There are two types of gum tissue in the mouth, one of which surrounds the necks of the teeth and is thick and protective in nature (keratinized gingiva). The other of which lines our cheeks and floor of the mouth whose purpose is to be elastic and mobile in nature (mucosa).

Why is a gum graft needed?

Soft tissue grafts are used to replace missing thick tissue (keratinized gingiva), which has worn away from the necks of the teeth for a variety of reasons. The purpose of gum grafting is to minimize and/or arrest the progression of recession.

Unfortunately associated with every type of recession, there is bone loss, because the bone resides just beneath the gums. Therefore, if the gums have receded, then the bone too has receded. The purpose of gum grafting is to arrest the progression of recession and thereby halt the bone loss as well, by restoring a thick zone of protective tissue around the neck of the tooth / teeth which exhibits an absence of this thick keratinized gum tissue.

In certain instances it is not only possible to restore the missing keratinized (thick / protective) gum tissue, but also to cover the exposed root surface of the tooth / teeth in question. Other issues must be addressed as well, such as the biting forces being placed on the teeth.

Unbalanced forces placed on the teeth in the presence of clenching or grinding can predispose an individual to recession. Being a candidate for this root coverage procedure, which is achieved by a connective tissue graft, is to be determined by the individual practitioner.

Cosmetic Gum Grafts:

Esthetic gum grafting can be used to "plump up" the gum tissue in an area that is deficient and would result an unaesthetic cosmetic make-over. Remember the teeth and gums should exhibit symmetry, yet sometimes one side is deficient, therefore, gum grafting may be essential to achieve symmetry prior to a cosmetic make-over.

What causes recession?

1. Aggressive brushing - potentially? Some people believe that aggressive brushing with a hard bristled brush may be a co-factor in recession or erosion of the neck of the tooth

2. Excessive biting forces - clenching and/or grinding? This can result in bending / flexing of teeth, which will often result in fracture of a small portion of tooth structure at the gum line (abfractions) and consequently bone and gum recession

3. Maloccluded and misaligned teeth? Teeth that positioned outside the normal arch form of the jaw are subject to having abnormal forces placed on them causing recession
When treating recession by gum grafting, the causative factor must also be addressed in order for the grafting procedure to be successful.

What are the different types of Gum Grafts?

1. Soft tissue graft: There are many types of soft tissue grafts. This type of graft involves taking a small piece of tissue from the surface skin on the roof of the mouth and transplanting it to areas in the mouth that are lacking. This type of graft restores and augments the missing thick keratinized gingiva, but does not result in covering of the exposed root.

2. Connective Tissue Graft: In this procedure tissue is taken from the undersurface of the palatal tissue (roof of the mouth) via tiny incisions, and is used to not only restore missing thick keratinized gum tissue, but also used to cover exposed roots of the teeth.
Bone Grafting:

What is a bone graft?

Bone grafting is the replacement or augmentation of the bone around the teeth.

Why is a bone graft needed?

Bone grafting is performed to reverse the bone loss / destruction caused by periodontal disease, trauma, or ill fitting removable dentures. It is also used to augment bone to permit implant placement, such as augmenting bone in the sinus area for implant placement, or augmenting bone to enhance the fit and comfort of removable prostheses, or to enhance esthetics of a missing tooth site in the smile zone. When one loses a tooth, as in an extraction, the surrounding bone collapses. To preserve this bone for future implant placement or for esthetics, a bone graft is used.

What are the types of bone graft?

1. autogenous - bone taken from one area of the patient and transplanted to another area requiring such grafting
2. allograft - either synthetic bone or bone from a bone bank (cadaver bone)
3. xenograft - bovine /cow bone

Which graft is used and when and why?

Autogenous bone is the "gold standard" and oftentimes has the most predictable results. This is described as the best type of graft because such bone is live bone with live active cellular elements that enhance bone growth, whereas other types of grafts are devoid of any active cellular material.

Allografts and Xenografts both do not require a second surgical site as does the autogenous bone. Ample amounts can be easily obtained.

Barrier membranes

In conjunction with bone grafting, membranes are often used to help stabilize the bone graft as well as displace the gum tissue from invading the healing bone graft. Gum tissue grows at a much faster rate than bone, therefore, membranes are used to prevent gum tissue from growing in and displacing the bone graft before it matures.

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Crown Lengthening

Crown lengthening is a surgical procedure performed by a dentist to expose a greater height of tooth structure in order to properly restore the tooth prosthetically. This is done by incising the gingival tissue around a tooth and predictably removing a given height of alveolar bone from the circumference of the tooth or teeth being operated on. While a general dentist may perform this procedure, he or she may refer the procedure to be performed by a periodontist or an oral surgeon.

What Is It?

This common procedure involves the removal of gum tissue, bone or both to expose more of a tooth's structure.

What It's Used For

Crown lengthening is done when a tooth needs to be restored, but there is not enough tooth structure above the gum line to support a filling or a crown.
This can happen when a tooth breaks off at the gum line, or a crown or filling falls out of a tooth that has extensive decay underneath. If your dentist wants to repair the tooth using a crown or a large filling, he or she may need to expose more of the tooth by removing some soft tissue or bone.
In rare cases, a condition called gummy smile — when an unusually large amount of gum tissue shows around the upper teeth — can be treated using crown lengthening.

Preparation

You will visit a periodontist for a consultation before the procedure. During the consultation, the specialist will review your medical history and your X-rays, and set a date for the surgery.

Our periodontist will instruct you on how to keep the area clean after the surgery. You may receive a tooth cleaning before the procedure.
If the tooth needs a crown, your periodontist may have a temporary crown put on the tooth to protect it. This also makes the crown-lengthening procedure easier because the tooth is already prepared for the crown, and the periodontist can see precisely how much soft tissue or bone will need to be removed.
Once the area has healed completely — in about three months — your dentist will prepare the tooth again, and make a new temporary crown before making the final crown.

How It's Done

This procedure is done under local anesthesia. The amount of time it takes varies depending on the number of teeth that requiretreatmente. Although your problem may involve only one tooth, crown-lengthening surgery typically includes neighboring teeth so that the tissues can be reshaped gradually. If only soft tissue is removed, the procedure probably will take less time than if both soft tissue and bone are removed.

The periodontist will make incisions to "flap" the gums away from the teeth. This provides access to the roots of the teeth and the surrounding bone. In some cases, by simply removing a little gum tissue when the incisions are made, enough tooth structure will be exposed for your dentist to place a crown of filling. However, in most situations it will also be necessary for the periodontist to remove some bone from around the roots of the teeth. The bone is removed using a combination of hand instruments (resembling chisels) and rotary instruments (similar to the drill and burs used to treat cavities).

Once the periodontist is satisfied that enough tooth structure is exposed, the surgical area will be washed with sterile salt water and the flaps will be stitched together. At this point, your teeth will look longer because the gums are now sitting at a lower level then before the surgery. Some dentists use a periodontal dressing — called an intraoral bandage — to cover the surgical site.
Any temporary crowns will be removed before the procedure begins and replaced afterward.

The periodontist will make incisions to remove the soft tissue and to provide access to the tooth roots and the underlying bone. Bone removal allows more of the tooth structure to be exposed. If this is necessary, the bone is removed using a combination of hand instruments (like small chisels) and rotary instruments (similar to the drill used to treat cavities).

After the soft tissue and bone have been removed, the incisions are sutured. This will cause more of the tooth or teeth to be exposed. Some dentists use a periodontal dressing to cover the incisions.

You will be given prescriptions for pain medication and a chlorhexidine mouth rinse. Your dentist will review oral-hygiene instructions, and ask you to follow a somewhat soft diet. You can brush the teeth in the area that was worked on, but you should avoid the gums. You can remove food particles around the affected teeth with a toothpick or a water irrigator.

Follow-Up

For the first two days, use ice on your face to keep swelling down.
After the procedure, you will return to the periodontist in 7 to 10 days to have the sutures removed, and then return again 4 to 6 weeks later for a follow-up visit.
Your gums should heal for at least three months before the tooth is prepared for the final crown. If you don't wait this long, the gums may shrink as they heal and the margins of the crown could show, or other problems could develop. You will visit your regular dentist to have the crown or filling placed, and then again for a follow-up visit.

Risks

As with all surgical procedures, there is a risk of prolonged bleeding during crown lengthening, as well as a risk of developing an infection after the procedure. Additionally, many patients will experience sensitivity to hot and cold because the roots of the teeth are now exposed. This will go away when the roots are covered with new temporary crowns.

Because of the tissue and bone removal, the affected tooth may look longer than adjacent teeth. However, this is only a cosmetic consideration.
Removing bone from around a tooth can loosen it. In addition, if the tooth is ever lost, the removal of bone could reduce the chances of successfully placing a dental implant in that area. Your periodontist will consider these details during your consultation.

When To Call a Professional

Contact our Dentist if:
• You have bleeding that doesn't stop
• You have pain that cannot be controlled by medication prescribed by your dentist
• You think the area might be infected
• You have excessive swelling or discharge from the surgical area
• The protective dressing becomes loose or is displaced
• Lymph nodes beneath your lower jaw or in your neck become swollen

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GUMMY SMILE/Crown Lengthening

When you smile, do your teeth look short because they’re concealed
by too much gum tissue?
Do you have a gummy smile?
An uneven gum line?
Or is there insufficient tooth structure available for a needed
dental restoration?
Crown lengthening can more beautifully frame
your teeth and create the perfect setting for cosmetic restoration.

Dr. Phillip F. Ajaje has extensive training and experience in periodontic
plastic surgery and crown lengthening. He pays meticulous attention
to detail with an artist’s touch. This is crucial since minute details can
dramatically affect the final outcome.

Prior to crown lengthening, we will discuss your treatment goals and actually show you what to expect with digitally enhanced photos.

During the treatment, excess gum and supporting tissue is gently sculpted with a laser and other microsurgical procedures, on one or more teeth to create a more perfect frame and natural broad smile. Local anaesthetic is used to ensure a painless treatment, and recovery
is rapid and comfortable.

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