By Q. Olivier. Iowa State University. 2019.
Further tech- nical development as well as availability and local expertise will inﬂuence the diagnostic algorithm in different centres purchase antabuse pills in toronto. Additional to rupture cheap antabuse 500 mg amex, which is the main risk and consequence of intracranial infectious aneurysms 500mg antabuse with amex, these can cause minor focal deﬁcits in combination with systemic infection related symptoms. However, the clinical presentation of an infectious aneurysm is related to rupture in 80% of patients [51, 52]. Symptoms constitutes severe head- aches with sudden onset, visual loss, seizures, impaired consciousness, hemipare- sis or other focal neurological deﬁcits related to subarachnoidal or intraparenchymal haemorrhage. Intraparenchymal haemorrhage is relatively more common after rupture of infectious aneurysms compared to after rupture of congenital intracra- nial aneurysm. The size of the infectious aneurysm does not reliably predict potential to rupture but can be used to guide treatment in unruptured aneurysms as described in one recent review, suggesting the use of antibiotics and serial imaging for stable, small (<10 mm) unruptured aneurysms and endovascular treatment for large, enlarging, or symptomatic unruptured aneurysms . This recommendation has also been adopted in international endocarditis guidelines , but controversy remains and physicians will increasingly encounter this problem as improved imaging tech- niques visualize more asymptomatic unruptured aneurysms. If early cardiac sur- gery is required in patients with known intracranial aneurysms, preoperative endovascular intervention must be considered and is preferred to surgical intracra- nial intervention. Treatment of ruptured intracranial aneurysms requires immediate surgical or endovascular intervention, the choice of which depending on a large variation of factors not possible to cover algorithmically. Ruptured intracranial aneurysms with large intraparenchymal hematomas or those requiring occlusion of an artery supplying an eloquent territory should be treated with open microsurgery, the former to allow concomitant clot evacuation . Surgical clipping can also be preferred in young, symptomatic patients without signiﬁcant comorbidity who exhibit large and accessible aneurysms. In contemporary reviews endovascular techniques are favoured in a majority of patients but no speciﬁed endovascular approach (balloon occlusion, embolization, stent therapy) is shown to be superior . The risks of procedure related complications and postoperative intracranial infections seem to be low. Given the heterogeneity of published studies, mostly case series or reviews [50–53], these conclusions are based low level evidence (Fig. A conventional angiography veriﬁes an intracranial infectious aneu- rysm on the left arteria cerebri media (b). The detected rate of men- ingitis in different studies depends on the frequency of lumbar punctures performed in the speciﬁc study setting. The availability of non-invasive brain imaging methods have reduced this proportion, since meningism seldom is the only neurological symptom presented [19 , 56]. This is illustrated by two studies including patients from different time periods by Pruitt et al. While underlying endocarditis is uncommon in pneumo- coccal meningitis, the growth of S. Brain Abscess Bacterial brain abscesses are rare complications of endocarditis affecting 0. Small multiple abscesses are more commonly detected than a single large abscess, which only occasionally is caused by underly- ing endocarditis. Brain abscesses are deﬁned as focal infection within the paren- chyma starting in a localized area of cerebritis subsequently transformed to an encapsulated collection of pus. Evidence that detection of silent complications improve patient outcome is, however, still lacking. Risk Factors for Neurological Complications Several factors associated with a higher occurrence of neurological complications have been identiﬁed but the most consistent ﬁnding is that S. Vegetation mobility is investigator dependent but has been shown to be an inde- pendent indicator of embolic risk in several setting [9, 12 , 31]. Vegetation on the mitral valve also carries a higher tendency to embolize in some studies although this is a less uniform ﬁnding . A previous embolic event is a risk factor for a new embolic event and is used in surgical algorithms as a factor favouring early surgery. Other relatively large studies with a prospective inclusion of patients but a retrospective analysis of antiplatelet effect on embolic tendency cannot reproduce these ﬁndings [4 , 67]. The two areas where individual patient care is paramount is the time to institution of adequate antibiotic therapy, i. This has to be balanced to operative risk in the individual patient also taking previous embolic events and coexisting cerebral lesions, vegetation characteristics, duration of antibi- otic therapy and additional surgical indications or likelihood of progressive struc- tural damage in the heart with predicted later need for surgery into account. A prospective randomized trial from South Korea has inﬂuenced the level of evidence but areas of controversy remain. In this study, 76 patients with large (>10 mm) veg- etations and severe valvular regurgitation on the mitral or aortic valve but without urgent indication for valve surgery were randomised to early (<48 h) surgery to prevent embolism or treatment according to international guidelines . In-hospital and 6 month mortality was not inﬂuenced and the surgical rate in the conventional treat- ment group was also high (77%). A worse prognosis was seen in patients with large cerebral infarctions and patients with multiple types of neurological complications. The main issues are how to reduce the risk of neurological complications, how to diagnose and handle established complications and how to manage associated medical and surgical questions such as the need for cardiac surgery and on-going anticoagulant therapy. The question regarding how to minimize the risk of neuro- logical complications is addressed above in the risk factor section and is shortly summarized as early detection and institution of antibiotic therapy and cardiac sur- gery in selected patients, the latter based on assumed risk for new embolic events, surgical risk and presence of concomitant surgical indications. Management of Established Neurological Complications In ischaemic lesions no speciﬁc medical or endovascular intervention is indicated apart from initiation or optimisation of antibiotic therapy. On-going antiplatelet therapy should only be interrupted in the presence of major bleeding but is elsewise contin- ued. In the absence of stroke, replacement of oral anticoagulant therapy should also be considered in S. Published systematic reviews do not address the role of thrombolytic therapy in the setting of septic embolization to the brain such as in infective endocarditis . The haemorrhagic risk is documented in published case reports [75 – 78] although throm- bolysis has been effective and safe in individual patients [78, 79]. An alterna- tive to thrombolysis is mechanical thrombectomy with lower risk of complicating intracerebral bleeding in a few published successful cases [81 – 84]. However, shorter delay and successful outcome has been reported in one study when cerebral hematoma is small (<1–2 cm) . The handling of intracranial infec- tious aneurysms is outlined in the section above. Ongoing anticoagulation must be stopped and reversed in all cases of signiﬁcant intracerebral bleeding regardless of indication for anticoagulation, but the demand and tempo of reinstitution differ according to anticoagulation indication. Some authors favour 10–14 days without anticoagulation  but the decision is preferably made on an individual basis fol- lowing a multidisciplinary discussion. Reinitiation of anticoagulation should be started with unfractionated or low-molecular weight heparin. Four-vessel angiography shows proximal occlusion in the left arteria cerebri media (b). In large cerebral abscesses, drainage may be necessary and oedema surrounding an abscess frequently moti- vates the addition of steroids. Surgical decisions can typically be taken regardless of coexisting meningitis or small abscesses while large abscesses needing neurosurgi- cal intervention may inﬂuence surgical timing on an individual basis. Neurological deﬁcits can exacerbate due to heparinization and subsequent haemorrhagic conversion, while hypotension during surgery and anaesthesia might worsen cerebral ischemia and increase parenchymal damage.
Many lessons learned during this period of groundbreaking research are still commonly used in modern neuroanesthesia practice cheap antabuse 500mg overnight delivery. Obstetric Anesthesia Social attitudes about pain associated with childbirth began to change in the 1860s quality 500mg antabuse, and women started demanding anesthesia for childbirth discount antabuse 500 mg overnight delivery. Societal pressures were so great that physicians, although unconvinced of the benefits of analgesia, felt obligated to offer this service to their obstetric patients. This method gained popularity after German obstetricians Carl Gauss and Bernhardt Krönig widely publicized the technique. Numerous advertisements touted the benefits of Twilight Sleep (analgesia, partial pain relief, and amnesia) as compared to ether and chloroform, which resulted in total unconsciousness. Because of the effects of scopolamine, many patients became disoriented and would scream and thrash about during labor and delivery. Gauss believed that he could minimize this reaction by decreasing the sensory input; therefore, he would put patients in a dark room, cover their eyes with gauze, and insert oil- soaked cotton into their ears. The patients were often confined to a padded bed and restrained with leather straps during the delivery. Virginia Apgar’s landmark 1953 publication of a system for evaluating newborns (the Apgar Score) helped to demonstrate that there actually was a difference in the neonates of mothers who had general versus regional anesthesia. Her physicians claimed her death was not related to complications from the method of Twilight Sleep that was used. However, their benefits were underappreciated for many years because the obstetricians seldom used these techniques. Initially, spinal anesthesia could be administered by inexperienced personnel without monitoring. The combination of inexperienced providers and lack of patient monitoring led to higher rates of morbidity and mortality than those observed for general anesthesia. At the onset of the 21st century, anesthesia-related deaths during cesarean sections under general anesthesia were reported as being more likely than neuraxial anesthesia-related deaths, making regional anesthesia the method of choice. Transfusion Medicine Paleolithic cave drawings found in France depict a bear losing blood from multiple spear wounds, indicating that primitive man understood the simple relationship between blood and life. Denis had learned of Richard Lower’s transfusion of lamb’s blood into a dog the previous year. Lamb’s blood was most frequently used because the donating animal’s essential qualities were thought to be transferred to the recipient. His next two patients were not as fortunate, 102 however, and Denis avoided further attempts. Given the poor outcomes of these early blood transfusions, and heated religious controversy regarding the implications of transferring animal-specific qualities across species, blood transfusion in humans was banned for more than a 100 years in both France and England beginning in 1670. Landsteiner, an Austrian physician, originally organized human blood into three groups based on substances present in the red blood cells. On the basis of these findings, Reuben Ottenberg performed the first type-specific blood transfusion in 1907. Transfusion of physiologic solutions occurred in 1831, independently performed by O’Shaughnessy and Lewins in Great Britain. In his letter to The Lancet, Lewins described transfusing large volumes of saline solutions into patients with cholera. He reported that he would inject into adults 5 to 10 pounds of saline solution and repeat as needed. Professionalism and Anesthesia Practice Organized Anesthesiology Physician anesthetists sought to obtain respect among their surgical colleagues by organizing professional societies and improving the quality of training. The first American organization was founded by nine members on October 6, 1905, and called the Long Island Society of Anesthetists with annual dues of $1. Although the new organization still carried a local title, it drew members from several states and had a membership of 70 physicians in 1915. McMechan had been a practicing anesthesiologist in Cincinnati until 1911, when he suffered a severe first attack of rheumatoid arthritis, which eventually left him confined to a wheelchair and forced his retirement from the operating room in 1915. McMechan had been in practice for only 15 years, but he had written 18 clinical articles in this short time. A prolific researcher and writer, McMechan did not permit his crippling disease to sideline his career. Instead of pursuing goals in clinical medicine, he applied his talents to establishing anesthesiology 103 societies. He became editor of the first journal devoted to anesthesia, Current Researches in Anesthesia and Analgesia, the precursor of Anesthesia and Analgesia, the oldest journal of the specialty. Because Laurette was French, it was understandable that McMechan combined his own ideas about anesthesiology with concepts from abroad. Subsequently, he traveled throughout Europe, giving lectures and networking with physicians in the field. On his final return to America, he was gravely ill and was confined to bed for 2 years. Kaye become a devoted follower of McMechan, and in the following decades helped establish the Australian Society of Anesthesiologists, creating in the first floor of his home a meeting space, workshop, library, and museum. In 1931, work began on what would become the International College of Anesthetists. The certification qualifications were universal, and fellows were recognized as specialists in several countries. Although the criteria for certification were not strict, the college was a success in raising the standards of anesthesia practice in many nations. Ralph Waters and John Lundy, among others, participated in evolving organized anesthesia. Waters’ greatest contribution to the specialty was raising its academic standards. After completing his internship in 1913, he entered medical practice in Sioux City, Iowa, where he gradually limited his practice to anesthesia. His personal experience and extensive reading were supplemented by the only postgraduate training available, a 1-month course 104 conducted in Ohio by E. At that time, the custom of becoming a self-proclaimed specialist in medicine and surgery was not uncommon. Waters, who was frustrated by low standards and who would eventually have a great influence on establishing both anesthesia residency training and the formal examination process, recalled that before 1920, “The requirements for specialization in many Midwestern hospitals consisted of the possession of sufficient audacity to attempt a procedure and persuasive power adequate to gain the consent of the patient or his family. In 1925, he relocated to Kansas City with a goal of gaining an academic post at the University of Kansas, but the professor of surgery failed to support his proposal. The larger city did allow him to initiate his freestanding outpatient surgical facility, “The Downtown Surgical Clinic,” which featured one of the first postanesthetic recovery rooms. In accepting the first American academic position in anesthesia, Waters described four objectives that have been since adopted by many other academic departments. His goals were as follows: “(1) to provide the best possible service to patients of the institution, (2) to teach what is known of the principles of Anesthesiology to all candidates for their medical degree, (3) to help long-term graduate students not only to gain a fundamental knowledge of the subject and to master the art of administration, but also to learn as much as possible of the effective methods of teaching, (4) to accompany these efforts with the encouragement of as much cooperative investigation as is consistent with achieving the first objectives.
Because these procedures are done on an urgent or emergent basis order antabuse 250 mg visa, the patient often presents with a full stomach order 500 mg antabuse amex. Although lung transplant patients are understandably anxious order antabuse 500mg with mastercard, they also have minimal pulmonary reserve, and sedation must be given carefully under monitored conditions. After determining oxygen saturation, slow incremental dosing of a short-acting benzodiazepine (0. Premedication with narcotics such as fentanyl must be administered with extreme caution, if at all, because of their ventilatory depressant effect. Use of metoclopramide, histamine-2 antagonists, and a nonparticulate antacid are usually warranted because of “full stomach” status. Many patients are unable to rest in a supine or in Trendelenburg position for central venous catheterization. Placement of large-bore peripheral intravenous and arterial access is usually adequate for initiation of the anesthetic, with central access achieved after induction. Another option is to place the epidural in the early postoperative period, after coagulopathies are corrected. The epidural can be placed using light sedation during weaning from mechanical ventilation, allowing better neurologic monitoring and pain control prior to tracheal extubation. Other options for postoperative pain relief include postoperative paravertebral blocks, and intercostal nerve blocks performed intraoperatively. Multimodal analgesic techniques, including dexmedetomidine infusion, intravenous acetaminophen, and nonsteroidal anti- inflammatory agents, are now standard components of enhanced recovery after surgery programs. Intraoperative Management Single-lung Transplantation 3691 Lung transplant recipients are often chronically intravascularly volume depleted, and chronic pulmonary hypertension is common. These factors predispose the patients to hypotension and decreased cardiac output on anesthetic induction. Restriction of anesthetic doses because of this concern increases the risk of awareness in this patient population. Monitoring with processed electroencephalography may thus be useful; anesthetic management guided by bispectral index monitoring has been associated with a reduction of the incidence of intraoperative awareness in this population. A balanced technique combining narcotic and inhalation anesthetics or benzodiazepines is usually an effective approach to maintenance of the anesthetic. Possible plans for early extubation should be discussed with the surgeon, and minimizing narcotics while providing multimodal pain relief should be utilized if early extubation is planned. Muscle relaxation can be maintained with rocuronium or vecuronium and is associated with minimal hemodynamic side effects. Nitrous oxide is rarely used because it may exacerbate bullous emphysematous disease, pulmonary hypertension, or intraoperative hypoxemia. Lung isolation, preferably with a double-lumen endobronchial tube, is necessary for single and bilateral sequential lung transplantation. The double- lumen tube, compared to bronchial blockade techniques, allows better suctioning of secretions, improved deflation of the operative lung during dissection, and application of continuous positive airway pressure to the operative lung if indicated. A bronchial blocker is more easily dislodged with surgical manipulation, may not provide isolation of the right upper lobe, and requires repositioning midsurgery in the case of a bilateral sequential procedure. A left-sided endobronchial tube is preferred, because a right-sided tube may be difficult to position relative to the right upper lobe bronchus. Fluid restriction and lung ventilation strategies designed to protect the lung allograft are indicated, because these patients are at increased risk for acute lung injury and pulmonary edema. Strategies to improve oxygenation and ventilation are discussed in detail in Chapter 38. This can be accomplished via either anterior thoracotomy with partial sternotomy or lateral thoracotomy with decreased angulation of the hips to allow access to the femoral vessels. Determination of operative side is based on preoperative ventilation–perfusion studies and prior thoracic surgeries. Circulation is restored to the donor lung, suture lines are checked for hemostasis, and then ventilation is begun. Systemic hypotension can occur during reperfusion but is usually not as significant as that with liver graft reperfusion. The anesthesiologist is often asked to assess the bronchial anastomosis using fiberoptic bronchoscopy and to perform bronchopulmonary toilet on the transplanted lung if necessary (removal of blood, secretions). Along with ex vivo perfusion, Perfadex, a low–molecular-weight dextran solution, improves early graft function and is used widely for preservation during procurement. Pulmonary vein anastomotic obstruction can be diagnosed with careful Doppler examination of the pulmonary venous inflow (see Chapter 27). At the completion of the procedure, the patient should be evaluated for exchange of the double-lumen endotracheal tube to a large (8-mm internal diameter or larger) single-lumen tube. The large diameter facilitates postoperative bronchopulmonary toilet and diagnostic bronchoscopy, as needed. Double-lung Transplantation Bilateral lung transplant is performed in the supine position, using a “clamshell” incision. The arms can be suspended on a padded bar above the patient or tucked at the sides. If the arms are suspended, care must be taken to avoid stretching the brachial plexi. Bilateral sequential transplantation requires lung isolation, preferably via a double-lumen endotracheal tube. Bilateral sequential transplantation is now the preferred procedure because a tracheal anastomosis is unnecessary, and there is less surgical bleeding. Serial implantation implies longer ischemic time for the second lung, but this has not been shown to adversely affect outcome. One hundred and twenty-four pediatric lung transplants were reported worldwide in 2013, compared to only 73 in 1999. There now appear to be age-related survival differences, with infants doing better than adolescents, but overall, survival is improving. Grade 3 is defined as PaO2/FiO2 less than 200 with radiographic infiltrates consistent with pulmonary edema. Grade 0 is essentially a normal lung, in which the PaO2/FiO2 ratio is greater than 300 and there are no pulmonary infiltrates. However, data are limited on transfusion during lung 3695 transplantation, in contradistinction to the data available on transfusion requirements during liver transplantation. Further study is needed to determine whether transfusion negatively affects lung transplant outcomes. Because a tracheal anastomosis is performed, a single-lumen endotracheal tube is sufficient. Pulmonary reperfusion injury can also occur, requiring management of acute lung injury as described for lung transplantation. Heart Transplantation Since Christian Barnard performed the first successful heart transplant in South Africa in 1967,197 the procedure has become accepted practice for treatment of heart failure recalcitrant to medical therapy. Over 50,000 individuals have received heart transplants in the United States since 1988.
Com- If a provisional restoration is placed the same day as the posite resins purchase antabuse 500mg without a prescription, especially those that harden on exposure to implant cheap 500mg antabuse visa, the patient should be seen the next day purchase 250mg antabuse visa. Self-curing materials, such as instructions include the use of dental foss, toothbrush, and acrylics (e. For this reason, many clinicians prefer it should be delivered, with instructions for use. Lareau Armamentarium Appropriate sutures Kirkland gingivectomy knife Palatal stent (if needed) Castroviejo needle holder Korn pliers Scalpel blades: #12 or #12B and #15 or Cyanoacrylate with pipette LaGrange scissors #15C DeBakey needle holder Local anesthetic with vasoconstrictor Surgical suction tip Dental mirror Minnesota retractor Suture scissors Gauzes: 2 × 2 and 3 × 3 North Carolina periodontal probe Woodson elevator Gerald tissue forceps or cotton pliers Orban gingivectomy knife then, numerous publications have verifed the predictability History of the Procedure of autogenous soft tissue grafts around implants, including their excellent clinical results and long-term stability. Te aim Te use of an autogenous soft tissue graft that did not include of this chapter is to enhance the implant surgeon’s armamen- the epithelium layer was frst reported in 1974 by Alan Edel. Tey than just osseointegration of the implant to achieve an 7 harvested autogenous connective tissue from the palate and esthetically successful outcome. Te esthetic success of an placed it underneath a partial-thickness fap to esthetically implant case lies in attention to fne details, through which rehabilitate soft tissue irregularities and concavities of adequate connective tissue can (1) provide a natural emer- resorbed edentulous ridges. During the 1980s, many authors gence profle for the restoration through healthy peri-implant attempted to develop soft tissue grafting techniques that gingiva, (2) create a labial profle over the bone and implant could improve anterior esthetics in edentulous areas, provid- body similar to the root prominence of a natural tooth, ing a natural emergence profle for pontics of fxed partial and (3) support papillae, fll interdental embrasures, and dentures. A site that shows adequate bone thickness for ideal 3D place- ment of an implant should also be evaluated for its soft tissue profle and the need for soft tissue grafting. Soft tissue augmentation can be performed simultaneously with implant placement and/or during the second-stage surgery (as described later in the Technique section). Tere is no evidence in the literature to support any advantage of simul- taneous soft tissue augmentation over augmentation during second-stage surgery. Both treatment modalities have been shown to lead to better esthetics and increased soft tissue 20 Figure 27-1 Note the exposed metal margin on #10. Even though both techniques yield favorable gingiva labial to the implants at sites #7 and #10 were attributed to esthetics, in accordance with the authors’ experience, the a thin gingival biotype, which allows the dark color of the metal earlier the intervention is performed, the more options the cervical collar and implant body to transilluminate through the clinician has to better control the fnal outcome. Asymmetric clinical crown heights and gingival contours dis- when the residual ridge has undergone signifcant atrophy, tract from the harmony of the dentogingival and implant-mucosa simultaneous soft tissue augmentation in conjunction with complex. Tis case constitutes an esthetic failure despite successful frst-stage surgery allows enough healing time to properly osseointegration of the implants. Additional soft tissue augmentation then can be performed simultane- ously with uncovering of the implant or implants to achieve root prominence of the neighboring dentate sites (Figure a more ideal outcome. Labial inclination of implants and/or buccal implant prosthesis has been strongly correlated with an ade- placement contributes to a thin tissue biotype; this may quate soft tissue thickness around the implant, a thick peri- result in the grey shade of the implant structure showing 11,12 implant biotype. When a thin biotype is diagnosed, a through the tissue, recession, and exposure of the titanium subepithelial connective tissue graft can be used to prevent implant neck, for an inharmonious emergence profle of the potential long-term recession of the facial mucosa implant-supported restoration. Te level of clinical attachment on adjacent teeth to ated with soft tissue color mismatch to a level below clinical 23 support papillary height perception. Te thickness of the coronal soft tissue margin to ensure a proper emergence profle 3. Te thickness of labial soft tissue to simulate root emi- Limitations and Contraindications nence and prevent transillumination of underlying metallic structure General and specifc limitations apply to the use of this 4. Te position of the mucogingival junction and amount soft tissue augmentation technique around dental implants. Medical conditions associated with collagen disorders, such as erosive lichen planus, or pemphigoid may pose a risk to Connective Tissue Grafting During Implant the viability of autogenous connective tissue grafts placed on Surgery a recipient bed that exhibits a pathologic healing mechanism. A thorough, three-dimensional (3D) preoperative evaluation Tere is no published evidence to support the use of this of the edentulous site is critical to properly plan an implant technique in such cases. Two A key determinant in the success of this technique is diagnostic variables that should be taken into account preop- revascularization of the graft. Te preoperative assessment revealed a concave labial profle of the edentulous sites due to an inadequate amount of hard and soft tissues. Te preoperative prosthesis used ridge-lap pontics that rested on ridge concavi- ties at the edentulous sites. Autogenous block grafts were used for horizontal hard tissue ridge augmentation to establish the ideal three-dimensional placement of the implants. Two separate con- nective tissue grafting interventions were required to achieve an esthetically pleasing outcome. Note the contours of the coronal facial mucosa, the natural emergence profle of the restorations, and the illusion of a root prominence. Te patient was very satisfed with the pink gingival esthetics and sought tooth whitening for additional esthetic enhancement. Nicotine-associated vaso- procedure in a smoker, bearing in mind that proper patient constriction, in combination with lack of adherence of the selection is imperative to achieving the desired treatment fbroblasts24 and an alteration in immune response, 25,26 outcome. Preoperative interruption of the smoking habit, diminishes the chance for a successful outcome. Preoperative followed by a smoke-free period during the critical stages of assessment should attempt to identify such patients, and the initial revascularization, and adjunctive measures (e. Local have the patient frst participate in a smoking cessation factors that may also limit patient selection include lack of program and then return later for surgery. However, in clini- adequate tissue thickness at the palatal donor site and cal reality, this is not always an option. Te surgeon must restricted surgical access to intraoral donor sites, such as the make the fnal decision on whether to proceed with a delicate posterior aspect of the hard palate or tuberosity. Preoperative identifcation of potential soft and/ tissue augmentation alone will be adequate to develop the desired or hard tissue defciencies allows for construction of an implant treatment outcome or whether bone augmentation also is needed restoration that closely mimics the natural dentogingival complex to achieve ideal implant positioning and soft tissue esthetics. The treatment alternatives for bone augmenta- hard tissue should be evaluated radiographically. The 3D position- tion of ridge defects are discussed in a later chapter (see Chapter ing of the implant should allow the fxture to be surrounded by at 20, Site Preservation and Ridge Augmentation) (Figure 27-3, A). When planning treatment Continued Bilateral ridge concavities A2 A1 A4 Bone reconstruction alone is not sufficient in A3 yielding an ideal esthetic outcome Figure 27-3 A1, Indents in the soft tissue profle at the sites of the congenital missing maxillary lateral incisors. A4, Four-month postoperative photograph with fxation screws showing through the thin mucosal fap. Various modes of 1 : 100,000 epinephrine is administered as a regional block and conscious sedation can be used, such as oral sedation with a followed by local infltrations for hemostasis. For effciency, the benzodiazepine, inhalation of nitrous oxide, or intravenous seda- anesthetic is frst administered to the graft donor site, so that tion, depending on the patient’s level of anxiety and the surgeon’s hemostasis can be verifed, to enhance visualization of the graft preference. Patients should be instructed to rinse preoperatively during procurement; the recipient site then is anesthetized. The quality of the tissue harvested from the tuberosity harvest for obtaining connective tissue grafts are the: and superfcial palate is superior to that of the tissue obtained • Tuberosity harvest27 from the deep palatal site because the former are predominantly 28 composed of dense connective tissue with little adipose tissue. This broad piece of tuberosity can be longitudinally sec- tuberosity or the palate. The tuberosity generally provides enough tioned to increase the amount of donor tissue available for graft- tissue to cover a single implant site or a two-implant site; ing (Figure 27-3, B). B2, Histologic microphotograph of a full- thickness tissue graft harvested from the tuberosity of the same patient. On the distal aspect of the tuberosity, a single, crestal, beveled Tissue forceps and the suction tip should be used delicately during incision is made from the mucogingival junction to the distal-facial procurement of the graft to minimize trauma to the donor tissue line angle of the most distal tooth. The incision is located on the and to make sure the graft is not lost down the suction, respec- buccal aspect of the ridge crest, rather than midcrestal, and is tively.