Gingival alteration techniques
In periodontal esthetic therapy, it often becomes necessary to alter gingival architecture in order to improve esthetics and/or function. Dr. Jesse Hofer discusses some of the indications, contraindications, and considerations with regard to mucogingival therapies.
In periodontal esthetic therapy, it often becomes necessary to alter gingival architecture in order to improve esthetics and/or function. Mucogingival therapies include techniques to increase attached gingiva, vestibular/gingival extension procedures, root coverage, crown lengthening, and interdental papilla reconstruction. This article will talk about some of the indications, contraindications, and considerations of these procedures.
Techniques to increase attached gingiva
If a patient experiences discomfort with brushing in recessed areas, gingival augmentation may help. There is not sufficient data to support the idea of grafting when patients have only a thin zone of asymptomatic keratinized tissue around teeth. However, grafting may be indicated if orthodontic/restorative procedures are planned that will move teeth, resulting in dehiscence, or restorations are planned that will be subgingival. Because it can be difficult to ascertain on an initial visit whether a mucogingival condition is getting worse, the goal of grafting will not typically be to correct a mucogingival problem but to treat symptoms the patient is experiencing (concern about esthetics, sensitivity, etc). If esthetics is the patient’s only concern, the practitioner must decide whether or not the patient will be satisfied with the outcome and plan accordingly. In order to have a mucogingival problem that actually indicates grafting, there should be recession, a lack of attached gingiva, and inflammation. (8)
Studies show that the thickness of gingival marginal tissue plays a greater role than apical-coronal width in determining whether or not recession will occur after improper hygiene practice. (2) When grafting tissue to reduce pocket depth, research has demonstrated that a graft thinner than 2.5 mm and a width greater than 50% attachment to periosteum is needed. This has been shown to hold true with subperiosteal and intraperiosteal grafting procedures. (1) When preparing the recipient site, as with any surgery, exposing bone will lead to more postoperative resorption compared to procedures that leave the periosteum intact. (2) Studies have shown similar coverage in comparing allodium grafting and autogeneous grafting. (3, 5)
A study performed in 1998 demonstrated that by free gingival grafting one could expect a doubling of the gingival thickness, an increase of clinical attachment, and an increase in the zone of attached gingiva in the nonsmoker. (6, 7) It has been demonstrated that it is possible to increase the attached gingiva using an apically positioned flap. This method, which leaves the marginal gingival intact, allows for better color matching, avoidance of recession, and is ideal in esthetic areas. (9)
In order to effectively maintain oral hygiene and have adequate retention with certain prosthetic devices, the vestibule needs sufficient depth. Techniques have been proposed in the past to extend the vestibule; however, long-term studies on techniques other than grafting show poor results. Therefore, grafting becomes the best means of deepening the vestibule. (4)
An effective way to ascertain what a patient can expect from a root coverage procedure is by using Miller’s classification system. One can often effectively cover Class I and II defects as long as there is no pocketing that extends deeper than 2 mm, there’s a soft-tissue margin located at the CEJ, and there is no bleeding on probing on a clinically attached root. (8) In 1985 the bilaminar technique was developed. This technique has a better predictability in root coverage. This is actually a combination of a connective tissue graft covered by a coronally displaced flap. (10)
Three good reasons to lengthen crowns include reducing the amount of displayed gingiva, exposing sound tooth structure, and ectopic tooth eruption. Studies have shown that the biological width initially shrinks but will return to its original dimension six months after surgery. (16) Crown lengthening can be contraindicated in cases where a single tooth needs exposure in the esthetic zone and can make the teeth appear asymmetrical as a result. (2) It is desirable to maintain biological width when preparing crown margins to avoid chronic inflammation that leads to bone defects. When force erupting a tooth, it is possible to control which part of the crestal bone will follow the tooth by selectively severing the fibers that attach to bone that one does not want to follow the tooth. (2)
In conclusion, there are many reasons to alter gingiva, which include increasing attached gingiva for prosthetics or avoidance of recession defects in thin gingiva after orthodontic movement of teeth, deepening vestibules for proper hygiene and appropriate support of prosthesis, covering Class I or Class II recession defects, crown lengthening for prosthetic placement, assistance in extruding teeth, and exposure of teeth in individuals with gummy smiles. In order to successfully build a clinical practice, one must consider the outcome in terms of patient desires. Before performing any gingival augmentation procedure, patients should be informed of possible complications and the likeliness of success.
Jesse J. Hofer, DMD, graduated from University of Utah with a bachelor's in bioengineering, and then graduated from the University of Pittsburgh Dental School. Dr. Hofer is currently enrolled in the postdoctoral periodontics program at the University of Stony Brook School of Dental Medicine.
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