Multidisciplinary Rehabilitation: Tunnel Grafting Techniques

Figure 1. Pre-op view shows teeth Nos. 6 to 11 with gingival recession and exposed margins on teeth Nos. 7, 8, and 10. Figure 2. Intrasulcular incisons were made. Note: The interdental papillae were left intact. Figure 3. Acellular dermal matrix (ADM) was rehydrated in sterile saline. Figure 4. ADM was then positioned within the subgingival tunnel. Exposed ADM to be covered later. Figure 5. A gingival flap was secured over the ADM and root surfaces using a continuous suture.

INTRODUCTION
The goal of cosmetic dentistry is to provide patients with a healthy, functional, and attractive smile. Complex rehabilitation may require a multidisciplinary approach.^1-3 To achieve optimal results, good communication is necessary among all dental team members.^4-6
The development of a harmonious relationship between the teeth and the soft-tissue architecture is critical to the successful rehabilitation of teeth in the aesthetic zone. Proper tooth size, shape, and tooth-to-tooth proportion is dependent on the gingival architecture.^1-3 A stable gingival margin is necessary to the long-term success of aesthetic restorations. Gingival biotype is the term used to describe the buccolingual thickness of the gingiva.^7-9 A thin gingival biotype has been associated with a greater risk of developing gingival recession following surgical and restorative procedures.^7-12
Connective tissue grafting has a long history of success in achieving root coverage and improving the thickness of the gingiva.^13,14 Tunnel techniques have reduced the aesthetic problems resulting from trauma to the interdental papillae.^15,16 The use of an acellular dermal matrix (ADM) has been demonstrated to be successful in the treatment of multiple adjacent sites.^17,18
A restorative pretreatment workup should identify problems and solutions. Restoration failures can occur due to a variety of reasons including exposed margins, discoloration/staining, caries, and fracture.¹⁹ The use of natural appearing and durable materials is an important component of aesthetic treatment.^20,21 Attention to tooth proportions and symmetry is vital to the overall success of treatment.²²
The purpose of this article is to demonstrate and discuss the multidisciplinary rehabilitation of a smile using tunnel connective-tissue grafting techniques and all-ceramic restorations.

CASE REPORT
Diagnosis and Treatment Planning
A 37-year-old nonsmoking female had a chief complaint of an unattractive smile (Figure 1). In particular, she was concerned about the dark shade of her teeth and gingival recession. She reported a history of having adult orthodontics and porcelain restorations to close diastemas between her incisors; this had been completed 15 years earlier. Following this treatment, she noticed her gingiva began to recede. The patient was referred by her restorative dentist for evaluation and treatment of gingival recession prior to replacement of failing anterior restorations.
Periodontal evaluation found teeth Nos. 6 to 11 to have mild to moderate gingival recession. The exposed facial margins of the veneers on teeth Nos. 7 to 10 were stained. The root surfaces of teeth Nos. 6 and 11 were stained but not carious. Periodontal probing depths were found to be between 1.0 to 3.0 mm. Sulcus probing at the midfacial aspect of teeth Nos. 6 to 11 revealed the gingiva to be delicate and almost translucent. The patient was determined to have a thin biotype.
Given these findings, the treatment was to occur in 2 phases. First, teeth Nos. 6 to 11 were to be treated with connective tissue grafting. Second, teeth Nos. 7 to 10 were to be restored with new veneers and crowns.

Clinical Treatment Begins
Profound local anesthesia was achieved using approximately 7.2 cc of 2% lidocaine with 1:100,000 epinepherine. Using a Bard-Parker No. 15 blade, initial intrasulcular incisions were made along the buccal surfaces of teeth Nos. 5 through 12 (Figure 2). An Orban knife was used to elevate a full-thickness flap. Once into the mucosal tissues, the flap became mobile and able to be repositioned in a coronal direction. The interdental papillae were left intact. Only in the areas between Nos. 5 and 6, and 11 and 12 was the buccal gingiva detached from the underlying interdental papillary bed. A continuous submucosal tunnel was made that extended from tooth Nos. 6 to 11. Prominent root surfaces and root surface irregularities were reduced with scaling root planing.
An ADM (AlloDerm [BioHorizons]) was trimmed to approximately 40 mm in length and 5 mm in height (Figure 3). The ADM was then inserted into the mucogingival tunnel where the gingiva had been detached between teeth Nos. 5 and 6. Using the Orban knife, the ADM was passed through the tunnel until it could be accessed through the gingival opening between teeth Nos. 11 and 12.
A continuous 4.0 plain gut suture was secured to the buccal gingiva between teeth Nos. 4 and 5. By weaving this suture around the palatal of the teeth and engaging the ADM on the buccal, the ADM was secured in a coronal position against its underlying wound bed (Figure 4). The suture was tied off on the buccal gingiva between teeth Nos. 12 and 13. The buccal gingival flap was coronally advanced to completely cover the root surfaces and the ADM. The gingiva was secured into using a continuous 4.0 chromic gut suture (Figure 5).
The patient took ibuprofen (600 mg) every 6 to 8 hours as needed for discomfort. The patient was prescribed amoxicillin (875 mg) every 12 hours for 10 days. The patient was instructed not to brush or floss the surgical site for 10 days. Instead, she was to rinse twice daily with 0.12% chlorhexidine gluconate (Peridex [3M ESPE]). After 10 days, the patient discontinued the rinse and began gentle tooth brushing and flossing.
After about 8 weeks, the treatment sites were found to be healing well (Figure 6). Complete root coverage was achieved with minimal shrinkage of the interdental papillae. The overall soft-tissue architecture was natural and aesthetic in appearance. The patient was then referred to begin the restorative phase of treatment.

Figure 6. Surgical site was healing very well with complete root coverage after 8 weeks of healing. Figure 7. Provisional restorations were placed on teeth Nos. 7 to 10. Figure 8. Shade determination. Figure 9. Six months following completion, the results were highly aesthetic and natural in appearance.

Restorative Phase
During the intial restorative consultation, photographs, impressions for diagnostic models, and a face-bow transfer were made. Using this information, it was determined that the patient had a Class I occlusion. There were, however, subtle changes that needed to be made. Minimal guidance contacts were present on tooth No. 6. The incisal edges on teeth Nos. 7 to 10 were positioned lingually. In addition, the patient felt her teeth were too dark. The preoperative models were mounted on an articulator and sent to the laboratory for a diagnostic wax-up.
The patient first whitened her teeth using 22% carbamide peroxide gel (Natural Elegance [Henry Schein]) in custom made bleaching trays for 3 weeks. After the desired tooth shade was achieved, restorative treatment was initiated. Approximately 12 weeks after the surgery had been completed, the old porcelain restorations were removed, and the teeth were prepared utilizing a putty reduction matrix made from the diagnostic wax-up. The reduction matrix enabled a precise amount of tooth reduction to allow a uniform thickness of porcelain. Tooth preparations placed the restoration margins no more than 0.5 mm below the gingival margin. The final impression was made using size 00 impression cord and Aquasil (DENTSPLY Caulk) heavy and light body vinyl polysiloxane. A face-bow transfer of the preparations was performed to accurately communicate the correct spatial relationship of her maxilla to the laboratory technician.
Temporary restorations were made utilizing a putty matrix of the diagnostic wax-up and Access Crown (Centrix) (Figure 7). Final occlusal equilibrations and contour changes were made to the temporaries. Shade determination was accomplished using a stump shade guide (Ivoclar Vivadent) and the VITA 3D system shade guide (Vident) (Figure 8). Shade, impressions, photographs, the reduction matrix, face-bow transfer, and model of the modified temporary restorations were sent to the laboratory. Teeth Nos. 7 and 10 received full-coverage crowns while teeth Nos. 8 and 9 received veneers. All restorations were fabricated by our dental laboratory team using lithium disilicate (e.max [Ivoclar Vivadent]) and returned to the dental office.

DELIVERY APPOINTMENT
Following patient approval, the restorations were cemented in place using translucent veneer cement (RelyX Veneer Cement [3M ESPE]). Excess cement was meticulously removed, while being careful not to traumatize the gingiva.
Six months following completion of treatment, the gingiva was healthy and the gingival margins were stable. The restorations appeared to be aesthetic and natural in appearance (Figure 9) and the patient reported being “very happy” with the treatment outcome.

DISCUSSION
Aesthetic rehabilitation cases may require a multidisciplinary approach. To achieve optimal results, good communication is necessary among all dental team members.^4-6 Understanding the patient’s concerns is an important part in developing a treatment plan because the aesthetic perceptions of the dentist and lay person can differ.²³ In this case the patient’s chief concern was dark colored teeth and progressive gingival recession. From a restorative perspective, creating ideal or golden tooth proportions was also an important goal.22 Being responsible for the final results of treatment, the restorative dentist often acts as treatment coordinator.
Accurate record taking and case evaluation is an important part of determining treatment objectives. Tooth-to-tooth proportions, tooth shape, tooth shade, occlusion, and the soft-tissue architecture are important variables that must be considered.^20,22 Preoperative photographs, diagnostic models, face-bow transfers, and case provisionalization enhance the communication of team members and adds to the predictability of the final results.^4-6 Gaining root coverage and stabilizing the gingival margin was deemed an important step in developing proper tooth proportions in this case.
Thicker biotypes are considered to have more stable gingival margins.^7-12 It would seem prudent, therefore, to determine the stability of the soft-tissue architecture prior to delivering restorations that have subgingival margins. One method of assessing the gingival biotype is with visual measurement using a periodontal probe.8,9 While this method is subjective and can only identify gingival as being thick or thin, it has been shown to have a high degree of reliability.⁹
Connective tissue grafting addresses 2 of the restorative goals. Connective tissue grafting increases the thickness of the facial gingival13,14 effectively transforming a thin biotype to a thicker biotype. It has been reported that connective tissue grafts approximately one mm in thickness are ideal for obtaining aesthetic gingival contours.24 ADMs are supplied with a uniform thickness between 0.89 to 1.65 mm. Uniform grafts adapt better to recipient sites and are easier to suture.25 The handling characteristics and uniformity of the ADM makes it an ideal material for use with a tunnel technique.²⁶
Connective tissue grafting is an effective method of achieving root coverage.^12,13 The use of connective tissue allografts permits treatment of multiple adjacent teeth.^17,18 Tunnel techniques further enhance the aesthetic results by protecting the interdental papillae.^15,16,26-28 Together, increasing gingival thickness, achieving root coverage, and minimizing shrinkage of the interdental papillae enables the predictable aesthetic restoration of teeth with proper shape and proportions.
Teeth Nos. 7 and 10 received full-coverage all-ceramic crowns, and teeth Nos. 8 and 9 received porcelain veneers. Preserving tooth structure and delivering durable restorations were important variables considered when determining the restoration type to be delivered. The amount of tooth structure remaining following removal of the failing restoration was a key factor in deciding on full or partial coverage.^28,29 Advances in ceramic technologies have made these restorations highly successful in full-and partial-coverage applications.^5,19,29,30 Lithium disilicate ceramics, in particular, have been reported to be a highly aesthetic and durable.^31-33

CONCLUSION
A multidisciplinary approach may be necessary to create an attractive smile. Connective tissue grafting using tunnel techniques can create a stable and natural appearing foundation necessary to aesthetic restoration of the teeth.

References

1. Lee EA, Jun SK. Aesthetic design preservation in multidisciplinary therapy: philosophy and clinical execution. Pract Proced Aesthet Dent. 2002;14:561-569.
2. Ohyama H, Nagai S, Tokutomi H, et al. Recreating an esthetic smile: a multidisciplinary approach. Int J Periodontics Restorative Dent. 2007;27:61-69.
3. Chu SJ, Hochman MN. A biometric approach to aesthetic crown lengthening: part I—midfacial considerations. Pract Proced Aesthet Dent. 2008;20:17-24.
4. Sanders KS, Rickert DG. Dentist-laboratory communication about a complex case. J Cosmetic Dent. 2010;26:108-117.
5. Jones BL. The predictability, beauty, and ease of pressable ceramics. J Cosmetic Dent. 2009;25:84-94.
6. Mahn DH. Interdisciplinary communication: part I—treatment planning. Collab Tech. 2004;2:33.
7. Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent. 2004;25:895-896, 898, 900.
8. Kan JY, Rungcharassaeng K, Morimoto T, et al. Facial gingival tissue stability after connective tissue graft with single immediate tooth replacement in the esthetic zone: consecutive case report. J Oral Maxillofac Surg. 2009;67(11 suppl):40-48.
9. Kan JY, Morimoto T, Rungcharassaeng K, et al. Gingival biotype assessment in the esthetic zone: visual versus direct measurement. Int J Periodontics Restorative Dent. 2010;30:237-243.
10. Weisgold AS. Contours of the full crown restoration. Alpha Omegan. 1977;70:77-89.
11. Seibert J, Lindhe J. Esthetics and periodontal therapy. In: Lindhe J, ed. Textbook of Clinical Periodontology. 2nd ed. Copenhagen, Denmark: Munksgaard; 1989:477-514.
12. Koke U, Sander C, Heinecke A, et al. A possible influence of gingival dimensions on attachment loss and gingival recession following placement of artificial crowns. Int J Periodontics Restorative Dent. 2003;23:439-445.
13. Langer B, Calagna LJ. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent. 1982;2:22-33.
14. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol. 1985;56:715-720.
15. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent. 1994;14:216-227.
16. Ribeiro FS, Zandim DL, Pontes AE, et al. Tunnel technique with a surgical maneuver to increase the graft extension: case report with a 3-year follow-up. J Periodontol. 2008;79:753-758.
17. Henderson RD, Greenwell H, Drisko C, et al. Predictable multiple site root coverage using an acellular dermal matrix allograft. J Periodontol. 2001;72:571-582.
18. Aichelmann-Reidy ME, Yukna RA, Evans GH, et al. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol. 2001;72:998-1005.
19. Neff A. “Doctor, my veneer just broke!” (How and why does porcelain fracture?). J Cosmetic Dent. 2010;26:90-96.
20. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby Elsevier; 2007.
21. Sheets CG. Paquette J, Wu J, et al. Porcelain-bonded restorations: designs and principles. Pract Proced Aesthet Dent. 2009;21:143-150.
22. Preston JD. The golden proportion revisited. J Esthet Dent. 1993;5:247-251.
23. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11:311-324.
24. Zucchelli G, Amore C, Sforzal NM, et al. Bilaminar techniques for the treatment of recession-type defects. A comparative clinical study. J Clin Periodontol. 2003;30:862-870.
25. Joly JC, Carvalho AM, da Silva RC, et al. Root coverage in isolated gingival recessions using autograft versus allograft: a pilot study. J Periodontol. 2007;78:1017-1022.
26. Mahn DH. Use of the tunnel technique and an acellular dermal matrix in the treatment of multiple adjacent teeth with gingival recession in the esthetic zone. Int J Periodontics Restorative Dent. 2010;30:593-599.
27. Allen EP. Subpapillary continuous sling suturing method for soft tissue grafting with the tunneling technique. Int J Periodontics Restorative Dent. 2010;30:479-485.
28. Spear F. Too much tooth, not enough tooth: making decisions about anterior tooth position. J Am Dent Assoc. 2010;141:93-96.
29. Alex G. Preparing porcelain surfaces for optimal bonding. Compend Contin Educ Dent. 2008;29:324-335.
30. Spear F, Holloway J. Which all-ceramic system is optimal for anterior esthetics? J Am Dent Assoc. 2008;139(suppl):19S-24S.
31. Tysowsky GW. The science behind lithium disilicate: a metal-free alternative. Dent Today. 2009;28:112-113.
32. Ritter RG, Rego NA. Material considerations for using lithium disilicate as a thin veneer option. J Cosmetic Dent. 2009;25:111-117.
33. Reynolds JA, Roberts M. Lithium-disilicate pressed veneers for diastema closure. Inside Dentistry. 2010;6:46-52.

     

Dr. Mahn is a periodontist in private practice in Manassas, Va. He graduated from State University of New York Stony Brook Dental School in 1990 and completed his periodontal residency at the Medical College of Virginia School of Dentistry in 1992. He also completed a residency on temporomandibular disorders and orofacial pain at New York University College of Dentistry in 1996. Dr. Mahn’s practice emphasizes perioplastic, regenerative, and dental implant therapies. He has several publications and has lectured on these topics. He can be reached at (703) 392-8844 or dmahn@cox.net.

Disclosure: Dr. Mahn reports no disclosures.

Dr. Woodside graduated cum laude from Virginia Commonwealth University School of Dentistry where he earned the Excellence in Prosthodontics Award from the Southern Academy of Prosthodontics, Predoctoral Achievement Award from the International Congress of Oral Implantology, Dental Implant Student Award from the American Association of Oral and Maxillofacial Surgeons, and was recipient of the Hinman Scholarship. He is a general dentist in private practice in Warrenton, Va, emphasizing cosmetic and implant dentistry. Dr. Woodside is a Fellow of the International Congress of Oral Implantologists, Fellow of the AGD and a sustaining member of the American Academy of Cosmetic Dentistry. He can be reached via e-mail at woodsidedds@yahoo.com.

Disclosure: Dr. Woodside reports no disclosures.