Gum grafting

What is gum tissue?

The gum is a soft tissue in the mouth that covers the alveolar bone (the bone that supports the teeth) and surrounds the base of the teeth to keep them in place.

Two types of gums are present in the mouth: the attached gum, which supports the teeth, and the free mucosa. We will focus here on the attached gums.

A healthy gum is characterized as follows:

  • It is pink and firm, has a texture similar to that of an orange peel, and is completely attached to the teeth;
  • Its volume allows it to support the teeth adequately;
  • It is not red or swollen (which can indicate inflammation);
  • It does not bleed when brushed or flossed;
  • It covers the tooth in a way that hides the root.

What is periodontitis?

The periodontium, sometimes called periodontium, is the tissue that supports the teeth, including :

  • gingiva (18, 19, 20, 21) ;
  • alveolar bone (23): part of the jawbone in which the teeth are implanted;
  • cementum (7): the protective layer that covers the root of the teeth in the alveolar bone;
  • periodontal ligament (22): the tissue that surrounds the root of the teeth and is located between the cementum and the alveolar bone;
  • nerve elements and blood vessels in the vicinity of the tooth.

A healthy periodontium protects and surrounds the teeth. When the periodontium is affected, it cannot fulfil its protective role. The roots of the teeth can then become exposed, unstable and more vulnerable to infection. In the most severe cases, unhealthy periodontium can lead to tooth loss.

Gingivitis can turn into periodontal disease

It is important to treat gingivitis quickly before it turns into periodontitis because the bone that supports the teeth could deteriorate and weaken the teeth.

Note that pregnancy gingivitis is usually only temporary, since it is caused by hormonal changes. Everything returns to normal after childbirth.

You think you might have gingivitis? Contact us quickly. Our experienced team will be able to make a diagnosis and give you advice that applies to you.

Gum disease

According to the Canadian Dental Association, gum disease is the most common dental problem. The development of gum disease can be sneaky. The slow progression of the disease and the absence of pain at the beginning of the disease mean that the person affected is often unaware of it.

The good news is that gum disease, although it can cause significant damage, can very often be prevented or treated when detected early. However, when the disease is too advanced, it can lead to tooth loss.

Risk factors

Several factors must be considered to determine the likelihood of a person developing gum disease. Here are the most important ones:

  • poor oral hygiene;
  • diseases that weaken the immune system (HIV/AIDS, leukaemia);
  • weakened immune system due to severe stress;
  • diabetes, especially if not properly controlled;
  • hormonal changes caused by pregnancy and menopause;
  • certain medications that have side effects on the gums;
  • smoking.

How does the mouth contribute to gum disease?

Many bacteria are present in the mouth. These bacteria produce acids when they digest sugar from food debris. These acids, together with salivary proteins and food particles, create a biofilm (slimy film) that is deposited on the teeth and surrounding structures. If this biofilm is not removed promptly by proper brushing, it becomes plaque, which, when mineralised, becomes tartar. It should be noted that tartar cannot be removed by brushing or flossing; only professional scaling can remove it.

Plaque and tartar are responsible for tooth decay and gum problems.

Gingivitis

Gingivitis is a widespread disease that is caused by the accumulation of plaque and tartar on the teeth, which leads to inflammation of the gums. It affects adults as well as children and adolescents. The symptoms of gingivitis are very easy to detect:

  • the gums become swollen, red and smooth or shiny;
  • Gums bleed when brushing, flossing or spontaneously for no apparent reason;
  • the appearance of periodontal pockets (spaces between the gums and the teeth) is also possible in some cases
  • persistent bad breath (halitosis), even after brushing the teeth.

Gingivitis is the first (least severe) stage of periodontal disease. At this point, no signs of the disease are visible on a dental X-ray, indicating that the structures that support the teeth are not affected. The patient does not usually complain of pain during gingivitis, but pain may occur when the gums become inflamed. The good news about gingivitis is that it is easily treatable and preventable when improvements are made to oral hygiene. This means that gingivitis is reversible and does not degenerate if treated early. If you see signs of gingivitis, it is very important to continue brushing and flossing properly even if your gums are bleeding.

Main types of gingivitis

  • Simple or chronic gingivitis: This is the most common form of gingivitis. It is caused by plaque and tartar and can be prevented by adopting healthy oral habits. The main symptoms are swollen, red, smooth and easily bleeding gums; there is almost always no pain.
  • Ulcero-necrotic gingivitis: This is often present in people whose immune system is compromised, either by disease or severe stress. The most serious consequence of this type of gingivitis, caused by very aggressive bacteria, is the destruction of the gums, which causes the appearance of spaces between the teeth and the gums. The symptoms are similar to those of chronic gingivitis, but with the addition of severe pain and heavier bleeding.
  • Hypertrophic (hyperplastic) gingivitis: This is mainly caused by the side effects of certain drugs. It differs from the other two types of gingivitis in that the gums are more swollen and can sometimes cover the teeth, making it more difficult to clean them. In hyperplastic gingivitis, the texture and colour of the gums are normal, but the gums are very fibrous.

Periodontitis

Periodontitis is gingivitis that has not been treated or has been detected at a late stage. It therefore affects the periodontium (tissues that support the teeth). It is the most advanced stage of gum disease and is serious because the damage it causes is irreversible.Le résultat le plus probant est la perte des dents entourées du parodonte atteint par la maladie. The most obvious result is the loss of teeth surrounded by periodontium affected by the disease. The damage of periodontitis is associated with periodontal pockets that form around the teeth where tartar has accumulated. Over time, the bacteria in these pockets destroy the periodontium, in particular, the periodontal ligament and the alveolar bone. In doing so, the teeth will gradually loosen, which may make them appear longer. The teeth will then become loose and eventually fall out if no intervention by a dental professional is made. The mobility of one or more teeth is what usually brings a patient to the dentist rather than pain, which is not usually present at this stage of the disease. Several factors can contribute to the development of periodontitis:

  • the amount and type of bacteria in the periodontal pockets
  • the presence of certain diseases that influence the effectiveness of the patient’s immune system and its ability to fight the bacterial infection that has set in
  • genetics;
  • smoking;
  • diabetes.

Evolution of gingivitis into periodontitis

As mentioned above, periodontitis is gingivitis that has not been treated properly. Gingivitis is usually painless and can progress very slowly, over several years, to the stage of periodontitis. It is therefore important to be alert to the signs of gingivitis in order to treat it at the source or stop its progression before it develops into periodontitis, as it is often too late to intercept periodontitis before irreversible damage occurs. Fortunately, not all gingivitis develops into more severe periodontal disease, but any signs of gingivitis should still be taken seriously.

The figure below shows the typical progression of gingivitis to periodontitis. By comparing the first image on the left and the one completely on the right, it is easy to see that bone destruction has occurred. In the terminal phase, the affected tooth is bound to fall out because it is no longer supported by a sufficient amount of periodontium, i.e. alveolar bone, periodontal ligament and gum.

Preventive measures

Gingivitis and periodontitis can be prevented by simple means:

  • IMPORTANT: contrary to what most people think, you should floss BEFORE brushing your teeth because when the floss comes out of the interdental space, it can propel food debris and bacteria onto the teeth.
  • Brushing: Brushing should be done at least twice a day, ideally after meals but especially before going to bed at night to remove the film created by bacteria with food deposits accumulated during the day.
  • Flossing: Flossing, when done correctly once a day, ideally at bedtime, helps to remove food debris and bacteria from between the teeth, areas that are difficult to reach with a toothbrush. To make good use of it, it’s best to wrap it around your middle fingers; this will give you more dexterity.
  • Stop smoking: Smoking greatly increases the risk of developing periodontal disease. It is therefore in a smoker’s best interest to stop smoking if he/she wants to keep his/her teeth long and his/her gums healthy.

Regular dental visits

An annual visit is essential, and sometimes more frequent visits may be recommended for individuals whose gums and teeth pose particular challenges.

  • During this check-up, a clinical examination is performed to assess the quality of the teeth and gums. X-rays are also taken to allow the dentist to obtain additional information about the teeth and surrounding structures that are not visible to the naked eye.
  • If tartar has accumulated on the teeth, professional scaling is performed. To prevent it from returning too quickly, advice can be given by the hygienist or dentist.
  • It is important for pregnant women to have their mouths examined by a dental professional at least once during pregnancy, preferably during the second trimester.

Gingival recession

When a significant amount of attached gum tissue is missing around one or more teeth, the survival of those teeth is at risk. This condition is called gum recession, also known as tooth loosening. Gum recession can cause, in the most severe cases, tooth loss if the level of attached gum is inadequate and too much of the tooth root is exposed.

Gum recession can occur as a result of gum disease or orthodontic treatment. In many other cases, it can be caused by improper tooth brushing (too vigorous or using the wrong technique).

In the example opposite, the tooth loosening is severe. Indeed, part of the root of the majority of the teeth is visible, making them appear much longer than normal and the amount of gum tissue to support them is now insufficient. If nothing is done to improve the situation, this person is at risk of losing the teeth that are most affected by decay.

Gingival grafting

Gingival grafting can be performed to restore sufficient gum tissue around teeth or around the roots of teeth that have been exposed by decay. Dental professionals who are qualified to perform this type of grafting are general dentists (for simple cases) and periodontists (for more complex cases). Several techniques are used to perform gum grafts:

  • Free autogenous graft: This is the oldest technique of gingival grafting. It consists in taking the graft from the patient’s palate and installing it at the level of the gum affected by loosening. The result of this method is less aesthetic than that obtained with other methods. It is also not recommended to use this type of graft in cases where the roots of the teeth need to be covered, as this technique only stops the progression of the loosening of the teeth in a minimal way. On the other hand, the advantage of this technique is that there is no risk of rejection of the graft because it is taken from the patient’s own mouth.
  • Connective tissue graft (connective tissue root canal graft): This is a relatively new and versatile technique. The connective tissue is taken from under the superficial gum of the patient’s palate and inserted under the gum adjacent to the teeth that are affected by loosening. Its main advantages are the very aesthetic results obtained and the possibility of re-covering the dental roots affected by gum recession. With this type of graft, the patient cannot reject the graft because it comes from tissue taken from the mouth.
  • Allogeneic tissue grafting (allograft): This type of graft is relatively new. A graft from an external donor, which has been processed and is very safe, is implanted into the gum of another patient. The main advantage of an allograft is that there is only one surgical site because the graft is not taken from the patient’s palate. It also gives results that are as aesthetically pleasing as a connective tissue graft. However, there is a small risk of graft rejection.

The success rate of gum grafts is very high. The beneficial effects of these grafts last for many years, although a little less in smokers.

Gingivectomy

A gingivectomy is a surgical procedure that removes part of the gum. It is performed under local anaesthesia and usually does not cause complications.

Recent techniques allow minor gingivectomies to be performed using a soft tissue laser, which causes even less discomfort and post-operative complications for the patient.

There are three main applications for gingivectomy:

  • Aesthetic application: Gingivectomy allows the removal of part of the gum around one or more teeth in order to harmonise the shape of the gum and improve the appearance of the smile.
  • Treatment of gingival hyperplasia: When the gums become unusually large to the point where part or all of a dental crown is hidden, a gingivectomy is recommended to reduce the excess gum tissue. If the situation remains as it is, the patient is at high risk of developing periodontitis. Gum growth can be caused by medications that are known to cause excess gum tissue, such as those for epilepsy and high blood pressure.
  • Periodontal treatment: As part of periodontal treatment, gingivectomy involves cutting away excess gum tissue not attached to a tooth in order to reduce the depth of a periodontal pocket that has formed during gum disease. This procedure will allow for a cleaning (known as periodontal curettage) and thus facilitate the patient’s dental hygiene.

Gingivoplasty

Gingivoplasty is a minor surgical procedure designed to reshape the contour of the gums. It is used to make a smile more attractive and harmonious and to complement a gingivectomy that would not give optimal results on its own.

The procedure is usually performed by the same dental professionals who perform gingivectomies, namely general dentists and periodontists. A local anaesthetic is required to perform a gingivoplasty and a soft tissue laser may be used. Complications are rare and post-operative discomfort is minimal.

Gingivoplasty is often used as part of orthodontic treatment to finalise the aesthetics of the smile. By moving teeth with different length crowns, the smile line may not be optimal due to the gum line around the teeth being irregular.

A dental professional may also use gingivoplasty as part of a treatment for gum disease. In this case, it restores the gum to its normal shape after treating deformed, damaged or necrotic alveolar bone.