Practical Periodontal Plastic Surgery E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 400

Veröffentlichungsjahr: 2017

Beschreibung

Practical Periodontal Plastic Surgery, Second Edition builds on the success of the first edition to provide the qualified and trainee periodontist with an essential guide to the clinical requirements and step-by-step procedures of periodontal plastic surgery. * Features additional clinical photographs to illustrate procedures * Brings together periodontal and plastic surgery expertise * Retains the popular step-by-step format for quick and clear reference

Leseprobe

PRACTICAL PERIODONTAL PLASTIC SURGERY

SECOND EDITION

Edited by

Serge Dibart, DMD

Professor and Chair Graduate Program Director Department of Periodontology and Oral Biology Boston University School of Dental Medicine Boston, MA, USA

This edition first published 2017 by John Wiley & Sons Inc.

First edition published 2006 by Blackwell Publishing Company. © Serge Dibart and Mamdouh M. Karima.

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Library of Congress Cataloging-in-Publication Data

Names: Dibart, Serge, editor. | Preceded by (work): Dibart, Serge.

 Practical periodontal plastic surgery.

Title: Practical periodontal plastic surgery / edited by Serge Dibart.

Description: Second edition. | Ames, Iowa : John Wiley & Sons

Inc., 2017. |

 Preceded by: Practical periodontal plastic surgery / Serge Dibart, Mamdouh

 Karima. 1st ed. c2006. | Includes bibliographical references and index.

Identifiers: LCCN 2016015697| ISBN 9781118360651 (cloth) | ISBN 9781118985489

 (Adobe PDF) | ISBN 9781118985502 (epub)

Subjects: | MESH: Periodontium–surgery | Reconstructive Surgical

 Procedures–methods | Oral Surgical Procedures,

 Preprosthetic–methods | Periodontics–methods

Classification: LCC RK361 | NLM WU 240 |

DDC 617.6/32059–dc23 LC record

available at https://lccn.loc.gov/2016015697

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: Courtesy of the editor

Table of Contents

List of Contributors

Foreword

Chapter 1 Definition and Objectives of Periodontal Plastic Surgery

Therapeutic Success

Indications

Factors That Affect the Outcome of Periodontal Plastic Procedures

References

Chapter 2 Surgical Armamentarium, Sutures, Anesthesia, and Postoperative Management

Armamentarium

Sutures

Anesthesia

Postoperative Instructions, Medications, and Regimen

References

Chapter 3 Introduction to Microsurgery and Training

Introduction

Training in Microsurgery

Basic Microinstrumentation

Suturing Techniques

An Animal Model for Microsurgery Technique Training

References

Chapter 4 Periodontal Microsurgery

Historical Perspective

Periodontal Applications

Periodontal Instrumentation

Periodontal Microsurgical Procedures

Microsurgical Applications for Implants

Incorporating the Surgical Operating Microscope in Practice

Summary

References

Chapter 5 Free Gingival Autograft

History

Indications

Armamentarium

Free Gingival Autograft to Increase Keratinized Tissue

Variation on the Same Theme: Free Connective Tissue Graft

Free Gingival Autograft for Root Coverage

References

Chapter 6 Subepithelial Connective Tissue Graft

History

Indications

Armamentarium

Technique (Envelope Flap)

References

Chapter 7 Pedicle Grafts: Rotational Flaps and Double-Papilla Procedure

History

Indications

Prerequisites

Armamentarium

Lateral Sliding Flap

Obliquely Rotated FLAP

Double-Papilla Procedure

The Palatal “Sliding” FLAP

References

Chapter 8 Pedicle Grafts: Coronally Advanced Flaps

History

Indications

Prerequisites

Armamentarium

Surgical Techniques

Semilunar Coronally Repositioned Flap

Coronally Advanced Flap: Single Stage

Coronally Positioned Flap: Two Stages

References

Chapter 9 Aesthetic and Morphometric Evaluation of the Periodontium

Introduction

Gingival Topography

Gingival Contour

Gingival Zenith

Lateral Displacement of the Gingival Zenith

Marginal Soft Tissue Level

Periodontal Phenotype: Tooth Crown/Gingiva Relationships

Gingival Color

Gingival Superficial Texture and Consistency

Gingival Dimensions

Periodontal Biologic Width

References

Chapter 10 Enamel Matrix Derivative: Emdogain

Introduction

Clinical Advantages

Indications

Prerequisites

Armamentarium

Technical Procedures

Post-Surgical Care

Possible Limitations and Complications

References

Chapter 11 Guided Tissue Regeneration

History

Indications

Armamentarium

Guided Tissue Regeneration for Root Coverage

References

Chapter 12 Acellular Dermal Matrix Graft (AlloDerm)

History

Indications

Armamentarium

Technique

Postoperative Instructions

Graft Healing

Removal and Correction of Amalgam Tattoo

Gingival Grafting to Increase Soft Tissue Volume

Possible Complications

References

Chapter 13 Labial Frenectomy Alone or in Combination with a Free Gingival Autograft

History

Indications

Armamentarium

Technique

Possible Complications

Labial Frenectomy in Association with a Free Gingival Autograft

References

Chapter 14 Preprosthetic Ridge Augmentation: Hard and Soft

History

Indications

Armamentarium

Soft Tissue Graft

Clinical Crown Reduction Using A Connective Tissue Graft

Hard Tissue Graft

Combination Grafts: Hard and Soft Tissues

Edentulous Ridge Expansion

Socket Preservation

References

Chapter 15 Exposure of Impacted Maxillary Teeth for Orthodontic Treatment

History

Indication

Armamentarium

Technique

Reference

Chapter 16 Peri-implant Soft Tissue Management

Foreword

Introduction

Gingival Tissues and Peri-Implant Mucosa

The Need for Keratinized Tissue

Biological Width and Gingival Biotypes

Aesthetic Predictability

One-Piece Implants vs Two-Piece Implants

Uncovering Techniques

Buccally Positioned Envelope Flap

Buccally Positioned Scalloped Flap for Multiple Implants

Connective Tissue Graft

Modified Roll Technique

Free Gingival Graft

Xenografts to Improve Peri-Implant Keratinization

Papilla Regeneration Techniques

Conclusion

References

Chapter 17 Improving Patients’ Smiles: Aesthetic Crown-Lengthening Procedure

History

Indications

A Few Words About Aesthetics

Armamentarium

Soft Tissue Crown Lengthening

Hard Tissue Crown Lengthening

Microsurgical Crown Lengthening

Minimally Invasive Crown Lengthening With or Without Lip Repositioning

References

Chapter 18 Introduction to Minimally Invasive Facial Aesthetic Procedures

Overview

Patient Selection and Assessment

Neurotoxins

Temporary and Semi-Permanent Fillers

Treatment Sequencing

Neurotoxin Injection Technique

Treatment of the Midface and Lower Face with Fillers

References

Chapter 19 Selection Criteria

Plaque-Free and Inflammation-Free Environment

Aesthetic Demand

Adequate Blood Supply

Anatomy of the Recipient and Donor Sites

Donor Tissue Availability

Graft Stability

Trauma

References

Index

EULA

List of Tables

Chapter 14

Table 14.1

Chapter 18

Table 18.1

Table 18.2

Chapter 19

Table 19.1

List of Illustrations

Chapter 2

Figure 2.1

Single interrupted suture.

Figure 2.2

Horizontal mattress sutures.

Figure 2.3

Vertical mattress suture.

Figure 2.4

Crisscross suture.

Figure 2.5

Sling suture.

Chapter 3

Figure 3.1

Basic setup for microsurgical training, including a chicken's foot (see text).

Figure 3.2

Microsurgical suturing exercise.

Figure 3.3

Dissection of a chicken foot, exposing an artery, a tendon, and a vein.

Chapter 4

Figure 4.1

Microsurgical triad.

Figure 4.2

Periodontal microsurgical knives: 1, blade breaker; 2, crescent; 3, minicrescent; 4, 260° spoon; 5, lamella, and 6, sclera.

Figure 4.3

Spoon knife shown in sulcular undermining incision.

Figure 4.4

(A) Half-inch and three-eighths-inch curved needles. (B) Spatula needle (6.6 mm) compared to FS-2 needle (19 mm).

Figure 4.5

(A) Connective tissue graft (CTG) placement via tunnel technique. (B) Final healing of CTG.

Figure 4.6

Pen grip used for microsurgical instruments.

Figure 4.7

Proper gripping of needle by needle holder.

Figure 4.8

Rearming of needle.

Figure 4.9

Proper entry and exit distance of needle.

Figure 4.10

Guiding the suture direction with tying forceps.

Figure 4.11

Microsurgical knot (surgeon's knot followed by square knot).

Figure 4.12

Recession on tooth #6.

Figure 4.13

Subepithelial connective tissue graft inserted and sutured.

Figure 4.14

Results 3 months post surgery. Notice the perfect outcome.

Figure 4.15

Implant replacing tooth #8 showing recession and metal collar.

Figure 4.16

Subepithelial connective tissue graft sutured in place.

Figure 4.17

Postoperative results 2 months later.

Chapter 5

Figure 5.1

Tooth 25 had a recession and lack of attached gingiva.

Figure 5.2

Preparation of the recipient site. A bleeding vessel has been tied with a black silk suture.

Figure 5.3

Anatomy of a donor region. Palatal vessels and nerve running from the greater and lesser palatine foramina to the interincisive foramen. The anterior palatal submucosa is mainly fatty, whereas the posterior palatal submucosa is mainly glandular.

Figure 5.4

Palatal donor site. The graft to be harvested had been delineated with a no. 15 blade.

Figure 5.5

The palatal graft has been harvested.

Figure 5.6

The graft is even and approximately 1.5 mm thick.

Figure 5.7

The graft is sutured in place with three single interrupted silk sutures (5-0). At this stage, when pulling on the lip, the graft should be immobile.

Figure 5.8

The mesiodistal horizontal suture.

Figure 5.9

The graft is kept in place by adding two circular intraperiosteal sutures to the four single interrupted sutures present.

Figure 5.10

The donor site at time of surgery. The connective tissue is left exposed to granulate.

Figure 5.11

The donor site 1 week later.

Figure 5.12

Results 2 years later. A band of attached gingival is present below and around tooth 25.

Figure 5.13

Compressive suture of the palatal artery.

Figure 5.14

Free gingival graft for root coverage.

Figure 5.15

A large periosteal bed is prepared to receive the graft. The large size of the bed is to compensate for the avascular area of the root to be covered and eliminate frenum fiber attachment.

Figure 5.16

The palatal graft is sutured to the recipient bed by using a mesiodistal horizontal suture and two circular intraperiosteal sutures.

Figure 5.17

The area 1 year later. Take note of the root coverage on tooth 25, the amount of keratinized gingiva, and the absence of labial frenum pull.

Chapter 6

Figure 6.1

The metal collar of the implant showing compromised aesthetics.

Figure 6.2

The trapdoor enabling the retrieval of the connective tissue graft.

Figure 6.3

The envelope flap (pouch) has been created and the connective tissue graft inserted.

Figure 6.4

The graft is sutured to the papillae, and the buccal flap is sutured over the graft by using a sling suture. It is important to cover as much of the graft as possible to maximize vascular supply.

Figure 6.5

After 3 months, the aesthetics have been improved tremendously by the procedure.

Figure 6.6

A Miller class II gingival recession affecting teeth 27 and 28.

Figure 6.7

Results of 100% root coverage 3 weeks after periodontal microsurgery.

Chapter 7

Figure 7.1

Recessions on teeth 24 and 25.

Figure 7.2

Two lateral pedicle flaps are raised adjacent to the receding areas.

Figure 7.3

The two partial thickness lateral pedicle flaps are sutured covering the exposed root surfaces of teeth 24 and 25.

Figure 7.4

The area 1 year later.

Figure 7.5

Moderate gingival recession affecting the canine.

Figure 7.6

A partial thickness flap is raised.

Figure 7.7

The papillae are secured with single interrupted 7.0 sutures.

Figure 7.8

The area 2 months later.

Figure 7.9

Siebert Class I soft tissue deficiency post extraction of tooth 8.

Figure 7.10

Occlusal view showing the buccal-lingual discrepancy. Tooth 9 has a compromised endodontic treatment. It will be extracted later.

Figure 7.11

The surgical palatal sliding pedicle flap on the patient's plaster model.

Figure 7.12

The sliding pedicle flap is harvested from within the thickness of the palatal tissue and rotated forward.

Figure 7.13

The “loose” end of the pedicle flap is tucked buccally under the gingiva.

Figure 7.14

The pedicle is sutured bucally.

Figure 7.15

Six months post surgery. The gingival volume is restored in a horizontal and vertical dimension. Tooth 9 has been extracted and grafted with bone particulates.

Figure 7.16

Occlusal view showing successful soft tissue volume restoration.

Figure 7.17

Two dental implants have been placed to restore teeth 8 and 9. The provisional restorations have shaped the inter-implant papilla and given a harmonious peri-implant gingival architecture that will complement the final prosthetic crowns.

Figure 7.18

Nine months later with the final prosthetic crowns for teeth 8 and 9. Image courtesy of Dr. Adam Ishgi.

Chapter 8

Figure 8.1

Gingival recession on left maxillary canine.

Figure 8.2

Semilunar incision performed. Flap is coronally advanced.

Figure 8.3

One-week healing.

Figure 8.4

Treated area 6 months later.

Figure 8.5

Comparison between (a) initial and (b) final aspects. CEJ (blue arrow), gingival margin (green arrow), and muco-gingival junction (yellow arrow).

Figure 8.6

Gingival recession on left maxillary canine.

Figure 8.7

Flap is coronally positioned.

Figure 8.8

Treated area 6 months later.

Figure 8.9

Comparison between (a) initial and (b) final aspects. CEJ (blue arrow), gingival margin (green arrow), and muco-gingival junction (yellow arrow).

Figure 8.10

Gingival recession is present on maxillary right second molar.

Figure 8.11

Beveled vertical releasing incision on distal aspect of the recession.

Figure 8.12

Sulcular incision on buccal aspect of the recession.

Figure 8.13

Beveled vertical releasing incision on mesial aspect of the recession.

Figure 8.14

Trapezoidal flap is designed.

Figure 8.15

Coronal portion of the flap is raised as full thickness.

Figure 8.16

A split-thickness dissection is performed in the apical aspect of the flap.

Figure 8.17

The epithelium is removed in the papillary region via split-thickness dissection.

Figure 8.18

Passive coronal sliding of the flap is obtained.

Figure 8.19

Flap is sutured 1–2 mm coronal to the CEJ.

Figure 8.20

Final healing demonstrating complete root coverage.

Figure 8.21

Comparison between (a) initial and (b) final aspects. CEJ (blue arrow), gingival margin (green arrow), and muco-gingival junction (yellow arrow).

Figure 8.22

Gingival recession is observed on maxillary right first premolar.

Figure 8.23

Flap is elevated.

Figure 8.24

Flap is sutured 1–2 mm coronally to the CEJ.

Figure 8.25

Treated area 6 months later.

Figure 8.26

Comparison between (a) initial and (b) final aspects. CEJ (blue arrow), gingival margin (green arrow), and muco-gingival junction (yellow arrow).

Figure 8.27

The flap is sutured in place.

Figure 8.28

Healing after 2 months.

Chapter 9

Figure 9.1

Gingival contour. Gingival zenith (green arrows) and interdental papillae (yellow arrows).

Figure 9.2

Position of the gingival zenith (green lines) in relation to the long axis of the teeth (black dashed lines).

Figure 9.3

Marginal soft tissue level. The gingival zenith of the lateral incisor is either located coronally or level with the zenith line of the adjacent central incisor and canine.

Figure 9.4

The gingival zenith (GZ) of the lateral incisor is located coronally to the zenith line (ZL) connecting the gingival zenith of the adjacent central incisor and canine.

Figure 9.5

Papilla dimension measurement. Papillary width (black dotted line), papillary height (green lines), and gingival zenith (blue lines).

Figure 9.6

Interdental soft tissue recession leading to the loss of the interdental papillae.

Figure 9.7

Flat papillary tip observed is area with a diastema.

Figure 9.8

Periodontal phenotypes: (A) thin and scalloped; (B) thick and flat (note the classical pale coral color).

Figure 9.9

A thin gingival phenotype (A) may be clinically determined by the transparence of the gingival tissues (B). Note that the periodontal probe tip can be seen through the gingival transparence (B).

Figure 9.10

In patients with physiologic melanin pigmentation, the gingival tissues present with brownish color.

Figure 9.11

Clinical and histologic comparison between the gingiva and the alveolar mucosa. The gingiva is limited coronally by the gingival margin (GM) and apically by the muco-gingival junction (MGJ), which continues apically as the darker reddish, smooth, highly elastic alveolar mucosa.

Figure 9.12

The marginal gingiva and areas of the attached gingiva (black stars) have a smooth surface, while the other areas (green stars) of the attached gingiva present with superficial depressions (stippling), which are not seen in every individual and are not uniformly distributed within the same individual.

Figure 9.13

With the use of histochemical methods, the alveolar mucosa is stained brown, allowing clear definition of the muco-gingival junction and, thus, separation of the alveolar mucosa and gingiva.

Figure 9.14

Periodontal biologic width (PBW) and supra-crestal gingival tissues (SCT). The PBW is the distance between the base of the gingival sulcus and the top of the alveolar bone crest and thus is composed of the junctional epithelium and the connective tissue attachment. The supra-crestal gingival tissues (SCT) extend from the bone crest to the gingival margin and correspond to the length of the gingival sulcus added to the PBW.

Chapter 11

Figure 11.1

Tooth 11 with a moderate gingival recession.

Figure 11.2

The exposed root surface is thoroughly scaled with a backaction chisel.

Figure 11.3

Two vertical incisions are placed, avoiding the interproximal papillae.

Figure 11.4

The flap is reflected, exposing some of the alveolar bone.

Figure 11.5

Trimming the reabsorbable membrane (Resolut) and adjusting it to fit the site.

Figure 11.6

The membrane (Resolut) is secured in place with resorbable sutures.

Figure 11.7

The buccal flap is sutured with the aim of covering as much of the membrane as possible.

Figure 11.8

By 2 years after surgery, there is 100% coverage of the root surface.

Figure 11.9

Membrane exposure 2 weeks after the surgery.

Chapter 12

Figure 12.1

Envelope incision: a pouch is created.

Figure 12.2

The roots are scaled, and the pouch is ready to accommodate the graft.

Figure 12.3

The AlloDerm is trimmed to fit the pouch, cover the roots, and suture to the papillae. These have been de-epithelialized.

Figure 12.4

The buccal flap is sutured over the AlloDerm by using a sling suture to provide the graft with maximum coverage; 100% coverage is ideal.

Figure 12.5

By 1 week after surgery, some of the AlloDerm is exposed. The whitishness is a normal feature of this healing process.

Figure 12.6

By 3 years after surgery, the recessions have been covered.

Figure 12.7

Amalgam tattoo on the gingiva, in the aesthetic zone.

Figure 12.8

Amalgam tattoo excised and AlloDerm grafted and sutured.

Figure 12.9

Results 1 week after surgery.

Figure 12.10

Results 1 year after surgery. The mucogingival problem has been corrected and the final prosthesis inserted.

Figure 12.11

Thin gingival biotype requiring soft tissue augmentation in conjunction with orthodontic treatment.

Figure 12.12

AlloDerm sutured in place.

Figure 12.13

Healing of the graft at 1 year.

Chapter 13

Figure 13.1

Maxillary labial frenum before frenectomy.

Figure 13.2

Excision of the maxillary frenum.

Figure 13.3

The area is secured with single interrupted sutures.

Figure 13.4

Another case of free gingival graft used to cover a buccal recession on tooth 24.

Figure 13.5

The recipient bed has been prepared, and the labial frenum excised to accommodate the gingival autograft.

Figure 13.6

The free gingival graft is in place, with the connective tissue side against the recipient bed.

Figure 13.7

The graft is secured with resorbable 5-0 gut sutures.

Figure 13.8

The area 1 year after surgery. Root coverage has been achieved, the amount of keratinized tissue has increased, and the frenum has been excised. Notice the restoration of the mesial papilla of tooth 24.

Chapter 14

Figure 14.1

Seibert class I defect. The gingival buccal concavity needs to be augmented for a better aesthetic outcome. The restoration planned here is a fixed partial denture; hence the need for a soft tissue graft only.

Figure 14.2

Occlusal view without the temporary restoration.

Figure 14.3

The horizontal incision is made and continued intrasulcularly to teeth 9 and 11. This helps with the sharp dissection and mobilizes the flap. An alternative would be to put two vertical incisions on each side of the area to be augmented.

Figure 14.4

A trapdoor is opened in the palate to harvest the connective tissue graft to be used to correct the defect.

Figure 14.5

The harvest of the piece of connective tissue. The desired length and thickness have been determined by the size and shape of the defect to be corrected.

Figure 14.6

The graft is inserted and positioned into the wound. It will be secured to the periosteum bucally with an intraperiosteal horizontal mattress resorbable suture.

Figure 14.7

Once the connective tissue graft has been secured, the flaps are secured using single interrupted sutures.

Figure 14.8

Buccal view of the augmented site 2 weeks after the surgery.

Figure 14.9

Occlusal view of the augmented site 2 weeks after the surgery. The buccal curvature has been restored.

Figure 14.10

The pontic of the temporary bridge has been modified to apply light positive pressure to the area. This will help simulate papilla presence on each side of the final restoration (tooth 10).

Figure 14.11

Unpleasant aesthetics as a result of iatrogenic dentistry (inadequate position of the crown margin and tooth preparation) requiring a correction of tooth 6. There is a gingival roll and inflammation around the maxillary canine and an inadequate amount of attached gingiva.

Figure 14.12

Removal of the old fixed prosthetic restoration and flattening of the exposed root and margin (rotary and hand instrumentation) in preparation for the connective tissue graft.

Figure 14.13

A connective tissue graft is inserted under a coronally positioned flap and secured using resorbable and silk sutures. The graft is placed on the freshly prepared root surface to re-create a zone of attached gingiva and modify the clinical crown length.

Figure 14.14

Final restoration 1 year later. A band of attached gingiva has been established, and pleasing aesthetics have resulted from the new position of the crown margin (tooth 6).

Figure 14.15

Unpleasant smile due to uneven marginal tissue height and loss of gingival volume (teeth 11 and 12).

Figure 14.16

A:

 Miller class III with localized severe chronic periodontitis affecting teeth 11 and 12.

B:

Periapical radiograph of teeth 11 and 12.

Figure 14.17

Extraction of tooth 12 and root preparation of tooth 11. Degranulation of the extraction site and preparation of the recipient bed.

Figure 14.18

A connective tissue graft extending from tooth 10 to tooth 13 is inserted to correct the existing gingival recession on tooth 11, reestablishing a normal buccal-lingual ridge dimension.

Figure 14.19

Healing at 2 months. An interdental papilla has been created by the judicious use of the temporary prosthesis (soft tissue conditioning).

Figure 14.20

Healing at 1 year. The result is acceptable, aesthetics have improved, and the patient is satisfied.

Figure 14.21

Seibert class I defect. The restoration planned here is an implant-supported crown; hence the bone tissue graft planned.

Figure 14.22

Occlusal view of the defect showing the buccal concavity that will be augmented with a bone graft.

Figure 14.23

A full-thickness flap has been elevated, with a horizontal incision that is slightly palatal to the midcrest and two vertical releasing incisions. A 10-mm OsteoMed screw has been inserted halfway through the alveolar bone. This screw will serve as an anchor to the bone allograft (Regenaform) that will be placed next. The area receiving the graft has been decorticated by using a small round carbide burr.

Figure 14.24

The Regenaform-block graft (10 × 10 × 5 mm), once softened, has been pushed through the screw and molded to fit the defect. When the defect is large, a second screw and a bigger graft may be necessary.

Figure 14.25

A resorbable membrane (Ossix) has been trimmed to the appropriate size and placed over the bone graft. The membrane is tucked under the palatal flap before suturing. The buccal flap is to be undermined to achieve coverage of the membrane and graft passively.

Figure 14.26

A horizontal mattress buccally and palatally with a Gore-Tex suture will hold the flaps up without tension and keep the membrane down on the bone. Additional single interrupted sutures will close the wound by primary intention.

Figure 14.27

The area 1 year later. Buccal view.

Figure 14.28

The area 1 year later. Occlusal view.

Figure 14.29

The area 1 year later at reentry and implant placement. The fixation screw was once where the red dot is.

Figure 14.30

Severe vestibular and occlusal defect filled with an acrylic prosthesis to provide lip support.

Figure 14.31

Two OsteoMed screws (1.6 × 10 mm) placed halfway into the alveolar bone.

Figure 14.32

Two blocks of Regenaform (10 × 10 × 5 mm) molded and placed on the OsteoMed screws.

Figure 14.33

AlloDerm is used as a membrane to protect the bone graft and as a soft tissue graft to build up the vestibule. The AlloDerm is tucked under the palatal flap and secured coronally and apically to the periosteum by using resorbable sutures.

Figure 14.34

The buccal flap is coronally advanced by releasing the flap apically and secured by using horizontal mattress and single interrupted sutures (Gore-Tex). Some of the AlloDerm is left exposed, which allows for minimal coronal advancement of the flap and maintenance of the original vestibular depth.

Figure 14.35

The area 3 months after the procedure.

Figure 14.36

Cross-section of the cast before the surgery.

Figure 14.37

Cross-section of the cast after the surgery. Notice the amount of tissue volume gained.

Figure 14.38

The patient's profile before the surgery. Notice the concavity of the upper lip due to the vestibular hard and soft tissue defect.

Figure 14.39

The patient's profile 3 months after surgery. Support has been provided to the upper lip, making for a better aesthetic profile.

Figure 14.40

Tooth 8 is missing and will be replaced by an implant-supported crown to restore aesthetics and function.

Figure 14.41

A computed-tomographic scan of the area shows a crestal bony width incompatible with successful implant placement.

Figure 14.42

A conservative full-thickness buccal flap is raised to expose the crestal bone. Two vertical releasing incisions are placed to help mobilize the flap coronally at the end of the procedure (the flap is full thickness at the top and partial thickness at the bottom). The splitting of the ridge is initiated by using a no. 15 blade that is gently hammered in for about 5 mm.

Figure 14.43

The splitting of the ridge is continued by using a bibevel osteotome chisel that will go slightly deeper than the blade and will expand the ridge to the buccal. Do not create a single large fracture. Note the minimal flap reflection.

Figure 14.44

Once the midcrestal groove has been created and adequate depth obtained, the osteotomy is performed to the desired length with a 2.0-mm twist drill. This is often followed by the use of expanding osteotomes, which will condense the bone as they are expanding the osteotomy site, or proceeding with the next 3.0-mm drill.

Figure 14.45

The implant is inserted carefully.

Figure 14.46

Occlusal view showing the satisfactory placement of the implant in the maxillary arch.

Figure 14.47

The blue mount has been removed and the cover screw tightened in place.

Figure 14.48

The flap is now gently advanced coronally by releasing it from the underlying periosteum (split-thickness flap) and sutured by primary intention with single interrupted sutures.

Figure 14.49

Occlusal view of the area 4 months after surgery.

Figure 14.50

Tooth 8 is restored with an implant-supported crown. A gingival graft was needed because of gingival scars from multiple endodontic procedures.

Figure 14.51

The patient's smile at the time of crown insertion.

Chapter 15

Figure 15.1

A buccal full-thickness flap is elevated to expose the crown of tooth 8.

Figure 15.2

The crown is exposed and the flap sutured apically (not shown).

Figure 15.3

Healing after 1 month.

Figure 15.4

A palatal semilunar flap to expose an impacted canine.

Figure 15.5

The tip of the flap has been trimmed and a bracket placed on the exposed crown.

Figure 15.6

Thirteen-year-old with impacted canine (tooth 6).

Figure 15.7

CT scan showing the level of impaction and the presence of the periodontal ligament.

Figure 15.8

The primary canine has been extracted and a full-thickness palatal flap has been raised. The permanent canine has been exposed and the follicular sac around the clinical crown removed. Piezocision cuts are made to accelerate tooth movement.

Figure 15.9

After the permanent canine has been exposed and a chain secured to the clinical crown the flap is closed using 4 × 0 chromic gut sutures.

Figure 15.10

A few months later the canine is coming down through the gingiva.

Figure 15.11

The patient has completed the treatment.

Chapter 16

Figure 16.1

Pre-operative buccal view. The first premolar is fractured.

Figure 16.2

Pre-operative palatal view. The fracture line extends several millimeters subgingivally.

Figure 16.3

At 6 weeks after the extraction, a single implant is placed into the residual socket and a xenograft is used to fill the voids between the implant and the osseous walls.

Figure 16.4

The final implant-supported restoration is in place. There is a harmonious integration of the prosthetic crown in between the natural dental elements and the healthy and natural appearance of the peri-implant gingiva.

Figure 16.5

Pre-operative view. The patient, treated with an implant-supported restoration 12 years ago, now complains about discomfort during daily oral hygiene procedures.

Figure 16.6

A decision is made to use a free gingival graft to increase the amount of keratinized tissue. The main goal is to simplify the home oral hygiene procedures. A periosteal bed has been prepared. There is dehiscence buccal to the otherwise osseointegrated implant.

Figure 16.7

A thick, free gingival graft is carefully adapted to the periosteal bed and stabilized with compressive 5-0 gut sutures. No attempt is made to cover the original marginal recession.

Figure 16.8

Final healing of the area. The patient did not experience any further discomfort during brushing. An unexpected creeping attachment phenomenon of about 2 mm was also obtained.

Figure 16.9

After 3 years, during a periodical hygiene recall, stability of the area is evident. The creeping phenomenon progressed for an additional 0.5 mm (compare with Fig. 16.8).

Figure 16.10

The sum of the connective tissue attachment (CTF) and the junctional epithelium (JE) forms the biological width (between the white arrows). A biological width around a tooth forms above the crest of bone differently from how it surrounds an implant, where it forms below the level of the bone.

Figure 16.11

Pre-operative view. A single implant is planned to replace the failing left central incisor (note the periapical X-ray in the lower left corner – a gutta-percha cone was inserted into a sinus tract). A guided bone regenerative procedure was necessary prior to implant insertion.

Figure 16.12

Postoperative view. An implant-supported zirconia ceramic crown successfully replaced the left central incisor whereas a zirconia ceramic crown was placed on the right central incisor and a porcelain laminate veneer was cemented on the right lateral incisor. Gingival recontouring was also performed to create better harmony in the final gingival outline. The final periapical X-ray is shown in the lower left corner.

Figure 16.13

Two adjacent implants were placed to restore the two upper left premolars. Note the short and less than ideal papilla in between the two implants. The vertical bite-wing X-ray of the area is shown in the lower left corner.

Figure 16.14

The maxillary left central incisor was recently replaced with a temporary implant-supported crown. Note in the clinical picture the proper symmetry of the gingival margins of the central incisors. The X-ray reveals the correct location of the osseous crest to the adjacent teeth but, in spite of this, there is no complete papilla between the centrals.

Figure 16.15

Final restoration of implant in Fig. 16.14 after 12 months. Note how the buccal gingival margin has slightly receded on the implant crown while the implant papillae have improved over time.

Figure 16.16

A single implant is planned to replace the failing maxillary right lateral incisor.

Figure 16.17

(A) During implant placement the buccal cortical bone appears thinner than 2 mm. (B) A resorbable membrane is placed on top of a bone graft to thicken the osseous anatomy.

Figure 16.18

Follow-up of the final restoration of the implant shown in Figs. 16.16 and 16.17.

Figure 16.19

Pre-operative view of the edentulous area of the first maxillary bicuspid. Note the marked concavity of the area and the frenum insertion.

Figure 16.20

Occlusal view of the edentulous area of the case depicted in Fig. 16.19. (A) Pre-operative view. (B) Same view of the area after implant placement with concomitant guided bone regeneration used to thicken the buccal osseous structure. Note the significant change in the buccal soft tissue profile.

Figure 16.21

During second-stage surgery a peduncolated soft tissue graft is obtained by flipping buccally the connective tissue plug that was lying on top of the cover screw.

Figure 16.22

Healing after 2 weeks of the area shown in Fig. 16.21.

Figure 16.23

Four-year follow-up of the final crown on the implant shown in Figs. 16.19–16.22 after guided bone regeneration and connective tissue thickening of the area. Note the major improvement in the quantity and quality of the tissue surrounding the implant.

Figure 16.24

Pre-operative view. The right central incisor is fractured and scheduled for extraction and immediate implant placement. The crown of the right lateral incisor is fractured as well, and a composite resin restoration will be done. Note the flat and thick biotype and the marginal recession of the gingival tissues.

Figure 16.25

Immediate implant placement at the time of extraction.

Figure 16.26

Seven-year follow-up. Despite a slight marginal disharmony between the two centrals, the overall esthetic result is acceptable because of the generalized gingival recession pattern and the flat biotype of the patient.

Figure 16.27

Two implants are placed after healing of a guided bone regeneration procedure that was previously performed to straighten the concave osseous anatomy of the area. Note the proper spacing of the implants, which should encourage maintenance of the inter-implant osseous crest height.

Figure 16.28

(A) Pre-operative view of the area implanted in Fig. 16.27. Note the significant soft tissue defect present in the canine area. (B) Completed case; a harmonious soft tissue profile has been recreated. In the lower part of the picture the 1-year follow-up X-ray displays a stable inter-implant osseous crest. Some deproteinized bovine bone used during hard tissue augmentation is still detectable.

Figure 16.29

Intraoperative view of adjacent implants. Note the proper spacing between the two fixtures and the provisional in place to anticipate the 3–3.5 mm distance between the osseous crest and the prosthetic contact point.

Figure 16.30

(A) Intraoperative occlusal view of the two implants of Fig. 16.29 before guided bone regeneration. (B) After guided bone regeneration the implants are submerged into newly formed osseous tissue. Note the significant thickening (black arrows) of the bone buccal to the implants.

Figure 16.31

Final prosthetic restoration of case depicted in Fig. 16.29. In order to avoid a black triangle the contact point was lowered to a distance of 3 mm from the osseous crest.

Figure 16.32

Pre-operative view of the area planned for an implant-supported restoration. There is a lack of proper bone width in the edentulous area.

Figure 16.33

After reflection of a full-thickness flap, the deficient buccolingual width of the edentulous ridge is obvious.

Figure 16.34

Radiograph showing the peri-implant osseous resorption pattern around one-piece transmucosal implants. Note the different resorption pattern from the two-stage submerged type of implants (compare with Fig. 16.32).

Figure 16.35

Clinical picture of the two one-piece transmucosal implants shown in Fig. 16.34.

Figure 16.36

According to the platform-switching technique, a 4-mm diameter abutment is used on a 5-mm diameter implant platform. Here an anatomical custom abutment has been manufactured.

Figure 16.37

Clinical view of the implant shown in Fig. 16.36.

Figure 16.38

Radiograph of the implant depicted in Fig. 16.27. Note how the platform-switching approach seems to abate the amount of peri-implant bone loss.

Figure 16.39

(A) A built-in platform-switched design characterizes the implant selected to be immediately placed in the first bicuspid socket. (B) Final implant-supported crown in place. The peri-apical X-ray on the left shows excellent marginal osseous profiles with bone persisting, coronal to the implant platform, in close proximity to the implant prosthetic components.

Figure 16.40

Pre-operative view of the area planned for an implant-supported restoration. There is a lack of proper bone width in the edentulous area.

Figure 16.41

After reflection of a full-thickness flap, the deficient buccolingual width of the edentulous ridge is obvious.

Figure 16.42

A block graft taken from the mandibular ramus, immediately posterior to the area, is secured in place with two fixation screws. An additional particulate xenograft is used to fill the voids and increase the volume of the graft.

Figure 16.43

A resorbable collagen membrane is used on top of the graft.

Figure 16.44

After periosteal releasing incisions, primary closure of the wound is achieved. In this maneuver, the mucogingival line is displaced coronally. Note how the provisional restoration has been adjusted to compensate for swelling in the area.

Figure 16.45

After 6 months of healing, the area is reopened. There is excellent graft integration and successful osseous regeneration.

Figure 16.46

Three standard-diameter implants are placed.

Figure 16.47

The day of the uncovering. The coronal displacement of the mucogingival line, in the edentulous space immediately mesial to the residual second molar, is still noticeable.

Figure 16.48

A partial-thickness flap is reflected and the temporary healing abutments are placed.

Figure 16.49

The flap is buccally and apically repositioned with 5-0 vicryl external mattress sutures. Single interrupted sutures are used to close the two vertical-releasing incisions. The mucogingival line has been newly moved toward its original, more apical, position.

Figure 16.50

After healing of the area, the width of the ridge appears significantly increased as a result of the osseous augmentation (compare with Fig. 16.40). The uncovering technique provided the fixtures with an adequate amount of keratinized mucosa surrounding them. By 4 weeks after the second-stage surgery, there is good healing of the area.

Figure 16.51

Final restoration in place.

Figure 16.52

Six-year follow-up of the case shown in Fig. 16.51. A slight recession of the peri-implant mucosal margin is noticeable on the middle implant. Mucosal tissues are otherwise stable and healthy.

Figure 16.53

(A) An ideal quality and quantity of the tissues in the previously implanted edentulous area allows for a modified tissue punch technique. (B) The initial half-moon incision is designed palatally with a blade no. 15C to find and expose the palatal half of the fixture head. (C) Completion of the modified tissue punch incision is performed towards the buccal side. (D) Final implant-supported crown in place. Note the good quality and quantity of the peri-implant mucosal tissues.

Figure 16.54

Pre-operative view. Three implants are buried under the tissue. Note the position of the mucogingival line. An apical repositioning of the keratinized mucosa is advisable to idealize the quality of the tissue surrounding the implants.

Figure 16.55

A slightly lingual horizontal incision has been designed on the crest, sparing the papilla distal to the canine. Two vertical-releasing incisions have been placed, mesial and distal to the first incision, and a partial-thickness flap has been raised.

Figure 16.56

After positioning of the healing abutments the flap is sutured apical to its original location.

Figure 16.57

(A) Healing of the peri-implant mucosa. Note the ideal keratinized tissue surrounding the implants and the shallow peri-implant sulcus that resulted from the uncovering procedure. (B) Final restoration in place. A good amount of keratinized mucosa is visible buccal to the implants.

Figure 16.58

A crestopalatal incision is placed to uncover three maxillary implants.

Figure 16.59

The splitting of the flap starts immediately at the level of the crestopalatal incision, leaving the inter-implant periosteum in place. A slight semilunar incision is done to expose the mesial implant further.

Figure 16.60

The flap is apically positioned with periosteal single interrupted sutures. A crossed-sling suture is used to obtain a tighter adaptation of the keratinized tissue buccally to the distal implant. A standard 4.1-mm diameter temporary healing abutment is placed on the distal fixture that has a 5-mm diameter according to the platform-switching concept.

Figure 16.61

(A) Pre-operative view of the area where three implants were previously placed. (B) Implants were uncovered via an apically positioned buccal flap and palatal semilunar incisions. View of the sutured buccal flap. (C) Healing of the tissue. Note the good quality and quantity of the peri-implant mucosa. (D) Occlusal view of the definitive screw-retained implant-supported restoration.

Figure 16.62

Pre-operative view of an area where four implants were previously placed.

Figure 16.63

Little triangular pedicles obtained from the mucosa palatal to the three last distal implants are interproximally rotated and stabilized in position by crossed horizontal external mattress sutures.

Figure 16.64

Postoperative healing of the area 4 weeks after the uncovering. There is good maturation of the inter-implant tissues.

Figure 16.65

Buccal view of postoperative healing of the area 4 weeks after the uncovering. There is good maturation of the interproximal areas and an adequate scalloped soft tissue profile. The provisional restoration was modified to make room for the temporary healing abutments.

Figure 16.66

Final implant-supported restoration in place. Note the harmonious soft tissue profiles.

Figure 16.67

(A) View of the incision of the area where three implants were previously placed; the first in position of the first bicuspid and the remaining two distal to the natural second bicuspid. The palatal flap is shortened and thinned to reduce final peri-implant probing depths and to eradicate a periodontal pocket palatal to the natural tooth (B) External vertical mattress sutures are used to position the incised tissue at the osseous crest. A screw-retained temporary crown was placed on the mesial implant while healing abutments were used for the distal ones. (C) Healing of the tissues. Note the good quality and quantity of the peri-implant mucosa.

Figure 16.68

(A) Pre-operative view of the area to be uncovered. Together with a buccally positioned envelope flap, a connective tissue graft is planned to plump up the buccal ridge. (B) A straight incision is designed from the canine to the premolar. No vertical incisions are placed. A full thickness flap is reflected and a connective tissue graft is slid under the buccal flap. Note the palatal donor area already sutured and the semilunar incision performed to fully expose the implant platform.

Figure 16.69

(A) The positioned temporary abutment helps to hold the flap up and buccal. Note how the pre-operative buccal concavity has already disappeared. (B) The temporary crown is in place and two internal horizontal mattress sutures are placed in the interproximal areas, while a third one is used to stabilize the connective tissue graft under the buccal flap.

Figure 16.70

(A) Pre-operative view of the edentulous area. Note the good amount of keratinized mucosa but also the marked buccal concavity present after the loss of the natural dental element. (B) After surgical uncovering of the implant the ideal quality and quantity of tissue are present.

Figure 16.71

Pre-operative view of the area where three implants were already placed in the canine and two bicuspids positions. The missing lateral was planned to be cantilevered off the canine. A guided bone regeneration was also performed at the time of implant placement, creating an almost ideal flat ridge profile.

Figure 16.72

(A) The provisional prosthesis is repositioned into place and the use of a surgical marker highlights the ideal desired final position of the gingival margin. (B) The marked line can not be incised where it is due to its proximity to the muco-gingival junction, and it is copied in its design by the actual incision line, which is shifted about 2 mm more coronally without reaching the summit of the ridge (hyphenated line). (C) View of the scalloped partial thickness buccal flap and the palatal semilunar incisions. Healing abutments are in place. (D) Sutures are in place. Note the good amount of keratinized mucosa sutured buccal to the healing abutments and how the inter-implant mucosa has not been incised during the procedure.

Figure 16.73

Final implant-supported prosthesis is in place. Note the good quantity and quality of the peri-implant mucosa surrounding the canine and the bicuspids.

Figure 16.74

A single implant was previously added to those already present to replace the missing left maxillary canine. The plan in the area was to position an implant bridge with the missing lateral cantilevered off the canine. Note at the time of uncovering the flat buccal soft tissue profile in the missing canine area and the slightly concave tissue profile in the lateral incisor location.

Figure 16.75

A partial thickness “envelope” flap is designed where the volumetric increase of the soft tissue is desired. Note the small periosteal elevator lifting the scalloped buccal flap.

Figure 16.76

Two parallel incisions are drawn in the palate: the coronal one at a 90° angle to the underlying osseous plane and the apical one (usually the bleeding one) almost parallel to the bone plane. Note the procured connective tissue graft in the lower left corner box.

Figure 16.77

(A) The connective tissue graft is in place and suturing is completed. (B) The screw-retained temporary bridge is seated in position.

Figure 16.78

(A) Frontal view of the definitive restoration. (B) Occlusal view of the definitive restoration. Note the good quality and quantity of the peri-implant mucosa.

Figure 16.79

Pre-operative view of the area. The mesiobuccal root of the first maxillary molar, now wearing a provisional crown, was previously resected for periodontal reasons. An implant was placed in the edentulous space of the missing second premolar. Note the buccal concavity.

Figure 16.80

A full-thickness flap with a palatine tail is buccally reflected.

Figure 16.81

Suturing is completed. There is an increase in the buccal volume of tissue (compare with Fig. 16.79).

Figure 16.82

Early healing in the area.

Figure 16.83

Mature healing in the area. A soft tissue convexity visible buccal to the implant simulates a root prominence.

Figure 16.84

(A) Completed case with final restorations on the root resected maxillary molar and on the premolar implant. (B) After 8 years the gingival tissue has slightly receded on the crowned molar and on the first premolar while stable mucosal tissue is noticeable buccal to the implant. Note how the previously visible scar distal to the implant has faded away with time.

Figure 16.85

Pre-operative view of the area to be uncovered. Three implants are buried under the tissue. The thickness of the edentulous ridge is reduced.

Figure 16.86

A modified roll technique is selected to uncover the three implants. To simplify the procedure, a vertical palatal release is placed, and the flap with its palatine connective tissue tail is buccally reflected.

Figure 16.87

The tail is tucked under the buccal flap to increase the buccal thickness of tissue while simultaneously reducing the thickness of the palatal tissue. With this technique, the volume of tissue is increased where it is most needed for aesthetics, and the peri-implant palatal probings are reduced.

Figure 16.88

While single interrupted sutures close the vertical-releasing incisions, combined internal (buccally) and external (palatally) mattress sutures close the interimplant areas. As a result, the buccal flap is held up against the healing abutments while compressing the connective tissue tail, and the thinned palatal flap is compressed down against the palatal bone. This kind of suturing will produce a ramp in the soft tissue from the buccal side toward the palate.

Figure 16.89

Final healing of the area. Note the increase in the volume of soft tissue buccal to the implants and the thin tissue palatal to the fixtures (compare with Fig. 16.85).

Figure 16.90

(A) Preoperative buccal view, at the time of second stage surgery, of an implant previously placed to replace the first mandibular molar. (B) The occlusal view of the area after removal of the provisional restoration shows a lack of keratinized mucosa buccal to the implant.

Figure 16.91

In preparation for a free gingival graft a periosteal bed is prepared buccal to the implant and the natural bicuspid.

Figure 16.92

A palatally procured epithelial and connective tissue graft is sutured in position with single and suspended 5-0 Vicryl sutures.

Figure 16.93

Final restorations after 5 years. Note the ideal quality and quantity of keratinized tissue present.

Figure 16.94

Pre-operative buccal view at the time of second-stage surgery to uncover two implants distal to the first mandibular premolar. Note the lack of keratinized mucosa in the edentulous area.

Figure 16.95

A xenogeneic bio-absorbable collagen matrix (Mucograft®, Geistlich Pharma AG) is chosen for the uncovering procedure.

Figure 16.96

The porcine collagenous matrix has been sutured with 6-0 Vicryl on a periosteal bed in a similar fashion of a free gingival graft.

Figure 16.97

Definitive implant-supported crowns are in place and a sufficient amount of immobile keratinized mucosa is now present buccal to the implants.

Figure 16.98

Pre-operative buccal view at the time of second-stage surgery to uncover two implants previously placed in the edentulous area. Note the lack of keratinized mucosa in the edentulous area.

Figure 16.99

A xenogeneic bio-absorbable porcine collagen matrix (Dynamatrix®, Keystone Dental) is sutured in the recipient periosteal bed, buccal to the second premolar and to the two dental implants.

Figure 16.100