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Typically, the first attempts to treat periodontal conditions involve non-surgical procedures such as scaling and root planing. However, more severe periodontal cases may be treated with periodontal surgery to repair or stabilize the gums and tooth-supporting bone. Surgeries, especially those involving the treatment of bone, are generally not the first option.

Periodontal surgery involves the surgical treatment of the gums and tooth-supporting bone.

Not all dentists perform periodontal surgery procedures. Your dentist may refer you to a periodontist for some or all of the procedures you may need.

Each periodontal surgical procedure is designed to address specific issues and provide specific benefits. There are two categories of procedures.

1. The removal of problematic tissue (resective periodontal surgery).
2. The rebuilding of gums and bone which have been lost to disease (regenerative periodontal surgery).

Treatments related to the removal of problematic tissue

• Apically positioned flap surgery may be performed to eliminate deep gum pockets around the teeth. This is where food and plaque accumulates and is especially difficult to clean even with good oral hygiene. This procedure is performed to help you manage periodontal disease more effectively.
• Your dentist may perform clinical crown lengthening to expose enough healthy tooth structure to restore the natural tooth and improve the chances of keeping it healthy.
• If you have enlarged gums due to periodontal disease, your dentist may perform a gingivectomy to reduce the inflammation and improve the appearance of your gums.

• A supracrestal fiberotomy can be performed to help ensure a tooth rotated by orthodontic treatment does not return to its original, incorrect orientation.
• Your dentist may perform a frenectomy to allow your teeth to move together more easily, prevent receding gums, and improve your ability to speak clearly.

Treatments related to the rebuilding of gums and bone

Your dentist may perform one or more surgical procedures to re-establish healthy gum and bone around an affected tooth to restore its proper appearance and function if you have one of these conditions:

• Receding gums.
• Areas in your mouth damaged by periodontal disease.
• Areas in your mouth where you do not have enough gum tissue or bone.

The procedures that may be recommended to help restore gums include the following:

• Free soft tissue graft
• Guided tissue regeneration
• Pedicle soft tissue graft
• Connective tissue graft

There are various types of bone grafts recommended to help repair damage affecting the tooth-supporting bone. This will help restore proper function to your natural teeth. Bone grafts may also be used by your dentist in advance of restorative dental procedures such as dental implants, bridges, and removable dentures.

Periodontal surgical procedures have several things in common:

Before the procedure

• Review your health status: You will share information that will help ensure that your dentist and their staff can provide safe and effective treatment and provide appropriate post-care guidance. Get important information here: Health history and current health status.
• Treatment review: Your dentist or periodontist will describe the intended goals of the procedure or procedures. It is important to prioritize and communicate your expected treatment goals in advance of the procedure to ensure you and your dentist both understand what to expect.
• Anti-anxiety medication: If you are anxious about dental procedures, your dentist may recommend sedation.

During the procedure

• Anesthetic: Your dentist will numb the surgical area with a local anesthetic. This also helps reduce the amount of bleeding that will occur during the procedure. A topical numbing gel may be applied to help reduce discomfort from the injection.
• Incision: Your dentist will make one or more incisions through the gums to expose the area to be repaired.
• Grafting: When performing a soft tissue graft with your own tissue, your dentist will numb the "donor site" before removing a portion of healthy soft tissue from that area. The connective tissue will be obtained from either the roof of your mouth or a tissue bank. Some dentists believe it is preferable to use your own tissue to achieve faster healing and better cosmetic outcomes. However, using your own tissue requires a second surgical site, which may increase your pain and risk of infection. Talk to your dentist about whether this is the best approach. Specific steps are outlined within the links to each procedure in the section at the top of the page.
• Your dentist will then perform the procedure(s).
• Closing: Your dentist will reposition the gums over the surgical site(s) and hold them in place with sutures. A "periodontal dressing" may be placed over the surgical area to protect it and promote healing.

After the procedure

• Pain management:
  • Your dentist will typically prescribe pain relievers following periodontal surgery. The specific medication will depend on your age and health history. Some medications are opioids. Be sure to discuss any particular concerns you may have with the medication prescribed.
  • Like any surgical procedure, periodontal surgery has post-surgical risks such as swelling, bruising, bleeding, and infection. You can manage most of the symptoms with anti-inflammatory medications if you can safely take them. You may be at greater risk for post-treatment bleeding if you take certain pain medications. Check with your physician or dentist before taking any unprescribed medication for these symptoms.
  • Follow-up care: Your dentist will give you specific instructions on how to take care of the surgical area(s). You should request a copy of the instructions. Although the instructions may seem straightforward at the time of your dental appointment, you may need to refer to them later.
    • It is essential to follow the specific, post-treatment home care instructions given by your dentist. This will improve healing time and avoid the risk of infections.
    • Your dentist will provide you with any suggested dietary modifications and when to schedule follow-up appointments you may need.
    • Periodontal disease can be treated, and the damage it causes can be repaired. Then it must be managed through good oral hygiene and regular periodontal maintenance. Your dentist may also recommend the use of antimicrobial agents. This is essential to keep it from progressing, causing additional damage, and negatively impacting your overall health.

• Medical conditions: Periodontal surgery, like any surgical procedure, comes with some risks. These conditions don't necessarily mean you cannot safely undergo periodontal surgery, but your doctor will need to take them into consideration so that you can be safely treated.
  • A history of bleeding, bruising, or taking blood thinning medications
  • Planned or existing prosthetic joints (like a knee or hip) within six months of the periodontal surgery
  • Organ transplants
  • Diabetes
  • Reduced immune function
  • Prosthetic heart valves
  • Rheumatic fever
  • Radiation therapy to the head or neck
• Anesthesia: Periodontal surgery requires the use of local anesthetic and/or sedation. You should be aware of the risks associated with these services.
• Pain management: Periodontal surgery has post-surgical risks such as swelling, bruising, bleeding, and infection. In most cases, your dentist will recommend or prescribe pain relievers or anti-inflammatory medications following periodontal surgery to manage your symptoms. Some medications are opioids. Be sure to discuss any specific concerns you may have with the medication prescribed.
• Excessive bleeding: Bleeding during and after periodontal surgery is normally minimal. If you feel you are bleeding more than expected, apply direct pressure to the area with a damp gauze and call your dentist immediately.
• Infections: Infections generally don't occur in the first few days after periodontal surgery. If you begin to experience pain, swelling, fever, or tooth sensitivity to hot or cold, call your dentist. They will evaluate your condition and provide guidance and treatment as necessary. Your dentist may prescribe an antibiotic if an infection is present.
• Success rates: Periodontal surgeries are not always successful at reducing periodontal disease or fully restoring proper tooth function and appearance. If the procedure did not achieve the expected goals, in many cases, it can be repeated. In all cases, ongoing maintenance and evaluations are essential.
• Nerve injury: Some surgical procedures involving bone may increase the risk of local or regional nerve injury. If nerve injury occurs, it is most often temporary but can be permanent in extreme cases. The incidence of this is relatively low, but you should discuss the possibility with your dentist ahead of time.

Additional care you may need

If your dentist recommends periodontal surgery, you may require one or more of the following additional treatments. Any of these treatments may also require additional appointments.

• Receding gums caused or complicated by misaligned teeth or bite stress may require one or more of the following procedures to prevent your gums from further receding: periodontal stabilization splints, occlusal adjustments, occlusal guards, or orthodontic treatment.
• Your dentist may perform clinical crown lengthening before restoring a tooth with a filling, inlay, onlay, or crown if you have a tooth which is decayed or broken below the gumline. If you delay or avoid a recommended clinical crown lengthening, your dentist may not be able to successfully restore the tooth to its former proper form, function, and appearance. You may also be at greater risk for periodontal attachment loss and bone loss.
• Your dentist may apply medications to densify exposed tooth roots created by some periodontal surgery procedures.
• Your dentist may recommend prescription-strength topical fluoride rinses or gels to reduce the likelihood of decayed tooth roots and tooth sensitivity. This may be necessary when a previous periodontal surgery resulted in exposed tooth roots.
• Root canal therapy may need to be performed on the affected tooth if you develop a localized infection in or around the tooth roots (periapical abscess).

For moderate to advanced periodontal disease, there may be no traditional care alternatives to periodontal surgery.

If saving your teeth requires multiple dental procedures and the anticipated outcomes are questionable, you may want to consider other treatment options. One option is tooth removal and replacement with a dental implant, bridge, or removable partial denture. You should understand that tooth removal and replacement with artificial appliances have risks and implications of their own.

• Delaying or refusing recommended procedures increases the risk of advancing periodontal disease.
• If you do not treat receding gums, it may result in tooth sensitivity and decayed tooth roots. Gums that continue to recede may result in bone loss, shifting teeth, and missing teeth.
• A high frenum attachment untreated with a frenectomy may result in receding gums and failure of the adjacent teeth to move into proper position.
• Failure to have guided tissue regeneration procedures when recommended frequently results in missing teeth.

• What caused my periodontal problem?
• How urgently do I need treatment? If I delay now, what are the chances that the problem will get worse?
• Can my periodontal disease be treated and managed without surgery? For example, can it be addressed with scaling and root planing, and periodontal maintenance?
• What might happen if I don't want to get periodontal surgery or treatment?
• I underwent radiation treatment in the past (or have other potential risk factors). How does this affect your approach to the surgery?
• Can you tell if my receding gums will recede even more?
• Can this surgery affect the nerves in my mouth, face, or jaws?
• How will we know the surgery was successful?
• What symptoms or problems should I look for between office appointments?
• What medication(s) are you recommending for pain management? Do any of them contain opioids?
• What should I do if I think I'm bleeding more than you said I should expect?