CONTEMPORARY ESTHETIC PERIODONTICS
Figure 1. 29 year-old white, male patient presents with fractured, hopelessly involved tooth # 21( Mucogingival defects of recession and inadequate keratinized gingiva are also present)
Figure 2. Periapical film showing failing tooth # 21
Figure 3. Tooth was extracted and ridge augmented with freeze-dried bone allograft and membrane; 4 months healing. Note keratinized gingiva was still lacking in buccal aspect of # 21 site
the denuded tooth surface. In the apical region of the flap, histological slides have shown repair by connective tissue attachment of the flap to the tooth surface 5. The approximation of the flap to the tooth is the prerequisite for proper wound healing. In tandem with the patient’ s compliance, the holding quality of the sutures determined by the skill level of the surgeon will prevent wound healing failure. The down growth of epithelium at the interface along the root surface is a barrier to connective tissue attachment. If a space is allowed between the flap and the tooth during the healing phase the epithelium will occupy that space first. Epithelium proliferates more rapidly than connective or osseous tissue. When the flap is allowed to remain tightly adapted by an undisrupted fibrin clot and adequate sutures during the ten days of initial healing, contact inhibition will stop the epithelium on the outside
Figure 4. Autogenous free gingival graft completed at # 21 ridge prior to implant placement to augment keratinized gingiva
of the flap from progressing and lining the inside of the flap that is facing the root surface 5. Healing by regeneration requires new formation of cementum, bone, periodontal ligament and gingiva with a short epithelial attachment to the tooth. This healing does not occur spontaneously or by resective procedures. Usually biomaterials and modifiers are added to the surgical site to induce or promote regeneration of lost tissues by new technologies. Guided tissue regeneration techniques and soft tissue coverage procedures are used today around teeth and implants. Soft tissue healing surrounding implants differs from periodontal healing around a tooth. The peri-implant mucosa is isolated from the implant surface by the long junctional epithelium coronally. The supracrestal connective tissue fibers are dense and oriented parallel to the long axis of the implant above the crest of the bone, since insertion of
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