Practical Techniques in Periodontics and Implant Dentistry

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 ofWound 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 SurgicalWound 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 onWound 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 (12–16Weeks) 144

Late Implant Placement Complete Bone Healing (>6 months) 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