Periodontal Surgery

Overview

Periodontitis is a form of gum disease.  It is a chronic infection of the gums which is characterized by a loss of attachment between the teeth and the jawbone.   Dental plaque is the primary cause of gum disease in genetically susceptible individual.  What is dental plaque? Dental plaque is formed by tons of bacteria..  When the plaque is accumulated around teeth, the bacteria will irritate the gum to turn red, swell and bleed easily.  As time passed by, the gum will gradually separate from the teeth forming infectious pocket spaces.  Plaque can also turn into hard, and rough porous substance known as calculus (tartar). Calculus can occur both above and below the gum line. As periodontal disease progresses, the supporting gum tissue and the bone that hold the teeth in place will deteriorate. If disease left untreated, the bone and the gum that support the teeth will be destroyed.  The teeth may eventually become loose and will lead to teeth loss.

The common visible signs of periodontal disease are bleeding, redness and swelling of the gum.  Nevertheless, active periodontal disease can also be present without any visible signs or pains.

The following diagrams are illustration of the Progression of Periodontal Disease

Healthy   

Pink Gingiva

No bone loss

Mild Periodontitis

Gum recession Gingiva is turning slightly pink

1% – 30% bone loss

Moderate Periodontitis

Gingiva is turning red and swelling Teeth become loose

30% – 50% bone loss

Severe Periodontitis

Teeth are so loose and falling out

>50% bone loss

Laser Periodontal Surgery (Laser Assisted New Attachment Procedure – LANAP)

Most patients associate pain with traditional periodontal surgery. In order to eliminate this anxiety, Dr. Wang utilizes innovative techniques that can replace traditional periodontal surgery. PERIOLASE laser system with its patented and FDA approved LANAP procedure can provide equivalent result to the traditional pocket reduction surgery. Laser periodontal therapy (LANAP) requires no cutting and no sewing. To patients this means: less pain, less bleeding, less swelling, less tissue removal, less recovery time.

The advantages of Laser Periodontal Therapy vs. traditional surgery are:

  1. No cutting and no sewing;
  2. The laser periodontal therapy removes ONLY the diseased tissue;
  3. Minimal gum shrinkage after surgery results in less root exposure. As a result, teeth do not appear longer;
  4. Minimal sensitivity to cold and hot due to less root exposure.

 

The Laser Periodontal Therapy procedures (LANAP) are as following:

A. Perio probe indicates excessive pocket depth.

B. Laser light (via small fiber optic rod) enters the periodontal pocket and sweeps the pocket. Laser energy kills bacteria and removes disease tissue (epithelium) and leaves the healthy tissue untouched.

C. Special hand and machine instruments remove the plaque and calculus on the root surface.

D. Laser light enters the periodontal pocket for the second time to induce blood clot within the pocket and seal the pocket to prevent more bacteria.

E. Bite trauma is adjusted.

F. Gums attach to the clean root surface at the pre-surgical level result in minimum post-surgery gum recession. The laser therapy can also induce bone regeneration.

Osseous Surgery

When pocket depth is greater or equal to 5mm, non-surgical treatment (deep cleaning) is no longer effective.  Cleaning instruments cannot reach the bottom of the pocket to completely remove plaque and calculus that are on the root surface.  In this situation, periodontal surgery is necessary.

Osseous surgery consists of cutting gum and pulling the gum away from the teeth and bone so that the periodontist has a direct view of and access to the diseased bone and the root surfaces. Having the direct view also allows the periodontist to thoroughly remove plaque and calculus from the root surfaces.

Then the gum is sutured back purposely at a position lower than the pre-surgical level.  Unfortunately, due to this gum placement, the teeth will appear longer and the roots will be exposed.  Patients may experience sensitivity to cold and hot.

The following diagrams are illustration of the Osseous Surgery procedure.

Healthy gum with no bone loss

Plaque and calculus accumulated on the tooth and root surface

Bone loss occurred due to plaque and calculus

Periodontal probe measures deep gum pocket due to bone loss

Gum is pulled away and exposes roots and bone

Removes all plaque and calculus with instruments

Bone is smoothed with high speed

Gum is re-attached with suture

Successful result with shallow gum pocket

Bone Regeneration / Guided tissue

Regenerating the lost bone can be achieved with certain clinical conditions. The most common technique is inserting the “processed” human bone particle into the bony defect. A membrane is then placed over the bone graft. The membrane is resorbable which means it will dissolve by the body itself. Therefore, secondary surgery is not necessary to remove the membrane.

Recent advances in tissue engineering have identified several growth factors such as Platelet Rich Fibrin (PRF), Emdogain, and Gem 21S. When these growth factors are combined with bone graft, Dr. Wang can obtain better results with shorter healing period.

The following diagrams are illustration of the Bone Regeneration/Guided Tissue Procedure.

Before Surgery

Bone defect #30

Placed Bone particulate into defect

Placed Bone particulate into defect

Surgical area was completely closed

Crown Lengthening

Crown lengthening (crown exposure) procedure is required when the edge of the new crown is significantly below the gum tissue. In same cases, the new crown edge is very close to the jawbone or even below the bone.

The crown lengthening procedure removes and reshapes the gum tissue and bone around the tooth.  As a result, the edge of the crown is at or above the gum line. This procedure ensures proper fit of the crown to the tooth and provides enough tooth structure so the new crown will not become loose in the future.

The following diagrams are illustration of the Crown Lengthening Procedure.

tooth has extensive decay

The crown portion of the tooth is missing and the root remains below the gum line

The gum is pulling away from the root and bone.  High speed hand piece with round bur can remove the bone to expose more root surface

The gingiva is purposely position below the edge of the remaining root.  As a result, small portion of the root is above the gum line

Metal post is placed into the root.  Dentist can take accurate impression because the edge of new crown is either above or at the gum line

A new crown is cemented

Gingivectomy

Some medications or orthodontics braces can cause the gums to enlarge and extend onto the front surface of the teeth.  Gingivectomy is a procedure that removes the excessive gingival and restore the natural smile.

Frenectomy

Frenectomy is a surgical procedure which removes the frenum.  It is a piece of tissue in the mouth that extends from the lip or the cheek to the gum.  There are several different locations in the mouth where frenum is found.  The most common location is between the two upper central incisors.

Frenum can prevent teeth from staying in place after they have been orthodontically moved together.  The frenum at the lower front teeth may pull the gum away from the teeth and cause gum recession.

Lingual frenectomy is the removal of the lingual frenum. The lingual frenum is often called tongue tie.

Labial frenectomy is the removal of the frenum between the maxillae or mandibular central teeth.

The following diagrams are illustration of the Labial Frenectomy

Prominent frenum is present between front central incisors

Blade or laser is used to cut away the frenum

Blade or laser is used to cut away the frenum

Sutures are placed

After 4-6 weeks of healing period, orthodontic braces are placed

Final result