perio esthetics
TRANSCRIPT
Perio-Esthetics
CONTENT
Root coverage procedures
Gummy Smile
Lip repositioning
Papilla reconstruction
Gingival depigmentation
NORMAL SMILE•Essentials of a smile
The teeth
Lip frame work
The gingival scaffold
1.Colour2. Size & Silhouette3. Position4. Incisal plane
THE LIPS• Define aesthetic zone • Classification of Liplines (Tjan et al.)
• Geometry of harmony
Low (20%) Average (70%) High (10%)
THE GINGIVAL SCAFFOLDS
1. Health2. Harmony and
continuity of form3. Symmetry central
incisors4. Balance to laterals,
cuspids and premolars
Gummy SmileDiagnosis and Rx
GUMMY SMILE• Excessive exposure of the maxillary gingiva during smiling
• Etiology:1. altered passive eruption,2. anterior dento-alveolar extrusion3. vertical maxillary excess,4. short or hyperactive upper lip,5. combination of these factors.
THE GUMMY SMILE- 1. Altered Passive Eruption (APE)
• Classification of APE by Coslet et al. (1977) based on amount of gingiva:• Type- I: Wide band of keratinized gingiva
• Type- II: Narrow to normal band of keratinized gingiva
• Type- I is subdivided based on the relationship of alveolar crest to the CEJ.• Type- IA: distance between crest and CEJ is more than
1.5 mm
• Type- IB: when the alveolar crest is at the level of CEJ
1 2 3 4
Type IA- APE Treatment
Type IB- APE Treatment
Treatment Options for APECondition Treatment
APE type IA Gingivectomy
APE type IB Apically displaced flap with osseous resection
APE type II Apically displaced flap with or without ossous resection
Gummy Smile-2. Vertical Maxillary Excess
Gummy Smile: 3. Hyperactive Upper Lip
• The average length of the maxillary lip:• 20‑22 mm in young adult females and
• 22‑24 mm in young adult males.
• According to Garber and Salama the normal shift of the upper lip during smiling is 6 to 8 mm and is increased by 1.5 to 2 times in cases of hyperactivity of the upper lip.
Rx modalities • botulinum toxin injection,• Lip repositioning• lip elongation associated with rhinoplasty,• detachment of lip muscles, and• mayectomy of lip
• Lip-repositioning surgery aims to limit the retraction of the elevator smile muscles.
Lip repositioning(Rubinstein and Kostianovsky) 1973
Modifications
• Litton and Fournier (1979) modified it by separating the muscles from the basal bony structures to coronally place the upper lip.
• Miskinyar (1983) using a more aggressive approach which included myectomy and a partial resection of the muscle‑ levator labii superioris along with nerve repositioning before muscle resection.
• Ribeiro et al. maxillary labial fraenum was preserved to maintain the midline and reduce post-op morbidity
Papilla ReconstructionDiagnosis and Rx
LOSS OF PAPILLA(Black Triangle)
Etiology:1. Loss of Periodontal support
due to plaque associated periodontal diseases.
2. High frenal pull3. Abnormal tooth shape 4. Improper prosthetic contour5. Traumatic oral hygiene
procedure
Classification of Papillary Height• Nordland and Tarnow (1998) based on three anatomic
landmarks:1. the interdental contact point,2. the coronal extent of the proximal CEJ3. the apical extent of the facial CEJ, and
• Tarnow et al. (1992) analyzed the correlation between the presence of interproximal papillae and the vertical distance between the contact point and the interproximal bone crest.
• When it was ≤5 mm- papilla was present almost 100%.• When it was ≥6 mm only partial papilla fill of the
embrasure.
If the bone crest–contact point distance is ≤5 mm and the papilla height is <4 mm
Class 1 and 2 Surgical intervention
If the contact point is located >5 mm from the bone crest
Class 3 methods to lengthen the contact area apically between the teeth
Rx Strategies
Orthodontic approach
Surgical Techniques1. Beagle (1992) described a pedicle graft procedure utilizing the soft
tissues palatal to the interdental area.
Surgical Techniques2. Han and Takei (1996) proposed an approach for papilla reconstruction (“semilunar coronally repositioned papilla”) based on the use of a free connective tissue graft
Surgical Techniques3. Azzi et al. (1999) described a technique in which an envelope‐type flap is prepared for coverage of a connective tissue graft
Recent advancement• Tissue engineering method by McQuire and Scheyer (JOP 2007)• Autologus fibroblast injection
GINGIVAL DEPIGMENTATION
Gingival Depigmentation• A treatment to remove the melanin hyperpigmentation.• Melanin is the physiologic pigment of the gingiva… but
conditions associated with hyper melanosis are:• Smoking• Drugs• Albright syndrome• Puetz- Jaghers syndrome• Malignant melanoma
Clinical assessment of pigmentation
• Dummett oral pigmentation index (DOPI): (1964)• 0 = pink tissue (no clinical pigmentation);• 1 = mild light brown tissue (mild clinical pigmentation);• 2 = medium brown or mixed brown and pink tissue (moderate); or• 3 = deep brown/ blue–black tissue (heavy clinical pigmentation).
• The Hedin melanin index: (1977)• 0 = no pigmentation;• 1 = one or two solitary units of pigmentation in the papillary gingiva;• 2 = >3 units of pigmentation in the papillary gingiva without formation of a
continuous ribbon;• 3 = >1 short continuous ribbons of pigmentation; or• 4 = one continuous ribbon including the entire area between the canines.
Methods of depigmentation• Bur abrasion (mechanical)
• Chemicals- 90% Phenol and 95% alcohol (Hirschfield et al. 1955)
• Surgical scraping- still a Gold standard… (Hegde et al. 2013)• Cryosurgery
• Electocauterization
• Free gingival graft
• Lasers ablation- Latest and reliable
SURGICAL SCRAPING
Laser ablationCo2 laser- epithelial
peeling
Er:Yag laser- Brush stroke
Conclusion
• Esthetic treatment of a smile line is often a multifaceted scenario where teeth, periodontal tissues, and lip position interact.
• Disciplines of oral surgery, orthodontics, periodontics and restorative dentistry all play a role in the treatment of excessive gingival display.
• Not enough scientific evidence concerning the predictability and long-term stability of Perio-esthetic techniques.
References:1. D. A. Garber and M. A. Salama, “The aesthetic smile: diagnosis and
treatment,” Periodontology 2000, vol. 11, no. 1, pp. 18–28, 1996.2. Rosenblatt A, Simon Z. Lip repositioning for reduction of excessive gingival
display: A clinical report. Int J Periodontics Restorative Dent 2006;26:433-437.
3. Simon Z, Rosenblatt A, Dorfmann W. Eliminating a gummy smile with surgical lip repositioning. J Cosmet Dent 2007;23:100-108.
4. Ribeiro-Junior NV, Campos TV, Rodrigues JG, Martins TM, Silva CO. Treatment of excessive gingival display using a modified lip repositioning technique. Int J Periodontics Restorative Dent 2013;33:309-314.
5. Seixas MR, Costa-Pinto RA, Araújo TM. Gingival esthetics: An orthodontic and periodontal approach. Dental Press J Orthod. 2012 Sept- Oct;17(5):190-201.
6. Hegde et al. Comparison of Surgical Stripping; Erbium-Doped:Yttrium, Aluminum, and Garnet Laser; and Carbon Dioxide Laser Techniques for Gingival Depigmentation: A Clinical and Histologic Study. J Periodontol 2013;84:738-748.
7. Foley et al. in Orthodontic Treatment —The Management of Excessive Gingival Display. J Can Dent Assoc 2003; 69(6):368–72.
8. Allen EP. Surgical crown lengthening for function and esthetics. Dent Clin North Am 1993; 37(2):163–79.
“”
Thank You