Advanced topics in dentoalveolar surgery [1 ed.]

Table of contents :
Preface
Pre-emptive and postoperative analgesia for dentoalveolar surgery
Predicting the success and failure of surgical endodontic treatment
Ultrasonic retrograde preparation
Root end filling
Periapical surgery: clinical decision making
Surgical exposure of impacted teeth
Surgical uprighting of second molars: rationale and technique
Suturing principles in dentoalveolar surgery
Antibiotic prophylaxis in dentoalveolar surgery
Oral connective tissue grafting: evidence-based principles for predictable success
Coding for dentoalveolar surgical procedures
Index

Citation preview

Oral Maxillofacial Surg Clin N Am 14 (2002) xi

Preface

Advanced topics in dentoalveolar surgery

Stuart E. Lieblich, DMD Guest Editor

As oral and maxillofacial surgeons have broadened their expertise and expanded patient care, the ‘‘bread and butter’’ procedures of dentoalveolar surgery can be overlooked. The restoration of function, improvement of cosmetics, and relief of pain are significant outcomes from dentoalveolar surgery. These are the procedures that truly define us as oral surgeons. The fact that few others perform similar surgical procedures is a testimony to our skills and the underlying complexity of these seemingly simple procedures. It is only natural that we are the most proud of significant reconstructive or orthognathic surgeries that substantially change a patient’s function and appearance. Yet for most of us, our practices are more frequently associated with intraoral surgery (eg, extracting teeth, performing preprosthetic surgeries). It is therefore valuable time that we spend reviewing some of these more common surgeries to improve our techniques and patient care. Dentoalveolar surgery also maintains our contacts in dentistry with our general dental colleagues and other dental specialists. The treatment planning associated with periapical surgery and collaboration with the orthodontist in the management of impacted canines can be daily occurrences in an oral and maxillofacial surgery practice.

The authors of this volume share their clinical experience, founded in sound biologic, clinical, and research principles, to augment our understanding of some of our most frequent surgical procedures. Their expertise ranges from coast to coast, and I am most grateful to them for spending the time to share this material with us. They have continued to advance our profession by providing the basis to perform predictable and important procedures for our patients. I trust this material fills a niche in this series of publications and will contribute to your practice, as it has to mine. I am indebted to so many: the teachers in my field, whose expertise I continue to assimilate into my practice; my patients, whom I’ve had the sincere privilege to care for; my practice partners, who are always there to give me guidance; and especially to my wife, Janot, and children, Brett and Margot, who give me the time and encouragement to continue to broaden my professional horizons. Stuart E. Lieblich, DMD Avon Oral and Maxillofacial Surgery 34 Dale Road, Suite 105 Avon, CT 06001, USA E-mail address: [email protected]

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 2 0 - 1

Oral Maxillofacial Surg Clin N Am 14 (2002) 137 – 151

Pre-emptive and postoperative analgesia for dentoalveolar surgery Mark C. Fletcher, DMD, MDa,b,*, Joseph F. Spera, DMDc,d a Private Practice, Oral and Maxillofacial Surgery, 34 Dale Road, Suite 105, Avon, CT 06001, USA Department of Oral and Maxillofacial Surgery, University of Connecticut Health Center, Farmington, CT, USA c The Maxwell S. Fogel Department of Dental Medicine, Division of Oral and Maxillofacial Surgery, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, USA d Thomas Jefferson University Hospital, Department of Oral and Maxillofacial Surgery and Dentistry, Philadelphia, PA, USA b

I. Introduction Pain after oral surgical procedures is one of the most studied models in pharmacology and pain research. Sensory nociception in the head and oral cavity is disproportionately greater than in most other areas of the body. Because of this phenomenon, appropriate pre-emptive and postoperative pain management is critical to achieve a successful outcome. This article provides the practitioner with a brief review of the acute pain mechanism as it relates to the effects of a surgical insult. A brief understanding of the physiologic modulation of acute pain establishes a rational framework for the concept of preemptive and postoperative analgesia. A brief review of commonly used analgesic agents is presented. Research in pain management and new drug development is ongoing as new concepts in neurophysiology and pharmacology are being elucidated.

II. Acute pain mechanisms When examining how to manage acute postoperative pain in the oral and maxillofacial surgery patient, it is important to review the physiologic mechanisms involved in acute postsurgical pain. Webster’s dic-

* Correspondence. 34 Dale Road, Suite 105, Avon, CT 06001, USA. E-mail address: [email protected] (M.C. Fletcher).

tionary describes pain as a basic bodily sensation induced by a harmful stimulus characterized by physical discomfort [1]. When tissue homeostasis is disrupted by a surgical insult, autonomic, hormonal, and chemical changes that play a role in the subjective perception of pain are observed physiologically. This article does not address every detail involved in the acute pain mechanism. Nonetheless, a simplified understanding of the neurophysiology of acute pain is important when reviewing pharmacotherapy (Tables 1 and 2). Peripheral pain stimuli are initially encountered at the nociceptor level on skin, joint, or end-organ surfaces, where they are processed and transmitted via first-order neurons to the dorsal horn neurons of the spinal cord. These first-order neurons vary in width and composition. These nerve fibers are classified into two general subtypes, A and C. A-fibers tend to be myelinated and fast conducting, while C-fibers tend to be unmyelinated, slower-conducting fibers. A-fibers produce a more localized sharp pain, while C-fibers produce a dull, poorly localized ache. These primary afferent fibers, through the release of specific neurotransmitters, transmit sensory information to the dorsal horn neurons of the spinal cord. The spinal cord is composed of various laminae, numbered 1 through 10. These laminar tracts are comprised of specific types of second-order neurons, each varying in function. Examples of dorsal horn neurons include nociceptive specific cells (NS), wide dynamic range cells (WDR), complex cells, viscerosomatic cells, and others. NS cells are specific for a

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 7 - 9

138

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

Table 1 Commonly used oral narcotic analgesics Drug

Trade name(s)

Usual dose

Combination drug

Codeine

Empirin with codeine Tylenol with codeine Lortab, Norco, Vicodin, Maxidone Darvocet, Darvon

30 – 60 mg

Aspirin (325 mg) Acetaminophen (300 – 650 mg) Acetaminophen (500 – 750 mg) Acetaminophen (300 – 650 mg) Aspirin (325 mg)

Hydrocodone Propoxyphene Hydromorphone Oxycodone

5, 7.5, 10 mg 50 – 100 mg 1 – 4 mg 2.25 – 5 mg, 7.5 mg

Pentazocine

Dilaudid Percocet, Percodan, Roxicet, Roxipirin, Tylox Talacen, Talwin

Meperidine

Demerol

50 – 150 mg

small receptive field and respond to high-threshold noxious stimuli. Conversely, WDR cells respond to a wide spectrum of stimuli, receiving mainly multisynaptic input from both A- and C-fibers. WDR cells have a wider receptive field than NS cells. Complex, viscero-somatic, and other types of dorsal horn neurons may play excitatory and inhibitory roles on pain stimulus transmission while having various receptive field sizes and pain characteristics [2]. Depending on the afferent fiber type and the neurotransmitters involved, primary afferent stimuli are directed to specific laminae within the spinal cord, where they are processed and transmitted, via the spino-thalamic tract, to the brain. Information is transmitted to third-order neurons in the thalamus for further processing. Afferent information is then relayed to the somatotopic areas of the cerebral cortex, where conscious pain perception arises. It is at this sophisticated supraspinal level that such factors as anxiety, depression, fear, and learned behavior exert their influences on the phenomenon of perceived pain (Figs. 1 and 2). Although pain transmission in the head is quite similar to transmission in the spinal system, some distinct differences exist. Sensory nociception is dis-

12.5 – 25 mg

Acetaminophen (300 – 500 mg) Aspirin (325 mg) Acetaminophen (650 mg) Aspirin (325 mg) None

proportionately greater in the head and oral cavity when compared to other parts of the body. This amplification probably results from speech, taste, and masticatory functions. Cranial nerves V, VII, IX, and X relay sensory information to the trigeminal ganglion. The spinal nucleus of the ganglion transmits afferent sensory information through the medullary dorsal horn of the spinal cord to the thalamus [3]. This amplification in sensory distribution is what makes postsurgical dental pain one of the most studied models in pharmacology and pain research.

III. Modulation of the acute pain mechanism Peripheral sensitization: With the basic neuroanatomic architecture described above, the modulatory processes involved at the various levels of impulse transmission can be better understood. Free nerve endings, or nociceptors, are peripherally activated in response to tissue damage. Afferent conduction of information is transmitted through myelinated A fibers or unmyelinated C fibers to the dorsal horn neurons. At the level of the

Table 2 Properties of oral narcotic analgesics Drug

Analgesia

Sedation

Nausea or vomiting

Constipation

Euphoria

Comment

Codeine Hydrocodone Propoxyphene Hydromorphone Oxycodone Pentazocine Meperidine

+ ++ +/ ++ +++ ++ ++

+++ + +++ ++ ++ + ++

++ + + + + + ++

++ + ++ + + + +

+ ++ + +++ +++ + +++

Low potency

CNS = central nervous system. Plus and minus symbols indicate estimations of degree of negative or positive effect.

Rarely indicated

CNS side effects Rarely indicated

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

139

Fig. 1. (A) Primary somatic sensory cortex located in the postcentral gyrus. Note the relatively large proportional area dedicated to the facial region. (B) Schematic of Penfield and Rasmussen’s homunculus [36] depicting disproportionately large areas dedicated to the face and jaw regions. (From Martin, JH. Neuroanatomy text and atlas. 2nd edition. Old Tappan, NJ: Appleton and Lange; 1996. p. 379; with permission.) (C) A simplified view of the ascending sensory pathway depicting first-, second-, and third-order neurons leading to the primary somatic sensory cortex. (From Snell, RS. Clinical neuroanatomy for medical students. 5th edition. Copyright 2001 Philadelphia: Lippincott Williams and Wilkins; 2001. p. 146; with permission.)

140

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

Fig. 1 (continued ).

free nerve ending, there is interplay between the various surrounding structures, including blood vessels and mast cells. This contributes to the release of ‘‘pain mediators,’’ such as substance P, glutamate, and metabolites of arachadonic acid, among others. The release of histamine and cytokine activity in the face of mast cell degranulation can sensitize other free nerve endings in the area of insult. Plasma components, platelets, and the products of surgically

damaged cells themselves all contribute to the release of neuroactive substances involved in peripheral sensitization and hyperalgesia [2,3]. Central sensitization: Recent studies have demonstrated central sensitization of the dorsal horn neurons in the spinal cord. This concept was examined by using a surgical

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

141

Fig. 2. Pharmacologic interventions in arachidonic acid metabolism.

142

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

incision in the rat model. Three types of dorsal horn neurons, low threshold (LT), wide dynamic range neurons (WDR), and high-threshold (HT) cells were studied after surgical incision in the root foot. Decreased withdrawal thresholds to punctate mechanical stimuli after incision was observed. The activation of various neuropeptides and excitatory amino acids up-regulate centrally mediated impulse transmission. These findings suggest central sensitization and hyperalgesia in the face of surgical insult [4]. Additional studies on the concept of central sensitization are currently underway and may have significant implications in the concept of pre-emptive and preventive analgesia. Neuropeptide and amino acid modulators: Research in the area of neurophysiology has elucidated the existence of specific neuropeptides and excitatory amino acids released at central and peripheral nerve terminals [2,5 – 7]. Examples of such neuropeptides are substance P, calcitonin, generelated peptide, cholecystokinin (CCK), and somatostatin. These neuropeptides play a role in the modulation of transmitted afferent pain stimuli. The principle excitatory amino acid is N-methyl-D-aspartate (NMDA). Specific excitatory amino acid receptors also exist on postsynaptic dorsal horn neurons in the spinal cord. NMDA receptors are specific to Aand C-fiber stimulation [8]. These receptors, among others, have been the target of various experimental analgesic drugs. Excitatory and inhibitory modulation was further studied at the spinal level. ‘‘Wind-up pain hyperalgesia,’’ where repeated stimulus frequency beyond a critical threshold leads to enhancement of cellular responses, both in magnitude and duration, is thought to be a result of neurokinin excitatory modulation. Repeated stimulation of C-fibers converging on WDR cells in dorsal horn neurons is thought to elicit the release of substance P and the excitatory amino acid NMDA, leading to this clinical phenomenon [9,10]. Pharmacologic agents such as ketamine have been found to antagonize at the NMDA receptor, thus exhibiting some intrinsic analgesic properties [11]. Conversely, the release of inhibitory neuropeptides, such as g-amino-butyric acid (GABA), from the dorsal horn neurons is associated with the inhibition of primary afferent pathways by primary afferent depolarization. It is this phenomenon that has provided the basis for dorsal spinal cord stimulation in the treatment of chronic pain patients [12]. Enhancing the activity of inhibitory GABA provides another pharmacotherapeutic approach to analgesia.

Pharmacologic agents such as barbiturates and benzodiazepines achieve their biologic effect as GABA receptor agonists. Supraspinal modulation: Supraspinal modulation of impulse transmission in the thalamus and cerebral cortex is also observed. Monoamines, such as serotonin (5-HT) and norepinephrine (NE), and the release of endogenous enkephalins have been observed to down-regulate the afferent pain stimulus in the spinal cord directly or through second-messenger activation and provide excellent avenues for pharmacotherapy. Similarly, anxiolysis and patient education can modify cortical processing of pain perception [9,10]. This is extremely relevant in the ambulatory oral and maxillofacial surgery patient. Many new selective serotonin reuptake inhibitors and centrally acting analgesics such as clonidine achieve their biologic effect at this level.

IV. Pre-emptive analgesia An understanding of the cascade of neurophysiologic events that stem from a surgical insult provides excellent rationale for attempts at pre-emptive analgesia. The oral and maxillofacial surgery patient undergoing modern ambulatory dentoalveolar surgery requires a rapid return to the activities of daily living. Unlike other surgical disciplines, inpatient hospital stays and prolonged recovery are not a tolerated outcome in most cases. It has been suggested that lessening pain during the surgical procedure itself will reduce overall postoperative analgesia requirements [13]. Pre-emptive analgesic intervention is aimed at attenuating or entirely blocking central pain sensitization, leading to reduced pain in the postoperative period. Pre-emptive goals are to attain reductions in analgesic rescue medication requirements and to hasten overall recovery. Analgesia for postoperative dentoalveolar surgery has traditionally been approached by prescribing a particular analgesic drug of choice with instructions to ‘‘take as needed for pain.’’ Experience with this approach dictates that many patients will wait until the onset of significant pain before starting the medication. Recent studies have demonstrated efficacy in using adjunctive analgesic measures, such as administration of long-acting local anesthesia, corticosteroids, and intraoperative nitrous oxide analgesia, with regard to reducing postoperative pain [3]. Also, the concept of using analgesic pain medication post-

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

operatively, before the onset of significant pain (as ‘‘preventive analgesia’’), is being used [13]. Each of these modalities have lead to decreased total pain after surgery and decreased pain intensity at fixed postoperative time intervals when measured by visual analog scale [8,13]. Investigators have retrospectively explored the concept of pre-emptive blockade of central sensitization resulting from surgery [16]. In this analysis, the amount of time was measured between surgery and the first request of postoperative analgesia medication in patients who underwent a variety of surgical procedures under general anesthesia. Preoperative administration of local anesthesia delayed the postoperative request for analgesic medication by 6 hours when compared to control subjects. Preoperative opioid administration caused a 3-hour delay, and the contribution of both local anesthesia and an opioid showed additive effects on delaying the request of postoperative analgesic medications. This provided sound rationale for prospective investigational studies on pre-emptive analgesia. Subsequent prospective studies on pre-emptive analgesia were initiated in the oral and maxillofacial ambulatory surgery model [14,15]. The preoperative use of 0.5% bupivicaine, when compared with lidocaine and saline placebo injections in patients undergoing third molar surgery under general anesthesia, lead to statistically significant decreased pain perception at 4 and 48 hours after surgery. Additional studies have suggested that the use of nonsteroidal anti-inflammatory medications before surgery, with the pre-incisional administration of long-acting local anesthesia, significantly reduced the amount of postoperative pain, as measured by visual analog scale [11]. These results support the theory that blockade of factors leading to central sensitization will have a positive effect by decreasing postoperative pain perception. It should be pointed out that these studies support the supposition that blocking central sensitization reduces overall pain perception and pain duration. Nevertheless, the question remains: At which point is pre-emptive intervention most important, blocking the nociceptive input at surgery or blocking the postoperative pain resulting from surgery in the immediate postoperative period? A recent study indicates that whether or not the nociceptive input of surgery was blocked through the administration of long-acting local anesthesia, overall postoperative pain perception was the same [15]. This suggests the important contribution of immediate postoperative pain toward initiation of central sensitization in the ambulatory oral and maxillofacial surgical

143

patient. Additional studies are necessary to clarify this distinction. When looking at the data available, for patients undergoing complex dentoalveolar surgery, it would seem prudent for the practitioner to administer a longacting local anesthetic such as etidocaine or bupivicaine at the time of surgery or, at the latest, in the immediate postoperative period. This would preemptively block the initiation of central sensitization and resulting hyperalgesia. The use of nitrous oxide analgesia during surgery and corticosteroids for reduction of postoperative inflammation and local tissue injury should also lead to diminution of postoperative pain. Most recently, it has been demonstrated that pretreatment with nonsteroidal anti-inflammatory medications also lead to decreased postoperative pain and edema in the oral and maxillofacial surgery patient [11,17]. This may prove to be another effective pre-emptive analgesic approach. Further studies regarding pre-emptive analgesia in the surgical patient will undoubtedly change the standard approach to ambulatory surgical pain management.

V. Postoperative analgesic agents The opioid drug class: Mechanism of action: Opioids in oral and maxillofacial surgery have long been the mainstay drug class for the management of moderate to severe postsurgical pain. References to the opium poppy can be found dating back to 300 BC in Sumarian and Egyptian culture. The opium poppy, papaver somniferum gives rise to more than 20 different alkaloids. Morphine was isolated in 1806, followed by codeine in 1832 [18]. Opioid receptors are found throughout the body, providing sites for activation of endogenously released opioid substances. Beta-endorphins, enkephalins, and dynorphin compounds have been identified as agents for endogenous central analgesia [19]. These endogenous opioid receptors provide natural targets for centrally mediated pharmacotherapy. Opioid receptors are subdivided into delta, kappa, and mu subtypes. They are located centrally in C-fiber terminals within the dorsal horn of the spinal cord. They are also found supraspinally in nociceptive processing areas of the brain. A peripheral component of opioid analgesia has also been described at the afferent C-fiber terminals on skin and joint surfaces [9]. Current terminology has now classified delta, kappa, and mu opioid receptors as OP1, OP2, and OP3, respectively. It is primarily the

144

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

central analgesic action of opioids that makes them so effective in managing acute postsurgical pain. Opioid receptors, neuronal pools, exogenous and endogenous ligands, routes of delivery, and dosage of various compounds have contributed immensely to our ability to effectively manage postoperative pain in the oral and maxillofacial surgery patient [19]. All opioids act on stereo-specific, saturable membrane receptors. As previously mentioned, these receptors are widely but unevenly distributed throughout the central nervous system (CNS). In addition to the three opioid receptors delta, kappa, and mu, two additional receptors, epsilon and sigma, also exist. Studies have indicated that only mu, kappa, and delta receptors (OP3, OP2, and OP1, respectively) have analgesic properties. Mu/OP3 receptors are located widely throughout the CNS and have been identified in the limbic system, thalamus, striatum, hypothalamus, and midbrain [18]. Kappa receptors are located primarily in the spinal cord and cerebral cortex. Opiate receptors are coupled with G-protein receptors, which function as positive and negative modulators of synaptic transmission via second-messenger activation. These G proteins provide amplification of physiologic activity at the receptor level. Opioid receptors differ with respect to distribution, ligand affinity, and proposed behavioral action. Research has confirmed that the mu/OP3 receptor is not only associated with analgesic properties, but is also responsible for respiratory depression. Two mu receptor subtypes have been discovered. Although a certain degree of crossreactivity exists, mu1 is mainly responsible for analgesia and mu2 for respiratory depression. This has opened the door to research aimed at developing mu1-specific analgesic agents [19]. Pure agonists such as morphine sulfate, codeine, oxycodone, and meperidine act on the mu/OP3 receptor. The nomenclature for opioid classification is based on the type and degree of receptor activation. Drugs or neurotransmitters that act on receptors and cause a biologic effect are known as agonists. Opiate agonists produce analgesia by inhibiting excitatory neurotransmission of substance P, acetylcholine, noradrenaline, and dopamine. Opiate agonists also modulate the endocrine system and immune system. They inhibit the release of vasopressin, somatostatin, insulin, and glucagon [18]. Opiate antagonists will act on receptors to reverse a biologic effect. They will occupy a receptor without eliciting a physiologic response. This has clinical significance with the use of certain narcotic-reversal agents and mixed agonist-antagonist agents. Mixed agonist-antagonist drugs can be considered for use in postoperative analgesia. These drugs have potent

analgesic effects without the high potential for tolerance or dependency inherent in pure mu/OP3 agonists. The opioid agonist-antagonists have high affinity and low potency at the mu receptor while activating kappa, delta, and sigma receptors. Drugs in the agonist-antagonist class include such agents as butorphanol, pentazocine, and nalbuphine. The opioid agonist-antagonist agents have been proven effective for use in the control of moderate pain, but have not proven to be potent enough analgesics for severe postoperative pain. The most significant adverse reaction to the opioid agonists is respiratory depression. For this reason, most opioid agents used in outpatient postsurgical pain management are formulated in combination with non-narcotic analgesics. This potentiates the analgesic effects of the individual agents within the formulation while minimizing the potentially lifethreatening side effects of pure opioid administration. When these drugs are properly titrated and the recommended doses are not exceeded, the risk of respiratory depression is small because tolerance to this effect develops rapidly. Allergic reactions to opiate agonists are uncommon. Opiates can cause histamine release, resulting in pruritis. The most common gastrointestinal (GI) effects include nausea, vomiting, and constipation. Codeine: Codeine remains one of the most frequently prescribed narcotics to treat postoperative pain in the ambulatory surgical setting. It is also widely used for its antitussive properties. It is most commonly used in combination with acetaminophen. Codeine is closely related in structure to morphine, possessing a methyl group that protects it from rapid degradation in the liver. It is one third as potent as morphine [20]. Doses of 120 mg will produce respiratory depression similar to that resulting from 10 mg of morphine sulfate. Because of its low degradation on first pass, codeine’s oral efficacy is two thirds that of its parenteral activity. Studies assessing codeine’s ability to relieve postoperative oral surgical pain have been equivocal and have indicated that 60 mg of codeine is required to achieve therapeutic benefit in dental pain. The usual adult dosage is 30 to 60 mg orally every 4 to 6 hours as needed, with a maximum dose of 360 mg in 24 hours. This has led to formulations that combine codeine with other analgesics such as acetaminophen. In doing so, analgesic synergism will reduce the total dose requirements for codeine. The maximum dosage of acetaminophen should not exceed 4 g in a 24-hour period. The most common side effects are constipation, nausea, vomiting, and sedation.

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

A small percentage of patients have been found to be nonresponders to codeine and codeine-based derivative analgesic agents such as hydrocodone and oxycodone. These patients do not derive adequate analgesic efficacy from these types of analgesic agents. Manifestations of this phenomenon may be difficult to differentiate from drug-seeking behavior. It has been discovered that  5% to 10% of Caucasians lack functional cytochrome P450 2D6, a liver enzyme involved in the metabolism of many drugs, including codeine [21]. Assays of codeine and its metabolites have been compared to CYP2D6 phenotypic activity in human subjects, demonstrating a direct correlation between the two [22]. Although this phenomemon is still being investigated, there is a likely genetic contribution to poor codeine metabolization. Oral and maxillofacial surgery patients who do not respond to codeine-based analgesia in the immediate postoperative period may respond to alternative agents such as meperidine or propoxyphene. Hydrocodone: Hydrocodone was first synthesized in 1920. It is derived from the opioid alkaloid thebaine. It has antitussive and analgesic properties [23]. Hydrocodone is approximately six times more potent than codeine on a weight-per-weight basis [24]. Hydrocodone is an oral semisynthetic mu opiate receptor agonist. Structurally, hydrocodone is a ketone derivative of codeine. Equipotent doses of codeine and hydrocodone have similar efficacy and severity of adverse side effects [17]. The combination of acetaminophen and hydrocodone are used together to treat moderate to severe pain. Combination formulations of hydrocodone are available in doses of 5, 7.5, and 10 mg (such formulations include Vicodin, Vicodin E.S., Norco, and Maxidone). Hydrocodone and ibuprofen have also been combined (Vicoprofen) for the treatment of moderate to severe pain. The usual dose of 5 to 10 mg is effective for  3 hours. A 5-mg dose of hydrocodone is equipotent to 30 mg of codeine. Also, a 4-g/d ceiling dose of acetaminophen within the combination agents establishes daily dose limitations. Side effects of hydrocodone include constipation, nausea, vomiting, and sedation. Oxycodone: Oxycodone is an oral semisynthetic opiate agonist derived from the opioid alkaloid thebaine. It has been in clinical use since the early 1900s. Its pharmocologic action is similar to that of morphine. Oxycodone, similar to hydrocodone, is a cogener to codeine. It is  10 to 12 times more potent than codeine on a weight-perweight basis [24]. Because of resistance to extensive

145

first-pass metabolism, oxycodone is an excellent orally administered narcotic analgesic agent. Similar to other narcotic combination medications, acetominaphenoxycodone formulations (Percocet, Roxicet, Tylox ) work through a synergistic effect. Combinations produce additive analgesic effects compared to the same doses of either agent alone. Similar to the hydrocodone combination agents, increased dosage of oxycodone combination agents is limited by the maximum dose and ceiling effect of acetaminophen at 4 g/d. The typical dosage of oxycodone is 5 to 10 mg. Oral administration of acetaminophen-oxycodone has an onset of analgesia in 30 minutes and a peak analgesic effect in 90 minutes. The duration of analgesia is 3 to 4 hours. The metabolism of both drugs is mediated through cytochrome P450. Administration of other drugs, which affect these isoenzymes, may affect the efficacy and incidence of adverse reactions from this formulation. As in the case of codeine, a small percentage of nonresponders may be related to decreased CYP2D6 expression. A 5-mg dose of oxycodone is equivalent to 50 to 60 mg of codeine. Oxycodone is indicated for the treatment of moderate to severe postoperative pain. As a solo agent, 5 to 7.5 mg of oxycodone is administered orally every 6 hours, as needed for pain. Side effects to oxycodone are similar to all centrally acting narcotic agonists and include constipation, nausea, vomiting, and sedation. It is worthy to note that oxycodone can elicit a significant euphoric effect and carries an increased potential for abuse in both solo and combination formulations. Recent reports have shown this problem to be increasing in severity in the United States [25]. Sustained release oxycodone compounds (eg, Oxycontin) are not indicated in the management of acute pain after dentoalveolar surgery. Meperidine (Demerol): Meperidine hydrochloride is a synthetic opiate agonist belonging to the phenylpeperidine class. Other members of this group include alfentanil, fentanyl, loperamide, and sufentanil. Meperidine is recommended for moderate to severe acute pain and has the unique ability to interrupt postoperative shivers and chills. According to the Agency for Health Care Policy and Research Clinical Practice Guideline, for acute pain management in operative procedures, meperidine is recommended only for use in brief courses. Meperidine should be considered as a second-line agent to treat acute pain. Meperidine is metabolized to normeperidine, a compound capable of inducing seizures at high concentrations. Meperidine is available in oral and parenteral formulations and was approved for use by the FDA in 1942.

146

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

Meperidine is primarily a kappa-opiate receptor agonist and has local anesthetic effects. Its affinity for the kappa receptor is greater than that of morphine. The oral form of meperidine undergoes extensive firstpass metabolism. To treat moderate to severe pain in adults, the dose is 50 to 150 mg po or IM every 3 to 4 hours. The drug has a short analgesic effect and a significant euphoric effect [24]. The recommended IV dose is 50 to 100 mg. After oral administration, the onset of analgesia is within 15 minutes and peak effects occur in 60 to 90 minutes. Protein binding is 65%, primarily to albumin and a-1-acid glycoprotein. In patients with normal hepatic and renal function, the half-life is 3 to 5 hours. As previously mentioned, meperidine is a reasonable alternative for the rare patients who have been determined to be nonresponders to codeine-derived analgesics or those with a true allergy to the codeine class. Its use needs to be limited to 10 to 14 days, however, because of the potential buildup of toxic normeperidine byproducts. Also, meperidine is strictly contraindicated in patients taking MAO inhibitor – type antidepressants. Pentazocine (Talwin Nx): Pentazocine is a synthetic opiate agonist-antagonist analgesic used to treat moderate to severe pain. This drug is considered the prototype of the agonistantagonist class of analgesics, with a potency of approximately one sixth to one third that of morphine. It was approved for use by the FDA in 1967 and reformulated to include naloxone and approved for use in 1982. At therapeutic doses, pentazocine has less respiratory depression than morphine. It does have a tendency to produce dysphoric reactions. Pentazocine is an agonist at the kappa receptor and weak antagonist at the mu receptor. Its antagonism at the mu receptor is weaker than both butorphanol and nalbuphine. It is given orally, parenterally, or intramuscularly. It is well absorbed in the GI tract, and the onset of action is 15 to 30 minutes after administration. The analgesic effect of 50 mg of pentazocine is equipotent to 60 mg of codeine. The recommended oral dose is 50 mg every 3 to 4 hours. Butorphanol (Stadol): Butorphanol tartrate is a synthetic parenteral and intranasal opiate agonist-antagonist. There is good GI absorption of oral butorphanol, but it undergoes extensive first-pass metabolism, making its bioavailability low. Trans-nasal administration of butorphanol has an absolute bioavailability of 60% to 70% [26]. Although it is structurally related to morphine, it is more similar in action to nalbuphine. Butorphanol is used to treat moderate to severe acute pain. Butor-

phanol injection was approved in 1978; the nasal spray was approved in 1991. Although butorphanol was not a controlled substance in the United States when it was introduced, the DEA recommended in June 1997 that both the injection and the nasal spray be classified as a controlled substance. Butorphanol is an agonist at the kappa receptors, but is a weak antagonist at the mu receptor. A recent study indicates that butorphanol delivered transnasally is an effective analgesic for postoperative pain. Butorphanol is administered trans-nasally by spraying once in one nostril. Each spray is equivalent to 1 mg. In this study, the threshold dose for adequate analgesia was 1 mg . A 2-mg dose produced better analgesia, with an increased incidence in adverse events, namely dizziness and drowsiness. Butorphanol is reportedly being considered as an option for preand intraoperative analgesia. Additional studies will be needed to establish the exact role of butorphanol in perioperative pain management [27]. The nonsteroidal anti-inflammatory drug class (NSAIDS) Mechanism of action: Nonsteroidal anti-inflammatory drugs (NSAIDS) have been used since the discovery of sodium salicylate in 1875 and acetylsalicylic acid (aspirin) in 1899 for the treatment of pain, fever, and inflammation. Most recently, these drugs have become quite diverse and more specific in their mechanisms of action. The anti-inflammatory and analgesic properties of these drugs without the narcotic-related side effects of drowsiness, constipation, respiratory depression, and addiction potential make NSAIDs very popular in the ambulatory dentoalveolar surgical patient. With regard to analgesia, NSAIDs primarily act peripherally at the site of tissue injury. As previously discussed in this chapter, a cascade of events occurs at the tissue level immediately after making a surgical incision. Inflammatory mediators such as histamine, serotonin, bradykinin, platelet-activating factor, interleukin-1, and derivatives of arachadonic acid metabolism such as prostaglandins, thromboxanes, and leukotrienes are released. These mediators have been found to sensitize peripheral nociceptors, leading to inflammatory pain and hyperalgesia. NSAIDs block this cascade of events, thus leading to a reduction in inflammation and pain perception. NSAIDs exert their effect by inhibiting the synthesis of prostaglandins within the endoperoxide pathway. Inflammation will prompt the enzyme phospholipase A2 to break down cell membrane components and yield arachadonic acid. The endoperoxide

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

biosynthetic pathway leads to the metabolism of arachadonic acid and the synthesis of prostaglandins. The initial step of the endoperoxide pathway is driven by the enzyme cyclooxygenase (COX). Prostaglandins have varied physiologic effects that are both beneficial and detrimental to normal physiologic homeostasis. Beneficial effects of prostaglandins include maintenance of renal blood flow through the activity of prostacyclin, gastric mucin production and mucosal protection, and maintenance of platelet function. Conversely, pain, inflammation, fever, bronchial constriction, and decreased blood flow can also be attributed to the release of prostaglandins. The enzyme cyclooxygenase (COX) has been identified as a major actor in the endoperoxide pathway. Cyclooxygenase is subdivided into two isoenzymes, COX-1 and COX-2. Physiologically, it has been determined that COX-1 is constitutively released and contributes to normal physiologic homeostasis. It provides the beneficial aspects of prostaglandin function previously mentioned. Alternatively, the isoenzyme COX-2 is released primarily after tissue injury and plays an instrumental role in tissue inflammation and pain mediation. Interleukin-1, tumor necrosis factor, lipopolysacharide, mitogens, and reactive oxygen intermediates are all mediators released after tissue injury which have been found to induce COX-2 enzyme activity [28]. NSAIDS have been designed over the years to inhibit enzymatic reactions in the endoperoxide cascade. Historically, most of the drugs were nonselective cyclooxygenase inhibitors. Sodium salicylate, aspirin, ibuprofen, and others are included in this group. During the past 10 years, COX-2 selective inhibitors have been developed. These drugs are aimed at blocking the inductive, detrimental effects of the COX- 2 – mediated prostaglandins while maintaining the physiologically beneficial effects of the COX-1 isoenzyme. Specific COX-2 – inhibiting medications include rofecoxib (Vioxx) and celecoxib (Celebrex). These medications are slowly finding their place in the management of mild to moderate postoperative pain, with diminished side effect profiles when compared to the nonspecific cyclooxygenase inhibitors [29]. Adverse responses to NSAIDs are directly related to their mechanism of action. The most common are gastrointestinal disturbances, gastric irritation, increased bleeding time, and renal impairment. Less common effects are allergic reactions and asthma. These effects are all related to prostaglandin inhibition. Gastrointestinal adverse effects are the most common adverse reaction to NSAIDs and constitute the greatest risk of death [30]. Patients with peptic

147

ulcer disease and other disturbances in gastrointestinal mucosal integrity should avoid the usage of NSAIDs altogether. Increased risk of postoperative hemorrhage has been reported with the usage of NSAIDs mainly because of the drugs’ antiplatelet effects. Spontaneous hemorrhage in the postoperative period is rarely the cause of NSAID use alone, but may be significant in patients with thrombocytopenia, underlying bleeding dyscrasias, or concomitant use of anticoagulant drugs [28]. It is also worthy to note that patients who are taking aspirin daily for its antithrombotic effects should discontinue use of the drug for at least 5 days before the scheduled date of surgery. Also, NSAIDs’ effect on renal function is related to inhibition of renal prostacyclin, resulting in decreased renal blood flow and decreased glomerular filtration rate. This is an important issue in patients with underlying renal compromise, and the elderly who may be dependent on the vasodilatory effect of prostaglandins for baseline renal function [30]. Less commonly, aspirin and other NSAIDs can precipitate acute bronchospasm in asthmatic patients. Approximately 5% to 10% of adult asthmatics may be sensitive to NSAID administration [30]. When selecting NSAIDs for postoperative analgesia, the practitioner must evaluate not only which drug is most appropriate for a patient, but also the overall risk profile with regard to the above-mentioned issues. Acetylsalicylic acid (aspirin): Aspirin is the salicylic ester of acetic acid. Its uses are for analgesia, anti-inflammatory action, antipyretic action, and antithrombosis. Aspirin is the classic nonsteroidal anti-inflammatory drug. It was first introduced to medicine in 1899. It nonselectively inhibits cyclooxygenase (COX-1 and COX-2). For a long time, aspirin has been beneficial in oral and maxillofacial surgery for its anti-inflammatory action by inhibiting the formation of prostaglandin E and F subtypes. This results in decreased vasodilation, tissue permeability, edema, and leukocytic infiltration. Its analgesic activity is likely the result of prostaglandin inhibition in the periphery at the site of tissue injury. There may also be a centrally mediated analgesic component to aspirin, although this mechanism has not been clearly elucidated. Aspirin dosing for postoperative oral surgical pain is 325 to 650 mg po every 4 hours or 1000 mg po every 6 hours, as needed for pain in the adult patient. Aspirin therapy is effective for mild to moderate pain. Aspirin has fallen out of favor as a primary drug of choice in postoperative analgesia, mainly because of its significant and permanent effect of platelet inhibi-

148

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

tion. The administration of aspirin before third molar surgery has actually been shown to increase postoperative edema. This effect is likely due to decreased platelet aggregation. It is also associated with the classic adverse effects of the NSAID drug class, such as gastroenteric irritation and ulceration, renal impairment, and the potential for hemorrhage occurrence. Besides observing standard precautions with the usage of all NSAID drugs, absolute contraindications for aspirin usage include the incidence of aspirin-induced nasal polyps, salicylate hypersensitivity, and urticaria. It should also be used with extreme caution in asthmatic patients [18]. Ibuprofen: Ibuprofen is an oral NSAID with anti-inflammatory and antipyretic actions. It was initially approved for usage in 1974. It is most effective as an analgesic agent for mild to moderate postoperative pain. Similar to the other NSAIDs, its analgesic properties result from the peripheral inhibition of prostaglandins. Ibuprofen is a nonselective cyclooxygenase inhibitor and is associated with the classic adverse effects of the NSAID drug class, including gastroenteric irritation and ulceration, renal impairment, and alterations in platelet function. Dosing of ibuprofen in adults and adolescents is 400 mg po every 4 to 6 hours, as needed for pain. This can be increased to 600 mg for severe pain. The half-life of ibuprofen is 2 to 5 hours. Absolute contraindications to ibuprofen are similar to other NSAIDs. They are to be avoided in asthmatic patients, aspirin-induced nasal polyps, salicylate hypersensitivity, and urticaria. Ibuprofen provides excellent pain relief in postsurgical oral and maxillofacial surgery patients. It can be used as a transition drug after the need for pure or combination narcotic based pain control is obviated. Ibuprofen is available in combination form with hydrocodone (Vicoprofen) and provides significant relief of moderate to severe pain after third molar impaction surgery. This is accomplished by combining the centrally mediated analgesia of a narcotic with the peripherally mediated activity of an NSAID. Ibuprofen does not have the permanent effect on platelet activation that aspirin does, but nonetheless is associated with the potential for postoperative hemorrhage. This was demonstrated in a pediatric population after tonsillectomy [31]. This should be a consideration when selecting any NSAID. Naproxen (Naprosyn): Naproxen is an NSAID with analgesic and antipyretic activity. It is a propionic acid derivative related

structurally to ibuprofen. It was approved for use by the FDA in 1976 and became available over the counter in 1994 (Aleve). Like ibuprofen, naproxen is better tolerated than aspirin with regard to NSAIDrealated side effects. Naproxen is a nonselective inhibitor to the enzyme cyclooxygenase, providing peripheral analgesic properties by inhibiting the in vivo synthesis of prostaglandins. Nonspecific inhibition of the COX-1 isoenzyme contributes to this agent’s adverse side effects, including decreased gastric mucosal cytoprotection, impaired renal function, and alteration in platelet function. Naproxen is administered by mouth and has a halflife of 10 to 20 hours. It is an excellent drug of choice for mild to moderate pain, and compared to aspirin and ibuprofen, its extended half-life increases patient compliance through less frequent dosing requirements. The oral dose of naproxen sodium is initially 550 mg po, followed by 275 mg po every 6 to 8 hours, as needed. The maximum initial daily dose of naproxen sodium is 1375 mg and therefore should not exceed 1100 mg. Naproxen is available in enteric-coated and sustained-release tablets. Ketorolac (Toradol): Ketorolac is a NSAID that provides analgesic and anti-pyretic activity. It is similar in chemical structure to indomethacin. It was approved for parenteral usage in 1989 and oral usage in 1993. Like other NSAIDs, ketorolac is a peripheral analgesic agent. It inhibits prostaglandin synthesis through nonselective inhibition of cyclooxygenase. Ketorolac is an excellent drug for short-term post-operative pain control. Parenteral administration in the immediate postoperative period has been compared to morphine for adequacy of pain relief without the classic narcotic-related side effects [32]. Ketorolac is administered in parenteral and oral forms. Dosages are 30 mg IV or 60 mg IM in healthy adults who are greater than 50 kg in total body weight. It can be given as a single dose in the immediate postoperative period. If multiple parenteral dosing is desired, the drug can be repeated every 6 hours, with the maximum dose not to exceed 120 mg. Oral ketorolac can be administered for a maximum of 5 days postoperatively. In patients who have received IV or IM doses of ketorolac in the immediate postoperative period, 20 mg of ketorolac should be followed by 10 mg of the drug every 4 to 6 hours. The maximum oral daily dose should not exceed 40 mg. Ketorolac has been found to be an excellent alternative to narcotics in the ambulatory surgical patient. It is best administered after completion of the

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

surgical procedure. Similar to the other NSAIDs, contraindications and side effects are related to the drug’s nonspecific inhibition of the enzyme cyclooxygenase. Ketorolac has been found to elicit more profound adverse side effects than other classic NSAIDs, probably because of its increased potency. Absolute contraindications include asthma, breast feeding, cerebrovascular disease, dehydration and/or renal impairment, GI bleeding or peptic ulcer disease, aspirin-induced nasal polyps, urticaria, or salicylate hypersensitivity. Cyclooxygenase 2 (COX-2) inhibitors: The Food and Drug Administration in the United States has approved COX-2 inhibitors for the management of osteoarthritis, rheumatoid arthritis, primary dysmenorrhea, and acute pain management in adults. COX-2 inhibitors minimize the inflammatory response by inhibiting the release of the enzyme cyclooxygenase-2. COX-2 is released after tissue injury in macrophages, monocytes, synovial cells, leukocytes, and fibroblasts [29]. These COX-2 selective therapeutic agents alternatively leave the cytoprotective COX-1 enzymes intact. This provides protection against such side effects as GI tract irritation and decreased platelet aggregation, which are commonly observed with the nonselective cyclooxygenase-inhibiting agents. Advantages of COX-2 – inhibiting agents include extended half-lives, decreased frequency of dosing, and little to no effect on bleeding parameters (because of their minimal effect on platelet aggregation). COX-2 inhibitors are rapidly becoming excellent therapeutic alternatives to standard nonspecific COX inhibitors such as ibuprofen in the postsurgical and acute dental pain model. Disadvantages of the COX-2 inhibitors include the relatively high price of these drugs [29]. Continued research and drug development is being done with COX-2 –inhibiting agents, and they appear to have a very promising role in the future of postoperative and pre-emptive analgesia. Celecoxib (Celebrex): Celecoxib (Celebrex) is a COX-2 inhibitor and has been found to be most beneficial in the management of chronic pain. It offers the advantage of having an extended half-life, allowing limitation of the dose frequency to once or twice a day. A recent study evaluating the use of celecoxib after orthopedic surgery demonstrated that 400 to 600 mg of celecoxib administered orally for 2 to 5 days after surgery was as effective as 10 mg of hydrocodone and 1 g of acetaminophen given orally 2 to 3 times daily [33]. Alternatively, other studies have shown

149

celecoxib to be limited in efficacy when used for the management of acute pain after third molar extraction. It is evident that additional studies will be needed to clarify this issue. Celecoxib is administered in 200-mg daily doses or 100 mg twice daily in adults. It is used mainly in the management of chronic joint pain. As described above, higher doses have been described for the management of severe postoperative orthopedic pain; 200 mg of celecoxib has been found to be equivalent to 400 mg of ibuprofen [29]. Absolute contraindications to celecoxib include aspirin-induced nasal polyps, asthma, salicylate and sulfonamide hypersensitivity, and urticaria. Rofecoxib (Vioxx): Similar to celecoxib, rofecoxib (Vioxx) is a COX2 – inhibiting agent that has been found to act comparably to 400 mg of ibuprofen, but has a more profound analgesic effect in postoperative third molar patients [34]. This agent encouragingly provides measurable analgesia for up to 24 hours after surgery, whereas nonselective COX inhibitors such as ibuprofen tend to provide a maximum of 4 to 6 hours of postoperative analgesia. Studies comparing rofecoxib, celecoxib, ibuprofen, and placebo confirmed that 50 mg of rofecoxib had prolonged duration, lack of platelet inhibition, and superior analgesic efficacy [35]. For these reasons, rofecoxib has also been suggested as a good agent for pre-emptive and postoperative analgesia in the dentoalveolar surgery patient. Future studies in this area should elucidate this point further. The recommended initial dose of rofecexib is 50 mg once a day, then 50 mg each day after surgery, as needed for pain. The effects of postoperative rofecoxib therapy beyond 5 days have not been described clearly at this point. Absolute contraindications to this medication include aspirin-induced nasal polyps, asthma, salicylate hypersensitivity, and urticaria.

VI. Summary Oral surgical procedures provide a unique model for the study of pharmacology and pain. The role of central and peripheral sensitization and other modulating factors affecting the acute pain mechanism provide various opportunities for pharmacologic intervention in pain management. The concept of preemptive analgesia is rapidly being incorporated into the management of the ambulatory surgical patient and has lead to hastened recovery and less pain medication requirements. The modern practitioner

150

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151

has access to a variety of pharmacologic agents for the treatment of acute pain. Opioids, NSAIDs, combination formulations, and new analgesic agents are constantly being put to the test in light of the many new discoveries in neurophysiology and pharmacology research. Basic knowledge of how these agents exert their effects should lead to the most appropriate selection of pharmacotherapy for each patient.

[17]

[18]

[19]

References [1] Webster’s New Encyclopedic Dictionary. New York: Black Dog and Leventhal Publishers Inc., 1993. [2] Klein CM, Coggeshall RE, Carlton SM, et al. The effects of A- and C-fiber stimulation on patterns of neuropeptide immunostaining in the rat superficial dorsal horn. Brain Res 1992;580:121 – 8. [3] Desjardins P. Patient pain and anxiety: the medical and psychologic challenges facing oral and maxillofacial surgery. J Oral Maxillofacial Surg 2000;58(Suppl 2): 1 – 3. [4] Vandermeulen EP, Brennan T. Alterations in ascending dorsal horn neurons by a surgical incision in the rat foot. Anesthesiology 2000;93:1294 – 302. [5] Duggan AW, Hendry IA, Morton CR, et al. Cutaneous stimuli releasing immunoreactive substance P in the dorsal horn of the cat. Brain Res 1988;451:261 – 73. [6] Duggan AW, Morton ZR, Zhao ZQ, et al. Noxious heating of the skin releases immunoreactive substance P in the substantia gelatinosa of the cat: a study with antibody microprobes. Brain Res 1987;403:345 – 9. [7] Yaksh TL. Substance P release from knee joint afferent terminals: modulation by opioids. Brain Res 1988;458: 319 – 24. [8] Dickenson AH, Sullivan AF. Differential effects of excitatory amino acid antagonists on dorsal horn nociceptive neurons in the rat. Brain Res 1990;506:31 – 9. [9] Crane M, Green P, Gordon N. Pharmacology of opioid and non-opioid analgesics. Oral Maxillofacial Surg Clin N Am 2001;13:1 – 13. [10] Sorkin L, Wallace M. Acute pain mechanisms. Surg Clin N Am 1999;79:213 – 229. [11] Dionne RA. Suppression of dental pain by preoperative administration of flurbiprofen. Am J Med 1986;80: 41 – 9. [12] Barolat G. Spinal cord stimulation for chronic pain management. Arch Med Res 2000;31:258 – 62. [13] Dionne R. Pharmacotherapy update: preemptive versus preventive analgesia: which approach improves clinical outcomes? Compendium 2000;21:48 – 56. [14] Gordon SM, Dionne RA, Brahim J, et al. Blockade of peripheral neuronal barrage reduces postoperative pain. Pain 1997;70:209 – 15. [15] Gordon SM, Dionne RA, Brahim JS, et al. Differential effects of local anesthesia on central hyperalgesia [special issue]. J Dent Res 1997;76(153). [16] McQuay H. Do preemptive treatments provide better

[20]

[21]

[22]

[23]

[24]

[25] [26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

pain control? In: Gebhardt GF, Hammond DL, Jensen TS, editors. Proceedings of the Seventh World Pain Congress. Seattle: IASP Press; 1994. p. 709 – 23. Troullos ES, Freeman RD, Dionne RA. The scientific basis for analgesic use in dentistry. Anesth Prog 1986; 33(3):123 – 38. Reents S, Vieson K. Opiate agonist overview. Clinical Pharmacology 2000, Copyright 2001, Gold Standard Multimedia, http://cponline.hitchcock.org. Zuniga J. Current advances in anesthesia and pain control research, clinical relevance of neurotransmitterreceptor interactions. Oral Maxillofacial Surg Clin N Am 1992;4:875 – 85. Houde RW, Wallensteine SL, Beaver WT. Clinical management of pain. In: deStevens G, editor. Analgesic. New York: Academic Press; 1965. p. 75 – 122. Roberts R, Joyce P, Kennedy MA. Rapid and comprehensive determination of cytochrome P450 CYP2D6 poor metabolizer genotypes by multiplex polymerase chain reaction. Hum Mutat 2000;16:77 – 85. Haffen E, Berard M, et al. On the assessment of drug metabolism by assays of codeine and its main metabolites. Ther Drug Monit 2000;22:258 – 65. Eddy NB, Halbeck H, Braenden OJ. Synthetic substances with morphine-like effect. Bull WHO. 1957;17: 595 – 600,705 – 709. Turturro M, Paris P. Oral narcotic analgesics: choosing the most appropriate agent for acute pain. Postgrad Med 1991;90:89 – 90, 93 – 95. Kalb C. Playing with pain killers. Newsweek. April 9, 2001;137(15). Bristol Myers Squibb Co. Stadol (butorphanol tartarate) injectable and Stadol NS nasal spray [package insert]. New York: Bristol Myers Squibb Co.; 2001. Desjardins PJ, Norris LA, Cooper SA, et al. Analgesic efficacy of intranasal Butorphanol (Stadol NS) in the treatment of pain after dental impaction surgery. J Oral and Maxillofacial Surg N Am 2000;58(Suppl 2): 19 – 26. Power I, Barratt S. Analgesic agents for the postoperative period: nonopioids. Surg ClinN Am 1999;79: 275 – 95. Moore P, Hersh E. Celecoxib and rofecoxib, The role of COX-2 inhibitors in dental practice. JADA 2001; 132:451 – 6. Cashman J, McAnulty G. Nonsteroidal anti-inflammatory drugs in perisurgical pain management. Drugs 1995;49:51 – 70. Harley EH, Dattolo RA. Ibuprofen for tonsillectomy pain in children: efficacy and complications. Otolaryngol Head Neck Surg 1998;119:492 – 6. Jelinek GA. Ketorolac versus morhine for severe pain. Ketorolac is more effective, cheaper, and has fewer side effects. BMJ 2000;321:1236 – 7. Brugger AW, Richardson ET, Drupka DT, et al. Comparison of Celecoxib, Hydrocodone/acetaminophen, and placebo for relief of post-surgical pain (Abstract/ Poster 880). Presented at the 1999 Annual Meeting of the American Pain Society. Available at: www.

M.C. Fletcher, J.F. Spera / Oral Maxillofacial Surg Clin N Am 14 (2002) 137–151 ampainsoc.org/abstract99/data/44/index.html. Accessed November 11, 1999. [34] Morrison BW, Christensen S, Yuan W, et al. Analgesic efficacy of the cyclooxygenase – 2 specific inhibitor rofecoxib in post-dental surgery pain: a randomized controlled trial. Clin Ther 1999;21:943 – 53. [35] Malmstrom K, Daniels S, Kotey P, et al. Comparison

151

of Rofecoxib and Celecoxib, two cyclooxygenase-2 inhibitors, in postoperative dental pain: a randomized, placebo- and active comparator-controlled clinical trial. Clin Ther 1999;21:1653 – 63. [36] Penfield W, Rasmussen T. The cerebral cortex of man: a classical study of the localization of function. New York: Macmillan; 1950.

Oral Maxillofacial Surg Clin N Am 14 (2002) 153 – 165

Predicting the success and failure of surgical endodontic treatment Judd B. Fink, DDS Private Practice, 56 Retreat Avenue, Hartford, CT 06106, USA

Synopsis When evaluating a patient and his or her endodontically failing tooth, attention to detail is the first crucial step for attaining success in apical surgical procedures. Meticulous surgery performed with good lighting and magnification, as well as recently developed tools and materials for apical preparation and seal, decrease the failure rate of surgical endodontic procedures.

Introduction A practicing oral and maxillofacial surgeon often incorporates periapical surgery into the roster of services performed to treat patients. An endodontically failing tooth represents a substantial investment in time and money for the patient. After evaluating patients and their periapical problems, several cases each year may be deemed untreatable. Extraction of a failing tooth that has had root canal therapy frequently leads to a disappointed patient. Many such teeth can be salvaged and maintain function if surgical endodontic therapy is executed successfully. This article will review factors that influence the success and the potential failure of surgical endodontics. Many of the surgical endodontic cases treated are compromised from the start, skewing the success rate and causing a significant rate of failure. Many of the teeth sent for treatment already have crowns and posts with poorly treated canals and insufficient apical seals. Some patients are referred for the procedure to be performed under intravenous sedation because the

E-mail address: [email protected] (J.B. Fink).

tooth is ‘‘hot.’’ The patient may be frightened of the surgical procedure or dentistry in general. A moving, sedated patient can certainly complicate precision apical surgery. In these infected cases, it may be beneficial for the patient to undergo an initial incision and drainage or trephination before the definitive procedure. The patient is then placed on an antibiotic, and when the tooth becomes quiescent, a more comfortable, definitive surgical procedure can be performed with a better result. A common indication for a more complex surgery is to perform an apicoectomy on the distal abutment of a bridge. This can be a lower second or third molar tooth. Visualization and access in this field are difficult, making adequate surgery tedious and decreasing potential for success. Some patients have roots that appear to be well filled on the radiograph, but clinically, these cases are failing. These teeth are potentially anatomically compromised, with apices in the sinus or near the inferior alveolar canal. There are also teeth that the endodontist cannot retreat via orthograde therapy because of broken instruments, posts in the canal, or compromised dental anatomy. The endodontist may not be comfortable treating these complex cases surgically and, therefore, these are referred to the oral and maxillofacial surgeon. Some surgeries are ‘‘ redo’’ apicoectomies. These teeth may be symptomatic or asymptomatic, with a fistula, apical swelling, or positive radiographic finding. The preoperative radiograph may show that a good retrograde seal was obtained the first time. This may also be confirmed upon surgically entering and directly visualizing the apical area. After surgically exploring the region to look for a fracture, deficient leaking seal, or other source for the failure, the procedure is repeated. More of the apex is removed, the apex is reprepared and refilled, and

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 3 - 1

154

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

nonetheless in many cases, the reason for the primary failure may not be obvious. It is important to define what constitutes an apical surgical failure. Obvious signs of failure are pain and swelling or fistula secondary to infection. The tooth may be asymptomatic or ‘‘hot’’ and extremely tender to palpation and percussion. The apical lucency may get larger or not regress after surgery if the tooth is failing. Other origins for breakdown subsequent to endodontic surgery may be unrecognized pathology, such as an odontogenic cyst or other benign or malignant neoplasm or systemic disease. All suspicious lesions should be surgically removed and submitted to an oral pathologist for an accurate diagnosis. Imaging occasionally reveals that the lucent apical lesion may diminish in size but never completely resolve. The tooth is asymptomatic, and surrounding soft and hard tissues look good clinically. This phenomenon may represent an apical scar and is not considered a failure [1]. No further surgical therapy is required or indicated. If one enters this overtly asymptomatic lesion, there is no suppuration noted and only firm, soft tissue is identified in the bony defect. If this ‘‘lesion’’ is biopsied, fibrous tissue rather than cancellous bone would be found under the microscope. Success rates for apical surgery have been reported to be as low as 62% in molars [2] and as high as 95% [3] overall. A randomized study in Sweden compared healing outcomes on failing endodontically treated teeth. The researchers found the success rate for surgery to be higher than the rate of success in conventionally treated teeth [4]. Most texts and articles show orthograde enododontic therapy to have only a 3 – 4% failure rate, and it is obviously the procedure of choice if there are no contraindications to this treatment [5 – 7]. When conventional endodontic therapy fails or cannot be performed, apical surgery, despite its higher risk of failure, may be the only way to salvage a perfectly useful tooth. This discussion will focus on what many authors speculate is the cause for the failures in periapical surgery. This information will help all achieve a higher success rate when performing these surgical procedures.

Preoperative evaluation Obtaining a thorough history and performing a complete clinical and radiographic examination are initial steps in reducing failures in apical surgery. For instance, the patient may state that a sharp pain followed by swelling occurred after biting something hard. When the affected tooth is examined, swelling

may be noted from the midroot area to the apical region. The tooth may or may not be mobile and/or tender to percussion. The periodontal status of the tooth must be evaluated (Fig. 1A,B). Apical lesions may drain through the periodontal ligament space of the tooth and cause alveolar bone loss. Repair of the apical leakage of these teeth can stimulate bone regrowth and salvage some of these teeth. A tooth that is failing from an untreated periodontal condition, however, will be lost more quickly if a flap is elevated and an apicoectomy is accomplished. Periodontal probing is an essential part of the evaluation. In addition to checking for pathological pocket depth, one can use the probe to palpate the root surface for possible perforation or fracture. It is important to record preoperative pocket depths in the chart for comparison in the postoperative healing period. In a common scenario, the periodontal pocket depth may be 10 mm, and the radiograph may show a periapical lesion extending from the midroot region, where a metallic post ends. These findings indicate that this tooth may be fractured or perforated (Fig.2).

Intraoperative factors Flap design must be evaluated and modified for each situation to obtain success. If an apicoectomy is performed on a cracked root using a semilunar incision and flap, the vertical fracture that is difficult to view on an radiograph may also be clinically overlooked. An apicoectomy done on a tooth with a vertical fracture will surely fail. A poorly designed flap may increase probability for failure in periapical surgery. A semilunar flap, while seemingly easier in many cases, may lead to delayed wound healing and root dehiscence if the flap edges are not supported by alveolar bone. A semilunar flap, if done incorrectly, may compromise blood supply to the surgical site and provide poor access to the surgical site if it is designed and elevated in unattached mucosa only. A semilunar flap may allow for clinical success but lead to a cosmetic failure because of increased scarification noted when the patient smiles, leading to dissatisfaction. On the other hand, a sulcular flap exposing the root surface allows minor root planing and currettage procedures, periodontal bony defect contouring, and grafting to be performed. These procedures, if indicated and performed at the time of surgical endodontic treatment, will enhance chances for the long-term success of the involved tooth. This flap can be apically or coronally repositioned when closure is obtained. Teeth suspected of having a fracture that cannot be confirmed on a radiograph should be explored using a

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

155

Fig.1. (A) This radiograph was taken just before the extraction of this failing molar. Adequate apical seals, apparent on the film, were placed 2 years earlier. The severe bone loss was secondary to untreated furcal and palatal root periodontal disease. (B). The extracted tooth exhibits adequate root-end fills on both buccal roots. Concretions and granulomatous material are noted on the palatal root surface and in the trifurcation region. The patient had originally presented with pain and buccal swelling as the only symptom of infection. The asymptomatic palatal root was not probed at the time of surgery and was more than likely in a periodontally diseased condition.

sulcular incision with one or more vertical releases for flap elevation. This will make fractures easier to identify, especially if magnification is utilized. Root perforations may be visualized with a full flap, allowing repair. If the infected tooth is multirooted and one root is found to be fractured, irreparably perforated, or with nonrestorable caries, the offending root can be resected if a full flap design is used [3]. The root fracture occasionally will be present on the mesial, distal, or posterior aspect of the tooth, thus obscuring the crack from view. Missing this fracture will cause a surgical failure. A fistula noted in the midroot, as opposed to the apical area, is a clinical sign pointing to perforation or root fracture. A radio-

graphic finding pathognomonic of a root fracture is a perilateral ‘‘halo’’ lesion with diffuse or defined but not corticated borders. This may be combined with vertical bone loss and has been described in fractured maxillary premolars [8]. Fractures can sometimes be found when examining the surgically flattened root apical surface. It is imperative to use an excellent light source and magnification to find these small cracks. It is better to condemn the fractured and nonrestorable tooth at this time and avoid reinfection and failure at a later date. As an intraoperative aid in defining root-end fractures, a small amount of methylene blue can be applied with a cotton pellet to the surgically prepared

156

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

Fig. 2. A lucency on the distal aspect of this maxillary first bicuspid that communicates with a lesion at the poorly filled apex may represent both apical pathology and a midroot perforation. A flap that exposes maximum root surface is indicated for access, visualization, and repair of the defects.

apical surface. After gently irrigating away the excess dye, an apical root fracture may be highlighted by the residual blue material remaining in the crack. Fiber optic light sources are an excellent adjunct in the diagnosis of root fractures. When the concentrated light source is transilluminated through the natural tooth crown or alveolus or shined at the exposed apex, small cracks can sometimes be seen. This technique was described by Schindler and Walker in 1994 [9]. Using a straight fissure bur produces a smooth apical surface, facilitating the diagnosis of a root fracture. A crosscut fissure bur may roughen the apical surface, obscuring the fracture and leading to failure. All these modalities may be helpful during our diagnostic procedures to help prevent failure. Unfortunately, despite one’s experience and acumen in diagnosing these problems, the alveolar socket and possibly a prosthetic crown may co-apt the fractured segments, preventing the diagnosis until the tooth is extracted and found to be split. A tooth referred for an apicoectomy may frequently have a fistula midway between two endodontically treated teeth. Placing a gutta-percha cone lubricated with a topical anesthetic in the fistulous tract and taking a radiograph may delineate the infected root. It will certainly lead to an embarrassing failure if the incorrect apex of two adjacent teeth or the wrong apex of a multirooted tooth is erroneously identified and treated.

. . . . dental anatomy

Anatomical factors

Tooth and jaw anatomy must be taken in to account when doing the preoperative assessment for an apicoectomy. A very thin apex cannot be easily

filled. The root end is tapered apically, so by removing at least 3 mm, one widens the apical surface available for the retrograde preparation. The largest volume of lateral canals is located at the apex. An additional benefit derived from removing 3 mm of apical structure is excision of the bulk of these hardto-seal lateral canals, increasing chances for success. The root tends to curve the most at the apex. By performing an adequate apicoectomy, the straighter portion of the root is exposed and is less likely to perforate when making the preparation. Excessive root end beveling is discouraged. Current thinking suggests that flattening, rather than angled beveling of the root, provides for a higher success rate. Gilheany, Figdor, and Tyas performed a study resecting roots at 0, 30, and 45°. The root-end preparations were filled with Ketac silver (3M ESPE, St. Paul, MN). The deeper preparations with shallower bevels showed less microleakage [10]. A similar study using Super EBA cement showed the least apical leakage when the root-end cut was 90° and the vertical preparation was 3 mm or deeper [11]. With excessive beveling of the root, an elongated preparation is obtained with thinner root wall. The enlarged preparation subjects the tooth to a higher incidence of apical leakage caused by increased exposure of dentinal tubules and increased likelihood of fracture during condensation of the chosen retrofil material. The smaller preparation acquired by horizontally flattening the root allows less surface area for leakage and is more resistant to iatrogenic fracture. Also, by making the preparation parallel to the canal and 3mm in depth, a better seal is obtained. By using a small, commercially available front surface mirror specifically designed for these procedures, one can more accurately prepare the canal (Fig. 3).

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

157

Fig. 3. Observing the reflection of the apex and canal on the surface of the varied shaped and angled microsurgical mirrors assists in attaining parallelism and more accurate apical cavity preparation and fill. (Photo courtesy of Analytic Endodontics, Glendora,CA.)

Many roots, including those of single-rooted teeth, may have two canals. These canals may be connected by an isthmus, which can be seen under magnification. If the canals and contiguous isthmus are not prepared and filled, bacterial leakage and failure will result. Teeth with anomalous root anatomy may have unexpected multiple canals. All of these canals must be found, prepared, and filled to avoid bacterial leakage and failure (Fig. 4). Performing an apicoectomy on a tooth with calcified or unfilled canals can be more difficult and less successful. In this nonideal situation, there is no pink gutta-percha to guide the bur or ultrasonic tip, making this treatment more complex. One must use copious irrigation to avoid overheating any tooth, especially one with with calcified canals. The calcified root structure may be harder and more friction may be created during the preparation. One should be prepared to spend more time preparing these teeth inasmuch as overheating the tooth will transmit heat to the surrounding bone. Thermal damage to the

nearby osteogenic cells will inhibit healing potential and increase probability for root fractures. Once again, the preparation must be parallel to and within the perceived canal to avoid perforation of the root wall (Fig. 5). An indication of root perforation and communication with periodontal ligament space is bleeding in the freshly prepared canal. This is noted by frank oozing or detected when drying the apical cavity with a paper point before placing the retrofil material. If a perforation occurs, the root must be reduced to the level of the iatrogenic defect and the cavity must be reprepared. Clinicians have different thoughts on the size and depth of the preparation. While some feel that a ‘‘dot’’ of filling material may be adequate to seal the apex, most are now advocating a 3-mm deep preparation [11]. The preparation may be made with a small, round bur or an ultrasonic handpiece, tip, and unit specifically designed for root-end preparation. The ultrasonic tips are fabricated from stainless steel and are said to produce more conservative and less perforated

158

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

Fig. 4. All three buccal root canals on the fused roots of an abscessed maxillary molar require preparation and sealing to achieve clinical success.

cavities than those made with microhead handpiece burs [12]. Some of these tips are coated with diamond

particles [13]. There is controversy as to which method of preparing the cavity for the filling material causes

Fig. 5. A misdirected ultrasonic tip or round bur can cause perforation of the root end. Repair the defect if it is accessible, or remove root structure to a level at or below the perforation and carefully reprepare the cavity.

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

the least root damage. Some studies show that the ultrasonic tip coated with diamonds causes less roottip fracturing. Some feel, however, that the remaining microscopic diamond debris may affect the adequate root-end seal [14]. Other studies point out that there is no significant variation in the number of root tip fractures when using the coated or uncoated ultrasonic tip. One article points out that the intensity of the setting on the ultrasonic unit may fracture the root tip if set too high [15]. The lowest setting on the ultrasonic unit and the least pressure that can be applied with the ultrasonic tip or bur should be used for atraumatic and conservative root preparation. Other articles show significantly higher incidences of cracks in the walls of root-end cavities prepared by ultrasonic tips when compared to those prepared with a bur [16,17]. It should be noted that these two studies cited were performed on cadaver and extracted teeth. Incidence of root-end fracture after ultrasonic preparation may be significantly lower when done on our patients’ moist and vital teeth. The ultrasonic tip is easier to use for root-end cavity preparation in anatomic areas where space or visibility is limited. Small, round burs on a 45° highspeed oral surgery handpiece, microhead handpiece, or a straight hand piece are efficacious in the removal of old retrogrades, seals, or metallic posts that come to the apex and inhibit adequate apical preparation. If enough apical tooth structure allows, a channel can be made around the overextended post with an ultra-

159

sonic tip, and the exposed dentinal tubules can be sealed during the retrofil of this trough. When performing the actual apicoectomy on the root end, the apex can be ground down the required 2 – 3 mm or resected with a bur. It is important to remove the entire resected fragment. A floating apical fragment can act as a nidus for infection, thus causing a failure. Also, if the entire root tip is not completely flattened, canals, fissures, and lateral canals can be unnoticed and only partially treated. This is especially true in lower molar teeth, which have large, oblong roots that are deep in the bone, often extending to the lingual cortex of the mandible. One must take into account the figure-eight shape of many roots. The mesial concavity on many root tips is an easy place to perforate during orthograde endodontic preparation, post preparation, or retrograde preparation (Fig. 6). Curved apices that can cause root perforation during root canal or postpreparation may augment chances for perforation during apical preparation. It is of interest to note that bacteria of endodontic origin have been observed in the confines of this apical radicular groove, and this is felt to be a cause for failure after conventional endodontic therapy [18]. When filling the canal with any accepted filling material, excess force, especially lateral force, must not be used. The fragile root tip may fracture and go undetected until a later time, when leakage of bacteria leads to surgical failure. It is critical that one studies the apical anatomy and root tip angulation on the

Fig. 6. The mesial concavity and curved apices of this mandibular bicuspid may facilitate iatrogenic perforation during orthograde or retrograde root preparation.

160

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

radiograph before proceeding with the preparation and filling procedures. Accessory roots can cause failure of an endodontic or periapical surgical procedure if not adequately obturated. When performing surgery on a maxillary first bicuspid there are almost always two separate roots, both requiring treatment. The palatal root can be difficult to find if enough of the buccal root is not removed for visualization. The palatal apex is often anterior (mesial) to the buccal apex. A few lower molars may have two mesial roots, and maxillary molars can present with four distinct roots. The fourth root that is often missed during the initial root canal therapy is often only 4 – 5 mm in length. It is hidden behind one of the buccal roots and is not clearly seen on an radiograph. An accessory root may be unnoticed until the tooth is extracted after surgical failure (Fig. 7). One must assess the furcal areas for perforation. Furcal or root perforations can sometimes be repaired during the apicoectomy operation. The use of Pro

Root mineral trioxide aggregate (MTA, Dentsply Tulsa Dental, Tulsa, OK) cement has been advocated for root or furcal perforations and root-end seals [19].

Anatomical considerations

. . . . jaw anatomy

In the maxilla, one must take into account the maxillary sinus when achieving apical access. While sinus perforation is actually fairly common when carrying out apicoectomies on maxillary posterior teeth and a small number of maxillary canine teeth, this is usually of no consequence. In a study of 472 apicoectomies performed on the posterior maxillary teeth of 440 patients, antral perforations occurred in 10.4% of the teeth. No cases of acute or chronic sinusitis were observed [14]. If a sinus perforation occurs, antibiotics that are commonly used to inhibit growth of oral and respiratory bacteria are prescribed after evaluating the patient’s history for drug allergies. Ampicillin, amoxicillin, or erythromycin preparations

Fig. 7. An accessory root was detected after the extraction of this abscessed maxillary molar. The presence of an unrecognized accessory root will lead to failure if not treated by conventional or surgical endodontics

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

are commonly prescribed for infection prophylaxis in these cases. The patient is instructed in routine sinus precautions, including avoidance of nose blowing, sneezing with the mouth open, and the use of pre-

161

scribed or over-the-counter decongestants, if indicated. A clot will form above the reduced apex and the sinus membrane should repair itself to cover the iatrogenic defect. Excess filling material in the max-

Fig. 8. (A) Intentional replantation was used to save this third molar on an 80-year-old patient. The post prevented orthograde endodontics to be redone, and the excessively thick buccal bone prevented retrograde root-end repair. (B) The tooth is seen splinted immediately after repair. (C) The apical bone subsequently regenerated, the tooth became stable and asymptomatic, and has been functioning for several years.

162

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

illary sinus or root fragments in the sinus, may lead to apicoectomy failure and a sinusitis. Meticulous surgical technique and care must be used, and all foreign matter must be removed from the antrum before wound closure. During apical surgery in the mandible, one must take into account the incisor roots’proximity to each other. It is very easy to damage the root of an adjacent tooth or treat the wrong incisor during surgery. In the bicuspid zone one must consider the location of the mental foramen, and in the molar areas one must take into account the proximity of molar apices to the inferior alveolar canal. The mental foramen and the canal can safely be avoided by approaching the apices of posterior mandibular teeth from a superior locale rather than using the direct lateral approach [20]. It is safer to resect the apex in these situations, rather than to use the technique of grinding the apex flat. One must also be judicious when curretting lesions in these areas. Exuberant currettage of the lesion may cause nerve damage. The gentle disruption of the apical lesion and an excellent apical seal will cause spontaneous regression of the soft tissue lesion. In the second and third molar vicinities the lateral oblique ridge may be extremely thick, preventing safe access to the apical areas. Removal of too much buccal bone will cause the tooth to fail. These teeth may be candidates for intentional reimplantation [21] or extraction and replacement with a dental implant (Fig. 8A – C) If too much bone has been removed for apical access, if bone is missing secondary to apical pathosis, or if there is loss of the marginal soft tissue attachment, guided bone and soft tissue regeneration with the use of barrier membranes have been discussed as a way to prevent failures of affected teeth [22,23]. In regions of thick mandibular bone, a bone flap technique has been described as a way to perform apical procedures to avoid loss of the tooth secondary to excessive bone removal for the apical approach [24].

Filling materials

. . .striving for a successful

apical seal Many materials have been advocated for retrofilling the apices of teeth. For many years the dental alloy amalgam was the filling material of choice. Zincfree alloy, which does not expand when contaminated upon setting, is still being widely used with success by many surgeons. Some suggest the use of cavity varnish in the preparation before placing the amalgam to seal the dentinal tubules [25]. Another study shows decreased apical leakage with an amalgam fill if

dentin-bonding agents are used [26]. An in vitro study in South Africa showed significantly less dye penetration in teeth filled with glass ionomer cement than in those filled with amalgam [27]. In contrast, a study in 1995 showed that a 90% success rate after 1 year and an 85% success rate after 5 years could be obtained with either amalgam or glass ionomer cement [28]. In Table 1, Harris has reported the success rates by tooth, as well as the cause of failures, in his series of more than 2500 surgical endodontic procedures. In a study performed at Guy’s Hospital in London, light-cured glass ionomer cement was found to prevent leakage better than conventional glass ionomer cement when placed in a similar fashion as an apical seal [29]. A study in beagles showed apices filled with amalgam after the application of cavity varnish to have an 89% success rate, compared to a 60% success rate of apices retrofilled with light-cured composite. In the same study, a 69% success rate was obtained with glass ionomer cement. These researchers also treated 50% of the apices and bony cavities with a carbon dioxide laser to sterilize the area and occlude the dentinal tubules. The laser treatment did not affect the outcome [25]. Zinc oxide eugenol preparations, such as Intermediate Restorative Material (Dentsply International, York, PA), have been used for filling apices. Using a larger powder-to-liquid ratio is said to increase ease of handling and have decreased toxicity [30]. Super o-ethoxybenzoic acid (EBA, HJ Bosworth, Skokie, IL) cement, either the regular or quick-set version, has been used with equal success [31]. I personally find this material (Super EBA) hard to use unless the operating field is extremely dry. Gutta-percha was used for a retrograde filling material in a Japanese study in 1989. The authors of this study claimed a 95.3% success rate with this technique [32]. Finally, mineral trioxide aggregate cement was found to prevent dye leakage better than either amalgam or EBA cement in another in vitro study. The authors point out, however, that the extrapolation of this result into clinical practice may be impossible [33]. MTA cement is said to promote bone healing in apical defects and root perforations in several in vitro and in vivo studies. MTA cement is said to limit apical microleakage [19]. Keeping the apical region dry during the filling phase of an apicoectomy may be the difference between success and failure of these procedures. A bloody field makes visualization of the preparation difficult. Contamination with blood, saliva, or water may affect the adherence and seal of the material. Contaminated filling materials may corrode over time (ie, amalgam) causing failure at a later date. The

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

163

Table 1 Apicoectomy with retrograde amalgam 2919 consecutive cases Failure Success Maxillary Central incisors Lateral incisors Cuspids First premolars Second premolars First molars Second molars Third molars Mandibular Central incisors Lateral incisors Cuspids First bicuspids Second bicuspids First molars Second molars Third molars Totals Percentage of total

305 290 138 236 232 285 59 2

125 90 63 101 140 405 85 4 2560 87.7%

Retreat 39 41 16 39 35 39 7 1

13 7 3 11 22 62 7 342 11.7%

Periodontal 9 13 3 11 9 28 10

Fracture 8 8 6 10 15 6 1

8 1 1 4 4 25 11 1 138 4.7%

Post

1 2 4 5

Unknown 11 3 6 14 8 10 7

3 1 4 6 33 6 107 3.7%

1

13 0.4%

1 3 7 18 10 3 101 3.5%

Data courtesy of the private practice of Dr. Melvyn H. Harris. Dr. Harris uses amalgam for his retrofil material of choice and has also had recent success with MTA cement. Dr. Harris attributes his high success rate to experience and strict guidelines in patient selection. Teeth with root fractures, periodontal defects, or excessively thick buccal plate of bone (some lower second and third molars) are not treated (personal communications with Dr. Melvyn H. Harris, Boston, May 2001).

surgical site can be kept dry with the use of ferric sulfate preparations, bone wax, a cotton ball moistened with local anesthesia with a vasoconstrictor, a gelatin sponge, collagen preparations, or the precise use of mini suction tips. The use of 1: 1000 epinephrine solution placed in the bleeding bony crypt on a saturated cotton pellet or piece of gauze has been advocated [3]. Placing 1:1000 epinephrine solution adjacent to exposed haversian canals may precipitate cardiac dysrhythmias and is not recommended for procuring hemostasis. Failure to remove the cotton pellet or bone wax may cause persistent symptoms [34]. Even though bone wax is said to be resorbable, this otherwise benign substance can act as a foreign body or be a nidus for infection and failure [3].

Summary Some practitioners feel that it is easier to extract a failing endodontically treated tooth and replace it with a dental implant. In some instances this may be true; however, if a surgeon performs a satisfactory diagnostic procedure when evaluating an endodontic failure, probability for success or failure can be

predicted. Many teeth crucial to the patient’s health and dental well being can be saved with apical surgery. Newer methods for surgical root-end cavity preparation, flattening or minimally beveling the apex, carefully handling soft tissue, and thoughtful flap design work concomitantly to facilitate surgery and increase chances for success. Use of magnification, excellent lighting, and use of recently available filling materials found to promote bony healing may all contribute to a lower percentage of surgical failure when performing an apicoectomy.

Further Readings Gutman JL, Pitt Ford TR. Management of the resected root end: a clinical review. International Endodontic Journal 1993;26(5):273 – 83. Rapp EL, Brown Jr. CE, Newton CW. An analysis of success and failure of apicoectomies. Journal Of Endodontics 1991;17(10):508 – 12. Lustmann J, Friedman S, Shaharabany V. Relation of preand intraoperative factors to prognosis of posterior apical surgery. Journal of Endodontics 1991;17(5):239 – 41.

164

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

Ida RD, Gutmann JL. Importance of anatomic variables in endodontic treatment outcomes: case report. Endo Dent Traumatol 1995;11(4):199 – 203. Friedman S, Lustmann J, Shaharabany V. Treatment results of apical surgery in premolar and molar teeth. Journal of Endodontics 1991;17(1):30 – 3. Nagase M. A clinical study on treatment results of apicoectomy. Kokubyo Gakkai Zasshi 1999;66(4):339 – 50. Sutimuntanakul S, Worayoskowit W, Mangkornkarn C. Retrograde seal in ultrasonically prepared canals. Journal of Endodontics 2000;26(8):444 – 6. Bellizi R, Loushine R. A Clinical Atlas of Endodontic Surgery. Carol Stream, IL: Quintessence Publishing Co.; 1991. Adamo HL, Buruiana R, Schertzer L, Boylan RJ. A comparison of MTA, Super-EBA, composite and amalgam as rootend filling materials using a bacterial microleakage model. International Endodontic Journal 1999;32(3):197 – 203. Brent PD, Morgan LA, Marshall JG, Baumgartner JC. Evaluation of diamond-coated ultrasonic instruments for root-end preparation. Journal of Endodontics 1999;25(10):672 – 5.

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

References [17] [1] Mollven O, Halse A, Grung B. Incomplete healing(scar tissue) after periapical surgery – radiographic findings 8 to 12 years after treatment. J Endodontics 1996;22(5): 264 – 8. [2] Cheung LK, Lam J. Apicoectomy of posterior teeth – a clinical study. Australian Dental Journal 1993;38(1): 17 – 21. [3] Arens DE, Torabinejad M, Chivan N, Rubenstien R. Practical Lessons in Endodontic Surgery. Carol Stream, IL: Quintessence Publishing Co.; 1998. [4] Danin J, Stromberg T, Forsgren H, Lindner LE, Ramskold LO. Clinical management of nonhealing periradicular pathosis. Surgery versus endodontic retreatment. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1996;82(2): 213 – 7. [5] Scheffel GJ. Apicoectomy and retroseal procedures for anterior teeth. Dental Clinics of North America 1994; 38(2):301 – 24. [6] Molven O, Halse A, Grung B. Surgical management of endodontic failures: indications and treatment results. International Dental Journal 1991;41(1):33 – 42. [7] Grung B, Molven O, Halse A. Periapical surgery in Norwegian county hospital: follow-up findings of 477 teeth. Journal of Endodontics 1990;16(9):411 – 7. [8] Tamse A, Fuss Z, Lustig J, Ganor Y, Kaffe I. Radiographic features of vertically fractured, endodontically treated premolars. Oral Surgery, Oral Medicine, Oral

[18]

[19]

[20]

[21]

[22]

[23]

[24]

[25]

Pathology, Oral Radiology and Endodontics 1999;88 (3):348 – 52. Schindler WG, Walker WA 3rd. Transillumination of the beveled root surface: an aid to periradicular surgery. Journal of Endodontics 1994;20(8):408 – 10. Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with root end resection and retrograde filling. Journal of Endodontics 1994;20(1):22 – 6. Gagliani M, Tashieri S, Molinari R. Ultrasonic rootend preparation: influence of cutting angle on the apical seal. Journal of Endodontics 1998;24(11):726 – 30. Lin CP, Chou HG, Kuo JC, Lan WH. The quality of ultrasonic root-end preparation: a quantitative study. Journal of Endodontics 1998;24(10):666 – 70. von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type of sonic and diamondsurfaced retrotip: a 1 year follow-up study. Journal of Oral and Maxillofacial Surgery 1999;57(6):656 – 61. Freedman A, Horowitz I. Complications after apicoectomy in maxillary premolar and molar teeth. International Journal of Oral and Maxillofacial Surgery 1999; 28(3):192 – 4. Layton CA, Marshall JG, Morgan LA, Baumgartner JC. Evaluation of cracks associated with ultrasonic root-end preparation. J Endodontics 1996;22(4):157 – 60. Gray GJ, Hatton JF, Holtzman DJ, Jenkins DB, Neilsen CJ. Quality of root-end preparations using ultrasonic and rotary instruments in cadavers. Journal of Endodontics 2000;26(5):281 – 3. Abedi HR, Van Mierlo BL, Wilder-Smith P, Torabinejad M. Effects of ultrasonic root-end cavity preparation on the root apex. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1995;80 (2):207 – 13. Simon JHS, Dogan H, Ceresa LM, Silver GK. The radicular groove: its clinical significance. Journal of Endodontics 2000;26(5):295 – 8. Torabinejad M, Chivan N. Clinical applications of mineral trioxide aggregate. Journal of Endodontics 1999;25(3):197 – 205. Harris MH. Apicoectomy and retrograde amalgam in mandibular molar teeth. Oral Surg Oral Med Oral Pathol 1979;48(5):405 – 7. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol 1993;76:623 – 30. Uchin RA. Use of a bioresorbable guided tissue membrane as an adjunct to bony regeneration in cases requiring endodontic surgical intervention. J Endodontics 1996;22(2):94 – 6. Kellert M, Chalfin H, Solomon C. Guided tissue regeneration: an adjunct to endodontic surgery. Journal of the American Dental Association 1994;125(9):1229 – 33. Khoury F, Hensher R. The bony lid approach for the apical root resection of lower molars. International Journal of Oral and Maxillofacial Surgery 1987;16 (2):166 – 70. Friedman S, Rotstein I, Mahamid A. In vivo efficacy of

J.B. Fink / Oral Maxillofacial Surg Clin N Am 14 (2002) 153–165

[26]

[27]

[28]

[29]

various retrofills carbon dioxide laser in apical surgery. Endodontics and Dental Traumatology 1991;7(1): 19 – 25. Vignaroli PA, Anderson RW, Pashley DH. Longitudinal evaluation of the microleakage of dentin bonding agents used to seal resected root apices. J Endodontics 1995;21(10):509 – 12. Pretorius S, van Heerden WF. The use of tricure glass ionomer cement as an apical sealant after apicoectomy. Journal of the Dental Association of South Africa 1995;50(8):360 – 70. Jesslen P, Zetterqvist L, Heimdalhl A. Long-term results of amalgam versus glass ionomer cement as apical sealant after apicoectomy. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1995;79(1):101 – 3. Chong BS, Pitt Ford TR, Watson TF. Light-cured glass ionomer cement as a retrograde seal. International Endodontic Journal 1993;26(4):218 – 24.

165

[30] Crooks WG, Anderson RW, Powell BJ, Kimbrough WF. Longitudinal evaluation of the seal of IRM root end fillings. Journal of Endodontics 1994;20(5):250 – 2. [31] Yaccino JM, Walker 3rd WA, Carnes Jr. DL, Schindler WG. Longitudinal microleakage evaluation of SuperEBA as a root-end sealing material. Journal of Endodontics 1999;25(8):552 – 4. [32] Amagasa T, Nagase M. Sato T, Shioda S. Apicoectomy with retrograde gutta-percha root filling. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1989;68(3):339 – 42. [33] Aqrabawi J. Sealing ability of amalgam, super EBA cement, and MTA when used as retrograde filling materials. British Dental Journal 2001;88(5):266 – 8. [34] Ludlow MO, Brenneise CV, Haft RT. Chronic Pain associated with a foreign body left under the soft tissue flap during periapical surgery. Journal of Endodontics 1994;20(1):48 – 50.

Oral Maxillofacial Surg Clin N Am 14 (2002) 167 – 172

Ultrasonic retrograde preparation Stuart E. Lieblich, DMD a,b,*, Bernard McGiverin, DDS, FICD, FACD c a

University of Connecticut Health Center, 236 Farmington Avenue, Farmington, CT 06030, USA, b Avon Oral and Maxillofacial Surgery, 34 Dale Road, Suite 105, Avon, CT 06001, USA c 95 West Entry, Staten Island, NY 10304, USA

The use of ultrasonic devices for apical preparation has dramatically improved the ease of apical surgery and most certainly has contributed to the increase in success rates now reported. Ultrasonic preparation permits a deep retrograde restoration to be placed, one of the key factors to a positive outcome. The ability of these devices to precisely follow the internal root canal anatomy also contributes to this success. Before the development of ultrasonic retropreparation tips, preparation of the apical region was obtained with a rotary instrument. The Hall highspeed turbine drill or a conventional dental handpiece using long-shank friction grip surgical burs were the instruments of choice. A Micro-contra-angle head (Union Broach, Brooklyn, NY) was developed for use on a low-speed straight handpiece. Originally, it was not autoclavable, and many clinicians reported constant gear jamming and difficulty with its use no matter how gently it was handled or lubricated. The use of rotary burs can create preparations that do not follow the long axis of the tooth and, therefore, have decreased apical sealing potential. Off-axis preparation may also sacrifice additional tooth structure and potentially predispose the tooth to root fracture.

Ultrasonic instruments Ultrasonic devices have been used in dentistry for many years for removal of calculus. Applying elec-

* Corresponding author: Avon Oral and Maxillofacial Surgery, 34 Dale Road, Suite 105, Avon, CT 06001. E-mail address: [email protected] (S.E. Lieblich).

trical voltage to piezoelectric ceramics or quartz produces ultrasonic mechanical vibration. The usual frequency is in the range of 30kHz, with a vibration amplitude of  300 mm. Cavitation effects are created with the use of water for an additional physical effect to displace debris and improve cutting efficiency while preventing significant heat formation. Devices are available from many companies (Fig. 1). Advantages of the ultrasonic preparation include the accessibility to the apex, permitting a smaller flap reflection, less bone removal, and less of an apical bevel. Fig. 2 shows the accessibility achieved with an ultrasonic tip at the apex of a tooth. The current piezoelectric, ultrasonic units using stainless steel or diamond-coated autoclavable retrotips allow preparations of the apex for retrofill from a nearly perpendicular approach. Mehlhaff et al compared 76 roots from 29 bilaterally matched pairs of human teeth in cadavers [1]. In the first group, ultrasonic preparations were made in the roots and then filled with amalgam alloy. In the second group, high-speed rotary bur preparations were made in the remaining 50% and filled with the same alloy. The teeth were then extracted and radiographed from both a mesio-distal and bucco-lingual aspect. The same operator performed all the procedures and none of the root-end preparations resulted in perforation. It was determined that the ultrasonic tip produces a deeper root-end preparation with minimum bevel of the root ends. Lin and colleagues studied teeth that were prepared with ultrasonic devices versus rotary instruments [2]. With the aid of image processing, they found the ultrasonic preparations to be more conservative, with less perforations, than those made with the rotary instruments. A study of bacterial leakage by

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 1 9 - 5

168

S.E. Lieblich, B. McGiverin / Oral Maxillofacial Surg Clin N Am 14 (2002) 167–172

Fig. 1. Examples of ultrasonic units for apical preparations. All units have autoclavable tips and adjustable power settings.

Chailertvanitkul found significantly more leakage with rotary preparations in comparison with ultrasonic devices [3]. In their study, both groups had the same root-end filling material (super-EBA). Many ultrasonic devices have both stainless steel – and diamond-coated tips for apical preparation. The use of diamond-coated tips permits faster preparation with more gentle pressure. This was verified by Peters, who found a statistically significant reduction in preparation time with the diamond tips in comparison with stainless steel [4]. The diamond tips do remove more dentin and, therefore, should be used carefully to prevent overpreparation. Dye penetration studies that reveal leakage to bacteria

did not show a difference between diamond-coated tips and stainless steel [5].

Flap design Strict adherence to the surgical principles of sharp elevation of a mucoperiosteal flap is essential because perforation of the periosteum can nearly always guarantee hemorrhagic ooze throughout the operation and wound dehiscence afterward. Once the flap is elevated sufficiently, a broad-based retractor such as a Minnesota or Seldin retractor can be used. The McGivern Retractor (W. Lorenz, Jacksonville, FL) is also of

S.E. Lieblich, B. McGiverin / Oral Maxillofacial Surg Clin N Am 14 (2002) 167–172

Fig. 2. Example of ultrasonic tip for preparation of root apex.

value here because it combines the broad-based end of the Seldin 23 elevator with an ergonomic handle. Care must be taken to keep all retractors firmly situated on the bone to prevent periosteal tearing. Worse yet, impingement on the flap fold can result in ischemia and slough and cause a severe periodontal problem. Surgical technique The high-speed surgical bur (2 mm or #8 round) is used to remove enough cortical bone to expose the apical region. The root apex should not be resected until the full apical one third is identified. A straight or angled surgical curette is used to enucleate as much soft tissue as possible from the periapical area

169

without compromising adjacent structures, specifically the inferior alveolar nerve or maxillary sinus if possible. Removal of the soft tissue is accomplished to reduce bleeding and clear any apical debris that may have been forced out the apex during the initial endodontic treatment. If further enlargement of the bony window is needed, it can be done with the rotary instrument. At this point, removal of the apex is accomplished with either the round or a tapered fissure bur. The authors recommend just reducing the apex from the tip to the desired bevel with a #701 or #702 tapered bur. Two to three millimeters of the apex should be resected. This will reduce the apical bacterial concentration. In addition, the apex is the most unpredictable portion of the root canal system, with multiple foramina and lateral canals that may be unfilled. The removal of 2 to 3 mm of the apex also removes the portion of the root canal system that is usually the most poorly sealed. Ultrasonic preparation requires a small bevel, only 10 to 20 from horizontal (Fig. 3). Minimization of the bevel reduces the amount of dentinal tubules exposed that predispose to apical bacterial leakage. The minimal bevels permitted by the shapes of the ultrasonic tips contribute to the increased success with this technique. Once the root canal filling(s) or other positive apical identifications are made, the root end is prepared to receive the retrograde filling. Hemostasis is

Fig. 3. Use of ultrasonic root-end preparation for maxillary molar.

170

S.E. Lieblich, B. McGiverin / Oral Maxillofacial Surg Clin N Am 14 (2002) 167–172

critical to precisely prepare the apex and to create a dry environment for the placement of the retrograde filling material. Counted cotton pellets saturated with epinephrine-containing local anesthetic solution are packed tightly into the bony crypt. When exposing the buccal or palatal roots of upper molars, special care is taken not to force any pellets into the maxillary antrum. Usually, two to three pellets are placed and, after waiting 5 minutes, all are removed except for the most deeply placed one. By not removing the pellet in contact with the bone, the bleeding from the marrow spaces remain controlled. If this approach does not provide for complete hemostasis, a small electrosurgical tip can be used to attain hemostasis and to remove the last remnants of granulation tissue. The electrosurgery unit is used with the lowest numerical setting on coagulation to accomplish hemostasis and not burn surrounding bone. This will frequently leave a small hemostatic char that can remain until after the root-end filling is complete. The ultrasonic root preparations are performed with autoclavable ultrasonic tips chosen by the operator on the basis of access to the apical region. Constant irrigation is needed, and for surgical use, it is appropriate to have an assistant irrigate copiously with sterile saline. Using internal systems connected to public water supplies may not provide the level of asepsis required during surgery. The tips are used with gentle pressure in a stroking pattern. Vertical preparation is completed to the bevel on the shaft that will be 2 to 3 mm in depth. Gentle buccal-lingual preparation is done to check for the presence of an isthmus, which is then prepared. An isthmus can be found on any multiple root canal system on the same root. The surgeon should expect to find an isthmus on the mesio-buccal roots of upper molars and frequently on the mesial roots of lower first molars. Engle and Steiman compared isthmus preparation techniques and found adequate removal and sealing only with the use of ultrasonic devices [6]. One major advantage to this technique is that the instrument sizes are smaller the than those of contraangles using burs. This makes nearly all lesions accessible because the average active point length is 3 millimeters. Constant water spray is used on the cutting tip because the tip tends to heat up significantly during use. If not cooled properly, the tip can become hot enough inside the canal to cause gutta percha to melt in the canal with the resultant loss of an endodontic filling. Copious saline spray should be used on the cutting tip with a featherlike back-andforth motion. The attraction of these devices is the versatility of the cutting tips. The universal tip is similar to the end

of a #17 explorer. Two of these are configured to fit into the hard-to-reach apices of molar teeth. There is also a tip for the preparation of an isthmus and a bendable tip that can be adapted to the particular needs of the operator. The angled tips measure 3 mm in length, so an attempt should be made to create the preparation to this depth. Undercutting the preparation is not necessary because of the depth and parallelism of the ultrasonic preparation. After the preparation is complete and before filling, the apex should be irrigated copiously and dried with endodontic paper points. After completion of the root-end filling, a sharp curette is reintroduced into the bony crypt to remove any char from electrosurgical attempts at tissue removal and hemostatic agents used. Bleeding also helps the setting of certain retrograde filling materials, specifically mineral trioxide aggregate (ProRoot MTA, Tulsa Dentsply Endodontics, Tulsa, OK). Micosurgery and magnification Ultrasonic microapical preparation is best performed with the use of magnification. The surgical microscope has become the gold standard of enhanced vision; however, with surgical loupes 3X and 4X power (Designs for Vision, Ronkonkoma, NY), the level of magnification is adequate for these procedures. Magnification of the surgical field enhances the location of the root apex, appropriate preparation, and evaluation of existing root fractures. The presence of an isthmus of necrotic tissue can also be detected with surgical loupes. Specially designed apical mirrors enhance visualization of the apical region. Two types are generally available: hardened, polished stainless steel and ruby.

Cracks and infractions Some authors have reported that the use of ultrasonic devices for apical preparations can create fractures in the root structures [7,8]. Certain early studies by Abedi et al reported root cracking, especially in thinned areas [8]. Their study did not look at different power settings nor the use of irrigation. Other studies have recently compared the root surface after preparation by ultrasonic instruments with various power settings and rotary instruments [9]. These studies indicate that although some chipping occurs with the ultrasonic preparation, no cracks developed. Although the cavosurface margin of the rotary instrument was smoother, it was because of the remnants of the smear layer, which is undesirable. It is accepted

S.E. Lieblich, B. McGiverin / Oral Maxillofacial Surg Clin N Am 14 (2002) 167–172

171

Fig. 4. Ultrasonic preparation of mid-root perforation.

that the use of ultrasonic devices under medium power settings and adequate irrigation are not directly damaging to the root [10,11]. Von Arx has reported on the use of sonic instruments that use a frequency of 6000 Hz in comparison with ultrasonic instruments with a frequency of 30,000 Hz [12]. His reports with the use of sonic instruments compare favorably with that of the ultrasonic devices. At this time there is no clinical evidence that one has an advantage over the other.

as having a preparation that hermetically seals the root canal system. Microapical preparation provides that and facilitates the surgery by reducing the amount of bone removal. Patients seem to heal faster with less swelling and discomfort. This critical addition to endodontic surgery has made the procedure very predictable, with positive outcomes for many patients. Teeth that were previously condemned for extraction are now able to be routinely saved (Fig. 4).

Conclusion

References

Carr identified the following five major errors of retropreparation that can be reduced or eliminated with the use of the ultrasonic microapical techniques [13]: 1. 2. 3. 4. 5.

Preparation not down the longitudinal axis of the root canal system Preparation lacks significant retention form Preparation lacks proper buccal-lingual extension to assure adequate seal Isthmus area is not prepared and sealed Excessive removal of dentin weakens apical region

The multiple studies comparing one retrograde filling material with another may not be as significant

[1] Mehlhaff DS, Marshall JG, Baumgartner JC. Comparison of ultrasonic/and high-speed-bur root-end preparations using bilaterally matched teeth. J Endod 1997; 23:448 – 52. [2] Lin CP, Chou HG, Kuo JC, Lan WH. The quality of ultrasonic root-end preparation: a quantitative study. J Endod 1998;24:666 – 70. [3] Chailertvanitkul P, Saunders WP, Saunders EM, MacKenzie D. Polymicrobial coronal leakage of super EBA root-end fillings following two methods of rootend preparation. Int Endod J 1998;31:348 – 53. [4] Peters CI, Peters OA, Barabakow F. An in vitro study comparing root-end cavities prepared by diamondcoated and stainless steel ultrasonic retrotips. Int Endod J 2001;34:142 – 8. [5] Rainwater A, Jeansonne BG, Sarkar N. Effects of ultrasonic root-end preparation on microcrack formation and leakage. J Endod 2000;26:72 – 5.

172

S.E. Lieblich, B. McGiverin / Oral Maxillofacial Surg Clin N Am 14 (2002) 167–172

[6] Engle TK, Steiman HR. Preliminary investigation of ultrasonic root end preparation. J Endod 1995;21: 443 – 5. [7] Min MM, Brown CE, Legan JJ, Kafrawy AH. In vitro evaluation of effects of ultrasonic root-end preparation on resected root surfaces. J Endod 1997;23:624 – 8. [8] Abedi HR, Van Miefio BL, Wilder-Smith P, et al. Effects of ultrasonic root end cavity preparation on the apex. Oral Surg Oral Med Oral Path Endod Radiol 1995;80:207 – 13. [9] Waplington M, Lumley PL, Walmsley AD. Incidence of root face alteration after ultrasonic retrograde cavity preparation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:387 – 92. [10] Frank RJ, Antrim DD, Bakland LK. Effect of retrograde cavity preparation on root apexes. Endod Dent Traum 1996;12:100 – 3.

[11] Gray GJ, Hatton JF, Holtzmann DJ, et al. Quality of root-end preparations using ultrasonic and rotary instruments in cadavers. J Endod 2000;26:281 – 3. [12] Von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type of sonic and diamondsurfaced retrotip: a 1-year follow-up study. J Oral Maxillofac Surg 1999;57:656 – 61. [13] Carr GB. Ultrasonic root end preparation. Dent Clin NA 1997;41:541 – 54.

Further Reading Von Arx T, Walker WA. Microsurgical instruments for rootend cavity preparation following apicoectomy: a literature review. Endod Dent Traumatol 2000;16: 47 – 62.

Oral Maxillofacial Surg Clin N Am 14 (2002) 173 – 177

Root end filling Kamran Safavi, DMD, MEd Department of Endodontology, School of Dental Medicine, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-1715, USA

Elimination of the infected pulp space by extraction of the tooth almost always results in healing of periapical lesions [1,2]. As early as the 1880s, attempts were made to remove the offending segment of the tooth and leave the remaining portion for function [3,4]. Even in those days, the necessity of thoroughly cleaning, disinfecting, and filling of the pulp space before surgery was understood [5]. When the operator was unable to reach the apex of the root satisfactorily, the root canal was filled and the root was resected to the level where the filling ended [6]. Complete regeneration of periapical tissues in such cases was demonstrated histologically as early as 1930 [6]. In light of contemporary knowledge, one may conclude that many surgical procedures performed contemporaneously with root filling may have been unnecessary, since root canal treatment by itself may have resulted in success [7 – 13]. Techniques commonly referred to as ‘‘retrograde filling,’’ ‘‘retrofill,’’ or ‘‘retroseal’’ (ie, the preparation of a root-end cavity and insertion of a root-end filling in the prepared cavity while leaving the main portion of the root canal space untreated and unfilled) began to appear in the literature in the mid-twentieth century [8,14]. The advocates of these techniques presuppose that root canal treatment or retreatment [15,16] via the coronal access is not feasible (eg, when a retentive post is present) and that the root-end filling function is to establish a barrier between the infected root canal and periapical tissues. Experiments in conventional root canal treatment have clearly shown that, despite thorough instrumentation and liberal use of antiseptic irrigation, a bacteria-free root canal cannot predictably be pre-

E-mail address: [email protected] (K. Safavi).

pared, and any microorganisms left in the root canal are likely to proliferate. An intervisit antimicrobial medication is thus necessary to control the root canal infection [17 – 19]. After elimination of microorganisms from the root canal and root canal filling, resolution of periapical lesions is likely to occur, and it is shown that a residual periapical lesion is indeed a rare occurrence [20 – 23]. In periapical surgery, no antimicrobial irrigation or intervisit root canal medication is allowed for obvious reasons, and despite recent advances in surgical techniques and root-end preparation armamentaria [24 – 26], complete elimination of bacteria from the pulp space via the apical access is highly improbable. In fact, a recent clinical study showed that long after periapical surgery and root-end filling, viable bacteria may persist in the canals, constituting a potential risk of recurrence of periapical pathosis [27]. The sole reliance on root-end fillings, which are notoriously leaky [28], is probably responsible for a large number of periapical surgery failures [29,30]. The apical part of the root is often curved, contains accessory canals and ramifications, and is difficult to clean, disinfect, and fill through the coronal access cavity. Thus, by removing the apical part of the root, the infected root canal space may be eliminated. The apex of the root is resected, conventionally in an angle with the long axis of the root, to form a bevel facing the operator. The bevel is made to facilitate access, improve visualization of the root canal cross-section, help to diagnose fracture lines, and to facilitate preparation of a root-end cavity [31]. The angle of the bevel should be kept to a minimum because it is shown that an increase in the angle of the bevel increases the number of patent dentinal tubules [32] and may intensify apical microleakage [33].

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 6 - 7

174

K. Safavi / Oral Maxillofacial Surg Clin N Am 14 (2002) 173–177

Placement of a root-end filling in a resected root is shown to increase the success rate of periapical surgery [9 – 12,34]. The root-end cavity should be sufficiently deep and extend coronally beyond the level of the apical bevel [33]. When conventional rotary hand pieces or rotary surgical miniature hand pieces (micro hand pieces) are used, limited working space often does not allow preparation of a sufficiently deep root-end cavity parallel to the long axis of the tooth, and a root-end resection with a bevel of 45° or more is usually required. In recent years, a number of sonic and ultrasonic devices have been devised [35] to address the shortcomings of rotary bur preparation techniques. These devices, termed microsurgical tips or ‘‘retrotips,’’ are much smaller than rotary burs and are available in a variety of shapes to allow preparation of root-end cavities along the long axis of the root, in areas were conventional surgical miniature hand pieces may not reach. The advent of retrotips has decreased the need for a bevel and simplified the preparation of a root-end cavity [24 – 26]. After appropriate hemorrhage control [36,37], the prepared cavity is dried with paper cones before it is filled. Application of bone wax within the apical bony crypt before insertion of root-end filling has been advocated for hemorrhage and debris control [37,38]. Bone wax has been used for many years as a mechanical aid to hemostasis in surgical procedures. It should, however, be completely removed after insertion of root-end filling because it can potentially produce a foreign body giant cell reaction if left in the tissues [37,39]. A root end-filling remains in contact with periapical tissues and should be considered a foreign body implant. It may also be exposed to the oral environment via a leaky coronal restoration. A rootend filling material, therefore, should be biocompatible, adhere to dentinal walls, and prevent leakage. Furthermore, it should set quickly and be dimensionally stable and radiopaque [40,41]. To date, no such material is available. Dental amalgam has been the traditional root-end filling material for decades [8,42], and despite concerns regarding the hazards of mercury and toxicity of its constituents [43], neither long-term local toxicity [44] nor any systemic adverse effect has been demonstrated with its use in dentistry [45]. The material is readily available, easy to handle, has some antibacterial properties [46], and is radiopaque. There are, however, some negatives: it corrodes [47], stains the tissues (argyrosis, or amalgam tattoo), is moisture sensitive, and its long-term effectiveness as a root-end filling material has been questioned by some authors

[29]. Because of these disadvantages, it has been suggested that other materials be used as root-end fillings [45]. These include zinc oxide – eugenol – based materials, Cavit, glass ionomer cements, composite resins, and mineral trioxide aggregate cement (MTA). Prognosis studies comparing these materials are few, and hard facts are lacking [48]. Reinforced zinc oxide – eugenol – based cements advocated for root-end filling include IRM, Super EBA [49,50], and Kalzinol [51]. Zinc oxide – eugenol cements are shown to prevent filling material/dentin wall interface infection [52], but in contact with water, zinc oxide eugenolate is hydrolyzed and disintegrates. In the process, eugenol continues to be released from zinc oxide eugenolate until all zinc oxide eugenolate is converted to zinc hydroxide. The free eugenol is probably the reason for antimicrobial, obtundent, and toxic properties of zinc oxide – eugenol – based cements [53,54]. Cavit contains zinc oxide, calcium sulfate, zinc sulfate, glycol acetate polyvinyl acetate, polyvinyl chloride-acetate, triethanolamine, and red pigment, but has no eugenol [55]. Cavit sets hygroscopically, expands significantly upon setting [55], and is shown to provide a relatively tight seal [56]. Results of its clinical use as a root-end filling material, however, are reported to be less favorable than amalgam [57]. Glass ionomer cements have been suggested as an alternative to amalgam root-end fillings [58]. Glass ionomers are sensitive to moisture contamination for relatively long periods after setting [59], but as rootend fillings, they appear to have less microleakage than amalgam [60] and the outcome of their clinical use in periapical surgery is reported to be similar to that of amalgam [61]. The use of a composite resin root-end filling material (Retroplast) in combination with a dentin bonding agent (Gluma) has been the subject of a number of reports by the developers of the material [62 – 66]. Retroplast contains ytterbium trifluoride, which makes the composite resin radiopaque. Dentin bonding allows a concave preparation instead of a conventional root-end cavity and, as a result, application of the composite material to the entire surface of the resected root-end can potentially seal dentinal tubules as well as the main root canals [64,67]. Follow-up results of composite resin use in endodontic surgery have been reported to be favorable [64,65], and cementum formation together with tissue attachment on composite resin root-end fillings have been observed in a few human periapical biopsies [68]. An MTA cement (Proroot) was recently made commercially available for endodontic use. MTA

K. Safavi / Oral Maxillofacial Surg Clin N Am 14 (2002) 173–177

contains fine hydrophilic particles and sets in the presence of moisture. Hydration of the powder results in a colloidal gel with a pH of 12.5 that solidifies to a hard structure in  4 hours [69,70]. The exact composition of the powder is not known at the present time, but it contains calcium oxide, calcium phosphate, and silica and seems to be similar to that of Portland cement, a widely used and studied construction material. A constituent of both cements is calcium oxide. When water is added to the dry cement, calcium hydroxide is liberated, causing increased alkalinity. Biological effects of MTA may thus be similar to those of calcium hydroxide. The powder should be mixed with sterile water at a ratio of 3:1, and the mixture is carried into the root-end cavity with a plastic or metal carrier. If the mixture is too wet, the extra moisture can be removed with a dry piece of gauze [70]. MTA has been the subject of numerous biocompatibility, microleakage, and usage tests in recent years. The results of these tests, which were performed by the developers of the material and others, are quite favorable [69 – 77]. MTA seems to be biocompatible and can be inserted into the root-end cavity in the presence of moisture. On the other hand, the material’s long setting time is a disadvantage because the filling can be potentially washed out of the root-end cavity before it is set. Application of Zilactin (a film-forming, nonprescription oral analgesic gel) on MTA immediately after its insertion is suggested to protect the material from disintegration before it is set. The purpose of root-end filling procedures is to eliminate or block root canal infection. Insertion of root-end filling after root-end resection is believed to increase the success rate of periapical surgery. Dental amalgam has been the traditional root-end filling material of choice, but its long-term effectiveness has been questioned. A number of other materials have been advocated as amalgam substitutes, and the results of preliminary tests on these materials seem to be favorable.

References [1] Oehlers FA. Periapical lesions and residual dental cysts. Br J Oral Surg 1970;8(2):103 – 13. [2] Walton RE. The residual radicular cyst: does it exist? Oral Surg 1996;82(5):471. [3] Farrar JN. Radical and heroic treatment of alveolar abscess by amputation of roots of teeth. Dental Cosmos 1884;26(2):79 – 81. [4] Rhein ML. Amputation of the root as a radical cure in chronic alveolar abscess. Dental Cosmos 1890;32: 904 – 5.

175

[5] Farrar JN. Radical treatment of alveolar abscess. Dental Cosmos 1880;22(7):376 – 83. [6] Coolidge ED. Root resection as a cure for chronic periapical infection: a histologic report of a case showing complete repair. J Am Dent Assoc 1930;17(2): 239 – 49. [7] Federspiel MN. The indications for apicoectomy, with report of cases. Dental Cosmos 1936;78(7):726 – 31. [8] Luks S. Root end amalgam technic in the practice of endodontics. J Am Dent Assoc 1956;53(4):424 – 8. [9] Rud J, Andreasen JO, Jensen JE. A follow-up study of 1,000 cases treated by endodontic surgery. Int J Oral Surg 1972;1(4):215 – 28. [10] Rud J, Andreasen JO, Jensen JF. A multivariate analysis of the influence of various factors upon healing after endodontic surgery. Int J Oral Surg 1972;1(5): 258 – 71. [11] Rud J, Andreasen JO. Operative procedures in periapical surgery with contempraneous root filling. Int J Oral Surg 1972;1(6):297 – 310. [12] Rud J, Andreasen JO. A study of failures after endodontic surgery by radiographic, histologic and stereomicroscopic methods. Int J Oral Surg Int J Oral Surg 1972;1(6):311 – 28. [13] Sommer RF. Essentials for successful root resection. Am J Ortho Oral Surg 1946;32(1):76 – 100. [14] Nicholls E. Retrograde filling of the root canal. Oral Surg 1962;15(4):463 – 73. [15] Bergenholtz G, Lekholm U, Milthon R, et al. Retreatment of endodontic fillings. Scand J Dent Res 1979;87(3):217 – 24. [16] Kvist T, Reit C. Postoperative discomfort associated with surgical and nonsurgical endodontic re treatment. Endod Dent Traumatol 2000;16(2):71 – 4. [17] Bystrom A, Sundqvist G. Bacterial evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy. Scand J Dent Res 1981;89(4): 321 – 8. [18] Bystrom A, Sundqvist G. Bacteriologic evaluation of the effect of 0.5 percent sodium hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol 1983; 55(3):307 – 12. [19] Bystrom A, Claesson R, Sundqvist G. The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals. Endod Dent Traumatol 1985;1(5):170 – 5. [20] Nair PN, Sjogren U, Krey G, et al. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a longterm light and electron microscopic follow-up study. J Endod 1990;16(12):580 – 8. [21] Nair PN, Sjogren U, Sundqvist G. Cholesterol crystals as an etiological factor in non-resolving chronic inflammation: an experimental study in guinea pigs. Eur J Oral Sci 1998;106(2):644 – 50. [22] Nair PN, Krey G, Sundqvist G. Therapy-resistant foreign body giant cell granuloma at the periapex of a root-filled human tooth. J Endod 1990;16(12):589 – 95.

176

K. Safavi / Oral Maxillofacial Surg Clin N Am 14 (2002) 173–177

[23] Nair PNR. New perspectives on radicular cysts: do they heal? Int Endod J 1998;31(3):155 – 60. [24] von Arx T, Kurt B, Ilgenstein B, et al. Preliminary results and analysis of a new set of sonic instruments for root-end cavity preparation. Int Endo J 1998;31(1): 32 – 8. [25] von Arx T, Kurt B. Root-end cavity preparation after apicoectomy using a new type of sonic and diamondsurfaced retrotip: a 1-year follow-up study. J Oral Maxillofac Surg 1999;57(6):656 – 61. [26] von Arx T, Walker WA. Microsurgical instrument for root end cavity preparation following apicoectomy: a literature review. Endod Dent Traumatol 2000;16(2): 47 – 62. [27] Danin J, Linder LE, Lundqvist G, et al. Outcomes of periradicular surgery in cases with apical pathosis and untreated canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87(2):227 – 32. [28] Wu MK, Kontakiotis EG, Wesselink PR. Long-term seal provided by some root-end filling materials. J Endod 1998;24(8):557 – 60. [29] Frank AL, Glick DH, Patterson SS, et al. Long-term evaluation of surgically placed amalgam fillings. J Endod 1992;18(8):391 – 8. [30] Grung B, Molven O, Halse A. Periapical surgery in a Norwegian County Hospital: follow-up findings of 477 teeth. J Endod 1990;16(9):411 – 7. [31] Gutmann JL, Pitt Ford TR. Management of the resected root end: a clinical review. Int Endod J 1993;26(5):273 – 83. [32] Tidmarsh BG, Arrowsmith MG. Dentinal tubules at the root ends of apicected teeth: a scanning electron. Int Endod J 1989;22(4):184 – 9. [33] Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleakage associated with root resection and retrograde filling. J Endod 1994;20(1):22 – 6. [34] Hirsch JM, Ahlstrom U, Henrikson PA, et al. Periapical surgery. Int J Oral Surg 1979;8(3):173 – 85. [35] Carr GB. Ultrasonic root end preparation. Dent Clin North Am 1997;41(3):541 – 54. [36] Mattsson T, Kondell PA, Anneroth G, et al. ACP and Surgicel in bone hemostasis. A comparative experimental and histologic study. Swed Dent J 1990;14 (2):57 – 62. [37] Witherspoon DE, Gutmann JL. Haemostasis in periradicular surgery. Int Endod J 1996;29(3):135 – 49. [38] Selden H. Bone wax as an effective hemostat in periapical surgery. Oral Surg Oral Med Oral Pathol 1970; 29(2):262 – 4. [39] Aurelio J, Chenail B, Gerstein H. Foreign-body reaction to bone wax. Report of a case. Oral Surg Oral Med Oral Pathol 1984;58(1):98 – 100. [40] Safavi KE, Spangberg L, Sapounas G, et al. In vitro evaluation of biocompatibility and marginal adaptation of root retrofilling materials. J Endod 1988;14(11): 538 – 42. [41] Safavi K, Kazemi R, Watkins D. Adherence of enamel matrix derivatives on root-end filling materials. J Endod 1999;25(11):710 – 2.

[42] Messing JJ. Obliteration of the apical third of the root canal with amalgam. Br Dent J 1958;104(2):125 – 8. [43] Omnell KA. Electrolytic precipitation of zinc carbonate in the jaw. An unusual complication after root resection. Oral Surg 1959;12(7):846 – 52. [44] Feldmann G, Nyborg H. Tissue reactions to root filling materials. I. Comparison between gutta percha and silver amalgam implanted in rabbit. Odont Revy 1962; 13(1):1 – 14. [45] Johnson BR. Considerations in the selection of a rootend filling material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87(4):398 – 404. [46] Orstavik D. Antibacterial properties of and element release from some dental amalgams. Acta Odontol Scand 1985;43(4):231 – 9. [47] Hohenfeldt PR, Aurelio JA, Gerstein H. Electrochemical corrosion in the failure of apical amalgam. Report of two cases. Oral Surg Oral Med Oral Pathol 1985; 60(6):658 – 60. [48] Delivanis P, Tabibi A. A comparative sealability study of different retrofilling materials. Oral Surg Oral Med Oral Pathol 1978;45(2):273 – 81. [49] Dorn SO, Gartner AH. Retrograde filling materials: a retrospective success-failure study of amalgam, EBA, and IRM. J Endod 1990;16(8):391 – 3. [50] Oynick J, Oynick T. A study of a new material for retrograde fillings. J Endod 1978;4(7):203 – 6. [51] Chong BS, Ford TR, Wilson RF. Radiological assessment of the effects of potential root-end filling materials on healing after endodontic surgery. Endod Dent Traumatol 1997;13(4):176 – 9. [52] Cox CF, Keall CL, Keall HJ, et al. Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosthet Dent 1987;57(1):1 – 8. [53] Dewhirst FE. Structure-activity relationships for inhibition of cyclooxygenase by phenolic compounds. Prostaglandins 1980;20(2):209 – 22. [54] Markowitz K, Moynihan M, Liu M, et al. Biologic properties of eugenol and zinc oxide-eugenol. A clinically oriented review. Oral Surg Oral Med Oral Pathol 1992;73(6):729 – 37. [55] Widerman FH, Eames WB, Serene TP. The physical and biologic properties of Cavit. J Am Dent Ass 1971;82(2):378 – 82. [56] Bobotis HG, Anderson RW, Pashley DH, et al. A microleakage study of temporary restorative materials used in endodontics. J Endod 1989;15(12):569 – 72. [57] Finne K, Nord PG, Persson G, et al. Retrograde root filling with amalgam and Cavit. Oral Surg Oral Med Oral Pathol 1977;43(4):621 – 6. [58] Zetterqvist L, Hall G, Holmlund A. Apicectomy: a comparative clinical study of amalgam and glass ionomer cement as apical sealants. Oral Surg 1991;71(4): 489 – 91. [59] Um CM, Oilo G. The effect of early water contact on glass-ionomer cements. Quintessence Int 1992;23(3): 209 – 14. [60] Zetterqvist L, Anneroth G, Danin J, et al. Microleakage of retrograde fillings – a comparative investigation be-

K. Safavi / Oral Maxillofacial Surg Clin N Am 14 (2002) 173–177

[61]

[62]

[63]

[64]

[65]

[66]

[67]

[68]

[69]

tween amalgam and glass ionomer cement in vitro. Int Endod J 1988;21(1):1 – 8. Jesslen P, Zetterqvist L, Heimdahl A. Long-term results of amalgam versus glass ionomer cement as apical sealant after apicectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79(1):101 – 3. Rud J, Munksgaard EC, Andreasen JO, et al. Retrograde root filling with composite and a dentin-bonding agent. 1. Endod Dent Traumatol 1991;7(3):118 – 25. Rud J, Munksgaard EC, Andreasen JO, et al. Retrograde root filling with composite and a dentin-bonding agent. 2. Endod Dent Traumatol 1991;7(3):126 – 31. Rud J, Rud V, Munksgaard EC. Long-term evaluation of retrograde root filling with dentin-bonded resin composite. J Endod 1996;22(2):90 – 3. Rud J, Rud V, Munksgaard EC. Retrograde root filling with dentin-bonded modified resin composite. J Endod 1996;22(9):477 – 80. Rud J, Rud V, Munksgaard EC. Effect of root canal contents on healing of teeth with dentin-bonded resin composite retrograde seal. J Endod 1997;23(8):535 – 41. Vignaroli PA, Anderson RW, Pashley DH. Longitudinal evaluation of the microleakage of dentin bonding agents used to seal resected root apices. J Endod 1995;21(10):509 – 12. Andreasen JO, Munksgaard EC, Fredebo L, et al. Periodontal tissue regeneration including cementogenesis adjacent to dentin-bonded retrograde composite fillings in humans. J Endod 1993;19(3):151 – 3. Torabinejad M, McDonald F, Hong CU, et al. Physical

[70]

[71]

[72]

[73]

[74]

[75]

[76]

[77]

177

and chemical properties of a new root-end filling material. J Endod 1995;21(7):349 – 53. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25(3): 197 – 205. Bates CF, del Rio CE, Carnes DL. Longitudinal sealing ability of mineral trioxide aggregate as a root-end filling material. J Endod 1996;22(11):575 – 8. Koh ET, Torabinejad M, Pitt Ford TR, et al. Mineral trioxide aggregate stimulates a biological response in human osteoblasts. J Biomed Mater Res 1997;37(3): 432 – 9. Torabinejad M, Hong CU, Lee SJ, et al. Investigation of mineral trioxide aggregate for root-end filling in dogs. J Endod 1995;21(12):603 – 8. Torabinejad M, Hong CU, Pitt Ford TR, et al. Tissue reaction to implanted super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: a preliminary report. J Endod 1995;21(11):569 – 71. Torabinejad M, Abedi HR, Pitt Ford TR, et al. Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys. J Endod 1997;23(4): 225 – 8. Torabinejad M, Kariyawasam SP, Ford TR, et al. Tissue reaction to implanted root-end filling materials in the tibia and mandible of guinea pigs. J Endod 1998;24(7):468 – 71. Zhu Q, Haglund R, Safavi KE, et al. Adhesion of human osteoblasts on root-end filling materials. J. Endod 2000;26(7):404 – 6.

Oral Maxillofacial Surg Clin N Am 14 (2002) 179 – 186

Periapical surgery: clinical decision making Stuart E. Lieblich, D.M.D.* Departament of Oral and Maxillofacial Surgery, University of Connecticut Health Center, CT, USA Avon Oral and Maxillofacial Surgery, 34 Dale Road, Suite 105, Avon, CT, 06001, USA

Preoperative planning The decision to perform periapical surgery is based on factors decided by the clinical presentation of the symptomatic tooth and the needs of the patient. When root canal treatment fails, it can be frustrating to the patient, who may not understand why there still can be a problem with the tooth. Many endodontic failures will occur a year or more after the initial root canal treatment, often creating a situation where a definitive restoration has already been placed. Although endodontic care is typically successful, symptoms can persist or spontaneously reoccur in  10% to 15% of most cases [1]. Apical surgery can then be used to salvage many of these teeth. Failure of endodontic treatment is most commonly caused by the presence of bacteria within the root canal system with resultant apical leakage. Causes of endodontic failures can often be separated into biologic issues such as a persistent infection or technical factors (eg, a broken instrument in the root canal system; Fig. 1). Technical factors alone are a less common indication for surgery, comprising only 3% of the total cases referred for surgery [2]. From a medico-legal point of view, discussions with patients before surgery are critical for the patient to give appropriate, informed consent. The particular risks of surgery based on the anatomical location (sinus involvement or proximity to the inferior alveolar nerve) needs to be reviewed and documented. The potential of the surgery to be successful is often

* Avon Oral and Maxillofacial Surgery, 34 Dale Road, Suite 105, Avon, CT 06001, USA. E-mail address: [email protected] (S.E. Lieblich).

quantified for patients to give them information about the likelihood of success. Surgical endodontic success rates have dramatically improved over the years with the developments of newer retrofilling materials and the use of the ultrasonic preparation. Previously cited success rates of 60% to 70% have now increased to more than 90% in many studies [3,4] because of the routine use of ultrasonic retrograde preparation (see pp. 167 – 172). This significant improvement makes apical surgery a much more predictable and valuable adjunct in the treatment of symptomatic teeth. The primary option for the treatment of symptomatic endodontically treated teeth is that of conventional retreatment versus the surgical approach. An algorithm for a decision regarding retreatment vsersus surgery versus extraction is presented in Fig. 2. In discussions with patients, the option of conventional retreatment should be discussed. Clinical studies have not shown retreatment to be more successful than surgery, however, and in fact one prospective study found surgical treatment to have a higher success rate [5]. It is therefore appropriate to surgically manage cases that are technically difficult to retreat (eg, a nonretrievable post and core). In fact, the risk of damage to existing restorations may make the surgical approach more ‘‘conservative.’’ Retreatment also removes more tooth structure, and the potential for perforation during treatment or fracture in the future are risks not associated with surgical management. Surgical treatment of a radiographic failure also provides the opportunity to retrieve tissue for histologic examination to rule out a noninfectious cause of a lesion (Fig. 3). The option of extraction with either immediate or delayed implant placement must also be discussed as

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 2 2 - 5

180

S.E. Lieblich / Oral Maxillofacial Surg Clin N Am 14 (2002) 179–186

Fig. 1. Two examples of technical factors requiring apical surgery. Although less frequent in occurrence, the success rate is usually high because the canal system is likely to be well obturated. (A) Overfill of gutta percha causing symptoms including chronic sinusitis. (B) Broken endodontic instrument in apical third with pain and drainage.

an alternative to periapical surgery. It is helpful to have data to predict the expected success of the surgery so the patient can use that in their decisionmaking process. Factors that improve success include the following: Preoperative factors 1. Dense orthograde fill 2. Healthy periodontal status 3. No dehiscence 4. Adequate crown-to-root ratio 5. Radiolucent defect isolated to apical one third of tooth 6. Tooth treated 7. Maxillary incisor 8. Mesio-buccal root of maxillary molars Postoperative factors 1. Radiographic evidence of bone fill after surgery 2. Resolution of pain and symptoms 3. Absence of sinus tract 4. Decrease in tooth mobility In cases of an expected poorer success rate, such as the presence of severe periodontal bone loss, the decision to extract the tooth and place an implant may be a more efficacious and clinically predictable procedure. Other factors contributing to failure include:

3. 4. 5. 6. 7.

Marginal leakage of crown or post Poor preoperative periodontal condition Radiographic evidence of post perforation Tooth treated Mandibular incisor

Postoperative factors 1. Lack of bone repair after surgery 2. Lack of resolution of pain 3. Fistula does not resolve or returns In cases that have a final prosthetic restoration already in place, it is usually easier to recommend surgical intervention. In that situation, if the symptoms do not resolve, the patient has only expended the additional time and expense of the surgical portion of their care. The treatment of teeth with calcified canals that cannot be negotiated via an orthograde approach may be appropriately managed with apical surgery if the tooth is critical to a restorative treatment plan. Danin showed at least a 50% rate of complete radiographic healing and only 1 failure in 10 cases over a 1-year observation period of cases treated only surgically, with no endodontic treatment [6]. He did note that bacteria still remained in the canals of the tooth in 90% of these cases, which may lead to a later failure.

Determination of ‘‘success’’ Preoperative factors 1. Clinical or radiographic evidence of fracture 2. Poor or lack of orthograde filling

More complicated decisions are involved with teeth that have not been definitively restored. This

Fig. 2. Algorithm for apical surgery.

182

S.E. Lieblich / Oral Maxillofacial Surg Clin N Am 14 (2002) 179–186

situation requires that the surgeon consider the preoperative potential for a sucessfult apical surgery and then determine when the case is deemed successful and the patient can return to the general dentist for the final restoration. Once a final restoration is placed, considerably more time and expense has been invested and subsequent failure is more troublesome to the patient. Rud et al retrospectively reviewed radiographs after apical surgery to determine radiographic signs of success [7]. Their review of cases over at least 4 years after surgery showed that once radiographic evidence of bone fill occurs, which is noted as ‘‘successful’’ healing in their classification scheme, that tooth was stable throughout the remainder of their study period (up to 15 years). A waiting period of more than 4 years is not as acceptable in contemporary practice, but classification scheme of Rud et al has been validated over shorter observation times. They found that if radiographic evidence of bone fill of the surgical defect is noted, then the tooth has remained a radiographic success over their observation periods. Many of the partially healing cases, noted as ‘‘incomplete healing’’ in their study, tended to move into the complete healing group during the 2 years after surgery, with very little changes throughout the next 4 years of observation. An appropriate follow-up protocol is to obtain a repeat periapical film 3 months after surgery and to

do critical comparison with the immediate postoperative film. If significant bone fill has occurred, mobility has decreased, pain is resolved, and no fistula is present, the patient can be referred back for the final restoration. If significant bone fill has not been noted, however, the patient should be called again at 3 months for a new film. Any increase in the size of the radiolucency or no improvement should caution the dentist about making a final restoration. If the situation is not clear at that time (6 months postsurgically), a temporary restoration, loaded for at least 3 months, is often a good ‘‘litmus test’’ of the success of the surgery and predictive as to whether the final restoration will last for some time.

The cracked or fractured tooth Preoperative radiographs and a careful clinical examination should be done with a high index of suspicion of a vertical root fracture before undertaking surgery. Mandibular molars and maxillary premolars are the most frequent teeth to present with occult vertical root fractures (VRF). Although surgical exploration may be needed to definitively show the presence of a fracture (Fig. 4), subtle radiographic signs may alert the surgeon that a fracture is present and the surgery is unlikely to be successful. Tamse looked at radiographs of maxillary premolars for

Fig. 3. Atypical radiolucency along the lateral aspect of the root, not involving the apex. Although correctly treated at the time of referral because of the nonresolving radiolucency with periapical surgery, the suspicious nature of the lesion warranted submission of the tissue for histologic examination. Confirmation with the original treating dentist revealed that the indication for the endodontic treatment was solely the incidental finding of a radiolucency, and vital pulp tissue was noted. The final pathology was a cystic ameloblastoma.

S.E. Lieblich / Oral Maxillofacial Surg Clin N Am 14 (2002) 179–186

183

Fig. 4. (A) Vertical root fracture that was not diagnosed until it was explored during surgery. (B) The use of a sulcular flap permitted a resection of the mesio-buccal root and preservation of the tooth with its existing restoration.

comparison with the clinical findings at the time of surgery [8]. Very few (1 out of 15) teeth with an isolated, well-corticated periapical lesion had a VRF. In contrast, a ‘‘halo’’ type radiolucency was almost always associated with a VRF (Fig. 5). This type of radiolucency is also known as a ‘‘J’’ type, where a widened periodontal ligament space connects with the periapical lesion and creates the ‘‘J’’ pattern. It is critical in patient discussions to review the exploratory nature of the surgery, and this author routinely uses that as a descriptor of the planned surgery. If a fractured root is found, a decision to either resect a root or extract a tooth must be made during surgery. Obtaining the appropriate preoperative consent and determining how the extracted tooth site will be managed (with or without a temporary removable partial denture) must be established before surgery commences.

Concomitant periodontal procedures The use of guided tissue regeneration or alloplastic or allogenic bone grafting and root planing in conjunction with periapical surgery can be considered. In cases of severe bone dehiscence, the likelihood of success is known to be substantially compromised and may lead to the intraoperative decision to extract the tooth. Periodontal probing before surgery will often detect the presence of significant bony defects. Sometimes the amount of bone loss cannot be appreciated until the area is flapped (Fig. 6). Thus, the exploratory nature of the surgery needs to be stressed to the patient before surgery.

The placement of an additional foreign body, such as a Gore-tex membrane, to an area already infected is more likely to lead to failure of the surgery. Membrane stabilization and adequate mobilization of soft tissues to cover the membrane may increase the complexity of the surgical procedure. Nonresorbable membranes also require a second procedure for their removal that may not be tolerated by the patient and lead to increased scarring.

Surgical access Surgical access is a compromise between the need for visibility and the risk to adjacent structures. Many surgeons use the semilunar flap to access the periapical region. Although it provides rapid access to the apices of the teeth, it substantially limits the surgery to only a root resection and periapical seal. Proponents of this flap claim that it prevents recession around existing crowns, which could lead to a metal margin showing postoperatively. The semilunar flap is placed entirely in the nonkeratinized or unattached gingiva. By definition, this tissue is constantly moving during normal oral function, leading to dehiscence and increased scarring. Incisions placed in unattached tissues tend to heal slower and with more discomfort. Once a semilunar incision is made, the surgeon is limited to only the periapical region. If the root is noted to be fractured, extraction via this flap may lead to a severe defect. With a multirooted tooth, a root resection of one of the fractured roots may not be possible. Also, localized root planing or other periodontal procedures cannot be accomplished. The size

184

S.E. Lieblich / Oral Maxillofacial Surg Clin N Am 14 (2002) 179–186

Fig. 5. (A) Example of a periapical lesion isolated to the apical one third of the root. These are rarely associated with a vertical root fracture. (B) In contrast, this type of radiographic lesion, known as a ‘‘halo’’ or ‘‘J’’ type of radiolucency, has ill-defined cortical borders and is most likely associated with a vertical root fracture. (From Tamse A, Fuss Z, Lustig J, et al. Radiographic features of vertically fractured, endodontically treated maxillary premolars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:34852; with permission.)

of the bone defect may be greater than what had been anticipated based on the preoperative radiographs, and the possibility of the suture line being over the defect might cause the incision to open and heal secondarily. Finally, it is known that many cases of periapical surgery on maxillary molars and premolars will involve an opening into the sinus cavity [9]. By keeping the incision as far away from the sinus opening as possible (ie, a sulcular incision) the chance of an oral-antral communication is significantly reduced.

To biopsy or not? A recent clinical controversy has ensued over the consideration of whether all periapical lesions treated surgically should have soft tissue removed and submitted for histologic evaluation. An editorial by Walton questioning the rationale of submitting all soft tissue recovered for histologic examination [10] ignited a series of letters to the editor. Organizations such as the American Association of Endodontists have stated in their standards that if soft tissue can be

S.E. Lieblich / Oral Maxillofacial Surg Clin N Am 14 (2002) 179–186

185

Fig. 6. A combination endodontic and periodontal lesion has a very low likelihood of success. The decision was made preoperatively to treat the tooth surgically because an adequate final restoration had already been placed. Extraction with consideration of local bone grafting is otherwise indicated.

recovered from apical surgery then it must be submitted for pathologic evaluation. Past presidents of the American Association of Oral Pathologists have also supported this recommendation. On cursory review, it seems easier to make this recommendation than to have the surgeon determine if there is anything unusual about the case that warrants histologic examination. Walton makes a convincing argument against the submission of all tissues because similarly appearing radiolucencies that are not treated surgically do not have tissue retrieved for pathologic identification [10]. It also is accepted that the differentiation between a periapical granuloma or periapical cyst has no direct bearing on clinical outcomes and, therefore, cannot be used as a rationalization for the submission of tissue. What is a surgeon to do? The dilemma clearly falls back to the surgeon; if a rare lesion should present itself in the context of a periapical lesion and is not biopsied in a timely manner, the surgeon is exposed to a potential malpractice suit. Many surgeons have a case or two that have ‘‘surprised’’ them because of the final pathologic diagnosis. Careful review of these cases, however, usually depicts a clinical situation inconsistent with a typical periapical infection (Fig. 3). An approach more logical than a purely defensive one is to set up guidelines to determine the lack of

indication for tissue submission. The following are suggested indications for not submitting periapical soft tissues for histologic review: 1. Clear evidence of pre-existing endodontic involvement of a tooth 2. Presence of pulpal necrosis, not just a periapical radiolucency 3. Unilocular radiolucency associated with apical one-third of the tooth 4. Lesion is not associated with an impacted tooth 5. No history of malignancy that could represent spread of a metastasis 6. Patient will return for follow-up examinations and radiographs 7. No tissue recovered at the time of surgery It is recommended that in each specific case, the surgeon document in the patient’s record the rationale for electing not to submit tissue.

References [1] Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized technique. J Endod 1979;5:83 – 90.

186

S.E. Lieblich / Oral Maxillofacial Surg Clin N Am 14 (2002) 179–186

[2] El-Siwah JM, Walker RT. Reasons for apicectomies. A retrospective study. Endod Dent Traumatol 1996;12: 185 – 91. [3] Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periapical surgery: a clinical prospective study. Int Endod J 2000;33(2):91 – 8. [4] Von Arx T, Kurl B. Root-end cavity preparation after apicoectomy using a new type of sonic and diamondsurfaced retrotip: a 1-year follow-up study. J Oral Maxillofac Surg 1999;57:656 – 61. [5] Danin J, Stromberg T, Forsgren H, et al. Clinical management of nonhealing periradicular pathosis. Surgery versus endodontic retreatment. Oral Surg Oral Med Oral Pathol Endod Radiol 1996;82:213 – 7. [6] Danin J, Linder LE, Lundqvist G, et al. Outcomes of periradicular surgery in cases of apical pathosis and

[7]

[8]

[9]

[10]

untreated canals. Oral Surg Oral Med Oral Pathol Endod Radiol 1999;87:227 – 32. Rud J, Andreasen JO, Jensen JE. A follow-up study of 1,000 cases treated by endodontic surgery. Int J Oral Surg 1972;1:215 – 28. Tamse A, Fuss Z, Lustig J, et al. Radiographic features of vertically fractured, endodontically treated maxillary premolars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:348 – 52. Feedman A, Horowitz I. Complications after apicoectomy in maxillary premolar and molar teeth. Int J Oral Maxillofac Surg 1999;28:192 – 4. Walton RE. Routine histopathologic examination of endodontic periradicular surgical specimens—is it warranted? Oral Surg Oral Med Oral Pathol Endod Radiol 1998;86:505.

Oral Maxillofacial Surg Clin N Am 14 (2002) 187 – 199

Surgical exposure of impacted teeth Alan L. Felsenfeld, MA, DDS*, Tara Aghaloo, DDS, MD Section of Oral and Maxillofacial Surgery, UCLA School of Dentistry, 53-076, Los Angeles, CA 90095, USA

One of the more complicated aspects of orthodontic dentoalveolar surgery is the surgical exposure and orthodontic management of impacted teeth. While this can be a relatively simple procedure, it also can challenge the surgeon and orthodontist who are trying to preserve or retain a tooth that is key to the integrity of the arch or stability of the treatment for a patient. This chapter will explore the rationale for treatment, some historical concepts, and current techniques. While it is clear that the canine teeth are the second most frequently impacted (after the third molars), oral and maxillofacial surgeons and orthodontists have to deal with other impacted teeth on a regular basis. These other impactions include maxillary central incisors, mandibular second premolars, and mandibular second molars [1]. For the purposes of this chapter, the discussion will center on the maxillary canine teeth, but the techniques and problems presented are applicable to all impacted teeth that are to be salvaged. The treatment planning decision to be made conjointly between the oral and maxillofacial surgeon and the orthodontist is how to manage impacted teeth. In selected cases, extraction is indicated, which will facilitate treatment and minimize risk. Unfortunately, canine extraction can compromise the esthetics, function, and occlusion of the finished case. Other surgical options include transposition or surgical repositioning of the tooth. In this autotransplantation technique, the surgeon creates a socket where the tooth should be and the impacted tooth is extracted and transplanted into the socket. The procedure may be indicated when more conventional

* Corresponding author. E-mail address: [email protected] (A. Felsenfeld).

means of surgical exposure and orthodontic eruption are unable to move the tooth into the intended position. While this method of treatment is expedient, it is not commonly performed because there are significant risks to the extraction and replantation of the tooth [2,3]. The use of an osteotomy to move the entire segment of tooth and surrounding bone has been reported [4]. This technique presumes that the tooth is not ankylosed and will be orthodontically moveable once the osteotomy has healed. It is clear that the risks and complications of these small segmental osteotomies should be considered carefully in treatment planning for this type of procedure. More recently there has been an increase in the number of extractions of impacted teeth and the use of dental implants [5]. With the techniques and implant systems available today, this becomes a more predictable manner to restore the integrity of the arch and solve a complex problem where the likelihood of orthodontic success is decreased.

Incidence The most commonly impacted tooth that the oral and maxillofacial surgeon has to treat other than third molars is the maxillary canine. From an orthodontic standpoint, the canine is a key tooth in determining the occlusion, stability, form, and function of the arch. Estimates of the frequency of impaction of canine teeth are 2% according to Bass in his studies [6]. Palatal impaction of maxillary canines is more prevalent at 2:1 or 3:1 as compared to buccal or labial impaction [7]. In a German study, Stellzig and associates compared pre- and post-treatment cephalometric radiographs and models on patients with

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 1 ) 0 0 0 0 2 - 4

188

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

impacted maxillary canine teeth. It was shown that  85% of impacted teeth were on the palatal aspect of the maxilla while only 15% were on the buccal. Arch length deficiency was present in only 18% of palatally impacted canines, whereas 46% of buccal impactions demonstrated deficiency [8].

Etiology Before attempting the surgical exposure and orthodontic traction of an impacted canine tooth, etiologies of impaction and method of preventing this problem and facilitating spontaneous eruption should be considered. In the 1950s prophylactic extraction of deciduous canines was done to allow for spontaneous eruption of the succedaneous canines. This technique was applicable in children in the early teenage years, when there was sufficient arch length to accommodate the erupting teeth. The mechanism of impaction was unclear, but was possibly related to the failure of primary tooth resorption with subsequent impaction of the permanent tooth [9,10]. With proper case selection this is still a simple and effective manner to avoid impaction of the permanent maxillary canines. The literature demonstrates that impacted maxillary canines are associated with alteration in the anatomy or position of the central and lateral incisors; however, in a recent study by Brenchley in which he examined patients with unilateral impacted canines, he was unable to show any difference in the morphology of the central and lateral incisors [11]. For labially impacted teeth, arch length deficiency appears to be the most significant factor [12]. In the palatal location, interceptive extraction of primary teeth may be of value in preventing impaction of the permanent canine. Additional studies have shown a genetic predisposition toward canine impaction. One study evaluated first- and second-degree relatives with impacted canines and found that 35% of the relatives had congenitally missing teeth or hypodontia at a rate 4.5 times greater than the prevalence in the general population. Palatal displacement of canines is thought to be genetic and related to congenital absence of teeth. Impacted canine teeth are polygenic and multifactoral based on occurrences of other dental abnormalities, bilaterality, sex differences, familial occurrence, and population differences [13]; however, in a conflicting study, Becker demonstrated that palatal impactions were not genetically linked, but rather related to small or misshapen lateral incisors [14].

Localization One of the more challenging and unpredictable aspects of surgical exposure of impacted teeth is the localization of the tooth. Impacted canine teeth may be located on the buccal aspect of the maxilla or mandible or on the palatal or lingual sides. They may also be situated in the midalveolar area. Position and angulation of the tooth allows the crown to be in one part of the jaw and the root on the opposite side. This adds to the complexity in determining the location of the tooth as well as the orthodontic techniques necessary to guide eruption. To surgically expose the tooth, the surgeon must locate the crown. Radiographic evaluation of these patients usually consists of a series of periapical radiographs frequently combined with panoramic radiographs. Lateral cephalometric films are often helpful. Tomograms or CT scans may provide additional information in selected patients. Most surgeons initially will use a series of periapical radiographs utilizing the concept of parallax to locate the tooth. Clark pioneered this technique in 1910 using the cone head shift in the horizontal plane. By 1952 Richards had supplemented our ability to locate teeth by adding a vertical shift to the process [15,16]. This is more commonly known as the buccal object rule, or more traditionally called the rule of SLOB (same lingual-opposite buccal). Fig. 1 is an example of the use of this technique to localize an impacted maxillary canine. As the cone of the radiograph head moves away from the area in question, the clinician evaluates the relationship between the crown of the impacted tooth and the remaining teeth. If the crown appears to move away from the remaining teeth with the cone head being moved away, the crown is considered to be on the palatal, lingual, or medial aspect of the bone (samelingual) and should be approached accordingly. If the tooth moves in the opposite direction of the cone relative to the stationary teeth, it is considered to be on the buccal or lateral surface of the bone (oppositebuccal). When the movement is not apparent, consideration should be given to midalveolar placement of the tooth. Additional films may include true occlusal radiographs that give information about the location of an impacted maxillary canine. Lateral occlusal films or lateral cephalometric radiographs, as seen in Fig. 2, can demonstrate the buccal or lateral placement of an impacted tooth. Several studies have shown that properly calibrated panoramic radiographs may be helpful in determining the buccal or palatal position of impacted maxillary canines. This is predicated on

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

189

Fig. 1. Sequential periapical radiographs demonstrating buccal object rule.

the impacted tooth size relative to the contralateral side. If the tooth is further from the film, it will appear larger. Fig. 3 shows the same palatal impaction appearing larger on the left side. Angulation of the tooth is also considered [17].

In select cases the use of computerized tomograms, as shown in Fig. 4, may be helpful in accurately depicting the location of the impacted teeth and identifying root resorption of adjacent teeth [18]. One study demonstrates the accuracy of CT

Fig. 2. Cephalometric radiograph showing maxillary palatal impacted canine.

190

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

Fig. 3. Panoramic radiograph showing maxillary impacted canine teeth.

scans in localizing the teeth, but indicates that radiation exposure may be more than is necessary [19]. It is believed that impacted canines can be diagnosed by clinical as well as radiographic means. The prominent canine ridge will frequently be lacking on the buccal aspect of a maxilla with a palatally impacted canine. Significant asymmetry in the exfoliation and eruption patterns of primary canine teeth is also seen. If abnormal mesial-distal positioning or

unusual angles are noted in young children through radiographic evaluation, it is possible that the teeth will not erupt spontaneously.

Orthodontic considerations Orthodontic treatment for impacted teeth ranges from simple to very complex traction procedures.

Fig. 4. (A) Anterior section of coronal CT scan showing incisor teeth. (B) More posterior section demonstrating palatal location and inclination of impacted canine teeth. (C) Axial view illustrating position and proximity to adjacent roots.Note: CT scans were taken for other diagnostic purposes; impacted canines were an incidental finding.

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

191

Fig. 4 (continued ).

The application of traction forces depends on the relative looseness of the tooth within the crypt. If clinicians see no progress in the movement of the tooth with increased forces then the tooth may be ankylosed. In addition, sufficient room must be made in the arch to accommodate the tooth as it is brought into proper position. With premature loss of a deciduous tooth or an anomalous lateral incisor, arch length may be compromised. It is often possible to create space before the

tooth is exposed; however, many orthodontists will recapture lost space when the tooth is being transported into position. Vectors of forces are also important to prevent rotation of the impacted tooth and to minimize damage to the adjacent tooth. Displacement and root resorption are of primary concern to the orthodontist. Some orthodontists prefer to expose an impacted tooth early in the treatment plan to determine the feasibility of repositioning as opposed to extraction and compensation for the loss of arch

192

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

length. Others, however, will begin the bonding process early to provide adequate numbers of teeth for anchorage and opposing forces to the traction. Decisions whether to expose or remove impacted maxillary canines are frequently difficult. Retrospective studies by Stivaros and Mandall evaluated radiographic angulation to the midline, vertical height of the tooth, anterior-posterior root position, overlap with adjacent incisor teeth, and root resorption. The plan to remove impacted teeth was influenced by the position of the crown. Palatal impactions tended to be retained and exposed more frequently than teeth in line with the arch or labially positioned, which were more often extracted. As the angulation of the tooth to the midline increased, it was more likely to be extracted [20].

Historical techniques Many surgical procedures have been attempted in past years. The historical techniques will be reviewed briefly to understand the current procedures. There may also be the occasional patient in whom these techniques may be applicable. The simplest of the surgical procedures still in use today is gingivectomy. Historically, the employment of this technique gave little consideration to the need for attached gingiva on the buccal. The clinician

could simply expose the tooth by excising the overlying tissue regardless of the quality. This technique is most applicable in the palatal impaction with an abundance of attached gingiva. In a labial impaction there must be sufficient amounts of keratinized tissue to allow for the surgery and still maintain a clinically acceptable amount of attached gingiva. At least one half of the crown is surgically exposed for proper bonding [21]. More recently, the apically repositioned flap has replaced this technique if crown exposure is desired. For palatal canines, it is acceptable to remove the overlying gingiva and bone and leave the tooth open for subsequent bonding or spontaneous eruption. The tooth is exposed and the wound might be packed open with gauze or periodontal dressing to allow for preliminary healing. The exposure alone (without initial orthodontic intervention) will frequently cause the impacted tooth to erupt. In some cases when the tooth was exposed, the operator would drill a small hole in the enamel of the tooth and screw a pin into the dentin. With this pin in place, the orthodontist could attach elastics for traction into the arch. Once the tooth was in sufficient alignment, a small esthetic restoration was placed. The use of crown forms that were either cemented or snapped over the crown of the impacted tooth was popular for many years. The clinician exposes the tooth by a full-thickness flap. The overlying bone and

Fig. 5. Aluminum and plastic crown forms.

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

193

Fig. 6. Metal crown in position in closed technique.

soft tissue are removed, and a plastic or aluminum crown is adapted and cemented or snapped on. Figs. 5 and 6 illustrate the crowns and their application. The flap is then closed over the tooth and acts as a foreign body, causing erosion of the overlying tissue with ultimate exposure. At this time, the crown is removed

and conventional brackets or bonds are placed to continue the orthodontic manipulation. For many years, cervical neck wires were a popular technique to secure a tooth to allow for traction. The surgeon opened the area where the tooth was and removed the overlying bone and follicular

Fig. 7. Clinical application of cervical chain.

194

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

tissues. A small wire was placed around the neck of the tooth, and the tail of the wire or a gold chain attached to it was brought into the arch. This wire or chain could be tethered to an elastic, and the orthodontist could guide the tooth into the arch. Figs. 7 and 8 illustrate the clinical and radiographic findings in this technique. Unfortunately, the technical difficulty in securing the cervical wire coupled with the manipulation of the tooth have made this a difficult technique to use. In addition, cases of damage to the tooth secondary to erosion at the cementoenamel junction are reported in the literature.

Current techniques Despite the history of numerous procedures used in the past to manage impacted teeth, a review of the literature reveals two methods most commonly used to expose impacted teeth. Open techniques The first or the open technique is when the tooth is identified, uncovered, and left exposed to the oral cavity. An orthodontic bracket may or may not be

Fig. 8. Radiograph after cervical chain placement.

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

placed at the time of surgery. Good indication for this technique is in the palatally impacted canine. A window of the overlying gingiva and bone is removed and the tooth is exposed. At the time of surgery the wound may be packed open with gauze or periodontal dressings. In addition, a bracket may be bonded at that time. Fig. 9 illustrates an example of this technique. Studies have shown that the excision of overlying gingiva and bone to allow exposure of the impacted canine is sufficient to allow spontaneous eruption [22]. Apically repositioned flaps are the most desirable means to expose labial impactions [23]. They are especially useful when the maxillary canine teeth are impacted near the alveolus. The flap is raised and the bone overlying the majority of the crown of the tooth is removed with a sharp instrument. Bone should not be removed over the root surface to facilitate proper periodontal attachment as the tooth is brought into position. The flap is replaced and sutured apical to its original position. A bracket can be bonded at this time or may be attached at a subsequent appointment. The flap is shown in Fig. 10. By repositioning the flap apically, the surgeon is placing attached gingiva at the level of the cementoenamel junction of the canine, and with eruption of the tooth, the gingiva will be brought to the arch. This technique minimizes periodontal defects when the tooth is in the arch. It has been shown as a stable and periodontally sound method of crown exposure. Some authors, however,

195

have shown that when this technique is used instead of a closed technique, the patient will have a more unesthetic result [24]. Closed techniques Closed techniques are applicable when the tooth is not in position to allow for the repositioning of a flap and subsequent crown exposure. This is frequently used in palatal impactions that are not close to the alveolar process of the arch. In addition, where a canine tooth is impacted high on the buccal aspect of the maxilla or low relative to the occlusal plane of the mandible, this technique becomes a valuable means to provide exposure without periodontal compromise of the adjacent dentition. A full-thickness flap is raised and the impacted tooth is exposed and may be luxated. An orthodontic bracket is placed with a wire or chain brought from the impacted tooth to the arch. Fig. 11 shows the application of a bracket and the chain being brought to the arch through the incision. In cases where the tooth is distant from the arch, it may be necessary to penetrate the flap and bring the chain through the tissue to the arch wire [21].The flap is then sutured back into place, and the orthodontist can begin traction to mobilize the tooth after  1 week of soft tissue healing. The most common application for the closed technique is in management of palatally impacted canine teeth; however, when comparing the closed

Fig. 9. Open technique with bracket bonded to impacted tooth.

196

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

Fig. 10. (A) Apically repositioned flap with crown exposure. (B) Apically repositioned flap sutured in place.

technique with excision or gingivectomy, the latter technique offers certain advantages for the clinician. In his study of 104 patients comparing open and closed techniques, Pearson noted a doubling of complications, such as wire breakage or bond failure, in the closed technique. Complications in the open technique were primarily the need for reexposure of the tooth. They concluded that while both techniques were effective, simple exposure was a more reliable and easier procedure for the patient and the surgeon [25].] In one retrospective study of 72 patients treated

with open techniques, 5% required re-exposure [22].Only one study compared re-exposure with open and closed methods. Each technique was performed on 52 patients. Eight patients (15%) needed reexposure for gingival overgrowth with the open technique. With the closed method, however, 31% required a second procedure due to failure of eruption, bond failure, or fracture of ligature wires [25]. Overall periodontal evaluation of teeth brought to the arch by closed techniques compared to spontaneous eruption and orthodontic traction showed little differ-

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

197

Fig. 11. (A) Bracket bonded to impacted canine tooth in closed technique. (B) Gold chain being brought to the arch wire through the incision.

ence in the periodontal health of exposed tooth or adjacent tissues [26]. Only one study directly compared open and closed techniques for palatal impactions. The closed technique patient had deeper mean pocket depths, but attachment loss was greater in open technique patients. Neither was clinically significant [27]. In contrasting the two techniques, Iramaneerat found that there was no significant difference in

treatment time that could be demonstrated for palatally impacted canines using closed or open techniques [28]. Wisth found that the closed technique had longer orthodontic treatment time when all teeth were bonded immediately [27]. In contrast, Pearson showed a longer treatment time with the open technique when the tooth was allowed to spontaneously erupt for 6 months before bonding [25]. In a prospective study of 82 impacted maxillary canine teeth,

198

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199

Caminiti observed few problems with forced orthodontic traction. This study examined palatal closed techniques as well as apically repositioned flaps for buccal teeth [29,30].

Complications The surgical exposure of impacted teeth for orthodontic purposes is a challenging and technically tedious procedure. Moreover, postoperative management of these patients can provide a series of problems for the surgeon and the orthodontist. Inappropriate flap design can produce periodontal defects, particularly loss of adequate amounts of attached gingival tissue on the involved teeth. There can also be periodontal defects with bone loss and pocket formation adjacent to the surgical site from the procedure. In patients where the closed technique is used and the flap is repositioned, the bond of the bracket to the tooth may break and the chain becomes loose. This necessitates secondary surgical exploration with replacement of the bonded bracket. A large series of 155 patients showed 17% failure if the bracket was placed at operation [31].Moisture in the bonding process or inadequate light curing may cause this problem. Newer dental materials do not require absolutely dry fields to bond, but the problem still exits in some cases [32]. As orthodontic traction forces are applied to impacted teeth, it is difficult to predict or control the path of eruption. It is possible to damage the erupting tooth as well as the roots of the adjacent teeth. Root resorption or displacement of adjacent teeth also may be seen. In addition, the eruption of impacted teeth may cause root shortening [24]. A significant complication is ankylosis of the impacted tooth. Clinicians should consider the reason for impaction. When there is collapse of the arch due to premature exfoliation of deciduous dentition, it is easy to understand that lack of sufficient space may preclude the normal positioning of a tooth; however, when there is adequate space and the tooth does not erupt spontaneously, it may be ankylosed. The progress of eruption with the application of orthodontic forces should be followed carefully after surgery. After a reasonable amount of time and orthodontic force without movement, the tooth may be considered to be ankylosed. A significant dilaceration of the root of an impacted canine has been observed clinically to impair eruption. No studies could be found to document this concept. With application of forces on impacted teeth that are ankylosed, the surrounding

teeth in the arch will be intruded rather than the impacted tooth being extruded. It has been reported that during traction the tooth that is being repositioned can be damaged with subsequent ankylosis, root resorption, or pulpal necrosis. Older techniques, especially the use of cervical wires with chains, can cause erosion of the tooth structure in the area of the wire placement [33]. It is controversial whether or not a tooth should be luxated at the time of exposure. Some argue that the tooth should be gently moved within the bone to loosen any attachments and to determine if it is ankylosed. Others contend that luxation itself may induce ankylosis secondary to bleeding or inflammatory response.

Conclusions The surgical management of impacted teeth is a challenging problem for both the orthodontist and the oral and maxillofacial surgeon; however, exposure of impacted teeth with orthodontic alignment is a predictable and desirable procedure [34]. Treatment planning and close follow-up between the surgeon and orthodontist are the most important factors in the successful exposure and guided eruption of impacted teeth. Careful diagnosis and full discussion with the patient bring perspective to the problems that may be encountered during the course of treatment. Successful completion of the procedures will be beneficial in the salvaging of teeth that are important to provide orthodontic, functional, and esthetic stability for the patient.

References [1] Ricciani JF. Surgical exposure and orthodontic repositioning of an impacted mandibular premolar. J N J Dent Assoc 1999;70(3):42 – 5. [2] Schatz JP, Byloff F, Bernard JP, Joho JP. Severely impacted canines: autotransplantation as an alternative. Int J Adult Orthodon Orthognath Surg 1992;7(1):45 – 54. [3] Schatz JP, de Baets J, Joho JP. Intra-alveolar surgical uprighting of impacted teeth: a case report. Endod Dent Traumatol 1997;13(2):92 – 5. [4] Patrikiou AK, Katsavrias EG. Repositioning ankylosed maxillary canines by segmental osteotomy. J Clin Orthod 1995;29(10):625 – 8. [5] Mazor Z, Peleg M, Redlich M. Immediate placement of implants in extraction sites of maxillary impacted canines. J Am Dent Assoc 1999;130(12):1767 – 70. [6] Bass T. Observation on the misplaced upper canine tooth. Dent Pract Dent Rec Dental 1967;18(1):25 – 33.

A.L. Felsenfeld, T. Aghaloo / Oral Maxillofacial Surg Clin N Am 14 (2002) 187–199 [7] Johnson W. Treatment of palatally impacted canine teeth. Am J Orthod 1969;56(6):589 – 96. [8] Stellzig A, Basdra EK, Komposch G. The etiology of canine tooth impaction – a space analysis. Fortschr Kieferorthop 1994;55(3):97 – 103. [9] Jacobs SG. Palatally impacted canines: aetiology of impaction and the scope for interception. Report of cases outside the guidelines for interception. Aust Dent J 1994;39(4):206 – 11. [10] Jacobs SG. Reducing the incidence of unerupted palatally displaced canines by extraction of deciduous canines. The history and application of this procedure with some case reports. Aust Dent J 1998;43(1):20 – 7. [11] Brenchley Z, Oliver RG. Morphology of anterior teeth associated with displaced canines. Br J Orthod 1997; 24(1):41 – 5. [12] Jacobs SG. The impacted maxillary canine. Further observations on aetiology, radiographic localization, prevention/interception of impaction, and when to suspect impaction. Aust Dent J 1996;41(5):310 – 6. [13] Peck S, Peck L, Kataja M. The palatally displaced canine as a dental anomaly of genetic origin. Angle Orthod 1994;64(4):249 – 56. [14] Becker A, Gillis I, Shpack N. The etiology of palatal displacement of maxillary canines. Clin Orthod Res 1999;2(2):62 – 6. [15] Jacobs SG. Radiographic localization of unerupted maxillary anterior teeth using the vertical tube shift technique: the history and application of the method with some case reports. Am J Orthod Dentofacial Orthop 1999;116(4):415 – 23. [16] Jacobs SG. Localization of the unerupted maxillary canine: how to and when to. Am J Orthod Dentofacial Orthop 1999;115(3):314 – 22. [17] Chaushu S, Chaushu G, Becker A. The use of panoramic radiographs to localize displaced maxillary canines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88(4):511 – 6. [18] Preda L, La Fianza A, Di Maggio EM, Dore R, Schiffino MR, Campani R. The use of spiral computed tomography in the localization of impacted maxillary canines. Dentomaxillofac Radiol 1997;26(4):236 – 41. [19] Schmuth GP, Freisfeld M, Koster O, Schuller H. The application of computerized tomography (CT) in cases of impacted maxillary canines. Eur J Orthod 1992; 14(4):296 – 301. [20] Stivaros N, Mandall NA. Radiographic factors affecting the management of impacted upper permanent canines. J Orthod 2000;27(2):169 – 73.

199

[21] Kokich VG, Matthews DP. Surgical and orthodontic management of impacted teeth. Dent Clin North Am 1993;37(2):181 – 204. [22] Ferguson JW, Parvizi F. Eruption of palatal canines following surgical exposure: a review of outcomes in a series of consecutively treated cases. Br J Orthod 1997;24(3):203 – 7. [23] Lawton H, Sandler PJ. The apically repositioned flap in tooth exposure. SADJ 1999;54(9):423 – 6. [24] Vermette ME, Kokich VG, Kennedy DB. Uncovering labially impacted teeth: apically repositioned flap and closed-eruption techniques. Angle Orthod 1995;65(1): 23 – 32. [25] Pearson MH, Robinson SN, Reed R, et al. Management of palatally impacted canines: the findings of a collaborative study. Eur J Orthod 1997;19(5):511 – 5. [26] Hansson C, Rindler A. Periodontal conditions following surgical and orthodontic treatment of palatally impacted maxillary canines – a follow-up study. Angle Orthod 1998;68(2):167 – 72. [27] Wisth PJ, Norderval K, Booe OE. Comparison of two surgical methods in combined surgical-orthodontic correction of impacted maxillary canines. Acta Odontol Scand 1976;34(1):53 – 7. [28] Iramaneerat S, Cunningham SJ, Horrocks EN. The effect of two alternative methods of canine exposure upon subsequent duration of orthodontic treatment. Int J Peaediatr Dent 1998;8(8):123 – 9. [29] Burden DJ, Mullally BH, Robinson SN. Palatally ectopic canines: closed eruption versus open eruption. Am J Orthod Dentofacial Orthop 1999;115(6): 640 – 4. [30] Caminiti MF, Sandor GK, Giambattistini C, et al. Outcomes of the surgical exposure, bonding and eruption of 82 impacted maxillary canines. J Can Dent Assoc 1998;64(8):572 – 79. [31] Becker A, Shpack N, Shteyer A. Attachment bonding to impacted teeth at the time of surgical exposure. Eur J Orthod 1996;18(5):457 – 63. [32] Nordenvall KJ. Glass ionomer cement dressing for surgically exposed impacted teeth. J Clin Orthod 1999; 33(1):45 – 9. [33] Vanarsdall RL, Corn H. Soft-tissue management of labially positioned unerupted teeth. Am J Orthod 1977;72(1):53 – 64. [34] Blair GS, Hobson RS, Leggat TG. Post-treatment assessment of surgically exposed and orthodontically aligned impacted maxillary canines. Am J Orthod Dentofacial Orthop 1998;113(3):329 – 32.

Oral Maxillofacial Surg Clin N Am 14 (2002) 201 – 212

Surgical uprighting of second molars: rationale and technique Stuart Dessner, DMD Affiliated Oral & Maxillofacial Surgeons, Ltd., 3438 North Old Arlington Heights Road, Arlington Heights, IL 60004, USA

Orthodontists have long struggled with the challenge of uprighting mesially inclined second molars. The malpositioned second molar often goes unnoticed until roots have developed and orthodontic care is nearing completion. If the tooth is still submerged, the placement of conventional orthodontic attachments is restricted by soft tissue, leading to a surgical procedure. Control of second molar eruption and occlusion are implicit in the general standard of orthodontic care. According to the American Board of Orthodontics, second molars are an integral part of completed dental and skeletal treatment. Completed orthodontic treatment includes properly aligned second molar occlusion. When mesially tipped second molars are present, finishing orthodontic therapy can be problematic. In this chapter, a case is made for taking early action and making appropriate surgical referral for managing the mesially tipped, impacted mandibular second molar. Conventional orthodontic techniques for molar uprighting are sometimes difficult, uncomfortable, rely on patient cooperation, and may add months to treatment time. In contrast, surgical uprighting techniques are capable of correcting this problem and provide an important surgical service to orthodontic patients. The orthodontic approach is described in the literature [1,2]. All orthodontic uprighting techniques and appliances require at least partial eruption of the second molar. Since normal eruption is actually part of the clinical problem, orthodontic techniques can be limited. That is, at the time when orthodontic molar uprighting can facilitate treatment, the crown of the

E-mail address: [email protected] (S. Dessner).

mandibular second molar is only partially available to conventional orthodontic bands or brackets. To make matters worse, the issue of the mandibular second molar often becomes relevant when orthodontic therapy is nearing completion. Patient compliance may be difficult at this stage of treatment because most other alignment problems have been resolved. In affected cases, the second molars are not under appliance control and the soft tissue covering of the unerupted tooth is sensitive to manipulation, wire, and bracket placement. Treatment time is an important factor in management of impacted second molars. A mildly impacted second molar may be corrected with fixed appliances within six to nine months, whereas a severely impacted molar may need 9 – 12 months or more for resolution. In addition, since second molars are the last teeth to erupt into the lower arch (except for third molars), many times the impaction is not discovered until the final stages of active treatment. At a late stage of treatment, the orthodontist must decide how to correct the problem within an acceptable period of time. Failure of timely second molar alignment may result in a number of unfavorable sequeale. For instance, the opposing maxillary second molar may super-erupt, thereby decreasing the amount of space available to upright the lower molars. Overerupted maxillary molars may introduce occlusal interferences. These interferences could result in temporomandibular joint symptoms. Furthermore, continued root development of the impacted second molar may prevent orthodontic correction. Some practitioners have planned cases for elective second molar extraction in anticipation that the third molar will develop and erupt into the position pre-

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 2 - X

202

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

viously occupied by the second molar. This approach is somewhat controversial and dependent on the unpredictable nature of third molar development. This decision needs to be made before the roots of the third molar form, which often occurs before an impacted second molar is found. An inclined second molar, if left untreated, provides a mesially inclined environment that promotes caries at the distal of the first molar and the mesial of the second molar. In addition, the embrasure between the first molar and mesially tipped second molar is prone to periodontal disease. Considering the unreliable eruption of the third molar, not treating the tipped second molar may eventually lead to the loss of the first, second, and third molars. The standard of care with respect to the second molar is defined by the following: 1. 2. 3. 4.

Upper and lower second molars in occlusion Proper axial inclination Angle class I position Proper buccal/lingual positioning

The general dentist expects to have all erupted teeth in occlusion after orthodontic treatment. Furthermore, when alignment of teeth promises future pathology, orthodontic management can be questioned. It would be unacceptable to leave an impacted second molar untreated because of the potential for loss of the first second and third molars. Expectations of the general dentist also includes that the finished orthodontic product must promote dental health without damaging adjacent local structures, the temporomandibular joint, or the periodontium. The incidence of second molar impaction has been reviewed by several investigators. Dachi and Howell (1961) reviewed nearly 3874 patients and found 16.7% with impactions, but no second molar impactions were found in their study. Kramer and Williams (1970) reviewed 3745 patients demonstrating an 18.2% impaction rate, of which 95% were third molar impactions. Again, no incidence of second molar impaction was reported. Aitasalo et al. (1972) reported on 4063 cases with 14.1% incidence of impaction. They reported no incidence of second molar impaction. Mead reported that in 89.7% of 1462 cases reviewed, 89.7% showed third molar impactions. Second molar impaction incidence was 0.4% (4/1000). Grover reported a 0.03% (3/10,000) incidence of second molar impaction in his review of 5000 Pantographs of Army recruits. In the authors experience the clinical incidence of the mesially tipped second molar in the orthodontic population of suburban Chicago approaches 3 per

1000 patients. This represents a nearly 10-fold increase in incidence compared to the studies cited in this section. The substantial difference in these findings may be due to demographics of the area and population studied. Patients in this high socioeconomic group have excellent dental health. The dental care received by these patients results in maximum preservation of tooth mass, which leads to more posterior arch crowding (primary and adult dentition). The importance of a well-maintained primary dentition in the etiology of molar crowding is significant. Children in higher socioeconomic strata have a healthy primary dentition with a normal exfoliation pattern. Therefore, less dental crowding occurs anterior to the eruption site of the second molar, and the maximum amount of arch length is used to accommodate anterior eruption patterns. Available posterior arch length is minimized. Therefore, children in this group are more likely to be candidates for crowding of the second molar. Mead, Grover, and others may have examined a population with different clinical characteristics than seen in our experiences.

Etiology The etiology of the mesially tipped second molar is multifold. Slow or inadequate resorption of the anterior border of the mandibular ramus causes lack of arch length development in the posterior portion of the dental arch. To date, however, no study has directly correlated mandibular horizontal deficiency with posterior molar crowding or mandibular second molar tipping. When the second deciduous molar is lost, the first molar must move forward in the arch to accommodate second molar eruption. If this movement does not occur, the pattern of eruption of the second molar may be compromised, leading to tipping. That is, insufficient movement of the first molar after exfoliation of the primary second molar results in loss of space maintained by the primary deciduous second molar. This space is destined to be utilized by forward movement of the permanent first molar. When mandibular first molar mesial movement does not follow loss of the mandibular deciduous second molar, posterior dental crowding may be the result. Factors of tooth mass and excessive mesial inclination of the molar buds may also play a role in developing mesial tipping. When the developing third molar bud infringes upon the space required by the second molar bud, disturbances in eruption will follow (Fig. 1).

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

203

Fig. 1. Note the high position of the third molar buds and the position of the anterior ramus.

The bud of the third molar appears situated above and behind the bud of the second molar. When the spatial relationship of these two tooth buds orients the third molar bud above and slightly overlapping the second molar bud, mesial tipping of the second molar can occur (Fig. 2). Another potential cause is too much distance between the first and second molars buds (Fig. 3). The second molar eruption pattern may lack guidance of the first molar root surface when the distance between these developing teeth is too great. This similar situation is also seen when erupting cuspids do not have guidance from the root surface of adjacent lateral incisors (Fig. 4).

Iatrogenic causes of mesially impacted second molars deserve brief discussion. Ill-fitting first molar bands often impede the eruption of the second molar. The mesial marginal ridge of the erupting second molar gets caught on the inferior edge of an overcontoured first molar band. Early lip bumper therapy and early treatment of the lower arch tend to use space that would otherwise be available for second molar eruption. In addition, if separators are not consistently placed on each side of the mandibular arch, unequal use of space can lead to second molar impaction. The characteristics of impacted mandibular second molars are that more impactions are unilateral than bilateral. They occur more commonly in the

Fig. 2. The same patient with tipping and impaction of the second molars.

204

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

Fig. 3. Note the spacing between the developing second molar and the distal root of the first molar. The second molar leans into the root surface of the first molar.

mandible than in the maxilla and more in males than in females. Right-sided impactions are more common and mesial tipping is more common than distal tipping.

Clinical indications Clinical indications for uprighting tipped second molars are, as noted above, that architectural problems caused by improper posterior dental alignment leads to difficulties with oral hygiene. Periodontal pocketing, bone loss, and decay of both the first and second molars can be expected without treatment.

These factors, coupled with unpredictable third molar eruption patterns, could result in loss of all three molars in the quadrant. The decision to surgically upright a second molar is usually made by the orthodontist. The degree of impaction and tooth eruption determine whether an orthodontic, a combined, or a surgical approach is to be used for treatment. The orthodontic approach involves various uses of separating wires, helical springs soldered to the distal end of a lingual arch, partial loop springs from the distal end of a conventional arch wire, pins inserted into the buccal surface of the second molar crown, uprighting springs, attachment of wire loops, and attachment

Fig. 4. Demonstrates lack of space between the anterior ramus and the distal of the first molar and a high position of the third molar bud.

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

205

Fig. 5. An example of a fixed orthodontic uprighting appliance.

of buccal tubes, brackets, or buttons in conjunction with soldered auxiliaries (Fig. 5). All these appliances require the adequate coronal eruption of the second molar. A combined orthodontic and surgical approach involves the surgical exposure of the second molar crown with apical repositioning of the soft tissue. Osseous recontouring is often necessary around the crown of the tipped tooth. Direct bonded attachments are made at the time of surgery (Figs. 6 and 7), or the wound is packed open so that direct bonding procedures can be accomplished later. The orthodontic approach and the combined surgical/orthodontic approach is complicated by rapid

soft tissue healing over the appliance, inflammation, and patient discomfort. List 1: Surgical solutions for the inclined second molar 1. Extraction of the second molar to allow the third molar to erupt into the second molar position 2. Transplantation of the third molar into the second molar site 3. Extraction of the second and third molars and placement of a dental implant 4. Extraction of the third molar and surgically uprighting the second molar

Fig. 6. Surgical exposure with placement of orthodontic attachment.

206

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

Fig. 7. Typical presentation of the mesially tipped mandibular second molar.

The erratic eruption of third molars mitigates against removing the second molar and allowing the third molar to move forward into the vacated space. More often, the third molar will appear tipped and will not erupt favorably. The frequent result of this approach is a malposed third molar in the second molar site. A more practical surgical approach moves the impacted tooth bodily from its tipped position to a corrected position with proper vertical axis orientation. The timing for the surgical procedure is important. The procedure is most successful when the second molar is stable after being moved to its new position. Its stabilization between the buccal and lingual cortical plates of the alveolus is as important

for healing as the wedging effect between the distal marginal ridge of the first molar and the distal bone. The procedure is best done after two thirds of root development is completed. At this stage, risk of root fracture is minimal. Performing this procedure when less than two thirds of root development has been completed could result in the second molar floating within its new position. This procedure has been used when root development has been completed. The physical movement of the second molar does not appear to adversely affect root morphology. In 1956, Holland described a technique for surgical repositioning of unerupted teeth, which he termed ‘‘surgical orthodontics.’’ Holland used this technique mainly on canines, premo-

Fig. 8. Surgical exposure with bone removed from the mesial buccal line angle.

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

207

Fig. 9. Straight elevator used to apply redressment force.

lars, and central incisors. He warned that the age of the patient and the stage of root development were important limiting factors because as the apical foramen closed with age, it restricts blood supply to the pulpal tissue. He reasoned that if the surgery is performed on a tooth with completely formed roots, then necrosis would be the most likely outcome due to strangulation of the apical blood vessels. He also observed increased calcification in the pulp chambers of repositioned teeth [3]. In 1976 Davis et al. reported on 21 mesially inclined, partially impacted mandibular second molars. Davis questioned the validity of case selection on the basis of age or root maturity, since patients in his study ranged from 10 to 17 years,

an age span that encompasses all stages or root development [2]. This author reviewed panographic radiographs of 34 impacted mandibular second molars in patients referred by the orthodontic office for surgical uprighting. All patients received similar surgical procedures by the same oral surgeon. The surgical procedure is described as follows: An incision is made along the ascending ramus along the external oblique line of the mandible. The incision begins  1 cm behind the eruption site of the second molar and continues anteriorly to the distal of the first molar and then around that tooth to its mesial buccal line angle. A full-thickness flap is created with a periosteal ele-

Fig. 10. Sutures in place.

208

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

Fig. 11. Healed position of the uprighted tooth.

vator. The bone overlying the impacted third molar is removed with a rotary instrument, and the third molar is sectioned and removed. Removing bone over the mesial buccal line angle of its crown exposes the mesially inclined second molar (Fig. 8). A straight elevator is then used to apply continuous, judicious, redressment force using the buccal bone as a fulcrum (Fig. 9). Bone distal to the second molar becomes compressed in the process. Elevation continues until the distal marginal ridge of the first molar and the mesial marginal ridge of the second molar are level.

Where necessary, bone previously removed distal to the second molar can be wedged on the mesial surface of the uprighted tooth if stability is a concern. Most upright second molars, however, self-stabilize in the surrounding bone. Sutures are placed at the mesial and distal of the second molar (Fig. 10). Finally, a panorex film is taken to evaluate the postoperative position (Figs. 11 – 13). In each case, care is taken to instrument the second molar above the CEJ. The integrity of the periodontal ligament and the root surface are not violated. This precaution

Fig. 12. (A) Nearly horizontal second molar with delicate root form uprighted with a low axis of rotation. (B) Uprighting did not damage root structure. Orthodontic bracket placed at the time of surgery for control of root torque. (C) Lamina dura and cortical bone in the area of healing. Note correction of root torque.

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

209

Fig. 12 (continued ).

is thought to play a role in avoiding external root resorption and ankylosis. Each of the uprighted teeth were evaluated by comparing presurgical, immediate postsurgical, and follow-up panorex films. The follow-up radiographs were taken in a range of six months to four years after surgery. These radiographs were evaluated for presence of a periodontal ligament space, presence of lamina dura, pulp integrity, continuation of root development, position of the tooth as compared with the immediate postoperative film, and presence or absence of pathology. The findings of this retrospective analysis revealed that all stages of root development were represented. In all cases, favorable marginal ridge relationships

between the first and second molar were obtained. Thirty-one of the thirty-four cases demonstrated complete bony fill of the area formerly occupied by the crown of the uprighted tooth. All periodontal success criteria were met (ie, bone levels reached the CEJ), a lamina dura was evident, contiguous structures were normal, and there was absence of pathology. The remaining three cases showed bone levels just slightly below the CEJ. One of thirty-four teeth showed the absence of a PDL, which may be attributed to improper x-ray technique. Root development was considered normal in all but three of the cases. Three cases showed dilacerations of the apical third of the roots. One case, completed after one half of root development occurred,

210

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

Fig. 13. (A) Third molar bud will physically impede the upprighting procedure. Mesially tipped second molar with near complete root development. (B) Bone crypt formed by previous position of second molar crown plus follicle. (C) Bone healing noted on one-year follow-up demonstrating a healthy PDL, apex maturation, and lamina dura. Note calcification of pulp chamber and narrowing of pulp canals.

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

showed a lack of root development in the final x-rays. Therefore, uprighting should be considered only after two thirds to three fourths of root development has been completed. Pulpal changes were noted in 12 of the cases reviewed. These changes consist of calcifications and narrowing of the pulp chambers and canals. No evidence of internal or external resorption or apical pathology was noted. The position of all uprighted teeth reviewed remained stable. It is evident from the findings of this and other studies that surgical repositioning of malposed, impacted second molars is a feasible, reliable, and valuable technique. Long-term postoperative radiographic evaluation of surgically uprighted second molars demonstrates repair of the osseous defects with new bone, minor pulpal changes, and a healthy periodontium. The fact that some of these molars exhibit internal calcifications attests that they are vital and that secondary dentin deposition is taking place. This is further supported by the absence of periapical pathology, which would follow pulp necrosis. Therefore, risk of loss of pulpal vitality appears minimal after this type of surgery. Should devitalization occur, a functional, endodontically treated natural tooth is preferable to an artificial replacement. This study also demonstrates a very low risk of ankylosis after surgical uprighting of impacted mandibular second molars. Ankylosis can be circumvented by not disturbing the PDL space or root surface during the surgical procedure. It has been suggested that the periodontal ligament possesses inhibitory properties with respect to ankylosis. Injuries to the PDL, such as those seen after certain accidents and experimental or clinical procedures, have been shown to result in ankylosis. As long as the PDL remains viable, repair of the periodontium is possible since the ligament contains precursor or stem cells for cementum and bone. Moreover, the PDL protects the root from resorption and ankylosis to the bone. Therefore, care should be taken to maintain an intact PDL during this surgical procedure. Most of the uprighted teeth were found to be highly stable in their newly acquired position after surgery. There was no need for stabilizing techniques in this group. Since three of the teeth did experience a positional change, however, it might have been prudent to stabilize them with an orthodontic bracket and arch wire after surgery. This would also allow for orthodontic finishing of the tooth position after surgical healing (six to eight weeks). As with every surgical procedure, candidates for uprighting procedures should be properly informed

211

and give their consent before surgery. The uprighting procedure should be discussed with the following risk factors: 1. The risk of no treatment is a formidable problem. Patients should be made aware of the possibility of losing three teeth if no treatment is undertaken. That is, the periodontal status of the first and second molars is poor as a result of the architectural predilection to infection and subsequent bone loss. Furthermore, attendant difficulties with hygiene will make the area prone to decay and acute periodontal disease. Poor alignment of the mandibular second molar will cause supereruption of the maxillary second molar. The occlusal implications of this arrangement are significant and deserve some discussion. Lack of treatment will certainly have a negative effect on the prognosis of the mandibular first, second, and third molars and the maxillary second molar. 2. Risk of root injury to the second molar during uprighting should be explained as follows: Root injury can be caused by loss of vitality or physical injury to the root or root surface. A delicate root in well-calcified bone can be fractured in the process of moving the tooth to its new position. Furthermore, the movement can strangulate a small artery that normally supplies the tooth with nutrients. It is possible that an uprighted tooth will require endodontic therapy sometime after the uprighting surgery. In the worst-case scenario, the second molar will be lost secondary to internal root resorption. This author has never observed internal or external root resorption in teeth that have been uprighted. 3. External resorption or absence of bony fill of the bony crypt formerly occupied by the crown of an impacted second molar is a concern. Patients should be informed of a potentially adverse reaction in the periodontal ligament space that can cause proliferation of ‘‘-clastic’’ instead of ‘‘-blastic’’ cells. This unexpected reaction could destroy root structure and lead to tooth loss. If bone fill does not occur as expected, the resultant periodontal defect will require grafting at best and tooth loss at worst. It is clear that the risk-to-benefit ratio for most patients favors the surgical procedure. In fact, in view of the high success rate for this procedure, third molars can generally be recommended for extraction

212

S. Dessner / Oral Maxillofacial Surg Clin N Am 14 (2002) 201–212

at the same time. The third molar often occupies the space needed for coronal positioning of the second molar during the uprighting process and, therefore, must be removed. Based on the number and proportion of successful cases documented by this author and others, surgical uprighting of mesially inclined impacted mandibular second molars merits consideration as a feasible alternative in the management of these teeth.

References [1] Lang R. A simple technique for uprighting partially impacted molars. Ont Dent 1991;68:34 – 8. [2] Davis H. Patakas B, Kaminishi R, Parsch N. Surgically uprighting and grafting mandibular second molars. Am J Orthod Dentofac Orthodp 1976;69:555 – 61. [3] Holland D. The surgical positioning of unerupted teeth (surgical orthodontics). Oral Surg 1956;9:130 – 40.

Oral Maxillofacial Surg Clin N Am 14 (2002) 213 – 229

Suturing principles in dentoalveolar surgery W. Scott Jenkins, DMD, M. Todd Brandt, DDS, Jeffrey B. Dembo, DDS, MS* Department of Oral and Maxillofacial Surgery, University of Kentucky, D-508 College of Dentistry, 800 Rose Street, Lexington, KY 40536 USA

Introduction One of the most important aspects of dentoalveolar surgery is adequate closure of the surgical wound. To ensure proper healing, there must be proper positioning of the soft tissues closest to their original position in a stable fashion, with the least amount of tension. Closure in this fashion decreases fibrous scarring, decreases the risk for infection, provides enhanced cosmesis, and facilitates hemostasis. The variety of suture material available is expansive, and many companies manufacture sutures with seemingly unlimited sizes, needle designs, and materials. Oral and maxillofacial surgeons have traditionally selected sutures on the basis of materials that were available during residency training. A decision made in this manner, however, may overlook the distinct physical properties of a given suture or its effect on the surrounding tissues. This chapter focuses on the physical properties of suture materials and their tissue reactivity, and it reviews various suturing techniques used in contemporary dentoalveolar surgery.

Suture material A suture is a strand of material used to ligate vessels and reapproximate lacerated or incised tissue. Evidence of suture use dates back to 50,000 BC [1]. Materials historically used have included linen, horse hair, hemp, flax, silkworm gut, kangaroo tendon, umbilical tape, ligament, cotton, iron wire, bark

* Corresponding author. E-mail address: [email protected] (J.B. Dembo).

fibers, stainless steel, gold, and silver [1 – 3]. Synthetic fibers, such as nylon and polyester, first appeared in the 1940s [2]. Polyglycolic acid (Dexon) and polyglactin 910 (Vicryl) were developed in the early 1970s and polydioxanone (PDS) was introduced in the 1980s [2]. Suture materials are classified by performance, size, and physical configuration. Suture performance is categorized as either absorbable or nonabsorbable. The United States Pharmacopeia (USP) and the European Pharmacopeia (EP) govern the size or diameter of sutures and needles and prescribe the minimum and maximum standards and the diameter tolerances to which each manufacturer must adhere [4]. Physical configuration describes whether the suture is a monofilament or in braided, multifilament form [1,3,5]. The various suture characteristics all contribute to tissue reactivity, breaking strength, tensile strength, breaking strength retention, knot security, extensibility, memory, and absorbability [1,2,5 – 15]. A thorough knowledge of these properties is essential for the selection and proper use of the most appropriate suture for a specific clinical use. Ideally, suture material should persist and retain adequate tensile strength after surgery, until healing has reached a stage at which wound separation is unlikely to occur [1,2,5 – 15]. The chosen material should have easy handling qualities and excellent knot security [1,2,5 – 15]. The material should not impede healing or elicit an inflammatory response or toxic effect [3,5,10 – 16]. Ideal sutures should also be affordable, available, easily sterilized, and nonconducive to bacterial growth [2]. Surgeons should also be able to predict the absorbtion or encapsulation of the suture in the tissue [1,2,8]. No single ideal suture material exists, so surgeons must choose a suture

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 2 1 - 3

214

Table 1 Characteristics of absorbable suture material Types

Raw material

Tensile strength

Absorption rate

Tissue reaction

Surgical gut

Plain

Collagen derived from healthy beef and sheep

Individual patient characteristics can affect rate of tensile strength

Absorbed by proteolytic enzymatic digestive process

Moderate reaction

Contraindications

Being absorbable, should not be used where extended approximation of tissue sunder stress is required; should not be used in patients with known sensitivities or allergies to collagen or chromium Surgical gut Chronic Collagen derived Individual patient Absorbed by Moderate reaction Being absorbable, should from healthy beef characteristics can proteolytic not be used where extended and sheep affect rate of enzymatic approximation of tissue tensile strength digestive process sunder stress is required, should not be used in patients with known sensitivities or allergies to collagen or chromium Minimal acute Being absorbable, should Polyglactin 910 Braided Copolymer of lactide  75% remains Essentially complete Vicryl (Ethicon) Monofilament and glycolide coated at 2 wk;  50% between 56 and 90 d. inflammatory reaction not be used where extended Absorbed by approximation of tissue with Polyglactin 370 remains at 3 wk hydrolysis is required and calcium stearate Polyglycolic acid Braided Polyglycolic acid  65% remains Essentially complete Minimal acute Being absorbable, should Dexon (USS/DG) Braided Polycaprolate coating at 2 wk;  35% between 60 and 90 d; inflammatory reaction not be used where extended absorbed by hydrolysis approximation of tissue (coated) system (copolymer of remains at 3 wk glycolide and is required e-caprolactone)

Frequent uses General soft tissue approximation and/ or ligation

General soft tissue approximation and/ or ligation

General soft tissue approximation and/ or ligation General soft tissue approximation and/ or ligation

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Suture

Table 2 Characteristics of absorbable suture material Absorption rate

Tissue reaction

Poliglecaprone 25 Monofilament Copolymer of Monocryl (Ethicon) glycolide and e-caprolactone

Complete at 91 – 119 days; absorbed by hydrolysis

Minimal acute Being absorbable, should inflammatory reaction not be used where extended approximation of tissue under stress is required; undyed not indicated for use in fascia

Polydioxanone PDS II (Ethicon)

Slight reaction Minimal until  90th day. Essentially complete between 18 and 30 mo. Absorbed by slow hydrolysis

Polyglyconate Maxon (USS/DG)

Types

Raw material

Tensile strength

 50% – 60% (violet: 60% – 70%) remains at 1 wk;  20% – 30% (violet 30% – 40%) remains at 2 wk; lost within 3 wk (violet: 4 wk) Monofilament Polyester polymer  70% remains at 2 wk;  50% remains at 4 wk;  25% remains at 6 wk

Monofilament Polyglyconate

 75% remains at 2 wk;  65% remains at 3 wk;  25% remains at 6 wk

Essentially complete by 6 mo. Absorbed by slow hydrolysis

Slight reaction

Contraindications

Frequent uses General soft tissue approximation and/or ligation; not for use in cardiovascular or neurological tissues, microsurgery, or ophthalmic surgery

All types of soft tissue approximation, including pediatric cardiovascular and ophthalmic procedures; not for use in adult cardiovascular tissue, microsurgery, and neural tissue All types of soft tissue Being absorbable, should not be used where prolonged approximation; not for use in adult cardiovascular approximation of tissues tissue, microsurgery, under stress is required; and neural tissue should not be used with prosthetic heart valves or synthetic grafts

Being absorbable, should not be used where prolonged approximation of tissues under stress is required; should not be used with prosthetic heart valves or synthetic grafts

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Suture

215

216

Table 3 Characteristics of nonabsorbable suture material Types

Raw material

Tensile strength

Absorption rate

Tissue reaction

Contraindications

Frequent uses

Silk suture

Braided

Organic protein called fibroin

Progressive degradation of fiber may result in gradual loss of tensile strength over time

Gradual encapsulation by fibrous connective tissue

Acute inflammatory reaction

Should not be used in patients with known sensitivities or allergies to silk

Nylon Suture Ethilon (Ethicon) Dermalon (USS/DG)

Monofilament

Long-chain aliophatic polymers Nylon 6 or Nylon 6,6

Gradual encapsulation by fibrous connective tissue

Minimal inflammatory reaction

Should not be used where permanent retention of tensile strength is required

Polyester fiber suture Mersiline (Ethicon) Dacron (USS/DG)

Braided Monofilament

Poly (ethylene terephthalate)

Progressive hydrolysis may result in a gradual loss of tensile strength over time No significant change known to occur in vivo

General soft tissue approximation and/or ligation, including cardiovascular, ophthalmic, and neurological procedures Same

Minimal inflammatory reaction

None known

Same

Polypropylene suture Prolene (Ethicon) Surgiline (USS/DG)

Monofilament

Isotactic crystalline steroisomer of polypropylene

Gradual encapsulation by fibrous connective tissue Nonabsorbable

Minimal inflammatory reaction

None known

Same

Not subject to degradation or weakening by action of tissue enzymes

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Suture

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

217

material that will satisfy the majority of the aforementioned qualities.

Physical properties The physical properties of sutures must be reviewed before discussing individual suture characteristics. Tissue reactivity. Sutures are foreign bodies that elicit an inflammatory response. Tissue reaction can be slight, minimal, or severe [1,2,8 – 16]. Specific perisutural cellular and enzymatic changes vary with each suture material [16]. Breaking strength. Breaking strength is the maximum force applied to a suture at the point of breaking or disruption [5]. Tensile strength. Tensile strength is the ratio of the maximum load a suture can withstand without breaking while being stretched (breaking strength) to the original cross-sectional area of the given material [5,7]. The suture will first deform and then return to the original size or shape when stresses less than the tensile strength are applied and then removed [5,7]. Tensile strength is measured in units of force per unit area [5,7]. Breaking strength retention. Breaking strength retention is a measure of the tensile strength retained by a suture in vivo over time [5,7]. This is typically measured as a percent loss of the tensile strength calculated on the basis of perimplantation tensile strength [5,7].

Fig. 1. Degree of needle curvature: (1) 1/4 circle, (2) 3/8 circle, (3) 1/2 circle, (4) 3/4 circle. (From Peterson LJ, senior editor. Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 54.)

Fig. 2. Cross-sectional diagrams of needles used in dentoalveolar surgery. (left) Conventional. (right) Reverse cutting, regular cutting. (From Peterson LJ, senior editor. Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 54.)

Knot security. Knot security is defined as the force applied to a looped (knotted) suture at the point of knot slippage or disruption [5,7,8]. Extensibility. During closure of a wound, sutures will inevitably stretch during knot tying [5,8]. This ‘‘give’’ in the suture varies for each material; as a surgeon becomes familiar with a suture material’s extensibility, his or her knot-tying ability improves with less breakage of that suture material [5,8]. Memory. Most materials used in dentoalveolar surgery have memory — the tendency to not lay flat but to return to an original shape set by the material’s manufacturing processing or packaging [5]. This must be remembered during wound closure and knot tying. Absorbable sutures. The United States Pharmacopea (USP) defines an absorbable suture as a ‘‘flexible strand prepared from collagen derived from healthy mammals, or from a synthetic polymer. It is capable of being absorbed by living mammalian tissue, but may be treated to modify its resistance to absorption. It may be impregnated or treated with a suitable coating, softening, or antimicrobial agent. It may be colored by a color additive approved by the Food and Drug Administration (FDA).’’ [4] Nonabsorbable sutures. The United States Pharmacopea (USP) defines a nonabsorbable suture as a ‘‘flexible strand of material that is suitably resistant to the action of living mammalian tissue. It may be impregnated or treated with a suitable coating, softening, or antimicrobial agent. It may be colored by a color additive approved by the Food and Drug Administration (FDA).’’ [4]

218

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Fig. 3. Common tissue forcep, single-toothed Adson, 3 inches. (From Peterson LJ, senior editor. Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 90.)

Monofilament sutures. Monofilament sutures are made of a single strand or filament [1,3,5]. Multifilament sutures. Multifilament sutures are made of several braided or twisted strand or filaments [1,3,5].

Biologic response to suture materials Regardless of their physical composition, all sutures implanted in the human body act as foreign

bodies [1 – 3,5,6,9 – 16]. Intraoral placement of sutures produces a distinctly different inflammatory response than that witnessed elsewhere in the body [16]. Confounding factors in the oral cavity include humidity and an indigenous flora, which increase the likelihood for bacterial migration along the suture, resulting in infection [14,16]. Natural absorbable sutures are generally digested by enzymatic and macrophage activity [14,15]. This produces a greater degree of tissue reaction than the breakdown of synthetic absorbable sutures, which occur by hydrolysis [3,16]. Water

Fig. 4. Common needle driver, Hegar-Mayo type, 6 inches. (From Peterson LJ, senior editor. Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 97.)

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

gradually penetrates the synthetic suture, causing a breakdown in the polymer chain [3,16]. Some generalities exist regarding suture tissue reactivity [1]. Multifilament sutures elicit a greater inflammatory response than monofilament sutures

219

[2]. Polypropylene and steel elicit the least inflammatory response, while nylon, polyester, cotton, and silk all cause an increased tissue response, respectively [1,2]. Histological analysis demonstrates discrete temporal phases of tissue reactivity around

Fig. 5. Proper hand positioning of ringed instruments. (From Peterson LJ, senior editor. Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 99.)

220

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Fig. 6. Proper relationship between needle and needle driver. (From Peterson LJ, senior editor, Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 100.)

sutures [16]. Selvig et al found distinct concentric perisutural zones after histological processing and analysis [16]. An acute phase response of neutrophil infiltration was observed up to 3 days, mainly reflecting the initial surgical trauma and suture placement [16]. This response was comparable in all suture materials tested [16]. The neutrophilic infiltration is soon replaced by chronic cellular infiltrates, including

monocytes, plasma cells, and lymphocytes [13]. These stages of tissue reactivity serve to remove cellular debris and suture material [13]. Peak tissue reaction occurs between the second and seventh days [16]. Theoretically, under favorable healing conditions, this acute phase should be replaced by the formation of granulation tissue and a relative absence of inflammatory cells [16]. Progressive inflammatory

Fig. 7. Common suture scissor, Deans scissor with offset serrated blades, 7 inches. (From Peterson LJ, senior editor, Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 101.)

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

reactions caused by sutures may persist for as long as 7 to 14 days, however [16]. Bacterial migration along the suture tract has been documented [2,3,16]. Although braided suture has been reported to promote bacterial retention and growth because of its physical composition, Selvig et al found bacterial plaque migration extending more than 1000 mm into suture channels at 14 days regardless of the suture material tested, except for gut, which had rapidly dissipated by this time [16]. Sutures that

221

remain in intraoral wounds, such as silk, will cause epithelial tracts, thereby increasing the propensity for bacterial migration [16]. Thus, in general, sutures should be removed no later than 7 to 10 days [16]. It is important to note that the loss of tensile strength and rate of absorption are separate and distinct phenomena [3]. Sutures may rapidly lose adequate tensile strength but be absorbed slowly or vice-versa. Fever, infection, or protein-deficient states may accelerate the absorption process and cause an

Fig. 8. Most intraoral sutures are tied with instrument tie. A, Suture is pulled through tissue until short tail of suture (approximately 1½ to 2 inches long) remains. Needle holder is held horizontally by right hand in preparation for knot-tying procedure. B, Left hand then wraps long end of suture around needle holder twice in clockwise direction to make two loops of suture around needle holder. C, Surgeon then opens needle holder and grasps short end of suture near its end. D, Ends of suture are then pulled to tighten knot. Needle holder should not pull at all until knot is nearly tied, to avoid lengthening that portion of suture. E, End of first step of surgeon’s knot. Note that double wrap has resulted in double overhand knot. This increases friction in knot and will keep wound edges together until second portion of knot is tied. F, Needle holder is then released from short end of suture and held in same position as when knot-tying procedure began. Left hand then makes single wrap in counterclockwise direction. G, Needle holder then grasps short end of suture at its end. H, This portion of knot is completed by pulling this loop firmly down against previous portion of knot. I, This completes surgeon’s knot. Double loop of first pass holds tissue together until second portion of square knot can be tied. J, Most surgeons add third throw to their instrument tie. Needle holder is repositioned in original position, and one wrap is placed around needle holder in original clockwise direction. Short end of suture is grasped and tightened down firmly to form second square knot. Final throw of three knots is tightened firmly. (From Peterson LJ, senior editor. Contemporary oral and maxillofacial surgery, 3rd ed., Mosby Year Book, 1998, p. 188 – 9.)

222

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Fig. 8 (continued ).

increase in loss of tensile strength [2,7]. Moist or fluid-filled tissues such as the oral cavity, or soaking sutures in saline for extended periods may also accelerate the absorption process [2,3,7].

Suture selection When selecting a suture material, consideration must be given to the duration the suture must remain and the relationship this suture material has with adjacent tissue. The smallest suture that couples the

least immunogenicity with highest tensile strength is preferable [5]. This paper examines suture performance on the basis of degree of absorbability. Nonabsorbable sutures resist enzymatic activity and hydrolysis. One of the most widely used nonabsorbable sutures is silk. This raw fiber is harvested while the silkworm larvae are spinning their cocoons. This material is processed into a braided fiber, sterilized, and used in a variety of surgical settings. Although it is classified as a nonabsorbable suture, histologic analysis of silk in vivo after 2 years’ time revealed no evidence of remaining suture [5]. Syn-

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

thetic nonabsorbable materials include nylon, polypropylene, and polyester. These sutures are chemically synthesized polymers that vary in their physical properties on the basis of their chemical structure, and are manufactured as monofilament or braided strands. Nylon is a polyamide polymer that may be either monofilament or braided and can be dyed in a variety of colors [5]. Polyester sutures are polyethylene terephthalate braided multifilament strands that produce little inflammatory response but tend to create more tissue tearing [5]. Polypropylene-based sutures have very low immunogenicity when compared to most other nonabsorbable sutures and very high breaking strength. As with nonabsorbable sutures, absorbable sutures are classified as either monofilament or multifilament. The natural form of absorbable sutures is surgical gut that may be further subdivided as plain or chromic. Gut suture is rendered from bovine or sheep submucosal intestinal layer and processed to the desired size. Once processed, the gut suture is either packaged as plain gut or is treated to lengthen the absorption time. In vivo, gut is digested by proteolytic enzymes and macrophage activity. This

223

absorption can be prolonged if the suture is treated with a chromium salt solution. Thus, in infected wounds, the oral and maxillofacial surgeon may choose to use chromic gut suture for wound closure because of the delayed absorption. The synthetic absorbable sutures were designed to bypass problems encountered with gut suture immunogenicity and unpredictability in absorption. These synthetic absorbable sutures include polyglycolic acid (Dexon), polyglactin 910 (Vicryl), and polydiaxone (PDS). Polyglycolic acid (Dexon) was the first synthetic absorbable suture with handling characteristics similar to silk, but has greater tensile strength than gut [2]. It is produced in a braided multifilament form. Polyglactin 910 (Vicryl) is a copolymer of lactic and polyglycolic acid that has a 50% tensile strength at 3 weeks and then resorbs within 90 days. It is produced in a braided multifilament form. Poliglecaprone 25 (Monocryl) is composed of glycoside and e-caprolactone. It offers high initial tensile strength and absorbs by 119 days. The newest synthetic suture material is PDS, a polydiaxone polymer that is a monofilament suture with enhanced flexibility and significantly greater tensile strength than both

Fig. 9. (A) Vertical mattress suture. (From Pedersen GW. Oral surgery. Philadelphia, W.B. Saunders Co.; 1988. p. 55, with permission.) (B) Horizontal mattress suture. (From Pedersen GW. Oral surgery. Philadelphia, W.B. Saunders Co.; 1988. p. 55, with permission.)

224

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Needle selection

Fig. 10. Figure-of-eight suture techniques. (Kwon PH, Laskin DM, Cinician’s Manual of Oral and Maxillofacial Surgery, 2nd ed. Quintessence Publishing Co., 1997, p. 249, with permission.)

polyglycolic acid and polyglactin 910 [2] (Tables 1, 2, and 3).

The purpose of the needle is to transport the chosen suture material through the soft tissues with the least amount of traumatic injury. A balance must be maintained between needle rigidity and flexibility. Too rigid a needle may fracture when met with resistance, while one that is too flexible may not accurately travel to its designated exit point [5]. The material of choice in contemporary needle design is a corrosion-resistant stainless steel alloy [5]. The needle itself has three designated regions: the eye, body, and the point. The entire complex begins as a sharp point and expands in diameter to the eye. The eye of the needle harbors the interface of the suture material. There are three types of needle eyes: the closed, split (French), and swaged. The closed and split types are less desirable because the junction of the needle and suture is often enlarged, increasing the risk of tissue trauma, and must be threaded, which is time consum-

Fig. 11. A single, interrupted sling suture is used to adapt the flap around the tooth. (A) The needle engages the outer surface of the flap and (B) encircles the tooth. (C) The outer surface of the same flap of the adjacent interdental area is engaged, and (D) the suture is returned to the initial site and the knot tied. (Carranza FA: Glickman’s Clinical Periodontology, ed 7. Philadelphia, W.B. Saunders Co., 1990, p. 803, with permission.)

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

ing. The needle of choice today is the swaged eyeless needle, where the junction of the needle and suture is uniform and permanent. The body of the needle is manufactured in a variety of sizes, shapes, and curvatures. Needles may be round, flat, triangular, oval, or tapered. The needles most frequently used in dentoalveolar surgery are curved needles that range in shape from one fourth to five eights of a circle (Fig. 1). The appropriate needle must be based on the dimensions of the wound to be closed. The point of the needle is the initial contact point of the needle with the tissue. Three basic needle points exist: tapered, blunt, or cutting. In dentoalveolar surgery, cutting needles are preferred because tofo the thickness, resilience, and resistance of gingiva and oral mucosa. The two basic cutting needles used in dentoalveolar surgery are conventional (cutting) and reverse cutting needles (Fig. 2). Each has three cutting edges with two edges opposing each other. The conventional has the third edge facing upwards (toward the inside of the circle), while in the reverse cutting needle it faces down.

225

Suture manufacturers each have their own classification systems for needle size and shape. When selecting the desired suture and needle combination, close attention must be paid to each manufacturer’s supply/order charts for the proper needle selection.

Instrumentation Intraoral suturing requires two main instruments, the needle driver and the suture scissors. Tissue forceps may be occasionally be used to ensure proper needle entrance through tissue by ensuring stability of the soft tissue flap. These tissue forceps are manufactured in various sizes, with and without teeth. The most common tissue forcep used is the single-toothed 3-inch Adson forcep (Fig. 3). The needle driver most commonly used is the 6-inch version of the HegarMayo type (Fig. 4) [17]. Needle drivers also are manufactured with a variety of sizes and beaks, with or without teeth.

Fig. 12. (A to D) Distal Wedge Suture. This suture is also used to close flaps that are mesial or distal to a lone standing tooth. (Carranza FA: Glickman’s Clinical Periodontology, ed 7. Philadelphia, W.B. Saunders Co., 1990, p. 808, with permission.)

226

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

A needle driver can be most effectively used when using proper hand position. The needle driver is held in the palm with the fourth (ring) finger and the thumb within the rings of the instrument. The second finger is placed along the lower straight arm for stabilization, and the third ring finger is laid passively outside the ring of the fourth finger (Fig. 5). The beaks of the needle driver should be perpendicular to the needle and held one third of the distance from the origin of the suture (Fig. 6). The weakest part of the needle is located at the junction of the needle body and the portion where the suture is affixed to the needle. If the beaks of the needle driver are placed too close to the swaged end, bending or breakage of the needle may occur upon insertion into tissue. A bend in the needle may not be readily visible to the clinician, but nonetheless can cause sufficient metal fatigue to result in unexpected needle breakage. Holding the needle too close to the sharp tip will limit the length of needle available to pass through tissue. The most common suture scissor is the Dean scissor, an instrument that is 7 inches long and has offset serrated blades (Fig. 7) [17]. It should be held in the same fashion as the needle driver. It is most efficient when cutting the suture perpendicular to its blades. The Dean scissor is also a generalpurpose scissor that may be used in trimming or removing tissue.

Suture techniques There is a multitude of suturing techniques available to the oral and maxillofacial surgeon. The technique selected depends on the breadth and length of the wound, closure tension required, and the distance to which wound edges must move. Techniques may be broadly categorized as interrupted and continuous. Interrupted techniques include simple interrupted, horizontal/vertical mattress, and sling. Continuous suturing may be divided into running, locking, and continuous sling. Choosing between an interrupted and continuous technique requires striking a balance between the ease and rapidity of continuous techniques and the additional stability and control of wound edges offered by interrupted techniques. Simple interrupted. This is the most universal technique in practice today and may be used for small wounds or evenly spaced and continuous to close larger wounds. Placement requires entrance of the suture through both wound margins, with a surgeon’s knot for stability. Placed correctly, the suture should slightly evert the wound edges (Figure 8) [18]. Vertical mattress. This technique is primarily used extraorally and may be used when everted wound edges are desired. By its nature, this technique provides wound support at two levels, deep and superficial (Fig. 9A). These two levels of closure provide great resistance to wound separation. When fibrous

Fig. 13. When multiple sutures are to be placed, incision can be closed with running or continuous suture. (A) First papilla is closed and knot tied in usual way. Long end of suture is held, and adjacent papilla is sutured, without knot being tied but just with suture being pulled firmly through tissue. (B) Succeeding papillae are then sutured until final one is sutured and final knot is tied. Final appearance is with suture going across each empty socket. (C) Continuous locking stitch can be made by passing long end of suture underneath loop before it is pulled through tissue. (D) This puts suture on both deep periosteal and mucosal surfaces directly across papilla and may aid in more direct apposition of tissues. (Peterson LJ, senior editor, Contemporary oral and maxillofacial surgery, Chapter 8, Principles of Complicated Exodontia, p. 191, with permission.)

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

scarring and tissue contraction occur during healing, the everted wound edges created by this technique enhance the appearance of the final scar. It can be

227

difficult to place a vertical mattress suture in intraoral tissues because the limited degree of tissue elasticity often prevents placement of the deep portion of the

Fig. 14. The continuous, independent sling suture is utilized to adapt the buccal and lingual flaps without tying the buccal flap to the lingual flap. The teeth are utilized to suspend each flap against the bone. It is important to anchor the suture on the two teeth at the beginning and end of the flap so that the suture will not pull the buccal flap to the lingual flap. (Carranza FA: Glickman’s Clinical Periodontology, ed 7. Philadelphia, W.B. Saunders Co., 1990, pp. 806-7, with permission.)

228

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

Fig. 14 (continued ).

mattress across the wound edges. Furthermore, there is less wound contracture that occurs during healing because of the thinness of submucosal tissue, so creating everted wound edges is not essential for formation of a cosmetic scar.

Horizontal mattress. This technique is ideal for closure of soft tissue wounds across small bony defects because it everts the mucosal margins and provides a broader area of support (Fig. 9B). Considerable wound tension can be created using the

W.S. Jenkins et al. / Oral Maxillofacial Surg Clin N Am 14 (2002) 213–229

horizontal mattress technique; the mattress spreads the forces along a horizontal band of tissue instead of at a single point, thus decreasing the chance for the suture to pull through and lacerate tissue during wound approximation and knot tying. The horizontal mattress technique is frequently used during closure of an oroantral opening, where sufficient wound tension must be created to prevent exchange of air, saliva, and mucus between the sinus and the oral cavity. Figure-eight. This technique can be used effectively to close the tissue of an extraction site. While not frequently used to gain primary wound closure, it can provide a barrier to dislodgement of a clot after tooth extraction and may help stabilize materials placed into an extraction socket, such as gel foam or other packing material (Fig. 10). Sling ligation. This technique is ideally used in surgery where a flap is elevated only on one side of the alveolus. This technique allows repositioning of the flap without entering the opposing intact soft tissue (Fig. 11). Anchor suture. This technique is indicated for closure of mucosa in edentulous areas either mesial or distal to a tooth. This offers tight closure of buccal and lingual soft tissues and causes increased adaptation to the adjacent tooth (Fig. 12). Continuous sutures. This technique is commonly used in dentoalveolar surgery when longer wounds result. This method offers quicker closure because fewer knots are placed over the entire length of the wound. A major disadvantage in this type of suturing is the fact that if one knot fails, the entire closure is compromised. The simple technique has the potential to obliquely apply pressure along the length of the wound, while the locked technique decreases this tendency (Fig. 13) [18]. Continuous sling. This technique is the continuous version of the isolated sling technique, which may be used when both buccal and lingual flaps have been reflected. This closure allows both flaps to be repositioned independently of one another because their anchors are the abutment teeth at either end of the wound (Fig. 14) [19].

Conclusion When suturing is required for wound closure, the clinician should be aware of the characteristics of suture material so the most appropriate material can be selected, and the technique used should be one that is provides effectiveness and ease.

229

References [1] Macht SD. Sutures and suturing — current concepts. J Oral Surg 1978;36:710 – 2. [2] Gutman JL, Harrison JW. Surgical endodontics. St. Louis: Ishiyaku EuroAmerica, Inc; 1994. p. 278 – 99. [3] Wound closure manual. Somerville (NJ): Ethicon, Inc.; 2000. [4] United States Pharmacopeia. 24th edition. National Formulary. 17th edition. Philadelphia: National Publishing; 1998 – 1999. p. 1584 – 1586. [5] Knot tying manual. Somerville (NJ): Ethicon, Inc.; 2000. [6] Romfh RF, Cramer FS. Technique in the use of surgical tools. 2nd edition. Norwalk (CT): Appleton and Lange; 1992. p. 33 – 124. [7] Herrman JB. Changes in tensile strength and knot security of surgical sutures in vivo. Arch Surg 1973;106: 707 – 10. [8] Greenwald D, Shumway S, Albear P, et al. Mechanical comparison of 10 suture materials before and after in vivo incubation. J Surg Res 1994;56:372 – 7. [9] Maves TJ, Pechman PS, Gebhart GF, et al. Possible chemical contribution from chromic gut sutures produces disorders of pain sensation like those seen in man. Pain 1993;54:57 – 69. [10] Wallace WR, Maxwell GR, Cacalaris CJ. Comparison of polyglycolic acid suture to black silk, chromic, and plain catgut in human oral tissues. Oral Surg 1970;28: 739 – 46. [11] Lilly GE. Reaction of oral tissues to suture materials. Oral Surg 1968;26:128 – 33. [12] Lilly GE, Armstrong JH, Salem JE, et al. Reaction of oral tissues to suture materials. Part II. Oral Surg 1968; 26:592 – 9. [13] Lilly GE, Salem JE, Armstrong JH, et al. Reaction of oral tissues to suture materials. Part III. Oral Surg 1969;28:432 – 8. [14] Lilly GE, Cutcher JL, Jones JC, et al. Reaction of oral tissues to suture materials. Part IV. Oral Surg 1972;33: 152 – 7. [15] DeNardo GA, Brown AN, Trenka-Benthin S, et al. Comparison of seven different suture materials in the feline oral cavity. J Am Anim Hosp Assoc 1996;32: 164 – 72. [16] Selvig KA, Biagiotti GR, Leknes KN, et al. Oral tissue reactions to suture materials. Int J Perio Res Dent 1998;18:475 – 87. [17] Pedersen GW. Oral surgery. Philadelphia: W.B. Saunders Co.; 1988. p. 47 – 81. [18] Moore UJ. Principles of oral and maxillofacial surgery. Malden, MA: Blackwell Science, Inc.; 2001 p.77 – 81. [19] Carranza FA. Glickman’s clinical periodontology. 7th edition. Philadelphia: W.B. Saunders Co.; 1990. p. 800 – 10. [20] United States Surgical (a Division of Tyco Healthcare Group LP). Products by material. Available at:http:// sutures.ussurg.com. Accessed January 9, 2002.

Oral Maxillofacial Surg Clin N Am 14 (2002) 231 – 240

Antibiotic prophylaxis in dentoalveolar surgery Michael G. Savage, DDS Division of Oral Surgery, Department of Surgical Dentistry, University of Colorado School of Dentistry, 4200 East Ninth Avenue, Campus Box C-284, Denver, CO 80262, USA

Antibiotic prophylaxis in dentoalveolar surgery In England during the 1930s, it became evident that bacteremia from dental procedures could cause the distant infection of bacterial endocarditis [1,2]. With the onset of the antibiotic era, health care providers assumed that if antibiotics could cure an infection, they may also be able to prevent them. Work began more than 40 years ago to investigate how antibiotics may be able to prevent potentially devastating infections such as bacterial endocarditis. Therefore, the concept of using antibiotics as a prophylactic measure to prevent infection from dentally induced bacteremia has existed since at least 1955 [3]. Distant infections resulting from seeding of bacteria caused by dental manipulations have been a matter of controversy. Indeed, the incidence of bacteremia with dental treatment (including surgical procedures) is not vastly different from the bacteremia that can be generated by chewing and by home oral hygiene procedures. In addition, the net benefit of antibiotic prophylaxis is hard to quantify because only a few of the many patients who are given prophylactic antibiotics may actually benefit from them. This fact must be weighed against the potentially adverse side effects of the antibiotics themselves (allergy, toxicity, superinfection, and selection of resistant organisms) [4]. Nevertheless, the empiric use of antibiotic prophylaxis for dental procedures, especially surgical procedures, has become a wellestablished practice among dental professionals. This practice began for prevention of bacterial endocar-

ditis, but has spread to include patients at risk of developing infections of prosthetic joints, those with depressed immune systems from a variety of causes, those with synthetic implants of various kinds, and to prevent postoperative infection in a variety of patients undergoing intraoral procedures. Failure to provide prophylaxis when a distant or significant postoperative infection occurs has become a major source of malpractice lawsuits across the country [5]. Since there are far more attorneys than dentists in the United States, antibiotics are often readily prescribed with a lack of true medical indication. For some conditions (bacterial endocarditis and patients with prosthetic joint replacements), there are consensus guidelines published by reputable organizations. The dentist must be aware of these well-known conditions and guidelines. For other conditions, the indications and literature are conflicting or unclear. In addition, the dental practitioner who consults with the patient’s physician for guidance may receive inadequate, conflicting, or widely varying protocols [6]. The purpose of this article is to review current medical and dental literature and attempt to arrive at a rational guideline for the use of antibiotic prophylaxis in dentoalveolar surgery. Those conditions and procedures not requiring the use of antibiotics will also be discussed. Finally, there is a brief discussion concerning the global overuse of antibiotics and its consequences.

Conditions requiring antibiotic prophylaxis Bacterial endocarditis

E-mail address: [email protected] (M.G. Savage).

The first American Heart Association (AHA) recommendations for antibiotic prophylaxis to prevent

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 5 - 5

232

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

bacterial endocarditis were published in 1955 [5]. Since that time, those recommendations have been modified a number of times, the last time in 1997. This most recent consensus panel had two participating dentists, T.J. Pallasch, and T.W. Gage. This inclusion of more dentists on the ad hoc writing panel, at least in part, led to a more ‘‘user-friendly’’ set of guidelines for the use of antibiotics in conditions that might lead to bacterial endocarditis. The newest guidelines eliminated most needs for parenteral administration and second follow-up doses, and they clarified the conditions for which antibiotics were and were not necessary. Infective endocarditis is a relatively uncommon but life-threatening disease. It is defined as an exudative and proliferative alteration of the endocardium, characterized by growth of vegetations on the surface or within the endocardium. These vegetations consist of bacterially colonized fibrin and platelet masses. The platelet and fibrin masses are known as nonbacterial thrombotic endocarditis and are caused by turbulent blood flow or foreign bodies within the heart. Bacteria from a bacteremia from any source colonize these sterile masses and cause the infection in endocarditis [6]. There is substantial morbidity and mortality for its victims despite the advanced ability to diagnose and wide availability of antibiotics [7]. Prevention of this life-threatening disease is, therefore, highly desirable. The clinical presentation of endocarditis may be slow in onset and reveal classic Oslerian symptoms: bacteremia, valvulitis, peripheral emboli, and immunologic vascular phenomena. These latter signs are more typical of subacute infective endocarditis. Acute infective endocarditis usually develops so rapidly that the immunologic vascular phenomena do not have time to occur [8]. Not all bacteria have the ability to colonize the sterile thrombi, nor do all invasive procedures cause bacteremias that last long enough or carry a large enough inoculum of bacteria to cause an infection of endocarditis. Indeed, most cases of endocarditis caused by oral flora are not attributable to a dental invasive procedure [4,7,9]. There has been some progress lately with a well-designed populationbased case-control study from B.L. Strom et al and others. This study makes a case that prophylactic antibiotics should be used for only two populations, patients with a previous episode of endocarditis and those with a prosthetic heart valve. Furthermore, the only procedures to require antibiotics should be restricted to extractions, gingival surgery, and impactions [5,10]. This new information is intriguing and may well join other studies in a significant change from the AHA. The AHA has acknowledged this information, but they continue to stand behind the current recommendations published in 1997 [11].

The latest AHA recommendations [7] focus on those conditions known to have moderate and high risk of endocarditis in patients undergoing oral procedures (Table 1). Compared to previous recommendations, there has been substantial reduction in the number of conditions for which antibiotics are recommended. Those conditions for which the risk is minimal or negligible are well specified. The dental practitioner has less need to rely on medical providers who may not know or understand the recommendations and base their recommendations on anecdotal evidence. Hence, there is less chance that the dental provider will be forced to accept responsibility for giving antibiotics to inappropriate patients. The change in acceptable antibiotic regimens is welcome (Table 2). Amoxicillin, which attains higher blood levels than penicillin and lasts for hours, is the principal antibiotic for nonallergic patients [12]. Clindamycin, clairithromycin, and azithromycin are good choices in severely allergic patients because they work along entirely separate pathways and have acceptable levels of side effects. The cephalosporin alternatives

Table 1 Cardiac conditions associated with endocarditis Endocarditis prophylaxis recommended Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease(eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot) and any other congenital malformation other than those listed below Surgically constructed systemic pulmonary shunts or conduits Acquired valvular dysfuntion (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation and/or thickened leaflets Endocarditis prophylaxis not recommended Isolated secundum atrial septal defect Surgically repaired atrial septal defect, ventricular septal defect, patent ductus arteriosus (> 6 mo) Previous coronary artery bypass graft (CABG) Mitral valve prolapse without regurgitation Functional or innocent heart murmurs Previous Kawasaki disease without valvular dysfunction Previous rheumatic fever without valvular dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators (Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277:1795; with permission.)

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

233

Table 2 Prophylactic regimens for dental and oral procedures Situation

Agent

Regimena

Standard general prophylaxis

Amoxicillin

Unable to take oral medications

Ampicillin

Allergy to penicillin

Clindamycin

Adults: 2.0 g Children: 50 mg/kg 1 h before procedure Adults: 2.0 g Children: 50 mg/kg IM or IV within 30 min of procedure Adults: 600 mg Children: 20 mg/kg 1 h before procedure

or Cephalexin t or cephadroxil t

Adults: 2.0 g Children: 50 mg/kg 1 h before procedure

or Azithromycin or clairithromycin Allergy to penicillin and unable to take oral medications

Clindamycin

or Cefazolin t

Adults: 500 mg Children: 15 mg/kg 1 h before procedure Adults: 600 mg Children: 20 mg/kg IV 30 min before procedure Adults: 1.0 g Children: 25 mg/kg IM or IV 30 min before procedure

t Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins. (Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277:1798; with permission.) a Total children’s dose should not exceed adult dose.

are meant only for those patients who have not had Ig-E – mediated immediate reactions with penicillin or amoxicillin. It should be remembered that erythromycin is still acceptable if it has been used successfully in the past with individual patients [7]. The 1997 AHA recommendations also identify those procedures likely to cause clinically significant bacteremias (Table 3). Again, delineating the specific procedures is a welcome and appropriate change from previous recommendations, but these are not allencompassing. For example, there is no recommendation for antibiotics when performing intracanal endodontic therapy, but there is a recommendation for prophylaxis when performing endodontic therapy beyond the apex. Since the dentist may not be able to contain the endodontic treatment within the canal, the use of prophylaxis is indicated in high-risk patients. Likewise, there is a recommendation for prophylaxis when performing intraligamental injections. An intra-

osseous injection technique (available from at least three manufacturers) should warrant the same precautions. The American Dental Association (ADA) emphasizes that ‘‘these recommendations are not intended as the standard of care, and practitioners should use their own clinical judgement in individual cases or special circumstances’’ [13]. Special circumstances Patients already on antibiotics Patients often present on chronic daily doses of a drug (eg, penicillin) for secondary prevention of endocarditis. They may also be on a drug that is the same or similar to what would be used for prophylaxis, but are under therapy for an infection elsewhere in the body. In these cases, one should change to another family of antibiotics (Table 2) and prescribe the normal dose for that family of drugs.

234

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

Table 3 Dental procedures and endocarditis prophylaxis Endocarditis prophylaxis recommendeda Extractions and other open oral surgical and endodontic surgical procedures All periodontal surgery, scaling, root planing, probing, and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic instrumentation beyond apex Subgingival placement of antibiotic fibers, strips, or polymers Placement of orthodontic bands (but not acid etch brackets) Intraligamentary and intraosseous local anesthetic injections Hygiene procedures on teeth or implants where bleeding is anticipated Endocarditis prophylaxis not recommended Restorative dentistry and prosthodontics with or without retraction cordb Local anesthetic injections other than those listed above Intracanal endodontic treatments, including post and core Placement of rubber dam Postoperative suture removal Placement of any removable appliance Impressions Fluoride treatments Radiographs Orthodontic appliance adjustment Shedding of primary teeth Adapted from JAMA 1997;277:1797; with permission. a Prophylaxis recommended for patients with endocarditis risk conditions. b Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding.

Patients on anticoagulants Do not administer intramuscular injections of antibiotics to patients on heparin or coumarin derivatives because they may form a hematoma or have severe ecchymosis. Use an intravenous or oral route. Delay in treatment There are times when patients will take the prescribed prophylaxis regimen as directed, but for some reason cannot be treated at the time anticipated. How long is acceptable before redosing? There is no consensus answer. We do know that amoxicillin maintains a prolonged serum inhibitory activity of 6 to 14 hours against most oral streptococci [14]. Peak serum levels of amoxicillin occur  1 hour after ingestion. Serum levels of oral clindamycin occur slightly more rapidly and remain for  3 hours [15]. Amoxicillin retains microbial killing power for several hours [14]. If one

had to pick a number, it would therefore seem prudent to consider redosing if treatment will be delayed beyond 4 hours. Unanticipated indications It is possible that the dentist may have started a procedure for which antibiotic prophylaxis is not indicated, but then finds an indication. In a situation where the dentist has initiated intracanal endodontics, but a perforation develops with bleeding, the AHA/ ADA recommends administering the dose of antibiotics at that time. This necessitates the dentist to have an office supply of at least amoxicillin and clindamycin for patient use. Patients who have taken appetite suppressants There is a subset of the above group of patients whose potential for endocarditis has surfaced since 1997. This group consists of patients who have taken the drugs fenfluramine (Pondimin) or dexfenfluramine (Redux). Another drug, phentermine (Apidex, Fastin, or Ionamin), had often been combined with fenfluramine in ‘‘fen-phen,’’ but is not implicated in the clinical problem [16]. Initial concern linking valvular heart disease with the use of fenfluramine/ phentermine was generated by a report in the New England Journal of Medicine (vol. 337, August 28, 1997). This led to voluntary withdrawal of Redux and Pondimin from the market by Wyeth-Ayerst Laboratories in September 1997, a move praised by the AHA [17]. Interim guidelines for managing these patients were issued in November 1997 [18] and were endorsed by the American Heart Association with a media advisory soon after [19]. The guidelines issued from the US Department of Health and Human Services (DHHS) recommended the following: 1. All people exposed to these drugs should undergo a medical history and cardiovascular examination. 2. An echocardiogram should be performed on all people who exhibit cardiopulmonary signs and symptoms of cardiac valvulopathy 3. An echocardiogram is strongly recommended for all people exposed to these drugs for any period of time, regardless of cardiopulmonary signs or symptoms, if the patient was to have an invasive procedure for which they would have been given antibiotic prophylaxis, according to the 1997 guidelines. 4. For emergency procedures where cardiac examination cannot be performed, empiric

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

antibiotic prophylaxis according to the 1997 guidelines should be performed. Medical and dental literature point out some problems with the guidelines above [16,20,21]. There were no consistent physical examination criteria, a wide range of true valvulopathies were found, there was a wide range in the length of time the drugs were taken, and there was controversy regarding whether or not valvulopathy would regress over time. As a result, there is disagreement as to the true severity of the problem; some authorities agree with the DHHS guidelines and others see less of a problem. An additional problem, primary pulmonary hypertension, has a long clinical ‘‘tail’’ and has been largely overlooked. This problem is rare in the general population, but its frequency is 10 times greater in a population taking appetite suppressants and 20 times greater when the appetite suppressant is taken for more than 3 months [16]. The diagnosis is often delayed 1 to 2 years after symptom onset, and people with the disorder have a median survival of 2 to 3 years from symptom onset [22,23]. For the dental practitioner, it would seem prudent to refer all these patients to a physician for a cardiovascular examination. It would also be prudent to be specific regarding your concerns and include a set of the DHHS guidelines or refer the physician to the appropriate AHA web site [24] that would have a complete set of past advisories and recommendations. Patients with prosthetic joint replacement Before 1997, dental providers faced a conundrum with patients who had undergone total joint arthroplasty (TJA). The vast majority of orthopedic surgeons favored antibiotic prophylaxis before dental treatment for all TJA patients under all circumstances, even though they recognized that a consistent relationship between dentally induced bacteremia and prosthetic joint infections had not been established [4]. Othopedic surgery authorities themselves admit that orthopedic surgeons are among the heaviest users of prophylactic antibiotics [25]. Nevertheless, a prosthetic joint infection can be devastating, can occur from a variety of sources other than dental, and can occur long after the supposed insult, making cause and effect difficult to prove. Antibiotic protocols recommended by orthopedic surgeon colleagues varied widely and occasionally had no rationale against oral microbes. A study performed in 1990 concluded that it cost $480,000 in antibiotics to prevent one case of prosthetic joint infection [26]. An attempt to eliminate this overuse controversy was made in

235

1997 with a joint advisory statement from the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. The ADA and the AAOS convened an expert panel of dentists, orthopedic surgeons, and infectious disease specialists who performed a thorough review of all available literature and data to determine the need for antibiotic prophylaxis to prevent hematogenous prosthetic joint infections in dental patients who have undergone TJA [27]. The panel outlined consensus recommendations that simplified the target population and regimens to be used. These recommendations, though not completely accepted by all orthopedic surgeons [28,29], at least created an area of agreement between dentists and a national orthopedic group (Table 4). The specific joints replaced are not delineated with any differentiation; therefore, it is assumed that a total hip replacement should be treated the same as a digit replacement. The recommendations targeted those populations at most risk to have a hematogenous total joint infection: immunocompromised/suppressed patients; those with inflammatory arthropathies (eg, rheumatoid arthritis); insulin-dependent diabetics; those with previous episode of infected joint; malnourished persons; hemophiliacs; and those within 2 years of their joint replacement, regardless of health (Table 4).

Table 4 Prophylaxis for patients with total prosthetic joint replacement Patients at potentially increased risk of hematogenous joint infection Immunocompromised and immunosuppressed patients, including those with conditions caused by disease, drug, or radiation Inflammatory arthropathies, including rheumatoid arthritis and systemic lupus erythematosus Insulin-dependent (type I) diabetes First 2 y after total prosthetic joint replacement Previous prosthetic joint infection Malnourishment Hemophilia Procedures likely to cause hematogenous joint infection in the patients listed above Same as those in endocarditis (Table 3) Procedures less likely to cause hematogenous joint infection Same as those in endocarditis (Table 3) Suggested antibiotic regimens to use in the patients listed above Same as those in endocarditis a(Table 2) a

AAOS/ADA regimen places cephalexin and cephradine ahead of amoxicillin in suggested regimens and does not mention azithromycin or clairithromycin in suggested regimens for penicillin allergic patients.

236

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

The recommendations then specified those procedures likely to cause a higher incidence of bacteremia and those procedures less likely to cause bacteremia. Those procedures are identical to those specified in the AHA bacterial endocarditis recommendations. Likewise, the recommended antibiotic protocols were virtually identical to those recommended by the AHA for endocarditis. Some authorities take special pains to point out that the risk of causing a hematogenous spread of infection is higher when dealing with gross infection at the procedure site, such as a severe dental abscess or when procedures take longer than 45 minutes [29,30]. Patients with plates, screws and pins: These patients require no prophylaxis. The recommendations point out that the dentist may be presented with a patient carrying recommendations from their orthopedist which are inconsistent with these guidelines. This may result from unfamiliarity with the guidelines, or perhaps the patient has an overriding concern unknown to the dentist. Consultation is urged to come to an agreement between the providers. If a disagreement still occurs, the dentist may proceed with the recommendations of the orthopedic surgeon despite the disagreement, proceed with the procedure without antibiotics, or place the burden of prescription for the antibiotics on the orthopedic provider. Best clinical judgement is always appropriate. The total replacement of temporomandibular joints (TTMJR) is not specifically addressed nor excluded in these recommendations. The late infection of a TTMJR is exceedingly rare [31,32]. There is simply not enough data on which to base a sound recommendation. The very cautious practitioner may consider prophylaxis for that group of patients who fall under the AAOS/ ADA guidelines only. Shunts, catheters, and implanted materials Patients with surgically constructed shunts for hemodialysis are at somewhat increased risk for infection, both locally and as a cause for endocarditis. Moreover, if an infection occurs in these patients undergoing dialysis, the downside is devastating. Antibiotic prophylaxis for these patients, if undergoing invasive dentoalveolar procedures, is appropriate. AHA recommendations are probably adequate even though there is no consensus. The extent and length of surgery may induce stress and, because of anticoagulation, may result in significant bleeding. Many penicillin-type drugs are metabolized through the kidneys, so consultation with the nephrologist is warranted if therapy beyond a single dose is considered to treat infection. Regardless, the nephrologist

should be consulted regarding the timing and need for anticoagulation control before any extensive surgery [53]. Peritoneal dialysis requires no antibiotic prophylaxis [34]. Shunts are placed in patients with hydrocephaly to relieve the pressure of cerebrospinal fluid buildup on the brain. Shunts placed for treatment of hydrocephaly are of two types, ventriculo-peritoneal (VP) and ventriculo-atrial (VA). Infection of VA shunts is devastating and carries a mortality of 40%. These patients should receive prophylactic antibiotics [35,36]. VP shunts carry no higher risk of infection from dental sources and therefore require no antibiotics Indwelling catheters may be present for a variety of reasons, usually to deliver long-term intravenous drugs for chemotherapy or to treat infection. Unless the terminal end is near the right side of the heart, no prophylaxis should be necessary [37]. Pacemakers and implanted defibrillators may or may not be intracardiac. They can become infected, but most infections culture out Staphylococcu aureus, not viridans species [4]. The AHA does not recommend antibiotic prophylaxis before dental treatment for these patients [7]. Patients who have undergone heart transplant do not, per se, require prophylactic antibiotics. They are, however, prone to cardiac valvular dysfunction and are typically on multiple immunosuppressant drugs. Consultation is warranted and they may require antibiotic prophylaxis if a valvular abnormality exists [4]. Intracardiovascular artery stents, prosthetic artery grafts, angioplasty procedures, and coronary artery bypass grafts (CABG) are performed for patients with atherosclerotic cardiovascular disease and/or angina. Prophylactic antibiotic coverage for these patients is a controversial area, and some feel that the requirement for antibiotic prophylaxis hinges on the amount of epithelialization that will take place after the procedure is performed. Most infections take place within 6 months of surgery, but oral flora are rarely implicated [37,38]. Nevertheless, an infected graft or stent is devastating. There is no consensus, but a recommendation cited by several authors is that prophylaxis should be considered only within the first 6 weeks after surgery. Endotheialization of the stent occurs during this time period. Antibiotics are not needed after 6 weeks, except possibly for very large aortic grafts. Consultation is advised for these patients. Patients with penile implants or other cosmetic or functional implanted materials do not require prophylactic antibiotics before invasive dental treatment [6].

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

Immunocompromised patients This group of patients includes those with neutropenia for any reason, insulin-dependent diabetes, and asplenia. There have been no long-term, controlled studies that have looked at infection rates in dental patients with various levels of neutropenia [38]. Nevertheless, threat of infection exists and morbidity increases as the leukocyte count drops. Regimens of antibiotics have been suggested for patients with leukocyte levels of 3500/mm3, 2000/ mm3, and 1000/mm3 [39]. Difficulties arise as the oral flora changes in patients on chemotherapy. Whereas the AHA recommendations are fine for most patients, they may not be the best choices for neutropenic patients. Again, no controlled studies exist to provide the best regimen. Best recommendations appear to define neutropenia as 1000/mm3 and to treat patients only on a nonelective (emergency) basis. The AHA regimen or a recommended regimen by consultation with the patient’s hematologist or infectious disease specialist is appropriate [4,37,38]. Patients who are HIV positive are not at greater risk than non-HIV positive patients, provided that they currently have a satisfactory white blood cell count. They should not receive antibiotic prophylaxis for dental procedures unless they fall into another category that does require antibiotic prophylaxis. In addition, there is an additional risk of selecting antibiotic-resistant strains or causing fungal overgrowth [4,36 – 38]. Prophylactic antibiotics are not necessary for most diabetic patients undergoing dentoalveolar surgery. Most authors agree that insulin-dependent diabetic patients or non – insulin-dependent diabetics under good control are at no greater risk than other patients who are also undergoing minor but invasive surgical procedures [4,38 – 40]. Unless they are poorly controlled, non – insulin-dependent diabetics are usually not candidates for prophylaxis. If either population is well controlled, prophylactic antibiotics should be used only in situations where prophylactic antibiotics would be used for nondiabetic patients. A diabetic with an infection should receive appropriate antibiotics, and a poorly controlled diabetic should also be referred for stabilization. If emergency dentoalveolar surgery is required on a poorly controlled diabetic, then prophylaxis is indicated, as well as consultation with the patient’s endocrinologist. With no specific regimen established, the AHA recommendations would suffice. The question of prophylactic antibiotics in patients who have undergone splenectomy is also controversial. It is true that infections in post-splenectomy patients occur at a rate far above the normal

237

population. Most of these infections are not related to the mouth, and the population most at risk are those at two years or less post-splenectomy and children under 5 years old [4,38,41]. Therefore, routine prophylaxis for these patients is not recommended, but consultation is warranted for these latter two groups and antibiotic prophylaxis may be necessary. These patients also require consideration for pneumococcal vaccine from their physicians [41,42]. Risk of brain abscess Several recent high-profile lawsuits have resulted from patients who had minor infections or invasive dentoalveolar surgery and then suffered brain abscesses that cultured out oral flora. There are areas of the country where experienced, board-certified oral and maxillofacial surgeons who fear this litigation are providing prophylactic antibiotics for patients who require extractions or significant invasive surgery. In an elegant review of the literature and through the use of sound logic, Pallasch argues vigorously against this practice [4]. He makes the case that the incidence, etiology, and clinical course of brain abscesses indicate that the association with previous therapy is too small and the risk from the antibiotic is too great to warrant routine antibiotic prophylaxis for these patients. He argues that one million people would have to receive prophylactic antibiotics in an attempt to save the theoretical less than one person in that million from having a brain abscess. Even assuming that a correct antibiotic is chosen for this unknown pathogen, there is an unfavorable risk-to-benefit ratio. The death rate from anaphylaxis for the antibiotic would essentially be higher than the rate of brain abscess occurrence. There would be a net loss of life from use of antibiotics in this attempt at prevention [4]. Routine antibiotic prophylaxis in oral and maxillofacial surgery Antibiotics are commonly administered prophylactically for major oral and maxillofacial surgery, such as temporomandibular joint surgery, orthognathic procedures, and repair of facial trauma with contamination. There is evidence that this is a sound practice, though there is no need to continue the antibiotics beyond the perioperative period [43]. On the other hand, oral and maxillofacial surgeons commonly prescribe antibiotics to ‘‘prevent’’ postoperative infections in patients who are not at risk for serious infections from bacteremia and for relatively minor dentoalveolar procedures. In these scenarios,

238

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

there are many areas of disagreement and failure to adhere to basic principles [4,32,36,44]. In many cases, the antibiotic is given after the procedure as the patient is walking out the door. This violates the well-substantiated principle that antibiotics need to be given before a procedure, not after, and sufficiently in advance to obtain a high blood level [4]. This prophylaxis should ideally take place 2 hours before the incision if given orally, or immediately before surgery if given intravenously [45]. Strictly speaking, surgical antibiotic prophylaxis is indicated only (1) to prevent contamination of a sterile area, (2) where infection is unlikely but associated with significant morbidity, (3) in procedures with high rates of infection, and (4) during implantation of prosthetic material [4,36]. For antibiotics to be effective, they must be given in high doses and aimed at a specific pathogen or group of pathogens. They need not be continued after the procedure [46]. With the exception of implant placement, most dentoalveolar oral surgery procedures do not qualify for prophylactic antibiotics using the above criteria. The subject of prophylaxis for implant and bone graft surgery is another topic worth its own article. There are no published studies comparing one agent to another or the length of time of administration of one agent versus another. There are many technique articles in print recommending prophylaxis, but drugs vary from penicillin to Augmentin to clindamycin, and length of time of administration varies from perioperative only to 2 weeks. A well-cited and thoughtful chapter by Topazian does specifically address this question [30].

Although he recommends penicillin for noncompromised patients, it seems to me, in the interest of simplification, that the AHA regimen would supply similar efficacy and be easier to remember. Topazian recommends a first-generation cephalosporin (cephalexin) or the combination of amoxicillin/clavulanate for sinus grafting (see Table 5). The question then arises for prophylactic antibiotic use specifically for third molar surgery. Piecuch, Arzadon, and Lieblich looked at this question in 1995 [47]. They offered that oral surgeons prescribe antibiotics in third molar surgery for five reasons: (1) to treat an active infection, (2) as prophylaxis in medically compromised patients, (3) patient or family demand, (4) prevailing standard of care in community, and (5) risk of infection is high. They reviewed literature for and against use of antibiotics in third molar surgery and then interjected their own retrospective study of 2134 patients with 6713 third molar extractions. They answered the above justifications and recommended that antibiotic prophylaxis be justified only for full bony and partial bony impactions. In all other classes and positions of impacted third molars, prophylaxis provided no statistical improvement over no antibiotic prophylaxis. They also revealed, however, that tetracycline placed in the extraction site was just as efficacious as systemic antibiotics. This practice will continue to incite controversy and study. Indeed, a recently published doubleblind placebo control study appears to refute the above recommendations. This otherwise well-designed study suffered from a low number of subjects (151) and the

Table 5 ‘‘Bottom line’’ recommendations for antibiotic prophylaxis Condition

Prophylaxis warranted?

Regimen

Heart conditions Total prosthetic Joint replacement Vascular shunt for hemodialysis Ventriculoatrial shunt for hydrocephaly Vascular grafts Other cosmetic or functional implants Immunocompromised HIV positive Insulin-dependent diabetic Splenectomy

Possibly (see Table 1) Probably not (see Table 4) Yes Yes No unless large or >6 months No Possibly. Consult if < 1000 wbc/mm3 No No, unless poor control then No, unless spleen removed less than 6 mo before or < 5 y old then No No No, except possibly partial bony or full bony impactions Yes (immediate perioperative period only)

AHA (Table 2) AHA AHA AHA AHA

Risk of brain abscess Routine oral surgery procedures Third molar surgery Implants, endosseous, bone grafts, extensive membrane use

AHA Consult

No established regimen AHA (consider cephlosporin for sinus lift)

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240

fact that a prophylactic drug effective only against anaerobes was used [48]. Until similar studies are performed with higher numbers of subjects and drugs that are effective across the spectrum of oral pathogens, the practice of third molar prophylaxis will continue to be partly based on empiricism [33]. Patterns of use in prophylaxis There is no question that one of the problems with the use of antibiotics for prophylaxis is lack of knowledge and inconsistency among providers. This is true in this country and elsewhere [48]. Practitioners prescribe prophylactic antibiotics incorrectly for patients that require them and inappropriately for patients who do not require them. This occurs not only in private practices, but also in schools of dentistry, where one would hope the focus would be on accurate and appropriate prophylactic antibiotic use [49]. Antibiotics have been used as ‘‘drugs of fear’’ [50] to prevent lawsuits, to please patients or families, and to ‘‘cover’’ for errors of omission or commission [51]. This leads to overuse of these agents, and overuse of these agents leads to unnecessary growth of resistant strains of organisms. In the past, research and development from the drug industry has kept up with yet other new and more powerful agents for practitioners to use. To recoup the high cost of development, the drug industry encouraged providers to use the newest agents. Between the rising costs of development and the continued ability of the microbes to keep ahead of the curve by mutation, however, this is a ‘‘no-win situation’’ [51]. We are running out of arrows in the quiver. There are reports of vancomycinand methicillin-resistant S. aureus, dubbed the ‘‘andromeda strain.’’ In central Africa, some strains of shigella are no longer sensitive to quinolone antibiotics and, unable to treat recent outbreaks, thousands have died. S. pneumoniae resistant to penicillin have passed resistant genes to the previously susceptible S. viridans species [52]. The only sound solution is to use them less. As infectious disease specialist Norman Simmons, MD has stated, ‘‘We screwed up, and we ought to say so and apologize. Doctors were handed the wonderful gift of antibiotics but are destroying them through indiscriminate use. We don’t need another committee. We know what to do, we should use them less.’’ This article attempts to assemble the available literature to delineate those medical conditions and dentoalveolar procedures that would require the use of antibiotic prophylaxis (Table 5). It also aims to eliminate some of the overuse of antibiotics used by surgeons in inappropriate circumstances.

239

References [1] Okell CC, Elliott SD. Bacteraemia and oral sepsis: with special reference to etiology of subacute endocarditis. Lancet 1935;2:869 – 72. [2] Rushton MA. Subacute bacterial endocarditis following extraction of teeth and tonsils. Guys Hosp Rep 1930;80:39 – 44. [3] Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis through Control of Streptococcal Infection. Prevention of rheumatic fever and bacterial endocarditis through control of streptococcal infection. Circulation 1955;11:317 – 20. [4] Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontology 2000; 10:107 – 38. [5] Strom BL, Abrutyn E, Berlin JA, et al. Dental and cardiac risk factors for infective endocarditis. Ann Int Med 1998;129:761 – 9. [6] Tong DC, Rothwell BR. Antibiotic prophylaxis in dentistry: a review and practice recommendations. JADA 2000;131:366 – 74. [7] Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277: 1794 – 801. [8] Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation 1998;98:2936 – 48. [9] Guntheroth WG. How important are dental procedures as a cause of infective endocarditis? Am J Cardiol 1984;54:797 – 801. [10] Durack DT. Antibiotics for prevention of endocarditis during dentistry: time to scale back? Ann Int Med 1998;129:829 – 31. [11] Pallasch TJ. Dental treatment and bacterial endocarditis. J Calif Dent Assoc 1999;27:282 – 3. [12] Dajani AS, Bawdon RE, Berry MC. Oral amoxicillin as prophylaxis for endocarditis: what is the optimal dose? Clin Infect Dis 1994;18:157 – 60. [13] Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association (sidebar by ADA Council on Scientific Affairs). JADA 1997;128:1142 – 51. [14] Fluckiger U, Franciolo P, Blaser J, et al. Role of amoxicillin serum levels for successful prophylaxis of experimental endocarditis due to tolerant streptococci. J Infect Dis 1994;169:397 – 400. [15] Burnham TH, editor. Drug facts and comparisons. St. Louis: Facts and Comparisons; 2000. p. 1217, 1316. [16] Pallasch TJ. Current status of fenfluramine/dexfenfluramine-induced cardiac valvulopathy. J Calif Dent Assoc 1999;27:400 – 4. [17] American Heart Association. American Heart Association comment on Redux and Pondimin [science advisory]. September 15, 1997. [18] Centers for Disease Control and Prevention. Cardiac valvulopathy associated with exposure to fenfluramine or dexfenfluramine. 1997; U.S. Department of Health

240

[19]

[20]

[21]

[22]

[23] [24]

[25]

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 and Human Services Interim Public Health Recommendation, November MMWR 46; 45:1061 – 6. American Heart Association. American Heart Association supports interim guidelines for managing patients who have taken appetite suppressants [media advisory]. November 13, 1997. Pallasch TJ. Antimicrobials and periodontal disease: quo vadis? [guest editorial]. Int J. Perio Restor Dent 1998;18:212 – 3. Devereaux RB. Appetite suppressants and valvular heart disease [editorial]. N Engl J Med 1998;339: 765 – 7. Abenheim L, Moride Y, et al. Appetite-suppressant drugs and the risk of primary pulmonary hypertension. N Engl J Med 1996;335:609 – 16. Gaine SP, Rubin LJ. Primary pulmonary hypertension. Lancet 1998;352:719 – 25. American Heart Association. Science advisories. Available at: http://americanheart.org/Whats_News/ AHA_Science_Advisories/. Accessed March 1, 2000. American Academy of Orthopaedic Surgeons Advisory Statement. The use of prophylactic antibiotics in orthopaedic medicine and the emergence of vancomycin-resistant bacteria. Available at: http://www.aaos. org/wordhtml/papers/advistmt/vancomycin.htm. Accessed March 17, 2001. Jacobson JJ, Schweitzer S, DePorter DJ, et al. Antibiotic prophylaxis for dental patients with joint prostheses? A decision analysis. Int J Technol Assess Health Care 1990;6:569 – 87. American Dental Association/American Academy of Orthopedic Surgeons Advisory Statement. Antibiotic prophylaxis for dental patients with total joint replacements. JADA 1997;128:1004 – 8. Waldman BJ, Mont MA, Hungerford DS. Total knee arthroplasty infections associated with dental procedures. Clin Orthoped & Rel Res. 1997;343:164 – 72. Laporte DM, Waldman BJ, Mont MA, et al. Infections associated with dental procedures in total hip arthroplasty. J Bone Joint Surg 1999;81:56 – 9. Topazian RG. The basis of antibiotic prophylaxis. In: Worthington P, Branemark PI, editors. Advanced Osseointegration surgery. Chicago: Quintessence Publishing Co.; 1992. p. 57 – 66. Nawrocki JH, Ziccardi V, Sotereanos GC. Infection of a prosthetic temporomandibular joint in an intravenous drug abuser. J Oral Maxillofac Surg 1991;49:1339 – 40. Eppley BL, Delfino JJ. Use of prophylactic antibiotics in temporomandibular joint surgery. J Oral Maxillofac Surg 1991;43:675 – 9. Sekhar CH, Narayanan V, Baig MF. Role of antimicrobials in third molar surgery: prospective, double-blind, randomized, placebo-controlled clinical study. Br J Oral Maxillofac Surg 2001;39:134 – 7. Derossi S, Glick M. Dental considerations for the patient with renal disease receiving hemodialysis. JADA 1996;127:211 – 9. Zentner J, Gilsback J, Felder T. Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective random-

[36]

[37] [38]

[39]

[40] [41]

[42]

[43]

[44]

[45]

[46]

[47]

[48]

[49]

[50] [51] [52] [53]

ized trial in 129 patients. Neurosurg Rev 1995;18: 169 – 72. Pallasch TJ. Antibiotic prophylaxis: the clinical significance of its recent evolution. J Calif Dent Assoc 1997; 25:619 – 32. Pallasch TJ, Expert addresses ‘‘fen-phen,’’ CDA Update 9, #12, 2, 15. Hall EH, Sherman RG, Emmons WW, et al, Antibacterial prophylaxis. Dent Clin North Amer 1994;38: 707 – 717. Alexander RE. Routine prophylactic antibiotic use in diabetic dental patients. J Calif Dent Assoc 1999;27: 611 – 8. Rothstein JP. The care of dental patients with diabetes mellitus, part I. Dent Today 2001;20:72 – 7. Westerman E. Postsplenectomy sepsis and antibiotic prophylaxis before dental work. Am J Infect Control 1991;19:254 – 5. White KS, Covington D, Churchill P, et al. Patient awareness of health precautions after splenectomy. Am J Infect Control 1991;19:36 – 41. Aijderveld SA, Smeele LE, Kostense PJ, et al. Preoperative antibiotic prophylaxis in orthognathic surgery: a randomized, double-blind and placebo-controlled clinical study. J Oral Maxillofac Surg 1999;57:1403 – 6 [discussion, 1406 – 7]. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Eng J Med 1997;337:1142 – 8. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326:281 – 6. Peterson LJ. Principles and management of odontogenic infections. In: Peterson LJ, Tucker MR, Ellis E, Hupp JR, editors. Contemporary oral and maxillofacial surgery. 3rd edition. St. Louis: Mosby; 1998. p. 392 – 417. Piecuch JF, Arzadon J, Lieblich SE. Prophylactic antibiotics for third molar surgery: a supportive opinion. J Oral Maxillofac Surg 1995;53:53 – 60. Palmer NA, Pealing R, Ireland RS, et al. A study of prophylactic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J 2000;189:43 – 6. Johnson TE, Froeschle ML, Lange BM. Management of patients needing antibiotic prophylaxis in a dental education setting, J Dent Ed 2000;64:276 – 82. Kunin CA. Editorial response: antibiotic armageddon. Clin Infect Dis 1997;25:240 – 1. Pallasch TJ. Chemotherapy metastasis resistance revisited. J Calif Dent Assoc 2000;28:183 – 233. Pallasch TJ. A critical appraisal of antibiotic prophylaxis. Int Dent J 1989;39:183 – 96. Silverstein KE, Adams MC, Fonseca RJ. Evaluation and management of the renal failure and dialysis patient. In: Ogle OE, editor. Management of medical problems. OMFS Clinics of NA, 1998. vol. 10, p. 417 – 427.

Oral Maxillofacial Surg Clin N Am 14 (2002) 241 – 257

Oral connective tissue grafting: evidence-based principles for predictable success Michel Matouk, DDS, MD*, Anthony G. Sclar, DMD Private Practice, Oral and Maxillofacial Surgery, South Florida OMS, Center For Excellence In Dental Implant Surgery, 7600 Red Road, Suite 101, Miami, FL 33143, USA

As the scope of oral and maxillofacial surgery expands, modern surgeons face new challenges every day. We learn new principles that soon become applied to many of our daily treatment plans in facial and oral surgery. Intraoral soft-tissue grafting is one of the techniques that has gained popularity in response to increased public demands for cosmetic and reconstructive periodontal surgery procedures. Many of the intraoral gingival plastic surgery procedures that are required for a full smile makeover could benefit from grafting and tissue management principles that are based on sound wound-healing theories. This review focuses first on the different options available for softtissue augmentation, the application of these options to different intraoral soft-tissue defects, the specific technique for subepithelial connective tissue grafting, and ends with a discussion of some of the major scientific principles for grafting success.

History Biological transfer of soft tissue was first reported by the ancient Egyptians [1]. In 1869, the surgical intern Jean Reverdin presented a case of skin grafting to the Imperial Surgical Society of Paris, which was later published in their proceedings [2]. George David Pollock, a British surgeon, applied the first successful autograft to a burn wound. A few months later, he turned to other skin sources, first from an unspecified donor and eventually from himself [3]. Skin grafts

* Corresponding author. E-mail address: [email protected] (M. Matouk).

were very rapidly applied to oral and maxillofacial reconstruction. Schnitzler and Ewald successfully applied a Thiersch graft to a defect of the buccal mucosa in 1894 [4]. The use of local oral tissue as a free graft is a more recent advancement. Mucosal grafts are usually harvested from the cheek and have been used in vestibuloplasties and other oral procedures for many years [5]. The use of free gingival autografts (FGG) was described by Bjo¨rn in 1963 and has been investigated extensively since that time [6]. It is a versatile tissue that is also used for various eyelid procedures, [7] tracheoplasty [8], and vetibuloplasty [9]. The use of connective tissue was originally pointed out by Edel in 1974, when he used a rectangular ‘‘trap door’’ flap to obtain connective tissue from the palate and then applied it to the defective area, similar to FGG [10]. The modern subepithelial connective tissue graft (SCTG) technique was later introduced in 1980 by Langer and Calagna [11]. It was initially used to augment ridge soft-tissue defects and then modified for root coverage [12] to obtain ‘‘a closer color blend of the graft with adjacent tissue, avoiding the ‘keloid’ healing present with free gingival grafts.’’

Soft-tissue augmentation options When considering soft-tissue augmentation in the oral cavity, connective tissue grafts should be considered as part of a continuum of available options. Oral tissues may be augmented using either grafts or flaps. Grafting implies tissue transfer without a blood supply while a flap brings its own nutrient source to the host site.

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 8 - 0

242

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

Oral soft-tissue grafts Grafts may be autogenous or allogeneic. Autogenous grafts can be a variety of simple tissues or a composite of multiple tissues. The workhorse of modern oral soft-tissue grafting is the connective tissue graft. Even though it is thought of as a simple graft, it is in fact often a composite graft that contains submucosa, fat, periosteum, and even occasionally minor salivary gland tissue. Each component of these different tissues has been studied individually as a potential graft. Skin is classically one of the oldest grafts applied to the oral mucosa and is well tested in both the split thickness and full thickness varieties. Periosteum itself is not usually used as a simple graft in the mouth, as opposed to pericranial grafts or flaps often used in craniofacial surgery [13]. A simple fat graft is used in facial soft-tissue augmentation on a regular basis but has the reputation of being a transient graft that often maintains only 50% of its original volume. In facial surgery, there has been a move away from en bloc tissue grafts, toward injectable autogenous fat, dermis, and fascia micrografts [14,15]. The smaller particles are used to allow faster revascularization. Both gingival tissue and oral mucosa have been used extensively as oral grafts. When oral soft-tissue augmentation is performed, an alternative treatment that is available is bony augmentation. This is usually achieved by bone grafting and by following the principles of guided tissue regeneration (GTR). Another important option is distraction osteogenesis. Distraction allows full histiogenesis of local tissues and is especially useful in vertical ridge augmentation. This same concept can also be applied to pure soft-tissue augmentation by using tissue expansion appliances. Even though autogenous grafting is the gold standard, research is continuing to improve regarding the use of allogeneic options. Clinical and histologic success was shown in case reports using an acellular dermal matrix graft [16,17]. Other studies have since been published using this method and newer methods such as epithelial tissue culture technology [18,19]. Oral soft-tissue flaps Flaps are classified according to their blood supply as random, axial, or mixed. They can also be pedicled (single or multiple pedicles) or free (microvascular). There are many oral random flaps that are useful as alternatives to connective tissue grafts. These include the lateral pedicled flap, the coronally repositioned flap for root coverage, and a few other

tissue flaps that are used for papilla regeneration and root coverage. The oral surgeon is also very familiar with other flaps used for oral-antral and oronasal fistulae closure. All these flaps have a limited range, however, which leads the surgeon to consider the more robust axial and mixed flaps. Local axial flaps that are used in the mouth may be based on the facial and labial vessels; the lingual vessels are also used in a variety of tongue flaps. The most commonly used vessels, however, are the palatine vessels. They are used in many fistula and cleft reconstruction flaps. The greater palatine vessels proceed anteriorly through the incisive canal, where they anastemose with septal branches from the sphenopalatine artery, which are also useful but underused in gingival reconstruction [20]. Finally, regional axial flaps and microvascular free flaps are also useful in oral reconstruction; they may be used for general augmentation that may eventually be covered with mucosa but they do not provide any gingival augmentation. Most of these flaps are myofasciocutaneous; they have also been described as osteomyofasciocutaneous, but the bony component, which is randomly vascularized, is not routinely dependable.

Subepithelial connective tissue grafts and the management of specific conditions Gingival recession and mucogingival defects around natural teeth Attached gingiva is not synonymous with keratinized gingiva. The width of attached gingiva is determined by subtracting the depth of the sulcus or pocket from the distance from the crest of the free gingival margin to the mucogingival junction. Reduced attached gingiva may therefore result from worsening periodontal pockets, high frenal attachments, and worsening recession caused by overzealous hygiene. There are many studies that refute the old concept that a wide attached gingiva is required for the maintenance of optimal gingival health [21]. The need for a wider zone of attached gingiva, however, persists in teeth that serve as abutments for fixed or removable partial dentures [22]. In 1985, Miller classified marginal tissue recession by combining the four previously popular Sullivan and Atkins [23] classifications into his first two classifications (class I, with recession coronal to the mucogingival junction [MGJ], and class II, where the recession goes to or beyond MGJ) and then adding two more [24]. He identified that the presence of

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

interdental bone and soft-tissue loss, or malpositioned teeth, presented anatomic limitations that limit root coverage (class III) or preclude attempts at root coverage (class IV). Many surgical techniques have been described to manage marginal recession. The first approach, the lateral sliding flap by Grupe and Warren [25], dates back to 1956. This technique, however, only provides 65% to 75% mean root coverage [26]. It also requires a deep vestibule and good gingival dimensions lateral to the site of recession. Miller showed good success for root coverage with FGG [27]. The lack of esthetic color blending, however, discouraged the use of FGG in the esthetic zone. It was later suggested that SCTG achieved greater root coverage than thick gingival grafts [28,29]. Once SCTGs were popularized for root coverage, the success of this technique prompted many modifications in the literature, especially when considering the flap coverage design. Allen described a coronally repositioned flap [30]. Nelson then described a full-thickness, double-papilla flap to cover the connective tissue [31]. He used subperiosteal dissection of the recipient site and also included periosteum with his SCTG. Harris later modified this by designing a split-thickness, double-papilla flap [32], with success rates up to 97% [33]. Raetzke designed the ‘‘envelope’’ technique, where the connective tissue graft is seated in an undermined partial-thickness incision [34], with an 80% mean root coverage. He obtained a semilunar wedge of tissue from the palate, which was placed in the envelope and secured with cyanoacrylate, without sutures. Raetzke’s technique was then modified by Allen, who introduced the ‘‘tunnel’’ technique, in which no horizontal or vertical incisions are made, allowing for the coverage of multiple and single areas of recession [35]. It is used for adjacent recessions where a tunnel is developed supraperiosteally underneath the interproximal papilla. This technique provided predictable results for root coverage, up to 97%, in shallow and narrow recessions; however, these results deteriorated to 75% when the recession was wider than 3 mm or deeper than 4 mm. This deterioration is believed to result from the lack of blood supply to the coronal edge of the graft because envelope-type designs do not allow for coronal repositioning and, thus, the graft is left bare. Although these designs may allow for increased blood supply from lateral and papillary tissues by keeping them intact, the dissection technique may embarrass circulation, thereby compromising results. In an attempt to improve this, other flaps were devised to allow bolstering nutrition to the graft by coronally or laterally positioning external gingival tissues. Blanes

243

and Allen modified the pouch technique to improve the reliability of SCTG in deep, wide recessions by the use of a bilateral pedicle flap – tunnel technique [36]. Most of these methods are reliable for Miller classification I and II, and they may also be of benefit for class III. On the other hand, class IV recession is very unpredictable in its reconstruction. Multiple case reports exist, but no uniform methods exist which can claim predictable results [35]. Gingival recession can also be treated using guided tissue regeneration (GTR) techniques. Even though root coverage may be comparable using both techniques, it seems that mucogingival surgery is more predictable than GTR [37]. Also, some studies note that GTR does not increase the height of keratinized tissue and in fact displaces the mucogingival junction coronally [38]. Harris noted that even though the comparable root area was covered with GTR and SCTG, the grafted area actually had improved tissue bulk [39]. It is theoretically possible that including periosteum as a barrier membrane in the SCTG would combine the benefits from GTR and mucogingival surgery. Recession and mucogingival defects around dental implants The grayish color that may appear when implants are placed in areas of thin bone and gingiva can be adequately hidden by using an SCTG, often with a pouch technique [40]. The similarity between natural periodontium and the peri-implant soft tissues can sometimes be deceiving, however. By definition, an implant is surgically placed and, therefore, the surrounding tissues heal as a scar. This hypovascular tissue is further compromised by the lack of vascularity that would otherwise arise from the periodontium around the teeth. It is therefore important to be even more conservative with surgical manipulations once an implant is placed. Indeed, it is more beneficial to perform most of the required stages of site development before implant placement. Papilla reconstruction Papilla reconstruction remains an elusive goal. The presence of an interproximal papilla may be dependent on the distance from the base of the contact area to the crest of interdental bone. Tarnow showed that when that distance was 5 mm or less, the papilla was almost always present; when it was 6 mm, the papilla was still present in 56%; but when it was 7 mm or more, the papilla was present only up to 27% of the time [41]. Jemt recently observed a possibly related

244

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

event around implants when he reviewed the size of interproximal papillae adjacent to single implant restorations [42]. Over a three-year follow-up, he noted that 58% of the tested papillae had regenerated completely without any clinical manipulation. Papillae can also be grown nonsurgically in case reports where forced eruption had positive effects on the creation of normal interproximal tissues [43]. The majority of articles describing surgical techniques have been simple case reports. Some studies describe the use of pedicled flaps that resemble the palatal roll [44] or sliding flaps. These pedicled flaps were found to be more predictable than free gingival grafts [25]. The introduction of SCTG, however, has improved the overall results. Even if there is yet no agreement on the best flap design to use, it seems that the idea of bolstering up pedicled flaps with SCTG may be a reliable surgical method to reconstruct papillae. Han and Takei modified Tarnow’s semilunar, coronally repositioned flap [45] by displacing the interdental papilla coronally and packing SCTG underneath [46]. A recent case report describes class IV recession root coverage and papilla reconstruction using a coronally repositioned flap that is beveled at the mucogingival line with a maxillary tuberosity SCTG placed under the flap in the interdental area [47]. Another method that is based on the same idea of using tuberosity SCTG as a bolster left the papilla pedicled palatally and then the SCTG was placed in a supraperiosteal pouch at the level of the CEJ [48]. As the search for the best surgical reconstruction of the papilla continues, Tarnow’s effect of crestal bone height will eventually be applied by using better GTR principles in the interdental area. At this point, some bone height can be gained, but it still remains difficult to completely regenerate lost interproximal bone, which results in lost papillae. Hu¨rzeler discussed some of these GTR techniques combined with two- to three-layered closure of the interproximal area using microsurgical sutures [49].

itative long-term studies. Large-volume soft-tissue defects, especially in the vertical dimension, are less predictable with soft-tissue grafts. Sclar, however, has shown very good results using a new pedicled axial/ random flap design, the vascularized interpositional periosteal – connective tissue flap (VIP-CT flap) [20]. This flap is versatile and useful for large-volume softtissue reconstructions in areas where the vascular potential of the recipient site is diminished. In addition, the VIP-CT flap provides the biologic basis for simultaneous hard and soft-tissue augmentation of alveolar ridge defects in the anterior maxillary area, thereby enhancing esthetic implant site development.

Ridge defects

Recipient site preparation

Ridge defects are usually a combination of soft and hard-tissue problems. Bony reconstruction is now very predictable as long as good soft tissue coverage can be obtained. Ridge defects can be classified as buccolingual, apicocoronal, or a combination [50]. Small-volume soft-tissue defects can be treated by FGG or SCTG; however, it seems that better volume augmentation is achieved with SCTG [51]. The dimensional stability of these reconstructions seems good but has not been shown adequately in quant-

A horizontal right-angle incision is initially performed into the adjacent interdental papillae, slightly coronal to the CEJ (Fig. 1A). A butt joint is provided. In a Miller class III recession, the incision is placed at the crest of the residual papilla; in this case, a butt joint cannot be obtained and the papilla is carefully deepithelialized as part of the split-thickness dissection. If the ‘‘open’’ (flap) approach is used, beveled curvilinear incisions are placed one half to one full tooth wider than the area of planned grafting, without

Other indications The success of SCTGs has led to their use in many different applications. They are very useful in cases of thin, discolored gingiva. SCTG can be used as an adjunct to vestibuloplasty procedures [52]. They can also be used in conjunction with different socket preservation procedures [53], but this is not usually needed [54].

Subepithelial connective tissue graft technique Preparation Preoperative films and models are routinely obtained. The models are used to fabricate a palatal stent for postoperative comfort. If the patient is partially edentulous, this stent may also include an artificial tooth, such as in an Essex-type retainer. Tight frenal attachments that may compromise the desired flap design may be resected 4 to 6 weeks before the procedure. The patient undergoes full mouth scaling, root planing, and hygiene instructions by the dentist at least 2 weeks before the procedure. Pre-emptive analgesic medication is prescribed along with antibiotic prophylaxis, as needed.

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

245

Fig. 1. Graft insetting with the open approach using wide, diverging curvilinear incisions with a back cut at the base as needed for a tension-free closure (A). Supraperiosteal dissection and exposure should be atraumatic (B,C). The open technique allows maximal immobilization of the graft to the underlying periosteum (and not, as in the closed approach, to the cover flap, which is often mobile; D,E).

invading the interproximal papillae. Exposed root surfaces are planed to reduce tooth convexity only if it is excessive. This is done with manual or rotary instrumentation under copious irrigation. As tissue thickness permits, sharp dissection with a small surgical blade (Bard Parker 15C; Beckton Dickinson Frankin Lakes, NJ) is used to define a supraperiosteal plane (Fig. 1B). Extremely thin gingiva may require

careful full-thickness elevation. The dissection is carried well beyond the mucogingival junction. Salinemoistened gauze is placed over the recipient site while the donor tissue is procured. If the ‘‘closed’’ (pouch) approach is used, sharp dissection is used to form a partial-thickness supraperiosteal envelope extending 3 to 5 mm laterally and apically to areas of recession, undermining intermedi-

246

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

Fig. 2. Graft harvesting with the double-incision approach (A,B). Note that sectioning the base of the graft is done under tension (F) and only after all other undermining is performed (C,D,E), to allow maximal length. The wound is closed with simple sutures (G).

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

247

Fig. 2 (continued ).

ate papillae. The apical extent of dissection needs to be beyond the MGJ. Graft harvest The first incision on the palate is made full thickness and perpendicular to the bone (Fig. 2A).

It is 2 to 3 mm apical to the gingival margin of the maxillary premolars. The exact length of the incision is 1 to 2 mm longer than the amount of graft necessary for the recipient site. The second incision is the medial part of an elongated ellipse (Fig. 2B). It is also perpendicular to the bone but is only 0.5- to 1-mm deep. An undermining preparation toward the

248

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

median is then made in the superficial submucosal plane, using sharp dissection with a 15C blade parallel to the palatal bone with no attempt to go to bone at the apical depth (Fig. 2C). The preparation is observed externally without trying to elevate the tissue while cutting with the blade. The exact area undermined is also determined by the amount of graft that is necessary. The maximum supero-inferior length of the graft is 4 to 14 mm, depending on the shape of the palatal vault, allowing 2 mm above the CEJ and 1 mm below the neurovascular bundle [55]; therefore, in cases of shallow vaults or thin tissues, a second procedure may be required. The bony groove that houses the bundle is sometimes palpable posteriorly. The blade is then used to make two lateral tunneled release incisions (Fig. 2D). These incisions are made down to the bone, 0.5 to 1 mm medial to the end of the ellipse on either side so that the cover mucosa is not stretched or ruptured. At that point, a small periosteal elevator is used to raise a fullthickness periosteal connective tissue graft slightly further apically then the anticipated graft length (Fig. 2E). The graft can now be placed under slight tension, using atraumatic tissue pliers, which allows placing the final full-thickness incision in the deepest

part of the pocket, perpendicular to the lateral incisions and to the bone (Fig. 2F). This incision releases the SCTG. Before suturing the donor area, a collagen material (CollaPlug; Sulzer Calcitek, Carlsbad, CA) can be placed in the dead space created for hemostasis and to maintain the shape of the palate. The graft is placed between saline-moistened gauze squares while the palatal area is sutured. (Fig. 3) Graft insetting The graft is shaped as needed to fit the recipient bed. The graft edges may be beveled slightly where they will be submerged. Keratinized epithelium is usually removed but may be retained in exposed areas. In the open approach, the graft is secured in place by using 4-0 chromic gut sutures on a P3 needle. Apical sutures are placed into the recipient periosteum. The graft is secured coronally with a modified sling suture (Fig. 1D). The covering tissue is then reapproximated without attempting to completely cover the graft and is secured with sutures that do not pass through the underlying graft (Fig. 4). In the ‘‘closed’’ approach, mattress sutures originating from the vestibular area are placed in the most

Fig. 3. Graft harvesting with the double-incision approach (A). The size of the defect is minor even without doing the singleincision technique (B). Good graft dimensions are obtainable (C) and then the site is closed with interrupted sutures (D).

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

249

Fig. 4. A coronal soft-tissue defect is noted, and there is sufficient bony width for root-shape implant at the base (A). Graft insetting with the open approach using wide, diverging curvilinear incisions (B). Early healing (C) followed by a cosmetic restoration after implantation (D). Minimal crown lengthening may be performed as needed to match the contralateral lateral incisor.

apical and lateral area of the pouch dissection. A small suturing forceps (Corn suture pliers, SP 20; Hu-Friedy Chicago, IL) is used to place a 4-0 chromic gut suture 3 to 5 mm into the deepest part of the envelope. Tissue borders are gently teased into the envelope using a tissue forceps and the fine paddle end of a membrane placement instrument (Hu-Friedy). Once in place, mesial and distal sutures are completed. Intermediate papillae are anchored with vertical mattress sutures to ensure firm fixation of the graft within recipient site pouches that span multiple teeth. Pressure is then applied with moistened gauze to facilitate hemostasis with minimal clot thickness (Fig. 5).

ed, and the patient is instructed to cleanse the graft site with a cotton swab saturated with chlorhexidine.

Scientific principles The periodontium is a hostile wound-healing environment. It is plagued with a ferocious microflora, continuous speech and mastication motions, and a challenging architecture. Predictable tissue engineering can only be guaranteed by meticulous planning and attention to detail. I. Host factors

Postoperative care An acrylic palatal stent is placed immediately to protect the palate for patient comfort. Patients are instructed to keep the stent in place for 24 hours and then as needed to eat and to minimize discomfort. No surgical dressing is usually required at the graft site. The patient is prescribed a chlorhexidine rinse two times per day and placed on a soft diet. The patient is seen on the seventh postoperative day. The area is irrigated, sutures are removed as need-

1. Systemic equilibrium and healing potential Even if wound healing is a local event, it can be affected by many systemic factors, which should be taken into account. These are not discussed in detail, but include diabetes, collagen diseases, and other microvascular or immune diseases. Wound healing itself is a well-studied phenomenon. An incisional wound is described traditionally to heal in four phases: the inflammatory phase (day 1);

250

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

Fig. 5. A coronal soft-tissue defect is noted, and there is sufficient bony width for a root-shape implant (A). Graft insetting with the closed approach using a traction suture (B). Closure and early healing (C). Final cosmetic tissue morphology (D).

the lag or substrate phase, where the fibrin clot contributes to much of the strength (days 2 to 5); the proliferative phase, when epithelial regeneration, contraction, and fibroplasia take place (day 5 to third week); and finally the maturation or remodeling phase (may last up to a year). This temporal representation is a generalized guideline, and many different wounds demonstrate high variability in their healing patterns. Sullivan and Atkins described FGG healing in three comparable stages: plasmic circulation (0 to 2 days), vascularization (2 to 8 days), and organic union (4 to 10 days) [56]. Raetzke noted that SCTG at 5 days is covered with a grayish membrane and a few tiny red dots are visible. At 7 days, the graft is edematous; it blanches to pressure and then redness reappears immediately after release of pressure, indicating initial vasculariation. At 2 weeks, grafts are completely epithelialized. These findings were noted ultrastructurally in subepithelial capillaries as they matured in FGG [57]. The ultimate evidence-based soft-tissue grafting study would, in a prospective double-

blinded manner, evaluate the results of each procedure by a human histologic evaluation. Such a study is difficult to perform, however; there are a few case reports of individual histologic evaluations. These studies used different protocols, healing periods, and patient selection criteria, making their comparison difficult. Pasquinelli demonstrated that new bone growth, new cementum, and new connective tissue attachment were possible with a free gingival graft [58]. Sugarman reported with a human histologic evaluation that new connective tissue occurred with a laterally positioned flap [59]. Common and McFall demonstrated with human histology that a laterally positioned flap combined with citric acid conditioning resulted in new cementum and collagen fibers that were oriented parallel to the root [60]. Root coverage with GTR techniques has also been studied and shown to produce new bone, new cementum, and new connective tissue attachment [61]. The same type of study was recently applied to SCTG and double-pedicle graft coverage [62]. In that study, Harris noted a repair, as opposed

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

to regeneration, response. Two patterns were noted: a long junctional epithelium in one pattern, and in the other pattern, a short junctional epithelium and connective tissue adjacent to the tooth with little other epithelial attachment. Overall, healing after different root coverage procedures is represented by a combination of long junctional epithelium and a new connective tissue attachment with cementum formation. 2. Management of modifiable factors Removing the cause of the disease is often the key to curing it. In many patients, forceful brushing is the reason the recession develops in the first place. The value of patient education by the dentist with respect to correct technique should not be underestimated because it may be just as important as the type of procedure selected [63]. Smoking is another well-known factor that may affect success rates [64,65]. 3. Compliance and expectations Patient preparation is very important. They must understand the limitations of the procedure and that an operation may often need to be staged for optimal results. They must also understand the importance of preoperative and postoperative care. Even the best graft may not survive if immediately subjected to a rough diet. Eventually, at 2 weeks, periodontal wounds acquire sufficient tensile strength (1700 g) to tolerate most mechanical challenges such as a regular diet [66]. 4. Treatment sequencing for optimal site development SCTG may be placed before bony reconstruction or prosthetic treatments in cases where the gingiva is so thin that it may be lost when future surgical interventions are performed. Another good time to sequence SCTG is at the end of a complicated treatment, at which point it serves to fine-tune the esthetic result. II. Donor factors 1. Optimal site selection Connective tissue can obviously be harvested from many areas in the mouth. Even if the palatal premolar area is the best studied and usually most reliable [50,55], other sites have occasionally been used. Attached gingiva has the required characteristics but is usually limited in availability. Any masticatory mucosa from an edentulous ridge may be used. A

251

distal wedge incision allows the harvest of connective tissue from the tuberosity area; this tissue, notwithstanding its small area, is thicker (4 to 5.7 mm) and more dense, which allows for better bulk support in selective cases [48,67]. Knowledge of the anatomy of the donor site is essential. Suitable palatal masticatory mucosa is found in a rectangular area [68]. That area is delineated anteriorly by the canine root and posteriorly by the palatal root of the first molar. The root of the first molar represents a natural barrier because the tissue is thinnest in this area [67]. The lateral border is formed by a horizontal line 2 mm from the palatal gingival margin. The rectangle is medially limited by the greater palatine neurovascular bundle. Reiser measured the distance to the neurovascular bundle from the palatal CEJ of premolar teeth and noted that this dimension is highly dependent on the shape of the palate [55]. In shallow, average, and high vaults, that distance was 7, 12, or 17 mm, respectively. This distance is reduced anterior to the canine as the vessel courses anteriorly toward the incisive foramen. The greater palatine foramen is 1.5 cm from the midline and positioned usually opposite the third molar at the junction of the vertical and horizontal parts of the palatine bone (Fig. 6) [69,70]. 2. Atraumatic harvest The method most commonly used for harvesting SCTG is the parallel double-incision approach. For isolated areas of recession, Raetzke advocated gradually converging semilunar incisions to define a palatal graft of adequate thickness and contour. The single-incision approach may have a slight advantage in that it leaves a smaller denuded area, but this has not been shown to be clinically significant [68]. The discomfort and delayed healing of a trap door ‘‘free gingival graft knife’’ method, however, was shown to be significantly worse than the standard double-incision approach [71]. A tunneling incision, on the other hand, is only advantageous if performed atraumatically. 3. Tissue quality Gingiva is a specialized mucosal tissue that originates as the crown of erupting teeth (with the surrounding reduced enamel epithelium) enters the oral cavity. There is an interaction between this epithelium and the connective tissue. Before emergence of the crown, the

252

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

Fig. 6. Quantitative topography of the harvest site. The tissue thickness measurements are adapted from Studer’s study [59]. The graft measurements are based on Reiser’s dimensions, depending on the shape of the palate [55]. They account for the 2-mm distance from the CEJ of the premolars and the 1-mm lateral distance to the neurovascular bundle.

connective tissue in the future eruption pathway is induced to degenerate, thus accelerating the rate of eruption [95]. Even though keratinization is an epithelial characteristic, when connective tissue is transplanted from a keratinized area to a nonkeratinized area, it eventually becomes covered by a keratinized epithelium [72]. This finding suggests a connective tissue – based genetic determination of the type of epithelial surface. This hypothesis remains controversial, however, and has been rejected in a few studies [73 – 75]. In fact, it has been suggested that the position of the MGJ is genetically determined and cannot be altered [76]. The hard palatal tissues may be defined in three zones. There is a peridental gingival zone, an anterior fatty zone, and a posterior glandular zone [77]. Inclusions of epithelial islands or epithelial projections were found deep in the connective tissue of SCTG biopsy specimens [78]. This suggests that SCTG may contain epithelium that survives transplantation to the recipient site. The effects of epithelium, fatty tissue, and possible trans-

plantation of minor salivary gland tissue remain to be studied. 4. Adequate graft size Gingival grafts, as opposed to skin grafts, contain very little elastic tissue. They undergo minimal primary contraction. They may, however, undergo significant secondary contraction because of cicatrisation of tissues, especially if they are thin and poorly stabilized [23]. In fact, Edel noted a mean contraction of 28% after 6 months, and Block stated a contraction of 20% to 50% [10,96]. 5. Adequate graft thickness Proper thickness is important for survival of the graft. It should be thin enough to permit ready diffusion of nutritive fluid from the recipient site, which is essential in the immediate post-transplant period. Also, the graft should not be too thin, so as not to shrivel and expose the recipient site. The ideal thickness of a free gingival graft is between 1 and 1.5 mm [79]. The descriptive terms used to classify graft thickness are often used interchangeably. Free gingival grafts are defined as partial thickness when they consist of epithelium and varying amounts of lamina propria, or full thickness when all the lamina propria but no glandular tissue or submucosa is included [23]. Healing of a free gingival graft of intermediate thickness (0.75 mm) is complete by 10 weeks, while thicker grafts (1.75 mm) may require 16 weeks or longer [97]. While specifically discussing SCTGs, many authors recommend a minimum graft thickness of 1.5 mm [35], but none actually go on to prove that hypothesis. It should be noted that the original description of the harvest of connective tissue for root coverage required two incisions, an apical inverse bevel incision and a coronal incision that converged apically, creating a wedge of tissue that was always very thin at the base. This is avoided by the described technique. The tissues are very thin in some cases, so a second graft will be needed later to achieve appreciable results. The second graft can be harvested from the same donor site within a 3-month period. This allows the harvest of an improved quality of connective tissue with less adipose or glandular elements. Sclar described that the ‘‘second harvest effect’’ may yield three to five times the volume of good quality connective tissue with double the graft thickness when compared to the initially harvested graft [80].

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

6. Management of the epithelial band When the SCTG is harvested with the doubleincision approach, a band of epithelium remains as part of the graft. It has been hypothesized that covering this epithelium may later lead to cyst formation [81]. If the epithelium is left exposed, it may provide slightly more keratinized tissue, but better esthetic results were shown when the epithelium was removed and the entire graft was covered with the facial flap [82]. There are no comparison studies that evaluate covering the epithelium as opposed to removing it before covering the flap, however. A combination of maintenance of epithelium and its removal only in areas that will be covered is often suggested [12,55]. 7. Preservation of the periosteal complex Another point of contention is whether periosteum should be harvested along with the SCTG, or if it should be left on the palate. Even if no studies support this, it is clear that harvesting periosteum improves both the thickness and the consistency of the graft. Reiser suggested that the retention of periosteum on the donor tissue may provide increased circulation to the graft [55]. On the other hand, Sullivan and Atkins hypothesized that fat may act as a barrier to both diffusion and vascularization [23,56]. Not harvesting periosteum tends to lead to wedge-shaped grafts where the coronal 3 to 5 mm are composed of dense lamina propria, while the apical portion will contain loosely organized submucosal elements and fat with very little structural support. The use of autogenous periosteal grafts (SCTG including periosteum) as barriers for the treatment of furcae and intrabony defects has been successfully demonstrated [83,98]. 8. Tissue preservation The efficacy of SCTG results from a combination of the effects of two principles of tissue transplantation: the ‘‘host replacement theory,’’ which states that the graft merely acts as a matrix for host cell repair, and the ‘‘cell survival theory,’’ which claims that some of the donor tissue actually survives. It seems that most of the effect is caused by replacement, but the exact role of cell survival has not been elucidated. Therefore, a concerted effort should be made for the graft tissue to be left out for as little time as possible. Cellular viability is maintained for a

253

short time by placing the graft between saline-moistened gauzes. III. Recipient site factors 1. Proper diagnosis It is important to understand the healing potential and extent of disease in the planned graft area. Sequencing of treatment and the possible need for multiple procedures should be clearly explained to the patient, as with any surgical procedure. 2. Vascular potential of recipient bed A free soft-tissue graft is, by definition, totally dependent on the recipient site for its survival. It is difficult to sustain a free softtissue graft in a hypovascular area, such as in the aftermath of trauma, multiple surgeries, or infectious episodes. Among other options, the use of autologous platelet-rich plasma may improve results in these cases. 3. Reduced bacterial load Even if bacterial byproducts are often implicated (at least partially) in the etiology of oral and gingival problems, some authorities have recommended against prophylactic management of diseased tissues. Indeed, Miller suggests that a ‘‘pathologically involved papilla offers a larger papilla for suturing and bleeds more profusely when cut’’ [84]. This goes against the most basic wound-healing principles. Skin grafts are known to have better success in wounds with bacterial density less than 105/g of organisms [85]. Because of good vascularity, oral wounds may tolerate higher levels than that; however, this should be the exception, not the driving principle. As for ease of suturing, an edematous papilla may offer more surface for a 4-0 or 5-0 suture, but a small, healthy papilla offers a more predictable result, even if it requires a 6-0 or 7-0 suture. 4. Adequate exposure An area one half to a full tooth wider than the recipient site should be exposed. This can even be carried further when dealing with relatively avascular areas, to take advantage of peripheral circulation from adjacent sites. When Allen described the use of the envelope technique [35], he suggested that beveled incisions are preferable to ‘‘butt joint’’ incisions because they provide intimate bilaminar contact with the involved tissues and ensure better lateral blood supply to the graft. This impression was actually never

254

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

proven in clinical trials, but it is easy to appreciate that beveled incisions improve light transmission and provide a less conspicuous scar [80]. The decision of whether to use an envelope technique or an open flap should not be an absolute one. Similar to all dentoalveolar surgery, some cases may be simply treated with an envelope flap while others may require one or two releases to allow for better exposure. This must be an individual decision. If significant tissue augmentation is planned, a long, curvilinear incision provides better elasticity of the flap than a traditional trapezoidal flap. Furthermore, this design allows for tension-free coronal advancement. This is obviously not possible with a ‘‘closed’’ flap design. On the other hand, the ‘‘closed’’ approach enhances cosmesis and is useful in compromised sites where preservation of circulation would otherwise be difficult. 5. Management of interdental papillae Using papilla-preserving flaps allows a reduced change in papillary height. Horizontal incisions are used at the level of the CEJ. 6. Tissue bed preparation It is believed that a supraperiosteal dissection in the recipient site offers a better blood supply; however, in some cases, it is also possible to have some parts of the dissection carried subperiosteally. The use of free gingival grafts on denuded bone has been studied in both animal models [86] and humans, with good success [87]. In fact, some clinicians noted that apical and lateral fenestrations might be helpful by reducing graft mobility [56]. The preservation of periosteum, however, remains indicated to reduce healing time, reduce alveolar bone resorption, and allow for a surface conducive for suturing [88]. Of course, if an implant is being placed at the same time, full thickness dissection is performed at the area of the osteotomy and the rest of the ridge is dissected supraperiosteally. Adequate hemostasis is very important. It is best achieved by pressure and by avoiding dead space. This is allowed by the preparation of a uniform bed to which a uniform graft is fixated. 7. Root/implant surface preparation When SCTG are used to cover avascular surfaces (root, implant), many techniques are available to improve success rate. Root surface conditioning remains a controversial

issue. Miller has been a strong advocate for the use of citric acid treatment of the root before soft-tissue grafting [89]. While his rationale has been compelling, others have not found efficacy for its routine use in humans [90,91]. Using autoradiographic techniques on dogs, neither citric acid nor tetracycline treatment offered any advantage over treatment with sterile water [92]. In a human histologic study, the use of citric acid seemed to allow better tissue regeneration; however, the only controls were untreated teeth, and citric acid was not compared to other conditioners [60]. Root prominence, especially when the tooth is facially positioned in the arch, may be a factor in reduced root coverage [84]. This should be corrected by judicious reshaping. 8. Graft insetting and fixation A fixed graft allows minimal interruption of nourishment via plasmatic circulation and facilitates further capillary ingrowth. The recipient site morphology must offer the means to immobilize the graft. Adequate exposure and supraperiosteal dissection will allow fixation to the stable periosteum. On the other hand, envelope-type preparations often fix the graft apically to the cover tissue, which itself is not a fixed structure. This is even more pronounced in shallow vestibules. Shallow vestibular depth, thus, is often a contraindication to the closed technique because of immobilization difficulty. 9. Cover-flap integrity The covered areas of the graft actually have a dual blood supply from the periosteum and from the flap. Good blood supply to these areas allows a more predictable survival of the uncovered parts. Many flap designs have been devised to reduce that uncovered area with variable success. There is no literature that describes the maximal survivable denuded graft surface area at this point. In their original article, Langer and Langer state that an uncovered area that was one half to one third of the total graft area usually survives well [12]. This raises the question regarding the necessity for strict cover flap integrity. 10. Tension-free closure Even if some authors recommend a ‘‘stretched’’ graft, this seems to contradict woundhealing principles [35,93]. A tension-free graft and closure where the graft passively lays in its recipient site has the best chance for success.

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

In fact, Raetzke recommended no use of sutures; he used tissue adhesive instead. 11. Interim provisional restoration The use of tooth-borne interim restorations in implant cases reduces micromovement of the graft. This will optimize the volume yield and allow for more predictable healing [94].

[14]

[15]

[16]

Summary Subepithelial connective tissue grafting is a predictable technique that has become the workhorse for cosmetic, small-volume soft-tissue augmentation. Many modifications have been designed, demonstrating the versatility of the procedure. Consistent results will be obtained as long as sound scientific principles are followed.

[17]

[18]

[19]

References [20] [1] Foman S. Cosmetic surgery. Philadelphia: Lippincott and Co.; 1960. p. 161 – 200. [2] Reverdin J.L. Greffe epidermique. Arch Gen Med 1872;19:277,555,703. [3] Freshwater FM, Krizek TJ. Skin grafting of burns. A centennial. J Trauma 1971;11:862 – 5. [4] Schnitzler J, Ewald K. Zur technek der haut transplantation noch Thiersch [The Thiersch technique of skin grafting]. Centrif Cher 1894;21:148 – 52 [in German]. [5] Steinhauser EW. Free transplantation of oral mucosa for improvement of denture retention. J Oral Surg 1969; 27:955 – 61. [6] Bjo¨rn H. Free transplantation of gingival propria. Sveriges Tandla¨karfo¨rbunds Tidning 1963;22:684 – 8. [7] Siegel RJ. Palatal grafts for eyelid reconstruction. Plast Reconstr Surg 1985;76:411 – 4. [8] Yoshimura Y, Nakajima T. Tracheoplasty with palatal mucoperiosteal graft. Plast Reconstr Surg 1990;86: 558 – 62. [9] Morgan LR, Gallegos LT, Frileck SP. Mandibular vestibuloplasty with a free graft of the mucoperiosteal layer from the hard palate. Plast Reconstr Surg 1973; 51:359 – 63. [10] Edel A. Clinical evaluation of free connective tissue grafts to increase the width of keratinized gingiva. J Clin Periodontol 1974;1:185 – 96. [11] Langer B, Calagna L. Subepithelial connective tissue graft to correct ridge concavities. J Prosthet Dent 1980; 44:363 – 7. [12] Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1983; 56:715 – 20. [13] Argenta LC, Friedman RJ, Dingman RO, et al. The

[21]

[22]

[23]

[24] [25] [26]

[27]

[28]

[29]

255

versatility of pericranial flaps. Plast Reconstr Surg 1985;76:695 – 702. Erol OO. Facial autologous soft-tissue contouring by adjunction of tissue cocktail injection (micrograft and minigraft mixture of dermis, fascia and fat). Plast Reconstr Surg 2000;106:1375 – 89. Cortese A, Savastano G, Felicetta L. Free fat transplantation for soft tissue augmentation. J Oral Maxillofacial Surg 2000;58:164 – 9. Harris RJ. Root coverage with a connective tissue with partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histological evaluation of a case report. J Periodontol 1998;69: 1305 – 11. Tal H. subgingival acellular dermal matrix allograft for the treatment of gingival recession: a case report. J Periodontol 1999;70:1118 – 24. Lauer G, Otten JE, von Specht BU, et al. Cultured gingival epithelium. A possible suitable material for preprosthetic surgery. J Cranio Max Fac Surg 1991; 19:21 – 6. Ueda M, Hata KI, Sumi Y, et al. Peri-implant soft tissue management through use of cultured mucosal epithelium. Oral Surg Oral Med Oral Path 1998;86: 393 – 400. Sclar AG. The vascualrized interpositional periostealconnective tissue flap: a new technique for large-volume soft-tissue reconstruction and simultaneous hard and soft tissue augmentation of alveolar ridge defects in the anterior maxillary area. In: Sclar AG, editor. Soft tissue and Esthetic considerations in implant therapy. Chicago: Quintessence; 2001. p. 106 – 10. Wennstrom JL. Lack of association between width of attached gingiva and development of gingival recession. A 5-year longitudinal study. J Clin Periodontol 1987;14:181 – 4. Stetler KJ, Bissada NF. Significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restorations. J Periodontol 1987; 58:696 – 700. Sullivan HC, Atkins JH. Free autogenous gingival grafts. III. Utilization of grafts in the treatment of gingival recession. Periodontology 1968;6:152 – 60. Miller PD. A classification of marginal tissue recession. Int J Periodont Rest Dent 1985;5:8 – 13. Grupe H, Warren R. Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27:92 – 5. Caffesse R, Guinard E. Treatment of localized recessions. Part IV. Results after three years. J Periodontol 1980;51:167 – 70. Miller Jr. PD. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep wide recession. Int J Periodont Rest Dent 1985;5: 14 – 37. Jahnke PV, Sandler JB, Gher ME, et al. Thick free gingival and connective tissue autografts for root coverage. J Periodontol 1993;64:315 – 22. Paolantonio M, di Murro C, Cattabriga A, et al. Subpedicle connective tissue graft versus free gingival graft

256

[30]

[31]

[32]

[33]

[34]

[35]

[36]

[37]

[38]

[39]

[40]

[41]

[42]

[43]

[44]

[45] [46]

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257 in the coverage of exposed root surfaces. A 5-year clinical study. J Clin Periodontol 1997;24:51 – 6. Allen EP. Pedicle flaps, gingival grafts, and connective tissue grafts in aesthetic treatment of gingival recession. Pract Periodontics Aesthet Dent 1993;5: 29 – 38. Nelson S. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95 – 102. Harris RJ. The connective tissue and partial thickness double pedicle graft: a predictable method of obtaining root coverage. J Periodontol 1992;63:477 – 86. Harris RJ. The connective tissue with partial thickness double pedicle graft: the results of 100 consecutively treated defects. J Periodontol 1994;65:448 – 61. Raetzke P. Covering localized areas of root exposure employing the ‘‘envelope’’ technique. J Periodontol 1985;56:397 – 402. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodont Rest Dent 1994;14:217 – 27. Blanes RJ, Allen EP. The bilateral pedicle flap-tunnel technique: a new approach to cover connective tissue grafts. Int J Periodont Rest Dent 1999;19:471 – 9. Mu¨ller HP, Stahl M, Eger T. Root coverage employing an envelope technique or guided tissue regeneration with a bioabsorbable membrane. J Periodontol 1999; 70:743 – 51. Borghtetti A, Glise JM, Monnet-Corti V, et al. Comparative clinical study of a bioabsorbable membrane and subepithelial connective tissue graft in the treatment of human gingival recession. J Periodontol 1999; 70:123 – 30. Harris RJ. A comparison of two root coverage techniques: guided tissue regeneration with a bioabsorbable matrix style membrane versus a connective tissue graft combined with a coronally positioned pedicle graft without vertical incisions. Results of a series of consecutive cases. J Periodontol 1998;69:1426 – 34. Silverstein LH, Kurtzman D, Garnick JJ, et al. Connective tissue grafting for improved implant esthetics: clinical technique. Implant Dent 1994;3:231 – 4. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995 – 6. Jemt T. Regeneration of gingival papillae after single implant treatment. Int J Periodont Rest Dent 1997;17: 327 – 33. Ingber JS. Forced eruption: alteration of soft tissue cosmetic deformities. Int J Periodont Rest Dent 1989; 9:417 – 25. Beagle JR. Surgical reconstruction of the interdental papilla: case report. Int J Periodont Rest Dent 1992;12: 145 – 51. Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol 1986;13:182 – 5. Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol 2000 1996;11:65 – 8.

[47] Azzi R, Etienne D, Sauvan JL, et al. Root coverage and papilla reconstruction in class IV recession: a case report. Int J Periodont Rest Dent 1999;19:449 – 55. [48] Azzi R, Etienne D, Carranza F. Surgical reconstruction of the interdental papilla. Int J Periodont Rest Dent 1998;18:467 – 73. [49] Hu¨rzeler MB, Weng D. Functional and esthetic outcome enhancement of periodontal surgery by application of plastic surgery principles. Int J Periodont Rest Dent 1999;19:37 – 43. [50] Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent 1983;4:437 – 53. [51] Studer SP, Lehner C, Bucher A, et al. Soft tissue correction of a single-tooth pontic space: a comparative quantitative volume assessment. J Pros Dent 2000;83: 402 – 11. [52] Cabrera PO. The connective tissue graft with labial vestibular extension. Pract Periodont Aesthet Dent 1994; 6:57 – 63. [53] Cohen ES. Ridge enhancement and socket preservation utilizing the subepithelial connective tissue graft: a case report. Pract Periodont Aesthet Dent 1995;7: 53 – 8. [54] Sclar AG. Preserving alveolar ridge anatomy following tooth removal in conjunction with immediate implant placement: the Bio-Col technique. Atlas Oral Maxillofacial Surg Clin N Am 1999;7:39 – 59. [55] Reiser GM, Bruno JF, Mahan PE, et al. The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons. Int J Periodont Rest Dent 1996;16:130 – 7. [56] Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics 1968;6:121 – 9. [57] Nobuto T, Imai H, Yamaoka A. Ultrastructural changes of subepithelial capillaries following graft epithelialization. J Periodontol 1988;59:570 – 6. [58] Pasquinelli KL. The histology of new attachment utilizing a thick autogenous soft tissue graft in an area of deep recession: a case report. Int J Periodont Rest Dent 1995;15:248 – 57. [59] Sugarman EF. A clinical and histological study of the attachment of grafted tissue to bone and teeth. J Periodontol 1969;40:381 – 7. [60] Common J, McFall WT. The effect of citric acid on attachment of lateral positioned flaps. J Periodontol 1983;54:9 – 18. [61] Cortellini P, Clauser C, Pini Prato G. Histological assessment of new attachment following the treatment of a human buccal recession by means of a guided tissue regeneration procedure. J Periodontol 1993;64: 387 – 91. [62] Harris RJ. Human histologic evaluation of root coverage obtained with a connective tissue with partial thickness double pedicle graft. A case report. J Periodontol 1999;70:813 – 21. [63] Wennstrom JL, Zucchelli G. Increased gingival dimen-

M. Matouk, A.G. Sclar / Oral Maxillofacial Surg Clin N Am 14 (2002) 241–257

[64]

[65]

[66]

[67]

[68]

[69]

[70]

[71]

[72]

[73]

[74]

[75]

[76]

[77]

[78]

[79]

[80]

sions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996;23:770 – 7. Akef J, Weine FS, Weissman DP. The role of smoking in the progression of periodontal disease: a literature review. Compend Contin Educ Dent 1992;13:526 – 30. Zucchelli G, Clauser C, De Sanctis M, et al. Mucogingival versus guided tissue regeneration procedures in the treatment of deep recession type defects. J Periodontol 1998;69:138 – 45. Hiatt WH, Stallard RE, Butler ED, et al. Repair following mucoperiosteal flap surgery with full gingival retention. J Periodontol 1968;39:11 – 6. Studer SP, Allen EP, Rees TC, et al. The thickness of masticatory mucosa in the human hard palate and tuberosity as potential donor sites for ridge augmentation procedures. J Periodontol 1997;68:145 – 51. Hu¨rzeler MB, Weng D. A single incision technique to harvest subepithelial connective tissue grafts from the palate. Int J Periodont Rest Dent 1999;19:279 – 87. Ajmani ML. Anatomical variation in position of the greater palatine foramen in the adult human skull. J Anatom 1994;184:635 – 7. Westmoreland EE, Blanton PL. An analysis of the variations in position of the greater palatine foramen in the adult human skull. Anatom Rec 1982;204:383 – 8. Harris RJ. A comparison of two techniques for obtaining a connective tissue graft from the palate. Int J Periodont Rest Dent 1997;17:261 – 71. Karring T, Lang NP, Lo¨e H. The role of gingival connective tissue in determining epithelial differentiation. J Periodontol Res 1975;10:1 – 11. Borghetti A, Louise F. Controlled clinical evaluation of the subpedicle connective tissue graft for the coverage of gingival recession. J Periodontol 1994;65: 1107 – 12. Mackenzie JC, Fusenig NE. Regeneration of organized epithelial structure. J Invest Dermatol 1983;81: 1895 – 945. Ouhayoun JP, Sawal HM, Goffaux JC, et al. Reepithelialization of a palatal connective tissue graft transplanted in a nonkeratinized alveolar mucosa: a histological and biochemical study in humans. J Periodontol Res 1988;23:127 – 33. Ainamo A, Bergenholtz A, Hugoson A, et al. Location of the mucogingival junction 18 years after apically repositioned flap surgery. J Clin Periodontol 1992;19: 49 – 52. Orban BJ. Oral mucous membrane. In: Bhaskar SN, editor. Oral histology and embryology. 11th edition. St Louis: Mosby Co.; 1991. p. 283 – 89. Sefarty R, Itic J, Sawaf A. Subepithelial connective tissue grafts in periodontal surgery and implantology. J Dent Res 1991;70:509 – 14. Mo¨rmann W, Schaer F, Firestone AC. The relationship between success of free gingival grafts and transplant thickness. J Periodontol 1981;52:74 – 80. Sclar AG. Cosmetic soft-tissue enhancement for dental implants. Alpha Omegan 2000;93:38 – 46.

257

[81] Breault L, Billman MA. Report of a gingival surgical cyst developing secondarily to a subepithelial connective tissue graft. J Periodontol 1997;68:392 – 5. [82] Bouchard P, Etienne D. Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of two procedures. J Periodontol 1994; 65:929 – 36. [83] Lekovic V, Kenney EB, Carranza FA, et al. The use of autogenous periosteal grafts as barriers for the treatment of class II furcation involvements in lower molars. J Periodontol 1991;62:775 – 80. [84] Miller PD. Root coverage with the free gingival graft. Factors associated with incomplete coverage. J Periodontol 1987;58:674 – 81. [85] Robson MC, Krizek TJ. Predicting skin graft survival. J Trauma 1973;13:213 – 7. [86] Bissada NF, Sears SB. Quantitative assessment of free gingival grafts with and without periosteum and osseous perforation. J Periodontol 1978;49:15 – 20. [87] James WC, McFall Jr. WT. Placement of free gingival grafts on denuded alveolar bone. Part I: Clinical evaluations. J Periodontol 1978;49:283 – 90. [88] Burdinsky S, Bori JEF, Ruben MP. Role of periosteum in the attachment of free autogenous gingival grafts to cortical bone: a histological study in dogs. Int J Periodont Rest Dent 1985;5:61 – 77. [89] Miller Jr. PD. Root coverage using a free soft tissue autograft following citric acid application. I. Technique. Int J Periodont Rest Dent 1982;2:65 – 70. [90] Caffesse RG, Dela Rosa M, Garza M, et al. Citric acid demineralization and subepithelial connective tissue grafts. J Periodontol 2000;71:568 – 72. [91] World Workshop in Clinical Periodontics VII. Proceedings of the Seventh World Workshop in Clinical Periodontics. Chicago: American Academy of Periodontology; 1989. p. 1 – 25. [92] Sammons PR, Wang H, Chiego DJ, et al. Effect of root conditioning on periodontal wound healing with and without guided tissue regeneration: a pilot study. II. Autoradiographic evaluation. Int J Periodont Rest Dent 1994;14:63 – 9. [93] Holbrook T, Oschenbein C. Complete coverage of the denuded root surface with a one stage gingival graft. Int J Periodont Rest Dent 1983;3:9 – 27. [94] Wikesjo UME, Nilveus R. Periodontal repair in dogs: Effect of wound stabilization on healing. J Periodontol 1990;61:719 – 24. [95] Cho M, Garant PR. Development and general structure of the periodontium. Periodontology 2000;24:9 – 27. [96] Block MS. Subepithelial connective tissue grafting with dental implants. Atlas Oral Maxillofac Surg Clin N Am 1999;7:95 – 107. [97] Gordon HP, Sullivan HC, Atkins JH. Free autogenous gingival grafts. II. Supplemental findings-histology of the graft site. Periodontics 1968;6:130 – 3. [98] Kwan SK, Lekovic V, Camargo PM, et al. The use of autogenous periosteal grafts as barriers for the treatment of intrabony defects in humans. J Periodontol 1998;69:1203 – 9.

Oral Maxillofacial Surg Clin N Am 14 (2002) 259 – 267

Coding for dentoalveolar surgical procedures Eric T. Geist, DDS Private Practice, Oral and Maxillofacial Surgery, 2003 Forsythe Avenue, Monroe, LA 71201, USA

Dentoalveolar surgery is the pillar upon which most contemporary oral and maxillofacial surgery practices are built. Reimbursement for these procedures by third party carrier requires identification of the specific service rendered from a list of codes. For dentoalveolar surgical procedures, these codes may be found in Current Dental Terminology and Current Procedural Terminology 2002. Claims reported using CDT-3 codes are filed on a dental claim form designed by the American Dental Association (ADA) which had been updated for the year 2000 (see Fig. 1). The most recent version of dental procedure codes are all preceded by a ‘‘D,’’ which replaces the initial numeral ‘‘0’’ from previous versions. This should reduce the overlap and confusion with the anesthesia series of codes in CPT 2002 that start with a ‘‘0.’’ Claims reported using CPT 2002 codes are filed on a HCFA 1500 claim form designed by the Health Care Financing Administration. CDT-3 codes currently do not require the use of an accompanying diagnostic code, although the ADA has compiled a diagnostic coding system termed SNODENT (systemized nomenclature of dentistry). Conversely, CPT 2002 codes require a diagnostic code to establish medical necessity for the procedure performed. Each procedure reported must be associated with a specific diagnosis code. These codes are contained in ICD-9-CM. The use of CPT 2002 codes permits the addition of modifiers to further describe the procedure performed. For example, the ‘‘-22’’ modifier indicates that the procedure was more difficult than usual and may justify an additional fee, whereas the ‘‘-52’’

E-mail address: [email protected] (E.T. Geist).

modifier indicates reduced services, thereby explaining a lower fee than usual without affecting the surgeon’s ‘‘profile.’’ Other useful modifiers include ‘‘-50’’ to indicate a bilateral procedure. At this time, there are no provisions to add modifiers to the CDT-3 series of codes. To properly codify dentoalveolar surgical procedures for submission to a third party, oral and maxillofacial surgeons must be familiar with the language used within the coding systems. This will significantly reduce the time and greatly improve the accuracy of coding. In addition, familiarity with the conventions of the carrier-specific coding system being used is essential and beyond the scope of this paper. The issue of local nuances of individual third party carriers is also beyond the scope of this article. This paper will identify the essential codes for reporting dentoalveolar surgical procedures. There will be some overlap in the use of diagnostic codes because different procedures may be done for the same diagnosis. For example, the diagnosis of an impacted tooth may be used with a procedure code indicating that the tooth was surgically exposed and an orthodontic attachment was placed. The same diagnosis may be used with a procedure code indicating that the tooth was surgically removed. In this article, codes listed in a particular category will not be repeated in subsequent categories, even when overlap may exist. It is recommended that readers review all the codes contained in this article and choose the code(s) that best describes the clinical condition being treated. To expedite reimbursement and reduce the need for the office to resubmit claims, the most specific diagnosis and procedure codes should be used. The diagnosis codes need to be carried out to the fifth

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 4 - 3

260

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267

Fig. 1. Most recent version of Dental Claim Form as published by the American Dental Association. The claim is coded for the removal of two impacted third molars under general anesthesia. The anesthetic lasted for 45 minutes.

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267

digit, if applicable. If only three or four digits are listed in the ICD-9 text, however, no additional ‘‘0s’’ are to be added. More than one diagnosis code can be attributed to a single surgical procedure. For organizational purposes, dentoalveolar surgical procedures will be grouped into four categories: 1. 2. 3. 4.

Removal of teeth Preprosthetic surgery Dentoalveolar infections Adjunctive procedures a. Frenectomies b. Orthodontic-assisted eruption c. Apical/periradicular surgery d. Nitrous oxide, anesthesia, and sedation

Removal of teeth There are no specific procedure codes in CPT 2002 for the removal of teeth. Therefore, for reporting purposes, using a CPT 2002 code, the unlisted dentoalveolar procedure code is 41899. The use of unlisted or nonspecific codes should generally be accompanied with an attachment supporting the use of this type of code. For removal of impacted teeth, an example of a completed medical HCFA is shown in Fig. 2. The diagnosis code for impacted tooth is used and associated with each of the tooth numbers removed. Some medical carriers may cover surgical removal of impacted teeth and some may even cover the surgical removal of erupted teeth. Since these are carrier specific, the participating office needs to determine how to report these codes to each carrier. For example, some carriers prefer to use CDT-3 codes (eg, D7240) on the HCFA form and attribute each tooth in the diagnostic code section. Others prefer to list all the extractions of the same type together, with the correct number shown in the unit section of the HCFA claim (see Fig. 3). CDT-3 contains several relevant extraction codes that are categorized in the following manner: (It should be noted that the fee for the extraction includes the administration of local anesthesia, any necessary suturing, and routine postoperative care.) Nonsurgical removal May include soft-tissue incision and suturing (if necessary). Single tooth: D7110 Additional tooth in the same quadrant at the same visit: D7120 Exposed roots: D7130

261

Surgical removal Always requires a soft-tissue incision and removal of bone, except for a soft-tissue impaction. The fact that a suture is placed does not justify a surgical extraction code. Erupted tooth: D7210 Soft-tissue impaction: D7220 Partial bony impaction: D7230 Complete bony impaction: D7240 Complete bony impaction with unusual complications: D7241 Residual roots: D7250 Notes: 1. ADA defines residual roots as loss of greater than 75% of the crown; therefore, there is potential overlap between D7210 and D7250. 2. Soft-tissue impactions are defined as having the occlusal surface covered by soft tissue and do not require bone removal. Mucoperiosteal flap removal is needed. 3. Partial bony impactions require part of the crown to be covered by bone. Bone removal and/or sectioning of the tooth is required. 4. Complete bony impactions must have most of the crown (greater than 50%) covered by bone and require removal of bone and sectioning of the tooth. 5. The use of the D7241 code requires that unusually difficult circumstances present, such as the need for nerve dissection or separate closure of the maxillary sinus. A significantly aberrant tooth position would also dictate the use of this code. An attachment, which includes either a radiograph and/or explanation, is often needed to justify the use of this code. ICD-9-CM diagnostic codes used as justification for removal of teeth when filing on a medical claim forms are found in Volume 1 under ‘‘Diseases of the Digestive System.’’ Some of the commonly used diagnostic codes include the following: *

*

520 Disorders of tooth development and eruption  520.1 Supernumerary teeth  520.6 Disturbances in tooth eruption (impacted tooth) 521 Diseases of hard tissue of teeth  521.0 Dental caries  521.4 Pathological resorption  521.6 Ankylosis of teeth

262

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267

Fig. 2. ‘‘Medical’’ claim form, HCFA, completed for the extraction of two impacted molars under general anesthesia. The use of unlisted codes creates delays in processing, but there are no specific impaction codes in the CPT references.

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267

263

Fig. 3. ‘‘Medical’’ claim form, HCFA, completed for extraction of impacted molars under general anesthesia. This example mixes dental codes on the medical form, but is accepted by some third party carriers. It avoids the use of unlisted codes and may speed processing.

264

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267

*

522 Diseases of pulp and periapical tissue 522.1 Necrosis of the pulp 522.5 Periapical abscess without sinus 522.7 Periapical abscess with sinus 522.8 Radicular cyst 523 Gingival and periodontal diseases  523.3 Acute periodontitis  523.4 Chronic periodontitis 524 Dentofacial anomalies, including malocclusion  524.3 Anomalies of tooth position 525 Other diseases and conditions of the teeth and supporting structures  525.3 Retained dental root 873.6 Open wound, internal structures of mouth, without mention of complication  873.63 Broken tooth 873.7 Open wound, internal structures of mouth, complicated  873.73 Broken tooth    

*

*

*

*

*

Preprosthetic dentoalveolar surgery CPT 2002 contains several codes that can be used when filing preprosthetic procedures on a medical claim form. Soft-tissue procedures are found in the digestive section, and in the case of skin grafts, they are found in the integumentary section. Some hardtissue procedures are found in the musculoskeletal section, while others are found in the digestive section. Procedure codes include the following: Soft tissue  40818 Excision of mucosa of vestibule of mouth as donor graft  40840 Vestibuloplasty, anterior  40842 Vestibuloplasty, posterior unilateral  40843 Vestibuloplasty, posterior bilateral  40844 Vestibuloplasty, entire arch  40845 Vestibuloplasty, complex (includes ridge extension and muscle repositioning  41805 Removal of embedded foreign body from dentoalveolar soft tissue  41820 Gingivectomy, per quadrant  41821 Operculectomy  41822 Excision of fibrous tuberosities  41828 Excision of hyperplastic alveolar mucosa  41870 Periodontal mucosal grafting  41872 Gingivoplasty, per quadrant  15000 Free skin graft and preparation of recipient site

Hard tissue  21031 Excision of mandibular torus  21032 Excision of palatal torus  21210 Bone graft to maxilla, includes graft harvest  21215 Bone graft to mandible, includes graft harvest  41806 Removal of embedded foreign body from dentoalveolar bone  41823 Excision of osseous tuberosities  41874 Alveoplasty per quadrant CDT-3 codes for preprosthetic dentoalveolar surgery include the following: Alveoplasty  D7310 alveoplasty in conjunction with extractions – per quadrant  D7320 alveoplasty not in conjunction with extractions – per quadrant Vestibuloplasty  D7340 Secondary epithelialization  D7350 Includes soft-tissue grafting Excision of bone  D7471 Removal of exostosis – per site Excision of soft tissue  D4210 Gingivectomy or gingivoplasty – per quadrant  D4245 Apically positioned flap  D7970 Excision of hyperplastic tissue – per arch  D7971 Excision of pericoronal gingiva  D4274 Distal or proximal wedge – separate procedure Soft-tissue grafts  D4270 Pedicle graft  D4271 Free soft-tissue graft (includes harvesting of graft)  D4273 Subepithelial connective tissue graft  D7920 Skin graft Hard-tissue grafts  D4263 Bone replacement graft, periodontal defect, first site in quadrant  D4264 Bone replacement graft, periodontal defect, each additional site in quadrant  D4266 Guided tissue regeneration – resorbable barrier, per site  D4267 Guided tissue regeneration – nonresorbable barrier, per site  D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones – autogenous or nonautogenous

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267 

D7955 Repair of maxillofacial soft- and hard-tissue defect

 

Notes: Procedures referring to specific quadrants are reported using the UR (upper right), UL, LL, and LR symbols in the ‘‘tooth number’’ section of the ADA form. Some of the commonly used ICD-9-CM diagnostic codes for reporting of preprosthetic dentoalveolar surgery include the following: *

524.7 Dental alveolar anomalies 524.71 Alveolar maxillary hyperplasia 524.72 Alveolar mandibular hyperplasia 524.73 Alveolar maxillary hypoplasia 524.74 Alveolar mandibular hypoplasia 525 Other diseases and conditions of the teeth and supporting structures  525.0 Exfoliation of teeth due to systemic causes  525.1 Loss of teeth due to accident, extraction, or local periodontal disease  525.2 Atrophy of edentulous alveolar ridge  525.8 Other specified disorders of the teeth and supporting structures 526.8 Other specified diseases of the jaw  526.81 Exostosis of jaw    

*

*

Dentoalveolar infections CPT 2002 contains multiple codes that can be used when filing medical claims for treatment of dentoalveolar infections. These codes are used to report treatment of soft-tissue infections, dental infections extending into soft tissue, and osteomyelitis. The following is a numerical listing of appropriate codes:       

10060 Incision and drainage of skin abscess; simple or single 10061 Incision and drainage of skin abscess; complicated or multiple 20000 Incision of soft-tissue abscess, musculoskeletal system; superficial 20005 Incision of soft-tissue abscess, deep or complicated 21025 Excision of bone (eg, osteomyelitis or bone abscess, mandible) 21026 Excision of bone, (eg, osteomyelitis or bone abscess, facial bone) 40800 Drainage of abscess, vestibule of mouth; simple











    

265

40801 Drainage of abscess, vestibule of mouth; complicated 41000 Intraoral incision and drainage of abscess of tongue or floor of mouth; lingual 41005 Intraoral incision and drainage of abscess of tongue or floor of mouth; sublingual, superficial 41006 Intraoral incision and drainage of abscess of tongue or floor of mouth; sublingual, deep 41007 Intraoral incision and drainage of abscess of tongue or floor of mouth; submental space 41008 Intraoral incision and drainage of abscess of tongue or floor of mouth; submandibular space 41009 Intraoral incision and drainage of abscess of tongue or floor of mouth; masticator space 41015 Extraoral incision and drainage of abscess of floor of mouth; sublingual 41016 Extraoral incision and drainage of abscess of floor of mouth; submental 41017 Extraoral incision and drainage of abscess of floor of mouth; submandibular 41018 Extraoral incision and drainage of abscess of floor of mouth; masticator space 41800 Drainage of abscess, from dentoalveolar structures

CDT-3 codes for reporting treatment of dentoalveolar infections include the following: 

D7510 Incision and drainage of abscess – intraoral soft tissue  D7520 Incision and drainage of abscess – extraoral soft tissue  D7550 Sequestrectomy for osteomyelitis  D7480 Partial ostectomy (to remove nonvital bone) ICD-9-CM diagnostic codes useful in reporting dentoalveolar infections include the following: *

522 Diseases of pulp and periapical tissue 522.5 Periapical abscess without sinus 522.7 Periapical abscess with sinus 526 Diseases of jaws  526.4 Inflammatory conditions (includes abscess and osteomyelitis) 528 Diseases of oral soft tissues, excluding gingiva and tongue  528.3 Cellulitis and abscess  

*

*

266

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267 

*

*

528.5 Diseases of lips (cellulitis and abscess) 529 Diseases and other conditions of the tongue  529.0 Glossitis (includes abscess) 682 Other cellulitis and abscess  682.0 Cellulitis and abscess; face (cheek, chin, submandibular)

  



D3421 Apicoectomy/periradicular surgery – bicuspid tooth (first root) D3425 Apicoectomy/periradicular surgery – molar tooth (first root) D3426 Apicoectomy/periradicular surgery (each additional root, whether a molar or premolar) D3430 Retrograde filling – per root

Other periapical surgical procedures include: Adjunctive dentoalveolar procedures CPT 2002 contains codes that can be used when filing adjunctive dentoalveolar procedures on a medical claim form. Among those most often used are:       

40804 Removal of foreign body vestibule of mouth, simple 40805 Removal of foreign body vestibule of mouth, complicated 40806 Incision of labial frenum 40819 Excision of frenum, labial or buccal 41010 Incision of lingual frenum 41115 Excision of lingual frenum 41520 Frenoplasty

CDT-3 adjunctive dentoalveolar procedure codes include the following: 

   

D7280 Surgical exposure of impacted or unerupted tooth for orthodontic reasons (includes orthodontic attachments) D7281 Surgical exposure of impacted or unerupted tooth to aid eruption D7290 Surgical repositioning of teeth D7291 Transseptal fiberotomy D7960 Frenulectomy

Apicoectomy and periradicular service codes describe surgery to the root surface of teeth. These codes are used for treatment of periapical pathology and include curettage, exploration for root fractures, and removal of broken root fragments or extruded filling materials. For example, if an apical surgery was initiated and the root was determined to be fractured and therefore removed, these codes would still apply. The placement of a retrograde filling material is coded separately for each root treated. 

D3410 Apicoectomy/periradicular surgery – anterior tooth



  

D3450 Root amputation – per root (removal of a root of a multirooted tooth while leaving the crown intact) D3460 Endodontic endosseous implant (extends from pulp, beyond root apex, into bone) D3470 Intentional reimplantation (intentional removal and reimplantation, includes splinting) D3920 Hemisection of tooth – includes root removal, not including root canal therapy

There are a few additional ICD-9-CM diagnostic codes useful in reporting adjunctive dentoalveolar procedures: *

750 Other congenital anomalies of the upper alimentary tract  750.0 Tongue tie  750.26 Other specified (congenital) anomalies of mouth

Analgesia, sedation, and general anesthesia Coding for anesthesia services rendered by the operating surgeon can be done with either dental or medical forms. The CPT 2002 guidelines separate anesthesia from conscious sedation with or without analgesia. For reporting general anesthesia administered by the surgeon, the code 09947 can be listed to report anesthesia given by the surgeon, or the modifier ‘‘-47’’ can be attached to the procedure. These codes refer to both regional and general anesthesia, usually creating problems with reimbursement by third party carriers. Alternatively, when general anesthesia is administered by a qualified individual other than the surgeon, the code 00170, which reports anesthesia for intraoral procedures, may be appropriate, or 00190 may be used for procedures on facial bones or skull. Under the units section of the HCFA-1500 form (Fig. 2, Box 24-G), the time is reported according to ‘‘custom in the local area.’’ Time is started from

E.T. Geist / Oral Maxillofacial Surg Clin N Am 14 (2002) 259–267

preparation of the patient until the patient is safely under postoperative supervision. Sedation codes are defined as achieving a medically controlled state of depressed consciousness while maintaining the patient’s airway, protective reflexes, and ability to respond to stimulation or verbal commands. Code 99141 reports administration via an intravenous, intramuscular, or inhalation route. Code 99142 reports oral, rectal, or intranasal administration. These codes require a separate, trained observer to monitor the sedation. Additional text also does not permit separate coding for monitoring, such as pulse oximetry, when these codes are used. A major weakness is that time is not reported, nor is there a differentiation between conscious versus deep sedation, as practiced in oral surgery. The CDT-3 updates anesthesia codes by adding a separate sedation code. Relevant analgesia, sedation, and anesthesia codes are as follows:      

D9220 general anesthesia, first 30 minutes D9221 general anesthesia, each additional 15 minutes D9230 analgesia, anxiolysis, inhalation of nitrous oxide D9241 intravenous sedation/analgesia, first 30 minutes D9242 intravenous sedation/analgesia, each additional 15 minutes D9248 nonintravenous, conscious sedation (by route other than IV, such as oral, rectal, nasal, or intramuscular)

It is interesting to note that code definitions for general anesthesia include both pharmacologic and nonpharmacologic methods.

267

The information contained in this text is intended to facilitate the selection of codes that most accurately reflect the dentoalveolar surgical procedure performed. However, it is not meant to be a substitute for the coding manuals referenced herein. Familiarity with the format, as well as additional descriptor information contained within these manuals, is necessary for precise and accurate coding. New developments in dental coding will include specific diagnostic codes known as SNODENT. The SNODENT codes will follow the format of SNOMED, the Systematic Nomenclature of Medicine developed and maintained by the College of American Pathologists (CAP). SNODENT codes will be developed and maintained by the ADA in collaboration with the CAP. The use of SNODENT codes further defines a procedure by the classification of disease process, morphology, topography, and social conditions relevant to the disease (eg, smoking). These are currently not in common use, nor are they required by third party payers, although the most recent dental claim forms published by the American Dental Association (1999, version no. 2000) have space for up to eight diagnosis codes for each procedure performed (Fig. 1).

Further Readings Terminology CD. CDT-3, version 2000. Chicago: American Dental Association; 1999. Terminology CP. (CPT-2002). Chicago: American Medical Association; 2001. International Classification of Diseases. 9th revision. Clinical modification. Dover, DE: American Medical Association; 2001.

Oral Maxillofacial Surg Clin N Am 14 (2002) 269 – 272

Index Note: Page numbers of article titles are in boldface type.

A Abscess, brain, dentoalveolar surgery and, 237

Celebrex, for dentoalveolar surgical pain, 149

Accessory roots, in endodontic treatment, 160

Central sensitization, in pain modulation, 140, 142

Acetylsalicylic acid, for dentoalveolar surgical pain, 147 – 148

Cervical neck wires, for impacted teeth, 193 – 194

Amino acid modulators, in pain modulation, 142 Anchor sutures, in dentoalveolar surgery, 226 Ankylosis after surgical uprighting, of mesially inclined second molars, 210 – 211 of impacted teeth, 198

Celecoxib, for dentoalveolar surgical pain, 149

Codeine, for dentoalveolar surgical pain, 144 – 145 Composite resin, in root end filling, 174 Connective tissue grafts, oral. See Oral connective tissue grafts. Continuous sling, in dentoalveolar surgery, 227 – 228

Antibiotics, in dentoalveolar surgery. See Dentoalveolar surgery.

Continuous sutures, in dentoalveolar surgery, 226 – 227

Anticoagulants, patients on, and antibiotics, for dentoalveolar surgery, 233

COX-2 inhibitors, for dentoalveolar surgical pain, 149

Apical preparation, ultrasonic. See Ultrasonic apical preparation.

Crown forms, for impacted teeth, 1912 – 193

Appetite suppressants, patients on, and antibiotics, for dentoalveolar surgery, 234 – 235

D Demerol, for dentoalveolar surgical pain, 145 – 146

Aspirin, for dentoalveolar surgical pain, 147 – 148 Asplenia, and antibiotics, for dentoalveolar surgery, 237

B Bacterial endocarditis, antibiotics for, 231 – 233 Biopsy, in periapical surgery, 184 – 185 Brain abscess, dentoalveolar surgery and, 237 Butorphanol, for dentoalveolar surgical pain, 146

C Catheters, patients with, and antibiotics, for dentoalveolar surgery, 236 Cavit, in root end filling, 174

Dental anatomy, in endodontic treatment, 156 – 160 Dentoalveolar surgery analgesia for, 137 – 151 postoperative, 143 – 149 acetylsalicylic acid in, 147 – 148 butorphanol in, 146 celecoxib in, 149 codeine in, 144 – 145 COX-2 inhibitors in, 149 hydrocodone in, 145 ibuprofen in, 148 ketorolac in, 148 – 149 meperidine in, 145 – 146 naproxen in, 148 nonsteroidal anti-inflammatory drugs in, 146 – 149

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 4 0 - 7

270

Index / Oral Maxillofacial Surg Clin N Am 14 (2002) 269–272

opioids in, 143 – 144 oxycodone in, 145 pentazocine in, 146 rofecoxib in, 149 pre-emptive, 142 – 143 and risk of brain abscess, 237 antibiotics in, 231 – 240 for bacterial endocarditis, 231 – 233 for immunocompromised patients, 237 – 237 for patients already on antibiotics, 233 for patients on anticoagulants, 233 for patients on appetite suppressants, 234 – 235 for patients with prosthetic joints, 235 – 236 for patients with shunts, catheters, and implants, 236 for unanticipated indications, 234 patterns of use of, 239 routine use of, 237 – 238 when treatment is delayed, 234 coding in, 259 – 267 adjunctive procedures, 266 analgesia, sedation, and general anesthesia, 266 – 267 dentoalveolar infections, 265 – 266 preprosthetic dentoalveolar surgery, 264 – 265 removal of teeth, 261, 264 pain mechanisms in, 137 – 138 modulation of, 138, 140, 142 central sensitization, 140, 142 neuropeptide and amino acid modulators, 142 peripheral sensitization, 138, 140 supraspinal, 142 suturing in, 213 – 229 instruments in, 224 – 225 materials in, 213, 217 bacterial migration in, 221 biologic response to, 218 – 221 choice of, 221 – 223 nonabsorbable versus absorbable, 221 – 223 physical properties of, 217 – 218 needles in, 223 – 224 techniques for, 225 – 228 anchor sutures, 226 continuous sling, 227 – 228 continuous sutures, 226 – 227 figure-eight, 226 horizontal mattress, 226 simple interrupted, 226

sling ligation, 226 vertical mattress, 226 Diabetes, and antibiotics, for dentoalveolar surgery, 237

E Endocarditis, bacterial, antibiotics for, 231 – 233 Endodontic treatment, predicting success or failure of, 153 – 165 definitions in, 154 dental anatomy in, 156 – 160 filling materials in, 162 – 163 intraoperative factors in, 154 – 156 jaw anatomy in, 160, 162 preoperative evaluation in, 154 Envelope technique, for oral connective tissue grafts, 243

F Figure-eight sutures, in dentoalveolar surgery, 226 Filling materials, in endodontic treatment, 162 – 163 Flap design for impacted teeth, 195 inappropriate, 198 in endodontic treatment, 154 in periapical surgery, 183 in ultrasonic apical preparation, 168 – 169 Fractures identification of, in endodontic treatment, 155 – 156 of root structures and periapical surgery, 182 – 183 due to ultrasonic apical preparation, 170 – 171

G Gastrointestinal effects, of nonsteroidal anti-inflammatory drugs, 147 Gingival recession, oral connective tissue grafts for, 242 – 243 Gingivectomy, for impacted teeth, 192 Glass ionomer cements, in root end filling, 174 Grafts, oral connective tissue. See Oral connective tissue grafts. Guided tissue regeneration, for gingival recession, 243

Index / Oral Maxillofacial Surg Clin N Am 14 (2002) 269–272

H HIV infections, and antibiotics, for dentoalveolar surgery, 237

271

surgical approach to, 204 – 205 technique for, 207 – 209 timing of, 206 treatment time in, 201

Horizontal mattress sutures, in dentoalveolar surgery, 226

Microsurgery, in ultrasonic apical preparation, 170

Hydrocodone, for dentoalveolar surgical pain, 145

Mineral trioxide aggregate cement, in root end filling, 174 – 175

I Ibuprofen, for dentoalveolar surgical pain, 148 Immunocompromised patients, and antibiotics, for dentoalveolar surgery, 236 – 237 Impacted teeth etiology of, 188 incidence of, 187 – 188 localization of, 188 – 190 radiographs of, 188 – 189 surgical exposure of, 187 – 199 closed techniques for, 195 – 198 complications of, 198 historical aspects of, 192 – 194 open techniques for, 194 – 195 orthodontics in, 190 – 192 Implants patients with, and antibiotics, for dentoalveolar surgery, 236 recession and mucogingival defects around, oral connective tissue grafts for, 243 J Jaw anatomy, in endodontic treatment, 160, 162 Joint arthroplasty, and antibiotics, for dentoalveolar surgery, 235

K Ketorolac, for dentoalveolar surgical pain, 148 – 149

M Magnification, in ultrasonic apical preparation, 170 Meperidine, for dentoalveolar surgical pain, 145 – 146 Mesially inclined second molars etiology of, 202 – 203 incidence of, 202 surgical uprighting of, 201 – 212 and ankylosis, 210 – 211 indications for, 204 options in, 205 risks of, 211 – 212 root development and, 209 – 210

Mucogingival defects, oral connective tissue grafts for, 242 – 243 N Naprosyn, for dentoalveolar surgical pain, 148 Naproxen, for dentoalveolar surgical pain, 148 Neck wires, cervical, for impacted teeth, 193 – 194 Neuropeptides, in pain modulation, 142 Neutropenia, and antibiotics, for dentoalveolar surgery, 236 – 237 Nonsteroidal anti-inflammatory drugs, for dentoalveolar surgical pain, 146 – 149 O Opioids, for dentoalveolar surgical pain, 143 – 144 Oral connective tissue grafts, 241 – 257 donor factors in, 250 – 253 adequate graft size, 252 adequate graft thickness, 252 – 253 atraumatic harvest, 251 management of epithelial band, 253 optimal selective site, 250 – 251 preservation of periosteal complex, 253 preservation of tissue, 253 tissue quality, 251 – 252 for gingival recession and mucogingival defects around implants, 243 for gingival recession and mucogingival defects around natural teeth, 242 – 243 for papilla reconstruction, 243 – 244 for ridge defects, 244 graft harvest for, 247 – 248 graft insetting in, 248 historical aspects of, 241 host factors in, 248 – 250 compliance and expectations, 250 management of modifiable factors, 250 systemic equilibrium and healing potential, 248 – 250 postoperative care for, 248 preparation for, 244

272

Index / Oral Maxillofacial Surg Clin N Am 14 (2002) 269–272

recipient site factors, 253 – 255 adequate exposure, 253 – 254 cover-flap integrity, 254 graft insetting and fixation, 254 management of interdental papillae, 254 proper diagnosis, 253 reduced bacterial load, 253 root/implant surface preparation, 254 tension-free closure, 254 – 255 tissue bed preparation, 254 vascular potential of recipient bed, 253 recipient site preparation for, 244 – 245, 247 soft-tissue augmentation options in, 241 – 242 Orthodontics, for impacted teeth, 190 – 192 Oxycodone, for dentoalveolar surgical pain, 145

P Papilla reconstruction, oral connective tissue grafts in, 243 – 244 Pentazocine, for dentoalveolar surgical pain, 146 Periapical surgery, 179 – 186 biopsy in, indications for, 184 – 185 cracked or fractured teeth and, 182 – 183 preoperative planning for, 179 – 80 radiographs in, 182 success of, determination of, 180, 182 surgical access in, 183 – 184 with periodontal procedures, 183 Periodontal procedures, with periapical surgery, 183 Peripheral sensitization, in pain modulation, 138, 140 Proroot, in root end filling, 174 – 175 Prosthetic joints, and antibiotics, for dentoalveolar surgery, 235 – 236

R Radiographs in periapical surgery, 182 of impacted teeth, 188 – 189

Rofecoxib, for dentoalveolar surgical pain, 149 Root end filling, 173 – 177 material for, 174 – 175 Root fractures, identification of, in endodontic treatment, 155 – 156 S Second molars, mesially inclined. See Mesially inclined second molars. Semilunar flaps in endodontic treatment, 154 in periapical surgery, 183 Shunts, patients with, and antibiotics, for dentoalveolar surgery, 236 Simple interrupted sutures, in dentoalveolar surgery, 226 Sling ligation, in dentoalveolar surgery, 226 Stadol, for dentoalveolar surgical pain, 146 Supraspinal modulators, in pain modulation, 142

T Talwin, for dentoalveolar surgical pain, 146 Toradol, for dentoalveolar surgical pain, 148 – 149

U Ultrasonic apical preparation, 167 – 172 cracks and fractures due to, 170 – 171 errors in, 171 flap design in, 168 – 169 instruments in, 167 – 168 microsurgery and magnification in, 170 technique for, 169 – 170

V Vertical mattress sutures, in dentoalveolar surgery, 226 Vioxx, for dentoalveolar surgical pain, 149

Respiratory depression, opioids and, 144 Retroplast, in root end filling, 174 Ridge defects, oral connective tissue grafts for, 244

Z Zinc oxide-eugenol, in root end filling, 174