Periodontal Approach To Esthetic Dentistry: February 2015

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Periodontal Approach to Esthetic Dentistry

Article · February 2015

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Periodontics
Review Article

PERIODONTAL APPROACH TO ESTHETIC DENTISTRY


1
SHANKAR BABU
2
KHUSHBU ADHIKARI
ABSTRACT
It is the responsibility of the dental team to understand optimal esthetics, the indications for
treatment, and to be able to effectively communicate with the patient. Currently, periodontal surgery
is considered to be of two components – Excisional periodontal surgery and Regenerative periodontal
surgery. The former includes gingivectomy, flap surgery to eliminate pockets without using regener-
ative techniques and resective osseous surgery. The latter includes use of bone grafts, guided tissue
regeneration, guided bone regeneration, root conditioning procedure and periodontal plastic surgery.
This comprehensive review focuses on the various indications and procedures in periodontal esthetic
surgeries.
Key Words: Periodontal esthetic procedure, resective periodontal surgeries, regenerative esthetic
surgeries. esthetic smile.

INTRODUCTION THE AESTHETIC SMILE


The word ‘Aesthetics’ is derived from ‘Asthetisch’ Until recently, a misconception prevailed among
(German) or ‘Esthetique’ (French). It means “the science dentists and the general public that the concept of den-
which treats the conditions of sensuous perception”. tal aesthetics was limited to alteration in teeth alone.
Today cosmetic concerns as well as increased intra-oral The dentist was forced to accept the pre existing rela-
awareness have created a demand for esthetics in tionship between teeth, gingival scaffold and the lips.1
periodontal practice. Esthetic improvements are the Any changes in the pre-existing “Lip-Gingival-tooth”
primary indication for performing periodontal plastic relationship was thought to require orthodontic therapy
and soft tissue reconstruction surgery. It is the re- in conjunction with orthognathic surgery or aggressive
sponsibility of the dental team mainly periodontists periodontal procedures.2 However, with the advent of
to understand optimal esthetics, the indications for soft tissue plastic surgery, much of this has changed.
treatment, and to be able to effectively communicate The sphere of Periodontics has been upgraded from
with the patient. Modern dentistry not only provides strictly being a health service to one which provides
us with better material and technology but ensures optimal aesthetics.
that today’s procedures are performed with minimal
discomfort and maximal safety. The essentials of a smile involve:
“Mucogingival surgery” is a term that was initially The teeth
introduced by Friedman; The Glossary of Periodontal
terms defined Mucogingival surgery as – Periodontal The gingival scaffold
surgical procedure designed to correct defects in the
morphology, position and/or the amount of gingiva. The lip framework3
This literature review focuses on Periodontal Plastic The teeth: The color, position and the shape or
Surgery- its scope, limitations and esthetic implications silhouette form of the teeth are of importance. The
in periodontal practice. This comprehensive review advent of adhesive dentistry allows instantaneous and
focuses the basic guidelines and need for the esthetic aesthetic change in color, position and shape of teeth
management taking into consideration the periodontal using various bonding techniques such as laminate
health. veneers and direct composite bonding.4
Corresponding Author: 1Dr Shankar Babu, TP MDS, Periodon-
tist and Oral Implantologist New Abha Dental Specialty Center, The gingival scaffold: Periodontal therapy is
Kuwait E-mail: dr_shankartp@rediffmail.com
2
Dr Khushbu Adhikari, MDS, Resident, Department of Periodon- associated with restoring periodontal health and main-
tology and Oral Implantology, CODS, Universal College of Medical taining the integrity of the attachment apparatus5.
Sciences, Bhairahawa, Nepal E-mail: adhkhush@gmail.com But in today’s practice, apart from being healthy, there
Received for Publication: November 29, 2014
Revised: January 19, 2015
should be a certain degree of harmony and continuity
Accepted: February 7, 2015 of the free gingival margin.6

Pakistan Oral & Dental Journal Vol 35, No. 1 (March 2015) 91
Periodontal approach to esthetic dentistry

The lips: The lip form frames the smile and defines PERIO-AESTHETIC PROCEDURES
the aesthetic zone.7 Lip lines can be classified as high, SURGICAL CROWN LENGTHENING FOR
medium or low, depending on relation of inferior border FUNCTION AND AESTHETICS
of lip with gingiva and teeth.8
Crown lengthening involves the surgical removal of
1 High lipline – shows a large exposure of the gingiva hard and soft periodontal tissues to gain supracrestal
extending from the inferior border of the upper lip tooth length, allowing for clinical crowns and reestab-
to the free gingival margin. lishment of the biological width.12 Crown lengthening
2 Medium lipline – when the patient smiles, a nominal has been described as a procedure similar to an apically
exposure of 1-3 mm of the gingiva from the apical repositioned flap with ostectomy/osteoplasty.13 The
extent of the free gingival margin to the inferior lengthening procedure is indicated to provide tooth
border of the upper lip is exposed. length for caries removal, restoration of the tooth with-
out violating the biologic width, restoration retention
3 Low lipline – only a portion of the teeth are exposed and aesthetics.14
below the inferior border of the upper lip.
The biologic width
The teeth are exposed in their entirety as well as
the interdental gingival tissue and the border of the In 1961 Gargiulo et al studied human cadavers
free gingiva around the cervical area of the tooth.8 to study the dimensions of the normal dentogingival
unit.15 The dentogingival complex comprises of the
Horizontal and vertical reference lines of the face: connective tissue fibrous attachment, the junctional
Most clinicians have the tendency to focus on the epithelium/ epithelial attachment and the gingival
defect, but when evaluating aesthetic problems, the
clinician needs to widen the focus, studying first the
proportions of the face9, how these proportions relate
to the smile and how the lip line relates to the teeth
and the mucogingival complex.7 The “perioaesthetic”10
defect should then be evaluated. In an aesthetic analysis
of the dentogingival complex, the midline of the face,
the position of the incisal edges and the gingival line
are important landmarks. The gingival line is defined
as the tangent running through the height of contours
of the maxillary central incisors and canines, ideally
should be parallel to the bipupillary line and the incisal
• Vertical lines can be drawn from the pupil of the
edges. Additionally, the papilla between the maxillary
eye to the corners of the mouth
central incisors should coincide with the midline of the
face.9 • The face can also be horizontally divided into thirds
as can be seen by line.11
Root coverage techniques
Currently numerous surgical techniques are proposed for root coverage

1 Pedicle soft tissue grafts 2 Free soft tissue grafts 3 Additive treatments
A) Rotational flaps A) Non-submerged graft A) Root surface modification agents
- Laterally positioned flaps - One stage (free gingival graft) A) Enamel matrix proteins
- Double papilla flaps - Two stage (free gingival graft + cor- B) Guided tissue regeneration
onally positioned graft)
B) Advanced flaps B) Submerged graft -Non-resorbable membrane barriers
- Coronally repositioned flap - Connective tissue graft + laterally - Resorbable membrane barriers
positioned flap
- Semilunar flap - Connective tissue graft + double
papilla flap
- Connective tissue graft + coronally
positioned graft (Subepithelial con-
nective tissue graft)
- Envelope techniques

Pakistan Oral & Dental Journal Vol 35, No. 1 (March 2015) 92
Periodontal approach to esthetic dentistry

sulcus or periodontal pocket. He noted a consistency ABERRANT FRENUM


in the dimension of the various components:
A frenum is a mucous membrane fold containing
The average sulcus depth of 0.69mm: The average muscle and connective tissue fibers.28 It attaches the lip
junctional epithelium of 0.97mm and the average supra and the cheek to the alveolar mucosa, the gingiva and
alveolar connective tissue attachment of 1.07mm (range the underlying periosteum.29 The frenum may jeopar-
of 1.06-1.08mm). dize gingival health when they are attached too closely
The combined dimensions of the connective tis- to the gingival margin either because of interference
sue attachment and junctional epithelium averages with proper placement of the tooth brush or through
to 2.04mm this is called the “biologic width”.15 After opening of gingival crevice by muscle pull.30 Frenum
invasion of this zone, a healthy situation will not con- attachments are classified based on its location, as:
tinue; instead it will develop crestal bone loss, gingival Mucosal attachment, Gingival attachment, Papillary
recession, and or localized gingival hyperplasia.16 attachment and Papillary penetrating.31 Generally the
frenum is evaluated in conjunction with vestibular
The gummy smile depth. The frenum is of little clinical significance, if
A gummy smile17 or high lip line case can result there is an adequate zone of attached gingiva coronal
from two basic problems – altered passive eruption to the frenum.32 However, sometimes maxillary frenum
and vertical maxillary excess.18 One of the clinical may present with esthetic problems or compromise
criteria in determining which of these factors is re- orthodontic result.33 Over the years, the relationship
sponsible for a gummy smile relates to the basic shape between the maxillary midline diastema and the labial
of the teeth.19 If teeth appear to be somewhat short frenum has been the subject of much controversy and
and squat – vertical dimension appears too short as confusion. Currently, surgical correction is not gener-
compared to the horizontal dimensions, the gummy ally considered until, the eruption of the permanent
smile is probably due to altered passive eruption.19 If maxillary anterior teeth is complete.34
however the silhouette form of the tooth appears to be Techniques to correct the aberrant frenum
normal and an expanse of tissue is exposed below the
inferior border of the upper lip, it is probably due to Frenotomy is the simple excisional release of the
the overgrowth of the maxilla in a vertical dimension frenum from the apex of its insertion to its base and
or vertical maxillary excess. In many cases a gummy to the alveolar process. Frenectomy is the complete
smile is due to combination of these two factors.17,18 removal of the frenulum, including its attachments
to the underlying alveolar process. Frenotomy and
ROOT COVERAGE frenectomy can be performed separately as localized
procedures or in conjunction with other procedures to
Role played by the attached gingiva in maintenance
increase the zone of attached gingiva.35
of gingival health is controversial.20 It was originally
believed that a minimum width of attached gingiva RECONSTRUCTION OF INTERDENTAL
was required to maintain optimal gingival health and PAPILLA
prevent recession.21 It was demonstrated that with
proper oral hygiene and absence of bacterial plaque In health, the interproximal papilla fills the em-
and gingival health in the form of no attachment loss brasure space to the apical extent of contact area36.
and absence of infection can exist with minimal or no The position of the gingival tissues around the tooth
attached gingiva.22 Various longitudinal studies have is determined by the connective tissue attachment
demonstrated that the lack of or the presence of min- level and bone level. The most common reason for
imal amount of attached gingiva does not necessarily loss of interproximal soft tissue in adult individuals
result in the progression of soft tissue recession.23 is loss of periodontal support due to plaque associated
lesions37. Orthodontic movement of crowded teeth
Studies have also shown that a narrow zone of gingiva
that are broad and bell shaped invariably results in
possess the same resistance to continuous attachment
gingival black holes38. Over divergence of adjacent
loss as the tooth with wide zone of attached gingiva.22
roots during orthodontic therapy can also result in loss
Dorfman, Lang and Loe on the other hand suggested
of interproximal tissue.39
that a minimum width of 2mm of gingiva needs to be
present for gingival health to exist.24,25 Areas with 1mm Reconstruction of interdental papilla can be
or less of attached gingiva often presented with clinical achieved by periodontal procedure (true reconstruction)
signs of inflammation.22 Gingival recession is defined or restorative procedure (pseudo papillary reconstruc-
as the location of the marginal tissue apical to the ce- tion). In true reconstruction free connective grafts are
mentoenamel junction.26 Since the soft tissue margin used sandwiched between full thickness flap and al-
may not be always be composed of gingiva the terms veolar bone or between the connective tissue of partial
“soft tissue recession” and “marginal tissue recession” thickness flap. After the healing period, gingivoplasty
is commonly used.27 may be required to recontour the papilla. Restorative

Pakistan Oral & Dental Journal Vol 35, No. 1 (March 2015) 93
Periodontal approach to esthetic dentistry

procedure involves not exactly the manipulation of Any treatment intended for ablation of melanin
the papilla but it also involves orthodontic forces or should be non-scarring, safe and easy to handle, leave
prosthesis placement so as to move the contact point no melanin remnants and carry a low risk of repigmen-
more apically to close the gingival black hole. tation.47

GINGIVAL DE-PIGMENTATION ADVANCES IN SURGICAL INSTRUMENTA-


TION: MICROSURGERY
The color of attached and marginal gingiva is gen-
erally described as coral pink and is produced by the Microsurgery is defined as a “Refinement in existing
vascular supply, the thickness and degree of keratini- basic surgical techniques that are made possible by the
zation of the epithelium and the presence of pigment use of the surgical microscope and subsequent improved
containing cells (melenocytes).40 The color varies among visual acuity”.48 Microsurgery has wide implications
different persons and appears to be correlated with the when applied to all mucogingival surgery procedures,
cutaneous pigmentation. It is lighter in blond individu- including the free gingival graft for root coverage,
als, with fair complexions than in swarthy, dark haired because it causes minimal trauma and enhances the
individuals.41 The distributions of various pigments in wound-healing process.49 Microsurgery techniques
oral mucosa are quite variable, ranging from a focal involve minimally invasive procedures utilizing special-
macule to broad diffuse area. The specific coloration, ized instruments. The combination of small instruments
tint, location, multiplicity, size and configuration of and delicate surgical technique allows for extremely
the pigmented lesions are of diagnostic importance.42 fine and accurate incisions, gentle tissue handling, and
precise approximation of wound margins. As a result,
The mucosal tissues can assume a variety of discol- rapid wound healing is achieved with low morbidity
oration. Blue, black and brown discoloration constitute and less discomfort for the patient. Aesthetic results
the pigmented lesions of oral mucosa, and such color can also be enhanced with microsurgery through the
changes can be attributed to the deposition of either creation of small surgical wounds and narrow incision
endogenous or exogenous pigments.43 lines. Finally, microsurgery provides the operator with
The saturation of melanin pigments can causes improved ergonomics and less fatigue.50
unaesthetic dark gingival display.42 This looks even
CONCLUSION
more unaesthetic in people with fair skin and high
lip lines. The pigmentation usually occurs in diffuse Periodontal plastic surgery, evolved from mucogin-
patches, but sometimes continuous area can be seen.44 gival surgery. The goal of mucogingival surgery is to
produce a functional result, but that of periodontal
The choice of treatment is mostly based on the plastic surgery is to produce both a functional and aes-
patient’s esthetic demands. thetic outcome.51,52 Mucogingival surgeries are the main
Surgical methods for depigmentation include stream of esthetics in Periodontics. Newer techniques
are constantly being developed and are slowly being
i. Gingivo-abrasion technique: stone/acrylic burs with incorporated into periodontal practice. The practitioner
low speed should be aware that, at times, new methods are pub-
ii. Split thickness epithelial excision: using sharp lished without adequate clinical research to ensure the
dissection predictability of the results and the extent to which the
technique may benefit the patient. Critical analysis of
iii. Combination of abrasion a split thickness epithelial newly presented techniques should guide our constant
excision. evolution toward better clinical methods.
Cryotherapy is a method of tissue destruction by rap-
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