Dr. Andre Saadoun – March 27, 2009

Implant Seminars
Gingival Recession Coverage
Dr. Andre Saadoun – March 27, 2009

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· High level of perio surgery
o 40% of the face is a smile
o Beautiful smile: healthy dentition, harmonious gingival contour
· Aslund, Suvan J Periodontal 2008:79:1031-1040
o The periodontal health of the subjects affects their smiling pattern and their smile-related to their quality of life
o Poor perio health may prevent adults from smiling…
· Periodontal Biological Parameters
o Lip Line
o Gingiva
o Bone
o Teeth
o Interdental papilla
o Biological width
· Lip Line
o Fxn: rest, speech, smile
§ Low lip line: 20%; Medium:70%; High:10% (Beyond 3mm)
· Gingiva
o Look at gingival level
o Form: Scalloped, flat
o Biotype: thin, thick
§ Thick – flat contour of gingiva
o Quantity: small, large
· The amount of keratinized gingival extends from the FGM (Free Gingival Margin) to the MGL (Muco-Gingival Line) minus the pocket depth in the absence of inflammation
· Stetler and Bissada 1987
o Higher chance of gingival inflammation wih subgingival restorations
· Bone
o In healthy patients, the gingival follows the underlying osseaous/CEJ contours
· Chu’s Aesthetic Gauges Proportions: (Hu-Friedy)
o See drawing for esthetic proportions
· In-line tip
o Another esthetic gauge
· Maxillary teeth
o Women have longer teeth than men due to aggressiveness of men
o Tell lab about gender (especially anteriors)
· Interdental papilla (Note IHB – Interproximal bone height)
o Class 1 IHB – Optimal prognosis 2mm from CEJ
o Class 2 IHB – Guarded prognosis 4mm from CEJ
o Class 3 IHB – Poor prognosis >5mm from CEJ
· Tamow et al 1991 2008
o The height of the contact decreases from the central to the molar
§ 4mm at cental incisors, 3mm at laterals, 2mm cuspids, 1.5mm premolars, 1mm molars (Chu, Tamow)
§ The ideal length of the ID papillae is about 40% of the length of the tooth from the gingival zone
o The mesial and distal papilla are about equal height
o The apical pt of the contact surface area determines the height
· Biological width
o Junction of epithelium and connective tissue (Not gingival sulcus)
o See drawing for Biological width
o Also see drawing for Chu’s biological width instruments
o 3mm from gingival crest to bone
Crown Lengthening
· Use this when you have THICK tissue
· Without osseous resection
o No flap elevation
o Initial display: excessive gingiva when she smiles (AA Female who models)
§ Models, x-rays, photos
§ CEJ to bone 1mm (normal) – but 6mm from gingiva to bone: can remove 3 mm
§ Internal bevel gingivectomies (Blade 15C)
· Vicryl 5-0 to hold the papillae in place and to slow down the bleeding
· Continuous vertical mattress sutures throughout
§ Must suture this kind of case to maintain papillae when cutting papillae
o If you can not touch papillae - e.g. for long, triangular teeth OR diastema
§ Crescent incisions (like croissant leaving papillae alone)
§ Zenith on canine is on distal, lateral in middle, centrals slightly distal

· With osseous resection and no flap (use bur in sulcus on bone)
o Short teeth, chipped edges but only 3mm sounding
o Must sound the bone
o Need to remove some bone: use fine diamond – don’t touch papillae
§ Leave 2-3 months before doing final restorations
§ No flap elevation during bone removal
o Can do this with moderate and thick type gingiva
· Want to achieve predictability
o Plan PROPERLY
o Everything in the body needs to work in HARMONY
o Think before jumping
o NEVER touch the palate on the esthetic zone
· With osseous resection and flap elevation
o Lip line uneven: will need perio with laminates
o Do a wax-up
o Do a full thickness flap
o Papillae will take 6-8wks to drop back down
· If you do single tooth crown lengthening: DO NOT INCLUDE THE PAPILLAE
· When probing: CEJ should be 1.2mm incisal to bone
· From diagnosis comes multiple treatment plans
Treatment of Gingival Recession
· Use this when you have THIN tissue
o The demand on thin tissue increases – demand is increasing
· Miller’s gingival recession classification
o I No extension to MGJ: no periodontal loss in the interdental bone/papilla
o II Extension to or beyond the MGJ, no periodontal loss in the interdental papillae
o III Extension to or beyond the MGJ, partial periodontal loss in the interdental papillae
o IV Extension beyond the MGJ, full periodontal loss in the interdental papillae
· Success rates per diagnosis
o Class I – Can 100% cover the recession
o Class II – Can get 100% coverage
o Class III – Can get 50-75% coverage
o Class IV – Only get 0-10%: Not worth even trying
· Zuchelli et al J Perio 2006; 4:714-721
o The line of root coverage is predetermined by calculating
· Restore cervical region AFTER perio surgery
· Connective tissue graft
o Get CT from palate
o Place it, and let it heal
o Tell pt in advance about prognosis
· Alloderm grafts will not work with no bone present
· Submerged Connective Tissue Graft
o Bridge with pink acrylic
o Do surgeries in stages if needed
o You can use pouch or flap
§ Pouch: Apical to MGJ
§ Make sure you loosen circumferentially
· Horizontal tunneling
o Premedication: Prednisone 40mg/50kg morning of; Antibiotics day before; Chlorhexidine; Ibuprofen 600mg 1 hr before
o Prepare bed with ophthalmic blade or 15C
§ Tie suture around 1 end, pull through, suture it into place
· Enamel matrix derivative (alloderm) emdogain
o Report the recession length on the papillae with perio probe
o 1mm deep full thickness, then do partial thickness flap
o Keep the papillary tips
o Emdogain – embryonic acid gel on for 3 minutes after scaling and root planning/acid/wash and then emdogain
§ Must use suspensory sling vertical sutures
· Knot is on occlusal
§ Excellent results
§ Circular incisions
§ Fine diamond burs to root plane
§ Keep the tip of the papilla
§ Use round diamond to decrease root abrasion and remove epithelium interproximally
§ Vicryl 5-0 is used with 19 needle (instead of 13)
· Alloderm Free Gingival Graft – Acellular dermal graft material
o Lower incisor case
o Use Blade 15C
o Need to see patient every 3 days for 6 weeks
o The alloderm needs to be VERY firmly bound down
§ Basal side goes toward roots
§ Alloderm dermal side goes toward the flap
§ Must suture the alloderm in a specific way to steady the flap
§ Never allow the alloderm to be visible at the end
o There will be a lot of gingival deformities
§ Heals very slowly
· Combining alloderm and emdogain
o To increase the length and the thickness
o Emdogain with alloderm increases the amount of keratinized tissue
o Emdogain is injected underneath the alloderm
· After alloderm: WAIT 10 weeks – for ortho, or restorative tx
· I’m not going to cut your gums… I’m going to raise your gums
· Smokers have less root coverage than non-smokers (58% versus 83%)
o Smoking destroys grafts
o No sinus elevations on smokers
o No grafts on smokers
· Can create membranes with PRF
o Platelet rich plasma is the best membrane
o EXCELLENT results with PRP, PRF
Conclusions
· If there is less than 3mm of gingiva around the recession, you must augment the qulity and quantity with emdogain and alloderm
o Suture any mistakes early
· Tunnel: Less complications, less discomfort, minimally invasive
· Beauty: Based on culture
· Details make perfection
· Smiles are important ways to communicate to people
· In perio-plastic surgery: you can improve the smile of a patient
o Gingival disharmony
o Gingival Excess
o Buccal Gingival recessions
· Know the classifications
· mailto:andre.p.saadoun@wanadoo.fr