Prerestorative Periodontal Plastic Surgery Creating the Gingival Framework for the Ideal Smile

It has been said that a beautiful painting or photograph is enhanced by the frame that encompasses it, but a beautiful picture with the wrong frame results in less than ideal results. So, too, it can be said of the gingival framework around teeth and restorations in the aesthetic zone (the facial tissues of the maxilla, occasionally as far distal as the maxillary first molars). Gingival form plays a critical role in the shape, width, and length of teeth. In the case of a pontic, gingival form also helps determine how natural the pontic appears.

In periodontics during the mid to late 1980s, a significant paradigm shift occurred. Periodontists began to consider resective surgery as a tool to sculpt a prettier smile in addition to its traditional objective of pocket reduction. Techniques such as papillae preservation were modified and developed to accommodate this new application in the aesthetic zone.1 Anterior crown-lengthening procedures soon led to other applications of widely used periodontal surgical techniques for smile enhancement. Connective tissue grafts became not only a means to increase attached gingiva and decrease recession but also a means to a more aesthetic smile. In addition, these grafts were increasingly being used for ovate pontic site development in ridge augmentation.2 Site preservation techniques following anterior tooth extraction have also been developed in response to aesthetic demands.

The term periodontal plastic surgery was introduced by Miller3 in 1988. It includes both  (1) resective procedures (ie, anterior crown lengthening) and (2) augmentation procedures (ie, root coverage grafting, ridge augmentations, and site preservation in conjunction with tooth extraction).

In some cases, a combination of procedures is utilized to achieve an ideal aesthetic result. Periodontal plastic surgery is classified under the umbrella term "oral plastic surgery," which includes those surgical procedures of soft and hard tissue associated with the oral cavity performed to enhance aesthetics and/or function.

The purpose of this article is to discuss the role of the gingival framework in enhancing aesthetic restorative dentistry and to provide case reports that demonstrate the various periodontal plastic surgical methods that can be used to assist the restorative dentist in achieving optimal aesthetic results. The procedures themselves have been thoroughly defined and described.4-6

The characteristics of an ideal smile have been defined. Generally, they include teeth whose length either meets the upper lip when the patient smiles or parallels the lip form. In addition, the canines and central incisors are often the same length, with the lateral incisors 0.5 to 1 mm shorter in length. It is also common to see an aesthetic smile where the incisors are all the same length with only papillary gingiva displayed. Very important in an aesthetic smile is right-to-left symmetry in regard to tooth length and shape, particularly for the 2 central incisors.7

PROCEDURES 
Anterior Crown Lengthening

The objectives of this procedure include (1) creating ideal tooth lengths, shapes, and right-to-left symmetry, (2) retention of papillary form, and (3) establishment of biologic width.8-11 The indications include the following: the "gummy" smile; prior to restorative treatment to achieve smile enhancement; and prior to restorative treatment to achieve smile enhancement when there is a need for increased axial wall length. (In this case, there is inadequate tooth structure to assure resistance, retention form, and/or appropriate biologic width.)

Biologic width, defined here as the distance on the tooth occupied by the junctional epithelium plus the connective tissue attachment and the sulcus depth, deserves special mention in the maxillary anterior region because this region appears to be sensitive to violations of biologic width. It is important that this dimension be determined for the individual patient prior to anterior crown lengthening, thus allowing the clinician to recreate this dimension in the postsurgical position of the gingival margin and alveolar crest. After local anesthesia is administered, a periodontal probe is used to measure from gingival margin to bone. This dimension, from the newly sculpted gingival margin to the bone, can range anywhere from 3 to 4 mm or more.10,12

Figure 1. Pretreatment view. This postorthodontic patient desired a "toothier" smile. Figure 2. View after anterior crown lengthening and veneers. (Restorations by Dr. D. Baird.)

Figures 1 and 2 demonstrate the pretreatment and posttreatment views of anterior crown lengthening in conjunction with placement of veneers. This patient had completed orthodontic therapy and wanted a smile that revealed more of the anterior teeth. The patient required the combination of crown lengthening and prosthetic treatment because the desired tooth length, in consideration of the high smile line, dictated that the periodontist place the gingival margins 2 mm more apically on the root surface. Exposure of the root surface required the restorative dentist to create what appears to be natural looking enamel tooth structure.

The procedure included (1) a combination of sculpting the gingival height and form based on the estimated tooth length relative to the cemento-enamel junction (when no restorations are planned) or to the desired gingival margin position of the final restorations (exposing no more than 1 to 2 mm of root surface) and (2) osseous surgery to recreate the predetermined biologic width. Interproximal tissues were left intact since there was no need to increase axial wall length or access the interproximal bone.

Figure 3. Pretreatment view. A patient with excess gingiva following orthodontic therapy with concurrent violation of biologic width. Figure 4. View after anterior crown lengthening and final crowns. (Restorations by Dr. G. Kinzer.)

In Figures 3 and 4, the patient presented with gingival enlargement following orthodontic therapy and violation of biologic width by the temporary restorations on the central incisor teeth. Crown lengthening was completed by the periodontist both to expose more tooth structure and to position the attachment apically prior to the final restorations. The elevation of both buccal and palatal flaps was required, as was osseous surgery. The challenge here was to retain the papillae between the central incisors while still removing enough excess soft tissue to provide a natural appearance.

 

Root Coverage Grafts

The objectives of this procedure include the correction of defects in morphology, position, and/or the amount of soft tissue. The goal of treatment is to achieve health, function, aesthetics, and restoration of anatomic form.13 The clinical indications include (1) root sensitivity, (2) root exposure that compromises aesthetics, (3) the treatment of carious and noncarious lesions in the cervical region of teeth, and (4) minimal zone of attached gingiva.

The treatment modalities that can be used for root coverage include a connective tissue graft, lateral pedicle graft, coronally advanced pedicle graft, double papillae graft, a semilunar graft, and a coronally advanced flap with a dermal allograft (Alloderm, Lifecel) or barrier membrane. With the development of other techniques, the use of free gingival grafts for root coverage has declined over the last few years.14-16

Pedicle grafts involve releasing keratinized gingiva and advancing it either coronally or laterally to cover the root surface. Semilunar grafts require a broad zone of keratinized tissue and apical incisions that are made parallel to the gingival margin in alveolar mucosa. The keratinized tissue is then released and advanced coronally over the exposed root(s). Connective tissue grafts utilize connective tissue harvested from the hard palate that is then positioned over the recipient site and secured with either partial or complete coverage with a coronally or laterally advanced flap at the recipient site. Dermal allograft or barrier membranes require full tissue coverage with adjacent keratinized tissue (ie, coronally advanced or lateral pedicle flaps).

Figure 5. Pretreatment view. A patient with maxillary right and left canines (in place of the right and left laterals) with gingival margin discrepancies on the central incisors. Figure 6. View after connective tissue grafting of the right and left cuspids in combination with crown lengthening of the central incisors.
Figure 7. Pretreatment view. Exposed root with a noncarious lesion at the maxillary right first biscupid without attached gingiva. A high frenum insertion is noted. Figure 8. View after a connective tissue graft showing root coverage and reattachment with the frenum relocated away from the gingival margin.

Figures 5 and 6 demonstrate a patient who had combined therapy. The periodontist utilized connective tissue grafts to shorten the maxillary canines (which were in the position of the maxillary lateral incisors) as well as crown lengthening to lengthen the central incisors in order to assist the restorative dentist in creating the illusion that the canines were lateral incisors. Figures 7 and 8 demonstrate the use of connective tissue grafts to solve a restorative dilemma. This patient received a connective tissue graft to reduce recession, apically reposition the frenum attachment, and fill the noncarious cervical lesion with connective tissue. This recently reported technique has the additional benefit of enhancing aesthetics.17

Ridge Augmentation

The objective of this procedure is to establish ideal dimensions in an edentulous area in preparation for an ovate pontic. This allows the pontic to appear to emerge from the soft tissue, versus the use of other pontic designs that overlap the ridge. The clinical indications for ridge augmentation include a ridge area with loss of vertical height and/or loss of buccal-lingual dimension. Ridge augmentation can be accomplished with connective tissue grafts or dermal allograft material to recreate ideal soft-tissue form. Ridges may also be enhanced with a bone graft (autograft, allograft, or xenograft) or grafting of a bone substitute (alloplast). Direct pressure contact with an ovate pontic is used in conjunction with graft placement to help mold the gingival tissues around the pontic.

Figure 9. Pretreatment view. Porcelain overlay of the maxillary left central and lateral to match the right cental and lateral that are covering a ridge deficiency. Figure 10. View showing the new bridge after ridge augmentation in the right central and lateral.
Figure 11. Pretreatment view. A ridge defect is present in the left lateral area, and the left central is clinically short compared to the right central and canine. Figure 12. View showing the new bridge after a ridge augmentation in the left lateral pontic site in conjunction with crown lengthening of the left central incisor. (Restorations by Dr. S. Carstensen.)

Figures 9 and 10 demonstrate a compromised restorative situation where excess porcelain was used over the gingival margins of the maxillary left central and lateral incisors to match the tooth lengths of the maxillary right lateral and central incisor pontics. These pontics masked a deficient ridge. Soft-tissue ridge augmentation combined with a frenectomy procedure were completed by the periodontist prior to the restoration, resulting in a very natural and aesthetic appearance. Figures 11 and 12 demonstrate a combination procedure that was necessary to create an aesthetic gingival form. The procedure involved crown lengthening of the maxillary left central incisor in conjunction with soft-tissue ridge augmentation in the area of the maxillary left lateral incisor. The gingival framework enhanced the prosthetic treatment that was ultimately provided.

Tooth Socket Site Preservation

The objective of this procedure is to maintain the natural anatomy (both hard and soft tissue) of the periodontium following extraction. Indications include all anterior extractions and all tooth sites being considered for implants. When this procedure is not utilized following an extraction, ridge defects often result. Ridge defects can be minimized by an atraumatic extraction technique that carefully retains the buccal soft and hard tissues. Then graft material is placed in the socket and a connective tissue graft can be used to augment the edentulous region.

Figure 13. Pretreatment view. The right lateral incisor requires extraction. Figure 14. The new bridge after extraction of the lateral incisor, followed by a socket site graft and connective tissue graft that masked the discoloration in the aesthetic zone.

Figures 13 and 14 demonstrate extraction of the maxillary right lateral incisor with both a socket site graft and connective tissue graft to preserve and create the gingival framework to ensure proper pontic form. In the final prosthesis, it can be seen that the pontic emergence profile mimics that of a natural tooth, enhancing the aesthetic result.

DISCUSSION

It has been reported that more than 2 million individuals considered to be baby boomers had plastic surgery in 1999, which is double that of 1997.18 It is clear that elective procedures aimed at improving appearance are increasing in popularity. This same trend regarding popularity of dental cosmetic procedures is occurring. In addition to new restorative procedures, periodontal plastic surgery began to emerge in the mid to late 1980s. It is one of the major topics at various annual dental meetings. Indeed, entire journal issues19 and entire conferences, such as the American Academy of Periodontology's  "Enhancing Esthetics With Periodontal Plastic and Reconstructive Surgery," presented in May 2002, have been dedicated to this subject in the last few years.

Today, there is a high demand for ideal dental, oral, and facial aesthetics. It is extremely important to have many approaches available to achieve the end result, and it is important to understand how to integrate the various dental disciplines so that patient expectations can be met. Every day, patients will evaluate the cosmetic procedures that are performed.

It is clear that prerestorative modification of the gingival framework often has a very significant impact on the final aesthetic outcome. Whether it is one tooth or many, this multidisciplinary approach to treatment will improve the chances for achieving the desired result.


References

1. Takei H, Yamada H, Hau T. Maxillary anterior esthetics. Preservation of the interdental papilla. Dent Clin North Am. 1989;33:263-273.

2. Seibert JS. Reconstruction of the partially edentulous ridge: gateway to improved prosthetics and superior aesthetics. Pract Periodontics Aesthet Dent. 1993;5(5):47-55.

3. Miller PD Jr. Regenerative and reconstructive periodontal plastic surgery. Mucogingival surgery. Dent Clin North Am. 1988;32:287-306.

4. McGuire MK. Periodontal plastic surgery. Dent Clin North Am. 1998;42:411-465.

5. Pasquinelli KL. Periodontal plastic surgery. J Calif Dent Assoc. 1999;27:597-610.

6. Miller PD Jr, Allen EP. The development of periodontal plastic surgery. Periodontol 2000. 1996:11:7-17.

7. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000. 1996;11:18-28.

8. Allen EP. Surgical designs for crown lengthening. Presented at: American Academy of Periodontology Annual Session, San Francisco, Sept. 24, 2003. 

9. Allen EP. Surgical crown lengthening for function and esthetics. Dent Clin North Am. 1993;37(2):163-179.

10. Kois JC. Altering gingival levels: the restorative connective. Part I. Biologic variables. Esthet Dent. 1994;6:3-9.

11. Townsend CL. Resective surgery: an esthetic application. Quintessence Int. 1993:24:535-542.

12. Padbury A Jr, Eber R, Wang HL. Interactions between the gingiva and the margin of restorations. J Clin Periodontol. 2003;30:379-385.

13. Miller PD Jr. Root coverage grafting for regeneration and aesthetics. Periodontol 2000. 1993:1:118-127.

14. Sonick M. Root coverage: a comparison of techniques: the free gingival graft versus the subepithelial connective tissue graft. Pract Periodontics Aesthet Dent. 1992;4:39-48.

15. Harris RJ. A comparison of 2 root coverage techniques: guided tissue regeneration with a bioabsorbable matrix style membrane versus a connective tissue graft combined with a coronally positioned pedicle graft without vertical incisions. Results of a series of consecutive cases. J Periodontol. 1998:69:1426-1434.

16. Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol. 1986;13:182-185.

17. Terry DA, McGuire MK, McLaren E, et al. Perioesthetic approach to the diagnosis and treatment of carious and noncarious cervical lesions: Part 1. J Esthet Restor Dent. 2003;15:217-232.

18. American Society of Plastic Surgeons. Available at: http://www.plasticsurgery.org

19. Nowzari H. Aesthetic periodontal therapy. Periodontol 2000. 2001:27.

Acknowledgement

Many thanks to Drs. Vincent Iacono and Barry Wagenberg for their support and contributions to this article.



Dr. Townsend is in periodontal practice in Bellevue, Wash. She has lectured nationally for 22 years and has published several articles. She was selected in both 1989 and 1996 as one of 100 worldwide participants in the World Workshop in Periodontics. She currently serves as a District VI trustee to the American Academy of Periodontology and has served as president of the Washington State Society of Periodontists as well as the Seattle-King County Dental Society.



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