PerIodoNtics2 INSIDE DENTISTRY—MARCH 2007

In the contemporary reconstructive,cosmetic, or surgical dental practice, pa-tients requesting cosmetic enhancement oftheir dentition have a much higher aware-ness of procedures that are available tothem to correct/enhance their current den-tal health state. The replacement of old,ill-fitting restorations is commonplacein the modern practice, and the ability tomanage any situation that may present it-self has never been more demanding tothe profession than now.

Esthetic enhancement of the existingdentition often requires alteration to theexisting free gingival margin of the tooth/teeth to be treated. Crown-lengtheningprocedures are often used to balance gin-gival margins and to provide a symmetri-cal appearance of the gingival complexprior to veneers or full-coverage restora-tions being placed. This process is usual-ly required when an excessive amount ofkeratinized gingival tissue is present, orwhen preexisting restorations are pres-ent and a biologic width invasion exists.

In the latter case, repositioning of thealveolar crest is usually required, along withapical repositioning of the free gingivalmargin of the gingival tissues present. Toallow for adequate maturation of the newgingival complex, 2 to 3 months of healingis usually required before manipulationby the restorative clinician with routinecosmetic dental procedures.

Correction of the free gingival marginalso may require the addition of soft tissuegrafting for root coverage, free gingivalgrafting to increase the zone of keratin-ized tissue, sliding pedicle grafts for rootcoverage, and/or coronal repositioningof the free gingival margin. These proce-dures have been well documented in thedental literature.1-8 Sources of additionaltissue are donor tissue from the palate,

collagen membranes, or acellular dermalmatrix grafts. The use of these productsalso has been well documented in the den-tal literature.9-13

A particular dilemma that presents it-self is the lack of keratinized tissue faciallyin the presence of a preexisting restora-tion, where the facial margin of the prep-aration is too far apically positioned. Thisusually results in a lack of symmetry of theheights of contour of the existing gingi-val complex. The solution here is to length-en the adjacent natural teeth to matchthe tooth/teeth in question, which maylead to excessive length of the teeth, ororthodontic extrusion to bring the mar-gin of the preparation more coronally.

This article will outline a new approachto the correction of discrepancies in the fa-cial heights of contour of adjacent teethin the esthetic zone (due to a pre-existingrestoration resulting in a biologic widthinvasion) using a combination of the afore-mentioned procedures, and demonstrat-ing a new product to increase the thicknessof gum tissue around natural teeth and/or dental implants.

CASE PRESENTATIONA 27-year-old non-smoking man presen-ted for the esthetic enhancement of hisleft central incisor, which had a preexist-ing, full-coverage restoration that requir-ed replacement (Figure 1). The patient hadbegun orthodontic treatment in the man-dibular arch to correct a minor occlusalimbalance and required coronal reposi-tioning and soft tissue grafting to correctgingival recession at the facial of the rightcanine, in addition to correction of thefree gingival margin at the facial of theleft central incisor, which was asymmet-rical to the free gingival margin of toothNo. 8. Additionally, the facial gingival

tissues were of a thin biotype, which atthe facial surface of the left central inci-sor allowed for the darkened root surfaceto be seen through the tissue (Figure 2).

The treatment plan was to accomplishan increased zone of keratinized tissue attooth No. 6 and increase the thickness ofthe facial tissue around tooth No. 9, in ad-dition to coronally repositioning the freegingival margin. Complicating this treat-ment plan was the fact that at the facialof tooth No. 9 a biologic width invasionwas present, which was a result of the pre-pared margin for the pre-existing restor-ation being placed too close to the facialalveolar crest of bone. (The patient pre-sented to the periodontist with a provi-sional restoration in place). Any correctionto the area would require movement ofthe facial margin of the tooth in a coro-nal fashion to re-establish the appropri-ate distance from the facial height of boneto the margin of the restoration. Addi-tionally, options were given to the patientfor harvesting of the soft tissue, using con-nective tissue from the palate, or the useof an acellular dermal matrix graft, whichwould nullify harvesting tissue from thepalate region.

The patient opted for the use of the acel-lular dermal matrix material for the pro-cedure, along with platelet-rich plasma(PRP) enhancement to aid in the re-vas-cularization of the graft. The tissue sel-ected for the augmentation procedure atteeth No. 6 and No. 9 was a dermal graft(Puros® Dermis Allograft Tissue Matrix[Zimmer Dental, Carlsbad, CA]) that wasprepared by the Tutoplast® process (Tuto-gen Medical, Alcoa, FL).

Puros Dermis Allograft Tissue Matrixis recovered following the rigorous stan-dards of both the Food and Drug Admin-istration and the American Association

of Tissue Banks (AATB) with either a scal-pel or dermatome from the back of thethighs of the donor. The tissue is recov-ered within 24 hours of death using anaseptic process by a recovery team thatmeets the standards set by AATB. Thetissue does not enter the Tutoplast processuntil it passes serologic tests (eg, HIV,hepatitis, human t-lymphotrophic virus,and syphilis). The Tutoplast process is amulti-step process that:14

• removes all antigenicity• inactivates all kinds of pathogens• preserves tissue structure and collagen• preserves biomechanics • guarantees sterility• results in graft healing comparable to

autografts

The process itself consists of:14

• donor selection• osmotic treatment• oxidative treatment• alkaline treatment—different from bone• solvent dehydration• low-dose gamma irradiation• full documentation

The Tutoplast process is fully validat-ed for biomechanics, virus inactivation, pri-on inactivation, antigenicity, and healing.The Puros Dermis Tissue allograft has astrength-to-failure measurement of 5pounds ± 0.8 and can be stored at roomtemperature, has a 5-year shelf life, and,because of the Tutoplast process, has noresidual chemicals as it is packed anddelivered to the clinician. Compared tothe dermal matrix available on the mar-ket, which has a failure measurement of4.5 pounds ± 1.1 and must be refrigerat-ed, has only a 2-year shelf life, and ispacked with a variety of residual antibi-otics, the Puros Dermis Tissue offers asuperior graft product to the clinician.

The enhancement with PRP has beenwell documented in the dental literature.PRP (autologous platelet gel) is developedfrom autologous blood with a cell sepa-rator.15-18 A 60-mL syringe is prefilled

Correction of Iatrogenic GingivalRecession in the Esthetic ZonePaul S. Petrungaro, DDS, MA

“Esthetic enhancement of the existing dentition oftenrequires alteration to the existing free gingival

margin of the tooth/teeth to be treated.”

insidePerIodoNtics

Figure 1 Preoperative facial view of the leftcentral incisor, centric occlusion.

Paul S. Petrungaro, DDS, MADirector

The Institute for Advanced Dental Education, Inc

Lake Elmo, Minnesota

Private Practice

Chicago, Illinois and Lake Elmo, Minnesota

Figure 2 Preoperative facial view.

with 5 mL of a citrate-based anticoagulant.For each 60-mL syringe, approximately 45mL to 55 mL of the patient’s blood is with-drawn from a venous puncture in the upperarm. The anticoagulated blood is dispensedinto the blood chamber of the process-ing disposable. The blood must be drawnbefore the commencement of surgery, be-cause surgery itself leads to platelet acti-vation of the coagulation system.

A processing disposable is loaded in-to the centrifuge rotor cup of the SmartPReP™ Platelet Concentrate System (Har-vest Technologies Corporation, Munich,Germany). A counterbalance is then placedin the opposing rotor cup unless a sec-ond processing disposable is required.During processing, the blood is initiallycentrifuged at 3,650 rpm to separate thered blood cells from the plasma. Thecentrifuge then slows to approximately60 rpm, allowing the plasma to automat-ically decant into the plasma chamber.The centrifuge then accelerates to 3,000rpm to form a pellet of pure plasma con-centrate in the bottom of the plasma cham-ber. The entire process of separating thewhole blood into red blood cells, platelet-poor plasma (PPP), and platelet concen-trate is completely automatic and com-pleted in approximately 12 minutes.

The blood chamber of the processdisposable contains red blood cells. Thesecond chamber contains the platelet con-centrate (a button-like precipitate) andPPP (supernatant). Approximately twothirds of the PPP are removed and canbe saved for hemostatic applications. Theplatelet concentrate is then resuspendedin the remaining PPP, thereby creating avery concentrated PRP solution.

The activator for the PRP and PPP isa mixture of 5,000 units of topical bo-vine thrombin and 5 mL of 10% calciumchloride. The activator is drawn into two1-mL syringes and 10 mL of PRP is thendrawn into one syringe and 10 mL of PPPis drawn into the other syringe. The twosyringes are attached to a 20-guage dualcannula applicator tip where the con-tents are mixed as they are applied into/onto the bone graft, wound, connectivetissue graft, or incisions.

The following growth factors are foundin PRP: platelet-derived growth factor;transforming growth factor-beta; plate-let-derived endothelial cell growth fac-tor; platelet-derived angiogenesis factor;insulin-like growth factor; and vascularendothelial growth factor.15,16

After administration of an appropri-ate local anesthetic, correction of the gin-gival tissue at the facial of tooth No. 6was accomplished in a fashion consistentwith the soft tissue grafting techniquethat will be described below.

After removal of the provisional restor-ation (Figure 3), further examination ofthe prepared facial margin was made.

Sounding measurements were obtained,and demonstrated a distance from thefree gingival margin to the crest of boneat the mesial-facial point to be 2 mm, atthe mid-facial point to be 2.5 mm, and atthe distal-facial point to be 3 mm. Nor-mally, crown lengthening could managethis problem; however, because of theesthetic and periodontal requirements ofthe esthetic dentist, and the esthetic de-sires of the patient, the existing margin ofthe tooth preparation needed to be mov-ed in a more coronal fashion. The proce-dure required moving the facial marginof the tooth preparation coronally by rootplaning the existing margin off, and re-preparing a new facial margin 1 mm morecoronally, followed by Puros Dermis graft-ing to increase the zone of tissue thickness,in addition to coronally repositioning thefacial gingival margin.

Before incision, the trimmed Puros Der-mis was rehydrated in the PRP solutionpreviously obtained (Figure 4). A broad-based, papillary spacing incision was madeat the facial of tooth No. 9 (Figure 5), fol-lowed by full-thickness, mucoperiostealflap elevation. The facial root surface of

the tooth exhibited notches and an un-even root surface.After extensive root plan-ing of the facial root surface with handroot planing and rotary instrumentationto eliminate not only the notched root sur-face but also to eliminate the pre-existingfacial tooth preparation margin, a newchamfer margin was prepared in thetooth 1 mm from the pre-existing mar-gin (Figure 6). This was followed by appli-cation of a citric acid solution (pH 1) overthe facial root surface for 1 minute to aidin sterilization of the root surface. Ad-justment to the facial aspect of the preex-isting provisional restoration by shorteningthe facial margin by 1 mm was accom-plished, and the provisional restorationwas cemented with temporary cement(Figure 7).

The outline of the pre-existing facialmargin can be seen in Figure 7, approxi-mately 0.75 mm from the facial aspect ofthe temporary restoration. Also note thesymmetry between the facial aspect ofthe clinical crown on tooth No. 8, andprovisional restoration of tooth No. 9.Preceding fixation of the Puros Dermis,application of PRP was performed (Figure

INSIDE DENTISTRY—MARCH 2007 3

Figure 3 Preoperative facial view of the toothpreparation.

Figure 4 PRP-activated Puros Dermis AllograftTissue Matrix.

Figure 5 A broad-based, papillary spacing incisionwas made at the facial of the left central incisor.

Figure 6 A new chamfer margin was preparedin the tooth 1 mm from the pre-existing margin.

Figure 7 Adjusted margins on the provisionalrestoration.

Figure 8 Platelet Rich Plasma application. Figure 9 Puros Dermis Allograft Tissue Matrixsecured to root surface.

Figure 10 Closure was accomplished with 4.0Vicryl Rapide sutures using a horizontal mattressand continuous sling suturing method.

PerIodoNtics

Figure 12 10-day postoperative view. Figure 11 Additional application of PRP over thesurgical site served as a bioactive wound dressing.

Figure 13 30-day postoperative view.

PerIodoNtics8). The PRP-enhanced Puros Dermis wasthen placed over the root surface (Figure9) and secured with 4.0 Vicryl Rapide(Ethicon, Inc, Somerville, NJ) in a slingfashion around tooth No. 9. Additionalapplication of PRP preceded a tension-free flap closure, totally covering the Pu-ros Dermis with the pre-existing facialgingival tissues. Closure was accomplishedwith 4.0 Vicryl Rapide sutures using ahorizontal mattress and continuous slingsuturing method (Figure 10). Note thecoronal repositioning of the facial gingi-val margin. Additional application of PRPover the surgical site served as a bioactivewound dressing (Figure 11).

The 10-day postoperative view can beseen in Figure 12. Note the level of softtissue healing at this early time frame. A30-day postoperative view can be seen inFigure 13. A comparison with Figure 2demonstrates the new facial gingival mar-gin, the thickness in biotype of tissue ob-tained, and the excellent color/tissue matchobtained. A dermabrasion procedure willbe necessary at the distal papillary tissueto remove the ledge of tissue before therestorative clinician proceeds with thenew, full porcelain restoration at toothNo. 9, after an additional 30 days of heal-ing and maturation.

CONCLUSIONThe blending together of multiple proce-dures to achieve a desired result is oftenrequired with the contemporary recon-structive and surgical dental practice.The use of various allogenic materials inthe surgical dental practice can allow thepatient to undergo more advanced graft-ing procedures without the necessity ofharvesting tissue from a donor site. ThePuros Dermis Allograft Tissue Matrixhas been clinically observed by the au-thor to provide excellent soft tissue inte-gration and tissue color matching whenused as a soft tissue graft to increase theheight and width of the zone of keratin-ized tissue. Additional controlled clinicalstudies and evaluations are necessary todetermine the value of this material.

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4 INSIDE DENTISTRY—MARCH 2007