Noninvasive Soft Tissue Advancement in Conjunction with Aesthetic Dentistry.
Part 1: Treating Gingival Recession
Over the past couple years, several patients have asked me how they developed gingival recession and how it can be treated. Gingival recession can have a number of etiologies. It can be triggered by periodontal disease, which may stem from a patient’s lack of home care.
Patients can also get gingival recession from overzealous brushing—applying too much pressure in an effort to get cleaner teeth, but aggravating the gingiva instead. In women, hormonal shifts can cause gingival recession at different times of life.
One of the most common causes of gingival recession is grinding and clenching, which many people do at night without being aware of it. Grinding places pressure on the teeth and can cause the gingiva to recede. Malaligned teeth can contribute to gingival recession as a result of bony architecture. Because the gingiva follows the bone, bone with irregularities will also result in irregular gingiva.
Traditionally, dentists treat gingival recession with a free gingival graft. The dentist makes an incision on the area of the mouth where the recession exists. A graft from the palate is then transferred to the recessed site, and the tissue is re-approximated back together with sutures. Because there are two surgical sites and sutures, it’s a painful procedure for the patient. Everyone heals a little differently, but recovery normally takes anywhere from three to six months.
Also, because the graft tissue comes from a different site of the mouth, the color and texture of the tissue is often not aesthetically pleasing. Some patients get bumps and irregularities in the gingiva at the surgical site and aren’t happy with the results.
Another treatment option is to fill recessed areas with composite to eliminate the yellow hue from the root where the gingiva has receded. While this option helps with aesthetics, it does not really address the underlying problem. The gingiva may continue to recede, and the use of composite may make the teeth appear longer.
A Different Method
A periodontist colleague introduced me to the Chao Pinhole® Surgical Technique. It’s a scalpel free, suture free, graft free, minimally invasive procedure that corrects gingival recession.
John Chao, D.D.S., M.A.G.D., from Alhambra, CA, invented and patented the instruments to use in the technique. He teaches a course to train and certify dentists on the procedure. I attended the course in August 2017. It was an intensive, two-day course packed full of instruction and hands-on training.
During those two days, dentists learned first from a lecture, followed by practicing the technique on typodonts and then pig jaws. Finally, we practiced on a cadaver. Dr. Chao gave each student a case and I completed a full upper and lower arch. On my own time, I returned to the classroom and put in extra time to practice another arch.
This session included five doctors, so we all benefitted from one-on-one time with Dr. Chao. I was thankful that he took extra time to sit chairside with me to go through a case.
While the Pinhole® Surgical Technique is a highly technical procedure, it requires less time to complete than traditional techniques and relatively minimal overhead. Upon completion of the course, I was able to implement the technique in our practice immediately.
Pinhole® Surgical Technique
To perform the procedure, a dentist uses a needle to make a small hole apical to the area that has the recession. All the work is then done through this pinhole. The dentist uses Dr. Chao’s patented instruments to loosen the gingiva from the bone. Once the gingiva is loosened, the dentist gently glides it over the receded area. There is no cutting or stitching involved. Patients have very minimal post-operative pain, swelling, and bleeding.
Although the Pinhole® Surgical Technique is a minimally invasive process, post-op instructions are very rigorous. The patient must carefully follow instructions or risk reversing the procedure. Major restrictions include: the patient can’t brush, floss, or even use a Waterpik® for six weeks. Patients must be as gentle as possible with the gingiva for it to heal properly.
In addition to hygiene instructions, the patient has to follow a soft diet protocol, since biting into certain foods could disturb the recovering tissue. Candy, gum, sticky, or crunchy foods are off-limits. Drinks should be lukewarm—the patient shouldn’t drink anything hot, such as soup, coffee, or tea. During that time, patients should also abstain from drinking alcohol and smoking.
If patients have a history of clenching and grinding, it is important to either dial in their orthotic or fabricate one for them to use during the recovery period. Patients with sleep apnea can’t use a CPAP device during recovery. The goal is for patients to leave the site alone to allow the tissue to integrate and heal.
Following the procedure, the patient has post-op appointments after one day, one week, one month, three months, and six months. During the initial post-op visits, I want to see as much plaque as possible in this area, because then I know that the patient is compliant with post-op instructions. I often use a plaque-disclosing tablet to show the patient that they are doing a good job. After the first six weeks, patients can brush with a soft toothbrush.
The pinhole technique is beneficial because dentists can correct gingival recession in as little as one treatment session, depending on the extent of recession. Patients experience minimal discomfort and swelling, because there is no cutting or suturing. Treatment sessions normally last between one and two hours, depending on how many teeth need to be done.
Dr. Chao conducted long-term studies demonstrating the procedure’s effectiveness before introducing it to the public. The pinholes that are made during the procedure heal within about 24 hours. Most patients end up taking two Advil® and don’t require any narcotic pain medication.
Since taking the course, I’ve completed four cases using the Pinhole® Surgical Technique. The first one was for Abby (not her real name), a long-time patient of our practice.
She had significant anterior recession on her upper arch and had been dealing with it for quite some time. She also had some bite issues (which Dr. Downs addresses later in this story). Abby finally decided to do something about both her receding gingiva and her bite issues.
Dr. Downs had talked to her about veneers and correcting her bite, but indicated to her that she first needed to restore some gingival tissue so that her teeth did not look as long inciso-gingivally when she smiled. He suggested that she undergo the pinhole technique, so I had a consultation with her to discuss the process.
We discussed the pros and cons of traditional grafting as opposed to this procedure. She was skeptical at first, especially when I told her that she couldn’t brush her teeth or floss for six weeks after treatment. I made it clear that we would have to wait six months after the pinhole treatment to proceed with restorative treatment. It was not a quick fix.
As dentists, we want the outcome to be aesthetically satisfactory. Patients are typically concerned with the intensity and duration of the post-op pain, whether there is bleeding, and whether they will be satisfied with the overall outcome.
I emphasized that this procedure has been deemed a predictable, effective, minimally invasive, time- and cost-effective alternative to a free connective tissue graft, in both the short and long term. Together, Abby and I decided to move forward.
On the day of treatment, we proceeded carefully and systematically with the technique. Abby had recession that ranged from about two to four and a half millimeters across her maxillary anterior, from tooth numbers 5 through 12.
With the pinhole technique, to treat one tooth, you have to go two teeth and three papilla in each direction from the tooth you are working on in order to get a full release of the tissue for the desired coverage. Since we were treating tooth numbers 5 through 12, we ended up doing the entire maxillary arch to get full release of tissue.
The following are steps we took during the treatment:
1. On the day of the procedure, I anesthetized the areas we would be working on.
2. After she was numb, I made four pinholes on tooth number 4, tooth number 7, tooth number 10, and tooth number 13.
3. Using the instruments and the protocol, I achieved full release of the tissue across the entire maxillary arch on the buccal surface from an apical to a coronal direction.
4. I was then able to pull her gingiva about halfway down, covering half of her teeth. (You want as much coverage of the teeth as possible, so that when you’re done, the patient looks like they have an extremely “gummy” smile.)
5. After this full release, I placed collagen in the pinhole in each of the papillas first, and then over the zenith of each tooth.
6. I packed the collagen in, so the gingiva looked very puffy and bulbous, and the patient had to sit with cotton rolls in for about 10 minutes to let everything settle.
And with that, Abby’s procedure was completed. The entire process took 1 hour and 15 minutes. Immediately after we finished, Abby was surprised that she wasn’t in much discomfort. When I made my post-op call that night, she said her gingiva felt mildly “agitated,” but she didn’t have any pain or discomfort.
When she came in the next day, everything looked like it was healing well. She mentioned that her gingiva felt a little tight, which was due to the packed collagen. She also said that it felt different when she smiled, which was because the musculature of her lips was affected when we released the tissue underneath. She ended up with great coverage on her gingiva. Her recovery went smoothly, and she followed the post-op procedures perfectly.
When Abby presented for her six-month appointment, Dr. Downs took over and started with the restorative work. He was pleased with how good everything looked. Without this procedure, Abby would have had very long veneers, which would not have fit her facial profile, and which would neither have been symmetrical nor aesthetically pleasing.
This case is definitely not something I do every day, but the gratification I’ve gotten from training in the procedure and successfully performing it with Abby has been tremendous. Although skeptical at first, she too is very happy with the results.
The Pinhole® Surgical Technique can be a valuable extra tool in a dentist’s back pocket that offers a patient concerned with gingival recession a nearly painless alternative to traditional gingival grafts.