Perio-Esthetics

CONTENT

Root coverage procedures

Gummy Smile

Lip repositioning

Papilla reconstruction

Gingival depigmentation

NORMAL SMILE•Essentials of a smile

The teeth

Lip frame work

The gingival scaffold

1.Colour2. Size & Silhouette3. Position4. Incisal plane

THE LIPS• Define aesthetic zone • Classification of Liplines (Tjan et al.)

• Geometry of harmony

Low (20%) Average (70%) High (10%)

THE GINGIVAL SCAFFOLDS

1. Health2. Harmony and

continuity of form3. Symmetry central

incisors4. Balance to laterals,

cuspids and premolars

Gummy SmileDiagnosis and Rx

GUMMY SMILE• Excessive exposure of the maxillary gingiva during smiling

• Etiology:1. altered passive eruption,2. anterior dento-alveolar extrusion3. vertical maxillary excess,4. short or hyperactive upper lip,5. combination of these factors.

THE GUMMY SMILE- 1. Altered Passive Eruption (APE)

• Classification of APE by Coslet et al. (1977) based on amount of gingiva:• Type- I: Wide band of keratinized gingiva

• Type- II: Narrow to normal band of keratinized gingiva

• Type- I is subdivided based on the relationship of alveolar crest to the CEJ.• Type- IA: distance between crest and CEJ is more than

1.5 mm

• Type- IB: when the alveolar crest is at the level of CEJ

1 2 3 4

Type IA- APE Treatment

Type IB- APE Treatment

Treatment Options for APECondition Treatment

APE type IA Gingivectomy

APE type IB Apically displaced flap with osseous resection

APE type II Apically displaced flap with or without ossous resection

Gummy Smile-2. Vertical Maxillary Excess

Gummy Smile: 3. Hyperactive Upper Lip

• The average length of the maxillary lip:• 20‑22 mm in young adult females and

• 22‑24 mm in young adult males.

• According to Garber and Salama the normal shift of the upper lip during smiling is 6 to 8 mm and is increased by 1.5 to 2 times in cases of hyperactivity of the upper lip.

Rx modalities • botulinum toxin injection,• Lip repositioning• lip elongation associated with rhinoplasty,• detachment of lip muscles, and• mayectomy of lip

• Lip-repositioning surgery aims to limit the retraction of the elevator smile muscles.

Lip repositioning(Rubinstein and Kostianovsky) 1973

Modifications

• Litton and Fournier (1979) modified it by separating the muscles from the basal bony structures to coronally place the upper lip.

• Miskinyar (1983) using a more aggressive approach which included myectomy and a partial resection of the muscle‑ levator labii superioris along with nerve repositioning before muscle resection.

• Ribeiro et al. maxillary labial fraenum was preserved to maintain the midline and reduce post-op morbidity

Papilla ReconstructionDiagnosis and Rx

LOSS OF PAPILLA(Black Triangle)

Etiology:1. Loss of Periodontal support

due to plaque associated periodontal diseases.

2. High frenal pull3. Abnormal tooth shape 4. Improper prosthetic contour5. Traumatic oral hygiene

procedure

Classification of Papillary Height• Nordland and Tarnow (1998) based on three anatomic

landmarks:1. the interdental contact point,2. the coronal extent of the proximal CEJ3. the apical extent of the facial CEJ, and

• Tarnow et al. (1992) analyzed the correlation between the presence of interproximal papillae and the vertical distance between the contact point and the interproximal bone crest.

• When it was ≤5 mm- papilla was present almost 100%.• When it was ≥6 mm only partial papilla fill of the

embrasure.

If the bone crest–contact point distance is ≤5 mm and the papilla height is <4 mm

Class 1 and 2 Surgical intervention

If the contact point is located >5 mm from the bone crest

Class 3 methods to lengthen the contact area apically between the teeth

Rx Strategies

Orthodontic approach

Surgical Techniques1. Beagle (1992) described a pedicle graft procedure utilizing the soft

tissues palatal to the interdental area.

Surgical Techniques2. Han and Takei (1996) proposed an approach for papilla reconstruction (“semilunar coronally repositioned papilla”) based on the use of a free connective tissue graft

Surgical Techniques3. Azzi et al. (1999) described a technique in which an envelope‐type flap is prepared for coverage of a connective tissue graft

Recent advancement• Tissue engineering method by McQuire and Scheyer (JOP 2007)• Autologus fibroblast injection

GINGIVAL DEPIGMENTATION

Gingival Depigmentation• A treatment to remove the melanin hyperpigmentation.• Melanin is the physiologic pigment of the gingiva… but

conditions associated with hyper melanosis are:• Smoking• Drugs• Albright syndrome• Puetz- Jaghers syndrome• Malignant melanoma

Clinical assessment of pigmentation

• Dummett oral pigmentation index (DOPI): (1964)• 0 = pink tissue (no clinical pigmentation);• 1 = mild light brown tissue (mild clinical pigmentation);• 2 = medium brown or mixed brown and pink tissue (moderate); or• 3 = deep brown/ blue–black tissue (heavy clinical pigmentation).

• The Hedin melanin index: (1977)• 0 = no pigmentation;• 1 = one or two solitary units of pigmentation in the papillary gingiva;• 2 = >3 units of pigmentation in the papillary gingiva without formation of a

continuous ribbon;• 3 = >1 short continuous ribbons of pigmentation; or• 4 = one continuous ribbon including the entire area between the canines.

Methods of depigmentation• Bur abrasion (mechanical)

• Chemicals- 90% Phenol and 95% alcohol (Hirschfield et al. 1955)

• Surgical scraping- still a Gold standard… (Hegde et al. 2013)• Cryosurgery

• Electocauterization

• Free gingival graft

• Lasers ablation- Latest and reliable

SURGICAL SCRAPING

Laser ablationCo2 laser- epithelial

peeling

Er:Yag laser- Brush stroke

Conclusion

• Esthetic treatment of a smile line is often a multifaceted scenario where teeth, periodontal tissues, and lip position interact.

• Disciplines of oral surgery, orthodontics, periodontics and restorative dentistry all play a role in the treatment of excessive gingival display.

• Not enough scientific evidence concerning the predictability and long-term stability of Perio-esthetic techniques.

References:1. D. A. Garber and M. A. Salama, “The aesthetic smile: diagnosis and

treatment,” Periodontology 2000, vol. 11, no. 1, pp. 18–28, 1996.2. Rosenblatt A, Simon Z. Lip repositioning for reduction of excessive gingival

display: A clinical report. Int J Periodontics Restorative Dent 2006;26:433-437.

3. Simon Z, Rosenblatt A, Dorfmann W. Eliminating a gummy smile with surgical lip repositioning. J Cosmet Dent 2007;23:100-108.

4. Ribeiro-Junior NV, Campos TV, Rodrigues JG, Martins TM, Silva CO. Treatment of excessive gingival display using a modified lip repositioning technique. Int J Periodontics Restorative Dent 2013;33:309-314.

5. Seixas MR, Costa-Pinto RA, Araújo TM. Gingival esthetics: An orthodontic and periodontal approach. Dental Press J Orthod. 2012 Sept- Oct;17(5):190-201.

6. Hegde et al. Comparison of Surgical Stripping; Erbium-Doped:Yttrium, Aluminum, and Garnet Laser; and Carbon Dioxide Laser Techniques for Gingival Depigmentation: A Clinical and Histologic Study. J Periodontol 2013;84:738-748.

7. Foley et al. in Orthodontic Treatment —The Management of Excessive Gingival Display. J Can Dent Assoc 2003; 69(6):368–72.

8. Allen EP. Surgical crown lengthening for function and esthetics. Dent Clin North Am 1993; 37(2):163–79.

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