Periodontal Surgery May Include Gum and/or Bone Surgery
Sometimes periodontal surgery can be cosmetic, but it is more often used to prevent future or advanced tissue and bony problems which surround the teeth and gums. One of the primary procedures is gum grafting. This grafting technique is utilized to cover the root surfaces of the teeth which are not covered with the protective enamel and do not have bone or gum tissue covering the root. The periodontist (gum specialist) usually removes a thin slice of attached gingiva (gums) from the palate and attaches it to the area of the tooth with the receding gums. The initial cause or etiology may be brushing too hard (toothbrush abrasion), traumatic occlusion, or other reasons. The end result is more aesthetic, lessens root sensitivity, and renders the area more resistant to decay.
Before any periodontal surgery, the teeth must be thoroughly cleaned of any debris, such as tartar (calculus), bacterial plaque, rough fillings, and toxins. This is done by scaling and root planing. This procedure alone, many times, will return the area to health and forego the need for periodontal surgery. This is often referred to as non-surgical periodontal treatment and it precedes any surgery. If the patient complies to a rigid oral hygiene program, further treatment may not be necessary. If not, surgical correction may be required.
It is important that the patient consult and truly understand the purpose of scaling and root planing, as well as the periodontal surgery itself. And, it is also important to understand the cause for this treatment, and the preventive requirements for the future. A thorough understanding of the cause of the problem tends to help the patient prevent its recurrence. A periodontist will stress that the periodontal health must be achieved with the least invasive and least expensive delivery method possible. Non-surgical periodontal treatment may be the answer. Scaling. curettage, and root planing often achieves this.
Then dentist uses an instrument called a periodontal probe which has segments of silver and black, each 3 mm in length. It goes from 0 to 12 mm’s and is gently slipped between the tooth and the gums. The normal periodontal pocket (the depth of the “turtle neck” of gum tissue around the tooth) is healthy at 2-3 mm. A 4 mm pocket is acceptable at times. Any pocket deeper than that becomes almost impossible for the patient to clean on a daily basis and the condition is called periodontitis. Chronic infection sets up at the bottom of the pocket, inflames the gums making them swell and bleed, and the end result is loss of bone. If it is strictly swollen gum tissue causing the increase in pocket depth, many times scaling and curettage, along with improved oral hygiene may be all that is necessary. This is called a pseudo-pocket or false pocket. If the pocket cannot be brought down to the 3-4 mm range, gum surgery may be necessary. The deeper the pocket, the more bacteria is collected, and the more bone loss occurs. Failure to lessen the pocket depth may result in the loss of some or all of the teeth.
After scaling and root planing, if there is still an unacceptable pocket depth but no bone loss, periodontal pocket gum surgery may be necessary. This procedure simply loosens the gums and sutures them tightly in a position that lessens the pocket depth. This makes the gum tissue and pockets easy to clean again. If there is the presence of bony or osseous pockets, then the gum tissue is reflected and the bony pockets are reduced (osseous recontouring) and as before, the tissue is sutured back tightly into position. Often the area is covered with a sedative periodontal pack.
Deep pockets ( 5 plus mm) are difficult for the patient, dental hygienist, or the dentist to properly clean and therefore must be reduced in-depth. Loss of bone, depending on how much, is called moderate or advanced periodontitis. Periodontal surgery, of course, eliminates the pockets but sometimes exposes a small portion of the roots of the teeth which can make them sensitive to cold for a short period. Meticulous oral hygiene is required to maintain proper oral health after treatment to keep the problem from recurring. Sometimes a bite appliance may be necessary to stabilize the teeth. This aids in the healing and helps prevent recurrence of the problem.
The periodontal ligament is the fibrous ligament that attaches the tooth to the bone. The tooth does not actually touch the bone, but the periodontal ligament is between the two and creates the attachment. The gum tissue must not grow down into this area when correcting a defect, so a membrane barrier is placed under the gums. This procedure is called Guided Tissue Regeneration (GTR) or Guided Bone Regeneration (GBR) and is performed by the periodontist, It basically is the placement of barrier membranes under the tissue and over the bony defects in order to grow new bone or gum tissue. Your periodontist can give you further details.
Another often used periodontal surgery procedure is called Crown Lengthening and is most used to improve “gummy smiles“. It is quite simple and straight-forward with immediate results. It is necessary when the gum tissue covers too much of the tooth and makes is look too short. The excess gum tissue is simply trimmed away and there is an immediate improvement in aesthetics. This surgery is often part of another type of crown lengthening procedure in which there is an inadequate amount of tooth structure above the bone to create a prosthetic crown for restoration of the tooth. In addition to the above, a mm or so of bone is removed around the tooth which renders the tooth acceptable to receive an aesthetic porcelain crown.
A labial frenectomy, sometimes called a labial frenulectomy, is considered to be periodontal surgery. The frenulum is the tissue which extends from inside the upper lip down between the upper front teeth or inside the lower lip extending up between the lower front teeth. One that is too long may cause a pulling of the gum tissue away from the tooth, or it may cause a space (diastema) between the two teeth. This can affect aesthetics, orthodontic spacing, or even the fit of dentures. It is a simple and quick procedure that is often performed by the general dentist or periodontist. The lingual frenectomy is similar except that it may be related to a tongue-tie which can easily and quickly be corrected.
If a tooth is lost, the bony ridge no longer has external stimulation and the ridge shrinks drastically in size. Immediate bone grafting into the extraction site or even later can restore the bone to its original shape and create an aesthetic ridge for an implant or other type tooth replacement. The graft may be performed by your general dentist, oral surgeon, or periodontist.
It also must be remembered that certain conditions may prohibit periodontal surgery completely, or at a minimum, cause lesser than desirable results. As always, smoking and alcohol will delay healing and sometimes make the periodontal condition even worse. Medical conditions such as heart disease, HIV, and diabetes have an adverse affect. Certain medicines also may affect the outcome; those being blood thinners like coumadin and aspirin may cause excess bleeding, and dylantin which may cause over-growth of gums.
The precise micro-surgery performed by the modern periodontist can regenerate or repair gum tissue. This is done with local anesthetic in a painless manner with minimal discomfort or bleeding which can ensure longevity and health for your teeth and gums.
Life Member of American Dental Society, Emeritus Fellow of Academy of General Dentistry, American Association of Implant Dentists