Surgical Procedures

OSSEOUS SURGERY

This is one of the most common surgical procedures where incisions are made around the tooth and the gum tissue is pulled back slightly. This provides access to thoroughly remove all plaque and calculus. Irregularities of the bone caused by the disease are smoothed over and the tissue placed at a higher level around the tooth, closer to the bone. When the procedure is completed, dissolving sutures are used. A protective dressing often is placed around the necks of the teeth to cover the surgical area and to help secure the new gum-to-tooth relationship. You will need to be seen in 10-14 days to remove any remaining sutures and evaluate your healing.

By moving the gum closer to the bone, the pockets will be reduced or eliminated. However, the tooth will appear longer and the spaces between the teeth will be larger. In cosmetic areas, other treatment options may be considered depending on how much gum tissue is exposed (smile line).

POCKET REDUCTION/ELIMINATION

When periodontal pockets are greater than 5mm, there is a high probability that the disease process will continue. In these cases, surgical procedures designed to reduce pockets as close to 2-3 mm as possible are often the best treatment. This will provide the patient the greatest potential for infection control by improving access to the bacterial plaque.

CROWN LENGTHENING

Crown lengthening (or crown exposure) is required when your tooth needs a new crown or other restoration due to decay or fracture. The edge of the new restoration would be too deep below the gum tissue and not accessible. It is also usually too close to the bone or below the bone.

The procedure involves adjusting the levels of the gum tissue and bone around the tooth in question, to create a new gum-to–tooth relationship. This allows us to reach the edge of the restoration, ensuring a proper fit to the tooth. It should also provide enough tooth structure so the new restoration will not come loose in the future. This allows you to clean the edge of the restoration when you brush and floss to prevent decay and gum disease. The procedure essentially is osseous surgery on a smaller scale.

When the procedure is completed, dissolving sutures are used. A protective dressing often is placed around the necks of the teeth to cover the surgical area and to help secure the new gum-to-tooth relationship. You will need to be seen in 10-14 days to remove any remaining sutures and evaluate your healing.

SOCKET/RIDGE AUGMENTATION

Periodontal Bone Grafting/Guided Tissue Regeneration
In the last 10-15 years, extensive research has developed techniques that re-grow some or all of the supporting bone around the teeth destroyed as a result of periodontal disease. Although not applicable in all cases, these procedures have increased the number of teeth saved and our ability to successfully treat moderate to advanced periodontal disease.

Performed at the same time as osseous surgery, the lost bone is replaced with synthetic, naturally derived, or combination of bone grafting materials. They act as a “scaffold” for the patient’s own bone to “regenerate” and are usually reabsorbed by the body.

Many regeneration techniques utilize “membranes” which are inserted over the bone defects. This guides the growth of bone by excluding the more rapidly healing gum tissue. Some of these membranes dissolve while others are easily removed. Other regenerative procedures involve the use of bioactive gels, such as Emdogain, which stimulate the body’s own cells to form new tissues.

Hard Tissue Ridge Augmentation
After a tooth is lost, the jawbone begins to shrink. The shrinkage is most rapid over the first year following extraction. Up to 60% of the original width and 40% of the height of the bone can be lost during this period. Bone atrophy usually continues and in certain cases where all the teeth are missing, can even lead to jaw fracture! This loss of bone often leaves a condition of poor quality and quantity of bone, which is unsuitable for placement of dental implants, permanent bridgework, or to support dentures. In many cases, we now have the ability to grow bone where needed. This gives us the opportunity to place implants of proper length and width. By rebuilding lost jawbone, we can also provide better support for removable dentures and more cosmetic permanent bridgework

Extraction Site Preservation
After tooth extraction, the jawbone begins to shrink. The shrinkage is most rapid over the first year following extraction. Up to 60% of the original width and 40% of the height of the bone can be lost during this period. Replacement of the lost tooth with an implant may be impossible or impractical if the extraction socket is left to heal on its own. If permanent bridgework is planned, uncontrolled shrinkage can result in a very long and unsightly false tooth which can be very difficult to clean underneath. To prevent this, we often recommend extraction site preservation. This technique involves very careful extraction to prevent damage to the surrounding bone, and filling the socket with various types of bone grafting materials. Often this is done in conjunction with membranes to prevent the gum tissue from filling the space before bone can form. Proactive treatment will allow us to control and minimize shrinkage after extraction. This results in more predictable and cosmetic results. Treating the problem before it occurs is always preferable.

Soft Tissue Ridge Augmentation
When teeth are extracted without extraction site preservation, the bone often shrinks during healing and leaves a depression in the gum. When a permanent, non-removable bridge is placed, this concavity prevents the artificial tooth from looking real — it’s too long and out of proportion. In other words, it looks “fake”. By repairing the jaw defect with soft tissue ridge augmentation, the artificial tooth now looks like it is growing out of the gum and cannot be distinguished from the natural teeth.

Utilizing a combination of gingival grafts and connective tissue grafts, the defective area is built up to match the surrounding tissue levels. Depending on the size of the defective area and the thickness of the available donor tissue, several procedures may be necessary to obtain the optimum result.

The best way to treat a ridge deficiency is to prevent it from occurring. Performing extraction site preservation at the time of extraction can minimize the amount of bone loss from an extraction.

GUM RECESSION

Types of Gum Tissue
There are two types of gum tissue found in the mouth. Normally, the gum tissue around the neck of the teeth is attached (keratinized) gingiva. This is a firm, non-movable, pink colored tissue which is resistant to normal forces of chewing and brushing as well as bacterial invasion. The darker colored, flexible tissue that lines the cheeks, floor of the mouth, and inside of the lips is called alveolar mucosa. Muscles within the alveolar mucosa are constantly contracting and pulling down on the bottom edge of the attached gingiva. In health, the attached gingiva is wide and strong enough to act as a barrier which prevents the gum from being pulled down (receding). Various procedures have been developed to deal with problems related to these soft tissues

What Can Happen with Injury to the Gum Tissue?
Trauma to attached gingiva from overzealous brushing (use a soft toothbrush and change it every month), injury, malpositioned teeth, or habits can cause gingival recession. If genetically, there is minimal attached gingiva, this tissue can be totally lost. The result may be continued recession. If left untreated, this can cause tooth loss.

With recession and a lack of attached gingiva, the body loses its natural defense against both bacterial penetration and trauma. This can result in sensitivity to hot and cold foods, an unsightly appearance, and exposure of the root surface. The tooth root is softer than enamel, leading to root decay and gouging.

This type of recession is not an infection as with periodontal disease, but an anatomic condition. However, if bone recession is occurring at the same time the gum is receding, there is same potential for tooth loss.

Treatment of Recession and Inadequate Attached Gingiva
When gum recession or inadequate attached gingiva is a problem, reconstruction using gingival (gum) grafts is often indicated. Treatment with gingival grafts can be divided into two categories:

Functional
Repair aimed at stabilizing the gum at its current level without root coverage. Used in areas where cosmetics are not a factor.

Cosmetic
Repair aimed at covering exposed root surfaces for cosmetic purposes or to decrease sensitivity. Can also increase the amount of attached gingiva. Covering the root surface does not strengthen the tooth.

Gingival Graft
The gingival graft procedure is highly predictable and results in a stable, healthy band of attached tissue around the tooth.
The replacement of missing attached gum is called gingival grafting and is very similar to a skin graft. First, a small pouch is created in the tissue next to the tooth being treated. Next, a small piece of gum tissue is taken from the roof of the mouth adjacent to the back teeth or gently moved over from adjoining areas and transplanted around the tooth. The donor tissue reattaches and forms a new layer of attached gum which, with proper care, should last indefinitely. The roof of the mouth heals quickly just like a skinned elbow. At times, a temporary, clear plastic retainer is made to cover the donor area for further comfort. Usually, the exposed root is not covered and the tissue stays at the same level as before. However, the weak tissue has been replaced with stronger attached gingiva. A protective dressing often is placed around the necks of the teeth to cover the surgical area and to help secure the new gum-to-tooth relationship. You will need to be seen in 10-14 days to remove any remaining sutures and evaluate your healing.

Alloderm Gingival Grafts
When multiple grafts are necessary or the patient does not wish to have a donor site, healthy, highly-processed, sterile tissue from a tissue bank can be utilized. This product, Alloderm has been used to safely treat burn patients for a number of years. Over three million procedures have been performed using Alloderm without any transmission of HIV/AIDS or hepatitis. This tissue is equally successful with that obtained from the roof of the mouth. It is especially useful with children where adequate donor tissue is not available. Alloderm grafts eliminate a secondary surgical site along with its associated discomfort.

Gingival Grafting & Restorative Dentistry
Enhancing the zone of attached gingiva is particularly important when gingival recession is progressing or restorative dentistry is planned. Usually, the edge of a crown (cap) or white filling is placed just below the edge of the gum for optimum aesthetics. If the attached gingiva is too thin or inadequate, the gum may then recede after the restoration or crown is placed which will result in a poor cosmetic result.

Gingival Grafting & Orthodontics
Prior to orthodontics, it is important to evaluate the attached gingiva. Some types of orthodontic movement will result in the teeth being pushed outward. If the attached gingiva is too thin or inadequate, the gum may then recede during or shortly after active orthodontics.

It is not unusual for young children to require gingival grafting just before they get braces. This can help prevent unnecessary recession.

Root Coverage
When there is gum recession, the root of the tooth often shows and is unsightly. It is often desirable to recover the root surface. This is primarily done for cosmetics, but can also be done for root sensitivity. If there is also a lack of attached gum tissue (see gingival grafting), root coverage surgery can be designed to correct both problems at the same time. A connective tissue graft, which provides new attached gingiva while covering the root surface, is usually the procedure of choice. It is important to note that covering the root does not make the tooth stronger, since the bone, which actually holds the tooth in place, does not change regardless of the new gum level.

Connective Tissue Graft for Root Coverage
The procedure for a connective tissue graft is similar to a gingival graft. Incisions are made to release the gum leaving it connected at the base. Because the root has been exposed to bacteria in the oral cavity, all plaque and calculus must be thoroughly cleaned to provide a healthy root surface. This may be followed by root conditioning with citric acid or EDTA to promote better attachment of the graft. The donor tissue is obtained from the same area of the palate. However, only the inner tissue is taken, leaving the outer tissue to cover the wound. The graft is then placed over the exposed root and the original tissue is placed over it and secured with dissolving sutures (stitches). A surgical bandage or packing is then placed over the graft to protect it.

FRENECTOMY

A frenum is a naturally occurring muscle attachment, normally seen between the front teeth (either upper or lower). It connects the inner aspect of the lip with the gum. A lack of attached gingiva, in conjunction with a high (closer to the biting surface) frenum attachment (which exaggerates the pull on the gum margin) can result in recession. Additionally, an excessively large frenum can prevent the teeth from coming together resulting in a gap between the front teeth. If pulling is seen or the frenum is too large to allow the teeth to come together, the frenum is surgically released from the gum with a frenectomy. Often a gingival graft is added to re-establish an adequate amount of attached gingiva.

When orthodontic treatment is planned or initiated, the removal of an abnormal frenum (with or without a gingival graft) can increase stability and improve success of the final orthodontic result.