A common question that I often get is: “When should the soft tissue root coverage procedure be completed if the teeth also need to be restored?” This is a great question: Do you graft first and then restore the teeth, or restore the teeth and then graft?
Let me begin by saying this question can be answered in a couple of ways depending on the clinical situation at hand, so there really may not be a wrong sequence. My recommendation is to always consult with your periodontist prior to treatment to determine the most appropriate sequence. The following will provide the “general beliefs” that my periodontist and I tend to follow.
Graft first and then restore? Or restore and then graft?
To answer this dilemma, we usually ask two questions:
- Where are the teeth located in the arch ... are they anterior or posterior?
- What is the restorative plan ... are the restorations direct or indirect?
In the posterior, if the restorations are “direct,” we tend to restore the teeth first, followed by grafting.
The benefit of this is that by restoring first, I don’t have to come back in and risk traumatizing the tissue during the retraction and restoration process.
In order to determine where to end the new restoration on the root, it is imperative to consult with the periodontist prior to treatment. They will determine how much root coverage can be expected and hence inform you where to end your restoration on the root. To help estimate how much root coverage can be expected, we use the 3mm rule.
Measure down 3mm from the height of the papilla. This estimates the height of the interproximal bone and hence the height that the soft tissue root coverage can be expected (given that we can’t graft more coronal than the height of the interproximal bone).
In the anterior, we tend to graft first and then restore the teeth. The benefit of this sequence in the esthetic zone is that if the surgeon isn’t able to cover to the coronal extent that was anticipated, the restoration can cover the remaining root to maintain the esthetics rather than leaving the visible root. In the posterior, if there is a little root still showing post treatment, the esthetics aren’t compromised as significantly.
With regard to the sequencing of root coverage procedures and indirect restorations, we generally always graft first and then restore the teeth. Again, this allows us to help cover any remaining root that may still be visible. It also helps us create better gingival margin symmetry by doing a simple gingivectomy prior to restoration if required.