The Brown PerioDontaLetter PDL tm I. Stephen Brown, D. D. S., Periodontics & Implant Dentistry Winter From Our Office Mucogingival Grafting to Yours... Around Teeth and Implants An adequate width of keratinized gingiva is important for maintaining eratinized gingiva pro- Without attached gingiva, the gingival health. tects the tissue around more fragile, freely-movable Studies show that areas with less teeth and implants from alveolar mucosa would be sub- than 2mm of keratinized gingiva, K ject to trauma during eating and which means less than 1mm of inflammation and trauma, stabi- attached gingiva, are more likely to lizes the position of the gingival consequent cleaning and more become inflamed. margin, aids in dissipating the prone to recession. Adequate keratinized gingiva is physiological forces exerted by This makes the width of the important around dental restorations, muscle fibers, and is esthetical- attached keratinized tissue criti- but especially around dental implants ly pleasing. cal: the more attached gingiva which in the absence of a periodontal ligament do not enjoy the ample blood supply natural teeth do. In this current issue of The PerioDontaLetter, we discuss muco- gingival grafting to create adequate keratinized, plaque-resistant attached gingiva around teeth and implants. As always, we welcome your com- ments and suggestions. Figure 1. Significant Figure 2. Connective recession was affecting the tissue grafting and root gingival health and esthetic coverage improved the appearance of this patient’s health of the gingiva and maxillary anterior arch. created a very pleasing esthetic appearance. I. Stephen Brown, D. D. S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660 Figure 3. As a result of gingival recession and Figure 4. Gingival reconstruction stabilized inflammation, the long-term prognosis for this the periodontal health of the patient and patient’s lower anterior arch was questionable. increased the patient’s ability to control plaque. available, the greater the mucosal Mucogingival • Less than 2mm of keratinized protection. gingiva Furthermore, the tight connec- Grafting • Sensitivity of exposed root tion of the keratinized attached Around Teeth surfaces gingiva which extends from the • Esthetic dissatisfaction: to gingival margin to the mucogin- Keratinized tissue around natural reestablish a pleasing esthetic gival junction is essential for the teeth can be lost due to dehiscence gingival architecture. health and maintenance of teeth caused by: • Preventively, prior to and dental implants. • Orthodontic movement initiation of orthodontic Hemidesmosomal fibers attach • Thin biotype therapy in areas with a the junctional epithelium to the • Trauma thin labial osseous plate. teeth and implants and is normal- • Inflammatory periodontal • Preventively, in conjunction ly about 1mm long. disease with fixed or removable Subjacent to the junctional • Occlusal forces prosthetic dentistry, epithelium is a dense connective • Toothbrush trauma and especially when intrasulcular tissue layer about 1mm long. flossing margins are planned. Around teeth, these fibers are • Facial tooth positioning Surgical procedures to increase perpendicular to the root surfaces • Aberrant frenums the width and thickness of and insert into the cementum. • Restorative dentistry trauma attached gingiva around teeth are Around implants, these connec- Soft tissue augmentation should among the most highly pre- tive tissue fibers are circular or be considered in the following dictable, minimally invasive and oblique and do not insert into the situations: most satisfying periodontal implant’s surface. • Progressive recession procedures. They include: • Gingival augmentation apical “Keratinized gingiva protects the tissue around teeth and to the area of recession. implants from inflammation and trauma, stabilizes the A free graft is placed on a position of the gingival margin, aids in dissipating the recipient bed apical to the physiological forces exerted by muscle fibers, and is esthetically pleasing.” recessed gingival margin. The denuded root surface is Figure 5. Gingival recession caused sensitivity Figure 6. Connective tissue grafting eliminated and esthetic concerns for this patient. the root sensitivity and created an extremely pleasing esthetic appearance. generally not covered. The Mucogingival bent upon the clinician to remain free gingival graft effectively sensitive to the need to preserve widens the attached gingiva. Grafting the quantity, quality and volume • Gingival augmentation Around of the peri-implant tissues. coronal to the recession Dental Implants (root coverage). Conclusion A connective tissue graft is Reconstruction of keratinized placed covering the denuded root mucosa around implants is an Advances in our understanding surface creating a dense connec- important adjunct in ensuring suc- of indications and contraindica- tive tissue. cessful outcomes of dental im- tions for mucogingival graft thera- Both the apical and the coronal plant treatment. py, and the utilization of newer widening of attached gingiva The establishment of healthy materials and techniques have dra- enhance oral hygiene procedures, tissue around implants results in matically altered both the patient but only coronal widening can more predictable maintenance experience and predictability of correct esthetic problems. and improved esthetics. favorable treatment outcomes. Connective tissue grafts are As with natural teeth, the tissues used to achieve enhanced esthet- should be enhanced if there is ics because a better color match insufficient keratinized gingiva. of the tissues can be attained. It should be noted that gingival The connective tissue graft pro- tissue may be lost during stage I duces a most desirable gingival or stage II implant surgery. contour. As one stage implant proce- The new tissue covers the crest dures have evolved, it is incum- of the bone and is attached to the cemental root surface producing a firm, well-formed, tapered gingival margin. “Reconstruction of keratinized mucosa around implants is As in all grafting procedures, a an important adjunct in ensuring successful outcomes of well-vascularized donor and reci- dental implant treatment.” pient site is of critical importance. PerioDontaLetter, Winter Getting to Yes: The Science of Persuasion he science of influence can be 1. Is it better to present the more the more motivating it is. It is particu- helpful to us in getting what we expensive option first or last? larly valuable, if only you have this T ask for because of the way we Cialdini says it is better to give the exclusive information. present our requests. more expensive option first because it 4. Should you present weaknesses Understanding and applying these sets a high standard which makes the in your message first or last in your principles can make us more effective less expensive option appear more presentation? not only in treatment presentations to affordable. Restaurants often price It is best to present weaknesses first patients, but also in our relationships wine by the glass three ways: one high and then overcome them by presenting with our teammates, friends and family. at $19, one low at $9, and one in the the strength of the benefits. Robert Cialdini has done much of the middle at $14. Most people will Acknowledging the weaknesses in a research in this area and recently pub- choose the most profitable one in the presentation makes the presenter a more lished a book called “Yes! 50 middle. believable authority since almost every Scientifically Proven Ways to be If there are genuinely beneficial presentation has some weaknesses. For Persuasive.” requests or treatment plans you can offer example, you might say that while an In his book Dr. Cialdini describes the at different levels, always start with the implant may cost more, it lasts longer six basic laws that motivate people to ideal plan to give people a chance to say and doesn’t get cavities. say “yes” to a request: “yes” to it. 5. What should you say after some- 1. Reciprocation and concessions. Cialdini notes there is another one thanks you for a favor you’ve Be first to give. People feel obligated to moment of power when someone says done or an excellent treatment result? return favors. If you make a concession “no” to a request. At that time, we can Often we will say, “Oh, it was noth- first, people will often meet you use the principle of concession to offer a ing. Don’t think anything of it.” This halfway. less expensive option. Patients will see is another moment of power. If we miss 2. Liking. Noting similarities with this as a favor and will often feel more this moment, it is lost forever. them and with others, giving compli- obliged to accept the new offer. The best response in a personal situa- ments and finding areas of agreement Offering another option allows you to tion according to Cialdini, is to say, “I facilitates a good relationship. win even after they say “no.” know if the situation is ever reversed, 3. Consistency. Once people have 2. Is it better to tell people what you would do the same for me.” agreed to start their treatment, they they stand to lose or what they stand In our practices, this is the moment to are more likely to proceed with fur- to gain? say, “It was a pleasure working with ther recommendations. People want The science is clear that people are you; please tell your friends about our to be consistent with what they’ve more highly motivated by what they office.” If you miss this moment to ask agreed to do. stand to lose than by what they stand to for referrals, it is lost forever. 4. Authority. People look to experts gain. However, using fear of loss to 6. If you want someone to like you for guidance. Our patients need to be motivate only works if you can offer an and you want them to cooperate with aware of our knowledge, skill and cre- immediate solution. For example, if we you, what is the most important thing dentials before we can influence them. tell patients they are likely to lose their you can do? Have someone give you a strong intro- teeth if they don’t get dental treatment, Look for similarities with them and duction before you see them.