Optimal Gingival Biotype for predictabl perio esthetics
1st Author
Dr. KaushalLuthra
Professor& Head
SGT Dental College Hospital & Research Institute
Gurgaon
India
([email protected])
nd
2 Author
Dr. NidhiAggarwal
Resident
SGT Dental College Hospital & Research Institute
Gurgaon
India
([email protected])
Abstract
It is imperative to appreciate that the differences in thequalitative and quantitative
nature of gingival tissue can affect treatment outcomes. The concept of thick versus thin
gingiva has been expanded to describe the myriad ways these tissue types respond to
irritants, inflammation, surgical and restorative trauma. The resulting defects from
these traumatic events will dictate varying management modalities. The purpose of this
case report is to not only attain the esthetic demands of patient, but ensure its longevity
by changing the quality of tissue for more-predictable treatment outcome.
Introduction
This article is focussed to the view point that the predictability of perio-esthetics will be
determined by the patient’s presenting anatomy rather than the clinician’s ability to
manage state-of-the-art procedures.Clinicians are often confronted with changes in the
anatomy of the local site, successful management of which can be challenging,
particularly in the esthetic zone.
Previous studies have already shown considerable variation between individuals with
regard to the morphological characteristics of the periodontium and teeth. Already in
1989 the existence of distinct morphotypes – so-called ‘‘periodontal biotypes’’ – was
suggested (Seibert &Lindhe(1989) Later on, the specific features of these biotypes were
well defined by Olsson et al. (1993).1
The gingival biotype is gaining considerable attention as one of the key elements
influencing aesthetic treatment outcome.Both the quality and quantity of soft tissue
architecture is important for clinical standpoint and usually fall in either of two
categories as follows:
1.
Thin gingival tissue tends to be delicate and almost translucent in appearance.
The tissue appears friable with a minimal zone of attached gingiva. The soft-tissue
topography is highly accentuated and often suggestive of thin or minimal bone
over the labial roots. Surgical evaluation often reveals thin labial bone with the
possible presence of fenestration and dehiscence. Limited blood supply is believed
to be one of the major reasons why papilla preservation and regeneration are
difficult. This tissue is highly sensitive to trauma and inflammation
2.
Thicker tissue may resist collapse and contraction due to increased vascularity
and extracellular matrix volume. In addition, thicker KG epithelium may be
more resistant to physical damage and bacterial ingress.Therefore, thick gingival
biotype has been considered more favourable for achieving optimal aesthetics.
The biotype proposed here is an optimal type and is an objective for future perioesthetics. Proper planning and management is necessary to ensure that the optimal
biotype will remain stable. 2,3
From both a consent form and clinical standpoint, this brings clarity to the patient
avoiding surprises and disappointment. It also guides the practitioner whose best
clinical intention may not always materialize and guarantee the best and most
reasonable possible achievement.4
. Periodontal phenotype as a key will enable the clinician to develop treatment options
and clinical procedures that are more specific to the desired therapeutic outcome. 5
Optimal biotype is a silver lining enabling for complex surgical approaches where
ultimate decisions may have to be taken extemporaneously as the case develops.
Understanding how the patient’s pretreatment presentation impacts the method of how,
and to what degree, these criteria may be met, is critical to formulating an appropriate
treatment plan and improves one’s ability to restore natural esthetics, function, longterm health, and patient comfort.6,7
Conceivably, a close mutual interrelationship exists between gingival dimensions and
thickness of the underlying alveolar bone. Therefore, the periodontal phenotype might
actually influence the individual’s course of developing periodontal disease and
treatment planning.
Although it is beyond the scope of this article to fully elucidate the myriad
considerations involved in perio-esthetics, it should be noted that patients may vary
widely in their level of esthetic demands and expectations.
Case report
A 35 year-old female patient reported with a chief complaint of long appearing upper
front teeth along with sensitivity to hot and cold food items.
Her medical history was uncomplicated with no untoward findings in the dental
history.
On Examination
The patient presented with the following characteristics:
1. Multiple Miller’s Class II Type gingival recessions defects (Figure 1,2,3)
2. Gingiva: Accentuated scalloping with translucent thin delicate soft tissue; (Figure 4)
3. Bone: Thin osseous pattern with underlying multiple bony dehiscences
4. Teeth: Relatively squatic in form with contact areas are located more apically and
usually are broad incisogingivally and faciolingually. The cervical convexity on the
facial surface was reasonably prominent.
No signs of inflammation or ulcerations were there.
Management
The selected and agreed treatment plan was to thicken the gingiva using Sub Epithelial
Connective Tissue graft along with complete root coverage by coronally repositioning
the flap over soft tissue autograft. An informed Consent was obtained.
1. The initial management was conservative and consisted of cleaning and hygiene
instruction. Follow-up a few weeks later showed a clear improvement in oral
hygiene. The patient was explained treatment goals and different available
treatment options.
2. Adequate anesthesiawas administrated. The surface of the root were scaled and
planed thoroughly. Partial thickness flap incision was made using 15c blade
from mesial of first premolar on right side to mesial of first premolar on left side
in maxillary arch sparing the papilla. The papilla was left intactto improve blood
supply to the graftduring the healing phase.
3. Partial
thickness
flap
was
reflected
leaving
periosteumintact
anda
mucoperiosteal pouch(past the mucogingival junction) was created for sub
epithelial graft placement and its stabilization. (Figure 4)
4. Then sub epithelial connective tissue graft was harvested from both sides of
palate and was placed from the mesial of the lateralincisor to the distal of the
canine on either sides covering the recession defects.
5. The graft was then made stable in muco-periosteal pouch. The margins of the
graft was fixed to the periosteum withvicryl sutures. Flap was approximated
back and sutured.
The patient was instructednot to brush the area for 6 weeks,to start rinsing the
mouth withsaline solution for seven days. Afterseven days, disinfection
wasperformed with oral rinse with CHX solution. The patient wasseen for
postsurgical check up on weekly basis .(fig 5-8)
After eight weeks, a thoroughcleaning was performed and thepatient was instructed to
restart regularhygiene. Healing was uneventful and recession coverage was 98%.
Onexamination it was noticed that maxillary left lateral incisor showed minimal
root coverage. Therefore second stage surgery was planned. Taking the advantage of
optimized biotype at first stage surgery , coronally advanced flap was performed.
(Fig9-10)
Discussion
Based on thepreceding discussion, it should be apparent that thick gingival tissue is
easier and more predictable to manage restoratively and surgically. The literature on
restorative treatment supports this finding. Until 10 to 15 years ago, restorative dentists
had little choice in determining the type of gingiva with which they had to work. Recent
advances in periodontal surgery have eliminated many of these constraints.
Restorative dentists now have the option of referring the patient to the periodontist for
corrective procedures. These procedures will develop the gingival environment into a
"pseudo-thick" case. For areas with thin gingiva or gingival recession, a connective
tissue graft procedure may be performed. This not only thickens the soft tissue so it is
more resistant to trauma, but it can also cover exposed root surfaces. Similarly, the
periodontist can manage extraction in the thin case with ridge preservation procedures
to minimize ridge atrophy and/or ridge augmentation to correct ridge deficiencies.In
incidences where implants are desired, immediate implants can be placed to preserve
not only the bone, but also the soft tissue, including the papilla.These periodontal
procedures convert a thin case into a tissue type that the restorative dentist can work
with more easily and predictably.
Conclusion
A new paradigm shift has occurred in periodontics. In this new era it is important for
restorative dentists to consider the thick and thin gingival-osseous housing of the
dentition. As clinicians begin to appreciate how thick versus thin tissues respond to
infectious, restorative, and parafunctional trauma, they will be better able to predict the
defects that will result and prescribe the appropriate treatment. Even more important
for the restorative dentist is the realization that thick gingiva is a more favorable tissue
environment for restorative procedures. With advances in periodontal plastic surgery, it
is possible to transform a thin case into a more manageable optimal case. This paradigm
shift will permit clinicians to be more effective in diagnosing periodontal problems and
prescribing treatment. Additionally, these new procedures give them the ability to
modify the tissue environment when they need to deliver esthetic restorations.
References
Fig 9 :coronally advanced flap wrt 22
Figure 10 : 2 months post op showing 100% root coverage