Otto Zuhr Marc Hürzeler

PLASTIC-ESTHETIC PERIODONTAL AND IMPLANT SURGERY

OTTO ZUHR MARC HÜRZELER

PLASTIC-ESTHETICPERIODONTALAND IMPLANTSURGERYA Microsurgical Approach

With the support of Bärbel Hürzeler and Stephan Rebele

London, Berlin, Chicago, Tokyo, Barcelona, Beijing, Istanbul, Milan, Moscow, New-Delhi, Paris, Prague, São Paulo, Seoul, Singapore, and Warsaw

British Library Cataloguing-in-Publication Data

Zuhr, Otto.

Plastic-esthetic periodontal and implant surgery :

a microsurgical approach.

1. Periodontium--Surgery. 2. Dental implants.

3. Microsurgery. 4. Surgery, Plastic.

I. Title II. Hurzeler, Marc.

617.6’320592-dc23

ISBN 978-1-85097-226-6

Quintessence Publishing Co. Ltd,

Grafton Road, New Malden, Surrey KT3 3AB,

United Kingdom

www.quintpub.co.uk

© 2012 Quintessence Publishing Co, Ltd

All rights reserved. This book or any part thereof may not be repro-

duced, stored in a retrieval system, or transmitted in any form or

by any means, electronic, mechanical, photocopying, or otherwise,

without prior written permission of the publisher.

Design: fpm, Factor Product München

Drawings: Angelika Kramer, Stuttgart

Translation: Suzyon O’Neal Wandrey, Berlin, Germany

Editing: Bryn Grisham, Quintessence Publishing Co, Inc

Medical editing: Dr. Chee Wan Ang, BDS, Singapore

Production and Reproduction:

Quintessenz Verlags-GmbH, Berlin

Print: Bosch Druck GmbH, Landshut/Ergolding

Printed in Germany

for Kira, Emma, Paula, and Oskar

  vii

Preface

One of the really significant stories relating to the creation of this book happened at the beginning of 2005, in our old apartment in Munich, Germany. Like so often, my little daughter Emma was sitting beside me at my desk chatting while I was working at the computer, desperately trying to make some progress on the book manuscript. I can still remember the exact moment when she suddenly changed the subject and more or less asked me pointblank what color the book would be. Taken by surprise, I tried to explain to her that I had just started working on the book and that the last thing on my mind at that moment was the color of the book. However, she did not let up. To make a long story short, I finally had no other choice but to actually swear on my “great princess’s honor” that the cover of the book, should it one day ever get finished, would be printed up in her favorite color. So it happened that I had to insist on having the book bound in pink despite the serious concerns raised by the publisher. In the end, the responsible parties at Quintessence accepted under protest. My reason for choosing that color, therefore, was not to attract more attention or to make allusions to “pink esthetics” but solely to honor my reckless promise to my daughter Emma, whose favorite color is pink…

At this point, I would like to extend my sincere gratitude and appreciation to the senior management of Quintessence Publishing—HorstWolfgang Haase, Alexander Ammann, Christian Haase, and Johannes Wolters—not only for bearing with my color choice but also for the great confidence and trust they have placed in me, for their enduring patience throughout this book project, which was indubitably trying at times, and, not least, for their tremendous support, cooperation, and partnership over the last few years. Many thanks also to Janina Kuhn, Ina Steinbrück, Valeri Ivankov, and Peter Rudolf for turning the manuscript into an actual book. In partic ular, I am deeply indebted to Peter Rudolf, who gave me the reassurance and peace of mind straight from the beginning that he was doing everything possible to make this book the best it could be. Thanks also to Christine Rose, Florian Curtius, Andreas Dollinger, and Jens Hoepfner

for processing the clinical photographs for print and to the Quintessence TV team of Gerd Basting, Martin Jakovljevic, Fabian Pietsch, and Ireneusz Watola for producing the videos for the accompanying video compendium. Credit also goes to Angelika Kramer for her dedication and commitment in preparing the drawings and to Stefan Bogner, Annette Bauer, and Stephen Wittmann for their assistance in developing the layout for this book. My thanks also go to Suzyon O’Neal Wandrey for the English translation and to Chee Wan Ang for the enormous effort he undertook in proofreading the English version of this manuscript.Furthermore, I would like to take this opportunity to thank all of my teachers, even if it is not possible to mention every single one of them by name here and now. In my years as a dentist and periodontist, I have had the extraordinary luck to work with a lot of great personalities in our field. I was not only able to see them in action and learn from these great teachers but also had the chance to engage in intense discussion, discourse, and debate with some of them on a large number of topics. In particular, I would like to thank Wolfgang Bolz and Hannes Wachtel for their longstanding support of my professional development and for many inspiring years of common ground…

Looking back, I can hardly put into words how much time and energy have actually gone into work on this book. This inevitably led to gaps in coverage of the daily needs and requirements for qualityoriented practice management and treatment, which had to be compensated for and closed by others. In this context, my most profound thanks to my dental practice team, Bärbel Hürzeler, Marc Hürzeler, Wolf Richter, and all our hardworking dental assistants, dental hygienists, and administrative staff: Thank you for your openminded and sincere teamwork and for your ceaseless and unswerving pursuit of our ultimate goal of making patient care at our dental practice a little bit better each day, year after year. To Stefan Fickl, who stepped in to help us when we had just started and were shorthanded, many thanks indeed. In addition, I owe my respect to the ar

viii  Preface

tist and sculptor Gerd Bischur, who was instrumental in the creation of object images and provided support in all aspects relating to digital photography. I am also deeply indebted to the dental laboratory technicians who performed all the prosthetic work in the scope of this book project and who have basically been a part of my team ever since I started my professional life: Rainer Janousch, Uli Schoberer, and Uli Werder. My special thanks go to Uli Schoberer for his exceptional analytical, creative, and technical skills, for his fundamental belief that a treatment outcome that is inferior to that which is technically feasible is never acceptable, and for his spirit of brotherhood.The idea of having the book manuscript critically reviewed from the student perspective prior to its final completion proved to be a correct and rewarding decision: I would like to thank Stephan Rebele not only for drafting the rough sketches of the illustrations in this book but also for critically reading and creatively evaluating the manuscript. His input ultimately led to didactically valuable changes and additions in different parts of the book. I am also deeply indebted to Bärbel Hürzeler for the enormous amount of time she spent proofreading our manuscripts without complaint at various stages of development of this book, for the razorsharp intellect with which she consistently enriched and constructively supported the book’s development, and for her big heart.

Last but not least, I would like to thank Marc Hürzeler for his unparalleled way of practicing dentistry with a passion that is irresistibly motivating and contagious, for always being a model of partnership and team spir it for me, for standing by me all these years, and for helping whenever I needed him, without exception, without question, and without having to be asked: I feel extremely grateful and fortunate that our paths crossed. Without you, this book would never have become reality—my colleague, partner, very best friend…

With the deepest respect, I would like to thank my parents, Marianne and Otto, and my sisters, Marianne and Barbara, for showing and setting the example for me of what a home and family should be, for always allowing me to be who I really am, and for giving me their unconditional love.From the bottom of my heart, I would most like to thank my children, Emma, Paula, and Oscar, for opening my eyes and, especially, my wife, Kira, for her endur ing strength, serenity, and wisdom and for the contin uous flow of energy, warmth, and love with which she has supported and motivated me over the years—I could not imagine living without you for one second. I love you, to the moon and back…

Uffing (Germany), September 2011 Otto Zuhr

ix ix

10

8

4

976

5

2

1

3

1 Uli S. 2 Stefan 3 Stephan 4 Wolf 5 Rainer 6 Gerd 7 Otto 8 Bärbel 9 Marc 10 Uli W.

xi

It is our deepest conviction that the surgical potentials of the present can only be achieved by consistently following a surgical approach in which minimal soft tissue trauma and maximally perfect wound closure are key elements.

xiii

Contents

A Principles

1 BasicPrinciplesofPeriodontalAnatomyandStructuralBiology 22 Microsurgery:ANewDimension 363 PrimaryHealing:TheKeytoSuccess 684 Incisions,FlapDesigns,andSuturingTechniques 845 GingivalEsthetics:Criteria,Guidelines,andDiagnosticStrategies 1186 PatientManagement 156

B Procedures

7 AutograftHarvesting 1928 GingivalAugmentation 2549 TreatmentofGingivalRecession 28210 EstheticCrownLengthening 40611 PapillaReconstruction 47012 ManagementofExtractionSockets 51213 ReplacementofMissingTeeth 608

C Complications

14 IntraoperativeBleeding 80215 FlapPerforation 80816 PostoperativeBleeding 81217 PostoperativeInfection 81618 FlapandConnectiveTissueGraftNecrosis 82219 FailureswithAutogenousBoneBlocksandCorticalBonePlates 82620 ImplantLoss 83021 Scars,Tattoos,andExcessSoftTissue 83422 BiologicWidthViolation 842

Appendix

Materiallist 850 Index 851

102    A  Chapter 4  Incisions, Flap Designs, and Suturing Techniques

e

a b

c d

Fig 4-16(atoe)  The internal horizontal mattress suture is the most commonly used tension-relieving suture in plastic periodontal and implant surgery. The needle is inserted buccally, 2 to 4 mm from the flap margin, and is passed through both flaps. Next, the needle is inserted at a horizontal distance of 3 to 5 mm from the first insertion site and is passed back from lingual to buccal, form-ing a parallel (or crossed) suture.

ten result in inversion of the wound margins, which com-plicates suture closure and promotes postoperative scar formation. Inverted wound margins can also complicate future scar correction.For these reasons, the internal horizontal mattress su-ture is the type of tension-relieving suture most com-

horizontal, internal or external. The type best suited for relieving tension on the wound margins is the internal horizontal mattress suture. Internal horizontal mattress sutures result in eversion of the wound margins, which greatly simplifies closure with interrupted sutures or with one continuous suture. External mattress sutures of-

Incisions, Flap Designs, and Suturing Techniques  Chapter 4  A    103

f g

h

Fig 4-16(ftoh)  Tension-relieving sutures facilitate tension-free approximation of the wound margins. When the knot is tied, the wound margins are everted, facilitating wound closure.

monly used in plastic-esthetic periodontal and implant surgery. The needle is inserted 2 to 4 mm from the flap margin and passed through both flap segments. At a horizontal distance of 3 to 5 mm from the first insertion site, the needle is passed back in the opposite direction, forming a parallel suture. After the last stitch, the suture

is tied. The number of mattress sutures needed depends on the length of the incision. The actual wound closure sutures are placed after the tension-relieving sutures are finished (Fig 4-16). For a detailed description of the pro-cedure, see chapter 13.

h

122    A  Chapter 5  Gingival Esthetics: Criteria, Guidelines, and Diagnostic Strategies

5.1 Esthetic CriteriaGenerally recognized and established criteria for gingi-val esthetics in terms of an esthetic and harmonious gin-gival morphology and gingival margin are described in the following sections.14–16

5.1.1 Gingival Health

Gingival and periodontal health is a basic prerequisite for an esthetic gingival morphology. Gingival inflamma-tion not only produces pathophysiologic changes in the marginal periodontium but also causes changes in the color and surface texture of the gingiva. Inflamed gin-

giva bleeds easily and has a red, swollen, plump, and shiny appearance.Therefore, a proper assessment of gingival esthetics can only be performed under inflammation-free periodontal conditions. The continuous personal oral hygiene moti-vation and support accompanying initial and support-ive periodontal therapies are important for oral health and gingival esthetics.15 Any dental treatment having a negative impact on gingival health in terms of biology and esthetics must be absolutely avoided for the same reasons (Fig 5-2).

Fig 5-2  Periodontal health is a basic requirement for gingival esthetics.

Gingival Esthetics: Criteria, Guidelines, and Diagnostic Strategies  Chapter 5  A    123

5.1.2 Anatomical and Morphologic Features

ColorHealthy gingiva is light pink in color. Variably intense brownish pigmentation of the gingiva is not uncommon in dark-skinned individuals.16

The alveolar mucosa has a dark red color, making it readily distinguishable from the gingiva (Fig 5-3). Its dark color is attributed to the strong blood supply to the subepithelial connective tissue under a nonkeratinized and thus relatively translucent epithelium.

Surface textureThe surface texture of the healthy gingiva is mainly de-termined by the supracrestal fiber attachment of the sub-epithelial connective tissue to the keratinized gingival epithelium (see chapter 1). The epithelial surface of the attached gingiva bound to underlying alveolar bone of-ten displays stippling (orange peel texture).16 Evidence suggests that stippling is more pronounced in individu-als with thick gingival biotypes than in those with thin biotypes.7 Keratinization gives the gingival epithelium a firm texture and a dull surface appearance.The adjacent alveolar mucosa has a shiny and smooth appearance that stands out against the background of the gingiva (Fig 5-4).

Fig 5-3  The alveolar mucosa is generally dark red and can be readily distinguished from the light pink gingiva.

Fig 5-4  The surface of the gingiva is firm, dull, and stippled like an orange peel, whereas that of the alveolar mucosa is shiny and smooth.

272    B  Chapter 8  Gingival Augmentation

WOrKPLACE PrEPArATION ChECKLIST

1 Macrosurgical instrument set2 Microsurgical instrument set3 Tunneling blades I and II4 Suture materials: Gore-Tex CV-5 and 6-0 Seralene

DS-155 No. 15 macroblade and Keydent microblade6 Glass slab7 0.1% chlorhexidine solution in a metal dish8 Sterile water in a metal dish9 Blunt cannula10 10-mL syringe11 Local anesthetic12 Large and small pledgets13 Periodontal stent

11

12

5

13

Gingival Augmentation  Chapter 8  B    273

48

32

1

9

710

6

5

CHAPTER 10

ESTHETIC CROWN LENGTHENING

572    B  Chapter 12  Management of Extraction Sockets

Figs12-43and12-44  Positioning sutures made of Gore-Tex CV-5 have proved useful for graft positioning. The needle is inserted bluntly (back-first) into the tunnel one tooth lateral to the extraction socket and exits on the buccal side of the edentulous space. The needle en-gages the connective tissue graft laterally, from the inner to the outer aspect, and then, slightly more apically, from the outer to the inner aspect. The needle then passes back through the tunnel and returns to the starting point lateral to the edentulous space.

Figs12-47and12-48  Bone substitute material (Bio-Oss) is placed in a metal cup, moistened with sterile saline solution, and loaded in an insulin syringe with the tip cut off. The material is carefully injected in the extraction socket and compacted with light pressure.

Figs12-45and12-46  The graft is very precisely placed in the desired position by pulling on the sutures.

Management of Extraction Sockets  Chapter 12  B    573

Fig 12-49  The provisional adhesive fixed partial denture is tried in. The base of the pontic must completely seal the filled extraction socket and provide a circular base of support to the overlying soft tissues. Exact place-ment of the provisional prosthesis in the planned position is crucial. A posi-tioning guide is used for this purpose. When the provisional restoration is bonded, it is important to ensure that the wound is not exposed to phos-phoric acid.

Fig12-50  Two vertical double-crossed sutures (6-0 Seralene DS-15) are used to secure the graft. First suture: From the buccal aspect, the needle enters at the level of the mucogingival junction and engages the graft. It then passes beneath the contact point between the provisional pontic and the adjacent tooth and ex-its on the palatal side, slightly apical to the tip of the papilla. Next, the needle glides over the incisal edges and returns to the buccal side and then passes back-first (without engaging the tissue) under the contact point and returns to the palatal side.

Index    851

IndexPagenumbersfollowedby“f”indicatefigures;thosefollowedby“t”indicatetables

AAbutmentteeth

descriptionof,612designof,676–677,679femergenceprofileof,676high-fluorescenceshoulderporcelains

fusedto,682f–683fmaterials,677,680,681f–683ftitanium,677zirconia,677,680,681f–682f

Adolescentsimplantsin,691–693,692frootcoveragein,310

AIDS,79–80,80t,174–175,177tAll-ceramiccrown,414fAllogeneicmaterials

bonesubstitute,212connectivetissue,215

Alloplasticmaterialsbonesubstitute,213connectivetissue,215

Allotransplantation,194Alveolarbone

anatomyof,28f,515fbundlebone,515,515fdehiscenceandfenestrationof,27,

29fremodelingof,13resorptionof,515,516f

Alveolarmucosa,123,123fAlveolarprocess,12–13,12f–13fAlveolarridgedefects

ClassIbuccaltissuedeficitsassociated

with,629,630fcharacteristicsof,615,648textensivetissuedeficitsassociated

with,630,631ffixedpartialdenturesfor,618–621,

619f–620f,648tillustrationof,616fimplantsfor,621–624,622f–624f,

626–632,628f–631f,633f,648tinlaygrafts,618,619fmodifiedrollflaptechnique,

629–630,630f,779,780f–798fmucosalpunchprocedure,629f,

629–630pouchprocedures,618,620f,621f,

697,698f–717fClassII

characteristicsof,615,648tfixedpartialdenturesfor,634f–635f,

636f,648thardtissueaugmentationin,632illustrationof,616f

implantsfor,636,648tinlaygraftingfor,653f–654f

ClassIIIautogenousboneblocksin,636characteristicsof,615,648tdistractionosteogenesisin,636–637,

638ffixedpartialdenturesfor,637,

639–640,648tguidedboneregenerationwith

autogenousboneparticles,636hardtissueaugmentationin,636–637illustrationof,616fimplantsfor,640–641,642f–647f,

648,648timplant-supportedprosthesisfor,638fsandwichosteotomyin,636–637

classificationof,613–615,614f,616fguidedboneregenerationfor,613,

621–626,636hardtissueaugmentationof.

SeeHardtissueaugmentation.horizontal,613morphologyof,613–615,614f,616fsofttissueaugmentationin,639,

639f–640fsofttissuesculptinginedentulous

areas,650f,651,652f–659f,655verticalaugmentationof

corticalboneplatemethodfor,761,762f–778f

descriptionof,636–637Alveolarridgepreservation

aftersandwichosteotomy,524–525approachesto,532clinicalaspectsof,549–561,550f–561fexternalgingivalsupportsplintfor,546fixedpartialdenture.See Fixedpartial

denture.guidedboneregenerationfor,532–533,

547timmediateimplantplacementfor,

535–537,536f,547timplantsfor,549–555,550f–555f,579,

580f–592fmechanicalsofttissuesupportfor,

546,547f,547tprognosisfor,548tsingle-stageimplantsfor,579,580f–592fsocketfillingfor,533,534f–536f,537,

547tsocketsealsurgeryfor,593,594f–607fsofttissueaugmentationfor,544–545,

545f,547t,559fAlveolarridgereconstruction

autogenousbonegraftsfor,621–626,622f

clinicalaspectsof,616–650guidedboneregenerationfor,621–626hardtissueaugmentationfor,616softtissueaugmentationfor,616–617f

Alveolarsockethealing,514f–516fAnalgesics,181–184Antibacterialprophylaxis,184–187,187fAnticoagulants,171–172,176t

Anti-inflammatories,181–184Apicallypositionedflaps

biologicwidthestablishedusing,844estheticcrownlengtheningusing

illustrationof,416findicationsfor,423–426,424f–425ftechnique,455,456f–468f

Atraumatictoothextraction,529f–531fAttachedgingiva,7,7fAutogenousbonegrafts

descriptionof,194,196,198donorsitesfor,198–199,200f–201fexposureof,828failureof,828–829guidedboneregenerationusing,

621–626,622f,636harvestingof

descriptionof,198–199,200f–201f,768f

excessivebleedingafter,807,807fillustrationof,198ffrommandibularangle,219,220f–226f,

807,807fmandibularsymphysealregion,199

Autograftsboneblockgraftfrommandibularangle

excessivebleedingafter,807,807ftechniquefor,219,220f–226f

connectivetissue.See Connectivetissueautografts.

subepithelialconnectivetissuegraftsfrommaxillarytuberosity,212,213f,

245,246f–252ffrompalate,201–212,203f–212f,

227,228f–236f,327fsubstitutesfor,212–216,213f–216fthickmucosalgraftfrompalate,237,

238f–244f,601fAutotransplantation,194

BBarriermembranes

collagen,625–626,632,634f,751f,770f,784f

expandedpolytetrafluoroethylene,532,625

guidedboneregenerationuseof,624–626

nonresorbable,624–625resorbable,624–625

Basstechnique,modified,166,168f,169Biologicwidth

apicallypositionedflapfor,844definitionof,16,18dentalprostheticsand,18–21illustrationof,19f–20fimplantdentistryconsiderations,

23–26,24f–26forthodonticextrusionforreestablish-

mentof,844,845f–847fresectiveperiodontalsurgeryconsid-

erations,22,23frestorationmarginsand,21,22fvariationsin,20

852    Appendix

Biologicwidthverticalbonelossassociatedwith,552violationof,18–20,19f,21f,844,

845f–847fBlacktriangles

descriptionof,124,412illustrationof,474finterproximalbonelossascauseof,

473maskingof,489f

Bleedingafterbonegraftharvestingfromman-

dibularangle,807,807fintraoperative,804–807,805f–806fpostoperative,814,815f

Boneblockgraftsdescriptionof,194,196,197fguidedboneregenerationusing,

621–622,623ffrommandibularangle,219,220f–

226f,807,807fBonedehiscence,284,286fBonemorphogeneticproteins,196Bonesubstitutematerials

descriptionof,213–215,214f–215fguidedboneregenerationusing,

621–626socketfillingusing,533,536fxenogeneic,212–213,623

Buccaltunnelflap,570f,790fBundlebone,515,515fBurs

carbide,599fdiamond,422f,447f

CCancellousbone,13Cementoenameljunction

descriptionof,4f–5f,28f,128f,298,308,376f

estheticcrownlengtheningand,426Cementum,9–11,11fChlorhexidine,164f–165f,166,184–185,

819fClassIalveolarridgedefects.See Alveo-

larridgedefects,ClassI.ClassIIalveolarridgedefects.See

Alveolarridgedefects,ClassII.ClassIIIalveolarridgedefects.See

Alveolarridgedefects,ClassIII.Clinicalcrowns,short,409,410fCollagenbarriermembranes,625–626,

632,634f,751f,770f,784fComplications

abscess,820,821fautogenousbonegraftfailure,828–829biologicwidthviolation,844,845f–847fconnectivetissuegraftnecrosis,824,

825fcorticalbonegraftfailure,828excesssofttissue,836,837f–841fflapnecrosis,824flapperforation,810,810f–811f

greaterpalatinearteryinjuryduringsubepithelialconnectivetissuegraftharvestingfrompalate,804,805f–806f

implantloss,832f–833fintraoperativebleeding,804–807,

805f–806fpostoperativebleeding,814,815fpostoperativewoundinfection,

818–821,819f,821fscars,836,837ftattoos,836wounddehiscence,818–820,819fwoundinfection,818–821,819f,821f

Compositeresinrestorations,forinter-dentalclosure,491f–493f

Connectivetissuegingival,7,7f,14,18peri-implant,16,23–24

Connectivetissueautograftscoronallyadvancedflapswith,306,307fdescriptionof,194,198donorsitesfor,199–212doublelateralbridgingflapwith,337,

338f–356fgingivalrecessiontreatedwith,337,

338f–356f,357,358f–370fharvestingof,199–212illustrationof,199fmodifiedtunneltechniquewith,357,

358f–370fsubstitutematerialsfor,215–216,216f

Connectivetissuegraftscoronallyadvancedflapswith,295,

296f,306,307fexcesssofttissuecausedby,836,

837f–841fextractionsocketcoverageusing,

544–545free,496fgingivalaugmentationusing,258fgingivalrecessiontreatedwith,297,

297f,305illustrationof,112fkeratinizedgingiva,294–295,296fmodifiedtunneltechnique,299f–301fnecrosisof,824,825fpouchproceduresusing,forClassI

alveolarridgedefects,618rootcoverageusing,297,297f,305subepithelial.See Subepithelial

connectivetissuegrafts.thickgingivacreatedusing,297f,

297–298Continuoussutures,100–101,101fControlledpressuretechnique,forsoft

tissuesculpting,650f,651“Cookiecutter”technique,forsofttissue

sculpting,651,655,656f,733fCoronallyadvancedflaps

connectivetissueautograftwith,306,307f

descriptionof,289–290enamelmatrixderivativewith,292,

371,372f–388f

gingivalrecessiontreatedwith,292,295,296f,319,320f–336f,371,372f–388f

keratinizedgingiva,295rootcoverageusing,297subepithelialconnectivetissuegraft

with,295,296f,319,320f–336fCorticalboneblocks,199Corticalboneplates

descriptionof,624,624fexposureof,828failureof,828–829necrosisof,829resorptionof,829verticalridgeaugmentationusing,

761,762f–778fCribriformplate,12f–13f,12–13Crowns

estheticlengtheningof.See Estheticcrownlengthening.

implant-supported,437f,503f–504fsurgicallengtheningof,481,488

Customimpressiontray,668,670f–671f

DDentogingivalcomplex

anatomyof,20f,21,27,27fcoronaldisplacementof,435fcoronalgrowthof,426dimensionsof

insufficient,420,423fnormal,4173mmormore,418withoutosseousresection,420,

420f–422f,424fDenture.See Fixedpartialdentures.Deproteinizedbovinebonemineral

boneblockgraftscoveredwith,622,625f

guidedboneregenerationand,625fsocketfillingwith,533,534f,537,

552,553f,558fDiagnosticprovisionalrestorations

estheticcrownlengthening,426,463fgingivalestheticsanalysis,137,139,

142f–143f,146fDiagnosticwax-up,684,685fDistractionosteogenesis

inClassIIIalveolarridgedefects,636–637,638f

guidedboneregenerationand,comparisonsbetween,637

beforetoothextraction,522–529,523f–529f

Doublelateralbridgingflapwithconnectivetissueautograft,for

localizedgingivalrecession,337,338f–356f

illustrationof,108fDouble-crossedsutures,107f,366f,368f,

400f,508f,573f,588f,792fDouble-slingsutures,104,104f,449f,

729f,753fDrapes,162–163,164f

Index    853

E

Edentulousspace.See Alveolarridgedefects.

Emergenceprofileabutments,676definitionof,676ofsofttissuecontouringtransferredto

provisionalimplant-supportedprosthesis,660,661f–667f

Enamelmatrixderivativecoronallyadvancedflapwith,for

gingivalrecession,292,371,372f–388f

descriptionof,290–292,291f,305Enamelmatrixproteins,80Endocrinedisorders,173–174Envelopetechnique,298Epithelialattachment,5,18Eruption,409–412Estheticcrownlengthening

apicallypositionedflapforillustrationof,416findicationsfor,423–426,424f–425ftechnique,455,456f–468f

caseexampleof,484fcementoenameljunctionasreference

pointfor,426dentogingivalcomplexdimensions

for.See Dentogingivalcomplex.diagnosticprovisionalrestorations,

426,463fgingivectomy.SeeGingivectomy.goalof,415irregulargingivalmarginstreated

with,412,413f–414fkeratinizedgingivawidth,415,

415f–416flong-termstabilityof,426predictabilityof,426technicalaspectsof,415–425,

426ttheoryof,408–410inyoungpatients,426–427

Expandedpolytetrafluoroethylenebarriermembranes,532,625sutures,57,115,115f

Explantationinstruments,forimplantremoval,833,833f

Extractionofteeth.See Toothextraction.Extractionsockets

connectivetissuegraftsforcoverageof,544–545

fillingof,533,534f–536f,547t,552,553f,555,558f

healingof,514–516,514f–516fhopelessteeth,546,548,554,556f,596fmorphologytypes,548tosseousremodelingof,514

FFixationsutures,109,112fFixedmock-ups,139

Fixedpartialdenturesadhesive,613,709falveolarridgedefectstreatedwith

ClassI,618–621,619f–620fClassII,634f–635f,636fClassIII,637,639–640

alveolarridgepreservationwithprotocolsfor,548tsingle-stageapproach,555,556f–561fsocketsealsurgerywith,593,

594f–607ftechniquefor,565,566f–577f

disadvantagesof,612–613softtissueaugmentationforrestora-

tionof,617fsofttissueimpressionfor,660

Flap(s)apicallypositioned.See Apically

positionedflaps.bloodsupplytomarginsof,78,79tbuccaltunnel,570fcoronallyadvanced.See Coronally

advancedflaps.doublelateralbridging

withconnectivetissueautograft,forlocalizedgingivalrecession,337,338f–356f

illustrationof,108ffull-thickness,90,91f,746f,783fmucoperiosteal,77,90,91f–92fmucoperiosteal-mucosal,95–96,

95f–96fmucosal,77,91–96,92f–96fnecrosisof,824partial-thickness,91–96,92f–96f,

344f,362f,422,461f,482f,724fperforationof,810,810f–811fsplit-thickness,325ftensionof,78,79ttension-freeclosureof,303thicknessof,78,79t,86,303toothextractionand,515woundhealingaffectedby,77–78,79t

Flaplessimmediateimplantplacement,549,552f

Forcederuption,517Freeconnectivetissuegrafts,496fFreegingiva,5f,5–7Freetissuegrafts

physiologicprinciplesof,194–196requirementsfor,196–198

Full-thicknessflaps,90,91f,746f,783f

GGingiva

anatomyof,4–9,4f–9f,123–131attached,7,7fbiotypesof,29–30bloodsupplyto,16–17colorof,123,262fconnectivetissueof,7,7f,14,18displayof,insmile,121f,130,131fexcessivedisplayof

abrasionascauseof,410,411falteredactiveeruptionascauseof,

410,411falteredpassiveeruptionascauseof,

409,410f,432fcausesof,408–410descriptionof,408,409fovereruptionascauseof,410,411f

free,5f,5–7healthof,122,122finterdental,8f,9,124,124finterproximal,462fkeratinized.See Keratinizedgingiva.marginal,284openembrasurespaces.See Black

triangles.scalloped,29–30,31f,124,481stipplingof,123,123fsurfacetextureof,123,123fthick,29–30,31fthicknessof,5,262tthin,29–30,31f,285,297translucencyof,gingivalaugmentation

forreductionof,260,261f–265f,275f

widthof,5Gingivalaugmentation

connectivetissuegraftfor,258fgingivalrecessionpreventionusing

afterorthodontictreatment,266–268,266f–268f

afterprosthetictreatment,256,257f–260f

gingivaltranslucencyreducedwith,260,261f–265f

prognosisfor,269subepithelialconnectivetissuegrafts

for,269,271,272f–281ftechnicalaspectsof,269

Gingivalcontour,127,128f–129fGingivalesthetics

age-relatedchanges,153criteriafor,122–131ethicalconflictsin,153mucogingivalsurgeryforcorrection

of,132,133toverviewof,120

Gingivalestheticsanalysisagingconsiderations,153caseexampleof,145f–152fdiagnosticprovisionalrestorations,

137,139,142f–143fformfor,144,144fincisaledgeposition,134,136f,144landmarks,134–136,135f–136fmock-ups,137–139,138f,140ftoothlength,135,137t

Gingivalinflammation,20,21f,77,79t,122

Gingivalmarginanatomyof,5,5f,32,127,127fassessmentof,134–135coronaldisplacementof,417incisionsalong,86,87firregular

854    Appendix

Gingivalmarginaroundnaturalteeth,412aroundprostheticallyrestoredteeth,

412,413f–414fillustrationof,411fperiodontalsurgeryfor,412

inmaxilla,129fsymmetryof,450f

Gingivalmarginprofile,125–127,126fGingivalrecession

bonedehiscenceassociatedwith,284,286f

buccal,285fclassificationof,303,304f,322f,340f,

361f,375f,393fdescriptionof,20epidemiologyof,284–285etiologyof,284–285,286tgingivalaugmentationforpreventionof

afterorthodontictreatment,266–268,266f–268f

afterprosthetictreatment,256,257f–260f

illustrationof,21f,107f–108flabial,267flocalized

coronallyadvancedflapwithsub-epithelialconnectivetissuegraftfor,319,320f–336f

descriptionof,301,302tdoublelateralbridgingflapwith

connectivetissueautograftfor,337,338f–356f

modifiedtunneltechniquewithconnectivetissueautograftfor,357,358f–370f

Millerclassificationof,303,304f,322f,340f,361f,375f,393f

multiplecoronallyadvancedflapwithenamel

matrixderivativefor,371,372f–388f

descriptionof,301–302,302tperiodontitis-related,284fprostheticallytreatedteeth,310,311fStillman’scleftsversus,285,287ftreatmentof

connectivetissuegrafts,289,305coronallyadvancedflaps,289–290,

319,320f–336fgoals,288–298indicationsfor,287,288fperiodontalhealthafter,288–292rootcoverage.See Rootcoverage.subepithelialconnectivetissue

grafts,319,320f–336ftechnicalaspects,298–302

wedge-shapeddefectswith,308,308f–309f,343f

Gingivalzenith,124–127,125f–126f,434f,446f

Gingivectomydentogingivalcomplexdimensions

sufficientfor,420,420findicationsfor,416f

ostectomyand,439,440f–454fsofttissuecontouringandthinning

after,435ftechniquefor,429,430f–438f

Greaterpalatinearteryanatomyof,202,203fdamageto,duringsubepithelialcon-

nectivetissuegraftharvestingfrompalate,804,805f–806f

Guidedboneregenerationalveolarridgedefectstreatedwith,

613,621,636alveolarridgepreservation

descriptionof,532–533,547timmediateimplantplacementwith,

537autogenousbonefor,621–626,622fbarriermembranesfor,624–626boneblockgraftsfor,621–622,623fbonesubstitutematerialsfor,621–626deproteinizedbovinebonemineral

particlesand,625fdistractionosteogenesisand,compari-

sonsbetween,637hardtissueaugmentationusing,621

Guidedtissueregenerationconnectivetissueattachmentsusing,

290,290fdescriptionof,38

Gummysmilecausesof

abrasion,410,411falteredactiveeruption,410,411falteredpassiveeruption,409,410f,

412,432fovereruption,410,411f

correctionof,410,412definitionof,408descriptionof,408,409festheticcrownlengtheningfor.See

Estheticcrownlengthening.illustrationof,409f

HHardtissueaugmentation

autogenousboneblocksfor,636ClassIIdefects,632ClassIIIdefects,636–637descriptionof,621distractionosteogenesisfor,636–637guidedboneregeneration,621–626,636modifieddouble-layertechnique,626,

627f,739,740f–760fsandwichosteotomy,636single-stage,626–632,628ftwo-stage,626–632,829

HIV,79–80,80t,174–175,177tHopelessteeth,546,548,554,556f,596fHorizontalalveolarridgeaugmentation,

626,627f,739,740f–760fHorizontalmattresssuture,602f–603f,

752fHorizontalpapillaaugmentation

freeconnectivetissuegraftsfor,496f

predictabilityof,484subepithelialconnectivetissuegraft

for,499,500f–511fHorizontalreleasingincisions,88,88fHorizontalslingsutures,104,106,107f,

109f,328f–330f,350f,381f

IImmediateimplantplacement

alveolarridgepreservationusing,535–537,536f,547t

flapless,549,552f,582fperiodontaldiseaseeffectson,535socketfillingwithdeproteinized

bovinebonemineral,533,534f,537,552,553f,558f

softtissuerecessionafter,535Immediateprovisionalizationof

implants,553–554,554fImmunosuppression,woundhealing

affectedby,79,80tImplant(s)

inadolescents,691–693,692falveolarridgedefectstreatedwith

ClassI,621–624,622f–624f,626–632,628f–631f,633f,648t

ClassII,636,648tClassIII,640–641,642f–647f,648,648t

alveolarridgepreservation,549–555,550f–555f,579,580f–592f

biologicwidtharound,23–26,24f–26fdesignsof,26finestheticzone,686–691explantationinstrumentsforremoval

of,833,833ffixedpartialdentureversus,formiss-

ingteethreplacement,610–613immediateprovisionalizationof,

553–554,554fkeratinizedgingivaaround,30,32,33finliningmucosa,32lossof,832f–833fmissingteethreplacementusing,

610–613positioningof,684,686–691radiographictemplatesfor,684,685fselectionof,684,686–691surgicaltemplatesfor,684,685funcoveringof

inClassIIalveolarridgedefects,630–631,632t

modifiedrollflaptechniquefor,629–630,630f,779,780f–798f

second-stage,774finyoungpatients,691–693,692f

Implantplacementcomputer-assisted,684delayed,544,545fhorizontalridgeaugmentationwith,

modifieddouble-layertechniquefor,739,740f–760f

immediate.See Immediateimplantplacement.

multistage,554–555,555f,632,633f

Index    855

single-stage,549–554,550f–554f,579,580f–592f

socketsealsurgerywith,593,594f–607fverticalridgeaugmentationwith,cor-

ticalboneplatemethodfor,761,762f–778f

Implantshoulderapicocoronalpositioningof,689–690,

690fillustrationof,686fmesiodistalpositioningof,687–688,

688forofacialpositioningof,687,687f

Implant-supportedcrowns,437f,503f–504f

Implant-supportedprosthesisClassIIIalveolarridgedefectstreated

with,638fprovisional,emergenceprofileofsoft

tissuecontouringtransferredto,660,661f–667f

screw-retained,680,681fIncisaledgeposition,134,136f,144,444fIncision(s)

crestal,727fgingivalmargin,86,87fintrasulcular,504f,724f,745f,767f,789fmarginal,86,87f,395fparamarginal,86,87f,461freleasing,88–89,88f–89f,97f,222f,

331f–332f,384f,708f,754f,773fsulcular,86,87ftrainingin,66

Incision-freeflaplessprocedures,forrootcoverage,298

Incisorscongenitallymissing,701forthodonticextrusionof,518f–519f

Infection,wound,818–821,819f,821fInfectiousdiseases,174–175,177tInflammation

gingival,20,21f,77,79t,122surgerycontraindications,162

Informedconsent,158–159,159f,160tInfraorbitalarteries,14Inlaygrafts

alveolarridgedefectreconstructionusing

ClassI,618,619fClassII,653f–654f

modifiedpouchtechniqueversus,621palatalislandflapand,forsofttissue

augmentation,719,720f–738fsofttissuecontouringafter,656ftissuevolumelossassociatedwith,617

Interdentalpapilla.See Papilla.Internalhorizontalmattresssuture,

102f,102–103Interproximalboneloss,472–473,474fInterruptedsutures,98f,98–100,353f,

605f,730fIntraoperativebleeding,804–807,

805f–806fIntrasulcularincisions,504f,724f,745f,

767f,789f

J

Junctionalepithelium,5–7,6f,9f,16,16f,19f,25,289f

KKeratinizedgingiva

causesof,292–293connectivetissuegraftsfor,294–295,

296fdescriptionof,17,18f,30,32,33f,

123,256widthof

descriptionof,303estheticcrownlengtheningaffected

by,415,415f–416fgingivectomyrequirements,445fmeasurementof,433f

Knottying,62–63,64f–66f,114f–116f,115–116

LLightsource,foroperatingmicroscope,

45,45f–46fLiningmucosa,4,32Localanesthesia,179–181Loupes,43,43f–44f,46t,47

MMacrosurgicalinstruments,39f,47,

48f–49fMagnificationsystems,41,43–47,43f–47fMandibularangle,boneblockgrafthar-

vestingfromexcessivebleedingafter,807,807ftechniquefor,219,220f–226f

Marginalgingiva,284Marginalperiodontitis,162Masticatorymucosa,4,201,292Mattresssutures,100f,100–103,

102f–103f,331f,383f,448f,602f–603f,752f,771f–772f

Maxillarytuberosity,subepithelialcon-nectivetissuegraftfrom,212,213f,245,246f–252f,505f

Microsurgeryadvantagesof,38,40fdefinitionof,38,41macrosurgeryversus,39f,42fopticalmagnificationsystems,41,

43–47,43f–47f,60suturematerialsfor,56–58,56f–59f,

57t,59ttechnicalrequirementsfor,43–59trainingin,60–66,61f–67fwoundhealingbenefitsof,77,79t

Microsurgicalinstrumentscombinationforceps,51,52fillustrationof,47,49fneedleholder,52–53,53f,60,99fneedles,57–58,58fpapillaelevator,52,53f

scalpelblades,47,51,51fscalpelhandle,47,50f–51f,51scissors,53,54f,66traininginuseof,60–62,61ftunnelingknives,55,55f,299,396f,

725fMinimallyinvasivesurgery,38Missingteeth

abutmentsdesignof,676–677,679femergenceprofileof,676high-fluorescenceshoulderporce-

lainsfusedto,682f–683fmaterials,677,680,681f–683ftitanium,677zirconia,677,680,681f–682f

alveolarridgedefectsassociatedwith.See Alveolarridgedefects.

fixedpartialdenturesforabutmentteethconsiderations,612adhesive,613,709fconventional,612–613disadvantagesof,612–613implantversus,610–613

implant-supportedprosthesesfordescriptionof,612provisional,emergenceprofileofsoft

tissuecontouringtransferredto,660,661f–667f

incisors,697,698f–717fpontics.SeePontics.softtissue

augmentationof.SeeSofttissue.customimpressiontray,668,670f–671femergenceprofiletransferredto

implant-supportedprovisionalrestoration,660,661f–667f

impressionof,forfinalrestorationfabrication,660–674

sculptingof,inedentulousareas,650f,651,652f–659f,655,733f

transferringprovisionalponticcon-tourstoworkingcastforfinalrestoration,668,668f–674f

Mock-ups,137–139,138f,140fModifieddouble-layertechnique,for

horizontalhardtissueaugmen-tation,626,627f,739,740f–760f

Modifiedpouchtechnique,621,697,698f–717f

Modifiedridgelappontics,675Modifiedrollflaptechnique,629–630,

630f,779,780f–798fModifiedtunneltechnique

buccalpartial-thicknesstunnelcreatedwith,583f

withconnectivetissueautograft,357,358f–370f

descriptionof,299,300f–301f,313fgingivalrecessiontreatedwith,357,

358f–370f,389,390f–404fpapillareconstructionusing,495–496withsubepithelialconnectivetissue

graft,389,390f–404f

856    Appendix

Mucogingivalsurgery,132,133tMucoperiostealflaps,77,90,91f–92fMucoperiosteal-mucosalflaps,95–96,

95f–96fMucosalflaps,77,91–96,92f–96fMucosalgraftfrompalate,237,

238f–244f,601fMucosalpunchprocedure,629f,

629–630Mucosal-mucoperiosteal-mucosalflap,96Multistageapproach

fixedpartialdenture,555implantplacement,554–555,555f,

632,633f

NNecrosis

connectivetissuegraft,824,825fcorticalboneplates,828–829flap,824woundmargin,38

Needleholder,52–53,53f,60,99fNeedles,suture,57–58,58fNonabsorbablesutures,56f,57Nonresorbablebarriermembranes,

624–625

OOnlaygrafts,617Opengingivalembrasurespaces.See

alsoBlacktriangles.orthodonticapproachesfor,484–488,

485f–487fsurgicalapproachesfor,481,484,484f

Openwoundhealing,818Operatingmicroscope,43–47,44f–46f,46tOralhygiene

postoperative,165,169tpreoperative,162

Oralmucosa,4,123,123fOralsulcularepithelium,5,5fOrthodonticextraction,844Orthodonticextrusion

biologicwidthreestablishmentwith,844,845f–847f

orthodonticextractionversus,844beforetoothextraction,517–521,

518f–522fOrthodontictreatment,gingivalaug-

mentationforpreventionofgingivalrecessionafter,266–268,266f–268f

Osseouscrest,27–29,28f–29f,29tOsseousremodeling,ofextraction

sockets,514Ostectomyandgingivectomy,fores-

theticcrownlengthening,439,440f–454f

Osteosynthesisscrews,768f–769fOsteotomy

illustrationof,223fsandwich,522,524,524f,636–637

Overeruption,410,411f

P

Palatalislandflapandinlaygraft,719,720f–738f

Palatebloodsupplyto,203fsubepithelialconnectivetissuegraft

harvestingfromcomplicationsof,804,805f–806fgreaterpalatinearteryinjuryduring,

804,805f–806fillustrationof,327f,397f,545f,571f,

585f,707f,729f,752ftechniquefor,201–212,203f–212f,

227,228f–236fthickmucosalgraftharvestedfrom,

237,238f–244f,601fPapilla

anatomyof,9,124ClassIIIdefect,485fheightof

classificationforlossof,474,479fdeterminants,472

lossofetiologyof,472–474generalized,472iatrogeniccausesof,474,476flocalized,472periodontalsurgeryascauseof,477f

softtissuedefectscausedbydamageto,475f

Papillaelevator,52,53f,396f,399fPapillareconstruction

caseexampleof,480f–483fhorizontalaugmentation

freeconnectivetissuegraftsfor,496fpredictabilityof,484subepithelialconnectivetissuegraft

for,499,500f–511finlaygraftingfor,618long-termstabilityof,496modifiedtunneltechniquefor,

495–496orthodonticapproaches,484–488,

485f–487frestorativeapproaches,488–494,

488f–494fsurgicalapproaches,481,484ftechnicalaspectsof,495–496

Partial-thicknessflaps,91–96,92f–96f,344f,362f,422,461f,482f,724f

Patientmanagementinformedconsent,158–159,159f,160tpostoperative,165–169,166f–168f,169tpostoperativeinstructions,160,161fpreoperative,162–163,163f–164friskfactors.See Riskfactors.

Peri-implantdehiscencedefects,310,312f–313f

Peri-implantmucosa,17–18Peri-implantsofttissuerecession,641Peri-implantstructures

anatomyof,16–17,16f–17fconnectivetissue,16

Periodontaldiseaseimmediateimplantplacementaffected

by,535woundhealingaffectedby,77,79t

Periodontalfibers,9–11,16,17fPeriodontalligament

anatomyof,9,14ffibersof,419f,447f,464f,529,530f,

569fPeriodontalpretreatment,162,163fPeriodontalprobe,323f,433fPeriodontalsurgery

aftercare,166biologicwidthconsiderations,22,23finstrumentsfor,47–55,48f–55firregulargingivalmarginstreated

with,412papillalosssecondaryto,477fpostoperativemanagement,165–169,

166f–168f,169tpreoperativemanagement,162–163,

163f–164friskfactors.See Riskfactors.

Periodontitis-relatedgingivalrecession,284f

Periodontiumalveolarprocess,12–13,12f–13fbloodsupplyto,14–15,14f–15fgingiva.See Gingiva.healthof,122,122f,162,288–292innervationof,14–15,14f–15f

Periostealslitting,90,91fPeriostealsutures,108–109,110f–111f,

465fPeriosteum

descriptionof,13subepithelialgraftswith,207f–208f

Plaquecontrol,162,163fPlastic-estheticperiodontalsurgery,38Pontics

designsfor,675–676,676f–678fmaterials,677,680,680fmodifiedridgelap,675ovate,675,676fporcelain-fused-to-metal,680fprovisional,transferringcontoursto

workingcastforfinalrestora-tion,668,668f–674f

requirementsof,675totalridgelap,675

Positioningsutures,109,111,113f,365f,398f,506f,572f

Posteriorsuperioralveolararteries,14,15fPostoperativebleeding,814,815fPostoperativeinstructions,160,161fPostoperativemanagement,165–169,

166f–168f,169tPostoperativemedications,165,178–187Postoperativewoundinfection,818–821,

819f,821fPouchprocedures

connectivetissuegrafts,618modified,621,697,698f–717f

Preoperativemanagement,162–163,163f–164f

Index    857

Preoperativemedications,178–187Pressurecontouringtechnique,forsoft

tissuesculpting,650f,651Primarywoundhealing,70–71,72f–73fProsthetictreatment

gingivalrecessionaftergingivalaugmentationforprevention

of,256,257f–260ftreatmentof,310,311f

irregulargingivalmarginsaroundteethafter,412,413f–414f

softtissueaugmentationbefore,639f–640f

Provisionalrestorations,137,139,142f–143f,146f

RRadiographictemplates,forimplants,

684,685fReleasingincisions,88–89,88f–89f,

97f,222f,331f–332f,384f,708f,754f,773f

Replacementofmissingteeth.See Miss-ingteeth.

Resorbablebarriermembranes,624–625Restorationmargins

biologicwidthand,21intrasulcular,21,22f

Riskfactorscardiovasculardiseases,170–172,176tdiabetesmellitus,173–174,177tendocrinedisorders,173–174infectiousdiseases,174–175,177tliver function impairment, 172–173,

177torgantransplants,172,176tpulmonarydisease,172,176trenalfunctionimpairment,173,177t

Rootcoverageinadolescents,310inchildren,310complete,298connectivetissuegraftsfor

free,297,297fsubepithelial,290f

coronallyadvancedflapsfor,297defect-specificfactorsthataffect,303estheticconsiderations,298,299fgraftorientationeffectson,303,305fgraftthicknesseffectson,303incision-freeflaplessproceduresfor,298long-termstabilityof,303,305–306modifiedtunneltechniquefor,301fpatient-specificfactorsthataffect,302periodontalhealthafter,292,293fpredictabilityof,302–303rootcleaningbefore,293ftechniquesfor,302ttechnique-specificfactorsthataffect,

303Rootfracture,556f,596fRootsurfacebiocompatibility,wound

healingaffectedby,77,79tRubberdamtraining,60–66,61f–62f

S

Sandwichosteotomy,522,524,524f,636Scallopedgingiva,29–30,31f,124Scalpelhandle,microsurgical,47,50fScarring,71Scars,836,837fScissors,microsurgical,53,54f,66Screw-retainedimplant-supportedpros-

thesis,680,681fSecondarywoundhealing,70–72,73fSedation,178–179Sharpey’sfibers,9,10f–11f,291Shellprovisionalrestorations,139,142fSingle-stageapproach

fixedpartialdenture,555,556f–561f,565,566f–577f

implantsurgery,549–554,550f–554f,579,580f–592f

Slingsutures,104–108,107f–109f,328f–330f,350f,381f,449f

Smilegingivaldisplayin,121f,130,131fincisaledgeposition,134,136fnaturallybeautiful,120typesof,130,131f

Smileline,130,131fSmoking,79,80tSocket.See Extractionsockets.Socketsealsurgery

advantagesanddisadvantagesof,547tforalveolarridgepreservation,593,

594f–607fdescriptionof,546woundclosureafter,fornecrosispre-

vention,555fSocketshieldtechnique,537,538f–543fSofttissue

augmentationofalveolarridgepreservationusing,

544–545,545f,547t,559finlaygraftandpalatalislandflapfor,

719,720f–738fmodifiedpouchtechniqueof,621,

697,698f–717fbeforeprosthetictreatment,639f–640fsubepithelialconnectivetissuegrafts

for,553f,628f,631fexcess,fromconnectivetissuegraft,

836,837f–841fsculptingof,inedentulousareas,651,

652f–659f,655,733fSplitsheets,162–163,164fStillmantechnique,modified,166,167f,

169Stillman’sclefts,285,287fStippling,123,123fSubepithelialconnectivetissuegrafts

alveolarridgepreservationuseof,544coronallyadvancedflapwith,295,

296f,319,320f–336fdescriptionof,200gingivalaugmentationusing,269,271,

272f–281f

gingivalrecessiontreatedwith,295,296f,319,320f–336f,389,390f–404f

harvestingoffrommaxillarytuberosity,212,213f,

245,246f–252f,505ffrompalate,201–212,203f–212f,

227,228f–236f,327f,397f,545f,571f,585f,707f,729f,752f,804,805f–806f

horizontalpapillaaugmentationus-ing,499,500f–511f

modifiedtunneltechniquewith,389,390f–404f

rootcoverageusing,290fsofttissueaugmentationusing,553f,

628f,631fSulcularincisions,86,87fSulcus

anatomyof,5,5fdepthof,20–21

Superioralveolarnerve,14Supra-alveolarfiberapparatus,9,9fSurgeon’sknot,simple,62–63,64f–66f,

114f,115Surgicalinstruments,47–55,48f–55fSurgicalstent,208,211f,804Surgicaltemplates,forimplants,684,

685fSuspensionsutures,104–109,105f–111fSuture(s)

continuous,100–101,101fdouble-crossed,107f,366f,368f,400f,

508f,573f,588f,792fdouble-sling,104,104f,449f,729f,

753f,771f–772ffixation,109,112ffunctionof,96horizontalsling,104,106,107f,109f,

328f–330f,350f,381finterrupted,98f,98–100,353f,605f,

730fmattress,100f,100–103,102f–103f,

331f,383f,448f,602f–603f,752f,771f–772f

periosteal,108–109,110f–111f,465fpositioning,109,111,113f,365f,398f,

506f,572fremovalof,116,116f,165sling,104–108,107f–109f,328f–330fsuspension,104–109,105f–111ftension-relieving,101–103,102f–103ftypesof,56f–59f,56–58,57t,59t,66woundclosure,98f–101f,98–101

Suturingknottying,62–63,64f–66f,114f–116f,

115–116needlesfor,57–58,58fpreparatorymeasuresfor,97simplesurgeon’sknot,62–63,64f–66f,

114f,115techniquesfor,111tthrows,115–116trainingin,60–66,61f–67f

858    Appendix

T

Teethabutment.See Abutmentteeth.extractionof.See Toothextraction.innervationof,14replacementof.See Missingteeth.

Tension-freeflapclosure,303Tension-relievingsutures,101–103,

102f–103fThickgingiva

descriptionof,29–30,31fthingingivatransformedinto,using

connectivetissuegrafts,297f,297–298

Thingingivaconnectivetissuegraftsfortransform-

ingof,intothickgingiva,297f,297–298

descriptionof,29–30,31f,285gingivalrecessionrisks,297

Throws,115–116Toothextraction

alveolarridgepreservationafteraftersandwichosteotomy,524–525approachesto,532clinicalaspectsof,549–561,550f–561fexternalgingivalsupportsplintfor,

546fixedpartialdenture.See Fixed

partialdenture.guidedboneregenerationfor,

532–533,547timmediateimplantplacementfor,

535–537,536f,547timplantsfor,549–555,550f–555f,

579,580f–592fmechanicalsofttissuesupportfor,

546,547f,547tprognosisfor,548tsingle-stageimplantsfor,579,

580f–592fsocketfillingfor,533,534f–536f,

537,547tsocketsealsurgeryfor,593,594f–607fsofttissueaugmentationfor,

544–545,545f,547t,559fatraumatic,529,530f–531fdecision-makingalgorithmfor,649fdefectssecondaryto

cosmeticandfunctionaleffectsof,610–611

descriptionof,515,516fdistractionosteogenesisforpreven-

tionof,522–529,523f–529fpreventionof,517–548

sandwichosteotomyforpreventionof,524,524f

socketfillingforpreventionof,533,534f–536f,547t,552,553f,555,558f

socketshieldtechniqueforpreven-tionof,537,538f–543f

softtissueaugmentationforpreven-tionof,544–545,545f,547t

distractionosteogenesisbefore,522–529,523f–529f

flapsurgeryand,515hardtissuedefectsafter,23healingafter,514–516,514f–516fhopelessteeth,546,548,554,556f,

596fmultistagesurgery,546,548orthodonticextrusionbefore,517–521,

518f–522fsandwichosteotomybefore,522,524,

524fsingle-stagesurgery,546volumetricchangesafter,514

Toothlength,135,137tToothbrushing

gingivalrecessioncausedby,285fmodifiedStillmantechnique,166,

167f,169Training,microsurgical,60–66,61f–67fTranslucency,gingival,260,261f–265f,

275fTransplantation,194Tunneltechnique

descriptionof,298–299modified

buccalpartial-thicknesstunnelcreatedwith,583f

withconnectivetissueautograft,357,358f–370f

descriptionof,299,300f–301f,313fgingivalrecessiontreatedwith,357,

358f–370f,389,390f–404fpapillareconstructionusing,495–496withsubepithelialconnectivetissue

graft,389,390f–404fTunnelingKnives,55,55f,299,396f,725f

UUpperliphypermobility,408

VVerticalalveolarridgeaugmentation

corticalboneplatemethodfor,761,762f–778f

descriptionof,636–637

Verticalmattresssutures,383f,448fVerticalmaxillaryexcess

definitionof,408gummysmilecausedby,410

Verticalreleasingincisions,88–89,89f,97f,222f,331f–332f,384f,708f,754f,773f

WWedge-shapeddefects,gingivalreces-

sionwith,308,308f–309f,343fWoundclosuresutures,98f–101f,

98–101Wounddehiscence,628f,629,818–820,

819fWoundhealing

clinicalassessmentof,74–75,76fdisordersof,820,821fexudativephaseof,74factorsthataffect,77–81,79t–80tinflammatoryphaseof,72localfactorsthataffect,77–78,79topen,818palataldonorsites,202patient-specificfactorsthataffect,

80–81phasesof,72,74primary,70–71,72f–73fprinciplesof,70–75proliferativephaseof,74repairphaseof,74resorptivephaseof,74restorationphaseof,74secondary,70–72,73fsubepithelialconnectivetissuegraft

harvesting,205f–206fsystemicfactorsthataffect,78–81,80ttoothextraction,514f–516f,514–516

Woundinfection,postoperative,818–821,819f,821f

XXenogeneicmaterials

bonesubstitute,212–213,623connectivetissue,216guidedboneregenerationuseof,626

Xenografts,213Xenotransplantation,194

ZZirconiaabutments,677,680,681f–682f