Surgical treatment

Daily brushing and flossing, along with regular visits to the dentist, will help keep your teeth healthy and strong. But good oral hygiene isn’t just for your teeth-it also keeps your gums healthy. Regular oral exams give your dentist the chance to detect gum disease in its early stages and treat it before it progresses.

When you skip your dental visits for too long, untreated gum disease can leave you with infected and damaged gums that require surgery. If you have been advised by your dentist in Amirad Family Dentistry to have gum surgery, here is what you need to know.

 
 

 

 

Gingivitis, a mild form of gum disease, can usually be treated by a dentist. Periodontal disease begins with bacteria present in the mouth attaching to the teeth. The bacteria collect and multiply, forming a biofilm called dental plaque.

If this plaque is left on the teeth, the adjacent gingival tissues can become inflamed, resulting in the development of gingivitis, an early form of gum disease.

Daily flossing and twice-daily brushing with a tooth paste that fights bacteria can help prevent gingivitis. Plaque and food debris are removed by oral hygiene practices and thus clean the surface of the teeth and eliminate bacterial plaque at the gum line of the teeth. [It needs to be clear from this section that gingivitis is an early form of gum disease that can lead to periodontitis, a serious form gum disease, if left untreated]

However, if plaque and food debris are not removed and oral hygiene practices are not maintained, then gingivitis will get worse and the gum tissue can become more inflamed, bleeding can occur, the area between the tooth and gum tissue can become deepened to form a periodontal pocket and periodontal disease can develop.

A periodontal pocket develops as the plaque bacteria from the biofilm continues to accumulate and moves below the gum line. At this point, home care is not very effective in removing the dental plaque. If it is left untreated by the dentist or dental hygienist, the biofilm will continue to spread below the gum line and infect the inside of the pocket. The bacteria in the plaque produce by products that cause the adjacent soft and hard tissue to degrade, forming a deeper pocket in the process. This type of advanced periodontal disease can affect the roots of the teeth and they can become infected, too. The teeth may become loose or uncomfortable and the patient will require Gum Surgery.

The patient would be required to have initial therapy to treat diseased periodontal pockets through scaling and root planning. The dental hygienist would utilize an ultrasonic scaling device to remove plaque, Tartar and food debris below the gum line and would hand scale the tooth and root surface to make it smooth and disease free.

Scaling and root planning can be completed in two or four sessions depending on how much oral disease the patient may have. Thorough oral hygiene procedures would be reviewed with the patient to improve oral care cleaning techniques at home.

After improving gum health, the next step is periodontal surgery.

Periodontal surgery can regrow damaged bones and tissues, prevent tooth loss, reduce gum gaps between the teeth, and reshape the jawbone to eliminate bacterial growth.

However, gum disease is not the only reason for gum surgery. Some patients opt for cosmetic gum surgery. Such as when their gums cover too much of their teeth, a condition known as a “gummy smile”.



 
 

 

 

-You will be given a local an aesthetic injection to numb the gum.
-We will then make a cut around the edge of the gum and carefully lift the gum away from the teeth so that we can see the roots of the teeth. This allows us to remove more plaque and Tartar than was possible when the gum was covering the roots.
-The procedure then involves the careful use of fine powered and hand operated cleaning instrument on the tooth surfaces.
-Occasionally we will remove some of the gum to reshape it.
-Once we have cleaned the roots the gum is replaced and held in place with a few stitches that will be removed seven to ten days later.

-The gum will feel sore after the surgery and you may need to take painkillers, for example paracetamol, for a few days (as prescribed on the pocket).
-Occasionally the gums may bleed after surgery and you may also experience bruising and swelling of the gums or the face near the treated teeth.
-The teeth may feel looser after the surgery but this is usually temporary.
-The teeth may become sensitive to hot, cold or sweet substances.
-You may notice that spaces appear between the teeth and the teeth may also appear longer.

-No treatments:
The result of not having treatment will depend on how severe your gum disease is. With no treatment the gum disease could get worse. Your teeth may become painful and you may lose your teeth sooner.

-Regular scaling:
(Scaling) by the dentist or hygienist. This may still be necessary after the surgery, but it is usually needed on fewer teeth after the surgery.

-Extraction of some teeth:
Removal (extraction) of teeth may be an acceptable alternative if your gum disease is severe. This may mean that you need replacement teeth such as a denture or bridge and you may need to return to your own dentist for this treatment. Some people find it easier and more enjoyable to eat with natural teeth than a denture. However, if your front teeth have a poor appearance a denture may look better. Extractions would reduce the time spent treating your gums now and in the future.

 
 

 

 

You may feel some discomfort when we give you the local an aesthetic injection to numb the areas where we will be performing the gum surgery. But this should ease fairly quickly.

After the procedure you will not be able to brush the treated teeth immediately, so you will need to use an antiseptic mouthwash for at least one to two weeks.

You will be able to return home straight away after the surgery. However, you will need to follow the aftercare instructions given to you by the dentist performing your surgery. This will vary depending on the treatment you receive.

Types of gum surgery

The type of gum surgery you need depends on the severity of your gum disease and the specific damage it has done, or the type of cosmetic results you desire.

Types of gum surgery include:

-Gingivectomy
-Gingivoplasty
-Periodontal plastic surgery procedure
-Pocket reduction procedures (flap surgery)
-Dental crown lengthening
-Bone surgery
-Soft tissue grafts
-Bone grafts
-Guided tissue regeneration (GTR)
-Tissue-stimulating proteins
-Laser therapy

At Amirad Family Dentistry, all of the above operations are performed in full, with more information each being described in detail.

 
 

 

 

Gingivectomy is a Time-honored procedure for removal of gingiva. The indications range from access to esthetics. The Gingivectomy can be used when supra bony pockets are present and access to osseous structures is not necessarily important. The procedure assists in decreasing gingival tissue in cases of enlargement and in altering fibrotic gingiva.

Figure A – Excision versus incision. The excisional gingivectomy incision is created on an external bevel (small arrow). If the bevel cannot be created owing to difficulties with access, the incision can be blended into the apical gingiva using the laser tip. The internal incision (large arrow) also can be created for purposes of the flap procedure.

Gingivectomy is the oldest surgical approach in periodontal therapy and is usually done for improvement of aesthetics or prognosis of teeth.

By removing the pocket wall, gingivectomy provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots, creating a favourable environment for gingival healing and restoration of a physiologic gingival contour.

The procedure may also be carried out so that access to sub-gingival caries or crown margins is allowed. A common aesthetic reason for gingivectomy is a gummy smile due to gingival over growth.

• Indications

1-Elimination of supra bony fibrous and firm pockets
Gingivectomy is the primary treatment method available in reducing the pocket depths of patients with periodontitis and supra bony pockets. In a retrospective comparison between different treatment approach to periodontitis management based on the initial and final gingival health, conventional gingivectomy was proven to be more successful in reducing pocket depths and inflammation compared to non-surgical treatments in pockets measured 3mm or more.
Removal of supra bony deep pockets will allow better visibility and access for the removal of calculus. As a result, this provides a suitable environment for the healing of the gingiva and the physiological contour of the gingiva to be restored.

2-Elimination of gingival enlargement

In cases of gingival enlargement induced by drugs, surgical treatment through a gingivectomy proved to be effective with most patients showing no clinical sign of recurrence after one year. Even though it is the most frequent method of treatment, it is only indicated when overgrowth is severe.

Another cause of gingival enlargement would be a hereditary

condition known as gingival fibromatosis. The extensive overgrowth of gingival tissue is usually treated with a gingivectomy, as it produces good aesthetic results.

3. Increase clinical crown height

• Sub-gingival margins

A gingivectomy can also be done to increase the clinical crown height of teeth. This is suitable in treatment planning for teeth with inadequate tissue for retention of prosthetic restorations as a result of sub gingival carious lesions or coronal fractures.

• Gummy smiles

Up to 3mm of gingival display when smiling is described to be cosmetically acceptable.
Gummy smiles are often used to describe smiles where there is more than 3mm of gingival tissue seen clinically and is usually deemed unaesthetic to the individual.
Similar to sub gingival crevices margins, gingivectomy to increase the crown height can be performed to provide better aesthetics and normal gingival architecture.

• Contraindications

1- Need for bone surgery
2- When bottom of the pocket is apical to the mucogingival junction
3- Aesthetic considerations, particularly in anterior region of maxilla

Dental/ gingival morphologic characteristics and peri-oral variables influence patient’s smile frame. They are essential in achieving a predictable successful rehabilitation of patient’s smile.
In males and females, the mean vertical height of the maxillary central incisors averages 10.6 mm and 4.8 mm respectively.
With the lip line at the rest, the mean maxillary incisors display is 1.91 mm for men and 3.40 mm for women.

• Techniques and post-operative

Gingivectomy can be performed by various techniques:
1. Surgical gingivectomy

It is performed by scalpel. To reduce post-operative pain for the patient, the surgery should be as atraumatic as the surgeon can make it.
If the procedure has been carried out carefully, the patient’s post-operative pain is minimized.

2. Gingivectomy by electro surgery

Electro surgery is defined as the international passage of high-frequency ware forms or currents, through the tissues of the body to achieve a controllable surgical effect. It has been used in dentistry for more than 60 years.

The basic types of electrosurgical techniques are coagulation, desiccation, fulguration and electro section (cutting).

There are two main types of electro surgical units, mono polar and bi polar.

The results of studies which have looked at healing of electrosurgical wounds compared to scalpel wounds vary widely but it has been found that electro surgical equipment minimizes bleeding and most patients experience very little post-operative pain after the procedure. There may be more inflammatory response than the scalpel technique.

3. Laser gingivectomy

The laser types include:

• Nd: YAG
• Co2
• Diode laser

It has been suggested that lasers can give a substantial reduction in bacteria such as Actinobacillus actinomycetemcomitans (Aa) which will reduce inflammation and facilitate the healing process.

It has been suggested that laser treatment result in minimal or no post-operative swelling, bleeding, scar tissue formation or pain. A part from ablating and coagulating the laser also sterilizes the tissues and eliminates the need for a post-surgical dressing.

Recurrence was minimal or eliminated when comparing laser gingivectomy to scalpel gingivectomy.

 
 

 

 

Gingivoplasty is the process by which the gingiva are reshaped to correct
Deformities.

Gingivoplasty is similar to gingivectomy but with different objective. This is a procedure performed to eliminate periodontal pockets along with the reshaping as part of the technique. This procedure is followed to create physiological gingiva in the absence of the pockets.

Gingival and periodontal disease often produces deformities in the gingiva that are conductive to the accumulation of plaque and food debris, which prolong and aggregate the disease process.

Such deformities include the following:

a) Gingival clefts and craters
b) Crater- like interdental papilla caused by acute necrotizing ulcerative gingivitis
c) Gingival enlargements

Gingivoplasty is accomplished with a periodontal knife, a scalpel, rotary coarse diamond stones, electrodes or laser.

The technique resembles that of the festooning of an artificial denture, which consists of tapering the gingival margin, creating a scalloped marginal outline, thinning the attached gingiva, creating the vertical interdental grooves and shaping the interdental papillae.

 
 

 

 

If you are looking to improve your smile, a dental surgeon may be able to help.

1. Gummy smile or uneven gum line

If your teeth look too short and your smile is too gummy or your gums cover too much of some teeth while leaving the others the right length, dental crown lengthening might be the solution for you.

During this procedure, excess gum tissue is removed to expose more of the crown of the tooth. Then your gum line is sculpted to give your new smile just the right look.

2. Long teeth / exposed roots

Sometimes gum recession causes the tooth root to become exposed. Gum graft surgery and other root coverage procedures are designed to cover exposed roots, to reduce further gum recession and to protect vulnerable roots from decay.

3. Indentations in the gums and jaw bone

Tooth loss can cause an indentation in the gums and jaw bone where the tooth used to be. This happens because the jaw bone recedes when

it no longer is holding a tooth in place. Not only is this indentation unnatural looking, it also causes the replacement tooth to look too long compared to the adjacent teeth.
Ridge augmentation can fill in this defect recapturing the natural contour of the gums and jaw. A new tooth can then be created that is natural looking- easy to clean and beautiful.


 
 

 

 

Your bone and gum tissue should fit snugly around your teeth like a Turtleneck around your neck. When you have periodontal disease, this supporting tissue and bone is destroyed, forming pockets around the teeth.
Over time, these pockets become deeper, providing a larger space for bacteria to live. As bacteria develop around the teeth, they can accumulate and advance under the gum tissue. These deep pockets collect even more bacteria, resulting in further bone and tissue loss. Eventually, if too much bone is lost, the teeth will need to be extracted.

Your dentist has measured the depth of your pocket(s), and then
A periodontal pocket reduction procedure has been recommended if you have pockets that are too deep to clean with daily at- home oral hygiene and a professional care routine.

During this procedure, your dentist folds back the gum tissue and removes the disease – causing bacteria before securing the tissue into place. In some cases, irregular surfaces of the damaged bone are smoothed to limit areas where disease-causing bacteria can hide.
This allows the gum tissue to better reattach to healthy bone. Reducing pocket depth and eliminating existing bacteria are important to prevent damage caused by the progression of periodontal disease and to help you maintain a healthy smile. Eliminating bacteria alone may not be sufficient to prevent disease recurrence. Deeper pockets are more difficult for you and your dental hygienist to clean. So it’s important for you to reduce them. Reduced pockets and a combination of daily oral hygiene and professional maintenance care increase your chances of keeping your natural teeth- and decrease the chance of serious health problems associated with professional disease.

According to flap reflection or tissue content there are two kind of periodontal flaps:

1- Full thickness flap
2- Split thickness flap

 
 

 

 

Crown lengthening (CL) is a surgical procedure performed by a dentist, or more frequently a specialist periodontist.

There are a number of reasons for considering crown lengthening in a treatment plan. Commonly, the procedure is used to expose a greater amount of tooth structure for the purpose of subsequently restoring the tooth prosthetically.

However, other indications include accessing subgingival caries, accessing perforations and to treat aesthetic disproportions such as a gummy smile. There are a number of procedures used to achieve an increase in crown length.

 
 

 

 

Smooths shallow craters in the bone due to moderate and advanced bone loss. Following flap surgery, the bone around the tooth is reshaped to decrease the craters. This makes it harder for bacteria to collect and grow.

The goal of this surgery, is to eliminate bacteria, reduce pockets and smooth the damaged bone so that the gum tissue can reattach to strong bone.

This type of periodontal surgery is performed under local anesthesia. The dentist makes a small incision in the gum tissue so that it can be flapped back to expose the surrounding bone and root of the tooth. The dentist will scrape deposits off the root surface and trim and recontour any jagged bone.

The tissue will be sutured back so that there will be minimal pocket depth when healed. Depending on the severity of the bone loss, the dentist may also perform a bone graft or guided tissue regeneration before reattaching the gum tissue.

Length of time for the surgery will vary depending on the procedure and how many teeth are involved, but your dentist should be able to give you an estimate of how long you will be in the dental chair.


A gingival graft, also called gum graft. The aim may be to cover exposed root surfaces or merely to augment the band of keratinized tissue.

Three different types of gum tissue grafts are typically performed. Which type your dentist uses on you will depend on your specific needs? The graft procedure include:

• Connective-tissue grafts
• Free gingival grafts
• pedicle grafts

 
 

 

 

This procedure is performed when periodontitis has destroyed the bone surrounding your tooth root. The graft may be composed of small fragments of your own bone, or the bone may be synthetic or donated. The bone graft helps to prevent tooth loss by holding your tooth in place. It also serves as a platform for the regrowth of natural bone.

Bone grafting is the most common form of regenerative therapy today and is usually essential for restoring all types of periodontal supporting tissue.

To date, histologic evidence in humans indicates that bone grafting is the only treatment that leads to regeneration of bone, cementum, and a functionally oriented new periodontal ligament coronal to the base of a previous osseous defect.

 

Guided bone regeneration (GBR) and guided tissue regeneration (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival tissue at sites with insufficient volumes or dimensions of bone or gingiva for proper function, esthetics or prosthetic restoration. Guided bone regeneration (GBR) typically refers to ridge augmentation or bone regenerative procedures; guided tissue regeneration(GTR) typically refers to regeneration of periodontal attachment.

Guided bone regeneration is similar to guided tissue regeneration, but is focused on development of hard tissues in addition to the soft tissues of the periodontal attachment. At present, guided bone regeneration is predominantly applied in the oral cavity to support new hard tissue growth on an alveolar ridge to allow stable placement of dental implants. When Bone grafting is used in conjunction with sound surgical technique, guided bone regeneration is a reliable and validated procedure.

 
 

 

 

Enamel matrix proteins occur during natural tooth development. Emdogain is a matrix protein product which is usually placed on the affected site before the gum is sutured. It mediates the formation of acellular cementum on the tooth which provides a foundation to allow periodontal attachment to occur. Tissue stimulating proteins help create lost support in areas affected by periodontal defects.

 

Soft tissue lasers are a good choice in bacteria reduction and coagulation. The erbium group of laser has shown significant bactericidal effect against some bacteria responsible for periodontitis.

Reduction of pocket depth was noted with laser therapy.

Many studies showed an increased coagulation and a relatively dry surgical filed and better visualization. Laser increases tissue surface sterilization which reduces bacteremia, and decreases swelling, edema, and scarring. Laser is effectively used to perform gingivectomies and gingivoplasties.

Gingival depigmentation using laser ablation has been recognized as an effective, pleasant, and a reliable technique.

At present, lasers are employed for frenectomy, free gingival graft procedures, crown lengthening, operculectomy, and many more.

Lasers can be used for the hyperplasia removal as well as in the treatment for peri-implantitis.

 

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