The Beauty in periodontal plastic surgery

PERIO FOR THOUGHT - November 05, 2020

I could never have refused the invitation to write an article for this issue of the Periocampus Herald: as an aspiring academic and as an active member of SidP I totally recognized myself in his initial presentation by Filippo Graziani, full professor of periodontology and Past President of the EFP, of the first issue of the Herald.

I too hated dentistry. I also chose it because it was written in my family's DNA. In the end, I too became passionate about my work and I wouldn't change it for the world. But what am I passionate about? And above all why did I choose mucogingival surgery?

Surely because those who taught it to me passed on the passion. And he gave me the passion to teach it. As Socrates says: "the mediocre teacher tells, the good teacher explains. The excellent teacher demonstrates. The master inspires ”. I was inspired. And I want to inspire in turn. The term inspiration describes a particular state of mind, of feeling, which pushes an individual to give life to a work and is perfectly associated with mucogingival surgery. Yes, because after all, mucogingival surgery has the aim, like art, of creating "beauty".

The term periodontal plastic surgery, which replaced that of mucogingival surgery, emphasizes the electivity of this type of procedure. These are not surgical procedures aimed at eliminating a disease such as traditional periodontal surgery, or aimed at restoring functionality such as implant surgery. It is a surgery that is performed mainly for the treatment of a blemish. We can argue that the non-acceptance of one's own aesthetics may represent psychological suffering comparable to a physical illness, but this is not the point I want to dwell on. I like to think that plastic surgery has the "only" cosmetic goal, because this concept gives rise to the challenge inherent in this type of treatment: the obligation to achieve aesthetic success.

What does it mean to evaluate aesthetics? Is it possible to objectify it?

In 2009 the Root Coverage Esthetic Score (RES) was proposed for the objective evaluation of the result obtained following treatments to cover single gingival recessions. The index takes into account 5 clinical variables: the final position of the gingival margin, the shape / contour of the gum margin, the texture of the soft tissues, the position of the mucogingival line and the color of the soft tissues. Each variable is assigned a numerical value and the maximum score obtainable is 10.

The parameter that has the greatest impact in numerical terms on the total result is that relating to the final position of the gingival margin (6 points out of 10). This aspect is of fundamental importance as it underlines the need to achieve complete root coverage (CRC) to ensure a successful outcome. The literature always reports the percentage of root coverage obtained in the patient sample under examination, but from a clinical point of view, in my opinion, this parameter is not significant if the main outcome is aesthetic success. Let's take a concrete example that helps us to clarify this aspect: an 8 mm recession, which causes an aesthetic problem to the patient because it exposes during the smile the millimeter of root (more yellowish in color than the enamel) more coronal. 90% root coverage is achieved following plastic surgery. An excellent result and absolutely in line with the data of the literature, but unfortunately not sufficient to solve the aesthetic problem of the patient who continues to expose exactly the same millimeter that she exposed before surgery. This example brings out another aspect that must always be taken into consideration when performing cosmetic therapies: the subjective evaluation of the result by the patient. The final judgment of the patient, inseparable from his emotional background and from the perception of himself, and the objective evaluation of the periodontist, linked instead to more technical-surgical aspects, should ideally match to define a successful treatment in a complete way.

Recessioni gengivali multiple (a) trattate con lembo a busta spostato coronalmente (b) e applicazione sito specifica dell’innesto sul 16 (c). La guarigione a 1 anno (d) mostra copertura completa, assenza di cicatrici/cheloidi e armonia di texture e colore dell’area trattata.
Multiple gingival recessions (a) treated with coronally displaced envelope flap (b) and site-specific application of the graft on 16 (c). Healing at 1 year (d) shows complete coverage, absence of scars / keloids and harmony of texture and color of the treated area.

How to obtain an optimal aesthetic result?

Ideally, the technique that guarantees to obtain the best aesthetic result is that of the coronally displaced flap (CAF) in which the apical soft tissue at root exposure is used for root coverage. In particular, it is indicated in patients with high aesthetic demands in its envelope variant which guarantees optimal tissue trophism since the vascular supply to the marginal portion of the flap is not interrupted with release incisions. This is of fundamental importance in root covering techniques where the survival of the flap on the avascular root surfaces largely depends on the blood supply from the flap pedicle. However, from a clinical point of view, a height (1 mm) and a minimum thickness of keratinized tissue (0.8 mm) are necessary to ensure marginal stability to the coronally displaced surgical flap. In the absence of these characteristics it is necessary to add a connective graft. The connective tissue, made up of dense collagen tissue, will help the flap remain stable in its final potion and will increase the thickness of the soft tissues, reducing the risk of recurrence over time. On the other hand, in the event of early contraction of the cover flap, exposure of the graft may occur which will show itself as an unsightly keloid, significantly affecting the final result. The site-specific use of the graft, in particular in the treatment of multiple recessions, represents one of the main advantages of CAF compared to other root coverage techniques (e.g. tunnel) allowing to change the tissue phenotype only where necessary and significantly reducing the patient's morbidity. The clinician's experience plays a fundamental role in the subtle balance of the choice between CAF alone and CAF + CTG.

The secret of success to obtain an optimal aesthetic result in periodontal plastic surgery able to satisfy the expectations of the patient and the periodontist is knowing how to dose a lot of knowledge, a good dose of surgical skills and a pinch of passion for beauty.

Literature and suggested reads:

Mounssif I., Stefanini., Mazzotti C., Marzadori M., Sangiorgi M., Zucchelli G. (2018) Esthetic evaluation and patient-centered outcomes in root-coverage procedures. Periodontol 2000 (77) 19–53.

Chambrone L, Salinas Ortega MA, Sukekava F,Rotundo R ., Kalemaj Z., Buti J., Pini Prato G.P.(2018) Root coverage procedures for treating localised and multiple recession-type defects. Cochrane Database Syst Rev.;10(10):CD007161.

Stefanini M., Zucchelli G., Marzadori M., de Sanctis M. (2018) Coronally Advanced Flap with Site-Specific Application of Connective Tissue Graft for the Treatment of Multiple Adjacent Gingival Recessions: A 3-Year Follow-Up Case Series. Int J Periodontics Restorative Dent.38(1):25-33. doi:10.11607/prd.3438

Zucchelli G, De Sanctis M.(2000) Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol. 71(9):1506-14.

Stefanini M., Marzadori M., Aroca S., Felice P., Sangiorgi M., Zucchelli G.( 2018) Decision making in root-coverage procedures for the esthetic outcome. Periodontol 2000 (77) 54–64

Cairo F, Rotundo R, Miller PD, Pini Prato GP. Root coverage esthetic score: a system to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases. J Periodontol 2009: 80: 705–710.