Figure 1: Tooth #28 is in need of a restorative procedure due to a lack of attached gingiva. There is no way other than adding connective tissue to change the present environment.

Figure 2: The tissue is reflected and a subepithelial graft is placed to add connective tissue.

Figure 3: The final restoration on tooth #28 shows a significant increase in connective tissue for long-term maintenance of the periodontal foundation.

Figure 1: Severe recession and bone loss in a 22-year-old patient. The need to increase connective tissue is apparent. A soft tissue procedure is advisable to increase the connective tissue, which is needed for long-term periodontal stabilization.

Figure 2: Reflection of flap shows significant bone loss.

Figure 3: PerioDerm™ thick (DENTSPLY Tulsa Dental Specialties; Tulsa, Okla.) is used to increase the connective tissue.

Figure 4: Flap closure is performed, covering the PerioDerm completely.

Figure 5: Total root coverage is provided by the use of PerioDerm.

Figure 6: Reflection of the mucosa exposes a beautiful zone of connective tissue.

Figure 1: Severe subgingival location of tooth structure following caries removal. This case requires the removal of bone and possibly tooth surface to create a space for a new biologic width to establish, so that it will not be violated by the new restorations.

Figure 2: A beautiful core is placed to be used as a marker to gauge the amount of space needed for a new biologic width to form. Note: The photo is reversed because it is a mirror shot.

Figure 3: A flap is reflected exposing the location of cores to bone, revealing the need for crown lengthening procedures. Note: This can only be accomplished with surgery.

Figure 4: Completed crown lengthening and suturing. Removal of previous margins and a conservative amount of bone will allow for a new biologic width to establish during healing. A new crown margin will be placed just coronal to the gingival collar to prevent periodontal interference from occurring in the future.

Figure 5: An occlusal view shows 360 degrees of perfect interface between tooth surface and bone for long-term maintenance.

Figure 1: A crown placed within the biologic width is causing significant inflammation. This inflammation needs to be dealt with prior to the placement of another permanent restoration.

Figure 2: The existing crowns are removed and cores and provisionals are placed.

Figure 3: Occlusal view.

Figure 4: With the tissue reflected, severe bone destruction is clearly seen due to the biologic width invasion.

Figure 5: Cratered defects are corrected, and a parabolic architecture of the bone to mimic the soft tissue is created.

Figure 1: Developmental groove is causing bone loss on tooth #9.

Figure 2: A flap is laid showing visible developmental defect with small amount of blood in it.

Figure 3: Removal of developmental defect creates a smooth root surface for long-term maintenance.

Figure 4: Connective tissue is added for long-term periodontal stability.

Figure 5: Flap is positioned to cover the connective tissue graft.

Figure 6: Postoperative view showing stable environment with zero probing.

Figure 1: A recent article by Cobb and Rapley, et al.¹ discusses the problems associated with CEJs and the accumulation of biofilm, plaque and calculus. When performing biologic shaping, permanent removal of the CEJ can be undertaken to produce a long-term, maintainable environment for the hygienist and patient. Note the plaque and calculus approximating the CEJs.

Figure 2: Removal of all CEJs with a handpiece to allow for long-term maintenance.

Figure 1: A patient with an excessive display of gingiva and no interest in orthognathic surgery. Crown lengthening will be necessary. A strong biologic background is necessary to properly treat this case for long-term stability. A clinician with a limited background biologically might consider doing a gingivectomy, which could present major difficulty.

Figure 2: Upon reflection of the tissue, massive tori or exostoses are noted. The cause of the problem is tissue having to extend over the excess bone and up onto the enamel.

Figure 3: Bone is removed to create a biologic environment between the bone and soft tissue.

Figure 4: Simple interrupted sutures are placed using 5-0 chromic gut material. Because of primary closure, the patient will have minimal discomfort.

Figure 1: Patient with excessive soft tissue on enamel. Once again, the surgeon needs a strong background in biology to offer this patient the proper surgical approach for a long-lasting result.

Figure 2: Severe bleeding is noted with minimal probing.

Figure 3: Upon reflection of the soft tissue, it is noted that the CEJ and bone are approximating each other, thus creating a condition called “altered active eruption.”

Figure 4: Space created for the biologic width through removal of bone. This procedure could never be undertaken without surgery.

Figure 5: Flap is sutured back into place just coronal to the CEJs with 5-0 chromic suture material.

Figure 1: Teeth #18 and #19 with existing crowns to be replaced. Cores and provisionals will be undertaken so ideal periodontal therapy can be performed.

Figure 2: The buccal margin of tooth #18 approximates the furcation area and furcation involvement is evident. Tooth #19 also has furcation issues and calculus is located just apical to the CEJ on the mesial.

Figure 3: Definitive biologic shaping removes all irregularities on the tooth surface and eliminates the furcation. This treatment is a definitive approach to comprehensive periodontal and restorative treatment that can only be accomplished surgically.

Figure 4: Perfectly contoured restorations following the prepared tooth surface with margins placed just coronal to the gingival collar. Furcations are barreled into the occlusal surface, allowing for long-term maintenance.