1
Maynard and Ochsenbien have postulated that the best solution to this problem is to initiate treatment at its earliest stage of development, during the mixed dentition, in order to avoid the more advanced gingival recession seen in the adult (Fig. 2). They feel that mucogingival problems in the permanent dentition are a developmental problem. They reasoned that the apico-coronal dimensions of keratinized tissue is af fected by two factors: (1) the eruption patterns of permanent incisors and (2) the labio-lingual width of the alveolar process. If a tooth erupts in labioversion, (Fig. 5a) usually a minimal amount of keratinized tissue is seen. Whereas, if the tooth erupts in linguoversion there is usually a wide dimension of both bone and gingiva on the labial aspect. In this instance the gingival margin usually will be more coronal on the facial aspect of the tooth in linguoversion as compared to the tooth in labio version. Maynard and Ochsenbien also explained that occasionally the labiolingual dimen sion of the alveolar process and gingiva is only slightly larger than the labiolingual dimension of the tooth. This they feel will lead to insufficient width of bone and gingiva after the tooth has erupted (Fig. 2). These authors have further postulated that if there is 1 mm or less of keratinized tissue, then a procedure (prefer ably a free soft tissue autograft) should be done to increase this dimension.The work of Lang and Löe gives justification to the necessity of this procedure. They found that gingival inflammation persists in areas where there is less than 1 mm of attached gingiva in spite of effective plaque control.
Mucogingival Considerations and Their Relationship to Orthodontics by ROBERT L . BOYD* C L I N I C A L information concerned with the treatment of gingival recession in children has empha sized the initiation of therapy in these areas as soon as they are recognized in the mixed dentition. The ra tionale behind this approach is "mucogingival problems that have been observed developing in the mixed denti tion stage of eruption could result in the more advanced denuded labial root problems seen in the adult." The effect of orthodontic therapy has been suggested to be detrimental to the repair of these areas of gingival recession if performed before the mucogingival proce dure. This has led to the recommendation that the mucogingival procedure be performed prior to tooth movement. This paper will review and discuss the indications and timing of mucogingival therapy with respect to orthodontic intervention. The suggestion is made that orthodontic therapy may actually improve or even eliminate gingival recession under certain conditions if coordinated with certain anatomic and biomechanical principles. Documented case reports will be used to illustrate specific conditions and principles. RECENT
1
1
17
Influence of Malocclusion on Mucogingival Treatment Priorities The question of how orthodontic therapy affects the mucogingival relationship, in the view of this author, is related to the preoperative position of the involved tooth. Specifically, there are three instances where the tooth in question should be evaluated orthodontically prior to any mucogingival procedure: 1) When the area of mucogingival involvement is related to a shearing effect of one tooth with another. Figure 3 shows a mucogingival problem related to the incisal edge of the upper tooth mechanically stripping away the gingiva from the facial surface of the lower incisor with which it occludes. It will be necessary to open the bite orthodontically and change the interincisal angle prior to any treatment directed at correcting the mucogingival problem. Another example would be in a buccal crossbite(s) of posterior teeth where the cusp tip of the offending tooth lies against the gingival margin of the opposing tooth and is free to erupt further and thereby strip the gingival tissue away from the facial surface of the opposing tooth. 2) When the involved incisor may be selected for extraction. Occasionally a tooth size discrepancy prob-
R E V I E W OF T H E LITERATURE 2-15
Numerous reports in the last 2 decades have been concerned with new attachment procedures de signed to cover denuded roots. It has been proposed that frequently the means of attachment in these areas is a long epithelial type. This attachment is not considered to be as resistant to the initiation of peri odontal disease as a connective tissue type attach ment. Several authors have tried to classify the topography of the defects with regard to their widths and lengths and to correlate these with the prognosis for new attachment. These studies indicate that only the narrow type defects are amenable to reattachment at a more coronal level. Unfortunately, these narrow de fects are the least common type. The main conclu sion that can be drawn from these studies is that covering denuded roots is unpredictable at best (Fig. 13-15
16
11-12
11-12
i). * Department of Orthodontics, College of Dentistry, Box J-444, J H M Health Center, University of Florida, Gainesville, Fla.
67
68
Boyd
J. Periodontal. February, 1978
FIGURE 1 A . Thisfigureshows a patient who exhibits gingival recession on both lower central incisors. No labial prominence or malocclusion is present. B . Photograph of the case 1 ½ years after a free soft tissue autograft was placed. Reattachment at a more incisal level was achieved on only one of the teeth in spite of their similar preoperative position and appearance. The incisal edges were shortened for esthetics.
lem (Bolton's Analysis discrepancy) requires the treat ment plan of choice to be removal of one or more lower incisors. Figure 4 shows a patient with a mucogingival problem on a lower central incisor. If only the periodontist evaluates this area he may overlook the possibility that the orthodontist may prefer to remove this incisor as the best way to manage the orthodontic treatment. The periodontist should offer a prognosis of repair of a mucogingival problem area and, if the
prognosis is poor, this may alter the orthodontist's treatment plan in favor of lower incisor extractions, rather than nonextraction or bicuspid extractions (Figs. 4, 5, and 6). 3) In those areas where a tooth exhibits a mucogin gival problem and is in labioversion, consultation with an orthodontist to determine if it is feasible to move the tooth lingually is advised. If the tooth is to be moved back onto the ridge, then it would be better to wait
Volume 49 Number 2
until after tooth movement to decide whether a muco gingival procedure would still be necessary. As can be seen from Figures 7 and 8, there is a marked improve ment in the mucogingival defects after tooth movement has occurred. The preoperative probing from the cemento-enamel junction to the deepest portion of the defect (Fig. 7) was 5½ mm. After othodontic therapy, the defect probed only 2½ mm. In Figure 8, the defect probed 3 mm initially and after tooth movement
Mucogingival Considerations 69 the area probed only 1½ mm to the cemento-enamel junction. In both subjects, the width of the defect has decreased, a phenomenon which has been shown by several authors, to offer a better prognosis for repair. In addition, the gingival inflammation also has decreased as evidenced by color and consistency changes. Instructions concerning oral physiotherapy given to these patients were to use a soft-bristled toothbrush in the Modified Bass Technique. However, 11,12
FIGURE 2 A. A 9½-year-old boy who has no attached gingiva on the labial aspect of the lower central incisors. These teeth are not in labioversion and no orthodontic therapy is anticipated. B . The same area 2 years after a free soft tissue autograft was placed. An adequate zone of attached gingiva now exists which may act as a buffer zone to resist displacement of the gingival margin from muscle pull.
70 Boyd
J. Periodontal. February, 1978
F I G U R E 3 A . A set of preoperative orthodontic models exhibiting an incisor relationship in which during maximum intercuspation, the incisal edge of the upper right central incisor is shearing away the labial attachment of the lower right central incisor causing the loss of attachment seen in Figure 3B. C . This figure shows the same patient after the bite was orthodontically opened and a free sof tissue autograft was placed. Probing indicates reattachment has occurred to the cemento-enamel junction and there is now an adequate band of attached gingiva present.
Volume 49 Number 2
Mucogingival Considerations 71
4 A . A 9½-year-old boy who exhibits 3 mm of gingival recession and an inadequate zone of attached gingiva on the lower left incisor. B . The same patient 5 months after the tooth has been removed. Full banded orthodontics will be performed to gain more favorable alignment.
FIGURE
no periodontal therapy other than an initial prophylaxis with a rotating rubber cup, prior to banding, was performed. These data support the observations of others, that by moving a labially-positioned tooth back onto the ridge, the factors which had predisposed the mucogingival area to breakdown have been removed, thereby allowing a reversal in the pathogenesis of the lesion. These factors include: (a) 12,18-19
trauma due to toothbrushing on an area that is quite prominent, (b) very thin, soft tissue and bone overlying the tooth, (c) a more apical level of the free gingival margin on the involved tooth (see Fig. 8). The latter is thought to be due to the tooth not being able to erupt to the same height as the other incisors because of crowding. Such areas are problematical because when the other teeth are being brushed, the bristles will not
72 Boyd
J. Periodontal. February, 1978
FIGURE 5 A . Another patient in which there is a severe amount of gingival recession associated with a lower left central incisor which is in labioversion. As can be noted, both the crown and most of the root are in labioversion. Repair of the mucogingival problem was considered to have a poor prognosis. An orthodontic evaluation surmised that the case could be managed with a lower incisor extraction and fixed appliances. B . This figure shows the case at debanding.
be contacting the more apical level of the gingival margin of the tooth in labioversion, (d) any rotation of the teeth places the line angle of the tooth in relative prominence toward the labial rather than the more flat facial surface. Evidence of this can be seen in the greater portion of the recession seen on the more labial line angle of the left central incisor shown in
Figure 7. In Figures 7 and 8 a free gingival graft was necessary to provide for complete repair of the lesion. The postoperative probing, 6 months after the graft was placed, indicated less than 1 mm distance from the cemento-enamel junction to the depth of the sulcus in both cases. Also, it is noted that an adequate band of
Volume 49 Number 2
73 Mucogingival Considerations
attached gingiva is now present in both areas. According to Buchin, it may be necessary to apply forces which will move bodily the involved tooth in these instances so that the root apex also will be moved lingually as well as the crown (see Fig. 5a). This would be necessary if the root portion of the involved tooth was significantly labial to the adjacent teeth, for, if the tooth crown is merely tipped lingually, the apex will actually move labially, and the mucogin gival problem would probably worsen. 18
CONCLUSIONS
1. Where mucogingival problems exist in the mixed dentition with no malposition of the involved teeth, surgical procedures designed to eliminate the problem should be performed as soon as possible to prevent further breakdown. 2. If a malocclusion exists, consultation with an orthodontist would be advisable to find out what type of tooth movement and extractions can be anticipated. If a mucogingival problem exists coincidentally with a
FIGURE 6 A . Patient similar to Figure 5 with a lower left central incisor in labioversion and a severe mucogingival defect present. B . This figure shows the patient 1 year after orthodontics was completed.
74 Boyd
J. Periodontol. February, 1978
FIGURE 7 A . Thisfigureshows a mucogingival defect on the labial surface of a lower left central incisor. B . The same patient after 7 months of orthodontic therapy to retract the lower incisors back onto basal bone. C. The same patient 6 months after a free sof tissue autograft.
Volume 49 Number 2
75 Mucogingival Considerations
FIGURE 8 A . Photograph of a problem similar to that shown in figure 7. B . Patient after 8 months of orthodontics. C. Patient 3 months after a graft was placed.
76
J. Periodontol. February, 1978
Boyd
tooth in labioversion and the orthodontic treatment plan includes positioning the tooth lingually over basal bone, then it would be advisable to perform the orthodontic therapy first. The mucogingival situation should be reevaluated after the orthodontic therapy has been completed to decide whether any additional treatment is indicated. NOTE
ADDED
IN P R O O F
After this manuscript was submitted, H . S. Dorfman reported that "a decrease or increase in the width of keratinized gingiva can be significantly cor related with labial or lingual mandibular incisor tooth movement, respectively." The author came to this con clusion after studying cephalometric changes of the lower incisor position in 1150 patients and correlated this with changes in the width of gingiva on the facial aspect. 20
REFERENCES
1. M a y n a r d , G . , and Ochsenbien, C . : Mucogingival problems, prevalance and therapy in children. J Periodontol 46: 5 4 3 , 1 9 7 5 . 2. G r u p e , H . E . , and Warren, R . F . : Repair of gingival defects by a sliding flap operation. J Periodontol 27: 290, 1956. 3. R o b i n s o n , R . E . : Utilizing an edentulous area as a donor site in the lateral repositioned flap. Periodontics 2: 79, 1964. 4. C o r n , H . : Technique for repositioning the frenum in periodontal problems. Dent Clin North Am p 79, M a r c h , 1964. 5. Staffileno, H . : Management of gingival recession and
root exposure problems associated with periodontal disease. Dent Clin North Am p i l l , M a r c h , 1964. 6. C o r n , H . : Edentulous area pedicle grafts in mucogin gival surgery. Periodontics 2: 229, 1964. 7. A r i a u d o , A . : Problems in treating a denuded labial root surface of a lower incisor. J Periodontol 37: 276, 1966. 8. Pennel, B . M . , Higgason, J . D . , Towner, J . D . , K i n g , K . O . , Fritz, B . D . , and Sadler, J . F . : Oblique rotated f l a p . / . Periodontol 36: 305, 1965. 9. G r u p e , H . E . : Modified technique for the sliding flap operation. J Periodontol 37: 4 9 1 , 1966. 10. Rose, G . J . : Receding mandibular labial gingiva on children. Angle Orthod 37: 147, 1967. 11. Sullivan, H . D . , and A t k i n s , J . H . : Free autogenous gingival grafts, III. Utilization of grafts in the treatment of gingival recessions. Periodontics 6: 152, 1968. 12. M l i n e k , A . , Smukler, H . , and Buchner, A . : T h e use of free gingival grafts for the coverage of denuded roots. J
Periodontol 44: 249, 1973. 13. Levine, L . , and Stah S.: Repair following periodontal flap surgery with the retention of gingival fibers. J Periodon tol 43: 9 9 , 1 9 7 2 . 14. Wilderman, M . , and Wentz, F . : Repair of a dentogingival defect with a pedicle flap. J Periodontol 36: 218, 1965. 15. Sugarman, E . : A clinical and histological study of the attachment of grafted tissue to bone and teeth. J Periodontol 40: 381, 1969. 16. Ramfjord, S., and Nissle R . : T h e modified Widman flap. J Periodontol 45: 601, 1974. 17. L a n g , N . P . , and L o e , H . : T h e relationship between the width of keratinized gingiva and gingival health. J Perio dontol 43: 6 2 3 , 1 9 7 2 . 18. B u c h i n , Irving, Personal Communication. 19. Vanarsdall, Robert L . , Personal Communication. 20. D o r f m a n , H . S.: Evaluation of mucogingival changes resulting from mandibular incisor tooth movement. I . A . D . R . Abstract N o . 595, J Dent Res 56: B 2 0 0 , 1977.
Announcement T E M P L E UNIVERSITY S C H O O L O F DENTISTRY Temple University School of Dentistry announces the following Continuing Education course: TITLE: DATES: FACULTY:
Participation Course in Basic Periodontal Therapy (6 consecutive Wednesdays) March 15, 22, 29; April 5, 12, 19, 1978 D R . D . LITWACK, D R . I. A B R A M S and Staff, Department
of Periodontology, Temple University In addition to the introduction of startling new theories on periodontal regeneration, pocket control, and periodontal surgical procedures, there will be full day of lecture, lab, and practical application of occlusal principles. The doctor will treat a selected patient in initial therapy and basic surgery. TITLE:
Adult Tooth Movement
DATES:
April 6, 7, 1978
FACULTY:
D R . A L L A N SCHLOSSBERG, D . M . D . , M . S . Associate Pro
fessor, Department of Periodontology, Temple Univer sity School of Dentistry
Tooth movement is indicated for many adult patients as a part of their comprehensive dental treatment. The course will consist of lectures, demonstrations, and lab sessions. TITLE: DATES:
Clinical Periodontal Surgery May 16, 17, 19, 1978-the morning of the 18th is optional for those interested in observing surgery.
FACULTY:
D R . I. A B R A M S , D R . D . LITWACK, D R . A . SCHLOSSBERG,
D R . B . W A L L , Department of Periodontology, Temple University This course will describe many new advances in periodontal surgery as well as the surgical procedures now in practice, through lectures, closed circuit T V , and direct patient observation. Instru ments used and their care, a lab in sutures and the techniques along with other necessary information for successful periodontal surgery will be covered. For information contact: Continuing Education, Temple Univer sity School of Dentistry, 3223 N . Broad St., Philadelphia Pa 19140. (215) 221-2955
Maynard and Ochsenbien have postulated that the best solution to this problem is to initiate treatment at its earliest stage of development, during the mixed dentition, in order to avoid the more advanced gingival recession seen in the adult (Fig. 2). They feel that mucogingival problems in the permanent dentition are a developmental problem. They reasoned that the apico-coronal dimensions of keratinized tissue is af fected by two factors: (1) the eruption patterns of permanent incisors and (2) the labio-lingual width of the alveolar process. If a tooth erupts in labioversion, (Fig. 5a) usually a minimal amount of keratinized tissue is seen. Whereas, if the tooth erupts in linguoversion there is usually a wide dimension of both bone and gingiva on the labial aspect. In this instance the gingival margin usually will be more coronal on the facial aspect of the tooth in linguoversion as compared to the tooth in labio version. Maynard and Ochsenbien also explained that occasionally the labiolingual dimen sion of the alveolar process and gingiva is only slightly larger than the labiolingual dimension of the tooth. This they feel will lead to insufficient width of bone and gingiva after the tooth has erupted (Fig. 2). These authors have further postulated that if there is 1 mm or less of keratinized tissue, then a procedure (prefer ably a free soft tissue autograft) should be done to increase this dimension.The work of Lang and Löe gives justification to the necessity of this procedure. They found that gingival inflammation persists in areas where there is less than 1 mm of attached gingiva in spite of effective plaque control.
Mucogingival Considerations and Their Relationship to Orthodontics by ROBERT L . BOYD* C L I N I C A L information concerned with the treatment of gingival recession in children has empha sized the initiation of therapy in these areas as soon as they are recognized in the mixed dentition. The ra tionale behind this approach is "mucogingival problems that have been observed developing in the mixed denti tion stage of eruption could result in the more advanced denuded labial root problems seen in the adult." The effect of orthodontic therapy has been suggested to be detrimental to the repair of these areas of gingival recession if performed before the mucogingival proce dure. This has led to the recommendation that the mucogingival procedure be performed prior to tooth movement. This paper will review and discuss the indications and timing of mucogingival therapy with respect to orthodontic intervention. The suggestion is made that orthodontic therapy may actually improve or even eliminate gingival recession under certain conditions if coordinated with certain anatomic and biomechanical principles. Documented case reports will be used to illustrate specific conditions and principles. RECENT
1
1
17
Influence of Malocclusion on Mucogingival Treatment Priorities The question of how orthodontic therapy affects the mucogingival relationship, in the view of this author, is related to the preoperative position of the involved tooth. Specifically, there are three instances where the tooth in question should be evaluated orthodontically prior to any mucogingival procedure: 1) When the area of mucogingival involvement is related to a shearing effect of one tooth with another. Figure 3 shows a mucogingival problem related to the incisal edge of the upper tooth mechanically stripping away the gingiva from the facial surface of the lower incisor with which it occludes. It will be necessary to open the bite orthodontically and change the interincisal angle prior to any treatment directed at correcting the mucogingival problem. Another example would be in a buccal crossbite(s) of posterior teeth where the cusp tip of the offending tooth lies against the gingival margin of the opposing tooth and is free to erupt further and thereby strip the gingival tissue away from the facial surface of the opposing tooth. 2) When the involved incisor may be selected for extraction. Occasionally a tooth size discrepancy prob-
R E V I E W OF T H E LITERATURE 2-15
Numerous reports in the last 2 decades have been concerned with new attachment procedures de signed to cover denuded roots. It has been proposed that frequently the means of attachment in these areas is a long epithelial type. This attachment is not considered to be as resistant to the initiation of peri odontal disease as a connective tissue type attach ment. Several authors have tried to classify the topography of the defects with regard to their widths and lengths and to correlate these with the prognosis for new attachment. These studies indicate that only the narrow type defects are amenable to reattachment at a more coronal level. Unfortunately, these narrow de fects are the least common type. The main conclu sion that can be drawn from these studies is that covering denuded roots is unpredictable at best (Fig. 13-15
16
11-12
11-12
i). * Department of Orthodontics, College of Dentistry, Box J-444, J H M Health Center, University of Florida, Gainesville, Fla.
67
68
Boyd
J. Periodontal. February, 1978
FIGURE 1 A . Thisfigureshows a patient who exhibits gingival recession on both lower central incisors. No labial prominence or malocclusion is present. B . Photograph of the case 1 ½ years after a free soft tissue autograft was placed. Reattachment at a more incisal level was achieved on only one of the teeth in spite of their similar preoperative position and appearance. The incisal edges were shortened for esthetics.
lem (Bolton's Analysis discrepancy) requires the treat ment plan of choice to be removal of one or more lower incisors. Figure 4 shows a patient with a mucogingival problem on a lower central incisor. If only the periodontist evaluates this area he may overlook the possibility that the orthodontist may prefer to remove this incisor as the best way to manage the orthodontic treatment. The periodontist should offer a prognosis of repair of a mucogingival problem area and, if the
prognosis is poor, this may alter the orthodontist's treatment plan in favor of lower incisor extractions, rather than nonextraction or bicuspid extractions (Figs. 4, 5, and 6). 3) In those areas where a tooth exhibits a mucogin gival problem and is in labioversion, consultation with an orthodontist to determine if it is feasible to move the tooth lingually is advised. If the tooth is to be moved back onto the ridge, then it would be better to wait
Volume 49 Number 2
until after tooth movement to decide whether a muco gingival procedure would still be necessary. As can be seen from Figures 7 and 8, there is a marked improve ment in the mucogingival defects after tooth movement has occurred. The preoperative probing from the cemento-enamel junction to the deepest portion of the defect (Fig. 7) was 5½ mm. After othodontic therapy, the defect probed only 2½ mm. In Figure 8, the defect probed 3 mm initially and after tooth movement
Mucogingival Considerations 69 the area probed only 1½ mm to the cemento-enamel junction. In both subjects, the width of the defect has decreased, a phenomenon which has been shown by several authors, to offer a better prognosis for repair. In addition, the gingival inflammation also has decreased as evidenced by color and consistency changes. Instructions concerning oral physiotherapy given to these patients were to use a soft-bristled toothbrush in the Modified Bass Technique. However, 11,12
FIGURE 2 A. A 9½-year-old boy who has no attached gingiva on the labial aspect of the lower central incisors. These teeth are not in labioversion and no orthodontic therapy is anticipated. B . The same area 2 years after a free soft tissue autograft was placed. An adequate zone of attached gingiva now exists which may act as a buffer zone to resist displacement of the gingival margin from muscle pull.
70 Boyd
J. Periodontal. February, 1978
F I G U R E 3 A . A set of preoperative orthodontic models exhibiting an incisor relationship in which during maximum intercuspation, the incisal edge of the upper right central incisor is shearing away the labial attachment of the lower right central incisor causing the loss of attachment seen in Figure 3B. C . This figure shows the same patient after the bite was orthodontically opened and a free sof tissue autograft was placed. Probing indicates reattachment has occurred to the cemento-enamel junction and there is now an adequate band of attached gingiva present.
Volume 49 Number 2
Mucogingival Considerations 71
4 A . A 9½-year-old boy who exhibits 3 mm of gingival recession and an inadequate zone of attached gingiva on the lower left incisor. B . The same patient 5 months after the tooth has been removed. Full banded orthodontics will be performed to gain more favorable alignment.
FIGURE
no periodontal therapy other than an initial prophylaxis with a rotating rubber cup, prior to banding, was performed. These data support the observations of others, that by moving a labially-positioned tooth back onto the ridge, the factors which had predisposed the mucogingival area to breakdown have been removed, thereby allowing a reversal in the pathogenesis of the lesion. These factors include: (a) 12,18-19
trauma due to toothbrushing on an area that is quite prominent, (b) very thin, soft tissue and bone overlying the tooth, (c) a more apical level of the free gingival margin on the involved tooth (see Fig. 8). The latter is thought to be due to the tooth not being able to erupt to the same height as the other incisors because of crowding. Such areas are problematical because when the other teeth are being brushed, the bristles will not
72 Boyd
J. Periodontal. February, 1978
FIGURE 5 A . Another patient in which there is a severe amount of gingival recession associated with a lower left central incisor which is in labioversion. As can be noted, both the crown and most of the root are in labioversion. Repair of the mucogingival problem was considered to have a poor prognosis. An orthodontic evaluation surmised that the case could be managed with a lower incisor extraction and fixed appliances. B . This figure shows the case at debanding.
be contacting the more apical level of the gingival margin of the tooth in labioversion, (d) any rotation of the teeth places the line angle of the tooth in relative prominence toward the labial rather than the more flat facial surface. Evidence of this can be seen in the greater portion of the recession seen on the more labial line angle of the left central incisor shown in
Figure 7. In Figures 7 and 8 a free gingival graft was necessary to provide for complete repair of the lesion. The postoperative probing, 6 months after the graft was placed, indicated less than 1 mm distance from the cemento-enamel junction to the depth of the sulcus in both cases. Also, it is noted that an adequate band of
Volume 49 Number 2
73 Mucogingival Considerations
attached gingiva is now present in both areas. According to Buchin, it may be necessary to apply forces which will move bodily the involved tooth in these instances so that the root apex also will be moved lingually as well as the crown (see Fig. 5a). This would be necessary if the root portion of the involved tooth was significantly labial to the adjacent teeth, for, if the tooth crown is merely tipped lingually, the apex will actually move labially, and the mucogin gival problem would probably worsen. 18
CONCLUSIONS
1. Where mucogingival problems exist in the mixed dentition with no malposition of the involved teeth, surgical procedures designed to eliminate the problem should be performed as soon as possible to prevent further breakdown. 2. If a malocclusion exists, consultation with an orthodontist would be advisable to find out what type of tooth movement and extractions can be anticipated. If a mucogingival problem exists coincidentally with a
FIGURE 6 A . Patient similar to Figure 5 with a lower left central incisor in labioversion and a severe mucogingival defect present. B . This figure shows the patient 1 year after orthodontics was completed.
74 Boyd
J. Periodontol. February, 1978
FIGURE 7 A . Thisfigureshows a mucogingival defect on the labial surface of a lower left central incisor. B . The same patient after 7 months of orthodontic therapy to retract the lower incisors back onto basal bone. C. The same patient 6 months after a free sof tissue autograft.
Volume 49 Number 2
75 Mucogingival Considerations
FIGURE 8 A . Photograph of a problem similar to that shown in figure 7. B . Patient after 8 months of orthodontics. C. Patient 3 months after a graft was placed.
76
J. Periodontol. February, 1978
Boyd
tooth in labioversion and the orthodontic treatment plan includes positioning the tooth lingually over basal bone, then it would be advisable to perform the orthodontic therapy first. The mucogingival situation should be reevaluated after the orthodontic therapy has been completed to decide whether any additional treatment is indicated. NOTE
ADDED
IN P R O O F
After this manuscript was submitted, H . S. Dorfman reported that "a decrease or increase in the width of keratinized gingiva can be significantly cor related with labial or lingual mandibular incisor tooth movement, respectively." The author came to this con clusion after studying cephalometric changes of the lower incisor position in 1150 patients and correlated this with changes in the width of gingiva on the facial aspect. 20
REFERENCES
1. M a y n a r d , G . , and Ochsenbien, C . : Mucogingival problems, prevalance and therapy in children. J Periodontol 46: 5 4 3 , 1 9 7 5 . 2. G r u p e , H . E . , and Warren, R . F . : Repair of gingival defects by a sliding flap operation. J Periodontol 27: 290, 1956. 3. R o b i n s o n , R . E . : Utilizing an edentulous area as a donor site in the lateral repositioned flap. Periodontics 2: 79, 1964. 4. C o r n , H . : Technique for repositioning the frenum in periodontal problems. Dent Clin North Am p 79, M a r c h , 1964. 5. Staffileno, H . : Management of gingival recession and
root exposure problems associated with periodontal disease. Dent Clin North Am p i l l , M a r c h , 1964. 6. C o r n , H . : Edentulous area pedicle grafts in mucogin gival surgery. Periodontics 2: 229, 1964. 7. A r i a u d o , A . : Problems in treating a denuded labial root surface of a lower incisor. J Periodontol 37: 276, 1966. 8. Pennel, B . M . , Higgason, J . D . , Towner, J . D . , K i n g , K . O . , Fritz, B . D . , and Sadler, J . F . : Oblique rotated f l a p . / . Periodontol 36: 305, 1965. 9. G r u p e , H . E . : Modified technique for the sliding flap operation. J Periodontol 37: 4 9 1 , 1966. 10. Rose, G . J . : Receding mandibular labial gingiva on children. Angle Orthod 37: 147, 1967. 11. Sullivan, H . D . , and A t k i n s , J . H . : Free autogenous gingival grafts, III. Utilization of grafts in the treatment of gingival recessions. Periodontics 6: 152, 1968. 12. M l i n e k , A . , Smukler, H . , and Buchner, A . : T h e use of free gingival grafts for the coverage of denuded roots. J
Periodontol 44: 249, 1973. 13. Levine, L . , and Stah S.: Repair following periodontal flap surgery with the retention of gingival fibers. J Periodon tol 43: 9 9 , 1 9 7 2 . 14. Wilderman, M . , and Wentz, F . : Repair of a dentogingival defect with a pedicle flap. J Periodontol 36: 218, 1965. 15. Sugarman, E . : A clinical and histological study of the attachment of grafted tissue to bone and teeth. J Periodontol 40: 381, 1969. 16. Ramfjord, S., and Nissle R . : T h e modified Widman flap. J Periodontol 45: 601, 1974. 17. L a n g , N . P . , and L o e , H . : T h e relationship between the width of keratinized gingiva and gingival health. J Perio dontol 43: 6 2 3 , 1 9 7 2 . 18. B u c h i n , Irving, Personal Communication. 19. Vanarsdall, Robert L . , Personal Communication. 20. D o r f m a n , H . S.: Evaluation of mucogingival changes resulting from mandibular incisor tooth movement. I . A . D . R . Abstract N o . 595, J Dent Res 56: B 2 0 0 , 1977.
Announcement T E M P L E UNIVERSITY S C H O O L O F DENTISTRY Temple University School of Dentistry announces the following Continuing Education course: TITLE: DATES: FACULTY:
Participation Course in Basic Periodontal Therapy (6 consecutive Wednesdays) March 15, 22, 29; April 5, 12, 19, 1978 D R . D . LITWACK, D R . I. A B R A M S and Staff, Department
of Periodontology, Temple University In addition to the introduction of startling new theories on periodontal regeneration, pocket control, and periodontal surgical procedures, there will be full day of lecture, lab, and practical application of occlusal principles. The doctor will treat a selected patient in initial therapy and basic surgery. TITLE:
Adult Tooth Movement
DATES:
April 6, 7, 1978
FACULTY:
D R . A L L A N SCHLOSSBERG, D . M . D . , M . S . Associate Pro
fessor, Department of Periodontology, Temple Univer sity School of Dentistry
Tooth movement is indicated for many adult patients as a part of their comprehensive dental treatment. The course will consist of lectures, demonstrations, and lab sessions. TITLE: DATES:
Clinical Periodontal Surgery May 16, 17, 19, 1978-the morning of the 18th is optional for those interested in observing surgery.
FACULTY:
D R . I. A B R A M S , D R . D . LITWACK, D R . A . SCHLOSSBERG,
D R . B . W A L L , Department of Periodontology, Temple University This course will describe many new advances in periodontal surgery as well as the surgical procedures now in practice, through lectures, closed circuit T V , and direct patient observation. Instru ments used and their care, a lab in sutures and the techniques along with other necessary information for successful periodontal surgery will be covered. For information contact: Continuing Education, Temple Univer sity School of Dentistry, 3223 N . Broad St., Philadelphia Pa 19140. (215) 221-2955
