Perio plastic surgery (compressed)
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Making a smile beautiful requires attention to detail not only with regards to teeth but to subtle features of the soft tissue to enhance or detract from the overall picture we know as the smile. This power point reviews the golden proportion of the teeth, gums and lips and reviews surgical procedures to enhance ones beautiful smile. Feel free to email me with questions or comments drsmith@cpident.com
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Perio plastic surgery (compressed)
- 1. Periodontal Plastic Surgery: Framework for the Perfect Smile Dr. Scott K. Smith Valley Forge Dental Forum March 27, 2013
- 2. Peri-oral Plastic Surgery Treatment Options Resective Therapy Augmentation Therapy • Root coverage procedures • Hard and soft tissue ridge augmentation Combination Procedures
- 4. Anterior Crown Lengthening Prerestorative For smile enhancement Biologic width sensitive Papillary retention critical
- 6. Crown Lengthening Before After CL Townsend, DDS Restorations by G Kinzer, DDS
- 8. Crown Lengthening Immediate Post-Suturing One-Month Healing CL Townsend, DDS
- 9. Crown Lengthening Before Two-Months Postsurgical CL Townsend, DDS
- 11. Crown Lengthening Before After BL Butler, DDS Restorations by T Bridgeman, DDS
- 12. Crown Lengthening Before One-Month Postsurgical CL Townsend, DDS
- 14. Crown Lengthening Surgical Immediate Post-Op BL Butler, DDS
- 15. Crown Lengthening Before After BL Butler, DDS Restorations by G Kinzer, DDS
- 16. Augmentation Therapy Hard and Soft Tissue Augmentation Procedures
- 17. Clinical Indications Augmentation Therapy Recession Deficiency in Gingival Form • Ridge Collapse • Loss of Papilla Anterior Extractions
- 21. Root Coverage Before Prepared Root Surfaces
- 22. Root Coverage
- 27. Root Coverage for Implants Before After
- 30. Ridge Augmentation Before Post-Suturing CL Townsend, DDS Restorations by S Carstensen, DDS
- 31. Ridge Augmentation Before After CL Townsend, DDS Restorations by S Carstensen, DDS
- 34. Site Preservation/ Root Coverage Before One-Month Post-Extraction CL Townsend, DDS Restorations by R Hsu, DDS
- 35. Site Preservation Before After CL Townsend, DDS Restorations by R Hsu, DDS
- 36. Site Preservation/ Ridge Augmentation BL Butler, DDS
- 38. Site Preservation BL Butler, DDS
- 39. Site Preservation Before After BL Butler, DDS Restorations by G Kinzer, DDS
- 41. Combination Procedures Before After BL Butler, DDS Restorations by G Chyz, DDS
- 42. Combination Procedures Before After with Provisional Restoration
- 43. Combination Procedures Before After CL Townsend, DDS Restorations by L Jones, DDS
- 45. Combination Procedures Before Immediate Post-Suturing CL Townsend, DDS
- 58. Implant Site Development Before Guided Bone Regeneration
- 70. Lip and Peri-Oral Augmentation • Lip Proportion • Smile Lines • Rhytids • Skin Tone
- 73. Peri-Oral Plastic Surgery Begin with the End in Mind! The End!
Notas do Editor
- Gingival tissues are to a tooth, restoration, or implant what a frame is to a picture. A perfect picture with the wrong frame results in less than ideal results. The gingival architecture influences the shape, width, length and – in the case of a pontic –position of the crown relative to a normal tooth. This is why an interdisciplinary approach to ideal esthetics is vitally important.
- Gingiva and bone can be taken away by reshaping or sculpting – also known as resective therapy – or can be enhanced in volume, which is referred to as augmentation therapy. This presentation will cover both resective therapy and augmentation therapy, as well as procedures that use a combination of both therapies.
- There are several treatment choices available today to help achieve ideal gingival esthetics. They include: Resective therapy for symmetry, parabolic form, and to match tooth length to the smile line. Augmentation therapy for root coverage, restorative site development, and extraction site preservation. A combination of resective therapy and augmentation therapy in cases requiring multiple procedures for optimal esthetic outcomes.
- The first section of this presentation will begin with examples of resective therapy; specifically, I’ll show cases where anterior crown lengthening was used both in the natural dentition and as a prerestorative measure.
- In some cases, anterior crown lengthening can improve clinical crown length so that a restoration is possible. Anterior crown lengthening also can help improve tooth length relative to the smile line, establish acceptable biologic width, and retain papillary tissues whenever possible.
- This slide depicts a 13 year old young woman in the postorthodontic photo on the left. As you can see, she exhibits a common indication for anterior crown lengthening, which is excess gingival display after orthodontics. The after photo on the right taken 18 months later shows the beautiful esthetic results achieved after anterior crown lengthening on teeth numbers 5 through 12. The amount of change in this case is dramatic. It demonstrates the importance of matching tooth length to the lip line.
- This is a photo of the same patient we saw in the previous slide. She is now 18 years old. As you can see, the results have been stable over a 4-year interval.
- In this case the patient presented with excessive gingival hyperplasia following orthodontic therapy with concurrent violation of biologic width on the #8 and #9 crowns. Crown lengthening was performed to reposition the attachment as well as to expose more tooth structure prior to the final restorative work. The patient was referred by her general dentist for correction of encroachment on biologic width. Both the patient and general dentist desired improved esthetics as well. The surgery improved gingival health by re-establishing biologic width.
- Here we have a more complex postorthodontic case. As you can see in the photo on the left, the length of the teeth appears to slope down to the patient’s right side. Incisions, shown in the second image, vary a great deal in the amount of tissue resected in order to create more even tooth lengths. This patient also has an asymmetrical lower lip, so that, even though the incisal edges of #6 and #11 appear to meet the lower lip in similar positions, the gingival display on #6 is much greater than #11. Also, #9 is not incisally in the same plane as #8. These are special issues to be considered at the incision design phase of crown lengthening procedures. This patient was referred by an orthodontist after the bands were removed to reduce gingival display and improve esthetics.
- These two images represent immediate postsuturing and one-month healing. You can see that some inflammation is still present and #6 is slightly longer than #11.
- In the pretreatment smile and two-month post-surgical smile views, you can see that, while significant display of gingival tissues is present, tooth length and symmetry are greatly improved. The main factor that inhibited this case from achieving the perfect results seen in the previous case was the CEJ, which impacted where the gingival margins had to be placed. Further reduction in gingival display would have required intrusion of the pre-maxilla and additional orthodontic therapy.
- This patient was referred by her general dentist. She wanted to improve the appearance of her crown to enhance her smile prior to her wedding. The general dentist recognized the need for crown lengthening first for increased retention of the new crown and also to achieve symmetrical crown lengths. This case depicts esthetic crown lengthening of the right central incisor. The procedure was completed with a minimally invasive microsurgical technique. An envelope flap was utilized to allow for needed osseous recontouring.
- This final photo shows the results of crown lengthening and the new crown.
- This case demonstrates another consideration in decision making regarding the shape of the initial incisions for anterior crown lengthening. Prior to the procedure, teeth shapes and lengths were projected using radiographs and tactile probing of the CEJ. The postsurgery view is just one month after the procedure with no gingivoplasty. This patient was referred by a general dentist who focuses on esthetics. Both the patient and general dentist wanted a “toothier” smile.
- In this case, the restorative dentist requested crown lengthening on the central incisors to gain increased restorative access and a more symmetrical gingival pattern. The ferrel was increased for better restorative retention and resistance.
- The photo with the probe on the right incisor illustrates the necessary amount of osseous reduction prior to completing osseous resection on the left incisor. The photo on the right shows closure with minimal trauma using 7.0 sutures.
- These before and after photos illustrate that crown lengthening can be performed without an esthetic compromise. As you can see, the papilla form has been preserved with a nice cosmetic result.
- Now that we’ve covered resective therapy, let’s talk about augmentation therapy.
- Indications for augmentation therapy can include recession, deficiency in gingival form and thus the need for pontic site development (as indicated by ridge collapse or loss of papilla), and extraction site preservation/ development.
- Let’s take a look at the use of root coverage procedures.
- This patient’s chief complaint was significant sensitivity to cold. He wanted the roots covered, but also a natural esthetic look in the end result. In this case, subepithelial connective tissue grafts were completed on #3, #5, and #6 to augment the width of keratinized gingiva and increase root coverage.
- In the after photo on the right, you’ll note the final results are very positive. Full root coverage was achieved on #5 and #6 for esthetics. Number 3 has an increased thickness of keratinized gingiva to decrease future recession. The procedure has also corrected the sensitivity and decreased the risk of future root decay.
- This patient was referred by her general dentist due to concern about progressive recession and the resulting unattractive appearance. In this case, a subepithelial connective tissue graft was completed with acellular human dermis on teeth #11 and #12. The root surfaces are first prepared as depicted in the slide on the right.
- Then, as depicted in the photo on the right, the acellular dermis was completely covered with the split thickness flap.
- In these before and after photos, you can see that full root coverage was achieved with a very natural look as to color and gingival consistency. The root coverage also will improve the patient’s ability to perform plaque control.
- This patient was referred by his orthodontist prior to undergoing comprehensive orthodontic treatment including surgery. Augmentation was completed from #19 through #30 in one surgery with a subepithelial connective tissue graft using acellular human dermis. The patient underwent orthodontic therapy three months later. The width of keratinized gingiva will now be adequate to decrease the risk of recession during orthodontic treatment.
- This patient self referred to a periodontist to improve her appearance. This case involved autogenous connective tissue grafts from #4 through #13. As you can see in the after photo on the right, near full coverage was achieved, which greatly enhanced the cosmetic appearance. The thickness of the periodontium is also significantly improved, again showing how esthetic procedures also enhance function.
- The root coverage procedure subepithelial connective tissue graft can also be utilized with implant cases to enhance esthetics.
- This patient was referred by a prosthodontist. The existing #8 implant was placed too far labially with a resulting esthetic complication. The subepithelial connective tissue graft was placed, so the restorations did not have to be replaced. Root coverage procedures are less predictable with implant sites but, as seen here, they can provide a dramatic cosmetic improvement.
- Another type of augmentation procedure can be used to expand edentulous ridges, making them more compatible with ovate pontics. They appear to naturally emerge from the gingival tissues.
- As seen in the before view, this patient presents with an unusual restorative solution to a significant ridge deficiency on #7 and #8. The crowns on adjacent abutment teeth have porcelain extensions extending over the gingival margins to create symmetry with the abnormally long #7 and #8. The pre-existing bridge was replaced with a temporary bridge. A ridge augmentation procedure was then performed to create a convex profile to the ridge for #7 and #8. The slide on the right shows the new bridge in place with completely revised teeth lengths and a much enhanced ridge profile.
- This is a case that involves a ridge augmentation procedure for a fixed bridge to replace a “flipper.” You can see in the before view on the left that there is a concavity in the ridge between numbers 9 and 11. It’s also important to note how this concavity affects the asymmetry in tooth lengths, again when comparing numbers 9 to 11. This patient is a dental assistant who desired ideal esthetics for her new bridge. She was referred by a general dentist for the ridge augmentation to help create a ridge that would allow an ideal ovate pontic to be developed.
- As seen here in the before and final after photo, the connective tissue ridge augmentation procedure to repair the concavity has created an ovate gingival form. This provides a natural esthetic result.
- In addition to areas of recession and deficient ridges, augmentation therapy can be used at tooth extraction to prevent ridge collapse.
- This is an extremely complex case that required a lot of pretreatment planning to stage therapy and achieve the best esthetic results. The before slide illustrates severe excess length on #8. This was due to attachment loss secondary to periodontal disease. The site preservation technique prevented a severe ridge deficiency. This patient was referred by her general dentist for treatment of periodontal disease on #8. Once disease activity had been reduced, extraction of #8 was deemed necessary. Treating this area would eliminate the periodontal defect, greatly improving both health and function.
- These photos compare pretreatment and one-month postextraction views. Number 8 was first extruded orthodontically to bring the gingival margin to the #9 level. The tooth was then extracted and a socket site graft was completed in conjunction with a connective tissue graft. In addition, crown lengthening was performed on #7 to make it more closely resemble #10.
- These before and after views compare pretreatment and postrestorative esthetics. Although there are some asymmetries still present, they are greatly improved compared to the before view. The patient could not thank the dental care providers enough for giving her her smile back.
- This patient had the right central incisor ankylosed as a teenager. The treatment plan was a fixed bridge with ridge preservation and augmentation. The right photo depicts the provisional bridge with the clinical crown resected on the ankylosed incisor.
- This is a nice case because it demonstrates a combination of connective tissue grafting and crown lengthening. Crown lengthening was completed on the central incisors and connective tissue grafts were completed on the canines. The goal was to create the illusion of the canines being the laterals. This patient was referred by a general dentist whose practice is limited to cosmetic dentistry. Both the patient and general dentist desired improved gingival symmetry on #6 through #11.
- The incisor was extracted by the periodontist. The site was then preserved and augmented with anorganic bovine bone and a connective tissue graft to increase the gingival volume. The periodontist also added an ovate form to the pontic.
- As seen here, the before and after photos show a dramatic improvement. The bridge shown in the after photo is the provisional fixed restoration. Six months elapsed prior to placing the final restoration.
- Now that we’ve learned how resective and augmentation therapies can be used independently to achieve beautiful esthetic outcomes, let’s take a look at cases that include a combination of the two procedures to achieve optimal esthetic results.
- This patient was having veneers placed and was referred to improve the gingival form first. In this case, a connective tissue graft was placed on the right canine. Simultaneously, esthetic crown lengthening was completed on the lateral and central incisors. The combination of procedures that helped to achieve these harmonious gingival levels is an everyday event in many periodontal practices.
- The after slide depicting postoperative results with a provisional restoration in place demonstrates the amount of change that can be achieved by combining augmentation and resective therapies.
- And finally, these views demonstrate the level of change that can be achieved in some cases using a combination of augmentation and resective therapy and restorative procedures.
- This is a post-orthodontic case with two gingival issues to resolve. This patient was referred by an orthodontist to correct the recession on #11 and increase tooth lengths on #6 through #10. In the pretreatment view on the left, you can see that #11 is too long and #6, #7, and #10 are too short. A root coverage procedure was done as the first step to shorten #11. A lateral pedical flap procedure with the abundant tissue over the lateral tooth #9 was used for this root coverage procedure. The second procedure involved crown lengthening on tooth #6, #7, and #10 using #11 as the reference length, as depicted in the slide on the right.
- This is the same case, with these views depicting pretreatment and immediate postsuturing. You can see that a frenectomy was also completed in this case. The #8 gingival position was not altered.
- Finally, these are the pre- and postsurgical views. Although there is some gingival display still evident, symmetry is greatly improved.
- These full face before and after photos illustrate that just as there are different tooth shapes, there are also different types of faces and smiles. This patient can be described as having the “girlish” smile that still displays some gingival tissues. This case is an example of how slight modifications in our incision design can better match the individual patient.
- Implants in the esthetic zone require special planning to achieve the best cosmetic results. The augmentation procedures are even more important and complex with implants. This last section will demonstrate procedures the periodontist must do to achieve ideal results with implants.
- Just as procedures are used to prevent ridge collapse prior to bridge placement, site preservation therapies can be successfully applied prior to implant placement. Although challenging, it is critical with implants that actual bone develops for implant placement.
- In this case, a central incisor was extracted due to a vertical root fracture. The left photo depicts the incisor prior to the extraction. The right photo shows suturing after the extraction and ridge preservation procedure was completed. The site was augmented with anorganic bovine bone graft and a collagen membrane.
- The use of a cantilever provisional bridge helped to preserve the gingival form, as noted in the photo on the right.
- The preserved osseous ridge can be seen here in the photo on the left, as well as the implant placement in the right photo.
- In these two photos, the implant is placed with direction from a surgical guide.
- In the photo on the left, you’ll see primary closure at implant placement. The right photo also depicts primary closure after the provisional restoration was recemented.
- In these two after photos, you’ll notice that the final restorations on the implant and natural incisor appear very similar. The functional success of this implant is now a total success with an optimal esthetic result.
- And finally, in this after photo and final x-ray, you’ll see that the end result is a well-supported implant.
- In addition to site preservation with crown or pontic restorations, augmentation procedures are necessary in implant therapy to achieve esthetic results.
- This case demonstrates commonly staged procedures necessary to achieve ideal esthetic results with implants. Before implant placement, the ridge required hard tissue augmentation. Autogenous bone was harvested and a collagen membrane was used for guided bone regeneration, as depicted in the right photo.
- At this stage, implant placement was completed together with vertical soft tissue augmentation. An interpositional connective tissue graft was placed over the implant prior to closure.
- Utilizing periodontal microsurgical techniques, predictable implant closure is obtained.
- These x-rays verify implant placement and full use of the bone available for successful integration.
- The results are seen here in a very happy patient.
- The before and after photos are shown here. As you can see, the amount of vertical and horizontal volume gained during these procedures has created the architecture necessary for natural looking restorations.
- Crown lengthening (resective procedures) can also be used in conjunction with implant placement to enhance esthetics.
- In this case, the patient had congenitally missing lateral incisors. Prior orthodontic treatment had placed the permanent canines in the lateral sites, as seen in the before photo on the left. Our treatment plan was to orthodontically move the canines back to the proper location. The patient declined orthodontic treatment again and wanted implants to replace the primary canines. The photo on the right is after treatment was completed.
- Immediate implant placement was completed with the extraction of the primary canines. Crown lengthening was completed in the entire premaxilla to establish optimal crestal bone levels simultaneously with implant placement.
- The after photo shows the final stable results one year after treatment. Not only are the cosmetic results obvious but the gingival health is ideal.
- And, finally, the left side at one year.
- This x-ray and right side view demonstrate the position and esthetics for the #6 implant at one year post-therapy.
- In conclusion, an interdisciplinary approach is the best way to achieve ideal esthetics. This approach requires ongoing and accurate communication among the professionals involved in treating patients, as well as with the patients themselves. We need to be working toward the same esthetic endpoint, and patients must have realistic expectations about what can be accomplished. Independent of our clinical abilities, these things can only be accomplished with excellent communication. Thank you.