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Clinical Advances in Periodontics

IN THIS ISSUE:

An Online Journal of the American Academy of Periodontology

www.clinicalperio.org

■ Implant Microsurgery

■ Surgical Correction of TwoAnterior Implants

■ Pocket-Lining Pedicle FlapProcedure

■ Xenogeneic Collagen Matrixin Implant Therapy

■ Treatment of SpongioticGingival Hyperplasia

■ Isotretinoin and Gingivitis

■ Gingival DepigmentationWith Laser-PatternedMicrocoagulation

■ Treatment of Trisomy21–Associated AggressivePeriodontitis

■ Dental Suture Techniques

■ Surgical Crown Lengthening

Volume 1 Number 3 November 2011

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VOLUME 1 | NUMBER 3 | NOVEMBER 2011

Clinical Advances in Periodontics

TABLE OF CONTENTS

CASE-BASED LEARNING

161 Implant Microsurgery: Immediate Implant Placement WithImplant-Supported ProvisionalDennis A. Shanelec, Leonard S. TibbettsThe SMILE Technique, which offers benefits including rapid healing, minimal discomfort, and enhanced patientacceptance for immediate replacement of damaged teeth in the maxillary anterior region, is described in thiscase series.

174 Surgical and Prosthetic Correction of Two Adjacent Anterior Implants:A Clinical Case ReportDennis P. Tarnow, Stephen J. ChuVertical and horizontal hard- and soft-tissue deficiencies between two adjacent anterior implants werefifi

reconstructed using dermis allograft material.

183 Use of the Pocket-Lining Tissue as a Pedicle Flap to Facilitate WoundClosure After Extraction to Preserve the Alveolar Ridge or Protect anImplant SiteShane J. McCreaThe pocket-lining epithelium found at periodontally compromised sites was used to produce primary woundclosure following implant placement and socket/ridge preservation surgery.

193 The Use of a Xenogeneic Collagen Matrix as an Interpositional Soft-TissueGraft to Enhance Peri-Implant Soft-Tissue Outcomes: A Clinical CaseReport and Histologic AnalysisGeorge A. Mandelaris, Mei Lu, Alan L. RosenfeldHistologic evaluation of a xenogeneic collagen matrix used as an alternative to autogenous graft harvest for thepromotion of peri-implant soft tissue thickness indicated a benign tissue response with organized and attachedconnective tissue similar to native, undisturbed periodontal tissue.

199 Conservative Treatment of Localized Juvenile Spongiotic GingivalHyperplasiaSimon R. MacNeill, James W. Rokos, Michael R. Umaki, Keerthana M. Satheesh,Charles M. CobbLocalized juvenile spongiotic gingival hyperplasia, a recently recognized pathologic entity, was successfullymanaged through the combined use of light surface cauterization and application of 0.05% clobetasol propionateointment.

(continued on page iii )

ON THE COVER:A typical case treated with the

SMILE Technique, showing the

preoperative view and the

immediate post-surgical view after

extraction, implant placement,

socket graft, provisional restoration,

connective tissue graft, and

microsuturing.

(Shanelec and Tibbetts)

An Online Journal of the American Academy of Periodontology

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205 Non-Plaque-Induced Gingivitis Associated With Isotretinoin: A Case ReportAjay Mahajan, Ashu Bharadwaj, Poonam MahajanThis case report describes the diagnosis and treatment of gingivitis that was an adverse effect of isotretinoin use.

210 Successful Gingival Depigmentation With Laser-PatternedMicrocoagulation: A Case ReportEdward P. Allen, Natalia D. Gladkova, Yulia V. Fomina, Maria M. Karabut, Elena B. Kiseleva,Felix I. Feldchtein, Gregory B. AltshulerMinimally invasive gingival depigmentation was successfully performed with laser-patterned microcoagulation,a new laser treatment technology.

215 Trisomy 21–Associated Aggressive Periodontitis: A Five-Year Follow-UpAlon Frydman, Fernando Verdugo, Krikor Simonian, Kian KarThis five-year followupof a patientwith Trisomy21describes how the extent of diseaseprogressionwas controlledand the overall periodontal health status was improved through frequent mechanical therapy despite continuousmicrobial challenges even after systemic and local antibacterial therapy.

CLINICAL DECISION MAKING

221 Basic Suture Techniques for Oral MucosaTerrence J. Griffiff n, Yong Hur, Jing BuThis paper reviews basic suturing techniques used in periodontics and presents the results of a national surveyfor their clinical applications.

233 Crown Lengthening RevisitedMarianne Ong, Shih-Chang Tseng, Hom-Lay WangThis review and opinion article summarizes esthetic and restorative crown-lengthening procedures.

T A B L E O F C O N T E N T S

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VOLUME 1 | NUMBER 3 | NOVEMBER 2011

Clinical Advances in PeriodonticsAn Online Journal of the American Academy of Periodontology

Co-Editors

Interleukin GeneticsWaltham, MA

Dr. Michael S. ReddyUniversity of Alabama at BirminghamBirmingham, AL

Associate EditorsDr. Steven P. EngebretsonNew York UniversityNew York, NY

Dr. Nadeem Y. KarimbuxHarvard School of Dental MedicineBoston, MA

Dr. David W. PaquetteStony Brook UniversityStony Brook, NY

Dr. Frank A. ScannapiecoUniversity at BuffaloBuffalo, NY

2010-2011 Officers of the AAPPresidentDr. Donald S. Clem IIIFullerton, CA

President ElectDr. Pamela K. McClainAurora, CO

Vice PresidentDr. Nancy L. NewhouseIndependence, MO

Secretary/TreasurerDr. Stuart J. FroumNew York, NY

Past PresidentDr. Samuel B. LowGainesville, FL

Founding Editorial Board

Dr. Richard T. KaoPrivate practiceCupertino, CA

Dr. Paul S. RosenPrivate practiceYardley, PA

Dr. Hom-Lay WangUniversity of MichiganAnn Arbor, MI

Dr. Thomas G. Wilson Jr.Private practiceDallas, TX

Editorial Advisory Board

Dr. Edward P. Allen

Dr. Steven B. Blanchard

Dr. Daniel Buser

Dr. Joseph V. Califano

Dr. Jack G. Caton

Dr. David L. Cochran

Dr. Manuel De La Rosa Jr.

Dr. Joseph P. Fiorellini

Dr. Paul A. Fugazzotto

Dr. Nicolaas C. Geurs

Dr. Henry Greenwell

Dr. Dan J. Holtzclaw

Dr. T. Howard Howell

Dr. Vincent J. Iacono

Dr. Georgia K. Johnson

Dr. Niklaus P. Lang

Dr. Samuel B. Low

Dr. Angelo Mariotti

Dr. Pamela K. McClain

Dr. Michael K. McGuire

Dr. Brian L. Mealey

Dr. Michael P. Mills

Dr. Dean Morton

Dr. Francisco H. Nociti

Dr. Terry D. Rees

Dr. Mark A. Reynolds

Dr. Louis F. Rose

Dr. Mariano Sanz

Dr. Robert G. Schallhorn

Dr. Anton Sculean

Dr. Thomas C. Waldrop

Dr. Hans-Peter Weber

Dr. Jan L. Wennström

Dr. Ray C. Williams

Dr. Hiromasa Yoshie

The American Academy of PeriodontologyExecutive Director, Alice DeForest

Publications Director, Katie Goss

Managing Editor, Julie Daw

Production Manager, Bethanne Wilson

737 N. Michigan Avenue, Suite 800

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Clinical Advances in Periodontics is dedicated to advancing clinical management of patients by translating knowledge into practical therapy. It is an online publication of the American Academy ofPeriodontology. The statements and opinions expressed in this publication reflect the views of the author(s) and do not reflect the policy of the Academy unless so stated.

Clinical Advances in Periodontics (ISSN 2163-0097) is published quarterly by the American Academy of Periodontology, 737 North Michigan Avenue, Suite 800, Chicago, Illinois 60611-6660. Manuscripts shouldbe submitted online at http://mc.manuscriptcentral.com/clinicalperio. For assistance with submissions, please contact Bethanne Wilson (telephone: 312/573-3217; fax: 312/573-3225; e-mail: [email protected]). Inquiries relating to advertisements should be addressed to the Academy’s advertising agent Todd Goldman (telephone: 813/949-0006 ext. 222 or 813/949-0054; e-mail: [email protected]). Inquiriesrelating to subscriptions should be addressed to Product Services (telephone: 312/787-5518; fax: 312/573-3225; e-mail: [email protected]). Inquiries relating to permissions should be requested by completingthe Permissions Request Form at www.joponline.org/page/permissions/permission.jsp. Inquiries relating to reprints should be addressed to the Academy’s reprint agent Beth Ann Rocheleau (e-mail:[email protected]; telephone: 803/359-4578).

Manuscripts must conform to the Instructions to Authors, which are available online at www.clinicalperio.org and http://mc.manuscriptcentral.com/clinicalperio. Subscriptions are available only as bundledsubscriptions with the Journal of Periodontology. Annual rates for individuals for Clinical Advances in Periodontics þ Jounal of Periodontology: United States and Canada, $232; rest of world, $278. Pleasecontact [email protected] for institutional rates.

Copyright 2011 by the American Academy of Periodontology; all rights reserved.

All advertising appearing in Clinical Advances in Periodonticsmust be reviewed and accepted prior to publication. Advertisers should allow a minimum of six (6) weeks for the review process. The publication ofan advertisement in Clinical Advances in Periodontics is not to be construed as constituting an endorsement or approval of the product or its claims by the American Academy of Periodontology or any of itsmembers.

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CASE SERIESMaster Clinician Series

Implant Microsurgery: Immediate Implant Placement WithImplant-Supported Provisional

Dennis A. Shanelec*† and Leonard S. Tibbetts‡

Introduction: Implants have become the preferred method of single tooth replacement. One of the challenges is theability to do immediate implant placement and provisionalization on the day of extraction in a consistent and estheticallypredictable manner.

Case Presentations:Using a newly developedmicrosurgical approach, the SMILE (SimplifiedMicrosurgical ImplantLifelike Esthetics) Technique, successful outcome of 298 of 300 cases has been achieved. The success is attributed tomicrosurgical precision associated with this technique. The goal of this technique report is to establish some of the benefitsand versatility of dental implant microsurgery and the SMILE Technique for these esthetically challenging situations.

Conclusions: With the SMILE Technique, a clinician has an orderly treatment sequence for providing immediateimplant placement and provisionalization. It results in excellent esthetics, as well as predictable success of dental implantosseointegration. Clin Adv Periodontics 2011;1:161-172.

KEY WORDS: Dental atraumatic restorative treatment; dental implants, single-tooth; dental prosthesis, implant-supported;microsurgery; tooth extraction; tooth fractures.

The Master Clinician Series features invited papers by authors who havereceived the American Academy of Periodontology’s Master ClinicianAward. This award is given to a member who has practiced anddemonstrated clinical excellence in periodontics and who has willinglyand unselfishly shared that expertise with members of the profession.

BackgroundDentists worldwide have striven to realize the potential ofdental implants for restoring failedmaxillary anterior teeth.Root form implants have proven exceptionally predictableand successful1 and have undergone many biologic, techno-logical, and restorative improvements in recent years.2 Theculmination of these innovations has been a convergence ofclinical research with restorative experience to favor imme-diate dental implant replacement of a failing maxillary an-terior tooth.3,4 Furthermore, immediate provisionalizationof single tooth dental implants has been shown to be a via-ble treatment.5-7 The challenges for immediate implantplacement and provisionalization, despite these reports,are significant when done macrosurgically versus microsur-gically. The differences include poor visualization, greatertrauma and less precision in tooth removal, a poorly litand often bloody field, incorrect implant placement and

* Private practice, Santa Barbara, CA.

† Recipient, 2010 Master Clinician Award, American Academy ofPeriodontology.

‡ Private practice, Arlington, TX.

Submitted April 13, 2011; accepted for publication June 9, 2011

doi: 10.1902/cap.2011.110040

Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 161

angulation, difficulty with contours and soft-tissue supportassociated with immediate provisionalization, and pooresthetics, including having no polished custom impressiontransfer coping replicating the provisional emergence pro-file. The advantages of the SimplifiedMicrosurgical ImplantLifelike Esthetics (SMILE) Technique microsurgical ap-proach compared to a macroscopic approach include: 1)precision of the surgical procedure and enhanced motorskills; 2) the application of microsurgical instruments to re-duce tissue trauma, resulting in little to no prolonged bleed-ing; 3) excellent surgical field illumination; 4) precisionin implant site preparation; 5) exactness with provisionalcrown fabrication; and6) anemphasis onpassivewound clo-sure with exact primary apposition of the wound edges.8-10

Immediate provisionals consistently maintain mesialand distal papilla height when the implant platform is £5mm below the crest of the papilla (Fig. 1). However, wehave found buccal recession of z1 mm to occur unlessa concurrent subepithelial connective of 1.5 mm thicknessis performed. If preexisting recession is present on the fail-ing and adjacent teeth, this must be corrected at the time oftreatment (Fig. 2). Preexisting infection around the failingtooth is not a contraindication to treatment. However,complete debridement of the socket under the microscopeis required. The socket must also be flooded with a 3% tet-racycline solution to decontaminate the osteotomy (Fig. 3).Fractured or avulsed teeth should be treated as soon aspractical. If possible, the fractured root segment should

FIGURE 1 Clinical case 1. A typical case treatedwith the SMILE Technique. 1a Preoperative view,maxillary right central incisor, with disto-buccalexudates. 1b Immediate post-surgical view afterextraction, implant placement, socket graft, pro-visional restoration, connective tissue graft, andmicrosuturing. 1c Two-week postoperative viewwith no postoperative pain reported. 1d Twoyears postoperative of final restoration.

FIGURE 2 Clinical case 2. 2a Preexistingrecession is seen on both central incisors, andthe lateral incisor must be corrected at the timeof treatment. 2b Implant placed in the extractionsocket of tooth #8, provisional placed, socketbone graft, and connective tissue graft toadvance the gingival tissue over the implantplatform and exposed root of the adjacentcentral and lateral incisors. 2c Eight-week post-operative view. 2d Post-restorative view after4 years.

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162 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Implant Microsurgery

be retained and mimicked when the implant is placed,permitting papilla regeneration after resupport of the gin-gival tissue when the screw-retained provisional is placed(Figs. 4 and 5).

To address these issues and techniques that may result inpotentially compromised results, we have developed theSMILE Technique, which adds the advantage of microsur-gical precision. From our prospective, the advantages ofthe SMILETechnique are an extremely high rate of success,

excellent immediate esthetics and patient acceptance, anda final restoration that is fabricated from replication of theprovisional emergence profile.

The SMILE Technique procedure comprises the stepsseen in Table 1. The technique has been followed for a caseseries of 300maxillary central incisors, lateral incisors, andcuspids. The clinical success rate from both the prospectiveof osseointegration and esthetics has been 99.3%. Usingthe SMILE Technique, a predictable sequence of orderly

FIGURE 3 Clinical case 3. 3a Preexistinginfection around the left central incisor as seenin the preoperative view is not a contraindicationto treatment. 3b Tooth extracted, socket de-brided, and decontaminated with a 3% solutionof tetracycline, implant and provisional crownplaced with socket bone graft and connectivetissue graft. 3c Ten-week postoperative view. 3dPost-restorative view after 2 years.

FIGURE 4 4a

4b 4c

4d4e

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Shanelec, Tibbetts Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 163

treatment arrangement has been developed. To present thistechnique, selective segments from seven representativecases will be composited in this technique report to intro-duce the SMILE Technique. Appreciate that this is techni-cally challenging and time-consuming and requires bothmicrosurgical and microrestorative skills.

Case PresentationsThe SMILE Technique has been used for the past 10 plusyears with excellent success.

Step 1: Implant MicrosurgeryAll phases of implant treatment are possible using a micro-scopewith aworkingmagnification above�10. Because ofthe minimized tissue trauma associated with microsurgery,

patients report little or nodiscomfort after the combinationof microsurgical tooth removal, precise implant placementin the socket, and seating an anatomically correct provi-sional restoration (Fig. 1). In this overview case, theesthetic presentation is presented 2 years after placement.Six additional cases are presented (clinical cases 2through 7) that demonstrate that consistent and predict-able results can be achieved with this technique. Clinicalcase 6 supports the concept that not only can osseointegra-tion and esthetic results be achieved but that these resultscan be stable for 10 years.

Steps 2 to 5: Minimal Extraction TraumaThe microscope enhances visual acuity and improves sur-gical dexterity. Microsurgical principles and instruments

FIGURE 5 Clinical case 4. 5a Preoperative caseof maxillary right central with fractured root tipremaining. 5b Radiograph showing fracturedroot tip. 5c Immediate postoperative view afterextraction, implant placement, socket bone graft,connective tissue graft, and provisional crown.5d Two-week postoperative image. 5e Fourteen-week postoperative image. 5f Fourteen-weekpostoperative radiograph.

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TABLE 1 SMILE Technique Sequential Flowchart

Step Instructions

1 All procedures performed under the microscope at magnifications 310 to 320

2 Atraumatic extraction, avoiding buccal and lingual flaps

3 De-epithelialization of former sulcus

4 Complete microscopic socket debridement of lateral and apical granulation tissue

5 Irrigation of the socket with 3% tetracycline solution for 30 seconds

6 Use lateral side cutting drills to align the osteotomy to the palatal wall of the socket

7 Position the implant apex lingually to tip the implant platform buccally 2 mm

8 Position the implant platform z5 mm below the mesial and distal papilla

9 Position the lingual aspect of the platform at the palatal crest of the socket

10 Use a 4-mm diameter implant 15- to 18-mm long

11 Use a standard platform external hex implant

12 Use a 28 tapered textured surface implant

13 Place the implant with at least 67 Ncm torque

14 Create an opaqued temporary screw-retained titanium abutment substructure

15 Take a clear silicon impression of the failing tooth

16 Create a flowable composite shell crown that replicates the anatomy of the failing tooth

17 Lute the shell crown to the opaqued abutment in the mouth

18 Eliminate the flash and fill the subgingival contours with flowable composite

19 Create and check the emergence profile to support but not distorting the buccal tissue and the papillae

20 Take an impression of the gingival half of the provisional attached to an implant analog

21 Highly polish and glaze the provisional

22 Cure the provisional with a high intensity xenon light to eliminate free monomer

23 Create a custom impression transfer coping

24 Fill the buccal socket gap with osseous xenograft to the level of the implant platform

25 Compress the surface xenograft 1 to 2 mm to create a fine powered xenograft seal

26 Place an autograft bone graft filtered from the drilling bone dust and compress it to the platform level

27 Mold a collagen membrane free form over the autograft

28 Create a buccal envelope split-thickness flap through the former buccal sulcus

29 Harvest a connective tissue graft from the palate and place it into the buccal envelope

30 After freeing the papillae, advance the flap with 6-0 polypropylene sutures as needed

31 Reduce the occlusion on the palatal of the provisional, allowing 1 mm of clearance, using green indicator wax

32 Fill the screw space inside the implant with metronidazole gel

33 After installing the provisional with the proper torque, place polytetrafluoroethylene tape above the screw head and seal the access with composite

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are applicable to teeth extractions to preserve gingivaland osseous anatomy (Fig. 6). Roots can be verticallylifted from their sockets with minimal lateral forces, thusavoiding damage to the gingival papillae.8 Additionally,magnification allows surgeons to determine subtle nu-ances in direction of luxation that are not otherwise ap-parent. After the extraction, the sulcus is deepithelializedwith a flame diamond. Subsequently, the sockets arethoroughly debrided of granulation tissue, and irrigated

and filled for 30 seconds with 3% tetracycline solution(Video 1).

Step 6: Drilling in the SocketDrilling in extraction sockets requires different skills thandrilling in edentulous sites.11 The most favorable bone inthe anterior maxilla lays both palatally and apically to thesocket12 (Fig. 7a); therefore, drilling must be done at an an-gle to the socket wall. Twist drills are not designed for that

TABLE 1 (Continued) SMILE Technique Sequential Flowchart

Step Instructions

34 Perform postoperative evaluation at 2 and 6 weeks

35 Proceed to final restoration after 8 weeks

36 Restore with custom impression coping and scanned zirconium abutment*

Each of the steps and procedures were developed and initially taught by the author (DAS).*Procera, Nobel Biocare, Yorba Linda, CA.

FIGURE 6 Atraumatic flapless extraction re-quires the use of periotomes (6a through 6c) andanchorage extraction device (6d through 6f).ffExtraction of teeth with periotomes involvesusing microsurgical principles as shown in 6athrough 6c. 6a Interproximal periotome luxationof the fractured root helps to preserve gingivaland osseous anatomy. 6b Palatal periotomeluxation of fractured root. Ultrasonic instrumen-tation can also be used. 6c Periotome extractionsite: note the lack of bleeding and trauma and thepreservation of the gingiva and underlyinganatomy. For extraction of teeth where there isinadequate leveraging surfaces, anchorage ex-traction device should be used as shown in 6dthrough 6f. 6d Fractured maxillary right canineroot. 6e Placement of an internally threaded rootpuller (tapping mechanical device) for extraction.6f Extracted canine lifted vertically with the pullerfrom socket with minimal lateral forces, thusavoiding damage to gingival papillae. Thesesockets are thoroughly debrided and irrigatedwith 3% tetracycline solution for 30 seconds.

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purpose and tend to track in the directionof least dense bone.The result is that using a twist drill for this step will often re-sult in directing the preparation toward the labial plate. Theosteotomy site must be redirected using lateral cutting burrsor ultrasonics before each incremental increase in twist drillsize or the implant osteotomy angulation and position willinvariablymove to the buccal aspect (Fig. 7b).With themag-nification and lighting provided by the microscope, drillingon the lateral socketwall can accomplish a stable and estheticplacement for maxillary anterior implants.

Steps 7 to 13: Implant PlacementIn our experience, we have found that implants with 4-mmdiameter and lengths of 15 to 18mm,with a 28 taperx can beplaced with the apex positioned palatally and the implantplatform buccally z2 mm toward the labial. These im-plants, placed into the extraction osteotomy sites, couldbe torqued to 67 Ncm.k The thread geometry of the 28

tapered implants used improves initial implant stabilitywithout danger of lateral bone compression.Of the 300 im-plants placed, 296 were 18 mm in length and four were 15mm in length. Bovine xenograft is packed into the buccalsocket gap to the crest of the socket. Milled autologousbone from the site preparation is filtered and rinsed withsterile water and a solution of 3% tetracycline. The boneis used to form a 2-mm laminar seal above the bovinexenograft. A layer of microfibrillar collagen{ is placed over

recycled bone before the implant provisional is placed. Inall 300 cases, connective tissue was transferred from thepalate into a split-thickness envelope prepared on the buc-cal aspect to restore or preserve gingival height lost as aresult of injury or inflammation.

Steps 14 to 23: Implant ProvisionalTo preserve natural esthetics, the implant provisional mustsupport the surrounding gingiva exactly like the extractedtooth12,13 (Fig. 8). This includes placing an opaqued screw-retained, titanium abutment, creating a hollowed compositeshell crown from a clear silicon impression of the failingtooth, luting the shell crown to the opaque abutment inthe mouth, and eliminating the flash.#** The subgingivalprofile is individually shaped for each patient at the timeof surgery.Voids and rough edges are eliminated and the pro-visional carefully contoured to support the gingival tissue.The emergence profile is created and checked so it supportsthe gingiva but does not distort the buccal and interproximaltissues. As a final step, the provisional is polished and glazed.Using light-cured composite ensures that no free monomeris present to irritate tissue or bone. An impression of the

FIGURE 7 Osteotomy in preparation for implantplacement requires an appreciation for both theanatomy of the maxilla as well as the cuttingpattern of the drills. 7a Osteotomy needs to beprepared on palatal side of socket. 7b Thisrequires redirecting preparation with side cuttingosteotomy drills: 2.0, 2.5, and 3.0 mm.

FIGURE 8a Before surgery, a clear silicone impression of failing tooth is facilitated with focus to accurately capture the dento-gingival junction. A flowablelight-cured composite replica of the tooth is fabricated from the impression for the provisional fabrication. The replica is trimmed to the exact location of thedento-gingival location, establishing the emergence profile. 8b The hollowed replica of failing tooth, in light-cured esthetic color-matched composite, is usedfor luting to the screw-retained temporary, opaqued titanium abutment. After filling the replica with composite and placing it on the abutment, the curing lightlutes the material to the abutment 8c The provisional crown is removed, using a screw access opening in the incisal third. The subgingival profile is individuallyshaped for each patient at the time of surgery, with voids and rough edges eliminated and the provisional carefully contoured to support the gingival tissue. Theprovisional is then polished and glazed.

x Nobel Mark IV Implant with TiUnite surface, Nobel Biocare.k Elcomed implant drilling unit, W&H Impex, Windsor, ON.{ Avitene microfibrillar collagen, Davol, Warwick, RI.# Elcomed implant drilling unit, W&H index.** Avitene microfibrillar collagen, Davol.

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gingival one-half of the provisional attached to the implant istaken to facilitate a custom impression transfer coping. Themachined titanium provisional abutment reduces the possi-bility of the provisional loosening. In these cases, only one ofthe 300 provisionals had its screw loosened.

Steps 24 to 30: Final Surgical Procedure forEsthetic SuccessThe buccal socket gap from the extraction and palatally an-gled implantplacement is filledwithosseousxenograft to thelevel of the implant platform. The surface is compressed tocreate a fine-powered xenograft seal. Before placing filteredautograft bone dust to the platform level, it is compressedand a collagen membrane is molded over the autograft. Abuccal envelope split-thickness flap is created, and a connec-tive tissue graft harvested from the palate is placed into thebuccal envelope. After freeing the papillae, the flap is ad-vanced with 6-0 polypropylene sutures as needed.

Step 31: Implant Provisional OcclusionPremature loading is avoided by adjusting the occlusion tominimal contact. Confirmation of no centric and lateralocclusal contact is performed using 1-mm green occlusalindicator wax (Fig. 9). Symmetrical and light proximalcontacts are established. This technique allows patients

to leave the dental office with a non-loaded esthetic provi-sional tooth securely anchored to the implant.

Steps 32 to 36: Final RestorationAn immediate provisional crown ensures that patients arenever without a natural-looking tooth. The provisionalcrown also ensures that the gingiva is not left unsupportedduring osseointegration. During the final impression, theexact subgingival profile of the provisional is transmittedto the ceramist by taking an impression made of the gingi-val third of the provisional crown with an implant analogattached.14 This creates a custom impression transfer cop-ing replicating the emergence profile of the provisional15

(Fig. 10). After final impressions, made with the customimpression transfer coping, a computer scan†† is used tocreate the permanent zirconium ceramic abutment andcrown16,17 (Fig.11).Thisprotocol ensures that the finalabut-ment exactly matches both the original tooth shape and theprovisional emergence profile. The occlusal is checked al-lowing for 1 mm of clearance. The screw space is filled withmetronidazole gel, and the provisional is installed. The pa-tient is checked postoperatively at 2 and 6 weeks, with thefinal restoration after 8 weeks, from the custom impressioncoping and a scanned zirconium abutment.‡‡

FIGURE 9 Clinical case 5. 9a Preoperative viewof right lateral incisor. 9b Implant placed inextraction site with opaqued screw-retainedtemporary titanium abutment. 9c Hollowed rep-lica of tooth luted to temporary abutment withlight cured composite. 9d Interproximal view offlash on hollowed replica crown luted to tempo-rary abutment. 9e Buccal view of compositeflash on the replica crown luted to temporaryabutment. 9f Finished provisional in place afterconfirming there is no centric or lateral contactusing 1-mm green occlusal indicator wax. 9gFour years after restoration.

†† Procera, Nobel Biocare.‡‡ Procera, Nobel Biocare.

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Working together as a team, surgeon, restorative dentist,and ceramist can combine their skills to create a tooth innatural harmonywith the smile and the overall appearanceof adjacent teeth (Figs. 12 and 13).

Clinical Outcome and DiscussionUsing the SMILE Technique on 300 consecutive patientsfrom a private practice in Santa Barbara, CA who re-quired extraction of maxillary central incisors, lateralincisors, or cuspid teeth, 298 implants resulted in suc-cessful functional and esthetic outcomes after 1 to 10years. No exclusion criteria were used. Of the 300patients, one patient was lost to follow-up after theimplant and provisional were placed. Of 300 implantsplaced, two implants failed to integrate. Two hundredninety-eight implants were cleared for restoration at8 weeks based on radiographic and clinical examination.Patient scheduling and restorative logistics determined res-toration delivery to be from 10 to 22 weeks.

FIGURE 10a Before surgery, a clear silicone impression of the failing toothreplica crown is used to assist with accurately capturing the dento-gingivaljunction area for an emergence profile. 10b The emergence profilerecording. 10c Rough acrylic custom impression transfer coping. 10dPolished custom impression coping replicating provisional emergenceprofile.

FIGURE 11a A machined zirconium abutment created from impressiontransfer coping of provisional emergence profile. 11b Ceramic crown oncustom abutment.

FIGURE 12 Clinical case 6. 12a Preoperative radiograph of maxillary leftcentral incisor. 12b Preoperative image of central incisors. 12c Ten-yearpostoperative restoration of left central incisor. 12d Ten-year postoperativeradiograph. 12e Ten-year postoperative smile.

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FIGURE 13 Clinical case 7. 13a Preoperativeview of failing left central incisor. 13b Preoper-ative radiograph. 13c Drill gauges to controlplatform depth. 13d Interoperative radiographwith depth and platform gauge. 13e Postopera-tive radiograph with screw-retained provisionalcrown. 13f Extraction, implant, socket one graft,and immediate screw-retained crown. 13g Con-nective tissue graft sutured. 13h Two-weekpostoperative appearance. 13i Twelve-weekpostoperative view. 13j Twelve-week postoper-ative radiograph. 13k Finished provisional emer-gence profile. 13l Custom impression copingwith replicated emergence profile. 13m Ceramiccrown on zirconium abutment replicating pro-visional emergence profile. 13n Zirconium abut-ment and crown separately viewed. 13oLaboratory model with zirconium abutment 13pLaboratory model with zirconium abutment andceramic crown. 13q Two-year postoperativeview. 13r Two-year post-restorative smile.

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The criteria for successful treatment included: 1) absenceof inflammation, infection, mobility, pain, or bleeding onprobing; 2) ability to withstand rotational torque of >65Ncm; 3) a peri-implant tissue sulcus <1 mm apical to theimplant platform; 4) radiographic evidence of bone tothe topmost implant thread; 5) restoration of the implantand it remains in function; and 6) a satisfactory estheticoutcome.

The learning value of this case series is that implant mi-crosurgery offers an opportunity for implant therapy thatcan enhance the esthetic results. Its benefits include rapid

healing, minimal discomfort, and improved patient accep-tance. Dentistry will see increasing use of themicroscope inmany phases of practice, including implant placement andrestoration.18 Microscopy has the potential to advancedentistry from an era of traumatic tooth loss to oneof exact and seamless replacement of a failing tooth.Although the technique described is multifaceted andrequires many steps to complete successfully, the clinicalbenefits are outstanding. Successful treatment requiresmicroscopemagnification, attention to detail, and a combi-nation of microsurgical and restorative skills. n

Summary

Why is this technique newinformation?

j Focuses on the immediate microsurgical replacement andprovisionalization of a single esthetically important maxillary anteriortooth

j Demonstrates the versatility of dental implant microsurgeryj Follows a systematic microsurgical approach for immediatelyreplacing and restoring such teeth

What are the keys to the successfulmanagement of such cases?

j Thorough planning and following the detailed sequential treatmentsteps using a microscope

j Implant placement precisionj Exactness in provisional crown fabrication and placementj Placement of a subepithelial connective tissue graft over the labialsurface of the implant

j Passive wound closure

What are the primary limitations tosuccess in these cases?

j Macrosurgery versus microsurgeryj Excessive tissue traumaj Inexact implant placementj Non-use of the polished provisional emergence profile in establishingthe final restration emergence profile

AcknowledgmentThe authors report no conflicts of interest related to thiscase series.

CORRESPONDENCE:Dr. Leonard S. Tibbetts, 916 W. Mitchell St., Arlington, TX 76013.E-mail: [email protected].

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References1. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt T. Long-term

follow-up study of osseointegrated implants in the treatment of totallyedentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-359.

2. Widmark G, Friberg B, Johansson B, Sindet-Pedersen S, Taylor A.Mk III: A third generation of the self-tapping Branemark Systemimplant, including the new Stargrip internal grip design. A 1-yearprospective four-center study. Clin Implant Dent Relat Res 2003;5:273-279.

3. Covani U, Crespi R, Cornelini R, Barone A. Immediate implantssupporting single crown restoration: A 4-year prospective study. JPeriodontol 2004;75:982-988.

4. Evian CI, Emling R, Rosenberg ES, et al. Retrospective analysis ofimplant survival and the influence of periodontal disease and immediateplacement on long-term results. Int J Oral Maxillofac Implants 2004;19:393-398.

5. Hui E, Chow J, Li D, Liu J, Wat P, Law H. Immediate provisional forsingle-tooth implant replacement with Branemark system: Preliminaryreport. Clin Implant Dent Relat Res 2001;3:79-86.

6. Degidi M, Piattelli A. Immediate functional and non-functional loadingof dental implants: A 2- to 60-month follow-up study of 646 titaniumimplants. J Periodontol 2003;74:225-241.

7. Romanos GE. Present status of immediate loading of oral implants. JOral Implantol 2004;30:189-197.

8. Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin NorthAm 1998;42:339-359.

9. Tibbetts LS, Shanelec DA. A review of the principles and practice ofperiodontal microsurgery. Tex Dent J 2007;124:188-204.

10. Tibbetts LS, Shanelec D. Principles and practice of periodontalmicrosurgery. Int J Microdent 2009;1:2-12.

11. Shanelec DA. Periodontal microsurgery. J Esthet Restor Dent 2003;15:402-407, discussion 408.

12. Saadoun AP. Immediate implant placement and temporization inextraction and healing sites. Compend Contin Educ Dent 2002;23:309-312, 314-316, 318 passim; quiz 326.

13. King KO. Implant abutment emergence profile: Key to esthetics. J OralImplantol 1996;22:27-30.

14. Hinds KF. Custom impression coping for an exact registration of thehealed tissue in the esthetic implant restoration. Int J PeriodonticsRestorative Dent 1997;17:584-591.

15. Buskin R, Salinas TJ. Transferring emergence profile created from theprovisional to the definitive restoration. Pract Periodontics AesthetDent 1998;10:1171-1179, quiz 1180.

16. Davarpanah M, Martinez H, Celletti R, Tecucianu JF. Three-stageapproach to aesthetic implant restoration: Emergence profile concept.Pract Proced Aesthet Dent 2001;13:761-767, quiz 768, 721-722.

17. Yildirim M, Edelhoff D, Hanisch O, Spiekermann H. Ceramicabutments d A new era in achieving optimal esthetics in implantdentistry. Int J Periodontics Restorative Dent 2000;20:81-91.

18. Shanelec D, Tibbetts L. Recent advances in surgical technology. In:NewmanMG, Takei HH, Carranza FA, eds. Clinical Periodontology, 9thyyed. Philadephia: W. B. Saunders; 2009:876-881.

indicates key references.

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*Histologic Evaluation of Autogenous Connective Tissue and Acellular Dermal Matrix Grafts in

Humans. Cummings LC, Kaldahl WB, Allen EP. J Periodontol 2005;76(2):178-186.MinerOss® is manufactured by Osteotech, Inc. Mem-Lok® manufactured by Collagen Matrix, Inc.

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CASE REPORT

Surgical and Prosthetic Correction of Two AdjacentAnterior Implants: A Clinical Case Report

Dennis P. Tarnow* and Stephen J. Chu†

Introduction: This clinical case presentation exemplifies the esthetic complications of two adjacent osseointegrated im-plants placed in themaxillary left central–lateral incisor region of a young female patient with a high smile line and the challengesassociated with surgical and prosthetic correction.

Case Presentation: The goal of treatment was to reconstruct the height of the interdental papilla between two adjacentanterior implants to match that of the contralateral teeth and create the proper individual tooth size and proportion of the naturaldentition in a stable occlusion. Dermis allograft material was chosen as the graftmaterial because it does not require a donor-siteand it is not dependent on the patient’s own tissue volume. Using autogenous tissue could potentially increase the number ofsurgical procedures and limit the extent of correction. Consecutive surgical procedures using dermis allograft were performed toreconstitute the lost hard and soft tissues. After the height of the interdental tissueswas reconstructed to the proper dimensions,then the concept of submerging the implant in a less favorable restorative position and surgically exposing the useful implantwas used. A custom implant abutment was fabricated on the exposed left central incisor implant, and two-unit cement-retainedfixed dental prosthesis (FDP) was fabricated with a cantilevered pontic as the definitive restoration.

Conclusions: Esthetic correction of lost hard and soft interdental tissues was successfully performed through multiplesurgical procedures using dermis allograft material. The concept of submerging one implant and engaging the useful onewas used to fabricate a two-unit cantilevered FDP. Clin Adv Periodontics 2011;1:174-181.

Key Words: Adjacent implants; case report; dermis allograft; esthetics, dental; interdental papilla; submerged implant.

BackgroundUse of dental implants for anterior tooth replacement hasincreased over the past decade. However, a high level ofskill and knowledge is required when placing implants in

the esthetic zone because a negative result is immediatelynoticeable. Frequently, errors can occur in treatmentplanning, execution, and/or both. Without perfection inthree-dimensional spatial placement, the implant maysurvive (i.e., osseointegrate) but may be a clinical failure ifthe esthetic outcome is less than ideal.

The decision to place two adjacent anterior implants hasbeen discussed by many clinicians and researchers.1-3 Theclinical dilemma is that the interdental papilla is invariablydeficient in height when compared to the contralateral nat-ural tooth.4 This is highlighted when the maxillary centraland lateral incisors have been replaced with dental im-plants. If a high interdental smile line exists, then the

* Department of Periodontics, Columbia University College of DentalMedicine, New York, NY.

† Department of Prosthodontics, Columbia University College of DentalMedicine.

Submitted December 23, 2010; accepted for publication March 22, 2011

doi: 10.1902/cap.2011.100009

174 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011

literature has proposed an implant–pontic treatment planscenario (i.e., placement of one implant in the central inci-sor location and cantilever an ovate-shaped pontic in thelateral incisor position) after ridge augmentation.1,5

The ensuing case report is a clinical situation in whicha patient with a high interdental smile line6-9 receivedtwo adjacent anterior implants in the central and lateral in-cisor region (Fig. 1). This clinical decision resulted in anesthetic failure because the patient could no longer smileas a result of the disharmony in tooth length, proportion,and papilla height (Fig. 2). The following case report exem-plifies and emphasizes interdisciplinary treatment planningand treatment required to restore the smile of a young vitalindividual.

Clinical PresentationA 30-year-old African-American female presented withthe chief complaint of ‘‘I don’t feel like I can smile.’’ Pastmedical history was non-contributory. The past dental his-tory revealed that the patient had been in a ski accident 11years previously, and consequently, was wearing

a removable prosthesis. Due to dissatisfaction of the re-movable prosthesis, the previous dentist and oral surgeonoffered a fixed dental solution using two implants replac-ing avulsed teeth #9 and #10. A full-coverage crown waspresent on tooth #8. Radiographic examination revealedthat the two implants appeared to be well integrated; how-ever, the soft tissue on the facial and interdental aspects ofboth implants was extremely deficient. Therefore, the pa-tient would cover her mouth when she spoke as well asconceal the defect with the drape of her upper lip. The pa-pillae on the contralateral teeth were normal in position andheight. The negative gingival architecture and asymmetryprompted the patient to seek alternative treatment opinions.

Alternative treatment plan options were presented, in-cluding removing or burying both implants. However, thetreatment option of submerging both implants and usingmultiple connective tissue grafts (CTGs) (i.e., autogenousCTG and dermis allografts) and then uncovering implant#9 and using it to support a two-unit fixed dental prosthesis(FDP) with tooth #10 cantilever pontic was chosen.This option was embarked upon with the understanding

that multiple surgical procedures would be required to cor-rect the vertical defect. This treatment option provided theopportunity to reconstitute enough interdental soft-tissueheight and volume that would be visible and pleasing inher smile while maintaining an implant-supported FDPwithout implant removal. The surgical goal was to elimi-nate all of the pink acrylic and replace it with vital tissuesthrough surgical reconstruction.

Case ManagementThe existing crowns and associated abutments were re-moved, and surgical cover screws were placed on implants#9 and #10 (Fig. 3). This is similar to the tooth decorona-tion/root submergence technique described for teeth.10,11

Tooth #8 was used to support a provisional restorationwith cantilevered pontics #9 and #10 with gingiva-shadedacrylic‡ to give a visual assessment of the treatmentFIGURE 2 Intraoral view showing the lack of symmetry, tooth size and

proportion, and gingival esthetics of the restored implants for teeth #8 and#9. The lack of interdental papilla between #9 and #10 is glaringly evident,as well as the excessive contact area attributable to the absence of papillaheight.

FIGURE 3 Surgical cover screws were placed over the healthy implants,and the tissue was allowed to heal and regenerate for future flap closure.

FIGURE 1 Dentofacial smile view showing the loss of the interdentalpapilla between the two adjacent anterior implants #9 and #10.

‡ DENTSPLY Denture Repair Acrylic, DENTSPLY, Tulsa, OK.

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Tarnow, Chu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 175

outcome (Fig. 4).12-14 A shallow overbite/overjet occlusalscheme and lack of parafunction lent to the stability of thistransitional provisional FDP.After 3 weeks, soft tissue grew over the cover screws,

which facilitated ridge augmentation. A papilla-saving inci-sionwas performed to allow the existing interdental papillaeto remain intact (Fig. 5).15 A full-thickness muco-periostealflap was raised (Fig. 6), and a thick dermis allograftx wasplaced over the surgical cover screws. The dermis allograftwas also covered with a section of palatal autogenous con-nective tissue (Fig. 7). This was done because: 1) the closureof the cover screws after 3 weeks of healing was incompleteand required complete coveragebecause the dermis allograftcannot be exposed to the oral environment during the healingperiod; 2) 5 to 7 mm of vertical interdental tissue augmenta-tion was required; and 3) the patient had insufficient donorconnective tissue. The buccal flap was undermined and re-leased, and passive closure was obtained with 5-0 chromicsutures.k The provisional restoration was relieved and ce-mented into place with temporary cement{ (Fig. 8). This

augmentation procedure was repeated two more times,and, at 4months after the last surgery (Fig. 9), stage II implantuncovering surgery was performed for the implant in the leftcentral incisor position. Care was taken during the uncover-ing surgery to prevent exposure of implant #10 (Fig. 10). Theprovisional was attached to the uncovered implant #9 withacrylic resin conscious of a flat subgingival profile to not en-courage mid-facial recession and allow flap adaption duringsuturing (Fig. 11). Gingivoplastywas performed on the facialaspect of tooth #8 to contour the gingival zenith of the rightcentral incisor in the correct position13 and to match that ofthe left central incisor implant–gingival contour.

An ovate pontic was then placed into the healed ridgeover the submerged implant16 in the left lateral incisor po-sition using a subtractive technique with an ovoid-shaped,diamond-coated bur# (Figs. 12 and 13). Two months later,

FIGURE 4 The teeth were fabricated with tooth-colored acrylic, and theremaining areas of deficient gingival tissues were restored with pink-shaded acrylic. This is an important step as a communication tool forpatient and surgeon to define whether a prosthetic or surgical solution isviable. In addition, the pink acrylic serves as a surgical guide to visualizeand quantify the height and width of tissue that must be reconstituted.

FIGURE 5 A papilla-saving incision was performed, exposing thepreviously placed implants.

FIGURE 6 A thick piece of dermis allograft was sutured in place, coveringthe existing implants.

FIGURE 7 Palatal CTG covering the dermis allograft in which the existingcoverage over the cover screws was incomplete.

x Tutoplast, IOP Ophthalmics, Costa Mesa, CA.k Ethicon, Johnson & Johnson, New Brunswick, NJ.{ TempBond NE, Kerr Corporation, Orange, CA.# Brasseler USA, Savannah, GA.

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176 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Correction of Two Anterior Implants

definitive impression making was performed,** and the fi-nal metal abutment and metal ceramic FDP was con-structed in the dental laboratory (Fig. 14).

Clinical OutcomesDespite regenerating a large amount of soft tissue over thetwo anterior implants, there was still a need to use some

gingival-shaded ceramics to help with the ‘‘pink’’ estheticsof the final restoration (Fig. 15). Subsequently, the surgeonwith the patient’s consent performed a papilla correctionprocedure to eliminate the use of the pink ceramics.

Leaving the existing soft-tissue relationships undis-turbed on the labial margins of the FDP, a split-thicknessflap was made at the mucogingival junction apical to thesmile line and was made to release the tissue incisally(Fig. 16). A thick wedge-shaped free subepithelial CTGwas taken from the palate and inserted into the space cre-ated by the opening. It was sutured around and over thecontact area of the FDP, which served as a scaffold to sta-bilize the flap coronally and reposition the interdental tis-sue between implant #9 and pontic #10, thereby limitingthe amount of tissue rebound (Fig. 17). The area was al-lowed to heal uneventfully without the need to recementthe FDP. Although the papilla between #9 and #10was stillslightly more apical than the contralateral side, it was nowesthetically acceptable for the patient who felt comfortable

FIGURE 11 Acrylic must be added to the subgingival aspect of theprovisional abutment to create the proper contour. A flat emergence profileis created to allow the tissue to lie in the proper vertical position. Theprovisional restoration is ready for insertion.

FIGURE 12 A bullet-shaped diamond bur was used to subtract tissue overthe buried implant #10 to create an ovate pontic form.

FIGURE 8 Area sutured with 5-0 chromic sutures. Note that almost all thepink acrylic of the provisional restoration has been removed with noresidual pressure on the ridge.

FIGURE 9 The third dermis surgery was allowed to heal for 4 months.

FIGURE 10 A small incision was made to expose implant #8 and allow forthe connection of the provisional restoration without exposure of thesubmerged implant #10.

** Flexitime Xtreme, Heraeus Kulzer, South Bend, IN.

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FIGURE 15 Intraoral view of the final prosthesis with gingival-shadedceramics. The gingival ceramics were added to match the papilla height ofthe contralateral teeth.

FIGURE 16 A horizontal incision at the mucogingival junction apical to thepatient’s smile line was made. The coronal tissue was mobilized usinga split-thickness flap. This technique was made possible because of all ofthe connective tissue that was augmented over the implants.

FIGURE 14 The definitive FDP, gold plated and ready for placement. Notethe pink ceramic required to close the black gingival triangle still presentbetween implant #9 and ovate pontic #10.

FIGURE 17 A wedge-shaped piece of CTG from the palate was placedinto the opening to prevent the coronal ` mini papilla flap'' from reboundingapically. The pink ceramic was removed, and the FDP contact area wasused as a scaffold to coronally reposition and stabilize the mini papilla flapbetween implant #9 and pontic #10 during healing.

FIGURE 18 Healing with lips retracted after 3 months, showing eliminationof the pink ceramic between implant #9 and pontic #10.

FIGURE 13 The provisional restoration was modified to create an ovatepontic shape. The intraoral clinical situation after the ovate pontic wasplaced. Note that the papilla between implants #8 and #9 is still slightlydeficient in height.

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and confident. Compared to the preexisting deformed den-tal condition (Figs. 1 and 2), the esthetic outcome is posi-tively dramatic in dental, dental–facial, and facialperspectives, respectively (Figs. 18 through 20).

DiscussionThis clinical case report exemplifies how an error in treat-ment planning by placing two adjacent anterior implantsin the maxillary central–lateral incisor position can leadto an esthetic deformity that not only caused great emo-tional trauma to the patient but also extensive time andmultiple corrective surgical procedures. It also demon-strates how an interdisciplinary approach is required tocorrect and reverse such esthetic deformities. The treat-ment mandated >7 mm of soft tissue over two adjacentimplants. It needed attention to provisional restorationduring the transitional healing periods of four correctivesurgeries to reconstitute the lost tissues in conjunction withquality restorative and laboratory care.

Eventually, two adjacent anterior implants can be placedinto the esthetic zone without the loss of the interdental pa-pilla, but presently, this is not a reality with predictability.However, it is clinically acceptable to place two adjacentimplants in the central incisor areas with a longer contactarea/papilla height ratio attributable to the symmetry ofthe central incisor teeth. However, if two implants areplaced in the central–lateral areas, then the resultant more

apical location of the papilla is glaringly noticeable sincethe contralateral papilla is of normal apical–coronallength.

This clinical case report exemplifies the importance ofthe correct diagnosis and treatment plan in the estheticzone when two adjacent teeth are missing other than thetwo central incisors. It also shows how this clinical scenariowas treated with an interdisciplinary approach that re-quired: 1) a clear vision in end-goal treatment using dentaland gingival determinants of esthetics, and 2) 1.5 years oftreatment to surgically reconstruct 7 mm of deficient softtissues interdentally. n

FIGURE 20 The patient was extremely pleased with the surgicalreconstruction and definitive crown restorations. In fact, the patient’s smileline is now higher (i.e., more visible) than before because she feltcomfortable and confident with her new smile.

FIGURE 19 Final dentofacial view of the patient smiling after 6 months ofhealing after the last surgical procedure. Compared to Figure 1, thereconstructed papilla height is almost coincident to the contralateral side.

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Summary

Why is this case new information? n The esthetic and biologic potential of dermis allograft as anaugmentation material is presented.

n The clinical case applies the concept of tooth decoronation describedby Langer10 and Salama et al.11 to implant therapy; biologicallyhealthy, yet poorly placed implants can be used in which one implantcan be submerged and the useful implant exposed.

n It uses recent biometric determinants for interdental papillae esthetics.

What are the keys to successfulmanagement of this case?

For the treatment to be successful, it is necessary to:n bury the implants first and use a tooth-supported transitionalprovisional restoration;

n perform the augmentation surgeries in a consecutive sequentialapproach;

n be realistic about not correcting the deformity in one surgicalprocedure;

n understand the limitations and potential of dermis allograft as anaugmentation material;

n know that an implant–pontic restorative design is currently the mostpredictable treatment plan option for consecutive anterior implants;

n ensure that the patient understands, has patience with, and complieswith the treatment goals and time required for esthetic reconstruction.

What are the primary limitations tosuccess in this case?

Limitations to success include:n patient non-compliance of required surgical procedures;n treatment time and cost.

AcknowledgmentThe authors report no conflicts of interest related to thiscase report.

CORRESPONDENCE:Stephen J. Chu, 150 E. 58th St., Suite 3200, New York, NY 10155. E-mail:[email protected].

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References1. Salama H, Salama MA, Garber D, Adar P. The interproximal height of

bone: A guidepost to predictable aesthetic strategies and soft tissuecontours in anterior tooth replacement. Pract Periodontics AesthetDent 1998;10:1131-1141, quiz 1142.

2. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance onthe height of inter-implant bone crest. J Periodontol 2000;71:546-549.

3. Grunder U. Stability of the mucosal topography around single-toothimplants and adjacent teeth: 1-year results. Int J Periodontics Re-storative Dent 2000;20:11-17.

4. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from the crest ofbone to the height of the interproximal papilla between adjacentimplants. J Periodontol 2003;74:1785-1788.

5. Funato A, Salama MA, Ishikawa T, Garber DA, Salama H. Timing,positioning, and sequential staging in esthetic implant therapy: A four-dimensional perspective. Int J Periodontics Restorative Dent 2007;27:313-323.

6. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. JProsthet Dent 1984;51:24-28.

7. Van Der Geld P, Oosterveld P, Berge SJ, Kuijpers-Jagtman AM. Toothdisplay and lip position during spontaneous and posed smiling inadults. Acta Odontol Scand 2008;66:207-213.

8. Vig RG, Brundo GC. The kinetics of anterior tooth display. J ProsthetDent 1978;39:502-504.

9. Dickens ST, Sarver DM, Proffit WR. Changes in frontal soft tissuedimensions of the lower face by age and gender. World J Orthod 2002;3:313-320.

10. Langer B. Spontaneous in situ gingival augmentation. Int J PeriodonticsRestorative Dent 1994;14:524-535.

11. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantagesof the root submergence technique for pontic site development inesthetic implant therapy. Int J Periodontics Restorative Dent 2007;27:521-527.

12. Chu SJ. Range and mean distribution frequency of individual toothwidth of the maxillary anterior dentition. Pract Proced Aesthet Dent2007;19:209-215.

13. Chu SJ, Tan JH, Stappert CF, Tarnow DP. Gingival zenith positions andlevels of the maxillary anterior dentition. J Esthet Restor Dent 2009;21:113-120.

14. Chu SJ, Tarnow DP, Tan JH, Stappert CF. Papilla proportions in themaxillary anterior dentition. Int J Periodontics Restorative Dent 2009;29:385-393.

15. Gomez-Roman G. Influence of flap design on peri-implant interprox-imal crestal bone loss around single-tooth implants. Int J OralMaxillofac Implants 2001;16:61-67.

16. Orsini G, Murmura G, Artese L, Piattelli A, Piccirilli M, Caputi S.Tissue healing under provisional restorations with ovate pontics:A pilot human histological study. J Prosthet Dent 2006;96:252-257.


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CASE REPORT

Use of the Pocket-Lining Tissue as a Pedicle Flap to FacilitateWound Closure After Extraction to Preserve the Alveolar

Ridge or Protect an Implant SiteShane J. McCrea*

Introduction:Because hard- and soft-tissue remodeling and resorption follows tooth extraction, postextraction ridge de-ficiencies and abnormalities may require correction before implants can be placed. Equally, where immediate implants areplaced, alveolar bone and gingival soft tissue must be protected; thus, primary wound closure of an extraction site is desirablebut remains challenging. Guided bone regeneration has made ridge preservation possible and more predictable. However,where barrier membranes remain exposed, infection and graft failure can occur. The technique presented here uses thepocket-lining epithelium that is found at periodontally compromised sites to facilitate primary wound closure. Tomy knowledge,this is the first report of this technique.

Case Presentations: All presented cases had periodontally compromised teeth that were extracted. After extractions, thepocket-lining epitheliumwas dissected and pedicalized (using the pocket-lining pedicle flap [PLPF] procedure). All vacated socketswere prepared, and dental implants were immediately placed. Guided bone regeneration was used to circumferentially fill theremaining alveolar voids and any bony defects. Thewell-vascularized attached epitheliumwas used to provide primary wound cov-erage at the surgical site. Wound healing was uneventful in all the considered cases. Sutures were removed at 4 weeks in all cases.No tissue sloughing occurred, and, when visible, early keratinization was apparent. No soft-tissue dehiscence formation occurred.

Conclusions: In this case report, the PLPF provided successful soft-tissue wound closure at extraction sites whereimplants were immediately placed. The technique appears to visually stabilize the position of the mucogingival junction andmay well preserve or enhance the width of keratinized gingival tissue, thus aiding optimal esthetics. Clin Adv Periodontics2011;1:183-191.

Key Words: Dental implants; granulation tissue; periodontal pocket; wound closure techniques.

BackgroundCoronally advanced flaps have been used for primary soft-tissue closure over extraction sites where immediateimplant insertion has been performed.1 However, suchflaps will move the mucogingival junction in a coronaldirection, thus moving the keratinized gingiva coronally.

In visibly sensitive areas, this coronal repositioning may beesthetically undesirable. Maintaining the width of kerati-nized gingiva is conducive to good oral hygiene tech-niques, and its reduction is seen as detrimental.2 Toincrease the width of the keratinized gingival tissue(wKGT) and stabilize the mucogingival junction posi-tion, subepithelial grafts have been used.3,4 Arguably,discussion as to the morbidity associated with the palataldonor site and the associated increase in patient discomfortthen arises.

Free gingival grafts have longbeenused to cover extractionsites. Problems arise with this technique because the blood

* Private practice, Dorset, UK.


doi: 10.1902/cap.2011.100006


supply depends on the alveolar blood clot and the periph-eral gingival wall of the vacated socket.5 This techniqueis reported to have a high failure rate.6 Palatal pedicle flapshave also been used for primary wound closure after ex-tractions in the maxilla.7-9 Unfortunately, their blood flowcan be compromised as a result of the 908 rotation they suf-fer at repositioning.10

Recently, Stimmelmayr et al.11 used a combined epi-thelialized subepithelial connective tissue graft (SCTG)for wound closure that showed very promising results.However, their method still involves morbidity at the

palatal donor site and the corresponding patientdiscomfort.

The placement of a dental implant into an alveolus vacatedby a periodontally compromised tooth is no longer contrain-dicated.12-15When extreme bone loss has been suffered, ridgeaugmentation is possible, and the subsequent placement ofimplants into such sites either concurrently or at an addi-tional (future) surgical sitting have reported success.

The rationale that wound closure must be accompaniedwith a tissue coverage technique that maintains a patent un-compromised blood supply and is capable of keratinization

FIGURE 1 Clinical case 1. 1a Preoperative clinical situation of teeth #11 and #21. 1b Preoperative radiograph. 1c through 1e Starting from the apicalextremity, dissection of the pocket-lining epithelium from the palatal bony wall, ensuring the patency of the coronal attachment. 1f Implant insertion under thePLPF.

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184 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Pocket-Lining Pedicle Flap Procedure

hasbeen applied. Thepocket-lining pedicle flap (PLPF) tech-nique involves the careful dissection of pocket-lining epithe-lium from the vacated socket, maintaining it as a pediclewith its own continued blood supply and using the flap toproduce primary wound closure. This method will thensee the local conversion of the non-keratinized pedicle intoa resilient keratinized overlaying crestal tissue that is neces-sary for the maintenance of the peri-implant mucogingivalcomplex, togetherwith an esthetically pleasing implant-sup-ported crown.

Case PresentationSinceMarch 2007, the author (SJM) has performedmanysuch PLPF procedures to facilitate primary wound clo-sure, at a private practice in Dorset, UK. All patients

had undergone supportive periodontal therapy and pre-sented with individual teeth for which extraction wasnecessary for continued adjacent periodontal healthand ridge preservation. All were diagnosed with chronicperiodontitis with generalized horizontal bone loss andlocalized vertical defects. This case report describesthe surgical approach used for the PLPF procedure andreports examples of clinical use.

Case ManagementFor preextraction, 1 hour before surgery, all patients receivedthe same systemic coverage: 2 g amoxicillin (or 600 mg clin-damycin when allergic), 400 mg ibuprofen, and 2 mg dexa-methasone. Additionally, mouthrinse of 2% chlorhexidinegluconate was used 20 minutes before surgery.

FIGURE 1 (Continued) 1g ded bonegment the

1h the PLPF1i nsion was

y with 5-0apically toound site.aced in an

1j 1k ures were

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McCrea Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 185

Teethwere sequentially extracted (Figs. 1 and 2). The va-cated sockets were explored for the patency of pocket-lining tissue using a trimmer† or a fine periosteal elevator.‡

All pocket-lining epithelium was dissected from the al-veolar walls with either instrument, after which a crestalincision, displaced to the palatal aspect, was made withrelieving incisions if visibility was impaired, or to aid inaccessing the site. The buccal mucoperiosteal flap wasraised, taking care to not damage the dissected PLPFs.All sockets were prepared for implant insertion with theaxis of all osteotomies displaced to the palatal aspect. All im-plants were insertedwith an initial seating torque of 40Ncm,and final seating was made with a hand wrench. A bovine-derived xenograftx was placed circumferentially into the al-veolar voids and covered with collagen membrane.k Woundclosure was facilitated with 6-0 and 5-0 polypropylenesutures,{ using minimal coronal tension (Figs. 3 through 5).

Clinical OutcomesIn all patients treated, no case had wound dehiscence;all 50 grafts had integrated completely by primary woundhealing. All the cases were assessed presurgically as to thelabial wKGT.When wKGT<2 mm, SCTGwas placed. Be-cause the PLPF provided complete primary wound closure,thus protecting the SCTG, no sloughing of SCTGs occurred.The surgery was able to provide a patent wound seal withminimal or no displacement of the mucogingival junction,which occurs in conventional coronal repositioning.

DiscussionAfter tooth extraction, there will be resorption of alveolarbone.16-18 Maintenance or reconstruction of the hard andsoft tissues is a prerequisite for implant site preparationand final esthetics. In ridge-preservation procedures, pri-mary wound closure is difficult to achieve without displac-ing the mucogingival junction in a coronal direction andalso reducing the natural depth of the labial sulcus, thus de-creasing thewKGT.When the patient is periodontally com-promised with deep pocketing, the preservation of thepocket lining and its use as the PLPF provides an effectivesolution for wound closure.

When the intention is to immediately place implants inextraction sockets, wound closure is critical to protect graftmaterial of choice with or without a protective membrane.Additionally, the covering and protection of soft-tissuegrafts with the PLPF enhances the early vascularizationof the grafts and prevents graft failures. n

FIGURE 2 Schematic of clinical case 1. 2a and 2b Tooth #11 was atraumatically extracted, and a full-thickness buccal flap was raised. The pocket lining onthe palatal bony wall was elevated and pedicalized (PLPF procedure) by dissection using a periosteal elevator. 2c The osteotomy was prepared and the implantwas inserted, taking care not to traumatize the PLPF. 2d Collagen membrane granules were placed circumferentially into the alveolar void and used to augmentthe buccal dehiscence. The collagen membrane was placed onto the xenografts. 2e The PLPF was folded forward to cover the collagen membrane. The buccalflap was placed onto the apical extremity of the PLPF to cover it. The site was then sutured with 5–0 polypropylene sutures.

† Mitchell trimmers, Trycare, Bradford, UK.‡ Buser periosteal elevator, STOMA, Emmingen-Liptingen, Germany.x Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland.k Bio-Gide, Geistlich Pharma.{ Prolene sutures, Ethicon, Johnson & Johnson, Livingston, West

Lothian, UK.

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FIGURE 3 Clinical case 2. 3a Preoperative situation. 3b Preoperative radiographs. 3c Crestal incision fully displaced to the palatal aspect; the buccal flap wasraised, preserving all the papillae and the pocket linings. The four incisors were removed, and implants were inserted conventionally with their axis displaced tothe palatal aspect. 3d The xenograft material was placed in the socket voids, and the sockets were covered with collagen membrane. 3e The flap wasreplaced, but on this occasion, because of the prominence of the papillae, crestal suturing was external. The pocket linings are visible. A temporary adhesivebridge was fitted with deep ovoid pontate surfaces. 3f Regardless of the deep ovate pontates, no tissue dehiscence is seen at 6 months after surgery. 3g At 24months after crown loading, the wKGT helps produce a visibly esthetic result. 3h Radiographs taken at 24 months after the crown fit.

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FIGURE 4 Clinical case 3. 4a Preoperative clinical situation. 4b. Preoperative radiographs. 4c No buccal flap was raised because of the very reduced wKGTand the circumferential bone loss. 4d The crestal incision was made through the papillae. The pocket linings are fully visible. 4e All pocket-lining epithelium wasdissected from the palatal and buccal socket walls. 4f Osteotomies were prepared. The multiple PLPFs are easily seen.

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FIGURE 4 (Continued) Clinical case 3 4g PLPFs are very apparent over the wounds. All were sutured through the buccal and palatal flaps to secure them. 4hPost-surgery radiographs. Nasal lifts were performed for implants in positions #11 and #21, using osteotomes. All socket voids were filled with bone substitutematerial particles and covered with collagen membrane. 4i and 4j Soft-tissue results at 6 months before the second-stage surgery. 4k Soft-tissue results at 12months after loading of the implants with their crowns. 4l Radiographs taken at 12 months after loading of the implants with their crowns.

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Summary

Why are these cases newinformation?

n After searching the literature, this is the first case report, to myknowledge, to report the use of the granulomatous tissue of thepocket lining as a PLPF to achieve wound closure.

What are the keys to successfulmanagement of these cases?

n Full periodontal assessment of the patient must be performed,including a six-point pocket-chart record, to determine the presenceof substantial granulomatous tissue that may be mobilized as a PLPF.

n Clarity of operative field must be achieved. Wearing binocular loupesis recommended for this technique.

What are the primary limitations tosuccess in these cases?

n Inexperience is the primary limitation because the technique isoperator sensitive. It is recommended that previous extensiveexperience of soft-tissue manipulation should be achieved beforeembarking on this technique.

AcknowledgmentThe author reports no conflicts of interest related to thiscase report.

CORRESPONDENCE:Shane J.McCrea, TheDental Implant andGingival–Plastic SurgeryCentre,717 Christchurch Rd., Bournemouth, Dorset, BH7 6AF, UK. E-mail:[email protected].

FIGURE 5 Schematic of clinical case 4. 5a and 5b Teeth #11, #12, #21, and #22 were atraumatically extracted. The palatal and buccal pocket linings weredissected from their bony walls using a trimmer and elevated, producing separate palatal and buccal PLPFs. 5c The osteotomies were prepared, and, in thiscase, nasal lifts were facilitated at #11 and #21 sites using osteotomes. The implants were then inserted. Throughout the techniques, the PLPFs were reflectedfor their protection from inadvertent surgical trauma. 5d Bone substitute material granules were then introduced circumferentially into the alveolar voids andcovered with its membrane. The palatal PLPF was then folded down onto the membrane, followed by the buccal PLPF. Suturing is “simple,” with interruptedloop sutures that penetrate the PLPFs, thus holding them securely over the membrane.

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References1. Becker W, Becker BE. Guided tissue regeneration for implants placed

into extraction sockets and for implant dehiscences: Surgical tech-niques and case report. Int J Periodontics Restorative Dent 1990;10:376-391.

2. Landsberg CJ. Socket seal surgery combined with immediate implantplacement: A novel approach for single-tooth replacement. Int JPeriodontics Restorative Dent 1997;17:140-149.

3. McCrea SJ. Comprehensive dental implantology: The complete surgicalapproach with 30-month follow-up. Oral Surg 2010;3:143-151.

4. Langer B, Calagna L. The subepithelial connective tissue graft.J Prosthet Dent 1980;44:363-367.

5. Jung RE, Siegenthaler DW, Hammerle CH. Postextraction tissuemanagement: A soft tissue punch technique. Int J Periodontics Re-storative Dent 2004;24:545-553.

6. Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach foroptimal single implant supported crown. Part I d The socket sealsurgery. Pract Periodontics Aesthet Dent 1994;6:11-17, quiz 19.

7. Khoury F, Happe A. The palatal subepithelial connective tissue flapmethod for soft tissue management to cover maxillary defects: Aclinical report. Int J Oral Maxillofac Implants 2000;15:415-418.

8. Nemcovsky CE, Artzi Z, Moses O, Gelernter I. Healing of marginaldefects at implants placed in fresh extraction sockets or after 4-6 weeksof healing. A comparative study. Clin Oral Implants Res 2002;13:410-419.

9. El Chaar ES. Soft tissue closure of grafted extraction sockets in theposterior maxilla: The rotated pedicle palatal connective tissue flaptechnique. Implant Dent 2010;19:370-377.

10. Fugazzotto PA. Maintaining primary closure after guided bone re-generation procedures: Introduction of a new flap design and pre-liminary results. J Periodontol 2006;77:1452-1457.

11. Stimmelmayr M, Allen EP, Reichert TE, Iglhaut G. Use of a combinationepithelized-subepithelial connective tissue graft for closure and softtissue augmentation of an extraction site following ridge preservationor implant placement: Description of a technique. Int J PeriodonticsRestorative Dent 2010;30:375-381.

12. Wennstrom JL, Ekestubbe A, Grondahl K, Karlsson S, Lindhe J. Oralrehabilitation with implant-supported fixed partial dentures in periodontitis-susceptible subjects. A 5-year prospective study. J Clin Periodontol 2004;31:713-724.

13. Baelum V, Ellegaard B. Implant survival in periodontally compromisedpatients. J Periodontol 2004;75:1404-1412.

14. Mengel R, Flores-de-Jacoby L. Implants in patients treated for general-ized aggressive and chronic periodontitis: A 3-year prospective longitu-dinal study. J Periodontol 2005;76:534-543.

15. Karoussis IK, Kotsovilis S, Fourmousis I. A comprehensive and criticalreview of dental implant prognosis in periodontally compromisedpartially edentulous patients. Clin Oral Implants Res 2007;18:669-679.

16. Covani U, Cornelini R, Barone A. Bucco-lingual bone remodelingaround implants placed into immediate extraction sockets: A caseseries. J Periodontol 2003;74:268-273.

17. Araujo MG, Lindhe J. Dimensional ridge alterations following toothextraction. An experimental study in the dog. J Clin Periodontol 2005;32:212-218.

18. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccalwall of extraction sockets of teeth with prominent roots. Int J PeriodonticsRestorative Dent 2006;26:19-29.


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CASE REPORT

The Use of a Xenogeneic Collagen Matrix as an InterpositionalSoft-Tissue Graft to Enhance Peri-Implant Soft-Tissue Outcomes:

A Clinical Case Report and Histologic AnalysisGeorge A. Mandelaris,*† Mei Lu,‡ and Alan L. Rosenfeld*†x

Introduction: Keratinized and dense peri-implant soft tissue around implants has been associated with better tissuehealth, less bone loss, and improved esthetics. The purpose of this case report is to evaluate a new, xenogeneic collagenmatrix (CM) as an interpositional soft-tissue graft to enhance peri-implant soft-tissue thickness. To our knowledge, this is thefirst such case report to include soft-tissue biopsies and histologic analysis.

Case Presentation: After extraction and bone grafting of a mandibular left first molar, the patient received a dental im-plant, and CMwas used as an interpositional soft-tissue graft. Clinical healing was uneventful, and the impression of enhancedsoft-tissue volume/thickness was observed. At 10 weeks, biopsies were taken from the operative site and from a contralateral,non-operated site. Histologic assessment of the operative site demonstrated normal squamous epithelium and lamina propria.Tissue growing into the residual CM also appeared normal, with no inflammatory cells seen in the graft area. Vascular bloodvessels were observed growing into the matrix. Control and test sites were comparable.

Conclusions: This case report and the first examination of a human biopsy around a dental implant demonstrate that CMholds promise as an effective, time-efficient, and reduced morbidity alternative to autogenous graft harvest for the promotionof peri-implant soft-tissue thickness. CM was easy to handle, place, and suture, and histologic analysis indicated a benigntissue response resulting in an organized and attached connective tissue similar to native, undisturbed periodontal tissue.Clin Adv Periodontics 2011;1:193-198.

Key Words: Case reports; collagen; dental implants; esthetics; transplants.

BackgroundAround teeth, gingival tissue thickness has been associatedwith improved root coverage predictability and recessionreduction.1 Around implants, keratinized and thick softtissue has been associatedwith better indices of tissue health,lower levels of bone loss, and improved esthetics.2-5 Based onthe bone loss observed on the facial aspect of implants ina thin buccal plate environment, in which susceptibility torecession is high, the establishment of a keratinized and thickperi-implant soft tissue would appear to be advantageous.

Interpositional soft-tissue grafts canbeused to increaseperi-implant soft-tissue thickness and keratinization.6 However,for clinicians, autogenous soft-tissue grafting procedures can

* Private practice, Park Ridge, IL and Oakbrook Terrace, IL.

† Advocate Lutheran General Hospital, Park Ridge, IL.

‡ Department of Oral and Maxillofacial Surgery, School of Dentistry, LomaLinda University, Loma Linda, CA.

x Department of Graduate Periodontics, College of Dentistry, University ofIllinois, Chicago, IL.


doi: 10.1902/cap.2011.100010


be time consuming, and for patients, harvest sites may be un-comfortable and associated with morbidity.7

A new porcine collagen matrix (CM)k has been investi-gated as a connective tissue graft substitute for root cover-age and for the generation of keratinized tissue (KT)around teeth and implants.8,9 We decided to investigateand understand the histologic implications for CM whenused as an interpositional connective tissue graft substitutesimultaneously with one-stage implant placement.

Case PresentationThe patient presented herein is a white, non-smoking, 38-year-old female with #19 failing root canal and a coronalfracture with inadequate tooth structure for proper resto-ration (Fig. 1). The patient was diagnosed with Angle’sClass I malocclusion, associated tooth wear, and compen-satory eruption, along with localized, early-to-moderatechronic periodontitis (#5, #9, #12, and #14 probing 4 to7 mm, with bleeding on probing). The patient was chosenas an interpositional graft candidate because she presentedwith thin coronal bone width after wide-diameter implantplacement and was considered ‘‘at risk’’ for bone resorp-tion, recession, and compromised, long-term soft-tissue/crown apposition esthetics. No IRB approval was neces-sary for this case study.

Case ManagementTooth #19 was extracted and the alveolus was preservedusing mineralized freeze-dried bone cortical allograft en-hanced with plasma rich in growth factors and coveredwith a collagen membrane{ for socket bone grafting (Fig.2a). An implant# was placed 12 months after extraction(Fig. 2b), with CM placed under the buccal flap at the timeof implant placement (Fig. 3).

Postoperative management included amoxicillin, 250mg every 8 hours, and chlorhexidine, 0.12% oral rinsetwice per day, applied with a cotton swab after the first2-week postoperative visit. Ibuprofen was prescribed,600 mg every 6 hours for the first day then as needed fordiscomfort.

After obtaining written informed consent, two biopsieswere performed 10 weeks after implant placement. Usingthe operative photo for orientation, a 3� 3 mm scalpel bi-opsy down to bone level was removed interproximally overthe grafted area. A second biopsy was taken from non-op-erated tissue on the contralateral side of the mouth. Spec-imens were stored in 4% paraformaldehyde and sent to theLoma Linda University Department of Oral MaxillofacialSurgery histology laboratory for analysis. Samples wereembedded for 4 to 5 hours in an aqueous encapsulatinggel,** placed into amega-cassette, and embedded in celloi-din–paraffin. Using a microtome, 5-mm sections were cutand stained with hematoxylin and eosin (H&E).

Clinical OutcomesThere was a clinical impression of enhanced soft-tissue vol-ume, although what appeared to be a significant gain in

tissue thickness at 2 weeks diminished somewhat at the10-week time point (Fig. 4). Healing was uneventful and be-nign,much asmight be expected for a traditional connectivetissue graft. CM was not exposed to the oral environment.

Histologic analysis of the native, control tissue specimenrevealedanormal-appearing, attachedgingivawith stratified

FIGURE 1a and 1b Baseline clinical photos with #19 failing root canal anda coronal fracture with inadequate tooth structure for proper restoration. 1cBaseline radiograph.

k Mucograft Collagen Matrix, Geistlich Pharma, Wolhusen, Switzerland.{ OSSIX PLUS, OraPharma, Warminster, PA.# 3i NanoTite Certain PREVAIL NT, BIOMET 3i, Palm Beach Gardens, FL.** HistoGel, Richard-Allan Scientific, Kalamazoo, MI.

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194 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Xenogeneic Collagen Matrix in Implant Therapy

squamous epithelium and underlying connective tissue, i.e.,lamina propria (Fig. 5). In the test CM specimen, squamousepithelium and lamina propria also appeared normal. Tissuegrowing into the residual collagen matrix of CM appearednormal, with no inflammatory cells (lymphocytes or macro-phages) seen in the graft area (Fig. 6). Vascular blood vesselswere observed growing into the matrix (Fig. 7). Control and

FIGURE 2a Twelve-month socket healing. 2b Radiograph of implantplacement.

FIGURE 3a CM interpositional graft substitute. 3b Surgical placement attime of implant placement.

FIGURE 4a Two-week soft-tissue healing. 4b Ten-week soft-tissuehealing.

FIGURE 5 Native tissue control specimen with normal oral mucosa:stratified squamous epithelium (SSE) rests on the lamina propria (LP) witha zone of a well-vascularized, relatively loose connective tissue. H&E stain.Original magnification �10.

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Mandelaris, Lu, Rosenfeld Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 195

test site specimens were comparable in terms of connectivetissue and vascular organization.

DiscussionThe aim of this case report is to understand the histologicimplications for CM when used as an interpositional

connective tissue graft substitute simultaneously withone-stage implant placement. A secondary goal was to ob-serve whether a thicker soft-tissue ‘‘cuff’’ around implantswas achieved that might not only benefit peri-implant tis-sue health but also provide improved esthetics at the pros-thetic interface.

CM was easy to handle, place, and suture and obviatedthe need and time required for donor graft harvest. Ourclinical impression was enhanced soft-tissue volume. His-tologic analysis revealed no inflammatory cell infiltratesand a benign response to the CM. Test and control site tis-sues biopsieswere comparable, and the test site biopsy con-sisted of an organized (as opposed to dense, disorganizedscar) tissue with normal, stratified squamous epitheliumand normal underlying connective tissueda positive indi-cation that an attached formof peri-implant soft tissuemayhave formed at the test site.In a recent animal study over chronic ridge defects,

Thoma et al.10 demonstrated that a porcine CM was ableto create soft-tissue volume enhancement comparable to anautogenous subepithelial connective tissue graft. Similarly,Wehrhan et al.11 found that mean epithelial thickness gen-erated in pig ear dermal wounds was equivalent, whetherCMor split-thickness skin grafts were used. In a controlledclinical study, Sanz et al.8 compared CM to free connectivetissue grafts (FCTG) as onlay soft-tissue augmentations toenhance KTaround fixed partial restorations on both teethand preplaced implants. CM was as effective as FCTG increating a band of KT but without the morbidity or addedtime associated with palatal graft harvest. A similar animalstudy and a clinical case series withmore extensive graftingwere performed by Herford, Boyne et al.12,13 These studiesappear to demonstrate the biocompatibility, rapid replace-ment with normal connective tissue, and epithelializationof CM, along with generation of new mucosa, both kerati-nized and non-keratinized. Finally, in a randomized, con-trolled, within-patient, contralateral study of recessiondefects, McGuire and Scheyer9 showed that CM was ableto provide root coverage and generate an equivalent bandof KT compared to autogenous connective tissue grafts. Aswith the case investigated herein, the authors noted: ‘‘bothtest and control sites appeared ‘thicker,’ particularly whenviewed along the margins (former vertical incision lines) ofthe treatment sites..’’9 n

FIGURE 6 CM test site biopsy with some residual collagen, normalappearing epithelium (SSE), and underlying connective tissue (LP). H&Estain. Original magnification �10.

FIGURE 7 Normal connective tissue and vascular extension into CM. H&Estain. Original magnification �20.

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Summary

Why is this case new information? n To our knowledge, this is the first case to include human histologicanalysis in the examination of CM as an interpositional graft substitutefor the enhancement of peri-implant soft-tissue thickness.

n Histologic assessment indicated a benign tissue response resulting inan organized and attached connective tissue structure similar tonative, undisturbed periodontal tissue.


n Previous studies indicated that soft-tissue volume and KT may begenerated by CM, but only sites with mucosal margins and somepreexisting KT were selected in this evaluation. As a conservative firststep, the presence of KT may allow for better flap manipulation anda greater likelihood that CM remains covered, heals uneventfully, andprovides optimal soft-tissue augmentation results.


n Although soft-tissue augmentation is simpler and more predictable toperform than bone augmentation, the key to health and estheticsaround implants and teeth is bone, so soft-tissue augmentation issecondary to adequate bone architecture. To make a more definitivejudgment about the utility of CM as an interpositional graft for peri-implant soft-tissue thickness, a controlled, comparative investigationwith longer-term clinical and histologic observations should beundertaken.

AcknowledgmentsThe authors thank Geistlich Pharma (Wolhusen, Switzer-land),which provided product samples and support for his-tometrics. All other costs were incurred by the authors.Drs. Mandelaris and Rosenfeld are occasional lecturersfor BIOMET 3i (Palm Beach Gardens, FL). Dr. Mandelarisis also an opinion leader for Geistlich Pharma. Dr. Lu re-ports no conflicts of interest related to this case report.

CORRESPONDENCE:Dr. George A. Mandelaris, Advocate Lutheran General Hospital, ParksideProfessional Center, 1875 Dempster St., Suite 250, Park Ridge, IL 60068.E-mail: [email protected].

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Mandelaris, Lu, Rosenfeld Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 197

References1. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally advanced flap

procedure for root coverage. Is flap thickness a relevant predictor toachieve root coverage? A 19-case series. J Periodontol 1999;70:1077-1084.

2. Bouri A Jr, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width ofkeratinized gingiva and the health status of the supporting tissuesaround dental implants. Int J Oral Maxillofac Implants 2008;23:323-326.

3. Chung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Significance ofkeratinized mucosa in maintenance of dental implants with differentsurfaces. J Periodontol 2006;77:1410-1420.

4. Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G.Evaluation of soft tissue around single-tooth implant crowns: The pinkesthetic score. Clin Oral Implants Res 2005;16:639-644.

5. Wiesner G, Esposito M, Worthington H, Schlee M. Connective tissuegrafts for thickening peri-implant tissues at implant placement. One-year results from an explanatory split-mouth randomised controlledclinical trial. Eur J Oral Implantology 2010;3:27-35.

6. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelialconnective tissue graft palatal donor site: Anatomic considerationsfor surgeons. Int J Periodontics Restorative Dent 1996;16:130-137.

7. Thoma DS, Benic GI, Zwahlen M, Ha� mmerle CH, Jung RE. Asystematic review assessing soft tissue augmentation techniques. ClinOral Implants Res 2009;20(Suppl. 4):146-165.

8. Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M. Clinical evaluation ofa new collagen matrix (Mucograft prototype) to enhance the width ofkeratinized tissue in patients with fixed prosthetic restorations: A random-ized prospective clinical trial. J Clin Periodontol 2009;36:868-876.

9. McGuire MK, Scheyer ET. Xenogeneic collagen matrix with coronallyadvanced flap compared to connective tissue with coronally advancedflap for the treatment of dehiscence-type recession defects. J Peri-odontol 2010;81:1108-1117.

10. Thoma DS, Jung RE, Schneider D, et al. Soft tissue volume augmen-tation by the use of collagen-based matrices: A volumetric analysis.J Clin Periodontol 2010;37:659-666.

11. Wehrhan F, Nkenke E, Melnychenko I, et al. Skin repair using a porcinecollagen I/III membrane d Vascularization and epithelization proper-ties. Dermatol Surg 2010;36:919-930.

12. Boyne PJ, Herford AS. Evaluation of a special collagen implant materialas a substitute for free mucosal or skin grafts in oral soft tissue surgery.Proceedings of the American Institute of Oral Biology. Palm Springs,CA. 2002:103-109.

13. Herford AS, Akin L, Cicciu M, Maiorana C, Boyne PJ. Use of a porcinecollagen matrix as an alternative to autogenous tissue for grafting oralsoft tissue defects. J Oral Maxillofac Surg 2010;68:1463-1470.


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CASE REPORT

Conservative Treatment of Localized Juvenile SpongioticGingival Hyperplasia

Simon R. MacNeill,* James W. Rokos,† Michael R. Umaki,* Keerthana M. Satheesh,‡ and Charles M. Cobb‡

Introduction: Localized juvenile spongiotic gingival hyperplasia (LJSGH) is a recently described uncommon and distinctiveform of inflammatory hyperplasia. Treatment of this condition has varied from surgical excision to no treatment followed by spon-taneous remission. This case report demonstrates successful management of the lesion using a conservative treatment approach.

Case Presentation: A 14-year-old male with negative medical and dental histories presented with LJSGH. The vivid redlesions involved the papillary and marginal gingiva of all maxillary anterior teeth. Initially, the lesion developed as a single redpatch-like area involving the maxillary left cuspid. Subsequently, the lesion displayed a linear pattern of spread to involve suc-cessivelymore teeth in the anterior sextant. Biopsy revealed hyperplastic elongated epithelial rete pegs, atrophy of the overlyingstratified squamous epithelium with mild spongiosis, neutrophilic exocytosis, and a highly vascular connective tissue witha dominant infiltrate of chronic inflammatory cells. The lesion responded to treatment consisting of a mild surface cauterizationfollowed by topical application of a 0.05% clobetasol ointment four times per day for a period of 4 weeks.

Conclusion: This case report demonstrates that LJSGH can be successfully managed by conservative therapy, therebyavoiding potential gingival margin defects that may result from a surgical ablation of the lesion. Clin Adv Periodontics2011;1:199-204.

Key Words: Gingival diseases; gingival hyperplasia; oral medicine; pathology, oral; periodontal diseases.

BackgroundAn unusual gingival condition affecting children andadolescents primarily was first noted by Darling et al.1 in2007. The authors examined 24 cases by light micros-copy and immunohistochemistry and designated the lesionas juvenile spongiotic gingivitis. Typically, the gingivallesions presented as localized patches of vivid red, slightlythickened, painless, and persistent lesions of the attachedgingiva that generally involve the marginal gingiva ofanterior teeth (Fig. 1). The histopathology (Fig. 2) ischaracterized by epithelial hyperplasia, spongiosis, loss of

* Graduate Periodontics, School of Dentistry, University ofMissouri-KansasCity, Kansas City, MO.

† Department of Oral and Maxillofacial Pathology, School of Dentistry,University of Missouri-Kansas City.

‡ Department of Periodontics, School of Dentistry, University of Missouri-Kansas City.

Submitted January 13, 2011; accepted for publication March 2, 2011

doi: 10.1902/cap.2011.110003


keratinization, neutrophilic exocytosis of the hyperplasticepithelium, and a highly vascular connective tissue with aninfiltrate of inflammatory cells consisting of neutrophils,lymphocytes, and plasma cells.1 With respect to treatment,Darling et al.1 reported that all but one of the 24 caseshad been treated by surgical excision (i.e., biopsy) with anz25% recurrence rate. They also noted that some casesmay resolve spontaneously after a variable and unpredict-able period of time.

A second paper, reporting 52 cases, was published in2008byChang et al.2 Basedon theobservationof a variableepithelial hyperplasia, the authors proposed the lesion bedesignated as a localized juvenile spongiotic gingival hyper-plasia (LJSGH). As applied to the hyperplastic epithelium,the term spongiotic implies the presentation of a sponge-likemorphology, i.e., prominent intercellular edemaor spongiosis.

Between the two studies,1,2 a total of 76 cases are re-ported, comprised of 48 females and 28 males with the fol-lowing agedistribution: 29cases (38.6%)aged5 to10years;41 cases (54.6%) aged 11 to 15 years; three cases (4%) aged16 to 20 years; and two cases (2.6%) aged ‡21 years. Theage of one case was not reported.2 Furthermore, Changet al.2 reported a female-to-male ratio of 2.3:1 and a racialdistribution within their 52 cases of 82% white, 14% His-panic, and 4% Asian, with three cases of unknown race.Thus, it would appear that a patient exhibiting this gingivallesion would most likely be a white female <20 years old(97% of reported cases). Regarding treatment, Changet al.2 recommended conservative surgical excision.

Clinical PresentationA 14-year-old Vietnamese male was referred for peri-odontal evaluation as a prelude to orthodontic treatment.The written and verbal medical history were non-contrib-utory, i.e., no history of systemic disease, drug therapy, orsurgery. The clinical examination of head and neck soft tis-sues was within normal limits. The only significant dentalhistory involved the surgical removal of an impacted me-siodens, 9 months prior to evaluation. The oral examina-tion revealed an intact dentition consisting of 28 teeth,unerupted third molars, and no caries or restorations.The patient had an open anterior bite and a habit of mouthbreathing. The initial periodontal examination revealeda normal-to-thick gingival biotype, generalized plaque-in-duced gingivitis of moderate severity (52%plaque-positivesurfaces) characterized by swollen and edematous gingivalpapillae, and generalized bleeding on probing (BOP) (48%or 80 of 168 possible sites exhibited BOP). At this appoint-ment, the patient was given a powered toothbrush andinstructions in oral hygiene.No definitive periodontal ther-apy was performed beyond the patient’s self-administeredoral hygiene.A photograph taken by the referring orthodontist z2

months before the initial periodontal examination showeda localized red patch-like lesion involving themarginal andattached facial gingiva of the maxillary left cuspid (Fig. 3).The remaining teeth exhibited plaque-induced gingivitis

FIGURE 2 View of biopsy taken from the case shown in Figure 1. Notethe pronounced vascularity, neutrophil exocytosis, hyperplastic stratifiedsquamous epithelium exhibiting spongiosis and loss of keratin, and denseinflammatory cell infiltrate. Original magnification of �200.

FIGURE 3 Localized patch-like lesion involving the facial gingiva of themaxillary left cuspid. Photograph taken z2 months before the initial peri-odontal examination.

FIGURE 1 Typical clinical presentation of LJSGH in a 13-year-old femalepatient. Note the velvet-like texture and highly vascular appearance.

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200 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Spongiotic Gingival Hyperplasia

with involvement of the marginal and papillary tissues. Atthe initial periodontal examination, the original lesion hadspread laterally to involve the adjacent incisors (Fig. 4). Ap-proximately 1 month later, despite significant improve-ment in oral hygiene (24% plaque-positive surfaces and18% BOP sites), the lesion had progressively spread to in-volve the gingival papillae of the remaining maxillary an-terior teeth (Fig. 5). Overall, the lesion was slightly raised,bright red in color, somewhat linear, and exhibited a softvelvet-like texture and vascular appearance that bled easilyon provocation but was otherwise asymptomatic.

Case ManagementBecause of extensive involvement of marginal gingiva andthe potential of creating an undesirable esthetic gingivaldefect requiring corrective surgery, it was decided touse an empirical and conservative approach to therapy.Consequently, treatment consisted of two episodes ofmild surface cauterization (Fig. 6), 1 month apart, pur-posely avoiding the marginal gingiva, followed by topicalapplication of a 0.05% clobetasol propionate ointment

four times daily over a 4-week period. Cauterization wasachieved by CO2 laser using 2.5 Wof power and a pulsedenergy beam at 80 Hz applied with a paintbrush move-ment. A soft-tissue biopsy was obtained immediately be-fore the first surface cauterization procedure.

Histologic examination of the biopsy specimen revealedhyperplastic elongated epithelial rete pegs, atrophy of theoverlying stratified squamous epithelium with loss of thekeratin layer, mild epithelial spongiosis, neutrophilic exo-cytosis, markedly vascular underlying connective tissuesupporting dilated capillaries with prominent endotheliallinings, and a florid chronic inflammatory cell infiltrate(Fig. 7).

Clinical OutcomesAfter the initial laser-mediated surface cauterization, therewas onlymoderate resolution of the lesion appearance (Fig.8). Consequently, a second cauterization was performed,followed by topical application of the 0.05% clobetasolpropionate ointment. At the 1 month post-treatment

FIGURE 4 Photograph taken at the initial periodontal examination showingextension of lesion to involve the maxillary left central and lateral incisorsand cuspid.

FIGURE 5 Photograph taken 1 month after that shown in Figure 4. Notethe linear nature of the lesion and progressive involvement of all teeth in themaxillary anterior sextant.

FIGURE 6 View of CO2 laser surface cauterization after the first irradiationepisode.

FIGURE 7 Histologic view of a biopsy taken from the present caseexhibiting features comparable to that of the typical LJSGH histologicpresentation seen in Figure 2. Original magnification of �200.

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MacNeill, Rokos, Umaki, Satheesh, Cobb Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 201

appointment, the lesion had sufficiently resolved so thatorthodontic therapy was initiated. There was a mild resid-ual inflammation of the gingival margins that appeared tobe plaque associated (Figs. 9 and 10). This latter presenta-tion has persisted over the following 6 months.

DiscussionLJSGH etiology remains unspecified. Both Darling et al.1

and Chang et al.2 studies noted that the presence of LJSGHappeared unrelated to dental plaque accumulation, andnothing about the present case seems to contradict thisobservation. In addition, given the lack of a immunohisto-chemical response for estrogen receptors and progesteronereceptors in the Darling et al.1 study, and the range of agesin patients presenting with the lesion,1,2 hormonal imbal-ance likely has minimal or no contribution to the etiology.To the best of our knowledge, no current literature, includ-ing this case report, has investigated a fungal or viraletiology.

Darling et al.1 noted that the LJSGH lesions were oftenlocalized to attached gingiva and separated from marginalgingiva by a strip of normal tissue. The present case, as wellas that depicted in Figure 1 (verified by biopsy), involvedboth attached and marginal gingiva. This would seem toindicate that LJSGH lesions can exhibit considerable vari-ation in their clinical presentation.

Chang et al.2 indicated that the majority of LJSGHbiopsies exhibited inflammation and papillary hyperplasiasimilar to that associated with inflammatory papillary hy-perplasia (IPH). IPHmay be associatedwithmouth breath-ing but is more commonly associated with ill-fittingmaxillary dentures.3,4 Gingival presentation in cases ofmouth breathing can vary from enlarged gingival papillaethat are red and edematous with a diffuse surface ‘‘shini-ness’’ to a more chronic condition characterized by a fi-brotic papillae.4 In the current case, although the patientadmitted to mouth breathing, the gingival lesions were ob-viously more acute in their clinical presentation when oneconsiders tissue color, texture, and density. Furthermore,the linear pattern of spread from an isolated lesion to pro-gressively more tissue involvement would be a highly un-usual clinical presentation for gingival IPH.

With respect to a differential diagnosis, one must considera number of possibilities, such as an atypical presentationfor plaque-induced gingivitis, gingivitis modified by hor-monal imbalance, intraoral contact allergy, linear gingival er-ythema, pyogenic granuloma, plasma cell gingivitis, chronichyperplastic candidiasis, capillary hemangioma, and foreignbody granuloma.Obviously, biopsy becomes an absolute re-quirement to establish a proper diagnosis and to ensure ap-propriate treatment.

Interestingly, Darling et al.1 suggested that what theytermed as ‘‘juvenile spongiotic gingivitis’’ is similar to themi-croscopic diagnosis of acute spongioticmucositis and, there-fore, may be analogous to acute spongiotic dermatitis of theskin. Both acute and subacute spongiotic dermatitis areforms of eczema or dermatitis and among the most com-monly diagnosed general types of dermatitis or eczema.5 n

FIGURE 8 Incomplete resolution of lesion at 4 weeks after the first lasercauterization. At this point, a second laser procedure was performed, andthe patient was prescribed 0.05% clobetasol propionate ointment fortopical application.

FIGURE 9 Facial view of 6-month post-treatment healing showing noevidence of original lesion. Residual gingival inflammation is a plaque-induced gingivitis.

FIGURE 10 Left lateral view of 6-month post-treatment healing showingno evidence of original lesion.

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Summary

Why is this case new information? n LJSGH has only recently been identified in the literature as a distinctclinical entity.1,2 As described by Darling et al.1 and Chang et al.,2 thetypical lesion presents clinically as a localized, red, elevated, patch-like lesion primarily affecting single anterior teeth. Although similar ininitial clinical presentation, the present case followed a progressiveclinical course that involved successively more teeth and exhibiteda linear pattern of spread.


n The lesion was managed by light cauterization of the surface tissue(two episodes) and topical application of a 0.05% clobetasolpropionate ointment, four times per day for a period of 4 weeks.Results at 6 months indicate that the lesion has resolved, and residualgingival inflammation appears to be plaque related.

What are the key limitations tosuccess in this case?

n Management of this case was complicated by habitual mouthbreathing that was promoted by a severe open anterior bite and lessthan optimal oral hygiene that eventually showed significantimprovement. Although the LJSGH lesions have not recurred, theliterature has reported an z25% rate of recurrence, even after totalexcision.1


CORRESPONDENCE:Dr. Charles M. Cobb, 424 West 67th Terrace, Kansas City, MO 64113.E-mail: [email protected].

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References1. Darling MR, Daley TD, Wilson A, Wysocki GP. Juvenile spongiotic

gingivitis. J Periodontol 2007;78:1235-1240.

2. Chang JY, Kessler HP, Wright JM. Localized juvenile spongioticgingival hyperplasia. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2008;106:411-418.

3. Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Chapter 12. In:Oral and Maxillofacial Pathology. St. Louis: Elsevier Saunders; 2009:507-570.

4. Carranza FA, Hogan EL. Gingival enlargement. In: Newman MG,Takei HH, Klokkevold PR, Carranza FA, eds. Clinical Periodontology.St. Louis: Elsevier Saunders; 2011:84-96.

5. Wu H, Brandling-Bennett HA, Harrist TJ. Noninfectious vesiculobul-lous and vesiculopustular diseases. In: Elder DE, ed. Histopathology ofthe Skin, 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:237.


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CASE REPORT

Non-Plaque-Induced Gingivitis AssociatedWith Isotretinoin: A Case ReportAjay Mahajan,* Ashu Bharadwaj,* and Poonam Mahajan*

Introduction: Isotretinoin (13-cis-retinoic acid), a synthetic vitamin A derivative, is used to treat a wide variety of derma-tologic conditions, including severe acne. Although isotretinoin has revolutionized the management of acne vulgaris, concernscontinue regarding the adverse effect profile of isotretinoin. Mucocutaneous reaction is the most commonly observed adverseside effect of isotretinoin use, but the involvement of gingival mucosa has rarely been reported. To our knowledge, this is thefirst-ever case report of gingivitis associated with isotretinoin.

Case Presentation: A 19-year-old female was referred to the Department of Periodontics, Himachal Pradesh Govern-ment Dental College and Hospital, Shimla, India, for the treatment of persistent severe gingivitis. The history of the patientrevealed that she had been on 10 mg/day isotretinoin regimen for the treatment of nodular facial acne for 6 months. In theabsence of an obvious cause, the condition was diagnosed as isotretinoin-associated gingivitis. After consultation with thedermatologist, the drug was stopped and the patient responded favorably to periodontal treatment.

Conclusion: Non-plaque-induced, isotretinoin-associated gingivitis should always be suspected in a patient who istaking isotretinoin and has persistent gingivitis that does not respond to periodontal treatment. Clin Adv Periodontics2011;1:205-209.

Key Words: Drug therapy; gingivitis; isotretinoin; mucositis.

BackgroundAcne vulgaris is a chronic inflammatory disease with a mul-tifactorial etiology involving the pilosebaceous unit. Althoughit is commonly accepted to be a disease of adolescence, it canalso be seen in the neonatal, infantile, prepubertal, and adult

periods when the sebaceous glands are active.1 Increasedsebum secretion, abnormal follicular keratinization, micro-bial colonization, and inflammation are thought to beinvolved in the pathogenesis of acne. A drug combinationthat aims to correct the abnormal keratinization and decreasePropionibacterium acnes proliferation is adequate in mostpatients with acne. Repressing sebum production is suggestedformore serious conditions not responding to this treatment.2

Isotretinoin (13-cis-retinoic acid) is a synthetic vitamin Aderivative. Isotretinoin is the only medication with an effecton all factors involved in the pathogenesis of acne.3 It reducesproduction of sebum, stabilizes keratinization, and prevents

* Himachal Pradesh Government Dental College and Hospital, Shimla,Himachal Pradesh, India.

Submitted January 18, 2011; accepted for publication March 1, 2011

doi: 10.1902/cap.2011.110006


comedones formation. Like other retinoids, isotretinoinworks by altering DNA transcription, although the exactmechanism of action is unknown.4

The widespread use of retinoids requires that not onlydermatologists but other health professionals be awareof the wide spectrum of adverse effects associated withtheir use. This includes dentists, who need to be particu-larly alert to the mucocutaneous reactions that developin almost all patients who receive these drugs. Althoughmany adverse effects of the drug have been identified,5

there is a paucity of literature related to the oral adverseeffects of the drug. To our knowledge, this is the first-evercase report of gingivitis associated with isotretinoin.

Clinical PresentationA 19-year-old female was referred to the Department ofPeriodontics, Himachal Pradesh Government Dental Col-lege andHospital, Shimla, India, for the treatment of persis-tent severe gingivitis that developed 6 months previouslyand did not improve despite repeated non-surgical peri-odontal therapy, which included thorough scaling and rootplaning and detailed counseling regarding maintenance ofher oral hygiene. Before this visit, the patient hadbeen testedfor any underlying desquamative condition, allergic reac-tion, and systemic reason responsible for the gingival inflam-mation, and these conditions were ruled out. However, thedetailed history of the patient revealed that she had been on10mg/day isotretinoin regimen for the treatment of nodularfacial acne for 6 months. Shortly after the initiation of thetreatment, she developed gingivitis. There was no other rel-evant medical or medication history. Clinical examinationrevealed severe gingival inflammation with minimal plaquedeposition. Probing depths and clinical attachment levelswere measured using a periodontal probe† and were foundto be within normal limits.

Case ManagementBecause the most common causes for gingivitis were ruledout before the patient was referred to us, a provisionaldiagnosis of non-plaque-induced, isotretinoin-associatedgingivitis was made, and with the consultation of the der-matologist, the drug was stopped. Two weeks after drugcessation, a basic treatment regimen was started which in-corporated thorough supragingival and subgingival de-bridement followed by regular toothbrushing and use of0.2% chlorhexidine gluconate twice daily and a regularfollow-up visit every week. In every follow-up visit, the pa-tient’s oral hygiene was reviewed and oral hygiene instruc-tions were emphasized.

Clinical OutcomesOne week after the drug was stopped, there was definitereduction in gingival inflammation without any profes-sional oral hygiene therapy, and the condition continuedto improve until the fourth week, when the gingivitiswas resolved completely (Figs. 1 through 4).

FIGURE 1 Severe persistent gingivitis in a patient on isotretinoin.

FIGURE 2 Marked reduction in gingival inflammation 1 week afterstopping isotretinoin.

FIGURE 3 Gingival condition 3 weeks after stopping isotretinoin.

† UNC-15 periodontal probe, Hu-Friedy, Chicago, IL.

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206 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Isotretinoin and Gingivitis

DiscussionGingivitis is a term used to describe non-destructive peri-odontal disease that results in inflammation of gingiva.6

Asdefined by the 1999 InternationalWorkshop for theClas-sification of Periodontal Diseases and Conditions, there aretwo primary categories of gingival diseases, each withnumerous subgroups: 1) dental plaque-induced gingivaldiseases; and 2) non-plaque-induced gingival lesions.7

The most common form of gingivitis is in response toplaque adherent to tooth surfaces, termed ‘‘plaque-inducedgingivitis.’’ In the absence of treatment, gingivitis mayprogress to periodontitis, which is a destructive form ofperiodontal disease.8 Although in some sites or individualsgingivitis never progresses to periodontitis,9 data indicatethat periodontitis is always preceded by gingivitis.10 Thefocus of treatment for gingivitis is removal of the etiologicagent and the reduction of oral bacteria, and may take theform of regular visits to a dental professional together withadequate oral hygiene home care.

Nodular and nodulocystic acne are forms of inflammatoryacne that do not respond easily to treatment. Isotretinoin isthe best treatment for nodulocystic acne when it does not re-spond to conventional treatment, suchas topical and systemic

antibiotics. Many adverse effects of isotretinoin have beenreported.5 The most common adverse effects include muco-cutaneous reactions presenting as dryness of the eyes, lips,mouth, and other epidermal surfaces. These effects are dosedependent, tolerable, and treatable.11Themost commonly re-ported mucocutaneous adverse effect is cheilitis; paronychiawith lengthening lateral ungual folds has rarely been seen.12

Patients should bemade aware of these adverse effects beforetaking isotretinoin and also that use of moisturizers and eyedrops can help to mitigate such adverse effects. Sometimes,however, the dose of isotretinoin needs to be decreased to re-duce the induction of adverse effects.

Although anecdotal reports suggest that gingival inflam-mation and bleeding from gums is associated with iso-tretinoin,13 to our knowledge, gingivitis associated withisotretinoin has not been reported in the scientific literature.

In the present case, because obvious reasons for gingi-vitis, i.e., visible plaque and calculus, were not responsiblefor the persistent gingivitis, and the patient’s condition didnot improve until the drug was stopped, there are strongreasons to believe that the gingivitis was attributable toisotretinoin therapy. Although the exact mechanism bywhich the drug caused gingivitis could not be established,it may be attributed to the various biologic effects of ret-inoids as a result of their profound effects on DNA tran-scription. The activity of retinoids ismediated through thebinding of nuclear retinoid receptors, which are function-ally and structurally related to a superfamily of nuclearDNA transcription factors that includes steroids, vitaminD, and thyroid hormone receptors. Therefore, retinoidsact like hormones, producing a variety of cellular modu-lations through alterations in DNA transcription.3,14 Inaddition, the vitamin B12 and folate deficiency anemiaassociated with isotretinoin could result in oral adverseeffects.15

Early diagnosis of gingivitis associated with isotretinoinis important because it can prevent undue stress and dis-comfort to the patient caused by unnecessary treatmentand investigations that will not be effective until the drugis stopped or its dose is reduced in consultation with a der-matologist. n

FIGURE 4 Absence of any gingival inflammation after 4 weeks.

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Mahajan, Bharadwaj, Mahajan Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 207

Summary

Why is this case new information? n Lack of sufficient data on oral adverse effects of isotretinoinn First-ever reported case of gingivitis associated with isotretinoin,to the best of our knowledge


n Early diagnosisn Altering the dose of or stopping isotretinoin in consultation witha dermatologist


n Unawareness of oral adverse effects of isotretinoinn Wrong diagnosis


CORRESPONDENCE:Dr. AjayMahajan, Department of Periodontics, Himachal PradeshGovern-ment Dental College and Hospital, Snowdon, Shimla, Himachal Pradesh171001, India. E-mail: [email protected] [email protected].

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208 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Isotretinoin and Gingivitis

References1. Cunliffe WJ, Simpson NB. Disorders of the sebaceous glands. In:

Champion RH, Burton JL, Burns DA, Breathnoch SM, eds. Textbookof Dermatology. Oxford: Blackwell Science; 1998:1927-1984.

2. Strauss JS, Thibautat DM. Diseases of the sebaceous glands. In:Freedberg I, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI,et al., eds. Dermatology in General Medicine. New York: McGraw-Hill; 1999:769-784.

3. Cunliffe WJ, van de Kerkhof PC, Caputo R, et al. Roaccutane treatmentguidelines: Results of an international survey. Dermatology 1997;194:351-357.

4. Kilic E, Sahin M, Sahin S, Ozer S. Isotretinoin (13-cis-retinoic acid)-associated premature ventricular contractions. Turk J Pediatr 2009;51:387-388.

5. Rademaker M. Adverse effects of isotretinoin: A retrospective review of1743 patients started on isotretinoin. Australas J Dermatol 2010;51:248-253.

6. American Academy of Periodontology. Glossary of Periodontal Terms,4th ed. Chicago: American Academy of Periodontology; 2001:25.

7. Armitage GC. Development of a classification system for periodontaldiseases and conditions. Ann Periodontol 1999;4:1-6.

8. American Academy of Periodontology. Parameter on plaque-inducedgingivitis. J Periodontol 2000;71(Suppl. 5):851-852.

9. Ammons WF, Schectman LR, Page RC. Host tissue response in chronicperiodontal disease. 1. The normal periodontium and clinical manifes-tations of dental and periodontal disease in the marmoset. J PeriodontalRes 1972;7:131-143.

10. Page RC, Schroeder HE. Pathogenesis of inflammatory periodontaldisease. A summary of current work. Lab Invest 1976;34:235-249.

11. McLane J. Analysis of common side effects of isotretinoin. J Am AcadDermatol 2001;45:S188-S194.

12. Kaymak Y, Ilter N. The results and side effects of systemic isotretinointreatment in 100 patients with acne vulgaris. Dermatol Nurs 2006;18:576-580.

13. Medscape Reference. Isotretinoin oral: Dosage, uses, and warnings.Available at: www.medscape.com/druginfo/dosage. Accessed December21, 2010.

14. Rodrigues MT, Albuquerque DF, Capelozza AL, Faria FA, Santos CF.Oral side effects of isotretinoin chronic intake. N Y State Dent J 2008;74:36-39.

15. Jasim ZF, McKenna KE. Vitamin B12 and folate deficiency anaemiaassociated with isotretinoin treatment for acne. Clin Exp Dermatol2006;31:599.


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CASE REPORT

Successful Gingival Depigmentation With Laser-PatternedMicrocoagulation: A Case Report

Edward P. Allen,* Natalia D. Gladkova,† Yulia V. Fomina,† Maria M. Karabut,† Elena B. Kiseleva,†

Felix I. Feldchtein,‡ and Gregory B. Altshuler‡

Introduction:Currentmethods for gingival depigmentation, includingmechanical surgery, cryosurgery, laser treatments,and radiosurgery, create significant patient discomfort and risk of complications, thereby reducing attractiveness of the depig-mentation procedure for many patients. To our knowledge, this case report presents a first-time application of a new technol-ogy, laser-patterned microcoagulation (LPM) based on the concept of fractional laser photothermolysis that was successfullyapplied in dermatology and ophthalmology.

Case Presentation: One patient was treated for local hyperpigmentation of the labial attached gingiva in the maxillaryanterior area. A diode laser with wavelength 980 nm and power 20Wwas used to create microcoagulation columns with a 30%area filling factor. Two treatments were performed, 2 weeks apart, without anesthesia. The patient was followed for 5 months.The discomfort during the procedure was tolerable without anesthesia. Healing was uneventful and visually completed with sig-nificant reduction of pigmentation at 2 weeks after treatment. Complete visual depigmentation was observed at both 2 weeksand 2 months after the second treatment.

Conclusions: To our knowledge, this is the first clinical case of hyperpigmentation treatment using LPM, demonstratingfeasibility of a new, minimally invasive and effective method of localized gingival hyperpigmentation removal. The patient dis-comfort is significantly less than that reported for other methods for depigmentation. Clin Adv Periodontics 2011;1:210-214.

Key Words: Hyperpigmentation; laser therapy; lasers, semiconductor; surgical procedures, minimally invasive.

BackgroundBrown or dark gingival pigmentation often presents anesthetic problem because it may be apparent during smile

or speech. The most frequent reason of hyperpigmentationis melanin deposits mainly located in basal and parabasallayers of the epithelium.1 The traditional approach fortreatment of gingival hyperpigmentation is surgical andincludes mucoperiosteal flap, free gingival graft, or deep-ithelization as a less invasive approach. Still, all thesesurgical procedures are painful and expensive and have allthe typical risks associatedwith surgery, including infection,scarring, gingival recession, damage to underlying perios-teum and bone, and delayed wound healing.2 Multiple lessinvasive deepithelization alternatives have been explored,

* Center for Advanced Dental Education, Dallas, TX.

† Nizhny Novgorod Medical Academy, Nizhny Novgorod, Russia.

‡ Dental Photonics, Walpole, MA.

Submitted February 8, 2011; accepted for publication April 6, 2011

doi: 10.1902/cap.2011.110010

210 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011

including erbium lasers,3-5 CO2 lasers,6,7 cryogenic de-struction,8 near-infrared lasers1,9 and radiosurgery.10 How-ever, the majority of existing techniques are still associatedwith significant patient discomfort and protracted healingtime, making gingival depigmentation an unattractive pro-cedure for the majority of patients.

In the past several years, esthetic dermatologywas signif-icantly enhanced by a new technology known as fractionalphotothermolysis.11,12 It was successfully used with severalmillion patients for skin rejuvenation, wrinkle removal,scar conversion to normal tissue, and melasma treatment.The concept of fractional photothermolysis may be ex-plained as ‘‘Formation of isolated non-contiguous micro-thermal wounds creating necrotic zones surrounded byzones of viable tissue in a geometrical pattern that is notdependent on chromophore distribution.’’12 It was foundthat, if the size and concentration (area filling ratio) ofthemicroscopic wounds arewithin certain limits, the tissuecan regenerate without scarring and result in younger,healthier tissue after healing is complete. In addition to der-matology, the same concept was successfully applied inophthalmology,13 but it has not been applied for oral tissues.Because oral mucosa is known to have better regenerationproperties than skin, we hypothesized that fractional treat-ment of oral mucosa and gingiva will result in a similar orbetter response, facilitating regeneration and creating newtissue without scarring. Near-infrared radiation easily pen-etrates into soft tissues, because absorption in water and he-moglobin is not very significant, but strongly absorbedin melanin,14 providing natural selectivity in laser–tissue in-teraction. The tissue regeneration cannot restore melanindeposits concentrated in the basal layer and therefore thepigmentation should be eliminated, at least in the areasin which melanin was destroyed by direct laser radiation.Because the treatment procedure is substantially creatinga pattern of microcoagulated columns in the tissue, it maybe called laser-patterned microcoagulation (LPM).

Clinical PresentationA 36-year-old male was seen at a routine dental hygieneappointment. Several irregular brown pigmented spotswere noted on the attached gingiva labial to the maxillaryincisor teeth (Fig. 1). The pigmented regions were flat and

asymptomatic. The patient had considered them as an es-thetic problem, but had not sought treatment to remove thepigmentation. The pigmentationwas diffuse, bilateral, andexisted forz30 years; therefore, it was considered as phys-iologic pigmentation.15 The patient was offered the optionto treat the most pronounced spots with LPM, a new tech-nology similar to fractional photothermolysis widely usedfor skin rejuvenation and hyperpigmentation treatment.

Case ManagementThe case treatment was performed under the local ethicalcommittee permission (Protocol #1 of Nizhny NovgorodMedical AcademyClinical andAnimal Study Ethical Com-mittee, 2010), and the patient signed an informed consent.

The laser microcoagulation treatment is a quasi-periodicpattern of columns covering a pigmented spot, in whicheach column is created by application of a single laser pulsefrom a diode laser system. A diode laser operating at 980nm wavelength and generating up to 20 W of power wasused in this case. The delivery system had replaceable tipswith 0.6 mm diameter.

In this case, each column was created by an 80 ms pulse.No anesthesia was used. The gingival surface facial to theleft maxillary incisors was dried with compressed air andisolated by cotton rolls (special attention was paid to pre-vent cotton fibers from getting to the treatment field). The

FIGURE 1 Preoperative view of maxilla with pigmentation spots.

FIGURE 2a Immediate postoperative view of the same area after first LPMtreatment. 2b Healing 2 weeks after first treatment. Pigmentation is significantlyreduced.

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pigmented spot was covered with laser columns with a fill-ing ratio (coagulated area divided by total treatment area)of z30%. Digital photos (Figs. 1 through 5) were takenbefore the procedure, immediately after, and during eachfollow up visit. Red articulating paper and untreated pig-mented spots were used for brightness and color referencein the photos. A second treatment was performed 2 weeksafter the first treatment, also with a 30% filling ratio andwithout anesthesia (Fig. 3a).

Clinical OutcomesThe patient reported a tolerable slight burning sensationduring and immediately after the laser pulse and minor

tingling in the treated area at 1 day after treatment. Noother discomfort or side effects were observed. At 1 weekafter the first treatment, a noticeable bleaching of pigmen-tationwas noted compared to another area of hyperpigmen-tation near the right maxillary incisor teeth. The healingcolumns were noticeable on the surface as small indenta-tions. Complete visual healing after the first treatmentwas observed at 2weeks after treatment. The surface texturewas restored, and the pigmentation was inhomogeneous,more at the mesial part of the spot (Fig. 2b). At this time,a second treatment was performed (Fig. 3a).

Two weeks after the second treatment (Figs. 3b and 5c),the surface was smooth and shiny, the pigmentation was ab-sent, and therewerenovisible tracesof columns.Twomonthsafter the first treatment (Fig. 5d), the surfacewas smooth andshiny with no repigmentation, and the patient expresseda high level of satisfaction and willingness to treat remainingareas of hyperpigmentation. No repigmentation was ob-served at 5 months after the second treatment (Fig. 5e).To our knowledge, this is the first clinical case of hy-

perpigmentation treatment using LPM, demonstrating fea-sibility of a new, minimally invasive and effective methodfor localized gingival hyperpigmentation removal. The pa-tient discomfort was significantly less than that reportedfor other methods for hyperpigmentation treatment, in-cluding surgical (mechanical) techniques, erbium laser,CO2 lasers, cryogenic destruction, near-infrared lasers,or radiosurgery. n

FIGURE 3a Immediate postoperative view after second LPM treatment. 3bHealing 2 weeks after second treatment. Pigmentation is reduced to normallevel of surrounding tissue.

FIGURE 4 Two months after treatments.

FIGURE 5 Close-up view of the pigmented spot. 5a Preoperative view. 5b Two weeks after first treatment. 5c Two weeks after second treatment. 5dTwo months after first treatment. 5e Five months after second treatment.

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212 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Gingival Depigmentation With Laser-Patterned Microcoagulation

Summary

Why is this case new information? n To our knowledge, this is the first case report of the application of newtechnologydLPMdfor a successful removal of local gingivalpigmentation.


n Optimization of LPM parameters determined in previous in vitro andanimal experiments led to a minimally invasive yet efficacious methodwith less discomfort.


n Additional cases and longer postoperative evaluations are necessaryto determine the long-term benefit of this technique.

AcknowledgmentsThis case reportwas supported byRussian Federation StateContract 02.740.11.5149 and Grant 10-02-01175 of theRussian Foundation for Basic Research. Dr. Feldchtein isa co-inventor of a patent related to the LPM technologyand is an employee of Dental Photonics (Walpole, MA),a company commercializing LPM treatment. Dr. Altshuleris a shareholder and consultant for Dental Photonics andhas a patent application in LPM treatment. Drs. Gladkova,Fomina, Karabut, and Kiseleva have received financialsupport for research and consulting fees from DentalPhotonics. Dr. Allen reports no conflicts of interest relatedto this case report.

CORRESPONDENCE:Dr. Felix Feldchtein, Dental Photonics, 1600 Boston-Providence Highway,Walpole, MA 02081. E-mail: [email protected].

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Allen, Gladkova, Fomina, et al. Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 213

References1. Yousuf A, Hossain M, Nakamura Y, Yamada Y, Kinoshita J,

Matsumoto K. Removal of gingival melanin pigmentation with thesemiconductor diode laser: A case report. J Clin Laser Med Surg2000;18:263-266.

2. Kanakamedala AK, Geetha A, Ramakrishan T, Emadi P. Managementof gingival hyperpigmentation by the surgical scalpel technique – Reportof three cases. J Clin Diagnostic Res 2010;4:2341-2346.

3. Rosa DS, Aranha AC, Eduardo Cde P, Aoki A. Esthetic treatment ofgingival melanin hyperpigmentation with Er:YAG laser: Short-term clinicalobservations and patient follow-up. J Periodontol 2007;78:2018-2025.

4. Azzeh MM. Treatment of gingival hyperpigmentation by erbium-doped:yttrium, aluminum, and garnet laser for esthetic purposes. JPeriodontol 2007;78:177-184.

5. Kawashima Y, Aoki A, Ishii S, Watanabe H, Ishikawa I. Er:YAG lasertreatment of gingival melanin pigmentation. Int Congr Ser 2003;1248:245-248.

6. Sharon E, Azaz B, Ulmansky M. Vaporization of melanin in oral tissuesand skin with a carbon dioxide laser: A canine study. J Oral MaxillofacSurg 2000;58:1387-1393, discussion 1393-1394.

7. Esen E, Haytac MC, Oz IA, Erdogan O, Karsli ED. Gingival melanin�pigmentation and its treatment with the CO2 laser.Oral Surg Oral MedOral Pathol Oral Radiol Endod 2004;98:522-527.

8. Tal H. A novel cryosurgical technique for gingival depigmentation. JAm Acad Dermatol 1991;24:292-293.

9. Atsawasuwan P, Greethong K, Nimmanon V. Treatment of gingivalhyperpigmentation for esthetic purposes by Nd:YAG laser: Report of 4cases. J Periodontol 2000;71:315-321.

10. Sherman JA, Gurkan A, Arikan F. Radiosurgery for gingival melanindepigmentation. Dent Today 2009;28:118, 120-121.

11. Altshuler G, Smirnov M, Yaroslavsky I. Lattice of optical islets: A noveltreatment modality in photomedicine. J Phys D Appl Phys 2005;38:2732-2747.

12. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractionalphotothermolysis: A new concept for cutaneous remodeling usingmicroscopic patterns of thermal injury. Lasers Surg Med 2004;34:426-438.

13. Paulus YM, Jain A, Gariano RF, . Healing of retinal photocoagulationlesions. Invest Ophthalmol Vis Sci 2008;49:5540-5545.

14. Welch AJ, Gardner CM. Monte Carlo model for determination of therole of heat generation in laser-irradiated tissue. J Biomech Eng 1997;119:489-495.

15. Kauzman A, Pavone M, Blanas N, Bradley G. Pigmented lesions of theoral cavity: Review, differential diagnosis, and case presentations. J CanDent Assoc 2004;70:682-683.


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CASE REPORT

Trisomy 21–Associated– Aggressive Periodontitis: A Five-Year Follow-UpAlon Frydman,* Fernando Verdugo,†‡x Krikor Simonian,* and Kian Kar*

Introduction: This report explores the effective treatment of aggressive periodontitis in a 23-year-oldmalewith Trisomy 21.Case Presentation: A 23-year-old male with Trisomy 21 presented with his mother with the chief complaint of "bleeding

gums andbad breath." Periodontal evaluation alongwith anaerobicmicrobiological culturewas performed. Systemic antibioticswere given after the completion of the initial mechanical scaling and root planing (SRP). After reevaluation, the patient wasplaced on a 2-month recall in which antimicrobial therapy in the form of diluted sodium hypochlorite (1:40) and povidone-iodine(10%) was delivered subgingivally in addition to SRP. The patient remained on a 1- to 2-month recall.

A reduction of mean probing depths, from 4.2 –1.3 mm at baseline to 2.98 – 0.89 mm, at 5 years (P(( <0.05) was observed.Percentage of sites with bleeding on probing showed a reduction from 100% at baseline to 16.66% at 5 years (P(( <0.05). Thenumber of sites with probing depths measuring ‡6 mm was reduced from 23 to four after 5 years.

Conclusion: Trisomy 21–associated aggressive periodontitis can be successfully treated and maintained over the longterm. Clin Adv Periodontics 2011;1:215-220.

Key Words: Aggressive periodontitis; dental infection control; Down syndrome; microbial analysis; microbiology; non-surgicalperiodontal therapy.

BackgroundTrisomy 21 is of particular interest in the field ofperiodontology because a majority of these patientspresent with aggressive periodontitis.1 The high incidence

and severity of periodontal breakdown may partially beexplained by the immunologic dysfunctions that occurwith the syndrome. Specifically, diminished neutrophilicchemotaxis and phagocytic ability, in addition to de-creased leukocyte lifespan,2 all hinder the ability of thesepatients’ immune system to effectively resist the pro-gression of periodontal disease. Bacteria commonlyassociated with aggressive periodontitis have a high in-cidence among those with Trisomy 21,3 specificallyAggregatibacter actinomycetemcomitans (Aa).4 Beyondbacterial challenges, patients with Trisomy 21 also havebeen reported to have coinfections with viruses, whichmay explain some of the extensive periodontal disease.5

Despite challenges in restoration of the dentition,6 peri-odontal therapy can be delivered with success. A completeunderstanding of the specific challenges within this

* Advanced Periodontology, Herman Ostrow School of Dentistry of theUniversity of Southern California, Los Angeles, CA.

† Veterans Affairs Hospital, Greater Los Angeles, Healthcare System, LosAngeles, CA.

‡ Private practice, Altadena, CA.

x Department of Immunology, Microbiology, and Parasitology, School ofMedicine and Odontology, University of Basque Country, Leioa, Spain.

Submitted February 10, 2011; accepted for publication April 24, 2011

doi: 10.1902/cap.2011.110013


population as well as the various modalities to treat the ag-gressive forms of periodontal disease that affects them isthe key to a successful outcome. This case report profilesthe therapy of a single patient with Trisomy 21–associatedaggressive periodontitis over a 5-year period.

Clinical PresentationThe patient, age 23 years at the time, presented with hismother to the Advanced Periodontology Department atthe Herman Ostrow School of Dentistry, University ofSouthern California. The patient’s cognitive ability waslimited, as was cooperation. His mother delivered the chiefcomplaint of persistent ‘‘bleeding gums and severe badbreath.’’ Review of the patient’s medical history revealeddiagnosis of Trisomy 21 at birth, with no other underlyingsystemic conditions. Discussion with the mother revealedthat the patientwas trustedwith his own oral hygiene usingamanual toothbrush. Themother also complained that thepatient suffered multiple herpetic outbreaks during thecourse of a year. Dental history revealed that the patienthad been seen for hygiene visits approximately once every5 months within the special patients’ clinic of the dentalschool. Save for prophylaxis visits, extraction of hopelessteeth was the only other therapy received since the patientpresented to the school (Figs. 1 and 2).

Case ManagementA comprehensive periodontal evaluation was performed,recording probing depths (PDs), clinical attachment levels,bleeding on probing (BOP), suppuration, mobility, reces-sion, and radiographic bone loss. Anaerobic microbial in-vestigation was performed to determine the need for anyspecific antibiotic. Sterile paper points were used to collectgingival crevicular fluid from the deepest pockets and thenstored in anaerobic media. The pooled samples were sentfor anaerobic-selective culture at the Oral MicrobiologyTesting Laboratory, Herman Ostrow School of Dentistry,University of Southern California within 24 hours andthen incubated for 10 days. Oral hygiene instructions weregiven to the mother, as well as other family members in the

householdwith the responsibility of delivering oral hygieneon a daily basis for the patient. The purchase of a mechan-ical toothbrush was also suggested to help in achievingmore efficient daily hygiene.

Four quadrants of scaling and root planing (SRP) wereperformed along with adjunctive antimicrobial therapyin the form of diluted sodium hypochlorite (1:40) and po-vidone-iodine (10%) delivered subgingivally.7 The labora-tory microbiologic culture results (Table 1) were obtainedbefore the completion of SRP. A diagnosis of Trisomy21–associated aggressive periodontitis was reached. A pre-scription for amoxicillin and metronidazole (each 250 mg,three times per day, for 7 days) was given as systemic ad-junctive antibiotic therapy after the completion of the ini-tial SRP. The systemic antibiotics were given to addresspossible intraoral reservoirs that could not be addressedwith mechanical therapy. Periodontal reevaluation wasperformed at 6 weeks after SRP. Because of the patient’slimited ability to cooperate, definitive surgical therapywas ruled out. Instead, the patientwas placed on a 2-monthperiodontal maintenance recall schedule. SRP along withdiluted sodium hypochlorite (1:40) and povidone-iodine(10%) delivered subgingivally was repeated at each visitalong with a record of periodontal indices.

Clinical OutcomesLong-term reevaluation showed a reduction of mean PDsfrom 4.2 –1.3 mm at baseline to 2.98 – 0.89 mm at 5 years(P<0.05). Percentage of sites with BOP showed a reductionfrom 100% at baseline to 16.66% at 5 years (P<0.05). Thenumber of sites with PDs measuring ‡6 mm was reducedfrom23 to four after 5 years (Figs. 3 and4, Table 2).No teethwere lost over the 5 years. At 5-year reevaluation, microbi-ologic sampling revealed an absence of Aa, Porphyromonasgingivalis (Pg), andEubacterium.However, Prevotella inter-media (Pi) (3.8%), Tannerella forsythia (Tf) (2.3%), Cam-pylobacter spp. (5.4%), Fusobacterium spp. (3.1%),Parvimonas micra (3.8%), enteric Gram-negative rods(3.1%), and Dialister pneumosintes (2.3%) were found.A prescription for ciprofloxacin (500 mg, twice daily for7 days) was given after recall to address the presence ofenteric rods. Sampling was repeated at reevaluation aftercompletion of the antibiotic regimen. Results of thefinal sampling show Pg (2.6%), Pi (4.3%), Tf (2.6%),Eubacterium (3.5%), Fusobacterium spp. (4.3%), and P.micra (4.3%). Enteric Gram-negative rods, D. pneumo-sintes, andAawere absent at the end of the study (Table 1).

DiscussionUnderstanding the etiopathogenesis of aggressive peri-odontitis, aswell as the unique host relationship in Trisomy21, is a prerequisite for the effective therapy of these pa-tients. Improvement in clinical parameters, such as BOPand periodontal PDs, was evident 6 months after SRP andinitial systemic antibiotic therapy in this case. The improvedclinical outcomes were stable for the 5-year follow-up.

FIGURE 1 Initial presentation shows spontaneous bleeding, open bite,large amounts of calculus, gingival recession, gingival enlargement, andgeneralized inflammation.

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216 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Trisomy 21–Associated Aggressive Periodontitis–

There was a reduction in all cultivatable periodontal path-ogens and an absence of Aa after 5 years. Despite the pres-ence of enteric Gram-negative rods, often associated withperiodontal abscess,8 clinical parameters were stable at 5years. Infection with Gram-negative rods may be a resultof poor hygiene habits or opportunistic infection after re-peated antibiotic therapy. A second course of systemic anti-biotic treatment with ciprofloxacin was rendered to targeta possible colonization by enteric Gram-negative rods.The patient was negative for both Aa and enteric Gram-negative rods after the second course of antibiotic therapy.Investigators have found higher occurrences of specific peri-odontal pathogens such as Aa, Pg, and Tf among patientswith Trisomy 21 and periodontitis9-11 versus controls. Thebacterial profile of this particular case appears similar to de-mographic reports of patients with Trisomy 21.

Several research groups attribute the periodontal attach-ment loss among Trisomy 21 patients to individual host

factors rather than a specific bacteriological etiology.12 Saxenand Aula13 did not find periodontal bone loss in patientsyounger than 19 years for a period of 5 years. An older agegroup,with significant baseline attachment loss, showed pro-gressive bone loss innearly all participants after 5 years.13Thepresent report shows a 23-year-old individual with Trisomy21 and generalized severe attachment loss and radiographicbone loss. Thus far, his attachment level and radiographicbone level are well maintained 5 years after treatment.In this particular case of Trisomy 21–associated aggres-

sive periodontitis, the clinical improvement and stability ofperiodontal parameters such as PDs and BOP can be attrib-uted to the frequency of mechanical therapy combinedwith use of systemic and adjunctive antimicrobial ther-apy.14,15 The most definitive results of pocket reductionand stabilization of the periodontal condition are usuallyachieved by means of periodontal flap procedures. How-ever, the typical comprehensive approach and use of surgi-cal means may not be an option for some patients with thelimitations associated with Trisomy 21. It seems plausibleto prevent the extent and severity of the disease and there-fore reduce tooth loss by increasing the frequency of peri-odontal maintenance (monthly to bimonthly) combinedwith adjunctive targeted systemic antibiotics and local

FIGURE 2 Initial radiographic presentation shows localized areas of severe bone loss as well as missing teeth.

FIGURE 3 Presentation after 5 years shows absence of generalizedinflammation, decrease in plaque and calculus levels, and generalizedrecession.

TABLE 1 Subgingival Microbial Findings in a Patient WithTrisomy 21

MicrobiotaBaseline

(%)5 Years(%)

5 YearsReevaluation (%)

Aa 0.6 0 0

Pg 4.8 0 2.6

Pi 12.0 3.8 4.3

Tf 7.2 2.3 2.6

Eubacterium spp. 5.6 0 3.5

Fusobacterium spp. 8.0 3.1 4.3

P. micra 5.6 3.8 4.3

Campylobacter spp. 0 5.4 0

Enteric Gram-negative rods 0 3.1 0

D. pneumosintes 0 2.3 0

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Frydman, Verdugo, Simonian, Kar Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 217

antibacterial therapy.Aa and Pg are highly associated withimmunomodulation and skewing of the immune responsethrough the influence of their lipopolysaccharides.16 Aahas also been shown to invade soft tissues and induce im-munomodulation through direct interaction with the hostimmune system.17 Systemic antibiotic therapy was suc-cessful in elimination of detectable levels of Aa at 5 years.Whereas periodontopathogen eradication may be an ulti-mate aim, the persistence of certain pathogens at low levels

may not hinder a stable long-term clinical outcome.18

Presence of a lower plaque index, translating to an overallreduction in the bacterial biofilm, underscores the signifi-cance of frequent periodontal supportive therapy whena patient’s self-care is limited.15 An increase in mainte-nance frequency appears to be essential for patients af-fected with Trisomy 21 because their self-compliance isgenerally challenged as a result of their physical and men-tal disability. n

FIGURE 4 Radiographic presentation after 4 years shows that all teeth were maintained within the mouth as well as minimal changes in bone levels.

TABLE 2 Clinical Findings in a Patient With Trisomy 21

Clinical Characteristic Baseline (%) 6 Weeks (%) 6 Months (%) 5 Years (%)

Sites with visible plaque 80 27 22 17

Sites with BOP 100 35 25 16

Sites with ‡5 mm PDs 38 59 8 7

Sites with 4 mm PDs 30 25 17 7

Sites with £3 mm PDs 32 16 75 86

Sites with mobility Class 1 12 12 29 8



Sites with recession 32 44 40 56

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218 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Trisomy 21–Associated– Aggressive Periodontitis

Summary

Why is this case new information? n Provides long-term follow-up in management of an aggressive form ofdisease in a specific population

n Provides a dynamic treatment approach in a patient population thatoften presents with limited treatment options

n Reveals methods of using both antibiotics and antimicrobials asadjuncts to therapy


n Frequent mechanical therapyn Use of antimicrobial agentsn Involvement of care takers as well as the patient when possiblen Understanding of the multifactorial nature of the disease presentationwithin this patient population


n Limited compliance with surgical interventionn Limited evidence of successful restorative options


CORRESPONDENCE:Dr. Alon Frydman, Herman Ostrow School of Dentistry of the Universityof Southern California, Dental Science Center, DEN 4375, 925 W. 34thSt., Los Angeles, CA 90089. E-mail: [email protected].

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References1. Cohen MM, Winer RA, Schwartz S, Shklar G. Oral aspects of

mongolism. I. Periodontal disease in mongolism. Oral Surg Oral MedOral Pathol 1961;14:92-107.

2. Mittwoch U. The polymorphonuclear lobe count in Mongolism and itsrelation to the total leucocyte count. J Ment Defic Res 1958;2:75-80.

3. Sakellari D, Belibasakis G, Chadjipadelis T, Arapostathis K, KonstantinidisA. Supragingival and subgingival microbiota of adult patients withDown’s syndrome. Changes after periodontal treatment. Oral Micro-biol Immunol 2001;16:376-382.

4. Barr-Agholme M, Dahllof G, Linder L, Modeer T. Actinobacillusactinomycetemcomitans, Capnocytophaga and Porphyromonas gingi-valis in subgingival plaque of adolescents with Down’s syndrome. OralMicrobiol Immunol 1992;7:244-248.

5. Hanookai D, Nowzari H, Contreras A, Morrison JL, Slots J. Herpes-viruses and periodontopathic bacteria in Trisomy 21 periodontitis. JPeriodontol 2000;71:376-384.

6. Allwork JJ, Edwards IR, Welch IM. Ingestion of a quadhelix appliancerequiring surgical removal: A case report. J Orthod 2007;34:154-157.

7. Slots J. Selection of antimicrobial agents in periodontal therapy. JPeriodontal Res 2002;37:389-398.

8. Jaramillo A, Arce RM, Herrera D, Betancourth M, Botero JE,Contreras A. Clinical and microbiological characterization of peri-odontal abscesses. J Clin Periodontol 2005;32:1213-1218.

9. Barr-Agholme M, Dahllof G, Modeer T, Engstrom PE, Engstrom GN.Periodontal conditions and salivary immunoglobulins in individualswith Down syndrome. J Periodontol 1998;69:1119-1123.

10. Sakellari D, Arapostathis KN, Konstantinidis A. Periodontal conditionsand subgingival microflora in Down syndrome patients. A case-controlstudy. J Clin Periodontol 2005;32:684-690.

11. Sreedevi H, Munshi AK. Neutrophil chemotaxis in Down syndromeand normal children to Actinobacillus actinomycetemcomitans. J ClinPediatr Dent 1998;22:141-146.

12. Reuland-Bosma W, van der Reijden WA, van Winkelhoff AJ. Absenceof a specific subgingival microflora in adults with Down’s syndrome.J Clin Periodontol 2001;28:1004-1009.

13. Saxen L, Aula S. Periodontal bone loss in patients with Down’ssyndrome: A follow-up study. J Periodontol 1982;53:158-162.

14. Pavicic MJ, van Winkelhoff AJ, Douque� NH, Steures RW, de Graaff J.Microbiological and clinical effects of metronidazole and amoxicillin inActinobacillus actinomycetemcomitans-associated periodontitis. A 2-year evaluation. J Clin Periodontol 1994;21:107-112.

15. Westfelt E, Bragd L, Socransky SS, Haffajee AD, Nyman S, Lindhe J.Improved periodontal conditions following therapy. J Clin Periodontol1985;12:283-293.

16. Tiranathanagul S, Yongchaitrakul T, Pattamapun K, Pavasant P.Actinobacillus actinomycetemcomitans lipopolysaccharide activatesmatrix metalloproteinase-2 and increases receptor activator of nuclearfactor-kB ligand expression in human periodontal ligament cells.J Periodontol 2004;75:1647-1654.

17. Saglie FR, Marfany A, Camargo P. Intragingival occurrence of Actino-bacillus actinomycetemcomitans and Bacteroides gingivalis in activedestructive periodontal lesions. J Periodontol 1988;59:259-265.

18. Teles RP, Haffajee AD, Socransky SS. Microbiological goals of peri-odontal therapy. Periodontol 2000 2006;42:180-218.


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220 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Trisomy 21–Associated Aggressive Periodontitis–

PRACTICAL APPLICATIONS

Basic Suture Techniques for Oral MucosaTerrence J. Griffin,* Yong Hur,* and Jing Bu†

Focused Clinical Question: What is the pre-ferred suture method for maintaining wound closure?

Summary: Optimal wound healing after surgicalprocedures requires good soft-tissue management.The final key step for a refined surgical technique is ade-quate closure by suturing. This article reviews the mostcommon suturing methods used in dentistry, and theirapplications in various periodontal surgeries are dis-cussed. The ninemost common periodontal suture tech-niques and six different periodontal surgical categorieswere selected by the periodontal faculty at Tufts Univer-sity School of Dental Medicine. A survey was distributedto periodontists in the United States, each of whom se-lected their choice of suture technique for each of theperiodontal surgical procedures. The results of this sur-vey show that simple interrupted sutures were used inthe majority for each surgical procedure.

Conclusion:Although suture selection and applica-tion is complex becauseofmultiple variables, an effortwasmade to establish a general consensus and current trendsregarding suturing techniques. Clin Adv Periodontics2011;1:221-232.

Key Words: Hemostasis, surgical; humans; surgicalflaps; sutures; suture techniques.

Soft-tissue healing in dental surgery depends on goodsurgical technique and soft-tissue management.1,2 Gentleflap manipulation, ideal incision placement, and appropri-ate suture techniques are required for optimal healing.3-7

Proper technique and material for suturing will promotewound healing through close approximation of the flapedges, minimized dead space, reduced postoperative bleed-ing, resistance to tension on the flap margins, and theprevention of infection.8-14

There are various suturing techniques used in dental ap-plications.15,16 Each technique has advantages and disad-vantages. The choice of suture technique comes with theunderstanding of the wound anatomy and the surgeon’spreference.17,18 With the proper technique, the dentist willbe able to overcome challenges, such as variations of theanatomy of the wound, tension of the flaps, thickness ofthe gingiva, and esthetic needs of the patient.

The purpose of this article is to review the basic suturingtechniques, their advantages and disadvantages, as well astheir applications in various periodontal surgeries. Thenine most common suturing techniques and six differentperiodontal surgical categories were selected by 25 peri-odontal faculty members at Tufts University School ofDental Medicine. An informal survey was sent out to peri-odontists in the United States to gauge the usage of eachsuture technique with various periodontal surgical proce-dures. Frequently, more than one suture technique is usedin a surgery. These survey results were tabulated, and thegeneral consensus for the applications of each suture tech-nique will be discussed.

Principles of SuturingAvoid Excessive Tension on SuturesExcessive tension on wounds will result in the blanching ofthe flaps and wound edges. This may result in necrosis atthe wound edge as a result of interference of the blood sup-ply (Fig. 1). Another complication is tearing of the flap bythe suture, resulting in ‘‘tracks,’’ which are small cuts left bythe suture as it dissects through the tissue. These tracks of-ten contribute to flap retraction, graft exposure, and post-operative pain.

Suture Whenever Possible From Movable toImmovable TissueThis allows formore precise positioning of tissue edges andbetter wound closure. It is easier to control the suture nee-dle andmanage the flap if themoveable tissue (i.e., the flap)is approximated to a steady base.

Always Try to Keep Knots Away FromWound EdgesKnots are both the most irritating and weakest part of anysuture technique. For this reason, place the knots so thatthey are away from the wound edges whenever possible.

Use as Few Knots as PossibleThis is a corollary to the previous principle for much thesame reasons. Avoid knots whenever possible because theyrepresent the weakest part of any wound closure and at thesame time can be the greatest irritant.

Use the Smallest Suture Possible toClose the WoundIt is generally better to use several small sutures rather thana lesser number of large-gauge ones. A number of smallersutures are less irritating to the tissues than a larger one,

* Department of Periodontology, Tufts University School of DentalMedicine, Boston, MA.

† Berkshire Medical Center, Pittsfield, MA.

Submitted May 10, 2011; accepted for publication July 19, 2011

doi: 10.1902/cap.2011.110053


especially if it is a multifilament material. In addition,smaller sutures result in smaller perforations than largersutures and heal much more quickly. Several smaller su-tures are better able to secure the wound and less likelyto result in tissue tears because they do not weaken the in-tegrity of the tissue as much.

Use the Least Amount of Sutures That WillSecure the WoundDo not over-suture. Excess suturing causes needless perfo-ration of the tissues bordering the wound and interfereswith the blood supply. This will, in turn, affect the integrityof the wound and its healing.

Advantages and Disadvantagesof Continuous SuturesMany surgeons prefer continuous suture techniques overinterrupted sutures. Both techniques have advantages anddisadvantages.19

Continuous Sutures: AdvantagesThe advantages of continuous sutures include: 1) involvingas many teeth as required; 2) minimizing the use of knots;3) using teeth to anchor the flap; 4) eliminating the needfor periosteal sutures; 5) enabling independent placementof buccal, lingual, or palatal flaps; and 6) requiring less timefor both placement and removal.

Continuous Sutures: DisadvantagesIf breakage or resorption occurs anywhere along its length,a portion of or the entire flap may loosen, exposing bone,implants, grafts, etc. The entire suture is only as secure as itsweakest knot.

Primary and Secondary Suture LineSecondary Suture LineThe secondary suture line (Fig. 2a) is used to give strength towound closure and compensate for muscle and soft-tissuepull. The suture line is usually away from the wound edges.It is used as an adjunct to the primary suture line by takingstress away from the edges of the wound. After using a sec-ondary suture line, a primary suture line is usually used toclose the edges of the wound and complete closure.

Primary Suture LineThe primary suture line (Fig. 2b) is themost common type ofsuture line used in surgery. This suture line is used to closethe incision. It is usually the only type of suture used exceptin largewounds inwhich resistance tomuscle and soft-tissuepull and wound security are of paramount importance.

Handling the NeedleThe needle consists of the needle point, the body, and theswaged end (Fig. 3). The needle point is sharp and is de-signed to pierce through tissues. Designs of the body includereverse cutting edge, tapered point, tapered cut, or conven-tional cutting edge. For the most part, the reverse cuttingedge is used because it prevents the needle from tearingthrough the tissue as the needle cuts through the tissue.The swaged end is pressed fitted around the suture line toprovide smooth passage of the needle through the tissue.

The needle holders have a cross-hatching pattern of teethfor its beak. This prevents the needle from being damaged aswell as gripping the needle adequately. Maximal control ofthe needle is achieved when the needle is held approximatelytwo thirds the length of the needle from the needle pointand z3 mm from the tip of the beak of the needle holder(Fig. 4). Gripping the needle point or swaged end should beavoided to prevent damage to the cutting edge or damage tothe swaged end. When suturing, the needle tip should pierceperpendicular to the soft tissue.Small circular twistsof the fore-arm should be used to pass the needle through the soft tissue.

Periodontal SutureTechniquesInterrupted Suture TechniquesSimple-Loop (Interrupted) SutureTechnique

This is the most commonly used suturetechnique in dentistry. It can be appliedinmost periodontal procedures to closeelevated flaps and vertical and horizon-tal incisions and to stabilize soft tissues.

FIGURE 1 Flap necrosis attributable to excessive swelling and tension forthe wound edges.

FIGURE 2a Horizontal-mattress sutures placed as a secondary suture line to approximate the woundedge. 2b Simple-loop interrupted sutures used to close the wound as a primary suture line.

P R A C T I C A L A P P L I C A T I O N S

222 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Dental Suture Techniques

The technique is as follows (Fig. 5) (Video 1):

n Pierce the outer surface of the buccal flap with the sutureneedle.

n Thread the needle under the interproximal contact andpierce the inner aspect of the lingual flap with the sutureneedle.

n Pass the suture needle under the interproximal contacttoward the buccal aspect.

nTie off the free ends of the suture. Cut off the suture, leav-ing 2 to 3 mm of suture material.

Figure-Eight (Interrupted) Suture Technique

This is another very commonly used suture technique indental surgery and is frequently confused with the simpleloop. The indications for its use are similar to simple-loopinterrupted sutures. The main advantage is easier access

between the teeth. A disadvantage is that there will be in-terposed suture material between the flaps that may pre-vent ideal approximation of the flap edges compared tothe simple-loop interrupted suture technique.


n Pierce the outer surface of the buccal flap with the sutureneedle.

n Thread the needle under the interproximal contact andpierce the outer aspect of the lingual flap with the sutureneedle.

n Pass the suture needle through the interproximal contactand tie and cut off the remaining suture, leaving 2 to 3mm.

Vertical-Mattress (Interrupted) Suture Technique

The vertical-mattress suture technique allows for precise flapandpapilla placement. It is oftenused in conjunctionwithperi-osteal sutures. It is frequentlyused inperiodontal resective ther-apy and guided tissue regeneration (GTR) procedures.


n Pierce the buccal flap just above the mucogingival junc-tion, anchoring the flap to the underlying periosteum.

n Note that the underlying periosteum has not been re-flected to engage.

n The needle should emerge from the center of the papilla2 to 3 mm from the flap edge.

n Pass the needle through the contact area and anchor thelingual flap the same way, starting from the center of thelingual papilla 2 to 3 mm from the flap edges.

nThread the needle through the interproximal contact andtie and cut the suture on the buccal side, leaving 2 to 3mm of suture material.

Horizontal-Mattress (Interrupted)Suture Technique (Including ` X`Modification)

The design of the horizontal-mattresssuture technique resists flap tensioncausedbymusclepullandsoft-tissuecon-traction. However, additional suturesare necessary to approximate the woundedges. The reason for this is that thehorizontal-mattress suture is a secondarysuture line.Theplacementof the suture isaway from the wound edges and doesnot provide complete closure of thewound edges. Primary suture linesare then placed to hold the woundedges together so that healing canoccur by primary intention. This su-ture can be left for an extended timesuch as in augmentation procedures.

The technique is as follows (Fig. 8)(Video 4):

FIGURE 4 Handling the needle holder. 4a Note that the index finger position allows for precise control ofneedle holder. 4b Use of thumb and ring finger permits the index finger to control the delicate movements.4c Castroviejo with pen grip. 4d Needle was grasped at two thirds of the diameter of the needle.

FIGURE 3 Anatomy of a needle.


Griffin, Hur, Bu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 223

n Pierce the external side of the buccal flap 3 to 4 mm fromthe flap margin.

n Pierce the internal side of the lingual flap 3 to 4 mm fromthe lingual flap margin.

n Penetrate the external side of the lingual flap 5 mm lat-erally from the second piercing.

n Pass the needle through the internal side of the buccal flapand tie the free ends.

Sling (Interrupted) Suture Technique

The indication for the sling suture is the need for re-positioning flaps in a coronal direction with additional

anchorage the teeth. The ability to varythe tension and vertical position of theflap to a tooth or implant allows the sur-geon good control of the extra forces ofthe flap.


n Pierce the outer aspect of the flap atits distal end and pass the needle un-der the interproximal contact.

n Wrap the suture mesially around thetooth and pass the needle throughthe interproximal contact and piercethe inner aspect of the flap.

n Thread the suture needle through themesial interproximal contactandwrapthe suture around the tooth, goingdistally.

n Pass the suture needle through the dis-tal interproximal contact and tie andcut the suture, leaving 2 to 3 mm ofsuture material.

Continuous Suture TechniquesContinuous Interlocking SutureTechnique

This is used for long edentulous spans,such as implant placements, ridge aug-mentations, or reductions. It is a quickand efficientwayof closing longhorizon-tal or vertical incisions.


n From the distal end, tie a simple loopand cut off only the free end.

n Pierce both flapmargins 5mm laterallyfrom the simple loop.

n Thread the needle under the last hor-izontal span.

n In increments of 5 mm from the lastlockingsegment,piercebothflapmar-gins until the entire span is closed.

n Leave a small loop of suture on the final segment afterpiercing both flap margins.

n Use the loop of suture to tie off the suture. Cut off all ex-cess ends, leaving 2 to 3 mm of material.

Continuous Horizontal-Mattress SutureTechnique

The continuous horizontal-mattress suture technique includes:

n Initial suture placement of simple-loop interruptedn Horizontal extension of the suture

FIGURE 5 Simple-loop interrupted suture technique. 5a Initial suture placement. 5b Lingual flappiercing. 5c Tying of the knot. 5d Clinical application.

FIGURE 6 Figure-eight interrupted suture technique. 6a Initial suture placement. 6b Lingual flappiercing. 6c Tying of the knot. 6d Clinical application.



n Locking of the suturen Final loopn Tying the suturen Clinical application

The continuous horizontal-mattress suture is an efficientway of obtaining secure adaptation of opposing flaps inedentulous areas. It will resist tension on the flaps frommuscle pull and will evert the flap edges and cause dehis-cence. Applications for the continuous horizontal-mat-tress technique are implants and regenerative procedures.Like with the simple interrupted horizontal-mattress tech-nique, it is used as a secondary suture line and will requireanother suture to maintain the approximation of the flapedges.


nTie a simple loop on the distal aspect and cut the free end.n Pierce both flaps 5 mm from the initial simple loop.nContinue the piercings in increments of 5mm, alternating

between buccal and lingual flaps.nOn the final segment, leave a small loop of suturematerial

after piercing both flaps.n Use the loop of suture to tie the suture. Cut off all excess

ends, leaving 2 to 3 mm of excess.

Continuous Vertical-MattressSling-Suture Technique

Continuous vertical-mattress suturescan be used for resective procedures toposition the flap apically and to preventthe recurrence of periodontal pockets. Itis frequently used for flaps in osseousand crown-lengthening procedures.


n Starting from themesial aspect, tie aninterrupted vertical-mattress sutureand cut off the free end.

n Wrap the suture distally around thetooth on the buccal aspect and performaverticalmattresson the lingual aspect.

n Pass the needle through the contactarea and perform a vertical mattresson the buccal aspect.

nAlternate the side of the placement ofthe vertical mattress and the slingthrough the entire span.

n Leave a small loop of suture on thefinal segment.

n Use the loop of suture to tie off thesuture.

Continuous Independent Sling-Suture Technique/ContinuousDependent Sling-SutureTechnique

Continuous independent sling sutures are indicated whena flap with multiple papillae are elevated on a single side.This is an extension of the sling-suture technique.The technique canbe applied for theother side if both sides

are elevated. The continuous dependent sling-suture tech-nique canbe used aswell if the surgery involves a periodontalflap for both sides. Surgeries that may require a muco-peri-osteal flap for both sides include osseous surgeries, crown-lengthening procedures, and open-flap debridement. Thecontinuous dependent sling-suture technique has a betterability to vary flap tension than the continuous independentsling-suture technique.

For continuous independent sling sutures, the technique isas follows (Fig. 13) (Video 9):

n Tie a simple loop and cut off the free end.n Sling around the tooth on the lingual side.n Pass the needle through the contact area and anchor the

buccal flap by piercing the center of the papilla z2 to 3mm from the flap margins.

n Continue the sling on the lingual side until the span isclosed.

n On the final segment, leave a loop of suture. Tie off thefree ends of the suture using the loop of suture.

FIGURE 7 Vertical-mattress interrupted suture technique. 7a Initial suture placement. 7b Note theengagement of the periosteum. 7c Buccal view with the second piercing. 7d Lingual flap piercing. 7eTying of the knot. 7f Clinical application.



For continuous dependent slingsutures, the technique is as follows(Fig. 14):

n Enter the outer aspect of the buc-cal flap from the mesial aspect andleave a free end.

n Pass the needle through the contactarea, first pierce the opposite sideflap from the inner aspect, and thenreturn the needle to the buccal as-pect where you tie off to the remain-ing free end. The papillae should beanchoredbypiercing 2 to3mmfromthe flap margins.

n Continue the sling around the lin-gual aspect and pierce the buccalflap from the outer aspect.

n Pass the needle under the contactarea and pierce the lingual flap fromits inner aspect.

nReturn the needle to the buccal aspectand then wrap around the tooth toenter the contact area of the next dis-tal tooth.

n Pierce the underside of the lingualflap and return to the buccal aspectwhere the inner side of the buccalflap is pierced.

n Now, return through the contactarea where a sling is formed distallyand then the inner aspect of the buc-cal flap is engaged.

n Continue distally by anchoring theflaps by alternating between thebuccal and lingual sides until the en-tire span is secured.

n On the final segment, leave a largeloop to tie off the free ends of thesuture.

National Survey of CurrentPeriodontal SutureTechniquesThe nine most common suturing tech-niques and six different periodontalsurgical categories were selected by25 periodontal faculty members atTufts University School of DentalMedicine. The protocol was approvedby the Tufts Medical Center Institu-tional Review Board. A survey wassent out to periodontists in the UnitedStates to gauge the usage of each suturetechnique with various periodontal sur-gical procedures. These survey resultsreflect the general consensus for theapplications of each suture technique.

FIGURE 8 Horizontal-mattress interrupted suture technique. 8a Initial suture placement. 8b Lingual flappiercing. 8c Second piercing on the lingual side. 8d Second piercing on the buccal side. 8e Tying of theknot. 8f Clinical application.

FIGURE 9 Sling-suture technique. 9a Initial suture placement. 9b Piercing after sling around the tooth. 9cTying the suture after the second sling. 9d Clinical application.



The nine suturing techniques in-cluded: 1) simple-loop (interrupted);2) figure-eight (interrupted); 3)vertical-mattress (interrupted); 4)horizontal-mattress (interrupted);5) sling (interrupted); 6) continuousinterlocking; 7) continuous horizontal-mattress; 8) continuous vertical-sling;and 9) continuous independent sling/continuous dependent sling.

The six categories of periodontalsurgeries were: 1) crown lengtheningor periodontal resective procedurewithout pocketing; 2) flap surgerywith osseous recontouring or otherresective procedures; 3) GTR; 4)soft-tissue grafting, such as free gingi-val graft or subepithelial connective tis-sue graft; 5) implant therapy withoutguided bone regeneration (GBR) proce-dures; and 6) GBR procedures or max-illary sinus augmentation.

ResultsFor crown lengthening and peri-odontal resective procedures withoutperiodontal pockets, the interruptedsimple-loop suture was used by 41.5%of the periodontists surveyed. The in-terrupted vertical-mattress suture wasused by 21%, whereas the continuoussling was used by 17% of the polledperiodontists. The continuous verticalmattress sling was used by 9.2% of therespondents. The other techniques eachattained a usage of <6% (Fig. 15).Flap surgery with osseous recon-

touring and other resective periodon-tal procedures again had interruptedsimple-loop sutures as the majority,coming in at 36.3%usage. Continuoussling sutures came in at a close secondat 26.2%use, whereas both continuousand interrupted vertical-mattress slingsutures gained the vote of 13.6% fromthe respondents. Other techniques eachwere used <7% of the time (Fig. 16).

With GTR, interrupted simple-loopsutures were used by 35.4% of thedentists. Interrupted vertical-mattresssutures were used for GTR by 28.7%.Interrupted horizontal-mattress su-tures were used by 10.9% and inter-rupted sling sutures were used by8.4%. The other techniqueswere eachused <5% by the polled periodontists(Fig. 17).

FIGURE 10 Continuous interlocking suture technique. 10a Initial suture placement of simple-loopinterrupted. 10b Horizontal extension of the suture. 10c Locking of the suture. 10d Final loop. 10e Tyingthe suture. 10f Clinical application.

FIGURE 11 Continuous horizontal-mattress suture technique. 11a Initial suture placement of simple-loop interrupted. 11b Horizontal extension of the suture. 11c Tying the suture. 11d Clinical application.



The interrupted simple-loop suture once again was usedmost frequently (46.1%) with soft tissue grafts such as thefree-gingival, or subepithelial connective tissue grafts. In-terrupted sling sutures were used 23.9% and continuoussling sutures was used 13.2% of the time. The other tech-niques were each used £5% of the time (Fig. 18).

Implant therapy without GBR was predominantly donewith interrupted simple-loop sutures. Interrupted simple-loopsutures were overwhelmingly used in 74.2% of the cases.Other techniques each were used <8% of the time (Fig. 19).

GBRwas generally sutured using simple interrupted suturesat 42.9% from the responding periodontists. Continuous

FIGURE 12 Continuous vertical-mattress sling-suture technique. 12a through 12c Vertical-mattress interrupted suture. 12d through 12f The second verticalmattress after buccal sling. 12g Continuation of the vertical mattresses after lingual sling. 12h Tying the suture. 12i Clinical application.

FIGURE 13 Continuous independent sling-suture technique. 13a and 13b Initial sling suture without tying. 13c Sling sutures on the same side on the buccalaspect. 13d and 13e Continuation on the lingual sling sutures. 13f Tying the suture.



sutures were frequently used at 18.6%,interrupted horizontal-mattress suturesat 15.8%, interrupted vertical-mattresssutures at 9.5%, and all other tech-niques each came in at <5% (Fig. 20).

DiscussionThe goal of this survey was to deter-mine the indications of each suturingtechnique for various periodontal sur-gical procedures for ideal conditions.Themethodology is simpledpollprac-ticing periodontists in what suturingtechnique they preferred to use foreach surgery type and then tabulatethe results. The suturing techniquewith the most number of votes clearlysupports that technique while tech-niques with the least number of voteswould mean that the technique is notwidely used.The survey results show that for

each of the various periodontal pro-cedures the interrupted simple-loop suture was the mostprevalent technique. However there were other techniqueswere used significantly aswell. In crown lengthening, inter-rupted vertical-mattress and continuous sling sutures wereused frequently. With flap osseous surgery, continuoussling and interrupted vertical-mattress sutures were usedfrequently. Implants without GBR were sutured primarilywith only simple interrupted sutures.

In GTR, interrupted vertical-mattress, interrupted hori-zontal-mattress, and interrupted sling sutures were usedwith themajority of periodontists.Comments left by the sur-veyed periodontists about this procedure stated that theyused multiple suture techniques for this type of surgery. In-terrupted sling sutures were frequently used to stabilize themembranes, whereas vertical- or horizontal-mattress su-tures were used to secure the flaps.

Soft-tissue grafts predominantly were sutured using eithercontinuous or interrupted sling sutures. The choice ofwhether to use a continuous or interrupted sling is dependenton the size of the site. A combination of sutures can be usedfor soft-tissue grafts, such as sling sutures on the recipient siteand horizontal-mattress sutures on the donor site. Anothercombination is with simple-loop interrupted sutures on therecipient site and sling sutures on the donor site. The choicein the various combinations is left up to operator preference.

The results revealed that the continuous interlocking suturewas frequently used for GBR. However, the combination ofhorizontal-mattress and simple-loop interrupted sutures wasthe most commonly used technique for this procedure.

The survey was simplified by allowing only a single choiceper surgical procedure. However, multiple suture techniquesare often required because of the complexity of the periodon-tal surgery, adjacent anatomy, and the operator’s preference.This survey did not have the depth to address this concern.We tried to overcome this shortcoming by addressing the

FIGURE 14 Continuous dependent sling-suture technique. 14a Initial sling suture. 14b and 14c Alternatethe placements of sling sutures. 14d Loop positions.

FIGURE 15 The usage of various suture techniques for crown lengtheningor periodontal resective procedure without pocketing. n ¼ 523.

FIGURE 16 The usage of various suture techniques for flap surgery withosseous recontouring or other resective procedures. n ¼ 523.



comments from the periodontists surveyed and integratingthem into a streamlined decision tree.

Suturing is empirical, so there is limited evidence to choosesuperior techniques. We propose a decision tree to aid thedentist in selecting the optimal suture technique basedon surgical goals and their experience (Fig. 21). In general,

interrupted sutures enable precise flap placement and bettercontrol compared to continuous sutures. In comparison,continuous sutures involve more efficient flap managementfor wide areas with less knotting.

n The simple-loop technique is easy to place and can beused in diverse applications.

nThe figure-eight technique can be applied in interproximalpapillae with limited access to approach under the flap.

n The horizontal-mattress technique is indicated whenmuscle pull will place tension on the flap.

n The vertical-mattress technique can be combined withperiosteal suture for apically positioned flap when theperiosteum is not reflected from the bone.

n Sling sutures can be used when additional coronal an-chorage is needed.

n Continuous interlocking sutures can be used to closea long-spanning edentulous ridge.

n The continuous horizontal-mattress technique has thesame indications as the interrupted horizontal-mattresstechnique for wide soft- and hard-tissue augmentationas a secondary suture line.

n The continuous vertical-mattress technique is indicatedfor resective surgeries for multiple teeth requiring api-cally positioned flap.

n The continuous sling-suture technique can be used forwide periodontal procedures with need of additionalanchorage.

ConclusionsKnowledge of the various suture techniques is required forthe optimal surgical wound healing in dentistry. There is nosingle technique that is the best choice because of the sophis-ticated characteristics of periodontal procedures. In this ar-ticle, the most common suture techniques in periodontalprocedures are reviewed. The survey tried to show the cur-rent trend of the selection of suturing techniques based onthe type of surgery. It is very important for the dentist toknow the current techniques and their clinical applica-tions to promote optimal healing of surgical wounds. n

FIGURE 17 The usage of various suture techniques for GTR. n ¼ 523.

FIGURE 18 The usage of various suture techniques for soft-tissuegrafting, such as free gingival grafts or subepithelial connective tissuegrafts. n ¼ 523.

FIGURE 19 The usage of various suture techniques for implant therapywithout GBR procedures. n ¼ 500.

FIGURE 20 The usage of various suture techniques for GBR procedures ormaxillary sinus augmentation. n ¼ 506.



AcknowledgmentThe authors report no conflicts of interest related to thisstudy.

CORRESPONDENCE:Dr. Terrence J. Griffin, Department of Periodontology, Tufts UniversitySchool of Dental Medicine, 1 Kneeland St., Boston, MA 02111. E-mail:[email protected].

FIGURE 21 Selection of proper periodontal suture technique.



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J Am Acad Dermatol 2001;44:265-272.

2. Adams B, Levy R, Rademaker AE, Goldberg LH, Alam M. Frequencyof use of suturing and repair techniques preferred by dermatologicsurgeons. Dermatol Surg 2006;32:682-689.

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4. Ratner D, Nelson BR, Johnson TM. Basic suture materials and suturingtechniques. Semin Dermatol 1994;13:20-26.

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PRACTICAL APPLICATIONS

Crown Lengthening RevisitedMarianne Ong,* Shih-Chang Tseng,† and Hom-Lay Wang‡

Focused Clinical Question: What are the keyconsiderations in selecting the best approach to crownlengthening?

Summary: Crown lengthening is a surgical proce-dure that involves manipulation of either soft tissue orboth soft and hard tissue around a tooth or teeth for es-thetic or restorative purposes. Esthetic crown lengtheningis indicated in patients with excessive gingival display(knownasagummysmile) or gingival overgrowth,whereasrestorative (or functional) crown lengthening aims to gainretention and resistance form of sound tooth structureabove the alveolar crest level in cases of subgingival car-ies, subgingival restorative margins, or tooth fracture.Both aim to increase the amount of supragingival toothstructure for esthetic and/or restorative purposes.

Conclusions: In selecting the type of procedure foresthetic or restorative (or functional) crown lengthening,the key considerations include assessment of the widthof keratinized gingiva and distance of the cemento-enamel junction or finished restoration margin to alveolarbone around the tooth/teeth involved. This article reviewsand presents a decision tree in the use of both types ofprocedures. In addition, the subtle differences betweenesthetic and restorative (or functional) crown lengtheningare highlighted. Clin Adv Periodontics 2011;1:233-239.

KeyWords: Crown lengthening, methods; decision trees;esthetics, dental; gingival hyperplasia, surgery; toothcrown, pathology; wound healing, physiology.

BackgroundCrown lengthening aims to increase the clinical crownlength of a tooth or teeth for either esthetic or restorativepurposes or a combination of both. The surgical procedureis designed to increase the extent of the supragingival toothstructure by apically positioning the gingival margin,removing supporting bone, or both.1 Factors taken intoconsideration include excessive gingival display (known asa gummy smile), altered passive eruption (in which thealveolar crest is £2 mm from the cemento-enamel junction

[CEJ]), lack of tooth structure, or access for restorativepurposes (requiring the removal of soft or hard tissue ora combination of both) and the adjacent periodontium ofneighboring teeth. Indications for crown lengthening thusinclude teeth with subgingival caries or extensive caries thatshortens the tooth, fractures, and short clinical crownscaused by incomplete exposure of the anatomic crowns.

The procedure is based on two principles: biologic width(BW) establishment and maintenance of adequate kerati-nized gingiva (KG) around the tooth. The BW is definedas the dimension of soft tissue that is attached to the por-tion of the tooth coronal to the alveolar bone crest.2,3 Stud-ies indicate that a minimum of 3 mm of space betweenrestorative margins and alveolar bone would be adequatefor periodontal health, allowing for 2mmof BW space and1 mm for sulcus depth.4,5 An adequate width of KG shouldbe maintained around a tooth (‡2 mm) for gingival healthwhenever possible.6 This article presents guidelines forboth types of crown lengthening, their indications and dif-ferences, and a decision tree in deciding when to use theprocedures.

Esthetic Crown LengtheningCrown lengthening for esthetic reasons aims to correct ei-ther a gummy smile or gingival overgrowth (Fig. 1). Theperiodontal status of the involved teeth is first assessed.In the presence of periodontal disease with an absence ofgingival overgrowth, regular periodontal treatment will re-solve the gingival inflammation and swelling with removalof local irritating factors. In cases in which tissues are in-flamed with the presence of gingival overgrowth, a gingi-vectomy/gingivoplasty procedure may be indicated if thegingival overgrowth persists even after gingival inflamma-tion has been reduced through initial periodontal therapy(e.g., in drug-induced gingival enlargements associatedwith cyclosporin and/or calcium channel blockers).

For a gummy smile with a healthy periodontium, the pa-tient’s facial proportion has to be assessed. A normal hu-man face is divided into thirds, and 2 to 3 mm of toothis usually shown with relaxed lips.7,8 If the facial propor-tion is normal, shallow probing depths (<4 mm) may indi-cate tooth malposition, and this can be corrected withorthodontic intrusion; deep probing depths (‡4 mm) mayindicate altered passive eruption (delayed apical migra-tion of the gingival margin), and this can be correctedwith crown-lengthening surgery. Vertical maxillary excess(VME) is a dentofacial condition associated with excessivevertical growth of the maxilla. Patients with VME maypresent with either a dental open or closed bite. An in-creasedmandibular ramus height is associated with the lat-ter.9 If the patient has VMEwith ‡8mmof gingival display,

* Department of Restorative Dentistry, National Dental Centre, Singapore.

† Private practice, Taipei, Taiwan.

‡ Department of Periodontics and Oral Medicine, University of MichiganSchool of Dentistry, Ann Arbor, MI.

Submitted May 2, 2011; accepted for publication June 7, 2011

doi: 10.1902/cap.2011.110048


then orthognathic surgerywould be the treatment of choiceto address the problem. Garber and Salama10 presentedthree classifications for excessive gingival display and theirproposed treatments. Degree I had 2 to 4 mm of gingivaldisplay, and treatment would be orthodontic intrusionalone, orthodontics and crown lengthening or crownlengthening followed by restorations. Degree II had 4 to8 mm of gingival display, and treatment would be crownlengthening and restorations or orthognathic surgery de-pending on the crown/root ratio. Degree III had ‡8 mmof gingival display, and treatment would be orthognathicsurgery with or without crown lengthening and restorativetreatment. A decision tree for management of a gummysmile is illustrated in Figure 2.

The amount of KG present around teeth and the distanceof the alveolar bone crest level in relation to the CEJ (CEJ–bone) is next determined clinically and radiographically.One of four possible treatment modalities may be consid-ered as described by Coslet et al.11 For Type I cases withadequate KG (‡2 mm), if CEJ–bone is ‡2 mm (subgroupA), a gingivectomy/gingivoplasty procedure can be done.If CEJ–bone is <2 mm or CEJ is at the same level as the

alveolar bone crest (subgroup B), thena flap with osseous surgery is done. InType II cases with inadequate KG (<2mm), an apically positioned flap (APF)is indicated for subgroup A. For sub-group B, an APF with osseous surgeryis done. Figure 3 illustrates a decisiontree for surgical crown lengthening.

The initial incision uses the CEJ asa reference point and follows the es-thetic smile line, ensuring that ‡2 mmof KG remains on the buccal aspectof teeth. A surgical stent may be usedto assist in placement of the buccal in-cisions according to the esthetic smileline. Only the buccal flap is raisedas a full-thickness flap and a partial-thickness flap raised over the interden-tal papillae area with the papillae leftintact. No vertical releasing incisionsare made, and a palatal flap is notraised. The CEJ–bone distance is as-sessed with a periodontal probe, and,when necessary, bone is removed onlyat the mid-buccal area, flushing it to-ward the mesio- and disto-buccal lineangles to establish the BW; carbide, di-amond round burs, and end-cuttingburs are used. The buccal flap is nextplaced at the level of the CEJ or slightlyabove it. Horizontal positional suturesare used to secure the flap in place. Awound dressing is not necessary overthe surgical site.

Based on wound healing principlesand studies,12-16 tissue maturation is

completed within 4 to 6 weeks if only a gingivectomy/gin-givoplasty was done. If a buccal flap was raised and boneexposed, then 8 to 12 weeks would be required for tissuematuration and stabilization. If bone was removed, then‡6months would be required for soft-tissue stabilization.17

A secondary surgery may be needed to refine the estheticoutcome of the smile line 6 to 12 weeks later.

Restorative (or Functional) CrownLengtheningCrown lengthening for restorative reasons include increas-ing retention and to expose subgingival caries, fracture, orrestorative margins by increasing the amount of soundtooth structure above the alveolar crest (Fig. 4).

Depending on the clinical and radiographic presenta-tion, there are five modalities for this procedure.18-23 Fora tooth with a probing depth ‡4 mm and in the presenceof adequate KG, a gingivectomy/gingivoplasty procedureis done. If there is inadequate KG, then an APF is done.If there is a need to remove bone to establish BW, thenan APF with osseous surgery is done. If there is a need to

FIGURE 1 Esthetic crown lengthening. 1a Pretreatment. 1b Buccal incision made according to theesthetic smile line. 1c Full-thickness buccal flap reflected and interdental papillae left intact; note CEJ atalveolar bone crest (i.e., case Type IB: adequate KG ‡ 2 mm and CEJ–bone <2 mm). 1d After osseoussurgery, 2- to 3-mm BW established. 1e Sutures in place. 1f Seven months after treatment. (photoscourtesy of Dr. Giorgio Pagni).


234 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Crown Lengthening

preserve adjacent structures and interdental papillae onneighboring teeth (e.g., fractured tooth in the anterior re-gion), then orthodontic forced eruption of the tooth isdone, which may require crown lengthening later. If thecrown-lengthening procedure would create an undesirablecrown/root ratio or induce more damage to the surroundingperiodontium of adjacent teeth, then an extraction should beadvised and a dental implant replacement can be consideredat a later time.

There is a possibility of reviolating the BW during toothpreparation after the crown-lengthening surgery healingperiod, especially in areas of limited access, such as the dis-tal line angles of a tooth. Immediate temporization crownlengthening has been described to alleviate this problem. Itaims to create an adequate BW by establishing the finishmargin of the restoration and fabricating a provisional res-toration at the time of surgery.24

Before surgery is performed, an impression is taken ofthe dental arch with the tooth to be crown lengthened

for awax-up of the crown. Avacuformis prepared for the provisional restora-tion. Initial preparation of the tooth isdone, and the prefabricated vacuformis used to make the provisional res-toration. Incisions are made on thebuccal and palatal/lingual aspects,following the APF concept, ensuringthat ‡2 mm of KG remain on the buc-cal and lingual aspects of the flaps formandibular teeth. For maxillary teeth,the palatal flap incision is one half totwo thirds of the palatal probing depth(an enhanced scalloped incision) be-cause the flap cannot be apically posi-tioned as a result of the immobility ofthe palatal tissue. Vertical releasing in-cisions are usually placed to assistin apically positioning the flap on thebuccal aspect. Buccal and palatal/lingual flaps are raised, and the finishmargin of the restoration is establishedto the best of the operator’s ability dur-ing the surgery. The provisional res-toration is then relined. With thefinished restoration margin (FRM)as a reference, the BW is establishedaround the tooth by removing boneto ‡3 mm below the FRM. If a ferruleeffect is required for endodonticallytreated teeth that need to be restoredwith a cast post and core, then 4 to 5mm of clearance is needed from thefinish margin to the alveolar bone.25,26

Osseous surgery is done with carbide,diamond round burs, and end-cuttingburs circumferentially around the tooth.

In some instances, an alternative toosseous resection alone would be to re-

shape the existing tooth/root surface in combination withconservative removal of supporting alveolar bone to createthe BW. Reshaping of the external surface or periphery ofthe tooth and the core buildup restoration aims to advancethe restoration coronally and minimize the amount of ostec-tomy required to create the BW.27

The provisional restoration is cemented on to the tooth.The buccal and palatal/lingual flaps are placed at the al-veolar bone crest and sutured. A vertical mattress suture isused to close the flaps if crown lengthening involved a singletooth. If crown lengthening involved multiple teeth, a con-tinuous sling suture may be used instead. A periodontaldressing is often used to protect the surgical site and to as-sist in positioning the flap apically.

Because bone removal is done during the procedure,a minimum of 6 months is needed for complete tissuematuration and stabilization before cementation of thefinal restoration.17 The development of black triangles be-tween teeth usually occurs if the post-surgery distance

FIGURE 2 Decision tree for management of a gummy smile (excessive gingival display). PD ¼ probingdepth.


Ong, Tseng, Wang Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 235

between the contact area and the interdental alveolarcrest is >5 mm.28 Thus, as a result of establishing theBW around the tooth, the interdental spaces becomelarger and the final restoration usually ends up witha square-looking crown and long contact points to closeup these spaces.

DiscussionVarious factors need to be taken into consideration forsurgical crown-lengthening indications of a tooth. Theseinclude the strategic value of the tooth, apical extent offracture or caries, level of the alveolar crest, and crown/root ratio before and after surgery. With the advent of im-plant dentistry, surgical crown lengtheningmay be contrain-dicated in cases with an unfavorable crown/root ratio,preexisting tooth mobility, possibility of compromising thesupport of the adjacent dentition, and in esthetic areas.22,23

The decision-making process in managing a gummysmile and techniques for crown lengthening under variousclinical scenarios are illustrated in Figures 2 and 3. The dif-ferences between esthetic and restorative (or functional)crown lengthening are summarized in Table 1.

Both procedures aim to establish theBWaround the tooth and to maintainan adequate width of KG for differentpurposes: one to create an estheticsmile line and the other to recreatethe BW tomaintain periodontal healtharound a tooth that needs to be re-stored. The reference lines with respecttomaking incisions and performing os-seous surgery are different: the CEJ foresthetic crown lengthening and theFRM for restorative crown lengthen-ing. The final outcomes also differ.With esthetic crown lengthening, oftenthe clinician is exposingmoreof the an-atomic crown height of the naturalteeth, with an esthetic smile resulting.In restorative crown lengthening, theteeth require restorations for a varietyof reasons and frequently estheticsare achieved with the final restorationshaving square-looking crowns andlong contact points.

ConclusionsThis article reviews esthetic and restorative (or functional)crown-lengthening procedures and highlights their indica-tions and differences. In addition, decision trees are pre-sented to aid the clinician in the decision-making process ofwhen these procedures should be used. n

AcknowledgmentsThis studywas partially supported by the University ofMich-igan Periodontal Graduate Student Research Fund. The au-thors thank Dr. Giorgio Pagni (private practice, Florence,Italy, and former resident, Graduate Periodontics at theUniversity of Michigan, Ann Arbor, MI) for providingFigure 1. The authors report no conflicts of interest re-lated to this study.

CORRESPONDENCE:Dr. Hom-Lay Wang, Department of Periodontics and Oral Medicine,University of Michigan School of Dentistry, 1011 N. University Ave., AnnArbor, MI 48109-1078. E-mail: [email protected].

FIGURE 3 Decision tree for surgical crown lengthening: esthetic and restorative (or functional). PD ¼probing depth.



FIGURE 4 Restorative (or functional) crownlengthening. 4a Pretreatment. 4b Initial crownpreparations done. 4c Vacuform placed to makeprovisional restorations. 4d Provisional restora-tions fabricated. 4e After flap reflection and soft-tissue debridement, finish margin of restorationsestablished and existing distance to alveolar bonedetermined. 4f End-cutting bur used for osseoussurgery to remove bone to ‡3 mm below finishmargin of restorations. 4g BW established aftersurgery. 4h Provisional restorations replaced. 4iProvisional restorations relined and subsequentlyadjusted and trimmed. 4j Sutures in place andprovisional restorations cemented. 4k Six monthsafter treatment with crown placement.



TABLE 1 Comparison Between Esthetic and Restorative (or Functional) Crown-Lengthening Surgery

Factors to Consider Esthetic Restorative (or Functional)

Goal To create an esthetic smile line and establish BW aroundthe tooth (2 to 3 mm)

To maintain periodontal health and establish BWaround the tooth (2 to 3 mm)

Reference line CEJ FRM

Techniques I (‡2 mm KG)

A: Gingivectomy/Gingivoplasty

B: Flap þ Osseous

Gingivectomy/Gingivoplasty

APF þ Osseous

Orthodontic forced eruption

II (<2 mm KG)

A: APF

B: APF þ Osseous

Incision Buccal only Buccal and palatal/lingual

CEJ (‡2 mm KG) and follow esthetic smile design Follow APF concept (leave ‡2 mm KG behind)

No vertical releasing incision Usually drop a vertical release to apically position flap

Surgical stent Often needed Not needed (use provisional crown)

Flap raised Buccal only (no raising of interdental papilla/palatal flap) Buccal and palatal/lingual

Osseous surgery Follow CEJ or esthetic smile line (alveolar crest 2 to 3 mmbelow CEJ)

Follow APF (alveolar crest ‡3 mm below FRM)

Osseous surgery location Only buccal side (not impinging on interproximal area) Both sides including interproximal area

Final flap position Located at CEJ or slightly above CEJ Located at bone crest

Recommended suture technique Horizontal positional Continuous sling/vertical mattress

Wound dressing Not necessary Often required

Healing period Soft tissue only (i.e., gingivectomy/gingivoplasty),4 to 6 weeks

Often 6 months because bone needs to be removedto recreate the BW

Bone exposed (i.e., flap raised), 8 to 12 weeks

Bone removed (i.e., osseous surgery), 6 months

Secondary surgery Often needed Not necessary (use restoration to make up the difference)

Final outcome An esthetic smile Square-looking crown(s), long contact point(s)



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