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Soft Tissue Grafting

Soft tissue grafting is often necessary to combat gum recession.  Periodontal disease, trauma, aging, over brushing, and poor tooth positioning are the leading causes of gum recession which can lead to tooth-root exposure in severe cases.

 

When the roots of the teeth become exposed, eating hot and cold foods can be uncomfortable, decay is more prevalent and the aesthetic appearance of the smile is altered.  The main goal of soft tissue grafting is to either cover the exposed root or to thicken the existing gum tissue in order to halt further tissue loss.

 

The three different types of common soft tissue grafts include:

 

 Free gingival graft – A strip of tissue is removed from the roof of the mouth and stitched to the grafting site in order to promote natural growth.  This type of graft is most commonly used for thickening existing tissue.

 Connective tissue graft – For larger areas or root exposure, subepithelial tissue is needed to remedy the problem.  This subepithelial connective tissue is removed from a small flap in the mouth and sutured to the grafting site.  This is the most common treatment for root exposure.

 Pedicle graft – This type of graft involves the “sharing” of soft tissue between the affected site and adjacent gum.  A flap of tissue is partially cut away and moved sideways to cover the root.  The results of this type of graft are excellent because the tissue that is moved to the adjacent area includes blood vessels that are left in place.

Reasons for soft tissue grafting

 

Soft tissue grafting is an extremely versatile procedure that has many uses.  Recent developments in dental technology have made soft tissue grafting more predictable and less intrusive.  Here are some of the main benefits associated with soft tissue grafting treatment:

 

 Increased comfort – Root exposure can cause substantial pain and discomfort.  Eating hot, cold or even warm foods can cause severe discomfort. Soft tissue grafts cover the exposed root, decrease sensitivity and restore good health to the gum area.

 Improved aesthetics – Gum recession due to periodontal disease can cause the smile to look “toothy” or the teeth to appear uneven in size.  Soft tissue grafting can be used as a cosmetic procedure to re-augment the gums, and make the smile appear more symmetrical.

 Improved gum health – Periodontal disease is a progressive condition that can destroy soft tissue very rapidly.  When used in combination with deep cleaning procedures, soft tissue grafting can halt tissue and bone loss, and protect exposed roots from further complications.

What does soft tissue grafting treatment involve?

 

Initially, deep cleaning will be performed both above and below the gum line to clear the teeth and roots of calculus (tartar).  The grafting procedure itself will generally be performed under local anesthetic, but this will depend on the size of the areas receiving grafts.  A small incision will be made at the recipient site in order to create a small pocket.  A split thickness incision is made in this pocket and the donor tissue is placed between the two sections of this area.  The donor tissue strip is generally larger than the incision, so some excess will be apparent.

 

Platelet rich growth factors which stimulate natural tissue growth and promote good healing may be applied to the site before suturing.  In addition, tissue-stimulating proteins may be added to encourage quicker tissue growth.  Finally, the wound site will be sutured to prevent shifting, and surgical material will be placed to protect the sensitive area.  Gum uniformity and substantial healing will take place in the first six weeks after the procedure.

                                Pocket Reduction Surgery

Pocket reduction surgery (also known as gingivectomy, osseous surgery and flap surgery) is a collective term for a series of several different surgeries aimed at gaining access to the roots of the teeth in order to remove bacteria and tartar (calculus).

 

The human mouth contains dozens of different bacteria at any given time.  The bacteria found in plaque (the sticky substance on teeth) produce acids that lead to demineralization of the tooth surface, and ultimately contribute to periodontal disease.

 

Periodontal infections cause a chronic inflammatory response in the body that literally destroys bone and gum tissues once they invade the subgingival area (below the gum line).  Gum pockets form and deepen between the gums and teeth as the tissue continues to be destroyed.

 

Periodontal disease is a progressive condition which, if left untreated, causes massive bacteria colonization in gum pockets and can eventually cause teeth to fall out.  Pocket reduction surgery is an attempt to alleviate this destructive cycle, and reduce the depth of the bacteria-harboring pockets.

 

Reasons for the pocket reduction surgery

 

Pocket reduction surgery is a common periodontal procedure which has been proven effective at eliminating bacteria, reducing inflammation and saving teeth.  The goals of pocket reduction surgery are:

 

 Reducing bacterial spread – Oral bacteria has been connected to many other serious conditions such as diabetes, heart disease and stroke.  Oral bacteria can travel to various parts of the body from inside the bloodstream and begin to colonize.  It is important to decrease bacteria in the mouth in order to reduce the risk of secondary infection.

 Halting bone loss – The chronic inflammatory response induced by oral bacteria leads the body to destroy bone tissue.  As the jawbone becomes affected by periodontal disease, the teeth lose their rigid anchor.  When the teeth become too loose, they may require extraction.

 Facilitate home care – As the gum pockets become progressively deeper, they become incredibly difficult for the patient to clean.  The toothbrush and dental floss cannot reach the bottom of the pockets, increasing the risk of further periodontal infections.

 Enhancing the smile – An oral cavity that is affected by periodontal disease is not attractive to the eye.  In fact, smiles may be marred by brown gums, rotting teeth and ridge indentations.  Pocket reduction surgery halts the progression of gum disease and improves the aesthetics of the smile.

What does pocket reduction surgery involve?

 

Before recommending treatment or performing any procedure, the dentist will perform thorough visual and X-ray examinations in order to assess the condition of the teeth, gums, and underlying bone. Pocket reduction surgery can be performed under local or general anesthetic depending on patient preferences.

 

The gums will be gently pulled back from the teeth and bacteria and calculus (tartar) will be eliminated.  Scaling and root planing will generally be required to fully remove the ossification (tartar) from the surface of the tooth root.  If the root is not completely smooth, a planing procedure will be performed to ensure that when the gums do heal, they will not reattach to rough or uneven surfaces.

 

The final part of the surgery is usually the administration of an antimicrobial liquid to eliminate any remaining bacteria and promote healing.  The gum is then sutured with tiny stitches that are left in place for 5-10 days.

 

Though the gums will be more sensitive immediately following the procedure, there will be a significant reduction in pocket depth and a vast improvement in the condition of the teeth and gums.

                                Gum Grafting

A gum graft (also known as a gingival graft or periodontal plastic surgery), is a collective name for surgical periodontal procedures that aim to cover an exposed tooth root surface with grafted oral tissue.

 

Exposed tooth roots are usually the result of gingival recession due to periodontal disease.  There are other common causes, including overly aggressive brushing and trauma.

 

Here are some of the most common types of gum grafting:

 

 Free gingival graft – This procedure is often used to thicken gum tissue.  A layer of tissue is removed from the palate and relocated to the area affected by gum recession.  Both sites will quickly heal without permanent damage.

 Subepithelial connective tissue graft – This procedure is commonly used to cover exposed roots.  Tissue is removed fairly painlessly from the outer layer of the palate and relocated to the site of gum recession.

 Acellular dermal matrix allograft – This procedure uses medically processed, donated human tissue as a tissue source for the graft.  The advantage of this is procedure is that there is no need for a donor site from the patient’s palate (and thus, less pain).

Reasons for gum grafting

 

Gum grafting is a common periodontal procedure.  Though the name might sound frightening, the procedure is commonly performed with excellent results.

 

Here are some of the major benefits associated with gum grafting:

 

 Reduced sensitivity – When the tooth root becomes exposed, eating or drinking hot or cold foods can cause extreme sensitivity to the teeth.  Gum grafting surgery permanently covers the exposed root, helps reduce discomfort, and restores the good health of the gums.

 Improved appearance – Periodontal disease is characterized by gum recession and inflammation.  Gum recession and root exposure can make the teeth look longer than normal and the smile to appear “toothy.”  Gum grafting can make the teeth look shorter, more symmetrical and generally more pleasing to look at.  In addition, adjacent tissue can be enhanced and augmented during the procedure for aesthetic purposes.

 Improved gum health – Periodontal disease can progress and destroy gum tissue very rapidly.  If left untreated, a large amount of gum tissue can be lost in a short period of time.  Gum grafting can help halt tissue and bone loss; preventing further problems and protecting exposed roots from further decay.

What does gum grafting treatment involve?

 

Once the need for gum grafting surgery has been determined, there are several treatments the dentist will want perform before gum grafting takes place.  First, the teeth must be thoroughly cleaned supra and subgingivally to remove calculus (tartar) and bacteria.  The dentist can also provide literature, advice and educational tools to increase the effectiveness of homecare and help reduce the susceptibility of periodontal disease in the future.

 

The gum grafting procedure is usually performed under local anesthetic.  The exact procedure will depend much on whether tissue is coming from the patient’s palate or a tissue bank.

 

Initially, small incisions will be made at the recipient site to create a small pocket to accommodate the graft.  Then a split thickness incision is made and the connective tissue graft is inserted into the space between the two sections of tissue. The graft is usually slightly larger than the recession area, so some excess will be apparent.

 

Sutures are often placed to further stabilize the graft and to prevent any shifting from the designated site.  Surgical material is used to protect the surgical area during the first week of healing.  Uniformity and healing of the gums will be achieved in approximately six weeks.

                                Gum Recession

Gingival recession (receding gums) refers to the progressive loss of gum tissue, which can eventually result in tooth root exposure if left untreated.  Gum recession is most common in adults over the age of 40, but the process can begin in the teenage years.

 

Gum recession can be difficult to self-diagnose in its earlier stages because the changes often occur asymptomatically and gradually.  Regular dental check ups will help to prevent gum recession and assess risk factors.

 

The following symptoms may be indicative of gum recession:

 

 Sensitive teeth – When the gums recede enough to expose the cementum protecting the tooth root, the dentin tubules beneath will become more susceptible to external stimuli.

Visible roots – This is one of the main characteristics of a more severe case of gum recession.

 Longer-looking teeth – Individuals experiencing gingival recession often have a “toothy” smile.  The length of the teeth is perfectly normal, but the gum tissue has been lost, making the teeth appear longer.

 Halitosis, inflammation, and bleeding – These symptoms are characteristic of gingivitis or periodontal disease.  A bacterial infection causes the gums to recede from the teeth and may cause tooth loss if not treated promptly.

Causes of Gum Recession

Gum recession is an incredibly widespread problem that dentists diagnose and treat on a daily basis.  It is important to thoroughly examine the affected areas and make an accurate diagnosis of the actual underlying problem.  Once the cause of the gum recession has been determined, surgical and non-surgical procedures can be performed to halt the progress of the recession and prevent it from occurring in the future.

 

The most common causes of gingival recession are:

 

 Overaggressive brushing – Over-brushing can almost be as dangerous to the gums as too little. Brushing too hard or brushing with a hard-bristled toothbrush can erode the tooth enamel at the gum line and irritate/inflame gum tissue.

 Poor oral hygiene – When brushing and flossing are performed improperly or not at all, a plaque build up can begin to affect the teeth.  The plaque contains various bacterial toxins which can promote infection and erode the underlying jawbone.

 Chewing tobacco – Any kind of tobacco use has devastating effects on the entire oral cavity, chewing tobacco in particular.  It aggravates the gingival lining of the mouth and causes gum recession when used continuously.

 Periodontal disease – Periodontal disease can be a result of improper oral hygiene or caused by systemic diseases such as diabetes.  The excess sugars in the mouth and narrowed blood vessels experienced by diabetics create a perfect environment for oral bacteria.  The bacterium causes an infection which progresses deeper and deeper into the gum and bone tissue, eventually resulting in tooth loss.

Treatment of Gum Recession

Every case of gum recession is slightly different, therefore many treatments are available. The nature of the problem which caused the recession to begin with needs to be addressed first.

 

If overly aggressive brushing techniques are eroding the gums, a softer toothbrush and a gentler brushing technique should be used.  If poor oral hygiene is a problem, prophylaxis (professional dental cleaning) may be recommended to rid the gum pockets of debris and bacteria.  In the case of a severe calculus (tartar) build-up, scaling and root planing will be performed to heal gingival inflammation and clean the teeth.

 

Once the cause of the gingival recession has been addressed, surgery of a more cosmetic or restorative nature might be recommended.  Gum tissue regeneration and gum grafting are two excellent ways to restore natural symmetry to the gums and make the smile look more aesthetically pleasing.

                                Ridge Modification

Ridge modification is an effective procedure for treating deformities in the upper and lower jaws.  These deformities can occur as a result of periodontal disease, trauma, injury, wearing dentures, or developmental problems.  Such defects can leave insufficient bone for the placement of dental implants and an additional unattractive indentation in the jaw line adjacent to the missing teeth.

 

During the ridge modification procedure, the gum is lifted away from the ridge to fully expose the defect in the bone.  The bony defect can be filled with bone graft material that can help regenerate lost bone or a bone substitute. Finally, the incision is closed and several months of healing will be required.  Depending on the case and type of implant and procedure, the dental implant might be placed during the ridge modification procedure or when healing is complete; this all depends on the condition of the bone.  Ridge modification improves the cosmetic appearance, functionality of the mouth, and the chance of enjoying dental implants for many years.

 

                                Crown Lengthening

Crown lengthening is generally performed to improve the health of the gum tissue or to prepare the mouth for restorative or cosmetic procedures.  In addition, crown lengthening procedures can also be used to correct a “gummy” smile, where teeth are covered with excess gum tissue.  Crown lengthening exposes more of the natural tooth by reshaping or recontouring bone and gum tissue.  This treatment can be performed on a single tooth, many teeth, or the entire gum line, exposing an aesthetically pleasing smile.

 

Reasons for crown lengthening

 

Crown lengthening is a versatile and common procedure that has many effective uses and benefits.  The vast majority of patients who have undergone this type of surgery are highly delighted with the results.

 

Here are some of the most common reasons for crown lengthening:

 

 Restoration of damaged teeth – Periodontal disease can cause severe damage to the teeth, as can trauma and decay.  Where teeth have been broken beneath the gum line, crown lengthening can be used to prepare the area for a new restoration to correct the damaged teeth.

 Cosmetic uses – Extra gum tissue can make teeth look unnaturally short and can also increase susceptibility to periodontal infections.  Removing excess gum tissue can restore a balanced, healthy look and improve the aesthetic appearance of the smile.

 Dental crowns – Crown lengthening provides more space between the supporting jawbone and dental crown.  This prevents the new crown from damaging gum tissues and bone once it is in place.

What does crown lengthening involve?

 

Crown lengthening is normally performed under local anesthetic.  The amount of time this procedure takes will largely depend on how many teeth are involved and whether a small amount of bone needs to be removed along with the soft tissue.  Any existing dental crowns will be removed prior to the procedure and replaced immediately afterwards.

 

Your dentist will make a series of small incisions around the soft tissue in order to separate the gums away from the teeth.  Even if only one tooth requires the re-contour, neighboring teeth are usually treated to provide a more even reshaping.  Separating the gums provides your dentist with access to the roots of the teeth and the underlying bone.

 

In some cases, the removal of a small amount of tissue will provide enough tooth exposure to place a crown.  In other cases, your dentist will also need to remove a small amount of bone from around the teeth.  The bone is usually removed using a combination of special hand instruments, and rotary instruments.  The rotary instruments roughly resemble the drill that is used in cavity treatment.

 

The teeth will look noticeably longer immediately after surgery because the gums will have been repositioned. The teeth will look noticeably longer immediately after surgery because the gums have now been repositioned.

 

Your dentist will secure the surgical site using an intraoral (periodontal) bandage which serves to prevent infection.  Prescriptions may be provided for pain medication, and a chlorhexidine (antimicrobial) mouth rinse may be given to help reduce any bacteria attempting to re-colonize.  The surgical site will be completely healed in approximately two to three months.

                                Bone Grafting

Periodontal disease is the leading cause of bone loss in the oral cavity, though there are others such as ill-fitting dentures and facial trauma.  The bone grafting procedure is an excellent way to replace lost bone tissue and encourage natural bone growth.  Bone grafting is a versatile and predictable procedure which fulfills a wide variety of functions.

 

A bone graft may be required to create a stable base for dental implant placement, to halt the progression of gum disease, or to make the smile appear more aesthetically pleasing.

 

There are several types of dental bone grafts.  The following are the most common:

 

 Autogenous bone graft – In this type of graft the bone is removed from elsewhere in the body and implanted in the mouth.  Common donor sites for bone grafting include the iliac section of the pelvis, the chin and the posterior third molar areas of the jaw.  If large amounts of bone need to be harvested, the hip or the shin bone (tibia) is generally used.

 Allograft – Synthetic bone (manmade) can be created in the laboratory and used in the bone grafting procedure.  Bone can also be obtained from a bone bank (cadaver bone).

 Xenograft – This is the implantation of bovine (cow) bone. A xenograft is perfectly safe and has been used successfully; ample bone can be obtained, and a secondary donor site is not necessary.

Reasons for bone grafting

 

There are a wide variety of reasons why bone grafting may be the best option for restoring the jaw bone.

 

Dental implants – Implants are the preferred replacement method for missing teeth because they restore full functionality to the mouth; however, implants need to be firmly anchored to the jawbone to be effective.  If the jawbone lacks the necessary quality or quantity of bone, bone grafting can strengthen and thicken the implant site.

 

Sinus lift – A sinus lift entails elevating the sinus membrane and grafting bone onto the sinus floor so that implants can be securely placed.

 

Ridge augmentation – Ridges in the bone can occur due to trauma, injury, birth defects, or severe periodontal disease.  The bone graft is used to fill in the ridge and make the jawbone a uniform shape.

 

Nerve repositioning - If the inferior alveolar nerve requires movement to allow for the placement of implants, a bone grafting procedure may be required.  The inferior alveolar nerve allows feeling and sensation in the lower chin and lip.

 

What does bone grafting treatment involve?

 

Bone grafting is a fairly simple procedure that can be performed under local anesthetic; however, if large amounts of bone area need to be grafted, general anesthetic may be required.

 

Initially, the grafting material needs to either be harvested or prepared for insertion.  A small incision is made in the gum tissue and then gently separated from the bone.  The bone grafting material is then placed at the affected site.

 

The bone regeneration process may be aided by:

 

 Gum/bone tissue regeneration – A thin barrier (membrane) is placed below the gum line over the grafting material.  This barrier creates enough space for healthy tissue to grow and separates the faster growing gum tissue from the slower growing fibers.  This means that bone cells can migrate to the protected area and grow naturally.

 Tissue stimulating proteins – 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 accellular 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.

 Platelet-rich growth factors – A high platelet concentration liquid can be used to create a blood clot at the site of a wound.  It has recently been discovered that PRGF also stimulates bone growth – meaning a denser graft in a shorter time period.

The gum is sutured in place and a follow-up appointment will need to be made within 10 days to assess progress.  Bone grafting is a highly successful treatment and a good base for further periodontal restorations.

                                Sinus Augmentation

A dental implant is essentially an artificial tooth root which is attached to the jaw bone.  Eventually, a replacement tooth or bridge will be firmly fixed to this root, restoring complete function to the tooth.  The key to a successful and long-lasting implant is the quality and quantity of jawbone to which the implant will be attached.  If bone has been lost due to injury or periodontal disease, a sinus augmentation can raise the sinus floor to allow for new bone formation.

 

In the most common sinus augmentation technique, a tiny incision is made near the upper premolar or molar region to expose the jawbone.  A small opening is cut into the bone and the membrane lining the sinus on the other side of the opening is gently pushed upward.  The underlying space is filled with bone graft material and the incision is closed.  The bone which is used for this procedure may be from your own body or from a cadaver.  Sometimes the dentist might use synthetic materials which can also stimulate bone formation.  The implants are placed after healing has occurred; this will depend on the individual case.  Sinus augmentation has been shown to increase the success of dental implant procedures.

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