The goal of periodontal plastic surgery is to regenerate form, function and esthetics of teeth, implants, and hard and soft tissues.
After making a diagnosis, it is very important not to start until you have the end in mind. Patients need to know what the diagnosis is, what their treatment options are, how long their treatment will take, how they will transition, what it will cost and how they might pay for treatment.
This 2-part article will focus on several cases that will take you through the evaluation, treatment planning and treatment. Each case includes a link to a video featuring the treatment.
Part 1 here spotlights a 22-year-old woman who received implants to restore failing centrals, a young man treated to manage multiple problems caused by tongue piercing, and tissue grafting to treat recession on lower centrals.
Part 2 will feature two more cases: treating a periapical lesion subsequent to a traumatic injury and an immediate-loading implant to replace fractured Tooth No. 5.
Case 1: Failing centrals with root resporption
When 22-year-old Julie was very young, she avulsed her two upper centrals and they were replanted. We saw Julie 2 years ago and the diagnosis was: failing centrals from root resorption. Among the options she was considering were implants. We were initially planning on extraction and bone grafting to prepare the sites for implants later. But because she waited 2 years to pursue treatment, she now had the immediate implant/immediate provisional option.
Implant reconstruction of two centrals is typically challenging because of the midline papilla. Julie, fortunately, had a thick periodontium and short papillae. Her centrals were actually too short so some recession would improve the width/length proportionality.
Treatment time with this transition is one appointment-- teeth are removed, implants are placed, and the provisionals are made at the same visit. This requires plenty of pre-planning, initial implant stability and attention to keeping the teeth out of occlusion and disclusion.
Julie's periodontal plastic surgery and new front teeth
Case #2: Recession, infection, pocketing from tongue piercing
Mark had a tongue piercing. Secondary to his seemingly “cool” piercing, he developed recession, infection and pocketing on the lingual of his lower central. His options were: 1.do nothing, 2. debridement, 3. grafting or 4. combination treatment. We elected to debride the pocketing using the Perioscope with root-coverage connective-tissue grafting--a one-appointment treatment.
His first step was to remove the piercing. His pocketing was debrided with micro ultrasonic endoscopic instrumentation. The site was prepped for the graft which was removed from the palate and placed under the flap. The surgical site was covered with perio pack.
Mark’s CT graft
Case #3: Recession on lower centrals without keratinized tissue
Brian has recession on the lower centrals, with no band of keratinized tissue. His options are: 1. do nothing and watch or 2. do some level of grafting. His grafting options are: 1. gingival grafting using palatal epithelium, 2. connective tissue grafting OR AlloDerm grafting. Brian elected to have AlloDerm grafting. This type of grafting will thicken the tissue, cover the roots and eliminate the need to use the palate as a donor using instead a purified acellular human donor dermis.
This procedure was done entirely through the sulcus using a modified Orban knife and a micro curette normally used in endo surgery to loosen and mobilize the soft tissue over the teeth and bone. The AlloDerm is shaped and inserted under the mobilized connected flap. Both layers are coronally positioned with sutures and the site is covered with perio pack.
AlloDerm grafting
Conclusion
With a microscope with a beam splitter that allows for still and video image capture, I can document procedures for teaching perio grad students at UCSF, including in lectures and now with YouTube, sharing with the world via the internet.
With periodontal plastic surgery we can provide hard and soft tissue reconstruction with ever evolving minimally invasive techniques and technologies. Magnification and illumination along with training and experience helps periodontics and your local periodontist provide functional and esthetic outcomes for our patients.