Clinical Periodontology and Implant Dentistry Fifth Edition Edited by Jan Lindhe Niklaus P. Lang Thorkild Karring Associate Editors Tord Berglundh William V. Giannobile Mariano Sanz COPYRIGHTED ciate Editors ciate Edito ord Berglun ord Berglu lliam V. G lliam V. G Marian Mari MATERIAL g ing ng MATERIAL Volume 1 BASIC CONCEPTS Edited by Jan Lindhe Niklaus P. Lang Thorkild Karring COPYRIGHTED MATERIAL ing ng © 2008 by Blackwell Munksgaard, a Blackwell Publishing company Blackwell Publishing editorial offi ces: Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Tel: +44 (0)1865 776868 Blackwell Publishing Professional, 2121 State Avenue, Ames, Iowa 50014-8300, USA Tel: +1 515 292 0140 Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia Tel: +61 (0)3 8359 1011 The right of the Author to be identifi ed as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. 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First published 1983 by Munksgaard Second edition published 1989 Third edition published 1997 Fourth edition published by Blackwell Munksgaard 2003 Reprinted 2003, 2005, 2006 Fifth edition 2008 by Blackwell Publishing Ltd ISBN: 978-1-4051-6099-5 Library of Congress Cataloging-in-Publication Data Clinical periodontology and implant dentistry / edited by Jan Lindhe, Niklaus P. Lang, Thorkild Karring. — 5th ed. p. ; cm. Includes bibliographical references and index. ISBN: 978-1-4051-6099-5 (hardback : alk. paper) 1. Periodontics. 2. Periodontal disease. 3. Dental implants. I. Lindhe, Jan. II. Lang, Niklaus Peter. III. Karring, Thorkild. [DNLM: 1. Periodontal Diseases. 2. Dental Implantation. 3. Dental Implants. WU 240 C6415 2008] RK361.C54 2008 617.6′32—dc22 2007037124 A catalogue record for this title is available from the British Library Set in 9.5/12 pt Palatino by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in Singapore by C.O.S. Printers Pte Ltd The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. For further information on Blackwell Publishing, visit our website: www.blackwellmunksgaard.com 1-6099-5 -6099- loging-in-Public oging-in-Pub plant dentistry / plant dentistry / Thorkild Karring Thorkild Karrin p. ; cm. p. ; cm. bliographical refe liographical refe 8-1-4051-6099-5 (h 1-4051-6099- eriodontal diseas eriodontal diseas Lang, Niklaus Pet g, Niklaus P dontal Diseases. dontal Diseas W A catalog A catalo Set in Set i The publisher’s The publish and which h which h practice cti MATERIAL All l ks or ks roduct or oduct o rd to the subject rd to the subject ed in rendering ed in renderin ed, the services ed, the services nksgaard 2003 sgaard 20 06 06 lishing Ltd lishing Lt Contents Contributors, xvii Preface, xxi Volume 1: BASIC CONCEPTS Editors: Jan Lindhe, Niklaus P. Lang, and Thorkild Karring Part 1: Anatomy 1 The Anatomy of Periodontal Tissues, 3 Jan Lindhe, Thorkild Karring, and Maurício Araújo Introduction, 3 Gingiva, 5 Macroscopic anatomy, 5 Microscopic anatomy, 8 Periodontal ligament, 27 Root cementum, 31 Alveolar bone, 34 Blood supply of the periodontium, 43 Lymphatic system of the periodontium, 47 Nerves of the periodontium, 48 2 The Edentulous Alveolar Ridge, 50 Maurício Araújo and Jan Lindhe Clinical considerations, 50 Remaining bone in the edentulous ridge, 52 Classifi cation of remaining bone, 53 Topography of the alveolar process, 53 Alterations of the alveolar process following tooth extraction, 54 Intra-alveolar processes, 54 Extra-alveolar processes, 62 Topography of the edentulous ridge, 66 3 The Mucosa at Teeth and Implants, 69 Jan Lindhe, Jan L. Wennström, and Tord Berglundh The gingiva, 69 Biologic width, 69 Dimensions of the buccal tissue, 69 Dimensions of the interdental papilla, 71 The peri-implant mucosa, 71 Biologic width, 72 Quality, 76 Vascular supply, 77 Probing gingiva and peri-implant mucosa, 78 Dimensions of the buccal soft tissue at implants, 80 Dimensions of the papilla between teeth and implants, 81 Dimensions of the “papilla” between adjacent implants, 82 4 Bone as a Tissue, 86 William V. Giannobile, Hector F. Rios, and Niklaus P. Lang Basic bone biology, 86 Bone cells, 86 Modeling and remodeling, 87 Growth factors and alveolar bone healing, 88 Local and systemic factors affecting bone volume and healing, 89 Metabolic disorders affecting bone metabolism, 89 Bone healing, 93 Bone grafting, 93 Human experimental studies on alveolar bone repair, 94 5 Osseointegration, 99 Jan Lindhe, Tord Berglundh, and Niklaus P. Lang The edentulous site, 99 Osseointegration, 99 Implant installation 99 Tissue injury, 99 Wound healing, 100 Cutting and non-cutting implants, 100 The process of osseointegration, 103 6 Periodontal Tactile Perception and Peri-implant Osseoperception, 108 Reinhilde Jacobs Introduction, 108 Neurophysiological background, 109 Afferent nerve fi bres and receptors, 109 Trigeminal neurophysiology, 109 Trigeminal neurosensory pathway, 109 Neurovascularization of the jaw bones, 109 Mandibular neuroanatomy, 110 Maxillary neuroanatomy, 111 Periodontal innervation, 112 Testing tactile function, 113 Neurophysiological assessment, 113 Psychophysical assessment, 114 Periodontal tactile function, 115 Active threshold determination, 115 Passive threshold determination, 115 Infl uence of dental status on tactile function, 116 COPYRIGHTED ge, 50 e, 50 dhe dhe edentulous ridg dentulous rid aining bone, 53 aining bone, 53 eolar process, 5 olar process, 5 veolar process f olar process olar processes, olar processe lveolar process veolar process phy of the eden phy of the The Mucosa a he Mucosa a Jan Lindhe, J Jan Lindhe, Tord Berg d Ber The gingiva he gingiv Biol Biol D Loca Loc healin hea Me M Bone Bone MATERIAL Karring Karring ssue, 86 ssue, 86 Giannobile, H Giannobile, H P. Lang P. Lan ne biology, 86 ne biology, 86 one cells, 86 e cells, 86 Modeling and Modeling and Growth fac Growth fac nd sys nd s vi Contents Activation of oral mechanoreceptors during oral tactile function, 117 Functional testing of the oral somatosensory system, 117 Oral stereognosis, 118 Infl uence of dental status on stereognostic ability, 118 Other compromising factors for oral stereognosis, 118 Receptor activation during oral stereognosis, 119 From periodontal tactile function to peri-implant osseoperception, 119 Tooth extraction considered as sensory amputation, 119 Histological background of peri-implant osseoperception, 120 Cortical plasticity after tooth extraction, 121 From osseoperception to implant-mediated sensory motor interactions, 121 Clinical implications of implant-deviated sensory motor interaction, 122 Conclusions, 122 Part 2: Epidemiology 7 Epidemiology of Periodontal Diseases, 129 Panos N. Papapanou and Jan Lindhe Introduction, 129 Methodological issues, 129 Examination methods – index systems, 129 Critical evaluation, 131 Prevalence of periodontal diseases, 133 Introduction, 133 Periodontitis in adults, 133 Periodontal disease in children and adolescents, 138 Periodontitis and tooth loss, 141 Risk factors for periodontitis, 141 Introduction – defi nitions, 141 Non-modifi able background factors, 143 Environmental, acquired, and behavioral factors, 145 Periodontal infections and risk for systemic disease, 156 Atherosclerosis – cardiovascular/cerebrovascular disease, 156 Pregnancy complications, 159 Diabetes mellitus, 162 Part 3: Microbiology 8 Oral Biofi lms and Calculus, 183 Niklaus P. Lang, Andrea Mombelli, and Rolf Attström Microbial considerations, 183 General introduction to plaque formation, 184 Dental plaque as a biofi lm, 187 Structure of dental plaque, 187 Supragingival plaque, 187 Subgingival plaque, 191 Peri-implant plaque, 196 Dental calculus, 197 Clinical appearance, distribution, and clinical diagnosis, 197 Attachment to tooth surfaces and implants, 200 Mineralization, composition, and structure, 201 Clinical implications, 202 9 Periodontal Infections, 207 Sigmund S. Socransky and Anne D. Haffajee Introduction, 207 Similarities of periodontal diseases to other infectious diseases, 207 Unique features of periodontal infections, 208 Historical perspective, 209 The early search, 209 The decline of interest in microorganisms, 211 Non-specifi c plaque hypothesis, 211 Mixed anaerobic infections, 211 Return to specifi city in microbial etiology of periodontal diseases, 212 Changing concepts of the microbial etiology of periodontal diseases, 212 Current suspected pathogens of destructive periodontal diseases, 213 Criteria for defi ning periodontal pathogens, 213 Periodontal pathogens, 213 Mixed infections, 225 The nature of dental plaque – the biofi lm way of life, 226 The nature of biofi lms, 226 Properties of biofi lms, 227 Techniques for the detection and enumeration of bacteria in oral biofi lm samples, 229 The oral biofi lms that lead to periodontal diseases, 229 Microbial complexes, 231 Factors that affect the composition of subgingival biofi lms, 232 Microbial composition of supra- and subgingival biofi lms, 238 Development of supra- and subgingival biofi lms, 239 Prerequisites for periodontal disease initiation and progression, 242 The virulent periodontal pathogen, 243 The local environment, 243 Host susceptibility, 244 Mechanisms of pathogenicity, 245 Essential factors for colonization of a subgingival species, 245 Effect of therapy on subgingival biofi lms, 249 10 Peri-implant Infections, 268 Ricardo P. Teles, Anne D. Haffajee, and Sigmund S. Socransky Introduction, 268 Early biofi lm development on implant surfaces, 268 Time of implant exposure and climax community complexity, 271 The microbiota on implants in edentulous subjects, 273 The microbiota on implants in partially edentulous subjects, 275 The microbiota on implants in subjects with a history of periodontal disease, 276 The microbiota of peri-implantitis sites, 277 COPYRIGHTED 1 s, 141 s, 141 ground factors, round factors quired, and beh ired, and beh ons and risk fo ons and risk clerosis – cardio osis – c ease, 156 ase, 156 egnancy compli ancy compli Diabetes mellit Diabetes mellit : M 226 The n The Proper op Tech Tech MATERIAL 208 ganisms, 211 ganisms, 211 s, 211 211 211 211 icrobial etiolog icrobial etiolog , 212 , 212 of the microbia of the microbi seases, 212 seases, 212 pathogens of d pathogens of d seases, 213 seases, 213 or defi defi ning per ning p fifi dontal pathogen ntal pathogen xed infections, 2 xed infections ure of dental ure of denta Contents vii Part 4: Host–Parasite Interactions 11 Pathogenesis of Periodontitis, 285 Denis F. Kinane, Tord Berglundh, and Jan Lindhe Introduction, 285 Clinically healthy gingiva, 286 Gingival infl ammation, 287 Histopathological features of gingivitis, 287 Different lesions in gingivitis/periodontitis, 289 The initial lesion, 289 The early lesion, 289 The established lesion, 290 The advanced lesion, 292 Host–parasite interactions, 294 Microbial virulence factors, 294 Host defense processes, 295 Important aspects of host defense processes, 295 The innate defense systems, 297 The immune or adaptive defense system, 299 12 Modifying Factors, 307 Richard Palmer and Mena Soory Diabetes mellitus, 307 Type 1 and type 2 diabetes mellitus, 307 Clinical symptoms, 308 Oral and periodontal effects, 308 Association of periodontal infection and diabetic control, 309 Modifi cation of the host–bacteria relationship in diabetes, 310 Periodontal treatment, 311 Puberty, pregnancy, and the menopause, 312 Puberty and menstruation, 312 Pregnancy, 312 Menopause and osteoporosis, 314 Hormonal contraceptives, 316 Tobacco smoking, 316 Periodontal disease in smokers, 317 Modifi cation of the host–bacteria relationship in smoking, 319 Smoking cessation, 322 13 Susceptibility, 328 Bruno G. Loos, Ubele van der Velden, and Marja L. Laine Introduction, 328 Evidence for the role of genetics in periodontitis, 331 Heritability of aggressive periodontitis (early onset periodontitis), 331 Heritability of chronic periodontitis (adult periodontitis), 332 A gene mutation with major effect on human disease and its association with periodontitis, 332 Disease-modifying genes in relation to periodontitis, 333 IL-1 and TNF-α gene polymorphisms, 334 FcγR gene polymorphisms, 336 Gene polymorphisms in the innate immunity receptors, 338 Vitamin D receptor gene polymorphisms, 338 IL-10 gene polymorphisms, 339 Miscellaneous gene polymorphisms, 340 Disease-modifying genes in relation to implant failures and peri-implantitis, 340 Early failures in implant dentistry, 341 Late failures in implant dentistry, 342 Conclusions and future developments, 342 Part 5: Trauma from Occlusion 14 Trauma from Occlusion: Periodontal Tissues, 349 Jan Lindhe, Sture Nyman, and Ingvar Ericsson Defi nition and terminology, 349 Trauma from occlusion and plaque-associated periodontal disease, 349 Analysis of human autopsy material, 350 Clinical trials, 352 Animal experiments, 353 15 Trauma from Occlusion: Peri-implant Tissues, 363 Niklaus P. Lang and Tord Berglundh Introduction, 363 Orthodontic loading and alveolar bone, 363 Bone reactions to functional loading, 365 Excessive occlusal load on implants, 365 Static and cyclic loads on implants, 366 Load and loss of osseointegration, 368 Masticatory occlusal forces on implants, 369 Tooth–implant supported reconstructions, 370 Part 6: Periodontal Pathology 16 Non-Plaque Induced Infl ammatory Gingival Lesions, 377 Palle Holmstrup Gingival diseases of specifi c bacterial origin, 377 Gingival diseases of viral origin, 378 Herpes virus infections, 378 Gingival diseases of fungal origin, 380 Candidosis, 380 Linear gingival erythema, 381 Histoplasmosis, 382 Gingival lesions of genetic origin, 383 Hereditary gingival fi bromatosis, 383 Gingival diseases of systemic origin, 384 Mucocutaneous disorders, 384 Allergic reactions, 392 Other gingival manifestations of systemic conditions, 394 Traumatic lesions, 396 Chemical injury, 396 Physical injury, 396 Thermal injury, 397 Foreign body reactions, 398 17 Plaque-Induced Gingival Diseases, 405 Angelo Mariotti Classifi cation criteria for gingival diseases, 405 Plaque-induced gingivitis, 407 Gingival diseases associated with endogenous hormones, 408 Puberty-associated gingivitis, 408 Menstrual cycle-associated gingivitis, 409 Pregnancy-associated gingival diseases, 409 Gingival diseases associated with medications, 410 Drug-infl uenced gingival enlargement, 410 COPYRIGHTED s, 317 s, 31 acteria relations teria relation 22 328 328 , Ubele van der bele van aine aine 328 328 for the role of g the rol eritability of agg ritability of onset period onset period Heritability Heritability periodo period A gene mu A gene mu nd its nd its Part Part 16 N 16 N MATERIAL eri-implant Ti eri-implant Ti ord Berglundh rd Berglundh nd alveolar bo nd alveolar b unctional loadin unctional load al load on impl al load on impl lic loads on im lic loads on oss of osseointe s of osseointe ory occlusal fo ory occlusal fo h–implant supp plant su Pe Pe viii Contents Oral contraceptive-associated gingivitis, 411 Gingival diseases associated with systemic diseases, 411 Diabetes mellitus-associated gingivitis, 411 Leukemia-associated gingivitis, 411 Linear gingival erythema, 412 Gingival diseases associated with malnutrition, 412 Gingival diseases associated with heredity, 413 Gingival diseases associated with ulcerative lesions, 413 Treatment of plaque-induced gingival diseases, 414 The signifi cance of gingivitis, 414 18 Chronic Periodontitis, 420 Denis F. Kinane, Jan Lindhe, and Leonardo Trombelli Clinical features of chronic periodontitis, 420 Overall characteristics of chronic periodontitis, 420 Gingivitis as a risk for chronic periodontitis, 422 Susceptibility to chronic periodontitis, 422 Prevalence of chronic periodontitis, 423 Progression of chronic periodontitis, 423 Risk factors for chronic periodontitis, 424 Bacterial plaque, 424 Age, 424 Smoking, 424 Systemic disease, 424 Stress, 425 Genetics, 426 Scientifi c basis for treatment of chronic periodontitis, 426 19 Aggressive Periodontitis, 428 Maurizio S. Tonetti and Andrea Mombelli Classifi cation and clinical syndromes, 429 Epidemiology, 431 Primary dentition, 432 Permanent dentition, 432 Screening, 433 Etiology and pathogenesis, 437 Bacterial etiology, 437 Genetic aspects of host susceptibility, 441 Environmental aspects of host susceptibility, 445 Current concepts, 445 Diagnosis, 445 Clinical diagnosis, 445 Microbiologic diagnosis, 448 Evaluation of host defenses, 448 Genetic diagnosis, 449 Principles of therapeutic intervention, 449 Elimination or suppression of the pathogenic fl ora, 449 20 Necrotizing Periodontal Disease, 459 Palle Holmstrup and Jytte Westergaard Nomenclature, 459 Prevalence, 460 Clinical characteristics, 460 Development of lesions, 460 Interproximal craters, 461 Sequestrum formation, 462 Involvement of alveolar mucosa, 462 Swelling of lymph nodes, 463 Fever and malaise, 463 Oral hygiene, 463 Acute and recurrent/chronic forms of necrotizing gingivitis and periodontitis, 463 Diagnosis, 464 Differential diagnosis, 464 Histopathology, 465 Microbiology, 466 Microorganisms isolated from necrotizing lesions, 466 Pathogenic potential of microorganisms, 466 Host response and predisposing factors, 468 Systemic diseases, 468 Poor oral hygiene, pre-existing gingivitis, and history of previous NPD, 469 Psychologic stress and inadequate sleep, 469 Smoking and alcohol use, 470 Caucasian background, 470 Young age, 470 Treatment, 470 Acute phase treatment, 470 Maintenance phase treatment, 472 21 Periodontal Disease as a Risk for Systemic Disease, 475 Ray C. Williams and David W. Paquette Early twentieth century concepts, 475 Periodontitis as a risk for cardiovascular disease, 476 Biologic rationale, 479 Periodontitis as a risk for adverse pregnancy outcomes, 480 Association of periodontal disease and pre- eclampsia, 486 Periodontitis as a risk for diabetic complications, 486 Periodontitis as a risk for respiratory infections, 488 Effects of treatment of periodontitis on systemic diseases, 489 22 The Periodontal Abscess, 496 Mariano Sanz, David Herrera, and Arie J. van Winkelhoff Introduction, 496 Classifi cation, 496 Prevalence, 497 Pathogenesis and histopathology, 497 Microbiology, 498 Diagnosis, 498 Differential diagnosis, 499 Treatment, 500 Complications, 501 Tooth loss, 501 Dissemination of the infection, 502 23 Lesions of Endodontic Origin, 504 Gunnar Bergenholtz and Domenico Ricucci Introduction, 504 Disease processes of the dental pulp, 504 Causes, 504 Progression and dynamic events, 505 Accessory canals, 507 Periodontal tissue lesions to root canal infection, 510 Effects of periodontal disease and periodontal therapy on the condition of the pulp, 516 Infl uences of periodontal disease, 516 Infl uence of periodontal treatment measures on the pulp, 518 Root dentin hypersensitivity, 518 COPYRIGHTED st susceptibility, t susceptibility ects of host sus ts of host sus s, 445 s, 445 agnosis, 445 gnosis, ologic diagnosis logic diag ation of host d ation of host netic diagnosis ic diagnosis ciples of therap iples of therap Elimination Eliminati flfl ora, 44 ora, 4 flfl Ass As ecla ec Periodontit Periodont Periodon Periodon Effect ffec d MATERIAL 469 46 tment, 472 tment, 472 se as a Risk fo se as a Risk f ms and David W s and David W century concep century conce as a risk for ca as a risk for c gic rationale, 47 rational ntitis as a risk ntitis as a risk mes, 480 mes, 480 ation atio Contents ix Part 7: Peri-implant Pathology 24 Peri-implant Mucositis and Peri-implantitis, 529 Tord Berglundh, Jan Lindhe, and Niklaus P. Lang Defi nitions, 529 Ridge mucosa, 529 Peri-implant mucosa, 529 Peri-implant mucositis, 530 Clinical features, 530 Prevalence, 530 Histopathology, 530 Peri-implantitis, 532 Clinical features, 532 Prevalence, 532 Histopathology, 534 Part 8: Tissue Regeneration 25 Concepts in Periodontal Tissue Regeneration, 541 Thorkild Karring and Jan Lindhe Introduction, 541 Regenerative periodontal surgery, 542 Periodontal wound healing, 542 Regenerative capacity of bone cells, 547 Regenerative capacity of gingival connective tissue cells, 547 Regenerative capacity of periodontal ligament cells, 548 Role of epithelium in periodontal wound healing, 549 Root resorption, 550 Regenerative concepts, 550 Grafting procedures, 551 Root surface biomodifi cation, 557 Growth regulatory factors for periodontal regeneration, 559 Guided tissue regeneration (GTR), 559 Assessment of periodontal regeneration, 561 Periodontal probing, 561 Radiographic analysis and re-entry operations, 562 Histologic methods, 562 Index, i1 Volume 2: CLINICAL CONCEPTS Editors: Niklaus P. Lang and Jan Lindhe Part 9: Examination Protocols 26 Examination of Patients with Periodontal Diseases, 573 Giovanni E. Salvi, Jan Lindhe, and Niklaus P. Lang History of periodontal patients, 573 Chief complaint and expectations, 573 Social and family history, 573 Dental history, 573 Oral hygiene habits, 573 Smoking history, 574 Medical history and medications, 574 Signs and symptoms of periodontal diseases, 574 The gingiva, 574 The periodontal ligament and the root cementum, 577 The alveolar bone, 583 Diagnosis of periodontal lesions, 583 Oral hygiene status, 584 Additional dental examinations, 585 27 Examination of the Candidate for Implant Therapy, 587 Hans-Peter Weber, Daniel Buser, and Urs C. Belser Dental implants in periodontally compromised patients, 587 Patient history, 590 Chief complaint and expectations, 590 Social and family history, 590 Dental history, 590 Motivation and compliance, 591 Habits, 591 Medical history and medications, 591 Local examination, 591 Extraoral, 591 General intraoral examination, 592 Radiographic examination, 592 Implant-specifi c intraoral examination, 592 Patient-specifi c risk assessment, 597 Risk assessment for sites without esthetic implications, 597 Risk assessment for sites with esthetic implications, 597 28 Radiographic Examination of the Implant Patient, 600 Hans-Göran Gröndahl and Kerstin Gröndahl Introduction, 600 Radiographic examination for implant planning purposes – general aspects, 601 The clinical vs. the radiologic examination, 601 What is the necessary radiographic information?, 601 Radiographic methods for obtaining the information required for implant planning, 603 Radiographic examination for implant planning purposes – upper jaw examination, 607 Radiographic examination for implant planning purposes – lower jaw examination, 610 Radiographic monitoring of implant treatment, 614 Radiation detectors for intraoral radiography, 618 Image-guided surgery, 621 29 Examination of Patients with Implant- Supported Restorations, 623 Urs Brägger Identifi cation of the presence of implants and implant systems, 623 Screening, 623 Implant pass, 623 COPYRIGHTED al l klaus P. Lang laus P. La ns, 573 573 nd medications, d medications s of periodontal of periodonta 574 574 dontal ligament dontal ligam alveolar bone, 5 lveolar b osis of periodon sis of period l hygiene status ygiene sta Additional dent dditional dent 27 Examin 7 Exam The The Gen G Ra R Pa P MATERIAL odontal ontal GTR), 559 GTR), 559 eneration, 561 eneration, 56 61 61 is and re-entry is and re-entry hods, 562 hods, 562 CONCEPTS NCEPT and Jan Lin and Jan Li x Contents Questionnaire for new patients, 625 Anamnestic information from patients on maintenance, 625 The development of implant recognition software, 625 Clinical inspection and examination, 625 Characteristics of implant-supported restorations, 625 Characteristics of prosthetic components and components of implant systems, 626 Technical failures/complications, 626 Function, 628 Functional analysis, 628 Articulation, phonetics, 628 Implant, 628 Clinical test of mobility, 629 Electronic tools to assess the quality of osseointegration, 629 Bacterial deposits, 629 Soft tissues, 629 Mucosa, 629 Palpation/sensitivity, 629 Recession, pocket probing depth, probing attachment level, bleeding on probing, 629 Esthetics, 630 Papillae, interdental space and type of mucosa, 630 Condition of adjacent teeth, 631 Color shades, 632 30 Risk Assessment of the Implant Patient, 634 Gary C. Armitage and Tord Lundgren Principles of risk assessment, 634 Clinical information required for risk assessment, 636 Technical procedures to help minimize risk, 636 Local risk factors and conditions, 637 Presence of ongoing oral infections, 637 Systemic risk factors, 639 Age, 639 Smoking, 640 Medication history, 640 Immunosuppression, 642 History of radiation therapy to the jaws, 642 Diabetes mellitus, 642 Metabolic bone disease, 643 Connective tissue and autoimmune disorders, 643 Xerostomia, 644 Hematologic and lymphoreticular disorders, 644 Genetic traits and disorders, 644 Importance of behavioral considerations in risk assessment, 645 Dental history of compliance behaviors, 645 Substance use/abuse, 645 Psychiatric/psychological issues, 645 Lack of understanding or communication, 645 Patient’s expectations, 646 Interest and commitment to post-treatment care and maintenance program, 646 Part 10: Treatment Planning Protocols 31 Treatment Planning of Patients with Periodontal Diseases, 655 Giovanni E. Salvi, Jan Lindhe, and Niklaus P. Lang Screening for periodontal disease, 656 Basic periodontal examination, 656 Diagnosis, 657 Treatment planning, 658 Initial treatment plan, 658 Pre-therapeutic single tooth prognosis, 660 Case presentation, 660 Case report, 667 Patient S.K. (male, 35 years old), 667 32 Treatment Planning for Implant Therapy in the Periodontally Compromised Patient, 675 Jan L. Wennström and Niklaus P. Lang Prognosis of implant therapy in the periodontally compromised patient, 675 Strategies in treatment planning, 676 Treatment decisions – case reports, 676 Posterior segments, 676 Tooth versus implant, 679 Aggressive periodontitis, 680 Furcation problems, 682 Single-tooth problem in the esthetic zone, 683 33 Systemic Phase of Therapy, 687 Niklaus P. Lang and Hans-Rudolf Baur Introduction, 687 Protection of the dental team and other patients against infectious diseases, 687 Protection of the patient’s health, 688 Prevention of complications, 688 Infection, specifi cally bacterial endocarditis, 688 Bleeding, 689 Cardiovascular incidents, 690 Allergic reactions and drug interactions, 690 Systemic diseases, disorders or conditions infl uencing pathogenesis and healing potential, 690 Control of anxiety and pain, 690 Smoking counseling, 691 Part 11: Initial Periodontal Therapy (Infection Control) 34 Motivational Interviewing, 695 Christoph A. Ramseier, Delwyn Catley, Susan Krigel, and Robert A. Bagramian The importance of behavioral change counseling in periodontal care, 695 Development of motivational interviewing, 696 History of motivational interviewing, 697 What is motivational interviewing?, 697 Evidence for motivational interviewing, 697 Implementation of motivational interviewing into the periodontal treatment plan, 698 Key principles of motivational interviewing, 698 Basic communication skills, 698 Giving advice, 700 Case examples for oral hygiene motivation, 700 Oral hygiene motivation 1, 700 Oral hygiene motivation 2, 701 Case example for tobacco use cessation, 702 35 Mechanical Supragingival Plaque Control, 705 Fridus van der Weijden, José J. Echeverría, Mariano Sanz, and Jan Lindhe ent, ent, isk, 636 sk, 636 , 637 37 642 642 n therapy to th therapy to th s, 642 s, 642 ne disease, 643 ne disease, 6 e tissue and aut tissue and au mia, 644 mia, 644 atologic and lym tologic and l enetic traits and ic traits a ortance of beha ortance of beha assessment, 64 sessment Dental hi Dental h bsta event Infect Infec Bleedin eed Card Card A Syst Syst MATERIAL tally 76 76 , 680 , 680 82 82 m in the esthet m in the esthet se of Therapy e of Therapy Lang and Hans- Lang and Han 687 of the dental te f the dental te st infectious dis st infectious d on of the pat on of the pat of com of com Contents xi Importance of supragingival plaque removal, 705 Self-performed plaque control, 706 Brushing, 706 Interdental cleaning, 714 Adjunctive aids, 717 Side effects, 718 Importance of instruction and motivation in mechanical plaque control, 719 36 Chemical Supragingival Plaque Control, 734 Martin Addy and John Moran Classifi cation and terminology of agents, 734 The concept of chemical supragingival plaque control, 735 Supragingival plaque control, 736 Chemical supragingival plaque control, 737 Rationale for chemical supragingival plaque control, 738 Approaches to chemical supragingival plaque control, 739 Vehicles for the delivery of chemical agents, 740 Chemical plaque control agents, 742 Systemic antimicrobials including antibiotics, 743 Enzymes, 744 Bisbiguanide antiseptics, 744 Quaternary ammonium compounds, 744 Phenols and essential oils, 745 Natural products, 745 Fluorides, 746 Metal salts, 746 Oxygenating agents, 746 Detergents, 746 Amine alcohols, 746 Salifl uor, 747 Acidifi ed sodium chlorite, 747 Other antiseptics, 747 Chlorhexidine, 748 Toxicology, safety, and side effects, 748 Chlorhexidine staining, 749 Mechanism of action, 750 Chlorhexidine products, 750 Clinical uses of chlorhexidine, 751 Evaluation of chemical agents and products, 754 Studies in vitro, 755 Study methods in vitro, 755 Clinical trial design considerations, 757 37 Non-surgical Therapy, 766 Noel Claffey and Ioannis Polyzois Introduction, 766 Detection and removal of dental calculus, 766 Methods used for non-surgical root surface debridement, 768 Hand instrumentation, 768 Sonic and ultrasonic scalers, 770 Reciprocating instruments, 770 Ablative laser therapy, 771 Choice of debridement method, 771 The infl uence of mechanical debridement on subgingival biofi lms, 772 Implication of furcation involvement, 773 Pain and discomfort following non-surgical therapy, 773 Re-evaluation, 774 Interpretation of probing measurements at re-evaluation, 774 Average changes in measurements due to non- surgical therapy, 775 Interpretation of longitudinal changes at individual sites, 775 Prediction of outcome and evaluation of treatment, 775 Full-mouth disinfection, 776 Part 12: Additional Therapy 38 Periodontal Surgery: Access Therapy, 783 Jan L. Wennström, Lars Heijl, and Jan Lindhe Introduction, 783 Techniques in periodontal pocket surgery, 783 Gingivectomy procedures, 784 Flap procedures, 786 Regenerative procedures, 793 Distal wedge procedures, 794 Osseous surgery, 795 Osteoplasty, 796 Ostectomy, 796 General guidelines for periodontal surgery, 797 Objectives of surgical treatment, 797 Indications for surgical treatment, 797 Contraindications for periodontal surgery, 799 Local anesthesia in periodontal surgery, 800 Instruments used in periodontal surgery, 802 Selection of surgical technique, 805 Root surface instrumentation, 808 Root surface conditioning/biomodifi cation, 808 Suturing, 808 Periodontal dressings, 811 Post-operative pain control, 812 Post-surgical care, 812 Outcome of surgical periodontal therapy, 812 Healing following surgical pocket therapy, 812 Clinical outcome of surgical access therapy in comparison to non-surgical therapy, 814 39 Treatment of Furcation-Involved Teeth, 823 Gianfranco Carnevale, Roberto Pontoriero, and Jan Lindhe Terminology, 823 Anatomy, 824 Maxillary molars, 824 Maxillary premolars, 825 Mandibular molars, 825 Other teeth, 826 Diagnosis, 826 Probing, 828 Radiographs, 828 Differential diagnosis, 829 Trauma from occlusion, 829 Therapy, 830 Scaling and root planing, 830 Furcation plasty, 830 Tunnel preparation, 832 Root separation and resection (RSR), 832 Regeneration of furcation defects, 840 Extraction, 843 Prognosis, 843 40 Endodontics and Periodontics, 848 Gunnar Bergenholtz and Gunnar Hasselgren Introduction, 848 COPYRIGHTED ects, 748 s, 748 s, 750 750 hexidine, 751 hexidine, 751 l agents and pro agents and pr 755 55 ods ds in vitro in v , 755 75 rial design cons ial design co surgical Thera urgical T oel Claffey and I el Claffey an duction, 766 uction, 766 etection and re etection and re Methods used Methods used debridem debride Han Han Ro R Sut S P MATERIAL nd ry, 783 , 783 793 4 es for periodon es for periodon of surgical tre of surgical tre ons for surgica ons for surgic traindications f traindications ocal anesthesia al anesthe Instruments u Instruments u Selection of Selection of ot sur ot su xii Contents Infectious processes in the periodontium of endodontic origin, 849 General features, 849 Clinical presentations, 850 Distinguishing lesions of endodontic origin from periodontitis, 851 Endo–perio lesions – diagnosis and treatment aspects, 856 Endodontic treatments and periodontal lesions, 858 Iatrogenic root perforations, 858 Vertical root fractures, 859 Mechanisms, 860 Incidence, 861 Clinical expressions, 861 Diagnosis, 862 Treatment considerations, 863 External root resorptions, 865 Mechanisms of hard tissue resorption in general, 865 Clinical presentations and identifi cation, 866 Different forms, 866 41 Treatment of Peri-implant Lesions, 875 Tord Berglundh, Niklaus P. Lang, and Jan Lindhe Introduction, 875 The diagnostic process, 875 Treatment strategies, 875 Resolution of peri-implantitis lesions, 877 Cumulative Interceptive Supportive Therapy (CIST), 878 Preventive and therapeutic strategies, 878 Mechanical debridement; CIST protocol A, 878 Antiseptic therapy; CIST protocol A+B, 878 Antibiotic therapy; CIST protocol A+B+C, 879 Regenerative or resective therapy; CIST protocol A+B+C+D, 880 42 Antibiotics in Periodontal Therapy, 882 Andrea Mombelli Principles of antibiotic therapy, 882 The limitations of mechanical therapy: can antimicrobial agents help?, 882 Specifi c characteristics of the periodontal infection, 883 Drug delivery routes, 884 Evaluation of antibiotics for periodontal therapy, 886 Systemic antimicrobial therapy in clinical trials, 888 Systemic antibiotics in clinical practice, 889 Local antimicrobial therapy in clinical trials, 890 Local antibiotics in clinical practice, 893 Overall conclusion, 893 Part 13: Reconstructive Therapy 43 Regenerative Periodontal Therapy, 901 Pierpaolo Cortellini and Maurizio S. Tonetti Introduction, 901 Classifi cation and diagnosis of periodontal osseous defects, 901 Clinical indications, 903 Long-term effects and benefi ts of regeneration, 903 Evidence for clinical effi cacy and effectiveness, 905 Patient and defect prognostic factors, 909 Patient factors, 911 Defect factors, 911 Tooth factors, 912 Factors affecting the clinical outcomes of GTR in furcations, 913 The relevance of the surgical approach, 913 Papilla preservation fl aps, 916 Modifi ed papilla preservation technique, 917 Simplifi ed papilla preservation fl ap, 920 Minimally invasive surgical technique, 922 Post-operative regime, 925 Post-operative morbidity, 926 Barrier materials for regenerative surgery, 928 Non-absorbable materials, 928 Bioabsorbable materials, 930 Membranes in intrabony defects, 930 Membranes for furcation involvement, 932 Surgical issues with barrier membranes, 937 Bone replacement grafts, 938 Biologically active regenerative materials, 938 Membranes combined with other regenerative procedures, 940 Root surface biomodifi cation, 943 Clinical strategies, 944 44 Mucogingival Therapy – Periodontal Plastic Surgery, 955 Jan L. Wennström, Giovanni Zucchelli, and Giovan P. Pini Prato Introduction, 955 Gingival augmentation, 955 Gingival dimensions and periodontal health, 956 Marginal tissue recession, 958 Marginal tissue recession and orthodontic treatment, 961 Gingival dimensions and restorative therapy, 964 Indications for gingival augmentation, 965 Gingival augmentation procedures, 965 Healing following gingival augmentation procedures, 968 Root coverage, 970 Root coverage procedures, 971 Clinical outcome of root coverage procedures, 990 Soft tissue healing against the covered root surface, 992 Interdental papilla reconstruction, 996 Surgical techniques, 997 Crown-lengthening procedures, 997 Excessive gingival display, 997 Exposure of sound tooth structure, 1002 Ectopic tooth eruption, 1005 The deformed edentulous ridge, 1008 Prevention of soft tissue collapse following tooth extraction, 1009 Correction of ridge defects by the use of soft tissue grafts, 1010 Surgical procedures for ridge augmentation, 1011 45 Periodontal Plastic Microsurgery, 1029 Rino Burkhardt and Niklaus P. Lang Microsurgical techniques in dentistry (development of concepts), 1029 Concepts in microsurgery, 1030 Magnifi cation, 1030 Instruments, 1035 COPYRIGHTED 79 79 protocol rotocol rapy, 882 rapy, 882 882 82 nical therapy: c nical therapy: c s help?, 882 help?, 882 tics of the perio cs of the perio routes, 884 routes, 884 ntibiotics for pe ntibiotics for pe c antimicrobial ntimicro stemic antibiotic mic antibioti Local antimicro Local antimicro Local antibio Local antibi Overall co Overall c D G ntroduct ntroduc Gingival au Gingival Gingi Ging Ma Ma MATERIAL 30 ement, 932 ement, 932 membranes, 937 membranes, 9 ve materials, 9 ve materials, 9 h other regene h other regen ifi ifi cation, 943 cation, 943 fifi , 944 44 ingival Therap ingival Thera gery, 955 y, 955 L. Wennström L. Wennström an P. Pin an P. Pin 95 9 Contents xiii Suture materials, 1035 Training concepts (surgeons and assistants), 1038 Clinical indications and limitations, 1039 Comparison to conventional mucogingival interventions, 1040 46 Re-osseointegration, 1045 Tord Berglundh and Jan Lindhe Introduction, 1045 Is it possible to resolve a marginal hard tissue defect adjacent to an oral implant?, 1045 Non-contaminated, pristine implants at sites with a wide marginal gap (crater), 1045 Contaminated implants and crater-shaped bone defects, 1046 Re-osseointegration, 1046 Is re-osseointegration a feasible outcome of regenerative therapy?, 1046 Regeneration of bone from the walls of the defect, 1046 “Rejuvenate” the contaminated implant surface, 1047 Is the quality of the implant surface important in a healing process that may lead to re-osseointegration?, 1048 The surface of the metal device in the compromised implant site, 1048 Part 14: Surgery for Implant Installation 47 Timing of Implant Placement, 1053 Christoph H.F. Hämmerle, Maurício Araújo, and Jan Lindhe Introduction, 1053 Type 1: placement of an implant as part of the same surgical procedure and immediately following tooth extraction, 1055 Ridge corrections in conjunction with implant placement, 1055 Stability of implant, 1061 Type 2: completed soft tissue coverage of the tooth socket, 1061 Type 3: substantial bone fi ll has occurred in the extraction socket, 1062 Type 4: the alveolar ridge is healed following tooth loss, 1063 Clinical concepts, 1063 Aim of therapy, 1063 Success of treatment and long-term outcomes, 1065 48 The Surgical Site, 1068 Marc Quirynen and Ulf Lekholm Bone: shape and quality, 1068 Clinical examination, 1068 Radiographic examination, 1068 Planning for implant placement, 1069 Implant placement, 1071 Guiding concept, 1071 Flap elevation, 1071 Flapless implant insertion, 1071 Model-based guided surgery, 1071 Bone preparation, 1071 Anatomic landmarks with potential risk, 1072 Implant position, 1073 Number of implants, 1074 Implant direction, 1074 Healing time, 1076 Part 15: Reconstructive Ridge Therapy 49 Ridge Augmentation Procedures, 1083 Christoph H.F. Hämmerle and Ronald E. Jung Introduction, 1083 Patient situation, 1084 Bone morphology, 1084 Horizontal bone defects, 1084 Vertical bone defects, 1084 Soft tissue morphology, 1085 Augmentation materials, 1085 Membranes, 1085 Bone grafts and bone graft substitutes, 1086 Long-term results, 1087 Clinical concepts, 1088 Ridge preservation, 1088 Extraction sockets (class I), 1089 Dehiscence defects (classes II and III), 1090 Horizontal defects (class IV), 1091 Vertical defects (class V), 1092 Future developments, 1093 Growth and differentiation factors, 1093 Delivery systems for growth and differentiation factors, 1093 Membrane developments, 1093 Future outlook, 1094 50 Elevation of the Maxillary Sinus Floor, 1099 Bjarni E. Pjetursson and Niklaus P. Lang Introduction, 1099 Treatment options in the posterior maxilla, 1099 Sinus fl oor elevation with a lateral approach, 1100 Anatomy of the maxillary sinus, 1100 Pre-surgical examination, 1101 Indications and contraindications, 1102 Surgical techniques, 1102 Post-surgical care, 1105 Complications, 1106 Grafting materials, 1107 Success and implant survival, 1108 Sinus fl oor elevation with the crestal approach (osteotome technique), 1110 Indications and contraindications, 1111 Surgical technique, 1111 Post-surgical care, 1115 Grafting material, 1115 Success and implant survival, 1116 Short implants, 1117 Conclusions and clinical suggestions, 1118 Part 16: Occlusal and Prosthetic Therapy 51 Tooth-Supported Fixed Partial Dentures, 1125 Jan Lindhe and Sture Nyman Clinical symptoms of trauma from occlusion, 1125 Angular bony defects, 1125 Increased tooth mobility, 1125 Progressive (increasing) tooth mobility, 1125 Tooth mobility crown excursion/root displacement, 1125 nd nd of the same the same following tooth following toot tion with impla ion with imp 61 ssue coverage o ssue coverage bone fi ne fill has oc ll has oc fifi et, 1062 et, 1062 veolar ridge is h veolar ridge i concepts, 1063 concepts, 1 Aim of therapy, m of therapy Success of tre Success of t 1065 065 48 The Su 8 The S Mar Mar Fut F 50 E 50 E MATERIAL t substitutes, 10 t substitutes n, 1088 n, 1088 ets (class I), 10 ets (class I), 10 defects (classes defects (classes al defects (class defects (class l defects (class defects (class evelopments, 1 evelopments, rowth and diff wth and Delivery syste Delivery syst factors, 1 factors, mbra mbr xiv Contents Initial and secondary tooth mobility, 1125 Clinical assessment of tooth mobility (physiologic and pathologic tooth mobility), 1127 Treatment of increased tooth mobility, 1128 Situation I, 1128 Situation II, 1129 Situation III, 1129 Situation IV, 1132 Situation V, 1134 52 Implants in Restorative Dentistry, 1138 Niklaus P. Lang and Giovanni E. Salvi Introduction, 1138 Treatment concepts, 1138 Limited treatment goals, 1139 Shortened dental arch concept, 1139 Indications for implants, 1139 Increase the subjective chewing comfort, 1141 Preservation of natural tooth substance and existing functional, satisfactory reconstructions, 1143 Replacement of strategically important missing teeth, 1144 53 Implants in the Esthetic Zone, 1146 Urs C. Belser, Jean-Pierre Bernard, and Daniel Buser Basic concepts, 1146 General esthetic principles and related guidelines, 1147 Esthetic considerations related to maxillary anterior implant restorations, 1148 Anterior single-tooth replacement, 1149 Sites without signifi cant tissue defi ciencies, 1152 Sites with localized horizontal defi ciencies, 1156 Sites with extended horizontal defi ciencies, 1156 Sites with major vertical tissue loss, 1157 Multiple-unit anterior fi xed implant restorations, 1161 Sites without signifi cant tissue defi ciencies, 1163 Sites with extended horizontal defi ciencies, 1164 Sites with major vertical tissue loss, 1165 Conclusions and perspectives, 1165 Scalloped implant design, 1165 Segmented fi xed implant restorations in the edentulous maxilla, 1166 54 Implants in the Posterior Dentition, 1175 Urs C. Belser, Daniel Buser, and Jean-Pierre Bernard Basic concepts, 1175 General considerations, 1175 Indications for implant restorations in the load carrying part of the dentition, 1177 Controversial issues, 1180 Restoration of the distally shortened arch with fi xed implant-supported prostheses, 1180 Number, size, and distribution of implants, 1180 Implant restorations with cantilever units, 1182 Combination of implant and natural tooth support, 1183 Sites with extended horizontal bone volume defi ciencies and/or anterior sinus fl oor proximity, 1184 Multiple-unit tooth-bound posterior implant restorations, 1187 Number, size, and distribution of implants, 1187 Splinted versus single-unit restorations of multiple adjacent posterior implants, 1189 Posterior single-tooth replacement, 1191 Premolar-size single-tooth restorations, 1191 Molar-size single-tooth restorations, 1191 Sites with limited vertical bone volume, 1192 Clinical applications, 1193 Screw-retained implant restorations, 1193 Abutment-level impression versus implant shoulder-level impression, 1196 Cemented multiple-unit posterior implant prostheses, 1197 Angulated abutments, 1198 High-strength all-ceramic implant restorations, 1199 Orthodontic and occlusal considerations related to posterior implant therapy, 1200 Concluding remarks and perspectives, 1203 Early and immediate fi xed implant restorations, 1203 55 Implant–Implant and Tooth–Implant Supported Fixed Partial Dentures, 1208 Clark M. Stanford and Lyndon F. Cooper Introduction, 1208 Initial patient assessment, 1208 Implant treatment planning for the edentulous arch, 1209 Prosthesis design and full-arch tooth replacement therapy, 1210 Complete-arch fi xed complete dentures, 1211 Prosthesis design and partially edentulous tooth replacement therapy, 1211 Implant per tooth versus an implant-to-implant FPD?, 1212 Cantilever pontics, 1213 Immediate provisionalization, 1215 Disadvantages of implant–implant fi xed partial dentures, 1215 Tooth–implant fi xed partial dentures, 1216 56 Complications Related to Implant-Supported Restorations, 1222 Y. Joon Ko, Clark M. Stanford, and Lyndon F. Cooper Introduction, 1222 Clinical complications in conventional fi xed restorations, 1222 Clinical complications in implant-supported restorations, 1224 Biologic complications, 1224 Mechanical complications, 1226 Other issues related to prosthetic complications, 1231 Implant angulation and prosthetic complications, 1231 Screw-retained vs. cement-retained restorations, 1233 Ceramic abutments, 1233 Esthetic complications, 1233 Success/survival rate of implant-supported prostheses, 1234 Part 17: Orthodontics and Periodontics 57 Tooth Movements in the Periodontally Compromised Patient, 1241 Björn U. Zachrisson COPYRIGHTED 52 1156 1156 es, 1156 s, 1156 57 orations, 1161 ations, 1161 fifi ciencies, 1163 ciencies, fifi defi defi ciencies, 1 encies, 1 fi sue loss, 1165 ue loss, 1165 s, 1165 , 1165 ign, 1165 ign, 1165 mplant restoratio plant restorati axilla, 1166 xilla, 1166 n the Posterior n the Posterio elser, Daniel Bu er, Dan Pierre Bernard ierre Bernar ncepts, 1175 epts, 1175 General conside General consid Indications fo Indications f carrying carryin ontrov ontrov D Com Co Prosthesis Prosthesi replacem replace Imp Imp MATERIAL ons ns related to related to s, 1203 s, 1203 mplant restoratio mplant restor d Tooth–Impl d Tooth–Im Partial Dentur Partial Dentur rd and Lyndon F rd and Lyndon F ssessment, 1208 sessment, 120 tment planning tment plannin osthesis design osthesis design herapy, 121 herapy, 121 ete-ar ete- Contents xv Orthodontic tooth movement in adults with periodontal tissue breakdown, 1241 Orthodontic treatment considerations, 1243 Esthetic fi nishing of treatment results, 1248 Retention – problems and solutions; long-term follow-up, 1248 Possibilities and limitations; legal aspects, 1249 Specifi c factors associated with orthodontic tooth movement in adults, 1252 Tooth movement into infrabony pockets, 1252 Tooth movement into compromised bone areas, 1253 Tooth movement through cortical bone, 1253 Extrusion and intrusion of single teeth – effects on periodontium, clinical crown length, and esthetics, 1255 Regenerative procedures and orthodontic tooth movement, 1261 Traumatic occlusion (jiggling) and orthodontic treatment, 1262 Molar uprighting, furcation involvement, 1262 Tooth movement and implant esthetics, 1263 Gingival recession, 1267 Labial recession, 1267 Interdental recession, 1271 Minor surgery associated with orthodontic therapy, 1274 Fiberotomy, 1274 Frenotomy, 1274 Removal of gingival invaginations (clefts), 1275 Gingivectomy, 1275 58 Implants Used for Orthodontic Anchorage, 1280 Marc A. Schätzle and Niklaus P. Lang Introduction, 1280 Evolution of implants for orthodontic anchor...