Gingival creep is a well-known and highly desirable effect of gingival augmentation procedures. Matter and Bell as early as the late seventies demonstrated this concept in what could be described as case series. At present, we do not definitely know what the predictive variables for this phenomenon are. It is strongly associated with:
The case demonstrated is of a severe peri-implantitis lesion with a 2 walled defect in a palatally positioned implant. Therefore, the position of the implant favours guided bone regeneration as well as gingival creep. There is a distinction between gingival creep and relapse of pocketing (ie oedema). The pictures demonstrate consistent pocketing with decreasing recession which basically means gain in attachment.
Rushing to label a tooth hopeless and proceeding to extract it can be a very costly affair for patients. Teeth with large apical pathosis should have the apical pathology managed and preferably bone regenerated prior to proceeding on to bridgework or implant based replacement. Teeth can have a regenerative potential from the PDL stem cells but also from the ability to retain soft tissue flap in a more coronal position than if the tooth was not present.
The case clearly demonstrates this. The lower incisors are buccally placed with poor endodontic obturations and poorly fitting crowns. Moreover, a large sinus resulting in dehiscence over the root of the LR1 was noted.
The options for management included:
The final result at 6 months was very favourable with complete healing of the dehiscence and resolution of the apical pathosis with bone regeneration. A further radiograph will be taken in 1 year to assess apical status of the incisors. Replacement with implants and further regeneration may be necessary if a relapse is noted.
The holy grail for the management for peri-implantitis is bone regeneration and re-osteointegration. These are difficult to achieve reliably and in fact most histological studies indicate that true reintegration is unpredictable and difficult to achieve. From a practical clinical perspective, we aim to achieve a pocket depth reduction to manageable levels (ie less than or equal to 5mm), no bleeding on probing and no erythema or suppuration around an implant. The German group lead by Frank Schwartz published a key study ( Schwartz et al 2009) demonstrating the clinical success of use of particulate bovine bone graft materials and barrier membranes in the management of intrabony defects around implants. Further analysis of their patient subsets demonstrated (Schwartz et al 2010) the impact of the defect anatomy (1,2,3 walls) on the regenerative potential around an implant. One aspect that was overlooked in this article is the overall alveolar anatomy and the thickness and orientation of the buccal bone on the surrounding teeth and implants. This has a strong influence on the regenerative potential and the clinical outcome.
This case demonstrates the effect of the ridge morphology on the extent of regeneration. The UL5 implant was an immediate implant placed 5 years prior to the patients referral to my care at Bowlane Dental. The patient was flagged up as a high risk patient by her dental hygienist due to the suppuration and edema affecting the soft tissues around the implant. As a result of the 9mm buccal pocket, the patient was diagnosed with an advanced peri-implantitis lesion despite the deceptive radiographic appearances. Surgical assessment and treatment were indicated rather than non surgical debridement which has been demonstrated as ineffective in the severe cases. Surgical exploration revealed a 2 walled defect interproximally and advanced bone loss on the buccal aspect despite an attempt at GBR during implant placement and also at the time of exposure.
We elected to attempt bone regeneration around UL5 due to the thickness of the buccal bone on the neighboring teeth. This was undertaken with particulate bovine graft materials as well as a de-epithelialised free gingival graft as a substitute for Collagen barrier membrane due to it ability to facilitate closure and an improvement of soft tissue thickness.
The regenerative surgery was followed by month supportive post-surgical maintenance by the hygienist team which consisted of plaque control advice and supragingival debridement of the implant and surrounding teeth. Six month reassessment reveal a healthier clinical situation with a 4mm buccal probing depth, resolution of erythema and suppuration and no bleeding. We also noted residual 2mm of recession which could be easily corrected but the patient was happy with the result given her low lip line. I would like to thank Sarah Urquhart for referring this patient in a timely manner and also for the diligent supportive therapy without which it would have been difficult to achieve this excellent result.
There are numerous clinical, logistic and financial advantages from linking teeth to implant restorations. Tarnow et al 2009 presented a literature review to on the subject of linking teeth and they sited a high risk of intrusion of abutment teeth in cases of parafunction or when semi-rigid (ie fixed movable) connectors were used. Palmer et al 2005 demonstrated high success rates with minimal critical complications like bone loss or tooth intrusion when linking teeth and implants with telescopic crowns and multi-unit bridge work cemented with temporary cement to allow for retrievability.
This approach was utilised for the presented patient to replace missing teeth in the posterior mandible which had extensive vertical and horizontal resorption. The resorption precluded placement of an implant in the LR5 region due to the proximity of the mental nerve and a concavity in the mental area of the mandible. Moreover, the LR4 was heavily restored in close proximity to the alveolar crest. This tooth would have an improved prognosis with crown lengthening and cuspal protection. It therefore became possible to consider placement of an implant in the LR6 position and to crown lengthen the LR4 at the same time. The eventual restorative plan would be to place a telescopic crown on the LR4 and a stock abutment on the LR6 implant and to link the two with a 3 unit bridge cemented with tempbond. This is in keeping with the Palmer et al proposed treatment journey.
The treatment plan was executed with ease and minimal morbidity. The alternatives include:
Gum recession so what and who cares?? Relax and keep cleaning it and it will be fine! NOT TRUE ANY MORE!!!!
These statements will soon be a thing of the past. Chambrone et al 2016 demonstrated with systematic review and a meta-analysis that about 80% of untreated recession defects worsened over 24 months moreover the number of recession defects also increased. The odds ratio of this happening is over 2 meaning it is likely to happen.
This is problematic for busy general practitioners who use BPE scores a method of monitoring periodontal health. Such a scoring system will not track changes in recession depths. Even conventional charting will not easily detect these changes. Clinical photographs are the best means to monitor and detect changes.
Given the high prevalence of gingival recession and the high likelihood of progression, when should we treat it? The answer is:
This patient was carefully and diligently monitored by James Goolnik and Christine at Bowlane Dental. They detected progression in her toothwear and recession. Following referral, I managed her with acellular dermal matrix grafts to reduce the risk factors for progression such as thin phenotype and lack of keratinised tissue. Composite resin restorations were used to restore the CEJ to reduce risk of wear and to obtain 100% root coverage on the uppers and close to 80% root coverage on the lowers despite the Miller II/III defects. Christine Arran provided exemplary post-operative maintenance that facilitated this result and James Goolnik will continue to follow the patient’s progress over time.
Free gingival grafts have high success rates in achieving:
1-increase in keratinised tissue
2-deepening of vestibule
4- eliminating frenal attachments
They have limited efficacy when it comes to improving cosmetics or root coverage. If these two aims are the holygrail for mucogingival surgery, why do we still utilise free gingival grafts??
The answer is in the nature of the free gingival graft procedure. It is considerably less complex than other grafting procedures with a very low risk of graft necrosis. This makes free gingival grafting the first option when it comes to extreme Miller class 3 or 4 cases particularly in the lower arch due to the limited working space resulting from a reduced sulcus depth (compared to uppers). Moreover, gingival colour mismatch in the lower anterior region is more acceptable and less visible.
This patient was referred Frank Goulbourn who was quite rightly concerned about the prognosis of the LR1 LL1. These teeth had suffered:
I would like to thank Frank for taking action and referring this patient quickly as soon as she presented. I would also like to thank Juliette Reeves for the fantastic post surgical maintenance and supportive therapy.
Maintenance is the corner stone of every dental treatment plan particularly a periodontal one. Periodontal patients with strict maintenance programmes have better outcomes in terms of tooth retention and dental implant survival. Is this the stuff of legend? Is this really necessary given the effectiveness of modern dentifrices and brushing aids?
The answer is a resounding YES!
A successful maintenance program needs:
1-an accurate periodontal diagnosis which a dentist or periodontist can provide
2-a dental state that is stable ie. no pockets greater than 5mm and no caries
3-a clear well thought out prescription to follow
The outcomes of maintenance programs have been studied extensively but a successful maintenance program is yet to be defined. One can safely say that the primary outcome variable for a successful maintenance program is tooth/implant loss. Cobb et al, Lang et al, Tonetti et al and Fardal et al as well as many others demonstrated higher tooth/ implant loss when:
The dental papilla is the 3 dimensional soft tissue feature that is influenced by the following:
1-underlying alveolar morphology in relation to the contact point (Tarnow, Chu and Palmer propose that a distance of 5-6mm is highly predictive of papilla presence)
As a periodontist, I can strongly affirm that restorative dentistry procedures cannot develop or produce dental papillae. If the above criteria are present then the papillae are usually present with sufficient patience ie. It can take time to develop particularly after implant placement or crown lengthening surgery.
Careful restorative procedures to develop papilla in my opinion only serve two roles:
Consider optimising points 1-4 above depending on indications within the overall patient journey. I would definitely not consider interproximal grafting due to the poor blood supply in the interproximal space. We do not know factor is most influential in papilla regeneration and as such keep an open mind and always have a plan B!
The case demonstrated is a simple example of altering tissue biotype with acellular dermal matrix graft to reduce recession on UR1 and to encourage the illusion of papilla around the pontics. This is a stable 6 month result. The resulting increase in the tissue biotype will facilitate easier closure during future bone augmentation if bridge fails. An alternative to this would be bridge removal and implant placement with ridge lap pontics which my patient wanted to delay for obvious reasons.
The use of soft tissue grafts to reduce recession has been shown to increase papillae height even in Miller Class 3 cases (Demirel et al 2015). This case is in keeping with the findings research reported in the scientific literature and discussed at the last Europerio 8 conference.
The primary measure for success in mucogingival surgery is the percentage of root coverage which is measured from the CEJ. It is important to note that the CEJ migrates coronally with toothwear, and as such, achieving a high level of dentine coverage is not possible in cervical wear patients. In order to optimise the aesthetic outcome and to reconstitute the anatomical dental harmony, restorations may need to be utilised to recreate a new enamel dentine junction. Zuchelli et al 2006 and Cairo et al 2011 demonstrated using the height of the interproximal attachment to predict the post-operative final position of the gingival margin. These predictive formulas are useful guides but are not conclusive because they do not take into account soft tissue type and tooth morphology and positon.
Restorative reconstitution of the CEJ is best undertaken preoperatively with indirect or direct restorations. This will allow for easy polishing and refining the margins and avoids traumatising the gingival margins post-operatively. Definitive restorations should be delayed 6 months post operatively to ensure stability of the gingival margin and successful cessation of any traumatic habits. Referring dentists usually undertake the restorative management of these patients and I often assist by denoting where the gingival margin is likely to be.
This is an example of a patient- KP who had two protracted courses of orthodontic treatment with fixed appliances resulting in severe gingival recession which was progressively worsening. Her smile aesthetics were further complicated by a high lip line which clearly displayed the asymmetric gingival aesthetic line. Previous dentists choose to mask the exposed dentine with composite resin rather than gingival tissue which did not improve aesthetics because it failed to address the discrepancy in the gingival margins.
The patient was successfully managed with a de-epithelialised free gingival graft and a coronally advanced flap. The CEJ was reconstituted with composite resin to produce 100% root coverage and an overall harmonious appearance. I would like to Thank Dr Andy Bolam for choosing to refer KP to my care and for correctly noting the progression of her recession. I would also like to thank Juliette Reeves, RDH for the excellent post operative maintenance which optimised the surgical result.
Peri-implantitis is report to affect approximately 7-10% of all implants after 10 years of service. We currently don’t know what the prevalence of peri-implantitis is after 10 years of service.
Mrs JN presented complaining of recurrent gum infection around two implants placed about 18 years ago. JN was diagnosed with per-implantitis and went on to have pocket reduction surgery around the implants and implantoplasty due to the non-regenerable defect around the implants. The result was as predicted from this type of treatment:
1-minimal bleeding on probing
2-pocketing reduced from 9mm to 3mm
3-increase in gum recession
A gingival silicone mask was constructed to optimise the smile aesthetics by disguising the advanced recession affecting the teeth and implants. JN was delighted with the outcome and we will continue to support her with a strict maintenance regime consisting of 2 monthly hygienist visit and annual reviews with me.