Periodontal Plastic Surgery and Laser Surgery

I. Cosmetic Periodontal Plastic Surgery
Cosmetic gum surgery has become more popular with the advent of new treatments and the addition of new lasers in dentistry and now that more Americans are living longer and maintaining their teeth. Periodontal plastic surgery has also become more necessary now that cosmetic veneers and more natural looking bonded dentistry have become so popular.

According to the Academy of Periodontology, a recent poll of 253 consumers found the following:

  • 50 percent consider the smile the first facial feature they notice
  • 80 percent are not happy with their smile
  • Respondents were seven times more likely to have periodontal, smile enhancement procedures, than face-lifts
  • Smile enhancement procedures outnumbered eyelid surgeries five to one

Below are listed a number of the most common periodontal cosmetic procedures done in our dental center. The word “periodontal” refers to the tissues surrounding the tooth, such as the gum or gingival tissues and the supporting bone and ligament holding the tooth into the bone.

Gummy Smile or Uneven Gum Line
This is a condition in which the gum tissues show too much when you smile or talk. If you feel 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, then this is how some gummy conditions manifest themselves. If you do have this condition, crown lengthening and/or gingivoplasty 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 a better look. With the Waterlase laser at our center, a gentle recontouring of the gum tissues to make them even is more comfortable and less time consuming than ever before possible. The laser actually often makes the procedure heal faster and more predictably. This same laser can be used to recontour the bone as-well-as the gum tissue gently and quickly.

Long Teeth/Exposed Roots/Gingival Clefts
Along with the tendency of the baby boomers getting older and more people keeping their natural teeth, sometimes gum recession causes the tooth root to become exposed, which makes your teeth look long and can make you look older than you are. Gum recession can happen as a result of a variety of causes, including tooth brushing, abnormal mouth habits, and periodontal diseases. Often these exposed roots are sensitive to temperatures and touching. They are more prone to toothbrush abrasion since the root is softer to tooth scrubbing and the root surface is more prone to cavities. Gum clefts areas can rapidly progress down the root surface and endanger the tooth to being lost.

Soft tissue grafts (gum tissue grafts) in which the gum is brought from the roof of the mouth to the receded areas and/or other root coverage procedures, such as grafts from tissue banks, are designed to cover exposed roots, to reduce further gum recession and to protect vulnerable roots from decay.

Ridge and Gum Shrinkage with Defects
Tooth loss can cause bone loss under the gums and jawbone where the tooth used to be. This can lead to indentation defects and ridge shrinkage. Once this happens, any replacement tooth placed by a dentist may look too long or have to be placed in an awkward place. This will not look normal. It may also not function properly.

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. Even more helpful would be the placement of a dental implant into the new augmented bone. This then helps keep the bone from resorbing all over again.

II. The Treatment of Gum Diseases
There are two common forms of periodontal disease (gum disease). The first is gingivitis in which the gum tissues are infected and not the bone. The second form is periodontitis in which the gum tissues and the bone are both infected. The second form is divided into three stages of severity. The first is mild periodontitis, the second is moderate periodontitis, and the third is severe periodontitis. In each stage the amount of bone loss increases to the point where teeth become loose and painful in the final stages. Gum disease does not hurt until very severe and unfortunately when that happens, it may be too late to save the teeth.

Research shows that 92 % of adults have calculus (tartar) in our mouths, and 3 out of every 4 adults have calculus beneath the gums, where it causes the most severe damage. Over 1/2 of the adults over the age of 35 are already in the early stages of periodontal disease. In fact, periodontal disease is the primary cause of tooth loss after the age of 35 .
- Statistics taken from:     Oliver, Brown and Loe, Journal of Periodontology, 1998
Albandar et al, 1999, Journal of Periodontology, 1999

The main cause of periodontal disease is the accumulation of plaque bacteria . Another cause is the body’s immune response to the bacteria may be to “over react” by producing too much collagenase enzyme, which destroys collagen in the tissues around the teeth. Plaque is often a colorless mass of bacteria that sticks to teeth, crowns and bridges, and other tissues in the oral cavity. Plaque is constantly forming on the teeth.  Plaque infects the gums, causing them to become red, tender, and swollen. It also progresses down the root surface destroying bone and deepening the pockets between the gum tissue and the teeth. Recession can result from this process too. Cosmetically, periodontal diseases can be very unpleasant to look at.

If not removed daily, plaque becomes the hard material known as calculus . (Most people know it as “tartar”). Calculus cannot be removed by brushing and flossing alone. A dentist, periodontist, or hygienist must remove it manually to stop the disease process. For those people who are more susceptible to periodontal disease, visits to the dentist for professional cleaning may be needed more frequently than every six months.

Other factors can modify how your gums react to plaque or calculus, thereby altering your body's response to periodontal disease and affecting your overall health :

  • Smoking/Tobacco Use
  • Dry Mouth/Xerostomia
  • Arthritis
  • Osteoporosis
  • Diabetes
  • Stress
  • Medications
  • Clenching or Grinding Your Teeth
  • Pregnancy and Puberty
  • Diet and Nutrition
  • Immunosuppression (i.e. leukemia, AIDS)

The other side of this relationship between overall health and gum disease is that periodontal diseases have been shown to affect overall health. Evidence is growing that periodontal disease can contribute to the development and/or speed and severity of the development of heart disease, premature births, pneumonia, diabetes, arthritis, and several other diseases.

Depending on how advanced gum disease is, treatment may involve any of the following:

  • Scaling and root planing. Scaling involves the removal of the plaque and calculus deposits on the tooth surfaces, while root planing is the smoothing of the root surfaces in order to promote reattachment of the gum tissue to the tooth.
  • Laser disinfection of periodontal pockets. One of the most advanced new adjuncts to the treatment of the chronic infection of periodontal disease is the use of the Waterlase laser to perform a disinfection procedure inside the pockets and sulcus around the teeth.   A number of lasers have been used for this purpose, including diode lasers and CO2 lasers.  These lasers can help but they have the disadvantage of producing heat.   The Waterlase laser produces no heat because the laser actually uses water and a specific wave length of  laser light that is attracted to water to clean out the pocket with tiny micro water explosions.  At a very low 1 watt of power a very safe and very effective debridment of the infection around the teeth can be accomplished with no heat production at all.  Bacteria are killed and irrigated out of the pockets with safety for the adjacent teeth and gum tissues.   This used in combination with medical irrigates such as Chorhexidine and stabilized chlorine dioxide gel and rinses, can produce results that can reduce numbers of the most virulent periodontal bacteria for many months, allowing the gum tissues to heal and remain resistant to more inflammation.   This procedure is done at the same time as the root planing is done or at a different appointment.
  • Nutrition and the use of a number of very special oral health products. It has been shown that certain nutritional foods and supplements can increase the resistance of gum tissues to breakdown.   Many vitamins and mineral supplements on the market do not dissolve in the stomach and intestines, therefore they do no good.   Many others on the market do not have the amount of each vitamin or mineral they claim to have.   Vitamin C, coenzyme Q-10, grape seed extract,  zinc and folic acid are just a few of the nutritionals needed to support the health of your gum tissues.   Some of these work topically in the mouth and internally through the blood stream.
    In addition to the nutritionals, oral health toothpastes, rinses and gels with ingredients such as zinc acetate, stabilized chlorine dioxide, tea tree oil, xylitol, aloe vera destroy volatile organic waste products produced by bacteria. These waste products directly contribute to gum inflammation and promote its infection. Special cleaning devices such as the home use of hydromagnetic irrigation can clean areas under the gum tissues, under bridges and between the teeth that a toothbrush or floss cannot reach.
  • Flap and osseous surgery allows the dentist to gain access to the root of the tooth for removal of plaque, calculus, and diseased tissue. The gum is then carefully sutured back into place. Flap surgery may sometimes be accompanied by minor osseous (bone) shaping or removal in order to ease tissue positioning, facilitate home care, and simplify your maintenance appointments. Sometimes a medicated form of doxyclycline is placed into the gum tissue for healing. Periostat medication in low 20mg doses may also be prescribed for home use to help prevent the over production of collagenase by the body during healing. Peridex antibacterial rinses will be prescribed for around two weeks following the surgery during the initial healing phase. A stabilized chlorine dioxide toothpaste, gel and rinse will also prescribed for long term home use.
  • Guided tissue regeneration(GTR) involves the use of a biocompatible membrane material, often in combination with a bone graft that promotes the growth of lost tissue and bone around teeth. The bone graft can be taken from other areas of a patients mouth or can be obtained from a tissue bank source. Not all cases can or need to have this done.

More and more periodontal treatment of gum diseases are relying on conservative therapies and less on surgery. The disease is being treated more as an infection and gum tissues are being reattached to the root surfaces through these methods.

If cosmetic procedures need to be done, they are becoming more effective and less invasive than before. Lasers have simplified and improved results for many. New medications are improving results like never before.

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