The tunneling procedure, performed by a Periodontist, for connective tissue grafting is very effective for covering tooth root surfaces that have been exposed due to gingival recession. Not only does it result in a very cosmetic result, but it also increases the amount of attached gingiva and is very stable for the long term.

The technique involves dissecting the gingiva away from the underlying bone and tooth root surface. This creates a space or tunnel in which connective tissue from the roof of the mouth can be transplanted. Prior to placing the tissue, the root surface is prepared by scaling and root planing. Once the graft is in place the gingiva is sutured into position over the graft.

The results are apparent at one week. There are variations for this technique. As opposed to harvesting tissue from the roof of the mouth, cadaver tissue, like Alloderm, can be used. I have found the results more consistent using the patients own tissue rather than the Alloderm. However when it is necessary to graft multiple teeth using the Alloderm makes for a much easier post operative recovery as most of the post operative discomfort results from the donor site on the roof of the mouth. Here is an example of a case using Alloderm. Other variations involve root surfaces treatments such as Emdogain, which is a protein gel that is applied to the root surface prior to graft placement.

As a generalization, for localized procedures 1-3 teeth I prefer to use the patients own connective tissue harvested from the palate (roof of the mouth). For larger cases I prefer using Alloderm. When palatal tissue is used, a palatal stint is made which covers the roof of the mouth. and is worn during the first week of healing. It protects and insulates the wound and is very helpful in controlling the discomfort that results from the donor site on the roof of the mouth.

When a gummy smile is due to a skeletal discrepancy and not excessive gum tissue covering the teeth, orthognathic, jaw, surgery is the most predictable way to treat this condition. Under the right circumstances, lip lowering plastic surgery can achieve dramatic results with a much less invasive surgery.

The procedure itself is a variation of a common periodontal surgery called a frenectomy. The lip lowering procedure is essentially a reverse frenectomy. The goal of the procedure is to reduce the vestibuluar lenghth or shorten the fold between the lip and gum thereby reducing the amount of movement of the lip.

Relapse of this procedure is common if good initial stability is not achieved and maintained during that first week. The lip musculature will override the surgery, drawing the flaps apart. The resulting space will granulate in very quickly but that results in increased vestibule which is counter productive to the goal of surgery.

Suturing is important to the success of the procedure. While this case shows the use of vertical interrupted sutures, I now favor the use of horizontal mattress sutures. With this technique the sutures and approximated flaps stay in position for the entire week. This contributes to a more stable adherence of the lip in its new position. A periodontist has a wide arsenal of suturing techniques and materials given the array of intra-oral plastic surgery procedures they perform. I also favor leaving the sutures for 10 days as opposed to one week.

Post surgical swelling can also be problematic for for wound stability. As the tissues swell this can cause tension against the flaps resulting in the same separation and granulation. I typically do this procedure with IV sedation and administer Dexamethasone upon completion to keep the swelling down during that first week. Dexamethasone can be given intra orally if IV sedation is not used during the procedure. I also prescribe Ibuprofen to be used during the first week to help control swelling.

Post operative discomfort from this procedure is controlled well with the ibuprofen, but I also prescribe Hydrocodone. Most patients will not need the Hydrocodone. Bleeding and infection is very uncommon but post surgical ecchymosis (black and blue) is common and can extend from the lip to the lower eyelids and can persist during the first week.

Patients with a gummy smile due to a hypermobile lip can be very self conscious about their smile. Lip lowering periodontal plastic surgery is a very cost effective and minimally invasive procedure to treat this condition. Careful patient selection is important, not everyone with hypermobile lip is a candidate for this procedure.

Welcome to Periodontist.Org. Periodontist.org is a collaborative effort to provide useful consumer information about periodontics that you will not find anywhere else on the web. Our goal is to educate you about the field of periodontics, what a periodontist does, and treatment options. Our intended audience is someone who needs treatment, is in treatment or has had treatment for some aspect of gum disease or dental implant therapy. Some of the topics that we cover are as follows:

• Current trends in the filed of periodontics
• Products that are used in treatment
• Procedures/ treatment and who should perform them
• Different practice settings that periodontists use and how this may influence your treatment
• How to find a periodontist / the referral process
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Gingival (gum) recession is a common problem for a Periodontist to treat. Typical causes of gingival recession are:

• Minimal zone of attached or keratinized gingiva
• Gum disease
• Trauma – Traumatic tooth brushing
• Orthodontic treatment
• Unbalanced occlusion (bite discrepancy)

There are two types of tissue surrounding the tooth, gingiva (gum tissue) and mucosa (cheek tissue). Gingiva is a tough leather like tissue whereas mucosa is very flexible and delicate. In the early stages of recession, the zone of gingiva thins. A normal zone of gingiva is 3mm or greater. When the zone of tissue becomes less than 3mm there is a greater risk of recession. Zones less than 3mm are considered unstable. The primary goal of a gum grafting procedure is to increase the zone of attached tissue. The secondary goal is to try to cover exposed tooth root surfaces. Even if the second goal cannot be met, by establishing an adequate zone of attached gingiva the recession can be arrested and maintained at their current levels. Other contributing factors such as those above must also be addressed.

One technique that can be employed to achieve both goals is a periodontal plastic surgery procedure called gingival tunneling. There are limitations to how much root coverage can be obtained. Usually the height of the gingival papillae, in-between the teeth, is the standard benchmark. As a rule you cant achieve root coverage beyond the height of the papillae and typically it is a few millimeters less.

In this case, there is severe gingival recession. Abrasion on the root surfaces is indicative tooth brush trauma. This type of trauma is from using a toothbrush with hard bristles instead of soft, over zealous brushing or improper technique – using the toothbrush in a side to side motion instead of up and down. The good news about this case is that the gingival papillae in-between the teeth are almost at normal height, thus this patient is a good candidate for a root coverage procedure. A gingival tunnel procedure is used. Given the extensive nature of the gum recession we opted to use Alloderm dermal matrix tissue instead of the patient’s own tissue from the roof of the mouth. We also used Platelet Rich Plasma to rehydrate the Alloderm tissue and facilitate healing.

After a local anesthetic is used The roots are scaled and planed smooth. A gentle incision is made between the gum and tooth. The incision does not extend through the side gingival papillae, they are still attached. The gum is then separated away from the tooth and that creates a tunnel. The Alloderm tissue is advanced through the tunnel by threading a suture under the papillae. Once the tissue is in place, the gingival flap is re-approximated higher on the tooth root surface and sutured in place using a sling suture design. Platelet rich plasma is also applied around the incision area once suturing is complete.

We achieved a very favorable result. At one week there has been almost complete root coverage. The patient’s tooth brushing technique has been modified and a soft toothbrush is being using.

Cant hold the floss
Its messy
It hurts
No time
Don’t think it is necessary
It makes my gums bleed

The list goes on. Flossing is important because tooth brushing alone will not clean in between the teeth. Its no secret that most gum disease starts in between the teeth for that reason. For people who refuse to floss, using toothpicks is almost as effective, but flossing is preferred.

Gingivitis – gum disease, is one of the most common diseases known to man. It is an inflammation of the Gingiva. Bleeding from brushing or flossing is a sign of gingivitis. Unfortunately a common misnomer of the lay person is that bleeding from brushing or flossing is normal because it is so common. But this is incorrect, if you have this condition you should seek help from your dental professional. Proper tooth brushing and flossing technique will prevent gingivitis and can cure it. While most people readily brush their teeth only a small percentage engage in flossing.

With proper technique, once a day is adequate for most people to floss their teeth. With that in mind, I have come up with an easy solution that many of my patients have adopted to become regular flossers. The solution is to get a mirror that can be used in the shower, and floss while in the shower. There is usually some down time while conditioning or whatever that allows a few minutes to floss. Flossing in the shower mitigates a lot of checks on the list above. Pain from flossing can result from gingivitis or improper technique. Proper technique is beyond the scope of this blog but you should allow the floss to move passively under the gum until you meet resistance. When gingivitis is present your gums may bleed initially but the bleeding will usually subside as the gums begin to get healthy. This will take about 7 to 10 days with daily use. If it doesn’t resolve in that time frame seek a dental professional for a consultation.

Developing the dexterity to floss can be cumbersome but easily mastered with a little practice. It usually takes a couple of weeks to develop the dexterity so don’t give up. Floss holders or flossing swords, are typically not that effective because they don’t hold the tension in the floss, but its better than nothing if dexterity is an issue.

Smiling at the shower water or using a water pick is not a substitute for flossing – I know what you are thinking. The water pick is useful for removing food particles but will not dislodge bacterial plaque from the tooth surface like a toothbrush or dental floss.

I admit that flossing is not an easy habit to get into but it is critical for optimal dental health. It takes some practice to develop the dexterity to floss but this is an easy obstacle to overcome with a little practice. Bleeding and mild discomfort from flossing is likely initially but should resolve within a couple of weeks of flossing, seek professional help if it doesn’t. The benefits of flossing are life lasting!