Esthetic gingival recontouring—A piea for honestyJ.William Robbins, DDS,

There continues to be a tremendous amount ot contusion in the dental iiterature and among practitionersregarding the diagnosis and treatment ot gingival discontinuities. The purpose ot this articie is to present arationale for gingivai recontouring, iiiustrated by a case report A patient requested gingivai recontouring.Because the preoperative evaiuation was inadequate, a simple gingivectomy procedure was performed.After healing, the tissue had rebounded to its preoperative ieveis. The patient was then evaluated morecomprehensiveiy, and gingivai recontouring was accomplished with a mucoperiosteai flap and osseousrecontouring.The tissue subsequently healed at the correct posilion and remained stable. To reliably per-form gingivai recontouring procedures, the dentist must have a clear understanding of the bioiogic width.By using diagnostic bone sounding, the practitioner can determine the appropriate surgical procedure thatwili ensure an esthetic and stabie postoperative resuit. (Quintessence Int 2000:31:553-556)

Key words: biologic width, bone sounding, crown lengthening, esthetics, gingivai recontounng,gingivai surgery

During the past 20 years, there has been a tremen-dous increase in the emphasis on dental esthetics.

This new era in restorative dentistry was made possi-ble by the dental scientists who deveioped adhesivetechnology and materials. Understanding of the adhe-sive interfaces of ename!, dentin, and porcelainenabled anterior restorations so natural that theydefied detection. The next step in the esthetic dentistryrevolution was a greater emphasis on the heauty andsymmetry of the soft tissues surrounding the lifelikeporcelain restorations.

Dentists continue to struggie with gingivai estheticstoday. The profession has become enamored with theconcept of gingival recontouring. The literature isreplete with articles that describe a cosmetic restora-tive case with a brief menfion of the preliminary gingi-val recontouring. The probiem is that the authorscommonly provide no diagnostic criteria or treatmentrationale for their gingival recontouring procedures.This misinformation leads to confusion among practic-ing cfinicians who are attempting to provide state-of-the-art therapy for their patients. It is the purpose ofthis article to provide a logical diagnostic and treat-ment approach to the management of gingivai issues.

'Ciinicai Protessor, Departr/ient of General Dentistry, University of Texas,Health Science Center at San Antonio Dentai Sctiooi, San Antonio, Texas.

Reprint requests: Dr J. William Robbins. Ciinicai Profsssoi. Department ofGeneral Dentistry Universily of Texas, Heaith Science Center at SanAntonio Dentai Schooi, 77C3 Fioyd Curl Drive, San Artorio, Texas 7B2B4.E-rrail:robbinsdds@aol.com

In 1961, Gargiuio and others' provided the profes-sion with the classic histoiogic study on the dentogingi-val attachment apparatus. This oft-quoted studydefined the average dimensions of the sulcus, epitheliaiattachment, and connective tissue attachment. In 1977,Ingher et al- discussed the relationship between theperiodontium and the margin of the restoration. Theytermed the distance from the alveolar crest to the baseof the sulcus the biologic width, based on the work ofDr D. Walter Cohen. This concept has withstood thetest of time, and the term is used aimost universallytoday. In 1980, Maynard and Wilson' described thisarea from the alveolar crest to the margin of therestoration and termed it the physiologic dimemion.More recently, Kois'''̂ has elegantly described this rela-tionship in simple and understandahle terms. Yet, thereis still a tremendous amount of confusion surroundingthis very important 3 mm of human anatomy.

It is self-evident that estheticaily driven periodontalsurgical procedures should only be accomplished inthe presence of gingivai health. However, the key ele-ment that determines the position and contour of thegingival margin is the position and contour of theunderlying alveolar bone. Kois^ has descrihed thisrelationship using the terms normal crest, low crest,and high crest. The normal crest relationship is a dis-tance of 5 mm from alveolar crest to gingival crestwhen measured midfacially on a maxillary anteriortooth; this relationship occurs approximately 85% ofthe time. In the low crest situation, this distance ismore than 3 mm; this occurs approximately 13% of

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Fig 1 Average biologic dimension Fig 2a Preoperative view showing lower gingivai ievels on themaxiilary right anterior feeth.

the time. Finally, the high crest relationship is a dis-tance of less than 3 mm from alveolar crest to gingivalcrest, which occurs approximately 2% of the time.

Thus, in the vast majority of patients, the distancefrom the alveolar crest to the gingival crest, measuredmidfacially on the maxillary anterior teeth, is approxi-mately 3 mm,-!"̂ This can be roughly divided into 1 mmof connective tissue, 1 mm of epithelial attachment,and 1 mm of gingival sulcus (Fig 1), This distance ismeasured by first anesthetizing the gingiva and theninserting the periodontal probe into the sulcus andpushing it apically until the tip engages the alveolarbone. This procedure is termed bone sounding.

The 3-mm distance (normal crest) is what naturerequires, in the majority of the population, for gingivalhealth and stability. If bone sounding reveals that thedistance from gingival crest to alveolar crest is 3 mm,it is not possible to remove any gingiva! tissue with asimple gingival rccontouring procedure, which wouldresuit in a postoperative distance of less than therequired 3 mm. In this circumstance, when tissue isremoved with a simple gingivectomy, the tissue willpredictably grow back to the preoperative 3-mmdimension. If a restoration margin is placed at the gin-gival crest immediately after the gingivectomy, the tis-sue will attempt to grow back to the preoperative posi-tion. If the margin of the restoration is less than 2,0 to2,5 mm from the aiveoiar crest, a biologic widthimpingement will have been created, resulting inchronic gingivai inflammation.

When gingival tissue recontouring is required, it isimperative that the dentist determine the existingrelationship of gingival crest to alveolar crest withbone sounding. If the distance is 3 mm or less, thegingivectomy procedure must be followed by osseousresection.'** This is generally accomplished by elevat-ing a mucoperiosteal flap and removing alveolar boneon the facial surface from the mesiofacial line angle to

the distofaciai line angle with high-speed burs andhand chisels. Enough bone is removed to ensure thatthe postoperative distance from gingival crest toalveolar crest is 3 mm. This will generally result in astable gingival complex that migrates neither coronallynor apically.

In the uncommon circumstance in which the dis-tance from gingival crest to alveolar crest is greaterthan 3 mm (low crest), gingival tissue can be removedwith a simpie gingivectomy, followed by a circumfer-ential fiberotomy. For example, if the measurement is4 mm from gingival crest to alveolar crest, then 1 mtnof gingival tissue can be removed with a simple gin-givectomy, resulting in the required postoperative dis-tance of 3 mm, A sulcular incision is then made frotntbe gingival crest to the alveolar crest to Incise theattachment apparatus. The healed gingival tissue willbe stable in its new position.

CASE REPORT

A 26-year-old woman presented with a chief complaintof uneven gingival margins; the gingival crests were 1mm more coronal on the maxillary right anterior teeththan on the left side (Fig 2a), The patient was not evai-uated correctly, and a simple gingivectomy procedure,which removed 1 mm of marginal gingiva on the max-illary right anterior teeth, was performed (Fig 2b),

At the 2-week postoperative appointment, it wasapparent that the tissue had grown back to the preop-erative levels (Fig 2c), At this time, a more thoroughevaluation was accomplished. The explorer was usedto determine whether the cementoenamel junctioncould be felt in the gingival sulcus on the maxillaryright central incisor. Because the cetnentoenameljunction could not be ielt, a diagnosis of altered pas-sive eruption was made,''*

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Fig 2b Gingivectomy pertormed to levei gingivai margins Fig 2c Postoperative view revealing tissue rebounding to pre-operative ievels.

Fig 2d Periodoniai probe bone sounding to the aiveolar crest Fig 2e Periodontai probe demonstrating the 3-mm clislance fromthe gingivai cresl to the aiveoiar crest.

Fig 2f Seoond surgery, involving a mucoperiosteai fiap andosseous resection.

Frg 2g Twenty-eight-month postoperative view demonstrating astable postoperative result

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• Robbins

The next diagnostic step was to measure the distancefrom the gingival crest to the alveolar crest, in order todetennine the indicated surgical procedure. The gingivawas anesthetized, and bone sounding was performed.The distance from the gingival crest lo the alveolarcrest on both maxillary central incisors was 3 mtn (Figs2d and 2e). The tissue had rebounded lo its originaipresurgical dimension of 3 tnm. The tissue remainedstable at this position for approximately 1 year.

Subsequently, a second surgery was performed. Itconsisted of a 1-mm gingivectomy coupled with amucoperiosteai flap and 1 mm of osseous resection(Fig 2f). The tissue heaied in the correct position andhas remained stabie for 28 months (Fig 2g). However,the surgicaily corrected gingival contour does not per-fectly mirror the gingival cotitour of tbe adjacent cen-tral incisor. Tbe contour of tbe alveolar crest ulti-mately determines the finai gingival contours.Tberefore, the alveoiar crest, after ostectomy, mustexactly mirror the desired gingival contour.

DISCUSSION

Tbis ciinical case clearly illustrates tbe correct andincorrect tecbniques for esthetic gingival recontouring.The required surgical procedure, a simple gingivec-tomy versus a mucoperiosteal flap plus osseous resec-tion, is dictated by the distance from the gingival crestto the alveolar crest. In the majority of patients (nor-mal crest), the simple gingivoplasty or gingivectomywill not provide predictable, long-term gingival recon-touring. Tbe instrument used to accomplish tbe gingi-val recontouring-knife, electrosurgery, or iaser—hasno impact on the surgical outcome, TTie resuh is dic-tated hy tbe levei of tbe underiying aiveolar crest.

CONCLUSION

It has been the purpose of this article to provide adiagnostic rationale for gingival recontouring. It isimperative that authors of articles and educators wholecture on tbe subject of gingival esthetics be heid to abigber standard. First, wben gingival recontouring isdescribed, tbe preoperative dimension of the gingivalcrest to the alveolar crest must be reported. Second, a1-year postoperative photograph must be provided toconfirm tbe long-term stability of the postoperativeresult. If the profession demands this higher ievel ofaccountability, the confusion caused by the currentgeneration of misinformation should diminish.

REFERENCES

1. Gargiuio AW, Wentz FM, Orban B. Dimensions and rela-tions of the dentogingival junction in humans. J Periodontol1961:32:261-267.

2. Ingber JS, Rose LF, Coslet |G. The hiologic width-a con-cepl in periodontics and restorative dentistry. AlphaOmegan 1977;10(3):62-65.

3. Maynard JG, Wilson RD. Physiolcgic dimensions of theperiodontium significant to the restorative dentist. JPeriodontcl 1979;50:170-174.

4. Kois JC. Altering gingival Isvels: The restorative connection.Part 1. Biologic variables, J Esthet Dent 1994;6(ll:3-9.

5. Kois JC. The restorative-peri o don ta I interface: Biologicalparameters. Periodontology 2000 1996;ll;29-38.

6. Kois JC. Managing the restorative periodontal interface:New paradigms for predictable results. Creating RestorativeExcellence Course 3 Syllabus, 15-18 July 1999, Tacoma,Washington.

7. Dolt AH, Rohbins JW. Altered passive eruption: An etiologyof short clinical crowns. Quintessence Int 1997;28:363-372.

8. Robbins JW. Differential diagnosis and treatment of excessgingival display. Pract Periodont Aesthet Dent ]999;U:265-272.

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