(cid:9)(cid:9)(cid:9)(cid:9)(cid:9) To my wife, Akiko; son, Kimihiko; daughter, Yuka; and parents, Keisuke and Yoko Sato for their support. Library of Congress Cataloging-in-Publication Data Sato, Naoshi. [Shishu geka no rinsho to tekunikku. English] Periodontal surgery: a clinical atlas/Naoshi Sato. P. ; cm. Includes bibliographical references. ISBN 0-86715-377-6 1. Periodontum Surgery Atlases. 2. Periodontics Atlases. I. Title. [DNLM: l. Periodontics methods Atlases. 2. Periodontal Diseases-surgery-Atlases. WU 17 S2528s 2000] RK361 .52813 2000 617.6'32059 dc21 99-059489 © 2000 Quintessence Publishing Co, Inc Quintessence Publishing Co, Inc 551 Kimberly Drive Carol Stream, Illinois 60188 All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher. Illustrations by: K. Kamimura Production: S. Robinson Printed in Japan Foreword When I reviewed Dr Sato's first book on periodontal-restorative interrelation- ships in 1993, 1 was most impressed, and regretted that it was not available in English. Upon seeing the Japanese edition of this second book, Periodontal Surgery: A Clinical Atlas, in 1997, I was convinced that it needed to be trans- lated into English. Fortunately, Quintessence has now done just that. I first met Dr Sato in 1977, just after he finished his postdoctoral training at the University of Iowa. He then came to the University of Pennsylvania for a brief period to study with Dr D. Walter Cohen and myself. From that time on I followed the amazing career of Dr Sato as he became one of Japan's most outstanding clinicians. It was fascinating to watch him practicing in apparent geographic isolation-become so knowledgeable and clinically expert. Dr Sato has already influenced many dentists in Japan; it is only fair that we in the English-speaking world should have access to the writings of this outstanding clinician. Periodontal diseases, including dental caries, are chronic in nature and acute in their ramifications, but they are also capable of creating deformities that in turn become important propagating factors in the progression of the disease. Dr Sato clearly recognizes this and knows that the best approach is early recognition of disease in the susceptible patient. He emphasizes the im- portance of selective differential diagnosis in his approach to periodontal surgery and, whenever possible, directs his efforts toward regeneration in restoring and maintaining form, function, and esthetics in the masticatory system. He takes us through basic periodontal surgical procedures, from curet- tage, to osseous plastic and resective surgery, to crown lengthening in all its various manifestations, but he also covers more advanced procedures-includ- ing mucogingival, periodontal, and osseous regenerative techniques, as well as the preparation and various applications of osseointegrated implants in the same detailed manner. The atlas format of this book, illustrating treatment through case by case study, is an excellent approach to learning and teaching. The photographic plates and illustrative drawings are beautiful, and the step-by-step method takes the reader through a clear, concise, and well-referenced discussion of the various subjects. This book is a must-read for the periodontist and the general practitioner and mandatory for the postdoctoral student. Morton Amsterdam, DDS, SeD Professor Emeritus of Periodontics-Periodontal Prosthesis Norman Vine Professor of Restorative Dentistry at the University of Pennsylvania School of Dental Medicine Clinical Professor of Surgery Medical College of Pennsylvania Hahnernann University 7 Preface Today, the objective of dentistry is not only to eliminate oral disease, but to improve function and esthetics; thus, patients' quality of life can be assured through oral health. In treating patients with periodontal disease, dentists should seek optimal results, including the regeneration of periodontal tissue lost through disease, the establishment of a functional and stable dentition, the creation of an easily maintained periodontal environment, and esthetic enhancement. This book was written to demonstrate how regenerative proce- dures, combined with fundamental periodontal surgery techniques, can achieve these goals and enhance the clinical outcome. With step-by-step explanations, this text elucidates clinically effective pro- cedures, each of which was evaluated and their clinical results compared with those of other studies. Abundant photographs and illustrations support the clear and concise descriptions of the procedures, and highlighted key points throughout each chapter enable the reader to conveniently integrate knowledge. Clinical wisdom is achieved only by rigorous and candid evaluation of each case and its outcomes. I hope you, the reader, will learn as much as I did from the cases presented in this book. I extend many thanks to Professor Kazuyuki Ueno (periodontal department of Iwate Medical University); Dr Haruhiko Abe (Abe Complete Denture Clinic); Dr Phillip A. Lainson (head of the department of periodontics at the University of Iowa College of Dentistry); Dr Norimasa Endo in Iwate; and Dr Hitoshi Shirahama, Dr Yoshiro-Hattori, and the staff at Tokyo Gas Clinic. Their support and guidance have encouraged me through years of research. I also gratefully acknowledge Mr Ikko Sasaki, president of Quintessence Tokyo, for publishing the Japanese edition of' this book, and Mr Hidetoshi Akimoto (Aki Editorial Company) for editing the drafts and for offering help- ful suggestions regarding the clinical photographs and illustrations. My special thanks to Dr Gissela Anderson, who kindly checked the English translation. 9 Objectives and Techniques of Periodontal Surgery Objectives and Techniques of Periodontal Surgery Objectives and Methods of Periodontal Surgery Objectives of Periodontal Surgery Periodontal surgery comprises initial treatment, in which the original cause of periodontal disease is eliminated, and definitive surgery, in which an environ- ment conducive to long-term health and maintenance is achieved. Procedures to eliminate the etiogenic factors of periodontal disease are closed curettage and flap curettage, which entail debridement and the elimi- nation of lesions. While shallow pockets can be eliminated by such procedures, in advanced periodontal disease recurrence is frequent. Additionally, esthetic problems may occur due to loss of attachment or irregular bone morphology even after the resolution of infection. In such cases, periodontal surgery is re- quired to improve the periodontal environment, in addition to eliminating the original factors and lesions (Table 1-1 and Table 1-2). The elimination of periodontal pockets enables a good environment to be maintained during therapy. If periodontal pockets of more than 4 mm remain vorable.1postoperatively, however, maintenance is very difficult and the outcome unfa- Periodontal disease is intimately related to the anatomic factors of affected teeth, including tooth surface and position. Furthermore, the results of treat- ment rely on patient adherence to hygiene and sometimes on chance. In severe periodontal disease, it is often difficult to devise a treatment plan that is read- ily accepted by the patient. Table 1-1 Objectives of Periodontal Surgery Table 1-2 Methods of Periodontal Surgery 1. Accessibility of instruments to root surface. 1. Closed curettage 2. Elimination of inflammation. 2. Gingivectomy 3. Creation of an oral environment conducive to plaque control. 3. Flap surgery a. Establish gingival sulcus for easy periodontal disease a. Flap curettage control (elimination of pocket). b. Osseous resection b. Correct abnormal gingiva and alveolar bone morpho- • osteoplasty logic characteristics that interfere with plaque control. • ostectomy c. Perform root-sectioning procedures or treatments to c. Bone graft improve morphology for easier oral hygiene mainte- d. GTR (guided tissue regeneration) nance. • GTR with bone grafts d. Create an easy to clean and proper embrasure space. • GTR without bone grafts 4. Regeneration of periodontal apparatus destroyed by peri- 4. Mucogingival surgery odontal disease. a. Attached gingiva augmentation 5. Resolution of gingiva-alveolar mucosa problems. • Free autogenous gingival grafts 6. Preparation of periodontal environment suitable to • Pedicle gingival grafts restorative and prosthodontic treatment. Periodontal • Apically positioned flap surgery surgery serves as the therapy prior to prosthodontic b. Root coverage treatment. • Pedicle gingival grafts 7. Esthetic improvement. • Semilunar coronally positioned flaps • Free autogenous gingival grafts • Subepithelial connective tissue grafts • GTR (guided tissue regeneration) c. Frenum operation 5. Combination of various periodontal surgical approaches 12 Objectives and Methods of Periodontal Surgery In a case like that shown in Fig 1-1, where closed curettage is performed only on single-rooted teeth, it is possible to achieve a relatively stable condition. However, closed curettage is an unwise first choice of treatment due to its lack of predictability in bone regeneration and attachment gain. Clinically, flexibil- ity is required in considering various treatment modalities, but decision-mak- ing must not be based on exceptional or incidental treatment outcomes. Therefore, while it is important to eliminate inflammation immediately, it is also necessary to consider factors influencing long-term prognosis, including the maximum pocket reduction suitable for the site in regard to bone defect, gingiva-alveolar morphology, and gingival attachment. Resective Procedures and Regenerative Procedures With shallow bony defects or moderate periodontitis with moderate periodon- tal pockets (5-6 mm), resectioe procedures such as apically positioned flap surgery with or without osseous resection help to create a shallow gingival sul- cus and physiologic morphology in which bone and gingiva are in harmony so that an easy-to-maintain periodontal environment is achieved. 3 ,4 Fig 1-1 Resolution of advanced periodontal disease by closed curettage. a. Thirty-seven-year-old man. The probing b. One year and 2 months after surgery. Note c. Six years and 5 months after surgery. depth is 7-10 mm, and marked bleeding and the extensive gingival shrinkage caused by Probing depths are within 2-3 mm, and there drainage are detected on probing. Pathologic closed curettage. is no bleeding on probing. The patient is re- tooth mobility is Class II-III. After splinting and called every other month for teeth cleaning. occlusal adjustment, closed curettage is per- formed several times with local anesthesia. d. Preoperative radiograph e. One year after closed f. Two years and 5 months g. Three years and 4 h. Six years and 5 shows remarkable bone curettage. later. The linea alba is months later. months after surgery. The resorption on 23, 24, 25, clearly seen. height of the alveolar and 26. crest is maintained. 13