PRACTICAL ADVANCED PERIODONTAL SURGERY

PRACTICAL ADVANCED PERIODONTAL SURGERY

Second Edition

Edited by
Serge Dibart, DMD
Professor and Chair
Department of Periodontology
Director Advanced Specialty Program in Periodontics
Boston University Henry M. Goldman School of Dental Medicine
Boston, MA, USA
This edition first published 2020
© 2020 John Wiley & Sons, Inc.

Edition History
Blackwell Munksgaard (1e, 2007)

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Library of Congress Cataloging‐in‐Publication Data

Names: Dibart, Serge, editor.

Title: Practical advanced periodontal surgery / edited by Serge Dibart.
Description: 2 edition. | Hoboken, NJ : Wiley-Blackwell, 2020. | Includes
bibliographical references and index.
Identifiers: LCCN 2019046551 (print) | LCCN 2019046552 (ebook) | ISBN
9781119196310 (hardback) | ISBN 9781119196334 (adobe PDF) | ISBN
9781119196341 (epub)
Subjects: MESH: Periodontium–surgery | Oral Surgical Procedures,
Preprosthetic–methods | Periodontics–methods | Atlas
Classification: LCC RK361 (print) | LCC RK361 (ebook) | NLM WU 317 | DDC
617.6/32–dc23
LC record available at https://lccn.loc.gov/2019046551
LC ebook record available at https://lccn.loc.gov/2019046552

Cover Design: Wiley

Cover Image: Courtesy of Serge Dibart

Set in 9.5/12pt Helvetica Light by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
Ziedonis (Zie) Skobe, PhD

29 April 1941–5 August 2018

Known as a “gentle giant” who had “a remarkable life and

career,” Zie guided and supported hundreds of projects
and grants, and countless young scientists, during his 40
plus years career at the former Forsyth Dental Institute.

Always proud of his immigrant background, he arrived in

the USA from Latvia as a refugee during World War II, over-
coming language barriers while learning English then
working in the construction industry as a laborer while
studying for his PhD

Throughout his long career, he always had a welcoming

smile and encouraging words for the young scientists
whom he mentored. His early experience with learning
English prepared him to enthusiastically help those for
whom English was not a first language. He is remembered
by all those whose lives he touched for being a great
friend, scientist, and mentor with a kind and generous
heart. You will not be forgotten, Zie. Rest In Peace.
Contents

List of Contributors xi Post‐Operative Care  41

Contraindications for Piezocision  42
Acknowledgments xiii Potential Complications  42

About the Companion Website xv 5. The Contribution of Periodontics to Endodontic

Therapy: The Surgical Management
Introduction 1 of Periradicular Periodontitis 43
Thomas Van Dyke Mani Moulazadeh
History and Evolution  43
1 Conscious IV Sedation Utilizing Midazolam 3 Tooth Conservation Versus Implants  43
Jess Liu Treatment of Failed Root Canal Therapy  44
Introduction 3 Rationale for Endodontic Surgery  44
Midazolam (Versed)  3 Indications for Endodontic Surgery  44
Armamentarium 4 Contraindications for Endodontic Surgery  46
Steps in IV Sedation  4 Types of Endodontic Surgery  48
Periradicular Surgery  51
2. Bone Physiology and Metabolism 11
Phases of Apicoectomy and Surgical
Jean‐Pierre Dibart
Technique 52
Bone Composition  11
Recall 60
Bone Types  11
Bone Formation  11 6. The Contribution of Periodontics
Bone Density Measuring Techniques  14 to Prosthodontics: Treatment Planning
Implications for Dental Treatments  15 of Patients Requiring Combined Periodontal
and Prosthodontic Care 61
3. Anatomy of the Dental/Alveolar Structures
Haneen N. Bokhadoor, Nawaf J. Al‐Dousari,
and Wound Healing 19
and Steven Morgano
Albert Price
Introduction 61
Anatomic Review (Emphasis on Vascular
Diagnostic Phase (Data Collection)  61
Supply) 19
Treatment-Planning Phase  63
Vascular Supply: Macro and Micro  19
Final Prognosis  63
Blood Supply Within the Alveolar and Basal Bone
Conclusion 105
of the Dental Arches  21
Microarchitecture of the Bone/Tooth
Relationship and the Interface of Soft and Hard 7. The Contribution of Periodontics
Connective Tissues  21 to the Correction of Vertical Alveolar
Anatomy and Vascular Supply of the  Ridge  Deficiencies 107
Investing Soft Connective Tissues  25 Serge Dibart 
Cementum 28 Alveolar Distraction Osteogenesis
Antatomy and Vascular Supply of the Epithelial Surgery 107
Structures 28
The Wound‐Healing Process  29 8. Papillary Construction After Dental
Implant Therapy 117
4. PiezocisionTM Assisted Orthodontics in  Peyman Shahidi, Serge Dibart, and
Everyday Practice 35 Yun Po Zhang
Serge Dibart, Elif Keser, and Donald Nelson History 117
Introduction 35 Indications 117
The Technique  35 Contraindications 117
Computer Guided Piezocision‐Orthodontics  35 Armamentarium 117
Dynamically Guided Piezocision  37 Technique 117
Piezocision Assisted Orthodontics With  Postoperative Instructions  119
Clear Aligners  38 Surgical Indexing  119
Incorporating Piezocision in Multidisciplinary Possible Complications  119
Treatment 39 Healing 119

vii
 9. Dental Implant Placement Including Squamous Cell Carcinoma  150
the Use of Short Implants 121 Verrucous Carcinoma  151
Albert Price and Ming Fang Su  Metastatic Disease  151
History 121 Infections 152
Indications 123 Herpes 152
Surgical Technique  123 HIV‐Associated Gingivitis  152
Implant Placement  125 Oral Soft Tissue Biopsy Techniques  153
Site Preparation  125 Armamentarium 153
The Fixture (Implant) Installation  130 Incisional Scalpel Biopsy  153
Possible Problems and Complications  130 Excisional Scalpel Biopsy  154
Biopsy Data Sheet  154
10. Periodontal Medicine Including Biopsy
Techniques 137 11. Sinus Augmentation Using
Vikki Noonan and Sadru Kabani Tissue‐Engineered Bone 159
Gingival Nodules  137 Ulrike Schulze‐Späte, Luigi Montesani,
Parulis 137 and Lorenzo Montesani
Fibroma 137 History 159
Peripheral Ossifying Fibroma  137 Indications 159
Pyogenic Granuloma  138 Contraindications 160
Peripheral Giant Cell Granuloma  138 Armamentarium 160
Diagnosis and Treatment of Reactive Gingival Sinus Augmentation Using Tissue-Engineered
Nodules 139 Bone Discs  160
Gingival Cyst of the Adult  139 Transplant Implantation Surgery (Sinus
Mucocele 139 Augmentation Procedure Using Tissue-
Desquamative Gingivitis  140 Engineered Bone Discs)  161
Lichen Planus  140 Sinus Lift Using Autogenous Mesenchymal Cells
Pemphigus Vulgaris  141 Processed Chairside  165
Mucous Membrane (Cicatricial)
Pemphigoid 141 12. Extraction Site Management in the Esthetic
Diagnosis and Treatment of Desquamative Zone: Hard and Soft Tissue Reconstruction 169
Gingival Lesions  142 Sherif Said 
Plasma Cell Gingivitis  142 Introduction 169
Erythema Multiforme  143 The Influence of Tissue Volume on 
Gingival Enlargement  144 the Peri‐Implant “Pink” Esthetics  169
Epulis Fissuratum  144 Tissue Volume Availability and 
Medication‐Induced Gingival Overgrowth  144 Requirements 169
Hyperplastic Gingivitis  144 Pre‐Operative Implant Site
Leukemia 145 Assessment 172
Gingival Fibromatosis  145 Tissue Augmentation at the Time of Tooth
Ligneous Gingivitis and Conjunctivitis  145 Extraction 175
Wegener’s Granulomatosis  146 Management of Class I Sockets  177
Pigmented Lesions  146 Armamentarium 177
Physiologic Pigmentation  146 Three‐Dimensional Implant
Medication‐Induced Pigmentation  146 Positioning 179
Smoker’s Melanosis  147 Selection of the Bone Graft Material  180
Amalgam Tattoo  147 Rationale 181
Melanotic Macule  148 Socket Seal  183
Oral Melanoacanthoma (Melanoacanthosis)  148 Autogenous Tissue for Concomitant Buccal
Oral Melanocytic Nevus  148 Volume Augmentation and Socket Seal
Oral Melanoma  149 Procedures 186
Sanguinaria‐Induced Leukoplakia  149 Sub‐Epithelial Connective Tissue Graft  186
Proliferative Verrucous Leukoplakia  149 Compromised Sockets  192
Malignant Neoplasia  150 Flapless Ridge Preservation  192

viii Contents
Ridge Preservation Utilizing 13. Digital Technologies in Clinical Restorative
Barrier Membranes 193 Dentistry 213
Esthetic Ridge Augmentation  194 Vygandas Rutkū nas, Rokas Borusevičius,
Open Flap Approach for Extraction Site Agnė Geč iauskaite,̇ and Justinas Pletkus 
Management 197 From Conventional to Digital Technologies  213
Site Analysis and Classification  197 Digital Solutions for Planning and Manufacturing
Surgical Phase  198 of Teeth‐Supported Restorations  214
Suturing of the Graft  203 Digital Solutions for Planning and Manufacturing
Stabilization of the Graft  205 of Implant‐Supported Restorations  223
Closure 205 Future Perspectives  227
Managing Implant Tissue Deficiencies  206
Conclusion 210 Index 233

Contents ix
List of Contributors

Nawaf J. Al‐Dousari, DDS, MSD Jess Liu, DDS, MSD

Practice Limited to Prosthodontics Clinical Assistant Professor
Armed Forces Hospital Department of Periodontology
Ministry of Defense Boston University School of Dental Medicine
Shamiya, Kuwait City, Kuwait Boston, MA, USA

Haneen N. Bokhadoor, DDS, MSD Lorenzo Montesani, DDS

Practice Limited to Periodontics and Dental Implants Practice Limited to Prosthodontics and
Bneid Al Gar Specialty Dental Center Implant Dentistry
Ministry of Health Rome, Italy
Shamiya, Kuwait City, Kuwait
Luigi Montesani, MD, DDS
Rokas Borusevičius, DDS
Practice Limited to Periodontology, Prosthodontics,
Division of Periodontology, Institute of Odontology
and Implant Dentistry
Faculty of Medicine
Rome, Italy
Vilnius University, Vilnius, Lithuania

Jean‐Pierre Dibart, MD Steven Morgano, DMD

Rheumatology and Sport Medicine Professor and Chair
Marseilles, France Department of Restorative Dentistry
Rutgers University School of Dental Medicine
Serge Dibart, DMD Newark, NJ, USA
Professor and Chair
Department of Periodontology Mani Moulazadeh, DMD
Director Advanced Specialty Program in Periodontics Assistant Clinical Professor
Boston University Henry M. Goldman School of Department of Endodontics
Dental Medicine Boston University School of Dental Medicine
Boston, MA, USA Boston, MA, USA

Thomas Van Dyke, DDS, PhD Donald Nelson, DMD

Vice President and Senior Member of Staff Assistant Clinical Professor
Forsyth Institute Department of Orthodontics
Professor of Oral Medicine, Infection and Immunity Harvard School of Dental Medicine
Faculty of Medicine, Harvard University Boston, MA, USA
Boston, MA, USA
Vikki Noonan, DMD, DMSc
Agnė Gečiauskaitė, DDS
Director and Associate Professor, Division of Oral
Division of Prosthodontics, Institute of Odontology,
Pathology
Faculty of Medicine
Boston University Henry M. Goldman School
Vilnius University, Vilnius, Lithuania
of Dental Medicine
Sadru Kabani, DMD, MS Boston, MA, USA
Co‐Director of Oral Pathology
STRATADX Justinas Pletkus, DDS
Lexington, MA, USA Division of Prosthodontics, Institute of Odontology
Faculty of Medicine
Elif Keser, DDS, PhD Vilnius University, Vilnius, Lithuania
Private Practice, London, UK
Adjunct Assistant Professor, Department of Albert Price, DMD, MS
Orthodontics & Dentofacial Orthopedics Clinical Professor
Boston University Henry M. Goldman School of Department of Periodontology and Oral Biology
Dental Medicine Boston University School of Dental Medicine
Boston, MA, USA Boston, MA, USA

xi
Vygandas Rutkūnas, DDS, PhD Peyman Shahidi, DDS, MScD
Associate Professor Practice Limited to Periodontology and
Division of Prosthodontics, Institute of Odontology Implant Dentistry
Faculty of Medicine Toronto, Ontario, Canada
Vilnius University, Vilnius, Lithuania
ProDentum Clinic, Vilnius, Lithuania Ming Fang Su, DMD, MS
Clinical Professor
Sherif Said, DDS, MSD Department of Periodontology and Oral Biology
Clinical Assistant Professor Boston University School of Dental Medicine
Department of Periodontology Boston, MA, USA
Boston University School of Dental Medicine
Boston, MA, USA Yun Po Zhang, PhD, DDS(hon)
Director
Ulrike Schulze‐Späte, DMD, PhD Clinical Dental Research
Diplomate, American Board of Periodontology Colgate‐Palmolive Company
Director, Section of Geriodontics Piscataway, NJ, USA
Department of Conservative Dentistry
and Periodontology
Center of Dental Medicine
University Hospital Jena
Jena, Germany

xii List of Contributors

Acknowledgments

I would like to thank my colleagues and students of Boston I would also like to thank Ms. Samantha Rose Burke for her
University Henry M. School of Dental Medicine for their invaluable help in formatting this manuscript, Mary Malin
invaluable help. I would also like to thank Ms. Leila Joy for copyediting and to the team at Wiley for bringing the
Rosenthal for drawing Figures 7.32 and 7.33, Dr. Alessia book to Production.
De Vit Dr. Trevor Fujinaka for the video on Piezocision and
Dr. Galip Gurel.

xiii
About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/dibart/advanced

The website includes 2 videos from Chapter 4.

xv
Introduction
Thomas Van Dyke

As reflected in this Second Edition, the surgical techniques IV sedation by Dr. Jess Liu, Digital Technologies in Clinical
that span the scope of dentistry have continued to evolve. Restorative Dentistry by Dr. Vygandas Rutkūnas and
Predictable implant placement and bone augmentation colleagues, and Extraction Site Management in the
techniques have become a common part of the repertoire of Esthetic Zone: Hard and Soft Tissue Reconstruction by
the periodontist. Importantly, these technical developments Dr. Sherif Said. The final five chapters of the book are
and the research on which they are based have impacted devoted to exploring the specialized needs of complex
other specialties, including orthodontics, endodontics, oral cases. The problems of inadequate vertical bone height
and maxillofacial surgery, and prosthodontics. and soft tissue defects can now be predictably addressed
in most cases. In ­particular, the esthetic issues of lack of
In Practical Advanced Periodontal Surgery, Second papillary redevelopment between adjacent implants are
Edition, Dr. Serge Dibart has updated, expanded, and addressed by established investigators in the field.
improved on the landmark First Edition with a team of Distraction osteogenesis and papilla regeneration tech­
experts who have played a major role in the development niques now provide a means to enhance the esthetics of
of these concepts, in some cases, and their implementa­ the most complicated cases.
tion, in all cases. It is arranged into 13 chapters that range
from a review of the science leading up to new technolo­ Periodontal medicine has its roots in oral pathology/oral
gies to their implementation and the evidence backing medicine. The forefathers of periodontics, physicians such
their veracity. The contribution of periodontal concepts to as Gottlieb, Orban, and Goldman, were oral pathologists
orthodontics and endodontics is just an example of how first. No book of advanced periodontal techniques would
modern periodontology adds to the armamentarium of all be complete without a review of the most common oral
aspects of the dental profession. lesions that face the periodontist and their treatment, along
with proper biopsy techniques.
The focus of this book is bone – the biology of bone and
how an understanding of the basic principles of biology The look to the future has also changed between the First
can be used to enhance treatment. The book begins with and Second Editions. The future of periodontology is
a review of bone biology and current understanding of bright; we are provided an exciting glimpse of what is next.
wound healing. The discovery that surgically injured bone
becomes rapidly osteopenic followed by increased turn­ Dr. Dibart has again brought together the subject, the
over has been updated to include new clinical techniques team, and the expertise to produce a most valuable com­
for rapid tooth movement through Piezocision. pilation of advanced techniques of modern periodontics.
The content is based in science and is well‐balanced, pro­
Notably, there are three new chapters in the Second viding a reference work and guide for the practitioner of
Edition. The topics are vital to modern practice, including advanced dentistry.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

1
Chapter 1 Conscious IV Sedation Utilizing Midazolam
Jess Liu

INTRODUCTION Training in Intravenous Conscious Sedation

Dental fear and anxiety are the common reasons why While IV conscious sedation is relatively safe to practice,
patients avoid seeking proper dental care. A survey con- only a qualified and well‐trained healthcare provider who is
ducted in the US has reported up to 30.5% of both US able to manage emergency complications should perform
adults and adolescents experience a moderate to high the practice. Dentists who practice IV conscious sedation
dental fear (Gatchel 1989). Therefore, it is important for are mandated by all states to be certified by an approved
dentists to understand the management of dental fear and continuing education program. Furthermore, each state is
anxiety as an integral component of the overall treatment. governed by its own rules and regulations for the adminis-
tration of conscious sedation, therefore it is important to
As defined by the American Society of Anesthesiologists verify with the individual state dental board for the proper
(see Table 1.1), the continuums of depth of sedation are: requirements to obtain a permit to practice IV conscious
sedation.
• Minimal Sedation: Normal response to verbal
stimulation. MIDAZOLAM (VERSED)
• Moderate Sedation: Purposeful response to verbal or Midazolam is a water soluble, short acting benzodiaze-
tactile stimulation. pine central nervous system (CNS) depressant.
Pharmacologically, it produces anxiolytic, hypnotic,
• Deep Sedation: Purposeful response following repeated
­anterograde amnestic, muscle relaxation, and anticon-
or painful stimulation.
vulsant effects (Reves et al. 1985). Metabolized in the liver
• General Anesthesia: Unarousable even with painful by cytochrome P450 enzymes, its mechanism of action is
stimulus. through binding of the GABAA receptors, (causing an
influx of chloride ion which causes hyperpolarization
According to the American Society of Anesthesiologists of  the neuron’s membrane potential) creating a neural
moderate sedation is also known as “Conscious Sedation,” inhibition effect.
and by definition, conscious sedation is “a drug‐induced
depression of consciousness during which patients The onset of intravenous administration of midazolam is
respond purposefully to verbal commands, either alone or relatively fast with a short acting duration. Intravenous
accompanied by light tactile stimulation. No interventions administration of 5 mg of midazolam in healthy adults has
are required to maintain a patent airway, and spontaneous shown to take effect one to two minutes after administra-
ventilation is adequate. Cardiovascular function is usually tion and has a half‐life of approximately one to three hours
maintained.” (Smith et al. 1981).

Conscious sedation can be achieved by different routes of It is important to understand that the use of midazolam is
administration such as enteral or parenteral administration. to produce conscious sedative effects and does not
For the purpose of this chapter, parenteral administration replace the need for proper local anesthesia. Therefore
of conscious sedation limited to intravenous administration proper anesthetic should be administered prior to the
of Midazolam (Versed) will be reviewed. starting of the dental procedure.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

3
Table 1.1  Continuum of sedation: definition and levels (2004).

Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia

Minimal sedation Moderate sedation/analgesia

(Anxiolysis) (Conscious sedation) Deep sedation/Analgesia General anesthesia

Responsiveness Normal response to Purposefula response to verbal Purposefula response following Unarousable even with painful
verbal stimulation stimulation repeated or painful stimulation stimulus
Airway Unaffected No intervention required Intervention may be required Intervention often required
Spontaneous Unaffected Adequate May be inadequate Frequently inadequate
Ventilation
Cardiovascular Unaffected Usually maintained Usually maintained May be impaired
Function

 Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

a

ARMAMENTARIUM STEPS IN IV SEDATION

Monitoring equipment for: Patient pre‐op evaluation: As with all dental procedures,
a thorough review of the patient’s medical history is essen-
• Non‐invasive Blood Pressure (NIBP)
tial to ensure safe and successful treatment. Review of
• Electrocardiogram (EKG) the  patient’s medical history with complete review of the
­system, current medications, as well as drug allergies will
• Pulse Oximetry
provide you the necessary information to assess the
• Capnography patient utilizing the ASA Physical Status Classification
IV Supplies: System (see Table  1.2). The authors recommend limiting
the administration of conscious sedation with patients with
• 0.9% Sodium Chloride Injection 250 ml bag ASA Physical status of 2 or less to reduce the chance of
• Primary IV set (100″) medical emergencies.

• 22 Gauge × 1″ Introcan Safety® IV Catheter Contraindication:

• 24 Gauge × ¾″ Introcan Safety IV Catheter • Hypersensitivity
Basic Supplies: • Acute narrow‐angle glaucoma
• 1 ml Insulin Syringe • Hypotension
• Blunt Plastic Cannula • Pregnancy
• Nasal Cannula • Renal disease
• Supplemental Oxygen • Critically ill patients
• 1″ Latex free Tourniquet Pre‐op instructions
• 3M Tegaderm Film Transparent Film Dressing • No food or drinks eight hours prior to procedure.
• 3M Transpore Tape • Please wear comfortable loose‐fitting clothing with short
• Gauze sleeves to allow for monitoring of your blood pressure.

• Band‐Aids • Must be accompanied by a person of legal age to escort

you home.
• Alcohol Wipes
• No sedatives for 24 hours before appointment.
Basic Medications:
Day of Procedure:
• Midazolam 5 mg/1 cc
• Seat the patient
• Flumazenil 5 cc
• Review medical history. If patient has medical history of
• ACLS Emergency Medical Kit (HealthFirst)
asthma instruct patient to take two puffs of asthma
Please see Figure 1.1. inhaler prior to starting of procedure.

4 Practical Advanced Periodontal Surgery

Figure 1.1  Armamentarium needed to provide sedation: monitor, drug, IV sedation set.

Table 1.2  ASA physical status classification (American Society of Anesthesiologists 2015).
ASA physical status classification system
ASA Physical Status 1 A normal healthy patient
ASA Physical Status 2 A patient with mild systemic disease
ASA Physical Status 3 A patient with severe systemic disease
ASA Physical Status 4 A patient with severe systemic disease that is a constant threat to life
ASA Physical Status 5 A moribund patient who is not expected to survive without the operation
ASA Physical Status 6 A declared brain‐dead patient whose organs are being removed for donor purposes

Conscious IV Sedation Utilizing Midazolam 5

Figure 1.2  Pulse oximetry, oxygen cannula, blood pressure cuff.

• Attach patient monitors (See Figure 1.2) for:

Average range
◦◦ Blood pressure
Pulse Rate Adult 60–80 beats/min
◦◦ Electrocardiography (EKG) Respiratory Rate 12–20 breaths/min
◦◦ Pulse oximetry (Oxygen saturation) Oxygen Saturation 95–100%
End tidal CO2 35–45 mm Hg
◦◦ Capnography (CO2 partial pressure) Give earliest
­warning of respiratory distress
• Starting of IV:
• Record pre‐operatory vital signs: Blood pressure, pulse,
respiratory rate, oxygen saturation, end tidal CO2 level. ◦◦ Complete assemble of Primary IV infusion set with
If vital signs not within normal range re‐evaluate patient 0.9% Sodium Chloride Injection bag See Figure 1.3.
for the procedure. ◦◦ Exam and select visible superficial vein for venepunc-
ture: Location: Dorsum of hand/wrist, Ventral Forearm,
Pre‐operative vital signs chart or Antecubital Fossa.
▪▪ Contraindication for venepuncture site are:
Diagnosis Systolic (mm Hg) Diastolic (mm Hg)
• Mastectomy
Normal Less than 120 and Less than 80
• Cannulas
Prehypertension 120–139 or 80–89
Hypertension Stage 1 140–159 or 90–99 • Scarring
Hypertension Stage 2 160 or higher or 100 or higher
• Vein with valves or bifurcations

6 Practical Advanced Periodontal Surgery

 Figure 1.4  IV catheters of various size.

▪▪ Caution: Initially exam the area of venepuncture

after starting IV drip for swelling to ensure proper
venepuncture has been performed
◦◦ Stabilize the catheter with 3M Tegaderm Film
Transparent Film Dressing and 3M Transpore Tape.
See Figure 1.7.
• Dosage and Administration
◦◦ Use the 1 ml Insulin Syringe U‐100 to draw up 1 ml of
5 mg/ml midazolam. See Figure 1.8.

Figure 1.3  Saline bag used for IV sedation. ◦◦ Dosage and administration indicated for the intrave-
nous administration of midazolam as provided by
pharmaceutical company Hospira Inc. is as follows:
▪▪ Methods of venous distension to facilitate
venepuncture. ▪▪ Healthy Adults Below the Age of 60: Titrate slowly to
the desired effect (e.g. the initiation of slurred
• Application of tourniquet 3–4 in. above collection
speech). Some patients may respond to as little as
area with appropriate compression
1 mg. No more than 2.5 mg should be given over a
• Opening and closing of hand period of at least two minutes. Wait an additional two
or more minutes to fully evaluate the sedative effect.
• Hanging of the arm below heart
If further titration is necessary, continue to titrate,
• Light slapping or rubbing of the area with alcohol using small increments, to the appropriate level of
wipe sedation. Wait an additional two or more minutes
after each increment to fully evaluate the sedative
◦◦ Select appropriate Introcan Safety I.V. Catheter (22/24
effect. A total dose greater than 5 mg is not usually
gauge is recommended). See Figures 1.4 and 1.5.
necessary to reach the desired endpoint.
◦◦ Disinfect selected area of venepuncture with 70% iso-
▪▪ Patients Age 60 or Older, and Debilitated or
propyl alcohol wipe
Chronically Ill Patients: Because the danger of
◦◦ Insertion of needle and observe for blood return in the hypoventilation, airway obstruction, or apnea is
flashback chamber greater in elderly patients and those with chronic
disease states or decreased pulmonary reserve,
▪▪ Caution: At no time should venepuncture be per-
and because the peak effect may take longer in
formed on an artery
these patients, increments should be smaller and
◦◦ Remove tourniquet the rate of injection slower. Titrate slowly to the
◦◦ Attach infusion set to catheter adaptor desired effect (e.g. the initiation of slurred speech).
Some patients may respond to as little as 1 mg. No
◦◦ Start IV drip, constant drip should be observed. See more than 1.5 mg should be given over a period of
Figure 1.6. no less than two minutes. Wait an additional two or

Conscious IV Sedation Utilizing Midazolam 7

Figure 1.5  Catheter insertion in the vein.

Figure 1.7  IV portal secured with transparent film dressing.

­ remedications are used in these patients, they will

p
require at least 50% less midazolam than healthy
young unpremedicated patients.
• Starting of procedure is initiated with administering of
appropriate local anesthesia after desired sedative
effect is achieved.
◦◦ Maintenance Dose: Additional doses to maintain the
desired level of sedation may be given in increments
of 25% of the dose used to first reach the sedative
endpoint, but again only by slow titration, especially
Figure 1.6  IV drip, monitoring the fluid that goes into the IV line. in the elderly and chronically ill or debilitated patient.
These additional doses should be given only after a
thorough clinical evaluation clearly indicates the
more minutes to fully evaluate the sedative effect.
need for additional sedation. For conscious sedation
If  additional titration is necessary, it should be
in diagnostic or surgical interventions carried out
given at a rate of no more than 1 mg over a period
under local anesthesia (Hospira, Inc., Midazolam
of  two minutes, waiting an additional two or more
Injection 2010).
minutes each time to fully evaluate the sedative
effect. Total doses greater than 3.5 mg are not usu- • Upon completion of the procedure, stop the flow of the
ally ­necessary. If concomitant CNS depressant IV infusion followed by the removal of the IV catheter.

8 Practical Advanced Periodontal Surgery

 Medical Emergencies: As with all medical procedures where
drugs are being introduced in the bloodstream while perform-
ing dental/surgical therapy, there is a risk of unexpected out-
comes. The list below is not exhaustive and the discussion
regarding these eventualities and how to deal with them is
outside the scope of this chapter.

• Laryngospasm
• Bronchospasm
• Airway Obstruction
Figure 1.8  Use the 1 ml Insulin Syringe to draw up 1 ml of 5 mg/ml
midazolam. • Aspiration
• Angina Pectoris
Place sterile gauze over site of venepuncture and
apply firm pressure for three to five minutes to prevent • Myocardial Infarction
hematoma. • Hypotension
• Escort patient to recovery room and continue to monitor • Hypertension
patient’s vital signs, once recovered release patient to
escort. • Phlebitis
• Intra‐Arterial Injection
Post‐operative instructions:
• Syncope
a. No sedatives 12 hours after procedure.
• Hyperventilation
b. No consumption of alcoholic beverages after procedure.
• Seizures
c. No stairs without assistance or heavy lifting until com-
pletely recovered. • Severe Allergic Reaction

d. Do not drive, operate heavy machinery, or do any • Bradycardia

­dangerous activities for the rest of the day. • Ventricular Tachycardia
e. Do not make important decisions for 24 hours after • Ventricular Fibrillation
your appointment.
• Asystole
f. Drink lots of water for at least 12 hours after your
appointment. • Malignant Hyperthermia

Reversal agent for midazolam:

REFERENCES
In a situation when a patient is oversedated and does not American Society of Anesthesiologists (2015). ASA Physical Status
respond purposefully to verbal commands. The reversal Classification System. N.p., n.d. Web. 06 Jan. 2015.
agent for benzodiazepine, flumazenil (Romazicon) can
Continuum of Depth of Sedation: Definition of general anesthesia and
be administered. It reverses the effects of benzodiaz- levels of sedation/analgesia (2009). (pdf). American Society of
epines by competitive inhibition at the benzodiazepine Anesthesiologists. Approved October 27, 2004, amended October
binding site on the GABAA receptor. The initial dose of 21, 2009. Retrieved 2010‐11‐29.
0.2 mg of flumazenil can be administered and takes about
Gatchel, R.J. (1989). The prevalence of dental fear and avoidance:
2–2.5 minutes to take effect.
expanded adult and recent adolescent surveys. J. Am. Dent.
Assoc. 118 (5): 591–593.
Initial dose: 0.2 mg IV one time over 30 seconds.
Hospira, Inc., Midazolam Injection (1985). USP Revised January
Repeated doses: 0.5 mg may be given every minute.
2010.
Maximum total dose 3 mg. Patients responding partially at
3 mg may receive additional doses up to 5 mg. Reves, J.G., Fragen, R.J., Vinik, H.R. et al. (1985). Midazolam: phar-
macology and uses. Anesthesiology 62: 310–324.
Most patients respond to 1–3 mg.
Smith, M.T., Eadie, M.J., and Brophy, T.O. (1981). The pharmacoki-
Resedation doses: 0.5 mg every 20 minutes to a total of netics of midazolam in man. Eur. J. Clin. Pharmacol. 19 (4):
1 mg/dose and 3 mg/hour. 271–278.

Conscious IV Sedation Utilizing Midazolam 9

Chapter 2 Bone Physiology and Metabolism
Jean‐Pierre Dibart

BONE COMPOSITION Cortical Bone

Bone consists of three types of cells and a matrix. Denser and more calcified than trabecular bone, cortical
bone is found in the diaphysis of long bones and in the
Cells: Osteoblasts, Osteoclasts, and Osteocytes exterior of short bones. It is also called compact bone, and
it has a high resistance to bending and torsion. Osteons
Osteoblasts and osteocytes (mature osteoblasts) are
(Haversian system) are the predominant structures found
involved in the deposition of bone matrix. Osteoblasts are
in compact bone. Each osteon is composed of a central
responsible for the formation of new bone; they secrete
vascular channel, the Haversian canal, surrounded by
osteoid and modulate the crystallization of hydroxyapatite.
concentric layers of matrix called lamellae. Osteocytes are
Osteocytes are mature bone cells; they communicate with
found between concentric lamellae. They are connected to
each other via gap junctions or canaliculi. Osteoclasts are
each other and the central canal by cytoplasmic pro-
involved in the resorption of bone tissue; they are respon-
cesses through the canaliculi. Osteons are separated from
sible for the resorption of bone, which is necessary for its
each other by cement lines. The space between separate
repair in case of fracture or remodeling.
osteons is occupied by interstitial lamellae. Osteons are
Matrix: Organic and Inorganic connected to each other and the periosteum by oblique
channels called Volkmann’s canals (Marieb 1998).
The organic matrix is composed of collagen fibers and a
ground substance. The collagen fibers are proteins that give Trabecular Bone
bone its flexibility. The ground substance is made of proteo-
Trabecular bone is more spongy than cortical bone, it has
glycans and glycosaminoglycans: keratin sulfate, chondroi-
a lower calcium content and a higher turnover rate, and it
tin sulfate, and hyaluronic acid. These components bind cells
is more vulnerable to bone loss. It is found at the metaphy-
together and are necessary for the exchange of materials.
sis and diaphysis of long bones and in the interior of the
short bones (spine). It is composed of bundles of short
The inorganic matrix is composed of hydroxyapatite, cal-
and parallel strands of bone fused together. The external
cium carbonate, and calcium citrate. Hydroxyapatite gives
layer of trabecular bone contains red bone marrow, where
bone its strength. Hydroxyapatite is a very hard substance;
the production of blood cellular components takes place
it is the main mineral component of bone and the enamel
and where most of the arteries and veins of bone organs
of teeth, and it contains calcium, phosphorus, oxygen, and
are located (Tortora 1989).
hydrogen.
BONE FORMATION
Bone is the body’s major reservoir of calcium (the skeleton
contains 99% of the body’s calcium, as hydroxyapatite). Intramembranous and Endochondral
Mature adults have about 1200 g of calcium. Ossifications
• Intramembranous ossification: Direct replacement of
BONE TYPES
connective tissue with bone (i.e. mandible and flat bones
There are two different types of bone: of the skull).
• Endochondral ossification: Cartilage is replaced by min-
• Cortical bone, also known as compact bone
eralized bone, and the bones become longer, explaining
• Trabecular bone, also known as cancellous bone growth during childhood (i.e. femur and humerus).

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

11
Bone Remodeling • Calcitonin (CT)

Remodeling is a sequence of activation, resorption, and • Estrogens

formation. The bone is continuously remodeling; osteo-
• Corticoids
clasts become activated and resorb the old bone, and then
osteoblasts begin formation of the new bone, giving rise to • Growth hormone (GH)
the Haversian system. The mature osteoclasts resorb bone
• Thyroid hormone
by forming a space on the matrix surface; then, the oste-
oids begin to mineralize, regulated by the osteoblasts.
Bone Remodeling and Periodontitis
Months later, the crystals are packed closely, and the den- After damage to the bone has occurred, the osteocytes
sity of the bone increases. send messages to the surface to produce preosteoblasts.
They express RANK‐L (receptor activator of nuclear factor
Remodeling is necessary to maintain bone structure after [NF]‐κB ligand). Preosteoclasts have receptors called
a fracture or after age‐related modifications; osteoclasts RANK (receptor activator of NF‐κB). RANK‐L activates
resorb aging bone in order to repair damage and maintain these receptors, which produce mature osteoclasts.
the quality of bone and to retain calcium homeostasis. RANK, RANK‐L, and osteoprotegerin (OPG) (RANK‐L
inhibitor) are the key factors regulating osteoclast forma-
Bone can also remodel according to stresses, such as tion in normal bone physiology. The molecular interactions
orthodontic tooth movement, in which there is resorption of these molecules regulate osteoclast formation and
on the pressure side and apposition on the traction side. bone loss in various diseases such as rheumatologic
inflammatory diseases, periodontitis, or peri‐implantitis
Complete rest results in accelerated bone loss, whereas (Haynes 2004). The change in the levels of these regula-
weight‐bearing activities are associated with bone forma- tors plays a role in the bone loss seen in periodontitis.
tion. Peak bone mass is the maximum bone mass achieved Significantly higher levels of RANK‐L protein were found
by midlife. Exercise programs increase bone mass at all to be expressed in the periodontally affected tissues,
ages; adolescence is a particularly critical period because whereas OPG protein levels are lower. RANK‐L protein is
the velocity of bone growth doubles. When women reach associated with lymphocytes and macrophages; many
menopause, bone resorption exceeds bone formation, leukocytes expressing messenger RNA (mRNA) are
osteoblastic activity cannot keep up with osteoclastic observed in periodontitis tissues (Crotti et  al. 2003).
activity, and women begin to lose bone. This puts them at RANK‐L is a TNF (tumor necrosis factor) receptor–related
high risk for osteoporosis and fractures. protein and a major factor for osteoclast differentiation
and activation. The levels of RANK‐L mRNA are higher in
There are five stages in bone remodeling: advanced periodontitis; although the levels of OPG mRNA
are lower in advanced and moderate periodontitis, the
1. Quiescence: Resting state of the bone surface ratio of RANK‐L to OPG mRNA is increased in periodonti-
2. Activation: Recruitment of osteoclasts to a bone sur- tis. RANK‐L mRNA is expressed in proliferating epithelium
face; osteoblasts secrete collagenase and in inflammatory cells, mainly lymphocytes and mac-
rophages. Upregulation of RANK‐L mRNA is associated
3. Resorption: Removal of bone by osteoclasts; Howship’s with the activation of osteoclastic bone destruction in
lacunae are excavated ­periodontitis (Liu et al. 2003).
4. Reversal: Short phase; cement line is formed; osteo-
clasts stop removing bone; osteoblasts fill the defect Markers of Bone Formation

5. Formation: Laying down of bone; osteoblasts produce Markers of bone formation measure osteoblastic activity:
osteoid; mineralization begins; then bone is again con- osteocalcin, P1NP (N‐terminal propeptide of type 1 procol-
verted to a resting surface lagen), and bone‐specific alkaline phosphatase (BALP).

Bone is remodeled through the following actions: Markers of Bone Resorption

These markers measure osteoclastic activity: deoxypyri-
• Osteoblasts
dinoline (DPD), pyridinoline, and associated peptides, NTX
• Osteoclasts (cross‐linked N‐terminal telopeptide of type I collagen), and
CTX I (cross‐linked C‐terminal telopeptide of type I colla-
• Parathyroid hormone (PTH)
gen) generated from bone by osteoclasts as a degradation
• Vitamin D product of type I collagen and released into circulation.

12 Practical Advanced Periodontal Surgery

Vitamin C Parathyroid Hormone
This vitamin is necessary for the osteocytes to form PTH is a hormone produced by the parathyroid glands. It
­collagen; in the case of vitamin C deficiency, collagen increases ionized blood calcium levels. The fall in ionized
formation is decreased, and so is the thickness of the blood calcium causes the release of PTH and vitamin D.
bone cortex. PTH stimulates osteoclast activity, and calcium is released
from the bone. PTH causes resorption of bone, calcium
Vitamin D absorption from the kidneys, and synthesis of active vita-
min D. Bone calcium mobilization is due to the transfer of
Vitamin D has an important role in calcium absorption. The
calcium ions from hydroxyapatite to blood, to ensure cal-
two major forms involved in humans are vitamin D2 (ergoc-
cium homeostasis.
alciferol) and vitamin D3 (cholecalciferol). 1,25‐Dihydroxy‐­
vitamin D3 [1,25‐(OH)2 vitamin D3] is produced by
PTH activates and increases the number of osteoclasts,
metabolism in the liver and the kidneys. It is the most active
causing resorption of the bone matrix. PTH also acts on the
form of vitamin D, and it increases calcium absorption from
kidneys to decrease urinary calcium.
the intestines. Conversion into the active metabolite 1,25‐
(OH)2 vitamin D3 from its precursor is affected by
Hyperparathyroidism causes increased bone resorption.
cytochrome P450 enzymes in the liver and the kidneys.
This is tightly regulated by the plasma levels of calcium,
Osteoprotegerin
phosphate, PTH, and 1,25‐(OH)2 vitamin D3 itself
(Tissandie et al. 2006). It affects the kidneys and the intes- OPG is an inhibitor of bone resorption and is involved in
tines and stimulates the mineralization of bone. Ultraviolet bone density regulation. High levels cause the develop-
irradiation from the sunlight to the skin will also affect the ment of dense bone. OPG blocks the differentiation of
production of vitamins D2 and D3. osteoclasts and impairs bone resorption.

Genetic polymorphisms in the vitamin D receptor (VDR) Low‐Density Lipoprotein Receptor–Related Proteins
gene are associated with parameters of bone homeostasis
Recent analyses revealed a new signaling pathway involved
and with osteoporosis and rapid bone resorption.
in the regulation of osteoblastic cells and the acquisition of
Interestingly, some authors have found VDR polymorphism
peak bone mass. Wnts are soluble glycoproteins that
to be associated with localized aggressive periodontal
engage receptor complexes composed of low‐density lipo-
­disease (Hennig et al. 1999).
protein receptor–related proteins Lrp 5 and 6 and Frizzled
proteins. The loss of function of Lrp 5 causes a decrease in
Childhood vitamin D deficiency syndrome is called rickets:
bone formation, and Lrp 5 mutations are associated with
unmineralized osteoid accumulates, and the bone formed is
high bone mass diseases. These mutations influence the
weak and can lead to permanent deformities of the skele-
Wnt‐beta‐catenin canonical pathway that increases bone
ton. In adulthood, the absence of adequate amounts of vita-
mass through a large number of mechanisms.
min D leads to osteomalacia: decalcification of bone occurs
by defective mineralization of newly formed bone matrix.
Osteoporosis
What are the sources of vitamin D? Only a few foods Osteoporosis means “porous bone.” Calcium deficiency
­contain appreciable amounts of vitamin D – fish liver, fish leads to decalcification of bones and aggravated fracture
(i.e. salmon, mackerel, tuna, sardines), eggs, liver, butter, risks (especially vertebrae, hip, and forearm).
and Shiitake mushrooms. Hyperparathyroidism can also cause decalcification.
Androgens and estrogens (especially before menopause),
Vitamin K on the other hand, stimulate bone formation.
This vitamin is required for the production of osteocalcin
Osteoporosis is characterized by low bone mass and micro-
(a protein produced by the osteoblasts); a good vitamin K
architectural deterioration due to decreased bone formation
status is necessary to prevent osteoporosis. Vitamin K is
and increased bone resorption; this phenomenon leads to
found in green leafy vegetables.
increased bone fragility and fracture. As we age, bone
resorption exceeds bone formation and the severe loss of
Calcitonin
bone mass results in gaps in the bone structure, leading to
This is a hormone secreted by the thyroid gland. Its effects fractures (hip, spine, and wrist being the most common).
are opposite those of the PTH (lowering of blood calcium).
Calcitonin inhibits matrix resorption by inhibiting osteoclast Bone strength is also determined by another important
activity; it reverses hypercalcemia. ­element, which is the trabecular microstructure. In estrogen

Bone Physiology and Metabolism 13

deficiency, resorption cavities are too deep, and the tra- is measured. This is the most widely used method to meas-
beculae are not well connected, resulting in increased ure bone density and provides whole‐body scans and
bone fragility. detailed measurements of the spine (lumbar spine), the
hip (femoral neck), and the forearm (wrist).
In women after age 30, bone resorption exceeds bone for-
mation and bone mass decreases slowly. After meno- The World Health Organization (WHO) definition of osteopo-
pause, because of a decrease in estrogen levels, bone rosis is based on BMD expressed as T scores and Z scores:
loss is accelerated. Peak bone density is lower in females
than in males, and bone mineral status depends on peak • T score is the comparison with the bone density of young
bone mass achieved before the age of 30. Optimizing people.
peak bone mass, especially in children and adolescents,
• Z score is the comparison with the bone density of age
between the ages of 10–18, is important in reducing the
peers.
future risk of osteoporosis.
• A T score superior to −2.5 standard deviation is the defi-
Although most of the variance in peak bone mass is con- nition of osteoporosis. The WHO based the diagnosis of
sidered to be genetic, bone mineral density (BMD) is postmenopausal osteoporosis on the presence of a
higher with sufficient consumption of calcium, fruits, and BMD T score that is 2.5 standard deviations or more
vegetables. Calcium‐rich foods include dairy products, below the mean for young women.
cereals, nuts, seeds, dried fruits, mineral water, and green‐
• A T score between −1 and −2.5 standard deviations is
leafed vegetables.
the definition of osteopenia.
Risk factors include the following:
Quantitative Ultrasound
• Female patients after menopause or age over 60
Quantitative ultrasound (QUS) is a radiation‐free reliable
• First‐degree female relative with osteoporosis or fracture technique to evaluate skeletal status. Three parameters
are measured: broadband ultrasound attenuation (BUA),
• Personal history of nontraumatic fracture
speed of sound (SOS), and stiffness index (SI).
• Low body mass index (BMI) (<19 kg/m2)
This is a technique performed with use of the calcaneous
• Anorexia–amenorrhea episodes
or radial bone; it measures the bone mass on the basis of
• Excessive sports participation the bone SOS.

• Prolonged use of cortisone

Quantitative Computed Tomography
• Early menopause before age 40, natural or surgically
induced Quantitative computed tomography (QCT) provides three‐
dimensional BMD of trabecular and cortical components.
• Smoking It is also used to analyze trabecular microstructure.
• Excessive alcohol intake
This technique measures an imaged slice of the forearm or
• Sedentary lifestyle the leg; it can be used to measure bone size and the width
• Excessive caffeine or salt intake of cortical and trabecular bone. It provides a volumetric
density of bone. It can also measure the volume and con-
• Low calcium intake tent of calcium hydroxyapatite.
• Thyroid hormone or PTH abnormalities
• Hypercortisolism Cone Beam Computed Tomography

• Prevalent radiographic vertebral fracture This technique offers a significant advantage because of
its three‐dimensional capability for osseous defects detec-
tion (Misch et al. 2006).
BONE DENSITY MEASURING TECHNIQUES
DEXA: Dual Energy X‐Ray Absorptiometry Fractal Analysis of Bone Texture
(Bone Densitometry)
The analysis of bone texture based on fractal mathemat-
In DEXA, an x‐ray with two energy peaks is sent through ics when applied to bone images on plain radiographs
the bones. One is absorbed by the soft tissues, and the can be considered as a reflection of trabecular bone
other is absorbed by the bones; through subtraction, BMD microarchitecture.

14 Practical Advanced Periodontal Surgery

IMPLICATIONS FOR DENTAL TREATMENTS Early diagnosis is important; it can make a difference in the
outcome of the disease. Technetium 99m‐methylene
Osteonecrosis of the Jaws diphosphonate (99mTc‐MDP) three‐phase bone scan can
Bisphosphonates are used in treatment of cancers and be used as a screening test to detect subclinical osteone-
osteoporosis; as a side effect, they may cause jaw necro- crosis. Computed tomography (CT) and magnetic reso-
sis. These necroses mostly appear after administration of nance imaging (MRI) are useful in defining the features
aminobisphosphonates. They are treated by resection of and extent of lesions. Radiography and CT display osteo-
necrotic bone, and repeated surgical interventions are lytic lesions with the involvement of cortical bone, and MRI
required. The management is difficult and includes surgi- shows the edema of soft tissue. 99mTc‐MDP three‐phase
cal procedures and antibiotic therapy (Eckert et al. 2007). bone scan is the most sensitive tool to detect necrosis at
an early stage (Chiandusi et al. 2006).
Bisphosphonates somehow cause cell death in the jaw-
bone, which makes it prone to chronic infection; the The mandible is more commonly affected than the maxilla
reduced resorptive ability of bone due to bisphosphonates and 60% of cases are preceded by a dental surgical pro-
hinders the formation of a fresh bone surface for reestab- cedure. Oversuppression of bone turnover is the primary
lishment of bone cell coverage (Aspenberg 2006). mechanism of necrosis, and there may be comorbid fac-
tors. All sites of jaw infection should be eliminated before
The clinical symptoms of jaw necrosis are swelling, exuda- bisphosphonate therapy in at‐risk patients. Conservative
tion, loosening of teeth, and pain. The radiographs show debridement, pain control, infection management, use of
persisting tooth sockets after extractions and radiolucency, antimicrobial rinses, and withdrawal of bisphosphonate
sequestra, or fracture. Risk factors are as follows: are preferable to aggressive surgical measures (Woo
et al. 2006).
• Intravenous or long‐term bisphosphonate therapy (over
three years of oral use, over one year of intravenous use) Dental Implants
• Chemotherapy Bone quality and its presurgical assessment are important
for long‐term implant prognosis; the implant length and
• Radiation
type can also influence bone strain, especially in low‐­
• Corticoids density bone (Tada et al. 2003).
• Age
The Process of Osseointegration
• Underlying malignant disease
In the early bone response to the implant, the first tissue
• Oral infection that comes in contact with the implant is the blood clot with
platelets and fibrin. During the first days, preosteoblasts
Bisphosphonate‐associated osteonecrosis is character- and osteoblasts adhere to the implant surface covered by
ized by the unexpected appearance of necrotic bone. an afibrillar calcified layer to produce osteoid tissue; within
Osteonecrosis can develop spontaneously or after an a few days, a woven bone and then a reparative trabecular
invasive surgical procedure such as dental extraction. bone are present at the junction between the implant and
Symptoms can mimic routine dental problems such as the bone. Trabecular bone is gradually substituted by a
decay or periodontal disease. Risk factors are intravenous mature lamellar bone, which characterizes osseointegra-
bisphosphonate therapy, duration of treatment, age greater tion (Marco et al. 2005).
than 60  years, myeloma, and history of recent dental
extraction (Migliorati et al. 2006). Osseointegration is a dynamic process: in the establish-
ment phase, there is an interplay between bone resorption
Before bisphosphonate therapy is started, infections in contact regions and bone formation in contact‐free
should be treated and risk of injuries to the mucosa should areas. During the maintenance phase, osseointegration is
be reduced. Regular dental recall is recommended, for the secured through continuous remodeling and adaptation to
prevention of infection combined with a follow‐up of remov- function (Berglundh et al. 2003).
able denture for possible ulcerations. Conservative treat-
ment measures are preferred; surgery is carried out The process of osseointegration is a reliable type of
nontraumatically using sterile techniques, appropriate oral cement‐free anchorage for prosthetic tissue substitutes
disinfectant, and antibiotic prophylaxis until the day of and bone, with a direct contact between living bone and
suture removal. For patients following bisphosphonate implant (Albrektsson et al. 1981).
therapy, the indications for dental implants should be very
strict; in case of the osteonecrosis, dental implants are It is important to note that senile and postmenopausal
contraindicated (Piesold et al. 2006). osteoporosis have important consequences for the

Bone Physiology and Metabolism 15

s­uccess of endosseous dental implants, for primary Mandibular Osteoporosis
­stability, biological fixation, and final osseointegration.
There are relationships between oral bone loss and osteo-
porosis. There is a positive correlation between systemic
Smokers are also at risk. Bone resorption is altered in smok-
bone mass and oral bone mass (Jeffcoat 2005).
ers; there are differences between the amounts of pyridino-
line around the teeth of nonsmokers and smokers. Smokers
Osteoporosis is a systemic disease in which the skeletal
have a higher level of pyridinoline than do nonsmokers in
condition is characterized by a decreased mass of nor-
the gingival crevicular fluid of implants, suggesting that
mally mineralized bone. Alveolar processes provide the
smoking may affect implant success (Oates et al. 2004).
bony framework for tooth support; the decline of skeletal
mass is correlated with an increased risk of oral bone loss
Bone‐stimulating Factors
and has a negative effect on tooth stability. Aging and
A bone differentiation factor can stimulate bone formation estrogen depletion have a negative influence on tooth
in peri‐implant bone defects. Bone morphogenetic proteins retention and residual alveolar crest preservation
(recombinant human bone morphogenetic protein‐2 (Sanfilippo and Bianchi 2003).
[rhBMP‐2]) can be used to stimulate bone growth around
and onto the surface of endosseous dental implants, placed Pixel intensity values and fractal dimensions on radio-
in sites with extended osseous defects (Cochran et al. 1999). graphic panoramic images are useful in detecting changes
Recombinant human osteogenic protein‐1 (rhOP‐1) accel- in the osteoporotic mandibular cancellous bone (Tosoni
erates the healing of extraction defects and the osseointe- et  al. 2006). The measurement of mandibular alveolar
gration of implants. New bone formation can be induced BMD, in postmenopausal women with periodontal disease,
around and adjacent to a dental implant with a recombinantly shows age‐related decrease of alveolar BMD, calcaneus
produced bone inductive protein (Cook et al. 1995). SOS, and vertebral BMD. There are significant correlations
between alveolar BMD, calcaneus SOS, and vertebral
Enamel matrix derivative (EMD) may contribute to induc- BMD (Takaishi et al. 2005).
ing osteoblast growth and differentiation by helping create
a favorable osteogenic microenvironment (reducing
RANK‐L release and enhancing OPG production) (Galli
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larities between EMDs and PTH on human osteoblasts tion partly caused by bisphosphonates – or another one, preferably
(Reseland et al. 2006). treated with them? Acta Orthop. 77 (5): 693–694.

Berglundh, T., Abrahamsson, I., Lang, N.P., and Lindhe, J. (2003). De

Periodontitis novo alveolar bone formation adjacent to endosseous implants.
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probing depth greater than 4 mm, clinical attachment loss
Cochran, D., Schenk, R., Buser, D. et  al. (1999). Recombinant
greater than 2 mm, and alveolar bone loss greater than
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2 mm. The percentage of sites with clinical attachment loss tion around endosseous dental implants. J. Periodontol. 70 (2):
is correlated with the levels of serum rheumatoid factor 139–150.
(Havemose‐Poulsen et al. 2006).
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Galli, C., Macaluso, G.M., Guizzardi, S. et al. (2006). Osteoprotegerin Pers, J.O., d’Arbonneau, F., Devauchelle‐Pensec, V. et al. (2005). Is
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Bone Physiology and Metabolism 17

Chapter 3 Anatomy of the Dental/Alveolar Structures
and Wound Healing
Albert Price

ANATOMIC REVIEW (EMPHASIS The Lingual branch of the external carotid ascends from its
ON VASCULAR SUPPLY) medial aspect, below the corner of the mandible to supply
the tongue and ends in a plexus with the submental branch
Knowledge of local anatomy and the physiology of
of the Facial Artery and the terminus of the Mylohyoid
healing tissues is the sine qua non of the surgeon’s
­
artery. This plexus, located to the lingual of the cuspid and
­ability to achieve stable results. A practical review of
lower incisor teeth, serves parts of the sublingual gland
regional and periodontal anatomy at both the macro and
and provides branches into the lingual foramina to supply
micro levels can be applied to a better performance of
the lingual bone mass of the chin. Injury to this area by
both periodontal and implant surgical procedures.
perforating through the lingual bone plate during a mis-
Following this anatomy review, the basic process, timing
placed or overextended trajectory of dental implant prepa-
and current knowledge of wound healing will be
ration may have fatal repercussions (Bernardi et al. 2017).
reviewed. Throughout this exploration a few underlying
themes are repeated:
The facial artery branches from the carotid just above the
Iingual artery passing inward beneath the mandibular
1. Understanding the local anatomy of microvascular pat-
angle, then courses forward through parts of the subman-
terns and local preservation of them is the key to mini-
dibular gland after which it curves outward to the facial
mal morbidity. Soft tissue flaps, designed for surgical
tissues just in front of the masseter muscle (where its pulse
access, without this understanding can lead to soft tis-
can be felt with light palpation of the area). From its lingual
sue necrosis and subsequent underlying bone loss or
aspect a small submental branch courses medial to join
sequestration.
the complex with the lingual and mylohyoid arteries previ-
2. The relative physical dimensions and nutrient demands ously noted. The main branch supplies tissues of the face
of the parenchymal and stromal content determine and lips.
blood vessel volume and its distribution
The maxillary artery branches inward off the external
3. Constant attention to these variations in anatomic
carotid just below the mandibular condyle. The tributaries
microarchitecture allows predictable, biologic manipu-
of the maxillary artery provide the major supplies to the
lation which minimizes risk in surgical procedures.
interior of the facial region. Its regional divisions are three
in number: the inferior alveolar (supplying the mandible),
VASCULAR SUPPLY: MACRO AND MICRO
the pterygoid (which supplies the major masticatory mus-
The external carotid is the major source of arterial supply cles) and the pterygopalatine (which contains the major
to the facial structures. After separating from the common supply to the maxillary arch – the posterior superior alveo-
carotid at about the level of the thyroid cartilage, the exter- lar) (Woodburne 1965) (Figure 3.1).
nal carotid provides a branch to the superior thyroid and
then ascends into the facial structures with major branches 1. The inferior alveolar artery: After providing a small,
in succession being the ascending phayrngeal, lingual, descending mylohyoid branch to the medial, the infe-
facial, occipital, posterior auricular, and the maxillary artery rior alveolar artery descends to enter the mandibular
before distributing into a variety of superficial temporal foramen and distributes internally to the ramus and
arteries. Our interests will be focused on the lingual, facial, body of the mandibular bone, to the posterior teeth, and
and maxillary branches. the periodontal ligaments (PDL) before branching

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

19
 Infraorbital a.
Posterior superior alveolar a.
Sphenopalatine a.

Descending palatine a.
Anterior deep temporal a.
Buccal a.
Posterior deep temporal a.
Med a lot pterygoid ms & os
Masseter a.
Access meningeal a.
Mid meningeal a.
Ant tympanic a.
Deep auricular a.

Maxillary a.

Super-
ficial
temporal a.
Post auricular a.
Ext carotid a.
Occipital a.
Inf alveolar a.

Facial a.

Mylohyoid a.
Mental a.

Figure 3.1  Distribution of the maxillary artery. Source: From Woodburne (1965).

below the mandibular bicuspid area in an upward, gingival margins through the PDL, and (in combina-
reverse curl, to exit through the mental foramen with the tion with the infraorbital and sphenopalatine) the tis-
mental nerve. The remainder of the inferior alveolar sues of the maxillary sinus (Solar 1999).
artery continues forward (although there is no clear
b. The descending palatine exits through the greater
description of its passage forward) to supply the ante-
palatine foramen apical to the maxillary 2nd molar
rior teeth and a major portion of the chin. A discrete
and courses forward along the inner surface of the
bony canal associated with this incisive branch is sel-
palatal vault (Figure  3.2), supplying glands and
dom seen on a CT Scan. (As noted above the lingual
mucosa before reaching the incisive canal. There it
aspect of the chin bone is also supplied through the
anastomoses with the incisive branch of the spheno-
lingual foramina from the lingual, mylohyoid, and facial
palatine artery.
submental plexus.)
c. The infraorbital passes slightly higher and medial
2. The pterygoid division supplies the major masticatory
through the floor of the orbit with terminal branches
muscles and the buccinator muscle of the cheek and
to the mid and anterior incisive areas, combines with
has secondary branches which complement the facial
branches of the posterior superior to supply the
artery in supplying the cheek mucosa and skin.
maxillary sinus (Solar 1999), and the lacrimal duct
3. The pterygopalatine division courses through the ptery- and then exits through the infraorbital notch to the
gopalatine fossa and sends four major branches: pos- soft tissues of the face under the eye.
terior superior alveolar, descending palatine, infraorbital,
d. The sphenopalatine artery ascends higher to the
and sphenopalatine.
roof of the nose and then distributes forward and
a. The posterior superior alveolar enters the distal of down along the lateral nasal wall (common with the
the maxillary tuberosity and coursing forward medial wall of maxillary sinus) and medially along
­supplies the basal and alveolar bone, the teeth, the the vomer groove to the incisive canal, within which

20 Practical Advanced Periodontal Surgery

 it descends to merge with the incisive branch of with the investing soft tissue supply of the mucogingival
the  greater palatine in the incisal papilla region soft tissues (Folkman and Klagsbrun 1987; Folke et  al.
(Woodburne 1965) (See Figure 3.1). 1965; Price 1974) (Figure 3.5).

MICROARCHITECTURE OF THE BONE/TOOTH
BLOOD SUPPLY WITHIN THE ALVEOLAR
RELATIONSHIP AND THE INTERFACE
AND BASAL BONE OF THE DENTAL
OF SOFT AND HARD CONNECTIVE TISSUES
ARCHES
Bone has two compartments: a hard mineralized compo-
The general pattern or trajectory of blood flow to both hard
nent and a soft, stroma filled inner marrow space. These
and soft tissues of the maxillofacial area is from distal to
two compartments are arranged in a variety of shapes and
mesial (posterior–anterior). The trabecular bone compart-
proportions  –  the local bony microarchitecture. The thick
ment of the basal and alveolar bone is supplied from within
mineralized layers that define the bone’s outer shape or
their defining cortical plates (i.e. from inside out) by their
line the major nerve/vessel channels (inferior alveolar
major vessels, the posterior superior alveolar and the infe-
canal, incisive canal, etc.) and tooth sockets (Figures 3.6
rior alveolar. If teeth are present, they are surrounded by a
and 3.7) are referred to as cortical or compact bone. The
compact woven bone socket that has numerous perfora-
inner compartment or marrow space is cross‐braced by
tions connecting the vascular net of the marrow spaces
mineralized struts of various thickness, the trabeculae.
with the vascular net of the PDL. This PDL net is also sup-
These trabeculae divide the inner bone space into cells of
plied from the apical where dedicated vessels enter the
various sizes and are referred to as cancellous bone
pulp canal of the tooth. The flow of the PDL net is apical–
(Figures 3.2, 3.5–3.7).
coronal into the marginal attached gingiva where it merges
The interface between the mineral compartment of the
interior trabeculae and the internal soft tissue (marrow) is
lined by a single cell layer of cells (the liner cells) which is
thought to be composed of resting osteoblasts. The inter-
face with the external surfaces of compact or cortical bone
and their investing soft tissues is enveloped by a more
complex periosteum, which varies in configuration
dependent on the surrounding connective tissue inter-
faces (see Figures 3.3, 3.14, and 3.16).

In clinical literature, the word density is often misapplied

when describing bone structure related to the drilling
experience of dental implant placement. Both cortical
bone and trabecular bone have a fairly uniform physical,
mineral density. What is more relevant to bone surgery is
the microarchitecture  –  the three‐dimensional size and
Figure 3.2  Palatal artery extension of greater palatine artery (black arrangement of these compact and cancellous layers
arrow). within a given site. As can be seen in the representative

Sinus Iining: ciliated

pseudostratified
SINUS SPACE columnar
Thin periosteum epithelium with
detached during mucous glands
tissue processing Black within lining is
More fibrous than perfused vascular
cellular Compare this to
periosteum of gingival
area Fig 3.14, 3.16

MAXILLARY
BONE SINUS
MEMBRANE

Figure 3.3  Maxillary sinus periosteum (Monkey/vascular‐India ink perfused). This is representative of a “lifted” sinus membrane.

Anatomy of the Dental/Alveolar Structures and Wound Healing 21

 FGM

3 4

2
MGJ

Figure 3.5  Normal dental/alveolar vascular supply. 1, Periosteal supply;

2, vessels from bone; 3, periodontal ligament supply to crest; 4, papillary
loops; FGM, Free Gingival Margin; MGJ, Mucogingival Junction.

implants at least 6–7 mm on center especially in the ante-

rior sites (See Figure 3.8).
Figure 3.4  Maxillary sinus periosteum (Monkey/vascular‐India ink
perfused). In contrast to the “lifted” membrane in Figure 3.3, this is The spatial position of teeth within the alveolar bone hous-
representative of an “intact” sinus membrane prior to “lifting.” (Compare ing requires special consideration in this review because it
also to Figures 3.14 and 3.16.) influences the vascular distribution to and within the adja-
cent bone mass, especially the buccal aspect of the tooth
socket wall. This in turn affects the reaction to periodontal
disease, socket grafts, and bone requirements for implant
tissue sections (Figures  3.2, 3.6, and 3.7), the size and
placement. In most cases, the teeth are set toward the
distribution of cancellous and cortical layers vary consid-
buccal limits of their confining bone “house,” commonly
erably from one tooth location to another. Perhaps a new
referred to as the alveolar bone. This often results in a
term, “structural density” would be more appropriate when
very thin, compact/cortical bone plate on the buccal
considering issues related to implant restoration.
(Figures 3.6b and 3.9), while the palatal often has a thicker
wall with marrow between the socket wall and the palatal
Cortical bone may be “without marrow” but it is not “with-
surface (See Figures 3.6 and 3.7). The vascular supply to
out a vasculature.” The cortical layers of bone are densely
these thin compact buccal plates is limited to diffusion
calcified collagen composites with entrapped live cells
externally from the investing buccal mucosal tissues and
(osteocytes). These enclosed cells maintain contact with
internally from the PDL. In the interproximal, lingual, and
each other and outside nutritional sources through tiny
furcal areas, the internal marrow supply supplements the
cytoplasmic extensions within spider web like channels
PDL and makes these areas less vulnerable to resorption
called canaliculi. (It should be remembered that the osteo-
after surgical interventions.
cyte functions physiologically in the homeostasis of Ca++
ions for the entire body.) There is a critical distance from
the adjacent vasculature to these canaliculi beyond which
Additional Issues of Anatomic Interest:
these cells cannot survive (0.1–0.2  mm) (Ham 1965;
the Maxilla vs Mandible
Figure 3.9). The latter biologic necessity should be consid- The maxilla and mandible have major differences in their
ered when reflecting upon the Branemark/Albrektson clini- bony microarchitecture, and this is reflected in the pattern
cal findings of the need for at least 1.0 mm circumferential of their vascular supply. The maxilla is of lighter, thinner
bone for a successful implant and the need to space trabecular construction and interfaces with other cranial

22 Practical Advanced Periodontal Surgery

 (a) (b)

B L

L B

Figure 3.6  Internal microarchitecture. (a) Maxillary bicuspid. (b) Mandibular first bicuspid. Note different cortical and trabecular thicknesses. B, buccal
area; L, lingual area.

(a) (b)

B L

L B

Figure 3.7  Internal microarchitecture of furcation area of first molars. (a) Maxillary first molar. (b) Mandibular first molar. Note differences in cortical and
trabecular dimensions at maxillary versus mandibular sites. B, buccal area; L, lingual area.

structures of intramembranous origin with which it shares nent of this encircling anastomosis may be located verti-
collateral vascular supplies. In the maxilla, as noted, the cally about 19 mm from the alveolar margin. It may be
major blood supply to bone and teeth comes from the found within the marrow of the antral wall (if the wall is thick
pterygopalatine division of the maxillary artery, the poste- enough) or within the periosteal layer of the sinus lining
rior superior alveolar. In the maxillary sinus, the blood flow immediately inside the wall (Figure 3.10). A third variation
also has contribution from the infraorbital and spheno- encountered by the author is illustrated in an ink perfused
palatine arteries. A major arterial circuit formed from specimen (Figure 3.11). This latter variation is not always
branches of the posterior superior alveolar and the infraor- readily apparent on CT scans and may result in significant
bital coursing from posterior to anterior around the buccal bleeding during sinus membrane elevation. The spheno-
and medial walls of the sinus was reported by Solar et al. palatine artery also distributes along the lateral nasal wall
(1999). Of interest in performing the lateral window which is paper thin bone separating the nose and the max-
approach to the sinus lift bone graft, the buccal compo- illary sinus (Rosano et al. 2009).

Anatomy of the Dental/Alveolar Structures and Wound Healing 23

Figure 3.8  Mature resting alveolar bone from core in human maxillary
first molar. Note fatty marrow, single layer liner cell layer over mineralized
compartment and minimal vascular tissue. Light blue lines in mineralized
areas are variously called cement lines, reversal lines, or resting lines and
indicate past periods of remodeling.

Because of the previously noted buccal displacement of

the teeth within the alveolar housing the external surface
of the maxillary alveolar bone is often sculpted with a
variety of eminences and depressions. Of particular Figure 3.9  Small, India ink perfused vessels in very thin buccal
importance in the maxillary arch are the central incisal plate (arrow). Note: Bone cells cannot live more than 0.1–0.2 mm
eminence and cuspid eminence and the adjacent fossae: from the blood supply. Note that resorption is proceeding from the
the incisal fossa above the lateral incisor and cuspid periodontal ligament side of the thin buccal plate, which has had a
fossa over the first bicuspid. If typical patterns of resorp- full‐thickness flap reflected and thus had a limited vascular response
tion occur (Caewood and Howell 1991) and this volume is from the buccal. The surgeon should reflect on the possible effects of
not recreated by grafting, it forces implant placement to disrupting this exterior microanatomy when reflecting access flaps for
the lingual which in turn affects implant proximity espe- implant placement and then disrupting the internal bone supply by
cially in the truncated cone geometry of the maxillary drilling/extraction prior to placing an endosseous implant.
anterior (Lee 2016).

The mandibular bone is a heavy, self‐contained structure

with a unique embryology (intramembraneous ossification
using Meckel’s cartilage and the inferior alveolar nerve for bone with minimal interconnection between marrow and its
patterning). The condyle alone is endochondral in forma- external, investing soft tissue (see Figures 3.6b and 3.7b).
tion. Vascular supply is less diffuse than the maxillary, with Interdental and furcal subdivisions of the alveolar bone
one major vessel, the inferior alveolar, entering through a have a rich marrow supply as noted in Figure  3.12. One
lingual foramen in the mandibular ramus and then spread- deviation from this pattern is noted under lingual artery
ing internally from within a dense mandibular canal located distribution to lingual of chin.
below the teeth within the basal bone. The flow is from the
distal through the marrow, into the periapical and peri- The buccal has a lesser “washboard effect” in the lower
odontal spaces and outward through the PDL and the arch but the bucco‐lingual thinness of the lower anterior
mental foramen. Periosteal supplies nourish the external and its resorption patterns post extraction (Caewood and
surfaces of the mandibular bone, but there are few inter- Howell 1991) can lead to significant issues in implant plan-
connections from outside with flow into the bone, and mini- ning. Additional planning constraints are presented by the
mal Volkman canal vessels running from inside out through major lingual concavities beneath the lower cuspid (sub-
the dense cortical plate. The mandibular lingual surface lingual gland) and beneath the lower molars (submandibu-
has the thinnest mucosal cover and thickest compact lar gland).

24 Practical Advanced Periodontal Surgery

 Interproximal
area
Interproximal
vessels

Blood supply to
interproximal
bone from
marrow below

Figure 3.12  Partial‐thickness flap at 14 days showing extensive

arborization and density of vessels in interproximal papilla supplied by
Figure 3.10  CT scan showing artery in buccal wall of sinus (arrow). interdental arteries.

to mesial first molar is favored as donor site for free gingi-

val grafts and connective tissue grafts. Starting at the
PERIOSTEUM CONTINUOUS mesial–palatal line angle of the first molar region, and mov-
WITH ARTERIOLE WALL ing to distal, the lamina propria layer thins and a thicker
layer of submucosa with increased fat and glandular con-
tent lies beneath. The main vascular supply is from the
greater palatine artery which emanates from the posterior
palatine canal just apical to the second molar and courses
forward within the submucosa, close to the bone
(Figure  3.2). It distributes to the palatal glands and con-
nective tissue stroma and ends with anastomosis to the
incisive branch of the sphenopalatine artery at the incisal
canal area. This arterial structure is sometimes severed
when making deep vertical release incisions in the palatal
ANTRAL WALL of cuspid/first bicuspid region.

On the lingual of the mandibular teeth, the thin mucosal

PERIOSTEUM
connective tissues reflect into the lingual vestibule with
Figure 3.11  (Monkey) Arteriole wall merged with periosteum of antral loose attachment to the mylohyoid muscle. The lingual
wall venules surround arteriole. NOTE! sinus elevation hazard. artery, complemented by the mylohyoid artery and medial
contributions from the submental branch of the facial dis-
tribute upward from below the mylohyoid to the muscles,
ANATOMY AND VASCULAR SUPPLY
lingual mucosa of the floor, sublingual, and submandibular
OF THE INVESTING SOFT CONNECTIVE
glands. The mylohyoid nerves also distribute along the
TISSUES
inferior surface of the mylohyoid having separated from
The soft investing tissues of the alveolar/basal bone (the the inferior alveolar nerve before it enters the mandibular
gingiva and mucosa) have internal structural variation, foramen while the lingual nerve distributes above the mylo-
which influences vascular supply. There are three regional hyoid but tracks to the midline at its distal edge. This lack
patterns to consider: the palatal tissues of the maxilla, the of extensive vascular or nerve within this thin elastic tissue
lingual covering of the mandibular teeth, and the buccal over the mylohyoid and below the tongue allows for
mucogingival tissues of both arches. detachment by blunt dissection which adds a few millim-
eters to tenting expansion over mandibular ridge grafts.
In the palatal area, the thick, dense collagenous lamina
propria of the anterior and bicuspid areas has minimal The buccal soft connective tissue over the alveolar bone of
submucosal thickness with a thin layer of fat content both arches is of greater interest from a number of surgical
toward the bone. This palatal zone from distal of the cuspid perspectives. As noted several times, the buccal soft

Anatomy of the Dental/Alveolar Structures and Wound Healing 25

 THICK SOFT TISSUE THIN SOFT TISSUE

Figure 3.13  Disruption of vascular at mucogingival junction (MGJ) depends on biotype.

t­issue is a major blood supply to the very thin cortical

plates over the teeth, and therefore the influence of soft
tissue biotype is more relevant to surgical disruption
(Figure 3.13). This is probably related to Caewood’s find-
ing (1991) that the dominant pattern of bone loss after
extraction occurs from the buccal (Figures 3.6 and 3.7). In
the buccal marginal attached gingiva of both arches, there
is no lamina propria. Densely woven collagen bundles are
attached into the cementum (supracrestal) between teeth
(interdental) and around teeth (circumferential) and apical
to this into the underlying marginal bone (Sharpey’s fibers)
above the mucogingival junction (MGJ) (Figure 3.14).

This heavy fiber insertion into the marginal bone continues

to the MGJ and is the “attachment” of the “attached gin-
giva” (Figure  3.14). The dense, compact structural
arrangement of the fiber distribution perpendicular to the
bone surface is interlaced with a fine capillary net fed by
both the PDL net and a subepithelial plexus of vessels that
flows just beneath the rete peg formation. The third source
of vascular supply to these tissues is from larger vessels
that branch from the thicker mucosal soft tissue corium just
below the MGJ (Figures 3.5 and 3.15). The general pattern
of external soft tissue flow is from the distal or (posterior) at
a slight angle toward the anterior and from apical to coro-
nal through the MGJ. Figure 3.14  Periosteum in attached gingival zone: dense Sharpey’s fiber
insertion.
The arrangement and type of fibers in the periosteal layer
of the mucosal zone is quite different. At the transition after detaching the more resistant tissues of the gingival
marked clinically by the MGJ, the dense, tight attachment zone, the remainder of the flap separates easily.
of fibers through the periosteum of the attached gingiva
(Figure 3.14) changes abruptly to a parallel layering of fib- Between the periosteum of the mucosal tissues and the
ers over the bone surface with very little attachment to the lamina propria in the buccal mucosal zone of both maxil-
bone interface (Figure 3.16). This change in attachment is lary and mandibular arches there is a less dense submu-
readily noted during full thickness flap reflection where, cosa of elastin, fibrillar collagen, and muscle fibers. The

26 Practical Advanced Periodontal Surgery

 Figure 3.16  Periosteum in mucosal zone: fibers run parallel to surface.
Bone surface to right side.

Figure 3.15  India ink perfused cleared specimen full‐thickness flap at

seven days (seen from the buccal). Note the differences in vessel size and
complexity of mucosa (below) versus gingival (above). GA, gingival area;
MGJ, mucogingival junction; MA, mucosal area. Compare the relationship
of size and distribution to the microarchitecture of the soft tissues seen in
Figures 3.14 and 3.16.

internal areolar structure of this submucosa allows for a

larger vascular net in the mucosa including arterioles and
large veins (Figures  3.15 and 3.17). The elasticity of this
submucosal compartment allows for the technique of flap
stretching or expansion over bone site augmentations by
incision through the confining periosteum, apical to the
MGJ, on the inner side of full thickness flaps made in these
areas.

Scattered through this submucosal stromal matrix are

active mesenchymal and inflammatory cells, which main-
tain and remodel the matrix; periosteal cells, which may
have bone‐repair potential; and the cells, platelets, and Figure 3.17  Large arteries and veins in mucosal area.

Anatomy of the Dental/Alveolar Structures and Wound Healing 27

Figure 3.18  Mucogingival junction (MGJ) transition from dense to Figure 3.19  Mucogingival junction (MGJ).
areolar base tissue.
The latter can result in loss of the flap’s gingival portion
and  subsequent bone exposure (see Figure  3.13). This
soluble biomolecules contained within the vascular chan- can  be reduced by dissection through a vertical from
nels. As noted before, it is at the MGJ that compaction of ­apical upward through the MGJ with a rolling motion toward
the gingival collagen fiber density reaches its most extreme the bone.
and constricts the corium blood supply most severely
(Figures 3.5, 3.18, and 3.19). It should be noted again that CEMENTUM
the periosteum of the external bone surfaces in the mucosal
The cemental structure at the cemento-enamel junction
zones receives nourishment through diffusion from the adja-
(CEJ) level is acellular with a tight adhesion at its interface
cent connective tissues but rarely from true Volkman canal
with the underlying dentine. While cellular cementum may
vessel penetrations from inside the bone outward through
persist at more apical layers, its contribution to wound
the cortical layers (Figures 3.5, 3.7b, 3.20b, and 3.21).
healing is poorly understood. The cemental layer derives
its maintenance from the surrounding PDL vessels and
As previously noted, the marginal gingiva of the teeth has
cells. Note the PDL net just below the cleared bone sur-
several sources of blood flow (Figure  3.5): the PDL, the
face of buccal cortex in Figure 3.21 and the dense internet
interdental, the subepithelial, and the deeper mucosal flow.
with the supracrestal tissue (Figure 3.12). Above the bone
The latter two sources, especially the central flow, become
margin of the tooth socket, connective tissue fibers from
constricted at the MGJ, which is compressed like an hour-
the attached gingiva are embedded into the cemental sur-
glass from buccal to lingual and is further limited by the
face. Below the bone crest, fibers bridge between the
dense fiber arrangement in the gingival tissues (see
cementum and the alveolar socket wall as the principal
Figures 3.5 and 3.14). The degree of confinement is influ-
structure of the PDL. There is no analogous structure for
enced by the individual biotype or tissue thickness. In rhe-
dental implants.
sus monkeys, it was observed that when the biotype was
thin, there was usually only one artery (45–55 μm) through
ANTATOMY AND VASCULAR SUPPLY
the MGJ, while in thicker tissue, the arteries were slightly
OF THE EPITHELIAL STRUCTURES
smaller (35–45 μm) but there were more of them (Price
1974). Negotiation of this compact zone while performing a Epithelial layers of the oral mucosa are connected by col-
split or partial thickness flap dissection often presents a lagen to the underlying soft connective tissues, which in
high level of risk for perforation or vascular embarrassment. turn are connected to hard tissues such as bone and tooth

28 Practical Advanced Periodontal Surgery

 (a) between the internal/external environment and isolates/
protects the hydrated environment of the vascular and
lymphatics below.

At the tooth–enamel interface, the epithelial attachment

allows a flow of sulcular or crevicular fluid outward which
helps to maintain this dynamic seal around the penetration
of the tooth through the body cover. Near the free gingival
margin, the epithelial layers thicken into a heavy, multilay-
ered keratinized surface that continues over the buccal
and lingual surfaces on both sides of the mandible. At the
MGJ, this heavy gingival keratin transitions to a thinner
nonkeratinized or poorly keratinized mucosal surface. On
the maxillary palatal surfaces, heavy keratin is present
throughout and the epithelial enclosure is punctuated by
salivary and sebaceous gland openings.
(b)
The bond of epithelial tissue to the varied underlying soft
connective tissues or lamina propria is composed of a
basement membrane of Type IV collagen that may have
contributions from epithelium but has collagen loops inte-
grating from the connective tissue side. Because there are
no blood vessels penetrating into the epithelial layers, the
only source of its nourishment is diffusion through this
basement membrane from an extensive subepithelial
plexus of capillaries interconnected with the mucosal
corium at several levels and at the alveolar socket crest
with the vascular net of the PDL (Figures  3.5, 3.12,
3.22–3.24).

Figure 3.20  (a) Partial‐thickness flap. (b) Full‐thickness flap. No Structural differences of the epithelial interface with a tita-
vessels are exiting bone surface. nium implant substitute include an epithelial attachment
with a circumferential collagen fiber zone apical to this.
There is no supracrestal fiber attachment and vascularity
mirrors mucosal supply pattern present below the MGJ
(Berglundh et al. 1994).
Volkman canal
vessel
THE WOUND‐HEALING PROCESS
While the wound‐healing process in periodontal surgery
involves mechanisms common to other areas of the body,
most notably, the skin, it has some unique features related
to the presence of a tooth. Rates of activity may vary (turn-
Buccal over rate of alveolar bone versus basal bone) (Garant
cortex 2003), and microenvironments of local tissue architecture
(attached gingiva, PDL, MGJ, etc.) may influence the local
microvasculature (Price 1974), but the general pattern and
sequence of healing activities seem to be the same as with
Figure 3.21  India ink–perfused specimen. skin healing. Because vascular disruption and regenera-
tion are central to wound‐healing response and we have
structure with a variety of collagen. The epithelial attach- seen how the microarchitecture of the tissue influences
ment is a unique exception to the continuous cover of the vascular patterns (compare Figures  3.14–3.16), we will
external surfaces and its reconnection to the tooth surface/ review the two compartments  –  soft tissues of gingiva/
implant abutment form the critical event in the wound- mucosa and hard tissues of tooth/bone  –  separately. As
healing process after surgical procedures around teeth and noted in the preceding anatomy review, while there is some
implants. Re-establishment of this seal recreates the barrier interconnection between hard and soft tissue supply at the

Anatomy of the Dental/Alveolar Structures and Wound Healing 29

Figure 3.22  Capillary buds at four days begin to cross the incision line
of flap (arrow).

gingival margin, the hard tissues receive their vascular Figure 3.23  Fourteen days: regeneration of papillary loops. At this
supply separately from major arteries inside the bone, stage, newly forming connective tissue papillas are supplied by a web of
while the soft tissues are predominately supplied from out- expanded vessels.
side the bone.

Closure of a soft tissue wound requires epithelialization, l­ayers and attract more PMNs and macrophages from
fibroplasia, and angiogenesis/vasculogenesis which occur adjacent leaky venules (6–10 hours) (Clark 1996). The non-
simultaneously but at different rates during the early stages collagenous protein vitronectin, which is produced by the
of healing. Immediately following an incision deep enough liver and circulates in the blood serum, possibly acts as a
to injure the vasculature, platelets from within the blood ves- preliminary substrate for migration of these early scaven-
sels (normal range, 150 000–400 000/μl, produced by mega- ger cells.
karyocytes in the bone marrow; Ganong 2001; Schmaier
2003) are exposed to perivascular collagen and begin to Epithelial cells adjacent to the wound edge respond almost
adhere to the wound margins. This adherence activates immediately to injury and begin to migrate across the fibrin
extrusion of granules from inside the platelets, some of clot surface at rates estimated to be 0.5 mm/day. Within
which facilitate the transformation of prothrombin to throm- 24 hours, adjacent epithelial cells, formerly quiescent, also
bin, which in turn catalyzes soluble fibrinogen to fibrin. begin to proliferate and migrate. Meanwhile, the PMNs
within the clot begin to phagocytize bacteria, necrotic
The fibrin net enmeshed with increasing numbers of plate- cells, and platelet debris. Resident macrophages are
lets, red blood cells, circulating polymorphonucleocytes joined by monocytes migrating out of leaking vascular
(PMNs), and macrophages contributes to an initial vascu- channels and begin to cleanse the wound of debris and
lar plug or clot, which slows and stops further bleeding. broken degenerating PMNs (PMNs survive 24–48 hours)
This temporary or provisional matrix of cells and fibers (Bartold et al. 1998; Garant 2003). At the same time, the
releases a variety of chemical attractants and activators macrophages release additional growth factors and cellular
(cytokines). Platelet‐derived growth factor (PDGF), vascu- fibronectin, which, with fibrin, become the attachment
lar endothelial growth factor (VEGF), and transforming surface for the subsequent wave of migrating cells – the
growth factor (TGF-ß) stimulate the surrounding tissue fibroblasts, endothelial, and epithelial cells.

30 Practical Advanced Periodontal Surgery

 four to five have started to enter the clot space (see
Figure 3.22). These early activities are clinically character-
ized by a red, granular appearance consistent with this
rapid vessel and matrix formation – the granulation tissue.

This granulation tissue is gradually replaced by mature fib-

ers, matrix, and reconnected blood vessels – the organiza-
tion phase. Extracellular fluids that had previously leaked
out into the wound area during the migratory phase are
resorbed, and clinical swelling begins to resolve at five to
six days. At 7 days, vessels can be found to be patent but
leaky, while at 14 days although expanded, the leakage
has stopped (see Figure  3.23). The new vascular net is
mature by 21–28 days with gradual reduction of vessel size
and vessel number and a regression to a regular distribu-
tion and flow in the new connective tissue (Price 1974)
(compare Figures 3.23 and 3.24).

Collagens and various noncollagen molecules (hyaluron,

elastin, fibronectin, etc.) are expressed into the matrix
(days 4–10), and this in turn provides further traction and
volume for migrating cells (Bartold et al. 1998). Meanwhile
the migrating fibroblasts/fibrocytes gradually assume a
new phenotype (myofibroblast), which has characteristics
of muscle (Bucala et al. 1994; Clark 1996; Mori et al. 2005).
The combination of traction and continued migration of
Figure 3.24  Twenty‐one–day regeneration of papillary loops: At this these cells pulls the edges of the wound inward in the phe-
stage, web has regressed to single long arching capillaries connected to nomenon of early wound contraction, which, with contin-
base by newly forming subpapillary plexus. ued epithelial reproduction and migration, closes the
wound surface to recreate the epithelial seal between
internal and external environments (Clark 1996; Kurkinen
The term fibroplasia embodies a sequence of shifting pri- et al. 1980).
orities within the fibroblast/fibrocyte cell population during
which it undergoes several changes in phenotypic expres- While this contraction phenomenon accommodates clo-
sion. Clark in 1993 and later in 1996 described several sure of puncture wounds and incision closure where mar-
phases: proliferation, migration, production, and transfor- gins are replaced, there may be quite different results with
mation to myofibroblast. The proliferation phase of fibro- more complex procedures such as a bone graft site aug-
blasts occurs in the first two to three days in the margins of mentation. In these cases, underlying volume is expanded,
the wound. These early fibroblasts are said to have vitron- and the release incisions noted in the section on soft con-
ectin adhesion capability but not fibronectin connectivity nective tissues to allow expansion create two zones of con-
on their membrane surfaces. By days four to seven, the traction. The total contraction forces may pull the wound
fibroblasts switch to a migrating mode and, aided by their margins apart at 7–10 days if the external soft tissue edges
adhesion to fibronectin (two sources: local made by macro­ of the opening incision were not approximated closely.
phages and another in circulating plasma) and fibrin,
invade the space formerly occupied by the provisional Healing in bone follows a different, delayed pathway. An
matrix. As they migrate, the fibroblasts deposit collagen exact chronology is only approximate. Injured bone areas
and matrix molecules externally (Bartold et al. 1998; Clark show osteoclast activity as early as 7 days, which persists
1993; Kurkinen et al. 1980). at 14 days and is coupled at 21 days by osteoblastic pres-
ence (Pfeiffer 1965). Osteoclast formation has been shown
Angiogenesis parallels this activity with venular endothe- to be regulated by the RANK/RANK-L/OPG interaction with
lium proliferating in place for the first few days forming osteoblasts (Ganong 2001; Schmaier et  al. 2003; Boyce
solid cords of cells. The cell layers thicken, and the outer and Xing 2007). Since vascular ingrowth always precedes
layer lifts off, forming a space or lumen as the endothelial osteogenesis (Albrektsson 1980a, 1980b) it would seem
intracellular cementation breaks down, enabling a migra- biologically consistent that osteogenesis would not start
tory phase. This activity at the ends of cut vessels results until the 2nd to 3rd week when vascular stability has
in an abundance of cord‐like arrays and loops that by days occurred (Price 1974; Winet 1996).

Anatomy of the Dental/Alveolar Structures and Wound Healing 31

Osteoblasts differentiate from mesenchymal precursor substitute (gingival, connective tissue) used to stabilize
cells present within the marrow, from circulating precursor esthetic or hygienic needs, the graft needs to be structur-
cells and possibly from pericytes around invading blood ally stabilized to allow the native wound healing process
vessels. Vascular penetration in bone chambers has been to follow its predictable course.
demonstrated to move at different rates in cancellous bone
(0.5 mm/day) versus cortical bone (0.05  mm/day) In the case of the dental implant it was Branemark’s flared
(Rhinelander 1974a, b; Winet 1996). With increasingly sta- cylinder stabilized with bicortical engagement which pro-
ble and maturing vascular and matrix formation, the cou- vided the model. In bone grafting the model is provided by
pled osteoblasts/osteoclasts initiate early clean-up and a native sheltered space (elevated sinus, intact tooth
bone matrix deposition. The maturing collagen/noncolla- socket) or Nyman’s guided tissue regeneration (GTR) con-
gen matrix then enters a phase where bone healing might cepts. In the latter techniques an increased space volume
begin (10–14 days). This critical period for bone formation can be created by combinations of selective permeable
at three to five weeks requires mechanical stability of the membranes supported with bone or bone substitutes,
soft tissue margins. stabilized with fixation devices and then covered by
expansion or stretching of soft tissues (released by blunt
Epithelial closure, which commences almost immediately mylohyoid detachment or sharp dissection periosteal
because the basal layer is in continuous replacement, is release) In the case of soft tissue grafts, thinning and fen-
well advanced by seven days. While the epithelial cover is estration of recipient beds followed by suture stabilization
mostly complete with matured layers by 21–28 days, soft are the most common techniques.
connective tissue including its vasculature continues to
mature for 35–42  days (5–6 weeks) (see Figures  3.22 It is hoped that this review of macro- and micro-anatomy
through 3.24). Bone healing continues for six to eight followed by the sequence and timing of healing events in
weeks, at which time a rapidly formed woven (fibrous different tissue compartments will enhance the reader’s
pattern seen in stained slides) bone is present. This is ability to understand and perform these and future tech-
gradually remodeled in a slower process, which creates niques on the infinite variation of conditions which present
mature lamellar bone with its distinctive reversal/cement during the course of a surgical career. In many ways every
lines composed of noncollagenous proteins‐ostepontin case is an N of 1.
and bone sialoprotein. All of these events assume a stable
environment with no re-injury or mobility of the site.
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(2017). Frequency and anatomical features of the mandibular
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and predictable results. In most of our procedures the Integrated Prostheses. Chicago: Quintessence.
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Whether the grafted unit is a bioactive root form destined cytes define a new leukocyte sub‐population that mediates tissue
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Anatomy of the Dental/Alveolar Structures and Wound Healing 33

Chapter 4 PiezocisionTM Assisted Orthodontics in Everyday
Practice
Serge Dibart, Elif Keser, and Donald Nelson

INTRODUCTION France) is inserted in the gingival openings previously

made and a 3 mm deep piezoelectrical corticotomy is
What is Piezocision assisted orthodontics? A minimally
done (Figure 4.1). The decortication has to pass the corti-
invasive surgical procedure aimed to accelerate orthodon-
cal layer and reach the medullary bone to get the full effect
tic tooth movement? A tool given to the orthodontist to con-
of the regional acceleratory phenomenon (RAP). In the
trol anchorage? A useful complement to treatment with
areas with thin or little gingiva (recessions) or with thin or
clear aligners? A way to modify/strengthen a patient’s thin
no cortical buccal bone (dehiscences, fenestrations) hard
biotype? Yes indeed, all of the above but further still…it is
and/or soft tissue grafts can be added via a tunneling pro-
a way of seeing and treating cases differently. Piezocision
cedure (Figures 4.2 and 4.3). The patient is seen every one
has evolved from being initially a minimally invasive surgi-
or two weeks post surgery by the orthodontist in order to
cal alternative to conventional corticotomies to a more
change aligners or activate wires and take advantage of
sophisticated “intellectual” approach to comprehensive
the temporary demineralization phase created by
orthodontic and lately multidisciplinary care. It is not just
Piezocision. This results in faster tooth movement and
about speed anymore, it is about the possibility for the
early completion of treatment (Charavet et al. 2016; Dibart
orthodontist to control selectively the anchorage value of
et al. 2015) (Figures 4.4 and 4.5).
teeth at will, potentially offering a means to successfully
treating cases which until now were beyond the scope of
As mentioned earlier this technique does not have to be
conventional orthodontic mechanics. It is also about being
used for full orthodontic treatments only. It is versatile
an essential part of a multidisciplinary team, providing the
enough and it reduces orthodontic treatment time in such
necessary space or spacings between teeth for optimal
a drastic yet friendly manner that it is a great adjunct to
implant placement or prosthetic rehabilitation. Piezocision
multidisciplinary therapy. The patients and the dental team
can be used in a generalized, localized, or sequential
appreciate that allowing teeth to be put in their ideal place,
manner (Dibart et al. 2015).
via short orthodontics, prior to restorative procedures is
actually beneficial to both parties as it allows for minimally
THE TECHNIQUE
invasive dentistry. Indeed crown preparations for veneers
For a full description of the technique I encourage you to or crowns can be kept to a minimum while creating space
read the chapter on Piezocision in “Practical Osseous for optimal volumes and esthetic outcome.
Surgery in Periodontics and Implant Dentistry” (Dibart
2011). In brief, Piezocision is performed one week after the
COMPUTER GUIDED PIEZOCISION
placement of orthodontic appliances (fixed or removable).
ORTHODONTICS
A small vertical incision is made buccally and interproxi-
mally. This mid‐level incision between the roots of the This technique using a surgical guide was first developed
teeth will allow for the insertion of the piezoelectric knife. and described by Milano et al. in 2014. This was meant as
Piezocision has a localized and selective effect on the a security measure to avoid injuring the dental roots of the
teeth, only the teeth or arch(es) to be moved need to be teeth undergoing Piezocision (Milano et al. 2014). Having
operated upon. The areas not surgerized have a higher taken a Cone Beam Computer Tomography, software is
anchorage value, since they are not affected by the being used to place the Piezocision incision (Digital
demineralization process following Piezocision and can be Surgery, S.R.L., Bologna, Italy). This is done in conjunction
used as such in the global treatment plan. The tip of the with the orthodontist as s/he is the one that decides which
Piezotome (PZ1 insert, Satelec, Acteongroup, Merignac teeth or group of teeth will be moving. Only the teeth that

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

35
Figure 4.1  Piezocision is done interproximally, making sure to Figure 4.4  Prior to Piezocision assisted orthodontics.
decorticate past the cortex into the medullary bone.

Figure 4.5  Twelve months after starting Piezocision assisted orthodontics.

Figure 4.2  Once the interproximal decortication has been done, a Notice how the recession on tooth # 11 has been treated (see Figure 4.2).
tunneling procedure is done and a connective tissue graft is inserted to
correct the mucogingival defect on tooth # 11. This is done during the
Piezocision assisted orthodontics procedure in order to benefit from the
enhanced healing potential coming from the RAP. will be moving will get Piezocision (Figure  4.6). This will
give the orthodontist the ability to “play” with the anchor-
age value of the teeth or group of teeth as the deminerali-
zation created by the Piezocision procedure is localized
and bring a negative anchorage value to the teeth that are
“piezocized.” As a corollary to this the non piezocized
teeth or group of teeth creates a positive anchorage that
can be used strategically by the treating orthodontist.

Once the cuts are planned digitally, a digital guide is cre-

ated (Digital Surgery, S.R.L., Bologna, Italy). Following the
finalization of the digital guide (Figure 4.7), a surgical plas-
tic guide is created using a chairside printer (Figure 4.8).
The surgical guide is then placed in the mouth of the
patient, and is checked for stability. Once that is done, the
guide is removed and the patient anesthetized using
­infiltration anesthesia (Xylocaine 2% with 1/100,000 epi-
Figure 4.3  Bone grafting at time of Piezocision assisted orthodontics to nephrine). Following that incisions with a scalpel and blade
strengthen or expand buccal alveolar bone. are made, making sure to cut the periosteum though the

36 Practical Advanced Periodontal Surgery

Figure 4.6  The incisions are planned digitally to avoid hitting the roots.

Figure 4.7  A surgical guide is being designed.

Figure 4.9  The minimal opening provided by the surgical guide allows for
precise incisions avoiding the danger of root damage during Piezocision.

openings (Figure 4.9). This is followed by the corticotomy

using the piezotome (Dibart et  al. 2009) (PZ1 insert,
Acteon, Satelec group, Merignac, France). The surgical
guide is then removed (Figure 4.10; Video 1).

DYNAMICALLY GUIDED PIEZOCISION

As technology evolves, we now have access to devices
that allow us to do dynamically guided surgeries. Such a
device is “Navident” (ClaroNav, Ontario, CA). Originally
developed for dental implant surgery, Navident dynami-
cally tracked the implant drill and the patient’s jaw, provid-
ing real time guidance and visual feedback to ensure
the  implants were placed according to plan. We used
Figure 4.8  This is with the surgical guide in place. this  technology to place the Piezocision cuts and avoid

PiezocisionTM Assisted Orthodontics in Everyday Practice 37

 (Figure 4.11). Her right posterior occlusion was Class I and
left side Class II. The lower incisors were significantly
extruded, impinging on the palate. Her main concern was
the pushed out and spaced from teeth (Figure  4.12).
Aesthetics was her main concern and she wanted to
achieve the results very quickly, therefore she chose the
treatment option that combined Invisalign with Piezocision.
The Clincheck views show the amount of correction of the
incisor positions and the amount of lower incisor intrusion
that was planned. Figure 4.13 shows the superimposition
from the Clincheck, demonstrating the amount of tooth
movement that was planned for the upper jaw (blue initial,
white final). After receiving the first Invisalign tray,
Piezocision was done (Figure 4.14) and the patient started
changing the aligners every five days (this was with the old
Figure 4.10  The Piezocision is done and the surgical stent is removed.
Invisalign protocol where the recommended usage time
was two weeks per tray).
damaging the roots of the teeth. This allowed us, together
with the use of the specific Piezocision inserts (PZ1, PZ2,
At the end of her treatment the patient was very satisfied
and PZ3) to deliver the alveolar corticotomy exactly
with her smile as the teeth had been retracted and the
where planned and avoid root damage. One of the added
diastemas closed (Figures 4.15 and 4.16).
advantages, beside the exquisite precision, is the allevia-
tion of the cooling obstacle that can be represented by the
surgical stent (Video 2).

PIEZOCISION ASSISTED ORTHODONTICS

WITH CLEAR ALIGNERS
Piezocision can be used advantageously to help acceler-
ate aligner change when patients are undergoing clear
aligner orthodontics (Keser and Dibart 2011) (i.e.
Invisalign™). Following Piezocision, the tray can be
changed every week, every five days or even earlier
depending on the orthodontic complexity of the case and
the tooth movements. The superimposition of the
Clincheck™ images (before and after) will dictate where
the Piezocision cuts should take place. Teeth that are not
moving should not be touched whereas the teeth that will Figure 4.11  Flared anterior teeth and multiple diastemas. Patient
be moving will receive the Piezocision cuts. The Clincheck unhappy with her smile.
superimposition serves as a “roadmap” to plan the surgi-
cal cut making the whole treatment planning quite simple
for the surgeon.

Typically the patient comes to the surgical appointment

one week after wearing the first tray. This will “condition”
the cells in the periodontal ligament to respond quickly
and extensively to Piezocision. The patient is anesthetized
using infiltration anesthesia on the buccal side of the max-
illa and/or mandible. The Piezocision cuts are done
according to the superimposed Clincheck image. The
patient wears the aligners immediately after the procedure
and for a minimum of 22 hours per day or more depending
on the orthodontist recommendations.

A 25 year old female presented with flared out upper inci-

sors and multiple diastemas, complaining about her smile Figure 4.12  Lower anterior teeth impinging in the palate.

38 Practical Advanced Periodontal Surgery

Figure 4.13  Super‐imposed before and after Clincheck showing projected teeth movements for the maxilla. Piezocision will be done only around the
white teeth as they are the only ones moving.

Figure 4.14  Piezocision on the maxilla and mandible is done after Figure 4.16  Patient has a better smile. The diastemas are closed and
Clincheck analysis. the teeth have been retracted to complement her profile.

INCORPORATING PIEZOCISION
IN MULTIDISCIPLINARY TREATMENT
A 42 year old woman presented with a Class I malocclusion
with anterior crowding. Her main concerns were the crowd-
ing and discoloration of her teeth as well as some white den-
tal spots (Figures 4.17–4.19). She was very happy with her
present profile and lip support, and did not want any change
to the position of her lips. A multidisciplinary treatment plan
was devised to address all of her concerns. The first stage
of the treatment was the resolution of the maxillary and man-
dibular crowding and the retraction of the anterior upper
teeth to create enough space for the minimally invasive
Porcelain Laminate Veneers preparations. When conven-
tional orthodontic therapy was initially suggested to the
patient, some resistance was encountered because of the
Figure 4.15  Finished treatment. length of treatment. The patient also clearly stated that she

PiezocisionTM Assisted Orthodontics in Everyday Practice 39

 orthodontic treatment time by approximately half (Charavet
et al. 2016; Dibart et al. 2014; Keser and Dibart 2011). Once
the teeth were put in an optimal position after short ortho-
dontics, the stage was set for the restorative team to address
the problem of teeth discoloration and white spots via prep-
less/minimally invasive Porcelain Laminate Veneers (PVL).
After resolving the crowding, the amount of anterior teeth
retraction was limited to 0.5 mm which is approximately the
thickness of the PLVs. By doing so, enough space was cre-
ated to finish the case with minimal preps and without
changing the lip support. After a week into wearing the first
aligner, Piezocision was done (Figure  4.20). The patient
wore the aligner immediately after the procedure and was
asked to change her aligners every five days (this was at the
time of the old Invisalign protocol when the recommended
Figure 4.17  Forty two year old female patient intra oral view (notice the
usage time was changing every two weeks, nowadays with
discoloration and white spots on the teeth).
the new Invisalign protocols one can change the aligners
even sooner post Piezocision). At the end of her orthodontic
treatment crowding was resolved and the anterior teeth
had been “over retracted” by 0.5 mm to accommodate the
thickness of the restorative material (Figures  4.21–4.23).

Figure 4.18  Occlusal view of maxilla showing mild crowding.

Figure 4.20  The patient wears the aligners after the Piezocision procedure.

Figure 4.19  Occlusal view of mandible showing mild crowding.

would not wear “braces.” An alternative treatment was

offered using clear aligners and the issue of time spent in
orthodontics was addressed by suggesting Piezocision Figure 4.21  At the end of the orthodontic treatment. Treatment time was
assisted orthodontics. Piezocision has been shown to cut cut by approximately half after Piezocision.

40 Practical Advanced Periodontal Surgery

 Figure 4.24  The patient is ready to see the restorative specialist for
Figure 4.22  Occlusal view of maxilla post treatment. veneer preparations. Because of the use of orthodontics the teeth are in an
ideal anatomical position and the removal of tooth structure is kept to a
minimum (Prosthetics: Dr. Galip Gurel).

Figure 4.23  Occlusal view of the mandible post treatment.

The patient was then sent to the restorative dentist who pre- Figure 4.25  Final restoration in place: porcelain laminate veneers
pared the teeth for the porcelain veneers (Figures 4.24 and (Prosthetics Dr. Galip Gurel).
4.25). Her total treatment time including the restorative work
was six months (Figure  4.26). Placing the teeth to be
restored in an ideal position prior to prosthetic work using
orthodontics allows for the practice of Minimally Invasive
dentistry which is most beneficial for the patient.

POST‐OPERATIVE CARE
Patients are usually given a short course of analgesic
drugs (acetaminophen or ibuprofen). Usually a three days
supply will suffice.

Antibiotics are given at the discretion of the operating

surgeon.

Chlorhexidine rinses are prescribed twice a day for five days.

Figure 4.26  The esthetic and functional concerns of the patient have
Ice packs are given to the patient immediately post sur- been addressed successfully in a time efficient manner (Prosthetics:
gery to control inflammation. Dr. Galip Gurel).

PiezocisionTM Assisted Orthodontics in Everyday Practice 41

CONTRAINDICATIONS FOR PIEZOCISION Dibart, S. (2011). Piezocision: minimally invasive periodontally accel-
erated orthodontic tooth movement procedure. In: Practical Osseous
1. Patients on anything that affects bone physiology (i.e. Surgery in Periodontics and Implant Dentistry (eds. S. Dibart and
Biphosphonates) J.‐P. Dibart). Wiley Publishing.

2. Medically compromised patients (specifically bone Dibart, S., Sebaoun, J.D., and Surmenian, J. (2009 Jul‐Aug).
pathology) Piezocision: a minimally invasive, periodontally accelerated ortho-
dontic tooth movement procedure. Compend. Contin. Educ. Dent.
3. Patients on long term anti‐inflammatory drugs 30 (6): 342–344.

4. Untreated periodontal diseases Dibart, S., Yee, C., Surmenian, J. et al. (2014 Aug). Tissue response
during Piezocision‐assisted tooth movement: a histological study in
5. Ankylosed teeth rats. Eur. J. Orthod. 36 (4): 457–464.
6. Noncompliant patients
Dibart, S., Keser, E., and Nelson, D. (2015). Piezocision™ assisted
7. Patients/operator with a pacemaker or any other active orthodontics: past, present and future. Semin. Orthod. 21: 170–175.
implants
Keser, E.I. and Dibart, S. (2011 Mar). Piezocision‐assisted invisalign
treatment. Compend. Contin. Educ. Dent. 32 (2): 46–48.
POTENTIAL COMPLICATIONS
Milano, F., Dibart, S., Montesani, L., and Guerra, L. (2014 Jul‐Aug).
• Root injury
Computer‐guided surgery using the piezocision technique. Int. J.
• Infection Periodontics Restorative Dent. 34 (4): 523–529.

• Mucogingival defects

REFERENCES
Charavet, C., Lecloux, G., Bruwier, A. et al. (2016 Aug). Localized pie-
zoelectric alveolar decortication for orthodontic treatment in adults: a
randomized controlled trial. J. Dent. Res. 95 (9): 1003–1009.

42 Practical Advanced Periodontal Surgery

Chapter 5 The Contribution of Periodontics to Endodontic
Therapy: The Surgical Management
of Periradicular Periodontitis
Mani Moulazadeh

HISTORY AND EVOLUTION superior retrofilling material, and more advanced hard and
soft tissue management techniques, procedures are more
Over the past century, surgical endodontics has been
conservative, and outcomes have become more successful.
performed for treatment and conservation of teeth with
Smaller osteotomy windows are made to conserve cortical
persistent post endodontic treatment infections.
bone. Root resection with shorter or no bevel angles, previ-
ously impossible due to lack of ultrasonic tips, are now
In 1964, with the formation of the American Association
feasible and conserve more root structure in order to pre-
of Endodontists and establishment of endodontics as a
serve a more favorable crown‐to‐root ratio. The SOM allows
dental specialty, surgical endodontics began to take on a
for locating and treating isthmuses and extra portals of exit
new face. Early on, much emphasis was placed on devel-
along the root’s long axis, ensuring a proper orientation
opment of a root‐end filling material that would provide a
and depth for the placement of a root‐end filling. It also
hermetic seal.
enables the surgeon to check for marginal integrity of the
apical seal once it is placed. This prevents leaving
While magnification and the use of a microscope for opera-
avenues for leakage, which will prevent the formation of an
tions date back to the early 1920s, it was not until 1984
impermeable seal and may ultimately result in treatment
that it was used in conjunction with an apical surgery
failure. Rubinstein and Kim (1999, 2002) reported the
(Reuben and Apotheker 1984). With the addition of the sur-
short‐term (one year) and long‐term (five to seven years)
gical operating microscope (SOM) to the armamentarium,
success rates for endodontic microsurgery to be 96.8 and
the technique and outcome for apical surgeries became
91.5%, respectively. These results are rather impressive
more conservative and predictable. After all, one cannot
considering that about 60% of the surgeries were performed
treat what one cannot see, and with the magnification of up
on premolars or molars.
to ×30 and illumination of up to ×12 with the dental over-
head light, the SOM can reveal details previously unseen to
TOOTH CONSERVATION VERSUS IMPLANTS
the surgeon. The use of the SOM has become the standard
of care in all endodontic procedures, and since 1998, all With the recent implant paradigm shift in dentistry, some
postgraduate programs in endodontics in the United States clinicians have made claims as to suggest the placement
are required to train their residents to perform procedures of immediate load implants is a more logical treatment over
under the SOM. As a result, instruments have been either treatment of the teeth via endodontics (Ruskin et al. 2005).
newly designed or modified by scaling them down to a As clinicians, we must not be easily affected or swept away
fraction of their original size to be used with the SOM. by advertisements or reading one such article. Rather, our
Ultrasonic tips and micromirrors were developed in the decisions for selecting treatment plans, modalities, and
mid‐1980s for the purpose of retropreparation and inspec- techniques should be made on an evidence‐based
tion under the SOM. Along with the introduction of new approach to dentistry and its specialties. Many have
root‐end filling material such as ProRoot mineral trioxide attempted to overplay the success of dental implants over
aggregate (MTA; Dentsply Tulsa Dental, Tulsa, OK, USA), nonsurgical and surgical endodontic therapy. However, in
the art of endodontic surgery has shifted toward endodon- a systematic review of the literature (M.K. Iqbal and S. Kim,
tic microsurgery and has reached new heights in its levels unpublished data) there were no significant differences
of precision, predictability, and success. between root canal therapy success rates and implants. In
fact, comparing the “success” rates of endodontics and
Today, microsurgical endodontics is considered to be the implants is sometimes beyond the scope of comparing
standard of care. With the advent of SOM, microinstruments, apples and oranges.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

43
Endodontically treated teeth are evaluated for success on support that in the event of a surgical approach, prior non-
the basis of clinical and radiographic criteria. An endodon- surgical retreatment will increase the chance of a positive
tically treated tooth that is asymptomatic while in function outcome (Zuolo et al. 2000). Therefore, unless nonsurgical
and displays no periapical radiolucency is classified as a retreatment is not feasible due to physical, anatomical,
successful treatment. Implants are often evaluated for their time, or financial hardships, surgical endodontics should
“success” based on their survival rate. This disparity in the not be considered as the treatment of choice.
evaluation criteria between endodontics and implants
immediately changes the “level ground” for comparison. In RATIONALE FOR ENDODONTIC SURGERY
addition, implant studies often exclude patients who have
underlying systemic diseases such as diabetes, smokers, Periapical surgery is performed to eradicate persistent
and patients with poor oral hygiene. In certain studies peri‐ infection/inflammation associated with teeth with previ-
implantitis was not regarded as a criterion for implant fail- ously negative post‐treatment outcome from either initial
ure. Also, at least presently, most implants in these studies endodontic therapy or retreatment. With advancement in
are being placed by trained specialists. microsurgical endodontics, surgery should not be labeled
as a last option, but it should be performed when either
Meanwhile, the success of endodontic therapy as evalu- initial endodontic treatment or retreatment is not possible
ated by studies did not abide to the same strict patient or feasibly cannot secure a better outcome. Factors such
exclusion criteria as did the implant studies. Persistent radio- as inability to properly access the root canal system in
graphic demineralization was considered to be a sign of order to adequately clean, shape, and obtain an apical
failure. Last, the success rate of endodontic therapy as seal may warrant surgery as the treatment of choice. The
reported by such studies as the Toronto Study is based on ability of the clinician to properly diagnose which case is
treatments performed by dental students, general dentists, suitable for surgery is as important as his or her clinical
and endodontists. In 1999, the American Dental Association skills. It was Dr. Irving J. Naidorf who said, “A good sur-
reported that only 25% of all endodontic cases were being geon knows how to cut, and an excellent surgeon knows
performed by endodontists (ADA Report 1999). when to cut” (Kim 2002).

It is clear that implants have changed the face of dentistry INDICATIONS FOR ENDODONTIC SURGERY
and the way we treatment plan restoring edentulous
Anatomical Challenges
spaces. They are a great adjunct when treatment is
planned properly and when bone quality and esthetics In certain cases, the tooth anatomy renders itself unwilling
allow for their placement. Implants are clearly not an alter- to proper debridement and obturation, leaving a portion of
native for periodontally sound and endodontically treat- canal untreated by nonsurgical methods. Teeth with canal
able (nonsurgical or surgical) teeth. Retaining our patients’ blockages due to severe calcification or with severe radic-
healthy natural dentition should be our main priority as ular curvatures fall under such category.
healthcare providers.
Also, in a few cases when endodontic therapy is performed
TREATMENT OF FAILED ROOT CANAL at a clinically acceptable level, symptoms may continue to
THERAPY persist when the apex of the root may be fenestrating
through the facial cortical plate of bone. In these cases, a
When the initial root canal therapy has resulted in a nega-
small surgical procedure to recontour the root end and
tive outcome, two revisions are possible:
align it within its bony housing may solve the problem.
• Nonsurgical retreatment aimed to eliminate bacteria
from the canal Iatrogenic Factors
• Surgical retreatment aimed to encapsulate bacteria Previous endodontic “misadventures” account for the
inside the canal need for surgery in cases with persistent symptoms. These
include but are not limited to canal blockages, ledges,
The decision as to which approach to take should be perforations, separated instruments or posts, underfilled
based on the level of evidence and other criteria such canals, and canals with dental material extruding beyond
as the dentist’s training and experience, availability of the the biologically tolerant buffer zone around the anatomical
necessary armamentarium, and the patient’s decision apex (Figures 5.1–5.3).
based on informed consent.
In most of these cases, proper canal debridement is com-
Historically, nonsurgical retreatment has enjoyed a higher promised as is the ability to properly obturate the canal
success rate than the surgical approach. Studies also and obtain a proper apical seal.

44 Practical Advanced Periodontal Surgery

Figure 5.1  Persistent inflammation associated with the mesial root of a Figure 5.3  Instrument recovery, root resection, and retrograde
mandibular molar with a separated instrument. obturation with MTA.

Figure 5.4  Persistent inflammation and symptoms associated with the

mesial root of a maxillary molar due to the missed MB‐2 canal.

Figure 5.2  Surgery reveals a hand file extending 3–4 mm beyond the
root tip.

Relentless Inflammation
Previously missed and untreated canals, bifurcations, fins,
and extraradicular infections often harbor bacteria and
present themselves as chronically and intermittently symp- Figure 5.5  Apicoectomy performed in conjunction with finding and
tomatic teeth. Apical surgery can be performed to eradi- obturation of the additional canal and the isthmus between MB‐1 and
cate such factors (Figures 5.4–5.6). MB‐2 canals.

Perioradicular Surgery, Tooth Replantation 45

Figure 5.6  A four‐year follow‐up shows complete healing.

Figure 5.8  An exploratory surgery and staining reveal a vertical root

fracture.

CONTRAINDICATIONS FOR ENDODONTIC
SURGERY
Medical History
Patients with recent myocardial infarction, with uncontrolled
diabetes, patients who are undergoing anticoagulant
­therapy, patients who received head and neck radiation, or
patients with severe neutropenia are not good candidates
for surgery. Surgery should be postponed until they are
cleared by their treating physician.

Compromised Periodontium
Periodontal pockets and tooth mobility reduce the success
of endodontic surgery. High success rates in endodontic
microsurgery was achieved in studies where the pro-
spective teeth did not exhibit any pathologic periodontal
pocketing or pocketing that either communicated with the
apical endodontic component or had completely denuded
the buccal or lingual cortical plate of bone resulting in a
Figure 5.7  Multiple sinus tracts trace to the location of the endodontic dehiscence (Rubinstein and Kim 1999).
lesion.
Skill, Knowledge, and Proper Instruments
General practitioners must be knowledgeable to properly
Exploratory Surgery
diagnose and refer patients with surgical needs to sur-
In certain cases, it may be difficult to properly diagnose a geons who have the specialized training in diagnosing
problem. In cases of root fractures, for example, a small and treating these cases.
soft tissue flap followed by dying the area in question with
methylene blue and inspection under the SOM can quickly Although the skill levels of the surgeons should theo-
reveal a root fracture, which can then prevent unnecessary retically be the same, in reality this may not be the
endodontic treatment to be performed on a nonrestorable case. A study reviewed the outcome of treatment in the
tooth (Figures 5.7 and 5.8). oral surgical and endodontics departments of a teaching
hospital four years following surgery. Complete healing
Also, collection of a biopsy specimen may be another indi- for cases performed by the endodontic unit was nearly
cation for performing an exploratory surgery. twice as high for those performed in the oral surgery unit.

46 Practical Advanced Periodontal Surgery

The single most important contributing factor was the qual-
ity of the procedure, which in turn translated into the sur-
geon’s skill and perhaps level of training and understanding
of the problem at hand (Rahbaran et al. 2001).

Despite the surgeon’s highest level of clinical competence,

proper instrumentation is required for achieving the high-
est level of technical excellence. It may sound anecdotal,
but it is impractical for a world class skier to win any race
while skiing on tennis rackets!

Finally, surgeons must keep the welfare of the patient

in  mind at all times. Case selection for surgery is very
important, and indiscriminant use of surgeries to treat
endodontic problems is discouraged. Remember, just
because you can, does not mean you should (Figures 5.9
and 5.10).

Anatomical Challenges
Proximity to the maxillary sinus, mental nerve, and inferior
alveolar canal and the thickness of the buccal bone in the
mandibular second molar area due to the external oblique
ridge may serve as a contraindication or deterrent for sur-
gery. As long as a properly trained clinician is aware of
such hurdles and conceivably knows how to work around Figure 5.10  Nonsurgical root canal treatment was performed with the
them and manage mid‐procedure and post-procedure aid of the SOM. The tooth was free of symptoms thereafter.

potential complications, these factors may be downgraded

to potential risks or contraindications. Extra caution or
modifications in the procedure may be required in order to
avoid damage to such structures.

As an example, the roots of many maxillary molars and

premolars are separated from the maxillary sinus by a thin
layer of cortical bone and the Schneiderian membrane.
Care must be taken not to violate this space. However, in
the event that the sinus is inadvertently perforated, with
proper care, the membrane usually heals uneventfully,
without any negative effect on the outcome of the apical
surgery (Figure 5.11).

Inadequate Root Length

As a critical part of thorough treatment planning, the length
of the root before surgery must be estimated. This will
allow the clinician to have an understanding whether a
favorable crown to root ratio is achievable once the root
is resected. If the length of the root after resection is con-
ceived to be inadequate, this may be ground for aborting
the surgical procedure and looking for an alternative plan.
Although, in select cases where the patient is free of perio-
dontal disease, parafunctional habits, and malocclusion,
Figure 5.9  Apicoectomy was performed on a “calcified” central incisor teeth have been known to survive with as low as 1 : 1 crown‐
without treating the tooth by nonsurgical root canal therapy first. to‐root ratio (Figures 5.12–5.14).

Perioradicular Surgery, Tooth Replantation 47

 Figure 5.14  Five‐year recall revealed complete healing with no signs of
Figure 5.11  Osteotomy and stained resected root ends of a maxillary the sinus tract or presence of mobility.
molar. Note the maxillary sinus and its lining deep to the root tips.
TYPES OF ENDODONTIC SURGERY
Incision and Drainage
Incision and drainage is used for treating necrotic teeth
with acute apical abscess. After primary drainage through
the tooth is established by performing a pulpectomy, a
small incision is made at the base of the fluctuant swelling.
Blunt dissection with a curved hemostat facing the bone
plate is carried out to dissect tissue planes and establish
further drainage. A drain must be placed for up to 48 hours
to prevent wound closure. Keeping the incision site open
will ensure continuous drainage and patient comfort by
allowing the pressure to be relieved (Figure 5.15).

In addition, by allowing oxygen to gain access to the site

of infection, the anaerobic bacteria are killed, the balance
Figure 5.12  Failing apicoectomy and sinus tract tracing in a maxillary of bacteria colony is disrupted, and the rate of healing may
second premolar. be accelerated.

Figure 5.13  Conservative apicoectomy and obturation with MTA was Figure 5.15  Incision and drainage of an intraoral abscess. Note the
performed despite the unfavorable crown‐to‐root ratio. latex drain was sutured to prevent its premature removal.

48 Practical Advanced Periodontal Surgery

Root Amputation and Hemisection a foreseeable positive outcome. Intentional replantation may
be considered to be the treatment of choice for treatment
Root amputation and hemisection involve surgical removal
of cases where surgical access to the site is impractical or
and surgical division of roots of multirooted teeth. Although
impossible. Teeth with root perforations in mesial, distal, or
once performed more frequently, with the increased preva-
furcal regions are great candidates. Teeth with expected
lence of dental implants, the frequency is declining. It is pre-
elaborate apical anatomy and portals of exit or teeth where
ferred that if a tooth is treatment planned for either of these
the apices are lying deep within the jaw bone and where
two procedures, the root canal treatment is performed before
surgical access is difficult are also good candidates.
the surgical phase. It should be noted that with proper case
selection, both procedures are viable options for maintaining
Case selection in intentional replantation plays a big role in
the natural teeth. As prudent dentists, we must subdue our
the success of the treatment. Teeth with conical fused
urges to perform “herodontics” at all cost in order to maintain
roots are generally good candidates because of their ease
a tooth in the oral cavity. Teeth that may serve as strategic
of extraction. On the other hand, teeth with periodontal
abutments, exhibit advanced periodontitis or nonrestorable
involvement, thick interseptal bone, or dilacerated roots
remaining segment, and have fused roots or very low furca-
are contraindicated for intentional replantation.
tions are not good candidates for these types of surgery.

Intentional Replantation Surgical Technique

As defined by Dr. Grossman, replantation is “the purposeful After proper case selection and review of the medical his-
removal of a tooth and its almost immediate replacement tory, local anesthesia is administered via block and local
with the object of obturating the canals apically while the infiltration to properly anesthetize the patient. The patient
tooth is out of its socket” (Kim et  al. 2001a). Intentional should start to rinse with 10 ml of 0.12% chlorohexidine
replantation is an artificial setting mimicking complete tooth gluconate twice daily 24 hours before the surgery and con-
avulsion, and its management as defined by the guidelines tinue this regimen for one week following the procedure.
of the American Association of Endodontists. However, the Although somewhat of a controversy, some advocate the
circumstancing factors are near ideal. The level of tooth administration of prophylactic antibiotics 24 hours before
contamination and physical damage is likely to be far less and for one week after the procedure. It is also recom-
than in the case of an accidental injury. Moreover, the single mended that unless the patient is allergic to NSAIDs, the
most important factor in the demise of an avulsed tooth, the maximum daily dose of a drug such as ibuprofen should
extraoral dry time, is not a factor because it is practically be prescribed and taken 24 hours before and for one week
nonexistent. During intentional replantation, the tooth is after the procedure. Once the patient is seated and anes-
immediately submerged in tissue culture medium, with the thetized, it is crucial to make sure that every step of the
tooth out‐of‐socket times being under 10 minutes. procedure is well thought out and ready to be executed.
Organization translates into minimized out‐of‐socket time
The procedure dates back to the late 1500s, when Paré (less than 10 minutes) and, in turn, maximizes the potential
replanted three avulsed teeth (Kupfer et al. 1952). Intentional for a successful outcome. After administration of local
replantation has been performed for over half a century with anesthesia, the tooth can be prepared by working a periot-
success rates being reported between 80 and 95% for fol- ome circumferentially into the gingival sulcus to dissect the
low‐ups of 2–22 years by Grossman, Kingsbury, and Bender fibers. Great care must be taken not to scrape the cementum
(Kim et al. 2001b). Although many of these teeth exhibited covering the root surface. Luxation with universal forceps
some degree of ankylosis and replacement resorption, they placed only on the anatomical crown is followed. At no
were clinically functional and did not exhibit any signs of time should the beaks of the forceps be making contact
periradicular pathosis. With the development of new proto- with any portion of the tooth apical to the CEJ (cemento­
cols that call for the use of Hanks balanced salt solution enamel junction) (Figures 5.16 and 5.17).
(HBSS) (BioWhittaker, Walkersville, MD, USA) as an inter-
mediate storage and operating medium, and the use of The use of elevators is contraindicated. It is critical to be
enamel matrix derived protein (Emdogain; Straumann, extra cautious during this step of the procedure, as a careful
Waldenburg, Switzerland) along with careful extraction and minimally traumatic extraction could be the rate deter-
techniques to prevent damage to the cementum and the mining step for the outcome. It is not unusual to take as
PDL cells, the chances of resorption can be minimized. long as 15 minutes to have the tooth fully avulsed. Forcing
the extraction could ultimately fracture the tooth or the
alveolus and cause its demise. Once the tooth is extracted,
Indications and Case Selection
the crown may be firmly wrapped with sterile gauze and
Intentional replantation should not be the treatment of choice grabbed tightly with a locking hemostat. Curettage of the
if endodontic retreatment or surgery can be performed with socket is not recommended. Making contact with the root

Perioradicular Surgery, Tooth Replantation 49

Figure 5.16  Mandibular second molar exhibiting persistent
radiolucency even after nonsurgical retreatment. Figure 5.18  Tooth wrapped in sterile gauze and submerged in HBSS.
Root resection was carried out by an Impact air 45 high‐speed handpiece.

Figure 5.17  Tooth extraction without placing the forceps on root

structure. Note the lesion attached at the root’s apical third. Figure 5.19  White MTA retrofill.

surface should be avoided at all times. The tooth is imme- The tooth is then reoriented properly and gently placed in
diately transferred into a basin which is filled with HBSS and its socket. Light apical pressure is applied until the tooth
submerged. Root resection is carried out by an impact air is seated in its correct, most apical position. It is prudent
handpiece under the microscope and approximately 3 mm to radiographically confirm the complete seating of the
of the root is resected (Figure 5.18). tooth in the socket at this time (Figure 5.20).

Methylene blue stain is applied to the root end and The tooth is then splinted by suturing a monofilament
observed under the microscope with mid‐range magnifi- suture over the occlusal surface of the tooth. Fishing line
cation for cracks, isthmuses, and extra portals of exit. and composite bonding can also be used by providing a
Retropreparation is made by using small pear‐shaped physiological splint when the treated tooth is splinted to its
carbide burs such as a 330 bur or ultrasonic tips. The neighbor on their buccal surfaces. The limitation of this
canals are then obturated with super ethoxybenzoic acid method is that it requires both of the teeth being splinted to
(Super‐EBA; Bosworth, Skokie, IL, USA) or MTA carried have enamel on their buccal surfaces to facilitate bonding.
in microcarriers and condensed with micropluggers. The This method excludes teeth with metal or porcelain coronal
root end is then polished or burnished and inspected coverage, which may be a good number of teeth treated
one last time under the microscope before replantation by intentional replantation. The patient should be instructed
(Figure 5.19). to maintain a maximum intercuspal position at least for the

50 Practical Advanced Periodontal Surgery

 they are highly recommended. Apicoectomy is perceived
to be technically more difficult than other endodontic sur-
geries due to difficulties in its accessibility, illumination, and
small operating field. This is especially true with the case of
posterior teeth, that the access more than the anatomy ren-
ders them more difficult to treat (Wang et al. 2004). However,
since the addition of the SOM to our armamentarium, we have
been able to overcome many of the challenges associated
with apicoectomy.

Indications
Apicoectomy is indicated for treatment of teeth with persis-
tent apical or periradicular pathosis due to anatomical
challenges, iatrogenic factors, irretrievable dental material
inside and outside of the canal, fractures, and repair of
Figure 5.20  Radiograph immediately post reimplantation.
resorptions or perforations (Figures 5.22–5.25).

Figure 5.21  Two‐year recall exhibits complete healing.

remainder of the day and to chew away from the side for Figure 5.22  Sinus tract tracing and the location of the mid‐root
about one week. Postoperative instructions are given, and radiolucency is suggestive of a post perforation.
the patient should be reappointed for follow‐up visit in one
week, at which time the sutures are removed if still intact.
Pain management instructions are given as described earlier.
Once regarded as a last resort before extraction, today
intentional replantation in selected cases is a viable and
logical mode of treatment. With the development of new
protocols for intentional replantation, the procedure has
become more predictable and should always be consid-
ered as a part of possible treatment planning (Figure 5.21).

PERIRADICULAR SURGERY
Periradicular surgeries, otherwise known as apicoectomy,
constitute the bulk of endodontic surgeries. By definition,
apicoectomy involves the reflection of a soft tissue flap, oste-
otomy of both cortical and cancellous bone, and resection of
the root segment, which is suspected to be associated with
a persistent inflammatory process. The preparation of a
­retrocavity and placement of a root‐end filling material are Figure 5.23  Upon the reflection of the soft tissue flap, an isolated
not necessary requirements for an apicoectomy, although endodontic fenestration is visible.

Perioradicular Surgery, Tooth Replantation 51

 Intraoral Examination
A thorough intraoral examination is crucial in postulating
and designing the appropriate approach for treatment via
surgery. Intraorally, the surgical site should be investigated
for any type of periodontal defect by careful probing.
Evaluation of periodontal recession, width of attached
gingiva, and the patient’s gingival biotype may ultimately
determine the type of incision used during the surgery.
Any sinus tracts, swellings, or areas sensitive to palpation
should be noted. Evaluation of muscle attachments and
patient’s opening are critical in determining accessibility to
the prospective surgical site.

Radiographic Examination
Exposure of two periapical radiographs is the minimum
Figure 5.24  Staining reveals a perforation on the mesial aspect of the requirement before commencement of surgery. The first
root. The defect was filled with Super‐EBA cement. radiograph should be exposed using a paralleling tech-
nique and the second should be deviated in its horizontal
component by 20° to the mesial or distal. The radiograph
should be studied for root length, number of roots, root
curvature, size of the potential lesion, and proximity of the
osteotomy to neurovascular bundles, maxillary sinus, and
neighboring teeth. It is strongly recommended that, when
possible, a panoramic radiograph is obtained, especially
when treating mandibular posterior teeth.

Presurgical Preparation
Preoperatively, unless contraindicated, the patient should
take 600–800 mg of ibuprofen just before surgery. The patient
should continue to take this regimen of anti‐inflammatory
every eight hours for up to three days after the surgery.

In addition, the patient should commence rinsing with

10 ml of 0.12% chlorohexidine gluconate twice daily,
Figure 5.25  A three‐month recall revealed partial healing and no signs 24 hours before surgery. This oral rinse should be used
of the sinus tract. before surgery to reduce the quantity of the microorgan-
isms in the mouth and decrease the chance of a post-
surgical flap infection.
PHASES OF APICOECTOMY AND SURGICAL
Local Anesthesia (Pain Control
TECHNIQUE
and Hemostasis)
Review of Medical History
Choosing and administering the appropriate localanes-
Once the patient has been selected as a candidate for api- thetic has a trifold effect. First, it provides pain control during
cal surgery, a complete review of the systemic health of the the surgery. Second, it provides hemostasis. Third, by
patient must be performed. High‐risk patients as defined administering a long‐lasting anesthetic, postoperatively,
by the American Heart Association are to be pretreated the cycle of pain is broken. This is in part due to prevention
prophylactically with oral antibiotics. After consultation in amplification of responses from the peripheral nerves,
with their physician, patients who are on anticoagulant which could ultimately lead to central sensitization.
therapy should be taken off of the medication in time before
the surgery. Last, patients who have been on oral or intra- Typically, local anesthesia is administered via nerve blocks
venous bisphosphonates should be informed about the and local infiltrations. Nerve blocks are aimed at achieving
potential risks and complications that may arise after the profound pain control but must be supplemented by local
surgery as sequelae of the drug therapy. infiltrations and papillary injections on both the buccal and

52 Practical Advanced Periodontal Surgery

lingual aspects of the teeth for additional pain control and retraction of the flap in different locations of the mouth. In
hemostasis. some cases, slipping of the retractor can be prevented by
placing a notch or a groove superficially on the cortical
Unless contraindicated, 2% lidocaine with 1  :  50 000 bone and subsequently placing the retractor in this groove.
epinephrine is the anesthetic of choice because of its high
concentration of epinephrine, which is suitable for hemo- The following is a list of flaps that are associated with
stasis. Although this high concentration of epinephrine endodontic surgery:
may cause a transient tachycardia in the patient, the
effects are generally short lived. It should be noted that Semilunar Incision
some clinicians prefer 3% marcaine with epinephrine for Although once frequently used by endodontists and oral sur-
nerve block because of its long duration of action. geons for performing apicoectomies, semilunar incisions are
an inferior and obsolete technique. Typically, they provide
In addition to the administration of one cartridge of anes- poor access to the site and do not allow for addressing
thetic for the appropriate nerve block when working on or treating periodontal–endodontic involvements. They often
maxillary or mandibular teeth, local infiltration into oral result in unsightly scars as the incision line is made in unat-
tissue for hemostasis is required. Generally, up to two tached, mobile oral mucosa, and over the osteotomy where
­cartridges of anesthetic should be infiltrated locally around healing by primary intention is impractical, if not impossible.
two or three teeth on either side of the surgical site.
Because most of the receptors in the masticatory mucosa Today, semilunar incisions are performed only during
are of α–adrenergic type, once bound to epinephrine, they emergency incision and drainage.
produce a desired vasoconstrictive effect. In contrast,
because the majority of the receptors in skeletal muscles Full‐Thickness Intrasulcular Incision
are of the ß2–adrenergic variety and their binding to
In this technique, the horizontal incision commences at the
­epinephrine causes vasodilation, care must be taken to
base of the gingival sulcus and is carried through to the
prevent injecting deep into these tissues.
crest of the bone by dissecting the periodontal ligament
fibers. Generally, the horizontal component should be
Soft Tissue Flap Design extended by the width of two teeth on either side of the
tooth being treated. Interproximally, the incision should be
Proper flap design not only should provide easy access to
made with a sharp 15C or a CK‐2 microblade (Sybron Endo,
the location of the pathosis but should also consider and
Orange, CA, USA) lingually while following the contour of
provide postsurgical aesthetics of the periodontium and
the teeth. The complete dissection of the interdental papilla
the gingiva, especially preserving marginal gingiva and
before elevation is desired to prevent recession and
papillary heights. With the evolution of periodontal surgery
formation of “black triangles” postoperatively.
and introduction of new techniques, some older tech-
niques have been phased out.
Two variations of the full-thickness intrasulcular flap exist:
Periodontal condition of the failing tooth and its neighbor-
• The triangular flap, which uses one vertical releasing inci-
ing teeth play an important role in the design of the soft
sion in the more medial aspect of the flap, typically requires
tissue flap; as does the prosthetic state of the surgical site.
a longer horizontal incision. The releasing incision should
When working on teeth with crowns or areas near the
begin perpendicular to the line of the free gingival margin
pontic of a fixed partial denture, modifications to the inci-
for a short distance of approximately 2–3 mm. It  is then
sion line may be needed to facilitate suturing and ensure
rounded off at the corner and transitioned into the vertical
soft tissue esthetics in the long term. Also of importance
component of the releasing incision. It is not unusual to
are anatomical factors, such as the mental foramen, which
extend the release incision up to the mucobuccal fold and
may ultimately play a role in the selection of the location for
up to two times the length of release incisions in periodontal
the placement of the vertical release incision.
surgery in order to access the root apex easily. Triangular
flaps are commonly used in surgeries of the posterior
In endodontic surgery, incisions are made to facilitate
region (Figures 5.26–5.28), or in the anterior region when
elevation and reflection of a full‐thickness flap. Generally, a
treating teeth with cervical resorptions or perforations.
horizontal component and two vertical release incisions
are used to provide easy access without pulling and tearing • The rectangular flap is similar to the triangular flap,
the corners of the flap. Once the tissue is reflected, great except it uses two vertical releasing incisions and as a
care must be taken to prevent the placement of the retrac- result, the horizontal incision may be shorter. This flap
tors on soft tissue. Many manufacturers have developed provides better access to the apex of anterior teeth than
contour specific retractors that provide good ergonomic the triangular flap.

Perioradicular Surgery, Tooth Replantation 53

 Full‐Thickness Submarginal Incision
Also known as the mucogingival flap, it is indicated ­primarily
in anterior surgeries to treat teeth with crowns and where
esthetics of the crown margin is of great importance. The
beveled scalloped horizontal component of the incision is
placed in attached gingiva and is terminated by rounding
off and transitioning into the placement of two parallel verti-
cal releasing incisions at either end. The scalloping aids
in exact repositioning of the flap postsurgically to ensure
healing by primary intention. It is critical to have a 2‐mm
band of healthy attached gingiva coronal and apical to the
horizontal incision line (Figures 5.29 and 5.30).

Figure 5.26  Maxillary first molar exhibiting persistent symptoms

despite the radiographically acceptable appearance of the nonsurgical
root canal therapy.

Figure 5.29  Submarginal incision and suturing with 6‐0 Vicryl sutures
in the esthetic zone.

Figure 5.27  Triangular full‐thickness flap provides access to the

surgical site.

Figure 5.28  Apicoectomy and retrofill with MTA was performed on all Figure 5.30  Suture removal four days later reveals great healing with
three roots via a buccal approach. minimal scar formation.

54 Practical Advanced Periodontal Surgery

Lack of such attachment especially coronal to the incision
may critically undermine the blood supply and result in disas-
trous postsurgical recession. Needless to say, acquiring
accurate preoperative periodontal probing depths is critical.

This flap differs from the Luebke‐Ochsenbein flap in that it

is not wider at the base because the two vertical releasing
incisions are made parallel to each other.

Papillary‐based Incision
This technique has been developed in recent years with
the purpose of maintaining the height of the interdental
papilla. The incision is similar to the full‐thickness intrasul-
cular incision. However, in the region of the interdental
papilla, instead of the incision including and dissecting the
papilla, it is placed at the base of the papilla. This incision Figure 5.31  Failing root canal treatment on maxillary first and second
is a curved incision that connects the sulcus of one tooth premolars.
at its mesial line angle to the sulcus of the more anterior
tooth at its distal line angle. This incision is carried out by a
microblade first to a depth of 1.5 mm. A second incision is
directed toward the osseous crest and retraces the initial
superficial incision.

Upon completion of the surgery, proper suturing is important

to guarantee optimal results. Generally, the use of 7‐0 or
smaller monofilament nonresorbable sutures has been rec-
ommended for closure of the papillary-based incision. A mini-
mum of two single interrupted sutures are placed to ensure
primary closure at the papillary base. Sutures are to be
removed within three to five days (Velvart and Peters 2005).

Osteotomy and Curettage
Once the flap is reflected and stabilized without causing
trauma to the soft tissue, the hard tissue management
phase of the surgery may begin. The root tip location must
be approximated from a pre-operative radiograph, pres-
ence of pathology, cortical bone fenestration, or a root
prominence underlying the cortical bone. In some cases
sounding the bone quality over the root apex with a sharp
endodontic DG16 explorer (Hu‐Friedy, Chicago, IL, USA)
may give information about the location and the extent of Figure 5.32  Flap elevation reveals fenestrations over the root
the underlying lesion (Figures 5.31 and 5.32). prominences identifying the location of the defects.

Once the location for the osteotomy is determined, using

an Impact Air 45 (Palisades Dental, Englewood, NJ, USA) Any soft tissue lesion attached to the root tip must be
high‐speed handpiece and Lindemann H 161 (Brasseler curettaged before root resection. This is achieved by the
USA, Savannah, GA, USA) bone‐cutting carbide bur, the back‐action use of long shank spoon excavators or bone
osteotomy is made under low magnification with copious curettes to detach the lesion from its bony housing in total.
irrigation with sterile saline to cool the surgical site. This is This tissue must be submitted for biopsy. Any remnants
done by brushing away at the bone until the root apex is still attached to the root can be removed via a 34/35
visualized (Figure 5.33). Jaquette scaler or a 13/14 periodontal curette (Hu‐ Friedy).
Excessive curettage of the bony crypt may cause excessive
With the advent of modern microsurgical instruments, the bleeding, which may in turn complicate and compromise
ideal osteotomy can now be only 5 mm in diameter. the stages of root‐end resection, retropreparation, and

Perioradicular Surgery, Tooth Replantation 55

 Up until the early 1990s, the practice was to resect the root
end with a 45° buccolingual bevel. This was practiced
because it was impossible to form a cavity preparation into
the canal even with the smallest handpiece. Presently, with
the development of microsurgical instruments, and, more
specifically, ultrasonic tips, micromirrors, and pluggers, the
recommended root‐end resection bevel angle is between 0
and 10°. This modification in technique has its many advan-
tages. It conserves root and buccal cortical bone and
reduces the chance of incomplete resection and perhaps
missing lingual anatomy. By reducing the cavity prepara-
tion, cavosurface margin, and number of exposed dentinal
tubules, the risk of microleakage is reduced (Kim 2002).

This phase of the procedure should be carried out under

mid‐range magnification using the Impact Air 45 hand-
piece and Lindemann H 161 bur with sterile saline irriga-
tion (Figures 5.34 and 5.35).

Staining and Inspection
Once the root end is perceived as being completely
resected, it is time to switch the magnification to the high
Figure 5.33  Osteotomy is initiated by slow removal of the buccal range for root‐end inspection. The root end should be
cortical bone until the root tips are visible. stained with sterile methylene blue dye (American Regent
Inc., Shirley, NY, USA) and rinsed away with sterile saline or
water. The dye will stain the PDL circumferentially, reveal-
retrofilling. Therefore, it may be more strategic to leave ing a circle or an ovoid blue perimeter. This is a sign that
small amounts of granulation tissue behind and clean it the root resection was completely carried out through the
after the root‐end filling is placed. lingual aspect. The blue dye will also penetrate into any

The Impact Air 45 high‐speed handpiece is designed in

such way that only a water coolant is sprayed out from the
front onto the bur. The air jet is contained within a closed
circuit and ejected from the rear of the handpiece. This
innovation allows for a much cleaner operation due to the
lack of splatter previously caused by the air stream forced
out of the head of conventional handpieces. Most impor-
tant, it creates a safer operation by eliminating the air that
may be forced into the open vessels of the surgical site
and potentially cause an air emphysema.

Root Resection
The logic behind root resection and its extent is derived
from the models developed by Hess. A 3‐mm reduction in
the root end will decrease the incidence of lateral canals
by 93% and apical ramifications by 98%. Therefore statisti-
cally, a 3‐mm apicoectomy will markedly favor the elimina-
tion of persistent bacteria and undebrided tissue in the
apical root canal portion (Kim et al. 2001b). This will also
enable the surgeon to remove and eliminate iatrogenic
factors more prevalent to the last 2–3 mm of the root canal
system. Once the root is resected, access to the canal is
possible for evaluation and formation of an impervious Figure 5.34  Endodontic lesion is enucleated in whole and the root tips
retroseal. are resected with almost a zero bevel angle.

56 Practical Advanced Periodontal Surgery

 used to create the cavity preparation along the long axis of
the root. This step should also be carried out under high
magnification and constant irrigation. Incorporating the
isthmus between two canals or a fin to the side of a canal
into the preparation is just as critical as preparing the
canals themselves (Figures 5.37–5.39).

Any tissue left in the isthmus could be a source for a poten-

tial failure. The preparation is carried out to a depth of
3–4 mm. The preparation should be inspected under the
microscope in order to ensure that no gutta percha remains
on the prepared portion of the canal walls. A microplugger/
condenser can be used to compact any residual gutta per-
cha coronally and away from the root tip.

Some surgeons prefer to treat the root end with 2% chlo-

Figure 5.35  One‐year follow‐up demonstrates complete healing of
rohexidine gluconate (Ultradent, South Jordan, UT, USA).
both teeth.
This antibacterial agent has proved to be effective against

Figure 5.37  Mandibular first molar exhibiting persistent pathology of

the mesial root.

Figure 5.36  The resected and stained mesial root of a mandibular

molar reveals an unfilled MB canal and the isthmus connecting the MB
and ML canals.

canal, isthmus, portal of exit, or fracture and reveal areas

that need to be prepared with the ultrasonic tips (Figure 5.36).

Prior to the use of ultrasonic tips, a CX‐1 microexplorer

(Sybron EndoA) may be used to probe into these areas.
Sometimes it is helpful to scribe the preparation outline
with the CX‐1 onto the root‐end surface before the use of
ultrasonic tips.

Retropreparation
After the areas to be retroprepared have been identified, Figure 5.38  Apicoectomy, retropreparation, and retrofill of the MB and
ultrasonic tips with the appropriate angulations can be ML canals and the isthmus connecting them.

Perioradicular Surgery, Tooth Replantation 57

 toward the osteotomy site and, therefore, promote bone
formation.

Retrofill
Once the moisture is controlled, it is time for sealing the
root end. The root end must be irrigated and air dried with
a Stropko irrigator/drier with a microtip (Sybron Endo).

Although amalgam was once the root‐end filling of choice,

today it is no longer the standard of care to place amalgam
as a retrograde filling. Today’s materials provide a better
seal, do not tattoo the gingiva, do not corrode, and are
more bio‐compatible than amalgam. Although an array of
materials are presently available, MTA and Super‐EBA are
the most promising and most widely used.
Figure 5.39  Near‐complete healing is noted at six‐month recall
appointment. MTA exhibits many of the desired characteristics of a retro-
fill material. MTA is radiopaque and gentle to the periapical
tissue, induces cementogenesis, has great sealing ability,
Enterococcus faecalis, the persistent bacteria species in and is tolerant to moisture. In fact, MTA requires moisture
many endodontic failures. to harden and set. Unfortunately, it is difficult to handle.
MTA is mixed with sterile water to form a wet sand–like
granular mixture. The easiest way to place it into the root‐
Moisture Control
end preparation is with the MAP System (Roydent, Johnson
The bone crypt must be dry before the placement of the City, TN, USA) or the MTA pellet forming block (G. Hartzell
retrofill material. If bleeding is present, it may be con- & Son, Concord, CA, USA). Once placed, MTA takes a
trolled by the application of topical hemostatic agents. long time to set and should not be rinsed out. The crypt
Racellet #3 (Pascal Co., Bellevue, WA, USA) epinephrine may be cleaned with a moist cotton pellet.
pellets are usually effective in controlling the bleeding in
most osteotomy sites. They contain racemic epinephrine, Super‐EBA, on the other hand, is difficult to mix but easier
which aid in hemostasis. These pellets are packed into to handle. It is mixed into a hard, dull, dough‐like mixture by
the osteotomy site with moderate pressure maintained incorporating powder into liquid with a thick spatula over a
on them for a few minutes. Once hemostasis is achieved, glass slab. Once ready, time is limited to place it because it
all but the last of the pellets are removed. The last pellet sets quickly, especially in the presence of heat and humid-
is deliberately left in the crypt to maintain the hemosta- ity. Super‐EBA is rolled into a small cone and picked up in
sis. Aspiration into the crypt once hemostasis has been small segments with an instrument such as a Hollenbeck or
achieved should be prevented, because it may draw the back side of a spoon excavator. It is then placed into
blood out of the capillaries and initiate bleeding again. It the root end, compacted gently with a microplugger, and
is important to keep track of the number of pellets placed, finally burnished with a microball burnisher. After the mate-
so at the end of the procedure, pellets are not forgotten rial is fully set, it may be polished with a composite finishing
and left behind. bur using a high‐speed handpiece with irrigation.

For more persistent bleeding in larger osteotomies, ferric Once the retrofill material is placed, it is a good practice to
sulfate solution such as Cut‐Trol (Ichthys Inc., Mobile, AL, radiographically verify the density and the depth of the fill
USA) may be used. Ferric sulfate has been shown to delay before suturing the flap. If any modifications need to be
postoperative healing (Lemon et  al. 1993). Therefore, it made, this is a good time for it.
should only be used sparingly and currettaged and rinsed
thoroughly at the end of the surgery before suturing. After the quality of the filling is confirmed to be satisfactory,
the crypt must be curettaged to remove any residual mate-
Calcium sulfate such as Surgiplast (ClassImplant, Rome, rial or coagulum and to induce bleeding. The surgical site
Italy) can also be used as a mechanical barrier to promote should be rinsed with sterile saline to wash off any parti-
hemostasis in large osteotomies. Calcium sulfate is an cles or loose debris and also to rehydrate the flap and the
osteoinductive resorbable agent that may act as a barrier cortical bone, which may have been drying under the
against the more rapid mobilization of soft tissue cells intense illumination from the SOM.

58 Practical Advanced Periodontal Surgery

Suturing and Suture Removal procedure, 1000 mg of acetaminophen or 800 mg of ibu-
profen should be taken by the patient as a preemptive
The flap needs to be reapproximated passively before
strike against pain when the local anesthetic slowly wears
suturing. Best results are obtained when the flap margins
off. Postsurgically, ibuprofen 800  mg three times daily
approximate without the use of force or under tension. For
should be prescribed and taken by the patient for three to
this purpose, a wet 2 × 2 gauze is compressed gently over
five days. This regimen should be followed regardless of
the flap and cortical bone until tissue margins assume their
the level of patient’s comfort as an anti‐inflammatory medi-
preferred position.
cation. For those patients who are allergic to ibuprofen,
1000 mg acetaminophen can be taken four times daily.
As for suture material, monofilament nonresorbable
Some more recent studies suggest combination therapy
Prolene (Ethicon Inc., Somerville, NJ, USA) sutures in sizes
with ibuprofen and acetaminophen will achieve more effec-
of 6‐0 or smaller provide the optimal results. The advan-
tive levels of analgesia (Menhinick et al. 2004).
tage of these types of sutures is that their size causes the
least amount of trauma and that they are nonresorbable,
Applying an ice pack to the face over the region of surgery
which minimizes the inflammation typically associated with
with moderate pressure for 20 minutes on and 20 minutes
suture materials. When suturing the apical margins of the
off is very important in controlling inflammation, swelling,
vertical release incision near the mucobuccal fold, how-
and ecchymosis. This regimen is most effective if followed
ever, it is advantageous to use a resorbable suture such as
up to eight hours postsurgically. Moist heat application is
a coated Vicryl or Monocryl (Ethicon Inc.). Sutures in this
recommended for 24–48 hours after surgery.
region sometimes have a tendency to become imbedded
into the wound closure and may be difficult to remove.
Rinsing with 10 ml of 0.12% chlorohexidine gluconate solu-
tion twice daily should begin 24 hours before surgery and
In terms of suturing technique, single interrupted and
continue for up to 2 days after suture removal. Gentle
­vertical mattress sutures are the most commonly used.
brushing with a soft bristle toothbrush should be limited to
Vertical mattress sutures are preferred when suturing
the areas away from the surgical site and to the occlusal
mobilized interdental papillae in the anterior esthetic zone.
surfaces of teeth proximal to the incision line.
Sling sutures in the posterior region can be used in place
of two single interrupted sutures. When suturing the verti-
Patients should be informed that in the event of a suture
cal releasing incision, a continuous interlocking suture
becoming untied, they should not pull on the loose end as
can be used to expedite suturing by eliminating the need
they may detach the flap from the underlying bone.
for multiple knots.
Consumption of a normal diet is recommended, although
Whatever the suturing technique, care must be taken that
a  soft diet is preferred for the first 48 hours. In addition,
the suture and the knots are free of any tension. Tissue
hot liquids should be avoided because they may promote
margins may be torn when sutures are tight and act as a
bleeding and cause pain if they come in contact with
guillotine. In addition, the underlying tissue may become
exposed tissue or bone. Smoking and consumption of
deprived of blood perfusion and ultimately necrose in
alcohol should be avoided until sutures are removed and
presence of over‐tight knots.
proper healing is confirmed.

Postsurgically, sutures should be removed within 3–5 days,

Patients should avoid physical activities that can increase
although some studies advocate suture removal by 48 hours.
their heart rate and increase bleeding. In addition, patients
should be discouraged to manipulate the areas of the face
Postoperative Instructions or mouth, which may pull on the sutures and ultimately
Postoperative instructions should be directed toward ensur- extricate them.
ing patient’s comfort, control of bleeding and swelling, and
prevention of infections.
Complications
Patient reassurance is an important part of postoperative Serious complications after endodontic surgery are infre-
instructions. It is better for the patient to know about quent. Most cases of pain, swelling, and bleeding are eas-
potential pain, swelling, or bruising ahead of time rather ily managed. In some rare cases, patients may have
than being caught by surprise. serious infection or paresthesia. Immediate attention is
required for such incidences.
Pain following endodontic surgery is usually mild. For this
reason, non‐narcotic analgesics are more than adequate Although paresthesia is often transient and is not due to
in controlling patient’s pain. Just before the start of the the complete severing of a nerve bundle, it may cause

Perioradicular Surgery, Tooth Replantation 59

some concern in the patient. Patients should be reassured REFERENCES
that the sensation will often return, and it could simply be
ADA (1999). Survey of Dental Services Rendered. ADA Report:
the result of inflammation and nerve compression. Only in September 2002.
rare occasions is paresthesia irreversible. The patient must
be re-evaluated at the office, and the affected area must Kim, S. (2002). Endodontic microsurgery. In: Pathways of the Pulp, 8e
be mapped intraorally by the use of a sharp dental instru- (eds. S. Cohen and R.C. Burns), 683–725. St Louis: Mosby.
ment. A diagram of this area must be drawn in the patient’s
Kim, S., Pecora, G., and Rubinstein, R. (2001a). Color Atlas of
dental record and compared to subsequent examinations Microsurgery in Endodontics, 125. Philadelphia: WB Saunders.
to check for signs of improvement. If no improvement is
noted, the patient should be referred to a specialist for Kim, S., Pecora, G., and Rubinstein, R. (2001b). Color Atlas of
further care and monitoring. Microsurgery in Endodontics, 85–94. Philadelphia: WB Saunders.

Kupfer, I.J., Sidney, R., and Kupfer, B.S. (1952). Tooth replantation
Infections after endodontic surgery are uncommon. following avulsion. N.Y. State Dent. J. 19: 80.
Routine prescription of oral antibiotics is not supported by
studies and therefore not recommended. The antibiotic of Lemon, R.R., Steele, P.J., and Jeansonne, B.G. (1993). Ferric sulfate
choice for treating endodontic infections is 500 mg penicillin hemostasis: effect on osseous wound healing. Left in‐situ for
maximum exposure. J. Endod. 19: 170–173.
VK every six hours for one week. If this initial therapy does
not provide the desired pharmaceutical result, it can be Menhinick, K., Gutmann, J.L., Regan, J.D. et al. (2004). The efficacy
supplemented with 500 mg metronidazole every six hours of pain control following nonsurgical root canal treatment using
for one week. Also, the patient can be taken off of the ibuprofen or a combination of ibuprofen and acetaminophen in a
Penicillin VK and placed on 300 mg clindamycin every randomized, double‐blind, placebo‐controlled study. Int. J. Endod.
37: 531–541.
eight hours for one week. In those rare cases where the
patient is severely swollen, febrile, and may have difficulty Rahbaran, S., Gilthorpe, M.S., Harrison, S.D., and Gulabivala, K.
breathing or swallowing, immediate referral to the hospital (2001). Comparison of clinical outcome of periapical surgery in
and administration of intravenous antibiotics is indicated. endodontic and oral surgery units of a teaching dental hospital: a
retrospective study. Oral Surg. Oral Med. Oral Pathol. Oral Radiol.
Endod. 91: 700–709.
Last, during maxillary posterior surgeries where the maxil-
lary sinus and the Schneiderian membrane have been Reuben, H. and Apotheker, H. (1984). Apical surgery with the dental
involved, the patient must be placed on a prophylactic microscope. Oral Surg. Oral Med. Oral Pathol. 57: 433–435.
dose of 875 mg of Augmentin twice daily for one week to
prevent invasion and infection of the sinus by normal oral Rubinstein, F.A. and Kim, S. (1999). Short‐term observation of the
results of endodontic surgery with the use of a surgical operation
flora. The patient should also be advised not to blow the
microscope and Super‐EBA as root‐end filling material. J. Endod.
nose and to take over‐the‐counter nasal decongestants. 25: 43–48.
A one‐week follow‐up visit is recommended to ensure no
complications have arisen. Maxillary sinus involvements, if Rubinstein, F.A. and Kim, S. (2002). Long‐term follow‐up of cases
treated in a timely manner, will often heal uneventfully. considered healed one year after apical microsurgery. J. Endod.
28: 378–383.

RECALL Ruskin, J.D., Morton, D., Karayazgan, B., and Amir, J. (2005). Failed
root canals: the case for extraction and immediate implant placement.
Patient’s healing must be monitored periodically. Because J. Oral Maxillofac. Surg. 63: 829–831.
the average healing time for surgical cases has been
Velvart, P. and Peters, C.I. (2005). Soft tissue management in endo-
reported to be seven months, it makes sense to recall the dontic surgery. J. Endod. 31: 4–16.
patient within one year post‐treatment. Earlier follow‐up
appointments may not indicate any healing, although healing Wang, N., Knight, K., Dao, T., and Friedman, S. (2004). Treatment
may be in progress. outcome in endodontics – the Toronto study. Phase I and II: apical
surgery. J. Endod. 30: 751–761.
For cases in which a timely secondary intervention would Zuolo, M.L., Ferreira, M.O.F., and Gutmann, J.L. (2000). Prognosis in
be imperative in case of a failure, a three‐ to four‐month periradicular surgery: a clinical prospective study. Int. Endod. J. 33:
recall schedule is justified and perhaps more beneficial. 91–98.

60 Practical Advanced Periodontal Surgery

Chapter 6 The Contribution of Periodontics to Prosthodontics:
Treatment Planning of Patients Requiring
Combined Periodontal and Prosthodontic Care
Haneen N. Bokhadoor, Nawaf J. Al‐Dousari, and Steven Morgano

INTRODUCTION medications. An example of a systemic disease affecting

oral health is diabetes mellitus. Patients with diabetes melli-
Treatment planning for patients with complex dental needs
tus are more likely to develop periodontal disease com-
involves multidisciplinary collaboration with the prostho-
pared with patients without diabetes, and periodontal
dontist, periodontist/oral surgeon, orthodontist, endodon-
disease is often considered the sixth complication of diabe-
tist, and patient. It is a carefully sequenced process and is
tes mellitus. Patients with uncontrolled diabetes are espe-
designed to eliminate or control etiologic factors, repair
cially at risk (Mealey and Oates 2006).
existing damage, and create a functional, maintainable
oral environment. Successful treatment depends on a thor-
The medical history can also alert the dentist to other disor-
ough evaluation of all available information, a definitive
ders, such as a prosthetic cardiac valve that requires antibi-
diagnosis, and a thorough integration of all necessary pro-
otic prophylaxis (Davies 1993). The presence of a pacemaker
cedures prescribed for the patient. The treatment process
contraindicates the use of electrosurgery (Flocken 1980).
is composed of a series of phases: a diagnostic phase, a
Previous radiation therapy for neoplastic diseases of the
treatment‐planning phase, a treatment phase, and a main-
head and neck region can have a profound effect on the oral
tenance phase.
cavity (AAP position paper 1997). Medications causing
xerostomia can lead to cervical dental caries and periodon-
DIAGNOSTIC PHASE (DATA COLLECTION)
tal disease, and can contribute to early failure of fixed resto-
Diagnosis involves the collection of data obtained from a rations (Thomson et al. 2006). Osteonecrosis of the jaw has
comprehensive patient history (medical and dental), a patient been observed in cancer patients who have undergone
interview (chief complaint), a clinical examination (inspection, invasive dental procedures, such as dental implant surgery
palpation, and percussion), a critical evaluation of mounted or tooth extractions, while receiving treatment with intrave-
diagnostic casts, and a radiologic interpretation. nous bisphosphonates. Invasive dental procedures should
be avoided for these patients whenever possible (Soileau
Patient History 2006; Wooltorton 2005).
Patient’s Social and Environmental History
Dental History
The patient’s social and environmental history are impor-
tant adjuncts to diagnosis and treatment planning and can The dental history serves as a companion to the medical
often determine the entire course of treatment. Examples history. It establishes information on the patient’s involve-
include a patient’s age, gender, occupation, alcohol intake, ment in previous dental treatment, when and why missing
tobacco use, and illicit drug use. teeth were removed, previous problems with dental treat-
ment, para-functional habits, and oral hygiene habits.
Medical History
Chief Complaint
The importance of an accurate comprehensive medical his-
tory cannot be overstated. The medical history reveals sys- The chief complaint can establish the need for additional
temic conditions that could be contributing factors related to diagnostic tests to assist in determining the cause of the
the existing dental disease or that could affect the prognosis dental problems. It is important that any recommended
of dental treatment. A thorough medical history and inter- treatment addresses this chief complaint and that the
view should reveal any previous systemic diseases, injuries, patient’s expectations with regard to the outcome of treat-
surgical procedures, allergies, adverse drug reactions, and ment are realistic.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

61
Clinical Examination bow transfer. Duplicate diagnostic casts are also made
and mounted. A diagnostic waxing of the proposed treat-
Extraoral Examination ment plan is then made. Diagnostic casts and the diag-
A thorough examination should include an evaluation of the nostic waxing represent the guide or “blue‐print” for the
size, shape, and symmetry of the head and neck including restorative plan that assists the dentist and laboratory
the patient’s profile (retrognathic, mesiognathic, prognathic). technician in coordinating the reconstruction of esthetics,
Normal and abnormal clinical findings should be noted in phonetics, and function (Morgano et al. 1989).
detail as a permanent component of the patient’s record.
Prognosis
Intraoral Examination The prognosis is a forecast of the probable course and out-
The intraoral examination includes screening for malignan- come of a disorder. The overall prognosis is concerned with
cies, an evaluation of the patient’s overall caries activity, a the entire dentition. Criteria used to assign a prognosis to
general overview of the periodontal status, and the quality individual teeth are subjective and are usually based on
and quantity of saliva. The dentist should then thoroughly clinical and radiographic findings. A favorable, questiona-
examine the existing restorations and their status, the pres- ble (guarded), unfavorable (poor), or hopeless prognosis is
ence of dental caries, and missing teeth. A complete peri­ assigned to each tooth depending on available bone sup-
odontal assessment is an important component of a port, probing depths, furcation exposure, mobility, crown‐
comprehensive oral examination. It includes an evaluation of to‐root ratio, root proximity, occlusal relationships, extent of
the oral hygiene, a description of the color, form, and texture tooth damage, abutment status, endodontic status, remain-
of the gingiva, a recording of probing depths, an assessment ing tooth structure (restorability), caries susceptibility, qual-
of bleeding on probing, a determination of tooth mobility, a ity and quantity of saliva, and parafunctional habits.
mucogingival evaluation, and an evaluation of furcations.
Making the decision to retain or extract a compromised tooth
Occlusal Examination and Analysis requires a thorough evaluation of all factors, including the
expense and discomfort involved in maintaining the tooth,
One of the most critical factors with regard to treatment plan-
the overall strategic value of the tooth, available literature
ning is an evaluation of the patient’s occlusion. Alterations
from clinical studies on the probability of success of the treat-
and deviations in the occlusal plane can result in a dysfunc-
ment required to retain the tooth, the prognosis of an artificial
tional maximal intercuspal position (MIP), attrition, bruxism,
replacement for the tooth, and the patient’s desires, expecta-
widened periodontal ligament spaces (trauma from occlu-
tions, and needs. Extraction of one or more teeth may be
sion), and impaired mastication. Mounted diagnostic casts
prescribed based on the presence of one or more of the fol-
represent an important diagnostic aid for the thorough evalu-
lowing factors: greater than 75% bone loss, Miller Class III
ation of a patient’s occlusion (Morgano et al. 1989).
mobility (greater than 1‐mm buccolingually, or a vertical
mobility) (Miller 1950), Glickman advanced Grade II or
Radiographic Examination Grade III/IV (through‐and‐through defect) furcation invasion
Basic knowledge of normal radiographic appearances is (Glickman 1958), recalcitrant probing depth(s) greater than
essential. The minimal examination requirements for a 8 mm, unfavorable crown‐to‐root ratio, and a history of recur-
comprehensive treatment plan include a panoramic radio- rent periodontal abscesses. A tooth can also be extracted
graph and a complete‐mouth radiographic series. The for esthetic reasons or to improve the results of orthodontic
presence of dental caries, loss of tooth‐supporting bone, treatment. When a surgical crown‐lengthening procedure
furcation invasions, and any other abnormalities should be will lead to compromised esthetics, furcation invasion, and/
carefully noted and recorded in the patient’s record. or poor crown‐to‐root ratio, extraction is commonly advised
(Becker et al. 1984; Chase Jr. and Low 1993).
Diagnostic Casts and Diagnostic Waxing
Diagnosis
Diagnostic casts are made from impressions of the dental
arches. Irreversible hydrocolloid (alginate) material is usu- Diagnosis is a determination of any variations from what is
ally used in stock metal trays. The trays should allow a considered normal. The dentist should be sensitive to the
uniform thickness of 3–5 mm of impression material. These signs and symptoms presented and note any variations
trays should be large enough to cover the retromolar pads from normal. The dental diagnosis commonly includes a
in the mandible and the hamular (pterygomaxillary) determination of the periodontal health, occlusal relation-
notches in the maxillary arch. The impressions should be ships, function of the temporomandibular joints (TMJs) and
poured immediately with cast (Type III) stone. Once the muscles of mastication, condition of edentulous areas, ana-
casts are retrieved, small nodules are removed. The casts tomic abnormalities, serviceability of existing prostheses
are mounted in a semiadjustable articulator with a face‐ and restorations, and status of the remaining dentition.

62 Practical Advanced Periodontal Surgery

TREATMENT-PLANNING PHASE Some of the considerations and suggestions a dentist
should follow when providing fixed prosthodontic treat-
Sequencing of the treatment plan involves the process of
ment include the following (Morgano et al. 1989):
scheduling the necessary procedures into a time frame.
Effective sequencing is critical to the success of any treat-
• A physiologic plane of occlusion
ment plan. Some treatment procedures must follow others
in a logical order, while other treatment procedures can or • A physiologic vertical dimension of occlusion (VDO)
must occur concurrently. Thus, thoughtful coordination is
• Simultaneous contacts of all anterior and posterior teeth
mandatory. Complex treatment plans are commonly
in MIP
sequenced into phases, including a control phase, an eval-
uative phase, a definitive phase, and a maintenance phase. • A functional anterior guidance free of posterior intercep-
tive occlusal contacts
Control Phase • An unlocked arrangement of cusps and fossae that will
The control phase is divided into two parts: an initial peri- allow comfortable jaw function
odontal phase and a provisional phase. This phase is • Axial loading of posterior teeth
intended to remove the etiologic factors, stabilize the
patient’s oral health, eliminate any active periodontal dis- • The use of a material that will not unduly abrade the
ease, and resolve inflammation. In this phase, often only a opposing dentition
tentative treatment plan can be presented to the patient. • Narrowed occlusal tables, especially with implant‐sup-
Changes commonly occur relative to the prognosis of indi- ported restorations, to minimize unfavorable leverage
vidual teeth at the termination of this phase. The initial peri- and bending moments
odontal phase includes extraction of hopeless teeth,
periodontal debridement and scaling, oral hygiene instruc-
Maintenance Phase
tions, and any indicated occlusal adjustments. The provi-
sional phase then strives to remove conditions preventing This phase includes regular recall examinations that may
effective maintenance, beginning the preventive dentistry reveal the need for adjustments to prevent future break-
component of the treatment. This phase includes caries down and provides an opportunity to reinforce home care.
control to determine restorability of teeth, replacement or The frequency of this phase depends on the patient’s risk
repair of defective restorations, minor tooth changes, and for developing new dental disease. Maintenance visits are
an endodontic evaluation of all remaining teeth. usually at three‐ to six‐month intervals.

Evaluative Phase FINAL PROGNOSIS

The evaluative phase occurs between the control and the The prognosis can be divided into a short‐ and long‐term
definitive phase. It allows for resolution of inflammation and prediction, based on an educated forecast of the response
time for healing. Home‐care habits are reinforced, motiva- to the planned treatment. It must take into account existing
tion for further treatment is assessed, and all preliminary dental and periodontal support, vulnerability to expected
treatment is re-evaluated before definitive care is initiated. disease, host resistance, the patient’s adaptability, the
dentist’s capabilities, and expectations with regard to the
patient’s compliance with prescribed measures. When
Definitive Phase
determining a prognosis, it should be tailored to the spe-
After completing the control and the evaluative phase, the cific clinical situations. The prognosis can be (i) favorable,
patient can enter the definitive phase. This phase begins (ii) guarded (questionable), (iii) unfavorable (poor), or (iv)
with presenting the definitive treatment plan to the patient, hopeless. The dentist should provide a treatment plan that
including a wax replica of the proposed treatment plan. This offers a favorable prognosis (McGuire 1991).
phase is also divided into two parts: a preprosthetic phase
and a prosthetic phase. The preprosthetic phase includes A favorable prognosis implies a high probability of success
preprosthetic periodontal, oral surgical, endodontic, or based on the best available evidence. A guarded or ques-
orthodontic procedures. If implant surgery is proposed, tionable prognosis suggests that one or more mitigating
then a computed tomographic (CT) scan is prescribed to factors are present that are known to adversely affect the
evaluate the width and height of available bone as well as outcome of care. As an example, an endodontically treated
the location of vital structures, such as the inferior alveolar tooth restored with a post‐and‐core and crown but lacking
nerve, artery, and vein (inferior alveolar canal and mental a ferrule would have a questionable prognosis (Morgano
foramen). The definitive phase is completed with the pros- and Brackett 1999). An unfavorable (poor) prognosis
thetic phase for the fabrication and delivery of prostheses. implies a high probability of failure. A molar with a Glickman

Periodontal and Prosthetic Treatment Planning 63

Grade III or IV furcation invasion will usually have a poor
prognosis. Teeth with a hopeless prognosis cannot be
treated with current materials and methods and must be
extracted. An example is a pulpless tooth with a longitudi-
nal root fracture that extends deeply into the alveolar bone.

Patients
Throughout this chapter, the Universal Numbering System
has been used to designate individual teeth. Figure  6.1
summarizes and illustrates this numbering system.

Patient I
A 43‐year‐old woman presented to the clinic with a chief
complaint of, “I don’t like my smile” (Figures 6.2 and 6.3).

Diagnostic Phase
The patient’s medical history was noncontributory. She did not
have any known drug or food allergies. She did not smoke
and drank alcohol only occasionally. Her dental history Figure 6.2  Full‐face frontal view of patient.
included orthodontic treatment that was performed many
years previously to move the maxillary canines into the posi-
tions of the lateral incisors. She brushed twice per day and did
not use dental floss. Extraoral examination revealed no cervi-
cal or submandibular lymphadenopathy and no signs of tem-
poromandibular disorders (TMD) or reports of muscle pain.

The intraoral and radiographic examinations noted the fol-

lowing (Figures 6.4 and 6.5):

• Missing Nos. 1, 5, 16, 17, and 32 and congenitally miss-

ing Nos. 7, 10, 20, and 19
• Maxillary canines in the position of the lateral incisors and
restored with metal‐ceramic crowns to mimic lateral incisors Figure 6.3  Smile line.

8 9
7 10
6
11
5 12
4 13
3 14
2 15
1 16

32 17

18 Figure 6.4  Intraoral view.

31

30 19
• MO silver amalgam restorations, Nos. 2, 15, 30, and 31
29 20

28 21 • Metal‐ceramic fixed partial dentures (FPDs), Nos.

22 3‐x‐5‐6, and splinted crowns, Nos. 12‐13‐14
27
26 25 24 23
• MOD silver amalgam restoration, No. 16
Figure 6.1  Numbering system used in this chapter. • Defective MO silver amalgam restoration, No. 18

64 Practical Advanced Periodontal Surgery

Figure 6.5  Complete‐mouth radiographs.

• DO silver amalgam restoration, No. 20 The diagnosis for this patient was as follows:
• Occlusal silver amalgam restoration, No. 30
• Generalized chronic mild gingivitis
• Generalized inflammation with supragingival calculus in
the mandibular anterior • Localized chronic moderate periodontitis

• Bony defect, site No. 4 (extraction site) • Partial edentulism

• Probing depths within normal range for most teeth with • Multiple defective dental restorations
the exception of teeth No. 3 (distal 5 mm) and No. 14
(distal 5 mm) (Figure 6.6) Treatment-Planning Phases
• Rotated tooth, No. 12 The objectives of therapy for this patient were elimination
of the etiologic factors (open margins and defective resto-
• Absence of hypermobility or furcation invasion rations), control and resolution of periodontal inflammation,

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Facial 323 533 323 312 313 323 323 323 323 335 323
Palatal 323 433 323 323 323 323 323 323 323 335 323
Mobility N N N N N N N N N N N
Furcation 0 0 0 0 0 0

Mobility N N N N N N N NN N N N
Furcation 0 0 0 0
Lingual 323 333 323 323 212 322 223 212 323 323 323 323
Facial 323 333 323 323 212 322 223 212 323 323 323 323

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure 6.6  Periodontal charting.

Periodontal and Prosthetic Treatment Planning 65

 (a) (a)

(b) (b)

Figure 6.7  (a) Teeth Nos. 3, 5, and 6 after removal of defective Figure 6.8  (a) Teeth Nos. 11, 12, and 13 after removal of defective
restorations. (b) Teeth after repreparation. restorations. (b) Teeth after repreparation.

and restoration of esthetics and function. Initially, only a in the area of No. 4. This discrepancy compromised the
tentative treatment plan was presented to the patient. This overall esthetic appearance and contributed to plaque
plan included the removal of artificial crowns, evaluation of accumulation. There was also a gingival line discrepancy
the restorability of teeth, and plaque control measures. between the central incisors and the lateral incisors
because the lateral incisors were originally canines that
Initial Periodontal Phase were orthodontically repositioned.

This phase included scaling and root planing on the distal In addition, there was a gingival line discrepancy between
surfaces of Nos. 3 and 14, oral hygiene instructions, and Nos. 11, 12, and 13 (Figure 6.9). Based on these findings,
reevaluation of any pocket reduction and oral hygiene. a definitive treatment plan was presented to the patient.
This plan was (Figure 6.10) as follows:
Provisional Phase
• Soft tissue augmentation, area No. 4
In the provisional phase, the defective fixed restorations
were removed (Figures  6.7 and 6.8) and replaced with • Microsurgical crown lengthening procedure, Nos. 8 and
physiologically and esthetically acceptable provisional 9 for esthetic purposes
restorations.
• Surgical crown‐lengthening procedure, No. 13 for
esthetic purposes
In evaluating the gingival line in the maxillae, a gingival
line discrepancy was noted that was caused by the pontic • Metal‐ceramic FPD, No. 3‐x‐5

66 Practical Advanced Periodontal Surgery

 • Ceramic crowns, Nos. 6 and 11
• Porcelain laminate veneers, Nos. 8 and 9
• Metal‐ceramic crowns, Nos. 12 and 13

Preprosthetic Periodontal Phase

Soft tissue inlay graft, site No. 4. A split‐thickness flap
was elevated. Soft tissue augmentation for site No. 4
was accomplished by using an autogenous connective
tissue inlay graft obtained from the patient’s palate. The
graft was sutured and secured to the periosteum. The
Figure 6.9  Provisional restorations, Nos. 3‐x‐5, 6, 11, 12, and 13. Note flap was positioned and sutured without tension. The tis-
the gingival line discrepancies at sites Nos. 3‐x‐5, 8‐9, and 11‐12‐13. sue surface of the pontic was relieved in the area of the
surgical site to prevent tissue impingement. The pontic
(a) was relined eight weeks after surgery with autopolymer-
izing acrylic resin (Coldpac; the Motloid Co., Chicago,
IL, USA) to allow gentle pressure on the graft to contour
the soft tissue at the pontic site and develop an esthetic
gingival line. The pontic was relined again one week
later to allow for additional contouring of the gingival line
(Figure 6.11).
Surgical crown lengthening, No. 13. A submarginal inci-
sion was made at the anticipated gingival line and a full‐
thickness flap was elevated. Ostectomy was performed
to allow a 3‐mm distance between the anticipated gingi-
val line and the crest of the alveolar bone (Rosenberg
et al. 1980).The flap was repositioned and sutured with
(b) 4‐0 chromic gut sutures (Figure 6.12).
Surgical crown lengthening, Nos. 8 and 9. Surgical
crown lengthening was required for esthetic reasons
on the facial surfaces of Nos. 8 and 9 only (Figure 6.13).

To preserve the papillae and the soft tissue around Nos.

7 and 10, a microsurgical crown‐lengthening procedure
was performed. There are many advantages of this
technique when compared with conventional surgical
crown-lengthening procedures (Dibart and Karima
2006). This procedure:
(c)
• Is less invasive
• Requires smaller incisions
• Allows greater precision when closing wounds
• Is less traumatic
• Is less painful postoperatively
• Allows faster healing and vascularization
• Produces more predictable results in areas with very thin
gingiva or in the “esthetic zone”

Figure 6.10  Preprosthetic treatment plan: (a) Soft tissue augmentation, area
No. 4. (b) Microsurgical crown‐lengthening procedure, Nos. 8 and 9, for esthetic
purposes. (c) Crown‐lengthening procedure, No. 13, for esthetic purposes.

Periodontal and Prosthetic Treatment Planning 67

 (a) (b)

(c) (f)

(g)

(d)

(h)
(e)

(i)

Figure 6.11  (a and b) Soft tissue inlay graft site No. 4, preoperative view. (c) Split‐thickness flap site No. 4. (d) Connective tissue graft obtained from
the patient’s palate. (e) Graft sutured to the periosteum with chromic gut sutures. (f and g) Flap sutured without tension. (h) One week after surgery. (i) Two
months after surgery.

68 Practical Advanced Periodontal Surgery

 (a) (c)

(b) (d)

Figure 6.12  Surgical crown lengthening procedure tooth No. 13. (a) Preoperative view. (b) 3‐mm distance allowed between anticipated finish line of
crown preparation and alveolar crest. (c) Site sutured with vertical mattress technique and 4–0 chromic gut sutures. (d) Two weeks after surgery.

Prosthetic Phase selected (Vita B1) (VITAPAN Classical Shade Guide; H

Rauter GmbH & Co., Sackinggen, Germany). Porcelain
Figure 6.14 is a wax replica of the proposed treatment plan.
laminate veneers for Nos. 8 and 9, zirconia copings for
Nos. 6 and 11, metal copings for No. 12 and 13, and a
Two months after completion of all periodontal surgical metal framework for No. 3‐x‐5 were made. All copings and
procedures, the margins for all crown preparations were castings were tried in the mouth, and the fit was verified
finalized, and Nos. 8 and 9 were prepared for porcelain with black and white silicone disclosing material (Fit
laminate veneers (Figure 6.15). Checker; GC Corporation, Tokyo, Japan) (Figure 6.18).

New provisional restorations were fabricated, relined, and The veneers were luted with resin cement (Variolink II,
cemented with temporary cement (Temp Bond; Kerr, Ivoclar Vitadent, Amherst, NY, USA). The provisional resto-
Romulus, MI, USA) (Figure 6.16). rations for Nos. 3‐x‐5, 12, and 13 were recemented with
Temp Bond cement. Because the resin luting agent
One week later, a final impression was made with polyether requires an average of two weeks for the shade to mature
impression material (Permadyne Penta L and Impregum beneath the veneers, the final shade selection for the
Penta; 3M ESPE, Seefeld, Germany) (Figure 6.17). remaining restorations was delayed. The final determina-
tion after two weeks was Vita A2 (Figure 6.19).
A face‐bow record was made and jaw relation records at
MIP were made. A definitive cast was fabricated, along At that stage, the application of porcelain to the remainder of the
with a cast of the provisional restorations, and these casts restorations was accomplished with Vita A2 porcelain.
were mounted in an articulator (Mark II Denar; Water Pik Restorations were glazed and the metal was polished. At the
Technologies, Fort Collins, CO, USA). The shade was day of final delivery, provisional restorations were removed.

Periodontal and Prosthetic Treatment Planning 69

 (a)
(b)

(c) (e)

(d)
(f)

(g)

Figure 6.13  Microsurgical crown‐lengthening procedure for the facial surfaces of Nos. 8 and 9 to correct gingival line discrepancy. (a) Preoperative
view. (b) Vertical incisions at the line angles of Nos. 8 and 9 by using a microsurgical blade. (c) Full‐thickness flap elevated. (d) Ostectomy completed. (e)
Flaps sutured with 7‐0 Vicryl sutures. (f) One week after surgery. (g) Two weeks after surgery.

70 Practical Advanced Periodontal Surgery

 Maintenance Phase
The maintenance phase included recall visits every four
months.

Prognosis
The overall prognosis for the treatment provided (short and
long term) is favorable.

Patient II
A 70‐year‐old man presented to the clinic with a chief com-
plaint of, “I need some implants for my lower jaw. My other
dentist just finished all my upper teeth last year, and he
sent me to you for the implants” (Figure 6.24).

Diagnostic Phase
The patient’s medical history was noncontributory. He
Figure 6.14  Wax replica of proposed treatment plan. did not have any known drug or food allergies. He had a
previous history of smoking for 30 years, but for the past
3 years he has been using a nicotine patch and nicotine
A  cleaning solution (Cavidry; Parkell, Farmingdale, NY, USA) supplement gum. He had been smoke‐free since
was applied to all preparations to remove any oily residue, and then.  He drank alcohol occasionally. His dental history
clinical try‐in of all restorations was completed. A resin‐modified included multiple extractions and fixed restorations.
glass ionomer cement (Rely‐X Luting; 3M ESPE) was used for Extraoral examination revealed no cervical or subman-
final cementation of all restorations (Figures  6.20–6.23) two dibular lymphadenopathy and no signs of TMD or reports
months after completion of all periodontal surgical procedures. of muscle pain.

(a) (c)

(b) (d)

Figure 6.15  Preparations for veneers, Nos. 8 and 9.

Periodontal and Prosthetic Treatment Planning 71

 (a) (b)

Figure 6.16  Provisional restoration, Nos. 3‐x‐5‐6‐8‐9‐11‐12‐13. (a) After contouring. (b) In the mouth.

(a) (b)

Figure 6.17  (a) Gingival displacement cord in place. (b) Final impression with polyether impression material.

The intraoral and radiographic examinations revealed the • No hypermobility of the teeth or furcation invasions,
following (Figures 6.25 and 6.26): except for No. 18, which had Class II hypermobility and
Grade III furcation invasion
• Missing, Nos. 1, 2, 3, 5, 14, 15, 16, 17, 19, 21, 23, 24, 25,
26, 29, 30, and 32 Maxillary and mandibular alginate impressions were made,
along with a face‐bow transfer and centric jaw relation
• Metal‐ceramic FPD, Nos. 4‐x‐6 record. The diagnostic casts were mounted in a semi­
• Metal‐ceramic crowns, Nos. 7, 8, 9, 10, 11, 12, and 13 adjustable articulator.

• Defective metal‐ceramic FPD, 22‐x‐x‐x‐x‐27‐28 The diagnosis for this patient was as follows:
• MOD silver amalgam restorations, Nos. 18 and 31
• Generalized mild gingivitis with localized moderate peri-
• Inadequate endodontic therapy, No. 20 with defective odontitis, No. 18
restoration
• Partial edentulism
• Normal probing depths (between 2 and 3 mm), without • Recurrent dental caries
bleeding upon probing, except for No. 18 where the
probing depths were 6 mm on the mesial surface and • Defective dental restorations
5 mm on the distal surface • Inadequate endodontic treatment

72 Practical Advanced Periodontal Surgery

 (a) (c)

(b) (d)

Figure 6.18  Porcelain laminate veneers, Nos. 8 and 9, on cast (a) and bonded (b). (c) Cast framework for FPD, Nos. 3‐x‐5, and zirconia coping, No. 6.
(d) Zirconia coping, No. 11, and castings for crowns, Nos. 12 and 13.

• Implant‐supported metal‐ceramic crowns, sites Nos.

19‐20‐21 (immediate implant placement for No. 20),
and 29
• Replacement of the defective metal‐ceramic FPD, Nos.
22‐x‐x‐x‐x‐27‐28, to restore esthetics and function

Initial Periodontal Phase

The initial periodontal phase included complete‐mouth
prophylaxis and oral hygiene instructions.

Preprosthetic Periodontal Phase

For the preprosthetic periodontal phase, a CT scan was
Figure 6.19  Two weeks after cementation of veneers, shade was prescribed and the proposed implant sites (Nos. 19, 20,
selected (Vita A2). 21, and 29) were evaluated (Figure 6.27).

Tooth No. 20 was extracted, and implants were placed at

Treatment-Planning Phases sites Nos. 19, 20 (immediate implant placement, No. 20),
The treatment plan for this patient included the following: 21, and 29 (Figure  6.28). Implants were uncovered four
months after placement, and healing abutments were
• Extraction of Nos. 18, 20, and 31 placed (Figure 6.29).

Periodontal and Prosthetic Treatment Planning 73

 (a) (c)

(b) (d)

(e)

Figure 6.20  (a) Final restorations after porcelain application and glazing. (b) Intraoral try‐in. (c) Corrected soft tissue profile Nos. 6, 8, 9, and 11. (d and
e) All‐ceramic crowns Nos. 6 and 11 with the clinical appearance of missing Nos. 7 and 10.

74 Practical Advanced Periodontal Surgery

Figure 6.21  Intraoral view of final restorations.

Figure 6.22  Postoperative view of the new smile line.

(a)

(c)

(b)

(d)

Figure 6.23  Before (a) and after (b) (full‐face view). Before (c) and after (d) (close‐up view).

Periodontal and Prosthetic Treatment Planning 75

 (a)

Figure 6.24  Full‐face frontal view of patient. (b)

Provisional Phase
The defective metal‐ceramic FPD Nos. 22‐x‐x‐x‐x‐27‐28
was removed (Figure 6.30).

After removal, it was discovered that No. 22 had a hori-

zontal coronal fracture. Endodontic therapy was com-
pleted. A custom‐cast post‐and‐core was made for No. 22
and cemented with zinc phosphate cement (Zinc Cement;
Patterson Brand, Saint Paul, MN, USA) (Figure 6.31).

An impression of the mandibular arch (implants Nos. 19,

20, 21, and 29 and all natural teeth) was made with poly-
ether impression material (Permadyne Pental L and
Impregum Penta) (Figure 6.32).

Alginate impression material (Jeltrate; Dentsply, Melford, (c)

DE, USA) was used for the maxillary arch. A face‐bow
transfer was made, and a centric jaw relation record was
made for the fabrication of the provisional restorations
(Figure 6.33).

The surgical mounts for the dental implants were prepared

to be used as provisional abutments (Figure 6.34).

A wax replica of the proposed treatment plan was prepared,

and the wax pattern was invested and heat processed to
produce an acrylic resin (Namilon; Justi, Oxnard, CA, USA)
provisional restoration (Figure 6.35).

The provisional FPD was cemented with Temp Bond Figure 6.25  Intraoral views. (a) MIP. (b) Maxillary arch. (c) Mandibular arch.
cement (Figure 6.36).

A centric jaw relation record was completed, and the man-

Prosthetic Phase
dibular cast was mounted. An alginate impression (Jeltrate)
Two weeks later, the patient presented for definitive impres- of the mandibular provisional restorations was made for
sions with polyether impression material (Permadyne the dental laboratory technician to use as a guide in the
Pental L and Impregum Penta) (Figure 6.37). fabrication of the final restorations (Figure 6.38).

76 Practical Advanced Periodontal Surgery

Figure 6.26  Complete‐mouth radiographs.

(a)

(b) (c)

Figure 6.27  CT scan evaluation. (a) Panoramic cut. (b) Horizontal cut. (c) Segmental cut.

Periodontal and Prosthetic Treatment Planning 77

 (a) (b) (c)

Figure 6.28  Preprosthetic phase. Tooth No. 20 was extracted atraumatically. (a) Incision. (b) Extracted tooth. (c) Undamaged socket (then implants were
placed, Nos. 19, 20, 21, and 29).

(a) (b) (a)

(b)

Figure 6.29  Implants were uncovered four months later. (a) Right side.
(b) Left side.

A clear plastic, vacuum‐formed shell of the mandibular

provisional restoration was also provided to the dental lab-
oratory technician as a three‐dimensional guide for the
fabrication of the custom abutments (Figure 6.39).

Metal castings and frameworks were fabricated. The fit of

all metal castings was verified with silicone disclosing
Figure 6.30  (a) Removal of defective FPD Nos. 22‐x‐x‐x‐x‐27‐28. (b)
material (Fit Checker). The selected shade was Vita A2
Horizontal tooth fracture No. 22 was noted.
(Figure 6.40).

Metal castings and frameworks were returned to the

for the cementation of implant‐supported restorations
dental laboratory for porcelain application (Figure 6.41).
(Figures 6.43–6.45).
Canine guidance was established for the dynamic
occlusal scheme (Figure  6.42). Final delivery of the
Maintenance Phase
fixed prostheses was completed by using zinc phos-
phate cement (Zinc Cement) for the cementation of the The maintenance phase included recall visits every three
tooth‐supported FPD and by using Temp Bond cement to four months.

78 Practical Advanced Periodontal Surgery

 (a) (b) Patient III
A 40‐year‐old woman presented to the clinic with a chief
complaint of, “I need new crowns, and I want a better
smile” (Figure 6.46).

Diagnostic Phase
The patient’s medical history was noncontributory. She
did not have any known drug or food allergies. She did
not smoke or drink alcohol. Her dental history included
multiple extractions and multiple restorations per-
formed outside of the United States in 2001. She
brushed twice per day and did not use dental floss.
Figure 6.31  Cast post‐and‐core. (a) Try‐in. (b) Delivery. Extraoral examination revealed no cervical or subman-
dibular lymphadenopathy and no signs of TMD or
reports of muscle pain.
Prognosis
The overall prognosis for the treatment provided (short‐ The intraoral and radiographic examinations noted the
and long‐term) is favorable. ­following (Figures 6.47 and 6.48):

(a) (b)

Figure 6.32  Impression was made for fabrication of provisional restorations. (a) Impression copings in place. (b) Impression.

(a) (b)

Figure 6.33  (a) Face‐bow transfer. (b) Casts mounted in centric relation.

Periodontal and Prosthetic Treatment Planning 79

(a) (c)

(b) (d)

Figure 6.34  Surgical mounts (a and b) of the dental implants were prepared to be used as temporary abutments (c and d).

• Generalized redness, edema, and glazing of the gin- • Distal carious lesions, Nos. 22 and 27
giva, especially in the maxillary anterior sextant
• Probing depths within the normal range (2–3  mm),
• Missing, Nos. 1, 3, 5, 9, 13, 14, 17, 18, 19, 28, 30, and 32 except for teeth Nos. 4, 6, 10, 11, and 15, where probing
depths ranged between 4 and 5 mm (Figure 6.49)
• Multiple defective restorations, Nos. 2‐x‐4‐x‐6, Nos.
7‐8‐x‐10, and Nos. x‐29‐x‐31 • Generalized bleeding upon probing

• Endodontic therapy, Nos. 4, 7, 11, 29, and 31 • No hypermobility or furcation invasions (Figure 6.49)

• Periapical radiolucency, No. 29 • Multiple defective FPDs

• Inadequate endodontic therapy, No. 31 • Multiple teeth with inadequate endodontic therapy
• Occlusal silver amalgam restoration, No. 16 with mesial • Localized bone loss (10–15%), distal surface of No. 15
and distobuccal carious lesions and the mesial surface of No. 10 (Figure 6.48)
• Mesial drift, Nos. 15 and 16
Impressions were made with alginate (Jeltrate). Her diag-
• Defective restorations, dental caries, and inadequate nostic casts were mounted in centric relation in a semi-
endodontic therapy, Nos. 20 and 21 adjustable articulator with a face‐bow record (Figure 6.50).

80 Practical Advanced Periodontal Surgery

 (a) (c)

(b) (d)

Figure 6.35  (a) Wax replica of the mandibular arch. (b) Heat processed provisional restoration. (c and d) Provisional restoration after reline and
temporary cementation.

The diagnosis for this patient was as follows:

• Generalized moderate chronic gingivitis

• Localized moderate chronic periodontitis, No. 15

• Partial edentulism

• Defective dental restorations

• Carious lesions

• Chronic periradicular periodontitis, No. 29

The etiologic factors contributing to this diagnosis were

bacterial plaque as the primary factor and previous den-
Figure 6.36  Patient’s smile after provisional restorations were placed. tistry and patient neglect as secondary factors.

Periodontal and Prosthetic Treatment Planning 81

 (a) (c)

(b) (d)

(e)

Figure 6.37  (a) Final impression made with polyether impression material. (b) Soft tissue replicas around implant analogs. (c–e) Fixed bilateral
mandibular record bases for centric relation record.

82 Practical Advanced Periodontal Surgery

 (a) (c)

(b) (d)

Figure 6.38  (a) Jaw relation record at centric relation with Lucia jig (Lucia 1983) on anterior teeth and silicone registration material (Blu Mousse) on the
posterior teeth. (b) Lucia jig was then replaced with hard wax and relined with Temp Bond cement for stability of the casts during the mounting. (c) Casts
mounted. (d) Diagnostic cast of existing mandibular provisional restoration was also mounted.

Treatment‐Planning Phase • Extraction of No. 16

The objectives of therapy for this patient were elimination • Metal‐ceramic FPDs, Nos. 2‐x‐4‐x‐6, 12‐x‐15, 27‐x‐29‐x‐31,
of the etiologic factors (open margins, overcontoured arti- and 8‐x‐10
ficial crowns, inadequate endodontic therapy, and dental
• Metal‐ceramic crowns, Nos. 7, 11, 20, and 21
caries), control and resolution of periodontal inflammation,
and restoration of esthetics and function. • Endodontic retreatment, cast posts‐and‐cores, and
metal‐ceramic crowns, Nos. 7, 20, 21, 29, and 31
Initially, only a tentative treatment plan could be presented
to the patient. This plan, according to the diagnostic wax-
Initial Periodontal Phase
ing, included the following (Figure 6.51): This phase included complete‐mouth dental prophylaxis with
scaling and root planing on the distal surface of No. 15, oral
• Removal of artificial crowns to evaluate the restorability hygiene instructions, re-evaluation of oral hygiene and pocket
of the teeth and to eliminate plaque retentive factors reduction, three to four weeks after the initial therapy.

Periodontal and Prosthetic Treatment Planning 83

 (a) (c)

(b) (d)

Figure 6.39  (a and b) Clear vacuum‐formed shell of duplicate cast of patient’s provisional restoration to be used as a three‐dimensional guide for
fabrication of custom abutments. (c and d) Milled custom abutments.

Provisional Phase replacement with an implant‐supported metal‐ceramic

crown. Caries control and temporization for teeth Nos. 20
The purpose of the provisional phase was the elimination
and 21 were completed. Evaluation of the abutments
of the etiologic factors and the maintenance of the health
indicated that surgical crown lengthening was required
of the treated periodontium. The defective fixed restora-
in the interproximal area between Nos. 20 and 21
tions were removed, and caries control was completed to
(Figure 6.53).
evaluate the remaining teeth and determine their restora-
bility and prognosis. At this stage, it was determined that
As a result of meticulous oral hygiene and replacement of
all of her abutment teeth were restorable except for No. 4.
the defective fixed restorations with physiologically and
Tooth No. 4 was compromised because of limited remain-
esthetically acceptable provisional restorations, the tissue
ing tooth structure and deep subgingival margins
health improved within two weeks, and the patient was sat-
(Figure 6.52).
isfied with her appearance (Figure  6.54). A gingival line
discrepancy was noted between Nos. 8 and 9 (Figure 6.55).
A crown‐lengthening procedure would lead to furcation
exposure and an unfavorable crown‐to‐root ratio. The At this stage, the definitive treatment plan was presented
recommended treatment was extraction of No. 4 and to the patient (Figures 6.56 and 6.57).

84 Practical Advanced Periodontal Surgery

 (a) (c)

(b) (d)

Figure 6.40  (a) Metal castings and frameworks. (b) Metal try‐in. (c) Fit Checker silicone disclosing material to verify fit. (d) Final shade was Vita A2.

The treatment plan consisted of the following: accepted an alternative treatment plan for the mandible
that included the following:
• Extraction of No. 16
• Endodontic retreatment, Nos. 20, 21, 29, and 31
• Metal‐ceramic FPD, Nos. 8‐x‐10, 12‐x‐15
• Metal‐ceramic crowns, Nos. 20 and 21
• Metal‐ceramic crowns, Nos. 2, 6, 11, 20, 21, and 27
• Metal‐ceramic FPD, Nos. 27‐x‐29‐x‐31
• Implant‐supported metal‐ceramic crowns, Nos. 3‐4‐5,
18‐19, 28, and 31
Preprosthetic Periodontal Phase
• Surgical crown‐lengthening procedure, Nos. 6–11
After the definitive treatment plan was presented to the
• Endodontic retreatment, cast posts‐and‐cores, and patient, the patient entered phase III of the treatment,
metal‐ceramic crowns, Nos. 7, 20, 21, 29, and 31 which was the preprosthetic periodontal phase. This phase
began with surgical crown lengthening in the anterior sex-
The patient accepted the proposed treatment plan for the tant to obtain more crown length and to improve esthetics.
maxillae, but because of financial constraints, she A surgical guide was used (Figure 6.58).

Periodontal and Prosthetic Treatment Planning 85

 (a) (b)

(c)

Figure 6.41  Restorations after porcelain application. (a) In occlusion. (b) Frontal view. (c) Occlusal view.

(a) (b)

Figure 6.42  Canine guidance. (a) Right side. (b) Left side.

86 Practical Advanced Periodontal Surgery

 (a) (b)

Figure 6.43  Clinical try‐in (a) and final delivery (b).

(a) (b)

Figure 6.44  Intraoral view before (a) and after (b) treatment.

Figure 6.45  Patient’s smile after treatment. Figure 6.46  Full‐face frontal view of patient.

Periodontal and Prosthetic Treatment Planning 87

 Figure 6.47  Intraoral view.

Figure 6.48  Complete‐mouth radiographs.

A full‐thickness flap was elevated and ostectomy was per- After crown‐lengthening procedures, a minimal healing
formed to obtain a 3‐mm distance between the anticipated period of six weeks was required before repreparation of
gingival line Pas displayed in the template and the osse- the teeth and relining of the provisional restorations
ous crest, allowing space for the supracrestal gingival tis- because 12 days are required for the junctional epithelium
sues. The flap was placed at the desired position and to form, but the lamina propria is not completely formed
sutured with a vertical mattress technique by using 4‐0 until six weeks (Listgarten 1972a, 1972b) (Figure  6.60).
chromic gut sutures (Figure 6.59). This patient also required a surgical crown lengthening

88 Practical Advanced Periodontal Surgery

 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Facial 323 325 524 323 323 325 423 323 323 333
Palatal 333 325 323 323 323 323 533 323 335 333
Mobility N N N N N N N N N N

Furcation 0 0 0 0 0

Furcation 0 0 0 0
Mobility N N N N N N N N N N
Lingual 332 323 323 323 323 323 323 333 323 333
Facial 323 323 323 323 323 323 323 333 323 323

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Figure 6.49  Periodontal charting.

Figure 6.50  Diagnostic casts.

procedure for Nos. 20 and 21. This procedure was required

primarily in the interproximal area to ensure sufficient
height of tooth structure to develop an acceptable ferrule Figure 6.51  Wax replica of tentative treatment plan.
effect. After flap elevation, ostectomy was completed, and
the area was sutured with a vertical mattress technique
and 4‐0 chromic gut sutures (Figure 6.61). For site No. 3, the available bone width was 5 mm and the
height was 4 mm. The implant size planned for this site was
The last phase of the preprosthetic periodontal phase was 4 × 11.5 mm. Because of the location of the maxillary sinus
the implant phase for sites Nos. 3, 4, and 5. For this phase, and the width of the bone, the treatment plan for this site
the patient was referred for a CT scan with a dual‐purpose included a sinus floor elevation along with buccal augmen-
template (Figure 6.62). tation of the residual alveolar bone with demineralized
freeze‐dried bone allograft (DFDBA; ACE Surgical,
The CT scan was evaluated for the selection of the size of Brockton, MA, USA) and bovine bone (Bio‐Oss;
the implants (Figure 6.63). Osteohealth, Shirley, VA, USA).

Periodontal and Prosthetic Treatment Planning 89

 (a) For site No. 5, the available bone width was 5 mm and the
height was 15 mm. The implant size planned for this site
was 3.75 × 13 mm. Placing this implant according to the
surgical guide would result in a thin buccal plate that is
primarily composed of cortical bone; therefore, the recom-
mended treatment included buccal augmentation with
DFDBA (ACE surgical) and bovine bone (Bio‐Oss).

A full‐thickness flap was elevated, and tooth No. 4 was

extracted. In evaluating the ridge at sites Nos. 3 and 5,
Seibert’s Class I ridge defect was noted (a defect in the
buccolingual direction) (Seibert 1983) (Figure 6.64).

Sinus floor elevation for the site was accomplished by

using the lateral window approach. The sinus membrane
was elevated to receive an implant 11.5 mm in length. The
(b) sinus was grafted with DFDBA (Ace Surgical), bovine bone
(Bio‐Oss), and autogenous bone obtained from the palatal
aspect of the surgical site. After the sinus was elevated
and grafted, guided bone regeneration for sites Nos. 3, 4,
and 5 was completed. The first step in accomplishing
guided bone regeneration was decortication of the site
with a No. 1 round carbide bur to increase the blood sup-
ply to the graft material. After decortication (Buser et  al.
1990, 1996), the site was grafted with DFDBA (ACE surgi-
cal) and bovine bone (Bio‐Oss). A resorbable membrane
(Osteohealth) was used to protect and contain the graft
material (Figure 6.65).
(c)
The surgical area was closed without tension, and the pon-
tic of the provisional FPD was trimmed away from the tis-
sue to avoid irritation and facilitate plaque control. Another
CT scan was made nine months after surgery to determine
the bone width and height in preparation for implant place-
ment after the sinus elevation and grafting procedure
(Figure 6.66).

A full‐thickness flap was elevated. The patient’s provisional

restoration was used as a surgical guide to place the
Figure 6.52  (a and b) Defective fixed restorations were removed. Note implants. The flap was repositioned and sutured with 4‐0
the compromised remaining tooth structure on No. 4 (c). chromic gut sutures (Figure 6.67).

(a) (b)

Figure 6.53  Caries control and temporization, teeth Nos. 20 and 21. (a) Facial view. (b) Lingual view.

90 Practical Advanced Periodontal Surgery

 (a) (b)

Figure 6.54  Intraoral views before (a) and after (b) provisional restorations were placed. Note improved oral hygiene in (b)

Figure 6.55  Gingival line discrepancy.

Figure 6.57  Wax replica of finalized treatment plan for mandibular arch.

Prosthetic Phase
The implants were uncovered six months after placement
(Figure 6.68). The provisional restoration was relined over
the healing abutments four weeks after uncovering
(Figure 6.69).

Four weeks later, final impressions of all teeth and implants

were made with polyether impression material (Permadyne
Penta L and Impregum Penta) and plastic stock trays (Coe
Spacer Trays, Disposable Plastic Trays: GC America Inc.,
Figure 6.56  Wax replica of finalized treatment plan for maxillary arch. Alsip, IL, USA) (Fig. 6.70). A face‐bow transfer and centric

Periodontal and Prosthetic Treatment Planning 91

 (a)

(b)

Figure 6.58  Crown lengthening for the anterior sextant to gain crown length and for esthetic purposes (a) with the use of a surgical guide template to
assist the periodontist (b).

(a)
(c)

(b) (d)

Figure 6.59  Crown‐lengthening procedure for teeth Nos. 6–11. (a) Preoperative view. (b) Full‐thickness flap elevated and ostectomy performed. (c)
Closure with 4‐0 chromic gut sutures. (d) One week after surgery.

92 Practical Advanced Periodontal Surgery

 (a) (c)

(b) (d)

Figure 6.60  Intraoral view before (a) and after (b) surgery. Smile before (c) and after (d) surgery.

jaw relation record were made for the mounting of the A clinical try‐in was accomplished to verify the position of
definitive cast and for the cross mounting with the cast of the custom abutments by using a verification jig fabricated
the provisional restorations. A jig described by Lucia from light polymerizing urethane dimethacrylate resin (Triad
(Lucia 1983) was used as an anterior stop and extra‐hard Tru Tray VLC Custom Impression Tray Material; Dentsply) on
baseplate wax (Tru Wax; Dentsply, York, PA, USA) was the definitive cast (Figure 6.75). At try in, it was noted that
used to make the record on the posterior teeth (Figure 6.71). the custom abutment for No. 4 was rotated on the cast. The
The definitive cast and the cast of the provisional restora- verification jig was relieved in the area of No. 4, and auto­
tions were mounted and cross‐mounted (Figure 6.72). polymerizing resin material (Pattern resin LS: GC America Inc.)
was used to reline and re‐register the position of the custom
Die relief was placed on the dies (Die Spacer; Patterson abutment in the mouth. This relationship was then transferred
Brand), and an artificial acrylic resin tooth (Pilkington to the definitive cast by altering the cast (Figure 6.76).
Turner 30° tooth, 230 LS; Dentsply) was arranged to
replace No. 19 at a height equal to half the height of the Metal castings and frameworks were fabricated. The cast-
retromolar pad (Figure  6.73). A putty (Exaflex Putty; GC ings were tried in the mouth, and the fit was verified with a
America Inc.) index of the provisional restorations was silicone disclosing material (Fit Checker). The framework
made to provide a three‐dimensional view of the available was sectioned between Nos. 3–4 and 4–5 and then sol-
space to the dental laboratory technician for the fabrica- dered (Figure  6.77). The soldered casting for Nos. 3‐4‐5
tion of the custom abutments (Figure 6.74). was tried again in the mouth, and the fit was verified.

Periodontal and Prosthetic Treatment Planning 93

 (a) (c)

(b)

(d)

(e)

Figure 6.61  Crown‐lengthening procedure for teeth Nos. 20 and 21. (a) Preoperative. (b) Provisional crowns removed. (c) Incision. (d) Suturing. (e)
After suture removal.

94 Practical Advanced Periodontal Surgery

 Figure 6.62  Dual‐purpose template for implants Nos. 3, 4, and 5.

(a)

(b) (c) (d)

Figure 6.63  CT scan evaluation for the implants. (a) Panoramic cut. The segmental cuts. (b) No. 3. (c) No. 4. (d) No. 5.

(a) (b)

(c)

Figure 6.64  Extraction of tooth No. 4. Note the Seibert’s Class I ridge defect. (a) Incision. (b) Socket. (c) Tooth sectioned and removed in two pieces.

Periodontal and Prosthetic Treatment Planning 95

 (a) (b)

(d)

(c)

(e)

(f)

Figure 6.65  Sinus floor elevation and guided bone regeneration. (a) Lateral window approach performed and sinus membrane elevated. (b) Sinus
augmented with DFDB, Bio‐Oss bovine bone, and autogenous bone. (c) Decortication of buccal plate for ridge augmentation. (d) Site grafted with DFDBA
and Bio‐Oss bovine bone. (e) Resorbable membrane placed. (f) Closure with 4‐0 Vicryl sutures.

A second jaw relation record was made at the desired lain application (Figure 6.78). The shade selected was Vita
VDO with the use of a Lucia jig as an anterior stop and B1, as per the patient’s request.
extra‐hard baseplate wax (Tru Wax; Dentsply) on the pos-
terior teeth. A pick‐up impression was made of the metal At the porcelain bisque try‐in, modifications to proximal
castings with the use of polyether impression material and occlusal contacts were made. Some adjustments
(Permadyne Penta L and Impregum Penta). The casts were made also to the contours of the restorations.
were mounted and sent to the dental laboratory for porce- Canine guidance was established. The restorations

96 Practical Advanced Periodontal Surgery

 (a)

(b) (c) (d)

Figure 6.66  CT scan evaluation after sinus floor elevation (a). Note the gain in the vertical height (b and c) and the gain in horizontal width (d).

(a) (c)

(b)
(d)

Figure 6.67  Implant placement sites Nos. 3, 4, and 5. (a) Full‐thickness flap elevated. (b) The provisional restoration used as a surgical guide. (c)
Osteotomy sites. (d) Implants placed.

Periodontal and Prosthetic Treatment Planning 97

 (a) (c)

(b) (d)

Figure 6.68  Uncovering of implants. (a and b) Implants uncovered six months after implant surgery. (c and d) Tissue healing, four weeks after
uncovering. Note formation of papillae.

(a) (b)

Figure 6.69  Provisional restoration relined four weeks after uncovering. (a) Intaglio surface. (b) Provisional restoration in the mouth.

98 Practical Advanced Periodontal Surgery

 (a) (c)

(b) (d)

Figure 6.70  Final impression of all teeth and implants. (a and b) Gingival displacement cords. (c and d) Impressions.

(a)

(b) (c)

Figure 6.71  Face‐bow transfer (a) and centric jaw relation record (b and c) by using a Lucia jig on the anterior teeth and extra‐hard baseplate wax on the
posterior teeth.

Periodontal and Prosthetic Treatment Planning 99

 (a) (c)

(b) (d)

Figure 6.72  Definitive casts mounted and cross-mounted with the provisional restorations. (a) Definitive cast against definitive cast. (b) Definitive cast
against cast of provisional restorations. (c) Cast of provisional restorations against definitive cast. (d) Cast of provisional restorations against cast of
provisional restorations.

(a) (b)

Figure 6.73  (a) Die relief placed on dies. (b) Acrylic resin artificial tooth placed in position of No. 19 to establish occlusal plane at a height equal to half
the height of the retromolar pad (marked in red).

100 Practical Advanced Periodontal Surgery

 (a) (b)

(c)

Figure 6.74  Putty index of the provisional restoration was made to provide a three‐dimensional view of the available space for custom abutments for
implants. (a) Facial view. (b and c) Proximal views.

(a) (b)

(c)

Figure 6.75  (a) Custom abutments were fabricated. (b and c) Verification jig was made.

Periodontal and Prosthetic Treatment Planning 101

 (a) (c)

(b) (d)

Figure 6.76  (a) Try‐in of custom abutments. (b) Verification jig indicated that custom abutment for No. 4 was malpositioned. Jig was hollowed out in
area of No. 4. (c) Autopolymerizing acrylic resin was used to register correct position of custom abutment. (d) Position was transferred to definitive cast,
and cast was altered. Note pink stone where cast was altered (arrows).

(a) (c)

(b) (d)

Figure 6.77  (a) Metal castings and frameworks were fabricated. (b) Castings were tried in the mouth. (c) Fit verified with silicone disclosing material (Fit
Checker). (d) Metal framework for implant‐supported splinted crowns, Nos. 3–5, was sectioned, and reconnected with autopolymerizing acrylic resin in
preparation for soldering.

102 Practical Advanced Periodontal Surgery

 (a)

(b) (c)

Figure 6.78  At the final try‐in appointment, new jaw relation records were made at the established VDO, and a pick‐up impression was made of the
maxillary castings. The maxillary cast was mounted. (a) Frontal view. (b and c) Side views.

were then sent for final glazing. At the day of final deliv- Reliance, Worth, IL, USA). Temporary cement was used for
ery, gold screws for the custom abutments Nos. 3, 4, the implant‐supported restorations to ensure retrievability
and 5 were torqued to 32 N·cm with a torque wrench (Figures 6.79 and 6.80).
(Torque Indicator; 3I, Palm Beach Gardens, FL, USA).
The abutments were then torqued again to 32 N·cm after
Maintenance Phase
a 10‐minute waiting period to compensate for embed-
ment relaxation of the screws. The maintenance phase included recall visits every three
to four months.
All restorations were cemented with Rely‐X Luting resin‐
modified glass ionomer cement, with the exception of the
Prognosis
implant‐supported restorations Nos. 3–4–5, which were
cemented with temporary cement (Temp Bond) after seal- The overall prognosis for the treatment provided (short and
ing the screw holes with a temporary sealer (Dura‐Seal; long term) is favorable.

Periodontal and Prosthetic Treatment Planning 103

 (a) (c)

(b) (d)

Figure 6.79  (a) Porcelain applied, Vita shade B1. (b) Restorations tried in the mouth and adjusted. (c) Porcelain glazed and metal finished and polished.
(d) Final cementation.

(a)
(b)

(c) (d)

Figure 6.80  Intraoral views before (a) and after (b). Smile before (c) and after (d).

104 Practical Advanced Periodontal Surgery

CONCLUSION Listgarten, M.A. (1972b). Ultrastructure of the dento‐gingival junction
after gingivectomy. J. Periodontal Res. 7: 151–160.
The overall quality of dental care depends on a concerted
effort among the various dentists involved, a thorough and Lucia, V.O. (1983). Modern Gnathological Concepts – Updated, 83–
107. Chicago: Quintessence.
complete diagnosis that addresses all disease processes,
and a realistic, carefully sequenced treatment plan that McGuire, M. (1991). Prognosis versus actual outcome: a long‐term
offers a favorable prognosis. survey of 100 treated periodontal patients under maintenance care.
J. Periodontol. 62: 51–58.

REFERENCES Mealey, B.L. and Oates, T.W. (2006). Diabetes mellitus and periodon-
tal diseases. J. Periodontol. 77: 1289–1303.
AAP position paper (1997). Periodontal considerations in the man-
agement of cancer patients. Committee on Research, Science and Miller, S.C. (1950). Textbook of Periodontia, 3e, 125. Philadelphia:
Therapy of the American Academy of Periodontology. J. Periodontol. Blackstone.
68: 791–801.
Morgano, S.M. and Brackett, S.E. (1999). Foundation restorations in
Becker, W., Berg, L., and Becker, B. (1984). The long‐term evaluation of fixed prosthodontics: current knowledge and future needs. J.
periodontal treatment and maintenance in 95 patients. Int. J. Prosthet. Dent. 82: 643–657.
Periodont. Restor. Dent. 2: 55–72.
Morgano, S.M., Garvin, P.M., Muzynski, B.L., and Malone, W.F. (1989).
Buser, D., Bragger, U., Lang, N.P. et  al. (1990). Regeneration and Diagnosis and treatment planning. In: Tylman’s Theory and Practice
enlargement of jaw bone using guided tissue regeneration. Clin. of Fixed Prosthodontics, 8e (eds. W.F. Malone, D.L. Koth, E.
Oral Implants Res. 1: 22–32. Cavazos Jr. et al.), 1–23. St Louis: Ishiyaku EuroAmerica.

Buser, D., Dula, K., Hirt, H.P. et al. (1996). Lateral ridge augmentation Rosenberg, E.S., Garger, D.A., and Evian, C.I. (1980). Tooth lengthen-
using autografts and barrier membranes: a clinical study with 40 ing procedures. Compend. Cont. Educ. Dent. 1: 161–173.
partially edentulous patients. J. Oral Maxillofac. Surg. 54: 420–432.
Seibert, J. (1983). Reconstruction of deformed, partially edentulous
Chase, R. Jr. and Low, S.B. (1993). Survival characteristics of ridges, using full thickness onlay grafts. Part I. Technique and
­periodontally‐involved teeth: a 40‐year study. J. Periodontol. 64: wound healing. Compend. Cont. Educ. Dent. 4: 437–453.
701–705.
Soileau, K.M. (2006). Oral post‐surgical complications following the
Davies, R. (1993). Antibiotic prophylaxis in dental practice. Br. Med. administration of bisphosphonates given for osteopenia related to
J. 307: 1210–1211. malignancy. J. Periodontol. 77: 738–743.

Dibart, S. and Karima, M. (2006). Practical Periodontal Plastic Thomson, W.M., Lawrence, H.P., Broadbent, J.M., and Poulton, R.
Surgery. Ames, IA: Wiley Blackwell. (2006). The impact of xerostomia on oral‐health‐related quality of
life among younger adults. Health Qual. Life Outcomes 4: 86 (pub-
Flocken, J.E. (1980). Electrosurgical management of soft tissues in lished online before print November 8, 2006).
restorative dentistry. Dent. Clin. N. Am. 24: 247–269.
Wooltorton, E. (2005). Health and drug alerts: patients receiving intra-
Glickman, I. (1958). Clinical Periodontology, 2e, 694–696. Philadelphia: venous bisphosphonates should avoid invasive dental procedures.
W.B. Saunders. Can. Med. Assoc. J. 172: 1684.

Listgarten, M.A. (1972a). Normal development, structure, physiology

and repair of gingival epithelium. Oral Sci. Rev. 1: 3–67.

Periodontal and Prosthetic Treatment Planning 105

Chapter 7 The Contribution of Periodontics to the Correction
of Vertical Alveolar Ridge Deficiencies
Serge Dibart

ALVEOLAR DISTRACTION OSTEOGENESIS • Patients on bisphosphonates

SURGERY • Irradiated patients (>40–60 Gy)
History • Malignancies
Alveolar distraction surgery is an application of Ilizarov’s
• Heavy tobacco use
­distraction osteogenesis method to the maxillofacial skeleton.
Between 1954 and 1971, Gavriel Ilizarov, a Russian
Advantages
orthopedic surgeon, developed a novel surgical approach
for reconstruction of skeletal deformities (Ilizarov 1971). This See Chiapasco et al. (2004).
involved the use of a mechanical device (the distractor) and
the formation of new bone between the bone segments • Eliminates the need to harvest bone
that were gradually separated by incremental traction
• Less operating time
(Birch and Samchukov 2004). This traction generated
­tension that stimulated new bone formation parallel to the • Distraction histogenesis
vector of distraction (Cope and Samchukov 2001; Samchukov
• Lower risk of morbidity of the surgical site
et  al. 1998). This technique had the added advantage of
displacing and preserving the soft tissue with the mobilized • Crestal part of the distracted segment has lower risk of
bony segment. This is particularly useful in the process of resorption
alveolar distraction where the alveolar housing and the sur-
• Greater vertical bone gain
rounding soft tissue are displaced together in a single, simul-
taneous process (Block et  al. 1996; Chin and Toth 1996;
McCarthy et al. 1995; Ortiz Monasterio et al. 1997).
Armamentarium
• Standard surgical kit, as described in Practical
Indications Periodontal Plastic Surgery plus:
• Combined deficiencies in hard and soft tissue not • Alveolar Distraction Track Plus Kit (KLS Martin,
allowing for dental implant placement Jacksonville, FL, USA) and oscillating and sagittal micro-
• Vertical alveolar ridge deficiency impairing the placement of saws (KLS Martin, Jacksonville, FL, USA)
a dental implant or fixed partial denture (Figures 7.1 and 7.2)
Technique for the Anterior Segment
• Axial correction of misaligned osseointegrated dental
implants or ankylosed teeth After proper local anesthesia (infiltration with xylocaine 2%
with 1 : 100 000 epinephrine and 1 : 50 000 epinephrine
• Orthodontics: Therapy of local open bite for hemostasis), an incision is made in the vestibule
using a No. 15 blade. The incision is made high enough in
Limitations
the mucosa to allow for proper mobilization of the flap
• Must have a minimum of 6 mm of residual bone height (Figure 7.3). The incision may be done in two steps: incision of
the mucosal layer first, then incision of the connective
• Must have adequate bone width (otherwise block graft
tissue, muscles, and periosteum. Keep the blade oriented
necessary before distraction)
toward the alveolar bone. The incision has to be long enough
• Thin residual bony arch, presenting the risk of fracture to allow for easy blunt dissection with a periosteal elevator.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

107
Figure 7.1  Patient presenting with a vertical height defect subsequent to Figure 7.4  The full‐thickness flap is reflected using a periosteal elevator.
the loss of teeth Nos. 8 and 9.

Figure 7.5  Reflection stops at the alveolar crest.

The role of the elevator is to now reflect the flap all the way
Figure 7.2  Tooth No. 8 will be extracted due to severe periodontal up to the alveolar crest of the edentulous site but not
disease. Notice the lack of vertical height of the alveolar bone. beyond (Figures 7.4 and 7.5). It is critical to leave the pala-
tal or lingual periosteum attached to the bone, because it
will be the only source of vascularization of the bony frag-
ment during the distraction process. Once the bony area
is exposed, it is useful to draw a picture of the segment
to be distracted on the bone using a sterile No. 2 pencil
(Figure  7.6). The base of the bony segment should be
wider at the crest than apically (Figure  7.7) to allow for
unimpaired sliding movement during the traction process.
Also at this point, it is important to remember that the dis-
tracted segment should be no shorter than 5 mm.

Once the segment is visualized, it is time to adapt the

distractor to fit the clinical picture. This is the most time‐
consuming part of the operation, because one has to
adapt (cut) and bend the upper and lower arms of the
distractor to fit the underlying bone architecture, while
Figure 7.3  The incision is high up in the vestibule to allow for flap preserving the proper direction of the vector (Figures
mobilization and access. 7.8–7.10). Distractors are available in 6‐, 9‐, 12‐, and 15‐mm

108 Practical Advanced Periodontal Surgery

Figure 7.6  The segment to be distracted is delineated with a sterile No. 2 Figure 7.9  The distractor is placed, verifying the correct direction of the
pencil. distraction vector.

Figure 7.10  One hole in each arm of the distractor is predrilled; this will
allow accurate repositioning of the device.
Figure 7.7  The segment to be cut is drawn on the bone. Notice the
divergence of the cuts that will allow for free movement of the segment.
lengths. After predrilling one hole for each arm while holding
the distractor in place, the sagittal saw (set at 20 000 RPM)
is used to cut the bone (Figure 7.11). It is better not to
do a through‐and‐through cut at the beginning but to
get as close as possible to the palatal/lingual bony plate
(Figure 7.12). Also, the orientation of the saw should always
be kept slightly angled toward the alveolar crest; this
will prevent invasion of anatomical structures (i.e. the nasal
spine, the nasal cavity, or the genial tubercules).

The bony segment is gently detached from the maxilla or

mandible using a very fine chisel and mallet while holding the
segment palatally or lingually with the finger (Figure 7.13). At
this point, the mobile segment is connected to the palatal or
lingual gingiva only through the palatal/lingual periosteum.
Once the segment is freed from the surrounding bone, the
distractor is put back in place and secured through the use of
screws that will engage in the predrilled holes previously
Figure 7.8  The distractor is modified to fit the clinical picture. mentioned (Figure 7.14). A minimum number of five screws is

Alveolar Distraction Osteogenesis 109

Figure 7.11  Using the oscillating microsaw (KLS Martin, Jacksonville, Figure 7.14  The distractor is repositioned very accurately due to the
FL, USA), the osteotomy is started. previously drilled holes and secured with the screws.

Figure 7.12  It is important to get as close as possible to the palatal/ Figure 7.15  The distractor is securely in place.
lingual cortical plate but not go through it with the sagittal microsaw, so as
not to injure the palatal/lingual periosteum.
recommended to secure the distractor (two screws for the
upper segment and three screws for the lower segment).

These screws are self‐drilling, but it is better to use the

drill and predrill; this way, you will avoid running the risk of
splitting the bony segment to be distracted. It is customary
to use the 5‐mm‐length screws (Figure 7.15).

Once the distractor is securely in place, it is useful to

activate it and see how the bony segment glides upward
(Figure 7.16). This is critical because if there is an imped-
iment to the smooth trajectory of the segment to be dis-
tracted, it should be corrected at this point. This is usually
the case when the mesial and distal cuts are somewhat
parallel to each other instead of being divergent. This can
be corrected using a fine fissure bur. The distractor is put
Figure 7.13  A fine osseous chisel (or modified spatula) is used very back in its inactive mode, and a small opening is made in
carefully with a mallet in order to detach the segment to be distracted. the gingiva (“button hole”) to allow for the passage of the
Notice the finger on the palate; it is used to counteract and control the distractor’s arm (Figure 7.17). The suturing is done in two
force of the blow. layers, using chromic gut sutures (Figures 7.18 and 7.19).

110 Practical Advanced Periodontal Surgery

Figure 7.16  The distractor is activated to make sure that there will be no Figure 7.19  Now that the deeper layers are sutured, the second layer
interferences during the distraction process. will approximate the edges of the wound without tension and the area will
heal by primary intention. You can use resorbable or nonresorbable
material for this suture (here, 4‐0 chromic gut was used).

Figure 7.17  After bringing back the segment to its original position, a
small incision is made close to the gingival crest to accommodate the
head of the distractor post. Figure 7.20  The temporary removable prosthesis is adjusted, so that it
will not interfere with the distractor. It will be ground down gradually as
the distraction progresses and the bone and tissues extend vertically.

The removable temporary partial denture is adjusted to fit

the new clinical situation (Figures 7.20 and 7.21).

The patient is seen seven days after the surgery (latency

period), and the distractor is then activated with one
complete turn of the screw (0.3 mm) (starting of the
distraction period). The patient is given the “distractor
key” and asked to repeat the procedure twice a day
(0.6 mm/day of distraction). The patient is monitored
weekly until the desired vertical bone height is achieved
(Figures 7.22 and 7.23). At this point, the consolidation
period begins.
Figure 7.18  A two‐layer suturing technique is used to close the wound.
First, the deeper layers (muscles, etc.) are sutured with an internal This is a three‐month rest period that allows for bone
horizontal or vertical mattress suture. You must use resorbable material remodeling and consolidation. After two months, the dis-
such as chromic gut for this first suture. tractor is removed (Figures 7.24 through 7.26), the wound

Alveolar Distraction Osteogenesis 111

Figure 7.21  The patient with the adjusted prosthesis in place. The Figure 7.23  The bone has been distracted to the desired length. We ask
device is not noticeable. the patient to stop activating the device. In two months, the distractor will
be removed.

Figure 7.24  Two months after the end of the distraction period, the
device is removed using a smaller incision.

Figure 7.22  Periapical radiograph of the segment at the end of the

alveolar distraction process.

is sutured, and the patient is sent home for another month

(Figure  7.27). At the end of the three months (2 + 1) of
consolidation, the patient is sent for a CT scan evaluation Figure 7.25  The distractor is exposed by blunt dissection with a
and the implants are placed. It is important to place the periosteal elevator.

112 Practical Advanced Periodontal Surgery

Figure 7.26  The screws are removed, as well as the device. Notice the Figure 7.29  An exact replica of the patient’s mandible. This
amount of bone gained in the vertical dimension in less than one month. model (ClearView Anatomical Model; Medical Modeling LLC, Golden,
CO, USA) obtained from the patient’s CT scan will allow the critical
landmarks (mental foramen, mandibular canal, roots, etc.) to be
located precisely. This in turn will make for guess‐free and
stress‐free surgery.

Figure 7.27  The surgical wound is closed with internal and external
sutures, as before, and the area is left to heal undisturbed for one month
before placing the implants.

Figure 7.30  Radiographic images (CT scan of the patient’s mandible)

showing the mandibular nerve, mental foramen, etc. Notice the posterior
vertical bony ledge due to the alveolar bone loss and its distance from the
mandibular nerve.

Figure 7.28  A 30‐year‐old patient presenting with a posterior vertical anatomical limitations, access, and proximity of vital
height defect. Tooth No. 17 cannot be used as an abutment for a fixed or structures (mandibular nerve, maxillary sinus). It is very
removable partial denture. useful to visualize the anatomy of the mandible using
a  plastic model (Figure  7.29). This model (ClearView
implants shortly after the removal of the distractor; other- Anatomical Models; Medical Modeling LLC, Golden, CO)
wise, you may run the risk of losing the newly formed bone. can be obtained after the CT scan is sent to the company
(Figure 7.30). The incisions are planned on this extremely
Technique for the Posterior Segment
accurate model, and the distractor is bent and adapted
The posterior segment is much more challenging beforehand (Figure  7.31). This will save considerable
(Figure  7.28) than the anterior segments because of time, stress, and aggravation during the surgery.

Alveolar Distraction Osteogenesis 113

 Figure 7.32  The arrow shows an incorrect vector of distraction. The
bony segment will be too lingual and therefore could not be used for
proper dental implant placement.

Figure 7.33  The arrow shows a correct vector of distraction. The bony
segment will be distracted parallel with the long axis of the adjacent teeth.
Dental implants can be placed in the proper alignment.
Figure 7.31  The segment to be distracted is drawn on the model and
will be replicated in the mouth precisely during the surgery. The distractor
arms are modified and bent prior to the surgery to fit the clinical situation. Preoperative Instructions
This will save a lot of time and aggravation during the surgery.
• Antibiotherapy (i.e. amoxicillin 500 mg three times a
day starting the day of surgery and for seven days) is
indicated.
A Few Words of Caution
• Mild oral sedation could be useful (i.e. diazepam
• Pay special attention to the direction of the vector in
5 mg  the night before and 5 mg one hour before the
the lower anterior mandibular region (Figures 7.32 and
procedure).
7.33).
• Analgesics are recommended (i.e. ibuprofen 600 mg
• Make sure that the distractor does not interfere with the
one hour before the surgery).
occlusion.
• Select patients who are reliable and compliant. Postoperative Instructions
• Always “overdistract” by a couple of millimeters to ensure • Corticosteroids for five days: dexamethasone 0.75 mg,
you will have enough bone. five tablets the day of surgery, then four tablets the

114 Practical Advanced Periodontal Surgery

 next day, then three tablets, and so on, to control the Chiapasco, M., Consolo, U., Bianchi, A., and Ronchi, P. (2004).
swelling Alveolar distraction osteogenesis for the correction of vertically
deficient edentulous ridges: a multicenter prospective study on
• Analgesics: acetaminophen with codeine (Tylenol #3) or humans. Int. J. Oral Maxillofac. Implants 19 (3): 399–407.
ibuprofen 600 mg (Motrin 600) to control the pain
Chin, M. and Toth, B.A. (1996). Distraction osteogenesis in maxillo-
• Ice pack 20 minutes on/20 minutes off for the first 24 hours facial surgery using internal devices: review of five cases. J. Oral
Maxillofac. Surg. 54 (1): 45–53.
• Chlorhexidine rinses twice a day for seven days
Cope, J.B. and Samchukov, M.L. (2001). Mineralization dynamics of
Possible Complications regenerate bone during mandibular osteodistraction. Int. J. Oral
Maxillofac. Surg. 30 (3): 234–242.
• Possible necrosis of the bony segment if it is too small or
completely detached from the periosteum Dibart, S. and Karima, M. (2006). Practical Periodontal Plastic
Surgery. Ames, IA: Wiley Blackwell.
• Fibrous tissue formation at the end of the traction period:
this is more likely to occur if the traction has been too Ilizarov, G.A. (1971). Basic principles of transosseous compression
and distraction osteosynthesis. Orthop. Travmatol. Protez. 32 (11):
vigorous (i.e. 1 mm/day or more)
7–15.
• Infection
Mazzonetto, R., Allais, M., Maurette, P.E., and Moreira, R.W. (2007).
• Fracture of transport segment A retrospective study of the potential complications during alveolar
distraction osteogenesis in 55 patients. J. Oral Maxillofac. Surg. 36:
• Fracture of anchorage segment 6–10.

• Premature consolidation McCarthy, J.G., Staffenberg, D.A., Wood, R.J. et  al. (1995).
Introduction of an intra‐oral bone lengthening device. Plast.
• Undesirable transport vector
Reconstr. Surg. 96 (4): 978–981.
• Fracture of the distraction rod or of the transport disc
Ortiz Monasterio, F., Molina, F., Andrade, L. et al. (1997). Simultaneous
(Mazzonetto et al. 2007)
mandibular and maxillary distraction in hemifacial microsomia in
adults: avoiding occlusal disasters. Plast. Reconstr. Surg. 100 (4):
REFERENCES 852–861.
Birch, J.G. and Samchukov, M.L. (2004). Use of the Ilizarov method to
Samchukov, M.L., Cope, J.B., Harper, R.B., and Ross, J.D. (1998).
correct lower limb deformities in children and adolescents. J. Am.
Biomechanical considerations of mandibular lengthening and
Acad. Orthop. Surg. 12 (3): 144–154.
widening by gradual distraction using a computer model. J. Oral
Maxillofac. Surg. 56 (1): 51–59.
Block, M.S., Chang, A., and Crawford, C. (1996). Mandibular alveolar
ridge augmentation in the dog using distraction osteogenesis.
J. Oral Maxillofac. Surg. 54 (3): 309–314.

Alveolar Distraction Osteogenesis 115

Chapter 8 Papillary Construction After Dental Implant Therapy
Peyman Shahidi, Serge Dibart, and Yun Po Zhang

HISTORY In brief, there is not one single technique that is universally

accepted to be the one that works 100% of the time. Tissue
The presence of a “black triangle” due to the absence of
engineering, with the implantation of fibroblasts in the pap­
interproximal papilla between two adjacent implants has
illary area, may, in the future, help solve this problem by
become a steady concern among implant surgeons and
providing more predictability.
restorative dentists. Three main surgical methods have
been proposed in the past at second‐stage surgery INDICATIONS
(uncovering) to correct the problem. Palacci (1995) sug­
gested that a full‐thickness flap be raised from the palatal • At second‐stage dental implant uncovering, between an
side of the implant and a portion of it be rotated 90° to implant and a tooth or between two or more implants, to
accommodate the interproximal space of the implant. minimize the formation of a “black triangle”
Possible compromise of the blood supply of the rotated • Thick periodontal biotype
small flap, limited amount of pedunculated soft tissue for
some larger interproximal areas, and lack of keratinized CONTRAINDICATIONS
tissue in cases with a narrow band of attached gingiva on
the facial seem to be some of the limitations of this tech­ • Thin periodontal biotype
nique. In 1999, Adriaenssens et al. introduced a novel flap • Lack of keratinized gingiva around the implant(s)
design, the “palatal sliding strip flap,” to help form papillae
between implants and between natural teeth on the ante­ • Need to correct underlying bone
rior area of the maxilla. The flap was designed and man­
aged in a way that allowed the palatal mucosa to slide in a ARMAMENTARIUM
labial direction after dissection of two mesial and distal
• A basic surgical set as described in Practical Periodontal
strips (to create papillae and at the same time augment the
Plastic Surgery (Dibart and Karima 2006)
labial ridge).
• Implant kit
Nemcovsky et al. (2000) introduced a U‐shaped flap raised
• Healing abutments
toward the buccal; the nature of this design was essentially
the same as the one introduced earlier by Adriaenssens,
TECHNIQUE
with some minor differences. In 2004, Misch et al. modified
Nemcovsky et  al.’s technique further by raising the U‐ In the single implant model, a small U‐shaped flap is
shaped flap toward the palatal rather than the buccal side. ­created to allow mobilization of the tissue in the mesial
In 2004, Shahidi developed a surgical procedure with the direction. Another U‐shaped flap, mirror image of the first
goal of guiding the soft tissue that formerly covered the one and sharing the same buccolingual incision, allows
implant over to the sides of the implant and to gently mobilization of the tissues to the distal direction. Occlusally,
squeeze this piece of tissue after insertion of the healing these full‐ or partial‐thickness U‐shaped flaps form an H‐
abutment. This was done to provide enough soft tissue in shape design (Figure 8.1). The exact location of the implant
the interproximal spaces to allow for papilla generation. is obtained using periapical/bitewing radiographs in

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

117
 (a)

(b)

Figure 8.3  Before uncovering implant Nos. 4 and 5.

­ ombination with alveolar ridge mapping with an explorer

c
(c)
following local anesthesia.

In a multiple implant model (Figure 8.2), the covering tis­

sue of the most mesial implant provides the proximal
papilla (i.e. mesial) of that implant using the U‐shape
design; the second implant provides the contralateral
Figure 8.1  Diagram showing the uncovering incision and procedures papilla (i.e. distal) of the first implant.
for a single implant occlusally (a) and buccally (b) and with the healing
abutment in place (c). After proper local anesthesia (Figure  8.3), the initial inci­
sions, made using a No. 15 blade, are done as follows:

1. The first incision is done in a buccopalatal–lingual

direction. The location ranges from the distal edge of
(a) the platform of the implant to the middle of the platform,
depending upon the amount of tissue needed between
implants or between implant and adjacent tooth.
2. The second step involves the placement of a mesio­
distal incision on the buccal side for each implant, per­
pendicular to the first buccolingual incision. The incision
is continued in a slight parabola buccally when there is
(b) adequate keratinized gingiva on the buccal to create a
gingival margin around the implant. The incision is con­
tinued in a slight parabola palatally if there is insufficient
keratinized gingiva on the buccal. Precautions must be
taken to preserve buccal keratinized tissue. The inci­
sion passes the mesial or distal platform of the implant
and ends halfway between the platform and the adja­
(c) cent implant or tooth.
3. The third step involves the placement of a mesiodistal
incision on the lingual/palatal parallel to the incision on
the buccal. The incision for the anterior implants curves
slightly off buccally in the middle, as the top of the
papilla should be smaller than its base in the bucco­
Figure 8.2  Diagram showing the uncovering incision and procedures lingual direction. In posterior implants, the incision is
for two implants side by side, occlusally (a) and buccally (b) with the also placed slightly palatally, because the width of the
healing abutments in place (c). platform of a posterior implant is usually smaller than the

118 Practical Advanced Periodontal Surgery

 Figure 8.5  The palatal view. The U‐ and H‐shaped flaps have been
folded, creating papillae.
Figure 8.4  The abutment and provisional restorations for Nos. 4 and 5
in place. Notice how the gingiva has been folded and maintained via the
temporary restorations.

width of its crown. This is essential in gaining an ade­

quate buccolingual/palatal papilla or col. width to cover
the interproximal space.
4. Flaps are elevated by using the tip of the blade and the
tip of an Orban knife. First, the soft tissues are reflected
from the underlying implant; then each mini‐flap is
undermined by the No. 15 blade and the Orban knife,
and the full‐ or partial‐thickness mini‐flap is extended to
about 1 mm from the adjacent implant or tooth.

Flaps are mobilized and pushed in the mesial and distal Figure 8.6  Two weeks postoperatively. The area has healed uneventfully.
directions to open a “window” and place the healing
­abutment. The application of gauze in the area for a few involves regular brushing with a soft bristle toothbrush
minutes facilitates the molding of the tissues while pushing (Colgate 360‐degree toothbrush) and rinsing for another
the tissues to the sides. After removing the cover screw, a week with chlorhexidine gluconate.
healing abutment with proper height, width, and shape is
inserted into the implant with or without a provisional resto­
ration. This shapes the future papilla by pushing the tis­ SURGICAL INDEXING
sues to the sides and holding them upright (Figures  8.4 This should be considered to increase predictability and
and 8.5). The same technique is repeated for implant(s) esthetic outcome.
distal to the first implant. No sutures are applied, because
healing abutments hold the tissues in the proper position. POSSIBLE COMPLICATIONS
The patient then receives postoperative instructions and is • Complications are very unusual due to the minimally
scheduled for a follow‐up visit within 7–10 days. invasive nature of the procedure.
• Infection is always a possibility and should be treated
POSTOPERATIVE INSTRUCTIONS with local antibiotherapy and antiseptic mouth rinses.
The patient is advised to rinse with chlorhexidine g­ luconate
HEALING
(PerioGard oral rinse; Colgate Palmolive) twice daily for
one week and take ibuprofen (Advil) 200 mg in case of The results are very stable 1.5 
years postsurgery
­discomfort. Postsurgical care after the first week of healing (Figures 8.6–8.9).

Papillary Construction After Dental Implant Therapy 119

Figure 8.7  Five months postoperatively. Notice the formation of the
papilla between implant Nos. 4 and 5. Figure 8.9  Area with the final restorations at 20 months postoperatively.

[P < 0.001], mean difference papilla height between implants

was 0.78 mm [P < 0.138] at six months). The papilla genera­
tion between an implant and a tooth was more stable and
predictable than papilla generation between two implants.

REFERENCES
Adriaenssens, P., Hermans, M., Ingber, A. et al. (1999). Palatal sliding
strip flap: soft tissue management to restore maxillary anterior
esthetics at stage 2 surgery: a clinical report. Int. J. Oral Maxillofac.
Implants 14: 30–36.

Dibart, S. and Karima, M. (2006). Practical Periodontal Plastic

Surgery. Ames, IA: Blackwell Publishing.

Figure 8.8  Five months postoperatively (palatal view). Notice the Misch, C.E., Al Shammori, K.E., and Wang, H.L. (2004). Creation of
presence of a papilla between implant Nos. 4 and 5. inter‐implant papillae through split finger technique. Implant Dent.
13: 20–27.

Nemcovsky, C.E., Moses, O., and Artzi, Z. (2000). Interproximal

The efficacy of this new uncovering technique compared papillae reconstruction in maxillary implants. J. Periodontol. 71:
­
with the conventional one for papilla generation has been 308–314.
tested on 33 patients with 67 implants that were adjacent to
either teeth or implants (Shahidi 2004). The mean difference Palacci, P. (1995). Optimal Implant Positioning and Soft Tissue
between the two surgical methods revealed that this new Management for the Branemark System, 35–39. Chicago:
Quintessence.
technique provided 1.5 mm greater papilla height (P < 0.001)
than the conventional one (mean difference for height of a Shahidi, P. (2004). Efficacy of a new papilla generation technique in
papilla between an implant and a tooth was 1.71  mm implantology. MS thesis. Boston: Boston University.

120 Practical Advanced Periodontal Surgery

Chapter 9 Dental Implant Placement Including
the Use of Short Implants
Albert Price and Ming Fang Su

HISTORY Branemark’s surgical technique required adherence to

­principles based on the results of his wound healing studies.
Branemark’s exploration of the vascular supply to healing
Most of these early studies were done on edentulous sub-
bone evolved into the concept referred to as osseointegra-
jects with severe vertical bone loss (primarily in basal bone):
tion. The geometry of his prototype dental implant was that
of a 3.0 mm titanium cylinder milled with an external thread 1. A minimally traumatic bone preparation should be done
depth of 0.375 or 0.5 mm and finished with an apical taper with careful attention to minimizing heat production.
inward and a coronal flare outward to 4.1 mm final diameter. This required constant irrigation with a sterile saline.
The restorative coronal platform presented a 0.7 mm high
hexagonal shaped extension which had a screw chamber 2. Primary surgical stability should be achieved with
tapped through its center into the body of the cylinder for bicortical stabilization between the compact bone of
fixation of a variety of external devices (Figure 9.1). opposing cortical plates.
3. Spacing of multiple implants was regulated to be 7.0–
According to Branemark’s surgical protocol for edentulous 7.5 mm on center in the mandibular anterior which pre-
areas, a full‐thickness pedicle flap with a partial thickness served sufficient vascular supply to the interproximal
margin was reflected and the bone crest surface exposed. compact bone usually present in this area. Slightly
The required buccal–lingual dimension was at least 6.0 mm closer approximation was allowed in the maxillary ante-
leaving 1 mm of circumferential bone around the standard rior due to the more cancellous nature of this bone.
4.0 mm implant after the osteotomy. The implant receptor
site or osteotomy was initiated by creating a cylindrical 4. A passive bone healing interval with no immediate
hole through the compact bone of the crest and extending direct load was prescribed to allow undisturbed bone
it vertically through intermediate trabeculated bone into and implant surface “osseointegration.”
the compact bone at the opposing base of bone in the 5. A minimum of 1 mm circumferential, vital bone was nec-
mandible, floor of the nose, or floor of the sinus. essary for long term success (early bone chamber
studies found at least 0.5 mm zone of osteocyte destruc-
This initial cylindrical hole in the bone represented the tion with the most careful osteotomy protocol.
body of the implant (3.0 mm in diameter) without threads
(Figures  9.2 and 9.3) Threads were then tapped into the Many of the early Branemark and Branemark clone
sides of the osteotomy when necessary. The coronal entry implants were placed in the mandible between the mental
was subsequently countersunk in line with the cylinder drill foramina and in the maxillary anterior/first bicuspid regions.
axis to enlarge the coronal aspect to accommodate the Most of these early patients had complete loss of alveolar
4.0 mm flared implant geometry. After installation of the bone and minimal vestibule. The objective was to create a
implant a cover screw was placed over the external hex fixed alternative to an inadequate removable prosthesis.
platform to seal the attachment chamber. The entire prepa- Implants have now become a standard of care and the
ration was done with careful attention to measurement treatment of choice for replacement of missing teeth. With
marks embedded in the drilling sequence so that in the the advancement in bone grafting techniques all areas of
finished installation the cover screw lay flush with the bone the mouth have been restored, and while the threaded cyl-
surface. The entry flap could then be sutured passively inder and tapered cylinder implants are still the dominant
with the marginal incision providing primary connective tis- forms, new surface treatments and attachment profiles
sue approximation and rapid healing. have evolved.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

121
Figure 9.1  Image of a Branemark implant depicting design and surface Figure 9.3  Implant fitted into the osteotomy site (cylindrical shape)
structure. Source: Reprinted with permission from Branemark et al. Threads were pre‐tapped or formed by self‐tapping implant design upon
(1985). Tissue‐Integrated Prostheses. Quintessence, Chicago. insertion of implant.

(a) (b)

Resistance
as bevel
contacts
Contersink
sets up
tension which
yields stability

Pressure
directed
upward as
implant is
driven in

Figure 9.2  (a) Branemark’s prototype implant geometry. (b) Osteotomy

outline created by cylinder and countersink burs representing the flared neck
and body shape plus allowance for the cover screw without thread tapping.
This protocol resulted in the cover screw flush with existing bone surface. Figure 9.4  Tapered implant and outline of osteotomy site without thread
tapping.
The current basic geometries include the cylinder with
screw threads (Branemark’s design), the tapered cylinder Branemark stressed bicortical stabilization as essential to
with threads (e.g. Zimmer [Figures 9.4 and 9.5]), and the secure his implant system. The mechanical shape of his
plate form without threads, (e.g. Bicon [Figure  9.6] and design created stability by the resistance of the counter-
Endopore). The microarchitecture of the bone influences sink flare to the draw or pull of the threads into the bony
the choice and effectiveness of these forms to gain the preparation (Figure  9.2a and b); this requires heavy
necessary stability at time of placement. (See bone micro- ­compact bone at each end of the osteotomy (the type of
architecture in Figures 3.2, 3.4, 3.5, Chapter 3.) bone profile usually found in his test cases of severe

122 Practical Advanced Periodontal Surgery

 finger in the nasal areas to feel the penetration of the floor
of the nose (cortex). If the intermediate internal architec-
ture had trabeculae of sufficient bulk, then the engage-
ment of the more compact border areas was not needed.
However, if the trabeculae were thin and widely spaced,
such as in most areas of the upper posterior, then the
screw pressures could break or strip the bone threads in
the body and apical area of the implant or collapse the
coronal bevel and result in a “spinner.” It is possible to
engage the cortical bone at the top of the mandibular
canal, but this was not recommended. As the scope of
placement widened to include more compromised poste-
rior areas, single tooth sites, and even immediate place-
ment in recent extraction sites, the need for alternate
designs which increase surface contact area within a
shorter bone profile evolved. (See Figure 9.6.)

The tapered screw form provides an alternative method of

achieving surgical stability. Its wedge‐shaped screw form
achieves compression of the tapered osteotomy along its
entire surface (see Figures 9.4 and 9.5). Originally referred to
as the “root form implant” it was designed to fit tapered cross
Figure 9.5  Tapered implant within the osteotomy site. sectional sites with natural depressions like the incisal fossa
(see oblique x‐section#27 in Figure 9.7) and the depressions
found over the upper first bicuspid. The tapered form is
especially useful in areas of thin, lightly trabeculated bone.

INDICATIONS
Dental implants are used to:

1. Replace individual teeth

2. Support fixed and removable dental prostheses
3. Anchor maxillofacial prostheses
4. Act as anchorage for orthodontic appliances

5.7 mm SURGICAL TECHNIQUE

Anesthesia
Some practitioners prefer only infiltration so that the patient
6.0 mm “feels” the proximity to vital structures and thus avoid
potential damage to nerves. Block anesthesia, however, is
the most efficient. Marcaine supplemented with lidocaine
provides three to four hours of good working anesthesia
with minimal local reinforcement. Oral sedation with
diazepam 5.0 mg can be used to complement this for most
Figure 9.6  Bicon short implant (5.7 × 6 mm) placed in the mandible nervous patients.
(especially useful in cases with insufficient bony height).
Pre-op visualization: Clinical observation of external bone
resorption). To ensure maximum use of bone and ­bicortical form and well directed periapical radiographs coupled
engagement (CT was not available then), the suggestion with sound anatomic knowledge is usually adequate in sin-
was made to place the finger firmly against the base of the gle tooth placement. In more advanced cases reformatted
mandible and to feel that the bur had penetrated the cor- CT or CBCT images, with a distortion level of 1% or less,
tex. In the maxillary anterior, the surgeon was to place the can be used with confidence (Figures 9.7–9.9).

Dental Implant Placement 123

Figure 9.7  Dry skull and CT scan showing limiting anatomic features both internal (incisal canal on palatal of central incisors #31–32) and external
(incisal fossa over lateral incisor #27) and varied trabeculation of the maxillary bone. (See also Figures 9.16 and 9.17.)

124 Practical Advanced Periodontal Surgery

 (a) (b)

Figure 9.8  (a) Panoramic radiograph (distortion ±25%). (b) Periapical radiograph (distortion ±15%).

IMPLANT PLACEMENT SITE PREPARATION

Entry Incision The only time one needs to reduce bone height at the site
is a requirement for increased restorative space. It should
The objective of the entry incision is to minimize marginal
be kept in mind that reducing the bone increases the
bone exposure at the site where the osteotomy is to be
crown–root ratio of the prosthesis, which increases stress–
placed and to minimize vascular disruption to sensitive
strain relationships at the abutment/implant and implant/
bone areas (Figure 9.10).
bone interface.
1. If one‐stage implant or immediate load, a mid crestal
(Vertical restorative space is the distance from the implant
incision with intrasulcular extensions buccal and lingual
restorative platform to the opposing occlusal surfaces.
is used. This requires retraction of two flaps during
This space varies for different restorative modes. Minimum
osteotomy.
vertical space needed for a crown direct to an implant with
2. If classic delayed, two‐stage implant, then no abutment [screw retained]  =  4.5 mm, vertical space
required for abutment + cemented crown requires 6.5–
a. In the maxillary arch, a horizontal incision is usually
7.0 mm, while a hybrid restoration with bar or bar overden-
made just to the palatal of line angles and two verti-
ture requires 11–12 mm accommodation.)
cal incisions sparing the proximal papillae are
extended through the mucogingival junction (MGJ)
on the buccal. The flap is reflected into the vestibule. The Osteotomy: Single Implant
Incisions vary with site objective and history of local The primary objective is to place the dental implant in the
trauma covered with a gauze pad and no retraction position which satisfies all the biologic and esthetic needs of
is needed (Figures 9.10 and 9.11). the restoration. The ideal position is centered beneath the
b. In the mandibular arch, an incision can be made crown form both buccal–lingual and mesio‐distal and verti-
just to the buccal of buccal line angles, or if the cally at least 3 mm below adjacent soft tissue level to allow
MGJ is close to this area, the incision is made for appropriate development of crown emergence profile. At
below the MGJ and reverse split for about 2 mm to the same time there must be at least 1.0 mm of bone circum-
leave a small bed of periosteum behind. Vertical ferential to allow healing and long term osseointegration. It
incisions sparing the papillae are extended over was estimated that at least 0.5 mm of bone is necrosed in
the crest and through the lingual MGJ. The flap is the most careful surgery (Rhinelander 1974a, b).
reflected to the lingual and usually placement of a
protective gauze pad in the lingual vestibule main- Preparation
tains access.
1. Using a small round bur approximating the size of the
3. If dealing with multiple implants in a severely resorbed first cylinder bur (Figure 9.12), the mesial–distal, buccal–
lower arch with no vestibular depth, then an incision is lingual location is marked with a small depression. This is
made in the middle of available keratinized tissue, remeasured and accepted or revised, and then the prep-
reflecting enough to expose the crest. aration is deepened for 2–3 mm to initiate ­penetration of

Dental Implant Placement 125

 (a)

(b)

Figure 9.9  Two radiographic techniques – same patient area: (a) Conventional tomography technique. The “foggy” quality is due to slice thickness
(5 mm) which distorts image. (b) Axial CT scan: distortion ±1% (reformat slice thickness ≤0.5 mm with 2 mm spacing).

126 Practical Advanced Periodontal Surgery

 (a) (a)

(b)
(b)

Figure 9.11  Full‐thickness flap reflected to the buccal, exposing

Figure 9.10  Incision design buccally (a) and palatally (b) before the alveolar crest, buccal, and palatal.
placement of implant No. 4.
or some method of judging distance to vital structures
should be used in treatment planning visualization prior
to surgery.
the crestal cortex. In some sites, after penetrating
1–2 mm, the bur may suddenly drop. If this happens, a
At this initial stage, it is prudent to drill only as deep as
periodontal probe should be inserted and pushed until
needed with the cylinder bur to check vertical angulation
resistance is detected. The probe may drop 10 mm in
(7–8 mm) with a direction guide. If a change is to be made
areas of very little trabecular content. A revised strategy
in position or direction, then it should be done before pro-
of under‐preparation should be utilized to achieve sur-
ceeding to larger drills. Sometimes it is necessary to use
gical stability. In contrast excessively dense compact
the round bur again to force this change in direction. The
bone might require a smaller round bur first.
direction guide with string attached should be placed
2. The starting cylinder bur is usually 2.0–2.5 mm in diam- (Figures  9.14 and 9.15). The cylinder bur is aligned with
eter (Figure 9.13) (in very dense bone, starting with a this guide and then reoriented to the new direction. (In a
1.5‐mm bur is more efficient). The burs should have given site the nature of internal microarchitecture can be
guide marks to mark vertical depth, and these should quite different from buccal to lingual – see Figures 3.4 and
be checked against a common rule (periodontal probe) 3.5 in Chapter 3. This difference in “structural density” can
for actual depth and reference to CT scan measure- cause the bur to drift into unintended angulation or drift to
ments. Please note that many drill systems do not count buccal or lingual.) The guide is pulled, and the correction
the bevel at tip of bur, and the markings may not repre- is made. Once the new direction is acceptable, the site is
sent millimeters but instead a preferred depth for ideal drilled to final depth. If the vertical dimension of bone
placement of that particular implant system. A CT scan allows, over-drill the depth of the site by about 1.0 mm in

Dental Implant Placement 127

 Figure 9.14  Directional guide used to check the proper alignment and 2
dimensional position of the implant.

(a)

Figure 9.12  Using a pilot or round bur, future site of implant osteotomy
is marked.

(b)

Figure 9.13  Initial cylinder drill is used to initiate the osteotomy.

the initial drill steps. This allows more flexibility as larger

burs are used because they are not efficient end‐cutters Figure 9.15  (a) Directional guide shows the proper alignment of the
and can generate heat if pushed too hard trying to achieve implant occlusally. (b) Using a periodontal probe, the proper depth of the
increased depth at later stages. (Internally irrigated burs osteotomy is being assessed.
have not been found practical, because they constantly
clog, and irrigation fails.) WARNING: DRILL SPEED: Each drill system has been
engineered to be run at certain speeds; failure to follow
Once the initial burs have created place and angulation, the recommendations may overheat bone. Irrigation should
­
site is gradually enlarged and deepened to the final size be  constant, and drilling is done in a pumping action to
according to the steps recommended by the implant sys- remove bone filings, especially in very compact bone. (In
tem guide. (Remember bur drift can occur at every step in the lower anterior, it is sometimes necessary to change to
the drilling sequence since internal microarchitecture var- a new bur after one osteotomy; remember that the smaller
ies. The surgeon must sense this and correct as needed.) burs are being used in every case.)

128 Practical Advanced Periodontal Surgery

 (a) (b)

B L

L B

Figure 9.16  Internal architecture notches on buccal of crown. (a) Maxillary bicuspid. (b) Mandibular first bicuspid. Note different cortex and trabecular
thickness. B, buccal area; L, lingual area.

(a) (b)

B L

L B

Figure 9.17  Internal architecture of furcation area of first molars. (Notches in tooth crown are too buccal.) (a) Maxillary first molar. (b) Mandibular first
molar. Note differences in cortical plates and trabecular dimensions at the maxillary versus mandibular sites. B, buccal; L, lingual.

During the final drill stages, a judgment needs to be threads, the osteotomy should be flushed free of debris
made about whether to tap threads. Reflecting on and then restimulated to bleed by probing the apical area.
the  internal arrangement of trabeculae seen in the pic-
tures (Figures 9.16 and 9.17), it is possible to start “soft” In some systems, a final coronal shaping is needed to
and end “hard” as the last bur encounters heavy tra- countersink or expand the coronal for a slightly enlarged
beculation or the inner aspect of bordering cortex or the collar. If resistance or drill debris has been minimal during
residual  compact socket framework from a recently the preparation, then one can eliminate or reduce these
extracted tooth. last steps. If the implant site is not bleeding enough to fill
the site after any of these steps, then have the patient open
If tapping threads is necessary, it should be done by hand and close several times after stimulating with a probe. This
or very low handpiece speed; the same speed used for “pumps” the maxillary artery and results in the desired fill
placement of the implant (30–50  rpm). After tapping of the osteotomy with blood.

Dental Implant Placement 129

THE FIXTURE (IMPLANT) INSTALLATION
The implant fixture may be placed by hand or with a
machine‐controlled drill speed and torque. A torque‐
metered speed of 30–50 rpm is preferred with torque set at
a low value to start. The resistance sensed during the drill-
ing sequence used to prepare the site should give one a
sense of the torque needed. If one is in doubt, it is best to
start the fixture placement with low torque of 15–20 N/cm.
If the insertion stalls, then reverse the driver for a half turn
and proceed with next highest torque. This reversal strat-
egy clears the threads of bone chips and allows for
momentum at the next torque/speed combination. If fixture
is stalled at 40 N/cm at collar level – the last 3–4 mm is still
exposed – then it should be reversed out and the osteot-
omy modified before proceeding. Note should be made of
final insertion torque on record, and this is used to deter-
mine waiting period for integration and/or loading. Hand
installation does not allow this objective measure of torque,
but sometimes it is preferred in very “delicate” sites. Hand
insertion after stalling at 40 N/cm or above with an unme-
tered ratchet wrench is discouraged because excess
stress can fracture buccal plates and/or strip threading,
over compress site or, worse, it can result in fracture of
implant collar. (EVERY IMPLANT SYSTEM HAS A
RECOMMENDED MAXIMUM INSERTION TORQUE – READ
THE DIRECTIONS.) A surgical insertion torque of 20 N/cm
would probably call for a six‐month wait while insertion at
35–45 N/cm could be loaded immediately. Experience will
guide in this judgment. After the fixture is adjusted to its
final position, either a cover screw or healing abutment is
placed. If trabeculation is light or thin and insertion torque Figure 9.18  The cover screw is used to seal the coronal portion of the
is minimal, then a passive healing period is required and implant before flap closure.
the final result should be at or slightly below crest with
cover screw in place (Figures 9.18 and 9.19).
4. Tipping or angulation of drill as depth increases from
use of finger rest on tooth and rotating around the finger
POSSIBLE PROBLEMS AND COMPLICATIONS
rest instead of vertical pumping movement.
Common Drilling Problems
5. Overdrilling depth or irregular uneven osteotomy can
1. Underdrill of site depth: This can result in thread strip- result in loss of implant into the sinus (Figure  9.21) or
ping as implant bottoms before engaging bevel; per- within the mandible when there is a “hollow” anatomy
tains to Branemark style hex top with countersunk neck (previous pontic area of bridge often has absence of
or rapid taper like the Astra ST. trabeculae), see Chapter 3, Figure 3.5b.
2. Excess drill speed over the implant system’s recom- In addition to drilling problems, several local site variables
mended speeds and/or lack of irrigation: Burns bone, may complicate placement. These include:
kills osteocytes, and results in early fixture loss.
3. Failure to “read” bone external contours: Perforation of 1. Surface slopes mesial–distal and/or buccal–lingual or
buccal or lingual concavities (Figures  9.7 and 9.20). both
This can be very dangerous with postoperative swelling 2. Vestibular depth may be very shallow (1–2 mm)
and closure of airway in case of lingual lower cuspid
3. Thin cortex at crest and thin trabeculae internally (max-
site; roughly the area where the sublingual gland is
illary posterior)
located; see multiple vascular supplies to this area
(Figure  9.22), see Chapter  3. Inferior alveolar artery 4. Dense 1‐ to 2‐mm crest with subjacent very poor
distribution. internal trabecular distribution (mandibular posterior;

130 Practical Advanced Periodontal Surgery

 (a) Minimal vestibular depth: This often happens in the lower
anterior with severe resorption, classic Branemark case.
If the crest was leveled and the implants are placed by
the standard protocol, then the connections could fall
below the floor and vestibular depth. By ignoring the
buccal and lingual deficiencies and seating implants at
mesial and distal bone level, the implants can be left
above the floor and still retain maximum bone integra-
tion. It is even possible to leave the majority of the bevel
above the crest, but this must be planned ahead and
use of mid crestal incision is necessary.

Thin bone and minimal internal support: The site can be

(b) underprepared (stop one drill diameter short of final or
use final bur for ½ vertical depth), laterally compressed
with osteotomes, or site abandoned and allowed to
reheal or even grafted internally and revisited at three to
four months.

Inadequate vertical height: Site can be grafted with a

block graft, or short implants with increased surface
area can be used (Figure 9.23). Current protocols call
for all‐on four to angle implants to distal over sinus or
mental foramen but this only gains 2–3 mm of extra dis-
talization at best.

Figure 9.19  (a) Cover screw is seated. (b) Implant is at level or below Buccal concavities: This can present the most difficulty.
alveolar crest. Sometimes threaded implants are placed and then
grafted. The implant may be placed at an acute angle
especially after failed bridge where pontic has and restored with an angled abutment. This often results
­covered site) in a “knee” at gingival margin, which with time and
recession can expose the restorative margin. Another
5. Inadequate vertical height; maxillary first molar/sinus, alternative in multiple site cases may be to skip this site
lower posterior over canal and bridge it with a pontic.
6. Buccal concavities: incisal fossa, cuspid fossa Lingual concavities: In the mandibular second molar, one
(Figures 9.7 and 9.20) can change the inclination with the direction closer to
7. Lingual concavities: submandibular gland below lower that of the Curve of Wilson; however, it is necessary to
molars, sublingual gland below lower cuspid/lateral avoid encroaching on tongue space. Lower cuspid lin-
areas (Figures 9.20 and 9.22) gual concavity has multiple vascular supplies, so it is
very dangerous to perforate this area; with the potential
Slopes: Major discrepancies in site restorative platform for submylohyoid swelling and closure of airspace (see
location (mesial–distal or buccal–lingual) should be cor- Figure 9.22). A CT scan is advised if anatomy too hard to
rected with grafting. Minor contour differences can be read clinically.
adjusted for by interplay between implant anatomy and
Multiple sites: Most of the issues with multiple sites are
site anatomy. For example, if a site has a 2‐mm defi-
solved by good prosthetic guidance. In general, the
ciency from mid crest to buccal line angles, then a
implants need to be placed in the center of the respec-
Branemark style implant can be used by placing the
tive crown shape.
implant at the level of the lingual crest. This intentionally
leaves the buccal bevel exposed, but at one year, this The limits of placement proximity are different for implant‐
bone would have been lost in the cupping resorption to‐implant versus implant‐to‐tooth. The general rule is to
usually seen with this style implant. As long as the pala- have at least 2 mm of bone between implant surfaces.
tal bone and half the mesial and distal bone serve the This proximity is problematic for two reasons: Tarnow
purpose of creating surgical stability, the implant used in et  al. (2003) published data supporting the need for at
this example can be left at a reasonable height and the least 3 mm to support interdental papillae. This would
C/R ratio is not affected. apply to Branemark style implants where the cupping

Dental Implant Placement 131

Figure 9.20  Mylohyoid insertion line (concavity below, submandibular gland) and canal proximity can limit angle and vertical depth of implant
placement.

132 Practical Advanced Periodontal Surgery

Figure 9.21  Implant displaced into maxillary sinus. Student failed to
sense resistance to abutment torque.

Figure 9.23  Anatomic limits. Sinus extension, resulting in less than

A Carotis Externa 1 mm bone at the alveolar crest (top). Crestal resorption: there is less
than 7 mm bone above the mandibular canal, impairing standard implant
A Facialis Bur placement (bottom).
A Lingualis profunda

A Lingualis A Sublingualis

Mandibula
A Submentals

A thyreoidea

Figure 9.22  Diagram showing sublingual and submental arteries that

can be injured during implant placement in the canine/premolar area due
to the presence of a lingual concavity. Source: Reprinted with permission Figure 9.24  Periapical radiograph showing mandibular molar
from JOMI 1993; 8[3]:329–333. necessitating extraction and replacement with implants. Due to insufficient
vertical bony height above the mandibular canal, short implants were
selected to restore missing dentition.

Dental Implant Placement 133

Figure 9.25  Short implants (Bicon, Boston, MA, USA) were placed to
overcome vertical limitation.
Figure 9.28  Short implants were used to overcome the anatomical
limitations of sinus proximity (avoiding extensive sinus grafting).

Figure 9.26  Periapical radiograph showing implants restored. Figure 9.29  Clinical picture of final implant‐supported restoration.

around adjacent implants would overlap and drop inter-

proximal bone and then the soft tissue above leaving the
“black triangle.” Other implant geometries may not pre-
sent this problem. In addition, if one is dealing with narrow
buccal–lingual but heavy compact bone such as found in
the lower anterior, then placing implants too close endan-
gers the endosseous vascular supply between them and
there is the risk of bone necrosis between and loss of both
implants and bone. (Branemark isolated this by trial and
error – suggesting 7.0 mm on center to allow 3 mm of bone
between the standard 4.1 mm implant head.)
Implants can be placed closer to teeth because they have
an increased vascular net in their periodontal ligamnet
(PDL), which is connected through numerous spaces to
the adjacent marrow.
Figure 9.27  Clinical picture of restored short implants.

134 Practical Advanced Periodontal Surgery

It may be more prudent to skip an implant and bridge a REFERENCES
site if mesial–distal proximity becomes a problem. For
Branemark, P.‐I., Zarb, G.A., and Albrektsson, T. (eds.) (1985). Tissue‐
example, in the upper anterior, it might be better to skip integrated prostheses: osseointegration in clinical dentistry.
the lateral site if inadequate spacing exists and/or to use Chicago: Quintessence Publishing Co.
the lateral and skip the central position if an overly large
incisal foramen is present. (Note  –  the incisal foramen Bruggenkate, C.M., Krekeler, G., Kraaijenhagen, H.A. et  al. (1993).
Hemorrhage of the Floor of the Mouth Resulting from Lingual
can sometimes be grafted with minimal post-op sequelae.)
Perforation During Implant Placement: A Clinical Report. Int. J. Oral
The general ­concept is to pay attention to the micro- Maxillofac. Implants 8: 329–334.
architecture of bone.
Gentile, M., Chuang, S.K., and Dodson, T. (2005). Survival estimates
Short implants: In the past, statistical analysis has shown and risk factors for failure with 6 × 5.7 mm implants. Int. J. Oral
decreased success rates with implants less than 10 mm. Maxillofac. Implants 20 (6): 930–937.
This is being challenged by newer forms and changed
surface textures and treatments. Roughened surfaces, Rhinelander, F.W. (1974a). Tibial blood supply in relation to fracture
healing. Clin. Orthop. 105: 34.
square threads, and plate form implants with greater
surface area have been used successfully (Gentile et al. Rhinelander, F.W. (1974b). The normal circulation of bone and its
2005). While success rates may not be 100%, it is still response to surgical intervention. J. Biomed. Mater. Res. 8: 87.
possible and judicious to use short implants in selected
cases, especially when patients refuse extensive graft Tarnow, D., Elian, N., Fletcher, P. et al. (2003). Vertical distance from
the crest of bone to the height of the interproximal papilla between
placement (Figures 9.24–9.29).
adjacent implants. J. Periodontol. 74: 1785–1788.

Dental Implant Placement 135

Chapter 10 Periodontal Medicine Including Biopsy Techniques
Vikki Noonan and Sadru Kabani

GINGIVAL NODULES that persist along a sinus tract following treatment may
cause the parulis to persist. In such instances, excision
Nodular proliferations on the gingiva are frequently
may be required.
encountered and represent a number of distinct entities
with different etiologies and treatment strategies. While
FIBROMA
most represent reactive or inflammatory processes, occa­
sionally lesions arise that are developmental in nature, A fibroma represents a nodular proliferation of dense fibrous
­perhaps resulting from stimulation of residua of odonto­ connective tissue that arises secondary to trauma or focal
genesis that persist in the oral mucosa following tooth irritation. Representing the most common reactive prolifera­
development. tion of the oral cavity, fibromas typically present as smooth‐
surfaced firm nodular lesions that are similar in color to the
PARULIS surrounding mucosa (Figure 10.2). If the lesion is frequently
traumatized or subjected to constant irritation, surface ulcer­
Inflammatory infiltrates at the apices of nonvital teeth occa­
ation or hyperkeratosis may result. One form of fibroma with
sionally channelize through medullary alveolar bone, pen­
distinctive clinicopathologic characteristics termed the giant
etrate the cortical bone and soft tissue, and drain into the
cell fibroma appears to have no association with trauma and
oral cavity. These inflammatory infiltrates typically follow a
is often described clinically as having a papillary surface
path of least resistance. Given this trend, in most regions
architecture. With a predilection for occurring on the gingiva
inflammatory apical lesions will drain into the oral cavity
(Magnusson and Rasmusson 1995), the giant cell fibroma is
through a sinus tract on the buccal aspect of the alveolar
typically diagnosed in patients under age 30. The histo­
bone due to decreased thickness of the buccal cortical
pathologic appearance is distinctive due to the presence of
plate compared with the lingual cortex. Exceptions to this
multinucleated and stellate cells throughout the densely col­
rule are the mandibular second and third molars, the pala­
lagenized connective tissue stroma thought to be derived
tal roots of maxillary molars, and the maxillary lateral inci­
from the fibroblast lineage (Souza et al. 2004); however, the
sors, which typically perforate lingually. At the orifice of the
presence of these stellate and multinucleated fibroblasts
sinus tract, a focal nodular proliferation of inflamed granu­
in this lesion is of no known clinical significance.
lation tissue may arise, termed a “parulis” or “gum boil”
(Figure 10.1).
PERIPHERAL OSSIFYING FIBROMA
The parulis represents a focus of communication between Representing a reactive nodular proliferation of fibrous and
a pathologic cavity associated with an odontogenic infec­ mineralized tissue, the peripheral ossifying fibroma is a fre­
tion and the oral cavity. Therefore, it is frequently possible quently encountered lesion arising exclusively on the gin­
to insert a gutta‐percha point into the sinus tract and trace giva, most often from the region of the maxillary interdental
its path to the tooth that represents the source of the infec­ papilla (Figure 10.3). More common in females, the lesion
tion. If the sinus tract remains patent, chronic drainage will typically presents in young patients anterior to the first
allow the offending tooth to be asymptomatic. If the sinus molars (Cuisia and Brannon 2001) and may exhibit surface
tract becomes obstructed, symptoms of odontogenic ulceration (Buchner and Hansen 1979). Although the
infection will typically arise. A parulis typically resolves fol­ pathogenesis is not completely understood, the peripheral
lowing endodontic therapy or extraction of the offending ossifying fibroma is thought to represent a reactive pro­
tooth; however, residual microorganisms and inflammation cess that frequently arises secondary to local irritation.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

137
Figure 10.1  Nodular erythematous mass of granulation tissue near the Figure 10.4  Erythematous nodular mass arising from the mandibular
mucobuccal fold and associated with an asymptomatic nonvital premolar. anterior gingiva.
Source: Image courtesy of Dr. Helen Santis.
PYOGENIC GRANULOMA
The pyogenic granuloma represents an acquired vascular
lesion of the skin and mucous membranes that occurs in
patients over a wide age range. Clinically presenting as a
nodular lesion remarkable for rapid growth and frequently
exhibiting surface ulceration, the pyogenic granuloma
often bleeds on subtle provocation secondary to its vascu­
lar nature. Pyogenic granulomas of the oral cavity most
commonly present on the gingiva in areas of focal chronic
irritation (Figure 10.4).

These lesions have been reported to occur with greater

frequency in pregnant women. This increased incidence is
likely related to increased levels of estrogen and proges­
terone, which have been shown to enhance angiogenesis
in traumatized tissues (Yuan et al. 2002).

Figure 10.2  Pink, smooth‐surfaced nodular mass of the mandibular PERIPHERAL GIANT CELL GRANULOMA
attached gingiva. Source: Image courtesy of Dr. Helen Santis.
Arising exclusively on the gingiva, the peripheral giant
cell granuloma presents as an exophytic sessile or
pedunculated nodular lesion that is often dark red or
purple. Although seen over a wide age range, the periph­
eral giant cell granuloma typically presents during the
fifth to sixth decades of life, is more commonly encoun­
tered in females, and is seen with greater frequency in
the mandible anterior to the first molars (Bodner et  al.
1997; Buduneli et al. 2001) (Figure 10.5). Focal irritation
is typically deemed the causative agent rather than a
true neoplastic process. At least one study suggests
diminished salivary flow rate and altered salivary compo­
sition may increase susceptibility to such lesions due to
reduced ability to clear local irritants (Bodner et al. 1997).
A pressure resorptive defect of the underlying bone
may  be appreciated in association with the peripheral
giant cell granuloma having a “scooped‐out” radiolucent
Figure 10.3  Erythematous ulcerated mass of the palatal gingiva. appearance.

138 Practical Advanced Periodontal Surgery

Figure 10.5  Ulcerated reddish‐purple mass of the mandibular anterior Figure 10.6  Fluid‐filled lesion in the mandibular premolar region of the
gingiva. attached gingiva.

DIAGNOSIS AND TREATMENT OF REACTIVE

GINGIVAL NODULES
Treatment of reactive gingival nodules, including the gin­
gival fibroma, the peripheral ossifying fibroma, pyogenic
granuloma, and peripheral giant cell granuloma, includes
both a thorough excision of lesional tissue and removal
of local irritants such as calculus or overextended resto­
rations. Despite a diligent effort at complete excision, the
recurrence rate for these lesions approaches 20%
(Buduneli et al. 2001; Carrera Grano et al. 2001; Walters
et al. 2001). To reduce the likelihood of recurrence, some
suggest that reactive gingival lesions be excised to
bone. In lesions recalcitrant to treatment, a wider exci­
sion including periosteum and curettage of the periodon­
tal ligament may be indicated to prevent recurrence
(Buduneli et al. 2001; Carrera Grano et al. 2001; Walters
et al. 2001).

GINGIVAL CYST OF THE ADULT

The gingival cyst of the adult represents an infrequently Figure 10.7  Bluish fluctuant swelling of the lower labial mucosa.
encountered lesion of odontogenic origin. Thought to origi­ Source: Image courtesy of Dr. Helen Santis.
nate from rests of dental lamina, the gingival cyst of the
adult presents as a fluid‐filled swelling typically arising on
MUCOCELE
the labial attached gingiva of the premolar‐canine region
of the mandible (Buchner and Hansen 1979; Nxumalo and The mucocele is a frequently encountered lesion of the
Shear 1992) (Figure  10.6). Reported to primarily present oral mucosa characterized by extravasated mucoid mate­
during the fifth and sixth decades of life (Nxumalo and rial that leads to a fluctuant nodular swelling of the mucosa,
Shear 1992; Giunta 2002), the gingival cyst of the adult often remarkable for a bluish hue. Typically found on the
may occasionally cause a pressure resorptive defect of lower labial mucosa lateral to the midline (Figure 10.7) but
the subjacent alveolar bone that may cause the entity to noted in the buccal mucosa, floor of the mouth (ranula),
be  mistaken for a lateral periodontal cyst (Giunta 2002). and the anterior ventral tongue, mucoceles frequently
Rare examples of multiple lesions have been described arise secondary to a focal traumatic injury that causes rup­
(Shade et  al. 1987; Giunta 2002). Treatment consists of ture of an excretory duct with subsequent spillage of mucin
simple surgical excision with submission of lesional tissue into the surrounding connective tissue. The feeder salivary
for histopathologic examination. gland typically retains its capacity to produce secretion;

Periodontal Medicine Including Biopsy Techniques 139

however, the damaged duct prevents passage of saliva
into the oral cavity. Patients typically complain of the lesion
waxing and waning as the gland produces saliva and then
empties. Occasionally, mucoceles are found on the poste­
rior palate, posterior buccal mucosa, and retromolar trig­
one; most frequently, these lesions represent superficial
mucoceles. These lesions typically present as small fluid‐
filled vesicles that rupture, leaving ulcerative lesions that
occasionally recur. Tartar control toothpaste (Navazesh
1995) has been linked to the formation of these lesions,
and they have also been described to occur more fre­
quently at mealtime.

Additionally, superficial mucoceles have been reported in

early stages of graft‐versus‐host disease (Garcia et  al.
2002). A mucous cyst represents a true cystic lesion; the Figure 10.8  Erosive lichen planus presenting as desquamative
lining is derived from salivary ductal epithelium. These gingivitis with erythema and discomfort. Source: Image courtesy of Dr.
lesions are frequently located in the lips and buccal mucosa Helen Santis.
and are seen in association with ductal obstruction such as
sialolithiasis that may increase intraluminal pressure; how­ reaction clinically indistinguishable from lichen planus.
ever, true developmental cystic lesions are seen. Termed lichenoid mucositis, clinical features, when corre­
lated with histopathologic findings, help to distinguish the
DESQUAMATIVE GINGIVITIS entity from bona fide lichen planus (Thornhill et al. 2006).
Diagnosis is based on a process of elimination of sus­
Desquamative gingivitis is a clinically descriptive term that
pected stimuli. This is frequently based on trial and error
is characterized by sloughing, erythematous areas of the
and is time consuming. If there is a reason to suspect medi­
attached gingiva. These desquamative gingival changes
cation‐induced mucositis, consultation with the patient’s
may be appreciated in the context of vesiculoerosive con­
physician may be helpful to explore the possibility of substi­
ditions, including pemphigus vulgaris, mucous membrane
tuting the medication. It is reasonable to treat this affliction
(cicatricial) pemphigoid, erosive lichen planus, linear IgA
with topical corticosteroids to control symptoms. Chronic
disease, graft‐versus‐host disease, paraneoplastic pem­
ulcerative stomatitis represents an infrequently encoun­
phigus, epidermolysis bullosa acquisita, systemic lupus
tered condition that shares clinical features of erosive lichen
erythematosus, chronic ulcerative stomatitis, contact
planus superficially and may present as desquamative
hypersensitivity reactions, and foreign‐body gingivitis
gingivitis. While the tongue and buccal mucosa are more
(2003). (Portions reprinted with permission from the Journal
commonly affected, gingival involvement is clinically indis­
of the Massachusetts Dental Society 2005 Fall; 54 (3): 38.)
tinguishable from the erosive form of lichen planus (Solomon
et al. 2003). This condition typically presents in women and
LICHEN PLANUS
is characterized by episodes of waxing and waning.
Lichen planus represents an immunologically mediated Differences in the immunofluorescence profile aid in distin­
mucocutaneous disease that affects the oral cavity in as guishing chronic ulcerative stomatitis from lichen planus.
much as 2% of the population. Typically presenting in the The immunopathologic pattern for lichen planus is nonspe­
fourth to fifth decades of life, lichen planus is character­ cific but frequently consists of shaggy deposition of fibrino­
ized by a variety of clinical manifestations including the gen along the epithelial–connective tissue interface,
reticular, erosive, and atrophic forms of the disease. The whereas that of chronic ulcerative stomatitis consists of IgG
most commonly affected site is the buccal mucosa, fol­ autoantibodies directed against parabasal and basal strati­
lowed by the tongue, gingiva, labial mucosa, and lower fied squamous epithelial cell nuclei. In some instances, a
labial vermilion (Eisen 2002). In just under 10% of patients lichenoid appearance of the gingiva is seen secondary to
lichen planus presents exclusively on the gingiva (Eisen the impregnation of dental materials into the gingiva during
2002; Mignogna et  al. 2005) (Figure  10.8). These cases dental treatment. The term foreign body gingivitis is used to
typically present as the reticular or erosive forms of the describe this entity. More common in females, foreign body
disease involving wide areas of marginal and attached gingivitis typically presents as an erythroplakic or erythro­
gingiva and most commonly affect women (Mignogna leukoplakic lesion of the gingiva (Figure 10.9) that does not
et  al. 2005). A number of medications (especially anti­ respond to improved oral hygiene measures or minimal
hypertensive agents), flavoring agents, oral hygiene prod­ improvement with topical steroid therapy as a result of its
ucts, and candies and chewing gum can elicit a mucosal anti‐inflammatory effect (Gordon 2000).

140 Practical Advanced Periodontal Surgery

Figure 10.9  Focal areas of painful erythematous marginal gingiva.

Figure 10.11  Desquamative gingival lesions representing the only

affected site in this patient. Source: Image courtesy of Dr. Helen Santis.

In this ­condition, circulating autoantibodies produced in

response to lymphoid neoplasia cross-react with antigens
associated with epithelial desmoplakins and desmosomal
proteins. Involvement of the oral mucosa is frequently seen
and has been reported as the only manifestation of the
disease (Bialy‐Golan et  al. 1996; Wakahara et  al. 2005).
Clinically, painful oral erosions and blister formation are
Figure 10.10  Erosive lesions affecting the anterior mandibular gingiva appreciated on any mucosal surface including the labial
and mandibular mucobuccal fold. vermilion. Skin eruptions are typically seen. Direct immu­
nofluorescence findings for paraneoplastic pemphigus
PEMPHIGUS VULGARIS show deposition of IgG and complement intercellularly
within the epithelium and in a linear fashion along the
Pemphigus vulgaris represents an autoimmune‐mediated
basement membrane. These findings together with a his­
mucocutaneous disease characterized by autoantibody
tory of lymphoproliferative disease and unique circulating
attack against components of desmosomes. Frequently
autoantibody profile help to distinguish paraneoplastic
representing the initial manifestation of the disease, oral
pemphigus from other vesiculobullous disorders.
lesions are found in most instances and typically present
as blisters or erosive lesions of the oral and pharyngeal
MUCOUS MEMBRANE (CICATRICIAL)
mucosa. Often the onset is insidious with lesions getting
PEMPHIGOID
progressively worse over time. Desquamative gingivitis in
the absence of other clinical features is a frequently Mucous membrane (cicatricial) pemphigoid represents a
encountered clinical presentation. Here, blisters and/or group of immune‐mediated mucocutaneous disorders in
erosive lesions are seen often extending to the free gingi­ which autoantibodies are directed against basement
val tissues (Mignogna et  al. 2001) (Figure  10.10). Direct membrane components. Although the disease typically
immunofluorescence findings from tissue submitted in affects patients in the fifth to sixth decades of life, rare
Michel’s media shows IgG or IgM antibodies and comple­ examples of pemphigoid have presented in childhood; in
ment (typically C3) deposited in the intercellular areas of some instances, lesions were limited exclusively to the gin­
the epithelium. A condition linked to underlying lymphopro­ giva (Laskaris et al. 1988; Sklavounou and Laskaris 1990;
liferative disease termed paraneoplastic pemphigus may Cheng et  al. 2001; Musa et  al. 2002) (Figure  10.11).
present with oral mucosal involvement yielding clinical Characterized by subepithelial separation from the under­
characteristics indistinguishable from pemphigus vulgaris. lying connective tissue, cicatricial pemphigoid presents as

Periodontal Medicine Including Biopsy Techniques 141

areas of erosive or vesiculobullous change throughout the ­ orticosteroids, it is not uncommon for patients to develop
c
oral mucosa with subsequent scarring. Ocular involve­ superimposed candidiasis. A one‐week course of flucona­
ment and conjunctival scarring caused by the disease can zole (Diflucan) 100‐mg tablets (two tablets the first day
lead to blindness. A subgroup of patients more severely and then one tablet each day following for two weeks)
affected by the disease appear to have both IgG and IgA should provide relief in the absence of contraindications.
circulating anti‐basement membrane zone antibodies and In lesions consistent with foreign‐body gingivitis, surgical
frequently require systemic management (Setterfield et al. excision of affected tissue is typically the requisite treat­
1998). One condition clinically indistinguishable from cica­ ment approach (Gravitis et al. 2005). In some instances, it
tricial pemphigoid termed linear IgA disease is character­ is possible to identify the source of the foreign material
ized by deposition of IgA along the basement membrane. using energy‐dispersive x‐ray microanalysis (Daley and
The immunostaining profile is distinct from that of cicatricial Wysocki 1990; Gordon and Daley 1997; Gordon 2000).
pemphigoid, which is characterized by linear deposition Chronic ulcerative stomatitis is frequently recalcitrant to
of IgG (and occasionally IgM and IgA) and C3 along the topical steroid therapy and may require management with
basement membrane and is used to distinguish the two hydroxychloroquine (Plaquenil) 200 mg/day; however, sys­
disease processes. temic side effects, including irreversible retinopathy, neuro­
myopathy, agranulocytosis, aplastic anemia, and toxic
psychosis (Solomon et al. 2003), associated with this med­
DIAGNOSIS AND TREATMENT
ication necessitates consultation with a patient’s physician
OF DESQUAMATIVE GINGIVAL LESIONS
and close clinical follow‐up. The management of pemphi­
Nonspecific inflammation frequently obscures critical fea­ gus vulgaris and mucous membrane pemphigoid typically
tures of underlying disease; therefore, it is recommended involves use of systemic corticosteroid therapy; however, a
to avoid marginal gingiva when choosing a biopsy site for contemporary management approach involves treatment
the diagnosis of mucosal fragility disorders. Prior to biopsy, with rituximab and intravenous immune globulin (Ahmed
verification of epithelial fragility should be sought by et al. 2006). It is necessary to have patients evaluated by a
assessing the presence of the Nikolsky sign. Here, firm lat­ physician knowledgeable about this contemporary
eral pressure along the mucosal surface of clinically unre­ approach to management.
markable tissue adjacent to involved mucosa will elicit
bulla formation. Specimens representing the surface of a PLASMA CELL GINGIVITIS
“de‐roofed” vesicle may occasionally yield useful diagnos­
Plasma cell gingivitis represents a unique entity character­
tic information; therefore, any tissue obtained from clinical
ized by sharply demarcated erythema and enlargement of
manipulation of the friable mucosa should be submitted for
the free and attached gingiva (Figure 10.12). This condi­
immunofluorescence analysis (Siegel and Anhalt 1993);
tion generally represents a hypersensitivity reaction to fla­
however, a biopsy of perilesional tissue is recommended
voring agents in oral hygiene products, candies or chewing
for diagnostic purposes. The specimen should be bisected
gum, medications, or a component of the diet (Macleod
with half submitted in formalin for routine hematoxylin
and Ellis 1989; Serio et al. 1991). Despite this fact, in many
and eosin staining, and the other half should be submitted
instances the offending antigen cannot be isolated.
in immunofluorescence medium such as Michel’s for
direct immunofluorescence. Immunofluorescence staining
in conjunction with light microscopy is often required to
make a definitive diagnosis of vesiculobullous disorders
(Gallagher et  al. 2005). Treatment of symptomatic lichen
planus should begin after biopsy and histopathologic
diagnosis. In mild cases, topical corticosteroids (0.05%
fluocinonide gel [Lidex]) applied to the affected areas
sparingly four times a day typically provides improvement
in the symptoms and clinical appearance of the lesions
within four weeks. For the most successful management,
the patient is instructed to eat, brush, and then apply the
gel with nothing per mouth for 30 minutes. It is important
that the patient understands this is not a “cure” but rather
an effort to maintain remission. More severe cases may
require a brief course of systemic corticosteroid therapy in
close consultation with the patient’s physician. Once the
patient is in remission, the patient can be maintained with Figure 10.12  Diffuse, erythematous changes of the attached and free
topical steroids. With the use of topical or systemic gingival tissues.

142 Practical Advanced Periodontal Surgery

Biopsies of such lesions show a dense infiltrate of plasma
cells within the connective tissue stroma subjacent to the
epithelium. Because a neoplastic plasma cell proliferation
cannot always be excluded on light microscopic examina­
tion alone, additional studies to determine the nature of the
infiltrate may be indicated. In cases of idiopathic plasma
cell gingivitis or cases representing a hypersensitivity
reaction, the plasma cell infiltrate is polyclonal and does
not show an atypical profile on immuno‐electrophoresis.
When other oral mucosal sites are involved, the condition
is termed plasma cell mucositis. Here, diffuse, erythema­
tous, and edematous changes may involve multiple areas
of the oral mucosa (Kaur et  al. 2001; Heinemann et  al.
2006). Treatment of plasma cell gingivomucositis requires
that the patient record all food intake and eliminate Figure 10.13  Ulceration and crusting lesions involving the labial
­possible dietary culprits. Additionally, discontinuance of vermilion.
use of chewing gums, candies, and oral hygiene products
remarkable for strong flavoring agents such as peppermint
or cinnamon should be encouraged. Unfortunately, in
some instances the underlying causative agent cannot be epidermal necrolysis (Lyell’s disease) involves sloughing
identified. Topical steroid agents (fluocinonide 0.05% gel and ulceration of large areas of the skin and mucosa.
[Lidex]) applied to the affected areas sparingly four times Mucosal lesions of EM are characterized by painful ulcera­
a day may provide some improvement. This regimen is tive lesions of acute onset (Figure 10.13), often involving
most effective if the patient eats, brushes, and then applies the labial mucosa with crusting of the vermilion. Gingival
the gel to the affected areas with nothing per mouth for involvement is rare but is occasionally reported. Classic
30 minutes following application. It is generally recom­ skin eruptions are described as “target lesions” and are
mended that follow-up evaluation after four weeks of topi­ seen in approximately 25% of all patients presenting with
cal corticosteroid application be done, and the frequency EM (Ayangco and Rogers 2003). Here, concentric erythe­
of use adjusted until improvement is optimal. matous rings likened in appearance to a target or “bull’s
eye” are appreciated on the extremities initially and occa­
sionally extending to involve other cutaneous sites. Unlike
ERYTHEMA MULTIFORME
other vesiculobullous disorders, the attached mucosae
Representing an acute hypersensitivity reaction involving including that of the gingiva and hard palate are typically
the skin and the mucosa, erythema multiforme (EM) most unaffected by the process. In most instances, EM resolves
typically presents in the third and fourth decades of life; spontaneously over the course of a two‐ to four‐week
however, a significant number of patients diagnosed with period. Treatment is typically supportive and directed at
EM are children (Huff et  al. 1983; Wine et  al. 2006). managing symptoms. In severe cases one may consider
Although the pathogenesis is poorly understood, the con­ systemic corticosteroid therapy. Here, prednisone tablets
dition is likely an immune‐mediated disorder. EM is induced (10 mg) may be prescribed with the instruction to take six
by a variety of factors, of which the most common include tablets in the morning until the lesions recede and then
bacterial and viral infectious agents and medications, decrease by one tablet on each successive day (Arm et al.
most typically analgesics and antibiotics. Approximately 2001). Dexamethasone (Decadron) elixir 0.5 mg/5 ml can
50% of cases arise subsequent to infection with herpes also be used. Here, one can recommend the patient rinse
simplex virus. Two forms of EM are typically described: EM with one tablespoonful (15 ml) for three days four times per
major and EM minor. EM minor presents with lesions involv­ day and swallow. Then, for three days, rinse with one tea­
ing the skin and oral mucosa. It is often recurrent, with the spoonful (5 ml) four times a day and swallow. Then, for
most frequent cause of recurrent EM being a herpes sim­ three days, rinse with one teaspoonful (5 ml) four times a
plex virus infection (Huff et al. 1983; Sinha et al. 2006). EM day and swallow every other time. Last, the patient should
major is also referred to as Stevens Johnson syndrome rinse with one teaspoonful (5 ml) four times per day and
and is typically triggered by mycobacterium and medica­ expectorate (Arm et al. 2001). If recurrent EM is thought to
tions (Huff et al. 1983). Here, in addition to cutaneous and be precipitated by herpes simplex virus, antiviral medica­
lesions, ocular and/or genital mucosae are affected. tions are typically prescribed such as systemic acyclovir
Symblephara or bands of scar tissue within the conjunc­ (Zovirax) 400 mg capsules administering one tablet three
tiva can lead to blindness akin to ocular lesions of cicatri­ times daily or valacyclovir (Valtrex) 500‐mg capsules
cial pemphigoid. The most severe form of EM termed toxic administering one tablet per day.

Periodontal Medicine Including Biopsy Techniques 143

Figure 10.14  Redundant hyperplastic folds of tissue in the anterior
maxillary associated with a maxillary denture.
Figure 10.15  Marked gingival hyperplasia in a patient using calcium
channel blocker agents.
GINGIVAL ENLARGEMENT
Gingival enlargement may be focal or diffuse in nature.
s­ urfaces of the gingiva most prominently along the inter­
Focal gingival enlargement is seen in association with a
dental papillae several weeks following the initiation of a
number of entities ranging from benign reactive prolifera­
medication. Over time, the tissue overgrowth extends to
tions to malignant epithelial neoplasia. Generalized gingi­
the lingual surfaces of the gingiva and can completely
val enlargement is likewise seen in association with a
cover the dentition. Typically, hyperplastic changes are not
variety of conditions. Systemic medications, neoplastic
appreciated in edentulous areas unless the tissues
infiltration, infection, and hereditary conditions may all pre­
approximate poorly fitting prostheses or surround dental
sent with generalized gingival enlargement. The diagnosis
implants. Oral hygiene dictates the clinical appearance of
and treatment of such lesions are discussed later.
the hyperplastic gingival tissues. In patients with adequate
oral hygiene, the hyperplastic tissues maintain a pink color
EPULIS FISSURATUM
and stippled appearance. In patients with marginal oral
Epulis fissuratum is characterized by folds of hyperplastic hygiene, the tissues may become friable and bleed on
fibrovascular connective tissue that develop in association subtle provocation.
with an ill‐fitting denture. These redundant folds of tissue
frequently extend into the vestibule with invaginations to Treatment for medication‐induced gingival hyperplasia
accommodate the denture flange (Figure 10.14). Treatment includes substitution of the inciting medication with a differ­
consists of surgical excision to ensure improved soft tissue ent agent that is less likely to cause gingival hyperplasia
contour for impression making and fabrication of a new when possible and encouraging meticulous oral hygiene.
prosthesis. Additionally, supplementation with folic acid may reduce the
incidence of medication‐induced gingival overgrowth; how­
MEDICATION‐INDUCED GINGIVAL ever, the results of such efforts have been mixed (Drew et al.
OVERGROWTH 1987; Backman et al. 1989; Brown et al. 1991; Prasad et al.
2004). Azithromycin has been shown to significantly reduce
Numerous medications have been implicated as the caus­
gingival overgrowth in patients taking cyclosporine (Tokgoz
ative agent for diffuse gingival enlargement. The medica­
et al. 2004). In some instances, however, surgical interven­
tions most commonly associated with gingival overgrowth
tion is indicated. Although a variety of surgical techniques
include calcium channel blockers (Figure  10.15), cyclo­
may be used, such as gingivectomy or flap surgery, laser
sporine, and anticonvulsant medications. Although incom­
excision with submission of lesional tissue for histopatho­
pletely understood, it seems such medications target a
logic examination has been shown to represent a favorable
common pathway of collagen degradation; interference
method of management (Mavrogiannis et al. 2006).
with this pathway induces fibrosis and extracellular matrix
overgrowth in the gingival tissues (McCulloch 2004;
HYPERPLASTIC GINGIVITIS
Kataoka et al. 2005). Introduction of the causative medica­
tion in childhood seems to increase the likelihood of occur­ Diffuse erythematous enlargement of the gingival tissues
rence. The most typical clinical course for the process is frequently seen secondary to poor oral hygiene
begins as diffuse gingival enlargement of the facial (Figure  10.16). Diabetes mellitus (Mealey 2006) and

144 Practical Advanced Periodontal Surgery

 ­ isease. The systemic signs and symptoms of leukemia are
d
numerous and include malaise, fever, fatigue, and lymph­
adenopathy. Gingiva ranks among the most common sites
of extramedullary disease (Wiernik et al. 1996) and is most
typically involved in patients with acute myeloid leukemia,
particularly the subtypes of acute monocytic and myelo­
monocytic leukemia. Diffuse gingival enlargement charac­
terized by a boggy consistency with spontaneous bleeding
or bleeding on subtle provocation should be viewed with a
high index of suspicion. A scalpel biopsy with submission
of lesional tissue for histopathologic and immunohisto­
chemical analysis is indicated.

GINGIVAL FIBROMATOSIS
Figure 10.16  Diffuse enlargement and erythema of the marginal and
papillary gingiva. Gingival fibromatosis represents a disorder characterized
by progressive enlargement of gingival tissues secondary
to increased numbers of collagen fiber bundles. While gin­
gival fibromatosis may be idiopathic, it is often hereditary,
with most cases showing autosomal dominant inheritance.
While most cases represent isolated examples of the dis­
order, gingival fibromatosis is also seen in association with
a number of hereditary syndromes. In addition to functional
concerns such as difficulty eating, speaking, and main­
taining oral hygiene, gingival fibromatosis causes esthetic
concerns for the patient. Gingival fibromatosis is charac­
terized by painless diffuse gingival enlargement of normal
color and firm, fibrous consistency with minimal bleeding
(Coletta and Graner 2006). Typically arising at the time of
primary or permanent tooth eruption, gingival fibromatosis
frequently causes malpositioning of teeth, retention of pri­
mary dentition, delayed eruption of the permanent denti­
Figure 10.17  Diffuse gingival enlargement and hemorrhage in this tion, and other functional and esthetic concerns.
patient subsequently diagnosed with monocytic leukemia.
Treatment traditionally involves gingivectomy using serial
s­ moking have also been implicated in the development of gingival resections together with strict oral hygiene meas­
hyperplastic gingivitis. Treatment requires professional ures. One recent report suggests a more aggressive surgi­
scaling and curettage and improved oral hygiene meas­ cal protocol of gingivectomy, odontectomy, and alveolar
ures. Chemopreventive measures such as 0.12% chlor­ ridge ostectomy of an entire arch at a time eliminates
hexidine rinse may be used if debridement and improved recurrence (Odessey et al. 2006); however, the manage­
oral hygiene measures alone do not provide resolution. ment strategy employed depends on the individual case
Surgical recontouring of the gingival tissues using a scal­ and wishes of the patient.
pel or laser may be indicated for patients who are recalci­
trant to conservative treatment. LIGNEOUS GINGIVITIS AND CONJUNCTIVITIS
Ligneous gingivitis represents a rare disorder character­
LEUKEMIA
ized by deposition of amyloid‐like material within the gingi­
Leukemia represents a hematopoietic stem cell malig­ val connective tissue subjacent to the oral mucosa.
nancy that produces a number of clinical signs and symp­ Ligneous conjunctivitis is frequently seen in association
toms intimately associated with a proliferation of atypical with gingival lesions and represents an autosomal reces­
leukocytes and subsequent reduced numbers of normal sive form of chronic membranous conjunctivitis (Bateman
circulating leukocytes and erythrocytes. The most typical et  al. 1986). Many cases of ligneous conjunctivitis are
oral lesions associated with leukemia include ulcerative related to plasminogen deficiency and present in patients
lesions, spontaneous gingival bleeding, and gingival of Turkish origin (Gokbuget et al. 1997; Gunhan et al. 1999).
hyperplasia (Weckx et  al. 1990) (Figure  10.17). In many It is hypothesized that plasminogen deficiency caused ina­
instances, oral lesions represent the first sign of the bility of fibrinolytic activity to clear fibrin d
­ eposits, allowing

Periodontal Medicine Including Biopsy Techniques 145

accumulation of this material. Clinical presentation can
include gingival enlargement with multiple areas of ulcera­
tion involving both arches (Scully et al. 2001), a change that
mimics gingival enlargement associated with leukemia. At
least one case of ligneous gingivitis affecting the alveolar
mucosa in the absence of conjunctivitis in a patient without
plasminogen deficiency has been reported (Naudi et  al.
2006). The best management strategy for these lesions at
the present is uncertain. In individuals with plasminogen
deficiency, intravenous purified plasminogen concentrate
has been used (Schott et al. 1998); however, this therapy is
not widely available.

WEGENER’S GRANULOMATOSIS
Wegener’s granulomatosis represents a necrotizing granu­
Figure 10.18  Band‐like pigmentation of the attached gingiva. Source:
lomatous vasculitis most commonly involving the respira­
Image courtesy of Dr. Helen Santis.
tory tract and kidneys. Oral lesions have been described
and are characterized by gingival hyperplasia remarkable
for a rough, granular appearance often likened to that of a be appreciated within the buccal mucosa, lips, tongue
strawberry, which bleed with subtle provocation (Manchanda (particularly of the fungiform papillae), and hard palate
et  al. 2003). Isolated gingival lesions may represent the and is notable for a macular appearance with indistinct
initial manifestation of the disease in approximately 7% of borders (Kauzman et al. 2004). Although physiologic pig­
patients (Patten and Tomecki 1993) and begin initially in mentation is not a medical concern, recent publications
the interdental papilla spreading to the adjacent gingival suggest social pressures influence some patients to
tissues. In one case report, the disease initially presented request gingival depigmentation for esthetic purposes (Tal
as a poorly healing extraction socket in a young patient et al. 2003). The most significant factor for clinicians is to
(Kemp et al. 2005). Other oral lesions may also be present, recognize the entity as a normal manifestation as opposed
including mucosal ulcerations, nodular lesions of the to a pathologic process.
labial mucosa, and palatal osteonecrosis. Biopsy with con­
firmation using antinuclear cytoplasmic antibody (ANCA) MEDICATION‐INDUCED PIGMENTATION
testing is critical. It is important to include Wegener’s gran­ Drug‐induced discoloration of the oral mucosa is caused
ulomatosis in a differential diagnosis of gingival hyperpla­ by an increasing number of medications. The discoloration
sia, particularly in a patient with a history of sinusitis, given can occur after direct contact with the medication or fol­
the poor prognosis associated with the condition if left lowing its systemic absorption. In some instances, medi­
untreated. cation stimulates melanocytes to increase melanin
production; in other instances, medication causes forma­
PIGMENTED LESIONS tion of metabolites that are thought to be the cause of
Pigmented lesions are encountered with some frequency increased pigmentation. Medications typically associated
in the oral cavity. In some instances, these lesions repre­ with pigmentation of the oral mucosa include minocycline
sent generalized or diffuse changes; in other instances, (Figure  10.19), antimalarial medications, estrogens, tran­
the pigmented change is focal in nature. quilizers, phenolphthalein found in laxatives, chemother­
apy medications, and medications used to manage
patients with HIV infection (Abdollahi and Radfar 2003). In
PHYSIOLOGIC PIGMENTATION
some instances, discoloration caused by medication
Most commonly noted on attached gingiva in darker‐ resolves in the weeks following discontinuation of the med­
skinned patients, physiologic pigmentation presents as a ication; however, in some instances, the change is perma­
diffuse brown‐black pigmentation secondary to increased nent. Many accounts of exposure to metals such as gold,
melanocyte activity. Here, pigmentation develops during lead, mercury, and silver have been historically docu­
the first two decades of life. Physiologic pigmentation is mented in the literature with a classic presentation of linear
typically bilaterally symmetrical in distribution and most pigmentation following the gingival margins described.
prominent along the labial attached gingiva in the region of Other presentations of drug‐induced pigmentation vary
the maxillary and mandibular incisors. The distribution is but include diffuse pigmentation of the palate and rare
likened to a ribbon‐like band that spares the marginal gin­ descriptions of pigmentation changes of the soft tissues of
giva (Eisen 2000) (Figure  10.18). Pigmentation may also the lips, tongue, eyes, and perioral skin.

146 Practical Advanced Periodontal Surgery

Figure 10.19  Pigmentation of the gingiva associated with use of Figure 10.21  Multifocal areas of mucosal pigmentation at the apices of
minocycline. teeth treated with apical retrofill procedures. Source: Image courtesy of Dr.
Helen Santis.

physiologic pigmentation, smoker’s melanosis does not

spare the marginal gingiva, is of recent onset, and increases
in intensity and number of lesions with an increase in the
number of cigarettes used daily. In patients who consume
alcohol in addition to smoking, areas of oral depigmenta­
tion surrounded by hyperpigmentation are frequently noted
(Natali et  al. 1991). In a study of dark‐skinned patients,
while most non‐tobacco users exhibited some level of
physiologic oral melanin pigmentation, tobacco smokers
had significantly more oral surfaces pigmented than did the
non‐tobacco users (Ramer and Burakoff 1997). Reports
have been described of reduction in smoking leading to the
disappearance of smoking‐induced melanosis (Hedin et al.
Figure 10.20  Diffuse pigmentation of the anterior attached gingiva in a 1993). Given that these lesions present in patients in adult­
heavy smoker. Source: Image courtesy of Dr. Brad Neville. hood and often darken progressively over time, biopsy is
often indicated to rule out melanoma. (Portions reprinted
Antimalarial agents are typically linked to discoloration of with permission from the Journal of the Massachusetts
the palate; minocycline use is frequently associated with Dental Society 2007 Spring; in press.)
palatal and occasionally skin lesions (Treister et al. 2004);
phenolphthalein is associated with well‐circumscribed AMALGAM TATTOO
macular pigmented lesions of the skin and mucosa; and
An amalgam tattoo typically presents as a gray‐blue
estrogens are associated with diffuse melanosis and most
macular lesion of the oral mucosa that occurs following
typically seen in female patients. In some instances, a
implantation of dental amalgam into the oral soft tissues
biopsy may be indicated to confirm the diagnosis and rule
(Figure 10.21). Common clinical scenarios associated with
out the presence of underlying melanocytic pathology.
this phenomenon include introduction of amalgam into the
oral soft tissues by high‐speed hand pieces, contamination
SMOKER’S MELANOSIS
of extraction sites with amalgam debris, and linear impreg­
Smoker’s melanosis represents diffuse benign pigmenta­ nation of interdental tissues with amalgam‐laden dental
tion of the oral mucosa, particularly noted on the anterior floss following restorative procedures (Mirowski and Waibel
facial attached gingiva (Hedin 1977; Axell and Hedin 1982) 2002). Small radiopaque particles may be ­ evident on
(Figure  10.20). Typically, the distribution of pigmented radiographic examination to corroborate the clinical
changes begins in the interdental papilla region and may impression; however, the metallic particles are often too
extend to form continuous ribbons involving the anterior small to be appreciated. Over time, an amalgam tattoo may
attached gingiva with the apical extension of the lesions not appear to enlarge as the amalgam‐carrying macrophages
exceeding the mucogingival junction (Hedin 1977). Unlike migrate away from the initial site of implantation. In some

Periodontal Medicine Including Biopsy Techniques 147

Figure 10.22  Well‐demarcated brown macular lesion of the lower labial
mucosa. Figure 10.23  Smooth pigmented lesion of recent onset of the posterior
buccal mucosa.

individuals, an inflammatory response to the amalgam may

be accompanied by clinical discomfort that would predi­ f­ requently in black females, the lesion is characterized by
cate the need for biopsy. When a suspected amalgam tat­ a brown‐black appearance exhibiting a smooth to some­
too presents in an unusual location, a biopsy may be what raised surface contour (Figure  10.23). Typically
indicated to exclude other pigmented lesions such as mel­ found on the buccal mucosa, oral melanoacanthoma has
anoacanthoma and melanoma. (Portions reprinted with been reported to arise on the lip, palate, and gingiva
permission from the Journal of the Massachusetts Dental (Flaitz 2000). As the lesion arises suddenly with marked
Society 2005 Spring; 54 (1):55.) growth potential, melanoacanthoma cannot be differenti­
ated from other melanocytic lesions without biopsy.
MELANOTIC MACULE Distinctive histopathologic features, particularly the pres­
ence of dendritic melanocytes within the epithelial
The oral melanotic macule is a frequently encountered pig­
spinous cell layer, differentiate melanoacanthoma from
mented lesion of the oral mucosa. Typically found on the
other melanocytic lesions. Once definitive diagnosis is
lower labial vermilion, buccal mucosa, gingiva, and palate,
made, further treatment is unnecessary. Although rare,
the oral melanotic macule is characterized as a solitary,
cases of spontaneous resolution of oral melanoacan­
well‐demarcated, uniformly pigmented, macular brown
thoma have been reported (Wright 1988; Fatahzadeh and
lesion (Figure 10.22). Although exposure to ultraviolet radia­
Sirois 2002).
tion can clearly be excluded as a causative agent in intraoral
lesions, the relationship between lesions of the lower labial
vermilion and sun exposure is unclear. While the oral mel­ ORAL MELANOCYTIC NEVUS
anotic macule is generally not regarded as a lesion with Oral melanocytic nevi typically present as well‐circum­
potential to undergo malignant transformation, rare exam­ scribed papules that range in color from brown to black
ples of malignant transformation have been reported in the and may be devoid of pigmentation (Figure  10.24). The
literature (Kahn et al. 2005). Given the predilection for mela­ most common locations for melanocytic nevi in the oral
noma to present on the gingiva and palate, lesions present­ cavity include the buccal mucosa, gingiva, lips, and pal­
ing in these locations should be viewed with a high index of ate (Buchner and Hansen 1987a, b, c). One form of mel­
suspicion. Additionally, features such as asymmetry and anocytic nevus termed the blue nevus typically presents
color variegation are worrisome. Because malignancy can­ on the palate (Buchner and Hansen 1987a, b, c). Oral
not always be excluded on clinical presentation alone, an melanocytic nevi are somewhat more common in women
excisional biopsy may be indicated with submission of and occur over a wide age range, with most lesions noted
lesional tissue for histopathologic evaluation. in the third to fourth decades of life (Buchner et al. 2004).
Although the malignant transformation potential of oral
ORAL MELANOACANTHOMA
mucosal melanoma is not proved, given that oral melano­
(MELANOACANTHOSIS)
cytic nevi frequently present on the palate, similar to oral
Oral melanoacanthoma represents an acquired melano­ mucosal melanoma, and are relatively uncommon lesions,
cytic pigmentation that arises suddenly and most likely excision with submission of lesional tissue for histopatho­
represents a reactive phenomenon. Presenting most logic evaluation is recommended.

148 Practical Advanced Periodontal Surgery

 detection is critical. Pigmented lesions with irregular
borders presenting on the palate, maxillary gingiva, or
­
alveolar mucosa should be viewed with suspicion.
Treatment typically involves radical surgical excision
together with neck dissection and adjuvant chemotherapy
(Umeda and Shimada 1994).

SANGUINARIA‐INDUCED LEUKOPLAKIA
Exposure of the oral cavity to chemical substances, medi­
cations, or dentifrice can lead to specific mucosal changes.
Chronic use of mouth rinses containing sanguinaria extract
(also known as bloodroot extract) has been shown to pro­
duce leukoplakic lesions with an implied potential for
malignant transformation (Damm et al. 1999). The use of
Figure 10.24  Slightly raised pigmented lesion of the posterior hard Viadent brand mouth rinse (Colgate Oral Pharmaceuticals,
palate. Canton, MA) containing sanguinaria extract, a product of
the bloodroot plant, has been shown to produce leukopla­
kic lesions of the maxillary vestibule, a site that is uncom­
mon for white lesions (Figure  10.26). It is generally
recognized that these lesions frequently persist and even
recur following discontinuation of the product. Because
biopsy may show areas of mild to moderate epithelial dys­
plasia, these patients need to be kept under close surveil­
lance (Eversole et al. 2000). Given the apparent association
between sanguinaria‐containing dentifrice and dysplastic
leukoplakia, it is recommended that individuals presenting
with leukoplakic lesions and history of exposure to Viadent
submit for biopsy and discontinue use of the product
(Damm et  al. 1999). (Portions reprinted with permission
pending from Otolaryngol. Clin. N. Am. (38) 2005 21–35.)

PROLIFERATIVE VERRUCOUS LEUKOPLAKIA

Figure 10.25  Irregular pigmented lesion of the posterior palate.
One particularly persistent and importunate form of leu­
koplakia can be difficult to distinguish from verrucous
ORAL MELANOMA carcinoma. Proliferative verrucous leukoplakia (PVL) is
Typically occurring on the palate, maxillary gingiva, and
maxillary alveolar mucosa (Barker et al. 1997), oral mela­
noma represents an uncommon malignancy of the oral
cavity. The five‐year survival rate for oral melanoma per­
sists unchanged since initially being reported in the litera­
ture and ranges from 10 to 20% (Eisen and Voorhees
1991). Oral melanoma presents as pigmented plaques
remarkable for irregular asymmetric borders exhibiting
brown‐black coloration (Figure  10.25). Some melanomas
are notable for lack of melanocytic pigmentation (Eisen
and Voorhees 1991). Clinical evidence of ulceration, bone
erosion, or frank invasion of bone is not uncommon. When
intraoral melanoma represents metastatic rather than a pri­
mary oral lesion, such lesions typically present on the buc­
cal mucosa, tongue, and at the site of a nonhealing
extraction socket (Patton et al. 1994). Given that the prog­
nosis of oral melanoma depends on the stage of the dis­
ease at the time of diagnosis and that the depth of most
oral lesions at the time of diagnosis is advanced, early Figure 10.26  White plaque of the maxillary mucobuccal fold.

Periodontal Medicine Including Biopsy Techniques 149

characterized as an extensive exophytic papillary prolifer­ ­ otentiate the increased risk of developing invasive tumor
p
ation that often involves multiple sites and is recalcitrant to (Zakrzewska 1999; Scully and Porter 2000). Additionally,
treatment. Initial PVL lesions present in a solitary fashion exposure to ultraviolet radiation (lip) or betel quid (a mix­
characterized by thin hyperkeratosis and are well deline­ ture of slaked lime, areca nut, and tobacco wrapped in
ated from the surrounding mucosa. As the lesion evolves, betel leaf and chewed – a social habit quite prevalent in
it may develop a perceptually thickened quality with super­ the Indian subcontinent) may predispose susceptive indi­
ficial undulations consistent with verrucous hyperplasia. viduals to submucous fibrosis, a condition that has an
The lesions become multifocal and recur following exci­ approximately 17% chance of malignant transformation
sion. Over time, the lesions progress to verrucous carci­ and immunosuppression; these are well‐recognized etio­
noma or squamous cell carcinoma (Hansen et al. 1985). logic factors that when paired with a genetically suscepti­
ble individual may yield transformation to oral squamous
Unique in its predilection for women nearly 4:1 over men, cell carcinoma (Scully and Porter 2000).
PVL is generally diagnosed in the seventh decade of life.
Studies report from 70 to nearly 100% of PVL lesions pro­ The most common sites for oral squamous cell carcinoma
gress to squamous cell carcinoma (Silverman and Gorsky are the posterior lateral and ventral tongue, floor of the
1997; Batsakis et  al. 1999), with the gingiva and tongue mouth, and soft palate, although gingival lesions are also
being the sites showing the highest incidence of transfor­ reported (Seoane et  al. 2006) (Figure  10.27). In some
mation (Silverman and Gorsky 1997). Months to years may instances, the similarities between gingival squamous
transpire from the time of initial recognition of the process cell carcinoma and periodontal disease may lead to a
to its ultimate transformation to invasive carcinoma. No delay in diagnosis. The prognosis for oral squamous cell
apparent link between use of tobacco products has been carcinoma is largely based on the stage of presentation
firmly established with regard to PVL (Silverman and (Sanderson and Ironside 2002) and the lesion’s location.
Gorsky 1997; Fettig et  al. 2000), and the link between The presence of positive nodal involvement reduces
human papilloma virus and PVL is controversial (Palefsky long‐term survival by as much as 50% (Sanderson and
et al. 1995; Bagan et al. 2007). Given that PVL most likely Ironside 2002).
represents a disease that is multifactorial in nature, it is dif­
ficult to anticipate specifically who is at high risk for devel­ Clinical presentations that warrant immediate action to rule
oping the condition. (Portions reprinted with permission out squamous cell carcinoma include nonhealing ulcera­
pending from Otolaryngol. Clin. N. Am. (38) 2005 21–35.) tion or unexplained swelling of approximately three weeks’
duration and all red and/or white lesions. A biopsy is
MALIGNANT NEOPLASIA mandatory with definitive diagnosis via histolopathologic
examination. Additionally, it is recommended that tooth
Malignant neoplasia involving the oral cavity may repre­
mobility unrelated to periodontal disease receive thorough
sent primary disease or metastasis, particularly from the
investigation (Sanderson and Ironside 2002).
breast, lung, kidney, prostate, gastrointestinal tract, and
thyroid gland.

SQUAMOUS CELL CARCINOMA

Oral squamous cell carcinoma represents the most com­
mon intraoral malignancy and is remarkable for a variety of
clinical presentations ranging from erythroplakia to leuko­
plakia, or it may present as a combination of the two.
Incipient lesions are typically painless; however, as the
lesion progresses, areas of ulceration and induration may
be seen, and the lesion may become more nodular.
Fixation to underlying tissues and local‐regional lymph
node metastasis indicate further progression to an inter­
mediate stage of malignancy. Late‐stage lesions may pre­
sent with bony involvement, tooth mobility, pain, and
paresthesia (Zakrzewska 1999).

All forms of tobacco use are associated with an increased

risk of developing oral squamous cell carcinoma. When Figure 10.27  Exophytic erythroleukoplakic lesion of the anterior
combined, tobacco and alcohol work in synergy to maxillary gingiva.

150 Practical Advanced Periodontal Surgery

Early biopsy is recommended for any nonhealing or slowly advocated as the standard of care for treatment, and
resolving lesion even if the patient is young and/or denies many years of follow‐up are required to capture addi­
exposure to tobacco products. Although extremely rare, tional foci, as dictated by the multicentric nature of the
occasional accounts of squamous cell carcinoma arising process and apparent increased likelihood that recurrent
in pediatric patients have been made (Bill et  al. 2001). lesions may prove to be more poorly differentiated than
Additionally, recent reports have shown an increased inci­ their predecessor (Ferlito and Recher 1980; Medina et al.
dence of squamous cell carcinoma in female patients and 1984; Spiro 1998). Further, studies have reported a near
in those patients younger than 40 years (Martin‐Granizo 20% incidence of squamous cell carcinoma arising in
et  al. 1997). Ultimately, despite advances in treatment, lesions of verrucous carcinoma. Clinical distinction can­
prognosis depends heavily on tumor staging at the time of not be made between traditional verrucous carcinoma
presentation. Thorough clinical examination and a high lesions and those containing foci of invasive squamous
index of suspicion for mucosal alterations at high‐risk sites cell carcinoma (Medina et al. 1984). This finding dictates
provide the best chance for a positive outcome. (Portions thorough surgical excision extending deep into connec­
reprinted with permission pending from Otolaryngol. Clin. tive tissue to allow adequate assessment of the epithe­
N. Am. (38) 2005 21–35.) lial–connective tissue interface histologically and that
multiple levels through the specimen be subjected to his­
tologic evaluation. Given the propensity for verrucous
VERRUCOUS CARCINOMA carcinoma lesions to grow in a slow fashion, adequate
surgical excision coupled with rigorous clinical follow‐up
Verrucous carcinoma represents a low‐grade variant of
provides the most optimistic prognosis (McCoy and
squamous cell carcinoma with a characteristic papillary
Waldron 1981). (Portions reprinted with permission pend­
exophytic growth pattern (Figure  10.28). A superficial
ing from Otolaryngol. Clin. N. Am. (38) 2005 21–35.)
insidious neoplasm principally due to its indolent growth
course, verrucous carcinoma can be extensive and multi­
METASTATIC DISEASE
focal at the time of clinical presentation. Within the oral
cavity, the most common sites of occurrence are the buc­ Although metastatic disease is uncommon in the oral
cal mucosa and gingiva, sites typically not considered cavity, representing less than 1% of oral neoplasia (van
“high risk” with regard to traditional squamous cell carci­ der Waal et  al. 2003), in at least one third of patients,
noma (Koch et al. 2001). metastasis to the jawbones or oral soft tissues represents
the first clinical sign of the disease (Hirshberg and
Although verrucous carcinoma is not confined exclusively Buchner 1995; van der Waal et  al. 2003; D’Silva et  al.
in presentation to the upper aerodigestive tract, a signifi­ 2006). Of lesions inclined to metastasize to the oral soft
cant link between oral verrucous carcinoma and tobacco tissues, metastatic disease from the lung is the most
products has been made (Ferlito and Recher 1980; commonly encountered (Hirshberg and Buchner 1995).
Medina et  al. 1984; Spiro 1998). Surgical excision is When lesions metastasize to the gingiva, lesions typically

Figure 10.28  Extensive exophytic white papillary lesion involving the

edentulous maxillary alveolar ridge and vestibule. Figure 10.29  Metastatic melanoma to the anterior maxillary gingiva.

Periodontal Medicine Including Biopsy Techniques 151

present as polypoid masses that may be mistaken for a
benign reactive gingival nodule (Ramon Ramirez et  al.
2003) (Figure  10.29), and the most common primary
tumors to metastasize to the gingiva are those originating
in the lung, kidney, breast, bone, and liver (Elkhoury et al.
2004). Obviously, it is of utmost importance to distinguish
metastatic disease from benign lesions that can share
similar clinical features. Biopsy with submission of lesional
tissue for histopathologic analysis is important to ensure
the best prognosis.

INFECTIONS
The oral cavity is susceptible to infections with fungal,
bacterial, and viral organisms. Infections with herpes
­
­simplex virus and oral manifestations of HIV infection are
discussed later.
Figure 10.30  Multiple painful punctate areas of ulceration involving the
HERPES maxillary attached gingiva.
Primary herpetic infection typically presents as gingivo­
stomatitis with the recurrence manifesting as cutaneous/
mucocutaneous disease. Symptoms of primary herpetic
stomatitis arise after an incubation period of up to three day for five to seven days; however, the effectiveness of
weeks following infection. The prodromal symptoms are other antiviral medications such as famciclovir or valaci­
not pathognomonic and include malaise, fever, head­ clovir has not been fully evaluated (Arduino and Porter
ache, nausea, anorexia, and irritability. Acute onset of 2006). Further, the optimal timing of initiating therapy
pain in the oral cavity is seen with the development of and optimum dose are not fully defined. Reduction of
numerous small vesicular lesions that quickly coalesce clinical signs and patient symptoms has been reported
and ulcerate. These lesions may involve any area of the for recurrent herpetic stomatitis using acyclovir (Zovirax)
oral cavity, including the gingiva, buccal mucosa, cream (5%) one application topically every three to four
tongue, palatal mucosa, vermilion, perioral skin, and hours for five days and penciclovir (Denavir) cream (1%)
oropharynx. A severe complication of primary herpetic every two hours for five days, but studies are still needed
gingivostomatitis is ocular involvement. After initial infec­ to determine which is more effective (Arduino and Porter
tion, oral herpes simplex virus remains latent in the 2006). A recent report advocates the utility of oral famci­
trigeminal ganglion. Upon activation, the virus utilizes clovir (Famvir) in the management of herpes labialis
the axons of sensory neurons as a means to reach over­ (Spruance et  al. 2006). Here, 1,500 mg is taken within
lying tissues. Symptomatic recurrences are common and one hour of the onset of prodromal symptoms. This
can be preceded by a prodrome of “tingling” or discom­ ­protocol was reported to reduce duration of symptoms
fort in the affected region, sometimes initially mistaken by approximately two days. In immunocompromised
for a toothache. The typical clinical presentation for patients, topical therapeutics offer little benefit. Acyclovir
recurrent intraoral herpetic infection is of multiple remains the medication of choice (Arduino and Porter
“punched‐out” painful areas of ulceration that may coa­ 2006). As self‐inoculation is possible, it is recommended
lesce and often follow the distribution of the greater pala­ patients be advised to avoid touching the lesions and
tine nerve. Recurrences are frequently attributed to then touching the eyes, genitalia, or other body areas to
manipulation of oral tissues during routine dental proce­ prevent infection at new sites. (Portions reprinted with
dures. The distinction between recurrent herpetic lesions permission from the Journal of the Massachusetts Dental
and recurrent apthous stomatitis (canker sores) is that Society 2005 Winter; 53 (4):55.)
herpetic ulcerations typically involve keratinized tissues
(Figure  10.30) and recurrent apthous ulcerations are
seen on moveable mucosa. Systemic antiviral therapy is
HIV‐ASSOCIATED GINGIVITIS
generally accepted as being effective for management Initially termed “HIV‐related gingivitis,” linear gingival ery­
of primary herpetic stomatitis using acyclovir (Zovirax) thema presents as a red band involving the free gingival
200‐mg capsules administering one capsule five times a margin. This change is typically most prominent in the

152 Practical Advanced Periodontal Surgery

region of the anterior dentition but extends to involve the
posterior quadrants with some frequency (Reznik 2005).
Mild bleeding on subtle provocation has been reported,
and efforts at improved oral hygiene do not lead to resolu­
tion. Some reports suggest this pattern of gingivitis repre­
sents a form of candidiasis (Velegraki et al. 1999). Lesions
typically resolve following professional plaque removal
and rinses with a 0.12% suspension of chlorhexidine
­gluconate twice per day for two weeks. Additional HIV‐
related conditions involving the gingiva include necrotizing
ulcerative gingivitis (NUG) involving necrosis of one or
more interdental papillae and necrotizing ulcerative peri­
odontitis with features of NUG in addition to rapidly pro­
gressing loss of periodontal attachment. Treatment for
these conditions includes gentle debridement with povi­
done‑iodine irrigation. The standard management Figure 10.31  Excisional biopsy. Notice the angulation of the blade,
approach includes rinsing with a suspension of 0.12% which will create a wedge, as well as the amount of healthy tissue
chlorhexidine. Follow‐up with additional debridement at removed.
24 hours and again every 7–10 days is required. In the
acute phase with systemic symptoms of fever and malaise,
antibiotic therapy is ­indicated (amoxicillin 2 g a day for
seven days or metronidazole). • Needle biopsy
• Tissue punch biopsy
ORAL SOFT TISSUE BIOPSY TECHNIQUES
• Scalpel biopsy
It is usually prudent to recommend a biopsy on
lesions that have persisted for over two weeks after the • Laser biopsy
removal of a potential irritant. Lesions that are related
to  infection, inflammation, or local trauma may resolve This chapter will be limited to describing techniques using
during this time. scalpel biopsy.

Biopsies can be incisional or excisional depending on the

ARMAMENTARIUM
nature of the lesion and the comfort level and skills of the
practitioner. If the lesion is large or malignancy is sus­ Surgical set that is recommended is given in Practical
pected, an incisional biopsy is indicated in order to not Periodontal Plastic Surgery (Dibart and Karima 2006).
compromise the definitive treatment of the potentially
malignant lesion. If the lesion is benign, located away from
INCISIONAL SCALPEL BIOPSY
vital structures and of small diameter (less than 1 cm), an
excisional biopsy could be recommended. In both cases, After proper local anesthesia is achieved by infiltrating
it is important to include some of the surrounding healthy the area 1 cm peripheral to the lesion with xylocaine 2%
tissue in the biopsy specimen. The incision should be with 1 : 100 000 epinephrine, the surgeon focuses on the
made parallel to the normal course of nerves, arteries, and area where the incision will take place. With a No. 15
veins to minimize injury (Ellis 2003). Also, when opting for blade, a small wedge that is approximately 3 mm deep,
an incisional biopsy you should keep in mind that “deeper 5 mm long, and 3 mm wide is excised. The specimen
is better” and it is much better to take a deep, narrow needs to include a portion of the margin as well as some
biopsy rather than a broad, shallow one in order to not healthy tissue. The specimen is then very delicately trans­
miss the cellular changes at the base of the lesion (Ellis ferred to a biopsy container with 10% formalin. It is very
2003). Because of the size and morphology of the lesion important not to crush the tissues during excision or
requiring an incisional approach, it is sometimes neces­ transfer into the fixative solution as that may interfere with
sary to obtain more than one biopsy sample of the same the proper oral pathology diagnosis. The surgical site can
lesion (different locations). be closed with a single suture; the patient is given some
mild analgesics (acetaminophen 500 mg) and advised to
The following methods are used to collect tissue samples rinse with an antiseptic mouthwash (chlorhexidine 0.12%)
from the oral cavity (Campisi et al. 2003; Ellis 2003). for one week.

Periodontal Medicine Including Biopsy Techniques 153

Figure 10.32  Elliptical incision to remove a growth located on the lower
lip. The lip is stabilized here with a Chalazion clamp.

EXCISIONAL SCALPEL BIOPSY

After proper local anesthesia is achieved by infiltrating
the area 1 cm peripheral to the lesion with xylocaine 2%
with 1  : 
100 000 epinephrine, an elliptical incision is Figure 10.33  Biopsy container, the amount of liquid present should be
made around the lesion with the blade angled toward sufficient to completely cover the biopsy specimen.
the lesion (Figure 10.31). Tissue stabilization and hemo­
stasis can be achieved manually (assistant’s fingers
pinching the soft tissue on both sides of the biopsy) or
mechanically by using a clamp (i.e. Chalazion clamp for tissues during ­excision or transfer into the fixative ­solution
a biopsy of the lip) (Figure 10.32). Again, it is important as that may interfere with the proper oral pathology
to remember to remove some healthy tissue with the diagnosis.
specimen. The rule of thumb for easy closure is to have
an ellipse that is three times longer than wide. Also, The patient is given some mild analgesics (acetaminophen
depending on the location of the biopsy site and the 500 mg) and advised to rinse with an antiseptic mouth­
size of the wound, there may be a need to undermine wash (chlorhexidine 0.12%) for one week.
the mucosa (with scissors) in order to obtain tension‐
BIOPSY DATA SHEET
free closure. Primary closure of an elliptic wound is
­easily achieved provided that the margins of the wound Once the specimen has been placed in formalin and the
are gently undermined. patient discharged, the biopsy data sheet must be com­
pleted in its entirety. Patient’s information including age
Elliptical incisions on the attached gingiva or palate are and gender as well as the lesion’s size, location of the
not sutured but are left to heal by secondary intention. biopsy, and a clinical diagnosis are typically required
The excised specimen is then very delicately transferred (Figure  10.34). This sheet must accompany the biopsy
to a biopsy container with 10% formalin for fixation container and must be sent to the oral pathology labora­
(Figure  10.33). Again, it is very critical not to crush the tory without delay.

154 Practical Advanced Periodontal Surgery

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158 Practical Advanced Periodontal Surgery

Chapter 11 Sinus Augmentation Using
Tissue‐Engineered Bone
Ulrike Schulze‐Späte, Luigi Montesani, and Lorenzo Montesani

HISTORY Periosteum, a membrane that closely enfolds bone, c ­ onsists

of connective tissue and contains chondroprogenitor and
Implant placement in the edentulous maxilla often repre­
osteoprogenitor cell populations (Hutmacher and Sittinger
sents a clinical challenge due to insufficient bone height
2003). It has been shown that these progenitor cells can be
after crestal bone resorption and maxillary sinus pneuma­
isolated and stimulated in vitro to form cartilage and bone
tization. Surgical approaches that were developed over
using tissue‐engineering techniques (Arnold et  al. 2002;
the past years aim to restore bone height in the posterior
Breitbach et  al. 1998). In 2003, Schmelzeisen et  al.
maxilla to create a sufficient implant bed. Boyne and
described a clinical procedure, which substitutes auto­
James were the first ones to describe a procedure which
genous bone graft material with tissue‐engineered bone in
utilizes existing space in the maxillary sinus by lifting up
a sinus augmentation procedure. Periosteal tissue was har­
the Schneiderian membrane from its bony surface and fill­
vested from the oral cavity and its progenitor cells were iso­
ing this newly created space with augmentation material
lated and expanded in a three dimensional bioabsorbable
(Boyne and James 1980). Several modifications of the
polymer fleece matrix in vitro. The matured transplants were
originally described surgical procedure were developed,
inserted in the maxillary sinus in between the elevated
however, the basic principle of increasing maxillary bone
Schneiderian membrane and the bony floor of the sinus.
height by placing graft material in the maxillary sinus after
A number of follow-up publications and a prospective clini­
detaching the Schneiderian membrane remained the same
cal study demonstrated successful remodeling of the graft
(Davarpanah et  al. 2001; Fugazzotto and De Paoli 2002;
material, therefore, establishing sinus augmentation with
Summers 1994). Grafting materials used to augment bone
tissue‐engineered bone as a possible option for overcom­
height in the posterior maxilla can be categorized into four
ing current limitations of autogenous bone grafting in the
groups: autogenous bone, allografts (from humans), xeno­
posterior maxilla (Schimming and Schmelzeisen 2004;
grafts (from a nonhuman species), and alloplasts (synthetic
Schmelzeisen et al. 2003).
materials). Autogenous bone is the only grafting material
with an osteogenic potential and it has been shown that its
Implant placement can occur at the same surgical appoint­
use in sinus augmentation can achieve predictable results.
ment (immediate placement) or following a healing period
Furthermore, autogenous bone requires shorter healing
(delayed placement) depending on the remaining bone
times (4 months vs. 8–10 months) since it contains living
height. It is generally acknowledged that for an immediate
cells and growth factors. Unfortunately, its availability is
placement at least 4–5 mm of remaining ridge height is
limited due to anatomical confines and donor site morbid­
necessary to achieve sufficient immobilization of implants
ity (Block and Kent 1997; Cammack 2nd et al. 2005; Froum
during maturation of the sinus graft (Jensen et al. 1998).
1998; Garg 1999; Pikos 1996; Wheeler 1997). Several cur­
rent approaches aim to overcome those boundaries; one
INDICATIONS
novel approach uses concepts previously established in
the field of tissue engineering. In contrast to conventional • Insufficient bone height in the posterior maxilla for dental
one dimensional in vitro cell culture, tissue‐engineering implant placement.
techniques aim to mimic an in vivo environment by using
• Need for a large amount of autogenous bone grafting
scaffolds, which arrange cells in a three‐dimensional fash­
material
ion (Risbud 2001). Living tissues which otherwise would
be limited in their potential to grow can be contained and • Patient’s refusal to have a bone graft from a source that
even expanded in vitro before being re‐introduced in vivo. is not his/her own.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

159
CONTRAINDICATIONS
• The presence of uncontrolled diabetes, immune dis­
eases, or other contraindicating systemic conditions.
• Thrombocytopenia or allergically induced thrombocyto­
penia (type II).
• Radiation therapy to the head and neck area in the
12 month period prior to proposed surgical treatment.
• Chemotherapy in the 12 month period prior to proposed
surgical treatment.
• An active sinus infection or a history of persistent sinus
infections.
• Hypersensitivity to bovine albumin, penicillin, gen­
tamicin, amphotericin B.
• An excessive smoking habit.
Figure 11.1  Collection of a periosteal biopsy. Periosteal tissue was
• Alcohol and drug abuse. harvested from the goniac angle of the mandible.
• Physical and psychological handicaps.
• Pregnancy and lactating patients. relatively easy and not too invasive. After administering local
anesthesia, an intrasulcular or intravestibular incision parallel
ARMAMENTARIUM to the mucogingival junction is made using a #15 blade. The
incision on the buccal side of the first mandibular molar
1. For the harvesting procedure, a basic surgical kit such
should extend at least one and a half teeth toward the ante­
as the one described in Practical Periodontal Plastic
rior and posterior in order to obtain sufficient access. A partial
Surgery and an osseous coagulum collector (Citagenix
thickness flap is elevated to expose the underlying perios­
Inc., Quebec, Canada) can be used.
teum. After outlining the area with a #15 blade, the periosteal
2. For the sinus augmentation procedure, a basic surgical
biopsy (approximately 1 cm2) can be collected using a back
kit and the following can be used:
action chisel or osseous coagulum collector (see Figure 11.1).
• Angulated elevation instruments for separation of the
Alternatively, an alveolar bone biopsy (8x10x2mm) can be
Schneiderian membrane from the inner bony surface
taken from the same side or the tuberosity area after expos­
of the maxillary sinus (Hu‐Friedy, Chicago, IL, USA)
ing the bone using a distal wedge incision. The collected
• CollaTape (Zimmer Dental, Carlsbad, CA, USA) tissue biopsy needs to be stored in appropriate sterile tissue
containers and transferred to an in vitro cell/tissue facility for
• Bio-Oss (Geistlich Pharma North America Inc.,
further culturing and tissue expansion. In addition, a blood
Princeton, NY, USA)
sample (approximately 126 ml of blood will be sufficient for 10
• Resorbable membrane: Bioguide (Geistlich Pharma tissue-engineered discs) needs to be taken from the patient.
North America Inc., Princeton, NY, USA); RCM (Bicon, This blood sample will be used to produce serum, which is
Boston, MA, USA) essential for future culturing of the isolated periosteal cells
(Schimming and Schmelzeisen 2004). The donor side can
be sutured with either resorbable (5‐0 chromic gut) or non‐
SINUS AUGMENTATION USING
resorbable (5‐0 silk) suture material.
TISSUE-ENGINEERED BONE DISCS
Technique Postoperative Management
Sinus augmentation using tissue‐engineered bone requires Pain medications should be prescribed as needed. In
two surgical procedures, harvesting and transplant implan­ addition, chlorhexidine rinses twice a day for 21 days start­
tation surgery. ing 1 day after the surgery should be included in the post­
operative regimen.
Harvesting Procedure
Treatment and Expansion of Periosteal Biopsies
Periosteal tissue can be obtained from several locations in
the oral cavity. However, access to the lateral cortex of the The periosteal tissue biopsy can be cultured using a tissue
mandibular body in the apical region of the first molar area is engineering protocol described by Schmelzeisen et  al.

160 Practical Advanced Periodontal Surgery

 (a) (b)

Figure 11.2  Tissue-engineered bone discs. (a) Discs were kept in transportation medium until implantation. (b) Scaffolds need to be carefully handled
so as not to destroy the incorporated cells.

(Schmelzeisen 2003). In addition, commercial companies Austria) in a 1 : 10 PBS dilution. The transplant discs are
such as Bio Tissue Technology, Freiburg, Germany offer to cultured for an additional week in DMEM/Ham’s supple­
overtake laborious cell culturing and provide the clinician mented with 5% autologous serum, dexamethasone
with the finished tissue-engineered bone discs. 10‐7 Mol, β‐glycerophosphate 10 mM and ascorbic acid
(50 mg/l). At this point (approximately seven weeks after
The periosteum needs to be enzymatically digested to iso­ the harvesting procedure), the transplants are ready for
late progenitor cells. Collagenase CLSII (Clostridium histo- implantation. Each final disc contains around 1.5 × 106 cells
lyticum) at a concentration of 333  U/ml (Biochrom, and is circa 2 × 10 mm in size (see Figure 11.2a and b).
Cambridge, UK) in 1  :  1 DMEM/Ham’s F‐12 (Dulbecco’s
modified Eagle’s medium, Invitrogen, Carlsbad, CA, USA)
TRANSPLANT IMPLANTATION SURGERY
can be used and the resulting cell suspension needs to be
(SINUS AUGMENTATION PROCEDURE USING
washed with phosphate buffered saline (PBS, Invitrogen,
TISSUE-ENGINEERED BONE DISCS)
Carlsbad, CA, USA). Cells are counted using a hemocy­
tometer and stained with trypan blue dye to determine the Prior to the sinus augmentation procedure, a computed
overall cell viability. Afterwards, they are resuspended in tomography (CT) scan or panoramic radiograph should
1  :  1 DMEM/Ham’s F‐12 supplemented with 10% autolo­ be taken from the selected area (Figure  11.4a). The
gous serum and seeded into cell cuture flasks. The flasks ­procedure can be performed under local anesthesia. A
are cultured in a cell culture incubator adjusted to 37 °C, mid-crestal incision is made with mesial and distal releas­
3.5% CO2 and 95% humidity. The medium needs to be ing incisions extending well into the buccal fold. The
replaced every two days until cells reach a 70% conflu­ mucoperiosteal flap is reflected in a full thickness man­
ency. At this point, cells are trypsinized (0.02%trypsin and ner and care needs to be taken to completely release the
0.02% EDTA in PBS) for five minutes and seeded at a den­ tissue for a tension‐free access to the lateral wall of the
sity of 5000/mm2. This step needs to be repeated four times maxillary sinus. There are three classical approaches to
to increase cell number. Following trypsinization, cells are enter the maxillary sinus. In the Caldwell Luc approach
now ready to be incorporated into the transplant discs the window is anterior to the zygomatic buttress, in a low
(Perka et al. 2000). Several scaffold materials such as syn­ position the window is situated next to the alveolar crest
thetic and natural polymers, composites, and ceramics and in a mid‐maxillary position the lateral window is situ­
have been tested in recent years (Sittinger et  al. 2004). ated between the alveolar crest and zygomatic buttress
They need to be biocompatible and resorbable to facilitate (Lazzara 1996; Summers 1994; Zitzmann and Scharer
integration of the future graft into an in vivo environment. To 1998). In the above introduced application, a lateral win­
incorporate cells into the scaffold, cells are suspended dow approach is recommended. However, in any case,
in  1  :  1 DMEM/Ham’s and mixed with human fibrinogen the osteotomy window should be placed according to the
(TissueColl, Baxter Immuno, Austria) in a 3  :  1 ratio. The anatomical structure of the m
­ axillary sinus and its inferior
resulting cell solution is soaked into polymer fleeces (e.g. horizontal border should be  3–4 mm above the sinus
Ethicon, Cornelia, GA, USA) and subsequently ­polymerized floor. The oval window is ­outlined under continuous ster­
by adding bovine thrombin (TissueColl, Baxter Immuno, ile saline irrigation with a highspeed handpiece and

Sinus Augmentation Using Tissue‐Engineered Bone 161

either a carbide or a diamond bur (see Figure 11.3a). As lasting membrane (Biomend, Zimmer Dental, Carlsbad,
an alternative, piezoelectric surgery could be used, CA, USA) (Zimbler et al. 1998). In cases of major mem­
reducing the risks of underlying membrane perforation brane destruction, it is recommended to abort the graft­
(Vercellotti et  al. 2001). The bone covering the window ing procedure and wait six to nine months for membrane
can either be thinned uniformly all around or in a trap regeneration (Berengo et  al. 2004). It is important to
door manner, which uses the superior border as a hinge detach the membrane sufficiently from its walls since it
(see Figure 11.3b). In both techniques, the bony window has been shown that in an adequately elevated mem­
is carefully pushed inward and at the same time the brane tears can heal without complications. In contrast,
Schneiderian membrane gets detached from its underly­ laceration could stay open in membranes which are too
ing bony surface using angulated elevation instruments. stretched (Jensen et  al. 1998). In addition, insufficient
Attention should be paid to preserving the integrity of the membrane elevation might subsequently result in a graft,
sinus membrane by keeping elevation instruments in which is not adequate in its dimensions to support future
constant contact with the internal bony sinus wall during implants. Especially the medial and anterior walls are
the membrane elevation process. After elevation, mem­ common regions to display insufficient grafting. Therefore,
brane integrity can be checked with the valsalva maneu­ grafting the anterior wall first is a habit many surgeons
ver (Charkawi et  al. 2005). Occurring tears can be have developed to prevent this problem. Furthermore, it is
repaired. For small tears (less than 5 mm) a fast resorbing advised to hold up the membrane with a periosteal eleva­
collagen membrane such as Collatape (Zimmer Dental, tor while packing the bone graft against the medial wall
Carlsbad, CA, USA) can be used to cover the tear. Repair to prevent packing against a Schneiderian membrane
of larger perforations requires a more rigid and longer that has “come down” as a result of the patient’s breathing.

(a) (c)

(b) (d)

Figure 11.3  Sinus augmentation using tissue‐engineered bone discs. (a) A lateral window was outlined to access the maxillary sinus. (b) The Schneiderian
membrane was elevated from its bony surface to create space for the augmentation material. (c and d) Tissue‐engineered bone discs were implanted into the
maxillary sinus. (e) The discs were covered with Bio-Oss (Osteohealth) augmentation material (optional). (f) The grafted area was covered with a resorbable
membrane (Bioguide, Osteohealth). (g) The flap was sutured in its original position with single interrupted sutures (Gortex, Gore Medical).

162 Practical Advanced Periodontal Surgery

 (e) (f)

(g)

Figure 11.3  (continued)

It also should be kept in mind that the ostium which rep­ #15 blade in order to facilitate a tension free closure. The
resents the connection in between the middle meatus of flap can now be sutured with either resorbable (such as
the nose and the maxillary sinus is approximately 25 mm Vicryl, Ethicon, Carnelia, GA, USA) or nonresorbable
above the floor of the sinus. A ­blockade due to extensive (such as Gortex suture, Gore Medical, Flagstaff, Arizona)
sinus grafting can result in a chronic infection of the max­ suture material in single interrupted sutures (see
illary sinus (Doud Galli et al. 2001). Figure  11.3g). Whenever necessary, these sutures can
be replaced by a continuous suture and further secured
Assuming that the membrane is elevated sufficiently, the with horizontal mattress sutures.
tissue‐engineered discs which can be kept in the trans­
Postoperative Management
portation medium during the procedure are then inserted
into the sinus and gently packed until the space • Antibiotic therapy should be started the day before the
in between sinus membrane and bony walls of the sinus procedure: 500 mg amoxicillin three times daily for seven
is filled (see Figure  11.3c and d). In addition, bone days (300 mg clindamycin four times daily should be
augmentation material such as Bio-Oss (Osteohealth,
­ prescribed for penicillin sensitive patients)
Shirley, NY, USA) can be used as a protective layer on
• Analgesics: Acetaminophen + codeine (Tylenol #3) or
the outside of the graft (see Figure  11.3e). The window
ibuprofen (Motrin 600 
mg) three times a day or as
should be covered with a membrane that overlaps
necessary.
its  ­
outlines and therefore protects the grafted side.
Either  a nonresorbable membrane with securing tacks • Anti‐inflammatories: Dexamethasone can be prescribed
or a resorbable one can be used for this purpose for five days in the following manner (day of surgery:
(see Figure 11.3f). Afterwards, the mucoperiosteal flap is 3.75 mg; day 2: 3 mg; day 3: 2.25 mg: day 4: 1.5 mg; day 5:
positioned back to cover the surgical site. It might be 0.75 mg). This will control the swelling and alleviate the
necessary to release the periosteum of the flap with a discomfort.

Sinus Augmentation Using Tissue‐Engineered Bone 163

(a) (b) (c)

(d)

Figure 11.4  Radiographic evaluation of the grafted site. (a) A periapical radiograph was taken and revealed inadequate bone height prior to implant
placement. (b) Radiograph depicting the augmented site prior to implant placement. (c) Implant was placed successfully in the grafted site achieving
primary stability. (d) 10 year follow up. Graft material is still in place.

• Afrin spray: Patients should be given this spray to use in

order not to blow their noses for two weeks, as that will
impair proper healing of the graft.
• Antiseptic rinses: Chlorhexidine digluconate rinses twice
a day for 21 days starting 1 day after the surgery are
recommended.
• Patients can wear their complete dentures after the
procedure; however, the buccal flange needs to be
­
reduced and later on relined with a soft reliner. Partial
dentures should only be worn if they have an acrylic
base which allows appropriate relief and facilitates soft
relining. However, it is recommended to advise that the
denture is worn for esthetic reasons and not for function
until the day of suture removal.
Figure 11.5  Histological staining of core biopsy taken from the future
Healing implant side. Goldner’s staining shows mineralized bone (green; see white
Studies revealed sufficient new bone formation four arrow) and newly formed osteoid (red; see black arrow).
month after implantation of the tissue-engineered bone
discs (Schmelzeisen et  al. 2003). Therefore, dental staining to determine current mineralization status of the
implants can be placed four month after the grafting pro­ augmented bone (see Figure 11.5). Afterwards, implants
cedure (see Figure 11.4b and c). A core biopsy can be can be restored according to standard protocols (see
taken during the surgery and subjected to histological Figure 11.6).

164 Practical Advanced Periodontal Surgery

 (a)

Figure 11.7  Material taken from the bone marrow through aspiration.

(b) Possible Complications

Complications occurring after sinus augmentation with tis­
sue‐engineered bone should not be different from compli­
cations associated with other grafting materials assuming
that the discs were prepared and transported under sterile
conditions.

Swelling, Bruising, and Bleeding

Patients might experience swelling and bruising in the
­surgical areas after the procedure. Therefore, it is recom­
mended to use cold pads for the initial 24 hours. Afterwards,
the application of warm pads in combination with anti‐
Figure 11.6  Clinical view of the restored implant. (a and b) Implant was
inflammatory medications will help to reduce swelling and
restored with a single porcelain fused metal (PFM) crown.
discomfort. It is not unusual for patients to report an exac­
erbated feeling of pain five days after the procedure since
at this time point the corticosteroid regimen has ended.
Therefore, patients should be informed beforehand and
SINUS LIFT USING AUTOGENOUS advised to continue taking non‐steroidal anti‐inflammatory
MESENCHYMAL CELLS PROCESSED drugs for a week.
CHAIRSIDE
In case of nasal bleeding due to laceration of the
This technique mixing a xenograft with autogenous mes­
Schneiderian membrane, patients should be reassured
enchymal cells taken from the posterior iliac crest allows
(as this will happen after they have left your office), and
for quick maturation of the bone and implant placement at
pressure with a cotton ball should be applied to stop the
four months (Duttenhoefer et al. 2014).
nasal bleeding.
Harvesting Procedure
Infraorbital Nerve Paresthesia
After loco‐regional anesthesia, 60 ml of a bone marrow
Paresthesia of the area innervated by the infraorbital nerve
aspirate is taken from the posterior iliac crest of the patient
can be caused by blunt retraction over the neurovascular
(Figure 11.7). This material is then put through a centri­
bundle. It is usually transient and disappears within a few
fuge for 14  minutes according to the manufacturer’s
weeks. However, in some cases long‐lasting paresthesia
instruction (Harvest, Terumo BCT, Colorado USA) to sepa­
up to several months is possible.
rate the plasma from the mononuclear cells, granulocytes,
thrombocytes, and erythrocytes (Figure 11.8). The plasma
Infection of the Grafted Site and Membrane
layer is discarded, and the cellular layers are mixed with
Exposure
the xenograft (Bio‐Oss) (Figure 11.9). Following this the
graft mixture is ready to be loaded in a syringe (Figure Infection spreading from an infected graft can lead to
11.10) and to be inserted into the sinus (Figure 11.11). pansinusitis, spread to the orbit, dura, brain, and requires
The implants are placed simultaneously and after four intervention. An early sign is the occurrence of an intraoral
months final impressions can be taken in most cases swelling one week post‐surgery; however, signs of infec­
(Figure 11.12). tion can be detected as early as three days. In case of an

Sinus Augmentation Using Tissue‐Engineered Bone 165

Figure 11.8  The material is placed in the centrifuge and the plasma is separated.

Figure 11.9  The stem cell-rich material is mixed with the xenograft
(Bio‐Oss).

Figure 11.11  The bone graft is delivered into the sinus with simultane-
ous implant placement.

infection, prescription of antibiotics such as clindamycin

with a loading dose of 600 mg followed by 300 mg four times
daily is recommended. Metronidazole can be added for
anaerobic coverage at 500 mg three times daily. Most of
the time, a localized infection will respond to the treatment.
However, in case of persistent symptomatology it is imper­
ative to pursue aggressive treatment, which includes inci­
Figure 11.10  The graft mixture is loaded into the syringe. sion and drainage over the original incision line. In addition,

166 Practical Advanced Periodontal Surgery

Figure 11.12  Four months later prior to uncovering.

aerobic and anaerobic cultures could be used as a sup­ Boyne, P.J. and James, R.A. (1980). Grafting of the maxillary sinus
portive adjunct to determine future treatment. Sometimes floor with autogenous marrow and bone. J. Oral Surg. 38 (8):
613–616.
local debridement is appropriate and sufficient. If the graft
needs to be completely removed, a long-lasting collagen Breitbach, A.S., Grande, D.A., Kessler, R. et al. (1998). Tissue engi­
membrane should be used to cover the window. After a neered bone repair of calvarial defects using culture periosteal
healing period of three to four months, the site can be cells. Plast. Reconstr. Surg. 101: 567–574.
re-entered for an additional grafting procedure. In response
Cammack, G.V. 2nd, Nevins, M., Clem, D.S. 3rd et  al. (2005).
to an infection, oroantral fistulae can form which are treat­
Histologic evaluation of mineralized and demineralized freeze‐
able with antibiotics and oral chlorhexidine rinses. dried bone allograft for ridge and sinus augmentations. Int. J.
Nevertheless, large and persistent fistulae require surgical Periodontics Restorative Dent. 25 (3): 231–237.
intervention. In case of a premature exposure of the mem­
brane, it has been shown that oral bacteria can penetrate Charkawi, E., Hussein, G., Askary, E. et  al. (2005). Endoscopic
removal of an implant from the maxillary sinus: a case report.
the membrane surface within four weeks (Simion et  al.
Implant Den. 14 (1): 30–35.
1994). Thus, it is advised to continue the use of chlorhex­
idine mouth rinses until the final implant surgery. In any Davarpanah, M., Martinez, H., Tecucianu, J.F. et al. (2001). The modi­
case, the patient should be closely followed in order to fied osteotome technique. Int. J. Periodontics Restorative Dent. 21
intervene if an infection develops and the membrane (6): 599–607.
needs to be removed.
Doud Galli, S.K., Lebowitz, R.A., Giacchi, R.J. et al. (2001). Chronic
sinusitis complicating sinus lift surgery. Am. J. Rhinol. Allergy 15
Taken together, infection should be treated in a compre­ (3): 181–186.
hensive way to minimize the risk of spreading and maxi­
mize the success of the grafting procedure. Duttenhoefer, F., Hieber, S.F., Stricker, A. et  al. (2014 Apr 1).
Follow‐up of implant survival comparing ficoll and bone marrow
aspirate concentrate methods for hard tissue regeneration with
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Arnold, U., Lindenhayn, K., and Perka, C. (2002). In vitro‐cultivation of 75–76.
human periosteum derived cells in bioresorbable polymer‐TCP‐
composites. Biomaterials 23: 2303–2310. Froum, S.J., Tarnow, D.P., Wallace, S.S. et al. (1998). Sinus floor eleva­
tion using anorganic bovine bone matrix (OsteoGraf/N) with and
Berengo, M., Sivolella, S., Majzoub, Z., and Cordioli, G. (2004). without autogenous bone: a clinical, histologic, radiographic, and
Endoscopic evaluation of the bone‐added osteotome sinus floor histomorphometric analysis‐‐part 2 of an ongoing prospective
elevation procedure. Int. J. Oral Maxillofac. Surg. 33 (2): study. Int. J. Periodontics Restorative Dent. 18 (6): 528–543.
189–194.
Fugazzotto, P.A. and De Paoli, S. (2002). Sinus floor augmentation
Block, M.S. and Kent, J.N. (1997). Sinus augmentation for dental at the time of maxillary molar extraction: success and failure rates
implants: the use of autogenous bone. J. Oral Maxillofac. Surg. 55 of 137 implants in function for up to 3 years. J. Periodont. 73 (1):
(11): 1281–1286. 39–44.

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Garg, A.K. (1999). Augmentation grafting of the maxillary sinus Simion, M., Trisi, P., Maglione, M., and Piattelli, A. (1994). A prelimi­
for  placement of dental implants: anatomy, physiology, and nary report on a method for studying the permeability of expanded
­procedures. Implant Dent. 8 (1): 36–46. polytetrafluoroethylene membrane to bacteria in vitro: a scanning
electron microscopic and histological study. J. Periodont. 65 (8):
Hutmacher, D.W. and Sittinger, M. (2003). Periosteal cells in bone 755–761.
t­issue engineering. Tissue Engineering 9 (Suppl 1): S45–S64.
Sittinger, M., Hutmacher, D.W., and Risbud, M.V. (2004). Current strat­
Jensen, O.T., Shulman, L.B., Block, M.S., and Iacono, V.J. (1998). egies for cell delivery in cartilage and bone regeneration. Curr.
Report of the sinus consensus conference of 1996. Int. J. Oral Opin. Biotech. 15 (5): 411–418.
Maxillofac. Implants 13 (Suppl): 11–45.
Summers, R.B. (1994). A new concept in maxillary implant surgery:
Lazzara, R.J. (1996). The sinus elevation procedure in endosseous the osteotome technique. Compendium 15 (2): 152, 154‐6, 158
implant therapy. Curr. Opin. Periodont. 3: 178–183. passim; quiz 162.

Perka, C., Schultz, O., Spitzer, R.S. et al. (2000). Segmental bone repair Vercellotti, T., De Paoli, S., and Nevins, M. (2001). The piezoelectric
by tissue‐engineered periosteal cell transplants with bioresorbable bony window osteotomy and sinus membrane elevation: intro­
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Pikos, M.A. (1996). Chin grafts as donor sites for maxillary bone 561–567.
­augmentation‐‐part II. Dent. Implant. Update 7 (1): 1–4.
Wheeler, S.L. (1997). Sinus augmentation for dental implants: the
Risbud, M. (2001). Tissue engineering: implications in the treatment use of alloplastic materials. J. Oral Maxillofac. Surg. 55 (11):
of organ and tissue defects. Biogerontology 2: 117–125. 1287–1293.

Schimming, R. and Schmelzeisen, R. (2004). Tissue‐engineered bone Zimbler, M.S., Lebowitz, R.A., Glickman, R. et al. (1998). Antral aug­
for maxillary sinus augmentation. J. Oral Maxillofac. Surg. 62 (6): mentation, osseointegration, and sinusitis: the otolaryngologist’s
724–729. perspective. Am. J. Rhinol. Allergy 12 (5): 311–316.

Schmelzeisen, R., Schimming, R., and Sittinger, M. (2003). Making Zitzmann, N.U. and Scharer, P. (1998). Sinus elevation procedures
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Surg. 31: 34–39. Endod. 85 (1): 8–17.

168 Practical Advanced Periodontal Surgery

Chapter 12 Extraction Site Management in the Esthetic Zone:
Hard and Soft Tissue Reconstruction
Sherif Said

INTRODUCTION
contour, color, and texture surrounding the implant while
When considering implant therapy in the esthetic zone,
the white focuses on the implant supported crown.
replicating the natural soft tissue frame may present chal-
Objective assessment criteria have been introduced in the
lenges for the treating clinician. A harmonious gingival
literature (PES/WES) in an attempt to standardize how
form and architecture are not only fundamental for ade-
­clinicians and researchers evaluate the esthetics of implant
quate peri‐implant pink esthetics but also for simulating a
supported restorations. For anterior implant therapy, evalu-
natural emergence for the future restoration. When dealing
ation of both the pink and white esthetics is imperative, and
with clinical situations in which adequate tissue architec-
consequently surgical therapy should be geared toward
ture and volume are present, preserving or further
optimizing functional and biological outcomes without
enhancement of the available support may provide an
neglecting the esthetic component. This chapter will focus
improved esthetic outcome with less associated morbidity
on management and correction of deficient sites through
and treatment duration. Nevertheless, reconstruction of
combined hard and soft tissue volume ­augmentation pro-
atrophic sites due to lost hard and soft tissue volume is
cedures to offer improved peri‐implant pink esthetics and
often inevitable in the anterior zone, which may necessi-
functional long‐term outcomes (Figure 12.2).
tate more complex grafting procedures with varying
degrees of predictability in achieving ideal peri‐implant TISSUE VOLUME AVAILABILITY
soft tissues. This chapter will highlight clinical scenarios AND REQUIREMENTS
and evidence‐based treatment of cases in which the lack
of hard and soft tissue volume poses difficulty in achieving Preservation of the existing architecture of the soft tissues
optimal peri‐implant esthetics. Contemporary clinical strat- prior to tooth extraction offers clinicians a simple method
egies and minimally invasive techniques will also be dis- of obtaining a more “natural” appearance of the final
cussed in order to provide clinicians with different options implant restoration. The soft tissue “curtain” that sur-
to better manage hard and soft tissue deficiencies when rounds implant supported crowns requires sufficient,
dealing with implant therapy in the esthetic zone. three‐dimensional hard and soft tissue volume to attain a
long‐term stable result. Unfortunately, the tissue volume
requirements for dental implants is often more than what is
THE INFLUENCE OF TISSUE VOLUME
needed for maintenance of the natural dentition.
ON THE PERI‐IMPLANT “PINK” ESTHETICS
Consequently, preservation of the tissue architecture
Solely relying on objective criteria for osseointegration and alone following tooth extraction may not always be ade-
functional aspects of dental implants may not be sufficient quate to maintain tissue stability around the future implant
in modern day implant dentistry. Esthetics and patient‐ and thus additional soft and hard tissue augmentation is
centered outcomes have evolved to become integral com- often required. Spray and colleagues (2000) demon-
ponents of our daily practice, especially in the esthetic strated the importance of sufficient buccal bone in implant
zone. The clinician must consider that esthetics are also dentistry. It was found that when the bone buccal to an
highly subjective and should be suited towards providing implant fixture was less than 1.8 mm, bone remodeling
treatment that is tailored to each individual patient depend- and possible implant dehiscence was observed at the
ing on their particular situation (Figure 12.1). time of second stage uncovering. Other authors have
­corroborated these findings with recommendations of a
Implant esthetics can be further segmented into pink and minimum of 2 mm of bone buccal to the implant with a
white esthetics. The “pink” refers to the soft tissue form, range of 2–4 mm (Grunder 2000, 2011) for maintenance of

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

169
Figure 12.1  Triad of contemporary implant dentistry (Buser et al. 2017; Linkevicius et al. 2009).

Figure 12.2  : Pink and white esthetic score. (a) Mesial Papilla. (b) Distal Papilla. (c) Soft tissue level. (d) Soft tissue color, texture, and curvature. White
esthetic Score. (e) Tooth Form. (f) Tooth Outline. (g) Surface texture. (h) Color. (i) Translucency (Tettamanti et al. 2016).

(a) (b) (c) (d)

Figure 12.3  (a) Implant placement in an upper central incisor area. (b) Note the gray shadow of the implant fixture apparent through the thin buccal
bone. (c) Buccal bone thickness less than 1 mm will possess minimal vascularity and is highly susceptible to further resorption following implant
placement or loading. (d) Buccal veneer grafting to compensate for the remodeling of the thin buccal plate.

the peri‐implant crestal bone levels and long term tissue bone integrity and avoiding visibility of the implant
stability (Figures 12.3 and 12.4). ­restorative components. Owing to its reduced vascularity
and cellular content, thin peri‐implant mucosa has
With regards to the soft tissue demands, 2–3 mm of facial reduced resistance to bacterial plaque and subsequently,
peri‐implant soft tissue thickness has been shown to have peri‐implant disease. Soft tissue recession may then result
a protective function (Figure 12.5), maintain the underlying in “show through” of the underlying implant restorative

170 Practical Advanced Periodontal Surgery

components, leading to an unesthetic tissue shade or Teeth with intact periodontium may require minimal aug-
­further develop to involve the implant abutment and even mentation (Figure  12.6). However, in cases where the
the implant fixture in cases where the supporting bone is integrity of the socket is compromised or in cases with
compromised (Jung et al. 2009; Linkevicius et al. 2009). severe tissue deficiencies more extensive augmentation

(a) (b) (c)

Figure 12.4  (a) Buccal veneer grafting performed at the time of implant placement with a xenograft material to further augment the buccal contour.
(b) Grafting of more than 4 mm buccal to the anticipated implant position to compensate for remodeling of the bone graft material. (c) Utilizing a
­non‐­resorbable membrane to shape the bone graft to the desired ridge shape.

(a) (b)

Figure 12.5  (a and b) Robust buccal volume augmentation following combined connective tissue grafting and dual zone protocols to simulate a natural
emergence of the final restoration and mask any show‐through of the abutment material.

(a) (b) (c)

Figure 12.6  (a) Clinical situation following bone and soft tissue augmentation at the time of implant placemen (b) Note the bone graft particles
encapsulated within the soft tissue. (c) Occlusal view of the final abutment in place.

Extraction Site Management in the Esthetic Zone 171

 Figure 12.8  Close up view of the buccal plate of a canine socket
following extraction. Flap reflection was performed revealing a green‐stick
fracture of the bone that was not noted at the time of tooth removal.
Figure 12.7  Tissue thickness augmentation following connective tissue
grafting measuring 3.5 mm, providing a very stable soft tissue protective timeline, tissue augmentation may be performed at the fol-
seal for the implant. lowing phases of treatment:

1. At the time of Tooth Extraction

may be required to achieve the desired outcomes. The 2. At the time of Implant Placement
­initial part of this chapter will focus on post‐extraction tis-
sue changes in the esthetic zone with specific focus on 3. At the Time of Second Stage Uncovering or Post Implant
pre‐operative tissue assessment prior to tooth extraction Provisionalization
and implant placement (Figure 12.7).

PRE‐OPERATIVE IMPLANT SITE ASSESSMENT Key Factors in Diagnosis of the Surrounding

Tooth Support Prior to Extraction
Due to the inherent anatomy of the alveolar topography in
the anterior zone, post‐extraction ridge dimension Accurate diagnosis of the periodontal integrity of both the
alterations are more common than in posterior sites.
­ tooth to be extracted and neighboring teeth must be
Tomographic studies have demonstrated that the average attained in order to determine the need for prior corrective
buccal bone thickness is less than 1 mm in 90% of anterior procedures and/or plan for the augmentations required
teeth (Braut et al. 2011). prior to tooth extraction. Furthermore, analysis of the clini-
cal situation also becomes a critical determinant in the
The difficulty of management of anterior sites is compounded viability of proceeding with immediate implant placement
by the fact that the buccal plate (bundle bone) stems from upon tooth removal.
the periodontal ligament of the tooth and inevitably under-
goes remodeling once the tooth is removed (Figure  12.8). Prior to tooth removal, the following diagnostic criteria
Araújo et al. (2006, 2008) demonstrated a 40% reduction in should be considered:
ridge width following tooth extractions in dogs. Buser et al.
(2017) demonstrated similar findings in extraction sites that • Integrity of the interproximal height of bone
were not grafted. Such dimensional changes often require
• Integrity of the buccal plate of bone
more invasive procedures to restore sufficient ridge volume
to satisfy the biologic, functional, and esthetic demands. • Root angulation/inclination and its relationship to the api-
Subsequently, efforts to maximize the remaining ridge topog- cal bone topography
raphy and tissue volume should be made at the time of tooth
• Tissue integrity or presence of mucogingival defects in
extraction. If residual deficiencies are still present, further
the form of facial or interproximal tissue recession
augmentation may be required at the time of implant place-
ment and/or second stage uncovering.
Integrity of the Interproximal Height of Bone
The clinical decision making process of the appropriate It has been well established in the literature (Gastaldo
timing of implant placement and augmentation procedures et  al. 2004) that the height of the peri‐implant papilla is
will be discussed throughout the chapter. As a general not dictated by the level of bone ­surrounding the implant

172 Practical Advanced Periodontal Surgery

 Tooth Implant
Enamel

Dentogingival
fibers

Fiber attached Abutment

to the root surface Circumferential
fibers
Gum tissue No fiber
attachment
Periodontal
Bone
ligament

Implant

Figure 12.9  Schematic illustrating the differences between the peri‐implant and periodontal attachment. Note the perpendicular orientation of the
periodontal attachment which creates a protective barrier from physical and bacterial insults in addition to support of the supra‐crestal tissue. The
difference in fibers orientation histologically contributes to the difference in macroanatomy of the peri‐implant papilla and gingiva.

but by the presence of the supra‐crestal periodontal fib- and facial tissue recession exposing the underlying
ers on the adjacent teeth. It has been further shown in ­restorative components. If the level of the gingival margin
recent literature that the papillary height in sites of mul- in relation to the adjacent teeth and in relation to the final
tiple adjacent missing teeth is significantly less than implant supported restoration is located apically to the
when the tooth is present. Therefore, the periodontal contralateral tooth, it may be prudent for the clinician to
integrity and height of bone on the adjacent teeth consider soft tissue grafting either before tooth extraction
become a key determinant in the final esthetics of the or at any time point prior to finalization of the prosthetic
implant supported restoration. In the presence of perio- procedures to compensate for these discrepancies
dontal pathology, or interproximal attachment loss on (Figure 12.11).
the adjacent teeth, interdisciplinary techniques such as
orthodontic extrusion or changes to the tooth shape by Root Angulation/Inclination and its
restorative means may then be required to compensate Relationship to the Apical Bone Topography
for deficiencies in the interproximal papillary area
Kan (Kan et  al. 2011) classified sagittal tooth positions
(Figure 12.9).
on CT scans to evaluate the viability of immediate implant
placement in fresh extraction sockets based on different
Consequently, a comprehensive periodontal evaluation,
tooth inclination patterns (Figure  12.12). Sagittal tooth
radiographic analysis, and bone sounding are essential
position may facilitate or hinder implant placement in the
diagnostic factors prior to tooth extraction in order to
correct three‐dimensional restorative driven position.
­anticipate the final outcome and diagnose any deficien-
Since the objective is to place the implant in a more pala-
cies that may be present. Furthermore, the clinician must
tal position, a buccal tooth position may offer a more
be cognizant of any mesio‐distal tooth mal‐positioning
favorable situation due to the increased available palatal
and/or root proximity that may render the interdental bone
bone for implant anchorage. If the tooth occupies most
more susceptible to resorption. The choice of flap reflec-
of the socket as in class IV or if there is inadequate
tion and design may also be modified in an attempt to
apical bone to engage the implant, this may dictate
­
avoid stripping of the periosteum and blood supply overly-
additional hard tissue augmentation prior to implant
ing thin (<1.5 mm) or compromised inter‐radicular bone.
placement. The results of Kan studies have shown that
most of the anterior teeth lie in the class II and III catego-
Integrity of the Buccal Plate of Bone
ries, meaning that the tooth is either in the center of the
Conebeam CT scan, clinical periodontal evaluation, and socket or the root apex is angled toward the palatal
bone sounding are combined to ascertain the integrity and aspect. These positions consequently create difficulties
level of the buccal plate prior to extraction (Figure 12.10). in placement of immediate implants in a more palatal
Compromise in the buccal plate integrity can ultimately position to facilitate a palatal screw retained access.
yield to collapse of the tissue in the bucco‐lingual aspect Consequently, an angled screw channel may be utilized
yielding to an unesthetic implant supported restoration should a screw retained restoration be desired or the

Extraction Site Management in the Esthetic Zone 173

 (a) (c)

(b) (d)

Figure 12.10  (a–d) Pre‐operative assessment of the interproximal height of bone through bone sounding of the tooth to be extracted as well as adjacent
dentition to determine the integrity of the periodontal attachment prior to flap reflection.

(a) (b)

Figure 12.11  (a) Pre‐operative bone sounding of the buccal plate reveals probing depths in excess of 10 mm. (b) Intra‐surgical view showing complete
absence of the buccal plate.

­ linician may resort to a cement retained restoration with

c amount of apical bone to engage the implant if immediate
customized abutments. implant therapy is considered as well as determining the
need of augmentation procedures in lieu of immediate
It can therefore be established from the studies that the implant placement if the implant is not sufficiently encased
tooth position within the alveolar envelope determines the within the alveolar envelope.

174 Practical Advanced Periodontal Surgery

Figure 12.12  Tooth angulation in relation to the alveolar housing. Class I: the tooth is located buccal in relation to the ridge. Class II: The tooth is in the
center of the ridge. Class III: The tooth is located palatal within the ridge. Class IV: The remaining ridge topography is deficient to allow adequate implant
placement.

TISSUE AUGMENTATION AT THE TIME placed in the desired, restoratively driven position. Should
OF TOOTH EXTRACTION there be anatomical deficiencies or inadequate access to
achieve the desired therapeutic goal, alternative incision
Following pre‐operative assessment, management of the
designs/approaches can be utilized to allow for better
extraction socket now becomes the focus. As a general
access and augmentation while preserving the tissue
rule, the clinician should attempt every effort to minimize
architecture (further discussed in the chapter). N.B.
invasion and morbidity to the patient. Intact sites or sites
Implant placement in fresh extraction sockets does not
with minimal tissue deficiencies should be treated by
prevent subsequent bone remodeling (Araujo et al. 2005),
­trying to preserve as much of the available support as pos-
which further highlights the importance of bone augmenta-
sible with minimal disruption of the tissue architecture,
tion at the time of implant placement (Figure 12.13). It is at
while sites with extensive deficiencies may necessitate
the clinician’s discretion and skill set to incorporate soft
­further corrective procedures.
tissue grafting with conventional ridge preservation proce-
dure in order to further develop the tissue volume and
Salama and Salama (1993) reported on different types of
­simplify following implant procedures.
extraction sites in the anterior zone with recommended
extraction site management protocols. Tarnow (in Chu
et al. 2012) added a modification to the type II deficiencies Treatment Options for Class I Extraction Sockets
for the clinician to better assess the severity of the buccal Immediate implant placement in conjunction with:
dehiscence present at the time of tooth extraction.
Depending on the degree of involvement of the extraction • Placement of a bone graft material in the gap between
socket, the approach utilized by the clinician should allow the implant and the buccal plate.
for the best result both functionally and esthetically with the
least tissue distortion. • Soft tissue graft (either free or pediculated).
• Partial Extraction Therapy (i.e. Socket Shield Technique).
Class I sockets have been identified as intact sockets.
Those display no or minimal reduction (i.e. < 3 mm) of the All of the following options can be performed with immedi-
buccal bone height with healthy interproximal attachment ate implant non‐functional provisionalization, customizable
levels, and no marginal tissue recession. Class I sockets healing abutments, or if inadequate implant stability is
may be present in either thick or thin gingival biotype situ- achieved a fixed tooth supported provisional with ovate
ations. Should the patient have a thin tissue biotype, soft pontic design may be utilized. Tissue borne provisional
tissue augmentation may be often mandated either at the prostheses are not recommended during the early healing
time of tooth extraction or at second stage procedure. period as continuous micro‐motion and pressure may have
a negative impact on the underlying soft tissues and
In class I sockets a minimally invasive flapless approach implant integration. Utilizing fixed prosthetic appliances
can be utilized for both immediate implant placement and adds a benefit of capturing the present soft tissue scallop
any simultaneous grafting provided that the implant is of the interproximal papillae.

Extraction Site Management in the Esthetic Zone 175

 (a) (b) (c)

(d) (e)

Figure 12.13  (a–e) Immediate implant placement performed following extraction of the maxillary bicuspid. Note the bucco‐lingual reduction in ridge
volume following tooth extraction and implant placement, despite grafting of the residual gap surrounding the implant. Further soft tissue augmentation
can be utilized to enhance the bucco‐lingual contour following implant integration.

Figure 12.14  Clinical example of immediate implant placement in a class II extraction socket utilizing an open approach.

Class II sockets with deficient or severely compromised • Immediate Dento‐alveolar Restoration.

buccal plates have a higher risk of bucco‐lingual ridge
• Bone‐ring technique.
collapse and concomitant recession defects. Therefore,
­
flapless implant placement becomes more challenging and
If the site topography does not allow for implant place-
less predictable. These sites may be managed in either a
ment, treatment options may include:
flapless or “open” approach, depending on the clinician’s
experience, site topography, and ability to thoroughly
• Ridge Preservation procedures combined with either a
access the entirety of the defect (Figures 12.14 and 12.15).
cell occlusive membrane or growth factors.
Treatment Options for Class II Extraction • Ridge preservation w/ soft tissue grafting.
Sockets
• Early Implant Placement.
Sites where the remaining bone topography allows for
ideal three‐dimensional implant placement within the alve- Treatment Options for Class III Extraction
olar housing. In those cases, the following management is Sockets
indicated:
Class III sockets involve a significant compromise of the
interproximal bone height or extensive circumferential
Immediate implant placement in conjunction with:
alveolar bone. These defects require more elaborate sur-
gical procedures to correct the deficiencies and involve a
• Guided Bone Regeneration.
relatively high level of invasion and tissue alteration.
• Concomitant bone and soft tissue grafting. Alternative options may include pre‐surgical orthodontic

176 Practical Advanced Periodontal Surgery

 Tooth
extraction
Class I
Class II Class III
(Flapless)

Ridge preservation Interdicsiplinary

with bone graft Immediate
Partial extraction therapy such as Delayed
implant Open approach Flapless
material and soft combined therapy orthodontic approach
tissue with bone & extrusion
soft tissue

Subepithelial Immediate implant

De-epithelialized Ridge placement with Early implant
Socket seal connective tissue hard and soft Hard
FGG preservation placement
graft tissue preservation

Combined hard
Hard tissue and soft tissue
preservation only ridge
augmentation

Barrier Esthetic ridge

membrane augmentation w/
growth factors

Figure 12.15  Clinical example of Class II socket. Severe compromise of the buccal plate of the socket is noted with intact interproximal bone peaks.
Last picture showing immediate post‐extraction implant placement within the alveolar envelope of the socket.

extrusion of the teeth to optimize the tissue architecture Atraumatic Tooth Extraction
followed by implant placement or simply relying on restor-
Procedure:
ative techniques to replicate the deficient soft t­issues.
Immediate implant placement in these cases is not advis-
See Figure 12.16.
able, but procedures to maximize tissue volume preser-
vation at the time of extraction should be followed. These
1. Elevation of the tooth and luxation should be performed
procedures will be discussed throughout this chapter.
on all aspects except for the buccal to avoid damage to
MANAGEMENT OF CLASS I SOCKETS the buccal plate or greenstick fracture.

Tissue Architecture Preservation 2. If the tooth is not easily luxated due to an intact perio-
dontium or curvatures in the root, sectioning of the root
Flapless techniques in implant therapy have been shown to may be performed utilizing a surgical length fissure car-
yield minimal tissue alterations. Techniques to capture the bide bur or long‐shanked diamond bur. This allows the
pre‐operative soft tissue frame immediately following tooth operator to reach the apex of the tooth and create room
removal whether through immediate implant provisional for the root fragments to be luxated within the socket.
restorations, customized healing abutments, or even ovate Sectioning can be performed in a mesio‐distal or
pontics allow for better preservation of the soft tissue frame. bucco‐lingual direction, taking care not to injure the sur-
The first step in preservation of the hard and soft tissue is rounding socket walls (Figure 12.17).
atraumatic extraction utilizing appropriate instrumentation.
3. Mesio‐distal and rotational movements should be
ARMAMENTARIUM directed vertically to avoid fracture of the buccal plate.
• Basic Surgical Kit. N.B. Direction of elevation should never be toward the
buccal aspect.
• Periotomes, Extraction Forceps, and Luxating Elevators.
Following delivery of the tooth, thorough debridement of
• Piezosurgical unit with Periotome Inserts.
the socket should be performed to prevent any soft tissue
• Implant Placement Kit. encapsulation of the bone substitute material and/or
implant. This can be accomplished through the use of
• Micro‐blades and Soft Tissue Tunneling
spoon curettes or through rotary finishing diamonds or
Instrumentation.
carbides with ­irrigation. De‐epithelialization of the internal
• Micro tissue forceps, Castro Viejo and Scissors. lining of the socket allows for fresh connective tissue for

Extraction Site Management in the Esthetic Zone 177

 (a) (b)

Figure 12.16  (a and b) Separation of the supra‐crestal fibers with a micro‐blade in order facilitate tooth luxation and instrumentation through the sulcus
prior to tooth extraction.

(c)
(a)

(d)
(b)

Figure 12.17  (a and b) Long shanked diamond needle bur is utilized initiate the sectioning process through utilizing the root canal as a starting point.
The bur is advanced apically just beyond the tooth apex and the tooth is sectioned mesio‐distally utilizing the root canal as the guide for the long axis of
the sectioning process. (c) The mesial and distal walls of the tooth are thinned but not completely separated to protect the adjacent bone walls from injury.
Complete separation of the root fragments may be completed delicately with the bur or manually with a small luxating elevator. (d) Removal of the palatal
root fragment allows room to deliver the buccal portion of the root without risk of injuring the buccal plate.

178 Practical Advanced Periodontal Surgery

Figure 12.18  Socket degranulation may be performed by spoon currettes. N.B. The direction of socket debridement should always be toward the palatal
aspect taking caution not to use the buccal plate as a fulcrum to avoid unintentional fracture of the buccal bone.

graft nourishment and union with the donor tissue

(Figure 12.18).

The socket should be inspected for any fenestrations,

dehiscences, and/or fracture of the buccal plate. Should
there be any compromise of the socket integrity, the cli-
nician should be ready to repair the site. If the socket
walls are intact, then implant placement should be Figure 12.19  Correct implant positioning should be assessed during
attempted and performed in the correct three‐dimen- implant placement to emerge palatal to the incisal edge of the future
sional position. restoration. An accurate surgical guide is highly valuable when it comes
to esthetically sensitive implant restorations.
THREE‐DIMENSIONAL IMPLANT POSITIONING
Bucco‐Palatal Position occupy the embrasure in all of the cases observed. It can
Implant diameter and positioning are key elements in therefore be deduced from these studies that in addition to
facilitating the remainder of the surgical procedure. respecting the biological limitations, one must consider the
Implant diameter should allow at least a 1.5 mm distance esthetic repercussions of the implant to tooth proximity. As
from the buccal plate and should not occupy the entirety a general guideline, a 2 mm distance between implants
of the socket as that has negative implications on the and adjacent teeth, and a 3 mm inter‐implant should be
buccal plate and will not allow sufficient space for graft- respected to allow for adequate bone thickness to support
ing the site internally. The palatal positioning of the the interproximal papilla height, knowing that there is a
implant fixture also offers a restorative advantage by degree of crestal bone remodeling around the implants
allowing for a palatal position of the implant screw (Figure 12.22).
access, enabling the r­estorative dentist to have a final
screw retained implant r­ estoration and avoid the compli- Apico‐Coronal Position
cations associated with sub‐gingival excess cement
With regards to implant depth, 2–4 mm from the future
(Figures 12.19–12.21).
restorative gingival margin should be maintained. This
could be referenced during surgery with an accurately
Mesio‐Distal Position constructed surgical guide simulating the final tooth form
Sufficient implant to tooth and inter‐implant distances and/or the Cemento Enamel Junction (CEJ) of the contra‐
should be preserved. Conventionally, an implant to tooth lateral tooth. The range of implant placement depth also
distance of 1.5 mm was required to prevent any impinge- depends on the diameter of the implant to be placed and
ment on the PDL and avoid interproximal bone loss on the the diameter of the tooth to be restored. Narrower implants
adjacent tooth. Recent literature however demonstrates are placed deeper to allow sufficient “running room” for
that when there was a proximity of 2 mm or less between developing a natural emergence profile of the final restora-
an implant and adjacent tooth, the papilla failed to fully tion (Figure 12.23).

Extraction Site Management in the Esthetic Zone 179

Figure 12.20  Intra‐operative view of an immediate implant position in relation to an extraction socket. Note how correct anatomical implant positioning
offers a confined defect for augmentation of the buccal bone. Additional contour grafting can also be performed on the buccal aspect of the socket.

(a)

(b) (c) (d)

Figure 12.21  In class I (Kan) sockets, placing implants in the space occupied by the root will result in an implant that is positioned too facial.
Subsequently, in order to take advantage of the available palatal bone, the osteotomy has to be initiated in a more palatal position. (a and b) This can be
done by utilizing a round bur about 4 mm from the apex of the socket. The round bur is taken to a depth sufficient to have a ledge created to stabilize the
pilot drill. Not having a deep enough or wide enough osteotomy for the pilot drill, will result in continuous slippage into the socket space which can result
in loss of part of the bone that is critical for implant stability. (c) Picture shows the implant osteotomy (palatal) versus the buccal socket position, showing
how the implant osteotomy is entirely in the palatal bone which was made possible as a result of the buccal tooth position. (d) The implant diameter
utilized allows a 2–3 mm gap between the buccal plate and the implant platform to allow adequate room for graft material introduction.

SELECTION OF THE BONE GRAFT MATERIAL

properties are discussed in detail in previous editions of
Following implant insertion, the gap between the implant this book.
and the buccal plate should be evaluated for grafting with
a bone graft or bone substitute material. The graft is ­utilized Mainly allogeneic and xenograft materials are utilized as
mainly to decrease the bucco‐lingual remodeling of the the graft of choice. Utilizing allogeneic materials offers the
socket, not for the purpose of osseointegration. Material advantage of a faster rate of turnover with more vital bone

180 Practical Advanced Periodontal Surgery

Figure 12.22  Mesio‐distal positioning of implant placement in the esthetic zone, leaving 2 mm between the implant and adjacent tooth to avoid
compromise of the papillary esthetics.

(a) (c)

(b) (d)

Figure 12.23  Implant depth can be measured utilizing different clinical indicators. (a) Utilizing the gingival margin of the future restoration, only
possible in flapless procedures. (b and c) During flap reflection, the CEJs of the adjacent teeth can be used as a reference for implant placement depth.
(d) Surgical guides that are accurately fabricated to give the clinician an accurate indicator upon implant drilling and final placement (Funato et al. 2007).

compared to xenografts. However, a low turnover material graft may also act as a protective barrier for the underlying
may be of benefit in the esthetic zone as it offers less bone material and/or implant.
remodeling which provides more long term contour
maintenance.
RATIONALE
After selection of the appropriate graft material, soft tissue Spontaneous healing and epithelialization of the extraction
grafting should be considered. This may be done simulta- site orifice usually occurs over a period of three to five
neously with both implant placement and bone grafting or weeks. However, when site preservation procedures are
just with socket grafting as a form of hard and soft tissue employed, the bone graft is left exposed to the oral cavity
volume preservation/augmentation to compensate for the and is subjected to external contaminants and risk of early
expected post‐extraction remodeling of the site. The tissue dislodgment. Therefore, a physical barrier may be

Extraction Site Management in the Esthetic Zone 181

­ eneficial for the purpose of protection and containment of
b counteract early membrane resorption, closure over the
the bone graft particles during the early phases of healing. fresh extraction socket can be attempted to decrease the
The choice of a physical barrier may be a prosthetic one or membrane’s resorption time. However, flap reflection and
biologic material/tissue. tissue advancement has been shown to yield inferior bone
gain results in addition to having negative implications on
Prosthetic components such as ovate pontic designed the soft tissue architecture especially in the esthetic zone.
restorations have been utilized to maintain the tissue pro- N.B. flap reflection and periosteal reflection should be
file and architecture following tooth extractions. Regardless avoided in class I sockets. Flap reflection has been reported
of the material utilized for the provisional, the surface of the to orchestrate a series of tissue changes and bone remod-
material should be highly polished and clean to allow an eling. Therefore if a flap is reflected, osseous grafting
environment conducive to healing without excessive soft should be performed on both the internal and external
tissue irritation. If an implant is placed immediately, an aspects of the socket to compensate for subsequent tissue
implant supported provisional or custom healing abutment changes. Subsequent to bone grafting, sealing the socket
may be utilized to allow easier tissue contouring upon with a tissue graft may offer an advantage in the esthetic
implant restoration (Figures 12.24 and 12.25). zone in terms of tissue volume augmentation and physical
protection of the underlying tissue.
Alternatively, a barrier membrane could be utilized over the
extraction site to protect the graft from epithelial down‐ Options for Tissue Augmentation Procedures
growth and fibrous encapsulation of the superficial layers
• Socket Seal Approach
of the graft material. The choice of membrane may be a
resorbable or nonresorbable one. Resorbable membranes • De‐epithelialized Free Gingival Graft
such as collagen are highly tissue compatible but undergo
• Free Connective Tissue Graft
earlier degradation when left exposed. Nonresorbable
membranes on the other hand need additional stabilization • Rotated Pedicle Graft
and may be associated with soft tissue retraction and
dehiscences which can be unforgiving in the esthetic zone. With regards to volume augmentation, a rotated pedicle graft
Similar to tissue grafts, membranes can be placed only on offers the highest level of augmentation and vascularization
the occlusal aspect or further stabilized underneath the due to maintenance of its blood supply from the palate. This
buccal soft tissue by the aid of a sub‐periosteal tunnel. In procedure is usually reserved for areas with higher augmen-
class I sockets, the presence of the buccal plate acts to tation requirements, and not typically the first line of treatment
stabilize the blood clot thereby eliminating the necessity for in class I sites. More commonly, a free connective tissue graft
membranes. Should there be a buccal dehiscence defect, would be sufficient to augment the buccal contours following
the use of a membrane may be required. In an attempt to extraction. The connective tissue graft may be harvested as

(a) (d) (g)

(b) (e) (h)

(c) (f) (i)

Figure 12.24  From left to right columns: (a–c) Atraumatic extraction of upper central incisors. (d–f) Socket degranulation and grafting performed up to
the soft tissue margins of the socket. (g–i) Native collagen membranes were utilized over the socket orifice and sealed over with a fixed provisional
restoration.

182 Practical Advanced Periodontal Surgery

 Contra‐Indications
• Marginal tissue recession
• Compromised Periodontium
• Ability to place an implant supported restoration
• Smoking

Requirements for the Tissue/Tissue
Substitute Material
• The tissue should be slightly larger than the socket ori-
fice to allow for intimate fit between the socket walls and
the graft.
• Graft should be resistant to infection and early resorption.
• The thickness of the graft should allow sufficient surface
Figure 12.25  Five months follow-up of both volume and soft tissue
area for vascular connections to prevent early tissue
scalloped architecture preservation by combining minimal trauma with the
necrosis. The tissue should rest passively in a stable
provisional restoration to maintain the soft tissue architecture and volume
position overlying the bone graft and in contact with the
for future implant placement.
soft tissue walls of the socket.

a free gingival graft and then de‐epithelialized outside, or as Recipient Site Preparation
a sub‐epithelial connective tissue graft from the deeper lay-
ers of the palate. The tissue graft may be utilized to augment Simplicity of the recipient site is one of the advantages of
the buccal tissue contours as well as seal over the extraction the socket seal technique.
socket. In cases where an immediate implant supported
supra‐structure is going to occupy the socket orifice, then the De‐epithelialization of the internal socket lining is the critical
tissue graft may be placed solely on the buccal aspect. A step to this procedure, in order to remove the sulcular/
final treatment option could be simply performing a socket pocket epithelium and allow access to the underlying con-
seal procedure, in which the tissue graft or tissue substitute nective tissue and vasculature. Due to the fact that the con-
material is utilized to cover solely the extraction socket orifice. nective tissue bed is circumferential in nature and does not
This technique provides protection of the underlying bone offer a great amount of vascularity underlying the graft it is
graft and preservation of the underlying osseous tissue prudent to avoid any interference of the lining epithelium
­volume but has the least soft tissue volume enhancement with the donor tissue to maximize blood vessel anastomosis
effects when compared to other techniques. Specific advan- and organic union between the donor and recipient bed.
tages and disadvantages of each technique will be dis-
cussed further in the following paragraphs. De‐epithelialization can be performed with:

SOCKET SEAL • A carbide finishing bur either round or flame shaped

mounted on a high‐speed handpiece with copious
The socket seal technique as described by Landsberg is irrigation. The change between the epithelium and
­
discussed in previous editions of this book. In this edition, ­connective tissue will be discernible by change to the
advanced aspects of graft adaptation and immobilization tissue appearance to a slightly more reddish color, rough
will be reviewed. As previously mentioned, this technique texture, and appearance of bleeding points.
is mainly reserved for ridge preservation procedures when
implant placement is not performed as it does not offer any • A scalpel blade can also be used to internally dissect the
significant buccal soft tissue enhancement, but merely a epithelial attachment and remove it as a collar of tissue,
“seal” over the underlying graft material. exposing the underlying connective tissue (Figure 12.26).

Indications Note: Care should be taken to avoid injury to the interden-

tal papilla while performing this step.
• Class I extraction sockets with Thin Tissue Biotype
• Minimal hard and soft tissue deficiencies Donor Sites
• Intact socket walls • Lateral Palate (adjacent to the premolar/molar area)
• Inability to place an implant supported provisional • Tuberosity Area

Extraction Site Management in the Esthetic Zone 183

Figure 12.26  In the absence of a buccal plate or in severely compromised periodontal dentition or implants, the remaining socket walls could be lined
with the pocket epithelium. In these cases, a 15 blade can be utilized for gross tissue removal and freshening of the internal socket walls. A round diamond
bur can then be used to finalize the de‐epithelialization of the inner lining of the socket.

• Edentulous Ridge Spans socket. However, this is not always possible as in sites of
bicuspids and canines the socket orifice is not an even
• Collagen Based Tissue Substitute Materials
circle. At this point the clinician has to harvest a graft with
the aid of a template to satisfy the dimensional require-
A template may be used to allow accurate dimensions in
ments to seal the socket.
harvesting the graft. Utilizing a soft tissue punch of similar
dimensions as the internal aspect of the socket offers an
Stabilization of the Graft
easier and faster harvest of the graft. The tissue is har-
vested in a full thickness fashion through blunt dissection The focus in stabilization of any graft is immobilization of
using a periosteal elevator. Following which, hemostasis the free tissue to allow for a stable scaffold conducive to
can be achieved with the aid of a collagen sponge or sim- cellular migration and union of the graft to the recipient
ply cyanoacrylate or a periodontal dressing over the site. Regardless of the material or technique employed the
exposed donor site. end result must always be a stable graft with minimal
trauma. A clinical tip to assess graft stability is to place the
Tuberosity tissue has the advantage of higher collagen graft in the position and assess both the lateral extensions
content and dense connective tissue when compared to of the graft as well as the vertical alignment with the adja-
the lateral palate. This may be beneficial for pontic sites cent soft tissue margins. The graft should rest passively in
or for tissue augmentation around dental implants due contact with the adjacent soft tissue margins laterally and
to the absence of excessive glandular and adipose at a vertical level corresponding with the surrounding gin-
tissue. gival margins.

Immediate implant placement in the extraction socket with The most common technique to stabilize a graft uses 6–8
a healing abutment that occupies most of the socket interrupted microsutures with 6–0 or 7–0 filaments with a
space requires a different approach other than a Free microneedle. These sutures are placed in a and circum-
Gingival Graft (FGG) for sealing the socket as the abut- ferential, opposing manner to allow for even tension over
ment impedes the blood supply necessary for the future the graft and intimate, uniform contact of the graft to the
graft. donor tissue. Utilizing a microsuture filament and needle
offers the added benefit of minimizing trauma of the graft
The soft tissue punch may be taken as a preformed tissue while placing multiple sutures in close proximity to each
punch corresponding in diameter to the extracted tooth other.

184 Practical Advanced Periodontal Surgery

 (a) (b) (c) (d)

(e) (f) (g)

Figure 12.27  (a–d) Immediate implant placement was combined with bone grafting of the residual gap surrounding the implant. A socket seal approach
was utilized to seal the extraction site. Note the adaptation of the graft to the surrounding soft tissue margins. Lower pictures show the donor and recipient
sites at immediate post‐op (e), one week (f) and two weeks (g) intervals.

Figure 12.28  From left to right. Suture entry point: The needle is advanced within the thickness of the graft. This suture is an internal horizontal mattress
suture that helps adapt the connective tissue aspects of the graft to the recipient site to enhance early revascularization.

The use of tissue adhesives may be used in lieu of multi- Disadvantages of This Technique
ple sutures to aid in graft stability while avoiding exces-
The main disadvantage of the socket seal FGG is that there
sive trauma from the suture needle. N.B. tissue adhesives
is no true augmentation of the buccal tissue volume which
may not be used as the sole method of graft stabilization
is critical around implants for esthetic purposes and long
in this technique, but as a supplemental method to
term stability of the underlying buccal bone. This issue may
reduce the number of sutures needed to fixate the graft
be overcome at the time of implant placement and/or sec-
in place.
ond stage uncovering of the implant by either utilizing the
tissue previously augmented on the occlusal aspect and
A compressive suture as demonstrated in Figure 12.27
introducing it onto the buccal aspect or by adding a con-
offers the advantage of additional graft compression in
nective tissue graft at the time of implant placement:
both lateral and vertical directions. This suture is useful in
cases where the graft is is too small or too thin, as stretch-
• The predictability of the graft taking is low
ing the graft in opposing directions may result in a dead
space apical to the graft. • Technique sensitive

In addition to a compressive suture, utilizing an internal To overcome these disadvantages a partially de‐epithelial-
mattress suture aids in stabilization and adapting the graft ized free gingival graft or sub‐epithelial connective tissue
to the internal socket lining (Figure 12.28). graft may be utilized (Figure  12.29). The following

Extraction Site Management in the Esthetic Zone 185

Figure 12.29  Necrosis or delayed vascularization of the exposed portion of the graft may sometimes occur at one week. Use of an antiseptic mouth wash
for one more week is recommended. On the second week follow-up, any necrotic loose tissue should be removed and the site gently debrided and irrigated.

­ aragraphs will discuss modifications of the socket seal

p there has been no evidence in the literature reporting on the
technique, to incorporate tissue volume augmentation of success rates or survival of the different graft types, or the
the buccal contour. amount of shrinkage associated with either technique.

AUTOGENOUS TISSUE FOR CONCOMITANT De‐Epithelialized Free Gingival Graft

BUCCAL VOLUME AUGMENTATION
AND SOCKET SEAL PROCEDURES The technique for graft procurement is identical to harvest-
ing a free gingival graft as discussed in previous editions
Utilizing a SubEpithelial Connective Tissue Graft (SECTG) of this book. Obtaining adequate tissue dimensions have
to concomitantly augment the buccal tissue volume and to be assessed accurately prior to proceeding with this
seal the socket offers superior buccal bone maintenance, technique so as to avoid involvement of the palatal arteries
masking materials of abutments and crowns and enhanc- and their major branches.
ing the peri‐implant tissue contours when compared to
socket seal procedures alone. The use of a connective N.B. Should the required tissue pose an increased risk of
tissue graft at the time of implant placement or ridge
­ involvement of adjacent vital structures, then an alternative
­preservation to augment the tissue, sets up a better foun- harvest technique should be utilized.
dation for a more esthetic final restoration.
Once the graft dimensions are recorded, the graft may be
The lateral palate is usually the donor site of choice for harvested as a FGG and de‐epithelialized outside the
procurement of sufficient tissue quantity to augment the mouth using a fresh 15 blade. The area of de‐epithelializa-
buccal and occlusal aspects of the socket. The graft may tion corresponds to the portions of the graft that will be
be harvested as a subepithelial connective tissue graft or inserted underneath the buccal or palatal gingiva.
as a de‐epithelialized free gingival graft. Differences Alternatively, de‐epithelialize utilizing a round diamond bur
in compositions of these grafts will be discussed further in prior to graft procurement. The portion of the graft that is
this chapter. Sufficient tissue volume should be harvested sealing the extraction orifice however will not be dis‐epi-
to permit adequate vascularization of the graft. At least thelialized in order to maximize the thickness of the
5 mm of the tissue should be covered with the buccal tis- exposed part of the graft (Figure 12.30).
sue as well as 3–5 mm on the palatal side to allow ade-
quate vascularization of the exposed portion of the graft SUB‐EPITHELIAL CONNECTIVE
overlying the socket. TISSUE GRAFT
The difference in these techniques is more related to the Graft harvesting (Figure 12.31) is performed in the same
­quality of tissue harvested rather than quantity. For the lateral way that has been described in previous editions of this
palate, superficial layers of the connective tissue possess book. The advantage offered by this technique is mainly
less adipose and glandular tissue when compared to the related to achieving primary closure of the donor site.
deeper portions. This renders de‐epithelialized free gingival
Requirements
grafts a whitish color, with a dense, fibrous consistency when
compared to a sub‐epithelial connective tissue graft. The dif- Graft dimensions are determined by:
ferences in consistency are due to the microarchitecture of
• Augmentation volume on the buccal aspect of the
the graft. Free grafts tend to have denser collagenous
socket: Not less than 5 mm
­networks, with less vascular channels and loose interstitial
tissue when compared to connective tissue grafts. Despite • Bucco‐palatal dimension of the extraction socket
the differences in clinical handling and micro‐architecture, orifice.

186 Practical Advanced Periodontal Surgery

Figure 12.30  Following harvesting of a FGG, the edges of the graft that will be tucked underneath the buccal and lingual gingiva are de‐epithelialized
using a 15 blade. The graft is inserted with the epithelial portion over the exposed socket orifice and the connective tissue “tails” or dis‐epithelialized
portions are inserted underneath the gingiva to enhance the blood supply to the graft. A combination of internal mattress sutures and criss‐cross
compressive suture is utilized to enhance the graft stability and revascularization.

Figure 12.31  Immediate implant placement with connective tissue grafting augmenting both the buccal aspect of the soft tissue as well as sealing the
socket. Post‐op two years follow-up showing gingival marginal stability around the implant restoration.

• At least 3–5 mm of the graft should be covered by the If buccal plate dehiscences are present, the dimensions
palatal tissue. of the graft may be modified to allow the graft borders to
rest on sound bone margins whenever possible
• Width is determined by the mesio‐distal width of the
(Figure 12.32).
extraction orifice.

Extraction Site Management in the Esthetic Zone 187

Figure 12.32  Graft orientation may be horizontal or vertical depending on the augmentation needs of the case.

Recipient Site Preparation tissue in order not to overly thin the buccal tissue or perfo-
rate it which could result in decreased vascularity to the
It is important to note that the buccal plate of anterior denti-
soft tissue graft and subsequent tissue necrosis
tion is less than 1 mm in thickness in the majority of maxil-
(Figure 12.33).
lary anterior sites and is consequently devoid of any
cancellous or marrow components. This translates into
minimal vascularity to the buccal cortical bone which is Requirements of Tunnel Preparation
further compromised by severing the periodontal ligament • The tunnel should be performed in a single plane of dis-
attachment upon tooth removal and micro‐fractures that section to allow for passive introduction of the graft.
can occur during tooth luxation. Therefore, in cases with
intact or minimally involved sockets, it may prudent to • Usually the extension of the tunnel should be larger than
avoid flap reflection as excessive tissue manipulation can the tissue to be harvested by 2 mm circumferentially.
result in tissue distortion, scarring, and recession that is • Ensure adequate tunnel extension to avoid ischemia of
less forgiving in the esthetic zone. Subsequently tunneling the buccal tissue and subsequent flap necrosis.
procedures have been introduced and further developed
to offer a less invasive approach for tissue reconstruction N.B. over-extension of the tunnel can compromise the sta-
in more sensitive and esthetic sites. The tunnel preparation bility of the grafted tissue, leading to inadequate vasculari-
can be initiated either from a crestal (sulcular) or vestibular zation and integration of the graft. This can be overcome
approach, depending on the ease of access and desired with additional stabilizing sutures to immobilize the graft.
area to be regenerated. The vestibular approach was
­introduced as a submarginal incision. Modifications have If the tissue allows, the graft may be introduced with the
been proposed for vestibular access for horizontal ridge aid of the tunneling instruments or serrated tissue packers;
augmentation in the esthetic zone without affecting the soft however, this may not be always possible as it depends on
tissue architecture and avoiding visible scarring in patients the consistency and thickness of the graft. If the graft is too
with a high smile line (Dibart et al. 2009; Nevins et al. 2009a; thick, or is high in adipose contents, it can be often hard to
Zadeh 2011). The same approach may be utilized for both manipulate. In such cases the use of anchoring sutures
hard and soft tissue augmentation. can aid the clinician in guiding, positioning, and adapting
the tissue graft within the tunnel.
Tunnel Preparation
The plane of dissection may be performed in either a supra- Suturing Techniques
or sub‐periosteal fashion. If the purpose of the procedure
• Apical guiding “marionette” suture
is hard tissue augmentation, then it is necessary to per-
form a sub‐periosteal tunnel to avoid soft tissue ingrowth • Horizontal adaptive mattress suture
into the graft material. For soft tissue augmentation proce-
• Positioning mattress sutures
dures, supra‐periosteal dissection is advocated but should
be avoided in thin biotype cases to prevent excessive thin- The purpose of these techniques is to aid in navigating the
ning of the outer flap and compromising the blood supply tissue graft to its desired position within the prepared tunnel.
to the grafted tissue. This requires specialized, sharp tun- Appropriate selection of the suture needle and material are
neling instruments and micro‐blades that allow maneuver- critical, as this suture will be pulling the graft through an
ing over the convexity of the buccal plate. The tip of the entry point that could be narrower than some aspects of the
instrument should be aimed toward the bone and not the graft.

188 Practical Advanced Periodontal Surgery

 (a) (b) (c)

(d) (e) (f)

(g) (h) (i)

Figure 12.33  (a) Atraumatic extraction of the lateral incisor. (b) The buccal plate integrity is inspected. (c) Immediate implant placement is performed in
a flapless approach. (d) Note the contra‐angles in the tunneling instrument that facilitates by‐pass of the buccal plate, while still having the tip of the
instrument toward the bone to decrease the incidence of perforation of the buccal soft tissue. (e) The same tunneling instrument is inserted into the tunnel
to provide the space necessary for graft introduction. (f and g) Connective tissue graft insertion into the tunnel with the aid of a guiding suture (h) The
palatal portion of the connective tissue graft is left unsecured until the bone grafting procedure is complete. (i) Final suturing from apical to coronal:
Guiding suture, horizontal mattress suture, and final criss‐cross suture.

Figure 12.34  Apical guiding suture for introduction of the connective tissue graft into the prepared soft tissue tunnel. An instrument is utilized to keep
the suture taut and guide the graft in place from the other aspect.

Apical Guiding “Marionette” Suture

t­ echnique is used to correlate the apical border of the graft
This suture is beneficial in guiding the soft tissue graft into to the corresponding apical end of the area to be aug-
the prepared tunnel, ensuring that the graft is not ­displaced mented and may be used with either free or pediculated
or creased during its introduction into the tunnel. The grafts (Figure 12.34).

Extraction Site Management in the Esthetic Zone 189

Suture Requirement points of the buccal mucosa slightly wider than those
performed in the graft to stretch the graft and avoid
• A 3/8 16–19 mm suture needle is advocated in this tech-
creasing at the apical ends.
nique in order to facilitate by‐pass of the buccal bone
• A needle holder is then used to hold both ends of the
• Suture material with adequate tensile strength
suture thread coming out of the buccal to pull the graft
• Monofilament material is preferred to avoid excessive apically into the sulcus and desired position.
drag and friction through the tissue upon pulling. Simultaneously from the coronal aspect, a tunneling
instrument or tissue packer can assist in graft introduction
and adaptation process during insertion (Figure 12.35).
Steps
• Following inspection of the tunnel extension, the graft is Horizontal Adaptive Mattress Suture
placed on the buccal aspect of the socket to aid the
clinician in visualizing the size and position of the graft in This technique is utilized to allow an intimate adaptation
relation to the prepared area. between the graft and the overlying buccal tissue, to aid in
graft stabilization as well as guiding the graft through the
• Depending on the predetermined desired position of the tunnel. The suture is performed in the same steps as the
graft, the first suture bite is initiated from the buccal apical anchoring suture with two modifications:
aspect of the oral mucosa at the site corresponding to
the most apical corner of the final graft position. • The position where the suture is initiated is in a more
• The needle is exited from the buccal sulcus of the coronal aspect, and engages a more centralized portion
socket. This can be facilitated by introducing a micro‐ of the graft to offer better graft stability.
periosteal elevator to help slide the needle along the • Purchase points in the graft and corresponding buccal
smooth instrument surface. gingiva are larger (3–4 mm) and equidistant to engage a
• Two purchase points are then performed to anchor the larger portion of the graft and add conformity to the
graft at its most apical portion. The purchase points are suture pulling vectors.
done in a horizontal fashion from within a distance of
2–3 mm between the suture bites. Positioning Mattress Suture
• The needle is then entered once again through the buc- This technique is essentially a combination of the previous
cal sulcus to exit in the same horizontal point as the ini- two methods. For longer grafts it is often difficult to
tial entry point in the buccal oral mucosa to avoid uneven ­stabilize the entirety of the tissue with one suture. This
pull on the graft. It is preferred to have the two purchase technique offers the flexibility of positioning the sutures

Figure 12.35  From left to right, step by step procedure for the apical guiding suture for introduction of the graft into the apical aspect of the tunnel.
Depending on the desired area of graft insertion, the buccal purchase points are initiated at that level.

190 Practical Advanced Periodontal Surgery

where they are needed depending on the site and • The same procedure is then repeated on the distal
­extension of the graft. It involves utilizing smaller (2 mm) aspect in the same fashion to ensure stretching of the
internal mattress sutures which can be either vertical or graft and avoid any dead space that may form due to
oblique in orientation to help position the graft at two or inadequate graft adaptation underneath the tunnel.
more remote points (Figure 12.36).
• Additional sutures may be performed in the same fashion
should there be the need for additional graft stability.
Technique
• Following inspection of the tunnel extension, the graft is Bone Graft Procedure
placed on the buccal aspect of the socket or tunnel
preparation to aid the clinician in visualizing the size and Following soft tissue stabilization, the bone graft of
position of the graft in relation to the prepared area. choice is packed either in the socket or between the
buccal and the implant to bridge the gap. According to
• The first purchase point is performed from the buccal Tarnow (Chu et  al. 2012) the bone is packed in two
aspect on the most mesial aspect of the tunneled tissue. zones. The first zone is up to the level of the buccal plate
• Apico‐coronally, the purchase point is approximately followed by overfilling of the bone particles up to the
6 mm from the gingival margin. level of the soft tissue margins. The dual zone technique
can be used in lieu of the tissue graft as the particles
• The suture needle is passed to engage the graft at its placed in the tissue zone are encapsulated and allow for
most mesial portion from the lingual to the buccal aspect. thickening of the supra‐crestal implant mucosa provid-
• The needle is then returned in the opposite direction ing augmentation of the tissue without the need of addi-
2 mm coronal to that point and back through the buccal tional soft tissue grafting. This technique of overfilling
gingiva at a point 2 mm coronal to the initial entry point. may also be selected in cases where a soft tissue graft is
utilized (Figure 12.37).
• Utilizing a needle holder, the two ends of the suture
thread are pulled taut. With the aid of a micro-tunneling
Closure of the Extraction Socket
instrument, the graft is introduced into the tunneled buc-
cal tissue and the knot is secured following adequate To continue with sealing the socket with the tissue graft,
positioning of the graft. another anchoring suture may be utilized to engage the

(a) (b) (c) (d)

Figure 12.36  Two positioning mattress sutures are utilized to precisely position the graft at the mesial and distal aspects of the implant. The sutures
offer an anti‐rotational factor to the soft tissue graft and it is beneficial when utilized with longer grafts to be able to better position the tissue in the desired
location at different sites.

(a) (b) (c) (d)

Figure 12.37  (a) Palatal placement. (b) Connective tissue graft placement and internal mattress positioning sutures. (c) Bone grafting was performed up
to the level of the soft tissue margin. (d) A provisional restorarion was utilized to prosthetically seal the socket.

Extraction Site Management in the Esthetic Zone 191

Figure 12.38  Flapless Ridge preservation.

free end of the graft and adapt it underneath the palatal for implant placement in conjunction with hard and soft
tissue. Reflection of the palatal tissue is often necessary to ­tissue augmentation.
allow adequate room for the graft (Figure 12.38).
FLAPLESS RIDGE PRESERVATION
COMPROMISED SOCKETS Absence of the buccal plate poses a challenge for the
clinician as additional support is required to maintain
As previously mentioned, adequate pre‐operative diagnosis
the bone within the alveolar envelope and isolate it from
of the bone topography and root morphology/­angulation is
the soft tissues. Such defects are common in sites of
critical prior to tooth extraction. Teeth with peri‐radicular
fractured teeth and/or teeth with significant infections.
endodontic lesions that are chronic in nature are not a c
­ ontra‐
Absence of the buccal plate support to the overlying
indication to bone grafting or immediate implant placement
soft tissue may have significant repercussions on the
(Waasdorp et al. 2010). However, active infections should be
final esthetics of the implant. The same considerations
resolved prior to proceeding with any regenerative proto-
in implant placement should be taken into account in
cols. Inspection of the socket is critical following tooth
compromised sites but that implant placement may
removal. Should any d ­ eficiencies be detected additional
pose a risk if performed sub‐optimally (Figure 12.39) or
osseous regenerative procedures should be employed to
if careful pre‐operative case selection is not made.
allow for adequate site preservation for future implant
placement.

This section will focus on management of extraction sock-

ets with compromised buccal plate integrity, whether in the
form of a dehiscence or fenestration defects. For labial
dehiscence up to 5 mm, a simple bone graft combined
with a collagen barrier can be combined with implant
placement in a flapless approach. If additional access is
needed, a minimally invasive, site specific incisional tech-
nique may be employed to maximize the soft tissue archi-
tecture and integrity. The following sections will focus on
cases with complete loss of the buccal plate commencing
with flapless ridge volume preservation and moving to
more complex cases where open procedures are utilized Figure 12.39  Flapless ridge preservation membrane insertion.

192 Practical Advanced Periodontal Surgery

However, hard and soft tissue volume preservation • Following adequate debridement of the internal aspect
remains essential in sites with pre‐existing deficiencies of the buccal tissue, preparation of the buccal aspect of
as the post‐extraction remodeling results in more severe the socket is then commenced.
defects. • Utilizing a microtunneling instrument, the buccal gingiva
overlying the socket is reflected in a full thickness fashion.
Key Points
• Reflection is initiated from the apical aspect. The reason
Thorough debridement of the lesion is mandatory. If there for starting with the apical portion offers several
are areas that are hard to access from the socket opening, advantages:
a vestibular incision (explained later) may aid in accessi-
bility. Following thorough degranulation of the site a mem- ◦◦ Simplicity of access from the extraction site orifice in a
brane should be placed either buccal to the socket walls straight downward direction
or internally within the socket as an “ice‐cream cone” ◦◦ The bone topography apical to the extraction socket
­technique (previously described). is usually depressed or concave and subsequently
allows an easier and safer access corresponding to
Techniques the periosteal elevator’s curvature.
• Ridge Preservation with a resorbable or nonresorbable ◦◦ Once the buccal tissue is reflected, in the apical direc-
barrier. tion, it allows some “give” to the buccal flap, facilitat-
ing instrumentation to the adjacent areas.
• Esthetic ridge preservation utilizing growth factor
enhanced bone matrix. • Following adequate reflection of the apical portion to
allow for adequate membrane placement, the proximal
• Concomitant hard and soft tissue augmentation through areas are reflected.
free or pediculated soft tissue grafts.
• Different contra‐angles of tunneling instruments offers
versatility in the areas to be reached and therefore allows
Armamentarium
for easier reflection of the interproximal attached gingiva
• Basic Surgical Kit. underlying the papilla.
• Implant Placement Kit. • The dissection is continued from an apical to coronal
direction reaching the base of the interproximal papilla.
• Micro‐blades and Soft Tissue Tunneling Instrumentation
• There is no need to elevate the interproximal papilla in
• Micro tissue forceps, Castro Viejo and Scissors. order to avoid excessive remodeling of the underlying
bone which may lead to loss of the papillary height.
RIDGE PRESERVATION UTILIZING • If the coronal portion of the buccal plate is completely
BARRIER MEMBRANES absent, then it may be necessary to involve the inter-
Deficiencies in the socket buccal plate may be reconsti- proximal papilla. N.B. care should be taken when lifting
tuted through the use of barrier membranes to aid in bone the papillary complex to avoid separation of the buccal
graft containment and isolate the graft particles from soft and lingual aspects of the interdental tissue.
tissue encapsulation. The ice‐cream cone technique pro- • Once the tunnel is prepared circumferentially on the
posed by Tarnow (in Chu et al. 2012) involves placing a buccal aspect, a micro‐back-action chisel or piezo
collagen membrane that is trimmed to mimic the missing ultrasonic back‐action tip is used to ensure complete
portion of the buccal plate and is placed within the socket removal of any soft tissue remnants that may be left
palatal to the borders of the buccal bone peaks. This tech- behind during tunnel elevation.
nique offers a simple approach and may be modified to
address apical deficiencies in the same manner through • The tunnel is then measured, and a collagen membrane
the extraction socket opening. However, mere reconstitu- is trimmed to cover 2–3 mm of the peripheral boundaries
tion of the previously lost socket topography may not be of the socket (Figure 12.40).
sufficient for future implant placement. Subsequently a • N.B. it is not advisable to utilize a native cross‐linked
modification of this technique can be performed by place- membrane in these techniques for two reasons:
ment of the membrane on the outer aspect of the buccal ◦◦ Non‐cross‐linked membranes are softer and have no
socket walls. structural memory, consequently these membranes
do not offer sufficient resistance to allow its introduc-
Surgical Procedure tion into tight spaces without wrinkling and folding.
• Extraction is performed in the same steps as previously ◦◦ Cross‐linked membranes offer more structural durabil-
mentioned. ity and resistance to resorption when left exposed.

Extraction Site Management in the Esthetic Zone 193

Figure 12.40  Outline of the membrane placement underneath the prepared tunnel. The membrane is trimmed to circumferentially cover the peri‐implant defect
2–3 mm circumferentially. Above the crestal bone, the soft tissue graft is placed to boost the soft tissue profile without impediment of the underlying bone.

• Since the objective of this technique is to perform an in‐ 3 mm from the gingival margin on the mesio‐buccal
situ bone augmentation beyond the confines of the pre- aspect of the socket. The suture needle is then passed
vious socket housing, it may be prudent to trim the over the membrane and exited on the disto‐palatal
membrane slightly larger (1 mm circumferentially) than aspect with the same distance from the gingival margin
what is needed to compensate for the additional bone and mid‐line of the socket. The returning suture points
volume that will stretch the membrane and soft tissue are done from the mesio‐palatal to the disto‐buccal with
toward the buccal direction. the knot placed on the buccal. This technique offers
additional security and compression of the membrane
• Once the membrane is secured and stabilized, a tis-
coronally without compression of the suture thread over
sue plier is utilized to hold the visible occlusal portion
the free gingival margin of the socket which may end up
of the membrane taut to avoid displacement or folding
with depression and clefting of the socket margins
of the membrane during the bone grafting procedure.
(Figure 12.41).
• Typically, an allograft material would be the one of choice
• Peri‐acryl can be used to seal over the socket or an
for this technique.
ovate pontic provisional can also be utilized provided
• The bone graft particles are packed in increments both that the pontic does not extend on to the buccal aspect
in an apical direction and toward the buccal aspect to of the socket or form excessive compression onto the
counteract the compression resulting from the buccal bone graft material (See Figure 12.42).
soft tissue falling into the empty socket.
• A third blunt instrument can also be utilized from the
ESTHETIC RIDGE AUGMENTATION
outer aspect of the tunnel at the apical position to pre-
vent displacement of the bone graft apically. Utilizing a membrane has been reported to be effective in
Guided Bone Regeneration (GBR) techniques with
• Finger molding of the outer surface of the site can help
proven long‐term results (Figure 12.43). However, basic
spread and adapt the bone in a more uniform fashion.
GBR principles demand passive primary closure for an
• The bone graft is condensed up to a coronal level at the environment that is conducive to bone regeneration. In
bone crest level if a soft tissue graft is utilized. If no soft addition to the complexity in handling, stabilizing, and
tissue graft is combined at the time of bone augmenta- shaping membranes, in the anterior zone, primary clo-
tion, the graft may be packed up to the level of the soft sure over extraction sockets often results in an unnatural
tissue margins to support the supra‐crestal soft tissue soft tissue architecture by distorting the position of the
volume. muco‐gingival junction. Subsequently, the pursuit for
development and improvement of minimally invasive
• Following which the free occlusal tail of the membrane
technologies has been widely researched over the past
can be simply tucked underneath the palatal tissue with
decades. Among those advancements is utilizing recom-
the aid of an instrument or anchoring suture as described
binant growth factor technology to enhance regenerative
for the soft tissue graft procedures.
outcomes and minimize the use of additional barrier
• An additional criss‐cross securing suture can be per- membranes for guided tissue regeneration (Nevins and
formed entering 3 mm from the midline of the socket and Said 2018).

194 Practical Advanced Periodontal Surgery

 (a) (h)

(b) (c) (d)

(e) (f) (g)

Figure 12.41  Sub‐optimal implant placement correction. (a) Note the excessive labial positioning of the implant. (b–d) Implant removal is followed by
replacement with a new implant in a more palatal position. (e–f) A resorbable collagen membrane is trimmed according to the defect shape combined with
an allograft material and a rotated pedicle soft tissue graft to augment the labial contour of the site as well as seal over the socket (g).

Rationale
Recombinant technology allows for the availability of syn-
thetically engineered pure human growth factors.
Recombinant human bone morphogenic protein‐2
(rhBMP‐2) has been extensively studied for extraction
socket preservation and sinus elevation in multi‐center
randomized controlled trials (RCTs). (Fiorellini et al. 2005;
Triplett et al. 2009). Recombinant human platelet‐derived
growth factor‐BB (rhPDGF‐BB) has been approved for
periodontal regenerative procedures to enhance the peri-
odontal attachment apparatus (Nevins et al. 2003a, 2005,
2013). Human histologic studies support the ability of rhP-
Figure 12.42  Flapless ridge preservation and implant DGF‐BB to induce periodontal regeneration (Nevins et al.
replacement. 2003a, b). In addition, rhPDGF‐BB has demonstrated

Extraction Site Management in the Esthetic Zone 195

Figure 12.43  Esthetic Ridge Augmentation with growth factor induced bone matrix (Nevins and Said 2018).

­ ositive results in pre‐clinical models and human case

p • Tooth Removal and Degranulation are performed in the
reports for management of extraction socket preservation, same manner
sinus elevation, and vertical ridge augmentation proce-
• The growth‐factor enhanced bone matrix is incremen-
dures (Cooke et  al. 2006; Kaigler et  al. 2011; McAllister
tally condensed into the extraction socket defect.
et al. 2010; Nevins et al. 2009b, 2013; Simion et al. 2007).
The direct mechanism of action of platelet‐derived growth • The graft is over‐filled to the level of the gingival margin.
factor is on the osteoblast population of cells by recruiting
• A collagen membrane (Bio‐Gide, Geistlich Pharma
them to the wound and stimulating their proliferation and
North America Inc., Princeton, NJ) was trimmed to fit
production of matrix. Indirectly, rhPDGF‐BB stimulates the
within the outline of the gingival margin.
elevation of vascular endothelial‐cell growth factor which
upregulates neovascularization into the wound (Cooke • Membrane was stabilized with 6‐0 chromic gut suture or
et al. 2006). medical grade cyanoacrylate (GluStitch Inc. BC, Canada).
The provisional appliance was delivered and adjusted to
Advantages relieve any contact pressure at the surgical site.
• Eliminate need for barrier membranes
If the peri‐radicular pathology is inaccessible from the
• Reconstruction of large alveolar defects with less socket orifice, a vestibular approach is utilized.
invasion
• Simpler and less time consuming compared to the use Decision Making in Soft Tissue Augmentation
of a membrane Following Bone Graft Procedure
• Earlier soft tissue healing Although the importance of soft tissue augmentation has
been highlighted throughout the chapter, combining ade-
• Linear bone growth
quate site selection with the appropriate technique is essen-
tial. Due to their inherent limited access and space for
Disadvantages
augmentation, flapless approaches could offer limitations
when combined hard and soft tissue grafts are attempted
• Additional expenses
simultaneously. In sites where the buccal bone is intact, the
• Long term data is still not documented for the use of this buccal plate acts as a rigid space maintainer for the graft
technique material. If the integrity of the buccal plate is compromised,
the soft tissue flap will tend to compress the bucco‐occlusal
• Off‐label FDA use
aspect of the graft material and subsequently lead to a
depression in the soft tissue profile and underlying regener-
Procedure
ated bone. It is therefore advised that flapless ridge preser-
• Prior to beginning the surgical procedure, 1.0 g freeze‐ vation procedures are to be performed with this concept in
dried bone allograft (FDBA) (Regeneross Particulate the back of the clinician’s mind. In moderately compromised
Allograft, Zimmer Biomet, Palm Beach Gardens, FL) was sites, a barrier membrane may be utilized to augment the
combined with 0.5  ml of rhPDGF‐BB (Gem21S, missing portion of the buccal plate and the bone grafting
Osteohealth, Shirley, PA) and sterile water to hydrate the should be done actively against the buccal soft tissue to
graft and allowed to soak for at least 10 minutes. counteract for the future remodeling of that site. If a tissue

196 Practical Advanced Periodontal Surgery

Figure 12.44  Simultaneous soft tissue grafting with ridge augmentation in severely compromised sites may actually hinder the amount of bone
augmentation possible when utilizing flapless approaches.

graft is placed at the time of augmentation, the volume of the ­ ugmentation site. Alternatively, if the operator opts to
a
graft may compromise the hard tissue augmentation, yield- avoid vertical incisions, the intra‐sulcular incisions then
ing insufficient reconstitution of the alveolar defect for implant have to be extended two teeth away from the site to be
placement (Figure 12.44). It therefore may be beneficial to augmented.
stage such procedures and focus on hard tissue augmenta-
• Avoid vertical incisions directly over root prominences.
tion and perform soft tissue enhancement procedures at the
time of implant placement or second stage uncovering. • Minimal access flaps with singular or multiple vestibular
sub‐marginal incisions should only be performed follow-
OPEN FLAP APPROACH FOR EXTRACTION ing accurate assessment of the entire defect extension,
SITE MANAGEMENT and still maintain a remote location to avoid having the
incision line rest over the augmented site.
Conservative approaches in the esthetic zone are recom-
mended; often times however, limitations in access for ade- Incision Designs Diagram
quate debridement and augmentation are encountered. It is
up to the operator to determine the need for additional
access to the site if required. At that point, incision design SITE ANALYSIS AND CLASSIFICATION
becomes critical not only to allow sufficient access to the Determining the type and extent of augmentation is per-
site, but must also consider the esthetic endpoint of the formed mainly based on the pre‐operative assessments.
case. Consequently, certain requirements for incision design The operator should determine:
in the esthetic zone must be taken into consideration.
• Orientation of the defect:
Incision Design Requirements
◦◦ Horizontal
• Flaps should be planned to allow for adequate access
◦◦ Vertical
to the site to be addressed, this is pre‐determined
through adequate pre‐operative diagnosis of the defect ◦◦ Combined
topography and the augmentation needs.
• Augmentation needs for the site:
• Papilla reflection should be only performed on periodon-
◦◦ Simple
tally healthy dentition to avoid the compromise of the
interproximal papilla. If extension of the flap to the adja- ◦◦ Moderate
cent teeth is required, papilla sparing incisions should
◦◦ Complex
be considered in periodontally compromised patients.
• Intra‐bony and extra‐bony
• Vertical releasing incisions are not contra‐indicated in
the esthetic zone, but it is preferable to avoid vertical • Type of tissue to be augmented
incisions in the inter‐canine area, to avoid tissue scar-
◦◦ Hard Tissue
ring or clefting in a highly visible area.
◦◦ Soft Tissue
• Vertical releasing incisions should be performed in
remote sites, at least one tooth away from the ◦◦ Combination

Extraction Site Management in the Esthetic Zone 197

The following information is most accurately determined • The lack of primary closure resultant from the tooth being
based on the pre‐operative diagnostic wax‐up. The wax‐up present.
aids the clinician in visualizing the final restoration in relation
• Obtaining primary closure will result in displacement of
to the present tissue clinically. The mock‐up has to replicate
the muco‐gingival junction position.
the final restoration contours with respect to the tooth posi-
tion and more importantly, the proposed CEJ position. This
One of the possible methods of addressing these prob-
step is essential in ­obtaining an accurate guide for both the
lems is incorporating a soft tissue graft with the regenera-
regenerative procedure and implant position. The mock‐up
tive bone procedure whether free or pediculated. A
is then transferred into a radiographic guide to allow for cor-
combined approach provides both additional volume aug-
relation of the tooth position to the underlying bone topogra-
mentation as well as protection over the exposed regen-
phy. If the pre‐operative wax‐up indicates the necessity for
erative site. However, this technique is only recommended
soft tissue augmentation, this should be also replicated in
with resorbable membranes, as lack of primary closure
the radiographic guide utilizing a material of lower radio‐
over nonresorbable membranes may cause post‐opera-
density. The difference in radio‐densities between the tooth
tive infections and site contamination, leading to signifi-
and soft tissue replica aids the clinician in determining the
cant soft tissue esthetic defects. The section will focus on
augmentation needs and treatment sequence. Finally the
simultaneous hard and soft tissue augmentation of sites
pre‐existing radiographic guide can be transferred into a
with deficient buccal plates at the time of tooth extraction.
surgical guide conventionally, or scanned and milled or
printed with the aid of digital techniques. As provisional res-
Utilizing a combination therapy requires a more advanced
torations act as a blue‐print for the final prosthetic restora-
skill set, and is not intended for beginner operators.
tions, accurate diagnostic wax‐ups offer the clinician an
accurate guide for treatment planning and execution of
Surgical Procedure
­surgical procedures (Figures 12.45, 12.46, and 12.47).
• Extraction of the tooth can either be performed prior or
following flap elevation. It may be useful to remove
SURGICAL PHASE
severely decayed or fractured teeth following flap eleva-
Time of Tooth Removal tion and reflection.
Management of immediate post‐extraction sites poses two • Reflection should be extended to allow access of the
main challenges to the clinician entirety of the defect and surrounding area. Full t­ hickness

(a) (c)
(b)

(d) (e) (f)

Figure 12.45  Left column top: Dehisence defects with different severity levels. (a) shows a significant implant dehiscence defect which requires more
extensive flap reflection and management. (b) shows how minor dehiscence defects can be managed in a less invasive approach. Middle column shows
two horizontal type defects. (c) shows a non‐contained horizontal deficiency in which augmentation is required outside of the alveolar envelope. (d) shows
a horizontal deficiency that is more confined and provides a higher regenerative potential and a less demanding augmentation. The last column shows
the difference between two vertical defects with different regenerative potentials due to the amount of bone walls surrounding the defect. (e) Extra‐bony.
(f) Intra‐bony.

198 Practical Advanced Periodontal Surgery

 (a) (b) (c)

(d) (e) (f)

Figure 12.46  (a) CT scan with digital wax‐up and virtual implant placement exhibiting inadequate bone to stabilize the proposed implants. (b) shows
the vertical tissue deficiency in relation to the proposed future restoration. (c) The horizontal ridge deficiency can also be evaluated and augmentation
preplanned utilizing 3d printed models (d) to plan the case surgically. These models can also be sterilized to allow pre‐shaping membranes and block
grafts prior to surgical exposure of the site (e and f).

Figure 12.47  The diagnostic wax-up is then converted into a surgical guide to aid the clinician to establish the correct augmentation needs and
adequately place the implants conforming to the desired restorative position.

reflection is carried out until sufficient access is achieved • The guide is also utilized to aid the clinician with the
to expose the defect in addition to about 4 mm circum- amount and location of the site to be augmented in
ferentially around the defect. ­relation to the future implant supported restoration.

• Tooth extraction and site debridement is performed as • If the defect is only horizontal in nature, a collagen mem-
previously described. brane has been proven to be sufficient in obtaining ade-
quate horizontal augmentation for either a veneer graft
• Implant placement may also be attempted if correct buccal to the implant or reconstitution of sufficient alveo-
implant positioning can be achieved. lar dimensions for future implant placement.
• The surgical guide is utilized to give the operator the • The key to obtaining a predictable regenerative outcome
ideal CEJ/gingival margin position for adequate implant is adequate extension of the membrane and stability of
placement. the blood clot.

Extraction Site Management in the Esthetic Zone 199

Membrane Placement and Stabilization ­conforming to classical GTR principles. Should the clini-
cian decide to utilize a nonresorbable membrane, a 1.5 mm
Depending on the operator preference, the membrane
distance should be left away from the adjacent tooth roots
may be stabilized by different techniques. Stability of the
(Figure 12.48).
membrane is critical regardless of the membrane choice.
Stabilization through use of fixation tacks and pins allows
Important note: Membrane trimming should be per-
immobilization of the membrane and also permits packing
formed knowing that the bone graft material will tent the
the bone graft against the membrane. Depending on the
membrane overlying it, causing it to shift away from the
preference of the operator anchoring the membrane may
adjacent margins. Native collagen membranes (bio‐
be done on the buccal or palatal aspects first followed by
guide) may be trimmed to be relatively snug over the
bone packing. Care has to be taken when packing the
graft material as they are more elastic and stretchable
bone as there is usually a tendency to pack the bone api-
than cross‐linked or nonresorbable membranes. Cross‐
cal to the ridge crest if the membrane is stabilized pala-
linked membranes do not allow “give” and should be
tally. This may result in the bone graft particles being
trimmed slightly larger (about 15%) prior to the
displaced vertically which makes closure more difficult, as
augmentation.
well as displacing the graft. A high degree of cross‐linking
of collagen membranes produces stiffer membrane.
Technical tip: Oversizing the membrane by about 15% and
Therefore, appropriate selection of the material becomes
fixating it on one side first utilizing a tack. The bone graft
critical when performing these procedures. If mini‐screws
material is then packed to replicate the desired ridge con-
are utilized for fixation, the rotation may cause the mem-
tours and is then pulled with tension over the graft to the
brane to become “curled” around the screw. Therefore, it is
opposite aspect and fixated with another tack. This ensures
advisable to utilize an additional instrument to fixate and
stability of the graft and sufficient coverage of the bone
stretch the membrane while the screw is inserted.
graft material.

Regardless of the type of membrane or amount of aug-

Once the membrane is trimmed, the choice of stabilization
mentation stability is a mandatory requirement for a suc-
technique would dictate the sequence of procedures. In
cessful bone graft. This is a function not only of membrane
cases where internal stabilizing sutures are to be utilized,
stabilization but also is the result of packing the bone and
periosteal releasing incisions should be performed prior to
securing it under the membrane. The membrane must be
membrane fixation (Figure 12.49).
stretched to fully encompass the bone graft particles and
keep it in place to avoid excessive micro‐motion during the
Requirements and Evolution of the Periosteal
initial healing phase. Failure to immobilize the graft may
Releasing Incisions
lead to excessive graft resorption or infection.
• The periosteal release is composed of a continuous hori-
zontal incision to separate the tightly bound periosteal
Techniques for Membrane Stabilization
lining of a full thickness flap.
1. Periosteal Suture
• The incision should extend through the entire width of
2. Fixation pins and/or screws the flap. Partial separation of the periosteum prevents
passive release of the flap leading to uneven tension
The membrane is trimmed to cover 2–3 mm circumferen- and difficulty in coronal flap mobilization.
tially around the area to be augmented.
• The incision has to be performed apical to the muco‐gin-
gival junction to allow access to the elastic fibers of the
The shape of the membrane can be customized with the
oral mucosa.
use of one membrane to extend on the buccal as well as
occlusal aspects. • The depth of extension of the incision has evolved with
the introduction of different techniques. The incision
Alternatively, the membrane can be trimmed in two sepa- depth should extend only past the periosteal layer on
rate pieces to have part of the membrane dedicated for average (0.8 mm). If thicker muscular structures or scar
the buccal augmentation while the second piece is tissue exists within the internal aspect of the flap, sharp
trimmed into an hourglass shape to extend from the palatal dissection may be continued slightly deeper until the
to the buccal aspect covering the occlusal portion of the submucosal area is accessed. Following which, utilizing
socket. This technique offers the advantage of having a a hemostat or periosteal elevator with blunt dissection, a
double layer of membranes over the bucco‐occlusal coronal brushing motion is performed to allow stretching
aspect of the augmentation which increases the resorption of the flap and spreading apart the periosteal incision
time of the membrane in that area. Resorbable collagen margins to allow coronal advancement. This technique
membranes are trimmed to fit snug around the teeth offers two advantages:

200 Practical Advanced Periodontal Surgery

Figure 12.48  Example of membrane fixation with tacks placed to stabilize one horizontal membrane with a second membrane placed on the occlusal
aspect to completely seal off the regenerative site.

(a) (b) (c) (d)

(e) (f) (g) (h) (i) (d)

(j) (k) (l) (m)

Figure 12.49  (a–d) (a) Frontal view implant placement, guided bone regeneration was performed on the buccal aspect, with fixation tacks for added
membrane stability. A connective tissue graft was performed to further augment the tissue volume. The membrane and tissue graft were secured with a
stabilizing periosteal suture. (e–h) occlusal view of the procedure. (j–m) Showing the graft being engaged prior to periosteal anchoring as well as the
periosteal anchorage done with the same suture to stabilize the graft in place. Closure is done above the healing abutment.

Extraction Site Management in the Esthetic Zone 201

 ◦◦ Deep sharp dissection into the submucosa causes • Regardless of the membrane fixation technique, this
excessive trauma, post‐operative swelling, and pain same suture may be utilized to stabilize the soft tissue
as dissection into the deeper muscle layers involves graft, whether the graft is engaged in the suture or allow-
more nerves and larger vessels. ing the suture thread to compress it apically.
◦◦ Blunt dissection offers a safer alternative when in
close proximity to main nerves and vessels as this Tacks and Pin Fixation
technique can be used to release the buccal flaps in For a more rigid form of membrane stabilization, fixation
other areas of the mouth. tacks and pins may be utilized. Membrane fixation screws
• This form of dissection will result in the flap being split may also be utilized, but usually reserved for non‐­
into two portions: resorbable membranes or areas with a thick cortical plate
­(example: posterior mandible). When utilized with resorb-
◦◦ Apical to the periosteal incision line: This portion able collagen membranes, the membrane tends to rotate
remains bound to the underlying bone. and wrinkle owing to the rotational motion of the screw
◦◦ Coronal to the periosteal incision line: Passive portion insertion. Therefore, in the anterior maxilla, fixation tacks
of the flap. are both simple and predictable in their use but not without
drawbacks:
• Once the flap is checked for sufficient mobility, the cor-
responding palatal portion of the membrane is tucked
Advantages
under the palatal flap and the bone graft material is
packed on the buccal aspect. The periosteal stabilizing • Immobilization of the membrane and underlying graft
suture is commenced.
• Precise placement with narrow diameter, can be used in
between roots of the teeth
Steps for Periosteal Stabilizing Suture
• No creasing or wrinkling of the membrane
• The suture is entered from the palatal tissue about 5 mm
apical to the palatal gingival margin and off set to either • Have different lengths, with the same diameter which
mesial or distal about 3 mm from an imaginary line run- can help in cases with softer bone
ning through the center of the site.
Disadvantages
• The suture needle is passed to the buccal to engage the
connective tissue/periosteum attached to the bone, • Need a mallet for insertion, which is uncomfortable for
which allows a stable anchorage to the suture. the patient and may even cause paroxysmal vertigo

• The suture is passed to the opposite edge of the grafted • Need for retrieval
site to anchor the periosteum. • May cause minor tissue dehiscence
• It is then returned to the palatal flap to exit at a point
• Longer lengths 5 mm tend to bend easier
symmetrical to the entry point.
• Access for palatal placement may not always be
• This suture exerts pressure on the edges of the mem-
possible
brane, adapting it to the underlying bone whilst avoiding
compression of the graft material.
Procedure for Tack Insertion
• If the suture bites are taken too close to each other, the
• Following membrane trimming, the membrane fixation is
suture thread creates pressure on the regenerating bone
commenced either on the buccal or lingual aspect.
and may end with a depression of the buccal contour
(Figure 12.50). • The membrane is positioned in the desired orientation.

(a) (b) (c) (d)

Figure 12.50  (a–c) Incorrect choice of suture material and placement compressing the graft right in the mid‐buccal portion of the grafted site. (d) note
the point of depression of the buccal bone related to the previously performed suture.

202 Practical Advanced Periodontal Surgery

• An instrument is utilized to fixate the membrane in place, • Should additional stabilization of the second portion of
and the pin applicator is utilized to position the tack pin the membrane be needed, a stabilizing suture can be
onto the membrane to prevent its movement. used but usually is not necessary (Figure 12.51).
• The holding instrument is then left to the assistant and
Soft Tissue Stabilization
the free hand is utilized to operate the mallet.
Once the bone graft is performed, the connective tissue
◦◦ Note the long axes of the tack, applicator, and mallet
graft is introduced to the site.
have to be parallel. If the mallet and applicator are
offset to where the tack is directed, the forces will be
The connective tissue graft can be situated horizontally
directed to the peripheries of the pin and will either
or vertically. In cases where there is an extraction socket
cause it to bend or dislodge from the applicator.
orifice it may be advantageous to place a portion of the
• The mallet is gently tapped while maintaining the graft to protect the underlying bone graft during the initial
proper angulation until complete seating of the tack is healing as well as prevent excessive distortion of the
observed. MGJ. However, the graft must have no more than 20% of
its surface exposed, in order to attain sufficient blood
• At which point an instrument such as the back edge (non‐
supply and avoid necrosis. If primary closure is planned
cutting side of the blade) is inserted in between the grooves
then the graft can be oriented horizontally, i.e. mesio‐dis-
of the applicator head, with pressure over the tack.
tally to allow for augmentation of the interproximal papil-
• The applicator is then bent in the opposite direction lae in a horizontal dimension in addition to the buccal
of  the instrument insertion. N.B. attempting to pull the contours.
applicator in a direction opposite to the tack insertion
will often result in dislodgment of the fixation pin. SUTURING OF THE GRAFT
• Once the membrane is fixated on one side the bone is The tissue graft may be sutured utilizing different areas for
then packed into the defect site. its anchorage.
• A common mistake is incorrectly packing the bone.
The Buccal or Palatal Flap
• The membrane is pulled taut over the packed bone.
Anchoring Periosteal Suture
Tip: An instrument such as a periosteal elevator can be
utilized to maintain the bone in the desired shape to Depending on the homogeneity of the graft thickness the
maintain the space underneath the membrane. graft can be sutured to either the buccal or palatal flaps. If
sutured to the buccal flap a horizontal mattress suture is
◦◦ Common errors: If the membrane is tacked on the
used to ensure that the graft is stabilized in the desired
palatal initially, the bone particles will have a tendency
position in relation to the ridge and the flap. Following graft
to fall apically during the buccal fixation.
stabilization, the site must be inspected for any lack of
◦◦ If fixation is performed from buccal to the palatal, the conformity, excessive folding, or lack of adaptation of the
bone will tend to rise crestal and result in an inadvert- graft prior to flap closure.
ent vertical augmentation which makes closure much
more difficult. Steps (Figure 12.52):
• If the implant was placed the implant cover screw/­ 1. Suturing is started from the vestibular aspect of the flap,
healing abutment can act as the palatal anchorage and by holding the graft and flap with tissue forceps
a small slit performed with a 15 blade can allow for (Figure 12.52).
securing the membrane around the implant platform.
2. The suture needle is passed to engage the buccal flap
• The membrane is pulled taut over the bone particles and and connective tissue about 2 mm from the center of
fixation is continued in the same fashion at the apical the graft.
corners of the augmentation site.
3. The needle is then passed back through the connective
• Multiple tacks can be placed along the membrane tissue graft and inner aspect of the flap to emerge about
periphery to minimize any voids between the bone 3 mm away from the initial entry point on the same hori-
and  membrane, ultimately leading to complete clinical zontal plane.
immobilization of the membrane/graft complex.
4. Securing the suture should be done in a manner that is
• The same can be applied when the membrane is trimmed not too tight, as excessive pulling will cause the graft and
in two segments. The membrane is fixated in a horizontal flap to curl toward the center of the suture. The same
orientation initially followed by insertion of the second por- might occur if the suture bites are too far apart horizon-
tion of the membrane from the palatal to occlusal aspect. tally. Visual assessment is needed during this step.

Extraction Site Management in the Esthetic Zone 203

Figure 12.51  Immediate implant placement with horizontal ridge augmentation and simultaneous soft tissue grafting.

The purchase points should be 3 mm apart, sufficient to Suturing of the Graft and Simultaneous
adapt the graft well to the flap. If the bite sizes are too wide Flap Closure
apart or the suture too tight, the graft will have a tendency
In single tooth sites, where soft tissue grafting is per-
to curl toward the center. Sutures bites that are too close
formed, graft fixation can be combined with initial flap
will not encompass sufficient surface area of the graft to
approximation. This approach is essentially composed of
prevent its rotation and adequately stabilize it.
two vertical mattress sutures performed at the mesial and
distal interproximal papillae.
The graft could also be stabilized to the palatal flap though
the same approach. However, reflection of the palatal flap
Surgical Steps
is required to successfully accomplish closure of the flap
as the space occupied by the tissue graft elevates the In contrast to horizontal mattress sutures, vertical mattress
buccal flap (positions it more coronal), preventing ade- sutures allow coronal positioning and eversion of edges of
quate approximation of the buccal and lingual tissues. By the flap if needed.
elevating the palatal flap adequate closure with connective
tissue contact between the two flaps allows earlier union The suture entry point is from the palatal aspect below the
and better healing. base of the palatal interproximal papilla.

204 Practical Advanced Periodontal Surgery

 (a) (b) (c)

(d) (e) (f)

Figure 12.52  (a–c) A mattress suture is used to anchor the graft to the flap. (d) showing the graft sutured to the flap. (e) Buccal bone grafting was
performed. (f) Closure of the site.

The needle is passed through the palatal tissue, through crestal incision in a vertical plane. The graft is engaged,
the graft and in through the buccal flap at about 5 mm from and the needle is then passed into the connective tissue
the tip of the buccal surgical papilla. perpendicular to the buccal bone to ensure at least
2–3 mm of tissue for anchorage. For single tooth sites
The needle is then returned through the buccal flap one suture is usually sufficient. One or more of these
approximately 2 mm coronal to the initial exit point and sutures may be used for larger spans and bigger tissue
then passed straight to the corresponding site on the pala- grafts depending on the clinician’s judgment of the graft
tal aspect without engaging the graft. stability. A third alternative is engaging the periosteum in
two different points along the same horizontal plane con-
The end result of this suture is coronal repositioning of the sequently obtaining a larger surface area to stabilize the
flap and stabilization of the graft. graft. N.B. depending on the accessibility, the suture
may be criss‐crossed. The needle is then passed through
N.B. if the graft is engaged on the return passes of the the graft from a buccal to palatal aspect and finally exits
suture, both the graft and flap will become coronally posi- through the palatal tissue at the same horizontal plane as
tioned which will result in interference of the connective the entry point (Figure 12.53).
tissue graft with the flap edges and subsequently lack of
adequate adaptation of the tissue. The vertical approach is the same concept except in a ver-
tical orientation, meaning that at least two sutures are nec-
STABILIZATION OF THE GRAFT essary to stabilize the graft, one on either side of the graft
An alternative approach stabilizes the graft prior to flap at the mesial and distal edges.
closure which offers the advantage of having more control
of the buccal flap and less mobility of the tissue during the
CLOSURE
suturing process. The most stable tissue is usually the
attached periosteum and overlying connective tissue Closure of the flap should re‐approximate the tissue to its
below the level of the periosteal releasing incision. The tis- original position while utilizing the tissue to offer a protec-
sue is anchored into the periosteum by either a horizontal tive barrier to the underlying augmentation complex.
mattress or vertical mattress type of suture. Should a prosthetic component be placed such as a stock
or customized healing abutment, additional fine ­interrupted
Suturing is started from the palatal aspect and is offset to sutures should be utilized to achieve good adaptation
either the mesial or distal side and at least 3 mm from the around the abutment.

Extraction Site Management in the Esthetic Zone 205

 (a) (b) (c)

(d) (e) (f) (g)

(h) (i) (j)

Figure 12.53  (a–c) Extraction and implant preparation osteotomies. (d) Membrane fixation is performed on the palatal aspect. (e and f) Contour bone
grafting was performed combined with a collagen membrane. (g) Positioning of a free connective tissue graft on the buccal aspect prior to suturing.
(h) Horizontal mattress sutures overlapping the grafts and engaging the periosteum on the buccal flap. (i) Note how tightening of the mattress sutures
allows for coronal advancement of the flap while exerting downward pressure on the soft tissue to ensure adequate stability of the free graft. (j) Closure of
the flap, showing minor areas of the underlying connective tissue used to cover the extraction site openings.

MANAGING IMPLANT TISSUE DEFICIENCIES 2. CBCT evaluation revealed Class IV type sockets with
inadequate socket or apical topography for immediate
Regardless of efforts employed to preserve and augment
implant placement (Figure 12.54).
the tissue volume, certain deficiencies resulting from s­ urgical
complications, inadequate tissue management/augmenta- 3 . Teeth extraction was performed atraumatically with
tion, or simply severe anatomical deficiencies may comp­ FDBA allograft placed to the level of the soft
romise implant placement and long‐term implant function. tissue.
4. Prosthetic sealing of the socket was performed with a
As previously discussed, correct three-dimensional
fixed tooth supported provisional bridge.
implant placement may not always be possible at the time
of tooth extraction. Efforts to reconstitute the deficient tis- 5. Four months post extraction, note the preservation of
sue ­volume should then be maximized at the time of tooth the gingival architecture and support of the interproxi-
extraction, often requiring significantly larger procedures. mal the soft tissue profile (Figure 12.55).
However, certain patient related factors such as esthetics,
6. Five months CBCT scan revealed adequate bone fill,
patient refusal of more invasive procedures, and healing
but residual apical concavity preventing adequate
potential can often hinder clinicians in achieving the
implant placement (Figure 12.55).
­optimal results in one surgery. Therefore, alternative less
­invasive techniques may be performed in stages to spe- 7. Implant placement was planned through a digitally
cifically address deficient sites or complications. guided approach to avoid flap reflection and disruption
of the tissue architecture
Case Study: Apical Topography (Vestibular 8. Based on the pre‐operative planning, the site of implant fen-
Approach) estration was accounted for prior to the surgical procedure.
1. A 37 year old medically healthy patient presented with 9. Tissue punch and flapless implant placement was per-
severely decayed maxillary central incisors and failed formed. Note the bone graft encapsulation within the
root canal therapy. soft tissue. (Figure 12.56).

206 Practical Advanced Periodontal Surgery

Figure 12.54  Class IV type sockets with inadequate socket or apical topography for immediate implant placement.

Figure 12.55  Note the bone preservation of the ridge with maintanence of the soft tissue architecture.

Figure 12.56  Soft tissue punch performed for flapless implant placement. Note the bone graft particle encapsulation within the soft tissues which act to
preserve the tissue volume in the area.

Extraction Site Management in the Esthetic Zone 207

Figure 12.57  Implant placement and guided bone regeneration performed through a vestibular tunnel procedure.

Figure 12.58  Final implant restoration and veneers to mask the congenitally missing laterals.

10. A small vestibular incision was utilized to address the • Dual zone bone grafting protocols combined with pros-
site without the need for reflection of a full thickness thetic socket sealing may provide better maintenance of
flap that may have compromised the esthetics of the the soft tissue architecture and volume, offering a less
case. invasive approach to soft tissue grafting procedures.
11. F
 ull thickness reflection was performed to expose • The same philosophy can be performed with simultane-
the defect entirety with sufficient space to accom- ous implant sites and in more compromised sites,
modate for membrane placement and bone graft ­provided that:
material.
1. The implant is not placed outside of the alveolar enve-
12. Site closure with microsutures (Figure 12.57).
lope as the avascular implant surface will hinder cellular
13. Final case following finalization of the restoration. migration and subsequent bone formation buccal to the
implant.
14. P
 ost‐operative CT scan revealed adequate buccal
bone both in the coronal and apical portions. 2. Excessive buccal inclination or poorly positioned
implants should be removed and replaced with a more
Lessons learned: Staging procedures with less invasive palatally positioned implant either immediately or in
augmentation techniques may provide an alternative to staged fashion. A more palatal relocation of the implant
larger reconstructive procedures with more esthetically will also allow more space for the buccal hard and soft
acceptable results (Figure 12.58). tissue augmentation.

208 Practical Advanced Periodontal Surgery

3. The operator is able to operate with the correct instru- or a pre‐standardized tissue punch of the correspond-
mentation within the confines of the performed access ing diameter.
tunnel whether from a crestal or vestibular approach.
2. A large round diamond bur is utilized to de‐epithelialize
within the outline of the punch.
Same‐Site, Minimally Invasive Surgery 3. The incisions are then continued full thickness and the
In cases where soft tissue augmentation was performed at soft tissue is removed with the aid of a periosteal
the time of extraction and adequate reconstitution of the elevator.
hard and soft tissue contours has been achieved, a flap- 4. Depending on the shape and thickness of the soft tis-
less approach may be utilized for implant placement pro- sue harvested, the tissue can be trimmed to the desired
cedure provided there is sufficient keratinized tissue. In shape and size.
these cases, the soft tissue augmented socket orifice can
be an excellent donor site for additional buccal soft tissue 5. Following implant placement, a tunnel preparation
augmentation. is made to allow introduction of the graft. The tun-
nel in these cases will be coronal to the crest of
bone as the purpose of this procedure is to enhance
Procedure
the coronal soft tissue thickness and quality (tissue
Whether the area is being performed utilizing guided sur- zone). Should any additional bone grafting be
gery or conventional techniques, the outline of the soft tis- needed, this can be performed on the buccal
sue punch should be slightly greater than the diameter of aspect up to the implant platform (bone zone)
the final implant to be used. If a customized healing abut- (Figure 12.49f–i).
ment or provisional crown are planned, the soft tissue
6. The soft tissue is secured in place utilizing one of the
punch may be performed to replicate the root/restoration
pre‐mentioned securing sutures or even the healing
cross‐section. The benefit of applying these technical tips
abutment and/or provisional restoration to secure the
is to maximize the amount of tissue to be utilized for the
graft in place (Figure 12.49j).
soft tissue augmentation.
Combining this technique with a vestibular incision on the
1. The outline of the soft tissue punch is performed in a buccal aspect can provide the clinician with an alternative
partial thickness outline with the use of a scalpel blade for management of hard of soft tissue defects of a more

(a) (b) (c)

(d) (e) (f)

(g) (h) (i) (j)

Figure 12.59  (a–j) Sequential procedures for the treatment of a failed implant site with a “same‐site minimally invasive surgical approach.”

Extraction Site Management in the Esthetic Zone 209

Figure 12.60  Sequential procedures for the treatment of an implant dehiscence site with a “same‐site minimally invasive surgical approach” through the
aid of a vestibular incision.

severe nature in the esthetic zone with a single incision. This r­econstitution of tissue volume, as well as minimizing
is especially useful in esthetically sensitive areas with com- soft tissue architecture distortion through less invasive
plex peri‐implant deficiencies (Figures 12.59 and 12.60). approaches. As clinical practice becomes more
demanding our techniques have evolved to involve
less invasion while simultaneously enhancing the over-
CONCLUSION
all results. Therefore, as clinicians, our approaches to
The purpose of this chapter was to illustrate the more complex sites should be tailored to minimize the
d ifferent components of establishing optimum peri‐
­ invasiveness to the patient without compromising the
implant esthetics through correct implant positioning, end result (Figure 12.61).

210 Practical Advanced Periodontal Surgery

Figure 12.61  Fundamentals of tissue engineering and regeneration.

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212 Practical Advanced Periodontal Surgery

Chapter 13 Digital Technologies in Clinical Restorative
Dentistry
Vygandas Rutkū nas, Rokas Borusevičius, Agnė Geč iauskaitė,
and Justinas Pletkus

FROM CONVENTIONAL TO DIGITAL continuously integrating with the conventional workflow

TECHNOLOGIES and forming an array of dental devices:

Dental technologies are undergoing constant develop-

• Intraoral scanners (IOS) including photogrammetry‐
ment influencing current treatment modalities and
based intraoral scanning;
founding a basis for the new diagnostic, treatment, and
follow‐up concepts. In the past dentistry underwent • Laboratory and chair‐side CAD/CAM systems;
­considerable changes with invention and application of
• Face scanners;
anesthesia, X‐ray units, turbine handpieces, new restor-
ative materials and many other devices. These changes • Caries diagnosis devices;
were associated with economic, social, and technologi-
• Computer‐aided implant dentistry and oral surgery
cal improvements, which were altered by several indus-
(designing and production of implant placement guides,
trial revolutions. Introduction of the biological fusion of
cutting guides, etc.);
bone to a foreign material, or osseointegration, a concept
first described by Bothe et  al. in 1940 and later devel- • Surgical and restorative navigation systems with
oped by Prof. P. I. Branemark, reinvigorated the realm of augmented reality (AR);
implant dentistry.
• Digital radiography, cone beam computed tomography
(CBCT), magnetic resonance imaging (MRI);
The above mentioned developments have relied on
analog techniques involving physical means, mechani- • Piezoelectric handpieces;
cal and electrical tools (negative and positive molding,
• Occlusion and TMJ analysis and diagnosis tools;
hand modeling, lost wax casting technique, etc.), with no
digital component and are called conventional or analog • Extraoral and intraoral photo and video cameras;
techniques. Many of them have been improved to the
• Spectrophotometers and colorimeters for shade
level of high precision and even today serve as a gold
matching;
standard.
• Dental lasers;
However, with the third industrial revolution, came the
• Computerized dental anesthesia;
rise in electronics, computers, telecommunications, and
other fields, which opened the doors to the digitalization • Practice and patient record management  –  including
of healthcare. The first dental CAD/CAM was invented digital patient education;
in 1973 by French professor François Duret, who first
• Haptic devices;
described the principles of optical dental impressions.
The Nobel Prize in Physiology or Medicine 1979 was • Additive manufacturing (AM) devices;
awarded jointly to Allan M. Cormack and Godfrey N.
• Robotics;
Hounsfield “for the development of computer assisted
tomography.” Digital dentistry consistently evolved, • Others.

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

213
 DIGITAL SOLUTIONS FOR PLANNING
AND MANUFACTURING OF TEETH‐
The Mainstream SUPPORTED RESTORATIONS
Market Digital Tools for Analysis and Treatment
The Early The
Market Chasm Planning
The first papers discussing utilization of photography for
Figure 13.1  Adapted from technology adoption life cycle. Source: http:// smile analysis were published in the 1990s (Wichmann
www.insightsquared.com/2016/01/the‐saas‐startup‐guide‐to‐crossing‐ 1990). Over the years it has evolved to advanced tech-
the‐chasm. niques for design of restorations in the esthetic zone using
Powerpoint, Keynote, or Photoshop software packages
(Arias et al. 2015; Sundar and Chelliah 2018). In this way
These technologies in general follow the technology the 2D design was planned based on the facial and dental
adoption life cycle which vary in duration and intensity landmarks, such as:
(Figure 13.1). It is not clear if some of the currently devel-
oped technologies will cross the so-called “chasm” and • facial midline;
will be used by the majority of practitioners.
• inter‐pupillary, commissural line;

Nowadays, IOS, CBCT, CAD/CAM, and other systems are • upper teeth exposure during rest, speech, and
used extensively in daily practice. Merging of the images ­smiling, which in turn depends on: (i) mobility of the lips;
from various sources (IOS, lab scanner, CBCT, face scan- (ii) vertical length of upper lip; (iii) clinical crown length;
ner, digital camera) make the foundation for the “digital (iv) skeletal relationships (Ritter et al. 2006);
patient” concept. Fully‐digital workflow now is a reality, • buccal corridor;
especially for less extensive cases. While more extensive
cases (e.g. full‐arch restorations) still involve hybrid digital– • smile line;
conventional procedures. • lower lip line during smiling;

Digital technologies have empowered the conventional • exposure of the incisal edge;
techniques giving the opportunity for less invasive, more • dental midline;
controlled, faster, cheaper, and longer-lasting treatment
modalities, such as full‐arch four implant‐supported • proportions of the width and length of the teeth;
­restorations (Ayub et al. 2017). • progressive axial inclinations of the anterior teeth;
• papilla and teeth height ratio;
Currently available digital technologies are changing the
face of dentistry, forming new diagnostic (combining the • some others, including anterior teeth contact areas,
CBCT and ultrasonography data) (Chan et al. 2017), treat- incisal frames, etc.
ment (accelerated orthodontic treatment) (Piezocision™
2016), lab production (3D printing of dental ceramics) Subsequently, terms such as digital smile, virtual smile,
(Dehurtevent et  al. 2017), follow‐up (superimposition of digital smile design, etc. and protocols have been
IOS data) (Hartkamp et  al. 2017), and educational (AR) reported by different authors (Ackerman and Ackerman
(Kwon et al. 2018) tools. It is a huge challenge for practi- 2002; Coachman and Paravina 2016; McLaren et  al.
tioners to adapt to these changes and to decide which 2013). Sets of standardized facial and dental photographs
technology is worth the investment and can provide rea- are taken and imported to the above mentioned programs
sonable return on investment (ROI). Switching from analog or special software, dedicated to digital smile design
to digital workflow comes with the need to update profes- (e.g. DSD App, Smile Designer Pro, Romexis smile design,
sional terms. The American College of Prosthodontics 3Shape smile design, etc.). Based on the facial midline,
(ACP) has issued the Glossary of Digital Dental Terms inter‐pupillary, commissural, and additional lines the rota-
(Grant et al. 2016). Dental practices are facing demands tional calibration of the image is done (Figure  13.2.1).
to collect and store large amounts of 2D and 3D images. Preferred reference points are selected in order to cali-
Due to increased sharing of sensitive data, adhering to brate the photos of retracted and non‐retracted smile
guidelines, such as the Health Insurance Portability and (Figure  13.2.2). In order to do the measurements at the
Accountability Act (HIPPA) Privacy Rule and Security Rule design stage, the calibrated ruler should be used indicat-
becomes more crucial. ing real intraoral measurements (e.g. length of the central

214 Practical Advanced Periodontal Surgery

incisor, width of the central incisors, etc.) (Figure 13.2.3). the patient (Figure 13.2.5). The concept of visagism is also
Based on the preferred esthetic landmarks and biological used and allows clinicians to design the shape of the teeth
aspects the esthetic framework of the anterior teeth is that blends the patient’s physical appearance, personality,
defined and outline of the restorations is selected in frontal, and desires (Visagism: The Art of Dental Composition
occlusal and 12 o’clock projections (Figure  13.2.4). To 2018). Patients can evaluate the planning and 2D dental
facilitate the process, different libraries of the teeth shape after final adjustments, which can then be transferred to the
can be used and adjusted based on the patient or dentist lab for further procedures: wax‐up (digital or analog), model
preferences. The simulation of the final result can also be or mock‐up, or restoration fabrication (Figure 13.2.6).
done in order to better communicate the planned result to
However, it should be understood that such 2D planning
should be taken as guidance, rather than a precise and
final treatment plan. The shortcomings of such 2D planning
are related to the fact that only static images are taken,
under certain lighting conditions and projection. It has been
shown that lighting conditions can affect the buccal corri-
dor appearance on smile photography (Ritter et al. 2006).
Another disadvantage is that planning is done  based
mainly on esthetic criteria and fails to address biological
and functional circumstances. Despite these aspects, 2D
digital design is a very informative tool enhancing commu-
nication between dentist, patient, and dental technician.

Figure 13.2.1  Rotational calibration of the face photo based on the Figure 13.2.3  Calibration of the dimensions is done with the ruler, in
facial horizontal and vertical lines. order to indicate measurements on the final smile design version.

(a)

(b)

Figure 13.2.2  Photos of retracted and non‐retracted smile are calibrated by selecting reference points.

Digital Technologies in Clinical Restorative Dentistry 215

 (b)

(a)

Figure 13.2.4  Esthetic framework has been determined from the frontal, 12 o’clock, and occlusal aspects considering esthetic and biologic aspects.

(a) (b)

Figure 13.2.5  Different teeth form libraries can be employed to facilitate the smile design process and to create realistic simulation of the planned result.

After completion of the 2D design, it is transferred to the but also biological and functional aspects can be
3D design step, which can be done either on a conven- addressed in a more detailed way.
tional model or a digital model. There are different ways
to align a 2D model to a 3D model, however these tech- Based on 3D planning, mock‐ups, or temporary restora-
niques inevitably involve a certain level of inaccuracy. tions can be fabricated paying much attention to the smile
For  this reason, it would be more beneficial to proceed design. Mock‐up is a very powerful tool helping to evaluate
straight to 3D design, avoiding limitations of 2D treatment esthetics, phonetics, and occlusal relationships and gives
planning. a perfect opportunity for the patient to evaluate planned
final results (Simon and Magne 2008). Moreover, it is very
Merging of several 3D images obtained from face scanner, useful for guiding preparations of the teeth and ensuring
CBCT, IOS, combining it with virtual articulator and 2D minimal invasiveness during this and subsequent steps
intraoral and extraoral photographs, currently provides (Figure  13.2.8). The application of the mock‐up can be
the maximum diagnostic potential for complex treatment limited in cases where extensive crown lengthening and
planning (Figure 13.2.7). Based on this, not only esthetic, reduction of the tooth structure is anticipated.

216 Practical Advanced Periodontal Surgery

 Surgical crown lengthening can be planned in a similar
way by using patients’ CBCT, IOS data, and digital photo-
graphs. Fusion of these images can provide valuable infor-
mation about the needed extent of the gingivectomy and
bone reduction. Based on 2D design, digital wax‐up can
be accomplished and a 3D printed model produced.
Silicon index can be prepared on the 3D printed model
and mock‐up or directly made temporary restorations
applied at the same visit (Figure 13.2.9).

Clinical Applications of Digital Techniques

in Tooth‐Supported Restorations
Currently, the digital workflow can cover production of all
Figure 13.2.6  Planned smile design of upper anterior teeth with types of indirect restorations from partial crowns to remov-
calibrated measurements of anticipated modifications. able dentures. However, extended and complex cases

(a) (b)

(c) (d)

Figure 13.2.7  Lower jaw tracking device (a) can be used with CBCT data, allowing capability of functional CBCT, where individual patient movements
can be simulated on the mandible (b). With the aid of a special fork (c), the position of the maxilla as well as mandibular movement data file can be
imported to the CAD system, enabling reproduction of individual mandibular movements on virtual articulator and manufacturing dental prostheses with
functional occlusion design (d).

Digital Technologies in Clinical Restorative Dentistry 217

 (a) (c)

(b) (d)

(e)

Figure 13.2.8  Restorative treatment for upper incisors (a) was planned using smile design and mock‐up (b). Tooth reduction through mock‐up (c)
enabled controlling reduction of the teeth and thickness of the restorations (d). Final result (e) was achieved in a controlled way based on the initial plan.

can still be challenging. Therefore, hybrid workflow includ- The procedure for the single crowns is straightforward –
ing both analog and digital techniques can be employed. digital impression with IOS is taken after preparation.
CAD design can be done chairside or in the lab using
Three‐dimensional accuracy of digital impression with IOS is the pre‐preparation method, mirroring the opposite
of crucial importance. In addition, the ability of different IOS tooth form and designed individually using automated
algorithms to interpret finish lines is also essential. It has processes (Arslan et al. 2015). Many features, including
been reported that color output from IOS may enhance the occlusal surface anatomy, cut‐back technique, cement
identification of the finish line due to contrasting colors, but is gap, distance to margin and others, can be controlled
still dependent on the underlying technology (Nedelcu et al. during the CAD design phase (Figure 13.2.10a). A virtual
2018). Many studies have been published reporting similar articulator can be used to simulate mandibular move-
accuracy level at the margin of digitally and conventionally ments and automatically adjust the shape of the pros-
produced single crowns (Boeddinghaus et  al. 2015). thesis (Figure  13.2.10b). Master cast is an obligatory
However, some of them have reached conclusions, that con- step in conventional restoration fabrication workflow.
ventional impression and pressed restorations produced While in digital workflow full‐contour restorations can be
more accurate 2D and 3D margin fits (Anadioti et al. 2014). made, avoiding this step. A 3D printed or milled model

218 Practical Advanced Periodontal Surgery

is needed in order to proceed with layered restorations Due to the increased optical features (natural shade, trans-
and/or adapt the margins (Figure  13.2.10c). However, lucency, multi‐layered blank, etc.) of ceramic CAD/CAM
3D printed models still need to be validated consider- materials, full contour restorations became more estheti-
ing 3D accuracy in general, finish line accuracy, die cally appealing and a standard procedure for the posterior
repositioning, resulting inter‐arch relationship of the teeth.
models, occlusal contacts, etc. Some studies have indi-
cated, that the conventional method of die fabrication More complex restorations involving multiple teeth, reor-
was more reliable than that of investigated 3D printers ganization of occlusion, and layered restorations currently
(Park and Shin 2018). are more reliably implemented through the mixing of

(a)

(b)

(c)

Figure 13.2.9  Patient with worn dentition had esthetic demands (a), therefore 2D digital planning of the smile was done (b). Based on CBCT and IOS
data, prospective margin of the restoration was planned and need for the bone reduction estimated (c). 3D printed surgical guide for crown‐lengthening
was produced (d). Digital wax‐up was done, taking 2D planning as guidance (e and f) and models produced with a 3D printer. Silicon indexes were
produced on 3D printed models (g and h) and used for mock‐up, in order to evaluate esthetics, phonetics, and occlusion (i). Later, surgical guide was used
as the reference in order to perform crown lengthening.

Digital Technologies in Clinical Restorative Dentistry 219

 (d)

(e) (f)

(g) (h)

(i) (j)

Figure 13.2.9  (continued )

220 Practical Advanced Periodontal Surgery

 (a)

(b)

(c)

Figure 13.2.10  CAD software offers many useful tools to control the design of restorations (a), including the virtual articulator (b). A monolithic
full‐contour crown from translucent multi‐layered zirconia blank was milled, infiltrated, stained, and glazed after taking digital impression and using CAD
design. Die was printed using a 3D printer in order to adjust the margins of the restoration (c).

Digital Technologies in Clinical Restorative Dentistry 221

 (a) (c)

(b) (d)

(e) (f) (g)

Figure 13.2.11  Hybrid conventional‐digital method was utilized to restore upper and lower dentition. After initial situation evaluation (a), digital design
and mock‐up (b and c) was made. Conventional impressions were used to fabricate master models, and CAD design was applied based on data from
digital design, mock‐up, or temporary restoration phase. Restorations were finalized (d–g) according to the initial treatment plan.

­ onventional and digital techniques. Digital smile design

c reference. To control the contour of the restorations during
in 2D can be done during initial examination and used for the layering of ceramics, silicon indices should be used.
the digital wax‐up, which through the 3D printed model
can be used to fabricate mock‐up and evaluate esthetic Digital technologies are increasingly applied to aid fabri-
and functional aspects (Figure 13.2.11). Mock‐up can be cation of the removable prostheses. The classic approach
modified and scanned with IOS. This data can be used for is to use CAD software to design the framework of the
the fabrication of temporary CAD/CAM restorations main- removable partial denture (RPD), to print it from the wax
taining the 3D shape of the tested mock‐up. After endo- and cast the metal alloy framework. A combination of digi-
dontic and periodontal treatment, conventional impressions tal and analog techniques is more common due to many
and bite registrations are done and a plaster cast is reasons. Firstly, muco‐static or muco‐compressive impres-
scanned with a laboratory scanner. Shade determination is sion taking techniques and border molding could be
done using digital photography and spectrophotometry. employed only with conventional impression techniques.
During the CAD process, 3D data of mock‐up and tempo- Secondly, in cases where fixed and removable prostheses
rary restorations can be superimposed and used as the are combined, the digital workflow is not well established,

222 Practical Advanced Periodontal Surgery

especially when extracoronal attachments are planned to needed for more complex fixed and removable situations.
be used. Thirdly, not all clinical situations allow the use of In case of deep subgingival margins, elastomeric materi-
artificial teeth that are available in digital libraries. However, als, in contrast to optical impressions, are able to displace
with the advances in new CAD/CAM and materials, attach- the soft tissues and record it. A recent study stated that the
ment components and major connectors as well as den- curvature (sharpness) of the margin recorded by a com-
ture bases can be milled and 3D printed (Figure 13.2.12). mercial IOS is significantly affected by clinical factors
obscuring visibility (close interproximal contacts, etc.)
(Arslan et al. 2015). Using CAD/CAM systems, it could be
Advantages and Limitations
complicated to mill thin margins of the ceramic restora-
Digital workflow offers many new opportunities in diagnos- tions. If the master cast is needed (e.g. layered restora-
tic, treatment, and follow‐up stages. Merging of data from tion), the model should be 3D printed, which inflicts
various devices (CBCT, face scanner, digital camera, IOS) additional cost and potential problems of accuracy. Strict
provides an ultimate possibility for comprehensive diag- regulations should be followed to ensure secure sharing
nosis and treatment planning. From the perspective of the and storing of digital records.
dentist, the preparation for the impression taking remains
the same: proper preparation design and retraction tech-
niques are still prerequisite for an excellent impression.
DIGITAL SOLUTIONS FOR PLANNING
However, verification of the quality of the impression can
AND MANUFACTURING OF IMPLANT‐
be performed during the procedure and digital impression
SUPPORTED RESTORATIONS
can be corrected at ease by re‐scanning specific areas of Implant and Implant‐Supported Restoration
the teeth and soft tissues. Clearance at the occlusal and Planning with Digital Tools
axial surfaces can also be verified instantly. Some IOS
have an integrated shade measurement tool, allowing
Planning, Analysis (CBCT, Radiological Guides,
selection of the shade of the restoration at the same step
Dual‐Scan, Surgical Guides, Dynamic Guidance)
of impression taking. Also, there is no risk of 3D distortion
when data is kept digitally. Moreover, digital data is easy Treatment planning is of foremost importance for the pros-
to  share, which save the costs of transportation. With thetically driven dental implant placement. Technologies,
advances in ceramic materials, monolithic restorations are including CBCT, IOS, enabled clinicians to evaluate soft
becoming more and more popular. Avoiding the layering and hard tissues with an accurate precision prior to any
step enables better fulfillment of the planned shape of the surgical intervention. This data in combination with improv-
restorations and takes dentist–technician–patient commu- ing computer software allows to plan implant position
nication to the next level. In this way the CAD design phase regarding these tissues and future prosthesis. Finally, sur-
can be also facilitated as standard and custom teeth shape gical guidance systems are used to transfer the planned
libraries can be employed. Fabrication of full‐contour implant position to the patient’s mouth.
restorations from the digital impressions allows dental
technicians to avoid master‐cast fabrications, hence the CBCT with specially made radiological guides or existing
laboratory step takes less time and productivity is prostheses converted to radiological guides, is of great
increased. Patients can benefit from the digital workflow diagnostic value, helping to decide more favorable implant
as their situation is better visualized, and their final treat- location, which is also suitable from the prosthetic point of
ment plan is better communicated and controlled. They view.
can also benefit from more comfortable impression taking
procedures and reduced treatment time. Digital workflow CBCT and IOS data can be merged and virtual teeth set‐
does not eliminate the human factor completely; however, up accomplished, followed by production of the surgical
it enables an increase in the level of standardization of guide for dental implant placement. The surgical guide
restorative procedures, as well as reliability. Digital tools can be used only for the pilot drill during implantation, as
can be very efficient for follow‐up procedures, e.g. visual- well as for fully‐guided implant insertion. Many studies
izing the wear of the teeth. have evaluated the accuracy of fully‐guided implant
insertion. A recent systematic review reported a mean
However, the high price of digital technologies prevents implant deviation at the entry point of 1.25 mm, 1.57 mm
some practitioners from using them. Due to rapid at the apex, and 4.1° in angle with fully‐guided implanta-
improvements, time span for the ROI could be too short. tion protocol. A totally guided system using fixation
The learning curve for some of the devices could be steep screws with a flapless protocol demonstrated the great-
and the workflow sometimes cannot be integrated between est accuracy (Zhou et al. 2018). This level of accuracy in
different devices and software packages. Current levels of general is not adequate for the fabrication of final restora-
digital impression techniques, do not allow to completely tions based on planned implant positions. Nonetheless,
get rid of elastomeric impression materials, as they are still this  principle can be applied to a limited extent with less

Digital Technologies in Clinical Restorative Dentistry 223

 (a) (b)

(c)

(e)

(d)

(f) (g) (h)

Figure 13.2.12  Tooth‐ and implant‐supported removable partial denture and zirconia bridge with attachments were planned for the case. Conventional
impressions were taken and master cast fabricated (a). CAD software was used to design zirconia fixed partial denture with extracoronal attachments,
according to the selected path of insertion, which was done using digital parallelometer (b). Traditional pick‐up impression was taken with seated FPD and
overdenture attachments on implants. Master cast was scanned and CAD design or RPD was made (c). Using digital tools, isolation in the area of minor
connectors, finish lines, and thickness of the RPD framework can be easily controlled (d). High performance polymer PEEK blank was used to mill RPD
framework (e). Denture teeth were set and acrylics heat processed in a traditional way. Corresponding parts of the RPD attachments were glued to the RPD
and prosthesis finalized (f). Prosthesis was delivered to the patient and currently in service for four years (g and h).

224 Practical Advanced Periodontal Surgery

extensive rehabilitations. Besides static dental implant components from being placed. Therefore, this technique
placement, dynamic navigation surgery is also a possibil- is limited to cases of one or two missing teeth. Best prac-
ity (Block and Emery 2016). tice should be used in order to increase accuracy of fully‐
guided implant surgery.
Digital implant impressions (DII) with IOS can be taken at
the implant and multi‐unit abutment level using specific As accuracy of fully‐guided surgery is still not satisfactory
scan bodies. DII can also be taken from the custom pros- and does not enable producing screw‐retained implant‐
thetic abutment. 3D scan body position recorded by DII is supported restorations before the surgery, selected cases
very important, as dental implants lack periodontal liga- with adequate primary implant stability can be treated
ment and cannot compensate even minor misfit due to the using one crown–one time concept (Figure  13.3.4). This
absence of mobility. The level of misfit that could be technique became available due to improved accuracy of
acceptable clinically is fiercely debated in the literature. DII and CAM techniques, allowing usage of pre‐milled
Marginal gaps and static strains due to screw tightening blocks of ceramic materials.
were not found to have negative effects on initial osseo­
integration or peri‐implant bone stability over time Integration of digitally planed implant positions and CAD/
(Katsoulis et al. 2017). A few clinical studies reported that CAM temporary and final restorations can be accom-
the risk for technical screw‐related complications was plished in full‐arch cases as well. However, DII, bite regis-
slightly higher. Clinical tools are lacking in order to evalu- tration, and 3D printing accuracy is not well documented
ate objectively the fit of implant‐supported restorations. for full‐arch implant‐supported cases. Therefore, parts of
Therefore, it is useful to combine several techniques to the workflow still have to rely on conventional techniques
assess the accuracy of fit (Abduo et al. 2010). (Figure 13.3.5).

Clinical Applications of Digital Techniques Advantages and Limitations

in Implant‐Supported Restorations
Based on CBCT data, challenging anatomical situations
Similar principles as with tooth‐supported restorations can can be addressed and a proper treatment plan selected.
be employed in the diagnostic and treatment planning Radiological and surgical guides allow placing implants
phase of implant‐supported restorations. in a prosthetically oriented manner. With increased accu-
racy of implant placement and improvements in digital
Digital techniques are very useful in producing temporary prosthesis fabrication techniques, treatment time can be
restorations on implants, as teeth form before the extrac- shortened, risks minimized, and more predictable results
tion can be used as a reference, peri‐implant tissue thick- achieved.
ness and possibility to shape it can be evaluated well
during the 3D design (Figure 13.3.1). Later, the shape of However, CBCT images can be distorted by metallic arti-
temporary restorations can be duplicated into the final res- facts, patient movement, etc. complicating alignment with
toration. Spectrophotometers can be used in order to the images obtained from IOS. Due to multiple factors
accurately reproduce the shade of the neighboring teeth, (IOS, 3D printing accuracy, movement of the teeth, mobil-
as well as to evaluate the color change of the peri‐implant ity of mucosa, sleeve related factors, etc.) fully‐guided
tissues with different types of abutment materials. implant placement is still lacking the accuracy level
needed in order to integrate it better with prosthodontic
One abutment–one time concept may be offered in order procedures.
to avoid the irritation of the peri‐implant tissues during
re‐insertion of the healing abutment. For this purpose, Despite IOS continuously being improved, there are still
split file of the custom abutment and temporary restora- limitations to their use. IOS accuracy could be compro-
tion can be designed and fabricated using CAD/CAM mised by many aspects: movements of the object, saliva,
(Figure  13.3.2). This approach can be used in different fogging of the optics, occlusion registration challenges,
stages of the treatment: during implant planning, shortly and other patient‐, operator‐, and device‐related limiting
after implant placement, and during the second stage factors (Rutkū nas et  al. 2017). Scanning location can be
surgery. Custom abutment can be made from different important, as distant regions could be difficult to reach in a
materials: metal alloy, zirconia, or polymer. real clinical situation. Length of the edentulous ridge, lack
of attached gingiva, tongue, and cheek mobility could also
One abutment–one time can be used in combination with negatively affect the ability to stitch images. Scanning
fully‐guided implant placement, when final abutments and strategy and mode have also been demonstrated to be
temporary restorations on them are produced before sur- important aspects (Müller et  al. 2016). Repositioning
gical procedures (Figure  13.3.3). Deviation of implant accuracy of scan bodies and other prosthetic components
positions from the planned one will prevent prosthetic could be another source of limitations.

Digital Technologies in Clinical Restorative Dentistry 225

 (a) (b)

(c) (d)

(e)

Figure 13.3.1  Initial clinical situation resulting from previous dental trauma (a). Implant placement and soft tissue formation using CAD/CAM
temporary restorationas (b). Final restoration was produced taking temporary restorations as a reference (images from the frontal and side aspect – c and
d). Abutment material effect on the color of the peri‐implant tissues can be selected by using spectrophotometry readings (e).

226 Practical Advanced Periodontal Surgery

 (a) (b)

(c)

(d) (e)

Figure 13.3.2  Custom abutment and temporary cement‐retained crown is designed in the CAD (a and b). Abutment can be milled from zirconia and
cemented on the titanium base (c). Temporary crown on the abutment can be cemented extraorally. Custom abutment is placed in the mouth and attached
permanently using the final torque indicated by the manufacturer (d). Temporary crown is placed on custom abutment (e). After soft tissue healing, margin
on the custom abutment can be modified and abutment level impression taken for the final restoration.

Complex cases would need 3D printed models, which still biotechnology, 3D printing, artificial intelligence (AI), virtual,
lack the required level of accuracy. Conventional tech- and AR are very common, including the fact that available
niques today still have the edge with certain procedures: knowledge nowadays is shared between billions of
edentulous cases, VDO increase, implant‐supported people.
overdentures, etc.
Fusion of 3D and 2D data from various sources made the
foundation for the concept of “the virtual patient” and has
FUTURE PERSPECTIVES
further improved. This enables diagnostic, treatment, and
The currently developing fourth industrial revolution (4IR) follow‐up capabilities at much better level. Due to this,
is about to affect and disrupt all kinds of industry. Fusion of requirements to store, share, and protect huge amounts of
digital, physical, and biological realms is characteristic for data continue to increase. Large amounts of medical infor-
4IR. Developments in fields of robotics, nanotechnology, mation create a challenge of correct interpretation of the

Digital Technologies in Clinical Restorative Dentistry 227

 (a)

(b)

(c) (d)

(e) (f)

Figure 13.3.3  A two implant placement was planned as a fully‐guided procedure (a and b). Using the planned implant positions, final zirconia abutments
and temporary crowns were planned using split file (c and d). After fully‐guided implant placement, custom zirconia abutments were tightened and temporary
crowns placed and evaluated for the need for adjustment (e). Final full‐contour zirconia crowns were made two months after implant placement (f).

228 Practical Advanced Periodontal Surgery

 (a) (b)

(c)

(d)

Figure 13.3.4  Implant was planned in the site of missing molar tooth (a). Right after the implant placement DII was taken to record implant position and
the occlusion relationship. During the next few hours full‐contour ceramic crown was produced and cemented to the titanium base (b). Screw‐retained
crown was delivered on the same day under functional loading conditions (c). Restoration is now followed for a period of one year (d).

data. Moreover, static images are more and more supple- registration techniques should be further improved as
mented with dynamic 3D data, e.g. dynamic face scanner, ­currently complex cases belong more to the conventional
filming of mandibular movements with IOS, integrating side. Digital workflow should further be supplemented with
data from jaw tracking devices with CAD and CBCT soft- more accurate and faster 3D printing technology.
ware. New to dentistry, future imaging technologies like
OCT (optical coherent tomography), MSCT (multi‐slice Many advantages of digital workflow come from the array
computerized tomography), traditional, and dynamic MRI of dental materials that can be conveniently used only with
and others are making their way in to clinical applications. CAM equipment. CAM techniques enable high precision
and standardization of the work, minimizing the human
AR is used to show the planned esthetic outcome to the factor. Multi‐layered restorations are becoming more and
patient in real time (Figure 13.4). There is huge potential for more popular as this allows for dental restorations with a
integrating AR into surgical and restorative procedures. more natural appearance, with zones of different translu-
cency and color. This potential could be further increased
IOS usage for taking impressions revolutionized prostho- with additive technologies (e.g. 3D printing of ceramic
dontics. However, clinical procedures before taking digital materials) enabling production of different mechanical,
impressions from the teeth remain virtually the same, physical, and optical features at different volumes of the
including proper gingival retraction techniques and fluid restoration. AMF and other similar production file formats
control. Ability to supplement optical impression with OCT, will be used for this instead of STL. Subtractive and addi-
ultrasound, or other technology enabling avoidance of tive technologies are expected to be able to produce
gingival retraction could substantially change this clinical ultrathin restorations of good mechanical properties in
step. Accuracy of IOS for full‐arch scanning and bite order to reduce invasiveness of restorative procedures.

Digital Technologies in Clinical Restorative Dentistry 229

 (a) (b) (c)

(d) (e)

(f) (g) (j)

(h) (i)

Figure 13.3.5  Full‐arch implant‐supported fixed prostheses were planned for a patient with failing dentition (a). Surgical guides were produced based
on CBCT double scan technique with radiological guides (b). Immediately after teeth extraction and implant placement, milled temporary restorations were
produced (c). Based on digital smile design (d), shape of the final restorations was designed in CAD software and substructure from high performance
polymer (PEEK) was produced (e). After fitting substructure intraorally, digital bite registration with IOS was accomplished (f). Full contour individual
crowns were milled from wax (g) and pressed from lithium‐disilicate ceramics (h). Gingival part was modeled with composite resin (i) and prosthesis
delivered to the patient (j).

Direct additive technologies allowing avoidance of labora- AI will increase efficiency of diagnostic and treatment
tory steps are also under development. algorithms and automation will be used more in the pro-
duction of dental restorations. Mobile health applications
Besides 3D printing of models and restorations, bio‐printing will continue to improve oral public health (e.g. BruxApp
of the soft and hard tissue scaffolds with and without cell application to assess awake bruxism). Telemedicine in
cultures could offer new possibilities in cases demanding dentistry is expanding, with some attempts to exclude
regenerative procedures which can be combined with local dental offices. First attempts have been demon-
dental implant placement and restorative procedures. strated of autonomous robotic dental implant placement.

230 Practical Advanced Periodontal Surgery

 digital and conventional impressions in patients. Clin. Oral Investig.
19 (8): 2027–2034.

Chan, H.‐L., Wang, H.‐L., Fowlkes, J.B. et al. (2017 Mar). Non‐ionizing
real‐time ultrasonography in implant and oral surgery: a feasibility
study. Clin. Oral Implants Res. 28 (3): 341–347.

Coachman, C. and Paravina, R.D. (2016 Mar). Digitally enhanced

esthetic dentistry  –  from treatment planning to quality control. J.
Esthet. Restor. Dent. Off. Publ. Am. Acad. Esthet. Dent. Al. 28
(Suppl 1): S3–S4.

Dehurtevent, M., Robberecht, L., Hornez, J.‐C. et  al. (2017).

Stereolithography: a new method for processing dental ceramics
Figure 13.4  Kapanu AR application (Ivoclar Vivadent) allows visualiza- by additive computer‐aided manufacturing. Dent. Mater Off. Publ.
Acad. Dent. Mater 33 (5): 477–485.
tion of planned anterior restorations in real time.
Grant, G.T., Campbell, S.D., Masri, R.M., and Andersen, M.R. (2016
Oct). American College of Prosthodontists Digital Dentistry Glossary
Though many advanced digital technologies are currently Development Task Force. Glossary of digital dental terms: American
available in the market, high prices are limiting their wider College of Prosthodontists. J. Prosthodont. Off. J. Am. Coll.
Prosthodont. 25 (Suppl 2): S2–S9.
application into clinical practice. It should be also men-
tioned that traditional literature is struggling to catch up Hartkamp, O., Lohbauer, U., and Reich, S. (2017). Antagonist wear by
with rapidly improvements in hardware and software for polished zirconia crowns. Int. J. Comput. Dent. 20 (3): 263–274.
dental digital solutions.
Katsoulis, J., Takeichi, T., Sol Gaviria, A. et al. (2017). Misfit of implant
ACKNOWLEDGMENTS prostheses and its impact on clinical outcomes. Definition, assess-
ment and a systematic review of the literature. Eur. J. Oral Implantol.
We thank very much dental technicians Tomas Simonaitis 10 (Suppl 1): 121–138.
and Aušra Kleizienė for the laboratory work that was used
in the figures, as well as for their positive and supportive Kwon, H.‐B., Park, Y.‐S., and Han, J.‐S. (2018 Feb 21). Augmented real-
ity in dentistry: a current perspective. Acta Odontol. Scand.: 1–7.
attitude.
McLaren, E.A., Garber, D.A., and Figueira, J. (2013). The Photoshop smile
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studies/87112467/visagism‐art‐dental‐composition

232 Practical Advanced Periodontal Surgery

Index

Note: Page numbers in italics refer to figures, those in bold refer to tables.

3‐D implant positioning see three‐ micro architecture of the bone/tooth augmentation using tissue‐engineered
dimensional implant positioning relationship and the interface of soft and bone 160–161
4IR (fourth industrial revolution), future hard connective tissues  21–24, 25 bisphosphonate therapy, osteonecrosis of
perspectives 227–231 mucogingival junction (MGJ)  26–28 the jaws  15
normal dental/alveolar vascular supply  22 blood pressure cuff  6
alveolar distraction osteogenesis palatal artery‐extension of greater palatine blood supply within the alveolar and basal
surgery 107–115 artery  21 bone of the dental arches  21
advantages 107 vascular supply: macro and micro  19–21 bone composition  11
armamentarium 107 anesthesia, dental implants  123, 125, 126 cells: osteoblasts, osteoclasts, and
consolidation period  111–112 angiogenesis, wound healing  30, 31 osteocytes 11
history 107 apical guiding “marionette” suture, matrix: organic and inorganic  11
indications 107, 108 SubEpithelial Connective Tissue Graft bone densitometry (DEXA: Dual Energy
latency period  111 (SECTG) 189–190 X‐Ray Absorptiometry), bone density
limitations 107 apico‐coronal position, three‐dimensional measuring technique  14
possible complications  115 implant positioning  179, 181 bone density measuring techniques  14
postoperative instructions  114–115 apicoectomy  45, 47, 48, 51–60 cone beam computed tomography  14
preoperative instructions  114 see also endodontic therapy DEXA: Dual Energy X‐Ray Absorptiometry
technique for the anterior complications 59–60 (bone densitometry)  14
segment 107–113 definition 51 fractal analysis of bone texture  14
technique for the posterior segment  full‐thickness submarginal incision  quantitative computed tomography
113, 114 54–55 (QCT) 14
words of caution  114 indications 51 quantitative ultrasound (QUS)  14
amalgam tattoo  147–148 intraoral examination  52 bone formation  11–14
anatomy of the dental/alveolar local anesthesia (pain control and endochondral ossification  11
structures 19–32 hemostasis) 52–53 intramembranous ossification  11
see also wound healing moisture control  58 bone graft material, selection  180–181
arteriole wall merged with periosteum of mucogingival flap  54–55 bone graft procedure, SubEpithelial
antral wall venules surround arteriole  25 osteotomy and curettage  55–56 Connective Tissue Graft (SECTG)  191
blood supply within the alveolar and basal papillary‐based incision  55 bone implications
bone of the dental arches  21 phases 52–60 dental implants  15–16
buccal plate vessels  22–24, 24 postoperative instructions  59 osteonecrosis of the jaws  15
buccal wall of sinus, artery  25 presurgical preparation  52 periodontitis 16
cementum 28, 29 radiographic examination  52 bone remodeling  12–14
epithelial structures, anatomy and vascular recall 60 actions 12
supply 28–29, 30 retrofill 58 calcitonin 13
interproximal papilla vessels, arborization  25 retropreparation 57–58 low‐density lipoprotein receptor–related
investing soft connecting tissue, anatomy review of medical history  52 proteins 13
and vascular supply  25–28, 29 root resection  56, 57 markers of bone formation  12
mandible vs maxilla, issues of anatomic soft tissue flap design  53, 54 markers of bone resorption  12
interest 22–24 staining and inspection  56–57 osteoporosis 13–14
mandibular first bicuspid, internal surgical technique  52–60 osteoprotegerin (OPG)  13
microarchitecture  23 suturing and suture removal  59 parathyroid hormone (PTH)  13
mandibular first molar, internal arteriole wall merged with periosteum of periodontitis 12
microarchitecture of furcation area  23 antral wall venules surround arteriole  25 stages 12
maxillary artery distribution  20 vitamin C  13
maxillary bicuspid, internal Bicon short implants, dental vitamin D  13
microarchitecture  23 implants 123, 123 vitamin K  13
maxillary first molar, internal biopsy techniques, oral soft tissue  153–154, bone‐stimulating factors, dental implants  16
microarchitecture of furcation area  23 155 bone types  11
maxillary first molar, mature resting alveolar armamentarium 153 cortical bone  11
bone from core  24 biopsy data sheet  155 trabecular bone  11
maxillary sinus periosteum (Monkey/ excisional scalpel biopsy  153, 154 Branemark’s technique, dental implants 
vascular‐India ink perfused)  21, 22 incisional scalpel biopsy  153 32, 121–122
maxilla vs mandible, issues of anatomic biopsy techniques, treatment and expansion buccal plate vessels  22–24, 24
interest 22–24 of periosteal biopsies, sinus buccal wall of sinus, artery  25

Practical Advanced Periodontal Surgery, Second Edition. Edited by Serge Dibart.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/dibart/advanced

233
bucco‐palatal position safe‐zone green red osseointegration  15–16, 121 root canal therapy, treatment of failed  44
diagram, three‐dimensional implant osteotomy: single implant  125–129 surgical operating microscope (SOM)  43
positioning 179, 180 placement  121–135, 179, 180 tooth conservation vs implants  43–44
possible complications  130–135 types of endodontic surgery  48–51
calcitonin, bone remodeling  13 possible problems  130–135 entry incision, dental implants  125, 127
cementum 28, 29 pre‐operative implant site epithelial cells, wound healing  31
chronic ulcerative stomatitis  140 assessment 172–174, 175 epithelial closure, wound healing  32
cicatricial (mucous membrane) rationale 181–183 epithelial structures, anatomy and vascular
pemphigoid 141–142 short implants  123, 123, 131, 133, supply 28–29, 33
closure of the flap  205 134, 135 epulis fissuratum  144
combined periodontal and prosthodontic site preparation  125–129 erythema multiforme (EM)  143
care see treatment planning, socket seal  183–192 erythematous marginal gingiva  140, 141
combined periodontal and prosthodontic surgical technique  123–130 esthetic ridge augmentation  194–197
care tapping threads  129 decision making in soft tissue
compromised sockets: socket seal  192 three‐dimensional implant positioning  augmentation following bone graft
computer guided piezocision‐orthodontics 179, 180 procedure 196–197
see Piezocision™ assisted orthodontics tissue augmentation at the time of tooth Guided Bone Regeneration (GBR) 
cone beam computed tomography, bone extraction 175–177 194–197, 196
density measuring technique  14 tissue deficiencies  206–209, 209–210 exploratory surgery, endodontic therapy  46
conscious IV sedation utilizing tooth conservation vs implants  43–44
midazolam 3–9 wound healing  32 fibroma 137, 138
armamentarium 4, 5 desquamative gingival lesions, diagnosis fibroplasia, wound healing  31
ASA physical status classification  5 and treatment  142 fixture (implant) installation, dental
blood pressure cuff  6 desquamative gingivitis  140–142 implants 130, 131
catheter insertion in the vein  8 DEXA: Dual Energy X‐Ray Absorptiometry flapless ridge preservation, socket
continuums of depth of sedation, definition (bone densitometry), bone density seal 192–193
and levels  3, 4 measuring technique  14 foreign body gingivitis  140, 141
dosage and administration  7–8 digital technologies, clinical restorative fourth industrial revolution (4IR), future
IV catheters of various size  7 dentistry 213–231 perspectives 227–231
IV drip, monitoring that the fluid that goes advantages and limitations  223 fractal analysis of bone texture, bone density
into the IV line  8 clinical applications of digital techniques in measuring technique  14
IV portal secured with transparent film implant‐supported restorations  225–227 future perspectives  227–231
dressing  8 clinical applications of digital techniques in fourth industrial revolution (4IR)  227–231
maintenance dose  8–9 tooth‐supported restorations  217–223,
medical emergencies  9 224 GBR (Guided Bone Regeneration), esthetic
oxygen cannula  6 from conventional to digital ridge augmentation  194, 196
physical status  5 technologies 213–214 giant cell fibroma  137
post‐operative instruction  9 digital tools for analysis and treatment gingival cyst of the adult  139
pre‐operative vital signs chart  6 planning 214–217, 218, 219 gingival enlargement  144
pulse oximetry  6 implant‐supported restorations  223–227 gingival fibromatosis  145
reversal agent for Midazolam  9 planning, analysis (CBCT, radiological gingival nodules  137
saline bag used for IV sedation  7 guides, dual‐scan, surgical guides, gingival
steps in IV sedation  4–9 dynamic guidance)  223–225 overgrowth, medication‐induced  144
training in intravenous conscious planning and manufacturing of teeth‐ Guided Bone Regeneration (GBR), esthetic
sedation 3 supported restorations  214–223 ridge augmentation  194, 196
continuums of depth of sedation, definition tooth‐supported restorations  214–223, 224
and levels  3, 4 drilling problems, dental implants  130 herpes 152
cortical bone, bone type  11 drill speed, dental implants  128 HIV‐associated gingivitis  152–153
horizontal adaptive mattress suture,
dental implants  15–16 EM (erythema multiforme)  143 SubEpithelial Connective Tissue Graft
see also papillary construction after dental endochondral ossification, bone (SECTG) 190
implant therapy formation 11 hyperplastic gingivitis  144–145
anesthesia 123, 125, 126 endodontic therapy  43–60
Bicon short implants  123, 123 see also apicoectomy iatrogenic factors, endodontic therapy 
bone graft material, selection  180–181 anatomical challenges  44 44, 45
bone implications  15–16 contraindications for endodontic implants, dental see dental implants
bone‐stimulating factors  16 surgery 46–48 infections 152–153
Branemark’s technique  32, 121–122 exploratory surgery  46 herpes 152
drilling problems  130 history and evolution  43 HIV‐associated gingivitis  152–153
drill speed  128 iatrogenic factors  44, 45 necrotizing ulcerative gingivitis (NUG)  153
entry incision  125, 127 implants vs tooth conservation  43–44 necrotizing ulcerative periodontitis  153
fixture (implant) installation  130, 131 incision and drainage  48 insertion torque, dental implants  130
history 121–123, 124 indications for endodontic surgery  44–46 intentional replantation, endodontic
indications 123 intentional replantation  49–51 therapy 49–51
insertion torque  130 rationale for endodontic surgery  44 indications and case selection  49
options for tissue augmentation relentless inflammation  45, 46 surgical technique  49–51
procedures 182–183 root amputation and hemisection  49 interproximal papilla vessels, arborization  25

234 Index
intramembranous ossification, bone open flap approach for extraction site oral melanoma  149
formation 11 management 197 physiologic pigmentation  146
investing soft connecting tissue, anatomy oral melanoacanthoma (melanoacanthosis)  smoker’s melanosis  147
and vascular supply  25–28, 29 148 planning
oral melanocytic nevus  148, 149 see also treatment planning, combined
leukemia 145 oral melanoma  149 periodontal and prosthodontic care
lichenoid mucositis  140 osseointegration, dental implants  15–16, 121 planning, analysis (CBCT, radiological
lichen planus  140, 141 osteonecrosis of the jaws  15 guides, dual‐scan, surgical guides,
ligneous conjunctivitis  145–146 bisphosphonate therapy  15 dynamic guidance)  223–225
ligneous gingivitis  145–146 diagnosis 15 planning and manufacturing of teeth‐
linear IgA disease  142 osteoporosis supported restorations  214–223
low‐density lipoprotein receptor–related bone remodeling  13–14 plasma cell gingivitis  142–143
proteins, bone remodeling  13 mandibular osteoporosis  16 plasma cell mucositis  143
Lyell’s disease (toxic epidermal osteoprotegerin (OPG), bone remodeling  13 positioning mattress suture, SubEpithelial
necrolysis) 143 osteotomy: single implant, dental Connective Tissue Graft
implants 125–129 (SECTG) 190–191
malignant neoplasia  150–152 oxygen cannula  6 post‐operative care, Piezocision™ assisted
metastatic disease  151–152 orthodontics 41
squamous cell carcinoma  150–151 palatal artery‐extension of greater palatine pre‐operative implant site assessment 
verrucous carcinoma  151 artery  21 172–174, 175
mandible vs maxilla, issues of anatomic papillary construction after dental implant integrity of the buccal plate of bone 
interest 22–24 therapy 117–120 173, 174
mandibular first bicuspid, internal armamentarium 117 integrity of the interproximal height of
microarchitecture  23 contraindications 117 bone 172–173
mandibular first molar, internal healing 119, 120 key factors in diagnosis of the surrounding
microarchitecture of furcation area  23 history 117 tooth support prior to
mandibular osteoporosis  16 indications 117 extraction 172–174
markers of bone formation, bone possible complications  119 root angulation/inclination and its
remodeling 12 postoperative instructions  119 relationship to the apical bone
markers of bone resorption, bone surgical indexing  119 topography 173–174, 175
remodeling 12 technique 117–119 pre‐operative vital signs chart, conscious IV
maxillary artery distribution  20 paraneoplastic pemphigus  141 sedation utilizing midazolam  6
maxillary bicuspid, internal parathyroid hormone (PTH), bone proliferative verrucous leukoplakia
microarchitecture  23 remodeling 13 (PVL) 149–150
maxillary first molar parulis 137, 138 pulse oximetry  6
internal microarchitecture of furcation pemphigus vulgaris  141 PVL (proliferative verrucous leukoplakia) 
area  23 periodontitis 149–150
mature resting alveolar bone from core  24 bone implications  16 pyogenic granuloma  138
maxillary sinus periosteum  21, 22 bone remodeling  12
maxilla vs mandible, issues of anatomic peripheral giant cell granuloma  138, 139 quantitative computed tomography (QCT),
interest 22–24 peripheral ossifying fibroma  137, 138 bone density measuring technique  14
medication‐induced gingival overgrowth  144 periradicular surgery see apicoectomy quantitative ultrasound (QUS), bone density
medication‐induced pigmentation  physical status, ASA physical status measuring technique  14
146–147 classification  5
melanoacanthosis (oral physiologic pigmentation  146 reactive gingival nodules, diagnosis and
melanoacanthoma) 148 Piezocision™ assisted orthodontics  35–42 treatment 139
melanotic macule  148 computer guided piezocision‐ ridge preservation, socket seal  193
mesio‐distal position, three‐dimensional orthodontics 35–37, 38 ridge preservation utilizing barrier
implant positioning  179, 181 contraindications for piezocision  42 membranes, socket seal  193–194
metastatic disease  151–152 dynamically guided piezocision  37–38 root amputation and hemisection, endodontic
MGJ (mucogingival junction)  26–28 incorporating piezocision in therapy 49
micro architecture of the bone/tooth multidisciplinary treatment  39–41 root canal therapy
relationship and the interface of soft and piezocision assisted orthodontics with endodontic therapy  44
hard connective tissues  21–24, 25 clear aligners  38, 39 treatment of failed  44
midazolam post‐operative care  41
see also conscious IV sedation utilizing potential complications  42 sanguinaria‐induced leukoplakia  149
midazolam technique 35, 36 SECTG see SubEpithelial Connective Tissue
characteristics 3 pigmented lesions  146–149 Graft
mucocele 139–140 amalgam tattoo  147–148 sedation depth, definition and levels  3, 4
mucogingival junction (MGJ)  26–28 medication‐induced pigmentation  sedation using midazolam see conscious IV
mucous membrane (cicatricial) 146–147 sedation utilizing midazolam
pemphigoid 141–142 melanoacanthosis (oral melanoacanthoma)  short implants, dental implants  123, 123,
148 131, 133, 134, 135
necrotizing ulcerative gingivitis (NUG)  153 melanotic macule  148 sinus augmentation using tissue‐engineered
necrotizing ulcerative periodontitis  153 oral melanoacanthoma bone 159–167
normal dental/alveolar vascular supply  22 (melanoacanthosis) 148 armamentarium 160
NUG (necrotizing ulcerative gingivitis)  153 oral melanocytic nevus  148, 149 contraindications 160

Index 235
sinus augmentation using tissue‐engineered SubEpithelial Connective Tissue Graft tissue architecture preservation  177
bone (cont’d ) (SECTG) 186–192 treatment options  175–177
harvesting procedure  160 apical guiding “marionette” suture  tissue augmentation procedures,
healing 164, 165 189–190 options 182–183
history 159 bone graft procedure  191 tissue deficiencies, dental implants 
indications 159 closure of the extraction socket  191–192 206–209, 209–210
postoperative management  160, recipient site preparation  188 same‐site, minimally invasive
163–164 requirements 186–187 surgery 209–210
sinus lift using autogenous mesenchymal socket seal  186–192 tissue volume
cells processed chairside  165–167 suturing techniques  188–191 availability and requirements 
technique 160–164, 165 tissue augmentation at the time of tooth 169–172
tissue engineered bone discs  160–164, extraction 186–192 influence on the peri‐implant “pink”
165 tunnel preparation  188, 189 esthetics 169, 170
transplant implantation surgery  161–164, surgical operating microscope (SOM), toxic epidermal necrolysis (Lyell’s
165 endodontic therapy  43 disease) 143
treatment and expansion of periosteal surgical phase  198–203 trabecular bone, bone type  11
biopsies 160–161 membrane placement and training, intravenous conscious sedation  3
sinus lift using autogenous mesenchymal stabilization 200, 201 transplant implantation surgery, sinus
cells processed chairside  165–167 procedure for tack insertion  202–203 augmentation using tissue‐engineered
harvesting procedure  165, 166, 167 requirements and evolution of the bone 161–164, 165
infection of the grafted site and membrane periosteal releasing incisions  200–202 treatment planning, combined periodontal
exposure 165–167 soft tissue stabilization  203 and prosthodontic care  61–105
infraorbital nerve paresthesia  165 steps for periosteal stabilizing suture  202 diagnostic phase  64–65, 71–72, 79,
possible complications  165 surgical procedure  198–199 79–81, 88
swelling, bruising and bleeding  165 tacks and pin fixation  202 diagnostic phase (data collection) 
site analysis and classification  time of tooth removal  198 61–62
197–198, 199 suturing of the graft  203–205 final prognosis  63–104
site preparation, dental implants  125–129 simultaneous flap closure  204–205 initial periodontal phase  66, 73, 83
smoker’s melanosis  147 suturing techniques maintenance phase  71, 78, 103
socket seal  183–192 apical guiding “marionette” preprosthetic periodontal phase  67–69,
autogenous tissue for concomitant buccal suture 189–190 73, 77–78, 85–90, 92–97
volume augmentation and socket seal horizontal adaptive mattress suture  190 prognosis  71, 79, 103
procedures 186–192 positioning mattress suture  190–191 prosthetic phase  69–71, 71–75, 76–78, 76,
compromised sockets  192 SubEpithelial Connective Tissue Graft 82, 83, 84, 86, 87, 91–103
contraindications 183 (SECTG) 188–191 provisional phase  66–67, 76, 78, 79–81,
disadvantages of this technique  84–85, 90–91
185–186 tapping threads, dental implants  129 treatment planning phases  63, 65–66,
donor sites  183–184 three‐dimensional implant positioning  73, 83
flapless ridge preservation  192–193 179, 180
indications 183 apico‐coronal position  179, 181 vascular supply: macro and micro  19–21
recipient site preparation  183, 184 bucco‐palatal position safe‐zone green red verrucous carcinoma  151
requirements for the tissue/tissue diagram 179, 180 vitamin C, bone remodeling  13
substitute material  183 mesio‐distal position  179, 181 vitamin D, bone remodeling  13
ridge preservation  193 tissue augmentation at the time of tooth vitamin K, bone remodeling  13
ridge preservation utilizing barrier extraction
membranes 193–194 armamentarium 177 Wegener’s granulomatosis  146
stabilization of the graft  184–185 atraumatic tooth extraction  177–179 wound healing  29–32
SubEpithelial Connective Tissue Graft autogenous tissue for concomitant buccal angiogenesis  30, 31
(SECTG) 186–192 volume augmentation and socket seal bone 31–32
SOM (surgical operating microscope), procedures 186–192 dental implants  32
endodontic therapy  43 management of class I sockets  177–179 epithelial cells  30, 31
squamous cell carcinoma  150–151 SubEpithelial Connective Tissue Graft epithelial closure  32
stabilization of the graft  205 (SECTG) 186–192 fibroplasia 31

236 Index