What is Periodontal Surgery?
Periodontics is a surgical specialty of dentistry that involves treatment of disease processes affecting the gums and tooth supporting bone; in other words, 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 of Periodontal Surgery
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:
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.
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.
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.
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.
Some advantages and benefits of Periodontal Surgery
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.
Potential disadvantages and risks of Periodontal Surgery
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.
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