preoperative view o f 55-year-old fem ale
placement o f a classic (epithelialized) free palatal
with 5-mm recession (Class I) on maxillary canine.
graft. Color match o f tissue and attachment have been achieved.
F ig 10 ■ O n e-year p o s to p e r a tiv e view a fte r
Fig 11 ■ A 28-year-old patient after orthodontic
p lacem ent o f a subepithelial con n ective tissue
therapy. The smile features an excessive display of
graft (Courtesy o f Dr. Laurleen Langer, New York).
gingiva with insufficient clinical crown length and asymmetry.
A R T I C L E S
Fi g 12 ■ S u rg ic a l e x p o s u r e o f th e fu ll a n a to m ic
F ig 13 ■ Six w eeks p o s to p e ra tiv e ly , a d ra m a tic a lly
c r o w n w a s a c c o m p l i s h e d b y i n t e r n a l b e v e le d
im p ro v e d a p p e a r a n c e is s e e n . L e n g th e n in g o f th e
e x c is io n o f a g in g iv a l c o l l a r f a c ia lly o n a ll s ix
t e e t h b y s u r g i c a l e x p o s u r e h a s r e s u l t e d in
a n te r io r te e th
r e d u c t i o n o f t h e e x c e s s i v e g in g i v a l d i s p la y ,
a n d th e le f t a n d rig h t f ir s t
p re m o la rs . T h e in te r d e n ta l p a p illa e w e re le f t
e lim in a tio n o f a s y m m e try , a n d a d e n t iti o n
in ta c t.
h a rm o n io u s w ith th e u p p e r lip (C o u rte sy o f Dr. E.
M in im a l
o d o n to p la s ty
re m o v e d
irre g u la ritie s o n th e in c isal ed g e s.
P a t A lien , D allas).
smoking d oes.12 This is expecially tru e for palatal autografts and, to a lesser ex ten t, fo r c o n tig u o u s g rafts. S m o k in g cau ses constricture o f capillaries with dim inished blood flow to the graft site th at results in p o o r o x y g e n a tio n o f tis su e s a n d s u b sequent sloughing o f the graft. If a p atien t stops sm oking im m ediately before surgery an d does n o t smoke for 1 week (p re fe ra b ly 2) afte r surgery, th e n healing an d graft success is com parable to th at o f the nonsm oker.12
\ ; :
] I
Crown lengthening O fte n a p a t i e n t ’s p r o b le m is e i t h e r “show ing to o m u ch g u m ” o r “too sh o rt te e th ”— excessive gingival display.16 T his p r o b le m m ay b e a p p r o a c h e d o r th odontically o r by a co m b in atio n o f orth o d o n tic tr e a t m e n t a n d o r th o g n a t h ic surgery, b u t sim ply rem oving gingiva via precisely p lan n ed incisions often produces a satisfactory e sth etic result. A lle n 16 has o u tlin ed th e surgical criteria to treat this p r o b le m . G in g iv a l f o rm a n d to o th anatom y m ust be com pletely u n d ersto o d to obtain the m axim um esthetic result (Fig
j ; ' | I ’ ! i '
11-13). F ig 14 ■ P re o p e r a tiv e view o f 48-year-old fe m a le
Fig 15 ■ P o s to p e ra tiv e view b e f o r e p la c e m e n t o f
w ith a la r g e C la ss I I I r id g e d e f e c t . P a ti e n t h a d
f ix e d p r o s th e s is . A n o n la y g r a f t , f o llo w e d b y a
w o r n a r e m o v a b le p a r t i a l d e n t u r e w ith a c ry lic
seco n d -stag e o n la y g r a f t, w as u s e d to a u g m e n t th e
fla n g e o f s im u la te d g in g iv a f o r 18 years.
rid g e to its a p p r o x im a te d im e n s io n s b e f o r e e x tra c tio n
(C o u rte s y
of
D r. J a y
S e ib e r t,
P h ila d e lp h ia ).
result. Langer an d L anger13 have attem pted to solve th e se e s th e tic p ro b le m s by u sin g palatal connective tissue autografts rath er than epithelialized palatal autografts (Fig 9, 10). A gain, p alata l tissue is u sed fo r g ra ftin g , b u t only th e u n d e rly in g c o n n e c tiv e tis su e is h a r v e s te d . As th e connective tissue graft is th in n e r than the classic e p ith e lia liz e d g ra ft a n d has n o e p ith e liu m , a b e t t e r c o lo r m a tc h is g en erally achieved w ith th e co n n ectiv e tissue graft. If thick connective tissue grafts are used, then the color m atch is similar to th a t o f th e classic e p ith e lia liz e d g raft, especially after long-term healing. T h e palatal au to g raft is n o t lim ited to root coverage procedures. It can be used to o b tain an increase w idth o f attach ed g in g iv a, c o n c o m ita n tly in c re a s in g th e v e s tib u la r d e p th a n d e lim in a tin g th e te n s io n fro m an a b n o r m a l f re n u lu m . P a la ta l a u to g r a f ts u se d f o r g in g iv a l augm entation are generally th in n e r than th o se u se d fo r r o o t c o v e ra g e , a n d th e surgical technique is quite different.
T he palatal autograft is especially useful w h e n fu ll c o v e ra g e r e s to r a tio n s are planned for teeth with a minimal am ount o r la c k o f a t ta c h e d g in g iv a . W ith o u t recession, the decision to graft should be based on several factors. These include the age o f th e p a tie n t, th e m a in te n a n c e of m arginal tissue w ithout inflam m ation, and the type of restorative dentistry planned. O bviously th e c o n tig u o u s au to g ra fts should be used w henever possible as only one surgical site is involved. To maximize th e use o f a d ja c e n t tissu e, th e o b liq u e rotated flap an d the double papillae flap w ere la te r d e v e lo p e d . N e it h e r is n o t c u r r e n tl y r e c o m m e n d e d , a n d if th e laterally p o sitio n ed p ed icle g raft o r the coronally positioned flap is n o t feasible, a palatal autograft (eith er epithelialized or c o n n e c tiv e tissu e) p ro b a b ly s h o u ld be selected. Smoking and grafts No postoperative factor precipitates failure in soft tissue graftin g to th e d eg ree that
Ridge augm entation Reconstruction o f a p ro p er ridge form to re c e iv e p o n tic s is a p la s tic s u r g e r y pro ced u re. T he anatom ical configuration o f th e d e f e c t o f te n d e t e r m in e s th e s e le c tio n a n d s e q u e n c e o f tr e a t m e n t procedures. S iebert17 placed ridge defects in t h r e e g e n e r a l c a te g o rie s : C lass I, b u cc o lin g u a l loss o f tissue w ith n o rm a l ridge h eig h t in a apicocoronal dim ension; Class II, ap ico co ro n al loss o f tissue with n o r m a l r id g e w id th in b u c c o lin g u a l d im e n s io n ; a n d C lass I II, c o m b in e d b u c c o lin g u a l a n d a p ic o c o ro n a l loss o f tissue resu ltin g in loss o f n o rm al h eig h t an d width. A lth o u g h a C lass I d e f e c t m ay b e co rrected in a single surgical p ro ce d u re , C lass II a n d III d e fe c ts o f te n r e q u ir e second-and third-stage au g m en tatio n s to regain norm al ridge form. Plastic surgeons plan a sequence o f p ro ced u res to reconstru ct stru ctu res— a co n cep t th at dentists te n d to h av e d iffic u lty a c c e p tin g . We expect to “get it rig h t” the first time, and repeating a surgery is often viewed only as correcting a surgical failure. Obviously this is n o t th e case in rid g e a u g m e n ta tio n surgery. T h e first p eriodontal surgical proced u re fo r rid g e a u g m e n ta tio n was th e de-epithelialized connective tissue pedicle graft JADA, Vol. 121, O cto b er 1990 ■ 487
*
1
|
: I ;
I
; ■
j
or “roll” technique described by A brams.1» In this technique, epithelium is rem oved palatal to the defect before elevating this tissue and “rolling” it facially. Il is still used to treat Class I defects. Various “p o u c h ” p ro cedures to receive e ith e r co n n e ctiv e tis su e 19-20 o r synthetic b o n e m a teria l such as h y d roxylapatite21 have also been used to correct Class I and small Class II defects. Severe Class II to III defects are the greatest challenge and best m anaged by the onlay graft, a thick palatal autograft, d escribed by S eib ert17 (Fig 14, 15). Severe Class II an d III defects often r e q u ir e m u ltip le g r a f tin g . If m u ltip le g rafting is req u ired , 2 m onths is need ed betw een p ro c e d u re s fo r healing, shrink age, and tissue m aturation.
th e d e n tis t to r e c o n s tr u c t b u t also to regenerate lost tissues. ----------------------- J'A D A ----------------------T h e a u t h o r th a n k s P eg g y S p e c k f o r h e r e d ito r ia l assistan c e, a n d D rs. E. P at A llen , L a u re e n L a n g er, a n d Jay S e ib e rt fo r c lin ic al p h o to s. D r. M ill e r is c l i n i c a l p r o f e s s o r , d e p a r t m e n t o f p e r io d o n to lo g y , U n iv e rs ity o f T e n n e s s e e , M e m p h is. A d d ress re q u e s ts fo r re p rin ts to Dr. M iller, 6268 P o p la r Ave, M e m p h is 38119. 1. M ill e r P D . R e g e n e r a t i v e a n d r e c o n s t r u c t i v e p e r i o d o n t a l p la s t ic s u r g e r y . D e n t C lin N o r t h A m 1988;32:287. 2. F rie d m a n N . M u c o g in g iv a l s u rg e ry . T e x D e n t J 1957;75:358. 3. M aynard JG , W ilson RD. A tta c h e d gingiva a n d its c lin ic al sig n ifican ce . In: P ric h a rd JF, ed . T h e d ia g n o sis a n d tr e a tm e n t o f p e rio d o n ta l d isea se in g e n e ra l d e n ta l p ra c tic e . P h ila d e lp h ia : S a u n d e rs; 1979:138.
Summary
In th e 1980s, m u c o g in g iv a l s u r g e r y evolved in to p e rio d o n ta l plastic surgery w ith v a r io u s te c h n iq u e s d e s ig n e d to p ro d u c e ro o t coverage in areas o f m ar g in al tissue recessio n , to au g m en t d efi c ie n t ridges, a n d to le n g th e n crowns in cases o f excessive gingival display. P eri o d o n tal plastic surgery n o t only enables
4 8 8 ■ JADA, Vol. 121, O ctob er 1990
4. C o h e n D W . P e r i o d o n t i c s : r e f l e c t i o n s a n d p ro je c tio n s. A lp h a O m e g a n 1969;62:173-9. 5. G r u p e H E , W a rre n RF. R e p a ir o f gingival d efec ts by a slid in g fla p o p e ra tio n . J P e rio d o n to l 1965;27:92. 6. P e n n e l B M , H ig g a s o n J D , T o w n e r J D , e t al. O b liq u e ro ta te d fla p . J P e rio d o n to l 1965;36:305. 7. C o h e n DW , R oss SE. T h e d o u b le p a p illa e re p o s itio n e d fla p in p rio d o n ta l therapy. J P e rio d o n to l 1968;39:65. 8. H a r v e y P M . S u r g i c a l r e c o n s t r u c t i o n o f t h e gingiva. P a rt II, P ro c e d u re s. NZ D e n t J 1970;66:42. 9. T a rn o w D P. S e m i lu n a r c o r o n a lly r e p o s it io n e d flap. J C lin P e rio d o n to l 1986;13:182. 10. A lle n EP, M ille r P D . C o r o n a l p o s iti o n in g o f
e x istin g gingiva: s h o rt te rm resu lts in th e tr e a tm e n t o f s h a llo w m a r g i n a l tis s u e r e c e s s i o n . J P e r i o d o n t o l 1989,66:316. 11. B e r n im o u lir . J .
C o ro n a lly
r e p o s itio n e d
p e r io d o n ta l fla p . C lin ica l e v a lu a tio n a fte r o n e year. J C lin P e rio d o n to l 1975;2:1. 12. M ille r P D . R o o t c o v e ra g e u s in g th e f r e e s o ft tissue a u to g r a f t follow ing c itric ac id a p p lic a tio n . P a rt III. A su ccessful a n d p re d ic ta b le p ro c e d u re in a re a s o f d e e p -w id e r e c e s s io n . I n t J P e r io d o n t ic s R e s to ra tiv e D e n t 1985;5:15. 13. H o lb ro o k T, O c h s e n b e in C. C o m p le te c o v e ra g e o f d e n u d e d r o o t su rface w ith a o n e stag e gingival g raft. I n t J P e rio d o n tic s R esto rativ e D e n t 1983;3:8. 14. M ille r P D . A c la s sific a tio n o f m a r g in a l tiss u e re c e ssio n . I n t J P e rio d o n tic s R estorative D e n t 1985;5:9. 15. L a n g e r B, L a n g e r L. S u b e p ith e lia l c o n n e c tiv e tissue g ra ft te c h n iq u e fo r r o o t co v erag e. J P e rio d o n to l 1985;56:715. 16. A lle n EP . U s e o f m u c o g i n g i v a l s u r g i c a l p ro c e d u re s to e n h a n c e esth etics. D e n t C lin N o rth Am 1988;32:307. 17. S e ib e r t JS . R e c o n s tr u c tio n o f d e f o r m e d , p a rtia lly e d e n tu lo u s rid g e s u sin g fu ll th ic k n e ss o n la y g ra fts: I. T e c h n iq u e a n d w o u n d h e a lin g . C o m p e n d C o n tin E d u c D e n t 1983;4:437. 18. A b r a m s L . A u g m e n t a t i o n o f t h e d e f o r m e d r e s id u a l e d e n tu lo u s rid g e f o r fix e d p r o s th e s is . C o m p e n d C o n tin E duc D e n t 1980; 1:205. 1 9 . L a n g e r B, C a l a g n a L. T h e s u b e p i t h e l i a l c o n n e c tiv e tissu e g raft. J P ro sth e t D e n t 1980;44:363. 20. M ille r PD. R idge a u g m e n ta tio n u n d e r ex istin g fix e d p ro sth e sis. J P e rio d o n to l 1986;57:742. 2 1 . A lle n EP, G a in z a C S , F a r t h e r i n g G G , e t a l. Im p ro v e d te c h n iq u e f o r localized rid g e a u g m e n ta tio n . A r e p o r t o f 21 cases. J P e rio d o n to l 1985;56:195.