Aesthetic Periodontal Surgery
It was Miller (1988) who established the concept of aesthetic periodontal surgery. He saw opportunities for expanding classic mucogingival surgery that dealt with broadening the vestibule and removing troublesome frenula. Aesthetic periodontal surgery does not primarily treat functional disturbances, but rather aesthetic problems, such as gingival recessions, defects, excesses, and proliferations as well as defects of the alveolar ridge and incompletely or unerupted teeth.
Many new surgical techniques are available for these conditions. The miscellaneous techniques use sliding flaps, gingival and connective tissue grafts, guided tissue regeneration with resorbable or nonresorbable membranes, reconstruction of bone with bone substituting materials (e.g., tricalciumphosphate or decalcified freeze-dried bone), and growth factors to stimulate growth of new tissue and attachment.
While a multiplicity of gingival problems can be improved with aesthetic periodontal surgery, the most frequent task is that of covering gingival recessions. A variety of treatments is available:
Miller (1985) classified gingival recessions in order to facilitate treatment planning and prognosis (see Rateitschak and Wolf 1989).
Class I: The recession is flat and narrow, or flat and broad and does not reach the mucogingival junction. Interdental tissue has not been lost. Prognosis: very good.
Class II: The recession is profound and narrow, or profound and broad. It stretches apical of the mucogingival junction. Interdental tissue is not lost. Prognosis: good.
Class III: Recessions like those in classes 1 or 2. Interdental tissue (also bone) has partially been lost. Prognosis: complete root coverage is no longer possible.
Class IV: Recession extends apical of the mucogigingival junction. Interdental tissue has been extensively destroyed. Prognosis: poor.
Sliding flaps can be used for final coverage of gingival recessions. They can also be combined with oral mucosa grafts or membranes. Beside aesthetic indications, these techniques can also be used to eliminate mucogingival problems. In implantology they can be used for alveolar ridge augmentation and to expose impacted teeth.
Laterally Sliding Flap
This technique is described by Grupe and Warren (1956). To be successful, it is important that
—the flap is sufficiently thick and wide,
—the flap is sufficiently large and appropriately shaped, and
—sufficient attached gingiva is available.
The flap should be three times as wide as the recession it is going to cover. This ensures that the flap area is sufficiently vasculated, since the root surface cannot contribute to the vascularization of the flap. The flap should cover at least 3 mm of vasculated gingiva on each side.
The flap must also be sufficiently thick to reduce the risk of later recession. A sufficiently extendable, attached gingiva is necessary to elevate the flap. If the flap can only be held in place by means of a suture, recession is probable.
Indication: Individual recessions. It is not necessary to remove tissue from a second location. This technique is especially indicated in the case of recessions adjacent to edentulous ridge regions (simple flap mobilization).
Contraindication: Deep proximal pockets, prominently protuberant roots, severe root erosion, and advanced proximal bone loss.
Advantages: Only one surgical area, good vascularization of the flap, high success rate with root coverage.
Disadvantages: Limited amount of available keratinized gingiva, possible recession on the removal site, limited to one to two teeth.
1. A tissue bed is created adjacent to the exposed root at the recipient site. The incision begins at the adjacent tooth and is extended into the vestibulum.
2. The second incision begins at the border of the recession and reaches to the apical end of the recession. A slightly slanted incision connects the two incisions.
3. In this area, the epithelium and the uppermost layer of the tissue are removed in order to produce a suitable tissue bed. The recipient site is an exposed area where the uppermost layer of tissue has been removed, and it extends to the interpapillar region.
4. At the donor site, a vertical incision is performed to elevate a flap of sufficient size. The flap extends to the vestibulum and runs parallel to the former incision.
5. The flap is separated from the periosteum.
6. If a sufficiently large flap cannot be elevated, it is possible to extend the incision further into the mucosa.
7. This is a split thickness flap that should be as thick as possible. Therefore care should be taken during elevation to avoid perforation.
8. The first suture is embracing and should keep the flap in the correct position. For this purpose nonresorbable sutures are used. This suture keeps the flap in position over the entire healing period.
9. The edges of the flap are attached to the periost using resorbable sutures.
10. The wound can be closed at the donor side with a free gingival graft
Covering a class II recession with a laterally sliding flap
Causes of Possible Failure
—Tension in the flap—place a vertical releasing incision.
—The sliding flap is too narrow—no correction possible.
—Too much bone is exposed—this leads to recession.
—Inadequate stabilization of the flap—mobility prevents the formation of a contact between the flap and the recipient bed that leads to necrosis and loss of the flap.
Coronally Repositioned Flap
The coronally repositioned flap is a very successful and aesthetic technique used to cover exposed root surfaces. Prerequisites for success, however, are that the flap is large enough and that there is sufficient attached gingiva. Therefore, at least 3 mm of sufficiently stretchable and thick gingiva must be present apical to the recession. If this is not the case, recession can recur. Sufficient attached gingiva is needed so that the flap can be repositioned coronally.
Covering a recession with a coronally repositioned flap
This technique is suitable for several adjacent recessions and can be easily combined with other techniques.
Indication: To cover recessions, hypersensitive root surfaces.
Advantages: Several root surfaces can be treated simultaneously, high success rate. Adjacent teeth are not affected.
Disadvantage: Only possible with class I recessions.
1. The root is thoroughly scaled and planed.
2. Condition the root using citric acid or tetracycline. Other authors also use 32% phosphoric acid for this purpose. Regarding the possibility to improve reattachment, the root surface can be additionally treated with Emdogain (Biora). Emdogain is a derivative of the enamel matrix and stimulates cell growth on the root cementum-forming surface. After cementum is formed, a new periodontium can regenerate with a new periodontal ligament and new alveolar bone. However, further studies will be needed to prove that this treatment would be advantageous to cover root recessions.
3. After the root has been conditioned, the recession is measured from the gingival margin to the cemento-enamel junction (distance A).
4. An apically located point is selected from the top of the papillae at distance A.
5. At this point, the incision begins and extends well into the mucosa.
6. A split thickness flap is elevated.
7. The recipient bed is prepared, by means of removing the epithelial layer with a scalpel.
8. The flap is undermined so it moves easily and is easy to reposition coronally.
9. The flap is positioned coronally and is then attached with a nonresorbable embracing suture.
10. The lateral edges are sutured to the periosteum. Resorbable sutures are used for this purpose.
Coronally repositioned flap: surgical procedure
Allen and Miller (1989) and Harris (1994) have shown up to 98% root coverage can be achieved with this technique.
Free Gingival Grafts
A free gingival graft is used for root coverage or rebuilding gingiva if required (augmentation). This technique, which has been significantly altered over time, produces acceptable aesthetic results.
Augmentation of jaw ridges is a recommended preprosthetic treatment. Insufficient amount of attached gingiva often leads to chronic inflammation adjacent to dentures, implants, or orthodontic appliances.
Advantages: High success rate, simple technique. Several teeth can be covered simultaneously. The technique also works when there is an insufficient amount of keratinized gingiva.
Disadvantages: Two surgical regions are needed. If the blood supply is poor, it may result in a partially unsatisfactory aesthetic outcome at the region of the root coverage. Pain may also be felt at the two surgical sites, particularly at the donating site.
Surgical Augmentation Procedure
1. The recipient bed is prepared. A horizontal incision is made along the mucogingival junction and extended into the papillary region.
2. A vertical incision is made lateral to first incision and extends into the mucosa. The supraperiostal part of this area is exposed.
3. The flap is excised.
4. The recipient bed is measured and a 1-mm-thick gingival graft is taken from the palate.
5. The graft is adapted to the tissue bed with moist gauze and sutured to the papillae and the periosteum.