In most cases of periodontal disease , it is possible to establish periodontal health around teeth through non-surgical periodontal treatment. This generally involves scaling and root planing (a careful and thorough cleaning of the root surfaces to remove plaque and calculus [tartar] from deep periodontal pockets and to smooth the tooth root to remove bacterial toxins).
Non-surgical periodontal treatment does have its limitations, however, and when it does not achieve periodontal health, periodontal surgery may be required to restore periodontal anatomy damaged by periodontal diseases and to facilitate oral hygiene practices.
The bone and gum tissue around a tooth generally fits snugly around the tooth. When periodontal disease is present, this supporting tissue and bone is destroyed, forming “pockets” around the teeth. Over time and as the disease progresses, 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 become loose and need to be extracted.
Whilst non-surgical treatment by itself is adequate to treat most cases of periodontal disease, there are limitations to its use. Non-surgical treatment may be less effective in deeper pockets where there is limited access for cleaning instruments to reach. Periodontal surgery is often required to clean pockets that are too deep to be cleaned with non-surgical treatment.
During this procedure, the gum tissue is folded back and the disease-causing bacterial deposits are removed before the gums are stitched back in place. In some cases, irregular surfaces of the damaged bone are smoothed to limit areas where disease-causing bacteria can hide. This is known as osseous surgery and it allows the gum tissue to better reattach to healthy bone.
Periodontal regenerative procedures are a subset of surgical procedures that can be performed either by using special membranes or tissue-stimulating proteins. Both of these encourage your body to regenerate the original bone and periodontal ligament that was originally lost around the teeth. Eliminating existing bacteria and regenerating bone and tissue helps to reduce pocket depth and repair damage caused by the progression of periodontal disease . It is important to note that periodontal regeneration is best attempted only if selected conditions exist and that it is not always possible to regenerate periodontal tissue that has been lost due to periodontal disease.
Gum grafts are used to cover exposed root surfaces due to excessive gingival recession. Generally, gum tissue is taken from the palate (the donor site) and stitched onto the exposed root surface (recipient site). The graft eventually gets integrated into the recipient site. Gum grafting can be done for one tooth or for several teeth. It is important to note that not all areas of recession can be grafted.
Gum graft surgery is utilised to provide an increased band of firm gum tissue (also known as attached gingiva) around the tooth that will provide greater resistance to further gum loss in the area. As a bonus, some of the gum that was previously lost can also be regained although it is not always possible to regain all the lost gum tissue. Sensitivity caused by exposed root surfaces is also reduced following gum grafting surgery. If the recession is in an aesthetic area then the aesthetics of the area can also be greatly improved.
Natural bone loss following tooth extraction in the upper or lower jaw often leaves inadequate bone in which to place dental implants. To correct this problem, the gum is lifted away from the ridge to expose the bony defect and the defect is then filled with bone or bone substitute materials. A barrier membrane is then used to contain this bone graft and to prevent unwanted non-bone cells from migrating in. This helps build up the bony ridge and enables the placement of dental implants in the area. Ridge modification caused by bone grafting has been shown to greatly improve appearance and increase the chances for successful implant osseointegration. The materials used for bone grafting can either be autogenous bone (harvested from another area of the body such as the corner of the jaws or the chin) or xenografts (derived from an animal donor such as a cow) or alloplastic materials (synthetic bone graft materials) All these materials act as a scaffolding for new natural bone cells to migrate into the area and form new bone that eventually replaces the bone graft material.
A key to dental implant success is the quantity and quality of the bone where the implant is to be placed. The upper back jaw has traditionally been one of the most difficult areas to successfully place dental implants due to insufficient bone quantity and quality and the close proximity to the sinus. Sinus augmentation can help correct this problem by raising the sinus floor and developing bone through the use of bone grafts for the placement of dental implants.
An atraumatic extraction is when a tooth or tooth root is extracted with the intention of preserving as much of the bone surrounding the tooth as possible. This is of vital importance if a dental implants is to be placed in the area in the future. The technique used for atraumatic extractions is similar to that used for normal extractions except that a much greater level of care is taken to preserve the bone surrounding the tooth. Special instruments and techniques are required for atraumatic extractions. If there is only a tooth root present that requires extraction then an atraumatic extraction involves teasing the root out without drilling away the surrounding bone.
Socket preservation is a technique whereby bone graft material is added to the extraction socket at the time of tooth extraction. The intent of this procedure is to minimise the normal atrophy or shrinkage of the bone that occurs following extraction of a tooth. This, in turn, enables more bone volume to be preserved in the jaws in order to place a dental implants in the area in the future.
A frenum is a fibrous connective tissue attachment that adheres the lips to the gums. Whilst everyone has a dental frenum, in some individuals this attachment is particularly strong and can contribute to recession of the gums in the area. In these cases it is necessary to perform a frenectomy where the frenum is resected away to eliminate the pulling action of the lip muscles on the gums.
Crown lengthening is a procedure where the gum and bone around the teeth are re-shaped and sculpted to expose more of the natural tooth structure that was previously located underneath the gums. Crown lengthening is often used for smile line correction. This is used to treat gummy smiles where the gums around several teeth, usually the upper front ones, are trimmed back so that there is less gum visible when smiling. Smile line correction is also used to treat teeth that are short and squat in appearance. Performing crown lengthening on these teeth can provide more natural proportions to these short teeth.
Crown lengthening can be performed on a single tooth as well. This is most often necessary when a filling is located underneath the gums or when a tooth is broken underneath the gum line or when additional tooth structure is required to support a crown on a tooth. A crown lengthening procedure here will expose more of the tooth so that a crown or filling can be placed on it.
A gingivectomy is a procedure that is similar to crown lengthening except that no bone removal is performed. The gums are trimmed and sculpted back to their normal levels and to the desired shape. It is most commonly performed when there is an overgrowth of the gums, often caused by a side effect of certain medications or by poor plaque control.
Unerupted tooth exposure is often necessary in conjunction with specialist orthodontic treatment in cases where a permanent tooth has not erupted into the mouth but instead is stuck buried underneath the gums. In these cases the gums in the vicinity of the unerupted tooth are raised in order to expose the tooth. If the unerupted tooth is buried under bone then some bone removal may be necessary in order to fully expose the tooth. A bracket and chain is then bonded to the tooth before the gums are replaced. Following healing, the orthodontist can then use the bracket and chain to drag the tooth into its proper position in the mouth.
Tooth loss can cause an indentation in the gums and jawbone where the tooth used to be. This happens because the jawbone shrinks when it no longer is holding a tooth in place. Not only is this indention 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. This is done either with the use of a bone graft or gum graft to fill in the defect. A new tooth can then be created that is natural looking, easy to clean and beautiful.
Usually, after non-surgical and/or surgical periodontal treatment, most patients do not require any further active treatment. However, the majority of patients will require ongoing periodontal maintenance therapy to sustain their periodontal health. This involves periodic checking of the gums for early interception of any new disease and scaling and root planing of the gums to remove new calculus or tartar deposits that have been deposited onto the teeth since the previous clean.
Most patients with periodontal disease will benefit from a 3-4 monthly recall for periodontal maintenance. The frequency of this ongoing periodontal maintenance recall can vary from patient to patient. Generally, the more able a patient is to maintain meticulous levels of plaque control with their home oral hygiene regimen, the less of a need there is for this maintenance. A more regular recall is necessary in patients with deep residual periodontal pockets and in those with furcation involvements. These patients have areas of their mouth where good oral hygiene alone is not enough to eliminate plaque and bacteria and so regular professional maintenance is essential to eliminate plaque and calculus deposits before they have a chance to destroy additional bone and gum around the teeth.
All periodontal research is conclusive in stating that a long-term periodontal maintenance recall plan is critical in securing the long-term periodontal health of the teeth and avoiding tooth loss.