Perio-Esthetics

CONTENT

Root coverage procedures

Gummy Smile

Lip repositioning

Papilla reconstruction

Gingival depigmentation
 NORMAL SMILE
• Essentials of a smile

The teeth

1.Colour
2. Size &
Lip frame work Silhouette
3. Position
4. Incisal plane
The gingival scaffold
 THE LIPS
• Define aesthetic zone
• Classification of Liplines (Tjan et al.)
Low (20%) Average (70%)
High (10%)

• Geometry of harmony
THE GINGIVAL SCAFFOLDS

1. Health
2. Harmony and
continuity of form
3. Symmetry central
incisors
4. Balance to laterals,
cuspids and premolars
Gummy Smile
Diagnosis and Rx
 GUMMY SMILE
• Excessive exposure of the maxillary gingiva during smiling

• Etiology:
1. altered passive eruption,
2. anterior dento-alveolar extrusion
3. vertical maxillary excess,
4. short or hyperactive upper lip,
5. combination of these factors.
 THE GUMMY SMILE-
1. Altered Passive Eruption (APE)
• Classification of APE by Coslet et al. (1977) based on
amount of gingiva:
• Type- I: Wide band of keratinized gingiva

• Type- II: Narrow to normal band of keratinized gingiva

• Type- I is subdivided based on the relationship of 1 2 3 4

alveolar crest to the CEJ.

• Type- IA: distance between crest and CEJ is more than 1.5
mm
• Type- IB: when the alveolar crest is at the level of CEJ
Type IA- APE Treatment
Type IB- APE Treatment
 Treatment Options for APE

Condition Treatment

APE type IA Gingivectomy

Apically displaced flap with

APE type IB
osseous resection

Apically displaced flap with or

APE type II
without ossous resection
 Gummy Smile-
2. Vertical Maxillary Excess
 Gummy Smile:
3. Hyperactive Upper Lip
• The average length of the maxillary lip:
• 20‑22 mm in young adult females and
• 22‑24 mm in young adult males.

• According to Garber and Salama the normal shift of the upper lip
during smiling is 6 to 8 mm and is increased by 1.5 to 2 times in
cases of hyperactivity of the upper lip.
 Rx modalities
• botulinum toxin injection,
• Lip repositioning
• lip elongation associated with rhinoplasty,
• detachment of lip muscles, and
• mayectomy of lip

• Lip-repositioning surgery aims to limit the retraction of the elevator

smile muscles.
 Lip repositioning
(Rubinstein and Kostianovsky) 1973
 Modifications

• Litton and Fournier (1979) modified it by separating the muscles from the basal
bony structures to coronally place the upper lip.

• Miskinyar (1983) using a more aggressive approach which included myectomy

and a partial resection of the muscle‑ levator labii superioris along with nerve
repositioning before muscle resection.

• Ribeiro et al. maxillary labial fraenum was preserved to maintain the midline
and reduce post-op morbidity
Papilla Reconstruction
Diagnosis and Rx
 LOSS OF PAPILLA
(Black Triangle)
Etiology:
1. Loss of Periodontal support due to
plaque associated periodontal
diseases.
2. High frenal pull
3. Abnormal tooth shape
4. Improper prosthetic contour
5. Traumatic oral hygiene procedure
 Classification of Papillary Height
• Nordland and Tarnow (1998) based on three anatomic landmarks:
1. the interdental contact point,
2. the coronal extent of the proximal CEJ
3. the apical extent of the facial CEJ, and
• Tarnow et al. (1992) analyzed the correlation between the presence of
interproximal papillae and the vertical distance between the contact
point and the interproximal bone crest.
• When it was ≤5 mm- papilla was present almost 100%.
• When it was ≥6 mm only partial papilla fill of the embrasure.
 Rx Strategies

If the bone crest–contact Class 1 and 2 Surgical intervention

point distance is ≤5 mm
and the papilla height is
<4 mm

If the contact point is Class 3 methods to lengthen the

located >5 mm from the contact area apically
bone crest between the teeth
Orthodontic approach
 Surgical Techniques
1. Beagle (1992) described a pedicle graft procedure utilizing the soft tissues
palatal to the interdental area.
 Surgical Techniques
2. Han and Takei (1996) proposed an approach for papilla reconstruction
(“semilunar coronally repositioned papilla”) based on the use of a free connective
tissue graft
 Surgical Techniques
3. Azzi et al. (1999) described a technique in which an
envelope‐type flap is prepared for coverage of a connective
tissue graft
 Recent advancement
• Tissue engineering method by McQuire and Scheyer (JOP 2007)
• Autologus fibroblast injection
GINGIVAL DEPIGMENTATION
 Gingival Depigmentation
• A treatment to remove the melanin hyperpigmentation.
• Melanin is the physiologic pigment of the gingiva… but conditions
associated with hyper melanosis are:
• Smoking
• Drugs
• Albright syndrome
• Puetz- Jaghers syndrome
• Malignant melanoma
 Clinical assessment of pigmentation
• Dummett oral pigmentation index (DOPI): (1964)
• 0 = pink tissue (no clinical pigmentation);
• 1 = mild light brown tissue (mild clinical pigmentation);
• 2 = medium brown or mixed brown and pink tissue (moderate); or
• 3 = deep brown/ blue–black tissue (heavy clinical pigmentation).

• The Hedin melanin index: (1977)

• 0 = no pigmentation;
• 1 = one or two solitary units of pigmentation in the papillary gingiva;
• 2 = >3 units of pigmentation in the papillary gingiva without formation of a continuous
ribbon;
• 3 = >1 short continuous ribbons of pigmentation; or
• 4 = one continuous ribbon including the entire area between the canines.
 Methods of depigmentation
• Bur abrasion (mechanical)

• Chemicals- 90% Phenol and 95% alcohol (Hirschfield et al. 1955)

• Surgical scraping- still a Gold standard… (Hegde et al. 2013)

• Cryosurgery

• Electocauterization

• Free gingival graft

• Lasers ablation- Latest and reliable

SURGICAL SCRAPING
 Laser ablation
Co2 laser- epithelial peeling

Er:Yag laser- Brush stroke

 Conclusion

• Esthetic treatment of a smile line is often a multifaceted scenario where teeth,

periodontal tissues, and lip position interact.

• Disciplines of oral surgery, orthodontics, periodontics and restorative dentistry

all play a role in the treatment of excessive gingival display.

• Not enough scientific evidence concerning the predictability and long-term

stability of Perio-esthetic techniques.
 References:
1. D. A. Garber and M. A. Salama, “The aesthetic smile: diagnosis and treatment,”
Periodontology 2000, vol. 11, no. 1, pp. 18–28, 1996.
2. Rosenblatt A, Simon Z. Lip repositioning for reduction of excessive gingival
display: A clinical report. Int J Periodontics Restorative Dent 2006;26:433-437.
3. Simon Z, Rosenblatt A, Dorfmann W. Eliminating a gummy smile with surgical
lip repositioning. J Cosmet Dent 2007;23:100-108.
4. Ribeiro-Junior NV, Campos TV, Rodrigues JG, Martins TM, Silva CO.
Treatment of excessive gingival display using a modified lip repositioning
technique. Int J Periodontics Restorative Dent 2013;33:309-314.
5. Seixas MR, Costa-Pinto RA, Araújo TM. Gingival esthetics: An orthodontic and
periodontal approach. Dental Press J Orthod. 2012 Sept- Oct;17(5):190-201.
6. Hegde et al. Comparison of Surgical Stripping; Erbium-Doped:Yttrium,
Aluminum, and Garnet Laser; and Carbon Dioxide Laser Techniques for
Gingival Depigmentation: A Clinical and Histologic Study. J Periodontol
2013;84:738-748.
7. Foley et al. in Orthodontic Treatment —The Management of Excessive Gingival
Display. J Can Dent Assoc 2003; 69(6):368–72.
8. Allen EP. Surgical crown lengthening for function and esthetics. Dent Clin
North Am 1993; 37(2):163–79.
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