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The Art of Periodontal Surgery
Periodontal surgery is a plastic (reshaping) surgical procedure designed to restore and regenerate normal form and function to lost and damaged periodontal structures which support the teeth (the gum tissue, periodontal ligament and bone). This article is an overview of what a candidate for periodontal surgery can expect and a primer for further information and discussion.
Periodontal Surgery in Perspective — What makes it work
An understanding of what periodontal surgery is designed to do, what makes it successful and what sustains the results over time is critical to the successful treatment of periodontal disease. Periodontal surgery is not a cure, but rather an adjunct to making long-term treatment outcomes more favorable. Unlike surgery to take out an inflamed appendix, which removes the disease with it, the potential for the recurrence of the periodontal disease still remains in susceptible individuals. The long-term goal of periodontal surgery is to increase the life expectancy of the teeth.
Over a lifetime, the treatment for periodontal disease is primarily aimed at controlling its cause, microbial dental plaque. The purpose of periodontal surgery, therefore, is to treat deformities and tissue loss created by the disease process. This is accomplished by eliminating “pockets” of diseased tissue; regenerating and reconstructing gum and periodontal tissue attachment to the teeth and generally to provide an environment more conducive to daily oral hygiene and professional maintenance care.
The Consequence of Periodontal Infection
The end results of periodontal disease include loss of the tight attachment of the gum and periodontal tissues to the teeth. Just as one can put a hand in a pocket, a space by the side of clothing, pockets can also form around the teeth, into which fine probing instruments can be inserted to measure the degree of vertical tissue detachment [see illustration above]. This detachment results from chronic inflammation as described above. Breakdown ultimately causes bone and periodontal tissue destruction giving rise to different patterns and shapes of bony defects which surgical treatment aims to regenerate and repair. For the most part the detached gum tissues either recede or remain as a detached curtain around the teeth.
Initial Preparation Sets the Stage for Surgery
Behavior Change: Consistent behavior change is the most important element in maintaining long-term periodontal health since daily plaque removal in large part will set the stage for sustained, successful surgical treatment. For many people, this involves forming new oral hygiene habits, along with the cessation of smoking and other lifestyle changes.
Calculus (Tartar) Removal: Your dentist will also see that your teeth receive a thorough cleaning to remove the deposits of calcified plaque called calculus or tartar and other bacterial toxins which become ingrained into the root surfaces. This process of mechanical cleaning is generally known as scaling and root planing, using hand scaling, ultrasonic or laser instruments and will sometimes require local anesthesia.
Occlusal Bite Therapy: Generally, attention to the bite or bite disorders are treated during or after initial therapy once an inflammation free environment has been established. It is important to stabilize loose teeth prior to surgery because this in itself encourages healing of the periodontal structures and bone.
Re-evaluation Following Initial Therapy
After three or four weeks your dentist/periodontist will evaluate the response of your periodontal tissues to the initial therapy which is being used to control the inflammation and infection induced by dental plaque. This includes oral hygiene instruction, scaling and root planing (deep cleaning) among other possible treatments. In cases where pockets are deep, 5 mm and above, the chances of successfully removing all the bacterial deposits from the root surfaces diminish, which means that they may only be removed at surgery when they can be visualized. This also applies to areas that are impossible to clean adequately because of their shapes, like “furcations,” the areas of bone loss between roots of “multi-rooted” teeth, which may only be accessed surgically.
Superficial gum tissue health in response to plaque control is critical to surgical success. If the gum tissues have not responded adequately then bacteriological testing may be indicated to ensure removal of pathogenic (disease-causing) strains of bacteria by either local (applied at the site) or systemic (bodily) antibiotic treatment, or review of the diagnosis for medical conditions that may be limiting the response to initial treatment.
Periodontal surgical treatment today encompasses a variety of sophisticated plastic surgical procedures. These include techniques to repair and regenerate soft (gingival) and hard (bony) tissues and replacement of missing teeth with dental implants. Procedures are usually performed by a periodontal specialist trained in these techniques and in some cases general dentists who have taken advanced training in periodontal surgery. Most procedures are performed with local anesthesia (numbing of the gum/periodontal tissues and teeth), sometimes with the additional use of oral anti-anxiety/sedation medication or intravenous conscious sedation (twilight sleep).
The objective of surgery is generally to eliminate pockets, regenerate attachment and to create more normal periodontal form, function and esthetics. The goal is to provide an environment more conducive to oral hygiene and maintenance care so that teeth can be kept for a longer period.
Risks, Benefits and Alternatives
It is important to have a discussion with your periodontist or general dentist to educate yourself regarding the risks, benefits and alternatives before undergoing treatment:
- The specific procedure you need should be discussed so you can understand what is involved. It should include what to expect after the surgery; generally mild to moderate discomfort for a day or two, usually managed by non-steroidal anti-inflammatory and analgesic medication of the Ibuprofen or Celebrex family, antibiotics and antibacterial rinses. No vigorous activity should be undertaken for the first few days to ensure that bleeding does not occur. It is also likely that the teeth will be somewhat more sensitive to cold which will disappear over time, particularly with the application of fluoride varnishes.
- What are the benefits and likely outcomes of treatment including a determination of prognosis — what results to expect and how long they will last;
- What are the alternatives to surgical treatment; this will depend upon the type and the extent of periodontal disease you have and the procedure that is recommended.
These issues will differ somewhat depending upon the type of periodontal surgical procedures. This process is called informed consent, and you will probably be asked to acknowledge this process in writing.