Chapter 28 Perioesthetics
Therapy for periodontal diseases includes treatment for inflammation of the gingiva, regeneration of the periodontium, and maintenance of the dentition. The primary emphasis for initial periodontal treatment should be the reduction and control of inflammation. Erythematous, edematous gingiva contributes a very un-esthetic quality to the dentition and therefore should be primarily addressed during the initial phase of treatment.
Among the first stages of periodontal therapy are oral hygiene instructions, conservative scaling and root planing, and ultrasonic or piezoelectric débridement therapies. Antibiotics may be given systemically (usually not indicated) or locally as necessary. The second link between esthetics and periodontal therapy includes contouring crowns, improving the esthetic presentation of prostheses, and minimizing gingival overgrowth patterns that can develop around dental implants or prosthetic devices. A third relevant association between periodontal therapies and esthetic dentistry is the maintenance or establishment of adequate zones of keratinized gingiva around crowns, bridges, and dental implants.
The clinical recognition of periodontal therapy developed at least a half a century ago when studies first equated bacterial plaque with gingival inflammation. These studies were published in the 1960s and 1970s. Control of inflammation was primarily targeted at managing disease and preventing gingivitis and did not address esthetic qualities. Concomitantly with the development of esthetic dentistry and the dental materials associated with it, clinicians began to address the minimum clinical qualities of the periodontium needed to enhance the esthetic profiles of a restoration.
As periodontal procedures evolved, surgeries for clinical management of disease became more refined. For example, some medications contributing to gingival hyperplasia were managed with gingivectomy and other gingival resective procedures to ensure esthetically acceptable restorations. The recognition of the importance of keratinized gingiva modified periodontal treatment planning and surgery. More recently, dentists have become aware of the importance of keratinized gingiva for dental implants and crown and fixed prostheses. Clinical research has not fully supported the concept of keratinized gingiva for dental implants, but it is clear to most clinicians who place dental implants that it is preferable to have keratinized gingiva to manage rather than alveolar mucosa.
The two primary goals in periodontal esthetics are to (1) reduce gingival inflammation and erythematous, edematous gingiva and (2) manage the keratinized gingiva. Reduced inflammation eliminates un-esthetic edematous or bleeding gingiva, especially when the patient speaks or smiles. Enhancement of keratinized gingiva improves esthetics around dental implants, especially in the anterior region. In addition, function is improved for toothbrushing and other cleansing habits. There can be a dramatic improvement in periodontal support of the dentition with improved keratinized gingiva as well as reduced gingival inflammation.
The diagnosis of periodontal disease is one indication for reducing gingival inflammation. Redness, bleeding on probing, and the patient’s report of signs and symptoms of periodontal disease, such as sour taste in the mouth, odor, and shifting of teeth, are additional indications for proceeding with periodontal therapy. To the clinician, arresting bone loss and regenerating bone and attachment are also indications for proceeding with periodontal therapy.
The indications for enhancing keratinized gingiva include a lack of keratinized gingiva, which is established in the periodontal literature as 1 to 3 mm of keratinized gingiva. Amounts less than that or concerns about zones of inadequate keratinized gingiva related to oral hygiene suggest that periodontal therapy, including periodontal surgery, should be planned.
The contraindications for periodontal therapy are very few, but they include any medical and medication influences on wound healing or systemic health. For example, during the first trimester of pregnancy, an obstetrician-gynecologist may warn against more aggressive periodontal therapy.
Contraindications for mucogingival surgeries (which the American Academy for Periodontology now refers to as periodontal plastic surgery) include medical and medication considerations as already noted and the presence of anatomic structures in the mouth that mitigate against surgical treatment planning. Some of these anatomic landmarks include a coronally positioned mental foramen or a prominent mandibular ramus or other structures that may interfere with periodontal surgical procedures.
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.
With regard to esthetics, the clinician should be aware of the position of the area of keratinized gingiva. In the anterior part of the mouth, the clinician should ensure that the smile line is accurately recorded, perhaps with clinical photographs. Most important are the patient’s chief complaints and concerns regarding enhancement of keratinized gingiva. Another consideration is any patient concern related to oral hygiene. For example, are there areas of the dentition where the patient experiences gingival sensitivity owing to a lack of keratinized gingiva?
Further considerations also include medical and medication complications related to surgery, including periodontal therapy débridement procedures. Patients who have a history of cardiovascular disease may be taking “blood thinners,” resulting in increased bleeding risk. Frequently cardiologists will comply with the dental clinician’s request to either reduce or suspend the patient’s medication for the duration of periodontal or dental therapy.
One of the most exciting scientific approaches in periodontal therapy as it relates to esthetics involves the use of lasers. Research continues, but the FDA has approved several laser products for limited soft tissue management of periodontal tissues. This includes soft tissue débridement and control of inflammation.
Currently both the ultrasonic and piezoelectric approaches can be used to control inflammation. The tips and qualities of these devices have improved significantly. Most recently, a new ultrasonic tip (Cavitron THINsert, DENTSPLY Professional, York, Pennsylvania) was introduced that is about the size of a periodontal probe. This new tip permits deeper access into periodontal pockets and interproximal areas of teeth.
Another technologic approach for both ultrasonic and piezoelectric instruments is the use of plasticized or rubber tips with dental implants. Controversies remain regarding the use of metal tips on dental implants. However, the potential to scratch implant surfaces and enhance colonization of the plaque biofilm exists. Many companies have made technologic advances in this area, and the scientific literature supports the use of non-metal tips (Implacare, Hu-Friedy Mfg. Co., LLC, Chicago, Illinois) for the maintenance of dental implants.
With respect to the artistic elements involved in the control of periodontal disease and gingival inflammation, any reduction or elimination of redness around the teeth will improve the artistic qualities. This makes it pragmatic for the dental clinician to use “nature” and the healing process to reduce gingival inflammation.
With regard to the artistic qualities specific to the enhancement of keratinized gingiva, the dentist’s eye and clinical experience must be used to develop the shape, thickness, and quality of the gingiva to be transplanted into the site where keratinized gingiva is lacking. This would include use of the proper thickness (“biotype”) of either tissue taken from the palate (autogenous grafts) or allogeneic freeze-dried dermal matrix skin to enhance keratinized gingiva. Other artistic qualities could include the scope of the procedure and the mesial-distal width and apical coronal height of the keratinized gingiva in the periodontal plastic surgical site. Artistic techniques would include blending the periodontal graft into the existing gingiva to make it appear as if they are confluent with each other.
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.
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.
There is overwhelming support in the literature for periodontal therapy to reduce general inflammation, beginning in the 1960s and 1970s. Clinical research shows that the removal of bacterial plaque and débridement of the dental root surfaces result in improved gingival health; reduced redness, which is an esthetic concern; and, most important, management of the attachment surrounding the teeth.
Studies on enhanced keratinized gingiva around the dentition and dental implants have been conducted for several decades. Recently the keratinized gingiva principle has been applied to dental implants, although the literature is still sparse regarding how much keratinized gingiva is needed for a healthy dental implant. This is probably where the evidence-based principles are somewhat lacking. The strong clinical opinion of many clinicians is that they prefer keratinized gingiva during suture and soft tissue management when placing dental implants.
The conservation of the periodontium and the supporting structures around the teeth is essential to the esthetics and function of the patient. Although these procedures have worked for many patients, for others loss of periodontal attachment continues, bone is lost, and other soft tissue problems exist. The conservation concepts related to periodontal therapy are critical in maintaining the overall periodontal health and attachment apparatus. For example, the concepts of periodontal surgery have, over the last 10 to 20 years, emerged in regeneration procedures. The use of bone grafts, whether autogenous, allograph, or synthetic bone materials, or the use of membranes, resorbable or nonresorbable, to regenerate periodontal tissues is a primary method of conserving, preserving, and regenerating lost periodontal tissues. For conservation of the periodontium, these clinical concepts have shifted dramatically toward regeneration rather than resective surgery.
Maintenance for esthetic purposes is extremely important. There are strong evidence-based principles that a periodontitis patient must be monitored and undergo follow-up a minimum of four times per year, every 90 days, throughout his or her lifetime. Such patients need clinical examination and scaling and root planing to maintain the periodontal attachment. If the diagnosis is gingivitis, the recommendation is maintenance procedures twice a year. With regard to esthetics, especially with dental implants, no evidence-based research, clinical or scientific, currently gives recommendations for the ideal maintenance periods for follow-up care. Therefore the projections for implant maintenance have been adapted from the literature in reference to natural teeth. If patients have dental implants, they should be monitored and evaluated using a plastic periodontal probe to look for pocketing or signs of inflammation around implants or other prosthetic devices, and to reveal other signs of inflammation. Radiographs should also be taken, although the frequency and interval of radiographs or implant maintenance has not been established. The author’s recommendation is to perform radiographic follow-up of dental implants after 6 months and 1 year to monitor peri-implant bone loss, and then examine dental implants at least every 1 to 2 years radiographically (unless a problem develops earlier). Oral hygiene must always be monitored at each recall appointment.
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.
With regard to future developments, the author predicts that periodontal therapy will be more focused. For example, lasers, improved scaling and root planing, and perhaps root preparation using laser therapy may become common time-saving approaches. The laser appears to offer greater patient comfort as well.
Other future developments should address the area of keratinized gingiva. Currently, stem cells from the patient can be grown in cell culture in a laboratory to produce autogenous mats of keratinized gingiva. After several weeks or months, the “tissue-engineered” autogenous graft will be placed into the patient’s mouth surgically. Also on the horizon is enhanced growth of the gingiva either by different molecular- and cellular-induced methods of development or by use of other enhancements to improve areas of root recession. This is an exciting area especially applicable to esthetic dentistry. Surgical procedures may not be required in the future. Instead there will be cell culture and stem cell approaches to grow gingiva in the oral cavity.
A 24-year-old healthy white man had a fractured maxillary right lateral incisor (tooth No. 7 Universal system; tooth No. 1-2, FDI World Dental Federation notation). The treatment plan featured a surgical crown lengthening without osseous re-contouring in order to enhance the sound tooth structure for prosthetic replacement with a crown. At least 5 to 7 mm of sound tooth structure can be seen immediate postoperatively.
A 20-year-old African American woman was referred by orthodontics for esthetic improvement of the maxillary anterior dentition. An external bevel gingivectomy procedure involving soft tissues was performed. The postoperative image shows improved maxillary anterior teeth.
A 24-year-old African American woman has full-banded orthodontics and an interest in improving the “esthetics of her gum line.” External bevel gingivectomy was performed using a prefabricated stint to result in the images shown at 1 month and 1 year.
FIGURE 28-4 Patient with full-banded orthodontics requiring improvement of the “esthetics of her gum line.” Pre-treatment facial (A), radiographic (B), and intraoral views (C). D to F, External bevel gingivectomy performed using a prefabricated stint. G, Treatment results at 1 month (top) and 1 year (bottom).
(Clinician, Dr Kevin Suzuki.)
Drisko CL, Cochran DL, Blieden T, et al. Position paper: Sonic and ultrasonic scalers in periodontics. Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol. 2000 Nov;71(11):1792-1801.
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.
There is no improved smile without a symbiotic relationship between periodontics and restorative dentistry. To achieve an enhanced smile one first develops an image of the desired outcome and then physically tries to achieve that restoratively. The soft tissue must be present in the correct proportion if that outcome is to be achieved. For example, if the tissue level is altered, it may result in spaces between the teeth—the so-called “black diamonds.” No matter how wonderful the restorative work is, the eye will be drawn to these dark spaces. It is necessary to have a picture surrounded by a frame. Periodontics becomes the frame that helps visualize what is desired in the smile. Dentists can alter or enhance the frame. The results will be predictable if periodontic treatment achieves a healthy foundation. Then the smile not only looks good but can be maintained.