Cosmetic periodontal surgery: Multiple gingival graft techniques (Part 2)

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Cosmetic periodontal surgery: Multiple gingival graft techniques (Part 2)

The healed area four months after treatment. The recession is now reclaimed by a healthy attached gingival zone. (DTI/Photo David L Hoexter, DMD, FACD, FICD)

Mon. 5 December 2011


In today’s new information age, patients want a better quality of life. They want to keep their youthful, brighter-appearing smile more than ever; keep their natural teeth; have their teeth feel and look better; and have a glowing smile. In recent years, dentistry seems to be concentrating almost exclusively on accomplishing this “smile” by focusing on the crown portion of the tooth.

Restorative materials are creatively being made available to help dentists create the crown’s natural coloring, whitening, and hues. The crown has been lengthened, squared, made ovoid, rounded, and shortened. Reproduction of the crown’s original shape and color has also been attempted.

Esthetic dentistry must now turn its focus toward achieving an aesthetic totality, not just the perfect crown or restoration. Many materials have been developed to help achieve an artistic tooth color, but the desired aesthetic result still depends on the background accentuating the desired image — something great painters have long known and created in fine oil paintings. This background must drape around and significantly contrast the object to be emphasized. It can make or break the object that clinicians wish people to see. If the background is distracting, the object loses its importance.

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For example, cosmetically, if a crown is restored correctly against a healthy, pinkish-white gingiva, the patient’s illusionary smooth smile line can be successfully achieved and viewed. However, if that same crown is placed against an unhealthy, inflamed, reddish gingiva, the eye’s focus will be toward the unaesthetic area. A porcelain laminate placed against a natural pink gingival is simply more pleasing and compatible to its background.

As mentioned in part one of this series, achieving consistently successful dental aesthetics is mostly a function of creating desired illusions. The first step is ensuring that certain fundamental principles of health are preserved, respected and maintained.

Achieving a healthy periodontia is the prerequisite and basis for sustaining this illustration of oral health. It is essential for restorative aesthetics, as well as natural dentition, enabling clinicians to better their chances for successful restorative results and maintenance of the results. By incorporating the use of tissue colors, hues, shapes, forms, and symmetrical appearances one can achieve and maintain the desired aesthetic goal.

As in other forms of art, a symmetrical appearance tends to focus the observing eye on the overall illusion. Assuming there is no pathology, symmetry of color zones and hue are vital to gain the desired illusion and distract attention from a defective area.

The gingival layer of keratinized tissue is at the margin of natural teeth and around the crowns. The mucogingival junction separates the outstanding color demarcation of the pinkish keratinized attached gingival from the mobile alveolar mucosa, which is a bluish-red zone. Nature’s colorations of these zones in symmetrical form are what clinicians must strive for to achieve and maintain health and aesthetics.

If, for example, an adequate zone of attached gingival were unevenly distributed in the same quadrant, the reddish blue alveolar mucosa would be out of place and draw negative attention. In contrast, if the attached gingiva locally encroaches on the alveolar mucosa, a color reversal would occur, resulting in a large, uneven pink zone against an uneven reddish-blue background.

In the past, oversized free gingival grafts have frequently been used to replace absent or inadequate zones of attached gingival. Those large donor grafts were protective but had an unaesthetic appearance; an encroachment of colors into the alveolar mucosa would usually occur. Even though this pink invasion was subtler compared with the reddish-blue of the alveolar mucosa invading the gingival, it nevertheless broke the background symmetrical illusion.

As a further example, overgrowth of tissue, i.e., fibrous hyperplasia, changes the shape of the tissue, thereby partially covering the tooth and changing the appearance of its size. If covered by hyperplastic keratinized gingiva, the tooth appears smaller, especially when compared with the adjacent tooth. This overgrowth may be of developmental, iatrogenic or systemic origins. The result is unaesthetic. These can and should be corrected, which will be discussed in future parts of this series.

When referring to cosmetic illusion using gingival colors, it is important to reflect on examples of nonsymmetrical color breaks of the gingiva. They represent an unhealthy situation and are an eyesore because they disrupt esthetics.

In a case of inflammation, permanent pathology may occur, resulting in irreversible unaesthetic root exposure (recession). A vertical reddish color at the gingival margin may warn that pathology is starting.

Several techniques are reported to correct recession, but in reality, the result is not predictable for restored health. Therefore, it is predictably easier and aesthetically more achievable to treat the inflammation earlier. Without a healthy zone of attached gingiva, a crown’s margin will become exposed, thus exhibiting an unattractive contrasting color. It might be the underlying metal margin of the crown or the yellow color of the recessed tooth’s root.

Without a healthy zone, a laminate’s margin will probably collect plaque and lead to inflammation and bleeding gingiva. As mentioned previously, this can draw negative attention and most likely lead to recession and an irregular gingival pattern variations

Part two of this series discusses and illustrates cosmetic periodontal surgery, utilizing various gingival graft techniques to correct defects, obtain health, and produce symmetrically appearing color, hues and form.

This type of surgery is an ideal tool for making happy patients who smile with brilliant confidence.

Case presentation

A young woman was referred to my office with exposed, unsightly longer-looking teeth. They appeared longer due to her receding “gums.” Although the patient had a low caries rate and a good oral hygiene technique, she had been told by a previous dentist that she had weak and ugly gums. She noted that her gums bled periodically when brushing, and complained about their unattractive appearance, which made her stiffen her lower lip when smiling. She was intelligent and self-consciously aware of her problem. She desired to have the recession stopped and the aesthetics to smile with confidence.

Examination revealed that the lower right cuspid had recession (Fig. 1), showing an exposed buccal root. There was an absence of attached gingival, leaving the area surrounded by alveolar mucosa. Therefore, the tooth was surrounded by reddish tissue, which made the root more visibly unattractive. The contrast of deep red color surrounding an exposed root was accentuated when the lip was retracted, showing a frenum pull. This made it difficult for her to keep the area free of plaque. In contrast, adjacent teeth had pink attached gingiva.

The surgical technique chosen to correct this defect, restore her health, and enhance her aesthetics was a variation of the lateral oblique pedicle graft technique.

Case No. 1: Treatment

The LR Nos. 28, 27 and 26 area was anesthetized using lidocaine 1:100,000. The local anesthetic was infiltrated locally both buccal and lingual. A No. 15 blade was used to incise an outline, which included all the interproximal keratinized tissue of Nos. 28 and 27 as well as the buccal of No. 28. The poor, small buccal zone of tissue was removed from the No. 27 buccal area.

The recipient site was then prepared. The tooth was lightly scaled. A periodontal elevator (Hoexter elevator by Hu-friedy) was utilized to reflect the tissue. The incision also included into the alveolar mucosal area, allowing ease of mobility. The graft flap was rotated so the largest portion of the keratinized area could be employed to cover the recessed area and the newly exposed recipient buccal blood supply of No. 27. To stabilize the graft in our desired position, a sling-type suturing technique was utilized. The area was covered with a periodontal dressing (Coe Pak). Tetracycline 250 mg was prescribed qid for seven days. An analgesic was also prescribed.

The results present an obviously healthy and restored symmetrical, pink zone of attached gingival and continuity with the adjacent area. The recession was gone, the length and width of the attached gingival was symmetrically blended with the adjacent area, and the frenum-pull was corrected. Figure 2, taken 15 years postoperatively, attests to the durability of the results using this technique.

The result enabled the patient to smile with confidence, without hesitation; she no longer had the reflexive action of holding her lip back. The procedures also permitted her to maintain good oral hygiene, made her feel that she was keeping her teeth (recession indicates age to some), and achieved a maintainable, normal color balance, which collectively created an aesthetically pleasing appearance.

Case No. 2

Predictability of results of root recession coverage has been improved in recent years with the utilization of Guided Tissue Regeneration (GTR).

This case demonstrates another gingival graft technique: the coronal repositioned gingival graft. It uses guided tissue regeneration using an acellular collagen membrane, which adds to the predictability of acquiring a blood supply. The resultant zone of attached gingival and root coverage blend aesthetically into the background with a symmetrical width and lateral flow of healthy, pink keratinized tissue.

Viewing the initial appearance of #11, it displays the longer-appearing cuspid with recession (Fig. 3), which makes it stand out and causes the area to be unattractive and noticeable. Figures 4a and b show the acellular membrane placed over the exposed buccal root of No. 11, after the buccal flap is reflected. The tissue is sutured with a continuous suture covering the exposed root in the desired final position and the acellular membrane (Fig. 5). Figure 6 shows the healed area four months later. The recession is now reclaimed by a healthy attached gingival zone. The acellular collagen preferred in this technique in my office is supplied by CK Dental. The results allow a symmetrical appearing zone of pink, keratinized tissue to blend in the area. The cuspid is no longer “long in the tooth.” The linear, even shape of the teeth is aesthetically pleasing. The overall result is easily maintained by the background of correct color, texture, and symmetrical zone of appearance and health. Now the restoring of the #10 incisal edge will have options toward the desired appearance.


Fortunately, in these particular cases, the patients’ dental awareness made it possible for them to request correction of their oral health and aesthetics. These illustrations demonstrate the aesthetic awareness and desires of today’s society. Practitioners must be able to recognize and work toward these goals. By creatively using variations of techniques to achieve such results, the art of dentistry is recovered. Achieving health is primary, but providing a maintainable, healthy and pleasing appearance is also significantly desirable and important.

Note: This article was originally published in Dental Tribune U.S. Edition, Vol. 6 No. 17, November 2011. Part 1 is available here.

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