Periodontal surgery is a form of

dental surgery Dental surgery is any of a number of medical procedures that involve artificially modifying dentition; in other words, surgery of the teeth, gums and jaw bones. Types Some of the more common are: * Endodontic (surgery involving the pulp or root ...

that prevents or corrects

anatomical Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having it ...

, traumatic, developmental, or plaque-induced defects in the

bone A bone is a Stiffness, rigid Organ (biology), organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red blood cell, red and white blood cells, store minerals, provid ...

gingiva The gums or gingiva (plural: ''gingivae'') consist of the mucosal tissue that lies over the mandible and maxilla inside the mouth. Gum health and disease can have an effect on general health. Structure The gums are part of the soft tissue lini ...

, or

alveolar mucosa The oral mucosa is the mucous membrane lining the inside of the mouth. It comprises stratified squamous epithelium, termed "oral epithelium", and an underlying connective tissue termed ''lamina propria''. The oral cavity has sometimes been describ ...

. The objectives of this surgery include accessibility of

instruments Instrument may refer to: Science and technology * Flight instruments, the devices used to measure the speed, altitude, and pertinent flight angles of various kinds of aircraft * Laboratory equipment, the measuring tools used in a scientific lab ...

to root surface, elimination of

inflammation Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...

, creation of an oral environment for plaque control, periodontal diseases control,

oral hygiene Oral hygiene is the practice of keeping one's mouth clean and free of disease and other problems (e.g. bad breath) by regular brushing of the teeth (dental hygiene) and cleaning between the teeth. It is important that oral hygiene be carried out ...

maintenance, maintain proper

embrasure An embrasure (or crenel or crenelle; sometimes called gunhole in the domain of gunpowder-era architecture) is the opening in a battlement between two raised solid portions (merlons). Alternatively, an embrasure can be a space hollowed out ...

space, address gingiva-alveolar mucosa problems, and

esthetic Aesthetics, or esthetics, is a branch of philosophy that deals with the nature of beauty and taste, as well as the philosophy of art (its own area of philosophy that comes out of aesthetics). It examines aesthetic values, often expressed thr ...

improvement. The surgical procedures include

crown lengthening Crown lengthening is a surgical procedure performed by a dentist, or more frequently a specialist periodontist. There are a number of reasons for considering crown lengthening in a treatment plan. Commonly, the procedure is used to expose a greate ...

frenectomy A frenectomy is the removal of a frenulum, a small fold of tissue that prevents an organ in the body from moving too far. It can refer to frenula in several places on the human body. It is related to frenuloplasty, a surgical alteration in a f ...

, and mucogingival flap surgery.

Indications

Contraindications

Some contraindications include: * Patient with poor standard of plaque control * Questionable long-term prognosis of patient dentition * Pregnancy * Smoking * Severe cardiovascular disease * Malignancy * Bleeding disorders * Uncontrolled diabetes * Kidney disease * Liver disease

Considerations

* The procedural selection in a periodontal surgery should rely on

simplicity Simplicity is the state or quality of being simple. Something easy to understand or explain seems simple, in contrast to something complicated. Alternatively, as Herbert A. Simon suggests, something is simple or complex depending on the way we ch ...

predictability Predictability is the degree to which a correct prediction or forecast of a system's state can be made, either qualitatively or quantitatively. Predictability and causality Causal determinism has a strong relationship with predictability. Perf ...

efficiency Efficiency is the often measurable ability to avoid wasting materials, energy, efforts, money, and time in doing something or in producing a desired result. In a more general sense, it is the ability to do things well, successfully, and without ...

, Mucogingival considerations,

osseous A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, and e ...

topography, anatomic and physical limitations, age and systemic factors. * The incisions should be clear, smooth, and well-defined to minimize the healing time. Such incisions prevent occurrence of uneven ragged flap edges. * To maintain the functional zone of the attached keratinized gingiva, flaps should be designed for maximum use and retention of keratinized gingival tissue , as it prevents the need of secondary procedures. * In the design of flaps, it needs to be ensured that there is adequate access and visibility. The design should also prevent bone exposure as it can lead to formation of dehiscence or fenestration. * For prevention of excessive

bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

hematoma A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillary, capillaries. A he ...

formation, displacement, bone exposure, or

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...

, adequate flap stabilization should be ensured. * The

surgical procedure Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

should be carried out such a manner that the postoperative healing takes place by primary intention and not by secondary intention.

Surgical procedures

Crown lengthening

Crown lengthening Crown lengthening is a surgical procedure performed by a dentist, or more frequently a specialist periodontist. There are a number of reasons for considering crown lengthening in a treatment plan. Commonly, the procedure is used to expose a greate ...

is a technique for increasing

crown A crown is a traditional form of head adornment, or hat, worn by monarchs as a symbol of their power and dignity. A crown is often, by extension, a symbol of the monarch's government or items endorsed by it. The word itself is used, partic ...

height of teeth by flap surgery with or without bone surgery. There are two main types: # Aesthetic crown lengthening which is performed when a “gummy” smile is an issue for the patient # Functional crown lengthening is used to make an unrestorable tooth restorable. For example, a tooth with caries that extends below the gums may undergo crown lengthening so that the caries is no longer below the gums and a crown may be placed.

Contraindications

Untreated or unstable gum disease (periodontal disease) and gingival phenotype

Considerations

* Strategic value of tooth * Crown/root ratio that will remain following surgery * Aesthetics will be affected such as longer clinical crowns and loss of

interdental papilla The interdental papilla, also known as the interdental gingiva, is the part of the gums (gingiva) that exists coronal to the free gingival margin on the buccal and lingual surfaces of the teeth A tooth ( : teeth) is a hard, calcified struct ...

e leading to “black triangles” * It can result in exposure of furcations * Mobility of teeth * Post-op sensitivity due to root dentine exposure * Patient may need long-term treatment until gingival margin stabilised (3–6 months). * Patient must also be made aware prior to surgery that relapse is possible

Method

There are three main methods for surgical crown lengthening: *

Gingivectomy Gingivectomy is a dental procedure in which a dentist or oral surgeon cuts away part of the gums in the mouth (the '' gingiva''). It is the oldest surgical approach in periodontal therapy and is usually done for improvement of aesthetics or p ...

* Apically repositioned flap (APF) surgery * Apically repositioned flap (APF) with osseous reduction (

osteoplasty Osteoplasty is the branch of surgery concerned with bone repair or bone grafting. It is the surgical alteration or reshaping of bone. It may be used to relieve pain associated with metastatic bone disease. Percutaneous osteoplasty involves the use ...

/ostectomy)

Frenectomy

Frenectomy A frenectomy is the removal of a frenulum, a small fold of tissue that prevents an organ in the body from moving too far. It can refer to frenula in several places on the human body. It is related to frenuloplasty, a surgical alteration in a f ...

is indicated by thick, prominent muscle attachments known as fraena or a frenum with close attachment to the gum margin. Thick frenum attachment or close attachment to gum margin can contribute to increased plaque accumulation, persistent inflammation, muscular pull on gum and affect gum contour. Usual sites for frenectomy are buccal regions of upper and lower

incisors Incisors (from Latin ''incidere'', "to cut") are the front teeth present in most mammals. They are located in the premaxilla above and on the mandible below. Humans have a total of eight (two on each side, top and bottom). Opossums have 18, wh ...

, upper canines and

premolars The premolars, also called premolar teeth, or bicuspids, are transitional teeth located between the canine and molar teeth. In humans, there are two premolars per quadrant in the permanent set of teeth, making eight premolars total in the mouth ...

. Frenectomy is rarely required for lingual sites.

Procedure

Frenectomy procedure consists of: * Cutting the attachment of the frenum to the gums * Administering local

anaesthetic An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia ⁠— ⁠in other words, to result in a temporary loss of sensation or awareness. They may be divided into two ...

* Stretching the lip and gripping the frenum with forceps * Cutting through base of frenum on both sides of forceps * Incision on alveolar side near to bone leaving the

periosteum The periosteum is a membrane that covers the outer surface of all bones, except at the articular surfaces (i.e. the parts within a joint space) of long bones. Endosteum lines the inner surface of the medullary cavity of all long bones. Structure ...

intact. * Removal of the frenal tissue and suturing the edges of the wound closely with resorbable sutures * Placing Swabs over the wound * The patient is instructed to rinse twice daily with chlorohexidine mouthwash.

Mucogingival flap surgery

Mucogingival surgery is a procedure where the gums are separated from teeth and temporarily folded back to allow the dentist to directly view and reach root surface of the tooth and bone. It is used for crown lengthening surgery. It also, if required, can be used for guided tissue regeneration or open flap debridement (OFD) to treat gum disease (periodontitis/periodontal disease). The presence of bacteria, in the form of dental plaque/tartar/calculus on the root of a tooth, can cause inflammation of the gums resulting in gum disease. This can lead to bone loss around the affected teeth and if left untreated, lead to tooth loss. When a tooth has very deep

periodontal pockets Periodontology or periodontics (from Ancient Greek , – 'around'; and , – 'tooth', genitive , ) is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting ...

it may not be possible to fully remove the dental plaque/tartar/calculus from the tooth’s root surface with scaling alone. In open flap debridement (OFD) the gum is peeled back to make it possible for the dentist to see and ensure full removal of tartar/calculus from these difficult to access areas. Teeth with furcation defects as a result of

gum recession Gingival recession, also known as receding gums, is the exposure in the roots of the teeth A tooth ( : teeth) is a hard, calcified structure found in the jaws (or mouths) of many vertebrates and used to break down food. Some animals, parti ...

may require open flap debridement (OFD) as these areas can be very difficult to clean.

Mucogingival flaps thickness

Full thickness flap involves incision down to bone. Using blunt dissection, the flap is raised from bone. Full thickness flap is a simple procedure which provides access to root surface and bone. The procedure leaves minimal post-operative discomfort. It provides limited mobility of flap and is unsuitable for grafting. Split thickness flap involves sharp cutting of tissues and leaving the underlying periosteum intact. The procedure prevents exposure dehiscence and allows good blood supply for grafting. It does not provide access to underlying bone or root surface and results in greater post-operative discomfort.

References

{{reflist Dental surgical procedures

Surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...