Recent advances in periodontal plastic surgery techniques, such as periodontal regeneration, root coverage procedures with gum graft surgery, and procedures combined with dental extractions or post extraction for dental implant site development, have significantly improved the ability to restore damaged periodontal (gum) tissues. Early diagnosis is critical to periodontal disease management and offers a patient the best chance of preserving their natural teeth.
Gum Recession- Diagnosis And Treatment Planning
One of the challenges of diagnosing gingival or gum recession is determining the appropriate timing of intervention with corrective periodontal plastic surgery. The clinician must determine the key anatomic factors that influence the evaluation of the need for therapeutic intervention versus the option of monitoring and providing ongoing periodontal health maitenance. Critical decision factors for gum recession treatment include:
- Extent of gum recession
- Abscence of keratinized gingiva
- Less than 2 mm attached gingiva
- Evidence of progressive recession
- Compromised access for oral hygiene due to high frenum position or decreased vestibular depth
- Need for full coverage restoration
- Site of dental implant planned treatment
Options for gum graft surgery continue to increase as new technologies advance in the marketplace. It is important to assess the evidence of newer therapies in comparison to well-documented procedures such as the free gingival graft for gingival augmentation, and the connective tissue graft for root coverage.
Alternative therapies today include allogenic donor graft biomaterials (Alloderm Graft), biologic amelogenin-like proteins and growth factors combined with coronally positioned flaps, biomaterial membranes to scaffold new tissue formation and cell therapies.
The Gold Standard- Connective Tissue Graft
Langer and Langer introduced the connective tissue graft for root coverage procedures in 1985. When the treatment goal for gum recession is a combination of providing root coverage and augmenting the zone of attached gingiva, the connective tissue graft is the gold standard procedure.
The added vascular supply available utilizing a connective tissue graft allows for successful, predictable root coverage procedures,a s it is a layered procedure with the primary flap advanced coronally over the graft to achieve partial or complete primary closure. In comparison to the connective tissue graft, a free gingival graft has only a periosteal blood supply and is therfore more limited in achieving root coverage.
Connective tissue grafts can be harvested from either the maxillary palate or the maxillary tuberosity. A variety of successful incision designs have been developed over the years that, depending on the tissue thickness of the palate, are indicated to allow adequate graft thickness and potential primary closure of the donor site wound.
In general, connective tissue graft donor sites heal uneventfully with limited discomfort compared to a free gingival graft donor site from the surface of the palate. Advanced surgical techniques such as modified double pedicle techniques can allow for optimal healing by:
- Repairing clefting of the marginal gingival tissues
- Increasing the width of keratinized gingiva at the site of the cleft
- Strengthening the marginal gingival tissue
- Improving surface tissue contours associated with coronally advanced flap
Biologic Agent In Longevity Of Therapeutic Result
To promote longevity of the therapeutic result recent breakthroughs in combining the application of biologic agents such as Enamel Matrix Derivative (Emdogain) or recombinant human platelet-derived growth factor (Gem 21S) to stimulate healing with advanced surgical techniques have been shown to improve early wound healing.
These biologic agents have been documented to provide regeneration of the periodontal attachment apparatus with human histologic studies. These biologic agents tip the healing process toward regeneration with new connective tissue attachment, rather than reliance only upon repair with long junctional epithelial seal.
Root coverage procedures are not recommended over composite or porcelain restorations. Treating the site of a planed root coverage procedure first with surgical therapy is recommended with the understanding that if there is incomplete root coverage and a restoration is needed for caries control or esthetic reasons this can be provided after the healing is complete.
Where class V restorations are present, they can be removed at the time of surgical intervention and replaced after the healing is complete, adjusting to the new level of the marginal gingiva as needed. If a crown margin extends onto the receded root surface, this can also be altered prior to surgery to allow for esthetic correction. If a cavity preparation is shallow, it can be root planed or smoothed with high speed instrumentation, but a deeper preparation may pose a challenge for a root coverage procedure.
Treating Multiple Teeth
Multiple adjacent teeth can be treated with a single surgical procedure to alleviate the need for multiple surgeries. The palate donor sites available and the thickness of the palatal tissue will limit the extent of therapy at one time. Although some clinicians prefer the use of alternative techniques for multiple teeth such as allogenic acellular dermal matrix the predictability of root coverage should not be compromised and in most cases adequate donor tissue can be harvested atraumatically.
In closing, perioodontal plastic surgery can reduce further recession and bone loss. In some cases, it can cover exposed roots to protect them from decay. This may reduce tooth sensitivity and improve esthetics of your smile. Whether you have a soft tissue graft to improve function or esthetics, patients often receive the benefits of both: a beautiful new smile and improved periodontal health – your keys to smiling, eating and speaking with comfort and confidence.
If you enjoyed this article on periodontal plastic surgery, there is a good chance you will like these posts from my blog as well:
- “6 Ways A Healthy Mouth Equals A Healthy You“
- “The Mouth Is A Window To Your Overall Health“
- “6 Things Your Teeth Say About Your Health“
Thanks for reading !!