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t t r f e o ssence The Concept of the Interdental Gingival Midpoint Line in Cervical Line Management

Takeshi Nozawa, DDS Private Practice, Ojiya, Niigata, Japan

Shunzo Tsurumaki, CDT Sanjo, Niigata, Japan

Satoshi Yamaguchi, DDS Private Practice in Orthodontics, Yotsukaido, Chiba, Japan

Hiroaki Enomoto, DDS Clinical Professor, Oral Implant Center, Nippon Dental University, Niigata Hospital, Niigata, Japan

Koichi Ito, DDS, MSD, PhD Professor and Chairman, Department of , Nihon University School of Dentistry, Tokyo, Japan

Correspondence to: Dr Takeshi Nozawa, Nozawa Dental Office, 9-7 Sakae-cho, Ojiya-shi, Niigata-Ken, 947-0011, Japan Tel: 81 258 82 0468; Fax: 81 258 82 0357; e-mail: [email protected]

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t t r f e o ssence Abstract

The first purpose of this study was to inves- ment through some clinical cases. In a tigate the relationship between the lowest thick-flat biotype case using a clinical cervical point and the interdental gingival procedure, the lowest midpoint (IGM) line in the maxillary anteri- cervical points were adjacent to the IGM or region. After marking the lowest cervical lines following long-term coronal gingival points and the mesial and distal interden- growth. In a short-term observation of a tal gingival midpoints on study models of thin-scalloped biotype case, untouched fa- 77 patients, the shortest distances from the cial gingiva increased following interdental IGM lines that connect both interdental gin- gingival augmentation. In a case of Miller gival midpoints to the lowest cervical points class 1 , a coronally ad- were measured on silicone impressions. vanced flap combined with the roll tech- The findings showed that the average po- nique was performed based on the IGM sition of the lowest cervical points in the line concept. According to the results ob- central incisors coincides with the IGM line. tained from this study and these cases, it This position is located 0.24 mm palatally in seems that the IGM line could become a the lateral incisors, and in the canines diagnostic standard in cervical line man- 0.3 mm facially from the IGM line. The sec- agement in periodontal plastic surgery. ond purpose of the study was to verify the IGM line concept in cervical line manage- (Eur J Esthet Dent 2009;4:46–69).

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t t r f e o ssence Introduction odontal biotypes.9 As well as pathologic fac- tors, periodontitis, brushing trauma, and The cervical line is constituted by the tooth malposition, are also considered to be boundary between the tooth and gingiva. In involved in causing gingival recession.10 a healthy , the marginal free The lowest cervical point is an important gingiva slopes coronally and ends in a factor in determining tooth form. The length round or thin edge.1,2 Changing of the cer- of gingival recession is usually measured vical line occurs with aging, following active by following the shortest distance from the and passive tooth eruption.3,4 In adults, the CEJ to the lowest cervical point. Various free stops in the range of factors are considered to be causes of gin- 1.5 to 2.0 mm coronally from the cemento- gival recession. However, the concrete ele- enamel junction (CEJ).1,5 ments that affect the position of the lowest The apical shift of marginal free gingiva cervical point are unknown. from the CEJ is called gingival recession.6 Several surgical techniques have been Esthetic problems and dentin hypersensi- introduced for the improvement of gingival tivity sometimes occur in this area. Gingival recession since the 1950s. These include recession is caused by anatomic and laterally positioned and coronally advanced pathologic factors. The thickness of the pe- flaps, free gingival grafts, connective tissue riodontal tissue plays an important role in grafts, and guided tissue regeneration.10–12 gingival recession caused by the former. In Miller classified gingival recession into four line with previously published reports, the types in the light of predictability of root periodontal biotypes are usually classified coverage, and pointed out that a loss of in- into two types; thin-scalloped types and terdental papilla and buccal tooth malpo- thick-flat types.7, 8 It has been reported that sition affects success rate (Figs 1 to 8). In the possibility of gingival recession increas- orthodontic treatment, some studies have es in children and teenagers with thin peri- shown that lingual tooth movement caus-

Fig 1 At first examination, the maxillary left lateral in- Fig 2 Following intrusion of the lateral incisor, loss of cisor is extruded compared with the central incisor. The can be observed between the cen- lowest cervical point of the lateral incisor is located at tral and lateral incisors. The lowest cervical point is lo- the center of the tooth. cated mesially.

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t t r f e o ssence

Fig 3 At first surgery, a connective tissue graft has Fig 4 The coronally advanced flap has been sutured been placed on the central and lateral incisors. for interdental papilla reconstruction.

Fig 5 After orthodontic treatment, anterior teeth have Fig 6 One year after first surgery. Interdental gingival been stabilized using an A-splint. thickness has increased, and the interdental papilla has filled partially. The lowest cervical point has been displaced at the center of the tooth.

Fig 7 At second surgery, a subepithelial connective Fig 8 Four years after second surgery. The interden- tissue graft using the tunneling technique has been tal papilla has almost filled following horizontal interden- placed in the interdental space. tal gingival augmentation. The lowest cervial point has been displaced more distally, indicating the change of interdental gingival thickness is related to the displace- ment of the lowest cervical point.

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t t r f e o ssence es an increase in free gingival height.13,14 In line in cervical line management through recent years, two interesting articles have studying some clinical cases. reported improvements in the area of gin- gival recession using non-surgical treat- ments.15,16 However, the mechanisms in- Materials and methods volved have not yet been clarified. In esthetic implant dentistry, fixture posi- Study population tion is an important factor in obtaining suc- From 2006 to 2008, 77 patients (35 males cessful long-term results as well as hard and 42 females ranging from 10 to 57 and soft tissue augmentation.17–19 Several years of age, mean age 28.92±13.21 years authors have advocated the three-dimen- old) were selected from a private dental of- sional install position for the control of im- fice. All patients who participated were re- plant cervical lines.20–22 In facio-lingual quired to sign an informed consent state- placement, Saadoun et al21 stated that the ment at the beginning of the study. external implant collar surface should be 2 mm inside the buccal contour of the ad- Inclusion criteria jacent teeth. On the other hand, Enomoto22 The following entry criteria were used:23,24 stated that the collar of the implant should 1. symmetrical maxilla form from the mid- remain inside the virtual line that connects palatal suture cervical borders of adjacent teeth. Howev- 2. no periodontitis within 2mm probing depth er, there are very few reports on the horizon- in maxillary anterior teeth tal reference lines that are related to the po- 3. no gingival recession sition of the lowest cervical points in natural 4. no loss of interdental papilla teeth.23 The first purpose of this article is to 5. no excessive tooth rotation, investigate the relationship between the tooth extrusion, and incisal abrasion lowest cervical point and the interdental gin- 6. no caries, abrasion and restoration in the gival midpoint line in the maxillary anterior cervical area (Fig 9). region. The second purpose is to verify the concept of the interdental gingival midpoint Gingival biotypes were divided into two types using a CP11 . If the probe was visible during probing depth measurement, the gingival biotype was di- agnosed as a thin type. If the probe was not visible, the gingival biotype was diagnosed as a thick type.25

Measurement procedures Study models were made using alginate impressions. Firstly, the lowest cervical points in the maxillary anterior regions were determined bilaterally. The bilateral

Fig 9 Normal maxillary anterior teeth devoid of destruc- points of (MGJ), tive periodontitis were selected following the entry criteria. which are positioned apically from the low-

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t t r f e o ssence est cervical points were then determined for reference lines following Rose and App guidelines.26 Parallel lines were then drawn that passed through the lowest cervical points and lastly perpendicular lines were drawn from the top of the interdental papil- la to the reference lines. Subsequently, the position of the mesial and distal interdental gingival midpoints were determined as the point where the parallel lines crossed the perpendicular lines. Several points were marked using a 0.5 mm mechanical pen- Fig 10 The lowest cervical points (C), the bilateral cil on the study models, and silicone im- MGJ points (G), the mesial (M) and distal (D) interden- tal gingival midpoints were determined on the study pressions were taken (Fig 10). model. The impressions were cut horizontally thorough the lines that connected the low- est cervical points and the mesial and dis- tal interdental gingival midpoints (Fig 11). The line that connects the mesial and distal interdental gingival midpoints is called the interdental gingival midpoint (IGM) line. The actual lengths (i) of the IGM lines were measured using a digital slide caliper un- der x8 magnification. Digital photographs were taken, and the photographs of the IGM lines were expanded as much as was possible on a 15 inch monitor. The virtual Fig 11 The preceding points were marked on the sil- lengths (I) of the IGM lines, and the virtual icone impression, and cut horizontally. shortest distances (D) from the IGM lines to

Fig 12 The actual shortest distances (d) from the IGM lines were calculated using the actual length (i) of the IGM lines, the virtual length (I) of the IGM lines, and the virtual shortest distances D on the monitor (d = i x D / I).

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t t r f e o ssence Table 1 The average distance from the IGM line to the lowest cervical point (in mm).

Right Right Right Left Left Left canine lateral central central lateral canine incisor incisor incisor incisor

All biotypes 0.28 ± 0.29 -0.26 ± 0.25 -0.02 ± 0.27 0.01 ± 0.26 -0.21 ± 0.22 0.32 ± 0.31

Thick biotypes 0.18 ± 0.3 -0.35 ± 0.24 -0.13 ± 0.22 -0.06 ± 0.24 -0.29 ± 0.21 0.29 ± 0.26

Thin biotypes 0.33 ± 0.27 -0.21 ± 0.24 0.03 ± 0.28 0.05 ± 0.27 -0.18 ± 0.22 0.33 ± 0.33

the most palatal points of the lowest cervi-

㻦㼈㼑㼗㼕㼄㼏㻃㻃㼌㼑㼆㼌㼖㼒㼕 cal points, were measured on the monitor 㻖㻘 (Fig 12). The actual shortest distances (d) 㻖㻓 from the IGM lines were calculated using 㻕㻘 the following formula (d = i x D/I). 㻕㻓 㻹㼄㼏㼘㼈 A plus value was designated to the lowest 㻔㻘 cervical points that were displaced facially, 㻔㻓

㻘 and a minus value was designated to those 㻓 that were displaced palatally. 㻐㻔㻑㻕 㻐㻓㻑㻜 㻐㻓㻑㻙 㻐㻓㻑㻖 㻓 㻓㻑㻖 㻓㻑㻙 㻓㻑㻜 㻔㻑㻕

㻫㼒㼕㼝㼒㼑㼗㼄㼏㻃㻃㼇㼌㼖㼗㼄㼑㼆㼈 㼑㻠㻔㻘㻗

Fig 13 Graph showing the horizontal position of the Results central incisors. The average distance in the central in- cisors is 0 ± 0.27mm. Among the selected patients, 31 had thick biotypes and 46 had thin biotypes. The following results were classified into three types: all inclusive biotypes (all biotypes), 㻯㼄㼗㼈㼕㼄㼏㻃㻃㼌㼑㼆㼌㼖㼒㼕 thick biotypes, and thin biotypes (see 㻖㻘 㻖㻓 Table 1). The shortest distances from the 㻕㻘 IGM lines between the right and left max- 㻕㻓 illary anterior teeth were almost identical. 㻹㼄㼏㼘㼈 㻔㻘 In the thick biotypes, the average shortest 㻔㻓 distance from the IGM line to the lowest 㻘 cervical point in the central incisors was 㻓 㻐㻔㻑㻕 㻐㻓㻑㻜 㻐㻓㻑㻙 㻐㻓㻑㻖 㻓 㻓㻑㻖 㻓㻑㻙 㻓㻑㻜 㻔㻑㻕 -0.09 ± 0.23mm, the average in the later- 㻫㼒㼕㼝㼒㼑㼗㼄㼏㻃㻃㼇㼌㼖㼗㼄㼑㼆㼈 㼑㻠㻔㻘㻗 al incisors was -0.32 ± 0.23mm, and the average in the canines was 0.24 ± Fig 14 Graph showing the horizontal position of the lateral incisors.The average distance in the lateral inci- 0.29mm. In the thin biotypes, the average sors is -0.24 ± 0.28mm. shortest distance in the central incisors

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t t r f e o ssence was 0.04 ± 0.28mm, the average in the lateral incisors was -0.19 ± 0.23mm, and 㻦㼄㼑㼌㼑㼈 the average in the canines was 0.33 ± 㻖㻓

0.3mm. Compared with that of the thick 㻕㻘 biotypes measurements, the average 㻕㻓 shortest distance of the thin biotypes 㻹㼄㼏㼘㼈 㻔㻘 measurements were always longer. The 㻔㻓 average shortest distance from the IGM 㻘 line to the lowest cervical point in the cen- 㻓 㻐㻔㻑㻕 㻐㻓㻑㻜 㻐㻓㻑㻙 㻐㻓㻑㻖 㻓 㻓㻑㻖 㻓㻑㻙 㻓㻑㻜 㻔㻑㻕 tral incisors was 0 ± 0.27mm, the average 㻫 㼒㼕㼝㼒㼑㼗㼄 㼏㻃㻃㼇㼌㼖㼗㼄 㼑㼆㼈 㼑㻠㻔㻘㻗 in the lateral incisors was -0.24 ± 0.28mm, and the average in the canines was 0.3 ± Fig 15 Graph showing the horizontal position of the 0.3mm (Figs 13 to 15). canines. The average distance in the canines is 0.3 ± 0.3 mm.

Case presentation

Case 1 was a clinical crown lengthening procedure in a thick-flat biotype. A 41-year-old female visited the dental office requesting esthetic improvement in the maxillary anterior region. Wide form hard resin bonded crowns were placed on the bilateral central incisors and a right lat- eral incisor with a thick-flat biotype was ob- served (Fig 16). After the initial preparation, Fig 16 A case of clinical crown lengthening proce- a clinical crown lengthening procedure dure (CCLP) with a thick-flat biotype. Wide form hard (CCLP) was performed to attain symmet- resin bonded crowns have been placed on the bilater- al central incisors and a right lateral incisor. Asymmet- rical cervical lines (Fig 17). The first wound rical cervical lines are evident. healing stage showed that the cervical lines had changed in form, from a circular to a tapered form following an increase in interdental gingiva (Figs 18 and 19). One year after the CCLP, the definitive restora- tions were placed (Fig 20). A study model was manufactured using an alginate im- pression. The second stage showed that the coronal growth of the cervical gingiva had changed the teeth form following an increase in facial gingival thickness (Fig 21). Eleven years after the CCLP, the defin- Fig 17 At the time of suturing, cervical lines had ad- itive restoration form had changed from justed symmetrically. the tapered type to the ovoid type in the

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t t r f e o ssence

Fig 18 One week later. Horizontal thickness of the in- Fig 19 Six months later. Tapered form provisional terdental gingiva has increased. restoration can be observed following interdental gin- gival increase. An increase in gingival thickness at the lowest cervical points can be seen.

Fig 20 One year later. The definitive restorations have Fig 21 Five years later. Coronal gingival growth has been placed. The form of the marginal free gingiva is commenced. The form of the marginal free gingiva has of the dull-edged variety, and inflammation around the gradually changed from that of the dull-edged variety cervical lines is evident. to that of the sharp-edged variety.

right central incisor (Fig 22). A study mod- el of this was also manufactured. To compare the results 1 year after the CCLP with the results 11 years after, the lowest cervical points, the bilateral MGJ points, and the mesial and distal interden- tal gingival midpoints were marked on the study models. Virtual horizontal lines were drawn that were parallel to the reference lines of the MGJ points (Fig 23). On the study model 1 year after the CCLP, the Fig 22 Eleven years later, the definitive restoration form has changed from the tapered type to the ovoid most palatal position of the lowest cervical type in the right central incisor. Gingival recession can point was located palatally from the virtual be observed on the left lateral incisor. IGM line in the right central incisor and fa-

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Fig 23 The lowest cervical points (C), the bilateral MGJ Fig 24 The virtual IGM lines have been drawn on the points (G), and the mesial (M) and distal (D) interdental study model. The most palatal position of the lowest gingival midpoints have been marked on the study mod- cervical point in the right central incisor is located el 1 year after the CCLP. The virtual horizontal lines are par- palatally from the virtual IGM line. allel to the reference lines of the MGJ points.

Fig 25 Several points have been marked on the Fig 26 The most palatal position of the lowest cervi- study model eleven years after The CCLP. The virtual cal points in the central incisors is adjacent to the vir- horizontal lines were also drawn. tual IGM lines. This is located palatally in the lateral in- cisors. cially in the left lateral incisor (Fig 24). On 0.41mm 1 year after the CCLP and the study model 11 years after the CCLP, 0.14mm 11 years after. The shortest dis- the most palatal position of the lowest cer- tance in the left central incisor was 0mm vical point in the bilateral central incisors 1 year after the CCLP, and -0.07mm was adjacent to the virtual IGM lines. This 11 years after. The shortest distance in the was located palatally in the bilateral lateral right lateral incisor was -0.15mm 1 year af- incisors (Figs 25 and 26). ter the CCLP and -0.28mm 11 years after. After silicone impressions were taken, The shortest distance in the left lateral inci- the shortest distances from the IGM lines to sor was 0.21mm 1 year after the CCLP the lowest cervical points were measured. and -0.31mm 11 years after. The creeping Furthermore, the shortest distances from attachments were calculated by compar- the incisal edges to the lowest cervical ing the study model 1 year after the CCLP points were also measured. The shortest with the model 11 years after. The creeping distance in the right central incisor was - attachment was 1.05mm in the right cen-

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t t r f e o ssence Table 2 Comparisons of the study models (in mm) 1 year after CCLP with that of 11 years after.

Right lateral Right central Left central Left lateral incisor incisor incisor incisor

d: 1 year later -0.15 -0.41 0 0.21

d: 11 years later -0.28 0.14 -0.07 -0.31 Tooth length: 9.33 11.21 11.6 9.25 1 year later Tooth length: 9.45 10.16 10.8 10.33 11 years later

Creeping -0.12 1.05 0.8 -1.08 attachment

tral incisor, 0.8mm in the left central incisor, plastic surgery in a procedure that used a -0.12mm in the right lateral incisor, and connective tissue-bone onlay graft on the -1.08mm in the left lateral incisor (Table 2). maxillary right canine.27 A porcelain-fused Case 2 was interdental gingival augmen- metal bonded crown at the maxillary right tation in a thin-scalloped biotype. A 55- lateral incisor and a fixed partial denture year-old male patient presented at the at the canine and the second premolar dental office for maintenance therapy. In had been placed 3 years earlier. In the en- this patient, the periodontal biotype was suing 3 years, a 0.5 mm shallow gingival that of the thin-scalloped type, and there recession had occurred at the lateral inci- was little evidence of . The sor due to brushing trauma (Fig 27). Prob- patient had already received periodontal ing depth was 1 mm at the center of the

Fig 27 An IGA case with a thin-scalloped biotype. Fig 28 (a) 0.5 mm shallow gingival recession; the The maxillary right canine has already received peri- porcelain margin can be observed at the maintenance odontal plastic surgery using a connective tissue-bone phase. (b) IGA using hydroxyapatite, but the marginal onlay graft. free gingiva at the lowest cervical point has not been touched. (c) One week later, swelling is present at the interdental gingiva.

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t t r f e o ssence tooth, and the interdental papilla was par- at the lowest cervical point had also in- tially filled. The patient requested an im- creased (Fig 30). provement in gingival recession. However, To compare the case prior to surgery with periodontal plastic surgery using a subep- the 6 month postoperative surgery result in ithelial connective tissue graft was reject- the lateral incisors, the lowest cervical ed by the patient. Based on the IGM line points, and the mesial and distal interden- concept, the interdental gingival augmen- tal gingival midpoints were marked on the tation (IGA) technique for improvement of study models (Fig 31). The most palatal po- the cervical line was explained to the pa- sition of the lowest cervical points prior to tient. He then consented to the proposal. and after the IGA were located palatally After infiltration anesthesia of the alveo- from the virtual IGM lines (Fig 32). After sil- lar mucosa, an incision was made along icone impressions were taken, the shortest the mesial and distal cervical lines. How- distances from the IGM lines to the lowest ever, marginal free gingiva at the lowest cervical points were measured. The short- cervical point was not touched. A full est distance prior to surgery was -0.3mm, thickness flap was elevated beyond the and six months postoperative was -0.4mm. interdental gingival midpoints, and the in- The shortest distances from the incisal terdental space was filled with hydroxy- edges to the lowest cervical points were al- apatite. Vertical and horizontal soft tissue so measured. The length of the creeping change was observed after initial wound attachment was 0.55mm six months post- healing (Fig 28). Two weeks later, margin- operatively. al free gingiva at the lowest cervical point Case 3 was of a coronally advanced flap had covered the porcelain margin. Six combined with the roll technique in a Miller weeks later, the thickness of the interden- class 1 gingival recession. A 55-year-old tal gingiva had increased (Fig 29). Six male patient presented at the dental office months later, the thickness of free gingiva for periodontal treatment of the mandibular

Fig 29 (a) Two weeks later, marginal free gingiva Fig 30 Six months later, following augmentation of has covered the porcelain margin. (b) Six weeks later, the interdental gingiva, a coronal shift in the lowest cer- the thickness of the interdental gingiva has increased. vical point and horizontal increase in the marginal free (c) Twelve weeks later, the thickness of the marginal gingiva is observed and interdental papilla height has free gingiva at the lowest cervical point has increased. increased.

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t t r f e o ssence

a b a b

Fig 31 The lowest cervical points (12C1, 12C2), MGJ Fig 32 In the occlusal plane, the most palatal posi- (12G), mesial (12M1, 12M2), distal (12D1, 12D2) interdental tion of the lowest cervical points in the lateral incisors gingival midpoints were marked in the lateral incisors pri- is located palatally from the virtual IGM lines (a) prior or to IGA (a) and 6 months after IGA (b). The virtual IGM to IGA and (b) six months after IGA. lines have been drawn.

Fig 33 A case of Miller class 1 gingival recession at Fig 34 The lowest cervical point (13C1), the central the maxillary right canine. A composite resin filling is ev- point 3 mm coronally from the lowest cervical point

ident near the CEJ. The length of the keratinized gingi- (13C2), the pre-operative MGJ point (13G1), and the va is 2.5 mm. mesial (13M1, 13M2) and distal (13D1, 13D2) interdental gingival midpoints have been marked on the study model.

right first and second molars. After receiv- USA). The periodontal biotype of the patient ing regenerative therapy using enamel ma- was of the thin-scalloped type. Probing trix protein, teeth mobility decreased and an depths were 1mm at the mesial side, 1 mm improvement in masticatory function was at the facial side, and 1 mm at the distal observed. Subsequently, the patient re- side, respectively. The length of the kera- quested treatment for a Miller class 1 gingi- tinized gingiva was 2.5 mm. The gingival val recession on the maxillary right canine thickness at the lowest cervical point, and (Fig 33). At the re-evaluation a periodontal the mesial and distal interdental gingiva at examination was performed using a probe the CEJ level were measured using an ul- (I5 UNC color-coded Probe, Hu-Friedy, trasonic device (SDM, KRUPP Corporation,

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t t r f e o ssence Essen, Germany).28 Eger gingival thickness was 2.3 mm at the mesial side, 0.8 mm at the lowest cervical point, and 2.3 mm at the distal side. In order to achieve harmony with the cervical lines on the neighboring teeth, 3mm of root coverage was required. The lowest cervical point (13C1), the central point 3mm coronally from the lowest cer- vical point (13C2), the pre-operative MGJ point (13G1), and the mesial (13M1) (13M2) and distal (13D1) (13D2) interdental gingi- Fig 35 In the occlusal plane, the most palatal posi- val midpoints were marked on the study tion of the lowest cervical point (13C1) is adjacent to the virtual IGM line 1 (IGML ). The 3 mm coronal point model (Figs 34 and 35). A silicone impres- 1 (13C2) is located facially from the virtual IGM line 2 sion was taken, and the distances form the (IGML2). lowest cervical point and the 3mm coronal central point to the IGM lines were meas-

Fig 36 The actual length (i) of the IGM line 1 is 9.26mm. The actual shortest distance (d) from the IGM line 1

(IGML1) to the lowest cervical point is 0.25mm.

Fig 37 The actual length (i) of the IGM line 2 is 9.07mm. The actual shortest distance (d) from the IGM line 2 (IGML2) to the predicted lowest cervical point is 0.52mm.

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t t r f e o ssence ured. The shortest distance from the low- vertical incisions exceeding the muco-

est cervical point (13C1) to the IGM line 1 gingival junction were connected with was 0.25 mm (Fig 36). The shortest dis- these incisions to make a trapezoidal flap

tance from the 3 mm coronal point (13C2) (Fig 38). The epithlium was excised using to the IGM line 2 was 0.52 mm (Fig 37). a No. 15 surgical blade at the mesial and The average shortest distance of the thin distal interdental gingiva of the trapezoidal biotypes on the right canine was 0.33 ± flap and the lower portion of the interden- 0.27 mm in this study. On the other hand, tal papilla (Fig 39). A full thickness flap was the average shortest distance of the thick elevated, and two techniques were per- biotypes was 0.18 ± 0.3 mm. According to formed based on the IGM line concept. the average of the right canines in thick Firstly, both interdental gingiva of the biotypes, the predicted 3 mm coronal point trapezoidal flap were folded inside and had to be located at least 0.18 mm facially sutured with 4-0 soft nylon to increase in- from the IGM line 2 in order to avoid future terdental gingival thickness. Secondly, risk of gingival recession. If possible, it was root flattening was performed using a root desirable that the predicted 3 mm coronal planing bur for palatal displacement of the point was located 0.12 mm palatally from lowest cervical point (Fig 40). A peri- the IGM line 2 taking into consideration the osteum releasing incision was performed average and standard deviation value. To to release tension in the trapezoidal flap gain an improvement in the relation be- and the coronally displaced flap was su- tween the predicted lowest cervical point tured (Fig 41). Dentin hypersensitivity ap-

(13C2) and the IGM line 2, two procedures peared within 1 month (Fig 42). However, were applied. The first was palatal dis- 3 months later, dentin hypersensitivity had placement of the predicted lowest cervical disappeared. A periodontal re-evaluation point, and the second procedure was in- was performed 5 months after surgery; terdental gingival augmentation. In the first the probing depth was 2 mm at the mesial procedure, root flattening by removal of a side, 1 mm at the facial side, and 2 mm at composite resin filling was scheduled. As the distal side. The length of the kera- the patient expected surgical treatment tinized gingiva was 4 mm. with minimal intervention, a coronally ad- Gingival thickness was 2.4 mm at the vanced flap combined with the roll tech- mesial side, 1.4 mm at the postoperative nique was scheduled for the second pro- lowest cervical point, and 3.0 mm at the cedure. The patient had the procedures distal side, respectively (Fig 43). The post-

explained to him, he then consented to the operative lowest cervical point (13C3), the proposals. MGJ point (13G3) and the mesial (13M3) Following local infiltration anesthesia, a and distal (13D3) interdental gingival mid- composite resin filling was removed using points were marked on the study model a No. 330 carbide bur. Mesial and distal (Figs 44 and 45). Measurements of the horizontal incisions were performed 1mm amount of root coverage were compared below the CEJ using a No. 11 surgical using the pre- and postoperative study blade. An intercircular incision was per- models, and a 3.17 mm improvement was formed connecting the horizontal inci- evident. The shortest distance from the

sions. Subsequently, mesial and distal postoperative lowest cervical point (13C3)

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Fig 38 An intercircular incision, mesial and distal Fig 39 The epithlium was excised using a No. 15 horizontal incisions using a No. 11 surgical blade. Ver- surgical blade at the mesial and distal interdental gin- tical incisions were performed for the construction of a giva of the trapezoidal flap and the lower portion of the trapezoidal flap. interdental papilla.

Fig 40 After full thickness flap elevation, both inter- Fig 41 Following a periosteum releasing incision, dental gingiva were folded inside, and sutured with 4- the coronally displaced trapezoidal flap was sutured. 0 soft nylon to increase interdental gingival thickness. Furthermore, root flattening was performed using a root planing bur for palatal displacement of the lowest cer- vical point.

Fig 42 One week later, swelling was evident. Re- Fig 43 Five months after surgery 3mm root cover- moval of the suture was performed 2 weeks after sur- age was attained. The keratinized gingiva increased by gery.58 4mm.

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Fig 44 The postoperative lowest cervical point (13C3), Fig 45 In the occlusal plane, the postoperative most the MGJ point (13G3), and the mesial (13M3) and distal palatal position of the lowest cervical point (13C3) is ad- (13D3) interdental gingival midpoints have been marked jacent to the virtual IGM line 3 (IGML3). on the study model five months after surgery.

Fig 46 The actual length (i) of the IGM line 3 (IGML3) is 9.09mm. The actual shortest distance (d) from the IGM line 3 to the postoperative lowest cervical point (13C3) is -0.19mm.

to the IGM line 3 was -0.19mm on the sili- the chosen treatments for gingival reces- cone impression (Fig 46). sion are periodontal plastic surgery.29 This is often chosen due to the predictability of the results of the procedure, and with the Discussion viewpoint that desired results can be achieved in the short-term, and results can In a healthy periodontium, the form of the be accurately predicted.11 Although good cervical line is scalloped mesiodistally and results are obtained following periodontal marginal free gingiva slopes coronally to plastic surgery from the patient’s point of end in a round or thin edge.1,2 However, view, it would be better to avoid surgical several pathologic factors (periodontitis, operation if possible. brushing trauma, and tooth malposition) Two reports have been published on often cause gingival recession with an ir- the improvement of gingival recession in- regular gingival form.10 Recently, many of volving non-surgical treatment. According

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t t r f e o ssence to the case report by Ando et al,15 root cov- erage in multiple gingival recession was achieved following suitable control of plaque, scaling, root planning and polish- ing and the instruction of appropriate brushing methods. Over a long-term ob- servation period, inflammation around the cervical lines subsided and the positions of the marginal free gingiva gradually moved to the coronal side. In addition, the form of the marginal free gingiva changed from that of the dull-edged variety to the sharp- Fig 47 Several supracrestal fibers exist in gingiva. edged variety. A 12 month research proj- Under the middle portion of the interdental gingiva, crosslink transgingival fibers and intercircular fibers re- ect by Aimetti et al16 reported that the im- inforce the circular fibers between the neighboring teeth. provement of gingival recession occurred using periodical root planing. Following the flattening of the root surface, a reduc- the marginal gingiva decreases and the tion in the length of the gingival recession thickness of the marginal free gingiva at and also a reduction in the width were ev- the facial and interdental space increas- ident. Furthermore, the marginal free gin- es.32,33 Root flattening in non-surgical treat- giva changed from the dull-edged variety ment and in periodontal plastic surgery to the sharp-edged variety, and the thick- may ease tension in the gingiva and may ness of the facial gingiva increased. It is contribute to an increase in the thickness speculated that the relationship between and height of free gingiva.16,34 Therefore, to the form of the cervical line and the form understand the state of the cervical line, it of the marginal free gingiva exists in these is necessary to examine the relationship processes. between the position of the lowest cervical When orthodontic movement is per- point on the tooth surface and the neigh- formed in a facial direction, stretching will boring interdental gingiva. occur in the facial gingiva, and the thick- Several supracrestal fibers exist in the ness and height of free gingiva will de- gingiva.5 In particular, circular fibers are re- crease.13,14 In prosthodontic treatment, lated to the form of cervical gingiva and in- when a retraction cord is placed in a gin- terdental papilla. Under the middle portion gival sulcus, the circumferential distance of the interdental gingiva, crosslink trans- around the inner side of the free gingiva in- gingival fibers and intercircular fibers re- creases. The decrease in the thickness of inforce the circular fibers between the the free gingiva is related to the decrease neighboring teeth35 (Fig 47). It is likely that in the height of the free gingiva.13,14 Conse- the mesial and distal interdental gingival quently, the position of the free gingival midpoints are important points to support margin shifts apically.30,31 This situation is the free gingival height at the lowest cer- similar to an increase in root convexity. On vical point. In this study, it was important to the other hand, when a semi-lunar flap is decide on several baselines. Various performed for root coverage, the tension in anatomic elements might be considered

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t t r f e o ssence for the set up of the interdental gingival spatial relationship of the position of the midpoint line. Although hard tissue ele- anterior teeth. There was no difference in ments (tooth length and tooth width etc) the actual shortest distance between the are considered for the reference lines,36 right and left anterior teeth because the se- they are difficult to set up if the teeth are lected patients had symmetrical arch only partially malpositioned. According to forms from the mid-palatal suture. More- the orthopantograph study and long-term over, the difference in the periodontal bio- clinical study of comparisons of the api- types could be considered according to cally repositioned flap and the following points. In line with the May- by Ainamo et al,37,38 it is said that the lines nard classification,9 the class 1 biotype with of the mucogingival junction are stable. thick bone and thick gingiva is stable re- Furthermore, the length of keratinized gin- garding the risk of gingival recession. On giva is similar bilaterally in the maxillary the other hand, gingival recession tends to anterior region.26,39 Therefore, the bilateral occur in the class 4 biotype with thin bone MGJ points were selected for the set up of and thin gingiva. Thin-scalloped biotypes the reference lines. The mesial and distal have thin interdental gingiva and a pro- interdental gingival midpoints where the nounced tooth form. Thick-flat biotypes parallel lines crossed the interdental per- have thick interdental gingiva and a flat pendicular lines were also determined. tooth form.7, 8 Therefore, the position of the In esthetic dentistry, cervical line man- lowest cervical point in the thick periodon- agement is one of the most important top- tal biotype, which has a flat tooth form with ics. The anatomic factor is firstly consid- thick bone and thick interdental gingiva, ered for determining the position of the seems to be the most stable from the view- lowest cervical point. This study showed point of the concept of the IGM line. that the average position of the lowest cer- Blood supply affects the speed of soft vical point in the central incisors coincides tissue wound healing.1,3,41 In a 12 month with the IGM line. This is located 0.24 mm study of the CCLP by Pontoriero and Cal- palatally in the lateral incisors, and 0.3 mm nevale,42 a coronal shift of the free gingival facially in the canines from the line. There margin was observed over time. The were no differences in the average dis- speed of wound healing at the interdental tances between bilateral anterior teeth. gingiva was faster than that at the facial However, the average distances in thin bio- gingiva. Moreover, compared with the thin types were always greater than in thick biotype, a continuous coronal shift of the biotypes. Although the facial thickness of thick biotype was observed at 12 months. the alveolar bone on the maxillary lateral As for case 1, various changes were ob- incisor is the thinnest of all the teeth,40 the served in the 11 year period after the CCLP. shortest distance from the IGM line is that In the first wound healing stage, the cervi- of a minus value in the anterior region. cal lines changed from the ovoid form to Compared with the central incisor or the the tapered form following an increase in canine, the lateral incisor is usually locat- the interdental gingiva. The free gingival ed at the palatal side in the maxillary ante- margin changed to an obtuse angle form, rior teeth. Therefore, it is speculated to be and inflammation was evident in spite of the cause, as it is based on the relative quality plaque control.15 In the second

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t t r f e o ssence wound healing stage, the free gingival In case 2, although expectations concern- margin changed to an acute angle form ing long-term results depending on an im- with coronal gingival growth, and inflam- provement in the brushing method to be mation disappeared. The crown form used by the patient were considered, IGA changed from the tapered form to the was performed on the patient based on the ovoid form, and the lowest cervical points IGM line concept in order to achieve min- were close to the IGM lines. Therefore, imal intervention and quality short-term re- since the final wound healing period of the sults. When IGA was performed on a pa- CCLP is long-term in thick periodontal bio- tient with a thin periodontal biotype types, it seems to be necessary to post- (without touching facial marginal gingiva pone the definitive restorative treatment and the root surface at the lowest cervical and proceed with caution concerning free point) the height and thickness of the facial gingival form and inflammation of inter- marginal gingiva increased. The point that dental and facial gingiva. should be noted here is that the height and The term ‘creeping attachment’43 is used the thickness of the facial marginal gingi- to describe a gradual coronal migration of va increased following an increase in inter- the free gingival margin. Creeping attach- dental gingiva in case 1 and in case 2. It ment can often be observed in free gingi- may be assumed from these results that val grafts, connective tissue grafts and the three-dimensional volume of dentogin- dermal matrix allografts.44–47 Although sev- gival complex in facial gingiva may be eral factors are44–46 considered to be relat- guided to the form of the neighboring in- ed to the creeping attachment, the mech- terdental gingiva it assuming the physio- anism is still unknown. In case 1 using a logic form of the supracrestal fibers (see CCLP with a thick-flat biotype, various figure 47).48 changes have been shown in the relation- Many articles on the coronally ad- ship between the vertical and horizontal vanced flap have been written.49 The coro- position of the lowest cervical points. The nally advanced flap is mainly used in value of the shortest distance of the right Miller class 1 gingival recessions. How- central incisor from the IGM line was be- ever, systematic reviews comparing the low the limits of standard deviation in this coronally advanced flap with the connec- study at 1 year after surgery. Ten years lat- tive tissue graft have shown that the suc- er the value shifted above the limits of cess rate of the coronally advanced flap is standard deviation following 1mm of lower.11,50 It has also been pointed out that creeping attachment. On the other hand, the thickness of the gingival flap plays an the value of the left lateral incisor was important role in the success rate of coro- above the limits of standard deviation 1 nally advanced flaps. Pini Prato et al52,53 year later. Ten years later, the value shifted stated that the success rate of the coronal- to be within the limits of standard deviation ly advanced flap is dependent on the following 1 mm of gingival recession. From thickness of the gingival flap, whether or these things, it is speculated that the mar- not tension is present in the flap, and the ginal free gingival level at the lowest cervi- post-surgical position.51–53 Zucchelli et al23 cal point is related to the shortest distance stated that several factors affect the prog- from the IGM line. nosis of surgical techniques, and suggest-

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t t r f e o ssence ed that the predetermined line of root cov- crease in the amount of dentin, treatment erage was one of these factors. A coronal- of dentin hypersensitivity55 and pre-surgi- ly advanced flap combined with the roll cal orthodontic treatment57 all need to be technique54 is a new surgical technique taken into consideration. drawn from the concept of the IGM line. In It seems that the IGM line could become a this procedure, it is important to evaluate diagnostic standard from a viewpoint of the relationship between the pre-operative minimal intervention periodontal plastic lowest cervical point and the IGM line, and surgery method selection, selection of to evaluate the relationship between the non-surgical or surgical treatment, and se- predicted lowest cervical point and the lection of the operative surgery method. IGM line. In this study, the average posi- Furthermore, the concept of the IGM line tion of the lowest cervical point in the thick may be effective in setting up the cervical biotypes was 0.18 mm facially located line in peri-implant plastic surgery. There- from the IGM line, and in the thin biotypes fore, initially it is necessary to investigate was located 0.33 mm from the IGM line in the relationship between healthy periodon- the maxillary right canines. As the thick- tal tissue form and the IGM lines in detail. ness of the marginal ginigva influences the postoperative position, the roll tech- nique was added to the coronally ad- Acknowledgements vanced flap in order to convert the peri- The authors thank Mr Greg Tamplin for his assistance odontal biotype in the interdental gingival with the manuscript preparation. area.50,51,54 Furthermore, root flattening was performed to assist guidance of the inter- dental gingiva.15,16 In the postoperative pe- References riod, brushing instruction was given so 1. Lindhe J, Karring T, Araujo M. Anatomy of the that not only facial marginal gingiva, but periodontium. In: Lindhe J, Karring T, Lang NP also interdental gingiva would not be (ed). Clinical periodontology and implant den- tistry. 4th edition. Oxford: Blackwell Munksgarrd, 15 damaged. Dentin hypersensitivity contin- 2003;3–49. ued for 1 month in case 3. The cause of 2. Grant AG, Stern IB, Listgarten MA. Periodontal health and disease. Sixth edition. Missouri: The the dentin hypersensitivity was considered CV. Mosby Company 1988;4. to be the removal of a composite resin fill- 3. Dubrul EL. The dentition and occlusion. In Dubrul ing and root flattening. Miller stated that EL (ed). Sicher and Dubrul’s oral anatomy. 8th edition. St Louis: Ishiyaku, EuroAmerica, Inc pulpitis occasionally occurs in root cover- 1988;133–159. age using free gingival grafts.34 However, 4. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentoginigival junction in when a coronally advanced flap is used humans. J Periodontol 1961;32:261–267. for the treatment of gingival recession as- 5. Shroeder HE. Gingiva. In:Schroeder HE (ed). The sociated with non-carious cervical lesions, periodontium. Berlin:Springer-Verlag 1986;233–323. dentin hypersensitivity is often a by-prod- 6. The American Academy of Periodontology. uct of this procedure.55 Recently, CEJ has Glossary of Periodontal Terms, 3rd ed. Chicago: The American Academy of Periodontology been used as the standard for success in 1992;41. 56 root coverage procedures. Therefore, as 7. Ochsenbein C, Ross S. A reevaluation of osseous excessive root flattening near CEJ may surgery. Dent Clin North Am 1969;13:87–102. 8. Weisgold AS. Contours of the full crown restora- cause non-reversible pulpitis, the de- tion. Alpha Omegan 1972;10:77–89.

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A successful and pre- orthodontic tooth movement in Orthodontic diaganosis. dictable procedure in areas of monkeys. J Clin Periodontol Stuttgart: Georg Thieme Ver- deep-wide recession. Int J 1987;14:121–129. lag: 1993;207–234. Periodontics Restorative Dent 15. Ando K, Ito K, Murai S. 25.Kan JYK, Rungcharassaeng K, 1985;5(2):15–37. Improvement of multiple facial Umezu K, Kois J. Dimensions 35.Page RC, Ammons L, Schect- gingival recession by non-sur- of peri-implant mucosa:An man R, Dillingham A. Collagen gical and supportive periodon- evaluation of maxillary anterior fiber bundle of the normal tal therapy: A case report. J single implants in humans. J marginal gingiva in the mar- Periodontol 1999;70:909–913. Periodontol 2003;74:557–562. moset. Arch Oral Biol 16. Aimetti M, Romano F, Piccolo 26.Rose ST, App GP. A clinical 1974;19:1039–1043. DC, Debernardi C. 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t t r f e o ssence 39. Bowers GM. A study of width 49. Allen EP, Miller PD. Coronal 54. Abrams L. Augmentation of the of attached gingiva. J Peri- positioning of existing gingi- deformed residual edentulous odontol 1963;34:201–209. va:Short term results in the ridge for fixed prosthesis. 40. Ezawa T. The thickness and treatment of shallow marginal Compend Contin Educ Gen form of alveolar bone in con- tissue recession. J Periodontol Dent 1980;1:205–213. temporary dry skulls. J Jpn 1989;60:316–319. 55.Santamaria MP, Suaid FF, Soc Periodontol 50. Hwang D, Wang HL. Flap Casati MZ, Nociti FH, Salllum 1984;26:243–256. thickness as a predictor of root AW, Sallum EA. Coronally 41. Wikesjo UME, Selvig KA. Peri- coverage: A systematic review. positioned flap plus resin- odontal wound healing and J Periodontol modified glass ionomer regeneration. Periodontology 2006;77:1625–1634. restoration for the treatment of 2000 1999;19:21–39. 51. Baldi C, Pini Prato G, Pagliano gingival recession associated 42.Pontoriero R, Carnevale G. U, Nieri M, Saletta D, Muzzi L, with non-carious cervical Surgical crown lengthen- Cortellini P. Coronally lesions: A randomized con- ing:12-month clinical wound advanced flap procedure for trolled clinical trial. J Periodon- healing study. J Periodontol root coverage. Is flap thickness tol 2008;79:621–628. 2001;72:841–848 a relevant predictor to achieve 56.Wennstrom JL, Zucchelli G. 43.Goldman H, Schluger S, Fox L, root coverage? A 19-case Increased gingival dimensions. Cohen DW. Periodontal Thera- series. J Periodontol A significant factor for suc- py. 3 rd edition. St Louis: The 1999;70:1077–1084. cessful outcome of root cover- CV Mosby 1964:560. 52.Pini Prato G, Pagliano U, Baldi age procedures? A 2-year 44. Matter J, Cimasoni G. Creep- C, Nieri M, Saletta D, Cario F, prospective clinical study. J ing attachment after free gingi- Cortellini P. Coronally Clin Periodontol val grafts. J Periodontol advanced flap procedure for 1996;23:770–777. 1976;47:574–579. root coverage. Flap with ten- 57. Ito K, Gomi Y. Clinical trial of 45. Matter J. Creeping attachment sion versus flap without ten- perfoming coverage of of free gingival grafts. A five- sion:a randomized controlled exposed root surface induced year follow-up study. J Peri- clinical study. J Periodontol orthodontic treatment:A case odontol 1980;51:681–685. 2000;71:188–201. report. J Jpn Soc Periodontol 46.Harris RJ. Creeping attach- 53.Pini Prato G, Baldi C, Nieri M, 2001;43:80–82. ment associated with the con- Debora Franseschi, Cortellini 58. Clark RAF. Wound repair. nective tissue with partial-thick- P,Carlo Clauser, Rotundo R, Overview and general consid- ness double pedicle graft. J Muzzi L. Coronally advanced erations. In Clark RAF (ed). Periodontol 1997;68:890–899. flap:The post-surgical position The molecular and cellular 47. Haeri A, Parsell D.Creeping of the gingival margin is an biology of wound repair. 2nd attachment:autogenous graft important factor for achieving edn, New York, Plenum Press, vs dermal matrix allograft. complete root coverage. J 1996:3–50. Compend Contin Educ Dent Periodontol 2005;76:713–722. 2000;21:725–729. 48. Otero-Cagide FJ, Otero- Cagide MF. Unique creeping attachment after autogenous :case report. J Can Dent Assoc 2003;69:432–435.

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