Long-term Success of Gum Grafting in Portsmouth, NH

Now that we have been here for 5 years we are starting to see long-term follow-ups of our microsurgical grafting process. These align with voluminous research which has concluded that this process yields the most esthetic, long-lasting improvement when treating gum recession. Other techniques may be easier for the surgeon, but they have never been shown to be as successful. We will continue working hard to provide the best result with minimal postoperative discomfort, even if the procedure is technically challenging.
As you can see, our patient’s gumline is still perfect 4 years after grafting.

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Location: 185 Cottage St, Suite 2, Portsmouth, NH 03801

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Gum Grafting to Cover an Exposed Root and Crown Margin in Portsmouth, NH

Our patient was referred due to recession involving her molar and bicuspid teeth. Using a microsurgical tunneling grafting technique, we were able to rebuild her lost gum tissue to cover the exposed roots and prevent future recession. We were even able to cover most of the margin on the molar crown!
As you can see, she had previously had a white plastic filling placed on the first bicuspid tooth in front of the area we grafted. This prevents us from covering the root, and predisposes the recession to continue. The grafted teeth now appear normal, but the filled tooth looks abnormally long. This is why we recommend grafting instead of placing white fillings.

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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The Perio Perspective: Root Fractures

The Perio Perspective
WInter 2020


“Things fall apart; the centre cannot hold.”
WB Yeats, The Second Coming


Our job is to save teeth. This means preserving gingiva, alveolar bone, periodontal ligament, cementum, enamel and dentin. But nothing lasts forever. So our second duty is to restore lost tissues. In doing so, one of our challenges is that restoring lost tissue can require strategic removal of more tissue. An example is osseous surgery, which is the most predictable method for eliminating periodontal pockets, but which results in gingival recession. Other examples include essentially all restorative and endodontic procedures, which preserve the involved teeth but reduce their structural integrity. 


At a recent Spear Education seminar, Dr. Greggory Kinzer explored the reasons for loss of endodontically treated teeth. The primary causes are vertical root fracture and failure of the post and core and crown. Why do these happen?
One reason is NOT drying of the tooth due to endodontic treatment, as many of us learned in the past. This does not occur to any significant degree. The true culprit is loss of tooth structure. Several studies have concluded that preservation of structure should be a primary focus, and that vertical root fracture is best avoided using root canal therapy with conservative access preps and minimal instrumentation of the pulp chamber and canals. This is one reason for the recent adoption of Gentle Wave technology by many endodontists.


When crowning teeth, a critical determinant of success is ferrule length. Ferrule is the term for the amount of natural tooth structure coronal to the margin. It does not include restorative materials or buildups, which can be used to increase crown retention but do not add strength. Studies have shown that a minimal ferrule height of 1.5 to 2 mm is essential to avoid failure of the restoration. Since the biologic width averages 2 mm, this means that at least 4 mm of supracrestal tooth structure is ideal. The most important areas of the tooth for ferrule length are the ones under tension during function – the palatal surfaces in the maxilla and the buccal surfaces in the mandible. A chief rationale for crown lengthening surgery is to establish sufficient supracrestal tooth structure. During surgery, biologic shaping of the tooth’s emergence profile can often shift the crown margin coronally to minimize the amount of bone resection. Anyone who performs crown lengthening surgery should be adept at biologic shaping, whose principles have been most clearly presented by Dr. Danny Melker:



The minimal residual root length following crown lengthening is 9 mm. When this cannot be preserved, or when 4 mm of supracrestal tooth structure cannot be achieved, an implant may be a more predictable option.


A second parameter is thickness of axial walls of roots. There are no studies that set a specific dimension, but any procedure that thins these areas will increase the risk of fracture. For example, post spaces should be kept to a minimum.


On the topic of post and cores, there are a few principles to follow. First is to not place a post if there is sufficient tooth structure to retain the restoration. This often includes anterior teeth devitalized by trauma but not fractured. Second is that the post material should be stiff if the ferrule length is marginal. Examples of stiff post materials include zirconia, gold, and stainless steel. Fiber posts are stiff if they are bonded to place, since the bonding material has no flexibility. Dr. Kinzer prefers bonded posts instead of cemented posts when ferrule length is less than ideal. Finally, regardless of post placement, cuspal coverage is indicated whenever the endodontically treated tooth has a large pre-existing restoration.


We are of course not endodontists or restorative dentists, but we thought that this information was valuable. As the tide turns back toward salvaging teeth when possible, rather than reflexively extracting them and placing implants, we advocate any measures that can achieve this. 

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Smile Makeover Using a Microsurgical Grafting Procedure in Portsmouth, NH

Our patient was embarrassed at the staining and “long in the tooth” appearance of her upper left front teeth. We were able to completely restore a healthy, attractive gumline using a microsurgical tunneling grafting technique. She is back to smiling with confidence, knowing that her new tissue will be stable in the future.

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Bone Regeneration Without Gum Surgery in Portsmouth, NH

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Here’s a quiz: Take a look at the periapical images above, then guess which technique was used to regenerate an impressive amount of bone on the distal of the canine: LANAP? Bone grafting? Arestin? Emdogain? The answer is none of the above. Treatment consisted of scaling and root planing (SRP) followed by one week of systemic antibiotics. Why don’t we routinely see amazing results like this?
There are several possible answers, and they are often combined. The patient’s genetic makeup and mix of pathogenic microflora may play roles. These factors are poorly understood at present. But there are three other factors that are well-understood. First is smoking. Smokers have little or no potential to regenerate bone, and they are prone to persistence or recurrence of pockets and bony defects. They also achieve less root coverage and more relapse after gingival grafting. Our patient is not a smoker. The second factor is oral hygiene. Regeneration does not occur in the presence of plaque. Scrupulous (but not excessive) daily hygiene and close adherence to a maintenance program are essential. Our patient is spotless and never misses a hygiene appointment. The third factor is meticulous root debridement during SRP. This is challenging. SRP is one of the most difficult dental procedures to perform properly. It requires sufficient time (we allow 90 minutes for two quadrants), local anesthesia, and most importantly a highly skilled dentist or hygienist. Residual calculus and microbial biofilms on the root prevent regrowth of bone and attachment. Our hygienist is meticulous.
The result seen here can be achieved by several approaches, but each depends on the factors listed above. For example, the success of LANAP depends on effective root debridement, which is the goal of the procedure. But since LANAP, like SRP, does not allow for visualizing roots via elevation of a flap, it has the same rate of success and failure as conventional SRP. As with SRP, LANAP can yield impressive results or disappointing results. Surgical approaches allow for more predictable root debridement. And surgical approaches that eliminate deep pockets via osseous recontouring or bone grafting make post-treatment hygiene more effective, which is why these modalities have the greatest odds for success.
Most periodontal patients deserve the chance to heal themselves after meticulous SRP. When this does not occur, pocket elimination surgery has repeatedly been shown to be the most predictable next step, since it allows the surgeon to see and remove residual calculus and biofilms. This is most easily achieved with pockets 5-6 mm deep; beyond this it becomes increasingly difficult to eliminate pockets, and bacteria often recolonize residual pockets.
So the secret to successful periodontal therapy lies with both our patients and ourselves. Their responsibility is to take care of themselves. Ours is to give every pocket our best shot nonsurgically, and to move forward when we don’t achieve results like what we see here. As always, success depends on both what we do and how and when we do it.

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Teeth in One Day in Portsmouth, NH

Our patient had severe periodontal disease, with loose and shifting teeth. His upper left canine spontaneously fell out before he consulted with us!
We were able to remove his upper teeth, place 5 implants, and attach a fixed prosthesis in one morning. He is thrilled to have a solid, comfortable bite, and his smile has given him a new outlook on life, just in time for his daughter’s wedding. He plans to return next year for the same treatment for his lower jaw.

Boost Post

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Root and Crown Margin Coverage Using a Microsurgical Gum Graft

Our patient was unhappy about the root decay and patchwork silver filling around the edge of her crown. We were able to remove the filling and the decay and rebuild the missing gum tissue with a microsurgical connective tissue graft. This will prevent further gum recession and allowed her to avoid making a new crown. She is thrilled.

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Removal of Decay and Root Coverage With a Tunneling Connective Tissue Graft

Our patient had a deep notch and decay in the root of her bicuspid tooth. In the past this would have been treated with a white plastic (composite) filling. These fillings need periodic replacement and allow for continuing gum recession, which can eventually cause loss of the tooth. We prefer to remove the decay and place a connective tissue graft. After healing there is only a small amount of enamel staining present, and the tooth no longer needs a filling. The root has be re-covered with gum tissue. Good as new!

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Root Coverage With Gingival Grafting is More Predictable With Early Intervention

This a routine example of the near-perfect result we can predictably achieve from a tunneling connective tissue graft. Why? Because, as we have stressed before, the patient was referred to us early during the recession process. This meant that the papillae (the triangles of gum tissue between the teeth) had not yet been lost. Once recession becomes advanced and papillae are lost, grafting can prevent further recession, but it becomes very difficult to achieve 100% root coverage. Early intervention is wise.

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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Bone Grafting to Salvage a Periodontally Diseased Tooth in Portsmouth, NH

As much as we appreciate dental implants to replace missing teeth, we especially love to save natural teeth when possible. Our patient’s bicuspid tooth had severe bone damage due to periodontal disease. Rather than extracting it, we removed the disease-causing bacteria and rebuilt the bone with a bone graft. The tooth now has a good long-term prognosis.
Happy Thanksgiving!

Every patient is unique and we strive to create comprehensive treatment plans tailored to you.

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