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
