Practical Techniques in Periodontics and Implant Dentistry

Edgard El Chaar, DDS, MS, is the former Director of the Advanced Education Program in Periodontics at New York University and currently Professor at University of Pennsylvania, Philadelphia, PA, USA

List of Contributors xiii Introduction xv Part I Fundamentals 1 1 Anatomy and Physiology 3 Edgard El Chaar and Thierry Abitbol Overview of Gingival Tissue and Periodontium 3 Embryonic Development 3 Formation of the Epithelial Attachment 4 Formation of the Cementum, Periodontal Ligament, and Alveolar Bone 4 Soft Tissue Physiology 6 Gingiva 6 Width and Thickness of the Gingiva 6 Histological Composition 6 Epithelial-Connective Tissue Interaction 7 Gingival Fiber Groups 7 Alveolar Mucosa 7 Junctional Epithelium 8 Biotype 8 Periodontal Biotype 8 Anatomy Is Destiny 9 Anatomy 9 Root Surface Anatomy 9 Anterior Teeth 10 Developmental Anterior Grooves 10 Premolars 10 The Root Trunk 11 Maxillary First Molars 11 Mandibular First Molars 11 Cervical Enamel Projections (CEPs) 12 References 12 Further Reading 13 2 Wound Healing 14 Steven Engebretson Definitions and Terms for Clinical Outcomes 14 Inflammatory Phase 14 Proliferative Phase 14 Remodeling Phase 15 Epithelium and Connective Tissue Healing 15 Flap Surgery 15 Free Graft 15 Bone Healing 15 Healing of Extraction Sockets 16 Osseointegration 16 Modifiers of Wound Healing 16 References 17 3 Diagnosis and Pathology of Periodontal Diseases 18 Cecilia White Formulating a Periodontal Diagnosis 18 Periodontal Health and Gingival Health 18 Gingivitis: Dental Plaque-Induced 19 Necrotizing Periodontal Diseases 19 Periodontitis 19 Other Conditions Affecting the Periodontium 20 Periodontal Abscesses 20 Endodontic-Periodontal Lesions 20 Mucogingival Deformities and Conditions Around the Teeth 20 Traumatic Occlusal Forces 20 Prosthesis and Tooth-Related Factors 20 References 21 4 Oral Pathology and Oral Medicine 22 Edgard El Chaar and Arthi M. Kumar Introduction 22 Non-Dental-Biofilm Induced Gingival Diseases 22 Genetic/Developmental Disorders 22 Hereditary Gingival Fibromatosis (HGF) 22 Specific Infections 22 Infections of Bacterial Origin 22 Infections of Viral Origin 24 Infections of Fungal Origin 25 Inflammatory and Immune Conditions 27 Hypersensitivity Reactions 27 Autoimmune Diseases of Skin and Mucous Membranes 27 Granulomatous Inflammatory Conditions 30 Reactive Processes 31 Epulides 31 Pre-Malignant Lesions and Malignant Neoplasms 32 Endocrine, Nutritional, and Metabolic Diseases 34 Traumatic Lesions 34 Physical/Mechanical Insults 34 Chemical/Thermal Insults 36 Gingival Pigmentation 36 Endocrine, Nutritional, and Metabolic Diseases 38 Genetic Disorders 38 Diseases Affecting the Connective Tissues 39 Acquired Immunodeficiency Diseases 41 Inflammatory Diseases 41 Systemic Disorders that Influence the Pathogenesis of Periodontal Disease 41 Further Reading 44 5 Patient Examination and Initial Therapy 50 Claire Mc Carthy, Steve Engeberston, Edgard El Chaar, Mea Weinberg, Stuart L. Segelnick, and Dena M. Sapanaro Medical History for the Dental Patient 50 Clinical and Radiographical Examination 50 Clinical Examination 50 Radiographic Examination 51 Radiographic Artifacts 51 Oral Hygiene 51 Toothbrushing 52 Interproximal Cleaning 52 Interproximal Brushes 52 Dental Floss or Tape 52 Specialized Oral Hygiene Aids 53 Single Tufted Brush 53 Behavior Change Techniques 53 Non-surgical Periodontal Therapy 54 Benefits 54 Limitations 54 Armamentarium 54 Hand Instruments 54 Powered Instruments 54 Techniques 55 Supragingival Debridement 55 Fundamental Elements of Hand Instrumentation 55 Calculus Detection Technique 55 Fulcrums 56 Powered (Ultrasonic) Technique 56 Reevaluation of Initial Therapy 56 Occlusal Therapy 56 Medications and Implications for Periodontal Therapy 57 Sedation: Minimal and Moderate Sedation 57 References 58 Further Reading 58 Part II Principles and Practice of Periodontal Surgery 61 6 Surgical Anatomy and Local Anesthesia 63 Roya Afshar-Mohajer and Babak Hamidi Anatomic Landmarks 63 Mandible 63 Anatomic Spaces 65 Maxilla 65 Conclusion 67 Properties of Local Anesthesia 67 Properties of Ideal Anesthetic 68 Techniques of Local Anesthesia 68 Maxillary Anesthesia 68 Mandibular Anesthesia 68 Further Reading 69 7 Suturing Techniques 70 Mea A. Weinberg, Stuart L. Segelnick, and Edgard El Chaar Principles of Surgical Wound Closure 70 Properties of Suture Materials 70 Suturing Techniques and Indications for Use 72 References 76 8 Osseous Surgery 77 Thierry Abitbol Introduction 77 Osseous Surgery 77 Limitations and Contraindications to Osseous Resective Surgery 78 References 78 9 Functional Crown Lengthening 79 Thierry Abitbol Introduction 79 Checklist 79 Osseous Surgery 80 References 81 10 Root Amputation 83 Wayne Kye and Gretchen Stern Overview 83 Terminology 83 Indications and Contraindications 84 Indications Include 84 Contraindications Include 84 Advantages and Disadvantages 85 Armamentarium 85 Surgical Technique 85 Complications 86 Outcome and Follow-up 86 Implants Versus Root Resection 87 Vital Root Resection 87 References 88 Further Reading 89 11 Guided Tissue Regeneration 90 Edgard El Chaar and Michael Bral Overview 90 Indications 91 Repair and Regeneration in Periodontal Defects 91 GTR for Furcation Defects 91 Technique 91 GTR for Periodontal Intrabony and Circumferential Defects 93 Techniques 94 GTR for the Treatment of Recession Defects 95 Follow-up 97 Further Reading 97 12 Esthetic Crown Lengthening 98 Edgard El Chaar Overview 98 Etiology 98 Treatment 99 Case Surgical Description 99 Post-Elongation Gingival Margin Stability 101 References 101 Further Reading 102 13 Soft Tissue Management in Natural Dentition 103 Edgard El Chaar Overview 103 Classifications 104 Determination of the CEJ 104 Diagnostic and Treatment Considerations Based on Classification of Periodontal Biotypes, Gingiva Recession, and Root Surface Conditions 106 Surgical Management of Mucogingival Deficiencies 106 Free Gingival Graft (FGG) 106 Pedicle Soft Tissue Graft 106 Coronally Advanced Flap (CAF) 107 Sub-epithelial Connective Tissue Graft (SCTG) 107 Allograft 108 Acellular Dermal Matrix 108 Clinical Studies Comparing Soft Tissue Allograft to the SCTG 109 Histological Studies on Soft Tissue Allograft 109 Clinical Case 109 References 111 Further Reading 113 Part III Principles and Practice of Implant Dentistry 115 14 Principles of Implant Dentistry 117 Edgard El Chaar and Aikaterini Georgantza Introduction 117 Steps for Implant Success 117 Factors Affecting the Implant Success 118 Bone Quality Classification 118 Bone to Implant Contact 118 Transmucosal Attachment Around Dental Implants 118 Probing Around Dental Implants 118 Biological Width Around Implants 119 The Microgap: Interface Between Implant and Abutment 119 Platform Switching 119 Fundamental Criteria in Implant Placement: Healed Ridges 120 Implant Surface Topography 120 Implant Topography on Wound Healing 120 Implant Materials 120 Bone Healing 120 Principles of Surface Treatment, Topographies, and Roughness 121 Implant Design 121 Implant Surface Topography 121 Implant Surface Specificities: Advantages and Disadvantages 121 References 122 Further Reading 124 15 Examination and Diagnosis 125 Zahra Bagheri Radiographic Examination 125 Cone Beam Computed Tomography 125 Clinical Parameters 125 Clinical Examination 126 Factors Influencing Surgical Management 126 Factors Influencing Prosthetic Parameters 126 References 127 Further Reading 127 16 Prosthetic Considerations 128 Zahra Bagheri Review of the Esthetic Parameters 128 The Prosthetic Space 129 Temporization 129 Critical Space 129 Subcritical Space 130 Buccal Contour 130 Final Restoration 130 Abutment Options 130 Cemented Versus Screw Retained 130 Restorative Materials 130 References 131 17 Digital Workflow in Surgery 132 Edgard El Chaar Introduction to Digital Dentistry 132 Terminology 132 Description of STL 132 Description of 3D Volume 133 Applications of Interactive Software 133 Intra-Oral Scanners (IOS) 133 Virtual Implant Software Planning 133 Drilling Surgical Guide 134 Use of Guided Surgery in Immediate Implant Placement 134 Full Arch Guided Surgery 135 Aid in Ridge Deficiency Diagnosis 135 References 137 Further Reading 137 18 Socket Management 138 Aikaterini Georgantza Anatomical Features of the Alveolar Process 138 The Alveolar Process 138 The Alveolar Bone Proper 138 Alveolus and Extraction Socket 138 The Alveolar Ridge 138 Classification of Remaining Bone 138 Alterations of the Alveolar Process Following Tooth Extraction 138 Biological Events and Histologic Ridge Alterations 138 Overview of the Histologic Sequence of Healing 139 Dimensional Ridge Alterations 139 Clinical Implications for Ridge Preservation and Implant Treatment 139 Atraumatic Tooth Extraction 140 Indications for Ridge Preservation 140 Contraindications for Ridge Preservation 140 Ridge Preservation Procedures 140 Maintenance of the Root and the Socket Shield Technique 140 Forced Eruption 140 Socket Grafting 140 Management of Socket at the Esthetic Zone 141 Extraction Socket Classifications 141 Timing of Implant Placement 142 Immediate Implant Placement 142 Early Implant Placement with Partial Bone Healing (12-16 Weeks) 144 Late Implant Placement Complete Bone Healing (>6months) 144 References 145 Further Reading 146 19 Deficient Ridges Augmentation 147 Edgard El Chaar, Aikaterini Georgantza, and Wayne Kye Crestal Sinus Elevation 147 Background 147 Indications 147 Armamentarium 148 Surgical Technique 148 Complications 148 Follow-Up 149 Lateral Sinus Floor Elevation 149 Background 149 Indications 149 Grafting Materials 149 Anatomical Considerations 150 Armamentarium 150 Surgical Technique 150 Complications 151 Prevention of Complications 151 Follow-up 151 Ridge Augmentation 151 Fundamentals of Ridge Augmentation 151 Surgical Techniques 152 Ridge Classifications 152 Seibert 152 Expectations of Ridge Augmentation 153 Horizontal Ridge Augmentation 153 Vertical Ridge Augmentation 153 Fundamentals of Successful Surgical Technique 156 Clinical Case of Ridge Augmentation 156 References 158 Further Reading 159 20 Soft Tissue Assessment and Enhancement in Implant Dentistry 161 Edgard El Chaar Introduction 161 Techniques to Create Contour, Thickness, and Increase Keratinized Tissue 161 A-Flap Management 161 Roll Technique 163 Autograft Subepithelial Connective Tissue (CTG), a Free Gingival Graft (FGG), or Allograft Dermis 165 Free Gingival Graft (FGG) 165 Connective Tissue Grafts (CTG) 166 Techniques for Papilla Management 172 Rotated Pediculated Marginal Tissue 172 Rotated Pediculated Lingual Marginal Tissue 172 Techniques of Soft Tissue for Extraction Socket Grafting 173 References 176 Further Reading 177 21 Peri-Implant Diseases 178 Edgard El Chaar and Cecilia White Introduction 178 Prevalence 178 Criteria for Diagnosis of Peri-implantitis: Case Definition 179 Risk Factors 179 History of Periodontitis 179 Implant Maintenance 179 Number of Implants 179 Clinician Experience 179 Implant Brand 179 Smoking 179 Microbiota 180 Treatment 180 Nonsurgical Therapy 180 Peri-implant Mucositis 180 Peri-implantitis 180 Surgical Treatment 181 What Is the Most Predictable or Superior Treatment Modality? 181 Clinical Case to Illustrate Peri-implantitis Treatment 182 References 184 Index 187