Gum Surgery

Gum Surgery

Also called: Periodontal Surgery, Gingival Surgery

Summary

Gum surgery, or periodontal surgery, is a procedure to treat the gingiva, the soft tissues of the mouth that surround the necks of a person’s teethand support the bone. There are several different types of gum surgery procedures. They include:

  • Crown lengthening. Removal of gum tissue and/or bone to expose more of the tooth. It is performed when there is not enough of the tooth exposed above the gum line to fit a prosthetic crown or other restoration over a decayed or otherwise damaged tooth.

  • Gingival flap surgery. A procedure to temporarily separate the gums from the teeth giving the dentist access the roots of the teeth and their supporting bone. This access allows removal of inflamed tissue and removal of plaque and tartar. It is used primarily to treat moderate to severe cases of periodontal (gum) disease.

  • Gingivectomy. Surgical removal of gum tissue. It is one of the procedures used to reduce gaps or pockets between the teeth and gums that trap food particles. It is also used to reduce excessive and overgrown gum tissue around the teeth, particularly in patients taking certain medications.

  • Gingivoplasty. A procedure which involves surgically reshaping the soft tissue around a tooth to restore a more normal appearance and contour. It is used to treat gum tissue malformed due to genetic factors, disease or trauma.

  • Soft-tissue graft. Procedure in which tissue is taken from the palate or other tissue source and added to an area where the gums have receded.

Gum surgery is generally performed by a periodontist, a dentist who specializes in diagnosing and treating conditions that affect the gums and supporting bone. Patients may be asked to undergo a thorough cleaning of the teeth prior to the procedure. In nearly all gum surgeries, a local anesthetic is used to numb the gums so the patient feels little or no pain or discomfort during the surgery.

Following gum surgery, a special periodontal dressing is placed over the gums and left there for about 10 to 14 days. This acts as a bandage which protects and soothes the soft tissue making the patients feel more comfortable following surgery. Patients may receive prescriptions for pain medication and a mouthwash such as chlorhexidine (an antimicrobial agent) to prevent infection during the healing period.

Gum surgeries typically do not pose major risks to patients. Bleeding may occur initially but usually stops within 24 to 48 hours following these procedures. In very rare cases, infection may occur.

About gum surgery

Gum surgery involves any of a number of procedures designed to treat the gingiva, the soft tissues that surround the teeth as well as their supporting bone. These procedures are often employed for conditions affecting the gums that fail to respond to less invasive types of treatments (e.g., scaling, root planing).

Gum surgeries typically are performed by a periodontist, a dentist who specializes in treating gum-related disorders. There are many different types of gum surgery, including:

  • Crown lengthening. Removal of gum tissue and/or bone to expose more of the tooth. It is performed when there is not enough of the tooth exposed above the gum line to restore the tooth with a filling, crown, bridge or other restorative technique. Crown lengthening may be necessary when a tooth breaks at the gum line or when a filling dislodges from a tooth that has significant decay below it. In some cases, crown lengthening is used to treat gummy smile, a condition in which large amounts of gum tissue are evident around the upper teeth.

  • Gingival flap surgery. A procedure to separate the gums from the teeth temporarily so that the dentist can access the roots of the teeth and the bone for removal of inflamed tissue, plaque and tartar. It is used primarily to treat moderate to severe cases of periodontal (gum) disease by removing tartar in deep pockets or reducing the size of periodontal pockets. Sometimes, gingival flap surgery (also called pocket reduction surgery) is performed in conjunction with osseous surgery which involves removing or reshaping inflamed bone.

  • Gingivectomy. Surgical removal of gum tissue. It is a technique that is used to eliminate pockets between teeth and gums or to reduce excessive gum tissue around teeth. Pockets are crevices between the tooth and gums that trap food particles, plaque and tartar. Excessive gum tissue (gingival hyperplasia) and the presence of pockets are conditions that can be cosmetically unappealing and may trap bacteria around the teeth, which can make it difficult to perform good oral hygiene.

  • Gingivoplasty. A procedure which surgically reshapes gum tissue around the teeth when the tissue is malformed due to genetic factors, disease or trauma. It may also be performed for cosmetic reasons. This procedure can give the gums a more natural look and is often performed during or after a gingivectomy or a soft-tissue graft.

  • Soft-tissue graft. Procedure in which tissue is taken from the palate or other tissue source and added to an area where the gums have receded. When gums recede, the tooth root is exposed and the tooth becomes sensitive to hot and cold, is more vulnerable to tooth decay and may look unappealing. The procedure is also sometimes performed on patients whose gums are very thin or of poor quality, which puts them at higher risk of future recession of the gums. Different types of soft-tissue grafts are performed to prevent gum recession or bone loss and for cosmetic reasons, such as making the gum line appear more even.

Bone surgery, or osseous surgery, replaces or reshapes hard tissue (bone) that supports the teeth. It may be performed in conjunction with certain gum surgeries, such as crown lengthening or gingival flap surgery. For example, a patient undergoing gingival flap surgery may have experienced some amount of bone loss as a result of periodontal disease. The bone supporting the teeth may need to be reshaped before the gums are stitched together toward the end of gingival flap surgery. If too much bone loss has occurred, a tooth extraction may be necessary.

Bone grafts may be performed to help rebuild an area of bone. A technique called guided tissue regeneration involves inserting material which acts as a barrier between the bone and gums to encourage bone regrowth in the proper area (e.g., keeping gum tissue out of the area where bone regrowth is expected to occur). Sometimes bone harvested from another part of the patient’s jaw, bovine (beef) bone or freeze dried human bone is added.

Before the gum surgery procedure

When a dentist decides that a patient may need gum surgery, the patient is referred to a periodontist. This is a dentist who specializes in diagnosing and treating conditions that affect the gums.

During the initial consultation, the periodontist reviews the patient’s medical and dental history, including current medications, as well as the patient’s dental x-rays, to determine the most appropriate form of gum surgery. A date will then be scheduled for the surgery.

Prior to the procedure, patients are urged to follow any preparatory recommendations made by the periodontist. In addition, the periodontist is likely to outline any temporary changes to oral hygiene methods that should be made following the procedure.

Patients may be asked to undergo a thorough cleaning of the teeth prior to the procedure. This may include scaling and root planing to remove buildup of tartar(calculus). Patients scheduled to undergo crown lengthening on a tooth that needs an artificial crown may have a temporary crown placed on the tooth prior to the lengthening procedure. This helps protect the tooth and gives the dentist a clearer view of how much soft tissue or bone needs to be removed during the lengthening procedure.

Depending on a patient’s medical condition (e.g., immune system deficiency, certain heart conditions, artificial joints), a dentist or periodontist may prescribe antibiotics to be taken before and after the procedure. This may prevent infection in patients with an increased risk of infection. However, some medications may need to be avoided prior to gum surgery. For example, certain painkillers that may increase the amount of bleeding during the surgery typically are avoided.

During the gum surgery procedure

The sequence of eventa during gum surgery unfolds differently depending on what kind of procedure is being performed. The patient likely will receive a local anesthetic to numb the gums so that little or no pain or discomfort is felt during the surgery.

In most cases, gingivectomies and gingivoplasties are performed with a scalpel. Special instruments with angled blades may be used to get around the teeth. Other instruments used for these procedures include electrosurgery, laser surgery or dental burs (dental tools designed for cutting or grinding). Researchers are investigating ways to improve these surgical methods.   

Soft tissue grafts involve taking a piece of soft tissue from a donor site (e.g., roof of the mouth) and moving it to a recipient site (e.g., where the gum tissue needs to be replaced). Soft tissue grafts are placed in areas where gums have receded or are of poor quality. Some of the soft tissue grafts used are:

  • Connective-tissue graft. A flap is cut in the roof of the mouth to create a “trap door.” The underlying connective tissue is then removed so that only the outermost (epithelial) layer of tissue is left. The outer layer is stitched back into place and the tissue that was removed is slipped under the gum tissue around the exposed root surface and stitched into place. This is the most common treatment for tooth root exposure.

  • Free gingival graft. A strip of tissue is removed from the roof of the mouth (palate) and stitched to the gum in the area being treated. This may be performed on patients with very little gum tissue around their teeth.

  • Pedicle graft. A flap of gum tissue from an adjacent tooth is partially cut away and the flap (pedicle) is slid sideways over the exposed root before being stitched into place. This can only be done if the adjacent tooth has enough gum tissue to share. Pedicle grafts may be more successful than free gingival grafts because some of the original blood vessels remain in the area to help feed the grafted section. 

During gingival flap surgery, the periodontist uses a scalpel and other instrument to pull the pull tissue awaay from the bone. This allows the periodontist access to the tooth root and bone supporting the tooth. Any inflamed tissue is then removed. Scaling and root planing is performed to remove excess dental plaque and tartar (calculus). A process called osseous recontouring may be used to smooth out the edges of bone where holes or defects are present. After the procedure is complete, the gums are stitched back into place. Either these stitches dissolve or they have to be removed later.

Crown lengthening also begins with an incision that separates the gums from the tooth. The gum is then moved back off the bone to expose the roots of the teeth and the surrounding bone. The bone level is then adjusted so more of the tooth is exposed, thereby allowing a better fit of a dental restoration (e.g., crown). The soft tissue is then sutured pack into place. Crown lengthening can be performed on a single tooth or on multiple adjacent teeth.

In some cases, the periodontist may only have to remove a little bit of gum tissue to expose enough of the tooth to permit the restoration to take place. More often, the periodontist needs to remove bone from around the roots of the affected tooth and adjacent teeth. Hand instruments resembling chisels and rotary instruments resembling dental drills are used to remove the bone.

After enough tooth structure has been exposed, the periodontist stitches the gum flaps together. Gum surgery can take anywhere from a few minutes to several hours to complete, depending upon the type of procedure and the amount of tissue to be removed.

After the gum surgery procedure

Following gum surgery, a periodontal dressing, or pack, that can harden and protect the area is placed over the gums and left there for about seven to 14 days. This acts as a bandage which protects the soft tissue and makes the patients feel more comfortable. Patients are asked to avoid spicy and crunchy foods and to instead eat a soft diet. Patients may receive prescriptions for pain medication and mouthwash that contains chlorhexidine (an antimicrobial agent) to prevent infection during the healing period. Prolonged use of chlorhexidine can stain teeth, but this discoloration comes off with a routine cleaning.

Patients typically are instructed not to brush or floss in the affected area until after the periodontal pack is removed. Patients should continue to brush and floss other areas of the mouth. Following the dressing removal, gentle brushing and flossing of the area may be allowed. These tissues may bleed at first, but gums begin to look normal within a month and are completely healed within two to three months.

The use of tobacco is not advised following gum surgery. Smoking and other forms of tobacco use can interfere with the healing process, as well as contribute to additional oral health problems.

Patients who have a soft-tissue graft may feel discomfort at the donor site in the palate where the tissue was removed, similar to a burn from hot food. The pain can be relieved with over-the-counter or prescription pain medications.

Patients who have gingival flap surgery or crown lengthening may experience swelling, which can usually be relieved with an ice pack placed outside the mouth in the affected area. Even if a dressing (bandage) is not placed on the area following gingival flap surgery, the periodontist may want to reexamine the area within a week to 10 days after the procedure. Patients undergoing crown lengthening may need to return to the dental office within 7 to 10 days for suture removal, and again for a follow-up visit four to six weeks later.

Patients who need an artificial crown following crown-lengthening surgery may need to wait up to three months after the lengthening procedure. This gives the gums time to shrink as they heal. Waiting until healing is completed helps ensure that the margins of the crown do not show after it is placed on the tooth.

Antibiotics may be prescribed for patients who develop an infection as a result of gum surgery.

Potential risks with gum surgery

Gum surgeries typically do not pose major risks to patients. Bleeding may occur initially but usually stops within 24 to 48 hours following these procedures. In very rare cases, infection may occur. In general, complications are more likely to occur following longer surgeries or among patients who smoke.

There are no major risks associated with gingivectomy, gingivoplasty and soft-tissue grafts. Some patients may need to undergo gingivoplasty to reshape the gums after a soft-tissue graft for cosmetic enhancement.

Patients who undergo gingival flap surgery may experience some postsurgical bleeding and swelling. Gums in the area treated are at increased risk for receding over time, making the teeth in the area more sensitive to hot and cold and more susceptible to developing cavities in the roots. Patients may be instructed to use desensitizing toothpastes.

Because crown lengthening exposes more of the tooth root, patients may experience increased sensitivity to hot and cold in the tooth. Covering the tooth with a temporary crown usually eliminates this sensitivity. In some cases, removing bone from around a tooth can loosen the tooth.

Patients are urged to call their periodontist if the following symptoms occur after gum surgery:

  • Dressing on the gums becomes loose or displaced
  • Bleeding does not stop
  • Lymph nodes below the lower jaw or in the neck swell
  • Pain is so strong that medications cannot control it
  • Region affected by procedure swells or discharges fluids
  • Signs of possible infection (redness and extreme soreness) appear

Questions for your doctor about gum surgery

Preparing questions in advance can help patients have more meaningful discussions regarding their conditions. Patients may wish to ask their doctor the following questions related to gum surgery:

  1. What type of gum surgery do you recommend for me? Why?
  2. What type of soft-tissue graft is most appropriate for me?
  3. What are the risks associated with this procedure?
  4. Are there alternative treatments available?
  5. How should I prepare for my surgery?
  6. Will I need to avoid certain foods after my surgery?
  7. What changes should I make in my oral hygiene routine following surgery?
  8. How long will I likely experience pain or discomfort following the procedure?
  9. What should I do if my bandage becomes dislodged, or bleeding extends past 24 hours?
  10. What signs of infection should I look for?
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