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A second common use of crown lengthening is to access decay. If the dentist is unable to reach decay that is deep under the gum, the tooth will be lost. As a rule, simply trimming back the gum is not sufficient, as the underlying bone would be exposed. Rather, the periodontist must reflect a flap (See Flap Surgery), trim back the bone to allow for access to the decay, and then suture the gum back at the lower level. Sufficient bone must be removed to allow room below the decay for the gum to reattach to the tooth.
Most crown lengthening procedures are very straightforward, and there is little or no post-operative discomfort. Sutures and dressing are removed after about 2 weeks, and in many cases a 5-minute "touch-up" surgery is done after 4-6 weeks to establish ideal tissue form. This secondary procedure requires no sutures or dressing, and has no post-operative discomfort.
If a crown is to be placed in a cosmetic area, the restorative dentist should wait 8 weeks following crown lengthening before taking final impressions. This ensures that the gum, which shrinks slightly as it re-attaches to the tooth during healing, is in its final position. If the margin of the crown is placed at the gum level before final healing, and additional shrinkage occurs, the results may be unsightly. A temporary crown can be placed two weeks after surgery if the patient desires to cover the exposed root during this healing period.
Problems Associated with Gum Recession
In health, there are two types of gum tissues that surround the tooth. The part that is around the neck of the tooth is firmly attached to the tooth and underlying bone, and is called attached gingiva . The attached gingiva is immovable and tough, and deflects food as it hits the gum. Below the attached gingiva is looser gum, or alveolar mucosa. This tissue contains muscle, and is flexible to allow movement of the cheeks and lips. The muscles in the alveolar mucosa are constantly contracting, which pulls on the bottom edge of the attached gingiva. However, normally the attached gingiva is wide and strong enough to act as a barrier, which prevents the gum from being pulled down (receding).
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Some people are born without sufficient attached gingiva to prevent the muscle in the alveolar mucosa from pulling the gum down. In these cases the gum slowly continues to recede over time, even though the patient may be very conscientious with their oral health. This is not an infection, as is seen with periodontal disease, but rather simply an anatomic condition. Unfortunately, bone recession is occurring at the same time the gum is receding. This is because the bone, which is just under the gum, will not allow itself to become exposed to the oral cavity and moves down with the gum.
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A lack of attached gingiva is sometimes associated with a high frenum attachment, which exaggerates the pull on the gum margin. A frenum is a naturally occurring muscle attachment, normally seen between the front teeth (either upper or lower). It is normal to have a frenum, but it should not pull on the gum margin or recession will occur. If pulling is seen, the frenum is surgically released from the gum with a frenectomy . Often a new band of hard gum is also added to re-establish an adequate amount of attached gingiva.
With the wear and tear of time, even normal attached gum can be worn away, generally from vigorous brushing. This often happens in people with naturally thin tissues, or when the tissues have been stretched during orthodontics. If there is still adequate attached gum to act as a barrier to the muscle, the treatment for recession is to ensure further damage isn't done when brushing. However, if the attached gum is worn to the point where it cannot resist the constant pull of the mucosa, recession will continue unless a new hard band of gum is placed. Unchecked, the recession can cause tooth loss as the bone recedes with the tissue and tooth support weakens.
The replacement of missing attached gum is called gingival grafting . The muscle that is pulling down on the edge of the gum is first surgically resected and repositioned away from the gum margin. Then a small piece of attached gingiva is taken from an available source, often the roof of the mouth, and transplanted to the site in question. The new tissue reattaches and reforms a new layer of attached gum, which should last a lifetime with proper care. The donor source heals quickly, just like a skinned knee might. With this procedure the root is not covered, and the tissue stays at the same level as before, except with attached gingiva at the margin. These procedures are very easy on the patient, and rarely require more than over-the-counter pain prevention pills post-operatively (ibuprofen). The most difficult part of the surgery is not chewing on the area for 2 weeks. (See Free Gingival Graft-Clinical Case)
Routine gum grafts ("free gingival grafts") do not cover up the exposed root surface - if this is desired, a different technique is used (See Cosmetic Procedures, Root Coverage). Covering the root also makes the tooth stronger, for the bone, which actually holds the tooth in place, and will not change regardless of the new gum level. However, root coverage procedures are primarily done for cosmetic reasons when there is root sensitivity after recession, when there is decay on the root surface or when an old gum line filling needs replacement.
Ridge Augmentation and Extraction Sites
Ridge Augmentation
When teeth are extracted, the bone often resorbs during healing and leaves an indentation in the gum. When a bridge is placed, this concavity prevents the artificial tooth from looking real - it looks like it is just lying on the gum. By repairing the ridge defect with a ridge augmentation, the artificial tooth now looks like it is growing out of the gum, and cannot be distinguished from the natural teeth.
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The best way to treat a ridge deficiency is to prevent it from occurring. The amount of bone loss from an extraction can be minimized by performing a ridge augmentation at the time of extraction (See Treating Extraction Sites).
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Treating Extraction Sites
After a tooth extraction, the gum heals down in the socket before the bone has time to completely reform, leaving a resorbed ridge. To prevent bone resorption after extraction, we suggest the socket be filled with a material (bone graft) that reduces gum shrinkage or the socket be isolated with a membrane that prevents gum downgrowth (See Guided Tissue Regeneration). Treating the problem before it occurs is ideal.
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The best way to treat a ridge deficiency is to prevent it from occurring. The amount of bone loss from an extraction can be minimized by performing a ridge augmentation at the time of extraction (See Treating Extraction Sites).
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Treating Extraction Sites
After a tooth extraction, the gum heals down in the socket before the bone has time to completely reform, leaving a resorbed ridge. To prevent bone resorption after extraction, we suggest the socket be filled with a material (bone graft) that reduces gum shrinkage or the socket be isolated with a membrane that prevents gum downgrowth (See Guided Tissue Regeneration). Treating the problem before it occurs is ideal.
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The best way to treat a ridge deficiency is to prevent it from occurring. The amount of bone loss from an extraction can be minimized by performing a ridge augmentation at the time of extraction (See Treating Extraction Sites).
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Treating Extraction Sites
After a tooth extraction, the gum heals down in the socket before the bone has time to completely reform, leaving a resorbed ridge. To prevent bone resorption after extraction, we suggest the socket be filled with a material (bone graft) that reduces gum shrinkage or the socket be isolated with a membrane that prevents gum downgrowth (See Guided Tissue Regeneration). Treating the problem before it occurs is ideal.
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The best way to treat a ridge deficiency is to prevent it from occurring. The amount of bone loss from an extraction can be minimized by performing a ridge augmentation at the time of extraction (See Treating Extraction Sites).
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Treating Extraction Sites
After a tooth extraction, the gum heals down in the socket before the bone has time to completely reform, leaving a resorbed ridge. To prevent bone resorption after extraction, we suggest the socket be filled with a material (bone graft) that reduces gum shrinkage or the socket be isolated with a membrane that prevents gum downgrowth (See Guided Tissue Regeneration). Treating the problem before it occurs is ideal.
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The best way to treat a ridge deficiency is to prevent it from occurring. The amount of bone loss from an extraction can be minimized by performing a ridge augmentation at the time of extraction (See Treating Extraction Sites).
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Treating Extraction Sites
After a tooth extraction, the gum heals down in the socket before the bone has time to completely reform, leaving a resorbed ridge. To prevent bone resorption after extraction, we suggest the socket be filled with a material (bone graft) that reduces gum shrinkage or the socket be isolated with a membrane that prevents gum downgrowth (See Guided Tissue Regeneration). Treating the problem before it occurs is ideal.
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The best way to treat a ridge deficiency is to prevent it from occurring. The amount of bone loss from an extraction can be minimized by performing a ridge augmentation at the time of extraction (See Treating Extraction Sites).
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Treating Extraction Sites
After a tooth extraction, the gum heals down in the socket before the bone has time to completely reform, leaving a resorbed ridge. To prevent bone resorption after extraction, we suggest the socket be filled with a material (bone graft) that reduces gum shrinkage or the socket be isolated with a membrane that prevents gum downgrowth (See Guided Tissue Regeneration). Treating the problem before it occurs is ideal.
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