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Clinical Advances

in Periodontics
An Online Journal of the American Academy of Periodontology
Implant Microsurgery
Surgical Correction of Two
Anterior Implants
Pocket-Lining Pedicle Flap
Xenogeneic Collagen Matrix
in Implant Therapy
Treatment of Spongiotic
Gingival Hyperplasia
Isotretinoin and Gingivitis
Gingival Depigmentation
With Laser-Patterned
Treatment of Trisomy
21Associated Aggressive
Dental Suture Techniques
Surgical Crown Lengthening
Volume 1 Number 3 November 2011
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Clinical Advances in Periodontics
161 Implant Microsurgery: Immediate Implant Placement With
Implant-Supported Provisional
Dennis A. Shanelec, Leonard S. Tibbetts
The SMILE Technique, which offers benets including rapid healing, minimal discomfort, and enhanced patient
acceptance for immediate replacement of damaged teeth in the maxillary anterior region, is described in this
case series.
174 Surgical and Prosthetic Correction of Two Adjacent Anterior Implants:
A Clinical Case Report
Dennis P. Tarnow, Stephen J. Chu
Vertical and horizontal hard- and soft-tissue deciencies between two adjacent anterior implants were
reconstructed using dermis allograft material.
183 Use of the Pocket-Lining Tissue as a Pedicle Flap to Facilitate Wound
Closure After Extraction to Preserve the Alveolar Ridge or Protect an
Implant Site
Shane J. McCrea
The pocket-lining epithelium found at periodontally compromised sites was used to produce primary wound
closure following implant placement and socket/ridge preservation surgery.
193 The Use of a Xenogeneic Collagen Matrix as an Interpositional Soft-Tissue
Graft to Enhance Peri-Implant Soft-Tissue Outcomes: A Clinical Case
Report and Histologic Analysis
George A. Mandelaris, Mei Lu, Alan L. Rosenfeld
Histologic evaluation of a xenogeneic collagen matrix used as an alternative to autogenous graft harvest for the
promotion of peri-implant soft tissue thickness indicated a benign tissue response with organized and attached
connective tissue similar to native, undisturbed periodontal tissue.
199 Conservative Treatment of Localized Juvenile Spongiotic Gingival
Simon R. MacNeill, James W. Rokos, Michael R. Umaki, Keerthana M. Satheesh,
Charles M. Cobb
Localized juvenile spongiotic gingival hyperplasia, a recently recognized pathologic entity, was successfully
managed through the combined use of light surface cauterization and application of 0.05% clobetasol propionate
(continued on page iii )
A typical case treated with the
SMILE Technique, showing the
preoperative view and the
immediate post-surgical view after
extraction, implant placement,
socket graft, provisional restoration,
connective tissue graft, and
(Shanelec and Tibbetts)
An Online Journal of the American Academy of Periodontology
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205 Non-Plaque-Induced Gingivitis Associated With Isotretinoin: A Case Report
Ajay Mahajan, Ashu Bharadwaj, Poonam Mahajan
This case report describes the diagnosis and treatment of gingivitis that was an adverse effect of isotretinoin use.
210 Successful Gingival Depigmentation With Laser-Patterned
Microcoagulation: A Case Report
Edward P. Allen, Natalia D. Gladkova, Yulia V. Fomina, Maria M. Karabut, Elena B. Kiseleva,
Felix I. Feldchtein, Gregory B. Altshuler
Minimally invasive gingival depigmentation was successfully performed with laser-patterned microcoagulation,
a new laser treatment technology.
215 Trisomy 21Associated Aggressive Periodontitis: A Five-Year Follow-Up
Alon Frydman, Fernando Verdugo, Krikor Simonian, Kian Kar
This ve-year followupof a patient with Trisomy 21describes howthe extent of disease progressionwas controlled
and the overall periodontal health status was improved through frequent mechanical therapy despite continuous
microbial challenges even after systemic and local antibacterial therapy.
221 Basic Suture Techniques for Oral Mucosa
Terrence J. Grif ff n, Yong Hur, Jing Bu
This paper reviews basic suturing techniques used in periodontics and presents the results of a national survey
for their clinical applications.
233 Crown Lengthening Revisited
Marianne Ong, Shih-Chang Tseng, Hom-Lay Wang
This review and opinion article summarizes esthetic and restorative crown-lengthening procedures.
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011
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Clinical Advances in Periodontics
An Online Journal of the American Academy of Periodontology
Interleukin Genetics
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University of Alabama at Birmingham
Birmingham, AL
Associate Editors
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New York University
New York, NY
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Harvard School of Dental Medicine
Boston, MA
Dr. David W. Paquette
Stony Brook University
Stony Brook, NY
Dr. Frank A. Scannapieco
University at Buffalo
Buffalo, NY
2010-2011 Ofcers of the AAP
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Fullerton, CA
President Elect
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Aurora, CO
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Independence, MO
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New York, NY
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Gainesville, FL
Founding Editorial Board
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Private practice
Cupertino, CA
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Private practice
Yardley, PA
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University of Michigan
Ann Arbor, MI
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Private practice
Dallas, TX
Editorial Advisory Board
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Clinical Advances in Periodontics is dedicated to advancing clinical management of patients by translating knowledge into practical therapy. It is an online publication of the American Academy of
Periodontology. The statements and opinions expressed in this publication reect the views of the author(s) and do not reect the policy of the Academy unless so stated.
Clinical Advances in Periodontics (ISSN 2163-0097) is published quarterly by the American Academy of Periodontology, 737 North Michigan Avenue, Suite 800, Chicago, Illinois 60611-6660. Manuscripts should
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Master Clinician Series
Implant Microsurgery: Immediate Implant Placement With
Implant-Supported Provisional
Dennis A. Shanelec*

and Leonard S. Tibbetts

Introduction: Implants have become the preferred method of single tooth replacement. One of the challenges is the
ability to do immediate implant placement and provisionalization on the day of extraction in a consistent and esthetically
predictable manner.
Case Presentations: Using a newly developed microsurgical approach, the SMILE (Simplified Microsurgical Implant
Lifelike Esthetics) Technique, successful outcome of 298 of 300 cases has been achieved. The success is attributed to
microsurgical precision associated with this technique. The goal of this technique report is to establish some of the benefits
and versatility of dental implant microsurgery and the SMILE Technique for these esthetically challenging situations.
Conclusions: With the SMILE Technique, a clinician has an orderly treatment sequence for providing immediate
implant placement and provisionalization. It results in excellent esthetics, as well as predictable success of dental implant
osseointegration. Clin Adv Periodontics 2011;1:161-172.
KEY WORDS: Dental atraumatic restorative treatment; dental implants, single-tooth; dental prosthesis, implant-supported;
microsurgery; tooth extraction; tooth fractures.
The Master Clinician Series features invited papers by authors who have
received the American Academy of Periodontologys Master Clinician
Award. This award is given to a member who has practiced and
demonstrated clinical excellence in periodontics and who has willingly
and unselfishly shared that expertise with members of the profession.
Dentists worldwide have striven to realize the potential of
dental implants for restoring failed maxillary anterior teeth.
Root form implants have proven exceptionally predictable
and successful
and have undergone many biologic, techno-
logical, and restorative improvements in recent years.
culmination of these innovations has been a convergence of
clinical research with restorative experience to favor imme-
diate dental implant replacement of a failing maxillary an-
terior tooth.
Furthermore, immediate provisionalization
of single tooth dental implants has been shown to be a via-
ble treatment.
The challenges for immediate implant
placement and provisionalization, despite these reports,
are significant when done macrosurgically versus microsur-
gically. The differences include poor visualization, greater
trauma and less precision in tooth removal, a poorly lit
and often bloody field, incorrect implant placement and
* Private practice, Santa Barbara, CA.

Recipient, 2010 Master Clinician Award, American Academy of


Private practice, Arlington, TX.

Submitted April 13, 2011; accepted for publication June 9, 2011
doi: 10.1902/cap.2011.110040
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 161
angulation, difficulty with contours and soft-tissue support
associated with immediate provisionalization, and poor
esthetics, including having no polished custom impression
transfer coping replicating the provisional emergence pro-
file. The advantages of the Simplified Microsurgical Implant
Lifelike Esthetics (SMILE) Technique microsurgical ap-
proach compared to a macroscopic approach include: 1)
precision of the surgical procedure and enhanced motor
skills; 2) the application of microsurgical instruments to re-
duce tissue trauma, resulting in little to no prolonged bleed-
ing; 3) excellent surgical field illumination; 4) precision
in implant site preparation; 5) exactness with provisional
crownfabrication; and6) anemphasis onpassive woundclo-
sure with exact primary apposition of the wound edges.
Immediate provisionals consistently maintain mesial
and distal papilla height when the implant platform is 5
mm below the crest of the papilla (Fig. 1). However, we
have found buccal recession of z1 mm to occur unless
a concurrent subepithelial connective of 1.5 mm thickness
is performed. If preexisting recession is present on the fail-
ing and adjacent teeth, this must be corrected at the time of
treatment (Fig. 2). Preexisting infection around the failing
tooth is not a contraindication to treatment. However,
complete debridement of the socket under the microscope
is required. The socket must also be flooded with a 3%tet-
racycline solution to decontaminate the osteotomy (Fig. 3).
Fractured or avulsed teeth should be treated as soon as
practical. If possible, the fractured root segment should
FIGURE 1 Clinical case 1. A typical case treated
with the SMILE Technique. 1a Preoperative view,
maxillary right central incisor, with disto-buccal
exudates. 1b Immediate post-surgical view after
extraction, implant placement, socket graft, pro-
visional restoration, connective tissue graft, and
microsuturing. 1c Two-week postoperative view
with no postoperative pain reported. 1d Two
years postoperative of final restoration.
FIGURE 2 Clinical case 2. 2a Preexisting
recession is seen on both central incisors, and
the lateral incisor must be corrected at the time
of treatment. 2b Implant placed in the extraction
socket of tooth #8, provisional placed, socket
bone graft, and connective tissue graft to
advance the gingival tissue over the implant
platform and exposed root of the adjacent
central and lateral incisors. 2c Eight-week post-
operative view. 2d Post-restorative view after
4 years.
162 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Implant Microsurgery
be retained and mimicked when the implant is placed,
permitting papilla regeneration after resupport of the gin-
gival tissue when the screw-retained provisional is placed
(Figs. 4 and 5).
To address these issues and techniques that may result in
potentially compromised results, we have developed the
SMILE Technique, which adds the advantage of microsur-
gical precision. From our prospective, the advantages of
the SMILETechnique are an extremely high rate of success,
excellent immediate esthetics and patient acceptance, and
a final restoration that is fabricated from replication of the
provisional emergence profile.
The SMILE Technique procedure comprises the steps
seen in Table 1. The technique has been followed for a case
series of 300 maxillary central incisors, lateral incisors, and
cuspids. The clinical success rate fromboth the prospective
of osseointegration and esthetics has been 99.3%. Using
the SMILE Technique, a predictable sequence of orderly
FIGURE 3 Clinical case 3. 3a Preexisting
infection around the left central incisor as seen
in the preoperative view is not a contraindication
to treatment. 3b Tooth extracted, socket de-
brided, and decontaminated with a 3% solution
of tetracycline, implant and provisional crown
placed with socket bone graft and connective
tissue graft. 3c Ten-week postoperative view. 3d
Post-restorative view after 2 years.
4b 4c
Shanelec, Tibbetts Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 163
treatment arrangement has been developed. To present this
technique, selective segments from seven representative
cases will be composited in this technique report to intro-
duce the SMILE Technique. Appreciate that this is techni-
cally challenging and time-consuming and requires both
microsurgical and microrestorative skills.
Case Presentations
The SMILE Technique has been used for the past 10 plus
years with excellent success.
Step 1: Implant Microsurgery
All phases of implant treatment are possible using a micro-
scope with a working magnification above 10. Because of
the minimized tissue trauma associated with microsurgery,
patients report little or nodiscomfort after the combination
of microsurgical tooth removal, precise implant placement
in the socket, and seating an anatomically correct provi-
sional restoration (Fig. 1). In this overview case, the
esthetic presentation is presented 2 years after placement.
Six additional cases are presented (clinical cases 2
through 7) that demonstrate that consistent and predict-
able results can be achieved with this technique. Clinical
case 6 supports the concept that not only can osseointegra-
tion and esthetic results be achieved but that these results
can be stable for 10 years.
Steps 2 to 5: Minimal Extraction Trauma
The microscope enhances visual acuity and improves sur-
gical dexterity. Microsurgical principles and instruments
FIGURE 5 Clinical case 4. 5a Preoperative case
of maxillary right central with fractured root tip
remaining. 5b Radiograph showing fractured
root tip. 5c Immediate postoperative view after
extraction, implant placement, socket bone graft,
connective tissue graft, and provisional crown.
5d Two-week postoperative image. 5e Fourteen-
week postoperative image. 5f Fourteen-week
postoperative radiograph.
164 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Implant Microsurgery
TABLE 1 SMILE Technique Sequential Flowchart
Step Instructions
1 All procedures performed under the microscope at magnifications 310 to 320
2 Atraumatic extraction, avoiding buccal and lingual flaps
3 De-epithelialization of former sulcus
4 Complete microscopic socket debridement of lateral and apical granulation tissue
5 Irrigation of the socket with 3% tetracycline solution for 30 seconds
6 Use lateral side cutting drills to align the osteotomy to the palatal wall of the socket
7 Position the implant apex lingually to tip the implant platform buccally 2 mm
8 Position the implant platform z5 mm below the mesial and distal papilla
9 Position the lingual aspect of the platform at the palatal crest of the socket
10 Use a 4-mm diameter implant 15- to 18-mm long
11 Use a standard platform external hex implant
12 Use a 2
tapered textured surface implant
13 Place the implant with at least 67 Ncm torque
14 Create an opaqued temporary screw-retained titanium abutment substructure
15 Take a clear silicon impression of the failing tooth
16 Create a flowable composite shell crown that replicates the anatomy of the failing tooth
17 Lute the shell crown to the opaqued abutment in the mouth
18 Eliminate the flash and fill the subgingival contours with flowable composite
19 Create and check the emergence profile to support but not distorting the buccal tissue and the papillae
20 Take an impression of the gingival half of the provisional attached to an implant analog
21 Highly polish and glaze the provisional
22 Cure the provisional with a high intensity xenon light to eliminate free monomer
23 Create a custom impression transfer coping
24 Fill the buccal socket gap with osseous xenograft to the level of the implant platform
25 Compress the surface xenograft 1 to 2 mm to create a fine powered xenograft seal
26 Place an autograft bone graft filtered from the drilling bone dust and compress it to the platform level
27 Mold a collagen membrane free form over the autograft
28 Create a buccal envelope split-thickness flap through the former buccal sulcus
29 Harvest a connective tissue graft from the palate and place it into the buccal envelope
30 After freeing the papillae, advance the flap with 6-0 polypropylene sutures as needed
31 Reduce the occlusion on the palatal of the provisional, allowing 1 mm of clearance, using green indicator wax
32 Fill the screw space inside the implant with metronidazole gel
33 After installing the provisional with the proper torque, place polytetrafluoroethylene tape above the screw head and seal the access with composite
Shanelec, Tibbetts Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 165
are applicable to teeth extractions to preserve gingival
and osseous anatomy (Fig. 6). Roots can be vertically
lifted from their sockets with minimal lateral forces, thus
avoiding damage to the gingival papillae.
magnification allows surgeons to determine subtle nu-
ances in direction of luxation that are not otherwise ap-
parent. After the extraction, the sulcus is deepithelialized
with a flame diamond. Subsequently, the sockets are
thoroughly debrided of granulation tissue, and irrigated
and filled for 30 seconds with 3% tetracycline solution
(Video 1).
Step 6: Drilling in the Socket
Drilling in extraction sockets requires different skills than
drilling in edentulous sites.
The most favorable bone in
the anterior maxilla lays both palatally and apically to the
(Fig. 7a); therefore, drilling must be done at an an-
gle to the socket wall. Twist drills are not designed for that
TABLE 1 (Continued) SMILE Technique Sequential Flowchart
Step Instructions
34 Perform postoperative evaluation at 2 and 6 weeks
35 Proceed to final restoration after 8 weeks
36 Restore with custom impression coping and scanned zirconium abutment*
Each of the steps and procedures were developed and initially taught by the author (DAS).
*Procera, Nobel Biocare, Yorba Linda, CA.
FIGURE 6 Atraumatic flapless extraction re-
quires the use of periotomes (6a through 6c) and
anchorage extraction device (6d through 6f). ff
Extraction of teeth with periotomes involves
using microsurgical principles as shown in 6a
through 6c. 6a Interproximal periotome luxation
of the fractured root helps to preserve gingival
and osseous anatomy. 6b Palatal periotome
luxation of fractured root. Ultrasonic instrumen-
tation can also be used. 6c Periotome extraction
site: note the lack of bleeding and trauma and the
preservation of the gingiva and underlying
anatomy. For extraction of teeth where there is
inadequate leveraging surfaces, anchorage ex-
traction device should be used as shown in 6d
through 6f. 6d Fractured maxillary right canine
root. 6e Placement of an internally threaded root
puller (tapping mechanical device) for extraction.
6f Extracted canine lifted vertically with the puller
from socket with minimal lateral forces, thus
avoiding damage to gingival papillae. These
sockets are thoroughly debrided and irrigated
with 3% tetracycline solution for 30 seconds.
166 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Implant Microsurgery
purpose andtendtotrackinthe directionof least dense bone.
The result is that using a twist drill for this step will often re-
sult in directing the preparation toward the labial plate. The
osteotomy site must be redirected using lateral cutting burrs
or ultrasonics before each incremental increase in twist drill
size or the implant osteotomy angulation and position will
invariably move to the buccal aspect (Fig. 7b). With the mag-
nification and lighting provided by the microscope, drilling
onthe lateral socket wall canaccomplishastable andesthetic
placement for maxillary anterior implants.
Steps 7 to 13: Implant Placement
In our experience, we have found that implants with 4-mm
diameter and lengths of 15to18mm, witha 2
can be
placed with the apex positioned palatally and the implant
platform buccally z2 mm toward the labial. These im-
plants, placed into the extraction osteotomy sites, could
be torqued to 67 Ncm.
The thread geometry of the 2
tapered implants used improves initial implant stability
without danger of lateral bone compression. Of the 300im-
plants placed, 296 were 18 mm in length and four were 15
mm in length. Bovine xenograft is packed into the buccal
socket gap to the crest of the socket. Milled autologous
bone from the site preparation is filtered and rinsed with
sterile water and a solution of 3% tetracycline. The bone
is used to form a 2-mm laminar seal above the bovine
xenograft. Alayer of microfibrillar collagen
is placed over
recycled bone before the implant provisional is placed. In
all 300 cases, connective tissue was transferred from the
palate into a split-thickness envelope prepared on the buc-
cal aspect to restore or preserve gingival height lost as a
result of injury or inflammation.
Steps 14 to 23: Implant Provisional
To preserve natural esthetics, the implant provisional must
support the surrounding gingiva exactly like the extracted
(Fig. 8). This includes placing an opaqued screw-
retained, titaniumabutment, creating a hollowed composite
shell crown from a clear silicon impression of the failing
tooth, luting the shell crown to the opaque abutment in
the mouth, and eliminating the flash.
** The subgingival
profile is individually shaped for each patient at the time
of surgery. Voids androughedges are eliminatedandthe pro-
visional carefully contoured to support the gingival tissue.
The emergence profile is created and checked so it supports
the gingiva but does not distort the buccal and interproximal
tissues. As a final step, the provisional is polished and glazed.
Using light-cured composite ensures that no free monomer
is present to irritate tissue or bone. An impression of the
FIGURE 7 Osteotomy in preparation for implant
placement requires an appreciation for both the
anatomy of the maxilla as well as the cutting
pattern of the drills. 7a Osteotomy needs to be
prepared on palatal side of socket. 7b This
requires redirecting preparation with side cutting
osteotomy drills: 2.0, 2.5, and 3.0 mm.
FIGURE 8a Before surgery, a clear silicone impression of failing tooth is facilitated with focus to accurately capture the dento-gingival junction. A flowable
light-cured composite replica of the tooth is fabricated from the impression for the provisional fabrication. The replica is trimmed to the exact location of the
dento-gingival location, establishing the emergence profile. 8b The hollowed replica of failing tooth, in light-cured esthetic color-matched composite, is used
for luting to the screw-retained temporary, opaqued titanium abutment. After filling the replica with composite and placing it on the abutment, the curing light
lutes the material to the abutment 8c The provisional crown is removed, using a screw access opening in the incisal third. The subgingival profile is individually
shaped for each patient at the time of surgery, with voids and rough edges eliminated and the provisional carefully contoured to support the gingival tissue. The
provisional is then polished and glazed.
Nobel Mark IV Implant with TiUnite surface, Nobel Biocare.
Elcomed implant drilling unit, W&H Impex, Windsor, ON.
Avitene microfibrillar collagen, Davol, Warwick, RI.
Elcomed implant drilling unit, W&H index.
** Avitene microfibrillar collagen, Davol.
Shanelec, Tibbetts Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 167
gingival one-half of the provisional attached to the implant is
taken to facilitate a custom impression transfer coping. The
machined titanium provisional abutment reduces the possi-
bility of the provisional loosening. In these cases, only one of
the 300 provisionals had its screw loosened.
Steps 24 to 30: Final Surgical Procedure for
Esthetic Success
The buccal socket gap fromthe extraction and palatally an-
gledimplant placement is filledwithosseous xenograft tothe
level of the implant platform. The surface is compressed to
create a fine-powered xenograft seal. Before placing filtered
autograft bone dust to the platform level, it is compressed
and a collagen membrane is molded over the autograft. A
buccal envelope split-thickness flapis created, and a connec-
tive tissue graft harvested from the palate is placed into the
buccal envelope. After freeing the papillae, the flap is ad-
vanced with 6-0 polypropylene sutures as needed.
Step 31: Implant Provisional Occlusion
Premature loading is avoided by adjusting the occlusion to
minimal contact. Confirmation of no centric and lateral
occlusal contact is performed using 1-mm green occlusal
indicator wax (Fig. 9). Symmetrical and light proximal
contacts are established. This technique allows patients
to leave the dental office with a non-loaded esthetic provi-
sional tooth securely anchored to the implant.
Steps 32 to 36: Final Restoration
An immediate provisional crown ensures that patients are
never without a natural-looking tooth. The provisional
crown also ensures that the gingiva is not left unsupported
during osseointegration. During the final impression, the
exact subgingival profile of the provisional is transmitted
to the ceramist by taking an impression made of the gingi-
val third of the provisional crown with an implant analog
This creates a custom impression transfer cop-
ing replicating the emergence profile of the provisional
(Fig. 10). After final impressions, made with the custom
impression transfer coping, a computer scan

is used to
create the permanent zirconium ceramic abutment and
(Fig. 11). This protocol ensures that thefinal abut-
ment exactly matches both the original tooth shape and the
provisional emergence profile. The occlusal is checked al-
lowing for 1 mmof clearance. The screwspace is filled with
metronidazole gel, and the provisional is installed. The pa-
tient is checked postoperatively at 2 and 6 weeks, with the
final restoration after 8 weeks, from the custom impression
coping and a scanned zirconium abutment.

FIGURE 9 Clinical case 5. 9a Preoperative view

of right lateral incisor. 9b Implant placed in
extraction site with opaqued screw-retained
temporary titanium abutment. 9c Hollowed rep-
lica of tooth luted to temporary abutment with
light cured composite. 9d Interproximal view of
flash on hollowed replica crown luted to tempo-
rary abutment. 9e Buccal view of composite
flash on the replica crown luted to temporary
abutment. 9f Finished provisional in place after
confirming there is no centric or lateral contact
using 1-mm green occlusal indicator wax. 9g
Four years after restoration.
Procera, Nobel Biocare.

Procera, Nobel Biocare.

168 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Implant Microsurgery
Working together as a team, surgeon, restorative dentist,
and ceramist can combine their skills to create a tooth in
natural harmony with the smile and the overall appearance
of adjacent teeth (Figs. 12 and 13).
Clinical Outcome and Discussion
Using the SMILE Technique on 300 consecutive patients
from a private practice in Santa Barbara, CA who re-
quired extraction of maxillary central incisors, lateral
incisors, or cuspid teeth, 298 implants resulted in suc-
cessful functional and esthetic outcomes after 1 to 10
years. No exclusion criteria were used. Of the 300
patients, one patient was lost to follow-up after the
implant and provisional were placed. Of 300 implants
placed, two implants failed to integrate. Two hundred
ninety-eight implants were cleared for restoration at
8 weeks based on radiographic and clinical examination.
Patient scheduling and restorative logistics determined res-
toration delivery to be from 10 to 22 weeks.
FIGURE 10a Before surgery, a clear silicone impression of the failing tooth
replica crown is used to assist with accurately capturing the dento-gingival
junction area for an emergence profile. 10b The emergence profile
recording. 10c Rough acrylic custom impression transfer coping. 10d
Polished custom impression coping replicating provisional emergence
FIGURE 11a A machined zirconium abutment created from impression
transfer coping of provisional emergence profile. 11b Ceramic crown on
custom abutment.
FIGURE 12 Clinical case 6. 12a Preoperative radiograph of maxillary left
central incisor. 12b Preoperative image of central incisors. 12c Ten-year
postoperative restoration of left central incisor. 12d Ten-year postoperative
radiograph. 12e Ten-year postoperative smile.
Shanelec, Tibbetts Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 169
FIGURE 13 Clinical case 7. 13a Preoperative
view of failing left central incisor. 13b Preoper-
ative radiograph. 13c Drill gauges to control
platform depth. 13d Interoperative radiograph
with depth and platform gauge. 13e Postopera-
tive radiograph with screw-retained provisional
crown. 13f Extraction, implant, socket one graft,
and immediate screw-retained crown. 13g Con-
nective tissue graft sutured. 13h Two-week
postoperative appearance. 13i Twelve-week
postoperative view. 13j Twelve-week postoper-
ative radiograph. 13k Finished provisional emer-
gence profile. 13l Custom impression coping
with replicated emergence profile. 13m Ceramic
crown on zirconium abutment replicating pro-
visional emergence profile. 13n Zirconium abut-
ment and crown separately viewed. 13o
Laboratory model with zirconium abutment 13p
Laboratory model with zirconium abutment and
ceramic crown. 13q Two-year postoperative
view. 13r Two-year post-restorative smile.
170 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Implant Microsurgery
The criteria for successful treatment included: 1) absence
of inflammation, infection, mobility, pain, or bleeding on
probing; 2) ability to withstand rotational torque of >65
Ncm; 3) a peri-implant tissue sulcus <1 mm apical to the
implant platform; 4) radiographic evidence of bone to
the topmost implant thread; 5) restoration of the implant
and it remains in function; and 6) a satisfactory esthetic
The learning value of this case series is that implant mi-
crosurgery offers an opportunity for implant therapy that
can enhance the esthetic results. Its benefits include rapid
healing, minimal discomfort, and improved patient accep-
tance. Dentistry will see increasing use of the microscope in
many phases of practice, including implant placement and
Microscopy has the potential to advance
dentistry from an era of traumatic tooth loss to one
of exact and seamless replacement of a failing tooth.
Although the technique described is multifaceted and
requires many steps to complete successfully, the clinical
benefits are outstanding. Successful treatment requires
microscope magnification, attentiontodetail, anda combi-
nation of microsurgical and restorative skills. n
Why is this technique new
Focuses on the immediate microsurgical replacement and
provisionalization of a single esthetically important maxillary anterior
j Demonstrates the versatility of dental implant microsurgery
j Follows a systematic microsurgical approach for immediately
replacing and restoring such teeth
What are the keys to the successful
management of such cases?
Thorough planning and following the detailed sequential treatment
steps using a microscope
Implant placement precision
j Exactness in provisional crown fabrication and placement
j Placement of a subepithelial connective tissue graft over the labial
surface of the implant
j Passive wound closure
What are the primary limitations to
success in these cases?
Macrosurgery versus microsurgery
Excessive tissue trauma
Inexact implant placement
Non-use of the polished provisional emergence profile in establishing
the final restration emergence profile
The authors report no conflicts of interest related to this
case series.
Dr. Leonard S. Tibbetts, 916 W. Mitchell St., Arlington, TX 76013.
Shanelec, Tibbetts Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 171
1. Adell R, Eriksson B, Lekholm U, Branemark PI, Jemt T. Long-term
follow-up study of osseointegrated implants in the treatment of totally
edentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-359.
2. Widmark G, Friberg B, Johansson B, Sindet-Pedersen S, Taylor A.
Mk III: A third generation of the self-tapping Branemark System
implant, including the new Stargrip internal grip design. A 1-year
prospective four-center study. Clin Implant Dent Relat Res 2003;5:
3. Covani U, Crespi R, Cornelini R, Barone A. Immediate implants
supporting single crown restoration: A 4-year prospective study. J
Periodontol 2004;75:982-988.
4. Evian CI, Emling R, Rosenberg ES, et al. Retrospective analysis of
implant survival and the influence of periodontal disease and immediate
placement on long-term results. Int J Oral Maxillofac Implants 2004;
5. Hui E, Chow J, Li D, Liu J, Wat P, Law H. Immediate provisional for
single-tooth implant replacement with Branemark system: Preliminary
report. Clin Implant Dent Relat Res 2001;3:79-86.
6. Degidi M, Piattelli A. Immediate functional and non-functional loading
of dental implants: A 2- to 60-month follow-up study of 646 titanium
implants. J Periodontol 2003;74:225-241.
7. Romanos GE. Present status of immediate loading of oral implants. J
Oral Implantol 2004;30:189-197.
8. Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North
Am 1998;42:339-359.
9. Tibbetts LS, Shanelec DA. A review of the principles and practice of
periodontal microsurgery. Tex Dent J 2007;124:188-204.
10. Tibbetts LS, Shanelec D. Principles and practice of periodontal
microsurgery. Int J Microdent 2009;1:2-12.
11. Shanelec DA. Periodontal microsurgery. J Esthet Restor Dent 2003;15:
402-407, discussion 408.
12. Saadoun AP. Immediate implant placement and temporization in
extraction and healing sites. Compend Contin Educ Dent 2002;23:
309-312, 314-316, 318 passim; quiz 326.
13. King KO. Implant abutment emergence profile: Key to esthetics. J Oral
Implantol 1996;22:27-30.
14. Hinds KF. Custom impression coping for an exact registration of the
healed tissue in the esthetic implant restoration. Int J Periodontics
Restorative Dent 1997;17:584-591.
15. Buskin R, Salinas TJ. Transferring emergence profile created from the
provisional to the definitive restoration. Pract Periodontics Aesthet
Dent 1998;10:1171-1179, quiz 1180.
16. Davarpanah M, Martinez H, Celletti R, Tecucianu JF. Three-stage
approach to aesthetic implant restoration: Emergence profile concept.
Pract Proced Aesthet Dent 2001;13:761-767, quiz 768, 721-722.
17. Yildirim M, Edelhoff D, Hanisch O, Spiekermann H. Ceramic
abutments d A new era in achieving optimal esthetics in implant
dentistry. Int J Periodontics Restorative Dent 2000;20:81-91.
18. Shanelec D, Tibbetts L. Recent advances in surgical technology. In:
Newman MG, Takei HH, Carranza FA, eds. Clinical Periodontology, 9th yy
ed. Philadephia: W. B. Saunders; 2009:876-881.
indicates key references.
172 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Implant Microsurgery
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Surgical and Prosthetic Correction of Two Adjacent
Anterior Implants: A Clinical Case Report
Dennis P. Tarnow* and Stephen J. Chu

Introduction: This clinical case presentation exemplifies the esthetic complications of two adjacent osseointegrated im-
plants placed in the maxillary left centrallateral incisor region of a young female patient with a high smile line and the challenges
associated with surgical and prosthetic correction.
Case Presentation: The goal of treatment was to reconstruct the height of the interdental papilla between two adjacent
anterior implants to match that of the contralateral teeth and create the proper individual tooth size and proportion of the natural
dentition in a stable occlusion. Dermis allograft material was chosen as the graft material because it does not require a donor-site
and it is not dependent on the patients own tissue volume. Using autogenous tissue could potentially increase the number of
surgical procedures andlimit the extent of correction. Consecutive surgical procedures using dermis allograft were performed to
reconstitute the lost hard andsoft tissues. After the height of the interdental tissues was reconstructed to the proper dimensions,
then the concept of submerging the implant in a less favorable restorative position and surgically exposing the useful implant
was used. A customimplant abutment was fabricated on the exposed left central incisor implant, and two-unit cement-retained
fixed dental prosthesis (FDP) was fabricated with a cantilevered pontic as the definitive restoration.
Conclusions: Esthetic correction of lost hard and soft interdental tissues was successfully performed through multiple
surgical procedures using dermis allograft material. The concept of submerging one implant and engaging the useful one
was used to fabricate a two-unit cantilevered FDP. Clin Adv Periodontics 2011;1:174-181.
Key Words: Adjacent implants; case report; dermis allograft; esthetics, dental; interdental papilla; submerged implant.
Use of dental implants for anterior tooth replacement has
increased over the past decade. However, a high level of
skill and knowledge is required when placing implants in
the esthetic zone because a negative result is immediately
noticeable. Frequently, errors can occur in treatment
planning, execution, and/or both. Without perfection in
three-dimensional spatial placement, the implant may
survive (i.e., osseointegrate) but may be a clinical failure if
the esthetic outcome is less than ideal.
The decision to place two adjacent anterior implants has
been discussed by many clinicians and researchers.
clinical dilemma is that the interdental papilla is invariably
deficient in height when compared to the contralateral nat-
ural tooth.
This is highlighted when the maxillary central
and lateral incisors have been replaced with dental im-
plants. If a high interdental smile line exists, then the
* Department of Periodontics, Columbia University College of Dental
Medicine, New York, NY.

Department of Prosthodontics, Columbia University College of Dental

Submitted December 23, 2010; accepted for publication March 22, 2011
doi: 10.1902/cap.2011.100009
174 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011
literature has proposed an implantpontic treatment plan
scenario (i.e., placement of one implant in the central inci-
sor location and cantilever an ovate-shaped pontic in the
lateral incisor position) after ridge augmentation.
The ensuing case report is a clinical situation in which
a patient with a high interdental smile line
two adjacent anterior implants in the central and lateral in-
cisor region (Fig. 1). This clinical decision resulted in an
esthetic failure because the patient could no longer smile
as a result of the disharmony in tooth length, proportion,
and papilla height (Fig. 2). The following case report exem-
plifies and emphasizes interdisciplinary treatment planning
and treatment required to restore the smile of a young vital
Clinical Presentation
A 30-year-old African-American female presented with
the chief complaint of I dont feel like I can smile. Past
medical history was non-contributory. The past dental his-
tory revealed that the patient had been in a ski accident 11
years previously, and consequently, was wearing
a removable prosthesis. Due to dissatisfaction of the re-
movable prosthesis, the previous dentist and oral surgeon
offered a fixed dental solution using two implants replac-
ing avulsed teeth #9 and #10. A full-coverage crown was
present on tooth #8. Radiographic examination revealed
that the two implants appeared to be well integrated; how-
ever, the soft tissue on the facial and interdental aspects of
both implants was extremely deficient. Therefore, the pa-
tient would cover her mouth when she spoke as well as
conceal the defect with the drape of her upper lip. The pa-
pillae on the contralateral teeth were normal in position and
height. The negative gingival architecture and asymmetry
prompted the patient toseek alternative treatment opinions.
Alternative treatment plan options were presented, in-
cluding removing or burying both implants. However, the
treatment option of submerging both implants and using
multiple connective tissue grafts (CTGs) (i.e., autogenous
CTG and dermis allografts) and then uncovering implant
#9 and using it to support a two-unit fixed dental prosthesis
(FDP) with tooth #10 cantilever pontic was chosen.
This option was embarked upon with the understanding
that multiple surgical procedures would be required to cor-
rect the vertical defect. This treatment option provided the
opportunity to reconstitute enough interdental soft-tissue
height and volume that would be visible and pleasing in
her smile while maintaining an implant-supported FDP
without implant removal. The surgical goal was to elimi-
nate all of the pink acrylic and replace it with vital tissues
through surgical reconstruction.
Case Management
The existing crowns and associated abutments were re-
moved, and surgical cover screws were placed on implants
#9 and #10 (Fig. 3). This is similar to the tooth decorona-
tion/root submergence technique described for teeth.
Tooth #8 was used to support a provisional restoration
with cantilevered pontics #9 and #10 with gingiva-shaded

to give a visual assessment of the treatment FIGURE 2 Intraoral view showing the lack of symmetry, tooth size and
proportion, and gingival esthetics of the restored implants for teeth #8 and
#9. The lack of interdental papilla between #9 and #10 is glaringly evident,
as well as the excessive contact area attributable to the absence of papilla
FIGURE 3 Surgical cover screws were placed over the healthy implants,
and the tissue was allowed to heal and regenerate for future flap closure.
FIGURE 1 Dentofacial smile view showing the loss of the interdental
papilla between the two adjacent anterior implants #9 and #10.

DENTSPLY Denture Repair Acrylic, DENTSPLY, Tulsa, OK.

Tarnow, Chu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 175
outcome (Fig. 4).
A shallow overbite/overjet occlusal
scheme and lack of parafunction lent to the stability of this
transitional provisional FDP.
After 3 weeks, soft tissue grew over the cover screws,
which facilitated ridge augmentation. A papilla-saving inci-
sionwas performedtoallowthe existing interdental papillae
to remain intact (Fig. 5).
A full-thickness muco-periosteal
flap was raised (Fig. 6), and a thick dermis allograft
placed over the surgical cover screws. The dermis allograft
was also covered with a section of palatal autogenous con-
nective tissue (Fig. 7). This was done because: 1) the closure
of the cover screws after 3 weeks of healing was incomplete
andrequiredcomplete coverage because the dermis allograft
cannot be exposedtothe oral environment during the healing
period; 2) 5 to 7 mmof vertical interdental tissue augmenta-
tion was required; and 3) the patient had insufficient donor
connective tissue. The buccal flap was undermined and re-
leased, and passive closure was obtained with 5-0 chromic
The provisional restoration was relieved and ce-
mented into place with temporary cement
(Fig. 8). This
augmentation procedure was repeated two more times,
and, at 4months after the last surgery(Fig. 9), stage II implant
uncovering surgery was performed for the implant in the left
central incisor position. Care was taken during the uncover-
ing surgery to prevent exposure of implant #10 (Fig. 10). The
provisional was attached to the uncovered implant #9 with
acrylic resin conscious of a flat subgingival profile to not en-
courage mid-facial recession and allow flap adaption during
suturing (Fig. 11). Gingivoplasty was performed on the facial
aspect of tooth #8 to contour the gingival zenith of the right
central incisor in the correct position
and to match that of
the left central incisor implantgingival contour.
An ovate pontic was then placed into the healed ridge
over the submerged implant
in the left lateral incisor po-
sition using a subtractive technique with an ovoid-shaped,
diamond-coated bur
(Figs. 12 and 13). Two months later,
FIGURE 4 The teeth were fabricated with tooth-colored acrylic, and the
remaining areas of deficient gingival tissues were restored with pink-
shaded acrylic. This is an important step as a communication tool for
patient and surgeon to define whether a prosthetic or surgical solution is
viable. In addition, the pink acrylic serves as a surgical guide to visualize
and quantify the height and width of tissue that must be reconstituted.
FIGURE 5 A papilla-saving incision was performed, exposing the
previously placed implants.
FIGURE 6 A thick piece of dermis allograft was sutured in place, covering
the existing implants.
FIGURE 7 Palatal CTG covering the dermis allograft in which the existing
coverage over the cover screws was incomplete.
Tutoplast, IOP Ophthalmics, Costa Mesa, CA.
Ethicon, Johnson & Johnson, New Brunswick, NJ.
TempBond NE, Kerr Corporation, Orange, CA.
Brasseler USA, Savannah, GA.
176 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Correction of Two Anterior Implants
definitive impression making was performed,** and the fi-
nal metal abutment and metal ceramic FDP was con-
structed in the dental laboratory (Fig. 14).
Clinical Outcomes
Despite regenerating a large amount of soft tissue over the
two anterior implants, there was still a need to use some
gingival-shaded ceramics to help with the pink esthetics
of the final restoration (Fig. 15). Subsequently, the surgeon
with the patients consent performed a papilla correction
procedure to eliminate the use of the pink ceramics.
Leaving the existing soft-tissue relationships undis-
turbed on the labial margins of the FDP, a split-thickness
flap was made at the mucogingival junction apical to the
smile line and was made to release the tissue incisally
(Fig. 16). A thick wedge-shaped free subepithelial CTG
was taken from the palate and inserted into the space cre-
ated by the opening. It was sutured around and over the
contact area of the FDP, which served as a scaffold to sta-
bilize the flap coronally and reposition the interdental tis-
sue between implant #9 and pontic #10, thereby limiting
the amount of tissue rebound (Fig. 17). The area was al-
lowed to heal uneventfully without the need to recement
the FDP. Although the papilla between #9 and #10 was still
slightly more apical than the contralateral side, it was now
esthetically acceptable for the patient who felt comfortable
FIGURE 11 Acrylic must be added to the subgingival aspect of the
provisional abutment to create the proper contour. A flat emergence profile
is created to allow the tissue to lie in the proper vertical position. The
provisional restoration is ready for insertion.
FIGURE 12 A bullet-shaped diamond bur was used to subtract tissue over
the buried implant #10 to create an ovate pontic form.
FIGURE 8 Area sutured with 5-0 chromic sutures. Note that almost all the
pink acrylic of the provisional restoration has been removed with no
residual pressure on the ridge.
FIGURE 9 The third dermis surgery was allowed to heal for 4 months.
FIGURE 10 A small incision was made to expose implant #8 and allow for
the connection of the provisional restoration without exposure of the
submerged implant #10.
** Flexitime Xtreme, Heraeus Kulzer, South Bend, IN.
Tarnow, Chu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 177
FIGURE 15 Intraoral view of the final prosthesis with gingival-shaded
ceramics. The gingival ceramics were added to match the papilla height of
the contralateral teeth.
FIGURE 16 A horizontal incision at the mucogingival junction apical to the
patients smile line was made. The coronal tissue was mobilized using
a split-thickness flap. This technique was made possible because of all of
the connective tissue that was augmented over the implants.
FIGURE 14 The definitive FDP, gold plated and ready for placement. Note
the pink ceramic required to close the black gingival triangle still present
between implant #9 and ovate pontic #10.
FIGURE 17 A wedge-shaped piece of CTG from the palate was placed
into the opening to prevent the coronal ``mini papilla flap'' from rebounding
apically. The pink ceramic was removed, and the FDP contact area was
used as a scaffold to coronally reposition and stabilize the mini papilla flap
between implant #9 and pontic #10 during healing.
FIGURE 18 Healing with lips retracted after 3 months, showing elimination
of the pink ceramic between implant #9 and pontic #10.
FIGURE 13 The provisional restoration was modified to create an ovate
pontic shape. The intraoral clinical situation after the ovate pontic was
placed. Note that the papilla between implants #8 and #9 is still slightly
deficient in height.
178 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Correction of Two Anterior Implants
and confident. Compared to the preexisting deformed den-
tal condition (Figs. 1 and 2), the esthetic outcome is posi-
tively dramatic in dental, dentalfacial, and facial
perspectives, respectively (Figs. 18 through 20).
This clinical case report exemplifies how an error in treat-
ment planning by placing two adjacent anterior implants
in the maxillary centrallateral incisor position can lead
to an esthetic deformity that not only caused great emo-
tional trauma to the patient but also extensive time and
multiple corrective surgical procedures. It also demon-
strates how an interdisciplinary approach is required to
correct and reverse such esthetic deformities. The treat-
ment mandated >7 mm of soft tissue over two adjacent
implants. It needed attention to provisional restoration
during the transitional healing periods of four corrective
surgeries to reconstitute the lost tissues in conjunction with
quality restorative and laboratory care.
Eventually, two adjacent anterior implants can be placed
into the esthetic zone without the loss of the interdental pa-
pilla, but presently, this is not a reality with predictability.
However, it is clinically acceptable to place two adjacent
implants in the central incisor areas with a longer contact
area/papilla height ratio attributable to the symmetry of
the central incisor teeth. However, if two implants are
placed in the centrallateral areas, then the resultant more
apical location of the papilla is glaringly noticeable since
the contralateral papilla is of normal apicalcoronal
This clinical case report exemplifies the importance of
the correct diagnosis and treatment plan in the esthetic
zone when two adjacent teeth are missing other than the
two central incisors. It also shows howthis clinical scenario
was treated with an interdisciplinary approach that re-
quired: 1) a clear vision in end-goal treatment using dental
and gingival determinants of esthetics, and 2) 1.5 years of
treatment to surgically reconstruct 7 mm of deficient soft
tissues interdentally. n
FIGURE 20 The patient was extremely pleased with the surgical
reconstruction and definitive crown restorations. In fact, the patients smile
line is now higher (i.e., more visible) than before because she felt
comfortable and confident with her new smile.
FIGURE 19 Final dentofacial view of the patient smiling after 6 months of
healing after the last surgical procedure. Compared to Figure 1, the
reconstructed papilla height is almost coincident to the contralateral side.
Tarnow, Chu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 179
Why is this case new information? n The esthetic and biologic potential of dermis allograft as an
augmentation material is presented.
n The clinical case applies the concept of tooth decoronation described
by Langer
and Salama et al.
to implant therapy; biologically
healthy, yet poorly placed implants can be used in which one implant
can be submerged and the useful implant exposed.
n It uses recent biometric determinants for interdental papillae esthetics.
What are the keys to successful
management of this case?
For the treatment to be successful, it is necessary to:
n bury the implants first and use a tooth-supported transitional
provisional restoration;
n perform the augmentation surgeries in a consecutive sequential
n be realistic about not correcting the deformity in one surgical
n understand the limitations and potential of dermis allograft as an
augmentation material;
n know that an implantpontic restorative design is currently the most
predictable treatment plan option for consecutive anterior implants;
n ensure that the patient understands, has patience with, and complies
with the treatment goals and time required for esthetic reconstruction.
What are the primary limitations to
success in this case?
Limitations to success include:
n patient non-compliance of required surgical procedures;
n treatment time and cost.
The authors report no conflicts of interest related to this
case report.
Stephen J. Chu, 150 E. 58th St., Suite 3200, New York, NY 10155. E-mail:
180 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Correction of Two Anterior Implants
1. Salama H, Salama MA, Garber D, Adar P. The interproximal height of
bone: A guidepost to predictable aesthetic strategies and soft tissue
contours in anterior tooth replacement. Pract Periodontics Aesthet
Dent 1998;10:1131-1141, quiz 1142.
2. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on
the height of inter-implant bone crest. J Periodontol 2000;71:546-549.
3. Grunder U. Stability of the mucosal topography around single-tooth
implants and adjacent teeth: 1-year results. Int J Periodontics Re-
storative Dent 2000;20:11-17.
4. Tarnow D, Elian N, Fletcher P, et al. Vertical distance from the crest of
bone to the height of the interproximal papilla between adjacent
implants. J Periodontol 2003;74:1785-1788.
5. Funato A, Salama MA, Ishikawa T, Garber DA, Salama H. Timing,
positioning, and sequential staging in esthetic implant therapy: A four-
dimensional perspective. Int J Periodontics Restorative Dent 2007;27:
6. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J
Prosthet Dent 1984;51:24-28.
7. Van Der Geld P, Oosterveld P, Berge SJ, Kuijpers-Jagtman AM. Tooth
display and lip position during spontaneous and posed smiling in
adults. Acta Odontol Scand 2008;66:207-213.
8. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet
Dent 1978;39:502-504.
9. Dickens ST, Sarver DM, Proffit WR. Changes in frontal soft tissue
dimensions of the lower face by age and gender. World J Orthod 2002;
10. Langer B. Spontaneous in situ gingival augmentation. Int J Periodontics
Restorative Dent 1994;14:524-535.
11. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages
of the root submergence technique for pontic site development in
esthetic implant therapy. Int J Periodontics Restorative Dent 2007;27:
12. Chu SJ. Range and mean distribution frequency of individual tooth
width of the maxillary anterior dentition. Pract Proced Aesthet Dent
13. Chu SJ, Tan JH, Stappert CF, Tarnow DP. Gingival zenith positions and
levels of the maxillary anterior dentition. J Esthet Restor Dent 2009;21:
14. Chu SJ, Tarnow DP, Tan JH, Stappert CF. Papilla proportions in the
maxillary anterior dentition. Int J Periodontics Restorative Dent 2009;
15. Gomez-Roman G. Influence of flap design on peri-implant interprox-
imal crestal bone loss around single-tooth implants. Int J Oral
Maxillofac Implants 2001;16:61-67.
16. Orsini G, Murmura G, Artese L, Piattelli A, Piccirilli M, Caputi S.
Tissue healing under provisional restorations with ovate pontics:
A pilot human histological study. J Prosthet Dent 2006;96:252-
indicates key references.
Tarnow, Chu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 181
Use of the Pocket-Lining Tissue as a Pedicle Flap to Facilitate
Wound Closure After Extraction to Preserve the Alveolar
Ridge or Protect an Implant Site
Shane J. McCrea*
Introduction: Because hard- and soft-tissue remodeling and resorption follows tooth extraction, postextraction ridge de-
ficiencies and abnormalities may require correction before implants can be placed. Equally, where immediate implants are
placed, alveolar bone and gingival soft tissue must be protected; thus, primary wound closure of an extraction site is desirable
but remains challenging. Guided bone regeneration has made ridge preservation possible and more predictable. However,
where barrier membranes remain exposed, infection and graft failure can occur. The technique presented here uses the
pocket-lining epitheliumthat is found at periodontally compromised sites to facilitate primary wound closure. To my knowledge,
this is the first report of this technique.
Case Presentations: All presented cases had periodontally compromised teeth that were extracted. After extractions, the
pocket-lining epitheliumwas dissected and pedicalized (using the pocket-lining pedicle flap [PLPF] procedure). All vacated sockets
were prepared, and dental implants were immediately placed. Guided bone regeneration was used to circumferentially fill the
remaining alveolar voids and any bony defects. The well-vascularized attached epitheliumwas used to provide primary wound cov-
erage at the surgical site. Wound healing was uneventful in all the considered cases. Sutures were removed at 4 weeks in all cases.
No tissue sloughing occurred, and, when visible, early keratinization was apparent. No soft-tissue dehiscence formation occurred.
Conclusions: In this case report, the PLPF provided successful soft-tissue wound closure at extraction sites where
implants were immediately placed. The technique appears to visually stabilize the position of the mucogingival junction and
may well preserve or enhance the width of keratinized gingival tissue, thus aiding optimal esthetics. Clin Adv Periodontics
Key Words: Dental implants; granulation tissue; periodontal pocket; wound closure techniques.
Coronally advanced flaps have been used for primary soft-
tissue closure over extraction sites where immediate
implant insertion has been performed.
However, such
flaps will move the mucogingival junction in a coronal
direction, thus moving the keratinized gingiva coronally.
In visibly sensitive areas, this coronal repositioning may be
esthetically undesirable. Maintaining the width of kerati-
nized gingiva is conducive to good oral hygiene tech-
niques, and its reduction is seen as detrimental.
increase the width of the keratinized gingival tissue
(wKGT) and stabilize the mucogingival junction posi-
tion, subepithelial grafts have been used.
discussion as to the morbidity associated with the palatal
donor site and the associated increase in patient discomfort
then arises.
Free gingival grafts have longbeenusedtocover extraction
sites. Problems arise with this technique because the blood
* Private practice, Dorset, UK.
Submitted December 16, 2010; accepted for publication March 20, 2011
doi: 10.1902/cap.2011.100006
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 183
supply depends on the alveolar blood clot and the periph-
eral gingival wall of the vacated socket.
This technique
is reported to have a high failure rate.
Palatal pedicle flaps
have also been used for primary wound closure after ex-
tractions in the maxilla.
Unfortunately, their blood flow
can be compromised as a result of the 90
rotation they suf-
fer at repositioning.
Recently, Stimmelmayr et al.
used a combined epi-
thelialized subepithelial connective tissue graft (SCTG)
for wound closure that showed very promising results.
However, their method still involves morbidity at the
palatal donor site and the corresponding patient
The placement of a dental implant intoanalveolus vacated
by a periodontally compromised tooth is no longer contrain-
Whenextreme bone loss has been suffered, ridge
augmentation is possible, and the subsequent placement of
implants into such sites either concurrently or at an addi-
tional (future) surgical sitting have reported success.
The rationale that wound closure must be accompanied
with a tissue coverage technique that maintains a patent un-
compromised blood supply and is capable of keratinization
FIGURE 1 Clinical case 1. 1a Preoperative clinical situation of teeth #11 and #21. 1b Preoperative radiograph. 1c through 1e Starting from the apical
extremity, dissection of the pocket-lining epithelium from the palatal bony wall, ensuring the patency of the coronal attachment. 1f Implant insertion under the
184 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Pocket-Lining Pedicle Flap Procedure
has beenapplied. The pocket-lining pedicle flap(PLPF) tech-
nique involves the careful dissection of pocket-lining epithe-
lium from the vacated socket, maintaining it as a pedicle
with its own continued blood supply and using the flap to
produce primary wound closure. This method will then
see the local conversion of the non-keratinized pedicle into
a resilient keratinized overlaying crestal tissue that is neces-
sary for the maintenance of the peri-implant mucogingival
complex, together withanestheticallypleasing implant-sup-
ported crown.
Case Presentation
Since March 2007, the author (SJM) has performed many
such PLPF procedures to facilitate primary wound clo-
sure, at a private practice in Dorset, UK. All patients
had undergone supportive periodontal therapy and pre-
sented with individual teeth for which extraction was
necessary for continued adjacent periodontal health
and ridge preservation. All were diagnosed with chronic
periodontitis with generalized horizontal bone loss and
localized vertical defects. This case report describes
the surgical approach used for the PLPF procedure and
reports examples of clinical use.
Case Management
For preextraction, 1 hour before surgery, all patients received
the same systemic coverage: 2 g amoxicillin (or 600 mg clin-
damycin when allergic), 400 mg ibuprofen, and 2 mg dexa-
methasone. Additionally, mouthrinse of 2% chlorhexidine
gluconate was used 20 minutes before surgery.
FIGURE 1 (Continued) 1g ded bone
gment the
1h the PLPF
1i nsion was
y with 5-0
apically to
ound site.
aced in an
1j 1k ures were
McCrea Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 185
Teeth were sequentially extracted (Figs. 1 and 2). The va-
cated sockets were explored for the patency of pocket-
lining tissue using a trimmer

or a fine periosteal elevator.

All pocket-lining epithelium was dissected from the al-

veolar walls with either instrument, after which a crestal
incision, displaced to the palatal aspect, was made with
relieving incisions if visibility was impaired, or to aid in
accessing the site. The buccal mucoperiosteal flap was
raised, taking care to not damage the dissected PLPFs.
All sockets were prepared for implant insertion with the
axis of all osteotomies displaced to the palatal aspect. All im-
plants were inserted with an initial seating torque of 40 Ncm,
and final seating was made with a hand wrench. A bovine-
derived xenograft
was placed circumferentially into the al-
veolar voids and covered with collagen membrane.
closure was facilitated with 6-0 and 5-0 polypropylene
using minimal coronal tension (Figs. 3 through 5).
Clinical Outcomes
In all patients treated, no case had wound dehiscence;
all 50 grafts had integrated completely by primary wound
healing. All the cases were assessed presurgically as to the
labial wKGT. When wKGT <2 mm, SCTGwas placed. Be-
cause the PLPF provided complete primary wound closure,
thus protecting the SCTG, no sloughing of SCTGs occurred.
The surgery was able to provide a patent wound seal with
minimal or no displacement of the mucogingival junction,
which occurs in conventional coronal repositioning.
After tooth extraction, there will be resorption of alveolar
Maintenance or reconstruction of the hard and
soft tissues is a prerequisite for implant site preparation
and final esthetics. In ridge-preservation procedures, pri-
mary wound closure is difficult to achieve without displac-
ing the mucogingival junction in a coronal direction and
also reducing the natural depth of the labial sulcus, thus de-
creasing the wKGT. When the patient is periodontally com-
promised with deep pocketing, the preservation of the
pocket lining and its use as the PLPF provides an effective
solution for wound closure.
When the intention is to immediately place implants in
extraction sockets, wound closure is critical to protect graft
material of choice with or without a protective membrane.
Additionally, the covering and protection of soft-tissue
grafts with the PLPF enhances the early vascularization
of the grafts and prevents graft failures. n
FIGURE 2 Schematic of clinical case 1. 2a and 2b Tooth #11 was atraumatically extracted, and a full-thickness buccal flap was raised. The pocket lining on
the palatal bony wall was elevated and pedicalized (PLPF procedure) by dissection using a periosteal elevator. 2c The osteotomy was prepared and the implant
was inserted, taking care not to traumatize the PLPF. 2d Collagen membrane granules were placed circumferentially into the alveolar void and used to augment
the buccal dehiscence. The collagen membrane was placed onto the xenografts. 2e The PLPF was folded forward to cover the collagen membrane. The buccal
flap was placed onto the apical extremity of the PLPF to cover it. The site was then sutured with 50 polypropylene sutures.

Mitchell trimmers, Trycare, Bradford, UK.

Buser periosteal elevator, STOMA, Emmingen-Liptingen, Germany.

Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland.
Bio-Gide, Geistlich Pharma.
Prolene sutures, Ethicon, Johnson & Johnson, Livingston, West
Lothian, UK.
186 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Pocket-Lining Pedicle Flap Procedure
FIGURE 3 Clinical case 2. 3a Preoperative situation. 3b Preoperative radiographs. 3c Crestal incision fully displaced to the palatal aspect; the buccal flap was
raised, preserving all the papillae and the pocket linings. The four incisors were removed, and implants were inserted conventionally with their axis displaced to
the palatal aspect. 3d The xenograft material was placed in the socket voids, and the sockets were covered with collagen membrane. 3e The flap was
replaced, but on this occasion, because of the prominence of the papillae, crestal suturing was external. The pocket linings are visible. A temporary adhesive
bridge was fitted with deep ovoid pontate surfaces. 3f Regardless of the deep ovate pontates, no tissue dehiscence is seen at 6 months after surgery. 3g At 24
months after crown loading, the wKGT helps produce a visibly esthetic result. 3h Radiographs taken at 24 months after the crown fit.
McCrea Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 187
FIGURE 4 Clinical case 3. 4a Preoperative clinical situation. 4b. Preoperative radiographs. 4c No buccal flap was raised because of the very reduced wKGT
and the circumferential bone loss. 4d The crestal incision was made through the papillae. The pocket linings are fully visible. 4e All pocket-lining epithelium was
dissected from the palatal and buccal socket walls. 4f Osteotomies were prepared. The multiple PLPFs are easily seen.
188 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Pocket-Lining Pedicle Flap Procedure
FIGURE 4 (Continued) Clinical case 3 4g PLPFs are very apparent over the wounds. All were sutured through the buccal and palatal flaps to secure them. 4h
Post-surgery radiographs. Nasal lifts were performed for implants in positions #11 and #21, using osteotomes. All socket voids were filled with bone substitute
material particles and covered with collagen membrane. 4i and 4j Soft-tissue results at 6 months before the second-stage surgery. 4k Soft-tissue results at 12
months after loading of the implants with their crowns. 4l Radiographs taken at 12 months after loading of the implants with their crowns.
McCrea Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 189
Why are these cases new
n After searching the literature, this is the first case report, to my
knowledge, to report the use of the granulomatous tissue of the
pocket lining as a PLPF to achieve wound closure.
What are the keys to successful
management of these cases?
n Full periodontal assessment of the patient must be performed,
including a six-point pocket-chart record, to determine the presence
of substantial granulomatous tissue that may be mobilized as a PLPF.
n Clarity of operative field must be achieved. Wearing binocular loupes
is recommended for this technique.
What are the primary limitations to
success in these cases?
n Inexperience is the primary limitation because the technique is
operator sensitive. It is recommended that previous extensive
experience of soft-tissue manipulation should be achieved before
embarking on this technique.
The author reports no conflicts of interest related to this
case report.
Shane J. McCrea, The Dental Implant andGingivalPlastic Surgery Centre,
717 Christchurch Rd., Bournemouth, Dorset, BH7 6AF, UK. E-mail:
FIGURE 5 Schematic of clinical case 4. 5a and 5b Teeth #11, #12, #21, and #22 were atraumatically extracted. The palatal and buccal pocket linings were
dissected from their bony walls using a trimmer and elevated, producing separate palatal and buccal PLPFs. 5c The osteotomies were prepared, and, in this
case, nasal lifts were facilitated at #11 and #21 sites using osteotomes. The implants were then inserted. Throughout the techniques, the PLPFs were reflected
for their protection from inadvertent surgical trauma. 5d Bone substitute material granules were then introduced circumferentially into the alveolar voids and
covered with its membrane. The palatal PLPF was then folded down onto the membrane, followed by the buccal PLPF. Suturing is simple, with interrupted
loop sutures that penetrate the PLPFs, thus holding them securely over the membrane.
190 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Pocket-Lining Pedicle Flap Procedure
1. Becker W, Becker BE. Guided tissue regeneration for implants placed
into extraction sockets and for implant dehiscences: Surgical tech-
niques and case report. Int J Periodontics Restorative Dent 1990;10:
2. Landsberg CJ. Socket seal surgery combined with immediate implant
placement: A novel approach for single-tooth replacement. Int J
Periodontics Restorative Dent 1997;17:140-149.
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approach with 30-month follow-up. Oral Surg 2010;3:143-151.
4. Langer B, Calagna L. The subepithelial connective tissue graft.
J Prosthet Dent 1980;44:363-367.
5. Jung RE, Siegenthaler DW, Hammerle CH. Postextraction tissue
management: A soft tissue punch technique. Int J Periodontics Re-
storative Dent 2004;24:545-553.
6. Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach for
optimal single implant supported crown. Part I d The socket seal
surgery. Pract Periodontics Aesthet Dent 1994;6:11-17, quiz 19.
7. Khoury F, Happe A. The palatal subepithelial connective tissue flap
method for soft tissue management to cover maxillary defects: A
clinical report. Int J Oral Maxillofac Implants 2000;15:415-418.
8. Nemcovsky CE, Artzi Z, Moses O, Gelernter I. Healing of marginal
defects at implants placed in fresh extraction sockets or after 4-6 weeks
of healing. A comparative study. Clin Oral Implants Res 2002;13:410-
9. El Chaar ES. Soft tissue closure of grafted extraction sockets in the
posterior maxilla: The rotated pedicle palatal connective tissue flap
technique. Implant Dent 2010;19:370-377.
10. Fugazzotto PA. Maintaining primary closure after guided bone re-
generation procedures: Introduction of a new flap design and pre-
liminary results. J Periodontol 2006;77:1452-1457.
11. Stimmelmayr M, Allen EP, Reichert TE, Iglhaut G. Use of a combination
epithelized-subepithelial connective tissue graft for closure and soft
tissue augmentation of an extraction site following ridge preservation
or implant placement: Description of a technique. Int J Periodontics
Restorative Dent 2010;30:375-381.
12. Wennstrom JL, Ekestubbe A, Grondahl K, Karlsson S, Lindhe J. Oral
rehabilitation with implant-supported fixed partial dentures in periodontitis-
susceptible subjects. A 5-year prospective study. J Clin Periodontol 2004;31:
13. Baelum V, Ellegaard B. Implant survival in periodontally compromised
patients. J Periodontol 2004;75:1404-1412.
14. Mengel R, Flores-de-Jacoby L. Implants in patients treated for general-
ized aggressive and chronic periodontitis: A 3-year prospective longitu-
dinal study. J Periodontol 2005;76:534-543.
15. Karoussis IK, Kotsovilis S, Fourmousis I. A comprehensive and critical
review of dental implant prognosis in periodontally compromised
partially edentulous patients. Clin Oral Implants Res 2007;18:669-679.
16. Covani U, Cornelini R, Barone A. Bucco-lingual bone remodeling
around implants placed into immediate extraction sockets: A case
series. J Periodontol 2003;74:268-273.
17. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth
extraction. An experimental study in the dog. J Clin Periodontol 2005;
18. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal
wall of extraction sockets of teeth with prominent roots. Int J Periodontics
Restorative Dent 2006;26:19-29.
indicates key references.
McCrea Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 191
The Use of a Xenogeneic Collagen Matrix as an Interpositional
Soft-Tissue Graft to Enhance Peri-Implant Soft-Tissue Outcomes:
A Clinical Case Report and Histologic Analysis
George A. Mandelaris,*

Mei Lu,

and Alan L. Rosenfeld*

Introduction: Keratinized and dense peri-implant soft tissue around implants has been associated with better tissue
health, less bone loss, and improved esthetics. The purpose of this case report is to evaluate a new, xenogeneic collagen
matrix (CM) as an interpositional soft-tissue graft to enhance peri-implant soft-tissue thickness. To our knowledge, this is the
first such case report to include soft-tissue biopsies and histologic analysis.
Case Presentation: After extraction and bone grafting of a mandibular left first molar, the patient received a dental im-
plant, and CMwas used as an interpositional soft-tissue graft. Clinical healing was uneventful, and the impression of enhanced
soft-tissue volume/thickness was observed. At 10 weeks, biopsies were taken from the operative site and from a contralateral,
non-operated site. Histologic assessment of the operative site demonstrated normal squamous epithelium and lamina propria.
Tissue growing into the residual CM also appeared normal, with no inflammatory cells seen in the graft area. Vascular blood
vessels were observed growing into the matrix. Control and test sites were comparable.
Conclusions: This case report and the first examination of a human biopsy around a dental implant demonstrate that CM
holds promise as an effective, time-efficient, and reduced morbidity alternative to autogenous graft harvest for the promotion
of peri-implant soft-tissue thickness. CM was easy to handle, place, and suture, and histologic analysis indicated a benign
tissue response resulting in an organized and attached connective tissue similar to native, undisturbed periodontal tissue.
Clin Adv Periodontics 2011;1:193-198.
Key Words: Case reports; collagen; dental implants; esthetics; transplants.
Around teeth, gingival tissue thickness has been associated
with improved root coverage predictability and recession
Around implants, keratinized and thick soft
tissue has been associated with better indices of tissue health,
lower levels of bone loss, and improved esthetics.
Based on
the bone loss observed on the facial aspect of implants in
a thin buccal plate environment, in which susceptibility to
recession is high, the establishment of a keratinized and thick
peri-implant soft tissue would appear to be advantageous.
Interpositional soft-tissue grafts canbe usedtoincrease peri-
implant soft-tissue thickness and keratinization.
for clinicians, autogenous soft-tissue grafting procedures can
* Private practice, Park Ridge, IL and Oakbrook Terrace, IL.

Advocate Lutheran General Hospital, Park Ridge, IL.

Department of Oral and Maxillofacial Surgery, School of Dentistry, Loma

Linda University, Loma Linda, CA.
Department of Graduate Periodontics, College of Dentistry, University of
Illinois, Chicago, IL.
Submitted December 26, 2010; accepted for publication March 13, 2011
doi: 10.1902/cap.2011.100010
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 193
be time consuming, and for patients, harvest sites may be un-
comfortable and associated with morbidity.
A new porcine collagen matrix (CM)
has been investi-
gated as a connective tissue graft substitute for root cover-
age and for the generation of keratinized tissue (KT)
around teeth and implants.
We decided to investigate
and understand the histologic implications for CM when
used as an interpositional connective tissue graft substitute
simultaneously with one-stage implant placement.
Case Presentation
The patient presented herein is a white, non-smoking, 38-
year-old female with #19 failing root canal and a coronal
fracture with inadequate tooth structure for proper resto-
ration (Fig. 1). The patient was diagnosed with Angles
Class I malocclusion, associated tooth wear, and compen-
satory eruption, along with localized, early-to-moderate
chronic periodontitis (#5, #9, #12, and #14 probing 4 to
7 mm, with bleeding on probing). The patient was chosen
as an interpositional graft candidate because she presented
with thin coronal bone width after wide-diameter implant
placement and was considered at risk for bone resorp-
tion, recession, and compromised, long-term soft-tissue/
crown apposition esthetics. No IRB approval was neces-
sary for this case study.
Case Management
Tooth #19 was extracted and the alveolus was preserved
using mineralized freeze-dried bone cortical allograft en-
hanced with plasma rich in growth factors and covered
with a collagen membrane
for socket bone grafting (Fig.
2a). An implant
was placed 12 months after extraction
(Fig. 2b), with CMplaced under the buccal flap at the time
of implant placement (Fig. 3).
Postoperative management included amoxicillin, 250
mg every 8 hours, and chlorhexidine, 0.12% oral rinse
twice per day, applied with a cotton swab after the first
2-week postoperative visit. Ibuprofen was prescribed,
600 mg every 6 hours for the first day then as needed for
After obtaining written informed consent, two biopsies
were performed 10 weeks after implant placement. Using
the operative photo for orientation, a 3 3 mm scalpel bi-
opsy down to bone level was removed interproximally over
the grafted area. A second biopsy was taken from non-op-
erated tissue on the contralateral side of the mouth. Spec-
imens were stored in 4%paraformaldehyde and sent to the
Loma Linda University Department of Oral Maxillofacial
Surgery histology laboratory for analysis. Samples were
embedded for 4 to 5 hours in an aqueous encapsulating
gel,** placed into a mega-cassette, and embedded in celloi-
dinparaffin. Using a microtome, 5-mm sections were cut
and stained with hematoxylin and eosin (H&E).
Clinical Outcomes
There was a clinical impression of enhanced soft-tissue vol-
ume, although what appeared to be a significant gain in
tissue thickness at 2 weeks diminished somewhat at the
10-week time point (Fig. 4). Healing was uneventful and be-
nign, muchas might be expected for a traditional connective
tissue graft. CM was not exposed to the oral environment.
Histologic analysis of the native, control tissue specimen
revealedanormal-appearing, attachedgingivawithstratified
FIGURE 1a and 1b Baseline clinical photos with #19 failing root canal and
a coronal fracture with inadequate tooth structure for proper restoration. 1c
Baseline radiograph.
Mucograft Collagen Matrix, Geistlich Pharma, Wolhusen, Switzerland.
OSSIX PLUS, OraPharma, Warminster, PA.
3i NanoTite Certain PREVAIL NT, BIOMET 3i, Palm Beach Gardens, FL.
** HistoGel, Richard-Allan Scientific, Kalamazoo, MI.
194 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Xenogeneic Collagen Matrix in Implant Therapy
squamous epithelium and underlying connective tissue, i.e.,
lamina propria (Fig. 5). In the test CM specimen, squamous
epitheliumand lamina propria also appeared normal. Tissue
growing into the residual collagen matrix of CM appeared
normal, with no inflammatory cells (lymphocytes or macro-
phages) seen in the graft area (Fig. 6). Vascular blood vessels
were observed growing into the matrix (Fig. 7). Control and
FIGURE 2a Twelve-month socket healing. 2b Radiograph of implant
FIGURE 3a CM interpositional graft substitute. 3b Surgical placement at
time of implant placement.
FIGURE 4a Two-week soft-tissue healing. 4b Ten-week soft-tissue
FIGURE 5 Native tissue control specimen with normal oral mucosa:
stratified squamous epithelium (SSE) rests on the lamina propria (LP) with
a zone of a well-vascularized, relatively loose connective tissue. H&E stain.
Original magnification 10.
Mandelaris, Lu, Rosenfeld Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 195
test site specimens were comparable in terms of connective
tissue and vascular organization.
The aim of this case report is to understand the histologic
implications for CM when used as an interpositional
connective tissue graft substitute simultaneously with
one-stage implant placement. A secondary goal was to ob-
serve whether a thicker soft-tissue cuff around implants
was achieved that might not only benefit peri-implant tis-
sue health but also provide improved esthetics at the pros-
thetic interface.
CM was easy to handle, place, and suture and obviated
the need and time required for donor graft harvest. Our
clinical impression was enhanced soft-tissue volume. His-
tologic analysis revealed no inflammatory cell infiltrates
and a benign response to the CM. Test and control site tis-
sues biopsies were comparable, and the test site biopsy con-
sisted of an organized (as opposed to dense, disorganized
scar) tissue with normal, stratified squamous epithelium
and normal underlying connective tissueda positive indi-
cationthat an attached formof peri-implant soft tissue may
have formed at the test site.
In a recent animal study over chronic ridge defects,
Thoma et al.
demonstrated that a porcine CM was able
to create soft-tissue volume enhancement comparable to an
autogenous subepithelial connective tissue graft. Similarly,
Wehrhan et al.
found that mean epithelial thickness gen-
erated in pig ear dermal wounds was equivalent, whether
CMor split-thickness skin grafts were used. In a controlled
clinical study, Sanz et al.
compared CMto free connective
tissue grafts (FCTG) as onlay soft-tissue augmentations to
enhance KTaround fixed partial restorations on both teeth
and preplaced implants. CM was as effective as FCTG in
creating a band of KT but without the morbidity or added
time associated with palatal graft harvest. Asimilar animal
study and a clinical case series with more extensive grafting
were performed by Herford, Boyne et al.
These studies
appear to demonstrate the biocompatibility, rapid replace-
ment with normal connective tissue, and epithelialization
of CM, along with generation of new mucosa, both kerati-
nized and non-keratinized. Finally, in a randomized, con-
trolled, within-patient, contralateral study of recession
defects, McGuire and Scheyer
showed that CM was able
to provide root coverage and generate an equivalent band
of KT compared to autogenous connective tissue grafts. As
with the case investigated herein, the authors noted: both
test and control sites appeared thicker, particularly when
viewed along the margins (former vertical incision lines) of
the treatment sites..
FIGURE 6 CM test site biopsy with some residual collagen, normal
appearing epithelium (SSE), and underlying connective tissue (LP). H&E
stain. Original magnification 10.
FIGURE 7 Normal connective tissue and vascular extension into CM. H&E
stain. Original magnification 20.
196 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Xenogeneic Collagen Matrix in Implant Therapy
Why is this case new information? n To our knowledge, this is the first case to include human histologic
analysis in the examination of CM as an interpositional graft substitute
for the enhancement of peri-implant soft-tissue thickness.
n Histologic assessment indicated a benign tissue response resulting in
an organized and attached connective tissue structure similar to
native, undisturbed periodontal tissue.
What are the keys to successful
management of this case?
n Previous studies indicated that soft-tissue volume and KT may be
generated by CM, but only sites with mucosal margins and some
preexisting KT were selected in this evaluation. As a conservative first
step, the presence of KT may allow for better flap manipulation and
a greater likelihood that CM remains covered, heals uneventfully, and
provides optimal soft-tissue augmentation results.
What are the primary limitations to
success in this case?
n Although soft-tissue augmentation is simpler and more predictable to
perform than bone augmentation, the key to health and esthetics
around implants and teeth is bone, so soft-tissue augmentation is
secondary to adequate bone architecture. To make a more definitive
judgment about the utility of CM as an interpositional graft for peri-
implant soft-tissue thickness, a controlled, comparative investigation
with longer-term clinical and histologic observations should be
The authors thank Geistlich Pharma (Wolhusen, Switzer-
land), which providedproduct samples andsupport for his-
tometrics. All other costs were incurred by the authors.
Drs. Mandelaris and Rosenfeld are occasional lecturers
for BIOMET 3i (PalmBeach Gardens, FL). Dr. Mandelaris
is also an opinion leader for Geistlich Pharma. Dr. Lu re-
ports no conflicts of interest related to this case report.
Dr. George A. Mandelaris, Advocate Lutheran General Hospital, Parkside
Professional Center, 1875 Dempster St., Suite 250, Park Ridge, IL 60068.
Mandelaris, Lu, Rosenfeld Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 197
1. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally advanced flap
procedure for root coverage. Is flap thickness a relevant predictor to
achieve root coverage? A 19-case series. J Periodontol 1999;70:1077-
2. Bouri A Jr, Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width of
keratinized gingiva and the health status of the supporting tissues
around dental implants. Int J Oral Maxillofac Implants 2008;23:323-
3. Chung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Significance of
keratinized mucosa in maintenance of dental implants with different
surfaces. J Periodontol 2006;77:1410-1420.
4. Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G.
Evaluation of soft tissue around single-tooth implant crowns: The pink
esthetic score. Clin Oral Implants Res 2005;16:639-644.
5. Wiesner G, Esposito M, Worthington H, Schlee M. Connective tissue
grafts for thickening peri-implant tissues at implant placement. One-
year results from an explanatory split-mouth randomised controlled
clinical trial. Eur J Oral Implantology 2010;3:27-35.
6. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial
connective tissue graft palatal donor site: Anatomic considerations
for surgeons. Int J Periodontics Restorative Dent 1996;16:130-137.
7. Thoma DS, Benic GI, Zwahlen M, Ha mmerle CH, Jung RE. A
systematic review assessing soft tissue augmentation techniques. Clin
Oral Implants Res 2009;20(Suppl. 4):146-165.
8. Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M. Clinical evaluation of
a new collagen matrix (Mucograft prototype) to enhance the width of
keratinized tissue in patients with fixed prosthetic restorations: A random-
ized prospective clinical trial. J Clin Periodontol 2009;36:868-876.
9. McGuire MK, Scheyer ET. Xenogeneic collagen matrix with coronally
advanced flap compared to connective tissue with coronally advanced
flap for the treatment of dehiscence-type recession defects. J Peri-
odontol 2010;81:1108-1117.
10. Thoma DS, Jung RE, Schneider D, et al. Soft tissue volume augmen-
tation by the use of collagen-based matrices: A volumetric analysis.
J Clin Periodontol 2010;37:659-666.
11. Wehrhan F, Nkenke E, Melnychenko I, et al. Skin repair using a porcine
collagen I/III membrane d Vascularization and epithelization proper-
ties. Dermatol Surg 2010;36:919-930.
12. Boyne PJ, Herford AS. Evaluation of a special collagen implant material
as a substitute for free mucosal or skin grafts in oral soft tissue surgery.
Proceedings of the American Institute of Oral Biology. Palm Springs,
CA. 2002:103-109.
13. Herford AS, Akin L, Cicciu M, Maiorana C, Boyne PJ. Use of a porcine
collagen matrix as an alternative to autogenous tissue for grafting oral
soft tissue defects. J Oral Maxillofac Surg 2010;68:1463-1470.
indicates key references.
198 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Xenogeneic Collagen Matrix in Implant Therapy
Conservative Treatment of Localized Juvenile Spongiotic
Gingival Hyperplasia
Simon R. MacNeill,* James W. Rokos,

Michael R. Umaki,* Keerthana M. Satheesh,

and Charles M. Cobb

Introduction: Localized juvenile spongiotic gingival hyperplasia (LJSGH) is a recently described uncommon and distinctive
form of inflammatory hyperplasia. Treatment of this condition has varied from surgical excision to no treatment followed by spon-
taneous remission. This case report demonstrates successful management of the lesion using a conservative treatment approach.
Case Presentation: A 14-year-old male with negative medical and dental histories presented with LJSGH. The vivid red
lesions involved the papillary and marginal gingiva of all maxillary anterior teeth. Initially, the lesion developed as a single red
patch-like area involving the maxillary left cuspid. Subsequently, the lesion displayed a linear pattern of spread to involve suc-
cessively more teeth in the anterior sextant. Biopsy revealed hyperplastic elongated epithelial rete pegs, atrophy of the overlying
stratified squamous epithelium with mild spongiosis, neutrophilic exocytosis, and a highly vascular connective tissue with
a dominant infiltrate of chronic inflammatory cells. The lesion responded to treatment consisting of a mild surface cauterization
followed by topical application of a 0.05% clobetasol ointment four times per day for a period of 4 weeks.
Conclusion: This case report demonstrates that LJSGH can be successfully managed by conservative therapy, thereby
avoiding potential gingival margin defects that may result from a surgical ablation of the lesion. Clin Adv Periodontics
Key Words: Gingival diseases; gingival hyperplasia; oral medicine; pathology, oral; periodontal diseases.
An unusual gingival condition affecting children and
adolescents primarily was first noted by Darling et al.
2007. The authors examined 24 cases by light micros-
copy and immunohistochemistry and designated the lesion
as juvenile spongiotic gingivitis. Typically, the gingival
lesions presented as localized patches of vivid red, slightly
thickened, painless, and persistent lesions of the attached
gingiva that generally involve the marginal gingiva of
anterior teeth (Fig. 1). The histopathology (Fig. 2) is
characterized by epithelial hyperplasia, spongiosis, loss of
* Graduate Periodontics, School of Dentistry, University of Missouri-Kansas
City, Kansas City, MO.

Department of Oral and Maxillofacial Pathology, School of Dentistry,

University of Missouri-Kansas City.

Department of Periodontics, School of Dentistry, University of Missouri-

Kansas City.
Submitted January 13, 2011; accepted for publication March 2, 2011
doi: 10.1902/cap.2011.110003
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 199
keratinization, neutrophilic exocytosis of the hyperplastic
epithelium, and a highly vascular connective tissue with an
infiltrate of inflammatory cells consisting of neutrophils,
lymphocytes, and plasma cells.
With respect to treatment,
Darling et al.
reported that all but one of the 24 cases
had been treated by surgical excision (i.e., biopsy) with an
z25% recurrence rate. They also noted that some cases
may resolve spontaneously after a variable and unpredict-
able period of time.
A second paper, reporting 52 cases, was published in
2008by Chang et al.
Basedonthe observationof avariable
epithelial hyperplasia, the authors proposed the lesion be
designated as a localized juvenile spongiotic gingival hyper-
plasia (LJSGH). As applied to the hyperplastic epithelium,
the term spongiotic implies the presentation of a sponge-like
morphology, i.e., prominent intercellular edemaor spongiosis.
Between the two studies,
a total of 76 cases are re-
ported, comprised of 48 females and 28 males with the fol-
lowing age distribution: 29cases (38.6%) aged5to10years;
41 cases (54.6%) aged 11 to 15 years; three cases (4%) aged
16 to 20 years; and two cases (2.6%) aged 21 years. The
age of one case was not reported.
Furthermore, Chang
et al.
reported a female-to-male ratio of 2.3:1 and a racial
distribution within their 52 cases of 82% white, 14% His-
panic, and 4% Asian, with three cases of unknown race.
Thus, it would appear that a patient exhibiting this gingival
lesion would most likely be a white female <20 years old
(97% of reported cases). Regarding treatment, Chang
et al.
recommended conservative surgical excision.
Clinical Presentation
A 14-year-old Vietnamese male was referred for peri-
odontal evaluation as a prelude to orthodontic treatment.
The written and verbal medical history were non-contrib-
utory, i.e., no history of systemic disease, drug therapy, or
surgery. The clinical examination of head and neck soft tis-
sues was within normal limits. The only significant dental
history involved the surgical removal of an impacted me-
siodens, 9 months prior to evaluation. The oral examina-
tion revealed an intact dentition consisting of 28 teeth,
unerupted third molars, and no caries or restorations.
The patient had an open anterior bite and a habit of mouth
breathing. The initial periodontal examination revealed
a normal-to-thick gingival biotype, generalized plaque-in-
duced gingivitis of moderate severity (52%plaque-positive
surfaces) characterized by swollen and edematous gingival
papillae, and generalized bleeding on probing (BOP) (48%
or 80 of 168 possible sites exhibited BOP). At this appoint-
ment, the patient was given a powered toothbrush and
instructions in oral hygiene. No definitive periodontal ther-
apy was performed beyond the patients self-administered
oral hygiene.
A photograph taken by the referring orthodontist z2
months before the initial periodontal examination showed
a localized red patch-like lesion involving the marginal and
attached facial gingiva of the maxillary left cuspid (Fig. 3).
The remaining teeth exhibited plaque-induced gingivitis
FIGURE 2 View of biopsy taken from the case shown in Figure 1. Note
the pronounced vascularity, neutrophil exocytosis, hyperplastic stratified
squamous epithelium exhibiting spongiosis and loss of keratin, and dense
inflammatory cell infiltrate. Original magnification of 200.
FIGURE 3 Localized patch-like lesion involving the facial gingiva of the
maxillary left cuspid. Photograph taken z2 months before the initial peri-
odontal examination.
FIGURE 1 Typical clinical presentation of LJSGH in a 13-year-old female
patient. Note the velvet-like texture and highly vascular appearance.
200 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Spongiotic Gingival Hyperplasia
with involvement of the marginal and papillary tissues. At
the initial periodontal examination, the original lesion had
spread laterally to involve the adjacent incisors (Fig. 4). Ap-
proximately 1 month later, despite significant improve-
ment in oral hygiene (24% plaque-positive surfaces and
18% BOP sites), the lesion had progressively spread to in-
volve the gingival papillae of the remaining maxillary an-
terior teeth (Fig. 5). Overall, the lesion was slightly raised,
bright red in color, somewhat linear, and exhibited a soft
velvet-like texture and vascular appearance that bled easily
on provocation but was otherwise asymptomatic.
Case Management
Because of extensive involvement of marginal gingiva and
the potential of creating an undesirable esthetic gingival
defect requiring corrective surgery, it was decided to
use an empirical and conservative approach to therapy.
Consequently, treatment consisted of two episodes of
mild surface cauterization (Fig. 6), 1 month apart, pur-
posely avoiding the marginal gingiva, followed by topical
application of a 0.05% clobetasol propionate ointment
four times daily over a 4-week period. Cauterization was
achieved by CO
laser using 2.5 Wof power and a pulsed
energy beam at 80 Hz applied with a paintbrush move-
ment. A soft-tissue biopsy was obtained immediately be-
fore the first surface cauterization procedure.
Histologic examination of the biopsy specimen revealed
hyperplastic elongated epithelial rete pegs, atrophy of the
overlying stratified squamous epithelium with loss of the
keratin layer, mild epithelial spongiosis, neutrophilic exo-
cytosis, markedly vascular underlying connective tissue
supporting dilated capillaries with prominent endothelial
linings, and a florid chronic inflammatory cell infiltrate
(Fig. 7).
Clinical Outcomes
After the initial laser-mediated surface cauterization, there
was only moderate resolutionof the lesion appearance (Fig.
8). Consequently, a second cauterization was performed,
followed by topical application of the 0.05% clobetasol
propionate ointment. At the 1 month post-treatment
FIGURE 4 Photograph taken at the initial periodontal examination showing
extension of lesion to involve the maxillary left central and lateral incisors
and cuspid.
FIGURE 5 Photograph taken 1 month after that shown in Figure 4. Note
the linear nature of the lesion and progressive involvement of all teeth in the
maxillary anterior sextant.
FIGURE 6 View of CO
laser surface cauterization after the first irradiation
FIGURE 7 Histologic view of a biopsy taken from the present case
exhibiting features comparable to that of the typical LJSGH histologic
presentation seen in Figure 2. Original magnification of 200.
MacNeill, Rokos, Umaki, Satheesh, Cobb Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 201
appointment, the lesion had sufficiently resolved so that
orthodontic therapy was initiated. There was a mild resid-
ual inflammation of the gingival margins that appeared to
be plaque associated (Figs. 9 and 10). This latter presenta-
tion has persisted over the following 6 months.
LJSGH etiology remains unspecified. Both Darling et al.
and Chang et al.
studies noted that the presence of LJSGH
appeared unrelated to dental plaque accumulation, and
nothing about the present case seems to contradict this
observation. In addition, given the lack of a immunohisto-
chemical response for estrogen receptors and progesterone
receptors in the Darling et al.
study, and the range of ages
in patients presenting with the lesion,
hormonal imbal-
ance likely has minimal or no contribution to the etiology.
To the best of our knowledge, no current literature, includ-
ing this case report, has investigated a fungal or viral
Darling et al.
noted that the LJSGH lesions were often
localized to attached gingiva and separated from marginal
gingiva by a strip of normal tissue. The present case, as well
as that depicted in Figure 1 (verified by biopsy), involved
both attached and marginal gingiva. This would seem to
indicate that LJSGH lesions can exhibit considerable vari-
ation in their clinical presentation.
Chang et al.
indicated that the majority of LJSGH
biopsies exhibited inflammation and papillary hyperplasia
similar to that associated with inflammatory papillary hy-
perplasia (IPH). IPHmay be associated with mouth breath-
ing but is more commonly associated with ill-fitting
maxillary dentures.
Gingival presentation in cases of
mouth breathing can vary from enlarged gingival papillae
that are red and edematous with a diffuse surface shini-
ness to a more chronic condition characterized by a fi-
brotic papillae.
In the current case, although the patient
admitted to mouth breathing, the gingival lesions were ob-
viously more acute in their clinical presentation when one
considers tissue color, texture, and density. Furthermore,
the linear pattern of spread from an isolated lesion to pro-
gressively more tissue involvement would be a highly un-
usual clinical presentation for gingival IPH.
With respect to a differential diagnosis, one must consider
a number of possibilities, such as an atypical presentation
for plaque-induced gingivitis, gingivitis modified by hor-
monal imbalance, intraoral contact allergy, linear gingival er-
ythema, pyogenic granuloma, plasma cell gingivitis, chronic
hyperplastic candidiasis, capillary hemangioma, and foreign
body granuloma. Obviously, biopsy becomes an absolute re-
quirement to establish a proper diagnosis and to ensure ap-
propriate treatment.
Interestingly, Darling et al.
suggested that what they
termedas juvenile spongiotic gingivitis is similar to the mi-
croscopic diagnosis of acute spongiotic mucositis and, there-
fore, may be analogous to acute spongiotic dermatitis of the
skin. Both acute and subacute spongiotic dermatitis are
forms of eczema or dermatitis and among the most com-
monly diagnosed general types of dermatitis or eczema.
FIGURE 8 Incomplete resolution of lesion at 4 weeks after the first laser
cauterization. At this point, a second laser procedure was performed, and
the patient was prescribed 0.05% clobetasol propionate ointment for
topical application.
FIGURE 9 Facial view of 6-month post-treatment healing showing no
evidence of original lesion. Residual gingival inflammation is a plaque-
induced gingivitis.
FIGURE 10 Left lateral view of 6-month post-treatment healing showing
no evidence of original lesion.
202 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Spongiotic Gingival Hyperplasia
Why is this case new information? n LJSGH has only recently been identified in the literature as a distinct
clinical entity.
As described by Darling et al.
and Chang et al.,
typical lesion presents clinically as a localized, red, elevated, patch-
like lesion primarily affecting single anterior teeth. Although similar in
initial clinical presentation, the present case followed a progressive
clinical course that involved successively more teeth and exhibited
a linear pattern of spread.
What are the keys to successful
management of this case?
n The lesion was managed by light cauterization of the surface tissue
(two episodes) and topical application of a 0.05% clobetasol
propionate ointment, four times per day for a period of 4 weeks.
Results at 6 months indicate that the lesion has resolved, and residual
gingival inflammation appears to be plaque related.
What are the key limitations to
success in this case?
n Management of this case was complicated by habitual mouth
breathing that was promoted by a severe open anterior bite and less
than optimal oral hygiene that eventually showed significant
improvement. Although the LJSGH lesions have not recurred, the
literature has reported an z25% rate of recurrence, even after total
The authors report no conflicts of interest related to this
case report.
Dr. Charles M. Cobb, 424 West 67th Terrace, Kansas City, MO 64113.
MacNeill, Rokos, Umaki, Satheesh, Cobb Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 203
1. Darling MR, Daley TD, Wilson A, Wysocki GP. Juvenile spongiotic
gingivitis. J Periodontol 2007;78:1235-1240.
2. Chang JY, Kessler HP, Wright JM. Localized juvenile spongiotic
gingival hyperplasia. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2008;106:411-418.
3. Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Chapter 12. In:
Oral and Maxillofacial Pathology. St. Louis: Elsevier Saunders; 2009:
4. Carranza FA, Hogan EL. Gingival enlargement. In: Newman MG,
Takei HH, Klokkevold PR, Carranza FA, eds. Clinical Periodontology.
St. Louis: Elsevier Saunders; 2011:84-96.
5. Wu H, Brandling-Bennett HA, Harrist TJ. Noninfectious vesiculobul-
lous and vesiculopustular diseases. In: Elder DE, ed. Histopathology of
the Skin, 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:
indicates key references.
204 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Spongiotic Gingival Hyperplasia
Non-Plaque-Induced Gingivitis Associated
With Isotretinoin: A Case Report
Ajay Mahajan,* Ashu Bharadwaj,* and Poonam Mahajan*
Introduction: Isotretinoin (13-cis-retinoic acid), a synthetic vitamin A derivative, is used to treat a wide variety of derma-
tologic conditions, including severe acne. Although isotretinoin has revolutionized the management of acne vulgaris, concerns
continue regarding the adverse effect profile of isotretinoin. Mucocutaneous reaction is the most commonly observed adverse
side effect of isotretinoin use, but the involvement of gingival mucosa has rarely been reported. To our knowledge, this is the
first-ever case report of gingivitis associated with isotretinoin.
Case Presentation: A 19-year-old female was referred to the Department of Periodontics, Himachal Pradesh Govern-
ment Dental College and Hospital, Shimla, India, for the treatment of persistent severe gingivitis. The history of the patient
revealed that she had been on 10 mg/day isotretinoin regimen for the treatment of nodular facial acne for 6 months. In the
absence of an obvious cause, the condition was diagnosed as isotretinoin-associated gingivitis. After consultation with the
dermatologist, the drug was stopped and the patient responded favorably to periodontal treatment.
Conclusion: Non-plaque-induced, isotretinoin-associated gingivitis should always be suspected in a patient who is
taking isotretinoin and has persistent gingivitis that does not respond to periodontal treatment. Clin Adv Periodontics
Key Words: Drug therapy; gingivitis; isotretinoin; mucositis.
Acne vulgaris is a chronic inflammatory disease with a mul-
tifactorial etiology involving the pilosebaceous unit. Although
it is commonly accepted to be a disease of adolescence, it can
also be seen in the neonatal, infantile, prepubertal, and adult
periods when the sebaceous glands are active.
sebum secretion, abnormal follicular keratinization, micro-
bial colonization, and inflammation are thought to be
involved in the pathogenesis of acne. A drug combination
that aims to correct the abnormal keratinization and decrease
Propionibacterium acnes proliferation is adequate in most
patients with acne. Repressing sebumproduction is suggested
for more serious conditions not responding to this treatment.
Isotretinoin (13-cis-retinoic acid) is a synthetic vitamin A
derivative. Isotretinoin is the only medication with an effect
on all factors involved in the pathogenesis of acne.
It reduces
production of sebum, stabilizes keratinization, and prevents
* Himachal Pradesh Government Dental College and Hospital, Shimla,
Himachal Pradesh, India.
Submitted January 18, 2011; accepted for publication March 1, 2011
doi: 10.1902/cap.2011.110006
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 205
comedones formation. Like other retinoids, isotretinoin
works by altering DNA transcription, although the exact
mechanism of action is unknown.
The widespread use of retinoids requires that not only
dermatologists but other health professionals be aware
of the wide spectrum of adverse effects associated with
their use. This includes dentists, who need to be particu-
larly alert to the mucocutaneous reactions that develop
in almost all patients who receive these drugs. Although
many adverse effects of the drug have been identified,
there is a paucity of literature related to the oral adverse
effects of the drug. To our knowledge, this is the first-ever
case report of gingivitis associated with isotretinoin.
Clinical Presentation
A 19-year-old female was referred to the Department of
Periodontics, Himachal Pradesh Government Dental Col-
lege and Hospital, Shimla, India, for the treatment of persis-
tent severe gingivitis that developed 6 months previously
and did not improve despite repeated non-surgical peri-
odontal therapy, which included thorough scaling and root
planing and detailed counseling regarding maintenance of
her oral hygiene. Before this visit, the patient hadbeentested
for any underlying desquamative condition, allergic reac-
tion, andsystemic reasonresponsible for the gingival inflam-
mation, and these conditions were ruled out. However, the
detailed history of the patient revealed that she had been on
10 mg/day isotretinoin regimen for the treatment of nodular
facial acne for 6 months. Shortly after the initiation of the
treatment, she developed gingivitis. There was no other rel-
evant medical or medication history. Clinical examination
revealed severe gingival inflammation with minimal plaque
deposition. Probing depths and clinical attachment levels
were measured using a periodontal probe

and were found

to be within normal limits.
Case Management
Because the most common causes for gingivitis were ruled
out before the patient was referred to us, a provisional
diagnosis of non-plaque-induced, isotretinoin-associated
gingivitis was made, and with the consultation of the der-
matologist, the drug was stopped. Two weeks after drug
cessation, a basic treatment regimen was started which in-
corporated thorough supragingival and subgingival de-
bridement followed by regular toothbrushing and use of
0.2% chlorhexidine gluconate twice daily and a regular
follow-up visit every week. In every follow-up visit, the pa-
tients oral hygiene was reviewed and oral hygiene instruc-
tions were emphasized.
Clinical Outcomes
One week after the drug was stopped, there was definite
reduction in gingival inflammation without any profes-
sional oral hygiene therapy, and the condition continued
to improve until the fourth week, when the gingivitis
was resolved completely (Figs. 1 through 4).
FIGURE 1 Severe persistent gingivitis in a patient on isotretinoin.
FIGURE 2 Marked reduction in gingival inflammation 1 week after
stopping isotretinoin.
FIGURE 3 Gingival condition 3 weeks after stopping isotretinoin.

UNC-15 periodontal probe, Hu-Friedy, Chicago, IL.

206 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Isotretinoin and Gingivitis
Gingivitis is a term used to describe non-destructive peri-
odontal disease that results in inflammation of gingiva.
As definedby the 1999International Workshopfor the Clas-
sification of Periodontal Diseases and Conditions, there are
two primary categories of gingival diseases, each with
numerous subgroups: 1) dental plaque-induced gingival
diseases; and 2) non-plaque-induced gingival lesions.
The most common form of gingivitis is in response to
plaque adherent to tooth surfaces, termed plaque-induced
gingivitis. In the absence of treatment, gingivitis may
progress to periodontitis, which is a destructive form of
periodontal disease.
Although in some sites or individuals
gingivitis never progresses to periodontitis,
data indicate
that periodontitis is always preceded by gingivitis.
focus of treatment for gingivitis is removal of the etiologic
agent and the reduction of oral bacteria, and may take the
formof regular visits to a dental professional together with
adequate oral hygiene home care.
Nodular and nodulocystic acne are forms of inflammatory
acne that do not respond easily to treatment. Isotretinoin is
the best treatment for nodulocystic acne when it does not re-
spondtoconventional treatment, suchas topical andsystemic
antibiotics. Many adverse effects of isotretinoin have been
The most common adverse effects include muco-
cutaneous reactions presenting as dryness of the eyes, lips,
mouth, and other epidermal surfaces. These effects are dose
dependent, tolerable, andtreatable.
The most commonlyre-
ported mucocutaneous adverse effect is cheilitis; paronychia
with lengthening lateral ungual folds has rarely been seen.
Patients should be made aware of these adverse effects before
taking isotretinoin and also that use of moisturizers and eye
drops can help to mitigate such adverse effects. Sometimes,
however, the dose of isotretinoin needs to be decreased to re-
duce the induction of adverse effects.
Although anecdotal reports suggest that gingival inflam-
mation and bleeding from gums is associated with iso-
to our knowledge, gingivitis associated with
isotretinoin has not been reported in the scientific literature.
In the present case, because obvious reasons for gingi-
vitis, i.e., visible plaque and calculus, were not responsible
for the persistent gingivitis, and the patients condition did
not improve until the drug was stopped, there are strong
reasons to believe that the gingivitis was attributable to
isotretinoin therapy. Although the exact mechanism by
which the drug caused gingivitis could not be established,
it may be attributed to the various biologic effects of ret-
inoids as a result of their profound effects on DNA tran-
scription. The activity of retinoids is mediated through the
binding of nuclear retinoid receptors, which are function-
ally and structurally related to a superfamily of nuclear
DNA transcription factors that includes steroids, vitamin
D, and thyroid hormone receptors. Therefore, retinoids
act like hormones, producing a variety of cellular modu-
lations through alterations in DNA transcription.
addition, the vitamin B12 and folate deficiency anemia
associated with isotretinoin could result in oral adverse
Early diagnosis of gingivitis associated with isotretinoin
is important because it can prevent undue stress and dis-
comfort to the patient caused by unnecessary treatment
and investigations that will not be effective until the drug
is stopped or its dose is reduced in consultation with a der-
matologist. n
FIGURE 4 Absence of any gingival inflammation after 4 weeks.
Mahajan, Bharadwaj, Mahajan Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 207
Why is this case new information? n Lack of sufficient data on oral adverse effects of isotretinoin
n First-ever reported case of gingivitis associated with isotretinoin,
to the best of our knowledge
What are the keys to successful
management of this case?
n Early diagnosis
n Altering the dose of or stopping isotretinoin in consultation with
a dermatologist
What are the primary limitations to
success in this case?
n Unawareness of oral adverse effects of isotretinoin
n Wrong diagnosis
The authors report no conflicts of interest related to this
case report.
Dr. Ajay Mahajan, Department of Periodontics, Himachal Pradesh Govern-
ment Dental College and Hospital, Snowdon, Shimla, Himachal Pradesh
171001, India. E-mail: julius05@rediffmail.comor
208 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Isotretinoin and Gingivitis
1. Cunliffe WJ, Simpson NB. Disorders of the sebaceous glands. In:
Champion RH, Burton JL, Burns DA, Breathnoch SM, eds. Textbook
of Dermatology. Oxford: Blackwell Science; 1998:1927-1984.
2. Strauss JS, Thibautat DM. Diseases of the sebaceous glands. In:
Freedberg I, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI,
et al., eds. Dermatology in General Medicine. New York: McGraw-
Hill; 1999:769-784.
3. Cunliffe WJ, van de Kerkhof PC, Caputo R, et al. Roaccutane treatment
guidelines: Results of an international survey. Dermatology 1997;194:
4. Kilic E, Sahin M, Sahin S, Ozer S. Isotretinoin (13-cis-retinoic acid)-
associated premature ventricular contractions. Turk J Pediatr 2009;51:
5. Rademaker M. Adverse effects of isotretinoin: A retrospective review of
1743 patients started on isotretinoin. Australas J Dermatol 2010;51:
6. American Academy of Periodontology. Glossary of Periodontal Terms,
4th ed. Chicago: American Academy of Periodontology; 2001:25.
7. Armitage GC. Development of a classification system for periodontal
diseases and conditions. Ann Periodontol 1999;4:1-6.
8. American Academy of Periodontology. Parameter on plaque-induced
gingivitis. J Periodontol 2000;71(Suppl. 5):851-852.
9. Ammons WF, Schectman LR, Page RC. Host tissue response in chronic
periodontal disease. 1. The normal periodontium and clinical manifes-
tations of dental and periodontal disease in the marmoset. J Periodontal
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10. Page RC, Schroeder HE. Pathogenesis of inflammatory periodontal
disease. A summary of current work. Lab Invest 1976;34:235-249.
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Dermatol 2001;45:S188-S194.
12. Kaymak Y, Ilter N. The results and side effects of systemic isotretinoin
treatment in 100 patients with acne vulgaris. Dermatol Nurs 2006;18:
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15. Jasim ZF, McKenna KE. Vitamin B12 and folate deficiency anaemia
associated with isotretinoin treatment for acne. Clin Exp Dermatol
indicates key references.
Mahajan, Bharadwaj, Mahajan Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 209
Successful Gingival Depigmentation With Laser-Patterned
Microcoagulation: A Case Report
Edward P. Allen,* Natalia D. Gladkova,

Yulia V. Fomina,

Maria M. Karabut,

Elena B. Kiseleva,

Felix I. Feldchtein,

and Gregory B. Altshuler

Introduction: Current methods for gingival depigmentation, including mechanical surgery, cryosurgery, laser treatments,
and radiosurgery, create significant patient discomfort and risk of complications, thereby reducing attractiveness of the depig-
mentation procedure for many patients. To our knowledge, this case report presents a first-time application of a new technol-
ogy, laser-patterned microcoagulation (LPM) based on the concept of fractional laser photothermolysis that was successfully
applied in dermatology and ophthalmology.
Case Presentation: One patient was treated for local hyperpigmentation of the labial attached gingiva in the maxillary
anterior area. A diode laser with wavelength 980 nmand power 20 Wwas used to create microcoagulation columns with a 30%
area filling factor. Two treatments were performed, 2 weeks apart, without anesthesia. The patient was followed for 5 months.
The discomfort during the procedure was tolerable without anesthesia. Healing was uneventful and visually completed with sig-
nificant reduction of pigmentation at 2 weeks after treatment. Complete visual depigmentation was observed at both 2 weeks
and 2 months after the second treatment.
Conclusions: To our knowledge, this is the first clinical case of hyperpigmentation treatment using LPM, demonstrating
feasibility of a new, minimally invasive and effective method of localized gingival hyperpigmentation removal. The patient dis-
comfort is significantly less than that reported for other methods for depigmentation. Clin Adv Periodontics 2011;1:210-214.
Key Words: Hyperpigmentation; laser therapy; lasers, semiconductor; surgical procedures, minimally invasive.
Brown or dark gingival pigmentation often presents an
esthetic problem because it may be apparent during smile
or speech. The most frequent reason of hyperpigmentation
is melanin deposits mainly located in basal and parabasal
layers of the epithelium.
The traditional approach for
treatment of gingival hyperpigmentation is surgical and
includes mucoperiosteal flap, free gingival graft, or deep-
ithelization as a less invasive approach. Still, all these
surgical procedures are painful and expensive and have all
the typical risks associated with surgery, including infection,
scarring, gingival recession, damage to underlying perios-
teum and bone, and delayed wound healing.
Multiple less
invasive deepithelization alternatives have been explored,
* Center for Advanced Dental Education, Dallas, TX.

Nizhny Novgorod Medical Academy, Nizhny Novgorod, Russia.

Dental Photonics, Walpole, MA.

Submitted February 8, 2011; accepted for publication April 6, 2011
doi: 10.1902/cap.2011.110010
210 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011
including erbium lasers,
cryogenic de-
near-infrared lasers
and radiosurgery.
ever, the majority of existing techniques are still associated
with significant patient discomfort and protracted healing
time, making gingival depigmentation an unattractive pro-
cedure for the majority of patients.
Inthe past several years, esthetic dermatology was signif-
icantly enhanced by a newtechnology known as fractional
It was successfully used with several
million patients for skin rejuvenation, wrinkle removal,
scar conversion to normal tissue, and melasma treatment.
The concept of fractional photothermolysis may be ex-
plained as Formation of isolated non-contiguous micro-
thermal wounds creating necrotic zones surrounded by
zones of viable tissue in a geometrical pattern that is not
dependent on chromophore distribution.
It was found
that, if the size and concentration (area filling ratio) of
the microscopic wounds are within certain limits, the tissue
can regenerate without scarring and result in younger,
healthier tissue after healing is complete. In addition to der-
matology, the same concept was successfully applied in
but it has not been applied for oral tissues.
Because oral mucosa is known to have better regeneration
properties than skin, we hypothesized that fractional treat-
ment of oral mucosa and gingiva will result in a similar or
better response, facilitating regeneration and creating new
tissue without scarring. Near-infrared radiation easily pen-
etrates into soft tissues, because absorption in water and he-
moglobin is not very significant, but strongly absorbed
in melanin,
providing natural selectivity in lasertissue in-
teraction. The tissue regeneration cannot restore melanin
deposits concentrated in the basal layer and therefore the
pigmentation should be eliminated, at least in the areas
in which melanin was destroyed by direct laser radiation.
Because the treatment procedure is substantially creating
a pattern of microcoagulated columns in the tissue, it may
be called laser-patterned microcoagulation (LPM).
Clinical Presentation
A 36-year-old male was seen at a routine dental hygiene
appointment. Several irregular brown pigmented spots
were noted on the attached gingiva labial to the maxillary
incisor teeth (Fig. 1). The pigmented regions were flat and
asymptomatic. The patient had considered them as an es-
thetic problem, but had not sought treatment to remove the
pigmentation. The pigmentation was diffuse, bilateral, and
existed for z30 years; therefore, it was considered as phys-
iologic pigmentation.
The patient was offered the option
to treat the most pronounced spots with LPM, a new tech-
nology similar to fractional photothermolysis widely used
for skin rejuvenation and hyperpigmentation treatment.
Case Management
The case treatment was performed under the local ethical
committee permission (Protocol #1 of Nizhny Novgorod
Medical Academy Clinical and Animal Study Ethical Com-
mittee, 2010), and the patient signed an informed consent.
The laser microcoagulation treatment is a quasi-periodic
pattern of columns covering a pigmented spot, in which
each column is created by application of a single laser pulse
from a diode laser system. A diode laser operating at 980
nm wavelength and generating up to 20 W of power was
used in this case. The delivery system had replaceable tips
with 0.6 mm diameter.
In this case, each column was created by an 80 ms pulse.
No anesthesia was used. The gingival surface facial to the
left maxillary incisors was dried with compressed air and
isolated by cotton rolls (special attention was paid to pre-
vent cotton fibers from getting to the treatment field). The
FIGURE 1 Preoperative view of maxilla with pigmentation spots.
FIGURE 2a Immediate postoperative view of the same area after first LPM
treatment. 2b Healing 2 weeks after first treatment. Pigmentation is significantly
Allen, Gladkova, Fomina, et al. Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 211
pigmented spot was covered with laser columns with a fill-
ing ratio (coagulated area divided by total treatment area)
of z30%. Digital photos (Figs. 1 through 5) were taken
before the procedure, immediately after, and during each
follow up visit. Red articulating paper and untreated pig-
mented spots were used for brightness and color reference
in the photos. A second treatment was performed 2 weeks
after the first treatment, also with a 30% filling ratio and
without anesthesia (Fig. 3a).
Clinical Outcomes
The patient reported a tolerable slight burning sensation
during and immediately after the laser pulse and minor
tingling in the treated area at 1 day after treatment. No
other discomfort or side effects were observed. At 1 week
after the first treatment, a noticeable bleaching of pigmen-
tationwas noted comparedtoanother area of hyperpigmen-
tation near the right maxillary incisor teeth. The healing
columns were noticeable on the surface as small indenta-
tions. Complete visual healing after the first treatment
was observedat 2weeks after treatment. The surface texture
was restored, and the pigmentation was inhomogeneous,
more at the mesial part of the spot (Fig. 2b). At this time,
a second treatment was performed (Fig. 3a).
Two weeks after the second treatment (Figs. 3b and 5c),
the surface was smooth and shiny, the pigmentation was ab-
sent, andthere were novisible traces of columns. Twomonths
after the first treatment (Fig. 5d), the surface was smooth and
shiny with no repigmentation, and the patient expressed
a high level of satisfaction and willingness to treat remaining
areas of hyperpigmentation. No repigmentation was ob-
served at 5 months after the second treatment (Fig. 5e).
To our knowledge, this is the first clinical case of hy-
perpigmentation treatment using LPM, demonstrating fea-
sibility of a new, minimally invasive and effective method
for localized gingival hyperpigmentation removal. The pa-
tient discomfort was significantly less than that reported
for other methods for hyperpigmentation treatment, in-
cluding surgical (mechanical) techniques, erbium laser,
lasers, cryogenic destruction, near-infrared lasers,
or radiosurgery. n
FIGURE 3a Immediate postoperative view after second LPM treatment. 3b
Healing 2 weeks after second treatment. Pigmentation is reduced to normal
level of surrounding tissue.
FIGURE 4 Two months after treatments.
FIGURE 5 Close-up view of the pigmented spot. 5a Preoperative view. 5b Two weeks after first treatment. 5c Two weeks after second treatment. 5d
Two months after first treatment. 5e Five months after second treatment.
212 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Gingival Depigmentation With Laser-Patterned Microcoagulation
Why is this case new information? n To our knowledge, this is the first case report of the application of new
technologydLPMdfor a successful removal of local gingival
What are the keys to successful
management of this case?
n Optimization of LPM parameters determined in previous in vitro and
animal experiments led to a minimally invasive yet efficacious method
with less discomfort.
What are the primary limitations to
success in this case?
n Additional cases and longer postoperative evaluations are necessary
to determine the long-term benefit of this technique.
This case report was supported by RussianFederation State
Contract 02.740.11.5149 and Grant 10-02-01175 of the
Russian Foundation for Basic Research. Dr. Feldchtein is
a co-inventor of a patent related to the LPM technology
and is an employee of Dental Photonics (Walpole, MA),
a company commercializing LPM treatment. Dr. Altshuler
is a shareholder and consultant for Dental Photonics and
has a patent application in LPMtreatment. Drs. Gladkova,
Fomina, Karabut, and Kiseleva have received financial
support for research and consulting fees from Dental
Photonics. Dr. Allen reports no conflicts of interest related
to this case report.
Dr. Felix Feldchtein, Dental Photonics, 1600 Boston-Providence Highway,
Walpole, MA 02081. E-mail:
Allen, Gladkova, Fomina, et al. Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 213
1. Yousuf A, Hossain M, Nakamura Y, Yamada Y, Kinoshita J,
Matsumoto K. Removal of gingival melanin pigmentation with the
semiconductor diode laser: A case report. J Clin Laser Med Surg
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gingival melanin hyperpigmentation with Er:YAG laser: Short-term clinical
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4. Azzeh MM. Treatment of gingival hyperpigmentation by erbium-
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5. Kawashima Y, Aoki A, Ishii S, Watanabe H, Ishikawa I. Er:YAG laser
treatment of gingival melanin pigmentation. Int Congr Ser 2003;1248:
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and skin with a carbon dioxide laser: A canine study. J Oral Maxillofac
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pigmentation and its treatment with the CO2 laser. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2004;98:522-527.
8. Tal H. A novel cryosurgical technique for gingival depigmentation. J
Am Acad Dermatol 1991;24:292-293.
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hyperpigmentation for esthetic purposes by Nd:YAG laser: Report of 4
cases. J Periodontol 2000;71:315-321.
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depigmentation. Dent Today 2009;28:118, 120-121.
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treatment modality in photomedicine. J Phys D Appl Phys 2005;38:
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photothermolysis: A new concept for cutaneous remodeling using
microscopic patterns of thermal injury. Lasers Surg Med 2004;34:
13. Paulus YM, Jain A, Gariano RF, . Healing of retinal photocoagulation
lesions. Invest Ophthalmol Vis Sci 2008;49:5540-5545.
14. Welch AJ, Gardner CM. Monte Carlo model for determination of the
role of heat generation in laser-irradiated tissue. J Biomech Eng 1997;
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oral cavity: Review, differential diagnosis, and case presentations. J Can
Dent Assoc 2004;70:682-683.
indicates key references.
214 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Gingival Depigmentation With Laser-Patterned Microcoagulation
Trisomy 21Associated Aggressive Periodontitis: A Five-Year Follow-Up
Alon Frydman,* Fernando Verdugo,
Krikor Simonian,* and Kian Kar*
Introduction: This report explores the effective treatment of aggressive periodontitis in a 23-year-old male with Trisomy 21.
Case Presentation: A 23-year-old male with Trisomy 21 presented with his mother with the chief complaint of "bleeding
gums andbadbreath." Periodontal evaluation along with anaerobic microbiological culture was performed. Systemic antibiotics
were given after the completion of the initial mechanical scaling and root planing (SRP). After reevaluation, the patient was
placed on a 2-month recall in which antimicrobial therapy in the formof diluted sodiumhypochlorite (1:40) and povidone-iodine
(10%) was delivered subgingivally in addition to SRP. The patient remained on a 1- to 2-month recall.
A reduction of mean probing depths, from 4.2 1.3 mm at baseline to 2.98 0.89 mm, at 5 years (P (( <0.05) was observed.
Percentage of sites with bleeding on probing showed a reduction from 100% at baseline to 16.66% at 5 years (P (( <0.05). The
number of sites with probing depths measuring 6 mm was reduced from 23 to four after 5 years.
Conclusion: Trisomy 21associated aggressive periodontitis can be successfully treated and maintained over the long
term. Clin Adv Periodontics 2011;1:215-220.
Key Words: Aggressive periodontitis; dental infection control; Down syndrome; microbial analysis; microbiology; non-surgical
periodontal therapy.
Trisomy 21 is of particular interest in the field of
periodontology because a majority of these patients
present with aggressive periodontitis.
The high incidence
and severity of periodontal breakdown may partially be
explained by the immunologic dysfunctions that occur
with the syndrome. Specifically, diminished neutrophilic
chemotaxis and phagocytic ability, in addition to de-
creased leukocyte lifespan,
all hinder the ability of these
patients immune system to effectively resist the pro-
gression of periodontal disease. Bacteria commonly
associated with aggressive periodontitis have a high in-
cidence among those with Trisomy 21,
Aggregatibacter actinomycetemcomitans (Aa).
bacterial challenges, patients with Trisomy 21 also have
been reported to have coinfections with viruses, which
may explain some of the extensive periodontal disease.
Despite challenges in restoration of the dentition,
odontal therapy can be delivered with success. A complete
understanding of the specific challenges within this
* Advanced Periodontology, Herman Ostrow School of Dentistry of the
University of Southern California, Los Angeles, CA.

Veterans Affairs Hospital, Greater Los Angeles, Healthcare System, Los

Angeles, CA.

Private practice, Altadena, CA.

Department of Immunology, Microbiology, and Parasitology, School of
Medicine and Odontology, University of Basque Country, Leioa, Spain.
Submitted February 10, 2011; accepted for publication April 24, 2011
doi: 10.1902/cap.2011.110013
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 215
population as well as the various modalities to treat the ag-
gressive forms of periodontal disease that affects them is
the key to a successful outcome. This case report profiles
the therapy of a single patient with Trisomy 21associated
aggressive periodontitis over a 5-year period.
Clinical Presentation
The patient, age 23 years at the time, presented with his
mother to the Advanced Periodontology Department at
the Herman Ostrow School of Dentistry, University of
Southern California. The patients cognitive ability was
limited, as was cooperation. His mother delivered the chief
complaint of persistent bleeding gums and severe bad
breath. Review of the patients medical history revealed
diagnosis of Trisomy 21 at birth, with no other underlying
systemic conditions. Discussion with the mother revealed
that the patient was trusted with his own oral hygiene using
a manual toothbrush. The mother also complained that the
patient suffered multiple herpetic outbreaks during the
course of a year. Dental history revealed that the patient
had been seen for hygiene visits approximately once every
5 months within the special patients clinic of the dental
school. Save for prophylaxis visits, extraction of hopeless
teeth was the only other therapy received since the patient
presented to the school (Figs. 1 and 2).
Case Management
A comprehensive periodontal evaluation was performed,
recording probing depths (PDs), clinical attachment levels,
bleeding on probing (BOP), suppuration, mobility, reces-
sion, and radiographic bone loss. Anaerobic microbial in-
vestigation was performed to determine the need for any
specific antibiotic. Sterile paper points were used to collect
gingival crevicular fluid from the deepest pockets and then
stored in anaerobic media. The pooled samples were sent
for anaerobic-selective culture at the Oral Microbiology
Testing Laboratory, Herman Ostrow School of Dentistry,
University of Southern California within 24 hours and
then incubated for 10 days. Oral hygiene instructions were
given to the mother, as well as other family members in the
household with the responsibility of delivering oral hygiene
on a daily basis for the patient. The purchase of a mechan-
ical toothbrush was also suggested to help in achieving
more efficient daily hygiene.
Four quadrants of scaling and root planing (SRP) were
performed along with adjunctive antimicrobial therapy
in the form of diluted sodium hypochlorite (1:40) and po-
vidone-iodine (10%) delivered subgingivally.
The labora-
tory microbiologic culture results (Table 1) were obtained
before the completion of SRP. A diagnosis of Trisomy
21associated aggressive periodontitis was reached. Apre-
scription for amoxicillin and metronidazole (each 250 mg,
three times per day, for 7 days) was given as systemic ad-
junctive antibiotic therapy after the completion of the ini-
tial SRP. The systemic antibiotics were given to address
possible intraoral reservoirs that could not be addressed
with mechanical therapy. Periodontal reevaluation was
performed at 6 weeks after SRP. Because of the patients
limited ability to cooperate, definitive surgical therapy
was ruled out. Instead, the patient was placedon a 2-month
periodontal maintenance recall schedule. SRP along with
diluted sodium hypochlorite (1:40) and povidone-iodine
(10%) delivered subgingivally was repeated at each visit
along with a record of periodontal indices.
Clinical Outcomes
Long-term reevaluation showed a reduction of mean PDs
from 4.2 1.3 mm at baseline to 2.98 0.89 mm at 5 years
(P <0.05). Percentage of sites with BOP showed a reduction
from100%at baseline to 16.66%at 5 years (P <0.05). The
number of sites with PDs measuring 6 mm was reduced
from23tofour after 5years (Figs. 3and4, Table 2). Noteeth
were lost over the 5 years. At 5-year reevaluation, microbi-
ologic sampling revealed an absence of Aa, Porphyromonas
gingivalis (Pg), and Eubacterium. However, Prevotella inter-
media (Pi) (3.8%), Tannerella forsythia (Tf) (2.3%), Cam-
pylobacter spp. (5.4%), Fusobacterium spp. (3.1%),
Parvimonas micra (3.8%), enteric Gram-negative rods
(3.1%), and Dialister pneumosintes (2.3%) were found.
A prescription for ciprofloxacin (500 mg, twice daily for
7 days) was given after recall to address the presence of
enteric rods. Sampling was repeated at reevaluation after
completion of the antibiotic regimen. Results of the
final sampling show Pg (2.6%), Pi (4.3%), Tf (2.6%),
Eubacterium (3.5%), Fusobacterium spp. (4.3%), and P.
micra (4.3%). Enteric Gram-negative rods, D. pneumo-
sintes, and Aa were absent at the end of the study (Table 1).
Understanding the etiopathogenesis of aggressive peri-
odontitis, as well as the unique host relationship in Trisomy
21, is a prerequisite for the effective therapy of these pa-
tients. Improvement in clinical parameters, such as BOP
and periodontal PDs, was evident 6 months after SRP and
initial systemic antibiotic therapy in this case. The improved
clinical outcomes were stable for the 5-year follow-up.
FIGURE 1 Initial presentation shows spontaneous bleeding, open bite,
large amounts of calculus, gingival recession, gingival enlargement, and
generalized inflammation.
216 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Trisomy 21Associated Aggressive Periodontitis
There was a reduction in all cultivatable periodontal path-
ogens and an absence of Aa after 5 years. Despite the pres-
ence of enteric Gram-negative rods, often associated with
periodontal abscess,
clinical parameters were stable at 5
years. Infection with Gram-negative rods may be a result
of poor hygiene habits or opportunistic infection after re-
peated antibiotic therapy. A second course of systemic anti-
biotic treatment with ciprofloxacin was rendered to target
a possible colonization by enteric Gram-negative rods.
The patient was negative for both Aa and enteric Gram-
negative rods after the second course of antibiotic therapy.
Investigators have found higher occurrences of specific peri-
odontal pathogens such as Aa, Pg, and Tf among patients
with Trisomy 21 and periodontitis
versus controls. The
bacterial profile of this particular case appears similar to de-
mographic reports of patients with Trisomy 21.
Several research groups attribute the periodontal attach-
ment loss among Trisomy 21 patients to individual host
factors rather than a specific bacteriological etiology.
and Aula
did not find periodontal bone loss in patients
younger than 19 years for a period of 5 years. An older age
group, with significant baseline attachment loss, showed pro-
gressive bone loss innearlyall participants after 5years.
present report shows a 23-year-old individual with Trisomy
21 and generalized severe attachment loss and radiographic
bone loss. Thus far, his attachment level and radiographic
bone level are well maintained 5 years after treatment.
In this particular case of Trisomy 21associated aggres-
sive periodontitis, the clinical improvement and stability of
periodontal parameters such as PDs and BOP can be attrib-
uted to the frequency of mechanical therapy combined
with use of systemic and adjunctive antimicrobial ther-
The most definitive results of pocket reduction
and stabilization of the periodontal condition are usually
achieved by means of periodontal flap procedures. How-
ever, the typical comprehensive approach and use of surgi-
cal means may not be an option for some patients with the
limitations associated with Trisomy 21. It seems plausible
to prevent the extent and severity of the disease and there-
fore reduce tooth loss by increasing the frequency of peri-
odontal maintenance (monthly to bimonthly) combined
with adjunctive targeted systemic antibiotics and local
FIGURE 2 Initial radiographic presentation shows localized areas of severe bone loss as well as missing teeth.
FIGURE 3 Presentation after 5 years shows absence of generalized
inflammation, decrease in plaque and calculus levels, and generalized
TABLE 1 Subgingival Microbial Findings in a Patient With
Trisomy 21
5 Years
5 Years
Reevaluation (%)
Aa 0.6 0 0
Pg 4.8 0 2.6
Pi 12.0 3.8 4.3
Tf 7.2 2.3 2.6
Eubacterium spp. 5.6 0 3.5
Fusobacterium spp. 8.0 3.1 4.3
P. micra 5.6 3.8 4.3
Campylobacter spp. 0 5.4 0
Enteric Gram-negative rods 0 3.1 0
D. pneumosintes 0 2.3 0
Frydman, Verdugo, Simonian, Kar Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 217
antibacterial therapy. Aa and Pg are highly associated with
immunomodulation and skewing of the immune response
through the influence of their lipopolysaccharides.
has also been shown to invade soft tissues and induce im-
munomodulation through direct interaction with the host
immune system.
Systemic antibiotic therapy was suc-
cessful in elimination of detectable levels of Aa at 5 years.
Whereas periodontopathogen eradication may be an ulti-
mate aim, the persistence of certain pathogens at lowlevels
may not hinder a stable long-term clinical outcome.
Presence of a lower plaque index, translating to an overall
reduction in the bacterial biofilm, underscores the signifi-
cance of frequent periodontal supportive therapy when
a patients self-care is limited.
An increase in mainte-
nance frequency appears to be essential for patients af-
fected with Trisomy 21 because their self-compliance is
generally challenged as a result of their physical and men-
tal disability. n
FIGURE 4 Radiographic presentation after 4 years shows that all teeth were maintained within the mouth as well as minimal changes in bone levels.
TABLE 2 Clinical Findings in a Patient With Trisomy 21
Clinical Characteristic Baseline (%) 6 Weeks (%) 6 Months (%) 5 Years (%)
Sites with visible plaque 80 27 22 17
Sites with BOP 100 35 25 16
Sites with 5 mm PDs 38 59 8 7
Sites with 4 mm PDs 30 25 17 7
Sites with 3 mm PDs 32 16 75 86
Sites with mobility Class 1 12 12 29 8
Sites with mobility Class 2 33 33 20 25
Sites with mobility Class 3 8 8 0 0
Sites with recession 32 44 40 56
218 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Trisomy 21Associated Aggressive Periodontitis
Why is this case new information? n Provides long-term follow-up in management of an aggressive form of
disease in a specific population
n Provides a dynamic treatment approach in a patient population that
often presents with limited treatment options
n Reveals methods of using both antibiotics and antimicrobials as
adjuncts to therapy
What are the keys to successful
management of this case?
n Frequent mechanical therapy
n Use of antimicrobial agents
n Involvement of care takers as well as the patient when possible
n Understanding of the multifactorial nature of the disease presentation
within this patient population
What are the primary limitations to
success in this case?
n Limited compliance with surgical intervention
n Limited evidence of successful restorative options
The authors report no conflicts of interest related to this
case report.
Dr. Alon Frydman, Herman Ostrow School of Dentistry of the University
of Southern California, Dental Science Center, DEN 4375, 925 W. 34th
St., Los Angeles, CA 90089. E-mail:
Frydman, Verdugo, Simonian, Kar Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 219
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actinomycetemcomitans, Capnocytophaga and Porphyromonas gingi-
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Microbiol Immunol 1992;7:244-248.
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Periodontal Res 2002;37:389-398.
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Periodontal conditions and salivary immunoglobulins in individuals
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and subgingival microflora in Down syndrome patients. A case-control
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and normal children to Actinobacillus actinomycetemcomitans. J Clin
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12. Reuland-Bosma W, van der Reijden WA, van Winkelhoff AJ. Absence
of a specific subgingival microflora in adults with Downs syndrome.
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13. Saxen L, Aula S. Periodontal bone loss in patients with Downs
syndrome: A follow-up study. J Periodontol 1982;53:158-162.
14. Pavicic MJ, van Winkelhoff AJ, Douque NH, Steures RW, de Graaff J.
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Actinobacillus actinomycetemcomitans-associated periodontitis. A 2-
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indicates key references.
220 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Treatment of Trisomy 21Associated Aggressive Periodontitis
Basic Suture Techniques for Oral Mucosa
Terrence J. Griffin,* Yong Hur,* and Jing Bu

Focused Clinical Question: What is the pre-

ferred suture method for maintaining wound closure?
Summary: Optimal wound healing after surgical
procedures requires good soft-tissue management.
The final key step for a refined surgical technique is ade-
quate closure by suturing. This article reviews the most
common suturing methods used in dentistry, and their
applications in various periodontal surgeries are dis-
cussed. The nine most common periodontal suture tech-
niques and six different periodontal surgical categories
were selected by the periodontal faculty at Tufts Univer-
sity School of Dental Medicine. A survey was distributed
to periodontists in the United States, each of whom se-
lected their choice of suture technique for each of the
periodontal surgical procedures. The results of this sur-
vey show that simple interrupted sutures were used in
the majority for each surgical procedure.
Conclusion: Although suture selection and applica-
tionis complex because of multiple variables, an effort was
made to establish a general consensus and current trends
regarding suturing techniques. Clin Adv Periodontics
Key Words: Hemostasis, surgical; humans; surgical
flaps; sutures; suture techniques.
Soft-tissue healing in dental surgery depends on good
surgical technique and soft-tissue management.
flap manipulation, ideal incision placement, and appropri-
ate suture techniques are required for optimal healing.
Proper technique and material for suturing will promote
wound healing through close approximation of the flap
edges, minimized dead space, reduced postoperative bleed-
ing, resistance to tension on the flap margins, and the
prevention of infection.
There are various suturing techniques used in dental ap-
Each technique has advantages and disad-
vantages. The choice of suture technique comes with the
understanding of the wound anatomy and the surgeons
With the proper technique, the dentist will
be able to overcome challenges, such as variations of the
anatomy of the wound, tension of the flaps, thickness of
the gingiva, and esthetic needs of the patient.
The purpose of this article is to reviewthe basic suturing
techniques, their advantages and disadvantages, as well as
their applications in various periodontal surgeries. The
nine most common suturing techniques and six different
periodontal surgical categories were selected by 25 peri-
odontal faculty members at Tufts University School of
Dental Medicine. An informal survey was sent out to peri-
odontists in the United States to gauge the usage of each
suture technique with various periodontal surgical proce-
dures. Frequently, more than one suture technique is used
in a surgery. These survey results were tabulated, and the
general consensus for the applications of each suture tech-
nique will be discussed.
Principles of Suturing
Avoid Excessive Tension on Sutures
Excessive tension on wounds will result in the blanching of
the flaps and wound edges. This may result in necrosis at
the wound edge as a result of interference of the blood sup-
ply (Fig. 1). Another complication is tearing of the flap by
the suture, resulting in tracks, which are small cuts left by
the suture as it dissects through the tissue. These tracks of-
ten contribute to flap retraction, graft exposure, and post-
operative pain.
Suture Whenever Possible From Movable to
Immovable Tissue
This allows for more precise positioning of tissue edges and
better wound closure. It is easier to control the suture nee-
dle and manage the flap if the moveable tissue (i.e., the flap)
is approximated to a steady base.
Always Try to Keep Knots Away From
Wound Edges
Knots are both the most irritating and weakest part of any
suture technique. For this reason, place the knots so that
they are away from the wound edges whenever possible.
Use as Few Knots as Possible
This is a corollary to the previous principle for much the
same reasons. Avoid knots whenever possible because they
represent the weakest part of any wound closure and at the
same time can be the greatest irritant.
Use the Smallest Suture Possible to
Close the Wound
It is generally better to use several small sutures rather than
a lesser number of large-gauge ones. A number of smaller
sutures are less irritating to the tissues than a larger one,
* Department of Periodontology, Tufts University School of Dental
Medicine, Boston, MA.

Berkshire Medical Center, Pittsfield, MA.

Submitted May 10, 2011; accepted for publication July 19, 2011
doi: 10.1902/cap.2011.110053
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 221
especially if it is a multifilament material. In addition,
smaller sutures result in smaller perforations than larger
sutures and heal much more quickly. Several smaller su-
tures are better able to secure the wound and less likely
to result in tissue tears because they do not weaken the in-
tegrity of the tissue as much.
Use the Least Amount of Sutures That Will
Secure the Wound
Do not over-suture. Excess suturing causes needless perfo-
ration of the tissues bordering the wound and interferes
with the blood supply. This will, in turn, affect the integrity
of the wound and its healing.
Advantages and Disadvantages
of Continuous Sutures
Many surgeons prefer continuous suture techniques over
interrupted sutures. Both techniques have advantages and
Continuous Sutures: Advantages
The advantages of continuous sutures include: 1) involving
as many teeth as required; 2) minimizing the use of knots;
3) using teeth to anchor the flap; 4) eliminating the need
for periosteal sutures; 5) enabling independent placement
of buccal, lingual, or palatal flaps; and 6) requiring less time
for both placement and removal.
Continuous Sutures: Disadvantages
If breakage or resorption occurs anywhere along its length,
a portion of or the entire flap may loosen, exposing bone,
implants, grafts, etc. The entire suture is only as secure as its
weakest knot.
Primary and Secondary Suture Line
Secondary Suture Line
The secondary suture line (Fig. 2a) is used to give strength to
wound closure and compensate for muscle and soft-tissue
pull. The suture line is usually away from the wound edges.
It is used as an adjunct to the primary suture line by taking
stress away from the edges of the wound. After using a sec-
ondary suture line, a primary suture line is usually used to
close the edges of the wound and complete closure.
Primary Suture Line
The primary suture line (Fig. 2b) is the most common type of
suture line used in surgery. This suture line is used to close
the incision. It is usually the only type of suture used except
inlarge wounds inwhichresistance tomuscle andsoft-tissue
pull and wound security are of paramount importance.
Handling the Needle
The needle consists of the needle point, the body, and the
swaged end (Fig. 3). The needle point is sharp and is de-
signed to pierce through tissues. Designs of the body include
reverse cutting edge, tapered point, tapered cut, or conven-
tional cutting edge. For the most part, the reverse cutting
edge is used because it prevents the needle from tearing
through the tissue as the needle cuts through the tissue.
The swaged end is pressed fitted around the suture line to
provide smooth passage of the needle through the tissue.
The needle holders have a cross-hatching pattern of teeth
for its beak. This prevents the needle frombeing damaged as
well as gripping the needle adequately. Maximal control of
the needle is achieved when the needle is held approximately
two thirds the length of the needle from the needle point
and z3 mm from the tip of the beak of the needle holder
(Fig. 4). Gripping the needle point or swaged end should be
avoided to prevent damage to the cutting edge or damage to
the swaged end. When suturing, the needle tip should pierce
perpendicular tothesoft tissue. Small circular twists of thefore-
arm should be used to pass the needle through the soft tissue.
Periodontal Suture
Interrupted Suture Techniques
Simple-Loop (Interrupted) Suture
This is the most commonly used suture
technique in dentistry. It can be applied
in most periodontal procedures to close
elevated flaps and vertical and horizon-
tal incisions and to stabilize soft tissues.
FIGURE 1 Flap necrosis attributable to excessive swelling and tension for
the wound edges.
FIGURE 2a Horizontal-mattress sutures placed as a secondary suture line to approximate the wound
edge. 2b Simple-loop interrupted sutures used to close the wound as a primary suture line.
222 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Dental Suture Techniques
The technique is as follows (Fig. 5) (Video 1):
n Pierce the outer surface of the buccal flap with the suture
n Thread the needle under the interproximal contact and
pierce the inner aspect of the lingual flap with the suture
n Pass the suture needle under the interproximal contact
toward the buccal aspect.
n Tie off the free ends of the suture. Cut off the suture, leav-
ing 2 to 3 mm of suture material.
Figure-Eight (Interrupted) Suture Technique
This is another very commonly used suture technique in
dental surgery and is frequently confused with the simple
loop. The indications for its use are similar to simple-loop
interrupted sutures. The main advantage is easier access
between the teeth. A disadvantage is that there will be in-
terposed suture material between the flaps that may pre-
vent ideal approximation of the flap edges compared to
the simple-loop interrupted suture technique.
The technique is as follows (Fig. 6) (Video 2):
n Pierce the outer surface of the buccal flap with the suture
n Thread the needle under the interproximal contact and
pierce the outer aspect of the lingual flap with the suture
n Pass the suture needle through the interproximal contact
andtie andcut off the remaining suture, leaving 2to3mm.
Vertical-Mattress (Interrupted) Suture Technique
The vertical-mattress suture technique allows for precise flap
andpapillaplacement. It is oftenusedinconjunctionwithperi-
osteal sutures. It is frequentlyusedinperiodontal resective ther-
apy and guided tissue regeneration (GTR) procedures.
The technique is as follows (Fig. 7) (Video 3):
n Pierce the buccal flap just above the mucogingival junc-
tion, anchoring the flap to the underlying periosteum.
n Note that the underlying periosteum has not been re-
flected to engage.
n The needle should emerge from the center of the papilla
2 to 3 mm from the flap edge.
n Pass the needle through the contact area and anchor the
lingual flap the same way, starting fromthe center of the
lingual papilla 2 to 3 mm from the flap edges.
n Thread the needle through the interproximal contact and
tie and cut the suture on the buccal side, leaving 2 to 3
mm of suture material.
Horizontal-Mattress (Interrupted)
Suture Technique (Including ``X``
The design of the horizontal-mattress
suture technique resists flap tension
causedbymusclepull andsoft-tissuecon-
traction. However, additional sutures
are necessary to approximate the wound
edges. The reason for this is that the
horizontal-mattress suture is a secondary
suture line. The placement of the suture is
away from the wound edges and does
not provide complete closure of the
wound edges. Primary suture lines
are then placed to hold the wound
edges together so that healing can
occur by primary intention. This su-
ture can be left for an extended time
such as in augmentation procedures.
The technique is as follows (Fig. 8)
(Video 4):
FIGURE 4 Handling the needle holder. 4a Note that the index finger position allows for precise control of
needle holder. 4b Use of thumb and ring finger permits the index finger to control the delicate movements.
4c Castroviejo with pen grip. 4d Needle was grasped at two thirds of the diameter of the needle.
FIGURE 3 Anatomy of a needle.
Griffin, Hur, Bu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 223
n Pierce the external side of the buccal flap 3 to 4 mmfrom
the flap margin.
n Pierce the internal side of the lingual flap 3 to 4 mmfrom
the lingual flap margin.
n Penetrate the external side of the lingual flap 5 mm lat-
erally from the second piercing.
n Pass the needle through the internal side of the buccal flap
and tie the free ends.
Sling (Interrupted) Suture Technique
The indication for the sling suture is the need for re-
positioning flaps in a coronal direction with additional
anchorage the teeth. The ability to vary
the tension and vertical position of the
flaptoa tooth or implant allows the sur-
geon good control of the extra forces of
the flap.
The technique is as follows (Fig. 9)
(Video 5):
n Pierce the outer aspect of the flap at
its distal end and pass the needle un-
der the interproximal contact.
n Wrap the suture mesially around the
tooth and pass the needle through
the interproximal contact and pierce
the inner aspect of the flap.
n Thread the suture needle through the
mesial interproximal contact andwrap
the suture around the tooth, going
n Pass the suture needle through the dis-
tal interproximal contact and tie and
cut the suture, leaving 2 to 3 mm of
suture material.
Continuous Suture Techniques
Continuous Interlocking Suture
This is used for long edentulous spans,
such as implant placements, ridge aug-
mentations, or reductions. It is a quick
andefficient wayof closinglonghorizon-
tal or vertical incisions.
The technique is as follows (Fig. 10)
(Video 6):
n From the distal end, tie a simple loop
and cut off only the free end.
n Pierce both flap margins 5 mmlaterally
from the simple loop.
n Thread the needle under the last hor-
izontal span.
n In increments of 5 mm from the last
lockingsegment, piercebothflapmar-
gins until the entire span is closed.
n Leave a small loop of suture on the final segment after
piercing both flap margins.
n Use the loop of suture to tie off the suture. Cut off all ex-
cess ends, leaving 2 to 3 mm of material.
Continuous Horizontal-Mattress Suture
The continuous horizontal-mattress suture technique includes:
n Initial suture placement of simple-loop interrupted
n Horizontal extension of the suture
FIGURE 5 Simple-loop interrupted suture technique. 5a Initial suture placement. 5b Lingual flap
piercing. 5c Tying of the knot. 5d Clinical application.
FIGURE 6 Figure-eight interrupted suture technique. 6a Initial suture placement. 6b Lingual flap
piercing. 6c Tying of the knot. 6d Clinical application.
224 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Dental Suture Techniques
n Locking of the suture
n Final loop
n Tying the suture
n Clinical application
The continuous horizontal-mattress suture is an efficient
way of obtaining secure adaptation of opposing flaps in
edentulous areas. It will resist tension on the flaps from
muscle pull and will evert the flap edges and cause dehis-
cence. Applications for the continuous horizontal-mat-
tress technique are implants and regenerative procedures.
Like with the simple interrupted horizontal-mattress tech-
nique, it is used as a secondary suture line and will require
another suture to maintain the approximation of the flap
The technique is as follows (Fig. 11) (Video 7):
n Tie a simple loop on the distal aspect and cut the free end.
n Pierce both flaps 5 mm from the initial simple loop.
n Continue the piercings in increments of 5 mm, alternating
between buccal and lingual flaps.
n Onthe final segment, leave a small loopof suture material
after piercing both flaps.
n Use the loop of suture to tie the suture. Cut off all excess
ends, leaving 2 to 3 mm of excess.
Continuous Vertical-Mattress
Sling-Suture Technique
Continuous vertical-mattress sutures
can be used for resective procedures to
position the flap apically and to prevent
the recurrence of periodontal pockets. It
is frequently used for flaps in osseous
and crown-lengthening procedures.
The technique is as follows (Fig. 12)
(Video 8):
n Starting fromthe mesial aspect, tie an
interrupted vertical-mattress suture
and cut off the free end.
n Wrap the suture distally around the
tooth onthe buccal aspect and perform
avertical mattress onthe lingual aspect.
n Pass the needle through the contact
area and perform a vertical mattress
on the buccal aspect.
n Alternate the side of the placement of
the vertical mattress and the sling
through the entire span.
n Leave a small loop of suture on the
final segment.
n Use the loop of suture to tie off the
Continuous Independent Sling-
Suture Technique/Continuous
Dependent Sling-Suture
Continuous independent sling sutures are indicated when
a flap with multiple papillae are elevated on a single side.
This is an extension of the sling-suture technique.
The technique canbe appliedfor the other side if bothsides
are elevated. The continuous dependent sling-suture tech-
nique canbe usedas well if the surgery involves a periodontal
flap for both sides. Surgeries that may require a muco-peri-
osteal flap for both sides include osseous surgeries, crown-
lengthening procedures, and open-flap debridement. The
continuous dependent sling-suture technique has a better
ability to vary flap tension than the continuous independent
sling-suture technique.
For continuous independent sling sutures, the technique is
as follows (Fig. 13) (Video 9):
n Tie a simple loop and cut off the free end.
n Sling around the tooth on the lingual side.
n Pass the needle through the contact area and anchor the
buccal flap by piercing the center of the papilla z2 to 3
mm from the flap margins.
n Continue the sling on the lingual side until the span is
n On the final segment, leave a loop of suture. Tie off the
free ends of the suture using the loop of suture.
FIGURE 7 Vertical-mattress interrupted suture technique. 7a Initial suture placement. 7b Note the
engagement of the periosteum. 7c Buccal view with the second piercing. 7d Lingual flap piercing. 7e
Tying of the knot. 7f Clinical application.
Griffin, Hur, Bu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 225
For continuous dependent sling
sutures, the technique is as follows
(Fig. 14):
n Enter the outer aspect of the buc-
cal flap from the mesial aspect and
leave a free end.
n Pass the needle through the contact
area, first pierce the opposite side
flap from the inner aspect, and then
return the needle to the buccal as-
pect where you tie off to the remain-
ing free end. The papillae should be
anchoredby piercing 2to3mmfrom
the flap margins.
n Continue the sling around the lin-
gual aspect and pierce the buccal
flap from the outer aspect.
n Pass the needle under the contact
area and pierce the lingual flap from
its inner aspect.
n Returnthe needle tothe buccal aspect
and then wrap around the tooth to
enter the contact area of the next dis-
tal tooth.
n Pierce the underside of the lingual
flap and return to the buccal aspect
where the inner side of the buccal
flap is pierced.
n Now, return through the contact
area where a sling is formed distally
and then the inner aspect of the buc-
cal flap is engaged.
n Continue distally by anchoring the
flaps by alternating between the
buccal and lingual sides until the en-
tire span is secured.
n On the final segment, leave a large
loop to tie off the free ends of the
National Survey of Current
Periodontal Suture
The nine most common suturing tech-
niques and six different periodontal
surgical categories were selected by
25 periodontal faculty members at
Tufts University School of Dental
Medicine. The protocol was approved
by the Tufts Medical Center Institu-
tional Review Board. A survey was
sent out to periodontists in the United
States to gauge the usage of each suture
technique with various periodontal sur-
gical procedures. These survey results
reflect the general consensus for the
applications of each suture technique.
FIGURE 8 Horizontal-mattress interrupted suture technique. 8a Initial suture placement. 8b Lingual flap
piercing. 8c Second piercing on the lingual side. 8d Second piercing on the buccal side. 8e Tying of the
knot. 8f Clinical application.
FIGURE 9 Sling-suture technique. 9a Initial suture placement. 9b Piercing after sling around the tooth. 9c
Tying the suture after the second sling. 9d Clinical application.
226 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Dental Suture Techniques
The nine suturing techniques in-
cluded: 1) simple-loop (interrupted);
2) figure-eight (interrupted); 3)
vertical-mattress (interrupted); 4)
horizontal-mattress (interrupted);
5) sling (interrupted); 6) continuous
interlocking; 7) continuous horizontal-
mattress; 8) continuous vertical-sling;
and 9) continuous independent sling/
continuous dependent sling.
The six categories of periodontal
surgeries were: 1) crown lengthening
or periodontal resective procedure
without pocketing; 2) flap surgery
with osseous recontouring or other
resective procedures; 3) GTR; 4)
soft-tissue grafting, such as free gingi-
val graft or subepithelial connective tis-
sue graft; 5) implant therapy without
guided bone regeneration (GBR) proce-
dures; and 6) GBR procedures or max-
illary sinus augmentation.
For crown lengthening and peri-
odontal resective procedures without
periodontal pockets, the interrupted
simple-loop suture was used by 41.5%
of the periodontists surveyed. The in-
terrupted vertical-mattress suture was
used by 21%, whereas the continuous
sling was used by 17% of the polled
periodontists. The continuous vertical
mattress sling was used by 9.2% of the
respondents. The other techniques each
attained a usage of <6% (Fig. 15).
Flap surgery with osseous recon-
touring and other resective periodon-
tal procedures again had interrupted
simple-loop sutures as the majority,
coming in at 36.3%usage. Continuous
sling sutures came in at a close second
at 26.2%use, whereas both continuous
and interrupted vertical-mattress sling
sutures gained the vote of 13.6% from
the respondents. Other techniques each
were used <7% of the time (Fig. 16).
With GTR, interrupted simple-loop
sutures were used by 35.4% of the
dentists. Interrupted vertical-mattress
sutures were used for GTR by 28.7%.
Interrupted horizontal-mattress su-
tures were used by 10.9% and inter-
rupted sling sutures were used by
8.4%. The other techniques were each
used <5% by the polled periodontists
(Fig. 17).
FIGURE 10 Continuous interlocking suture technique. 10a Initial suture placement of simple-loop
interrupted. 10b Horizontal extension of the suture. 10c Locking of the suture. 10d Final loop. 10e Tying
the suture. 10f Clinical application.
FIGURE 11 Continuous horizontal-mattress suture technique. 11a Initial suture placement of simple-
loop interrupted. 11b Horizontal extension of the suture. 11c Tying the suture. 11d Clinical application.
Griffin, Hur, Bu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 227
The interrupted simple-loop suture once again was used
most frequently (46.1%) with soft tissue grafts such as the
free-gingival, or subepithelial connective tissue grafts. In-
terrupted sling sutures were used 23.9% and continuous
sling sutures was used 13.2% of the time. The other tech-
niques were each used 5% of the time (Fig. 18).
Implant therapy without GBR was predominantly done
with interrupted simple-loop sutures. Interrupted simple-loop
sutures were overwhelmingly used in 74.2% of the cases.
Other techniques each were used <8% of the time (Fig. 19).
GBRwas generally sutured using simple interrupted sutures
at 42.9% from the responding periodontists. Continuous
FIGURE 12 Continuous vertical-mattress sling-suture technique. 12a through 12c Vertical-mattress interrupted suture. 12d through 12f The second vertical
mattress after buccal sling. 12g Continuation of the vertical mattresses after lingual sling. 12h Tying the suture. 12i Clinical application.
FIGURE 13 Continuous independent sling-suture technique. 13a and 13b Initial sling suture without tying. 13c Sling sutures on the same side on the buccal
aspect. 13d and 13e Continuation on the lingual sling sutures. 13f Tying the suture.
228 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Dental Suture Techniques
sutures were frequently used at 18.6%,
interrupted horizontal-mattress sutures
at 15.8%, interrupted vertical-mattress
sutures at 9.5%, and all other tech-
niques each came in at <5% (Fig. 20).
The goal of this survey was to deter-
mine the indications of each suturing
technique for various periodontal sur-
gical procedures for ideal conditions.
Themethodologyis simpledpoll prac-
ticing periodontists in what suturing
technique they preferred to use for
each surgery type and then tabulate
the results. The suturing technique
with the most number of votes clearly
supports that technique while tech-
niques with the least number of votes
would mean that the technique is not
widely used.
The survey results show that for
each of the various periodontal pro-
cedures the interrupted simple-loop suture was the most
prevalent technique. However there were other techniques
were used significantly as well. In crown lengthening, inter-
rupted vertical-mattress and continuous sling sutures were
used frequently. With flap osseous surgery, continuous
sling and interrupted vertical-mattress sutures were used
frequently. Implants without GBR were sutured primarily
with only simple interrupted sutures.
In GTR, interrupted vertical-mattress, interrupted hori-
zontal-mattress, and interrupted sling sutures were used
withthe majority of periodontists. Comments left by the sur-
veyed periodontists about this procedure stated that they
used multiple suture techniques for this type of surgery. In-
terrupted sling sutures were frequently used to stabilize the
membranes, whereas vertical- or horizontal-mattress su-
tures were used to secure the flaps.
Soft-tissue grafts predominantly were sutured using either
continuous or interrupted sling sutures. The choice of
whether to use a continuous or interrupted sling is dependent
on the size of the site. A combination of sutures can be used
for soft-tissue grafts, such as sling sutures on the recipient site
and horizontal-mattress sutures on the donor site. Another
combination is with simple-loop interrupted sutures on the
recipient site and sling sutures on the donor site. The choice
in the various combinations is left up to operator preference.
The results revealedthat the continuous interlockingsuture
was frequently used for GBR. However, the combination of
horizontal-mattress and simple-loop interrupted sutures was
the most commonly used technique for this procedure.
The survey was simplified by allowing only a single choice
per surgical procedure. However, multiple suture techniques
are often required because of the complexity of the periodon-
tal surgery, adjacent anatomy, and the operators preference.
This survey did not have the depth to address this concern.
We tried to overcome this shortcoming by addressing the
FIGURE 14 Continuous dependent sling-suture technique. 14a Initial sling suture. 14b and 14c Alternate
the placements of sling sutures. 14d Loop positions.
FIGURE 15 The usage of various suture techniques for crown lengthening
or periodontal resective procedure without pocketing. n 523.
FIGURE 16 The usage of various suture techniques for flap surgery with
osseous recontouring or other resective procedures. n 523.
Griffin, Hur, Bu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 229
comments from the periodontists surveyed and integrating
them into a streamlined decision tree.
Suturing is empirical, so there is limited evidence to choose
superior techniques. We propose a decision tree to aid the
dentist in selecting the optimal suture technique based
on surgical goals and their experience (Fig. 21). In general,
interrupted sutures enable precise flap placement and better
control compared to continuous sutures. In comparison,
continuous sutures involve more efficient flap management
for wide areas with less knotting.
n The simple-loop technique is easy to place and can be
used in diverse applications.
n The figure-eight technique can be applied in interproximal
papillae with limited access to approach under the flap.
n The horizontal-mattress technique is indicated when
muscle pull will place tension on the flap.
n The vertical-mattress technique can be combined with
periosteal suture for apically positioned flap when the
periosteum is not reflected from the bone.
n Sling sutures can be used when additional coronal an-
chorage is needed.
n Continuous interlocking sutures can be used to close
a long-spanning edentulous ridge.
n The continuous horizontal-mattress technique has the
same indications as the interrupted horizontal-mattress
technique for wide soft- and hard-tissue augmentation
as a secondary suture line.
n The continuous vertical-mattress technique is indicated
for resective surgeries for multiple teeth requiring api-
cally positioned flap.
n The continuous sling-suture technique can be used for
wide periodontal procedures with need of additional
Knowledge of the various suture techniques is required for
the optimal surgical wound healing in dentistry. There is no
single technique that is the best choice because of the sophis-
ticated characteristics of periodontal procedures. In this ar-
ticle, the most common suture techniques in periodontal
procedures are reviewed. The survey tried to show the cur-
rent trend of the selection of suturing techniques based on
the type of surgery. It is very important for the dentist to
know the current techniques and their clinical applica-
tions to promote optimal healing of surgical wounds. n
FIGURE 17 The usage of various suture techniques for GTR. n 523.
FIGURE 18 The usage of various suture techniques for soft-tissue
grafting, such as free gingival grafts or subepithelial connective tissue
grafts. n 523.
FIGURE 19 The usage of various suture techniques for implant therapy
without GBR procedures. n 500.
FIGURE 20 The usage of various suture techniques for GBR procedures or
maxillary sinus augmentation. n 506.
230 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Dental Suture Techniques
The authors report no conflicts of interest related to this
Dr. Terrence J. Griffin, Department of Periodontology, Tufts University
School of Dental Medicine, 1 Kneeland St., Boston, MA 02111. E-mail:
FIGURE 21 Selection of proper periodontal suture technique.
Griffin, Hur, Bu Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 231
1. Kandel EF, Bennett RG. The effect of stitch type on flap tip blood flow.
J Am Acad Dermatol 2001;44:265-272.
2. Adams B, Levy R, Rademaker AE, Goldberg LH, Alam M. Frequency
of use of suturing and repair techniques preferred by dermatologic
surgeons. Dermatol Surg 2006;32:682-689.
3. Campbell JR, Marks A. Suture materials and suturing techniques. In
Pract 1985;7:72-75.
4. Ratner D, Nelson BR, Johnson TM. Basic suture materials and suturing
techniques. Semin Dermatol 1994;13:20-26.
5. Macht SD, Krizek TJ. Sutures and suturing d Current concepts. J Oral
Surg 1978;36:710-712.
6. Gustafson GT. Ecology of wound healing in the oral cavity. Scand J
Haematol Suppl 1984;40:393-409.
7. Takata T. Oral wound healing concepts in periodontology. Curr Opin
Periodontol 1994;119-127.
8. Postlethwait RW, Willigan DA, Ulin AW. Human tissue reaction to
sutures. Ann Surg 1975;181:144-150.
9. Bennett RG. Selection of wound closure materials. J Am Acad Dermatol
10. Chu CC. Mechanical properties of suture materials: An important
characterization. Ann Surg 1981;193:365-371.
11. Mejias JE, Griffin TJ. The absorbable synthetic sutures. Compend
Contin Educ Dent 1983;4:567-572.
12. Getzen LC, Jansen GA. Correlation between allergy to suture
material and postoperative wound infections. Surgery 1966;60:
13. Bussard DA, Lapp TH. Technique to assure proper intraoral wound edge
alignment. J Oral Maxillofac Surg 1990;48:531-532.
14. Moy RL, Waldman B, Hein DW. A review of sutures and suturing
techniques. J Dermatol Surg Oncol 1992;18:785-795.
15. Silverstein LH, Kurtzman GM. A review of dental suturing for optimal
soft-tissue management. Compend Contin Educ Dent 2005;26:163-166,
169-170; quiz 171, 209.
16. Silverstein LH, Kurtzman GM, Kurtzman D. Suturing for optimal soft
tissue management. Gen Dent 2007;55:95-100.
17. Mormann W, Ciancio SG. Blood supply of human gingiva following
periodontal surgery. A fluorescein angiographic study. J Periodontol 1977;
18. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial
connective tissue graft palatal donor site: Anatomic consider-
ations for surgeons. Int J Periodontics Restorative Dent 1996;16:
19. Wong NL. Review of continuous sutures in dermatologic surgery.
J Dermatol Surg Oncol 1993;19:923-931.
232 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Dental Suture Techniques
Crown Lengthening Revisited
Marianne Ong,* Shih-Chang Tseng,

and Hom-Lay Wang

Focused Clinical Question: What are the key

considerations in selecting the best approach to crown
Summary: Crown lengthening is a surgical proce-
dure that involves manipulation of either soft tissue or
both soft and hard tissue around a tooth or teeth for es-
thetic or restorative purposes. Esthetic crown lengthening
is indicated in patients with excessive gingival display
(knownas agummy smile) or gingival overgrowth, whereas
restorative (or functional) crown lengthening aims to gain
retention and resistance form of sound tooth structure
above the alveolar crest level in cases of subgingival car-
ies, subgingival restorative margins, or tooth fracture.
Both aim to increase the amount of supragingival tooth
structure for esthetic and/or restorative purposes.
Conclusions: In selecting the type of procedure for
esthetic or restorative (or functional) crown lengthening,
the key considerations include assessment of the width
of keratinized gingiva and distance of the cemento-
enamel junction or finished restoration margin to alveolar
bone around the tooth/teeth involved. This article reviews
and presents a decision tree in the use of both types of
procedures. In addition, the subtle differences between
esthetic and restorative (or functional) crown lengthening
are highlighted. Clin Adv Periodontics 2011;1:233-239.
Key Words: Crown lengthening, methods; decision trees;
esthetics, dental; gingival hyperplasia, surgery; tooth
crown, pathology; wound healing, physiology.
Crown lengthening aims to increase the clinical crown
length of a tooth or teeth for either esthetic or restorative
purposes or a combination of both. The surgical procedure
is designed to increase the extent of the supragingival tooth
structure by apically positioning the gingival margin,
removing supporting bone, or both.
Factors taken into
consideration include excessive gingival display (known as
a gummy smile), altered passive eruption (in which the
alveolar crest is 2 mm from the cemento-enamel junction
[CEJ]), lack of tooth structure, or access for restorative
purposes (requiring the removal of soft or hard tissue or
a combination of both) and the adjacent periodontium of
neighboring teeth. Indications for crown lengthening thus
include teeth with subgingival caries or extensive caries that
shortens the tooth, fractures, and short clinical crowns
caused by incomplete exposure of the anatomic crowns.
The procedure is based on two principles: biologic width
(BW) establishment and maintenance of adequate kerati-
nized gingiva (KG) around the tooth. The BW is defined
as the dimension of soft tissue that is attached to the por-
tion of the tooth coronal to the alveolar bone crest.
ies indicate that a minimum of 3 mm of space between
restorative margins and alveolar bone would be adequate
for periodontal health, allowing for 2 mmof BWspace and
1 mmfor sulcus depth.
An adequate width of KGshould
be maintained around a tooth (2 mm) for gingival health
whenever possible.
This article presents guidelines for
both types of crown lengthening, their indications and dif-
ferences, and a decision tree in deciding when to use the
Esthetic Crown Lengthening
Crown lengthening for esthetic reasons aims to correct ei-
ther a gummy smile or gingival overgrowth (Fig. 1). The
periodontal status of the involved teeth is first assessed.
In the presence of periodontal disease with an absence of
gingival overgrowth, regular periodontal treatment will re-
solve the gingival inflammation and swelling with removal
of local irritating factors. In cases in which tissues are in-
flamed with the presence of gingival overgrowth, a gingi-
vectomy/gingivoplasty procedure may be indicated if the
gingival overgrowth persists even after gingival inflamma-
tion has been reduced through initial periodontal therapy
(e.g., in drug-induced gingival enlargements associated
with cyclosporin and/or calcium channel blockers).
For a gummy smile with a healthy periodontium, the pa-
tients facial proportion has to be assessed. A normal hu-
man face is divided into thirds, and 2 to 3 mm of tooth
is usually shown with relaxed lips.
If the facial propor-
tion is normal, shallow probing depths (<4 mm) may indi-
cate tooth malposition, and this can be corrected with
orthodontic intrusion; deep probing depths (4 mm) may
indicate altered passive eruption (delayed apical migra-
tion of the gingival margin), and this can be corrected
with crown-lengthening surgery. Vertical maxillary excess
(VME) is a dentofacial condition associated with excessive
vertical growth of the maxilla. Patients with VME may
present with either a dental open or closed bite. An in-
creased mandibular ramus height is associated with the lat-
If the patient has VME with 8 mmof gingival display,
* Department of Restorative Dentistry, National Dental Centre, Singapore.

Private practice, Taipei, Taiwan.

Department of Periodontics and Oral Medicine, University of Michigan

School of Dentistry, Ann Arbor, MI.
Submitted May 2, 2011; accepted for publication June 7, 2011
doi: 10.1902/cap.2011.110048
Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 233
then orthognathic surgery would be the treatment of choice
to address the problem. Garber and Salama
three classifications for excessive gingival display and their
proposed treatments. Degree I had 2 to 4 mm of gingival
display, and treatment would be orthodontic intrusion
alone, orthodontics and crown lengthening or crown
lengthening followed by restorations. Degree II had 4 to
8 mm of gingival display, and treatment would be crown
lengthening and restorations or orthognathic surgery de-
pending on the crown/root ratio. Degree III had 8 mm
of gingival display, and treatment would be orthognathic
surgery with or without crown lengthening and restorative
treatment. A decision tree for management of a gummy
smile is illustrated in Figure 2.
The amount of KGpresent around teeth and the distance
of the alveolar bone crest level in relation to the CEJ (CEJ
bone) is next determined clinically and radiographically.
One of four possible treatment modalities may be consid-
ered as described by Coslet et al.
For Type I cases with
adequate KG (2 mm), if CEJbone is 2 mm (subgroup
A), a gingivectomy/gingivoplasty procedure can be done.
If CEJbone is <2 mm or CEJ is at the same level as the
alveolar bone crest (subgroup B), then
a flap with osseous surgery is done. In
Type II cases with inadequate KG (<2
mm), an apically positioned flap (APF)
is indicated for subgroup A. For sub-
group B, an APF with osseous surgery
is done. Figure 3 illustrates a decision
tree for surgical crown lengthening.
The initial incision uses the CEJ as
a reference point and follows the es-
thetic smile line, ensuring that 2 mm
of KG remains on the buccal aspect
of teeth. A surgical stent may be used
to assist in placement of the buccal in-
cisions according to the esthetic smile
line. Only the buccal flap is raised
as a full-thickness flap and a partial-
thickness flap raised over the interden-
tal papillae area with the papillae left
intact. No vertical releasing incisions
are made, and a palatal flap is not
raised. The CEJbone distance is as-
sessed with a periodontal probe, and,
when necessary, bone is removed only
at the mid-buccal area, flushing it to-
ward the mesio- and disto-buccal line
angles to establish the BW; carbide, di-
amond round burs, and end-cutting
burs are used. The buccal flap is next
placed at the level of the CEJ or slightly
above it. Horizontal positional sutures
are used to secure the flap in place. A
wound dressing is not necessary over
the surgical site.
Based on wound healing principles
and studies,
tissue maturation is
completed within 4 to 6 weeks if only a gingivectomy/gin-
givoplasty was done. If a buccal flap was raised and bone
exposed, then 8 to 12 weeks would be required for tissue
maturation and stabilization. If bone was removed, then
6 months would be required for soft-tissue stabilization.
A secondary surgery may be needed to refine the esthetic
outcome of the smile line 6 to 12 weeks later.
Restorative (or Functional) Crown
Crown lengthening for restorative reasons include increas-
ing retention and to expose subgingival caries, fracture, or
restorative margins by increasing the amount of sound
tooth structure above the alveolar crest (Fig. 4).
Depending on the clinical and radiographic presenta-
tion, there are five modalities for this procedure.
a tooth with a probing depth 4 mm and in the presence
of adequate KG, a gingivectomy/gingivoplasty procedure
is done. If there is inadequate KG, then an APF is done.
If there is a need to remove bone to establish BW, then
an APF with osseous surgery is done. If there is a need to
FIGURE 1 Esthetic crown lengthening. 1a Pretreatment. 1b Buccal incision made according to the
esthetic smile line. 1c Full-thickness buccal flap reflected and interdental papillae left intact; note CEJ at
alveolar bone crest (i.e., case Type IB: adequate KG 2 mm and CEJbone <2 mm). 1d After osseous
surgery, 2- to 3-mm BW established. 1e Sutures in place. 1f Seven months after treatment. (photos
courtesy of Dr. Giorgio Pagni).
234 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Crown Lengthening
preserve adjacent structures and interdental papillae on
neighboring teeth (e.g., fractured tooth in the anterior re-
gion), then orthodontic forced eruption of the tooth is
done, which may require crown lengthening later. If the
crown-lengthening procedure would create an undesirable
crown/root ratio or induce more damage to the surrounding
periodontium of adjacent teeth, then an extraction should be
advised and a dental implant replacement can be considered
at a later time.
There is a possibility of reviolating the BW during tooth
preparation after the crown-lengthening surgery healing
period, especially in areas of limited access, such as the dis-
tal line angles of a tooth. Immediate temporization crown
lengthening has been described to alleviate this problem. It
aims to create an adequate BW by establishing the finish
margin of the restoration and fabricating a provisional res-
toration at the time of surgery.
Before surgery is performed, an impression is taken of
the dental arch with the tooth to be crown lengthened
for a wax-up of the crown. Avacuform
is prepared for the provisional restora-
tion. Initial preparation of the tooth is
done, and the prefabricated vacuform
is used to make the provisional res-
toration. Incisions are made on the
buccal and palatal/lingual aspects,
following the APF concept, ensuring
that 2 mm of KG remain on the buc-
cal and lingual aspects of the flaps for
mandibular teeth. For maxillary teeth,
the palatal flap incision is one half to
two thirds of the palatal probing depth
(an enhanced scalloped incision) be-
cause the flap cannot be apically posi-
tioned as a result of the immobility of
the palatal tissue. Vertical releasing in-
cisions are usually placed to assist
in apically positioning the flap on the
buccal aspect. Buccal and palatal/
lingual flaps are raised, and the finish
margin of the restoration is established
to the best of the operators ability dur-
ing the surgery. The provisional res-
toration is then relined. With the
finished restoration margin (FRM)
as a reference, the BW is established
around the tooth by removing bone
to 3 mm below the FRM. If a ferrule
effect is required for endodontically
treated teeth that need to be restored
with a cast post and core, then 4 to 5
mm of clearance is needed from the
finish margin to the alveolar bone.
Osseous surgery is done with carbide,
diamond round burs, and end-cutting
burs circumferentially aroundthe tooth.
In some instances, an alternative to
osseous resection alone would be to re-
shape the existing tooth/root surface in combination with
conservative removal of supporting alveolar bone to create
the BW. Reshaping of the external surface or periphery of
the tooth and the core buildup restoration aims to advance
the restoration coronally and minimize the amount of ostec-
tomy required to create the BW.
The provisional restoration is cemented on to the tooth.
The buccal and palatal/lingual flaps are placed at the al-
veolar bone crest and sutured. Avertical mattress suture is
usedtoclose the flaps if crownlengtheninginvolvedasingle
tooth. If crown lengthening involved multiple teeth, a con-
tinuous sling suture may be used instead. A periodontal
dressing is often used to protect the surgical site and to as-
sist in positioning the flap apically.
Because bone removal is done during the procedure,
a minimum of 6 months is needed for complete tissue
maturation and stabilization before cementation of the
final restoration.
The development of black triangles be-
tween teeth usually occurs if the post-surgery distance
FIGURE 2 Decision tree for management of a gummy smile (excessive gingival display). PD probing
Ong, Tseng, Wang Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 235
between the contact area and the interdental alveolar
crest is >5 mm.
Thus, as a result of establishing the
BW around the tooth, the interdental spaces become
larger and the final restoration usually ends up with
a square-looking crown and long contact points to close
up these spaces.
Various factors need to be taken into consideration for
surgical crown-lengthening indications of a tooth. These
include the strategic value of the tooth, apical extent of
fracture or caries, level of the alveolar crest, and crown/
root ratio before and after surgery. With the advent of im-
plant dentistry, surgical crown lengthening may be contrain-
dicated in cases with an unfavorable crown/root ratio,
preexisting tooth mobility, possibility of compromising the
support of the adjacent dentition, and in esthetic areas.
The decision-making process in managing a gummy
smile and techniques for crown lengthening under various
clinical scenarios are illustrated in Figures 2 and 3. The dif-
ferences between esthetic and restorative (or functional)
crown lengthening are summarized in Table 1.
Both procedures aimto establish the
BWaround the tooth and to maintain
an adequate width of KG for different
purposes: one to create an esthetic
smile line and the other to recreate
the BWto maintain periodontal health
around a tooth that needs to be re-
stored. The reference lines with respect
to making incisions and performing os-
seous surgery are different: the CEJ for
esthetic crown lengthening and the
FRM for restorative crown lengthen-
ing. The final outcomes also differ.
With esthetic crown lengthening, often
the clinicianis exposing more of the an-
atomic crown height of the natural
teeth, with an esthetic smile resulting.
In restorative crown lengthening, the
teeth require restorations for a variety
of reasons and frequently esthetics
are achieved with the final restorations
having square-looking crowns and
long contact points.
This article reviews esthetic and restorative (or functional)
crown-lengthening procedures and highlights their indica-
tions and differences. In addition, decision trees are pre-
sented to aid the clinician in the decision-making process of
when these procedures should be used. n
This study was partially supported by the University of Mich-
igan Periodontal Graduate Student Research Fund. The au-
thors thank Dr. Giorgio Pagni (private practice, Florence,
Italy, and former resident, Graduate Periodontics at the
University of Michigan, Ann Arbor, MI) for providing
Figure 1. The authors report no conflicts of interest re-
lated to this study.
Dr. Hom-Lay Wang, Department of Periodontics and Oral Medicine,
University of Michigan School of Dentistry, 1011 N. University Ave., Ann
Arbor, MI 48109-1078. E-mail:
FIGURE 3 Decision tree for surgical crown lengthening: esthetic and restorative (or functional). PD
probing depth.
236 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Crown Lengthening
FIGURE 4 Restorative (or functional) crown
lengthening. 4a Pretreatment. 4b Initial crown
preparations done. 4c Vacuform placed to make
provisional restorations. 4d Provisional restora-
tions fabricated. 4e After flap reflection and soft-
tissue debridement, finish margin of restorations
established and existing distance to alveolar bone
determined. 4f End-cutting bur used for osseous
surgery to remove bone to 3 mm below finish
margin of restorations. 4g BW established after
surgery. 4h Provisional restorations replaced. 4i
Provisional restorations relined and subsequently
adjusted and trimmed. 4j Sutures in place and
provisional restorations cemented. 4k Six months
after treatment with crown placement.
Ong, Tseng, Wang Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 237
TABLE 1 Comparison Between Esthetic and Restorative (or Functional) Crown-Lengthening Surgery
Factors to Consider Esthetic Restorative (or Functional)
Goal To create an esthetic smile line and establish BW around
the tooth (2 to 3 mm)
To maintain periodontal health and establish BW
around the tooth (2 to 3 mm)
Reference line CEJ FRM
Techniques I (2 mm KG)
A: Gingivectomy/Gingivoplasty
B: Flap Osseous
APF Osseous
Orthodontic forced eruption
II (<2 mm KG)
B: APF Osseous
Incision Buccal only Buccal and palatal/lingual
CEJ (2 mm KG) and follow esthetic smile design Follow APF concept (leave 2 mm KG behind)
No vertical releasing incision Usually drop a vertical release to apically position flap
Surgical stent Often needed Not needed (use provisional crown)
Flap raised Buccal only (no raising of interdental papilla/palatal flap) Buccal and palatal/lingual
Osseous surgery Follow CEJ or esthetic smile line (alveolar crest 2 to 3 mm
below CEJ)
Follow APF (alveolar crest 3 mm below FRM)
Osseous surgery location Only buccal side (not impinging on interproximal area) Both sides including interproximal area
Final flap position Located at CEJ or slightly above CEJ Located at bone crest
Recommended suture technique Horizontal positional Continuous sling/vertical mattress
Wound dressing Not necessary Often required
Healing period Soft tissue only (i.e., gingivectomy/gingivoplasty),
4 to 6 weeks
Often 6 months because bone needs to be removed
to recreate the BW
Bone exposed (i.e., flap raised), 8 to 12 weeks
Bone removed (i.e., osseous surgery), 6 months
Secondary surgery Often needed Not necessary (use restoration to make up the difference)
Final outcome An esthetic smile Square-looking crown(s), long contact point(s)
238 Clinical Advances in Periodontics, Vol. 1, No. 3, November 2011 Surgical Crown Lengthening
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