Periodontal Plastic Surgery: Gum Reshaping Can Improve A Smile
May 4th, 2010
When most people think of a nice smile, they think of nice, white, healthy teeth. It is true that healthy teeth are essential, but those teeth are like a beautiful piece of artwork that must be appropriately “framed” to make them come to life. The frame of the teeth are the gums that surround them. Healthy and appropriately shaped gums bring harmony and visual contrast to the teeth they envelop.
A common complaint for many patients is that they feel they have a “gummy” smile. In fact, as much as 30% of women have some level of excessive gingival display (gummy smile). This condition can be associated with several different causes including tooth position, skeletal bone relationships, lip mobility, and position of gum tissues surrounding the teeth.
This month’s case highlights Caitlin, a 22 year old female patient who presented following orthodontic therapy (braces). The teeth were moved into an ideal position by the orthodontist. However, Caitlin felt that she had a gummy smile and inquired about addressing this. Caitlin’s teeth and gums were healthy. Following a thorough diagnostic workup, it was determined that Caitlin was a good candidate for a procedure known as esthetic gum recontouring (also known as esthetic crown lengthening).
The goal of gum recontouring is to create the natural flow and curvature of a pleasing gum line, while exposing the appropriate amount of tooth structure. In Caitlin’s case, she had beautiful teeth and healthy enamel. It was just covered by abundant gum tissue making the teeth appear short. Utilizing a periodontal laser, the gums are shaped to their ideal position. Following this step, the surrounding bone is gently reshaped to create the appropriate anatomy for sustaining a long-term result. Without this latter step, the tissue will regenerate once again. The final step is the securing of the tissue with small diameter, plastic-surgery style sutures. The entire surgery took less than one hour.
Following 12 weeks of healing, we can see dramatic changes in Caitlin’s gum line, and ultimately, her smile. The tissues will continue to remodel over the next 12 months to create ideal contours. In some situations, gum recontouring may be followed by restoration of the teeth with veneers.
Esthetic gum recontouring is one example of how periodontal plastic surgery may impact the smile. Most patients are focused on how their teeth appear, and may not realize that the position and harmony of the gums can have a dramatic impact on the presentation of the teeth they surround. Through addition, or in this case, subtraction procedures, a periodontist can help patients achieve their desired goals
This article first appeared in the 2010 May / June edition of the The New London Women’s Journal
I was always self-conscious about my smile, so when Dr. Toback suggested the procedure I was excited to see the difference. The procedure was unbelievably easy and quick. The results are amazing! My smile looks completely different and I couldn’t be happier with how my teeth look now! – Caitlin
Are Oral Piercings a Costly Fashion Statement?
February 2nd, 2010
It has been reported over the past five years, that individuals with oral piercings may be at risk for acute gum disease problems. Typically, gum disease is diagnosed in adults over the age of 35, and is the leading cause of tooth loss in the United States. However, younger patients with oral piercings put themselves at risk for gum recession, bone loss around teeth, and ultimately tooth loss.
We have seen young patients in our practice over the past several years, who have had dramatic gum defects, bone loss and tooth mobility associated with oral piercings. These problems are localized to areas in close proximity to the jewelry. These patients have no other signs of gum disease in other sites, and they would not normally be classified as high risk for gum disease. Clearly, there is a detrimental affect of the oral piercing to the supporting tissues of the teeth.
Tongue piercings are a common culprit and most frequently affect the lower front teeth. The tongue-ring will cause trauma to the gum tissue while eating and speaking. In addition, many individuals with tongue rings develop a tongue thrusting habit that causes hitting of the ring against the lower teeth and gum tissues. This trauma allows the bacteria within the oral cavity to infiltrate the tissues and create an acute inflammatory condition. Ultimately, infection ensues and will cause irreversible bone loss which could result in eventual tooth loss.
Overall the general public has not been well informed of these risks. Most patients who present to our practice with piercing related periodontal disease, are completely unaware of the risks associated with this fashion trend. Fortunately, most patients when faced with the possibility of losing their front teeth at a young age, decide to discontinue the use of oral jewelry. Some patients have been told that if the jewelry is made of plastic instead of metal, that the risk of damage is eliminated. Figures 1 & 2 show a plastic style tongue ring that a patient was using recently until diagnosed with rapid onset recession (stripping of the gum tissue away from the teeth). Use of plastic jewelry definitely does not eliminate the risk of damage.
Figure 3 depicts the inflamed and infected gums of another patient following use of a tongue ring. I have included a surgical photo demonstrating the incredible destruction of the supporting bone. This patient was facing imminent loss of at least one tooth prior to treatment. Bone and tissue grafting helped recover some of the lost bone. With suspension of use of the tongue ring, this patient will have a fairly good prognosis. Others who are diagnosed later may not be as fortunate and will lose their teeth.
If you wear oral piercing jewelry, you should seek a periodontal screening examination to assess whether you have experienced any of these problems. If a family member or friend wears an oral piercing, please share this information and you may save someone you care about from disastrous fashion fallout.
This article first appeared in the 2010 February / March edition of the The New London Women’s Journal
Dental Implants Restore Smiles
November 3rd, 2009
In the last issue of the Women’s Journal, we shared how dental implants and computers can restore the function and confidence of a patient with missing teeth. Our objective today is to demonstrate how dental implants can support beautiful teeth in the highly critical “esthetic zone.” Nothing is more alarming to an individual than when they hear the news that they will lose a front tooth. We know that beautiful teeth and healthy gums capture and frame a warming smile. Our smile is the core of the visual first-impression. Fortunately, dental implants now provide hope and peace of mind to those faced with losing a front tooth. With careful diagnosis, planning and teamwork, the implant surgeon and restorative doctor can bring back architecture and harmony to a smile.
Our featured patient this month is a 38 year-old female who had congenitally missing lateral incisors. This means that the permanent teeth had never formed and the primary teeth (“baby teeth”) were maintained by this young woman until the time of treatment. The primary teeth had no root formation to provide support, and therefore the teeth became extremely mobile (loose) and were facing imminent loss. After a detailed analysis, we determined that the removal of the baby teeth was necessary, and dental implants were the treatment of choice to create the necessary foundation for new incisors.
Whenever possible, utilizing minimally invasive approaches can help preserve normal gum architecture. Implant surgery without incision can be conducted in appropriate situations to avoid the disturbance of soft tissue contours. In addition, the use of immediate restorations can support the preservation of those tissues. This is a critical benefit to the patient seeking the most esthetic result.
Following removal of the primary incisors, the area is prepared for implant placement. Once the implants have been positioned, temporary posts and crowns are made chairside to be seated immediately. With this approach, the patient is able to leave the office with the first set of new teeth on the same day. The patient is instructed to avoid aggressive chewing with these teeth over the first 6 weeks while the implants are healing in the bone.
After approximately 4 months of healing, the implants have formed a “union” with the surrounding bone. This process is called osseo-integration, and allows the implant to absorb and withstand biting forces. The gum tissues have also healed and matured around the temporary restorations. The patient’s restorative dentist then begins the final process of making the porcelain crowns.
Successful implant therapy results in restorations that blend with the surrounding teeth and gum tissue, and are in harmony with the individual’s facial and oral features. Gum tissues that frame the restorations should mimic the scalloping shape and contours of gum tissue surrounding natural teeth. Most importantly, when our patient smiles, the new implant teeth appear natural, appropriate and pleasing to the eyes.
In conclusion, careful analysis and management of the soft and hard tissues during implant treatment can lay the foundation for a successful result in the esthetic zone. The restorative-surgical team approach can offer patients the most advanced implant options including minimally-invasive surgery and immediate restorations. I would like to thank Dr. Debra Daren for her excellent restorative work, and for allowing me to share with our Women’s Journal readers.
This article first appeared in the 2009 November / December edition of the The New London Women’s Journal
Computer Guided Implant Surgery
September 8th, 2009
p>Dental implants have clearly been positioned as the treatment of choice for the replacement of missing teeth. Successful results can be predictable with careful analysis of the anatomy of the region, and appropriate planning. Most patients prefer the team approach to implant rehabilitation; combining the expertise of a surgical specialist such as a periodontist, with the restorative skills of their general dentist. This “two doctor team” must communicate the desired goals of the patient and create a sophisticated plan that can be put into action. Computer guidance has been one of the single most important developments in implant surgery in the past twenty years. This technology now allows the implant team to digitally and virtually perform the implant surgery long before the patient is in the chair. A variety of treatment options could be explored and the potential complications can be identified. Ultimately, the best treatment plan can be selected and surgically executed with a precision never before possible.
The case reviewed here describes a 28 year-old male who had a developmental anomaly whereby his permanent teeth had never formed (fig. 1). With the exception of two back molars, this young man had only a primary dentition (“baby teeth”) to function with in the lower jaw. These teeth had cracked and become mobile. As an active individual, the patient desired to have implant treatment that would not require the use of removable dentures at any time during treatment. He desired a plan that was efficient with his time, and would allow him to enjoy chewing function, esthetics and ultimately, social freedom throughout treatment.
The first step to computer guidance is to obtain a detailed x-ray called a CT scan. CT scans (computed tomography) provide very precise images of the bone and can allow the visualization of the jaw bone in three-dimension (fig. 2). The image can be digitally manipulated to see the area of interest from many different perspectives. Once the case has been thoroughly diagnosed, implants can be virtually positioned in the desired locations. For the first time, the restorative doctor can be directly involved in the decision-making of the exact location for implant placement. The surgeon and the general dentist can interact in a meaningful way that results in the selection of the optimal positions for the implants to achieve the desired goals of the case.
Once the implant positions were finalized for this case, a template was made called a surgi-guide, that was utilized during the implant placement procedure (fig. 3). In addition, this template allowed the restorative doctor to make the temporary bridge for the patient prior to the removal of the baby teeth. The immediate restoration of the implants upon the day of placement has been termed “teeth in a day” (fig. 4). Following 4 months of healing, the final restoration was completed (figs. 5,6).
The great benefits of computer guided surgery include accurate diagnosis of the case, precision planning of implant placement, enhanced communication of the implant team and outstanding results. In addition, some of the greatest patient benefits of computer guidance is that surgery can be conducted in a minimally invasive fashion. Guided surgeries require fewer incisions and can be completed in a fraction of the time of traditional implant surgery. That translates to less post-operative swelling and discomfort and speedier recovery times. I would like to thank Dr. Dennis Sindel for his fine restorative work with this case, and allowing me to share with our readers.
This article first appeared in the 2009 September / October edition of the The New London Women’s Journal
