Title Page
Copyright Page
Foreword
Preface
Acknowledgements
Chapter 1 Principles and Practice of Periodontal Surgery 1: Case Selection and Planning
Aim
Outcome
The Art and Science of Surgery
The Right Procedure
The Right Patient
Preoperative Management
Record-Keeping
Antimicrobial Chemotherapy
Analgesia
Surgical Analgesia and Haemostasis
Operative Management
Post-operative Management
Achieving Post-operative Haemostasis
Analgesia
Post-operative Instructions
Review Visit
References
Further Reading
Chapter 2 Principles and Practice of Periodontal Surgery 2: Basic Surgical Principles
Aim
Outcome
Introduction
Tenets of Halsted
Operative Management
Flap Design
Incision
Reflection
Retraction
Bone Management
Flap Compression and Closure
References
Further Reading
Chapter 3 Surgical Management of Gingival Overgrowth
Aim
Outcome
Introduction
Drug-induced Gingival Overgrowth
Inflammatory Gingival Overgrowth
Epulides
Hereditary Gingival Fibromatosis
Presurgical Management
Reasons for Surgical Intervention
Some Medical Considerations
Surgical Management
Gingivectomy
Inverse Bevel Incisions for Tissue Debulking
Epulis Excision
Wedge Excision
Periodontal Dressings
Maintenance
Further Reading
Chapter 4 Access Flaps for Surgical Root Surface Debridement
Aim
Outcome
Introduction
Presurgical Management
Aggressive Periodontitis
Surgical Management
Objectives of Surgical Root Surface Debridement
Simple Replaced Flap (Envelope Flap)
Removal of granulation tissue
Root surface instrumentation
The Modified Widman Flap
Suturing
The Use of a Periodontal Pressure Dressing
Post-operative Instructions
Review
Periodontal Maintenance
Key Points
References
Further Reading
Chapter 5 Regenerative Periodontal Techniques
Aim
Outcome
Introduction
Terminology
Biological Principles Underpinning GTR
Surgical Planning for Membrane GTR
Indications
Contraindications
What Went Wrong in Practice and Why?
Objectives of GTR surgery
Criteria for Success
The Need for Two-stage Surgery
Case Selection and Planning
The Surgical Phase
Post-operative Care
The Outcome of GTR
Modifications to the Original Membranes
Resorbable GTR membranes
Enamel Matrix Proteins (Emdogain)
Bone Grafting and Bioceramic Bone Substitutes
Cocktail Procedures
Growth Factors
Guided Bone Regeneration
Key Points
References
Further Reading
Chapter 6 Periradicular Surgery
Aim
Outcome
Introduction
Orthograde Retreatment or Periradicular Surgery?
Case Selection
Indications for Periradicular Surgery
Contraindications for Periradicular Surgery
Holistic Restorative Treatment Planning
Tooth-specific Assessment
Site-specific Surgical Contraindications
Alternative Treatment Options and their Predictability
Operator-related Factors
Patient-related Factors
Pre-surgical preparation
Presurgical Endodontics
Informed Consent
The Surgical Phase
Analgesia
Flap Design
Incision
Reflection
Root End Identification and Curettage
Root End Resection
Crypt Control
Root-end Preparation
Root-end Restoration
Closure
Post-surgical Management
Key Points
Further Reading
Chapter 7 Resective Hard Tissue Surgery
Aim
Outcome
Introduction
Examination, diagnosis and treatment planning
Indications for Root Amputation/Resection and Hemisection
Contraindications to Resective Surgery
Assessment of Teeth for Resective Surgery
Tooth-specific Assessment
General Assessment
Procedure
Presurgical Preparation
When should endodontic treatment be performed?
Furcation Plasty
Tunnelling
Root Amputation and Hemisection
Definitive Restoration
Maintenance
Key Points
Further Reading
Chapter 8 Crown-lengthening Surgery
Aim
Outcome
Introduction
Biological Width
Case Selection
Indications for Croum-lengthening Surgery
Contraindications for Croum-lengthening Surgery
Holistic restorative treatment planning
Tooth-specific assessment
Gingival assessment
Aesthetic considerations
Alternative treatment options and their predictability
Presurgical Preparation
Tooth Preparation
Informed Consent
Surgical Procedures
Gingivectomy
Apically Repositioned Flap Surgery
Osseous Reduction
Post-surgical Management
Key Points
References
Further Reading
Chapter 9 Mucogingival Grafting Procedures – An Overview
Aim
Outcome
Introduction
Risk Factors for Gingival Recession
Miller’s Classification of Recession
Management of Gingival Recession
Presurgical Management
Indications for Surgical Intervention
Case Selection and Outcome-related Factors
Preparatory Treatment
Root Preparation
Surgery
Free Soft Tissue Graft Procedures
Free gingival grafts
Subepithelial connective tissue graft
Pedicle Soft-tissue Graft Procedures
Double-papilla repositioned flap
Coronally positioned flap
Post-operative Instructions
Creeping Attachment
Assessing Outcomes
Key Points
References
Chapter 10 Hard Tissue Surgery (Ridge Augmentation) for Dental Implants
Aim
Outcome
Introduction
Operative Management
Bone Augmentation Procedures for the Anterior Maxilla
Bone Augmentation Procedures for the Posterior Maxilla
Bone Augmentation Procedures for the Mandible
Factors Affecting Success
Key Points
References
Further Reading
Chapter 11 Soft Tissue Surgery Around Dental Implants
Aim
Outcome
Introduction
Peri-implant Soft Tissue Characteristics
Implants Do Not Have a Periodontal Ligament
Implant Components Affect Soft Tissue Behaviour
Soft Tissue Quality
Mucogingival Procedures Around Implants
Types of Peri-implant Surgical Procedures
Timing of Surgical Procedures Around Implants
Free Epithelialised Soft Tissue Graft
Recipient Site Preparation
Epithelialised Graft Harvest from Hard Palate (Fig 11-3a–d)
Graft Modification
Insetting the Graft
Grafting at Second Stage Surgery
Late Procedures
Free Connective Tissue Grafts
Local Peri-implant Flap Procedures
Simple Flap Adaptation
Semi-submerged Healing
Tissue Punch Exposure
Palatal “U” Flap Exposure
Papilla Creation Technique
The Roll Flap
Key Points
References
Further Reading
Quintessentials of Dental Practice – 21
Periodontology – 7
British Library Cataloguing in Publication Data
Contemporary periodontal surgery: an illustrated guide to the art behind the science. - (Quintessentials of dental practice; v. 21)
1. Periodontics 2. Dentistry, Operative
I. Bateman, Geoffrey
617.6′32
ISBN: 1850973024
Copyright © 2007 Quintessence Publishing Co. Ltd., London
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN: 1-85097-302-4
Periodontal surgery; an integral element of the clinical practice of periodontology is both a science and an art. It spans a broad range of procedures involving the supporting tissues of the teeth, and has been extended in recent years to include soft tissue surgery in relation to dental implants. Contemporary Periodontal Surgery: An Illustrated Guide to the Art behind the Science concludes an excellent collection of volumes on periodontology in the Quintessentials of Dental Practice series. In common with all the other Quintessentials volumes on periodontology, let alone the other titles in the series, this book is an engaging, easy to read and extensively illustrated, authoritative overview of the subject area. If you have formed the view that surgery has little, if any, part to play in the modern clinical practice of periodontology, then it is especially important that you become familiar with this book, and use it, as intended, as a close-to-hand aide memoire in your clinical environment. The few hours it takes to read this volume will be time exceedingly well spent, with the prospect of you changing your clinical practice of surgical periodontology. If every picture says a thousand words, then this neat Quintessentials-sized volume is a deceptively small sized tome on periodontology; it is a veritable feast of valuable information of immediate practical relevance. Intrigued? Well, read on, enjoy and learn; this book – a scientific and artful text on modern periodontal surgery, will exceed your expectations.
Congratulations to the authors and editor on adding to the excellence of the Quintessentials series.
Nairn Wilson
Editor-in-Chief
Contemporary Periodontal Surgery is a book that aims to take the practitioner on a journey through the fundamentals of careful case selection and holistic pre-surgical planning, through the informed consent process and into the intricacies of periodontal microsurgery and post-surgical care, in an illustrated and stepwise manner. One of the key factors that differentiates periodontal surgery from other forms of oral surgery, is that the condition, shape and contours of the marginal and interproximal tissues post-surgery are fundamental outcome measures of the success of the operation. Ifa patient is unable to effect high standards of home care following periodontal surgery due to poor tissue contours, the surgery is likely to fail in the medium to longer term. Thus, delicate tissue management and attention to detail when closing surgical wounds is a prerequisite for success, as is the use of magnification, good field illumination and microsurgical instrumentation. These are a vital component of contemporary periodontal surgery.
One of the key paradigms which differentiates the best surgeon from the average surgeon is the working philosophy that “the feasibility of an operation is not an indication for its execution”; in other words, just because an operation is technically feasible does not mean that it is the correct thing to do for every patient in every situation. Competent surgeons think beyond the operation to its consequences and in particular the relative suitability of other approaches: sometimes the correct decision is the decision not to operate. A further consideration is that as a general guide, surgery has no place in the management of medical conditions; these require medical management, unless all medical options have failed. In this scenario, surgery is a last resort and as such should be contemplated with great caution.
This text therefore aims to provide the reader with a clear guide to planning periodontal surgery and an illustrated approach to the execution of a range of periodontal surgical procedures. The core principles underpinning treatment decisions and planning are discussed alongside the fundamentals of preparing the patient and the surgeon for the operation. A number of tips are provided to ensure patient comfort and the creation of an optimal operative field, thereby ensuring a smooth procedure, which minimises the risk of unforeseen events.
The techniques covered include resective procedures for diseased or unsightly tissues, mucoperiosteal flap access procedures and plastic surgery procedures designed to regenerate and replace lost or inflamed tissues. Finally, procedures executed to augment hard and soft tissues in preparation for implant placement are discussed.
This text will not focus on the aetiology of lesions or conditions requiring surgical management; this is covered in earlier books in this series. It is hoped that having read this text the reader will be able to:
Appreciate the alternative approaches to surgical intervention and when these may be more appropriate than the proposed surgery for a particular patient.
Understand that managing medical conditions surgically is inadvisable and should only be contemplated as a last resort. Thus, no operation should be contemplated without a clear diagnosis, and clear surgical objectives that will benefit the patient.
Understand the scope of periodontal surgery and the principles underpinning its safe practice.
Appreciate the aims and objectives, indications and contraindications for periodontal surgery.
Understand the impact of a patient’s medical history upon the decision to operate or not.
Understand and appreciate the need for and importance of informed consent.
Appreciate the importance of sterile and aseptic technique.
Understand the importance of and stages required for, pre-surgical and surgical planning.
Be able to interpret the findings of routine clinical investigations (e.g. blood test results) and use these to inform their case planning.
Be familiar with analgesic methods and those necessary to manage haemorrhage.
Value and understand the tangible additional benefits of using appropriate magnification and field illumination.
Appreciate the complications that may arise during an operation and immediately afterwards as well as in the medium and longer term.
Have good knowledge of the principles of surgical flap design and execution as well as debridement and closure.
Understand the differences between different flap compositions and designs and what may be most appropriate for different situations.
Appreciate the importance of delicate handling of tissues and meticulous surgical technique to minimise tissue trauma.
Advise their patient about immediate and longer term post-operative care.
Identify their limitations and when to refer for advice or treatment by specialists.
Be prepared to commit to regular review and re-appraisal of the patient and take long term responsibility for surgical outcomes.
Iain L C Chappie (ILC)
Professor Chappie wishes to thank his wife Liz and daughters Jessica and Natasha for their love and continued patience and forbearance during the lost evenings and weekends spent on the preparation of this 7th book of the series. Thanks also to his parents Beryl and Arthur Chappie for their faith and gentle life coaching.
Dr Bateman wishes to thank his wife Shuva for her love and continual inspiration. He would also like to thank his mentor, Mr Chris Allan, whose clinical excellence in restorative dentistry is truly exemplary.
Dr Saha wishes to thank her husband, Geoff, for his love and support whilst writing this book. She would also like to thank her parents, Broja and Kalpana Saha for their guidance and unwavering encouragement.
We are also grateful to Mr Michael Sharland and Ms Marina Tipton (Multimedia Services, Birmingham Dental School), Mr Jason Pike and colleagues (Clinical Illustration, Birmingham Dental Hospital). Images 4-10, 4-11, 4-12, 8-8a–b and 9-3a–j were reproduced from Sato Periodontal Surgery: A Clinical Atlas, Quintessence 2000 (ISBN 0-86715-377-6) and images 10-1 and 10-4 to 10-8 were based on figures in Pallacci Esthetic Dentistry. Soft and Hard Tissue Management, Quintessence 2001 (ISBN 0-86715-392-X). Thanks also to Dr A Roberts for the use of Figs 7-5a–h and 7-12a–c; Dr Phil Tomson for the use of Figs 2-7, 6-7, 6-11, 6-12, 6-22 and to Professor Philip Lumley for the use of Figs 6-1a–c.
The aim of this chapter is to provide the reader with a philosophy for case selection and treatment planning in periodontal surgery. Treatment objectives for predictable surgical management will be detailed alongside the principles common to different surgical procedures.
Having read this chapter the reader will be able to carefully plan a surgical case and identify potential pitfalls on a case-by-case basis. The standardised evidence-based protocols described will help to enhance the operator’s existing surgical preparation, irrespective of the type of surgery planned.
Periodontal surgery is both a science and an art. The periodontal surgeon should be both knowledgeable and ready to adapt their practice in line with the best research evidence. They should be able to critically appraise this evidence in an objective manner. In addition, the technical aspects of surgery require fine motor skills, gentle tissue handling and the visual anticipation of how a flap will close: this is the art of surgery. Surgical management requires a marriage of both of these facets, if excellence is to be achieved. Surgical skill comes through both didactic and observational learning, thorough experience and, to a lesser extent, the surgeon’s innate dexterity. The importance of education, therefore, cannot be overstated.
The other key aspect of good surgical management is regular practice to guard against de-skilling. The practitioner should be ready to appraise their own abilities and not undertake cases beyond their limits of competence; these may change throughout the course of their career.
The archetypical Renaissance man, Leonardo da Vinci, was an example to modern-day surgeons. In his era, science and art were not regarded as mutually exclusive entities. His studies in science and engineering were as accomplished as his drawing and painting. Leonardo’s drawing skills developed through his study of anatomy. A reproduction of one of his head and neck dissections may be found on the front cover of this text.
It is axiomatic that careful diagnosis and prescription of the right procedure are a sine qua non of surgical management. Future chapters will explore a selection of more popular surgical techniques and their indications in greater depth. The dental surgeon should be aware, however, of the nature and sequelae of the proposed treatment and be competent to carry out that treatment where appropriate. It follows that a full and frank discussion with the patient is necessary to gain informed consent. Informed consent should detail benefits, risks, other treatment options to be considered and what will happen if treatment is not carried out. Under common law, a conscious and competent patient needs to provide verbal consent to any operative procedure, although where sedation or deeper anaesthesia is employed, written consent is mandatory. Patients should also be provided with a written treatment plan and an estimate of costs.
Appropriate patient selection is important if high success rates are to be achieved and maintained with surgery. There are few absolute contraindications to surgery in general dental practice.
Common contraindications include:
severe bleeding diatheses
congenital, e.g. haemophilia and von Willebrand’s disease
acquired, e.g. warfarinised patient with a high INR (international normalised ratio ≥ 3.5)
significantly immunocompromised patients, e.g. acute leukaemia
unstable angina
poorly controlled diabetes
uncontrolled hypertension.
With few exceptions, periodontal surgical procedures are elective in nature. All attempts should be made, therefore, to postpone surgery for medically compromised patients until such time as systemic complications are stabilised.
Those patients with relative contraindications require careful consideration. These include medical, social and compliance-related factors.
In the United Kingdom, management of patients who require antibiotic prophylaxis for endocarditis has been greatly simplified through the introduction of new guidelines from the British Society of Antimicrobial Chemotherapy (BSAC) (Gould et al., 2006). These guidelines have not, however, been universally accepted at the time of this book going to press.
Patient groups requiring antibiotic prophylaxis have been reduced to three:
those with previous endocarditis
those with heart valve replacement
those with surgically constructed systemic or pulmonary shunts.
All dentogingival manipulations for these patients require antibiotic cover. There is no longer a need to provide intravenous antibiotic cover; oral antibiotic cover is now considered sufficient. Older BSAC guidelines are still published in the British National Formulary (BNF), and medicolegally either is acceptable as the guidance and advice of a recognised and properly constituted expert group.
Other relative medical contraindications should be considered practically on a case-by-case basis and treatment provided following careful appraisal of risks and assessment of response to previous surgical intervention.
Addiction poses particular problems in the management of surgical patients. Smoking is a significant risk factor for periodontal surgical failure and failure of implant placement. Alcohol dependence will predispose to excess bleeding where liver function has been impaired. It is important to consider that patients with liver disease may be thrombocytopenic as well as having abnormal clotting factor levels. In such cases, a full blood count must be taken in addition to an INR (prothrombin time). Platelet levels below 60,000/ml of whole blood represent a risk for surgical intervention. The disordered lifestyle led by some alcoholics may compromise the delivery of the planned regular care necessary for surgical success. It may be sensible to suggest other treatment approaches for these patients.
Phobic patients or those with poor compliance are generally less suitable for periodontal surgery than others. Often these procedures may be relatively time-consuming and technically demanding for the operator. Whilst conscious sedation techniques may render treatment possible for these patients, anxiety and poor coping skills may render the post-surgical phase relatively stormy and future management more difficult. Again, simpler, nonsurgical treatment options may be more appropriate for such patients.
Careful preoperative management and planning will often simplify surgery itself and allow a more predictable post-operative healing phase. Meticulous record-keeping and the use of evidence-based practice should be observed in this regard.
As discussed previously, the informed consent process is vital and should be well documented. General risks are involved in any surgical procedure and should be discussed with the patient. These include pain, swelling, bruising and bleeding. Many of these can be minimised with careful technique. Risks specific to the particular procedure should also be discussed. These include, for example, gingival recession in areas of aesthetic importance and the potential for paraesthesia where surgery is in close proximity to neurovascular bundles. Consent forms are a useful adjunct in the consent process where sedation or general anaesthesia is contemplated. A copy should be retained in the patient notes and another given to the patient.
Where aesthetic change is planned or is a risk, it is valuable to obtain photographic records so that before and after comparisons may be made. Study models are also helpful in this regard. Recession defects, for example, may be monitored over time and assessed for change after surgery. Where there is chronic periodontitis, as a minimum standard an up-to-date detailed pocket chart should be recorded before any surgery is planned. Good quality contemporary radiographs are an invaluable patient record, as well as a useful aid for diagnosis and surgical planning.
Periodontal inflammation is most frequently plaque-induced. Whilst surgical insult to oral mucosal tissues will also induce an inflammatory response, this will be amplified by poor preoperative plaque control and prolonged by inadequate post-operative cleaning. Prolonged inflammation will potentiate post-operative discomfort and compromise healing by primary intention.
It is important to ensure that oral hygiene is optimal prior to surgery. A 0.2% chlorhexidine gluconate mouthwash (Fig 1-1) four times daily (q.d.s.) one week prior to and two weeks post-surgery is invaluable in this respect. This has been shown to reduce discomfort and promote healing (Newman and Addy, 1982). In addition, chlorhexidine used immediately preoperatively has been shown to reduce the bacterial load and aerosol contamination of the operative area and surrounding environment.
The notion of pre-emptive analgesia is growing in importance in surgical management. This is based on the principle that preoperative administration of NSAIDs (non-steroidal anti-inflammatory drugs) will diminish the tissue response to the cascade of pain messengers induced by surgical insult. This in turn will reduce the potential for peripheral or central sensitisation to pain and prolonged post-operative discomfort. The beneficial use of preoperative NSAIDs has been demonstrated in a number of studies. The authors would recommend a single dose of 800 mg ibuprofen preoperatively where appropriate. Currently, this drug and dosage taken three times daily represent the gold standard for pain relief. British National Formulary (BNF) guidelines would suggest commencing on 400 mg ibuprofen three times daily (t.d.s.), and this is a departure from the guidance. Practitioners should therefore exercise caution in this respect. Where ibuprofen is contraindicated owing to gastrointestinal erosion or asthma, 1000 mg of paracetamol is usually a safe alternative.
The term “anaesthesia” is used most often in dentistry to describe the local phenomenon of absence of painful sensation following delivery of local anaesthetic drugs. As the effect is, in fact, a local absence of pain, and patient consciousness is not altered, the term surgical analgesia is used preferentially throughout this book.
Profound analgesia is a prerequisite for high-quality periodontal surgery, and achieving this is time well spent to overcome partial or total loss of analgesia intra-operatively. Haemostasis, however, is also of critical importance as a relatively “dry” operating site will improve visibility and thus render treatment very much more predictable. The use of local anaesthetic drugs is important for delivery of these haemostatic agents (i.e. epinephrine).
Analgesia for surgery, unfortunately, is not wholly predictable. Studies have shown, for example, that a positive lip sign after administration of inferior alveolar block is a poor indicator of analgesic success (Dreven et al., 1987). The choice of local anaesthetic agent is important. The agent articaine has enjoyed widespread popularity in general practice. Anecdotally, this agent provides profound analgesia. It has not, however, been shown to be any more effective than lidocaine with 1:100,000 epinephrine (Mikesell et al., 2005). In addition, the incidence of paraesthesia with articaine has been shown to be significantly increased, presumably as a result of the increased concentration of anaesthetic agent.
Of particular significance in surgery is the concentration of vasoconstrictor agents. The use of greater concentrations of epinephrine in local anaesthetics has been shown to effect an improvement in haemostasis. In particular the use of lidocaine with 1:50,000 epinephrine (Fig 1-2) produced more than a 50% improvement as compared with lidocaine with 1:100,000 epinephrine (Buckley et al., 1984). This is an effective drug for local infiltration analgesia with proven safety. The use of a slow infiltration (1 ml/minute) technique has been recommended.