Regaining Gingival Symmetry for Optimal Aesthetics

By Rhys Spoor, DDS, FAGD, FADIA, Accredited Member of the American Academy of Cosmetic Dentistry

Many patients think a beautiful smile is just about straight, white teeth. But the gingival contours have as significant an influence as do the teeth. Attaining gingival symmetry with the contra-lateral tooth and attaining a flowing gingival form with the adjacent teeth can take a smile from poor to excellent (Figure 1 and Figure 2). Use of an ophthalmic scalpel (Figure 3) and tunneling with a full thickness intra-sulcular flap (Figure 4) allows for placement of augmentation materials or for crown lengthening. Sometimes combining both gives the optimal results for symmetry, with the added bonus of improvement of tissue health and reduction of root surface sensitivity. Many patients have an aversion to the word surgery, but with careful technique there is often no or little bruising and mild post-operative pain, which can be controlled with NSAIDs like ibuprofen or naprosyn.

Here is an example of moving the gingival tissue back coronally 10 years after placement of ceramic crowns: the disto-gingival margin of #8 had receded and an abfraction had begun to form. The patient complained of slight sensitivity to cold in the last few months (Figure 5). The biotype was thick and hygiene was acceptable.

The occlusion was checked and adjusted to remove a heavy, protrusive contact. Local anesthesia with 2% Lidocaine 1:100 epinepherine was administered and the abfraction was smoothed to remove any angular edges. An intra-sulcular incision was created with an opthalmic scalpel, and the tissue was blunt dissected beyond the mucogingival margin and laterally to the distal line angles of the adjacent teeth. The reflected tissue was gently positioned into the desired final position and assessed for tug-back by the adjacent tissues. If the flap had not rested passively, then the blunt dissection would have been extended until there was no tug-back on the tissue. The root surface was then ultrasonically and hand-curetted until perceptively smooth.

The palatal donor site was then anesthetized with approximately 1cc of 2% Lidocaine 1:50,000. Using an instrument like a periosteal elevator with a hole for injection allowed the application of pressure anesthesia before and during the injection, making it comfortable for the patient (Figure 6). A small envelope incision was made on the palate and a piece of subepithelial connective tissue removed and immediately placed into the prepared recipient site. The donor site was then closed with one interrupted 6-0 Prolene polypropylene suture and Peri-Acryl cyanoacrylate tissue adhesive (Figure 7).

The graft and the reflected flap were then stabilized with a single Prolene horizontal sling suture (Figure 8). The Prolene has almost no discernible tissue inflammation, but is non-resorbable and was removed at two weeks post operatively (Figure 9). By five weeks the tissue had healed very well and solved what is often an overlooked problem for our patients (Figure 10).

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