Procedures

Periodontal surgery

Procedure overview

Alternate terms: Gum surgery; Periodontics; Surgical periodontics.

Periodontics is a surgical specialty of dentistry that involves treatment of disease processes affecting the gums and tooth supporting bone (i.e. the tissues surrounding the teeth). A periodontist is a dentist who has obtained two to three years of advanced training in diagnosing and treating periodontal disease processes.

Most often, the first course of treatment for periodontal conditions involves non-surgical procedures. However, some periodontal conditions are most effectively treated with surgical techniques.

Periodontal surgery procedures can be divided into two basic types: resective treatment—removal of diseased tissue, and regenerative treatment—building back gums and bone which have been lost to disease processes.

Gingivitis

The term "gum disease" is a catch-all term for a group of bacterial illnesses that destroy gum attachment fibers and bone around teeth. The process begins when food or filmy residue from food and drink is allowed to accumulate on and around the teeth, and becomes infected with bacteria. The body attempts to protect itself from foreign invaders like bacteria by sending immune cells to the area to fight the infiltration. A side effect of this process is that the infected tissue fills with fluid, turns red, and bleeds easily. This is known as "inflammation."

Inflammation of the gums (or "gingiva") without breakdown of the attachment fibers holding the gums to the teeth is called "gingivitis" (Figure 1). A patient who has gingivitis will have enlarged, fluid-filled, red gums, instead of taut, firm, pink ones. The condition is often not painful, but the gums typically bleed easily.
Learn more: Diagnoses › Gingivitis

Periodontitis

When the gingiva enlarge, bacterial "plaque" accumulates in the pockets that develop where the teeth emerge from enlarged gums. Removal of the plaque at this stage by a dental professional, and effective oral hygiene by the patient can cure gingivitis. However, if the condition is allowed to progress, a more serious illness called "periodontitis" (or "periodontal disease") results. Periodontitis is not curable, but is treatable and can be successfully managed long-term. Periodontal disease is epidemic, with some 75% of adults suffering from it to one degree or another.
Learn more: Diagnoses › Periodontitis

Resective Periodontal Surgery

Pocket Reduction

If periodontitis progresses to the point where the gum pockets around the teeth exceed 6mm in depth, non-surgical therapy has been performed, and the patient is doing their part to manage their illness, resective periodontal surgery may be prescribed. This is especially true if a patient has a diagnosis of generalized moderate to severe periodontitis.

Moderate generalized periodontitis is diagnosed in patients who have uniformly lost 20% to 40% of the alveolar bone around their teeth (Figure 2). Severe generalized periodontitis is diagnosed in patients who have uniformly lost more than 40% of the alveolar bone around their teeth (Figure 3). Patients with these conditions are often treated by a resective periodontal surgical procedure known as "open flap curettage," a type of root surface cleaning which requires surgical access.

Sometimes it is necessary for the periodontist to surgically reposition the gingival tissues to allow a patient with periodontitis better access to clean their teeth. This is known as "apical positioning", and is often done at the time open flap curettage is performed.

Crown Lengthening

Crown lengthening is a resective periodontal procedure that is commonly performed when a tooth decays or chips below the gum level. In order for a dentist to be able to restore the damaged tooth so that the patient can clean it effectively, it is sometimes necessary to recontour the bone around the tooth and reposition the gingiva so that the chipped or decayed area is accessible. As an option to bone recontouring, it may also be possible to extrude the tooth out of the jawbone by a few millimeters—either surgically or orthodontically.

Gingivectomy

Patients whose gingival tissues have enlarged and grown over the teeth may require a procedure known as "gingivectomy". This may occur in response to very poor hygiene/dental neglect, or in response to chronic treatment with certain medications (e.g. phenytoin, more commonly referred to by the popular brand name, Dilantin®). Gingivectomy is simply surgical removal of the overgrown tissue.

It is also common to have one or more teeth which appear to be submerged in healthy gum tissue, as though the tooth/teeth didn't move into the mouth fully. Gingivectomies are frequently performed in such cases purely for cosmetic reasons.

Supracrestal Fiberotomy

If teeth are to be rotated as part of an orthodontic (tooth movement) treatment plan, the elastic fibers holding them into the jaw tend to rotate them back to their original orientation when orthodontic treatment is completed. To prevent this from happening, it may be necessary to surgically sever the elastic fibers between the gums and the affected tooth and to allow the fibers to re-attach themselves when the tooth is in its new position (which will happen if the gums had healthy attachment fibers to begin with). Generally, the procedure is performed after orthodontic treatment is completed to prevent the attachment of elastic fibers while teeth are still being turned.

Frenectomy

A frenum (or frenulum) is a small band of fibrous tissue located at a few positions in the mouth which have an origin in the gums and insertion in the lip or cheek. A "labial frenum" inserts into the lip (Figure 4), and a "buccal frenum" inserts into the cheek.

If a frenum origin is located too close to a tooth, contraction of the surrounding musculature can apply tension to the frenum and contribute to gum recession. If it is located between two teeth (most commonly the upper permanent central incisors), it can prevent those teeth from moving all the way together during development. A minor procedure called a "frenectomy" can be performed to remove the tissue and prevent these consequences.

Regenerative Periodontal Surgery

Localized areas of compromised periodontal health (or where the amount of gum tissue / bone are deficient) can often be treated by regenerative periodontal surgery techniques. The goal of regenerative procedures is to re-establish a normal amount of healthy gums and bone around the affected tooth or teeth to provide long-term functional and cosmetic stability.

Gingival Recession

Gingiva appear thicker, less vascular (fewer blood vessels) and tougher where the teeth emerge through them than they do over the root tips. In order for the gums to resist abrasion from food during chewing, and to hold up to the other functional demands of the teeth, there should be a band of at least a few millimeters (measured along a line between the biting edge and root tip of the tooth) of this toughened ("keratinized") soft tissue attached to the teeth and bone around each tooth. If there is less than that, the gums may recede (Figure 5), and the underlying bone may follow them.

Inflammation, abnormal tooth position, orthodontic tooth movement, and heavy bite stresses can all contribute to the gums receding. Aggressive tooth brushing may also be a contributing factor. If factors like these are eliminated, soft tissue grafting can be performed to produce adequate keratinized tissue around the teeth. Exposed tooth roots can frequently be covered in the process, reducing tooth sensitivity and providing a more esthetic appearance.

Some studies show that nearly 60% of adults (all ages) have at least one tooth with receded gums. Other studies report age-related gingival recession, and show that 50% of adults age 18 to 64 have gum recession, while nearly 90% of adults over age 65 have it. Many people are unaware they have the condition. Depending on the amount of recession and the amount of fibrous connective tissue ("keratinized" tissue) that remains, the recession may or may not be clinically significant, and treatment may or may not be recommended.

Should Gingival Recession Be Treated?

Some factors that are taken into consideration when deciding whether or not the condition should be treated include the following (only your dentist/periodontist can whether your particular situation warrants treatment):

• A patient with exposed tooth roots may complain of temperature sensitivity, sensitivity to sweets, or sensitivity to touch. Covering the exposed root(s) with a soft tissue graft can eliminate sensitivity, if exposed tooth roots are the cause.
• A patient may not like the appearance of receded gums, particularly if they are visible in the smile. Soft tissue grafting can cover exposed roots and restore the natural "scalloped" appearance of the gums.
• Exposed tooth roots are more vulnerable to decay, particularly in patients who have "xerostomia" (dry mouth). Covering the roots (when possible) eliminates the risk. Unfortunately, not all exposed tooth roots can be fully covered. It depends mainly on whether there is adequate bone present to support the gingival graft.
• Bands of keratinized tissue less than 2mm wide, or which are thin enough to see a dental instrument through may be recommended for treatment due to the risk of (or progression of) gum recession. It depends on where the tooth is located, whether the gums are inflamed, and what the functional demands of the affected tooth are. Other factors may be involved.

Common Methods of Treating Gingival Recession

Some commonly performed techniques for increasing the amount of soft tissue around the teeth and covering exposed tooth roots are listed below (your dentist or periodontist may know of others, and can provide details which can help you decide how best to treat your unique condition).

Subepithelial Connective Tissue Graft

A procedure in which an area of thin fibrous connective tissue (i.e. "keratinized tissue"—the tough, pink gum tissue) is widened and/or thickened by surgical placement of connective tissue into the site. A bed for the connective tissue is surgically prepared, and the connective tissue is tucked into it and held with sutures (stitches). When the graft has matured, it may not be possible to tell that the gums had ever receded, or that a graft was ever done (Figure 6).

The connective tissue can either be taken from the patient's palate, or human donor allograft (i.e. cadaver) tissue can be used. If taken from the palate, two parallel incisions are made about 1mm apart, and the tissue between them is removed. The "donor site" is then closed with sutures and protected with some type of surgical dressing (often a plastic tray is made ahead of the surgery for this purpose). The "donor site" heals relatively quickly because there is circulation from both sides of the incision, and the incision can be tightly closed (like a paper cut).

Using the patient's own tissue for the graft is preferable in most cases, because it is already filled with the patient's own healthy blood vessels which quickly perfuse with blood, may heal faster, and may result in a better cosmetic outcome.

Free Gingival Graft

A procedure in which soft tissue is again harvested from the palate and transferred to an area deficient in keratinized tissue. This procedure is similar to the Subepithelial Connective Tissue Graft, except that the harvested tissue includes the toughened surface layers (the "epithelium"), and not just the underlying connective tissue. The method of harvesting the graft tissue is also different. Instead of removing the tissue vertically between two thinly spaced parallel incisions, the graft is essentially stenciled out of the palate like a cookie cutter—in the required shape for the deficient area of gum tissue. The donor site may take longer to heal as a result, since a larger volume of tissue needs to granulate ("grow in") from the edges of the wound.

Pedicle Flaps

A procedure for covering exposed tooth roots in patients who have plenty of keratinized tissue around the affected tooth. The procedure simply involves making an incision to "loosen" a piece of keratinized gum tissue, and then moving it (without actually severing it from the underlying tissue) to cover the exposed root. Depending on the direction the tissue is moved to reposition it, the procedure may be referred to as a "coronally positioned flap" (the tissue is moved toward the crown of the tooth along its axis), or a "lateral pedicle flap" (the tissue is moved sideways along the dental arch).

Steps are sometimes taken to prepare the root surface for adherence of the repositioned tissue. This may involve scaling the root to clean it, treatment with etchants like citric acid, tetracycline, and/or EDTA (ethylenediaminetetraacetic acid), and application of antibiotic gels like chlorhexidine, to prevent infection of the site. Some studies suggest that treatment of the roots in such a way does not increase the likelihood of a successful treatment result.

Other Regenerative Periodontal Procedures

Osseous Grafting ("Bone Grafting")

Bone grafting is a technique used by dentists to rebuild areas of bone which have been lost following tooth removal, trauma, etc.
Learn more: Procedures › Bone grafting

Guided Tissue Regeneration (GTR)

GTR techniques employ multiple elements of the other surgical procedures discussed on this page. GTR is performed on localized defects, such as angular shaped bone depressions around or between tooth roots, in order to regenerate a healthy, stable environment for the affected tooth to be retained in the mouth long-term.

GTR may involve removal ("resection") of unhealthy bone and/or gum tissue, and placement of both bone and soft tissue grafting materials into the surgical site ("regeneration"). The roots of affected teeth may need to be prepared as described under "Pedicle Flaps". Other measures may be taken to protect the surgical site from infection or ingrowth of undesired soft tissue into bone graft areas. These include the use of barrier membranes, which may or may not dissolve on their own and may or may not require removal at a later date by the periodontist.

Treatment of Combined Periodontal/Endodontic Infections

Sometimes an infection originating inside a tooth finds its way out of the tooth and damages the bone and supporting soft tissues around the tooth. Sometimes an infection begins around or between tooth roots and finds its way into the tooth. In these cases, the affected tooth may require a combination of periodontal treatment (e.g. GTR) and endodontic (root canal) treatment.
Learn more: Procedures › Endodontic treatment