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Soft Tissue Augmentation onPreviously Restored Root Surfaces

Michael K. McGuire, DOS'

Three cases are presented demonstrating thot soft tissue ougmentotionprocedures can be accompiished on previousiy restored root surfaces.Diagnostic techniques to heip determine ideal taoth iength ore discussed,and clinical examples of haw to surgically monage the previousiy restoredroot surtaces are presented. (IntJ Periodont Rest Dent 1996;16:571-581.)

"Private Proctioe, Houstan. Texas; Assistant Clinical Professor.University of Texas Dental Branch, Hauston. Texos: ond AssistantClinical Professor. University ot Texas Health Science Center, DentalBranch, Son Antonio, Texos.

Reprint requests: Dr Mictioel K, McGuire. 3400 S, Gessner. No. 102.

Houston. Texas 77OÓ3.

The ultimate goal of periodon-tal therapy is not oniy the eiimi-nation of the diseose but olsothe restoration ot the onatomyot the periodontium to the pre-disease stote, Greot strideshave been made in recentyears in the regeneration ofboth the hard'-" ond sotttissues^-' lost in the diseaseprocess. We can now routinelycover most denuded root sur-faces ond augment deficientridges so that the moufh is pre-pared to receive ideal restora-tive dentistry with proper crowniength ond gingival contours.

The importance of thesepreprosthetic procedures hasbeen weil dooumentea'^-'^ butthere is another segment ot ourpatient population that has notbeen offered these proceduresbecause the root surfaoes asso-ciated with the periodontaidefect hove been restored. Ithas been ciinicai wisdom thatthe prepared root surface, espe-cially the subgingivGl margin otthe preparation, would interferewith the gratting procedure. This

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article wiil present a series ofcases demonstrating that theperiodontium adjacent to previ-ously restored root surfaces canbe rebuilt atfer the restorationsare removed. These proceduresultimately create a more es-thetic and hygienic environmentfor new restorations.

Ciiniooi guideiines far idealtooth length

Before any surgical augmenta-tion procedures are under-taken, the clinician must first de-termine the particuiar patient'sideal tooth length, in verysevere cases, where importantiandmarks such as incisai edgeand soft tissue relationshipshave been destroyed, thedetermir^ation is difficult. Allthree cases in this study presentvarious probiems in the creationot ideal tooth length.

in the author's opinion, thefollowing guidelines are usefulto clinicians who are consider-ing changing the length of amaxillary anterior tooth—whether that change in iengthresuits from crown iengtheningor root coverage grafts:

1. Incisai edge position mustbe established first. This isgeneroliy accomplishedphonetically by hqving thepqtient sqy '•55-55-55." '̂' Asthat sound is made, theincisai edge of the maxillarycentral incisors should lightly

touch the vermilion borderof the mandibuiar lip. Oncethe incisai edge position isestablished, it then becomesthe constant, and ali mea-surements are made from it.

2, A knowledge of averagetooth length is also useful(Fig 1), Although the partic-ular tooth length will varyfrom individual to individuai,the propcrtionai reiotionshipof one tooth to another usu-ally remains q constant. Thetooth's length-tc-width ratioshould also remain con-stant—the ideal ratio isapproximately 10:8. "-̂ s

3, The relationship ot the maxii-iary anterior teeth to themaxillary and mandibular lipline is on important consider-ation. (This reiationshipossumes q "medium" smileline.) The following guideiinesqre usefui in establishingproper tooth length and gin-gival contour. The free gingi-vql margins ot the maxiiiarycentrai incisors and caninesshould lightly touch the ver-miiion border ot the mqxillqrylip (Fig 2). Approximately 1mm of gingiva should showbetween the lip and the gin-Qivqi margin of the iqferalincisors. The incisai edge ofthe centrai incisors qndcqnines should touch thevermilion border of themandibulqr lip, qnd the lat-erol incisor's incisoi edgeshould be 1 to 2 mm abovethe vermilion border.

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Fig I Average tooth iength of the maxiiiory anterior teeth. Fig 2 Ideal relationship between the maxillary anterior teethand the vermilian border of the moxiiiary ond mandibuiar Up.

The Clinician, atten requiredto change the iength of thetooth incisaliy, ginglvaliy, orboth, wiii find these guidelinesheipfui. Any change in toothiength needs to be determinedthrough carefui analysis andconsuitation between thepatient and all of the cliniciansinvolved.

Case reports

Case I

This case represents a yaungwoman who desired to have amore naturai and esthetic fixedpartioi denture made torepiace the existing restorationof the maxiiiary right premolar,Conine, and iaterai incisor (Fig3a). A iarge aiveoiar ridge defi-ciency was present in theregion of the right canine, and

a tooth-iength anaiysis demon-strated that both of the existingretainers were too iong. Theauthor's goal in this case wasfo rebuiid the alveolar ridgedeficiency, to eliminate thedefect and create encughridge width to aiiow for anovate pontic, and to cover thepreviousiy restored root surfacean the premoiar and lateralincisor. The restorative dentistwas asked to repiace the exist-ing fixed partial denture withan acrylic provisional restora-tion that had ideai toothlengths and contours. In otherwords, the margin of the provi-sional restoration would end atthe ideal toath iength even ifthe restoration did not coverthe previousiy restored root sur-ioce. The provisionai restoraticncouid then be used as a surgi-cai stint to help position thegraft/ridge augmentation in

the most ideal reiationship. Thegênerai dentist was reiuctant, inthis case, to make a new provi-sional prosthesis because hewas able fo remove fhe exisf-ing fixed partial denture andrecement it provisionaiiy. Con-sequently, the outhor recon-toured the pontic and mar-ginal relationship of fhe existingfixed parfiai denture to refiectthe ideai tooth iength. Underiacai anesthetic the authorpianed the previousiy restoredroots with curettes and chiselsin an efforf fo create a bio-oompatible root surtace, to tlat-ten it as much as possible, andto eliminate any dead spaces(Fig 3b), Foiiowing root planing,the denuded raat surface wasburnished with a supersatu-rated soiution cf citric acid for 3minutes with a cotton pellet.The restorative margin thatwould be covered on the

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canine and lateral incisor wasa chamfer, and if was easiiyremoved during the rootpreparation. Other marginalrelationships, such as a buttjoint, are more diffiouit to man-age (see case 2). A partial-thickness tiap was raised facialto the teeth associated withthe prosthesis. A subepitheiialconnective tissue graft v̂ /asharvested from the palatalregion in a similar fashionto that described by Langerand Caianga''^' and Langerand Langer,2° The graft wasadapted over the previouslyrestored root surfaces and sus-pended over fhe void createdby the alveolar ridge defi-ciency It was then secured byinterrupted gut suture at eachpapilla and on the mesial anddistal extent of the graft. Asuspensory sling suture wasplaced from the periosteumbelow the graff, around theneck ot the tooth, and securedto ensure close adaptation ofthe graft to the prepared rootsurface. A wedge of tissue wastaken tram the tuberosity distaito the maxiilary second molar.The epitheiium was removed,and the remaining connectivetissue was shaped so that itcouid be interposed between

the periosteum oi the alveolarridge defect and the connec-tive tissue gratt (Fig 3c). Theoriginai mucogingival fiap wascoronaiiy repositioned wifhinterrupted gut suture to coverthe graft as much as possible(Fig 3d), and the recontouredbridge was provisionally rece-mented. Excess cement wasatraumatically removed, andthe newly graffed tissue waschecked for intimate contoctto the margins of fhe crownsand the undersurface of thepontic. Appropriate postopera-tive medications were pre-scribed and the patient wasadvised to avoid chewing onor mechanicaily cleaning thisarea for the firsf week foiiowingsurgery The patient was seen at7 days for the first postopera-tive evaiuation, and the graftappeared fo be maturing satis-factorily. Five weeks later thepatient was seen again, and ogingivoplasty was performed foblend the graft into the adja-cent tissue and refine the gin-givai contours. The patientreturned tor finai resforafivework at 8 weeks, and a newfixed parfial denfure that hadart ideal relationship betweentaath length, pontic, and softtissue was constructed (Fig 3e),

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Fig 3a (top left) Tooth length discrep-ancy ofthe maxilldry right premolarand lateral incisor and the alveolarridge deñciency in the region of themoxillory right canine.

fig 3b (top right) Retainers an theceromometal fixed partial denfure arelecontoured ta create a more ideaitooth length. The exposed portion otthe previously restored roots areplaned and burnished with citric acid.

Fig 3c Cleft) ConnecfiVe fissue wedgeñlis the deticiency and supports thegroft. Note the connective tissuewedge extending above and belowtrie graft.

Fig 3d (right) The original flap issutured over the gratts ond the fixedportiai denture is sedted. Note the inti-mate coritact ot the graft to the newlycreated margin on the lateral incisor.Ttie ridge augmentation extends forenough faciaiiy to allow fhe pontic toform an ovote reiationship.

Fig 3e Grafted areo with the finailestoronon in piace (restorative wori<couifesy of Dr Fdgar James, Houston,Texas),

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Case 2

This potient presented a similarbut more chalienging situationthan Case 1. This patient wqsalso a young woman who hodiost her mqxiiiary right iateralincisor in an automobile acci-dent 6 years eariier. The acci-dent caused extensive boneand sott tissue ioss in the area ofthe maxiilary right canine andlateral and centrai incisors, Alarge alveolar ridge deticiencywas encountered in the regionof the lateral incisor, and boththe canine and the centraiincisor lost 4 to ó mm of boneond soft tissue on their faciaiond proximol ospects. A fixedpartiai denture was constructedshortly atter the accident. Thepatient wos never pieased withttie esthetics ot the fixed partialdenture and was particuiarlyconcerned with the iength ofttie crawns in reiation to her nat-ural teeth. She hod seen severalperiodontists regarding her con-cerns, but had been toid thatwhiie it might be possible toresoive the aiveolor ridge deti-ciency if she was wiliing to havethe prosthesis remade, therewas nothing that couid bedone regarding the iength ofthe adjacent teeth because ofthe marginal relationship of fheexisting fixed partial denture onthe root surface,

Affer consultation, thepatient was sent back to therestorative dentist with a requesttor him to remove the existing

fixed partial denture and re-piace it with an acrylic provi-sional restoration with an idealtooth length and pontic rela-tionship, Affer the provisionalrestoration had been con-structed (Fig 4a). the hard andsoff tissue loss was even moreapporent. Under iacal anes-thetic the exposed (previouslyrestored) root surtace wasploned with curetfes and chiselsand burnished with citric acid aspreviously described (Fig 4b), Asplit-thickness tlap was raisedfocia! to the right canine ondincisors to expose the subgingi-val butt joint morgina! prepora-tion (Fig 4c), The butl joint wasremoved through odontopiastywith high-speed finishing burs,and potential dead spaceswere eliminated (Fig 4d),The restof the soff tissue augmentotionwas performed as desoribed inCase 1 (Figs 4e and 4f), Af óweeks a gingivoplasfy wos per-formed to blend the gratt intothe adjacent tissue, and thepatient wqs seen 1 month later,at which time the tooth iengfhand soff fissue contour ap-peared greatiy improved. Therestorative dentist was asked toconstruct a new provisionalrestoration and adapt it as ide-aily OS possible ta the newly cre-ated environment so that theneed for a secondary proce-dure could be determined (Fig4g), A decision was made fhaffurther surgery wouid nof benecessary and the tinai restora-tion was constructed (Fig 4h),

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Fig 4a The originai restoration hasbeen removed and fhe provisionoirestoration is now in piace. Nofe thealveolar ridge defecf associated wifhfhe region of fhe maxillary right iaferalincisor ond the exposed (previousiyrestored) root surface oh the canineand centrai incisor (Uhfortunofeiy aphotograph of the original bridge priorto its removai was naf made.)

Fig 4b Pencil is used to trace the ideaitooth length created by fhe provisionalrestoration onto fhe root surface. (Notefhe previousiy resfoisd roof surface cre-ates a Millers Ciass iV recession.) The pre-viousiy resfored root surface betweenthe son fissue and the pencii iihe isplaned and burnished wifh cifric acid.

Fig 4c After reflection of a split-fhickness fiap, fhe butfjoinf restorativemargih on the roots of bofh feeth cahbe visualized

Fig4d tdeai crown iengfh is ogammarked on the feefh wifh a pencil, andtrie buttjoinf is removed wifh high-speed finishing burs, eiiminating fhepotential dead space and creating aflat root surface from the pencil line fothe olveoiar ridge.

Fig 4e The graff is sutured with bothinterrupted and siing sufures, and owedge of connecfive fissue is inter-posed between fhe aiveolor ridgedefect and the graft.

Fig 41 The split-fhickness ñop is suturedover the subepithelial graft and con-hective tissue wedge.

Fig 4g (left) Nofe file firm attachmentof fhe grafted tissue ta the root surface.The tissue is healfhy and the sulcusdepth should be easily maintained.

Fig 4h (right) .Augmented oreo withthe final resforation in piace.(Resfcrotive work courtesy of Dr BillBayd. Houston, Texas).

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Case 3

This patient presented with astrong desire to improve hermaxillary anterior esthetics.Examination revealed generai-ized gingivai recession resuitingin excessive tooth iength of themaxiiiary incisors and canines,compiicated by existing com-posite Class V restorations anda provisionai crown on the rightlateral incisor (Fig 5a), Theauthor had had some experi-ence in gratting ever iocaiizedareas of cories or previouslyrestored Class V restorations,but never in such a generalizedsituatian. The benefits and risksof fhe prccedure were dis-cussed with the patient, andshe confirmed that she wouldwillingiy accept multiple surgi-oai appointments to achieveher goai.The restorative dentistwas requested to create a newprovisionai crawn with ideaitooth length on the right Iateraiincisor, and the patient wasscheduied for three separate

surgeries (for the right canineand right lateral incisor, thecentral incisors, and the ieftcanine and ieft iaterai incisor)at approximateiy ó-week inter-vais. A subepitheiial connectivetissue graft was performed ateach surgery. Any portion ofthe existing Class V restorotionthat extended beyond theideai tooth iength was re-maved, and the root surfacewas planed as described in theprevious cases. The previousiyrestored and/ar exposed rootsurface was covered with thegratt, creating a more ideaitooth iength and gingival con-tour (Figs 5b ta 5e). A gingivo-plasty was performed fo biendthe grafts info one another, butbecause of a propensity toscar, the graft's never blendedas well as expected. Neverthe-less, the procedures enabledthe patient to achieve her godct proper tooth iength and gin-gival contour and she is now inthe process of having the teethrestored (Fig 5t).

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Fig 5a Pfeoperafive photograph ofthe maxillary anterior segment. NotettiOt the margin af the provisianaicrown or) the maxillary right lateralir^dsor has beeh ieft at the ideal taothiength. Alsa note the Class V restara-frons on the other anterior teeth.

Fig 5b A preoperative photograph afthe maxiilary right canine and lateraland central incisors.

Fig 5c Pastoperative photograph ofthe right moxiiiary anterior segment. Theportion of fde Ooss V restoration thatextended onto the crown of the toothremains, but the portion of the restoro-tion that extended apical ta the idealtooth length has been removed ondthe previously restored root hos beencovered with the groft. The denuded(previously restored) roat surface of fheiaterai incisor was also covered, creot-ing o more ideal toath iength.

Fig Sd PfeC'Uerarivt; i"i"-ivtoty left anterior segment.

Fig 5e Postoperative photograph ofthe maxiiiary ieft anterior segment Thepartian of the Class V restoration thatextended onto the crown af the toothremains, but the portion of the restora-tion thaf extended apicai to the idealtaoth length was removed and the pre-viausiy restored roat surface was cov-ered with the gran. Note the mare idealtooth length and gingival contour

Fig Si Postoperative photograph ofthe patient's maxillary anferiar segmentfallowing periodontoi augmentationand neiv restorations. Note the moreideal tooth length and gingival canfourresulting in a more esthetic outcome.(t?estarative wark courtesy af DrMichael McCuiloch, Houston, Texas.)

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Discussion

These cases demonstrate thatprevious restorations need notbe a barrier to soft tissue aug-mentation procedures. Althoughthese cases were treated withadaptations of fairly routineperiodontai procedures, theydo require thoughtful preopera-tive treatment pianning andciose attention to surgicai tech-nique.

One contraindication to thisprocedure may be the depthot the previous restoration.There is the possibiiity that whenthe restorations are removed,the restorative preparation mayextend too for toward the pulpto Pe eliminated by aggressiveroot preparation. In such a casethe large dead space wouidnot be eliminated, and the pro-cedure would have to beaborted, it has been theauthor's experience that smalilocalized depressions (1 to 2mm in dimension) that cannotbe compietely eiiminated donot seem to adverseiy affectthe success of the graft,Anottier potentiai contraindica-tion would be the iack of ade-quate donor tissue in the palateor tuberosity region. The casespresented in this poper andothers hove been failowed forup to 2 years, and all ot themappear to retain dimensionaistabiiity. The type of soft tissueconnection to the root surface

is unknown, but the grofts arefirmly at tached to the rootsurface, resuiting in minimol sui-cus depth (see Fig 4g).

Good communication isnecessary between the perio-dontist, the restorative dentist,and the patient. Only throughan effective partnership conmiscommunication Pe re-duced, the need for secondaryprocedures minimized, andsuperior resuits achieved. Thisarticle demonstrates that softtissue augmentat ion is nowpossibie for many patients,who, because of the locationof their existing restorations,were denied that treatment.

Acknowiedgment

The author wouid like to thank DrJacauelyn Compbeli for her editoriaiassistonce.

References

1. Schoiihorn RG, McCiain PK. Com-bined osseous composite grofting,root conditioning ond guided tissueregeneration, int J Periodont RestDent 1988:8(4):8-31.

2. McCiain PK, Sohalihorn RG. Long-term ossessment of combinedasseaus composite graffing, rootconditioning, and guided tissueregeneration, int J Periodont iîestDent 1993:13:9-27.

3. Schollhorn RG, McCiain PK. Clinicaiand radiographie heoiing patternobservotions with combined regen-erotive techniques, int J PeriodontRest Dent 1994:14:391-403.

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4 Cortellini R Pini Prato G, Tonetti MS,Periodontal regeneration of tiumanintrabony detects. 11. Re-entry pro-oedures and bone meosures, JPenodontol 1993:64:261-268.

5, Miller PD Jr. Root coverage using ofree soft tissue autograft followingcitric Odd applicotion. I,Technique.int J Periodont Rest Dent 1982;2C1):65-70.

Ó. Miller PD Jr. Root coveroge using afree soft tissue outograft toilowingcitric acid opplication. II Treatmentof the corious root, Int J PeriodontRest Dent 1933:3:38-57.

7. Wilier PD Jr. Rool coveroge usingttie free soft tissue autogroft follow-ing citrio acid application. Part 111. Asuccesstui and predictable proce-dure in oreas of deep-wide reces-sion. Int J Periodont Rest Dent 1985;5:15-37

8. Allen ER Gainza GS, Farthing GG.Newbold DA, Improved techniquesfor localized ridge augmentotion, Areport of 21 oases J Periodontol1965:56: 195-199,

9. Holbrook T, Ochsenbein C, Com-plete coverage of denuded rootsurfooes witti a one-stoge gingivalgrott. Int J Periodont Rest Dent19B3.3(3):9-27,

10. McGuire MK, Pre-restorative Perio-dontics. Reriodontal Disedse Man-agement. Chicago. IL: The Amer-ican Academy of Periodontolagy.1994371-384,

l l , G o r b e r DA. Rosenberg ES. Theedentulous ridge in fixed prostho-dontios. Compend Cont in EducDent 1981:2:212-210,

12, Abrams L, Augmenta t ion of thedetormed residual edentulous ridgetor fixed prosthesis, C o m p e n dContin Eduo Dent 1980;l :205-209,

13. Seibert J, Reconstruct ion afdeformed part idl ly edentulousridges, using full-thickness onlaygrafts. Part I. Technique and woundhealing, Compend Contin EduoDent 1983;4:437-453.

14. Seibert J, Reconstruction of de-formed partially edentulous ridges,using full-thickness onlay grafts. PartII. Prosthetic/periodontal interrela-tionships. Compend Contin EducDent 1983:4:549-554,

15. Dzierzak J, Achieving optimal perio-esthetio results: The teom ap-proach. J Am Dent Assoc 1992:123(5);41-48.

1Ó. Boucher CD. Swenson's CompleteDentures. Saint Louis, MO: Mosby,1970:196-202.

17. Wheeler RC. An Atlos of Tooth Form.Philadelphia: Sounders. 1969:24.

18. Gillen RJ, Schwartz RS, Hilton TJ.Evons DB. An analysis of selectednormative tooth proportions, Int JProsthodont 1994;7:410-dl7,

19. Longer B. Calango LThe subepithe-lial oonnect ive tissue grott , JProsthet Dent 1980:44:363-367.

20. Langer B, Longer L. Subepithelialconnective tissue graft techniquefor root coverage. J Penodontol1985:56.715-720.

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