Beruflich Dokumente
Kultur Dokumente
12193
Fundamental principles in
periodontal plastic surgery and
mucosal augmentation a
narrative review
Abstract
Aim: To provide a narrative review of the current literature elaborating on fundamental principles of periodontal plastic surgical procedures.
Methods: Based on a presumptive outline of the narrative review, MESH terms
have been used to search the relevant literature electronically in the PubMed and
Cochrane Collaboration databases. If possible, systematic reviews were included.
The review is divided into three phases associated with periodontal plastic surgery: a) pre-operative phase, b) surgical procedures and c) post-surgical care. The
surgical procedures were discussed in the light of a) flap design and preparation,
b) flap mobilization and c) flap adaptation and stabilization.
Results: Pre-operative paradigms include the optimal plaque control and smoking
counselling. Fundamental principles in surgical procedures address basic knowledge in anatomy and vascularity, leading to novel appropriate flap designs with
papilla preservation. Flap mobilization based on releasing incisions can be performed up to 5 mm. Flap adaptation and stabilization depend on appropriate
wound bed characteristics, undisturbed blood clot formation, revascularization
and wound stability through adequate suturing.
Conclusion: Delicate tissue handling and tension free wound closure represent
prerequisites for optimal healing outcomes.
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The mucoperiosteal full- and splitthickness flaps are the most commonly applied procedures in periodontal plastic surgery. They may be
used in combination with or without
interposed connective tissue grafts.
The fundamental principles governing flap surgery may also be applied
to free mucosal grafting.
Flap surgery will be discussed
with respect to (a) flap preparation,
(b) flap mobilization and (c) flap
adaptation and stabilization.
Flap preparation
Flap design in periodontal plastic
surgery is substantially based on the
vascularization of the oral mucosal
and periodontal tissues to be incorporated in the surgery. In this
respect, the anatomical structures
and their vascular supply are key
issues. Recommendations for appropriate incision design have been presented in a human cadaver study
(Kleinheinz et al. 2005) applying
micro- and macroscopic visualization
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As periodontal plastic surgical procedures are performed in the contaminated oral cavity, it is evident
that wound infection may occur as a
result of the oral environment per se
or in conjunction with flap fixation
and suturing techniques. There is a
fine balance between the host resistance to infection and factors initiating or promoting infection. Insight
into this relationship between the
host and the pathogens may be
gained from quantitative bacteriologic studies. In most soft tissue injuries, the wound bacterial count
provides an accurate prediction of
subsequent infection (Edlich et al.
1977). Wounds combining >105 bacteria per gram of tissue are destined
to develop infection. When the bacterial count is below that level, the
wounds will usually heal by primary
intention without infection. This
large number of bacteria required to
elicit infection reflects the remarkable ability of soft tissues to resist
infection in the oral cavity. This
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As a consequence, a stringent
infection control programme has
been propagated and validated in an
experimental study (Heitz et al.
2004). In this protocol, tooth brushing with an ultra soft surgical toothbrush is introduced on the third day
after surgery. The brush is used as a
carrier for chlorhexidine application.
After 1 week, the ultra soft brush is
replaced with a soft brush that is
used for the next 2 weeks. Following
this, regular tooth brushing habits
are resumed and chlorhexidine rinses
discontinued. The study yielded
superiority in healing outcomes compared to conventional post-surgical
care (Heitz et al. 2004). It is understood that following periodontal
plastic surgical interventions, professional tooth cleaning once a week
has to be performed for the first
postsurgical month.
Last, but not least, it has to be
realized that wound healing may be
negatively affected by psychological
stress (Kiecolt-Glaser et al.1995).
Caregivers of patients with Alzheimers disease demonstrated a significantly delayed wound healing after
standardized punch biopsies than
their counterpart controls. Hence,
stress-related defects in wound repair
could have important clinical implications for recovery from surgery. In
a study with student volunteers
(Marucha et al.1998), students took
an average of 3 days longer to completely heal a 3.5-mm standardized
punch biopsy wound during examinations. This represents 40% longer
to heal a small, standardized wound
than during stressless vacation times.
Production of interleukin 1beta (IL1beta) messenger RNA (mRNA)
declined by 68% during examinations, providing evidence of one possible immune mechanism. It appears
that even a factor as transient, predictable and relatively benign as
examination stress may significantly
affect the wound healing process
(Marucha et al.1998).
In periodontal plastic surgery
where tissue handling is difficult and
procedures are delicate, the influence
of psychological stress contributing
to compromised wound healing
should not be underestimated.
Such psychological stress may also
be caused by patients anxiety of the
surgical intervention and the expectation of associated pain. Therefore,
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Address:
Rino Burkhardt, DMD, MAS
(Periodontology)
The University of Hong Kong
Prince Philip Dental Hospital
Hong Kong SAR and University of Zurich
Weinbergstr. 98
CH-8006 Zurich
Switzerland
E-mail: rino.burkhardt@bluewin.ch
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