Overview of Overview of Periodontal Surgical Procedures
Periodontitis is a common condition caused by harmful microorganisms in the mouth, usually due to poor oral hygiene, which cause inflammation around the teeth. It can lead to damage around your teeth and in severe cases, tooth loss. This condition affects about 1 in 10 adults worldwide and can greatly reduce life quality due to difficulty eating and pain. Spotting this condition early on and getting the right treatment not only saves money, but can prevent more serious problems like illness, tooth loss, and more complicated treatment procedures.
The first step in treating periodontitis is usually with non-surgical methods. One common treatment is called ‘scaling and root planing’. This process reduces the number of harmful microbes around your teeth by cleaning them thoroughly, removing plaque (a biofilm formed by bacteria), tartar (hardened plaque also known as calculus), and harmful bacterial toxins. Teaching the patient on how to maintain good oral hygiene is central to this non-surgical treatment for periodontitis. The goal is to control the formation of plaque by regular cleaning done by the patient themself.
Additionally, any factors that increase the risk of periodontitis, such as tobacco use or improper dental restorations (fillings, crowns, etc.) and bite issues, should be handled in this initial treatment stage. There may also be non-periodontal treatment, such as root canal therapy or even tooth extraction, particularly of really infected or non-essential teeth – like third molars (also known as wisdom teeth) or second molars, to improve the overall health status of the remaining teeth. This should be considered early in the treatment process.
About 6 to 8 weeks after the initial treatment (scaling and root planing), the success of this non-surgical periodontal therapy is evaluated. The aim is to look out for any ongoing signs of periodontitis like continued inflammation of the gums, deep pockets around teeth, further loss of attachment of teeth, gum recession, or increased movement of the teeth. The depth of the pockets around your teeth can indicate the severity of the disease. If they are 5mm deep or less, non-surgical treatment should continue. However, if they are 6mm or more, surgery may be the best next step to treat the periodontitis.
Anatomy and Physiology of Overview of Periodontal Surgical Procedures
Periodontal bone lesions, which are damages to the bones around your teeth, are caused by the spread of gum disease. Understanding how these bone defects look is really important for dentists to figure out how they’re going to carry out periodontal surgery. Bone losses are usually described as either horizontal or vertical, depending on how the tissues are destroyed. Bone defects can be described as either shallow or deep and can have up to three walls. Dentists consider how many remaining walls there are because it determines the possibility of restoring the gums, while the depth of the damage influences whether they will surgically remove the damaged portion, try to regenerate it, or potentially remove the tooth. Whether the damage is horizontal or vertical, this pattern will tell the doctor if the surgery will involve treating the alveolar bone, which is the thickened ridge of bone that contains the tooth sockets.
Horizontal bone defects are when the alveolar bone crest, the rim of bone that forms the borders of the sockets, moves generally towards the root of the tooth. If an X-ray shows that the distance from the junction where the enamel of the tooth and the root meet to the bone is greater than 1.9mm, this suggests there’s a high chance of bone and attachment loss. Vertical defects usually appear as area of decreased bone density close to the root surfaces or multiple bone levels. These vertical defects are also known as intrabony defects. Teeth tilting may cause unusual gaps in the bone crest as part of normal bone changing, but they differ from periodontal bone defects as in these cases, the bone crest will follow a line connecting the junction of adjacent teeth.
Shallow vertical bone defects range from uneven bone crests to defects about 3 mm deep, which can be easily seen on x-rays. A defect is considered deep if it’s more than 3mm. Three-wall defects are usually found in the back part of the mouth with wide bone consisting of three walls. As the volume of the remaining bone decreases, 3-wall defects may merge and form a 2-wall defect. One-wall defects are usually found with narrow remaining bone or front teeth like the lower incisors. Sometimes, localized bone loss can remove the remaining bone, especially in cases of close roots, resulting in a localized bone defect with no walls.
How these bone defects relate to gum pockets is significant. ‘Pseudopockets’ are gum pockets with a base near the bone crest that ends at or near the junction where the enamel of the tooth and the root meet. They are usually associated with thick gum tissue or changes in the position of teeth eruption. Suprabony pockets are periodontal pockets that may have attachment loss but have a base near the bone crest. If a periodontal pocket extends deeper than the most coronal aspect of the adjacent bone crest, it is called an infrabony pocket, and they are generally associated with deep probing depths and vertical bone defects, while suprabony pockets usually come with horizontal bone loss and shallow probing depths.
During the designing of a flap for periodontal surgery, dentists should also take vascular supply into consideration. The tissues around the teeth get blood from different directions, and the way it flows also matters during the surgery. Interproximal tissue gets blood from vessels emerging from the bone crest, vessels from the periosteum covering the alveolar cortex, and tiny blood vessels from the supporting ligaments of the teeth. If surgical access requires a rectangular flap with two vertical incisions, the surgeon would make sure that this flap has enough blood supply.
Considering important anatomical features when planning a periodontal surgery is also important. Near areas like the mental foramen, mental nerve, lingual nerve, and others, special care is taken to avoid damages during the surgery. Dentists use different precautionary methods to avoid harming any vital structures like the greater palatine bundle and the incisive papilla in the upper jaw. Harms to these areas could lead to prolonged bleeding and healing complications. Therefore, careful planning and consideration is vital when designing a periodontal surgery.
Why do People Need Overview of Periodontal Surgical Procedures
Periodontal surgery is a type of dental surgery used to treat deep pockets, or gaps between your teeth and gums, that remain after non-surgical treatments. This kind of surgery is commonly used for teeth that have a good-to-moderate chance of recovery and in situations where it’s likely the therapy will be effective. Based on the nature of these pockets, different surgeries may be recommended.
Gingivectomy is used to treat deep pockets where there’s a lot of fibrous tissue, but no bone defect beneath it. This procedure removes the extra gum tissue to reduce the depth of the pockets.
The “Wedge” technique is used for deep pockets at the side of a tooth that faces excessively thick gum tissue. This is usually at the rearmost tooth of the jaw, next to a chunk of tissue in the upper jaw or behind the last molar.
Gingival Flap Procedure is used to treat deep pockets without an underlying bone defect. This type of surgery allows dentists to clean the tooth roots and remove dental plaque. It can be used to treat “infrabony” pockets (pockets that extend beneath the bone line) linked to shallow bone defects, mainly in the front part of the upper jaw. This surgery can also be part of regenerative therapy, which aims to restore bone defects.
Osseous Surgery is another way to treat deep pockets linked with shallow bone defects or uneven bone contours. This can also be a part of regenerative therapy, assisting surgical access to bone defects and improve the bone shape.
Bone grafting or the use of biologically active agents or a combination of these can be used to treat deep pockets linked with deep bone defects, provided these defects are conducive to the regeneration.
Periodontal surgery is also used for improving tooth shape or aesthetics. The surgery commonly used is “clinical crown lengthening,” employed when imminent caries (tooth decay), tooth fracture, or restorative margin (the edge of a filling or a crown) cannot be fixed using usual dental procedures, and the tooth itself can be restored.
The Crown Exposure Surgery is used to treat an altered passive eruption, commonly referred to as “gummy smile,” where the bone covers the tooth’s junction. It is also used when the excessive gum covers the tooth with crestal bone (the bone around the root of a tooth) at a distance from the tooth’s junction. This surgery also removes the genetic or drug-induced gingival enlargement and pigmented gingiva (gum pigmentation).
Periodontal surgery can also be used to fix faults in the mucogingival (the boundary between the gums and the cheeks or lips). In this context, different surgical options such as Free/Autogenous Gingival Grafts, Lateral Sliding/Pedicle Flap, Connective Tissue Grafts, and Acellular Dermal Matrix Grafts are employed depending on the specific defect.
When a Person Should Avoid Overview of Periodontal Surgical Procedures
There are certain situations where dental treatments might not be the best option. For example, if your teeth are significantly damaged, to the point of losing more than two-thirds of the bone in most teeth, including your canines and first molars, or if your teeth move around a lot, it might be a better choice to remove your teeth and replace them with complete dentures.
There are also cases where treatment might still be possible, but there is a higher chance that it won’t work as well or might lead to complications. For instance, smoking can make it harder to achieve good results from gum surgery, and usually leads to more significant gum recession. Similarly, if you have diabetes, it could increase your risk of complications after surgery, like more swelling, wounds reopening or longer healing time. Medications that weaken your immune system, and conditions that make you more susceptible to infections, could increase your risk of getting an infection after surgery. Also, certain medicines that affect blood vessel formation and bone absorption might increase your risk of jaw bone death, but this risk is unclear. This risk is probably small for people taking oral bisphosphonates but can be more severe for those receiving this medication intravenously for cancer. However, people with conditions like diabetes, cardiovascular disease, problems with blood clotting or immune systems compromization (like HIV) can still get gum surgery, as long as their glucose levels, heart function, and other relevant blood tests are within the safe range.
Your age may also affect your treatment. As you get older, our body’s cells become less competent, and healing becomes slower. This might increase your risk of tissue tearing during surgery and bruising due to more fragile blood vessels. There are also several local factors related to the tooth structure and position which might lower the success rate for gum pocket reduction surgery.
In situations where you have excessive gum display due to your lip’s hyperactivity, skeletal structure, or short upper lip, showing the crown, which is the part of your tooth that’s visible, may not be possible. In addition, grafting procedures might be difficult to perform if you have a shallow palate, a large bony bump in your palate or thin tissue.
Preparing for Overview of Periodontal Surgical Procedures
Before a dental procedure, an antiseptic rinse can help minimize the number and volume of viruses and bacteria. This can lead to less spreading of germs during the use of instruments that generate a spray of saliva and other particles, such as during a cleaning or drilling procedure.
People who feel nervous or anxious about dental visits might find it helpful to use some form of relaxation aid. This could be something as simple as breathing in a gas called nitrous oxide, often known as laughing gas. Other options include taking a calming pill an hour before the treatment starts, or depending on the procedure, the option of oral, intravenous (through a vein) sedation or even general anesthesia may also be available to help keep the patient comfortable and calm.
Standard dental anesthetics, such as lidocaine combined with epinephrine, which is a drug that helps to reduce bleeding, are usually used to numb the mouth before periodontal (gum) surgery. Additional anesthesia can be given just before the surgery to further control bleeding and to make sure the patient doesn’t feel pain. Long-lasting anesthetics like bupivacaine are given after the surgery to help manage pain and reduce the need for pain medications.
Periodontal surgery personnel might decide to give anti-inflammatory medication before the procedure to help with pain control. They might also prescribe antibiotics to patients who are at a higher risk for developing infections. In cases where bone graft materials or substances containing growth factors are used, a drug called dexamethasone can be prescribed to help minimize swelling and the pain related to it after the surgery.
How is Overview of Periodontal Surgical Procedures performed
Gingivectomy and wedge procedures are two types of surgeries that are performed to remove excess gum tissue. These surgeries are typically needed when there’s too much gum tissue around a tooth because of an abnormal tooth eruption, a genetic cause, or the use of certain medicines. However, these surgeries may not be the best options in cases where there’s an underlying bone problem or if the excess gum tissue tends to grow back.
In a gingivectomy, the doctor will remove the excess gum tissue around the tooth. Here’s how it’s done:
- The doctor measures and marks the excess gum tissue.
- Then, the doctor removes the excess tissue using a scalpel, laser, or an electrosurgery tool. The removed tissue has a scalloped margin or curved edge. Often, the doctor uses electrosurgery or laser to stop any bleeding.
- Finally, the doctor smoothens the gums by removing any leftover thick tissue with a further incision. Afterward, the doctor will use gauze to stop any bleeding and may apply a dressing to protect the area as it heals.
The wedge procedure is another way to remove excess gum tissue. This procedure is used when the excess gum tissue is in between two teeth or around toothless areas. Here’s what this procedure looks like:
- The doctor makes a full-thickness, straight incision from the center of the middle and the extra soft tissue.
- Then, the doctor makes two more full-thickness incisions that are angled inward, on both sides of the tooth facing the extra soft tissue.
- The doctor also makes another incision connecting both sides of the interdental surface facing the excess soft tissue.
- Then, the doctor removes the extra soft tissue, leaving behind a wedge-shaped piece of gum.
- Finally, the doctor uses either a horizontal inverting mattress suture or two vertical inverting mattress sutures to close the gum flaps.
If the doctor needs to access the root surfaces of your teeth, they might perform a gingival flap procedure. This procedure may be needed if there is residual pocketing without an underlying bone defect. Here’s what this procedure looks like:
- The doctor identifies the area of pocketing and plans an envelope flap that extends 1 to 2 teeth from the area.
- Then, they make an incision following the outline of the gums around the tooth. If the area is filled with thick tissue, the doctor will do a distal wedge procedure as described above.
- The doctor then lifts the gum flap and removes any loose tissue. They clean the root surfaces and remove any visual debris on it.
- After removing any remaining interdental tissue, they elevate the flap to check for remaining calculus or mineral build-up.
- Next, if there are any bone defects, the doctor employs special treatments to address it.
- Finally, the doctor returns the flap and sutures it back into place.
Remember, your doctor is a professional and will choose the best procedure that fits your needs. You can rest assured knowing that your health and comfort are their top priorities.
Possible Complications of Overview of Periodontal Surgical Procedures
There can be two types of complications after periodontal surgery: those that can occur after any mouth surgery and those specific to gum surgery.
After any oral surgery, including gum surgery, you might experience bleeding, pain, swelling, some color changes in your gum tissues, and bruising. Generally, gum surgeries like pocket reduction (shrinking the space between gum and tooth) and crown lengthening (exposing more of the tooth above the gums) usually have less post-operative pain, bleeding, and swelling compared to tooth removal. However, surgeries involving grafting gum tissue (moving gum tissue from one part of the mouth to another) can cause pain, swelling, and bleeding at the source of the graft, usually the roof of your mouth.
A big study conducted in an academy showed that after gum surgeries, complications like tooth sensitivity, excessive pain, and bleeding do occur, but they’re not that common.
The pain from gum surgery can usually be managed with temporary use of anti-inflammatory medicines, like ibuprofen, and cold packs also help with pain control. The pain usually peaks 5 to 6 hours after surgery. For moderate to severe pain after surgery, your doctor might suggest a combination therapy of ibuprofen and acetaminophen.
When it comes to bleeding, it normally stops after the surgeon stitches the incision. Serious post-operative bleeding is only seen in patients taking blood thinners. Using local ways to stop bleeding usually work fine. Serious bleeding after gum surgery is rare, and is mainly a concern for those with bleeding disorders such as hemophilia or patients on coumadin therapy.
Infections after gum surgery are also rare, only 2% of patients experience this. Antibiotics aren’t usually given after gum flap surgery, bone surgery, pedicle flap surgery, or tissue graft surgery. But they are typically given after bone graft and guided tissue regeneration procedures. The correct duration for antibiotic therapy for these surgeries is still not agreed upon or supported with evidence. Patients who smoke, or have uncontrolled diabetes, are thought to be at a higher risk for post-operative infections.
Now for the complications specific to gum surgery, one possibility is that the surgery may not give the expected results and the unique risks that come with each type of gum surgery. Pocket depth reduction surgeries usually result in some gum recession, which can expose the roots of the teeth and make them look longer.
Exposed tooth roots are more sensitive to heat, cold, and sweet foods. While mild tooth sensitivity is normal after most gum surgeries, sensitivity after this surgery can be severe and may need treatment. Options for handling tooth sensitivity include over-the-counter and in-office desensitizing agents, the application of sealants, or, in severe cases, root canal therapy.
Also, gum recession might leave unsightly open spaces known as black triangles between teeth. If gum tissue has been grafted from one spot to another, the grafted areas may have a different color, affecting the appearance of your gums. Once the gums recede, the exposed root surfaces are also more likely to get tooth decay, especially if you don’t have good oral hygiene habits.
Lastly, surgeries that aim to make crowns appear longer, expose more tooth surface above the gum, and impact the shape of the tissue between teeth. Therefore, any restoration of the tooth must take these changes into account by making longer contacts between teeth.
Sometimes, the graft of tissue might look different during healing, which can be concerning for patients. It might partially wear away, be surrounded by yellowish debris, and change color significantly while new blood vessels are growing in it. These grafts often look thicker and paler once they have healed. The place in the palate where the graft came from may look concerning to patients until it fills in with tissue. Patients might also perceive changes in the feel of their mouth if the place the graft came from doesn’t completely regain its original shape, or if the change in depth in the recipient sites feels different.
What Else Should I Know About Overview of Periodontal Surgical Procedures?
Treatment for gum disease, which can include gum surgery, helps to prevent tooth loss. After about 5 years, we see similar improvements in patients who take rigorous care of their teeth and gums, no matter whether they had surgery or not.
Gum surgery is usually done after an initial deep cleaning of the teeth and roots (scaling and root planing). This is because the cleaning followed by surgery has shown to reduce the depth of gum pockets (spaces around the teeth where gum disease can form) and improve tooth attachment more than surgery without an initial cleaning.
Deep pockets of 7mm show the biggest reduction in depth after surgery, but this could also lead to more gum recession than scaling and root planing. The reduction in pocket depth is similar, whether you have a gum flap surgery or bone surgery for pockets deeper than 7mm. However, bone surgery could cause more gum recession.
If you have deep, narrow-angled bone defects in the pockets surrounding your teeth, they are more likely to heal and become filled with bone through regenerative gum therapy. The outcomes are typically similar, no matter what type of regenerative material is used.
