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    Oral and Implant Surgery: Oral and Implant Surgery: Document Transcript

    • J. Thomas Lambrecht (Editor) Oral andImplant Surgery:Principles and Procedures In collaboration with: A. Dunsche, R. Ewers, A. Filippi, B. Hoffmeister, Th. Kreusch, K. Wangerin Berlin, Chicago, Tokyo, Barcelona, Istanbul, London, Milan, Moscow, New Delhi, Paris, Peking, Prague, São Paulo and Warsaw
    • Dedication The Kiel Connection dedicate this book to their teacherProf. Dr. med. Dr. med. dent. Franz Härle Director of Department of Oral and Maxillofacial Surgery, Kiel University 1980–2004 and Dean of the Medical Faculty of Kiel University 1991–1992 v
    • PrefacePrefaceOutpatient surgery performed by oral surgeons and through to dealing with at-risk patients. This should,maxillofacial surgeons has been subject to various therefore, interest anyone already working in or cur-influences and exposed to new trends in recent years: rently studying this specialist field. Unfortunately, ever-expanding knowledge means some omissions are• patients are getting older and older inevitable in order to keep within the scope of this• owing to the associated increase in systemic dis- book. Readers may wish to refer to the extensive spe- eases, the operations are becoming more complex cialist literature published by Quintessence. and overall treatment involves more risk The bow ties on the cover were hand-made in• the forensic implications are more signigficant Vienna. The bow tie in the center is printed with the• innovations in operating technique and materials logo of the Congress of the German Society of Oral and have made surgical procedures possible that place Maxillofacial Surgery, which was held in Kiel in 1994 high demands on the infrastructure, logistics and and chaired by Professor Härle. expertise of the treatment team The Kiel Connection – former senior residents and• the forms of doctor–patient communication have lecturers of Kiel University Department of Oral and changed as a result of the Internet; patients no Maxillofacial Surgery – were generously supported in longer look for their doctor or dentist in the phone producing this book by Prof. Dr. A. Filippi, Basel, book but on their website and they no longer Switzerland, and colleagues from Vienna University attend a consultation uninformed, but are focused Hospital, Dr. H. Fahrenholz, Dr. Dr. A. Reichwein, Dr. K. and fully informed. Schicho, Dr. K. Sinko, Mag. E. Stein and Prof. Dr. D. Turhani.It is not easy to address all these points in a single text- We are grateful to all our colleagues who con-book or reference book. tributed their illustrations to the book. As well as our The book presents examples of intraoral opera- dental assistants and medical consultants, the follow-tions, in many cases showing the step-by-step operat- ing people have helped to make this book a reality: Dr.ing procedure, which can obviously vary from patient C. Bernsmeier, Prof. Dr. W. Ummenhofer, Prof. Dr. Dr.to patient and from clinic to clinic. A whole chapter is M. Kunkel and Prof. Dr. N. Zitzmann. Last, but notdedicated to endosseous implantology, contrasting it least, we would like to thank all our secretaries, espe-with tooth-preserving surgery as an alternative cially Ms. G. Oertlin and Ms. B. Olufsen, and give spe-approach. cial thanks to Ms. S. Holmes for her superb translation. A selection of cases is also presented, which must We would also like to thank Quintessence and itsbe aligned with the self-assessment and proficiency of staff for the flexible, swift and ever-friendly supporteach particular surgeon. A central theme of ‘safety’ they provide.runs throughout the entire book, from the principles ofpreoperative information to patients, to intraoperativecomplications and their possible consequences J. Thomas Lambrecht vii
    • AuthorsAuthorsProf. Dr. Dr. H. Anton Dunsche Prof. Dr. Dr. Thomas KreuschDirector of Clinic for Oral and Maxillofacial Surgery Professor of Oral and Maxillofacial SurgeryStädtisches Klinikum Karlsruhe Department of Oral and Maxillofacial Plastic SurgeryMoltkestrasse 120, D-76133 Karlsruhe, Germany Head and Neck Centremkgklinik@klinikum-karlsruhe.de Asklepios Klinik Nord, Campus Heidberg Tangstedter Landstrasse 400, D-22417 Hamburg, Germany kreu.mkg-heidberg@web.deProf. Dr. Dr. Rolf EwersChairman of the University Hospital of Cranio-,Maxillofacial and Oral Surgery Prof. Dr. Dr. J. Thomas LambrechtMedical University of Vienna Clinic DirectorWähringerstrasse 18-20, A-1090 Vienna, Austria Clinic for Oral Surgery, Oral Radiology and Oralrolf.ewers@meduniwien.ac.at Medicine University of Basel Hebelstrasse 3, CH-4056 Basel, Switzerland J-Thomas.Lambrecht@unibas.chProf. Dr. Andreas FilippiClinic for Oral Surgery, Oral Radiology and OralMedicineUniversity of Basel Prof. Dr. Dr. Dr. h. c. Konrad WangerinHebelstrasse 3, CH-4056 Basel, Switzerland Department of Oral and Maxillofacial SurgeryAndreas.Filippi@unibas.ch Marienhospital Stuttgart Böheimstr. 37, D-70199 Stuttgart, Germany mkg@vinzenz.deProf. Dr. Dr. Bodo HoffmeisterDirector of Clinic for Maxillary Surgery and PlasticFacial SurgeryCharité – Universitätsmedizin BerlinCampus Benjamin FranklinHindenburgdamm 30, D-1220 Berlin, Germanybodo.hoffmeister@charite.de ix
    • ContentsContents Anton Dunsche1 Patient information, preoperative preparation and medication ........................................................11.1 Patient information ..........................................................................................................31.1.1 Patients right to choose and informed consent ..................................................................................................31.1.2 The purpose of patient information ..........................................................................................................................31.1.3 Timing of information........................................................................................................................................................41.1.4 Information for non-competent patients and minors ......................................................................................41.2 Preoperative preparation ..................................................................................................51.2.1 Instruments ............................................................................................................................................................................51.2.2 Hygiene: accident prevention ........................................................................................................................................51.2.3 Disinfection ..........................................................................................................................................................................101.2.4 Sterilization ..........................................................................................................................................................................111.2.5 Equipment infrastructure..............................................................................................................................................121.3 Medication in the perioperative period........................................................................161.3.1 Sedatives ................................................................................................................................................................................161.3.2 Local anesthetics ..............................................................................................................................................................161.3.3 Analgesics..............................................................................................................................................................................171.3.4 Antibiotics ............................................................................................................................................................................18 References ......................................................................................................................20 Thomas Kreusch and J. Thomas Lambrecht2 Simple and complicated tooth extraction ........212.1 General principles ..........................................................................................................232.1.1 Indications for tooth removal......................................................................................................................................232.1.2 Contraindications to tooth removal ........................................................................................................................232.1.3 Anesthesia ............................................................................................................................................................................23 xi
    • Contents2.1.4 Preparation of the patient ............................................................................................................................................232.1.5 Instruments ..........................................................................................................................................................................242.1.6 Inspecting the extracted tooth ..................................................................................................................................262.1.7 Treating the tooth socket ..............................................................................................................................................262.1.8 Aftercare ................................................................................................................................................................................272.2 Special procedure ..........................................................................................................282.2.1 Position of practitioner and patient ........................................................................................................................282.2.2 Removal of primary teeth..............................................................................................................................................282.2.3 Removal of anterior teeth..............................................................................................................................................292.2.4 Removal of premolars......................................................................................................................................................292.2.5 Removal of molars ............................................................................................................................................................302.2.6 Serial extractions ..............................................................................................................................................................322.3 Complications..................................................................................................................342.3.1 Slipped instruments ........................................................................................................................................................342.3.2 Lesions to adjacent teeth ..............................................................................................................................................342.3.3 Crown fracture ....................................................................................................................................................................342.3.4 Root fracture ........................................................................................................................................................................342.3.5 Thermal damage caused by rotary instruments................................................................................................352.3.6 Nerve lesions........................................................................................................................................................................352.3.7 Oro-antral perforation ....................................................................................................................................................352.3.8 Maxillary antral cysts ......................................................................................................................................................412.3.9 Displacement of teeth/parts of teeth into soft tissue ....................................................................................432.3.10 Dry socket ............................................................................................................................................................................432.4 Pre-implantology tooth removal ..................................................................................442.4.1 Gentle tooth extraction ..................................................................................................................................................442.4.2 Stabilization of the alveolar process ........................................................................................................................44 References ......................................................................................................................46 J. Thomas Lambrecht and Bodo Hoffmeister3 Surgical removal of unerupted and displaced teeth ..............................................493.1 Mandibular third molars ................................................................................................513.1.1 Indications for surgical removal ................................................................................................................................513.1.2 Contraindications..............................................................................................................................................................543.1.3 Preoperative diagnosis....................................................................................................................................................54 xii
    • Contents3.1.4 Preoperative medication................................................................................................................................................563.1.5 Risks ........................................................................................................................................................................................563.1.6 Surgical technique ............................................................................................................................................................573.1.7 Aftercare ................................................................................................................................................................................603.1.8 Complications caused by third molar removal ..................................................................................................603.1.9 Complications caused by leaving third molars in place ................................................................................653.2 Maxillary third molars....................................................................................................673.3 Maxillary canines ............................................................................................................703.4 Other retained teeth ......................................................................................................72 References ......................................................................................................................76 J. Thomas Lambrecht and Andreas Filippi4 Tooth-preserving surgical procedures ................814.1 Periradicular surgery ......................................................................................................834.1.1 Aims ........................................................................................................................................................................................834.1.2 Indications and contraindications............................................................................................................................834.1.3 Operating technique ........................................................................................................................................................864.1.4 Hemostasis............................................................................................................................................................................874.1.5 Retrograde filling................................................................................................................................................................894.1.6 Wound closure ....................................................................................................................................................................914.1.7 Aftercare and prognosis ................................................................................................................................................914.2 Intentional replantation ................................................................................................954.2.1 Indications and contraindications............................................................................................................................954.2.2 Operating technique ........................................................................................................................................................954.3.3 Aftercare and prognosis ..............................................................................................................................................1004.3 Transplantation ............................................................................................................1024.3.1 Indications, contraindications and planning ....................................................................................................1024.3.2 Tooth transplantation technique ............................................................................................................................1034.3.3 Special features of third molar transplantation ..............................................................................................1044.3.4 Splinting ..............................................................................................................................................................................1054.3.5 Aftercare and prognosis ..............................................................................................................................................1054.4 Corrective surgery ........................................................................................................1074.4.1 Hemisection ......................................................................................................................................................................1074.4.2 Premolarization ..............................................................................................................................................................109 xiii
    • Contents4.4.3 Root amputation ............................................................................................................................................................1094.4.4 Crown lengthening ........................................................................................................................................................1124.4.5 Exposure..............................................................................................................................................................................112 References......................................................................................................................117 Konrad Wangerin5 Cysts, bone lesions, odontogenic tumors ............................................1215.1 Odontogenic cysts ........................................................................................................1255.1.1 Infant gingival cysts ......................................................................................................................................................1255.1.2 Follicular cyst ....................................................................................................................................................................1255.1.3 Eruption cyst ....................................................................................................................................................................1295.1.4 Lateral periodontal cyst ..............................................................................................................................................1295.1.5 Gingival cyst of adults ..................................................................................................................................................1305.1.6 Glandular odontogenic cyst ......................................................................................................................................1305.2 Non-odontogenic cysts................................................................................................1325.2.1 Nasopalatine duct cyst ................................................................................................................................................1325.2.2 Nasolabial cyst..................................................................................................................................................................1355.2.3 Fissural cyst........................................................................................................................................................................1355.3 Cysts of inflammatory origin ......................................................................................1365.3.1 Radicular cyst....................................................................................................................................................................1365.3.2 Residual cyst......................................................................................................................................................................1395.3.3 Periodontal cyst ..............................................................................................................................................................1395.3.4 Occlusion cyst ..................................................................................................................................................................1395.4 Operating techniques ..................................................................................................1415.4.1 Cystostomy (Partsch I) ................................................................................................................................................1415.4.2 Cystectomy (Partsch II) ..............................................................................................................................................1455.4.3 Biological filling materials ..........................................................................................................................................1465.4.4 Alloplastic and synthetic filling materials ..........................................................................................................1515.5 Bone lesions ..................................................................................................................1535.5.1 Osteolytic lesions ............................................................................................................................................................1535.5.2 Osteoplastic lesions ......................................................................................................................................................157 xiv
    • Contents5.6 Odontogenic tumors ....................................................................................................1625.6.1 Odontoma ..........................................................................................................................................................................1625.6.2 Keratocystic odontogenic tumor ............................................................................................................................163 References ....................................................................................................................165 Andreas Filippi6 Traumatology of permanent teeth ..................1696.1 Classification and nomenclature of dental injuries ..................................................1716.2 Epidemiology ................................................................................................................1736.3 Action at site of accident............................................................................................1746.4 Prevention of dental injuries ......................................................................................1766.4.1 Fabricating a multilayer mouthguard ..................................................................................................................1766.5 Post-traumatic diagnostic procedure ........................................................................1796.6 Prognosis of dental injuries ........................................................................................1816.7 Post-traumatic treatment............................................................................................1826.7.1 General treatment ..........................................................................................................................................................1826.7.2 Intra/extra-alveolar fractures of the teeth ..........................................................................................................1846.7.3 Concussion and loosening of the teeth................................................................................................................1866.7.4 Dislocation ........................................................................................................................................................................1876.7.5 Intrusion ..............................................................................................................................................................................1886.7.6 Avulsion................................................................................................................................................................................1926.7.7 Post-traumatic splinting..............................................................................................................................................1956.7.8 General medicinal treatment after dental trauma ........................................................................................2006.7.9 Anti-resorptive and regenerative medicinal treatments..............................................................................2006.8 Late sequelae after dental trauma..............................................................................2036.8.1 Late sequelae in the pulp ............................................................................................................................................2036.8.2 Late sequelae in the periodontium ........................................................................................................................206 References ....................................................................................................................220 xv
    • Contents Anton Dunsche and J. Thomas Lambrecht7 Intraoral soft tissue surgery ..............................2257.1 Biopsy ............................................................................................................................2277.1.1 Excisional biopsy ............................................................................................................................................................2277.1.2 Incisional biopsy ..............................................................................................................................................................2297.1.3 Punch biopsy ....................................................................................................................................................................2307.1.4 Brush biopsy ......................................................................................................................................................................2327.2 Periodontal surgery ......................................................................................................2337.2.1 Gingivectomy ....................................................................................................................................................................2337.2.2 Mucogingival surgery ....................................................................................................................................................2347.2.3 Flap surgery........................................................................................................................................................................2357.3 Pre-prosthetic surgery ................................................................................................2437.4 Surgery of minor salivary glands ................................................................................2497.5 Abscess incision ............................................................................................................2587.6 Benign tumors ..............................................................................................................2627.7 Epithelial precursor lesions..........................................................................................266 References ....................................................................................................................270 Rolf Ewers8 Implant surgery ....................................................2718.1 Basic principles ............................................................................................................2738.1.1 Indications and contraindications of endosseous implants......................................................................2738.1.2 Principles of planning by Harald Fahrenholz....................................................................................................2738.1.3 Imaging techniques........................................................................................................................................................2758.2 Clinical requirements ..................................................................................................2808.2.1 Bone quality ......................................................................................................................................................................2808.2.2 Bone supply........................................................................................................................................................................2818.2.3 Osseointegration and functional ankylosis ........................................................................................................2838.2.4 Loading ................................................................................................................................................................................2838.2.5 Soft tissue............................................................................................................................................................................2858.2.6 Esthetics by Harald Fahrenholz ..............................................................................................................................2868.2.7 Incisions ..............................................................................................................................................................................289 xvi
    • Contents8.3 Standard clinical situations ........................................................................................2928.3.1 Single-tooth gap in anterior region ........................................................................................................................2928.3.2 Lateral edentulous gap ................................................................................................................................................2958.3.3 Free-end situation in the maxilla ............................................................................................................................2988.3.4 Free-end situation in the mandible........................................................................................................................3008.3.5 Partially edentulous mandible..................................................................................................................................3018.3.6 Edentulous maxilla ........................................................................................................................................................3038.3.7 Edentulous mandible ....................................................................................................................................................3048.4 Augmentation ..............................................................................................................3068.4.1 Principles of augmentation........................................................................................................................................3068.4.2 Guided bone regeneration..........................................................................................................................................3128.4.3 Ridge preservation..........................................................................................................................................................3138.4.4 Defect filling ......................................................................................................................................................................3258.4.5 Condensing ........................................................................................................................................................................3278.4.6 Bone splitting ....................................................................................................................................................................3288.4.7 Inlay graft ............................................................................................................................................................................3378.4.8 Sinus lift (sinus graft) ....................................................................................................................................................3508.4.9 Onlay graft ..........................................................................................................................................................................3608.4.10 Distraction..........................................................................................................................................................................3748.5 Implant navigation ......................................................................................................3788.5.1 Basic principles by Astrid Reichwein and Kurt Schicho..............................................................................3788.5.2 Achievable accuracy levels by Astrid Reichwein and Kurt Schicho ......................................................3808.5.3 Computer-aided planning and template fabrication by Rolf Ewers......................................................3808.6 Implants for orthodontics by Klaus Sinko and J. Thomas Lambrecht ....................3918.6.1 Development ....................................................................................................................................................................3918.6.2 Micro-plates with micro-screws ..............................................................................................................................3928.6.3 Palatal implant ................................................................................................................................................................3938.7 Tissue engineering by Dritan Turhani and Elisabeth Stein ......................................3968.7.1 Basic principles ................................................................................................................................................................3968.7.2 Tissue engineering of bone ........................................................................................................................................3968.7.3 Tissue engineering with hydroxyapatite..............................................................................................................3978.8 Complications ..............................................................................................................4008.8.1 Suture dehiscence ..........................................................................................................................................................4008.8.2 Nerve injuries ....................................................................................................................................................................4018.8.3 Mucosal complications ................................................................................................................................................4038.8.4 Peri-implantitis ................................................................................................................................................................407 References ....................................................................................................................414 xvii
    • Contents J. Thomas Lambrecht9 At-risk patients and emergencies ....................4219.1 Cardiovascular diseases ................................................................................................4249.1.1 Endocarditis ......................................................................................................................................................................4249.1.2 Coronary heart diseases ..............................................................................................................................................4269.1.3 Arterial hypertension ....................................................................................................................................................4289.2 Lung diseases ................................................................................................................4309.2.1 Bronchial asthma ............................................................................................................................................................4309.2.2 Chronic obstructive pulmonary disease..............................................................................................................4309.2.3 Tuberculosis ......................................................................................................................................................................4309.3 Liver, kidneys and gastrointestinal tract ....................................................................4319.3.1 Liver diseases ....................................................................................................................................................................4319.3.2 Kidney diseases ................................................................................................................................................................4319.3.3 Gastrointestinal diseases ............................................................................................................................................4319.4 Diabetes mellitus ..........................................................................................................4329.5 Blood diseases ..............................................................................................................4339.5.1 Hemorrhagic diathesis ................................................................................................................................................4339.5.2 Patients taking anticoagulants ................................................................................................................................4349.6 Viral diseases ................................................................................................................4379.6.1 HIV infection ....................................................................................................................................................................4379.6.2 Hepatitis B infection......................................................................................................................................................4379.6.3 Hepatitis C infection......................................................................................................................................................4399.6.4 Herpes simplex virus ....................................................................................................................................................4399.7 Allergies ........................................................................................................................4409.8 Joint diseases ................................................................................................................4419.8.1 Rheumatoid arthritis ....................................................................................................................................................4419.8.2 Joint prostheses in osteoarthritis............................................................................................................................4429.9 Neurological and mental illnesses ..............................................................................4439.9.1 Neurological disorders..................................................................................................................................................4439.9.2 Mental illnesses................................................................................................................................................................445 xviii
    • Contents9.10 Pregnancy......................................................................................................................4479.10.1 Physiological changes ..................................................................................................................................................4479.10.2 Changes in the orofacial area....................................................................................................................................4479.10.3 Guidelines on dental treatment ..............................................................................................................................4479.10.4 Infections during pregnancy......................................................................................................................................4489.11 Emergencies ..................................................................................................................4499.11.1 Monitoring..........................................................................................................................................................................4499.11.2 Emergency equipment..................................................................................................................................................4509.11.3 Emergency measures ....................................................................................................................................................451 References ....................................................................................................................459 Appendix ..............................................................465 Abbreviations ................................................................................................................467 Acknowledgments and source of illustrations ..........................................................468 Internet links ................................................................................................................469 Index ..............................................................................................................................472 xix
    • 8 Implant surgery Fig 8-430 Finished work on the model; the acrylic resin teeth Fig 8-431 Fitting the drilling template on to the three tem- set up on the titanium framework are coated with polyan. porary ball head implants in preparation for implantation. Fig 8-432 Specially developed CAMLOG instruments are used for implant insertion through the drill sleeves: pilot drill, three drills in 9, 11 and 13 mm lengths and an implant applicator for the wrench instrument (arrows point to the stoppers). Fig 8-433 Drilling the implant bed with the 9 mm long drill. of error because inaccuracies at least remain ‘consis- instrumentation was developed for the CAMLOG sys- tent’; there is no accumulation of errors in the course tem (Fig 8-432). Three or four deep-hole drills are used, of the individual working steps. depending on the length of the implant (Fig 8-433). Implant insertion is performed manually, again Intraoperative realization through the drilling template, with torque control to The operation is performed under local anesthesia avoid overheating (Fig 8-434). The vertical position of using the same drilling template with which the model the implants (implant depth) is determined by the implants were inserted in the laboratory (Fig 8-431). guide sleeve position, while it is impossible to insert All the working steps described below are performed the implants too deeply because of the placing of the through the guide sleeves of the template. The implant three stoppers on the guide track (Fig 8-435). system is matched to the guide sleeves so that the Following implant insertion, the implant applica- mucosa can also be punched out through the tem- tors (Fig 8-436) are removed and the fixed partial den- plate. For preparation of the implant bed, special ture buildups are screwed on. The titanium sleeves 388
    • Implant navigation 8 5Fig 8-434 Inserting the implants through the sleeves in the Fig 8-435 The depth of implant insertion is mechanicallydrilling template with the torque wrench. determined by three stoppers (arrows).Fig 8-436 The six implants are placed; the drilling template Fig 8-437 Fitting the implants with titanium sleeves, whichwith the black base stone is still in situ. are intended to receive the long-term provisional appliance. In this case, a titanium bar is inserted. The temporary ball-head implants are still required for positioning the long-term provi- sional appliance.can be adapted to the implants with another screwconnection. In this way, it is possible to ensure ten-sion-free insertion of the prosthetic work already com-pleted preoperatively (Figs 8-437 and 8-438). Before final insertion of the prosthetic work, a try-in and verification of the exact accuracy of fit (over theball-head implants) takes place. Then the prostheticwork with titanium sleeves is finally bonded in thepatient’s mouth. After the bonding agent has set, theprosthetic work (e.g. a long-term provisional) can beunscrewed. The ball-head implants in the alveolar Fig 8-438 The framework is fitted, which can be bonded inprocess and the matrices in the prosthetic work are place. Performing this work intraorally is a prerequisite forthen removed. tension-free seating of the fixed partial denture. 389
    • 8 Implant surgery Fig 8-504 Decontamination with CO2 laser. Fig 8-505 Filling the peri-implant defect with a mixture of algisorb and Emdogain. Fig 8-506 Covering with a Bio-Gide membrane. Fig 8-507 Folding back the mucoperiosteum. Fig 8-509 Postoperative dental film showing that the peri-implant defect is filled up again. Fig 8-508 Condition after suture closure. 408
    • Complications 8 8Fig 8-510 An onlay plasty(class IVa bone) in the maxilla(left); owing to poor vascular-ization, the grafted bone isresorbed and the implant isexposed in the crestal area(right).Fig 8-511 Comparison ofbone interposition for the inlaygraft (class III bone) (left) withthe onlay bone apposition(class IVa bone) (right). Thebone should be locally vascu-larized in the area where theimplant passes through so thatcrestal bone resorption doesnot take place.Bone resorption: comparison between inlay and and hence exposure of the implants in the crestalonlay graft region.197 Figure 8-511 compares the onlay graftFinally the key theme of this chapter, the vasculariza- (class IVa), which is far simpler to perform, with thetion of different bone grafts and bone formation more difficult horseshoe Le Fort I osteotomy (class III).options, should be mentioned again. Autogenous monocortical bone grafts are used for The situation of an onlay graft (class IVa) in the both operation methods. There is adequate vascular-maxilla is illustrated in Figure 8-510. Owing to the lack ization as a result of the inlay interposition of graftedof vascularization with the onlay graft, there is pro- bone between the cranial bone of the maxilla, thenounced resorption (up to 50%) of the grafted bone nasal and maxillary sinus walls, the palatal bone and 409