April 1, 2015
by Dr. Holger P. Meiser, DDS, MAGD
This case involved a middle-aged female with a high lip line and small defects in the surface anatomy of teeth 11 and 21 as well as a gingival defect on tooth 21. The patient was not pleased with the appearance of her smile and her confidence to smile was affected. The nature and extent of the defects called for a minimally-invasive approach providing the patient with a predictable, long term result. The author utilized a combination of evidence-based procedures including a subepithelial connective tissue graft (SCTG), composite restorations and a diode laser for gingival recontouring to provide the patient with the result she desired.
A core principle of contemporary cosmetic dentistry is to minimize the loss of healthy tooth structure and tissues utilizing evidence-based and minimally-invasive treatment protocols. Following this principle, the cosmetic dentist can achieve predictable and long-term functioning restorations with high patient satisfaction. On the contrary, poorly executed cosmetic and restorative procedures can compromise the immediate or long-term health of the soft and hard tissues.1,2 A common and challenging problem can present itself when small imperfections of soft or hard tissues are in highly visible areas in esthetically highly demanding patients. Careful consideration of the available treatment options and techniques becomes critical to achieve the desired clinical outcome while maintaining or improving but certainly not compromising our patient’s health.3 This case report describes the application of a combination of minimally-invasive surgical and restorative techniques to enhance a compromised smile.
Clinical Evaluation, Diagnosis and Treatment plan
A middle-aged woman reported to our clinic with the request to correct the appearance of her central incisors. Teeth 11 and 21 presented with vertical enamel defects in the cervical third extending below the gingival margin onto the root surface of teeth 11 and 21. In addition tooth 21 had a Miller Class I4 gingival recession of 2mm (Fig. 1). The high smile line fully displayed the central incisors and the bordering gingiva (Fig. 2). The patient was concerned with the esthetics and the long term prognosis of the conditions.
After reviewing the diagnosis with the patient it was decided to repair the gingival defect on tooth 21 with a subepithelial connective tissue graft (SCTG). According to current research and literature, this approach has the best short and long term prognosis to repair the kind of defect present in this patient.5 To avoid future caries and recurring gingival recession it was decided to restore the enamel defects with minimally invasive direct composite restorations. The technically challenging restorations in this area were to be performed utilizing placement of a specialized mylar-type matrix strip to apply the composite below the free gingival margin and blend it into the root surface without transition.6 The prognosis for this conservative, combined restorative and surgical treatment approach was very favorable.
A subepithelial connective tissue graft (SCTG) can be predictably used for root coverage and to increase the amount of keratinized tissue.7,8 After cleaning of the root surface with a rubbercup and pumice to remove debris (Fig. 3), the root surfaces were treated with tetracycline HCL paste for five minutes (Figs. 4 & 5). Treating the root surface with one of several substances, such as tetracycline HCL, citric acid, or enamel matrix derivative, appears to have a positive effect on successful outcomes before connective tissue grafts.9,10
A sulcular incision on the buccal aspects of teeth 11 to 22 was performed (Fig. 6) using a microsurgical blade (Hu-Friedy MIM64). A set of microsurgial instruments (Devemed Tunneling Kit) was used to create a split-thickness dissection establishing a tunnel without raising the papillae (Fig. 7). This tunnel design, in combination with partial-thickness dissection, creates an optimized vascular subgingival environment for the placement of subepithelial or acellular collagen matrix type of grafts. Additionally, when adjacent recession defects are present and are connected by an esthetically critical papilla, the tunnel technique is an excellent approach to protect the positional height of the papilla.11
In the case described here, a SCTG was harvested from the maxillary tuberosity by means of distal wedge excision and trimmed and de-epithelialized (Fig. 8). This approach leaves an uncovered wound area, which must heal by secondary intention but is generally tolerated well by patients compared to palat
al donor sites. Furthermore, the maxillary tuberosity is reported to have thicker soft tissue than the hard palate and may therefore be a suitable donor source for a connective tissue graft.12
The Graft was sutured in the recipient site with a vertical sling mattress suture (5-0 Nylon, Hu-friedy Permasharp) (Figs. 9 &10). A microsurgical approach like this is much less traumatic to the surrounding tissue. Therefore, the vascularity of the surgical site during the critical early healing period is improved. A small tear in the tissue was repaired with a chromic gut 5-0 suture (Hu-Friedy).
The patient was instructed not to brush the surgical site for the first four weeks. Instead, she was instructed to rinse with an antiseptic mouth rinse (Listerine, Johnson & Johnson Healthcare Products) two to three times per day and carefully clean the site with a cotton swab and hydrogen peroxide. Anti-inflammatory (ibuprofen) and pain control (hydrocodone with acetaminophen) medications were prescribed for use as needed. The patient was followed up 1 week postoperatively (Fig. 11) to inspect healing progress and the sutures were removed at the four-week postoperative visit (Fig. 12). Oral hygiene and plaque control were reviewed and reinforced during those appointments.
Restorative and Laser Techniques
After 18 weeks of healing time and allowing the grafted site to mature the restorative treatment was initiated (Fig. 13). A conservative preparation was completed with a fine-grit, flame-shaped diamond (Brasseler, USA) and polishing discs (Soflex, 3M) to clean the enamel and root surfaces on the labial aspects of teeth 11 and 21.
A mylar matrix band system (Contour Strip, Ivoclar Vivadent) was placed on tooth 21 and secured with an unfilled bond resin (Heliobond, Ivoclar Vivadent), which was applied to the dried adjacent teeth and soft tissues, then cured with a visible light source (Elipar S10, 3M) for 10 seconds to hold it in place (Fig. 14). This created a sealed mold gingivally and interproximally that allowed for easy placement of the composite material. The contour strip technique eliminates some of the challenges associated with the shaping and polishing of anterior resin restorations, especially when working below the free gingival margin. Advantages of placing this matrix band include creating a sealed system for the operator that is free from saliva, hemorrhage, and crevicular fluids. It allows the clinician to apply the restoration in a clean, dry environment and obtain a superior seal with today’s dentin bonding agents. Additionally, the technique saves time and increases efficiency for shaping the restoration, since the Contour Strip establishes the contour of the final restoration when properly placed around the tooth. Another benefit is the absence of an oxygen inhibition layer below the free gingival margin where the composite material is cured against the mylar surface. This leaves a highly polished, very bio-compatible surface which eliminates the need to use rotary instruments below the free gingival margin for finishing and long term allows for ideal gingival health next to the composite restoration.6
Following the application of a low-viscosity 37 percent phosphoric etchant (Scotchbond etchant gel, 3M) for 30 seconds, the preparation was rinsed with water for 15 seconds and then air-dried. A filled, light-cure total-etch dental adhesive system (Optibond FL, Kerr) was applied according to the manufacturers directions and cured for 10 seconds. A thin bead of flowable resin (Filtek Supreme Flow, 3M) was applied along the cervical margins and a nanofilled composite material Shade B1 Body (Filtek supreme ultra, 3M) was applied and manipulated in the matrix band with a composite spatula (Hu-Friedy). The composite was light-cured for 20 seconds. The resin collar was removed with a scaler and the contour strip with a hemostat. Supragingival shaping and finishing was accomplished with 12-fluted, spiral-bladed carbides (Brasseler USA). Final polishing of the restoration was achieved using a series of abrasive discs (Soflex, 3M) and a polishing paste (Enamelize, Cosmedent). The gingival contour was then corrected with a diode laser (Ez-Lase, Biolase). This procedure provides highly predictable results and minimal patient discomfort (Fig. 15).13-15
At a follow up visit four weeks after the restorations were placed (approximately six months after the SCTG) the final esthetic result and the gingival health were evaluated. The desired treatment results were successfully achieved (Figs. 16-18).
The patient was very happy with the esthetic outcome and the conservative nature of the treatment to afford her the desired result. The restorations blended in undetectably with the enamel surface and the gingiva presented in good health.
All photographs shown in this case report were taken utilizing a compact camera (Fig. 19) (Canon Powershot G12; an updated version–the Powershot G16 – has replaced the G12 since; Canon Lens Adapter LA-DC58K; Bower Step-Down Adapter 58-55mm; Olympus Macro Conversion Lens; Diffuser and camera settings from www.rickspaulding.com). The author has these available in each operatory to facilitate easy capture of diagnostic photographs as well as treatment steps and outcomes. As seen in the photographs in this report, high quality images can be easily obtained which aid in diagnosis and patient communication.
To minimize the loss of healthy tooth structure and tissues when providing elective cosmetic dentistry today’s clinician has a wide array of evidence-based and minimally-invasive treatment options to choose from. Careful review of current literature and appropriate training to help with the selection and application of evidence-based materials and clinical techniques can enable the cosmetic dentist to achieve highly predictable and long-term functioning restorations with high patient satisfaction. This becomes even more critical when faced with seemingly minor soft or hard tissues imperfections where a minimally-invasive approach is called for to give our patients the desired clinical outcome, while maintaining or improving but certainly not compromising our patient’s health. As shown in this article, this can be achieved by correctly diagnosing the patient’s conditions and selecting an appropriate treatment protocol. In this case a combination of minimally-invasive, surgical and restorative techniques was used to successfully enhance a smile with minor imperfections and give the patient a satisfactory and predictable result.OH
Dr. Holger P. Meiser graduated from the Ruprecht-Karls University School of Dentistry in Heidelberg/Germany in 2002. He went on to complete residencies and fellowships in Advanced General Dentistry and Implant Dentistry at the University of Minnesota Dental School where he also earned a certificate in Contemporary Restorative and Esthetic Dentistry. He has fulfilled the requirements to achieve Mastership in the Academy of General Dentistry and Associate Fellowship in the American Academy of Implant Dentistry. He maintains a private practice in Minnetonka, MN, USA and serves as adjunct faculty in the Implant Program at the University of Minnesota and as an advisor to the Pankey Institute in Key Biscayne, FL, USA.
Oral Health welcomes this original article.
1. Puri K, Puri N, Dodwad V, Masamatti SS. Restorative aspects of periodontal disease: an update part 1. Dent Update. 2014 Jul-Aug;41(6):545-8, 551-2.
2. Reeves J. Periodontal health—challenges in restorative dentistry. Prim Dent J. 2014 May;3(2):73-6.
3. Burnett RR, Diaz R, Waldrop TC, Hallmon WW. Clinical perspectives of periodontal and restorative interactions. Compendium. 1994 May;15(5):644, 646, 648-55.
4. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent.1985;5(2):8-13.
5. Cortellini P, Tonetti M, Baldi C, Francetti L, Rasperini G, Rotundo R, et al. Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, double-blind, clinical trial. J Clin Periodontol.2009;36(1):68-79.
6. Belvedere PC, Lambert DL. Advancing your direct composites through the use of a specialized matrix. Oral Health. 2002;92(4):75-83.
7. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: a systematic review from the AAP regeneration workshop. J Periodontol. 2015 Feb;86(2 Suppl):S8-S51.
8. Tatakis DN1, Chambrone L, Allen EP, Langer B, McGuire MK, Richardson CR, Zabalegui I, Zadeh HH. Periodontal soft tissue root coverage procedures: a consensus report from the AAP regeneration workshop. J Periodontol. 2015 Feb;86(2 Suppl):S52-5.
9. Bouchard P, Nilveus R, Etienne D. Clinical evaluation of tetracycline HCl conditioning in the treatment of gingival recessions. A comparative study. J Periodontol.1997;68 (3):262-269.
10. Castellanos A, de la Rosa M, de la Garza M, Caffesse RG. Enamel matrix derivative and coronal flaps to cover marginal tissue recessions. J Periodontol.2006;77(1):7-14.
11. Zuhr O, Fickl S, Wachtel H, et al. Covering of gingival recessions with a modified microsurgical tunnel technique: case report. Int J Periodontics Restorative Dent.2007;27 (5):457-463.
12. Studer SP, Allen EP, Rees TC, Kouba A. The thickness of masticatory mucosa in the human hard palate and tuberosity as potential donor sites for ridge augmentation procedures. J Periodontol.1997;68(2):145-51
13. Lowe RA. Minimally invasive dentistry combined with laser gingival plastic surgery: maximize your aesthetic results. Dent Today. 2008 Aug;27 (8):102, 104-5.
14. Flax HD. Soft and hard tissue management using lasers in esthetic restoration. Dent Clin North Am. 2011 Apr;55(2):383-402.
15. Pang P. Lasers in cosmetic dentistry. Gen Dent. 2008 Nov-Dec;56(7):663-70.