Cut in my gum, who to see?

[gumgap]

5-6 months ago I gouged one of my upper canines pretty good on some food. Over time this has healed into a pretty large gap (at least I think it's pretty large). It is kind of triangle shaped maybe 3mm at the bottom and 1mm at the top and probably 3mm tall. I'm sure that what I am seeing is the "root" of the tooth but it has the same shine and look at the rest of my canine. When it was first cut the gum wase a little sore there but now everything seems to be pain free. The gum even looks pretty nice like the rest of my gums (health and color wise). It might also be good to note that I am 29 with no dental problems or gum diseases.

I decided to make an appointment with a periodontist and it is scheduled for Oct 31. The receptionist tried to convince me on the phone to see a Dentist first. With the size of this gap I convinced her to go ahead and make the appointment anyways. I don't want to waste time seeing a Dentist if he can't do anything about my problem.

Here are some questions I have to be prepared when I go:
- Was it a good idea to go straight to the periodontist and skip the dentist?
- Is there any possibility that they will be able to sew my gums together without a graph?
- If a graph has to be done, do they only cut along the gap in my gum and stitch in the new peice of gum (a.k.a. splice in a little peice where I have a peice missing)?
- Do all periodontists give the option of doing the allograph to fill in a small gap instead of cutting into the pallet?
- If this periodontist doesn't do the allograph is it a good idea to find one that does to get a second opinion?
- If I went with a connective tissue graph (from my pallet) since I am only filling in a very small gap would the cut into my pallet be small as well?
- What is the estimated cost of either types of graph for this small sized gap? I have Metlife insurance that covers 80% up to $1200 a year for oral surgery and periodontal surgery.

Thanks!

[Zzzdentist]

Here are some questions I have to be prepared when I go:
- Was it a good idea to go straight to the periodontist and skip the dentist?

If it's that bad, I think so. The specialists usually like to have the GD's (general dentists) screen the patients before they are sent over, but the trend over here at least seems to be that patients don't need a referral in some cases.

- Is there any possibility that they will be able to sew my gums together without a graph?

It might be possible, but I'm no periodontist! I have seen some gum surgeries that repair areas without a graft, but the perio dude would be able to tell you better. Sometimes it's just better to insert a small graft of tissue rather than trying to make due with the gum in the area.

- If a graph has to be done, do they only cut along the gap in my gum and stitch in the new peice of gum (a.k.a. splice in a little peice where I have a peice missing)?

Often a small flap is raised to insert a piece of tissue which over time integrates and blends into the area. There are a few different perio procedures so it's probably best to have the periodontist explain the one you need to you.

- Do all periodontists give the option of doing the allograph to fill in a small gap instead of cutting into the pallet?

Not all of them do. I have been to one lecture from a guy who did recommend processed cadaver graft material. Others prefer to harvest it from the palate. I don't know the percentage splits though.

- If this periodontist doesn't do the allograph is it a good idea to find one that does to get a second opinion?

It could get expensive as I believe they charge a fair bit for their exams, but that certainly is an option. You could just call to the office to ask about what preference they have before going in. Also ask about the difference in success rate between the two choices and which one works best in their hands.

- If I went with a connective tissue graph (from my pallet) since I am only filling in a very small gap would the cut into my pallet be small as well?

They usually do measure and size out the needed amount of tissue, but expect a slightly larger donor site as a bit is better than not enough.

- What is the estimated cost of either types of graph for this small sized gap? I have Metlife insurance that covers 80% up to $1200 a year for oral surgery and periodontal surgery.

Thanks!

Boy, that would vary I think depending on where you are in the world, but geez I'd guess anywhere from $800-1000 for the procedure? That's just a pick a number out of a hat I have no idea guess, mind you.

[gumgap]

It could get expensive as I believe they charge a fair bit for their exams, but that certainly is an option. You could just call to the office to ask about what preference they have before going in. Also ask about the difference in success rate between the two choices and which one works best in their hands.

The pd I have scheduled is only a couple minutes from my house and takes my dental insurance, so I'm hoping that they will cover most of the exam cost. If they didn't how much could they possibly charge to look at my gum and tell me the verdict, $90-$120? I could live with that. If they don't do the allograph then it will be good to have a second opinion with one on both sides of the scale I would think. I will definitely ask about those success rates too. I'll have to check and see if Metlife covers 2nd opinions, but I can always eat that cost.

Boy, that would vary I think depending on where you are in the world, but geez I'd guess anywhere from $800-1000 for the procedure? That's just a pick a number out of a hat I have no idea guess, mind you.

Lol, thanks for the guess. If the whole procedure was less than $2k then I would be pretty happy with that, but I expect it to be a bit less. I would also guess that the allograph will cost more since I'm having to buy that donor tissue. A few extra $$ to have less cuts in my mouth might be worth it though.

Thanks very much for the input, I wasn't expecting some expert advise but just some more information to take with me when I go so I am well informed. Usually when a doctor realizes you aren't an idiot they cut to the point and don't tiptoe around anything. It sucks that I have to wonder about it now until the 31st.

Do you think there was any harm in waiting 5-6 months to be getting this looked at?

[gumgap]

Made a secondary appointment with a place that gets real good reviews as a gum surgeon and does the AlloDerm grafts for a few days after my other appointment. They were actually so nice on the phone that I'm tempted to cancel the other one but it seems like two opinions would be better than one when it comes to cutting into my mouth. Has some nice pictures of before and after on their website too.

The girl on the phone said that they deal with little gaps like I describe all the time and sometimes they can move gum around to fill in they area and sometimes they use a little AlloDerm in the mix too. She also said that for just filling in one gap (not several teeth receeding or anything) that you are usually able to go back to your normal routine within a few days unlike if they gouged the roof of my mouth. She said their prices are higher than everyone else cause they won't botch it up.

Good thing I have about $500 left on my FSA card for the year to use up.

[Zzzdentist]

Good luck with your procedure. Hopefully everything will go fine. It sounds like you probably have one of the situations that respond better to periodontal surgery. If I recall correctly, the V type defects heal up quite well I think.

I think second opinion exams probably don't cost as much as complete periodontal exams so you're right in that it probably won't be too bad. If you don't mind, let us know how much it costs as I would be curious. Usually I end up referring people out, and I don't hear too much about the fee end of things from the periodontist as that's usually between them and the patient.

I think one of the advantages of using your own gum to graft over is that there's a better biocompatibility there, but from one periodontist's lecture that I attended, he didn't seem to have any issues with getting great results from processed donor tissue.

I think this was the fellow who's lecture I attended.

http://www.dredwardpallen.com/about.html

[gumgap]

I ended up going with an in-network periodontist that uses AlloDerm for the grafting procedure. My insurance covers 80% of the procedure but doesn't cover the AlloDerm at all. I guess they prefer the cheaper/more painful pallet method. I chose the AlloDerm of course and my part of the procedure was $868 and the total was ~$1700.

They didn't put me under but gave me a sedative and a valium like pill an hour prior. I'm on day 2 and so far almost zero pain or soreness in the graft area. I have not even needed to take any of the pain pills or even regular over-the-counter medicine. However, my jaw does hurt and is swollen up a bit. I assume from them wrenching my mouth wide open for 45 minutes. I have been eating soft foods like soup and mashed potatoes. They said after 4 days I can go back to solid meats but no hard food (chips, popcorn) for 4 weeks.

I'm dying to see what it looks like in there, but from the little bit I can pull my lip out and see it looks pretty amazing. Hopefully in the next few days when it's healed most of the way up I can take a better look. I go end of next week to get the stitches out. I took one picture aiming my digital camera up in there. I could post a link to it for those that are not weak stomached.

[Zzzdentist]

Hey that's great that your procedure went well so far. Sure, post up the link if you don't mind people checking it out. Usually at this stage they don't look like much, but after a couple of weeks things blend in quite well.

[gumgap]

Here is the gruesome picture...

http://img26.picoodle.com/img/img26/3/11/15/f_gumm_7599f65.jpg

[Zzzdentist]

That doesn't look too bad. Too bad you don't have a pre-op photo to post up to compare. There does still look like a small part of the neck of the tooth that might be exposed. It might just be the photo though.

[gumgap]

Yeah, I know exactly what you mean where the triangle goes up. However, my original root line (whatever that's called) is still a good millimeter or two higher up than where the top of the triangle is. The root line on that tooth was always higher than on the other side. Is it possible that the gum will stay as low as it is now or will it heal up to the original location? If it stayed where it is now it would be almost the same as the other canine.

I wish I had a preop photo too. The measured gap above the tooth by the periodontist was 6mm high.

[Zzzdentist]

Sorry, I don't have enough experience with periodontal surgery to tell you whether there would be much shrinkage as the area heals up. My gut instinct would be to think that there would be some recession as the gum achieves it's final position, but I'm not 100% certain. In any case I guess there's not a whole lot you can do except to see over time how it ends up. It sure looks a lot better than 6mm from before that's for sure!

[gumgap]

Here is a better shot from it this morning:
http://img34.picoodle.com/img/img34/3/11/16/f_gum1m_6767849.jpg

I drew some arrows on there for you. My original correct gum height of the canine was higher than the gum line on my front two teeth. In the picture you can see that the current canine gum position is below the front tooth canine so I'm hoping that I'm in good shape.

The periodontist tooth a pre-op picture for insurance filing purposes. I think I'll ask him for a copy of that when I go in for my post-op visit end of this week.

[Zzzdentist]

In that new view it actually looks darn good in relation to the central. I think once the swelling of the other parts of the gum subside it should end up quite nice actually. The gum scalloping height of the canine and the central incisor should be fairly close or with the canine just slightly higher than the central so you are right on the money I think.

[gumgap]

Went for my first preop on Thursday. The periodontist said that it looks 100% as it should and that the graft is filling in with my own cells very nicely. He said that the stitches might can come out in a couple more weeks.

Here is a picture from it today (9th day):
http://img32.picoodle.com/img/img32/3/11/22/f_gum9thdaym_9dd5ea8.jpg

What's weird is when you just look at it in the mirror you cannot see the difference between the old gum area and the gap area. When I take a picture with the flash you sure can see it though.

[gumgap]

What am I missing about the healing process here? The link is to a comparison of the 9th day gum to the 10th day.

http://img37.picoodle.com/img/img37/3/11/23/f_gum910m_9d9e0e8.jpg

You can see that on the 10th day (today) some of the area above the CEJ has turned a little white. Is this just a step in the healing process?

[Zzzdentist]

I think that area is the allograft material that you're seeing. It could just be the way the flash is catching the area. I would imagine that it takes some time for the cells to migrate into the graft and vascularize it (set up blood vessels). Until then it probably will look a bit on the pale side. If your periodontist felt it looked 100%, I'd probably trust his judgement! He's done several of these and knows exactly what each stage is supposed to look like.

Imagine grafting some skin from a donor onto a burned area of your arm. After 9-10 days, it's probably not going to look exactly right. Gums have an amazing healing potential that's fairly speedy, but maybe give it some more time over the next few weeks. I'm sure things will end up blending and looking much better over time.

[gumgap]

14th day image:
http://img34.picoodle.com/img/img34/3/11/27/f_gum15thdaym_ade7bf1.jpg

This one is a big one zoomed in. You can see the CEJ now I believe and it's looking pretty good with the allograft material right above it. I'm hoping that allograft material is like a dehydrated banana and once those cells fill it in it's going to be big thick gum.

How is the periodontist going to cut the knot in those stitches when it looks like gum has grew over them?

[Zzzdentist]

There are very fine, curved scissors that can be used to snip the sutures. Sometimes it's just a matter of slightly tugging on them to expose the suture and snip!

It will be interesting to see what the final result looks like. Please do post it up once things get back to normal.

[gumgap]

It's been 3 weeks and one day now since the graft surgery. I go for my second followup appointment Monday and hopefully get my stitches out depending on what the doc thinks.

Here is what it is currently looking like:
http://img19.picoodle.com/img/img19/3/12/5/f_gum3weeksm_018b680.jpg

I drew a yellow and a blue line. Where do you think my old CEJ is, cause I'm not sure.

[Zzzdentist]

That photo although blown up is a bit on the blurry side to see the really fine details of the CEJ, but that yellow arrow does appear to be pointing at where the CEJ would be. Things look like they are healing up pretty nicely. The blue arrow looks like the gingival crest where the tissue starts.

Are you going to do something about the crossbite?

[gumgap]

You mean the large underbite that I have? Been like that for over 10+ years I'd say. Can't tell it if I'm smiling, only when I bite down like that. It hasn't caused me any problems except for some teeth biting (not grinding, just hard clenching) in my sleep. I've fixed that by wearing a fitted mouth gourd periodically when I sleep.

I have been to an oral surgeon to see what could be done about it. They tell me that they can break my jaw out of place and wire my mouth shut with it in the correct position. Mouth would be wired shut for 4 weeks or so. They could not give my any guarantee that I would still not clench my teeth at night. I was told that it could be unrelated. Insurance wont cover any of it since it is cosmetic only.

Combine that with a failed knee surgery a few years back and I don't know that I'll be going under the knife for no reason at all, if you know what I mean! A normal bite might be nice though.

[Zzzdentist]

I don't blame you! I wouldn't like to have jaw surgery either, but sometimes the results can be pretty dramatic for the better. With the reverse bite the upper teeth can wear away in unusual patterns slowly over time. I noticed the wear facets on the front teeth in the first photo you posted up as they are quite characteristic of the lower jaw growing too far forwards resulting in the x-bite.

[gumgap]

Saw the doc today. Didn't get my stitches out though. He said maybe in 3 more weeks. I did get the preop photo and a he took a current photo.

Image:
http://img37.picoodle.com/img/img37/3/12/8/f_gum25daysm_b3831de.jpg

The current picture sure looks all gruesome along the gum line on several teeth but when I look at it in the mirror it looks more like normal pretty gum.

The doc says the gum line is now right at my CEJ and is right where it's supposed to be!

[Zzzdentist]

Good stuff! Glad to hear it is turning out well. It's quite nice to see the results of gum surgery. That original recession was quite stripped away! The good thing about gums is that they tend to reform themselves over time so eventually things usually blend in so well it's hard to tell anything was done.

[gumgap]

It's been about 3 months and I thought I would post up a current picture of the gum area:
http://img33.picoodle.com/img/img33/3/2/12/f_gum3monthsm_55f86b5.jpg

Looks pretty good to me. When I look in the mirror I can swear that I see some root in one spot but I think it's just lighting playing tricks since it looks spot on to me in the large picture. I hope eventually where the gum looks thick and funky that it will smooth out. I also wonder how long before the gun is "tight" again. All of my other gum is tight against the roots but in the surgery area its still puffy.

I go Monday to the periodontist for a gum checkup and teeth cleaning. I haven't had a cleaning in about 4 years so I'm not too excited. I do rinse, floss, and brush meticulously and have so sore teeth so I don't expect any or many cavities. Still hate cleanings though.

[Zzzdentist]

Thanks for the follow-up photo and information. It's actually nice to see the end result, and not many people post 3 month follow up shots! That site looks like it's healed up quite well. I wonder if the "puffiness" you seen is just the variation in thickness due to the surgery having added the grafting material in. I can see a slightly ridge, but I doubt that it's visible from any normal speaking distance.

Cleanings aren't too much fun, but you know what they say - a little bit of maintenance goes a long way!

[gumgap]

Been over a year now and I wanted to post some new information that has formed over the past month or two. I have noticed that I now have a small gap again, tremendously smaller but clearly visible.

http://img40.imagefra.me/img/img40/2/1/ ... 349903.jpg

All of the gum area looks nice and health and I don't have any pain in the area. What could have caused this?

I go for a cleaning at the office where I got it done mid February, so I figure there is no sense in rushing to the periodontist now and paying extra. Is there any chance they can somehow make the gum stick back down when I go in there or am I doomed to repeat the entire procedure down the road?

Thanks!

[Zzzdentist]

If you're referring to the very top of the gum around the canine tooth, I do see a slight recession occuring as compared to your previous photo. There could be a few reasons for this - brushing related recession, normal rebound after the surgery, and grinding related recession. Honestly though the amount of recession looks really minimal as far as I can tell from those photos. The two are at different angles so it could also be just the way the photos were taken.

I might suspect a combination of the brushing and grinding. Looking at the edges of your teeth they look quite worn down from some sort of parafunctional activity. That sort of stress on a tooth can lead to recession. A nightguard might be something to look at, but better yet ask your dentist when you see him to see what he thinks.

[gumgap]

Yeah my canines are worn down quite a bit due to previous grinding and an underbite. I've been wearing a custom nightguard for about 12 years now which has stopped all of that, so they haven't gotten any worse and it stops the grinding at night.

The recession is pretty minimal and I hope it doesn't get any worse. I try to be very delicate when brushing around that area.