“Plastic periodontal surgery has evolved a lot in the last decade.” – Markus Hürzeler / Otto Zuhr
Prof. Dr Markus Hürzeler and Dr Otto Zuhr, popularly known as Hürzeler/ Zuhr, have taken clinical excellence, education, and research in periodontics, implantology and microsurgeries to a different level. The Hürzeler/Zuhr academy is one of the truly world-class centres for education and training in dentistry. Drs Hürzeler/ Zuhr will answer the questions and share their expertise in this interview with three Perio-Implantologists from India - Drs Sudhindra Kulkarni, Neel Bhatavadekar, and Akshay Kumarswamy.
Prof. Markus B. Hürzeler received his dental degree from the University of Zurich, his certificate as a specialist in Periodontics from the Swiss Society of Periodontology, the Docent (Associate Professor) degree from the Department of Prosthodontics at Albert-Ludwigs University in Freiburg, Germany, and his certificate in Prosthodontics from the German Society of Prosthodontics. He is Clinical Associate Professor at the Albert-Ludwigs University of Freiburg, Department of the Operative Dentistry and Periodontology and Clinical Associate Professor at the University of Texas in Houston, Texas. Dr Hürzeler has produced more than 100 scientific publications within the field of implants, periodontology and tissue regeneration and is a regular national and international lecturer. He maintains a private practice focused on periodontics and implant dentistry in Munich, Germany.
Dr Otto Zuhr studied dentistry at the University of Aachen from 1986 until 1992. After finishing his studies in 1992, he received his DMD from the Department of Oral and Maxillofacial Surgery in Aachen and started his work as a dentist in Munich. Several educational programs led him to Switzerland, Scandinavia and the USA during the following two years. In 1994 he started to work at the Institute of Periodontology and Implantology (IPI) with Drs. Bolz and Wachtel. In 1996 he opened his own office focusing on periodontal surgery and aesthetic dentistry in Munich. In 1999 he founded a new clinic together with Drs. Bolz, Wachtel, and Hürzeler and became an associate member in the Institute of Periodontology and Implantology (IPI) in Munich. In 2001 he received his Specialist in Periodontology of the German Society of Periodontology (DGP). Otto Zuhr has written several articles in the field of periodontology and aesthetic dentistry and is lecturing nationally and internationally. In 2012 he published his book “Plastic-Esthetic Periodontal and Implant Surgery” with Quintessence.
Drs Huerzeler/ Zuhr will answer the questions and share their expertise in this interview with three Perio-Implantologists from India - Drs. Sudhindra Kulkarni, Neel Bhatavadekar, and Akshay Kumarswamy.
Akshay Kumarswamy: Having pioneered microscopic periodontal plastic surgery (PPS), what according to you is the ideal magnification that one should start with to do periodontal plastic surgery?
The minimal magnification depends on the instruments and suturing materials used. For the surgical set that we have developed and brought on the market, a 4.5 to 6 fold magnification would be ideal.
Sudhindra Kulkarni: Does Connective Tissue Graft (CTG) function better as a pedicle graft or as a free graft?
I don’t know. The additional primary blood supply of the pedicle might improve initial revascularization of the graft. If this is of clinical relevance is a matter of further research.
Neel Bhatavadekar: What are your sutures of choice for suturing the flap for mucogingival surgeries?
There is no suture of choice. Sutures can have different tasks and must consequently fulfil varying requirements. Whereas polypropylene is used in the vast majority of indications, needle lengths from 12 to 15 mm and threads from 6.0 to 8.0 are selected according to the clinical situation.
Akshay Kumarswamy: According to you, what is the lifespan of microsurgical instruments – How often does one need to change it?
Provided that we are talking about high-quality instruments, this is more a question of maintenance than a question of time - well-maintained instruments don’t need to be changed for many many years.
Sudhindra Kulkarni: What is more critical - vertical soft tissue thickness or horizontal bulk of soft tissue in the periodontal or peri-implant soft tissue stability and function?
It is probably not possible to give a general answer to this question. From a principle point of view, it becomes more and more evident that soft tissue thickness matters for the vertical soft tissue position and soft tissue stability. However, the thickness can counteract with quality-esthetic criteria of success and might be interpreted with caution having in mind that teeth, implants, pontics, etc.… create very different biological environments.
Neel Bhatavadekar: For tunnelling procedures, sometimes the time required may be higher than for conventional split-thickness flaps. In this scenario, do you, in your clinical experience, see the long term benefit of tunnelling versus conventional split-thickness flaps in terms of % root coverage, or better esthetics?
Yes, it is true. Tunnelling procedures need specific microsurgical instrumentation and take longer. Talking about research in gingival recession therapy, there doesn’t seem to be an advantage related to root coverage. The advantage can be found in the quality-esthetic outcomes. In principle, it is as simple as this: if there is no cut, there cannot be any visible scar tissue formation. From a broader scope, avoiding surface incision also results in maintaining the best possible vascularisation of the flaps. This might be important in particular in surgical sites with compromised blood supply like, for instance, around dental implants or in papilla areas. These advantages become more and more evident and are more and more addressed in the literature.
Akshay Kumarswamy: For general dentists, who want to start learning esthetic Periodontal Plastic Surgery, which learning model would you suggest before taking the plunge on patients?
I truly believe that successful treatment outcomes in these types of interventions are mainly dependent on a profound biological understanding combined with manual dexterity. Well established textbooks like for instance, the one from Jan Lindhe & Klaus Lang can be recommended to study the basic wound healing principles in the oral cavity. For manual skill development, any exercise can be recommended that brings the clinician to the limit of his or her existing manual abilities. To exercise specific surgical interventions, animal models like for instance pig jaws are til to this day very suitable.
The Hürzeler/Zuhr academy is one of the truly world-class centres for education and training in dentistry.
"For decades we have dreamed of sharing our knowledge and clinical experience with ambitious dentists from all over the world according to these principles. The dream became reality through the foundation of the Hürzeler/Zuhr Academy." - Hürzeler/Zuhr.
Neel Bhatavadekar: If you had to redo your mucogingival surgeries from 10 years ago, what would you change?
Many, many things would be changed. Plastic periodontal surgery has evolved a lot in the last decade. The further development of incision-free flap elevation concepts combined with selected harvesting procedures for soft tissue autografts at the palate has coined up to date clinical conceptions in an incomparable way.
Sudhindra Kulkarni: Do you think PRF and its ilk have any significant role in improving soft tissue biotypes?
There is no doubt that there is great potential in many indications. If LPRF will one day be actually able to replace soft tissue replacement grafts for soft tissue volume augmentation will most probably be dependent on finding suitable carrier or stabilization materials. A thrilling field of research - we will see...
In this book, Hürzeler/Zuhr provide the first comprehensive overview of the basic principles, indications and clinical techniques of plastic-esthetic periodontal and implant microsurgery.
It is an exemplary blend of scientific knowledge and practical experience.
All salient issues are analysed based on the available scientific literature and the current clinical evidence. Last but not least, the authors provide instructions on how to manage all major complications of each procedure.
This book is, without doubt, one of the foremost oral surgery publications in recent years and is a must for every implantologist and periodontist.
Editor's question: Although you were the earliest to come up with the Socket Shield technique, you didn't promote it as aggressively as others did. What's the reason? Are others missing out on something that you have observed and realized?