Periodontal Surgery

Dental procedure
Overview

Periodontics is a surgical specialty of dentistry that involves treatment of disease processes affecting the gums (gingiva) and tooth supporting (alveolar) 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: removal of diseased tissue (resective treatment) and building back gums and bone which have been lost to disease processes (regenerative treatment).

The process

Incision line and sutures on periodontal surgery model of gum (gingival) graft procedure.

Before periodontal surgery

When you have invasive dental procedures like periodontal surgery done, the dentist will review your health history. If you have replacement joints such as knees or hips, you may be pre-medicated with antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take an antibiotic pre-medication prior to the procedure.

If you take blood thinning medications or drugs that inhibit platelet aggregation, particularly if you take either with aspirin, your dentist and/or physician may require you to suspend those medications temporarily to have any oral surgical procedures, including periodontal surgery. This is due to the possibility for prolonged bleeding.

If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills like Valium®; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication, such as Versed®. Your dental plan may not pay benefits toward sedation.

Periodontal surgery procedures vary widely, but have several things in common. Your dentist or periodontist can more accurately describe the details of the procedure you require. Common steps in periodontal surgical procedures include:

Anesthetic

The surgical area is numbed by injecting local anesthetic around the nerve(s) that supply sensation to the area. Discomfort from the injection can be minimized by use of a topical numbing gel for a minute or two prior to the injection. Use of local anesthetics containing vasoconstrictors is common in periodontal surgery to reduce the amount of bleeding at the surgical site for improved visibility. Most commonly the ingredient is epinephrine, but other vasoconstricting agents are also in common use.

Surgical Access

An incision will be made through the gums, exposing the area of interest. The tissue is often reflected away from the site producing a surgical flap. There are many different flap designs used, depending on the procedure. Also, the incision may extend part way through the gums (partial thickness), or all the way through to the underlying bone (full thickness). It depends on the procedure.

If a soft tissue graft is being performed, and the patient’s own tissue will be harvested for the graft, there will be at least two surgical access points—the donor site, from which tissue is taken, and the host (or recipient) site, to which the graft is placed. If the donor tissue is obtained from a tissue bank, a surgical access point is eliminated.

The surgical goal(s) is/are accomplished

Whether the goal is to remove a frenum, to recontour the bone, to remove bacterial plaque and calculus (also called tartar), or treat other disease process, once the surgical access has been established, these procedures are accomplished next. Your dentist or periodontist can describe the intended surgical goals of your procedure before your surgery begins.

Accelerated Healing Using Platelet-Rich Plasma

Some periodontists now draw a small amount of the patient’s blood pre-operatively, and use a device called a centrifuge to separate out the platelets (a type of cell involved in healing and formation of blood clots). The platelet-rich plasma (PRP) is mixed with a surgical gel and applied to the wound to significantly accelerate healing of the surgical site. Use of PRP is optional, requires blood to be drawn from a vein pre-operatively, and generally adds cost to the procedure. Ask your dentist or periodontist for more information, and whether use of PRP may be helpful in your case.

Closure of the Surgical Access Flap

Once the goals of the procedure are accomplished, gums over the surgical site(s) are repositioned over the area and held in place with sutures (stitches in Figure 1). A periodontal dressing may be placed to protect the sutures and help stabilize the soft tissue. Your dentist or periodontist will tell you if and when the sutures require removal.

Post-operative instructions

You will be given specific instructions on what to expect following the procedure, how to take care of the surgical area(s), any dietary modifications that may be suggested, and when to return for follow-up.

Post-operative follow-up

You may be asked to return to the dentist/periodontist to have sutures removed, to evaluate the healing progress, and to address any concerns you may have.

Advantages and benefits

The main goal of periodontal surgery is to establish (or regain) a stable support base for maintenance of the teeth, jaw joints, and jaw muscles (the stomatognathic system). Periodontal treatment can be thought of as “foundation work” to use building construction as a metaphor. Recent studies have demonstrated the accuracy of this comparison, as periodontal disease has now been associated with cardiovascular disease (the blood vessels of the heart), peripheral vascular disease (the blood vessels of the body), diabetes, strokes, pre-term labor, and low birth weight. Controlling periodontal disease has the advantage of reducing a patient’s risk of experiencing these systemic problems.

Periodontal surgery enables patients to regain control over their oral health, when periodontal disease has progressed beyond a patient’s ability to control the disease non-surgically. Preserving
the teeth requires periodontal stability, and maintaining normal chewing function, jaw muscle and jaw joint health requires preserving the teeth.

Benefits of specific periodontal surgery procedures

Crown lengthening surgery allows teeth to be saved that otherwise may not be savable.

Supracrestal fiberotomy procedures prevent orthodontically straightened teeth from moving back to their previous orientation in the jaw.

Frenectomy (or Frenulectomy) procedures allow teeth to move into their ideal position in the jaw, and helps reduce the possibility of gums receding.

Soft tissue grafts provide durability to the gums around teeth, and can cover tooth roots, preventing sensitivity associated with receded gums.

Osseous (Bone) grafts allow ideal restorative dental procedures to be performed, including dental implants, fixed bridgework, and removable dentures. Bone grafts can also restore health around teeth with bone defects.

Disadvantages and risks

If you are taking bisphosphonate medications (a drug to reduce the effects of osteoporosis), you may be required to suspend the medication for a period of time prior to undergoing certain periodontal surgery procedures (those involving bone). Bisphosphonates decrease the blood circulation in the head and neck bones, possibly enough to impair healing and invite infection following surgical procedures like tooth extractions and bone grafts. This is especially true if you receive the medication intravenously, or are also taking immunosuppressive drugs like corticosteroids.

If you have a history of radiation treatment that may have involved the head and neck, you may be at risk for developing osteoradionecrosis following periodontal surgical procedures that involve bone. Essentially, this means “bone death” secondary to radiation, which destroys small blood vessels that supply the bone.

Periodontal surgery requires the use of local anesthetic, which has risks of its own. Generally, the risks of local anesthetic are minor compared to the benefits. Your dentist may provide you with specific information.

Periodontal surgery, like any surgical procedure, has general post-surgical risks: pain, swelling, bruising, bleeding, and infection. Most of the early symptoms (pain, swelling, bruising) can be managed with anti-inflammatory medications (check with your physician or dentist before taking any unprescribed medications). Your dentist may provide other specific instructions for addressing your symptoms following tooth extractions.

Most of the time, dentists will prescribe pain relievers for periodontal surgery procedures, but the specific medication will depend on the age and health history of the patient. Bleeding after periodontal surgery is normally minimal. If you feel you’re experiencing an abnormal amount, apply direct pressure to the area and call your dentist. Post-operative infections generally don’t occur in the first few days after periodontal surgery. When they do occur, your dentist will evaluate you and may prescribe antibiotics.

Periodontal surgery in a few areas of the mouth can be accompanied by the risk of nerve injury. If this occurs, the worst case scenario includes permanent numbness in the area supplied by the injured nerve. The incidence of this is relatively low, but you should discuss the possibility with your dentist ahead of time.

Periodontal disease is caused by a variety of microorganisms, and is not curable. Certain periodontal treatment regimens have become available that claim to be “cures” for the disease. These may involve laser debridement (cleaning) of infected gum pockets, and subsequent use of nutrition supplements. Unfortunately, these programs have not withstood the test of time, and have not been studied in prospective, randomized, multi-center trials. Follow the advice of your dentist until better long-term data are available to validate such claims of a cure.

Since periodontal disease is not curable, pocket reduction surgery is only a means of providing access for oral hygiene, to help a patient manage the disease more effectively.

Resective periodontal surgery that involves removal of healthy bone as part of a recontouring procedure may not always be the best solution to a periodontal problem. In general, ideal treatment involves preserving as much healthy bone as possible. It’s important to understand the long term goals of treatment. Your dentist is the most qualified individual to counsel you about the your periodontal treatment.

It has been said that control over periodontal disease is 25% up to the dental professionals managing the problem, and 75% up to the patient. Although periodontal surgery can help a patient retain their teeth long-term, if a patient is not motivated to keep the teeth, and cannot commit to the practice of effective daily oral hygiene, treatment is unlikely to succeed.

Like any surgery, periodontal procedures are not always successful. A graft can “slough”, or fail to be integrated into the host site (i.e. the place on you that needs the graft). In such cases, the procedure can generally be repeated, once the causes for its lack of integration can be identified. The most common reason a graft will fail is infection. Be sure to follow the specific instructions given by your dentist. Again, the likelihood of success is increased by patient compliance with the dental professional’s home care instructions.

A graft may successfully integrate, and still may not satisfy all of the intended goals of treatment. For example, a connective tissue graft may be performed to widen the band of tough, fibrous gum tissue and to cover the exposed root on a certain tooth. Sometimes the graft will integrate and satisfy the first goal—a wider band of abrasion-resistant tissue; but the second goal (root coverage) may not be achieved. In such a case, the procedure is a partial success. Good stability for the long-term health of the tooth has been achieved. However, the esthetic goal may not have been met, and the tooth may remain sensitive.

A dentist and patient may have a different view on whether the outcome was a success in such cases. Some studies have shown root coverage to be stable in as few as 70% of cases, while others show the procedure to be successful up to 98% of the time. Success rates are affected by many factors, including patient selection, the amount of recession (dentists use multiple classification systems to rate the location and severity of gingival recession), surgical technique, and the degree to which the underlying cause(s) of the patient’s gum recession has been addressed.

Early healing may be cosmetically unappealing, and may lead the patient to conclude that the procedure was unsuccessful. Generally, a soft tissue graft requires four to six weeks before it appears normal. Even then, the tissue is not “mature” for several weeks after that. If you are concerned about the outcome, talk it over with your dentist with these facts in mind.

Other care that may be needed

If periodontal surgery has been recommended for you, there may be related treatment you will also need to have. If gingival recession was caused (or complicated) by improperly aligned teeth (malocclusion) or bite stress, orthodontic tooth movement, periodontal stabilization splints, occlusal adjustments (equilibration), or occlusal guards (night guards) may be needed to prevent the gums from receding more.

Crown lengthening surgery is most often suggested in advance of restoring the affected tooth with a crown, inlay, onlay or filling.

Frenectomy procedures are generally performed after orthodontic tooth movement.

If you’ve had resective periodontal surgery which results in exposed tooth roots, your dentist may recommend daily use of prescription strength topical fluoride rinses or gels to reduce the likelihood of decayed tooth roots and tooth sensitivity.

Desensitizing medications may be applied to exposed tooth roots created by resective periodontal surgery.

If a localized periodontal defect occurs from an infection in or around the tooth roots, it may be necessary to have root canal (endodontic) treatment on the affected tooth.

Other treatment options

For treating moderate to advanced periodontal disease, there may be no traditional dental alternatives to periodontal surgery.

Nutritional Supplements and Herbal Remedies in Periodontal Treatment

There is evidence to support the use of certain vitamin and nutritional supplements to help maintain the periodontal health of stable periodontal patients. These supplements may or may not be helpful additions to traditional periodontal treatment in gaining control over compromised periodontal health. Supplements which have been studied and may be useful in promoting periodontal wellness include vitamin A, vitamin C, vitamin E, Coenzyme Q10 (CoQ10), calcium and folic acid. Appropriate use of these supplements should be in compliance with the recommendations of your dentist / periodontist, who can also track their effectiveness.

Certain essential oils (including thyme oil, tea tree oil, eucalyptus oil, peppermint oil, and chamomile oil) are present in some toothpastes and mouthwashes, and in appropriate doses may promote gingival health. There are many books and web sites dedicated to naturopathic remedies such as essential oils and herbal supplements. If you are unfamiliar with these non-traditional medicinal products, avoid using them unless you have involved a naturopathic doctor or someone with equivalent credentials who understands their limitations and risks.

Certain “natural” supplements whose safe dose has not been established, or whose formulations are not regulated have been found, or suspected to alter hormone levels, encourage tumor growth, produce chemical burns, cause prolonged bleeding, cause allergic reactions and produce other adverse effects.

In general, essential oils should not be taken internally or used full strength on skin or mucous membranes. Their use should also be avoided by patients with asthma, epilepsy, or allergies, as well as by cancer patients and pregnant or nursing women. Prescribed by a qualified naturopathic doctor, aromatherapist, herbalist, or nutritionist, unregulated supplements can potentially be used safely. However, your dentist/periodontist should be involved so that the effectiveness of such supplements can be measured and any potential oral side effects can be evaluated.

Formulation of many “natural” supplements is unregulated by the Food and Drug Administration, and their potency may not be well controlled. This means that identical-appearing bottles of the same substance, packaged and sold by the same manufacturer may contain significantly different concentrations of the medication inside. For many, there is no established recommendation for appropriate or effective doses.

Tooth Removal—Tooth extraction is an alternative to maintaining periodontal health, although one that comes with significant consequences.

Desensitizing Medications—Covering an exposed tooth root with a soft tissue graft is not the only method of eliminating sensitivity. The tooth roots can be treated with desensitizing medications or topical fluoride.

Fillings—Teeth which have developed root surface cavities can be restored with fillings.

What if I do nothing?

Failure to treat periodontal disease may result in pain, swelling, loss of teeth, inability to chew effectively, digestive problems, change in contours and proportions of the face, jaw joint pain and dysfunction, and systemic health problems. A growing body of research supports a link between chronic periodontal disease and heart disease, peripheral blood vessel disease, strokes, poor control over blood sugar levels (glycemic control) in diabetic patients, pre-term labor, intra-uterine growth restriction and low birth weight babies.

Teeth which have been decayed or broken below the gum level may have a low chance of being successfully restored to proper form, function and esthetics if a recommended crown lengthening surgery is not performed. The likelihood of decay developing under a new crown or filling in such cases is high. Periodontal attachment loss including bone loss may occur around the tooth near the deepest part of the crown or filling.

If the affected tooth would require multiple procedures to be saved (e.g. crown lenthening, endodontic treatment, core buildup, crown), and would have a questionable prognosis afterwards, consider any treatment options that may be available, including extraction of the tooth and replacement with a dental implant, fixed bridge, or removable partial denture.

Untreated gingival recession may result in tooth sensitivity and decayed tooth roots. Gums that continue to recede may result in bone loss, tooth mobility, and eventually, loss of teeth.

Teeth which have been orthodontically rotated may return to their original orientation when orthodontic treatment ends, unless supracrestal fiberotomy is performed on them.

“High” frenum attachments which are not treated may result in gingival recession and failure of the adjacent teeth to move into proper position.

Failure to have guided tissue regeneration procedures when recommended frequently results in loss of the affected tooth (or teeth).

Failure to have bone grafting procedures performed when recommended may result in compromised restorative treatment. Implant dentistry may not be possible in such cases, and fixed bridgework may be cosmetically unappealing.

Author: Thomas J. Greany, D.D.S. / Editor: Ken Lambrecht

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This page was last updated on July 7, 2015.

Evidence-based information for dentists and dental school students

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Links to dental and medical journals

Intended for dentists and dental students, ToothIQ.com links to additional information from over 100 U.S. and international dental and medical journals. Disclaimer: Full-text articles are linked to, when available. Some links lead to content requiring payment. Symbyos is not compensated by the organizations or authors whose articles are linked to. Symbyos is not responsible for the content linked to from ToothIQ.com.

Information you may wish to read before making a decision on treatment

Effects of Natural Cross-Linkers on the Stability of Dentin Collagen and the Inhibition of Root Caries in vitro
Walter, R., et al.
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2008 42 (4): 263-268

Effects of EDTA Gel Preconditioning of Periodontally Affected Human Root Surfaces on Chlorhexidine Substantivity—an SEM study
Ahmed Y. Gamal and Jason M. Mailhot
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2007 78 (9): 1759-1766

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Danek, Sofamor
Back.com web site
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2007
Editor’s notes: Scholarly article from the orthopedic literature, with relevance to dentistry. © Medtronic, Sofamor Danek 2007.

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Surgical lengthening of the clinical crown: a periodontal concept for reconstructive dentistry
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2007 4 (3): 193-201

Dental management of patients receiving oral bisphosphonate therapy: Expert panel recommendations
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2006 137 (8): 1144-1150
Notes: Association Report by American Dental Association Council on Scientific Affairs

Esthetic management of the upper labial frenum: A novel frenectomy technique
Sukhchain, Bagga, BDS, et al.
Quintessence International
2006 37 (10): 819-823

Grafting of Extraction Sockets: When and How
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Interdisciplinary management of anterior dental esthetics
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The Journal of the American Dental Association
2006 137 (2): 160-169

Maxillary Molar Sinus Floor Intrusion at the Time of Dental Extraction
Jensen, Ole T. DDS, MS, et al.
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2006 64 (9): 1415-1419

Predictability of connective tissue grafts for root coverage: Clinical perspectives and a review of the literature
Al-Zahrani, Mohammad S., BDS, MSD, PHD and Bissada, Nabil F., DDS, MSD
Quintessence International
2005 36 (8): 609-616

Maxillary sinus and ridge augmentations using a surface-derived autogenous bone graft
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Postextraction Tissue Management: A Soft Tissue Punch Technique
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Root Resorption Associated with a Subepithelial Connective Tissue Graft for Root Coverage: Clinical and Histologic Report of a Case
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Comparison of 3 bone substitutes in canine extraction sites
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2002 60 (1): 53-58

Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales
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2001 13 (9): 691-698

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Root Reshaping: An Integral Component of Periodontal Surgery
Melker, Daniel J., DDS, and Richardson, Christopher R., DMD, MS
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2001 21 (3): 297-304

Treatment of Multiple Adjacent Gingival Recessions with the Tunnel Subepithelial Connective Tissue Graft: A Clinical Report
Zabalegui, Ion, MD, DDS, et al.
The International Journal of Periodontics & Restorative Dentistry
1999 19 (2): 199-206

A classification system for loss of papillary height
Nordland, W.P. and Tarnow, D.P.
Journal of Periodontology
1998 69 (10): 1124-1126

The Interproximal height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement (PDF, 54K)
Salama, Henry, DMD, et al.
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1998
Notes: PDF of the article originally submitted to The Journal of Practical Periodontics and Aesthetic Dentistry for the Anthology Edition in 1998.

The subepithelial connective tissue graft palatal donor site: Anatomic considerations for surgeons
Reiser, et al.
The International Journal of Periodontics & Restorative Dentistry
1996 16 (2): 131-138

The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects
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Miller, P.D., Jr.
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Background information

Prognosis Revisited: A System for Assigning Periodontal Prognosis
Kwok, Vivien and Caton, Jack G.
Journal of Periodontology
2007 78 (11): 2063-2071

Gene Therapeutics for Periodontal Regenerative Medicine
Ramseier, Christoph A., DMD, et al.
Dental Clinics of North America
2006 50 (2): 245-263

Guest Editorial From Passive to Active: Will Recombinant Growth Factor Therapeutics Revolutionize Regeneration?
Wisner-Lynch, Leslie A., DDS, DMSc
The International Journal of Periodontics & Restorative Dentistry
2006 26 (5)

Periodontal infections and cardiovascular disease: The heart of the matter
Demmer, Ryan T., PhD and Desvarieux, Moise, MD, PhD
The Journal of the American Dental Association
2006 137: 14S-20S
Notes: Supplement to the Journal

Periodontal Infections and Coronary Heart Disease
Spahr, A., DDS, et al.
Archives of Internal Medicine
2006 166: 554-559

Medical-Grade Calcium Sulfate Hemihydrate (Surgiplaster) in Healing of a Human Extraction Socket—Histologic Observation at 3 Months: A Case Report
Guarnieri, Renzo, MD, DDS, et al.
The International Journal of Oral & Maxillofacial Implants
2005 20 (4): 636-641

Purpose and problems of periodontal disease classification
van der Velden, Ubele
Periodontology 2000
2005 39 (1): 13-21

Surgical Reconstruction of Interdental Papilla Using an Interposed Subepthelial Connective Tissue Graft: A Case Report
Carnio, Joao, DDS, MS
The International Journal of Periodontics & Restorative Dentistry
2004 24 (1): 31-37

Enamel Matrix Proteins (Emdogain) in Combination with Coronally Advanced Flap or Subepithelial Connective Tissue Graft in the Treatment of Shallow Gingival Recessions
Berlucchi, Ignazio, DDS, et al.
The International Journal of Periodontics & Restorative Dentistry
2002 22 (6): 583-593

Human mineralized bone in extraction sites before implant placement: Preliminary results
Block, Michael S., DMD, et al.
The Journal of the American Dental Association
2002 133 (12): 1631-1638

Periodontic and orthodontic treatment in adults
Ong, Marianne M.A., BDS, MS and Wang, Hom-Lay, DDS, MSD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (4): 420-428

Self-Inflicted Gingival Injury Due to Habitual Fingernail Biting
Krejci, Charlene B., Dr.
Journal of Periodontology
2000 71 (6): 1029-1031

Short-term effects of fiberotomy on relapse of anterior crowding
Taner, Tulin (Ugur), DDS, PD, et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2000 118 (6): 617-623

The Palatal Subepithelial Connective Tissue Flap Method for Soft Tissue Management to Cover Maxillary Defects: A Clinical Report
Houry, Fouad, Prof Dr Med Dent, PhD, DDS and Happe, Arndt, Rd Med Dent, DDS
The International Journal of Oral & Maxillofacial Implants
2000 15 (3): 415-418

The Hopeless Tooth: When is Treatment Futile?
Harrison, John W., DMD, MS, et al.
Current Topics in Dentistry
1999 30 (12)
Notes: Originally published in Quintessence International

Preventing Factitious Gingival Injury in an Autistic Patient
Johnson, C.D., MS, DDS, et al.
The Journal of the American Dental Association
1996 127 (2): 244-247

Gingival Swelling Due to a Fingernail-Biting Habit
Creath, Curtis J., DMD, MS, et al.
The Journal of the American Dental Association
1995 126 (7): 1019-1021

Crown lengthening and restorative treatment in mutilated molars
Parashis and Tripodakis
Quintessence International
1994 25 (3): 167-172

Comparison of electrosurgery with conventional fiberotomies on rotational relapse and gingival tissue in the dog
Fricke, Laurie Lee, BS, DDS and Rankine, Christopher A.N., DDS, MMedSc
American Journal of Orthodontics & Dentofacial Orthopedics
1990 97 (5): 405-412

The Mandibular Incisive Foramen
Serman, N.J.
Journal of Anatomy
1989 167: 195-198

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