28: Perioesthetics

Chapter 28 Perioesthetics

Section A Periodontal Esthetics and Periodontal Plastic Surgery

Clinical Considerations

Material and Technique Options

Among the material and technique options available for the different stages of periodontal therapy related to esthetic dentistry are optimal management to reduce gingival inflammation and control of periodontal disease. This includes the initial therapy phase. Generally, oral hygiene instructions with a wide variety of devices should be included in the treatment plan. Progression to ultrasonic or piezoelectric débridement of the dentition and implants should also be included in the periodontal treatment plan, followed by hand scaling and root planing. This is especially important if pockets exceed 3 to 5 mm and there are deposits on the teeth when dental implants are considered. These are the primary approaches available for débridement of the dentition and implants.

Other alternatives for treatment include local drug delivery devices such as doxycycline-impregnated spheres (Arestin, OraPharma, Warminster, Pennsylvania). This type of delivery system permits local antibiotic release in periodontal pockets for the purpose of controlling gingival inflammation (off-label use per the U.S. Food and Drug Administration [FDA]). Enhanced keratinized gingiva for prosthetics and dental implants can be obtained by using autogenous soft tissue grafts such as from the palate or the distal area of the most terminal molar as donor keratinized gingiva.

Alternatively, the clinician can use allograft material such as AlloDerm (BioHorizons, Birmingham, Alabama), which is freeze-dried human skin. The distinct advantages of allograft products include not requiring a second surgical site, greater patient comfort during the procedure, reduced time for the procedure, and improved postoperative management. The major disadvantage is cost; the estimated charge per square centimeter of allogeneic skin is about $150 (US), which may be prohibitive for some patients and may not covered by insurance. Other disadvantages are patient reluctance regarding use of freeze-dried allogeneic products and the learning curve required for the clinician to be able to handle these products.

Treatment Planning

Treatment planning is completed in two different areas based on the esthetic procedure to be performed. The treatment planning for conventional periodontal therapy has not changed over the past several decades. The periodontal treatment plan to control inflammation includes (1) a review of medical, medication, and dental history, (2) the accurate diagnosis and consultation with the patient, and (3) initial therapy, also termed nonsurgical therapy or phase one periodontal therapy. Initial therapy includes oral hygiene instructions, periodontal débridement including ultrasonic and piezoelectric approaches, hand scaling and root planing, occlusal control (if necessary), evaluation of initial therapy 4 to 6 weeks after the conclusion of the last débridement procedure, and periodontal surgical procedures (if necessary). The result is a reduction of gingival inflammation and arresting of disease progression.

When planning for the enhancement of keratinized gingiva, especially when this includes dental implants and crowns and bridges, one must include periodontal surgical treatment planning as already outlined. The enhancement of keratinized gingiva is referred to currently as periodontal plastic surgery. This includes the enhancement of keratinized gingiva by autogenous grafting from the palate or by allografts using freeze-dried human skin from a tissue bank. Other periodontal plastic surgical procedures in treatment planning are root coverage for teeth with exposed roots (connective tissue grafts). The two choices for such procedures are autogenous gingival and allograft freeze-dried skin.

Treatment Considerations during Preparation, Procedure, and Finishing

The most important preparation with regard to treatment planning considerations is an accurate medical and dental history of the patient. That includes ruling out any medical contraindications to therapy and also considering medications that may influence periodontal therapy, such as blood thinners or medications that would cause gingival hyperplasia. Three recognized drugs and drug types are phenytoin (e.g., Dilantin), calcium channel blockers (e.g., nifedipine), and drugs that prevent organ transplant rejection (e.g., cyclosporine). Use of these medications should be considered during preparation for treatment. The procedure itself requires timing. Some patients, such as those with early periodontitis, require two appointments for débridement and initial therapy, whereas other patients with moderate to advanced periodontitis need four or five appointments. This includes patients with periodontitis with furcation involvement.

The evaluation of initial therapy takes place 4 to 6 weeks after the last débridement procedure. Included is an assessment of the patient’s oral hygiene and wound healing. If the periodontal soft tissues are not healing or responding to therapy as anticipated and the patient’s oral hygiene is satisfactory, a medical consultation may be needed to rule out the influence of systemic diseases.

The results of plastic periodontal surgical procedures depend on wound healing, typically 2 to 5 weeks after surgery. Evaluation includes the number of millimeters of enhancement of keratinized gingiva, the blending of the color, and the size and shape of the grafted tissues.


The controversies relate to the use of plasticized instruments versus metal instruments in terms of implant care. Although many clinicians continue to use metal instruments on implants, others prefer to use titanium metal instruments for débridement. There is a growing acceptance of plasticized tips. Hu-Friedy makes a set of three implant instruments. Plasticized or rubber ultrasonic tips are also commercially available and are recommended.

The second controversy relates to the interval and frequency of maintenance care. Periodontitis follow-up is established to be four times per year of maintenance for the rest of the patient’s life. After gingivitis treatment, patients are checked twice per year. Currently there are no evidence-based principles for implant follow-up care. The controversy surrounds the frequency at which implant patients should be monitored. Currently, the author advocates four times per year as a follow-up schedule for implant maintenance.

A third controversy surrounds the use of local drug deli-very systems such as minocycline-impregnated microspheres (Arestin), doxycycline-impregnated polymer (Atridox), or chlorhexidine-impregnated collagen strips (PerioChip). The controversy surrounds the off-label application of these local drug delivery systems to periodontal pockets. The FDA has approved these products for reducing inflammation and managing periodontal health. Whether these local drug delivery systems can be applied to clinical situations involving dental implants and peri-implantitis remains untested. The FDA has not approved these products for peri-implantitis. However, two evidence-based peer-reviewed studies indicate that selected local drug delivery devices (Arestin, chlorhexidine gel) improve inflammation around dental implants and in treatment of peri-implantitis.

Clinical Cases

Section B Relating Function and Esthetics

David L. Hoexter

Relevance of Perioesthetics to Esthetic Dentistry

The link between health and appearance in the oral cavity is highly relevant. Without a healthy periodontal status, no matter what has been done with the teeth—crowns, veneers, whitening—the results will not last. Oral esthetic results need a background of health to enhance the image desired. For example, if the patient has a long-appearing tooth owing to excessive recession, and the desire is to create a more symmetrical illusionary smile line, it is necessary to move the tissue with its pink keratinized tissue background and then reattach it over the recession, which will make the tooth appear beautiful in a smile, depending on the patient’s lips and exposure of teeth. It is essential for health and esthetics to support the results achieved restoratively, and that means healthy soft tissue, good color, and proper maintenance by patient and dentist.

Jan 3, 2015 | Posted by in Esthetic Dentristry | Comments Off on 28: Perioesthetics
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