The Art and Science of Gingival Augmentation





By Rebecca Stone January 28, 2019

As we age, many of us will experience gingival recession and the problems associated with being “long in the tooth.” At the other end of the periodontal spectrum are those with the dreaded “gummy smile,” another esthetic handicap.

Fortunately, treatments for these conditions are continually improving, and many general dentists are capable of undertaking the more straightforward of these cases. Crown-lengthening and crown-shortening surgeries were initially performed purely for oral health reasons, but they have been gaining traction as esthetic procedures in today’s practices.

Crown Shortening

Everything from aging to periodontal disease, and even bruxism, can result in gingival recession. Recession exposes dentin and roots — not a great look for most people. But it can also leave them vulnerable to root caries, hypersensitivity and bone loss.1

Such conditions can be corrected via gingival grafting. Sources for grafting tissue include autografts (tissue taken from the patient, often the hard palate), allografts (cadaver tissue), xenografts (animal tissue), and alloplasts (synthetic tissue). Such tissues are typically sutured into place using a range of grafting techniques.

Gains in this kind of procedure, resulting in less pain and improved esthetics, include new incision designs and suture materials. They also include the use of plasma-rich growth factors and platelet-rich fibrin aimed at guided tissue regeneration. Obtained via blood draw, platelets are concentrated into a gel that can be used as grafting material. This has been shown to be highly effective and can eliminate the need to excise tissue from the hard palate.1–6

Crown Lengthening

Sometimes excessive gingival display is inherited, other times it can result from orthodontic or periodontal issues, or other anomalies. Many clinicians consider a gingival display over 2 mm above the tooth margin to be too much. The need to address this problem can have therapeutic and restorative implications, as well.1

In crown-lengthening procedures, both soft tissue and osseous tissue must be reshaped. Osseous recontouring is necessary to create space for soft-tissue attachment to tooth roots. As for sculpting of the gumline, many experts report that this is based on the establishment of biologic width, which is usually about 3 mm. This is the distance between the height of the gingiva and the crestal height of the alveolar bone.7,8

Part Art, Part Science

Those who perform it consider gingival contouring to be both an art and a science. Facial attributes, eye, cheek and lip positioning, how much gingiva is showing in relation to the lip line, and color must all be taken into account.1

But it is also essential for practitioners to understand what their patients want. After all, beauty is in the eye of the beholder. Fortunately, there are now digital programs available to help clinicians identify the looks patients are aiming for. 1,9

Armamentarium

Such treatments require the use of both traditional and microsurgical instruments, expedited by the use of magnification. Lasers, rotary burs and electrosurgery units are also critical tools of this trade.

Any time sharp instruments are involved, adequate isolation is a common-sense strategy. Systems such as the Isolite, Isovac and Isodry ensure that no instruments or debris go down a patient’s throat. And continual evacuation provided by these systems helps keep blood spatter and fluid buildup in check. The systems also keep soft tissues retracted, while the illumination provided by Isolite is sure to be a welcome addition to the field of operation.

 

REFERENCES

  1. Stone R. Change agents. Mentor. 2017;8(6):32–36.
  2. Tufts News. New Treatment for Receding Gums: No Pain, Lots of Gain. Available at: https://now.tufts.edu/news-releases/new-treatment-receding-gums-no-pain-lots-gain. Accessed December 20, 2018.
  3. Cheung WS, Griffin TJ. A comparative study of root coverage with connective tissue and platelet concentrate grafts: 8-month results. J Periodontol. 2004;75:1678–1687.
  4. Griffin TJ, Cheung WS. Guided tissue regeneration-based root coverage with a platelet concentrate graft: a 3-year follow-up case series. J Periodontol. 2009;80;1192–1199.
  5. Kumar NV, Murthy RV. A comparative evaluation of subepithelial connective tissue graft (SCTG) versus platelet concentrate graft (PCG) in the treatment of gingival recession using coronally advanced flap technique: A 12-month study. J Indian Soc Periodontol. 2013;17:771–776.
  6. Vahabi S, Vaziri S, Torshabi M, Esfahrood ZR. Effects of plasma rich in growth factors and platelet-rich fibrin on proliferation and viability of human gingival fibroblasts. J Dent (Tehran). 2015;12:504–512.
  7. Mahn DH. Decision making in managing excess gingival display. Decisions in Dentistry. 2018;4(6):30–32,35.
  8. Abraham BL, Pai BS, Francis B. Failures in periodontal therapy. Int J Scientific Res. 2018;7:44–45.
  9. Omar D, Duarte C. The application of parameters for comprehensive smile esthetics by digital smile design program: a literature review. Saudi Dent J. 2018;30:7–12.

 

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