Microsurgery in Periodontal and Implant Dentistry : Concepts and Applications

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The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Foreword A Tribute to Dennis A. Shanelec, DDS: The Father of Periodontal Microsurgery Acknowledgments Contents Introduction to Microsurgery 1 Introduction 2 History of Operating Microscope in Medicine 3 History of Operating Microscope in Dentistry 4 History of OM in Periodontology and Implant Dentistry 5 Advantages of Using OM in Surgical Dentistry 6 Current Trends that Favor Using OM 7 Future Directions 8 Conclusion 9 Key Points References The Impact of a Minimally Invasive Approach on Oral Wound Healing 1 Introduction 2 An Overview of the Biological Pathways to Mucosal Wound Repair and Regeneration 2.1 Inflammation Phase (First Stage of Mucosal Wound Healing) 2.2 Proliferation Phase (Second Stage of Mucosal Wound Healing) 2.2.1 Epithelialization 2.2.2 Angiogenesis 2.2.3 Granulation Tissue Formation 2.3 Remodeling Phase (Third Stage of Mucosal Wound Healing) 3 Impact of the Microsurgical Technique on the Healing Process of Oral Mucosal Wounds: Clinical Results and Potential Triggers for Enhanced Healing 3.1 Scientific Evidence of Improved Outcomes After Periodontal Plastic Microsurgeries: Some Critical Comments about the Clinical Relevance of the Results 3.2 The Interconnectedness of the Microsurgical Technique with the Healing Process of Mucosal Wounds 3.2.1 Influence of Modified (Minimal-Invasive) Incision Designs on Wound Stability and Wound Integrity 3.2.2 Healing of Periodontal Wounds Created by Traditional, but Microsurgically Modified Flap Designs 4 How to Translate Findings from Basic Research into Clinical Success? 4.1 Incision Design and Wound Healing from a Histological and Physiological Perspective 4.2 Micromechanical Properties of the Extracellular Matrix of the Oral Mucosa and the Blood Clot after Wounding 4.2.1 Micromechanical Aspects of Oral Mucosal Tissues 4.2.2 Micromechanical Aspects of the Blood Clot during Healing 4.3 Microsurgically Controlled Instrument Handling and its Impact on Tissue Mechanotransduction 5 Closing Remarks 6 Key Points References Fundamentals of the Operating Microscope 1 Introduction 2 Magnification 3 Loupes 4 Loupes Versus Operating Microscope 5 Parts and Functions of a Surgical Microscope 5.1 The Body of the Microscope 5.1.1 Microscope Eyepieces 5.1.2 Binocular Tube Head 5.1.3 Co-Observation 5.1.4 Microscope Objective Lens 5.1.5 Microscope Magnification Changer or Zoom system 5.1.6 Focusing 5.2 Light Source 5.2.1 Illumination 5.2.2 Augmented Visualization 5.3 The Suspension System 5.4 Imaging Systems and Documentation Devices 6 Conclusions 7 Glossary 8 Key Points References Design and Ergonomics of Microsurgical Instruments 1 Introduction 2 From Touch Perception to Prehensile Skilled Movements in Periodontal Microsurgery 2.1 Anatomy and Neurophysiology of the Human Hand 2.2 Tactile Sensing and the Threshold Concept 2.3 Dynamic Touch and Precision Grips in Periodontal Microsurgery 3 Instrument Design 3.1 Ergonomics of Microsurgical Instrument Handles 3.1.1 Instrument Handle’s Shape and Size 3.1.2 Materials and Weight of Microsurgical Instruments 3.1.3 Fine Surface Texture and Roughness of the Instrument Handle 3.2 Influence of Surgical Gloves on Tactile Sensitivity, Finger Pad Friction, and Surgical Performance 3.2.1 Touch Sensation and Haptic Perception Thresholds 3.2.2 Fingerpad Friction and Grasp Force 3.2.3 Influence of Gloves on Surgical Performance 3.3 Instrument use and How it Affects Hand Representation in the Brain 4 Basic Set of Instruments for Periodontal Microsurgery 4.1 Description of Microsurgical Instruments 4.2 Sterilization Process and Caring for Microsurgical Instruments 5 Conclusions 6 Key Points References The Science and Art of Microsuturing 1 Introduction 2 Historical Background of Suture Materials, Needles/Evolution 3 Wound Closure: Principles 4 Armamentarium 5 Sutures and Needles 5.1 Suture Classification 5.2 Suture Biocompatibility 5.3 Needles 5.3.1 Needle Parts 5.3.2 Needle Designs/Geometry 5.3.3 Needle Color Innovations 6 The Geometry of Suturing 7 Knots 7.1 Knot Coding/Nomenclature 7.1.1 Square Knot 7.1.2 Slip Knot 7.1.3 Surgeon’s Knot 7.2 Knot Tying: Instrument Tie 7.3 Knot Failure 7.3.1 Slippage 7.3.2 Suture Cutting Through Tissue 7.3.3 Mechanical Damage 7.4 Biomechanical Properties and Performance 7.4.1 Vectoring/Angulation 7.4.2 Compression Zones/Frequency/Symmetry 7.4.3 Suture Tension on Soft Tissues 7.5 Suture Removal 8 Suturing Techniques 9 The Microsurgical Training Institute 10 Methods for Developing Suturing Technique and Practicing 10.1 Training Models and Exercises 10.1.1 Gauze 10.1.2 Newspaper 10.1.3 Needles 10.1.4 Egg 10.1.5 Eggplant 10.1.6 Tomato-Star 10.1.7 Grass Blade 10.1.8 Flower 10.1.9 Mushroom 10.1.10 Tissue Paper Box-Silicone/Resin Dental Model 10.1.11 Plastic Micro-tubing 10.1.12 Training Simulators 11 Conclusion 12 Key Points References Practical Considerations in Incorporating Microsurgery to Daily Workflow 1 Introduction 2 Principles of Ergonomics 2.1 Musculoskeletal Disorders Associated with Dentistry 2.2 Working Mistakes When Using the Microscope 3 Implementation Stages of OM in Periodontal and Implant Procedures 4 Fundamental Aspects of Microsurgical Incorporation (Fig. 3) 4.1 Frame of Mind 4.2 Comfort 4.3 Hand Support 4.4 Armamentarium 4.5 Assisting 5 Economy of Movement 5.1 Assisting Models 6 Positioning 6.1 Operator (Microsurgeon) 6.2 Assisting Team 6.3 Patient Position 7 Infection Control 8 Conclusions 9 Key Points References Microscope-Assisted Periodontal and Peri-implant Plastic Surgery 1 Introduction 2 Historical Background of Periodontal Microsurgery Compared with Conventional Mucogingival Interventions 3 Periodontal Phenotype 4 Gingival Recessions 5 Recession Classification 6 Incisions 6.1 Horizontal 6.2 Vertical 7 Flap Designs 7.1 Mucoperiosteal Flap (Total Thickness) 7.2 Mucosal Flap (Partial Thickness) 7.3 Combined Flap (Partial/Total/Partial Thickness) 8 Suture Techniques 8.1 Closing Sutures 8.2 Tension-Relieving Sutures 8.3 Combined Sutures (Closing and Tension-Relieving Sutures) 8.4 Suspension Sutures 8.5 Point-of-Contact Sling Sutures 8.6 Fixation Sutures 8.7 Insertion Sutures 9 Treatment of Single Gingival Recessions 9.1 Trapezoidal Flap (CAF with Vertical Incisions) 9.2 Laterally Moved CAF 9.3 CAF in Envelope Without Vertical Incision 9.4 Envelope Without Incision 9.5 Laterally Closed Tunnel for Isolated Mandibular Recession 10 Treatment of Multiple Gingival Recessions 10.1 CAF in Envelope 10.2 Modified Tunnel 11 Microscope-Assisted Autograft Harvesting 11.1 Trapdoor Technique 11.2 Envelope Technique 11.3 Connective Tissue Graft (De-epithelialized Epithelium) 12 Treating Non-carious Cervical Lesions Associated with Gingival Recessions Defects 12.1 Classification of Root Defects 12.2 Digitally Guided Root Coverage Predetermination: A Multidisciplinary Approach 12.3 Treatment Options 12.3.1 Class 1 12.3.2 Class 2 12.3.3 Class 3 (Option 1) 12.3.4 Class 3 (Option 2) 12.3.5 Class 4 12.4 Restorative Treatment 12.5 Surgical Treatment 12.6 Restorative Treatment 12.7 Surgical Treatment Plan (Right Side) 12.8 Surgical Treatment Plan (Left Side) 12.9 Mandibular Surgical Plan (Left Side) 12.10 Clinical Outcomes 12.11 Restorative Treatment 12.12 Surgical Treatment 12.13 Clinical Outcomes 13 Treatment of Peri-implant Soft Tissues Dehiscences/Deficiencies in the Esthetic Zone 13.1 Immediate Management During the Placement of Implants 13.2 Later Management on Rehabilitated Implants 13.3 Classification of Peri-implant Soft Tissues Defects 13.3.1 Multidisciplinary Approach 14 Conclusions 15 Key Points References Microscope-Assisted Laser Ablation of Gingival Pigmentation 1 Introduction: Gingival Pigmentation 2 Application of Lasers in Gingival Depigmentation 3 Er:YAG Laser-Assisted Gingival Depigmentation 3.1 Indication for Depigmentation of Gingiva 3.2 Characteristics of Er:YAG Laser 3.3 Ablation Mechanism and Thermal Effects 3.4 Soft Tissue Ablation and Wound Healing Following Er:YAG Laser Surgery 3.5 Advantages of Er:YAG Laser Microsurgery in Esthetic Gingival Procedures 3.6 Er:YAG Laser Irradiation Safety 4 Removal of Melanin Pigmentation 4.1 Procedures of Melanin Depigmentation Under Microscope 4.2 Wound Healing and Pain Perception 4.3 Clinical Cases 4.3.1 Case 1 4.3.2 Case 2 5 Removal of Metal Tattoo Pigmentation 5.1 Procedures of Metal Tattoo Depigmentation Under Microscope 5.2 Wound Healing and Pain Perception 5.3 Clinical Cases 5.3.1 Case 1 5.3.2 Case 2 6 Closing Remarks 7 Key Points References Microscope-Assisted Periodontal Regenerative Therapy 1 Introduction 1.1 Definition of Terms 1.2 Role of the OM and Microsurgical Instruments and Materials in Periodontal Regenerative Therapy (PRT) 2 Historical Background 2.1 Landmark Events in Periodontal Regenerative Therapy of Intrabony Defects 2.2 Landmark Events in Minimally Invasive Surgery of Intrabony Defects 2.3 Landmark Events in Regeneration of Furcation Defects 2.4 Landmark Events in Regeneration of Combined Intrabony and Furcation Defects 3 Principles Behind the Biologically Driven Paradigm 3.1 Setting the Ideal Condition for Periodontal Regenerative Microsurgery 3.1.1 Patient Preparation: Patient-Related Factors 3.1.2 Site Preparation: Site-Related Factors 3.2 Biologically Driven Flap Design and Selection of the Regenerative Strategy 3.2.1 Soft Tissue Architecture 3.2.2 Hard Tissue Architecture 3.2.3 Presurgical Assessment of the Hard and Soft Tissue Morphology 3.2.4 Biologic Foundation of Periodontal Regeneration 4 Microsurgical Phase: Treatment of Intrabony and Furcation Defects 4.1 Workflow During PRT Utilizing the Operating Microscope 4.2 The Biologically Driven Flap Design 4.3 Technical Tips: Flap Design, Defect Debridement, Biomaterial Application, Suturing 4.3.1 Intrabony Defects 4.3.2 Key-Hole Furcation Defects 4.3.3 Combined Intrabony and Furcation Defects 5 Errors Most Frequently Committed/Actions to Avoid 6 Postsurgical Protocols and Complications 7 Surgical and Postsurgical Patient Morbidity 8 Long-Term Outcomes of Regeneration 9 Summary 10 Key Points References Microscope-Assisted Preprosthetic Surgery 1 Introduction 2 Donor Site Evaluation and Harvesting Techniques for Free Gingival Graft (FGG)/Connective Tissue Graft (CTG) 3 Root Coverage Procedures: Recipient Site Consideration and Preparation 4 Preprosthetic Gingival Augmentation 5 Surgical Crown Lengthening 6 Papilla Reconstruction 7 Conclusion 8 Key Points References Microsurgery in Guided Bone Regeneration 1 Introduction 1.1 History of Guided Bone Regeneration 1.2 Development of Microscopic Surgery and its Application in Regenerative Bone Therapy 1.2.1 History 1.3 Importance of the Surgical Microscope in GBR 2 Biological Basis and Anatomical Consideration During Microscope-Assisted GBR 2.1 Ridge Deformity Classifications 2.2 Physiology of Bone Regeneration, Histology, and Participating Cells 2.3 Intra-Operative Visualization of Anatomical Structures 2.4 Anatomical Considerations for GBR 2.4.1 Anatomical Considerations: Musculature Maxilla Mandible 2.4.2 Anatomical Considerations: Vasculature 2.4.3 Anatomical Considerations: Innervation 3 Microsurgical Soft Tissue Management 3.1 Incision Design 3.2 Decision to Place Vertical Incisions 3.3 Steps in Flap Releasing: Layered Releasing Incision, Linear Incision, and Selectively Releasing Incision 3.3.1 Microsurgical reflection 4 Special Considerations in Material Selection and Placement 4.1 Selection and Management of Regenerative Materials and Their Combination in Microsurgery 4.2 Autologous Bone Graft, Allografts, Xenografts, and Membranes 4.2.1 Xenografts 4.2.2 Allografts 4.2.3 Mixed Grafts 4.3 Use of Resorbable and Non-resorbable Membranes 4.4 Use of Dermis Allograft as Membrane 4.5 Use of Biologics 4.6 Membrane-Fixation Microsurgical Techniques 5 Microsurgical Sutures Specific to Bone Regeneration 5.1 Microsurgical Knots [68] 5.2 Suspensory Suture Technique 5.3 Different Suturing Materials 6 Post Microsurgical Management 6.1 Postoperative Indications 6.2 Microsurgical Suture Removal 7 Microsurgical Management of Postoperative Complications 8 Soft Tissue Management and Vestibular Repositioning After Bone Regeneration 8.1 Vestibular Deepening 8.2 Connective Tissue Grafts for Increased Thickness 8.3 Soft Tissue Grafts to Increase Keratinized Tissue 8.4 Allografts, Xenografts, and Their Use 9 Ultra-Minimally Invasive GBR Techniques 10 Conclusion 11 Key Points References Microscope-Assisted Sinus Augmentation 1 Introduction 2 Keys to Success in Sinus Augmentation Procedures 2.1 Historical Background and the Current Trend of Sinus Augmentation Surgery 2.2 The Rationale for Microscope-Assisted Sinus Augmentation 3 Anatomical Considerations and Clinical Implications 3.1 Schneiderian Membrane 3.2 Sinus Walls: Floor, Medial-Lateral Wall Distance, Angle, Lateral Wall Thickness, Septum 3.3 Residual Ridge Height and Width 3.4 Vascular Supply 3.5 Innervation 4 Fundamental Principles of Endoscopy as a Minimally Invasive Approach for Antral Interventions 5 Presurgical Sinus Assessment: Diagnosing Pathological Conditions of the Maxillary Sinus 6 Pre-op Diagnosis, Planning, and Evaluation of Case Difficulty 7 Microscope-Assisted Lateral Sinus Augmentation 7.1 Lateral Sinus Augmentation 7.1.1 Potential Benefits and Advantages 7.1.2 Incision Design and Osteotomy Preparation 7.1.3 Schneiderian Membrane Examination and Management 7.1.4 Management of Schneiderian Membrane Perforation 8 Microscope-Assisted Vertical Sinus Augmentation 8.1 Potential Benefits and Advantages 8.2 Osteotomy Site Preparation 8.3 Detection of Schneiderian Membrane Perforation and Management 8.4 Bone Graft Application and Simultaneous Implant Placement 9 Conclusions 10 Key Points 11 Appendix References The Shanelec SMILE Technique: Immediate Microsurgical Implant and Provisional Restoration Placement in Anterior Esthetic Sites 1 Introduction 2 Immediate Implant Placement in the Maxillary Anterior Area 3 Case Presentation 4 Step 1: Implant Microsurgery 5 Steps 2, 3, 18, and 19: Preparation of Provisional Replication of the Failing Tooth 6 Steps 4–6: Extraction with Minimal Trauma and Socket Debridement 7 Step 7: Socket Drilling 8 Steps 8–13: Implant Placement 9 Steps 14–16: Osseous Grafting of the Buccal Socket Gap 10 Steps 17–24: Implant Provisional Crown 11 Steps 25 and 27: Advancing the Flap 12 Steps 26, 28, 29, 30, 31: Provisional Restoration Seating, Adjusting Occlusion, Postoperative Care 13 Step 32: Final Restoration 14 Step 33: Postoperative CAT Scan 15 Clinical Results and Discussion 16 Key Points References Microscope-Assisted Implant Complication Management 1 Implant Complications 2 Trans-Surgical Accident 3 Early Complications 3.1 Edema, Bleeding, Ecchymosis, and Hematoma 3.2 Mucosal Dehiscence 4 Late Complications 4.1 Mechanical Complications 4.2 Biological Complications 4.3 Esthetic Implant Complications 4.3.1 Implant Position and Prosthesis 4.3.2 Phenotype 4.3.3 Surgical Technique and Morphology of the Recession 4.3.4 Papilla Reconstruction 5 Conclusions 6 Key Points References This book compiles all relevant information regarding fundamental concepts and advanced techniques related to the applications of minimally invasive procedures in periodontal and implant therapy facilitated with the operating microscope. Microsurgical therapy, wound healing principles as well as biomechanical and design aspects of micro-instruments and suturing armamentarium are discussed. The book offers information that is usually scattered in the dental and medical literature and not only hard to compile but also to frame in the appropriate clinical categories. Its unique emphasis on ergonomics (patient, operator and assistant positioning) and collaboration techniques like four to six hand assisting make this work unique. Each topic is discussed by world renowned experts in the field. The book is a valuable resource for the dental society including general dentists, periodontists, oral surgeons and implantologists.