I’ve always thought that my two top center teeth, while certainly handy for getting started on an apple, are a little long, aesthetically speaking. I came to this conclusion on my own, but kids at school confirmed it by calling me Bugs Bunny whenever the urge hit. While I sort of grew into them, shortening my chompers was one of the key reasons I got a same-day smile makeover last year.
But after cosmetic dentist Victoria Veystman beautifully re-contoured my central incisors so that they wouldn't look so conspicuous amongst their shorter row-mates, I quickly realized that their elongated look was due in large part to receding gums. Worse, the teeth were sort of yellowish-gray at the new gum line. While Veytsman is a cosmetic miracle worker, putting gums back where they belong is not her bag. That's the domain of a periodontist. Luckily for me, one of my best friends happens to be one.
Periodontists like my friend, Michelle Lee, concerns herself with what's going on around the teeth. In polite conversation, she refers to what she does for a living as "gum gardening." This involves but is not limited to placing dental implants, as well as the diagnosing, preventing, and treating gum disease. Periodontists also perform gingival or gum graft surgery, which entails taking tissue from a donor site in your mouth—or in some cases, tissue from a cadaver—and using it to recover what time, neglect, disease, and/or overzealous brushing have exposed.
I sent a picture of my teeth to Michelle, and she quickly confirmed that I'd likely be a good candidate for a gum graft. She also said that if I flew out to Vancouver, she'd give me a spectacular deal on a surgery. Namely, lunch. (The British Columbia Periodontal Specialty Fee Guide pegs the out-of-pocket cost of procedure at around $1,400 CAD [$1,030 US] per tooth, though that cost varies throughout North America and can be significantly more in some areas. Some dental plans cover gram grafting because it's markedly more than an aesthetic procedure.)
Once I sat across from her in her office a few weeks later, Michelle confirmed that my gum tissue had receded away where it had been, leaving some of the root of my tooth exposed to the horrors of my mouth. Though sheer vanity—fear of literally and figuratively looking long in the tooth—had prompted me to fly across the continent to let my friend start slicing and dicing in my maw, Michelle informed me that there are several more important reasons for dealing with gum recession. "The primary concern with gingival [gum] recession is, a loss of support on the front of a tooth," she explained, adding that unchecked, recession can, in extreme cases, lead to tooth loss.
The second reason she gave was that the nerves are more exposed at the root of the tooth than in the crown which can cause greater pain and sensitivity. Thirdly, because the root surface is made of cementum which is not as hard as the enamel that covers the crown of the tooth, it can be more easily abraded and eroded by friction and acidic foods respectively, thereby making it thinner. "It's also more porous meaning that there's a higher chance of getting cavities," she said.
Now that I knew about the horrors that could befall me if we didn't stage an intervention, Michelle reiterated what I could expect in the minutes, days, weeks, and months to come.
"So, I'm going to transpose connective tissue from your palette, put it on the exposed root material, pull the receded gum over the top of it and secure it in place with sutures," she said as if the whole thing wasn’t super weird. "In the weeks and months that follow, we want that connective tissue to reattach to the root surface and restore support. she added that connective fibers in the migrated tissue will eventually reattach the root, and moor my biters in place. I imagined these fibers like ropes, securing a boat to a dock. Connective tissue grafting is a relatively new development and was first described in 1985. Since then, it's become the most common type of gingival graft.
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"People often say that the donor site feels like a very intense pizza burn that can last for a while," she said. She then told me that for the next few days or maybe a week after surgery, I'd be sticking to eating soft foods and wearing a plastic shield to prevent my tongue and food matter from bothering the donor site. She also gave me a heads up about my mouth being a horror show for a week, maybe two.
"Your gums could appear red, grey, blue, purple, and you'll very likely have some clots on them," Michelle said. Of course, getting a toothbrush near the recipient site was a big no, and after fully absorbing all of this information, I decided to dramatically scale back all of my social plans during my stay in Vancouver. Instead, I vowed to hide out at Michelle and her husband's place, eating congee, yogurt, and ice cream.
After injecting me with lidocaine in both the recipient (palette) and donor site (Bugs Bunny area) surprisingly, the only mildly uncomfortable part of the procedure—Michelle cleaned the tooth root, which she described as being contaminated with saliva and food debris. She then applied a regenerative protein called Emdogain, derived from the developing tooth bud of a pig’s tooth. As she did so, she explained that this formula can stimulate the formation of new root cementum so that the gum tissue fibers can attach more naturally.
Then she undermined the receded gum line with a tool, to create a little pocket, made an incision in the epidermis of the roof of my mouth and from within it, cut out a rectangle of connective tissue sized to cover the exposed roots and deftly sewed the flap shut. The final step saw her tucking the harvested connective tissue into the pocket she'd created before securing it in place with stitches.
As incredibly intricate as the surgery seemed, it was all over in a little under 45 minutes, and Michelle was busily snapping post-surgery pictures. During this time, she reiterated that the success of the graft was going to be based mainly on how well I adhered to the post-operative care instructions. "I've put the graft there, now it's your job to keep it there," she said sternly. I pledged that I would follow her orders to the letter.
While I was convalescing, I spoke with Caroline Herron, a Seattle-based periodontist. (I wanted to have the risks explained by someone whose house I wasn’t staying in.) She confirmed that for a small number of patients, the graft doesn’t "take." Indeed this had been the case for a friend of mine who'd had a gum graft as a teenager. Herron also told me that risks of graft surgery are similar to most periodontal and dental procedures. "They include post-surgical infection, bleeding, swelling, pain, facial bruising, jaw joint pain or muscle spasm, cracking or bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, impact on speech, allergic reactions, tooth sensitivity to hot, cold, sweet or acidic foods, and transient, and on rare occasions permanent numbness of the jaw, lip, tongue, chin, or gums," she said.
Luckily, I experienced precisely zero of those effects during my stay in Vancouver and, for the record, I've had way worse actual pizza burns than the one Michelle gifted me with. Hiding my "Walking Dead" grin from view was easy enough, but I was aware that blobs of black congealed blood around my gum line was probably imparting me a mouth that smelled as bad as it looked. To help with that and the healing process in general, I swished with a special periodontal mouthwash and laid low as best I could. Again, vanity was at play.
Two weeks post op, Michelle removed my stitches and sent me back to New York on the understanding that I would return in a few months so she could evaluate whether the graft had been a success. Other instructions included more gentle flossing, and using soft head toothbrushes—preferably electric ones—in a gentle circular motion. "Back in the day, people used a scrubbing motion with a harder bristled brush," she said, implying that technique was as good for periodontists’ business as it was bad for gums. She also recommended I wait for her evaluation before getting my teeth professionally cleaned or examined. Simply put, Michelle wanted to confirm that the connective fibers had sufficiently attached themselves before people start poking around the recipient site.
By the time I arrived home to New York, the gore of the surgery was all gone. Still, if I pulled up my upper lip, the gum above my teeth was puffy, swollen, and slightly discolored—unsurprising, given that Michelle had tucked sliver of living flesh underneath it. Those closest to me did, however, notice that my two top teeth had shortened and imparted me with a more youthful—or at least less decrepit—smile. In essence, Michelle had turned back the clock and forestalled the arrival of periodontal problems down the line.
When I returned to Vancouver this spring, Michelle confirmed that the surgery had been a resounding success. "The soft tissue has matured very nicely, the color is nice and pink, the tissue is firm, and the probing depth is normal indicating that there has been reattachment of the tissue to the root surface." In short, I might've put off a host of bad things that could ruin my smile or cost me a fortune. Who says that vanity doesn't pay?
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