Soft Tissue Health

Recession ⟩

This patient had recession on her lower front three teeth. It was worse on the front two central incisors. As you can see in the first photograph the muscle attachment is approaching teh edge of the gum, where it meets the tooth root. The roots are exposed and more likely to develop cavities. We were concerned that this would continue to worsen if uncorrected. A sub-epithelial connective tissue graft (SECTG) was performed only on the two front teeth. The final photograph was taken three months after the surgery. Notice the increased thickness of tissue and the complete root coverage. Also notice the color and texture match. This is common in SECT grafts, but not in Free Gingival Grafts (FGG).

This patient had marked recession on her upper front two teeth. It was unesthetic and predisposed the root to caries. A sub-epithelial connective tissue graft (SECTG) was performed. Notice the complete root coverage in the two year follow up photograph. The color and contours around the necks of the teeth are beautiful. In the final photo also notice the thick scar tissue which developed above the grafted area. Since this final photograph was taken I have recontoured the tissue and am awaiting the final photographs. This demonstrates one of the possible outcomes which require a second procedure to correct. This problem is the easiest post operative complication to correct. It requires numbing the area and shaving off the excess tissue.

Gum Height ⟩

You can see in the second set of photographs how the gums form peaks or triangles between the teeth. These are called papilla and unfortunately are usually lost after teeth are extracted unless special procedures are performed. If you look at the upper left photograph, you can see how the patient's right central and lateral incisors look overlapped. This was done in order to eliminate a "black triangle", where the gums had shrunk. In this case we placed a Connective Tissue Onlay Graft in order to restore both vertical height as well as width of the tissues. In the final photographs you can see how the gums fill the triangles instead of air.

This section deals with the two main esthetic problems associated with the gingiva (gums). The first problem is called recession. This is when the gums which cover the root of a tooth begin to no longer cover the root, or recede. Recession has many causes, the main ones being 1)overly aggressive brushing, especially with a hard or medium brush, 2)prominent root with thin overlying bone, 3)strong muscle attachment, 4)very thin, delicate tissue which can easily be traumatized, and 5)Occlusal trauma. This last reason is still debated in the literature. Recession is usually treated when there is either an esthetic issue, a temperature sensitivity problem, when the root is susceptible to root caries, or when the tissue if just too thin to provide a good zone of attached gingiva (usually with a strong muscle attachment).

The second problem discussed here is general loss of tissue height secondary to tooth loss. The gums are lost once a tooth is lost and when a fixed tooth replacement is placed there is frequently an esthetic. This is usually seen as a black triangle between the teeth if the gums are not recreated prior to restoration.

Both of these problems can be treated with periodontal surgical procedures, also called periodontal plastic surgery. For recession there are at three main surgical approaches, 1)Free gingival grafts, 2)Sub-epithelial connective tissue grafts and 3)Guided tissue regeneration. Free gingival grafts is the oldest and most common graft. It is when a piece of the palatal tissue (skin from the roof of the mouth) is cut away and stitched into place over the recessed area. It works well, but the two main problems are 1)It usually heals looking like a scar, lighter in color and the texture is often not matched to the surrounding tissue, and 2)the roof of the mouth hurts like a pizza burn post operatively. The Sub-epithelial Connective Tissue graft it similar to the free gingival graft but instead of the surface cells (epithelium) being taken and transposed, the underlying cells are taken (connective tissue). This technique has much better color and texture healing and has a less painful healing of the roof of the mouth since the final wound is smaller. Guided tissue regeneration is the newest technique and the most costly. It is when a barrier membrane (usually Gore-Tex or resorbable membrane) is placed over the recession. The membrane blocks connective tissue cells from repopulating the area and allows bone cells to regrow into the area over the root. From a pure theory standpoint this technique is the most ideal since it is the only one which regrows lost bone. The others just attach gingiva to the root. From a clinical point of view, it is the most unpredictable and expensive. The most recent advance in periodontal surgery is the use of an operating microscope. While microscopes have been used in medical specialties for some time, their use in dentistry has been limited. Dr. Dennis Shanelec of Santa Barbara, CA, has pioneered the use of the microscope in periodontal surgery and his results are nothing short of amazing. With the use of the microscope smaller, more precise incisions can be made and sutures too small to place with the naked eye can be used for closure. Postoperative pain is minimized and healing takes place much more rapidly.

In my practice I mainly use the microscope assisted Sub-Epithelial Connective Tissue approach since it is predictable, esthetic and affordable, although once in a while I will regenerate lost bone using a membrane procedure if the bone loss in more than minor.

In order to replace lost gum height a procedure similar to sub-epithelial connective tissue grafting is used, except instead of placing the graft over a root, it is placed onto or into the defect area. Sometimes, depending upon the extent of the defect, the procedure needs to be repeated.