Periodontal Surgery
If you're diagnosed with periodontal disease, Dr. Kelk may recommend periodontal surgery. Periodontal surgery is necessary when the tissue around your teeth is unhealthy and cannot be repaired with non-surgical treatment. The two types of surgical treatments most commonly prescribed are Pocket Reduction Procedures and Regenerative Procedures.

In advanced cases of periodontal disease, the first line of treatment, scaling and root planing, combined with excellent home care to keep new bacterial deposits from forming, is sometimes not enough to bring the disease under control. In some cases, periodontal surgery is necessary.

When is periodontal surgery necessary? Surgery is only rarely needed to control periodontal disease, a disease that affects almost everyone. Most people can keep their teeth and gums healthy by careful daily removal of the bacterial film which causes the disease, in combination with periodic visits to a dentist or dental hygienist for the removal of bacterial deposits below the gum line. However, when there is periodontal disease, and the gum has unzipped so far down the root of the tooth that dental instruments are no longer effective (about 5-6 millimeters), periodontal surgery may be necessary. If not done, the bacterial deposits will remain on the tooth and cause further bone destruction; ultimately causing the teeth to develop painful abscesses or simply to loosen and fall out.

What exactly is periodontal surgery? It is a minor surgical procedure generally done in the dental office with a local anesthetic. It involves folding the gum back away from the tooth just enough so that a Periodontist, a dentist specializing in the treatment of gum diseases, can see the tooth root surfaces. Once they are seen, the deep bacterial deposits crusted on the tooth can be removed. In this way, the root surfaces can be made once again acceptable to the body, and the gum can reattach, at least to a degree. Surgical access also makes it possible to graft bone into defects to repair some of the damage. After root preparation, the gum is closed back with sutures and a dressing is often placed to keep the area undisturbed, especially for the first week.

Is periodontal surgery a cure for periodontal disease? No, it is not. The bacteria which cause the disease are normally in the mouth, and continually form on the teeth as a thin film, requiring meticulous personal removal on a daily basis. Periodontal surgery can achieve a complete cleansing of deeply hidden bacterial deposits at a point in time. If the bacteria are kept off of the teeth long enough afterward for reattachment and healing to occur, then a healthy and maintainable periodontal attachment can be achieved, and the teeth can be saved. However, if the bacterial film is allowed to build up during the healing period when the gum is actually less resistant to the destructive effects of bacteria, the result may be less than desired. Many people have undergone periodontal surgery to little avail when bacterial deposits have been allowed to quickly accumulate afterward, and consequently further extensive treatment has been necessary. To prevent a poor result, Periodontists are extremely choosy as to which patients receive periodontal surgery. Excellent home care is a strict requirement, and numerous postoperative visits are insisted upon to ensure frequent and complete removal of bacteria.

How much will it hurt? Of course, some soreness is normal the first day or so after periodontal surgery. Many persons, however, have very little discomfort. A more common complaint afterward is sensitivity to hot or cold liquids. This is caused by exposure of more of the tooth root surface, and may last for a short period of time.

Finally, what else do I need to know about periodontal surgery? Depending on exactly what types of defects or problems are present, many techniques may be used. These may include grafting of gum tissue and bone if needed, the correction of gum contours to improve their appearance and the ability to be cleaned more easily, the placement of dental implants, and the use of recent techniques for guided tissue regeneration. By the appropriate use of these of surgical procedures, as well as proper use of antibiotics, antiseptics, and anti-inflammatory agents, much can be done to control periodontal disease and save teeth from otherwise certain loss.

Pocket Reduction Therapy: Osseous Surgery
Periodontal or flap surgery in the simplest sense is designed to gain access to deeper areas of the roots of teeth and to clean the damaged areas. The main advantage in using this procedure is that visual access is obtained and therefore the thoroughness of the debridement (cleaning) is improved. Flap surgery is essentially similar to other various periodontal surgical procedures. The area to be treated will be numbed profoundly with a local anesthetic. After it is determined that the area is fully anesthetized, the surgery will open an access to the roots by elevating a "flap" of gum. The roots are thoroughly cleaned to achieve the desired result. Often a few sutures (stitches) are necessary and usually the area is covered with a puttylike packing material to protect the site for a week. Most patients are back to work the next day.

Once the pocket is cleaned, the gum may be returned to its original level. This results in a clean root, but the deepened space is still present. Frequent cleanings by the hygienist are necessary to remove the plaque in the residual pocket that the patient cannot reach with flossing and brushing (See Periodontal Maintenance). Even when there is good oral hygiene and regular quarterly recalls, the bacteria may still continue to cause the pocket to become reinfected. When cosmetics are not a concern (on the lower teeth, the inside of the upper teeth, and the outside of the upper back teeth), the surgeon may elect to suture the gum down to where the bone has resorbed, reducing the depth of the space. If the space is reduced to 3 millimeters or less, the patient is able to reach the bottom of the space with daily brushing and flossing, eliminating the disease.

In the majority of advanced cases, the bacteria has caused the bone to resorb and become pitted. In these cases flap surgery gives access not only for root cleansing, but allows for recontouring of the bone itself. By performing this osseous surgery, and reshaping the bone to its natural scalloped shape, it is generally possible to eliminate moderate pockets.

Crown Lengthening
When a tooth requires restoration with a filling material or a crown, the dentist must have adequate access to remaining tooth structure. It is a common occurrence that the dentist will not have adequate tooth structure to attach the restoration, and preserve favorable gum tissue health. Crown lengthening is a surgical procedure which adjusts the gum and bone level to expose more of the tooth so it can be restored.

Before Crown Lengthening, necessary tooth structure is below gum tissue and not accessible	After Brown Lengthening, necessary tooth structure is above gum disease.

This procedure remodels the contour of the gum tissue and surrounding bone around one or more teeth providing the exposure of previously covered healthy tooth structure. Crown lengthening is often used as part of a treatment plan for a crown needing more tooth structure. This provides the necessary space between the crown margin on the tooth and the bone level, thus preventing damage to the gum tissue.

Crown lengthening is also recommended for making certain restorative procedures possible. If part of a tooth is broken down below the gum line, whether due to fracture or decay, a crown lengthening procedure adjusts the level of the gum and bone around the tooth or teeth involved, thereby providing for more tooth structure and allowing for the final crown restoration to be constructed.

The benefits of crown lengthening is important for the overall strength of the final crown, and provides for better health, comfort, and function. With periodontal gum health, one will be able to smile, eat, and speak with comfort and confidence.

For more information about crown lengthening, click on the link below to view a video from the American Dental Association. ADA Video on Crown Lengthening

Soft tissue grafts
Exposed tooth roots are the result of gum recession. There are many causes of gum recession including periodontal disease, aggressive brushing, anatomic susceptibility, and tooth position. If recession progresses without treatment, it can lead to esthetic compromises, tooth sensitivity, tooth decay on roots, or even tooth loss. Recession does not always need to be treated. Therefore, it is important that an examination be completed to identify the potential risks for future progression. Soft tissue grafting is the most common treatment for recession. During this procedure, Dr. Forrest will move healthy gum tissue from the roof of the mouth (palate), and restore the tissue in the area of recession.

For more information about gum grafting, click on the link below to view a video from the American Dental Association. ADA Video on Gum Grafting

Periodontal Plastic Surgery
First impressions are everything! So why not make a good first impression when you meet someone, go on a job interview or a first date by dazzling him or her with your "Hollywood smile." Whatever the reason, periodontal plastic procedures can help you "knock the socks off" of anyone by giving you a perfect smile and boosting your confidence so you can be at your best.

Cosmetic surgery has become more popular than ever before especially now that more Americans are living longer and aging more gracefully with the help of plastic surgery. Periodontal plastic surgery has also felt this trend as it has experienced a significant shift toward cosmetic-related surgery to help make smiles last a lifetime.

A recent poll of 253 consumers conducted by the American Academy of Periodontology found the following:

Gummy Smile or Uneven Gum Line Do 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? If so crown lengthening 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 gumline is sculpted to give your new smile just the right look.

Long Teeth/Exposed Roots Do you feel you look older than you really are? 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. This recession can happen as a result of a variety of causes, including periodontal diseases. Whatever the reason, exposed roots are unappealing and can leave you at risk of developing cavities on your tooth root. Soft tissue grafts and other root coverage procedures are designed to cover exposed roots, to reduce further gum recession and to protect vulnerable roots from decay.

Dental Implants
Today, the preferred method of tooth replacement is dental implant treatment. Dental implants replace missing tooth roots, and form a stable foundation for replacement teeth that look, feel, and function like your natural teeth. Dental implants also help preserve the remaining bone by providing the stimulation previously provided by the natural tooth roots.

There are numerous advantages of dental implant treatment over other treatment options. It is not necessary to grind down the adjacent teeth for a bridge, or secure a partial denture to adjacent teeth with clasps or hooks, which can cause tooth loosening. Implant-supported replacement teeth spare patients many of the disadvantages of traditional false teeth.

Dental implants are available in several different forms. The most common dental implants are called "root form implants." Root form implants are similar to teeth in that they mimic roots of teeth. They can be used to support individual teeth or to help anchor removable dentures. The implants are placed under the skin and into the bone at the first surgical appointment. This surgical appointment is performed in the dental office under local anesthetic, and when necessary, with oral sedation. The dental implants are allowed to heal for a period of two to four months. Sometime after this healing time, the implants must be exposed at a brief second surgical appointment prior to placing a post (abutment) inside. The post becomes the extension to which a crown is attached. The total process tends to take a period of four to six months.

Implants are made of a bio-compatible material called titanium, which cannot decay and does not need root canal therapy. An advantage of implants is that they stimulate bone growth, and thus, prevent future bone loss. Bone behaves similarly to muscle. When the muscle is stimulated and active, it will grow. If the muscle stops being active, it shrinks. The same events occur with bone; however if bone disappears, it can only be replaced with a bone graft.

Bone Regeneration
Tooth loss can cause an indentation in the gums and jawbone where the tooth used to be. This happens because the jawbone recedes 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
Deformities in the upper or lower jaw can leave you with inadequate bone in which to place dental implants. To correct the problem, the gum is lifted away from the ridge to expose the bony defect. The defect is then filled with bone or bone substitute to build up the ridge. Ridge grafting modification has been shown to greatly improve appearance and increase your chances for successful implants that can last for years to come.

Ridge Preservation
Over a period of time, the jawbone associated with missing teeth atrophies or is reabsorbed. This often leaves a condition in which there is poor quality and quantity of bone suitable for placement of dental implants. In these situations, most patients are not candidates for placement of dental implants.

We now have the ability to grow bone where needed. This gives us the opportunity to place implants of proper length and width, and it also gives us a chance to more effectively restore esthetic appearance and functionality.