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Atlas of Cosmetic and Reconstructive Periodontal
Surgery 3 E 3rd Edition Edward S. Cohen Digital Instant
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ATLAS OF
COSMETIC AND
RECONSTRUCTIVE
PERIODONTAL
SURGERY
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page ii
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page iii

ATLAS OF
COSMETIC AND
RECONSTRUCTIVE
PERIODONTAL
SURGERY
THIRD EDITION

EDWARD S. COHEN, DMD

Clinical Instructor
Tufts Dental School
Associate Clinical Instructor
Boston University Goldman School
of Graduate Dentistry
Boston, Massachusetts

2007
BC Decker Inc EXIT
Hamilton
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page iv

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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord
with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to
check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly
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Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page v

Dedicated to
Meyer and Milton
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page vi

Contributors

Arun K. Garg, DMD

Eiji Funakoshi, DDS
Craig Misch, DDS
Dennis Shanelec, DDS
Leonard S. Tibbits, DDS
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page vii

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

PART I Basics
SECTION 1 Fundamentals

1. Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2. Surgical Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3. Sutures and Suturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4. Scaling, Root Planing, and Curettage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

SECTION 2 Basic Surgical Modalities

5. Gingivectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6. Mucogingival Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7. Palatal Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
8. Cosmetic Treatment of Maxillary Anterior Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

SECTION 3 Osseous Surgery

9. Resective Osseous Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

10. Inductive Osseous Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
11. Guided Tissue Regeneration Edward Cohen (with Eiji Funakoshi). . . . . . . . . . . . . . . . . . . . . . . . . 159
12. Furcations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

PART II Fundamentals of Dental Esthetics

SECTION 1 Analysis

13. Visual Perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

14. Esthetic Structural Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

SECTION 2 Anterior Tooth Exposure

15. Differential Diagnosis of Anterior Tooth Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

16. Biologic Width . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
17. Peiodontal Biotypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
18. Crown Lengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
19. Altered Passive Eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Cohen__i-xii_FM.qxd 11/28/06 1:22 PM Page viii

viii Contents

PART III Advanced Periodontal Procedure

20. Bio-Mechanical Root Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
21. Cosmetic Root Coverage and Gingival Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
22. Ridge Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
23. Socket Preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
24. Papillary Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
25. Surgical Exposure of Impacted Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

PART IV Advanced Surgical Procedures

26. Osteotome Technique Eiji Funakoshi and Edward Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
27. Sinus Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
28. Mandibular Block Grafts Arun K. Garg, Craig Misch and Edward Cohen . . . . . . . . . . . . . . . . . . . 419
29. Microsurgery Leonard S. Tibbits and Dennis Shanelec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Cohen__i-xii_FM.qxd 11/28/06 9:45 PM Page ix

Preface

Periodontics is both an art and a science, and this textbook is dedicated to the art of periodontics. The goal
of this atlas is to teach the novice, upgrade the skills of the average clinician, and act as a reference source
for the experienced clinician.
The modern paradigm for periodontal surgery has significantly changed since the last edition. Esthetics
and implantology are now the cornerstones of the modern periodontal practice.
Dental esthetics has altered the way we view our cases. No longer do we treat cases without consider-
ation being given to the facial, dentofacial, and dentogingival elements, especially in the esthetic zone. Pro-
cedures have been developed and refined to maintain, augment, and alter the dentogingival elements for
the purpose of achieving a satisfactory esthetic result.
Dental implants, although greatly expanding our treatment options, have significantly impacted neg-
atively upon the art of periodontics. Too often teeth are now prematurely extracted for implant placement.
As a consequence, clinical skills are reduced and the learning curve is expanded, further reinforcing extrac-
tion over treatment. This will change only when there is a greater emphasis placed on treatment and
preservation, which is the goal of this atlas.
No textbook of this kind can be completed without the help of others. In that regard, I must take spe-
cial note to thank Drs. Dennis Shanelec and Leonard S. Tibbits for their section on microsurgery, Drs.
Arun K. Garg and Craig Misch for their assistance with the section on mandibular chin and ramus grafts,
Dr. Eiji Funakoshi for his section on enamel matrix derivatives and his assistance with the section on
osteotomes, Dr. James Hanratty for his clinical contributions, especially to the chapters on mandibular
chin grafts and sinus lifts, and Dr. Periklis Proussaefs for his contribution of the Loma Linda technique. I
would also like to thank Drs. Scott Kissel, Roger Wise, Federico Brugnami, Irving Glickman, Kenneth
Kornman, and George Goumenous for their clinical contributions. Any omissions of recognition are acci-
dental and will be corrected in any future editions.
It must be noted that the chapters written on dental esthetics, esthetic diagnosis, and fundamentals of
esthetics relied in large part on the following source material: The Principles of Visual Perception and Their
Clinical Application to Denture Esthetics by Richard E. Lombardi, Esthetics of Anterior Fixed Prosthodontics
by Gerard J. Chiche and Alain Pinault, and Fundamentals of Esthetics by Claude R. Rufenacht.
I wish to thank the models for this edition of the atlas, Shanon O’Brien-Cohen, Christine Watson,
Judith Cohen, and Brigette Deveraux. Their help was greatly appreciated.
Lastly, special recognition must be given to Robert Ullrich, without whose artwork this and the pre-
vious atlases could not have been completed. He is a master medical illustrator whose work has been
copied in every textbook and atlas on periodontal surgery.

Edward S. Cohen
Boston, Massachusetts
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page x

Preface to the Second Edition

This surgical atlas was originally published with the intent of being the most complete periodontal surgi-
cal atlas and in 1988 it was. Since that time, there have been many important advances. The emphasis in
periodontics has clearly shifted toward reconstructive periodontics. Guided tissue regeneration, biome-
chanical root preparation, predictable bone regeneration procedures, and cosmetic root coverage have
made reconstructive periodontics a reality.
This edition will reflect these changes with new chapters on biomechanical root preparation, guided
tissue regeneration, cosmetic gingival reconstruction, cosmetic treatment of the maxillary anterior teeth, and
ridge augmentation, and expansion of the chapter on inductive osseous surgery. A new chapter has also been
added on sutures and suturing. All other chapters have been brought up to date, again with the intention
of again making this the most complete periodontal surgical atlas.
Any book of this kind requires the help of others in order to be completed. In this regard, a special
thanks must go to all those clinicians who so unselfishly contributed material for this edition (alphabeti-
cally): Burton Becker, Gerald M. Bowers, Daniel Buser, Robert Del Castillo, Stuart Froum, Bernard
Gantes, Gary Golovic, Jan Gottlow, Claude G. Ibbot, L. Laurell, James T. Mellovig, Sture Nyman, Knut
Selvig, Richard H. Shanaman, Athenos Spiros, Sigmond Stahl, Dennis P. Tarnow, and Theodore West.
Special acknowledgments must be extended to W.R. Gore Associates, Flagstaff, AZ, and Guidor AB,
Gothenburg, Sweden (Guided Tissue Regeneration, Chapter 13) and Ethicon, Inc. Somerville, NJ (Sutures
and Suturing, Chapter 2) for their help and permission for parts of their clinical manuals to be incorpo-
rated into this atlas.
To my dear friends and associates BobUllrich (artwork) and Harry Maskell (photography), without
whose talent and expertise this book most surely would not have been completed, I say again thank you.

Edward S. Cohen
Boston, Massachusetts
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page xi

Preface to the First Edition

Periodontology is both an art and science; as practiced daily, however, it is predominantly a surgical spe-
cialty. Although the major periodontal textbooks contain surgical sections, their general nature and scope
do not allow for an in-depth analysis of any one specific area. It is for this reason that this text is devoted
solely to the art of periodontics and designed for the student, general practitioner, and specialist.
Each procedure has been illustrated and laid out in a step-by-step fashion. Clinical examples have
been used secondarily only to supplement illustrations. The descriptive nature of the text is meant to be
both brief and simple. Each chapter presents indications, contraindications, advantages, disadvantages,
and related problems for each procedure.
This atlas incorporates most of the general techniques and concepts’ that are outlined in the major
textbooks. It can, therefore, easily be used as a supplement to any of these textbooks.
In the course of writing this text, careful attention has been paid to faithfully describing the proce-
dures as they were outlined originally, as well as attempting to give credit to their originators. Any over-
sights are unintentional and would gladly be corrected in the future. In this regard credit must be given
to Glickman’s Clinical Periodontology for serving as the model to base the drawings of gingivectomy on
and Lindhes: Clinical Periodontology for serving as a guide for the chapter on furcations.
I would like to thank my colleagues Edward Allen, Raul Caffesse, Jose Carvalho, Giovanni Castellucci,
David Garber, Barry Jaye, and Edwin Rosenberg for their clinical contributions; Mark Hirsh, Mayer Liebman,
and Peter Ferrigno for their helpful suggestions; and my assistants Jeanne McCormack, Rebecca Mugherini,
Christine Roberts, and Judith Cohen for their help.
Special notes of acknowledgment must be given to Harry W. Maskell for his photographic excellence;
to Robert H. Ullrich, Jr., medical illustrator, for his creative genius in the designing and drawing of the
illustrations; and to the educational media department of the New England Medical Center for the picto-
rial overlays.

Edward S. Cohen
Boston, Massachusetts
Cohen__i-xii_FM.qxd 11/23/06 4:20 PM Page xii
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 1

Prognosis
The term prognosis has been used to indicate the Newman and colleagues (1994) stated that Table l-1 Periodontal Risk Factors
prediction of the future course of a disease in terms the terms risk and prognosis are interchangeable,
of disease outcomes following its onset and/or treat- with “risk most often thought of as the probabil- Smoking
ment. As clinicians, we are constantly asked to ity of getting the disease (initiation) or having Subgingival plaque
evaluate the short- and long-term prognosis of the disease get worse (disease progression).” Gingival color changes
Initial attachment loss
both the individual tooth and the overall denti- Kornman and colleagues (2000) noted that we
Probing depth increases
tion. This is especially true in complex periodon- must not confuse risk potential by basing future
Bleeding on probing
tal prosthetic cases in which treatment decisions prognosis on the current diagnostic assessment: Suppuration
are based predominantly on subjective factors. “For unlike ‘diagnosis’ that looks at ‘what is,’ Level of plaque control
The modern paradigm for periodontal prognosis ‘prognosis’ determines ‘what may become’ of the Low socioeconomic level
can be seen in Figure 1-1. disease” (Figure 1-2). Sporadic dental care
In discussing prognosis, we must first differ- Historically, the pathogenesis of human Level of education
entiate among diagnosis, risk, and prognosis: periodontal disease was described by Page and Poor dietary habits
Schroeder (1976). It was agreed that the disease Infectious and other acquired diseases
1. Diagnostic factors: factors associated with the was initiated and perpetuated by a small group of Side effects of medication
analysis and determination of a disease process gram-negative anaerobic or microaerophilic bac- Adapted from Newman and Kornman (1994).
2. Risk factors: factors associated with dis- teria that form subgingival colonies (Page and
ease development in people who do not yet Kornman, 1997). The process was thought to be
have the disease (Table 1-1) (Newman and continuous in nature (continuous theory) until it of periodontal progression, which assumed all
Kornman, 1994) was shown to occur episodically or in random plaque to be similar, with equal susceptibility for
3. Prognostic factors: factors used to predict bursts (random burst theory) (Haffajee and col- everyone (Figure 1-3) (McGuire, 2000).
disease progression once the disease is pre- leagues, 1983; Haffajee and Socransky 1996). The Clinical paradigms for prognosis were then
sent (Table 1-2) (McGuire and Nunn, 1996a) continuous theory resulted in a simplistic model based predominantly on environmental or
anatomic factors that limited or increased plaque
Significant decrease in Less favorable
prognosis and prognosis with
increase in tooth loss increase in tooth loss
Table 1-2 Commonly Taught Clinical Factors
Used in Assigning Prognosis
+ +
Heavy Heavy
Smoking stopped Smoking stopped
smoking smoking Individual tooth prognosis
Percentage of bone loss
++
Deepest probing depth (in mm)
Can be successfully IL-1 IL-1 Favorable long term
POSITIVE
Patient
prognosis
Horizontal or vertical bone loss
treated and maintained NEGATIVE
even though they may Deepest furcation involvement: 0, 1, 2, 3
have greater tooth loss Mobility: 0, 1, 2, 3
Host systemic Host systemic
Crown-to-root ratio: favorable or unfavorable
factor negative factor negative Root form: favorable or unfavorable
Caries or pulpal involvement: yes or no
ENVIRONMENTAL FACTORS ENVIRONMENTAL FACTORS Tooth malposition: yes or no
*Mobility
**Occlusal
*Mobility Fixed or removable abutment: yes or no
Unfavorable crown-root ratio Unfavorable crown-root ratio
Percentage of bone loss discrepancies Percentage of bone loss
Initial bone level Initial bone level Overall prognosis
Furcation involvement Furcation involvement Age
Probing depth Probing depth Significant medical history (smoker and/or
Plaque control Plaque control
Parafunction without night guard Parafunction without night guard
diabetic)
Family history of periodontal disease (mother,
Significant decrease in A catalyst for A reliable methodology father, sibling): yes or no and whom
prognosis and increase periodontal for selecting teeth with Hygiene: good, fair, poor
in tooth loss breakdown a "good" prognosis
but “less” accurate for Compliant: yes or no
predicting the prognosis Maintenance interval: 2 months, 2 months
NOTE of teeth with a “less than alternate, 3 months, 3 months alternate
* Any factor that increased mobility decreases prognosis good” prognosis
** Untreated occlusal discrepancies are always significant Parafunctional habit with bite guard
+ Smoking is always a negative modifying factor Parafunctional habit without bite guard
++ Genotype appears to be significant in untreated or poorly maintained patients
Adapted from McGuire and Newman (1996).
FIGURE 1-1. Periodontal paradigm for determining prognosis.
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 2

2 Basics

Diagnosis Anatomical and Genotyping Interleukin-1. Kornman and col-

What is the degree environmental factors leagues (1997) felt that although bacteria were
of past destruction? essential for periodontal disease production,
Treatment plan there was currently no mechanism for determin-
What are the
options for this Plaque ing the clinical trajectory of the disease. It was
specific patient? accumulation clear to them (Kornman and colleagues, 2000)
Prognosis that although bacteria did not directly destroy
What is the future
risk of disease the bone or connective tissue, indirectly, they
Time
progression? activated an inflammatory process in the peri-
odontal tissue that did. The bacteria initiated a
FIGURE 1-2. Treatment analysis.
challenge, which was then modified by a combi-
Host disease level
nation of genetic and acquired (eg, smoking,
FIGURE 1-3. Continuous theory. diabetes) risk factors that amplified the response
development (see Table 1-2). Clinical theorems
(Figure 1-4).
were developed based solely on anatomic factors
Kornman and colleagues (1997) studied the
(Tjan, 1986):
and 35% at 8 years. This is consistent with the proinflammatory cytokines by identifying the
1. Ante’s law: periodontal surface area rule findings of Ghiai and Bissada (1994). polymorphic interleukin-1 (IL-1) gene cluster. IL-
(Ante, 1926) 5. Teeth with a questionable to poor prognosis 1, produced by the white blood cells, is a key
2. Reserve capacity rule (Smith, 1961) have a significantly less favorable survival rate. mediator of the inflammatory process and a regu-
3. Mesiodistal width of cusp rule (Reynolds, lator of prostaglandin E2 and matrix metallopro-
McGuire and Nunn (1996a) concluded: “A
1968) teinases, which, respectively, govern inflammation
coin toss would be an easier and more accurate
and the destruction of bone and connective tissue.
way for a clinician to assign a prognosis under
Clinical Prognosis They showed that the composite gene was present
traditional guidelines, if the initial prognosis is
in 78% of cases (age 40–60 years), with an 18.9
Environmental and Anatomic Factors less than good.”
odds ratio over mild cases, and that IL-1-positive
A review of their work did show a group of
In a series of long-term studies (5–14 years), patients and smokers accounted for 86% of the
clinical parameters that appeared to correlate
McGuire (1991) and McGuire and Nunn (1996a, severe cases (Figures 1-5 and 1-6).
with initial prognosis and tooth loss (Table 1-4).
1996b, 1999) attempted to determine if it was This was consistent with Packhill and col-
possible to predict the long-term prognosis Host Factors leagues (2000), who found that smokers testing
(Table 1-3) of individual teeth based on the com- positive displayed a 4.9 times higher risk of devel-
The random burst theory led to our modern con-
monly taught clinical criteria listed in Table 1-2. oping severe periodontitis than did smokers test-
cept that disease progression is unpredictable in
Their findings were as follows: ing negative.
quality, quantity, and time of progression (Brown
Kornman and colleagues concluded: “This
1. Projections using commonly taught clinical and Löe, 1993). Furthermore, the quantity (level
study demonstrates that specific gene markers,
parameters were ineffective in predicting of plaque control) and quality (nature and
that have been associated with increased IL-1
long-term prognosis. infectibility of the bacteria present) of plaque and
production, are a strong indicator of susceptibil-
2. Projections for posterior teeth were of little environmental or anatomic factors could not
ity to severe periodontitis in adults” (Figure 1-7).
or no value. solely explain disease variabilities when different
A number of other studies have shown IL-1
3. Prognosis tended to be more accurate for risk factors were evaluated (Newman and col-
to be positively associated with bone loss and dis-
single rooted teeth and for assigning a good leagues, 1994). This was consistent with Löe and
ease progression (Masada and colleagues, 1990;
prognosis than a less than good prognosis. colleagues (1986), who found that individual dis-
Stashenko and colleagues, 1991; Wilton and col-
4. When the good teeth were excluded, the abil- ease progression was marked by wide variations
leagues, 1992; Feldner and colleagues, 1994).
ity to determine prognosis was 50% at 5 years and a lack of predictability.
More recently, Cavanaugh and colleagues (1998)
showed a direct relationship between increased
crevicular fluid level and more severe bone loss.
Table 1-3 Definitions of Various Prognoses

Good prognosis (one or more of the following): control of the etiologic factors and adequate periodontal
Table 1-4 Clinical Parameters
support as measured clinically and radiographically to ensure that the tooth would be relatively easy to
maintain by the patient and clinician, assuming proper maintenance Mobility*†
Fair prognosis (one or more of the following): approximately 25% attachment loss as measured clinically Furcation involvement (severe)†
and radiographically and/or Class I furcation involvement. The location and depth of the furcation would Probing depth†
allow proper maintenance with good patient compliance. Unfavorable crown-to-root ratio

Questionable prognosis (one or more of the following): 50% attachment loss with Class II furcations. The Percent bone loss*†
location and depth of the furcations may limit proper maintenance. Parafunctional habit without a night guard
Malposed tooth
Poor prognosis (one or more of the following): greater than 50% attachment loss resulting in a poor crown- Smoking
to-root ratio; poor root form; Class II furcations not easily accessible to maintenance of Class III furcations;
2+ mobility or greater; significant root proximity Plaque control (compromised teeth tend not to
get worse under maintenance)*†
Hopeless prognosis: inadequate attachments to maintain the tooth; extraction performed or suggested
*Consistent with Ghiai and Bissada (1994).
†
Adapted from McGuire and Nunn (1996). Consistent with Nieri and colleagues (2002).
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 3

Prognosis 3

Axelson (2002), in a randomized 10-year

Enviornmental & acquired risk factors
analytic study of 283 50-year-old subjects, studied
the role of genetic IL-1 polymorphism on tooth
and alveolar bone loss. All patients were treated
periodontally and received regular periodontal
Antibody Cytokines maintenance. A PST® (Genetic Test for Suscepti-
& bility to Periodontal Disease, Kimball Genetics,
prostanoids Denver, Colorado) for genetic IL-1 polymor-
Clinical
PMNs
Host Connective signs of phism was administered to all subjects at the con-
Microbial tissue & disease
challenge
immunoinflammatory clusion of the study. The findings shown in Table
response bone initiation
Antigens metabolism & 1-6 were of significance (Figures 1-8 and 1-9:).
progression Thus, genetic polymorphism and smoking
Matrix
metallo- appear to be synergistic prognostic risk factors,
Lipopoly-
saccharide proteinases which is consistent with the findings of Kornman
(1997, 2002), Hart and Kornman (1997), McGuire
Other
virulence and Nunn (1999), and Meisel and colleagues
factors (2004) for tooth and attachment loss and Nieri
and colleagues (2002) for bone loss.
Genetic risk factors Nieri and colleagues (2002), in a 10-year
study of prognosis involving 60 (40–58 years old)
nonsmoking IL-1-positive (23 or 38.3%) and
FIGURE 1-4. The pathogenesis of human periodontitis. PMNs: Polymorphonuclear lym- IL-1-negative (37 or 61.7%) moderately to severe-
phocytes. Contributed by Dr. K Kornman. (Reprinted with permission of Munksgaard, ly involved periodontally treated and maintained
Copenhagen, Denmark) subjects (1,566 teeth), found the following:

1. There is a total tooth loss of 3.3% (52 of

Lang and colleagues (2000) also showed that IL- patients and that there was no correlation to
1,566) owing to a combination of selection
1-positive patients are more likely to have a high- family history. Using tooth loss as an indicator
and a high level of periodontal maintenance.
er frequency of bleeding on probing. Socransky of disease progression and advanced disease,
2. A prognostic relationship exists between ini-
and colleagues (2000) compared the subgingival they reported a total tooth loss of 4.5% (47 of
tial bone level and genotype.
microbial species on IL-1-positive and -negative 1,044 teeth), with 27 (57.5%) teeth being in IL-
3. Some clinical factors do correlate significant-
subjects. They found that IL-1-positive subjects 1-positive patients, who represented only 38%
ly with tooth loss in nonsmokers:
had higher mean counts of specifically related peri- of the patients. McGuire and Nunn’s findings
a. Mobility
odontal pathogens than IL-1-negative subjects. appear in Table 1-5.
b. Deep initial probing
DeSanctis and Zuchelli (1999) studied
c. Initial bone level (loss)
Clinical Prognosis versus Host Genotype. In regeneration in IL-1-positive and IL-1-negative
d. Plaque control
1999, McGuire and Nunn reevaluated 42 of their patients. They found that although the regenerat-
e. Depth of the infrabony defect
subjects who had been maintained for 14 years ed tissue was stable over 4 years in IL-1-negative
for the IL-1 genotype. They noted that clinical patients, the IL-1-positive patients lost up to 70% Nieri and colleagues (2002) stated: “Anything
parameters could not identify IL-1-positive of the regenerated tissue. that increases mobility decreases prognosis.”

Cumulative % of subjects
with ≥ 30% mean boneloss
35 Genotype Pos
Severe N=18
N=36
30
Genotype Neg
Moderate N=37 25 N=63
20

15
Mild N=44
10

0 10 20 30 40 50 60 70 80 5

0
Percentage of subjects who were genotype positive 35-40 41-45 46-50 51-55 56-60 >60
(IL-1A allele 2 plus IL-1B+3953 allele 2) Age
FIGURE 1-5. The occurrence of the composite genotype for nonsmok- FIGURE 1-6. The cumulative frequency distribution of nonsmokers with severe bone
ers in different disease groups. (Adapted from K Kornman et al. J Clini- loss (≥ 30%) at different age groups. (Adapted from Kornman et al, J Clinical Periodon-
cal Periodontology 1997) tology, 1997)
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 4

4 Basics

of the World Workshop in Clinical Periodontics

Genetic factors
(1989) summed it up best, stating that the rela-
tionship between periodontal disease and occlu-
EOP: EOP: Adult: ??: ??: Wound healing, sion was controversial and that there was no long-
lgG2 Fc-√ RII, IL-1 COX connective
LAD, tissue factors term evidence of the effectiveness of occlusal
Chemotaxis adjustment as a treatment for periodontal disease.
In 1992, Burgett and colleagues published a
significant human study on the effects of occlusal
adjustment on treated type IV periodontal cases.
They reported that occlusal adjustment resulted
Antibody in a significant increase in clinical attachment
levels over those not receiving occlusal adjust-
Cytokines Connective ment. They offered no explanation and said that
PMNs Host Clinical
Microbial tissue & further study was required. Wang and colleagues
immunoinflammatory signs oaf
challenge bone
Antigens response periodontitis (1994) found that molars with furcation involve-
metabolism
ment were 2.5 times more likely to be lost and
Prostaglandins
that mobility increased this tendency. Gilbert and
colleagues (2005) found that teeth classified as
LPS
mobile at baseline “were more likely to have expe-
rienced attachment loss incidence than those not
FIGURE 1-7. Genetic factors in periodontitis and their potential biologic influence. Shown in red are
mobile at baseline.”
candidate genetic factors for which there are current data to support a role in periodontitis. Shown
At the World Workshop in Periodontics
in yellow are candidate genetic factors for which there are data to support a role for the biochemi-
cal factors in periodontitis, but for which there are no current data associating a specific genetic
(1996), Gehr noted that “the articles clearly demon-
marker with disease (Reprinted from K Kornman, editor. Periodontology 2000 with permission of strate that occlusal forces are transmitted to the peri-
Munksgarrd, Copenhagen, Denmark). odontal attachment apparatus and those forces can
cause changes in the bone and connective tissue.
These changes can effect tooth mobility and clinical
IL-1 genetic testing is available from Kimball 1965), the theory of trauma from occlusion as a probing depth.” Wang and colleagues (1994)
Genetics and is called PST® (Genetic Test for Sus- codestructive factor of disease progression was showed that mobility resulted in attachment loss.
ceptibility to Periodontal Disease). It has been advocated by Glickman and Smulow (1962, 1965, In 2001, Nunn and Harrel published their
recommended in the following cases: 1967). This theory was based on the concept that classic “clinical” articles on the effects of occlusal
once bacteria initiate the disease process, trauma discrepancies (ODs) on periodontitis. Unlike
1. Patients with advanced periodontal disease
from occlusion altered the pathway of inflamma- other studies that looked at the overall general
requiring
tion, resulting in a greater destruction of the peri- effects of trauma from occlusion on disease pro-
a. Regeneration
odontal supporting structures (bone and peri- gression (Shefter and McFall, 1984; Philstrom and
b. Advanced prosthetics
odontal ligament) (Figure 1-11). colleagues, 1986; Cao, 1992), Harrel and Nunn
2. Smokers with advanced periodontitis who
Animal research in the beagle (Svanberg, looked at the effects of occlusion on the progres-
want implants
1974; Linane and Ericsson, 1976; Lindhe and sion of periodontal disease on individual teeth
3. Smokers with advanced periodontitis
Svanberg, 1976) and the squirrel monkey (Polson, (2,147) in treated (41), partially treated (18), and
4. Retreatment of recurrent periodontitis
1974; Kantor and colleagues, 1976; Polson and col- untreated (30) patients. Their results were divided
5. Establishing proper maintenance intervals
leagues, 1976) did not resolve the issue of the legit- into initial and post-treatment findings.
Note: It is important to point out that although imacy of trauma from occlusion. The proceedings
Greenstein and Hart (2002) and the American A. Initial findings
Academy of Periodontology Research, Science and In comparing teeth with ODs versus no occlusal
Therapy Committee (2005) concluded that there is Table 1-5 Clinical Prognosis versus discrepancies (NODs), they found that teeth with
currently an insufficient body of evidence to sup- Host Genotype ODs had significantly
port a modification of treatment protocols for 1. Deeper initial probing
Probability of Tooth Loss Risk Ratio 2. Worse initial prognosis
chronic periodontitis patients based on IL-1 test-
ing, there is enough evidence to recommend test- Genotype (IL-1) positive 2.7 a. OD was fair
ing in patients who smoke and have untreated Heavy smokers 2.9 b. NOD was fair to good
advanced periodontal disease so that a more accu- IL-1 positive/smoking 7.7 c. Greater mobility
rate long-term prognosis can be made if the IL-1 positive (nonsmokers):
patient were not to have treatment or if plaque clinical risk factors
Mobility 8.8 Table 1-6 Role of Genetic IL-1 Polymorphism
control were not to be maintained. on Tooth and Alveolar Bone Loss
Unfavorable crown-to-root ratio 9.2
Bone loss 6.2
Trauma from Occlusion Subject Tooth Loss Bone Loss (mm)
Probing depth 3.6
Occlusal trauma (Figure 1-10) was originally con- Furcations 3.2 PST– nonsmoker 0.16 0.26
sidered a primary etiologic factor in the progress PST+ nonsmoker 0.30 0.33
Mobility, unfavorable crown-to-root ratio, and bone loss
of periodontal disease (Stillman, 1917; Box, possess equal or greater predictability than the combi-
PST– smoker 0.43 0.55
1935). Once the actual pathogenesis of periodon- nation of smoking and IL-1 positive factors and should PST+ smoker 0.95 1.20
tal disease was determined (Löe and colleagues, therefore be considered significant. Mean tooth loss 0.40
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 5

Prognosis 5

n=22 siderations: esthetics and patient’s desires. This is

1.0 irrespective of prognosis.
0.9 Age. Although age, in and of itself, does not
0.8 affect the individual prognosis, it is still one of its
0.7

No. of teeth
most significant determinates. Younger patients,
0.6
n=28 although possibly possessing greater adaptability
0.5
0.4 n=101 and regenerative function, must retain their teeth
0.3 n=125 significantly longer than older patients. The peri-
0.2 odontal destruction observed in the elderly is one
0.1 of lifetime disease accumulation and not an age-
0 specific condition (American Academy of Perio-
Nonsmokers Smokers dontology, 1995). This disease accumulation pro-
PST + PST - vides us with a longer history of their

FIGURE 1-8. The mean number of lost teeth per subject per 10 years
in smokers and nonsmokers testing positive (PST+) negative (PST-) for
genetic polymorphism of interleukin. (Adapted from Ayelson et al. Diag-
nosis and Risk Prediction of Periodontal Disease, 2002. Quintessence
, Illinois)

They also found Note: Similar results were seen in patients with
1. No relationship to furcation involvement good oral hygiene, bringing into question the need
2. In patients with good oral hygiene, OD was for significant etiologic factors for occlusion to
the only significant predictor of increased prob- have a negative impact.
ing depth and initial unfavorable prognosis.
Harrel and Nunn concluded: “Based on the
3. Although cofactors such as smoking (increased
results obtained in this study, there is evidence
pocketing), gender (men had deeper probing
that untreated occlusal trauma is certainly a cat-
depths than women), and oral hygiene
alyst for the progression of periodontal disease.”
(patients with good hygiene had less probing
Harrel (2003) noted that occlusion should be
depth than patients with poor hygiene) had
considered a cumulative risk factor, similar to
an impact, there was no “casual pathway”
smoking, that should be (Hallmon and Harrel
(Kornman and colleagues, 1997; McGuire
2004) part of routine periodontal treatment.
and Nunn, 1999) and patients with OD still
had a 1 mm greater probing depth. Modifying Factors A
B. Post-treatment findings Anterior Eshtetics. The modern periodontal
Teeth with OD had significantly greater paradigm is predicated on papillary preservation
1. Likelihood of a worsening prognosis maintainable on gingival esthetics and the inter-
2. Risk of increased mobility relationship of the lip, gingival, and occlusal lines.
3. Increase in probing depth (Figures 1-12 Therefore in the esthetic zone, the clinician must
and 1-13) first evaluate all treatments on two primary con-

80
SMO-PST- SMO-PST+
70
60 SMO+PST- SMO+PST+
Patient (%)

50
40
30
20
10
0
0 1 2 3-4 5-7 8+ B
Number of lost teeth
FIGURE 1-10. Silastic model displaying,
FIGURE 1-9. Frequency distribution of lost teeth in nonsmokers testing A, Even force distribution of force applied
positive (SMO-PST+), smokers testing negative (SMO+PST-) and smokers in long axis of tooth; B, Uneven cervical
testing positive (SMO+PST+) for genetic polymorphism of interleukin-1. and apical distribution of forces when an
(Adapted from Ayelson et al. Diagnosis and Risk Prediction of Periodontal angular force is applied. (Courtesy of Dr.
Disease, 2002. Quintessence, Illinois) Irving Glickman.)
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 6

6 Basics

FIGURE 1-11. Glickman trauma from occlu-

sion. A, Radiograph of cadaver jaw showing
intrabony defects. B, Histologic section show-
ing angular bone loss. C, High magnification
showing extension of inflammation into tis-
sue. D, Showing destruction of transeptal
fibers. (Courtesy of Dr. Irving Glickman.) B C D

periodontal, functional, and restorative status, colleagues, 1984; Neuman and colleagues, 1994; with the prognosis for proper triage. They break
offering greater diagnostic insight and thus Nieri and colleagues, 2002). down their diagnostic parameters for risk and
enhancing our ability to determine or predict prognosis assessment into the following:
Clinical Skill Level and Knowledge. Modern
how their teeth may continue to function in the
periodontal therapy has become a highly com- 1. Periodontal
future. What might not be acceptable in a young
plex specialty requiring a diversity of skills, which 2. Biomechanical
person might be acceptable in an older patient.
come only with time, experience, continuing a. Caries susceptibility
Motivation, Cooperation, and Level of Plaque education, and personal application. It is difficult b. Extent of structural compromise
Control. Plaque control is the single most impor- to be an expert in all phases of therapy. Our per- 3. Functional
tant factor in the treatment of periodontal disease. sonal skill limitations should not restrict our a. Temporomandibular joint disorders
The long-term success of any case is predicated patients’ treatment options or their success. We b. Mobility
on a patient’s ability to maintain an adequate must therefore recognize our limitations and 4. Dentofacial
level of plaque control. This is even more so in refer our patients to someone who possesses a
Dentofacial risk is based on the degree of
advanced periodontal prosthetic cases. Complex greater degree of competence in a particular area.
tooth display and our ability to achieve ideal
advanced periodontal and or prosthetic cases
tooth position in relationship to the face.
require a highly motivated and cooperative Risk of Treatment
patient for successful resolution. Plaque control,
Barkman and Kois (2005) stated that the risk of Note: Barkman and Kois (2005) make the point
motivation, and cooperation must therefore be
treatment must be determined and combined that as the risk of treatment increases and prog-
carefully evaluated prior to starting (Becker and
nosis decreases, treatment begins to move toward
implant-supported restorations.
2.0
3.0 Summary
Changing probing depth (mm)

1.5
Changing probing depth (mm)

2.5 1. In the presence of smoking, all other clinical

factors become secondary (casual pathway)
2.0 1.0
except occlusal discrepancies.
1.5
2. ODs are one of the most significant local
0.5
factors.
1.0 3. Although traditional clinical parameters
0
may not be consistently reliable prognostica-
0.5
-0.5
tors, certain clinical factors, either individual-
0
1 2 3 4 5 6 7 8 9 10 ly or as a composite group, have been shown to
1 2 3 4 5 6 7 8 9 10 Time (in years)
have a higher level of confidence and should be
Time (in years)
Untreated occlusal discrepancies factored in when determining the prognosis:
Untreated occlusal discrepancies Treated occlusal discrepancies
a. Occlusal discrepancies
Treated occlusal discrepancies No occlusal discrepancies b. Mobility*
No occlusal discrepancies c. Unfavorable crown-to-root ratio
FIGURE 1-13. Change in probing depth over time by
FIGURE 1-12. Change in probing depth over time by occlusal adjustment group for nonsurgical treatment
occlusal treatment group. (Adapted from Harrel and group only. (Adapted from Nunn and Harrell, J Perio *Anything that increases mobility decreases prognosis
Nunn, J Perio 2001) 2001) (Nieri, 2002)
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 7

Prognosis 7

d. Increased probing depth 6. IL-1-positive smokers should be regarded as Note: Kaldahl (1996) studied the relationship
e. Greater initial bone loss potential higher-risk patients, whereas IL-1- between periodontal treatment and smoking and
4. Genotype is a prediction of potential future negative nonsmokers are considered at low concluded that “while the negative effects of
risk in untreated periodontal cases. risk of developing tooth loss and bone loss. smoking on therapy were sustained or increased
5. Patients who are IL-1 positive can be treated 7. Smokers can be treated successfully if they over time, it must be remembered that periodontal
successfully, be well maintained over the will cease smoking. therapy in all groups produced improvements of all
years, and do not require altered treatment 8. In the presence of good plaque control, long- clinical parameters.”
modalities. term success is improved and risk factor influ-
ence is diminished except when ODs are present.

Table 1-7. Periodontal Prognosis Checklist

Favorable Unfavorable Favorable Unfavorable

HOST FACTORS 3. Initial bone level lost
Local factors a. 0–25% √
1. Genotype b. 25–50% √–
a. IL-1 positive (PST+) √ c. 50% √
b. IL-1 negative (PST–) √ Note: The initial bone level is a greater prognosticator than the residual bone
2. Smoking level. Radiographs versus digital images Khocht and colleagues (2003) found
a. Nonsmoker √ that standard radiographs and digital images were not comparable and that
b. Heavy smoker √ digital images “tended to reveal a higher number of sites with early-to-moder-
3. Parafunction (see also occlusion) ate bone loss than did conventional images.”
a. With night guard √
4. Crown-to-root ratio
b. Without night guard √
a. 1:2–1:1.5 √
4. Motivation/cooperation
b. 1:1.5–1 √–
a. Low plaque √
c. 1:1 √
b. High plaque √
5. Bone topography (amenable
(Unfavorable) systemic factors
to guided tissue regeneration)
1. “Uncontrolled” systemic disease
a. Horizontal bone loss √
a. Diabetes
b. Intrabony defects (2–3 walls) √
b. Hyperparathyroidism
c. Hemiseptum (1 wall) √
c. Hyperthyroidism
2. Nutritional deficiencies Note: The deeper the intrabony defect, the greater the potential for bone
3. Alcohol and drug abuse regeneration and the more favorable the prognosis.
4. Stress 6. Furcations
5. Xerostomia a. No involvement √
6. Adverse medications b. Grade I √
a. Hydantoin (Dilantin) c. Grade II (early) √–
b. Nifedrin/cyclosporine d. Deep grade II and III √
8. Others Note: Deep grade II and grade III formations are treatable and maintainable
a. Human immunodeficiency on an individual basis, but hemisection and root amputation may be consid-
virus (HIV) ered for abutments.
b. Neutropenia 7. Occlusion
c. Hereditary gingival fibromatosis
Note: Increased or increasing mobility has been shown to have a significant
TOOTH AND SITE ANATOMIC FACTORS negative correlation to prognosis. Therefore, any factor or combination of fac-
Primary factors tors that predisposes a tooth to greater mobility is also significant.
1. Mobility
a. Stable √
a. None √
b. Unstable (missing teeth; posterior collapse; √
b. +-1 √
no incisal guidance; deep overbite;
c. 1-1+ √–
pathologic migration; crowding; centric
d. 1+-2 √
or balancing side contacts, fractured
Note: Mobility may be the essential element in prognosis. Simply stated, a tooth/teeth, thermal sensitivity; wear facets
loose tooth does not make for good long-term prognosis irrespective of the in conjunction with other indicators)
existing attachment levels. c. Parafunction without a night guard √
2. Initial probing depth 1. Bruxism √
a. 0–3 √ 2. Clenching √
b. 4–6 √– d. Fremitus √
c. 7–10 √ e. Primary trauma* √±1
Note: The greater the initial probing depth, the less favorable the prognosis. f. Secondary trauma √
Increasing probing is a very negative prognosticator. g. Progressive mobility √
Note: If primary occlusal trauma cannot be adequately corrected to reduce
mobility, the tooth should be considered questionable.

Continued
Cohen_001-008_01.qxd 11/16/06 8:19 PM Page 8

8 Basics

Table 1-7. continued

Favorable Unfavorable Favorable Unfavorable

h. Radiographic findings: trauma b. Enamel projections √
from occlusion c. Root form
• Crestal one-third widening • Divergent √
of the periodontal ligament • Convergent √
• Thickening of the lamina dura d. Root length
• Apical widening • Long √
Note: These radiographic signs are an indication of possible trauma from • Short √
occlusion, requiring further occlusal examination. 6. Additional abutments for prosthetics
a. Few
Secondary factors
• Good attachment levels √–
1. Shape of the crown
• Unsound √
a. Bell shaped √
b. Many
b. Ovoid shaped √
• Good attachment levels √
2. Root shape
• Moderate attachment loss √–
a. Long-flat √
• Advanced attachment loss √
b. Short √
7. Endodontics/pulpal status
c. Conical √
a. Health √
d. Curved (dilacerated) √
b. Pulpal disease
3. Root proximity
• Treatable √
a. Adequate √
• Untreatable √
b. Inadequate √
c. Previously treated
4. Decay
• Satisfactory √
a. Restorable √
• Unsatisfactory
b. Nonrestorable √
• Retreatable* √–
Modifying factors
• Untreatable √
• Root amputation √
• Hemisection √ *Note: Retreatment does not ensure success. Reinstrumentation may also
• Crown lengthening √ subject the tooth to fracture owing to overthinning. Surgical retreatment of a
• Orthodontic extrusion √ large lesion (>5mm) is unfavorable.
c. Caries susceptibility d. Residual apical area
• Low √ • No change from original lesion √–
• High (A strong indication • Smaller than original lesion √
for implant use.) √ • Larger than original lesion √
5. Molars e. Endoperiodontal problems √
a. Root trunk f. Unexplained tooth pain
• Long √ • Fracture √
• Short √ • Untreated canal √–

IL = interleukin.

Conclusion ratio of 51.9). This means that all of these cases, with a good or good to fair prognosis should be
irrespective of genotype, smoking, and/or clinical used as abutments and ODs should be eliminat-
It is important to note that of the 2,610 teeth (102 ed. Finally, it should always be remembered that a
parameters, can be successfully treated over a long
patients) followed in the studies by Nieri and col- highly motivated and cooperative patient can
period of time (10–14 years). In complex peri-
leagues (2002) and McGuire and Nunn (1999), very often overcome many if not all negative fac-
odontal-prosthetic cases involving patients with a
only 99 were lost (3.8%). Most of these teeth had tors and that the converse is also true (Table 1-7).
positive genotype and/or smokers, only teeth
an original prognosis of poor or hopeless (risk
Cohen_009-014_02.qxd 11/16/06 8:21 PM Page 9

Surgical Basics
Basic Incisions Classification of Surgical Procedures Increasing Dimension of
Exisiting Attached Gingiva.
Peridontal disease is multifaceted in the nature, Correction of Soft Tissue Pockets 1. Mucosal stripping
scope, and types of problems created (eg, 2. Periosteal separation
Closed Procedures.
mucogingival problems, osseous deformities, 3. Laterally positioned flap (pedicle)
1. Curettage
gingival enlargement); therefore, many types of a. Full thickness
2. Excisional new attachment procedure (ENAP)
treatment exist (Figure 2-1). There is no one way b. Partial thickness
and modified ENAP
to approach a single problem or procedure. Train- c. Periosteally stimulated
3. Modified Widman flap
ing, ability, philosophy, and objectives ultimately d. Partial/full thickness
4. Apically positioned (repositioned) flap
determine final treatment selection. The follow- 4. Papillary flaps
a. Full thickness
ing is a list of basic surgical incisions. a. Double papillae
b. Partial/full thickness
1. Curettage: The removal of the inner epithe- c. Partial thickness (supraperiosteal) b. Rotated papillae
lial lining, epithelial attachment, and under- 5. Palatal flap c. Horizontal papillae
lying inflamed connective tissue on the inner a. Full thickness 5. Edlan-Mejchar, subperiosteal vestibular
aspect of the pocket. This is a closed surgical b. Partial thickness extension operation, or double lateral bridg-
procedure (Figure 2-2A). 6. Distal wedge procedure ing flap
2. Gingivectomy: The excisional removal of tis- a. Tuberosity 6. Free soft tissue autografts
sue for treatment of suprabony pockets. This b. Retromolar area a. Partial thickness
procedure is indicated where bone loss is b. Full thickness
Open Procedures. 7. Connective tissue autograft
horizontal and there is an adequate zone of 1. Gingivectomy
attached keratinized gingiva (Figure 2-2B). 8. Subepithelial connective tissue graft
2. Gingivoplasty
3. Full-thickness (mucoperiosteal) flap: A flap
designed to gain access and visibility for Procedures Commonly Used
Surgery for Correction of Osseous for Root Coverage
osseous surgery, relocation of the frenulum, Deformities and Osseous Enhancement
maintenance of the attached tissue, and Procedures Pedicle Flaps (Full or Partial Thickness).
pocket elimination and regeneration proce- 1. Laterally positioned flaps
dures. The incision can be sulcular, crestal, or Closed Procedures. 2. Double-papillae flaps
inverse bevel, depending on the amount of 1. Full- or partial-thickness flap 3. Coronally positioned flaps
attached tissue present (Figure 2-2C). a. Apically positioned flap 4. Periosteally stimulated flaps
4. Partial- or split-thickness (mucosal) flap: A b. Unpositioned flap 5. Semilunar flap
flap designed to retain and maintain the c. Modified flap 6. Rotated or transpositional pedicle flap
periosteal covering over the bone. A sharp or d. Modified Widman flap
supraperiosteal dissection technique parallel 2. Distal wedge procedure Free Soft Tissue Autografts.
to the bone is used in this procedure. It is indi- 3. Palatal flap 1. Full thickness
cated mostly in areas of thin bony plates and 2. Partial thickness
Open Procedures.
for mucogingival procedures (Figure 2-2D). 1. Gingivectomy Subepithelial Connective Tissue Graft.
5. Modified full-thickness (mucoperiosteal) flap: a. Rotary abrasives
A flap for which a first-stage gingivectomy Acellular Dermal Matrix Grafts.
b. Interproximal denudation
incision is used for pocket reduction or elimi- c. Intrabony pocket procedure Guided Tissue Regeneration.
nation, followed by a secondary inverse- 2. Prichard procedure for osseous fill 1. Nonresorbable
beveled incision to the crest of bone. This tech- 2. Resorbable
nique requires an adequate zone of attached Guided Tissue Regeneration (GTR).
keratinized gingiva and is used primarily on Guided Bone Regeneration (GBR). Procedure Commonly Used
the palate, on enlarged tissue, or in areas in for Ridge Augmentation
which limited access may prevent a primary Correction of Mucogingival Problems
inverse-beveled incision (Figure 2-2E). Connective Tissue Graft.
Preservation of Existing Attached Gingiva. 1. Pouch procedure
Tables 2-1 and 2-2 compare the various 1. Apically positioned (repositioned) flap 2. Connective tissue graft/coronally positioned
treatment procedures. These should be used only a. Full thickness flap
as a general guide in deciding which technique to b. Partial thickness 3. Pediculated connective tissue graft
use. Table 2-3 is a comparative analysis of the var- 2. Frenectomy or frenotomy 4. Onlay interpositional graft
ious surgical techniques. 3. Modified Widman flap 5. Interpositional graft
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10 Basics

Historical review
Radical gingivectomy flap procedure
Unrepositioned flap 1862 - 1884 Apically displaced flap
Cizezinky 1914 S.Robicsek Neuman 1912
Coronally Bentler 1916 Widman 1916
repositioned flap
Norberg 1926
Semiflap All bone healthy Repositioned flap
Kirkland 1931 (Not necrotic) Zemsky 1926
Kronfeld 1935

Modified flap
Kirkland 1936

Treatment of
pre-maxilla
Ingle 1952

Preprosthetic Mucogingival surgery Development of Rationale for Treatment of

vestibular Goldman 1953 physiologic contours osseous surgery intrabony defect
deepening Friedman 1957 Goldman 1950 Schluger 1949 Goldman 1949

Kazanjian Gingival replacement

Repositioning of
1936 Pushback 1953
attached gingiva
Pouch 1953
Nabers 1954
Osteopathy and
Lateral sliding osteotomy
Mucosal stripping flap Use of oblique Friedman 1955
and frenectomy Grupe 1956 incision
1954 1957

Classification of
intrabony defects
Apical repositioned split-flap Split thickness Use of two 1958
Stewart 1960 lat. flap vertical incisions
1954 1964 1957
Autogenous
Periosteal bone chips
separation From edentulous The apically Palatal approach 1964
1961, 1962 ridge repositioned flap for osseous surgery
Obwegeser 1964 1962 1963, 1964
1956
Demineralized freeze
Double flap dried allografic bone
1963 Double lat. Grupe Classification (DFDAB) 1965, 1968
reposit. flap modification of flaps
1963 1966 1964
Fixed long labial Bone swaging
Elden - Mejchar
mucosal flap 1965
1963
1963 Oblique rotated Contiguous lat. Unrepositioned
Palatal ledge and
Flap sliding flap flap
wedge technique
1965 1967 1965
1958, 1965 Illac crest
Free gingival graft
bone implants
1966
1968
Horizontal sliding For furcation The distal wedge
Cosmetic root Ridge papillary flap involvement 1963, 1964,
coverage augmentation 1967 1968 1966
Bone from
extraction sites
1969
Classification Classification Double papillae Periosteal- Curtain Split-thickness
1968, 1985 1983 flap stimulated flap procedure palatal flap
1968 1968 1969 1969
Osseous
S.V.E. coagulum
1976 Coronally positioned flap Roll technique 1970
1976, 1986 1979 Rotated lat. Gingival fiber
sliding flap retention
1969 1972
Free gingival grafts Onlay grafting Tuberosity
1982, 1985 1979, 1983 grafts
1971
Modified Widman
flap
Subepithelial C.T. graft Subepithelial C.T. graft 1974
Double lat. 1985, 1986 1979, 1982 Bone
bridging fap blending
1985 1972
Envelope flap Pouch procedure E.N.A.P.
1985 1980, 1981 1976

Semilunar flap Modified or improved tech. Modified E.N.A.P.

1986 1985 1977
Guided tissue
regeneration
Guided tissue regeneration Socket preservation Open flap 1985, 1988, 1991
Lip switch
G-TAM 1991, 1992 1989 Semilunar flap curettage
1991
1986 1976 Palatal modification
for implant placement
GTR for ? 1983 Guided tissue regeneration 1990
G-TAM 1988
Transpositional Papillary
ADM flap preservation technique
Papillary 1996 1990 1988
reconstruction 1996 Pediculated flap

Interpositional graft 1996

FIGURE 2-1. Historical review.

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Surgical Basics 11

FIGURE 2-2. Outline of basic incisions. A, Curettage

incision and removal of an inflamed inner pocket
wall. B, Gingivectomy incision and subsequent
removal of excised tissue (note that the incision is
above the mucogingival junction [mgj]). C, Sulcular
(a) and crestal (b) incisions for full-thickness
mucoperiosteal flaps. D, Partial-thickness incisions
for partial-thickness flaps. E, Modified flap incisions
for ledge-and-wedge techniques.

C D E
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12 Basics

Table 2-1 Comparison of Open (Gingivectomy) versus Closed (Flap) Procedures Surgical Considerations
Open Closed (Partial- or 1. Procedural selection should be based on the
Variables (Gingivectomy) Full-Thickness Flaps) following:
Healing Secondary intention Primary intention a. Simplicity
Time requirement for completion of procedure Fast Slower b. Predictability
Reattachment No Possible c. Efficiency
Degree of difficulty Low High d. Mucogingival considerations
Bleeding postoperatively Yes Minimum e. Underlying osseous topography
Visibility for osseous surgery Inadequate Good f. Anatomic and physical limitations (eg,
Ability to treat irregularities and defects Inadequate Good small mouth, gagging, mental foramen)
Preservation of keratinized gingiva No Yes
g. Age and systemic factors (eg, cardiac
arrhythmias and murmurs, diabetes, his-
tory of radiation treatment, hypothy-
Procedures Commonly Used for Socket hemorrhagic disorders) should be under roidism, hyperthyroidism)
Preservation adequate control. Medications should be 2. All incisions should be clear, smooth, and
carefully noted, and medical consultations denifite. Indecision usually results in an
1. Basic procedure
and preoperative laboratory work should be uneven, ragged incision, which requires more
a. Socket filler
performed where indicated. It is important healing time.
b. Connective tissue graft
to note that the medical history consists of 3. All flaps should be designed for maximum
2. Socket seal
a review of drug abuse, transfusion, and use and retention of keratinized gingival tis-
3. CollaPlug (Sulzer Medica, Carlsbad, Cali-
alternative lifestyles in attempting to deter- sue so as to maintain a functional zone of
fornia)
mine the risk of acquired immune deficien- attached keratinized gingiva and prevent
4. Prosthetic support
cy syndrome (AIDS) or human immunode- needless secondary procedures.
ficiency virus (HIV). This should be 4. The flap design should allow for adequate
Procedures Commonly Used combined with a thorough oral examination access and visibility.
for Papillary Reconstruction (eg, ulcers, candidiasis, hairy leukoplakia). 5. Involvement of adjacent noninvolved areas
1. Connective tissue grafts Note: The best protection against AIDS and should be avoided.
2. Bone graft/connective tissue graft hepatitis is a proper barrier technique and 6. The flap design should prevent unnecessary
sterilization at all times. bone exposure, with resultant possible loss
Contraindications for Periodontal 2. Blood pressure should be recorded. and dehiscence or fenestration formation.
Surgery (Lindhe, 2003) 3. Surgical therapy should be considered only 7. Where possible, primary intention procedures
1. Patient cooperation after adequate control, scaling, root planing, are preferred to those of secondary intention.
2. Cardiovascular disease and all necessary restorative, prosthetic, 8. The base of a flap should be as wide as
a. Uncontrolled hypertension endodontic, orthodontic, and occlusal stabi- the coronal aspect to allow for adequate
b. Angina pecton’s lization and splinting procedures have been vascularity.
c. Myocardial infarction completed and the case has been reevaluat- 9. Tissue tags should be removed to allow for
d. Anticoagulant therapy ed. Without proper plaque control, there is no rapid healing and prevent regrowth of gran-
e. Rheumatic endocarditis, congenital heart need for surgery. ulation tissue.
lesions, and heart vascular implants 4. A surgical consent form should be complet- 10. Adequate flap stabilization is necessary to
3. Organ transplants ed in all cases, and periodontal documenta- prevent displacement, unnecessary bleeding,
4. Blood disorders tion (including tissue quality, pocket depths, hematoma formation, bone exposure, and
5. Hormonal disorders radiographs, and models) is a must. possible infection.
a. Uncontrolled diabetes
b. Adrenal dysfunction
6. Hematologic disorders
Table 2-2 Comparison of Full- and Partial-Thickness Flaps
a. Multiple sclerosis and Parkinson’s disease
b. Epilepsy Full Thickness Partial Thickness
7. Smoking—more a limiting factor than a Variables (Mucoperiosteal) (Mucosal)
contraindication Healing Primary intention Secondary intention
Degree of difficulty Moderate High
Note: No periodontal surgery should be undertaken Pocket elimination Yes Yes
on a medically compromised patient without a recent Osseous surgery, resective or inductive Yes No
physical evaluation and clearance by a physician. Periosteal retention No Yes
Relocation of frenum Yes Yes
Widen zone of keratinized gingiva No Yes
General Surgical Considerations
Increase in attached keratinized gingiva Yes Yes
Presurgical Considerations Combine with other mucogingival procedures No Yes
Suture variability Low High
1. A complete medical history should be taken
Presence of a thin periodontium—dehiscence or fenestration No Yes
and any underlying systemic disorders or
Bleeding and tissue trauma Limited Greater
problems (ie, hypertension, diabetes, or
Cohen_009-014_02.qxd 11/16/06 8:21 PM Page 13

Surgical Basics 13

Table 2-3 Comparative Analysis of Five Gingival Surgical Procedures

I II III

Curettage Scaling and root planing for

removal of calculus,
plaque, cementum
Curettage of inner inflamed
wall of pocket

ENAP Mark pocket with probe

Scallop internal beveled
incision to base of pocket
Remove incised epithelium
and granulation tissue
Root plane
Position flap and suture to
presurgical level

Modified Widman flap Primary incision 0.5–1 mm

from margin to crest
of bone
Reflect flap 2–3 mm off bone
2° sucular releasing incision
Horizontal 3° incision above
crest of bone
Remove epithelium and
granulation tissue
Scale and root plane
Reposition flap and suture
with interrupted sutures

Apically positioned Sulcularly, crestally, or

full-thickness flap labially positioned inverse
beveled incision to bone
Flap completed, reflected
off bone
Flap is apically positioned
and sutured

Apically positioned Crestal incision with blade

partial-thickness flap parallel to long axis
of tooth
Flap raised by sharp
dissection
Periosteum retained
over bone
Flap is apically positioned
at or below alveolar crest

Adapted from Kinoshita S, Wen RC. Color atlas of periodontics. St. Louis: Mosby-Year Book; 1985.
ENAP = excisional new attachment procedure.
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Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 15

Sutures and Suturing

Goals Use d. Periosteal suturing
Suture Site 4-0 or 5-0
A surgical suture is one that approximates the 1. Silk and synthetic sutures are employed most Needle Size J-1; P-3
adjacent cut surfaces or compresses blood vessels often. Material silk
to stop bleeding. Suturing is performed to 2. Gut sutures are used only when retrieval is e. Extractions
difficult when securing grafts and in younger Suture Site 3-0 or 4-0
1. Provide an adequate tension of wound clo-
patients. The limited physical characteris- Needle Size FS-2; X-1
sure without dead space but loose enough to
tics of gut sutures do not warrant their rou- Material silk
obviate tissue ischemia and necrosis
tine use. 2. Biocompatibility‡
2. Maintain hemostasis
3. When using gut (plain or chromic) sutures, 3. Clinical experience and preference
3. Permit primary-intention healing
it is often advantageous to soak the package 4. Quality and thickness of tissue
4. Provide support for tissue margins until they
in warm water for a half-hour and to pull 5. Rate of absorption versus time for tissue
have healed and the support is no longer
gently but firmly on the suture when healing
needed
opened. This will remove the kinks and
5. Reduce postoperative pain Table 3-2 outlines the charateristics and applica-
straighten the suture. Finally, lubricating the
6. Prevent bone exposure resulting in delayed tions of resorbable and nonresorbable sutures.
suture lightly with petrolatum or sterile bone
healing and unnecessary resorption
wax will prevent brittleness. Note: This is not
7. Permit proper flap position Note: Because silk is a multifilament material that
necessary with Ethicon sutures.
4. Monofilament sutures are recommended “wicks,” it is not the material of choice when any
Suture Material for bone augmentation procedures to pre- sterile materials are used (eg, implants, bone
vent “wicking,” reduce the inflammatory grafts, guided tissue regeneration, or guided bone
Surgical sutures have been used to close wounds regeneration) or in the presence of infection (Sil-
response, and permit longer retention
since prehistoric times (50,000–30,000 BC) gave verstein and Kurtzman, 2005). The ideal material
(10–14 days).
us the first written description of their use dating for these procedures is expanded polytetrafluo-
5. Gore-Tex (Flagstaff, Arizona) and coated
back as early as 4,000 BC (Macht and Krizek, roethylene (ePTFE).
Vicryl sutures are recommended for guided
1978). Many materials have been used through-
tissue regeneration procedures.
out the centuries, such as gold, silver, hemp, fas-
cia, hair, linen, and bark. Yet none have provided Knots and Knot Tying
all of the desired characteristics. Material Choice “Suture security is the ability of the knot and
Qualities of the Ideal Suture Material The choice of materials depends on the following: material to maintain tissue approximation during
the healing process” (Thacker and colleagues,
The following qualities of the ideal suture mater- 1. Surgical Procedure 1975). Failure is generally the result of untying
ial are compiled from Postlethwait (1971), Varma a. Plastic procedures owing to knot slippage or breakage. Since the knot
and colleagues (1974), and Ethicon (1985): Suture Site 4-0 to 6-0 strength is always less than the tensile strength of
Needle Size P-3* the material, when force is applied, the site of dis-
1. Pliability, for ease of handling
Material Chromic gut, silk, ruption is always the knot (Worsfield, 1961;
2. Knot security
monofilament Thacker and colleagues, 1975). This is because
3. Sterilizability
b. Regeneration shear forces produced in the knot lead to breakage.
4. Appropriate elasticity
Suture Site 3-0 to 5-0 Knot slippage or security is a function of the
5. Nonreactivity
Needle Size P-3; RT-16† coefficient of friction within the knot (Price,
6. Adequate tensile strength for wound healing
Material Gore-Tex, Vicryl 1948; Hermann, 1971). This is determined by the
7. Chemical biodegradability as opposed to
c. Apically positioned flaps nature of the material, suture diameter, and type
foreign body breakdown
Suture Site 4-0 of knot. Monofilament and coated sutures
Needle Size J-1; FS2; P-3 (Teflon, silicon) have a low coefficient of friction
With the possible exception of coated Vicryl
Material silk and a high degree of slippage; braided and twist-
(Ethicon, Somerville, New Jersey), none of the
sutures available today meet these criteria. Table ed sutures such as uncoated Dacron and catgut
3-1 lists the various materials—natural, synthet-
ic, absorbable (digested by body enzymes or *Small needles (P-3) are more difficult to negotiate the
hydrolyzed), and nonabsorbable—available for posterior interproximal areas. ‡
These recommendations are not for microsurgical
periodontal use. †
Gore-Tex. procedures.
 16 Basics

Table 3-1 Sutures and Suturing

Suture Tensile Tissue Knot Tensile
Suture Types Raw Material Absorption Strength Reaction Strength Indications Ease of Handling
Surgical gut Plain Collagen from healthy Digested by body + Moderate +++ Rapidly healing Absorbable; should not be used
mammals enzymes within (least) ++++ mucosa where extended approximation
70 d Avoid suture of tissues under stress is required
removal Should not be used in patients
with known sensitivities or
allergies to collagen or chromium
Surgical gut Chromic Collagen from healthy Digested by body + Moderate but less +++ As above; slower
mammals treated enzymes within than plain gut absorption
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 16

with chromic salts 90 d ++++

Coated Vicryl Braided Copolymer of lactide Hydrolysis +++ Mild ++ Subepithelial +++
(polyglactin 910) Coated and glycolide coated 56–70 d ++ mucosal surfaces
with polyglactin 370 Vessel ligation
and calcium stearate All types of
general closure
Dexon Braided Homopolymer of Slow hydrolysis after +++ Mild ++ Subepithelial ++++
(polyglycolic acid) Coated glycolic acid coated 60–90 d ++ sutures
with polaxamer 188 Mucosal surfaces
Vessel ligation
PDS (polydioxanone) Monofilament Polyester Slow hydrolysis ++++ Slight ++ Absorbable suture ++
Braided polymer 180–210 d + with extended
wound support
Surgical silk Monofilament Natural protein fiber Usually cannot be ++ Moderate + Mucosal surfaces ++++
Braided of raw silk treated found after 2 yr ++++ (least) Should not be used in patients
with silicon protein with known sensitivities or
or wax allergies to silk
Nylon Duralon Ethilon Monofilament Long-chain aliphatic Degrades at a rate +++ Extremely ++ Skin closure ++
polymers of 15–20%/yr low 0- +
Nylon 6 or nylon 6.6
Nylon Duralon Braided Polyamide polymer Degrades at a rate +++ Extremely ++ Skin closure ++++
Suegilon of 15–20%/yr low 0- + Mucosal surfaces
Polyester Mersilene Braided Polyester, Polyethylene, Nonabsorbable +++ Minimal + +++ Cardiovascular, +++
Dacron Ethibond Terephthalate coated plastic, general None known
with polybutilate surgery
Peolene Monofilament Polymer of propylene Nonabsorbable +++ Minimal+ ++ General, plastic, ++
(polypropylene) transient acute cardiovascular,
reaction skin surgery
Gore-Tex Monofilament Expanded Nonabsorbable +++ Extremely ++ All types of soft ++++
polytetrafluoroethylene low tissue approxi- Not known
(ePTFE) mation and
cardiovascular
surgery
Monocryl Monofilament Poliglecaprone 25 Hydrolysis 90–120 d ++++ Minimal + +++ Soft tissue +++
(poliglecaprone 25) Copolymer of glycolide closure Absorbable; should not be used
and caprolactone where extended approximation
of tissues under stress is required
Table 3-2 Characteristics and Applications of Resorbable and Nonresorbable Sutures
Suture Discipline Tensile Strength Type of Needle Diameter of Material Type of Material Recommended General and Specific
Technique Used Requirements Recommended Recommended Recommended Knot Situations Used
3
Interrupted Periodontology, dental Minimal to /8 reverse cutting, 4-0 Chromic gut, silk Slip knot Interproximal suturing
suture implant and oral surgery moderate tapered polytetrafluoroethylene
(PTFE)
1
/2 or 5/8 reverse 4-0 Polyester “color” braided, Surgeon’s knot
cutting, tapered polypropylene,
monofilament nylon
5-0 Chromic gut, gut Slip knot* Flaps not under tension
Taper-cut 5-0 Polyester “color” braided, Surgeon’s knot
polypropylene,
monofilament nylon
3
Figure eight Periodontology and dental Minimal to /8 reverse cutting, 4-0 Chromic gut, gut, silk, Slip knot Primary lingual of mandibular molar
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 17

suture implant surgery, moderate taper-cut PTFE region

extraction sites
3
Sling suture Periodontology, dental Moderate /8 reverse cutting, 4-0 Chromic gut, silk, PTFE Slip knot Used when a flap has been elevated on
implant and oral surgery taper-cut only one side
3
Horizontal Dental implant and oral High /8 reverse cutting, 3-0 Polyglycolic acid (PGA) Surgeon’s knot Used in anterior mandible or posterior
mattress surgery taper-cut region to resist muscle pull
suture
Vertical 4-0 Chromic, gut, silk Slip knot Used to resist muscle pull, closely adapt
mattress flaps to bone and either teeth or
suture dental implants
Can also be used to apically or coronally
position flaps
3-0 PGA Surgeon’s knot Used to resist muscle pull, closely adapt
flaps to bone and either teeth or
dental implants
Can also be used to apically or coronally
position flaps
3-0 Silk Slip knot Used to resist muscle pull, closely adapt
flaps to bone and either teeth or
dental implants
Can also be used to apically or coronally
position flaps
3
Vertical sling Periodontology, dental High /8 reverse cutting, 3-0 PGA Surgeon’s knot Used to resist muscle pull, closely adapt
mattress implant and oral surgery, taper-cut flaps to bone, regenerative barriers,
suture especially when and dental implants, along with
performing guided tissue maintaining approximation of flap
and bone regenerative edges
techniques
4-0 Silk Slip knot Used to resist muscle pull, closely adapt
flaps to bone, regenerative barriers,
and dental implants, along with main-
taining approximation of flap edges
3
Continuous Periodontology, dental High /8 reverse cutting, 3-0 PGA Surgeon’s knot Used primarily in edentulous areas such
independent implant and oral surgery taper-cut as mandibular anterior or posterior
sling suture region to resist muscle pull
4-0 Silk Slip knot Used often in dental implant and bone
augmentation procedures and in
hyperplastic/fibrous ridge reduction
for denture stability
*Restricted areas such as buccal vestibule maxillary molars or mucogingival surgery (eg, soft tissue grafts). (Silverstein L, 1999)
Sutures and Suturing
17
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 18

18 Basics

have greater knot security because of their high

coefficient of friction (Taylor, 1938).
It is interesting to note that basic suture silk,
although extremely user friendly, is distinctly
inferior in terms of strength and knot security
compared with other materials (Hermann, 1971).
It also shows a high degree of tissue reaction
(Postlethwait, 1968; Taylor, 1978), and the addi-
tion of wax or silicon to reduce the tissue reaction
and prevent wicking further diminishes knot
security (Hermann, 1971).
Knot selection is the last of the variables and
the one over which surgeons have the most influ-
ence. Knot security has been found to vary great-
ly among clinicians, and even the security of
knots tied by the same clinician varies at different
times (Hermann, 1971).
FIGURE 3-1. Knot anatomy. A, Various knot components prior to completion. B, Completed knot anatomy.
A sutured knot has three components (Fig-
ure 3-1) (Thacker and colleagues, 1975):
1. The loop created by the knot (Figure 3-1A) 8. Maintain adequate traction on one end mends the following principles for suture
2. The knot itself, which is composed of a num- while tying to avoid loosening the first loop. removal:
ber of tight “throws” (Figure 3-1B;); each 9. The surgeons knot and square knot strength,
1. The area should be swabbed with hydrogen
throw represents a weave of the two strands although generally not needing more than
peroxide for removal of encrusted necrotic
3. The ears, which are the cut ends of the suture two throws, will have increased strength with
debris, blood, and serum from about the
an additional throw.
In Figure 3-2, we see the four knots most sutures.
10. Granny knots and coated and monofilament
commonly used in periodontal surgery. In a 2. A sharp suture scissors should be used to cut
sutures require additional throws for knot
study, Thacker (1975) found that the granny knot the loops of individual or continuous sutures
security and to prevent slippage. Coated
was the least secure, always requiring more about the teeth. It is often helpful to use a no.
Vicryl will hold with four throws—two full
throws or ties to achieve the same knot strength 23 explorer to help lift the sutures if they are
square knots.
as the square or surgical knot. For materials with within the sulcus or in close opposition to
a high degree of slippage (monofilament or coat- Sutures should be removed as atraumatical- the tissue. This will avoid tissue damage and
ed sutures), flat and square throws were recom- ly and cleanly as possible. Ethicon (1985) recom- unnecessary pain.
mended, with all additional throws being squared.
Cutting the ears of the suture too short is con-
traindicated when slippage is great because the
knot will come untied if the slippage exceeds the
length of the ears. Loosely tied knots were shown
to have the highest degree of slippage, whereas in
tight knots, slippage was not a significant factor.

Principles of Suturing
Ethicon (1985) recommends the following prin-
ciples for knot tying:
1. The completed knot must be tight, firm, and
tied so that slippage will not occur.
2. To avoid wicking of bacteria, knots should
not be placed in incision lines.
3. Knots should be small and the ends cut short
(2–3 mm).
4. Avoid excessive tension to finer-gauge mate-
rials because breakage may occur.
5. Avoid using a jerking motion, which may
break the suture.
6. Avoid crushing or crimping of suture mate-
rials by not using hemostats or needle hold-
ers on them except on the free end for tying.
7. Do not tie the suture too tightly because tis-
sue necrosis may occur. Knot tension should
not produce tissue blanching. FIGURE 3-2. Suturing knots.
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 19

Sutures and Suturing 19

3. A cotton pliers is now used to remove the

sutures. The location of the knots should be
noted so that they can be removed first. This
will prevent unnecessary entrapment under
the flap.

Note: Sutures should be removed in 7 to 10 days to

prevent epithelialization or wicking about the suture.

Surgical Needles
Most surgical needles are fabricated from heat-
treated steel and possess a microsilicon finish to
diminish tissue drag and a tip that is extremely
sharp and has undergone electropolishing
(Ethicon, 1985). The surgical needle has a basic
design composed of three parts (Figure 3-3):
1. The eye which is press-fitted or swaged (eye-
less) permits the suture and needle to act as
a single unit to decrease trauma.
2. The body which is the widest point of needle
and is also referred to as the grasping area. The
body comes in a number of shapes (round,
oval, rectangular, trapezoid, or side flattened).
3. The point which runs from the tip of the
maximum cross-sectional area of the body. FIGURE 3-3. Needle anatomy. Needles are described by their arc. Most periodontal surgical needles are of
The point also comes in a number of differ- three-eighths or one-half curvature. Different components of the needle are described.
ent shapes (conventional cutting, reverse
cutting, side cutting, taper cut, taper, blunt)
(Figure 3-4).
4. The chord length is the straight line distance Placement of Needle in Tissue Suturing Techniques
between the point of a curved needle and the
Ethicon (1985) gives the following principles for Different suturing techniques may employ either
swage.
placing the needle in tissue: periosteal or nonperiosteal suture placement:
5. The radius is the distance measured from the
center of the circle to the body of the needle 1. Force should always be applied in the direc-
1. Interrupted
if the curvature of the needle was continued tion that follows the curvature of the needle.
a. Figure eight
to make a full circle. 2. Suturing should always be from movable to
b. Circumferential director loop
nonmovable tissue.
c. Mattress—vertical or horizontal
Needle Holder Selection 3. Avoid excessive tissue bites with small needles
d. Intrapapillary
because it will be difficult to retrieve them.
Ethicon (1985) gives the following pointers for 2. Continuous
4. Use only sharp needles with minimal force.
selecting a needle holder: a. Papillary sling
Replace dull needles.
b. Vertical mattress
1. Use an approximate size for the given needle. 5. Grasp the needle in the body one-quarter to
c. Locking
The smaller the needle, the smaller the nee- half the length from the swaged area. Do not
dle holder required. hold the swaged area; this may bend or break The choice of technique is generally made on
2. The needle should be grasped one-quarter to the needle. Do not grasp the point area the basis of a combination of the individual oper-
half the distance from the swaged area to the because damage or notching may result (see ator’s preference, educational background, and
point, as shown in Figure 3-5. Figure 3-5). skill level, as well as surgical requirements.
3. The tips of the jaws of the needle holder a. Prior to suturing, the needle holder is
should meet before the remaining portions repositioned to the forward half of the
of the jaws. needle with a few millimeters of the tip,
Periosteal Suturing
4. The needle should be placed securely in the tips as shown in Figure 3-5. Periosteal suturing generally requires a high
of the jaws and should not rock, twist, or turn. 6. The needle should always penetrate the tis- degree of dexterity in both flap management and
5. Do not overclose the needle holder. It sue at right angles. suture placement. Small needles (P-3), fine
should close only to the first or second a. Never force the needle through the tissue. sutures (4-0 to 6-0), and proper needle holders
rachet. This will avoid damaging or notch- 7. Avoid retrieving the needle from the tissue are a basic requirement. Periosteal suturing per-
ing the needle. by the tip. This will damage or dull the nee- mits precise flap placement and stabilization.
6. Pass the needle holder so that it is always dle. Attempt to grasp the body as far back
directed by the surgeon’s thumb. as possible. Technique
7. Do not use digital pressure on the tissue; this 9. An adequate tissue bite (≥ 2–3 mm) is The five steps here are used in periosteal suturing
may puncture a glove. required to prevent the flap from tearing. (Chaiken, 1977) and are seen in Figure 3-6:
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 20

20 Basics

FIGURE 3-4. Cutting needles. Both outline and cross-sectional views of the various forms of cutting needle are shown. Conventional
cutting and reverse cutting are also shown.

A A'

B B'

C C'
FIGURE 3-5. Correct handling of suture needles. A, Needle holder holding a suture needle just anterior to
the curvature; correct position; A', suture needle undamaged. B, Suture needle held incorrectly at tip; B', tip
of suture needle damaged. C, Suture needle held incorrectly behind curvature; C', needle bent as a result.
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 21

Sutures and Suturing 21

1. Penetration: The needle point is positioned tightly against the bone so as not to damage resulting in lifting or tearing of the perios-
perpendicular (90°) to the tissue surface and or dull the needle point (see Figure 3-6B). teum (see Figure 3-6, D and E).
underlying bone. It is then inserted com- 3. Glide: The needle point is now permitted to 5. Exit: The final stage of gliding and rotation is
pletely through the tissue until the bone is glide against the bone for only a short dis- needle exit. The needle is made to exit the
engaged. This is as opposed to the usual 30° tance. Care must be taken not to lift or dam- tissue through the gentle application of pres-
needle insertion angle (see Figure 3-6A). age the periosteum (see Figure 3-6C). sure from above, thus allowing the tip to
2. Rotation: The body of the needle is now 4. Rotation: As the needle glides against the pierce the tissue. If digital pressure is to be
rotated about the needle point in the direc- bone, it is rotated about the body, following used, care must be used to avoid personal
tion opposite to that in which the needle is its circumferenced outline. In this way, the injury (see Figure 3-6F).
intended to travel. The needle point is held needle will not be pushed through the tissue,

A B C

D E F

FIGURE 3-6. Periosteal suturing. A, Needle penetration; needle point is perpendicular to bone. B, Rotation of needle body about point.
C,D, The needle is moved along the bone below the periostum. E, Rotation about needle body permitting point to exit periosteum and
tissue. F, Completed periosteal suture.
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22 Basics

Interrupted Sutures Technique sure while avoiding suture contact with the implant
material, thus preventing wicking. They are left for
Indications Figure Eight and Circumferential Sutures. 14 to 21 days (Mejias, 1983) and therefore require
Interrupted sutures are most often used for the Suturing is begun on the buccal surface 3 to 4 mm a suitable material (eg, nylon, e-PTFE) that is
following: from the tip of the papilla to prevent tearing of the biologically inert and does not rapidly “wick.”
thinned papilla. The needle is first inserted into
1. Vertical incision
the outer surface of the buccal flap and then either Vertical Mattress Technique. The flap is stabi-
2. Tuberosity and retromolar areas
through the outer epithelialized surface (figure lized and a P-3 needle is inserted 7 to 10 mm api-
3. Bone regeneration procedures with or with-
eight) (Figure 3-8) or the connective tissue under cal to the tip of the papilla. It is passed through the
out guided tissue regeneration
the surface (circumferential) (see Figure 3-8A) of periosteum (if periosteal sutures are being used),
4. Widman flaps, open flap curettage, unreposi-
the lingual flap. The needle is then returned through emerging again from the epithelialized surface of
tioned flaps, or apically positioned flaps where
the embrasure and tied buccally. the flap 2 to 3 mm from the tip of the papilla. The
maximum interproximal coverage is required
When interproximal closure is critical, the needle is brought through the embrasure, where
5. Edentulous areas
circumferential suture will permit greater coapta- the technique is again repeated lingually or palatal-
6. Partial- or split-thickness flaps
tion and tucking down of the papilla because of ly. The suture is then tied buccally (Figure 3-9A).
7. Osseointegrated implants
the lack of intervening suture material between
Types the tips of the papilla. Horizontal Mattress Technique. A P-3 needle is
inserted 7 to 8 mm apical to and to one side of the
In Figure 3-7, we see the four most commonly Mattress Sutures. Mattress sutures are used for midline of the papilla, emerging again 4 to 5 mm
used interrupted sutures: greater flap security and control; they permit through the epithelialized surface on the oppos-
1. Circumferential, direct, or loop (see Figure more precise flap placement, especially when ing side of the midline (Figure 3-9B). The suture
3-7A) combined with periosteal stabilization. They also may or may not be brought through the perios-
2. Figure eight (see Figure 3-7B) allow for good papillary stabilization and place- teum. The needle is then passed through the
3. Vertical or horizontal mattress (see Figure ment. The vertical mattress (nonperiosteal) suture embrasure, and the suture, after being repeated
3-7C) is recommended for use with bone regeneration lingually or palatally, is tied buccally. For greater
4. Intrapapillary placement (see Figure 3-7D) procedures because it permits maximum tissue clo- papillary stability and control, the double parallel

A B

C D
FIGURE 3–7. Four interrupted sutures. A, Circumferential. B, Figure-eight. C, Vertical mattress. D, Intrapapillary.
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Sutures and Suturing 23

A B A B
FIGURE 3-8. A, Circumferential suture. B, Figure-eight suture. FIGURE 3-9. A, Horizontal mattress suture. B, Vertical mattress suture.

A B C

D E F
FIGURE 3-10. Sling suture about adjacent tooth.
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24 Basics

strands of this suture can be made to cross over predominantly when standard interproximal inci- sion and above the first suture (Figure 3-13A2).
the three tops of the papillae. This is the double sions are used. Start bucally below the papilla (2–4 The suture is passed through the interproximal
crossed-over suture. mm) and insert the needle to and then through papilla and returned as a horizontal mattress
the undersurface of the lingual flap (Figure 3- suture on the buccal surface and tied off.
Intrapapillary Placement. This technique is rec-
12A1). The suture needle is then reinserted lin-
ommended for use only with modified Widman
gually 2–4 mm above the initial suture and contin- Retromolar Suture Modification for Primary Cov-
flaps and regeneration procedures in which there is
ued to and then through the buccal flap (Figure erage. This technique (Hutchenson 2005) (Fig-
adequate thickness of the papillary tissue.
3-12A2). The suture is then brought lingually over ure 3-14) is specially designed for gaining inti-
A P-3 needle is inserted buccally 4 to 5 mm
the coronal aspect of the flap and through the loop mate tissue-tooth contact where regeneration is
from the tip of the papilla and passed through the
(Figure 3-12A3). The suture is afterwards returned being attempted. It is employed when there is an
tissue, emerging from the very tip of the papilla.
bucally and sutured (Figure 3-12A4). Figure 3-12B intrabony defect distal to the last tooth on the
This is repeated lingually and tied buccally, thus
shows the completed suture. lower teeth. It not only permits primary flap clo-
permitting exact tip-to-tip placement of the flaps
sure but close approximation of the tissue on the
(see Figure 3-7D). Modified Flap Suturing Technique. This tech-
distal aspect of the tooth. Figure 3-14A shows a
nique (Cortellini et al 1995) was introduced
Sling Suture. The sling suture is primarily used defect distal to the last tooth. The arrows on Fig-
specifically for achieving maximum interproxi-
for a flap that has been raised on only one side of ure 3-14B indicates desired movement of flap and
mal coverage and primary closure over intrabony
a tooth, involving only one or two adjacent papil- dotted lines indicate ideal flap position. Flap ide-
defect is treated by GTR. The modified flap tech-
lae. It is most often used in coronally and lateral- ally should be positioned against distal surface of
nique (Figure 3-13) requires the initial incision
ly positioned flaps. The technique involves use of tooth with primary closure. Suture is begun on
be made at the buccal line angles in the area of
one of the interrupted sutures, which is either the mesiobuccal of the terminal tooth (Figure
the interproximal defect. It is a papillary preser-
anchored about the adjacent tooth (Figure 3-10) 3-14C1). The suture is passed through interprox-
vation technique. The suturing permits coronal
or slung around the tooth to hold both papillae imal to the distal and inserted through only the
positioning, flap stabilization, and primary inter-
(Figure 3-11). undersurface of the buccal flap. The suture is
proximal closure. The first suture is begun buc-
brought almost 360° around the tooth starting
Specialized Interrupted Suturing Techniques for cally 5–6 mm below the initial incision (Fig-
lingually and continuing bucally until again
Bone Regeneration and Retromolar and Tuberos- ure 3-13A1). The suture is passed through the
reaching the distal surface (Figure 3-14C2). The
ity Areas. Laurell Modification. Laurell modi- buccal and palatal flaps. It is then reinserted
needle is passed through the undersurface of the
fied mattress suture (1993) (Figure 3-12) for coro- palatally and allowed to exit the buccal flap 2 mm
lingual flap and tied on the buccal surface (Figure
nal flap positioning and primary flap coverage is a above the initial placements. This is tied off and
3-14C3). Figure 13-14D shows suturing having
technique which, although capable of being should stabilize the body of the flap. The second
been completed and primary coverage attained.
employed for all regenerative techniques, is used suture is now begun 3–4 mm below the initial inci-

A B C

D E F
FIGURE 3-11. Sling suture about single tooth.
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 25

Sutures and Suturing 25

FIGURE 3-12. Laurell modified mattress suture (see text). FIGURE 3-13. Modified flap suturing technique (see text).

Continuous Sutures Sling loose or the suture may come untied from multi- interproximal embrasure (see Figure 3-15B) in
ple teeth. such a manner that the suture is made to encircle
When multiple teeth are involved, the continuous the neck of the tooth (see Figure 3-15C). The
suture is preferred. Types needle is then passed either over the papilla and
The choice of continuous suture depends on the through the outer epithelialized surface or under-
Advantages operator’s preference. These, too, can be periosteal neath and through the connective tissue under-
1. Can include as many teeth as required or nonperiosteal: surface of the papilla. The needle is passed again
2. Minimizes the need for multiple knots through the embrasure and continued anteriorly
1. Independent sling suture
3. Simplicity (Figure 3-15D). This procedure is repeated
2. Mattress sutures
4. The teeth are used to anchor the flap through each successive embrasure until all
a. Vertical
5. Permits precise flap placement papillae have been engaged.
b. Horizontal
6. Avoids the need for periosteal sutures
3. Continuous locking
7. Allows independent placement and tension Note: For maximum flap control, it is best to pass
of buccal and lingual or palatal flaps. Buccal the needle through the connective tissue under-
flaps can be positioned loosely, whereas lin-
Technique surface of the papilla.
gual and palatal flaps are pulled more tightly Independent Sling Suture
about the teeth. The continuous sling suture (Figure 3-15), A terminal end loop (Figure 3-15E) is then
8. Greater distribution of forces on the flaps although most often begun as a continuation of used if a single flap has been reflected or if the
tuberosity or retromolar suturing (see Figure flaps are to be sutured independently. In this
Disadvantages 3-15A), can also be started with a looped suture manner, the flaps are tied against the teeth as
The main disadvantage of continuous sutures is about the terminal papilla (buccal, lingual, or opposed to each other.
that if the suture breaks, the flap may become palatal). It is then continued through the next

A B

C D
FIGURE 3-14. Retromolar area modified suture technique (see text).
Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 26

26 Basics

Terminal End Loop. On completion of suturing, Modification. When two flaps have been Alternative Procedure. This technique simulta-
the suture is tied off against the tooth as opposed reflected and after the first flap has been sutured neously slings together both the buccal and lin-
to the other flap. This is accomplished by leaving a (Figure 3-16A), it is often desirable to continue gual or palatal flaps.
loose loop of approximately 1 cm length of suture about the distal surface of the last tooth (Figure INDICATIONS.
material before the last embrasure. When the last 3-16B), repeating the procedure on the opposing 1. When flap position is not critical
papilla is sutured and the needle is returned flap (Figure 3-16C) and then tying off in a termi- 2. When buccal periosteal sutures are used for
through the embrasure, the terminal end loop is nal end loop (Figure 3-16D and E). buccal flap position and stabilization
used to tie the final knot (Figure 3-15F–I). 3. When maximum closure is desired (unrepo-
sition or Widman flaps or bone regeneration)

4
1 3
2

A B C

D E F

G H I

FIGURE 3-15. Continuous sling suture with terminal end loop.

Cohen_015-028_03.qxd 11/16/06 8:23 PM Page 27

Sutures and Suturing 27

Technique Technique. The procedure is identical to that through the remaining loop of the suture, and the
After the initial buccal and lingual tie, the suture is previously described for the independent papil- suture is pulled tightly, thus locking it. This proce-
passed buccally about the neck of the tooth inter- lary sling suture (see Figure 3-15), except that dure is continued until the final suture is tied off at
dentally and through the lingual flap. It is then vertical or horizontal mattress sutures are substi- the terminal end (Figure 3-18).
again brought interdentally through the buccal tuted for the simple papillary sling. The tech-
papilla and back interdentally about the lingual nique is similar to that previously described for Suture Removal
surface of the tooth to the buccal papilla. Then it is the interrupted mattress sutures.
Sutures are used for wound stabilization and
brought about the lingual papilla and then the Locking. The continuous locking suture is indi- should be removed when sufficient tissue strength
buccal surface of the tooth. This alternating buc- cated primarily for long edentulous areas, has been achieved. This is usually between 5 and
cal-lingual suturing is continued until the suture is tuberosities, or retromolar areas. It has the advan- 10 days, and in most instances, these sutures are
tied off with a terminal end loop (Figure 3-17). tage of avoiding the multiple knots of interrupted removed in 7 days.
Vertical and Horizontal Mattress Suture. When sutures. If the suture is broken, however, it may
greater papillary control and stability and more completely untie. Materials
precise placement are required or to prevent flap Technique. The procedure is simple and repeti- 1. Scissors
movement, vertical or horizontal mattress sutures tive. A single interrupted suture is used to make the 2. Cotton pliers
are used. This is most often the case on the palate, initial tie. The needle is next inserted through the 3. Double-ended scaler
where additional tension is often required, or outer surface of the buccal flap and the underlying 4. Hydrogen peroxide
when the papillary tissue is thin and friable. surface of the lingual flap. The needle is then passed 5. Topical anesthetic
6. Cotton swabs

5
7 6
5 8
6
7
8
4
1
3
2

A B C

5
8 7 6

1 3
2

D FIGURE 3-16. Continuous independent sling suture of indi-

vidual flaps.
Exploring the Variety of Random
Documents with Different Content
considerable in Europe.” This announcement, which in great part
contained nothing out of the common, it turned out was inserted at
the instance of a Londoner who was going to see the fair for the first
time; and it had the effect of drawing together more people than
had been seen there for ten years. The visitor in question records in
the “Gentleman’s Magazine” that he regularly took coach every
afternoon at the Market-hill (Cambridge) with other gownsmen,
drinking tea at the Coffee-booth, “where now and then we had the
company of some very agreeable ladies of Cambridge town and
education, and a fortnight was thus spent.”
1709. There was published in London: “Nundinæ Sturbrigienses,”
a poem in Latin hexameters, of some five hundred lines, by Th. Hill,
Coll. Trin. Cant. Soc. It is included in vol. ii. “Musæ Anglicanæ,”
editio quinta. Londini, ex officina J. S. R. Tonson and J. Watts, 1741.
An * indicates that the poem in question was added to this edition,
and not found in former ones. The poem gives a description of the
fair as it existed in the reign of Queen Anne.
1710. The question of the preachership of the fair referred to
under date 1650, came up this year in strong force. The corporation
had usually appointed the minister of Barnwell, but this year they
appointed another, a fellow of King’s College. Their right to the
nomination was now disputed by the improprietor and minister of
Barnwell. The corporation resolved to maintain their nominee, and
the opposing parties advertised their intention of standing on what
they regarded as their rights. Proceedings were accordingly
commenced in the Bishop of Ely’s court. The following year (Sept.
1711) the Vicar of Barnwell published the following:—

Whereas ’tis the resolution of the corporation of

Cambridge, against the present incumbent of Barnwell, to set
up a preacher in Sturbridge Fair; being led thereinto by
artificially persuading some of his predecessors into an illegal
note, against the patron, his clerks and successors in the said
living: and Sturbridge Fair being in the parish of Little St.
 Andrew’s, Barnwell, and the ministers thereof have (when
right and law prevail) time out of mind, without any
disturbance (the said corporation of Cambridge finding
alwaies a pulpit) performed the service of the two Lord’s-days
during the said fair, with their congregation, service-books,
vestments, pulpit ornaments, and parish-clerk, in gratitude for
the collection that hath been there alwaies made, for the
better support of themselves under their small parochial
income, till the last year 1710; for which intrusion, then, the
unwary usurper was censured in the Bishop’s ecclesiastical
court: These do humbly give notice to the gentlemen of the
fair, that the pulpit not being allowed this year as usual, and it
not being known soon enough to provide one, the service of
the Lord’s day, during this present fair, will be performed in
the parish-church, morning and evening, by the minister of
Barnwell.
Will. Piers.

Mr. Piers appears to have carried his point, as no mention of a

Sturbridge fair preacher subsequently to 1711 occurs in the
Corporation books. Dr. Hurd, Bishop of Worcester, was, whilst fellow
of Emmanuel, preacher at Sturbridge fair.
Preaching in the Fair.—The services were performed during the
two Sundays occurring in the principal period of the fair, both
morning and afternoon. The sermon was preached from a pulpit
placed in the open air, in the centre of the large square, some 300
by 240 feet, called the Duddery, where the woollen-drapers,
wholesale tailors, and sellers of second-hand clothes took up their
residence, in spacious booths. In the centre of this square was
formerly a tall maypole, with a vane at the top. It was the most
orderly part of the fair.
Ned Ward, in his book already referred to (1700), mentions this
part of the fair, and says there stands “an old weather-beaten pulpit,
where on Sunday a sermon is delivered for the edification of the
strolling sinners, who give open attention, as in a field-conventicle”
(p. 242).
1718. On the 21st Sept. died, aged 89, Samuel Newton, one of
the Aldermen of Cambridge. By his will he gave to the town four
booths in the fair, and a sermon in his commemoration was for many
years preached at St. Edward’s before the mayor and corporation on
the Sunday next preceding the 22nd Sept.
1727. I do not know if there was any speciality in the procession
to proclaim the fair this year. The following details are given in
Cooper’s “Annals of Cambridge,” under this date. The order was
thus: The Crier in scarlet on horseback; twenty-eight petty
Constables on foot; three drums; banners and streamers; the Grand
Marshal; two trumpeters; the Town music (twelve in number), two
French horns; the Bellman in state with a stand, on horseback; four
Serjeants at Mace on horseback; the Town Clerk on horseback. The
Mayor in his robes mounted on a horse richly caprisoned, led by two
footmen called red coats with white wands. The two representatives
in Parliament on horseback. Twelve Aldermen according to seniority
on horseback (three and three) in their proper robes, the six seniors
having their horses attended by as many henchmen or red coats
with wands. The twenty-four Common Councilmen, three and three
according to seniority. Eight Dispensers in their gowns, two and two;
four Bailiffs in their habits (two and two). The Treasurers in their
gowns. The Gentlemen and Tradesmen of the town.
The procession was followed by a great number of the boys of the
town on horseback, who as soon as the ceremony of proclaiming
was over, rode races about the place; and on returning to Cambridge
each boy had a cake and some ale at the Town-hall.
This procession was maintained until about 1758, when it began
“to be abridged,” owing as it is said to the trouble and charge of
keeping it in suitable condition.
De Foe’s Description of the Fair.—1723. This year the fair was
visited by Daniel De Foe, and he gives an account of it which I
regard as of great value. He understood how to grapple with what
he saw, and how to record the results of his inquiry. I give his
description with very small curtailment. The account was not
published until 1724:
I now draw near to Cambridge, to which I fansy I look as if I was
afraid to come, having made so many Circumlocutions beforehand;
but I must yet make another Digression before I enter the Town;
(for in my way, and as I came in from Newmarket, about the
beginning of September;) I cannot omit, that I came necessarily
through Sturbridge Fair, which was then in its height.
If it is a Diversion worthy of a Book to treat of Trifles, such as the
Gayety of Bury Fair, it cannot be very unpleasant, especially to the
Trading part of the World, to say something of this Fair, which is not
only the greatest in the whole Nation, but in the World; nor, if I may
believe those who have seen them all, is the Fair at Leipsick in
Saxony, the Mart at Frankfort on the Main, or the Fairs at Nuremberg
or Ausburg, any way to compare to this Fair at Sturbridge.
It is kept in a large Corn-field, near Casterton, extending from the
side of the River Cam, towards the Road, for about half a Mile
square.
If the Husbandmen who rent the Land, do not get their Corn off
before a certain Day in August, the Fair-Keepers may trample it
under foot, and spoil it, to build their Booths: On the other Hand, to
ballance that Severity, if the Fair-Keepers have not done their
Business of the Fair, and remov’d and clear’d the field by another
certain Day in September, the Plowmen may come in again, with
Plow and Cart, and overthrow all and trample it into the Dirt; and as
for the Filth, Dung, Straw, &c., necessarily left by the Fair-Keepers,
the Quantity of which is very great, it is the Farmers Fees, and
makes them full amends for the trampling, riding, and carting upon,
and hardening the Ground.
It is impossible to describe all the Parts and Circumstances of this
Fair exactly; the Shops are placed in Rows like Streets, whereof one
is call’d Cheapside; and here, as in several other Streets, are all sorts
of Trades, who sell by Retale, and who come principally from London
with their Goods; scarce any trades are omitted, Goldsmiths, Toy-
shops, Braziers, Turners, Milleners, Haberdashers, Hatters, Mercers,
Drapers, Pewterers, China-Warehouses, Taverns, Brandy-Shops, and
Eating-Houses, innumerable, and all in Tents, and Booths, as above.
This great Street reaches from the Road, which as I said goes
from Cambridge to Newmarket, turning short out of it to the Right
towards the River, and holds in a Line near half a Mile quite down to
the River-side: In another Street parallel with the Road are like Rows
of Booths, but larger, and more intermingled with Wholesale Dealers,
and on one side, passing out of this last Street to the Left Hand, is a
formal great Square, form’d by the largest Booths, built in that Form,
and which they called the Duddery; whence the name is deriv’d, and
what its Signification is, I could never yet learn, tho’ I made all
possible search into it. [Duddery is evidently derived from the old
word Dudde, signifying cloth (“Promptorium Parvulorum,” ed. Way, i.
134). Duds for clothes is still used as a cant word, and by the Scotch
(Bailey’s “Dictionary;” Glossaries to Burns and Walter Scott).] The
area of this Square is about 80 to 100 yards, where the Dealers have
room before every Booth to take down, and open their Packs, and to
bring in Waggons to load and unload.
This place is separated, and Peculiar to the Wholesale Dealers in
the Woollen Manufacture. Here the Booths, or Tents are of a vast
Extent, have different apartments, and the Quantities of Goods they
bring are so Great, that the Insides of them look like another
Blackwell Hall, being as vast Ware-Houses pil’d up with Goods to the
Top. In this Duddery, as I have been inform’d, there have been sold
£100,000 worth of Woollen Manufactures in less than a Week’s time,
besides the prodigious Trade carry’d on here, by Wholesale Men,
from London, and all Parts of England, who transact their Business
wholly in their Pocket-Books, and meeting their Chapmen from all
Parts, make up their Accounts, receive money chiefly in Bills, and
take Orders: These they say exceed by far the Sales of Goods
actually brought to the Fair, and deliver’d in Kind; it being frequent
for the London Wholesale Men to carry back orders from their
Dealers for £10,000 worth of Goods a Man, and some much more.
This especially respects those People, who deal in heavy Goods, as
Wholesale Grocers, Salters, Brasiers, Iron-Merchants, Wine-
Merchants, and the like; but does not exclude the Dealers in Woollen
Manufactures, and especially in Mercery Goods of all sorts, the
Dealers in which generally manage their Business in this manner.
Here are Clothiers from Hallifax, Leeds, Wakefield and Huthersfield
in Yorkshire, and from Rochdale, Bury, &c., in Lancashire, with vast
Quantities of Yorkshire Cloths, Kerseyes, Pennistons, Cottons, &c.,
with all sorts of Manchester Ware, Fustians, and things made of
Cotton Wool; of which the Quantity is so great, that they told me
there were near a thousand Horse-Packs of such Goods from that
side of the Country, and these took up a side and a half of the
Duddery at least; also a part of a street of Booths were taken up
with Upholsterer’s Ware, such as Tickings, Sackings, Kidderminster
Stuffs, Blankets, Rugs, Quilts, &c.
In the Duddery I saw one Ware-house or Booth with six
Apartments in it, all belonging to a Dealer in Norwich Stuffs only,
and who they said had there above £20,000 value in those Goods,
and no other.
Western Goods had their Share here also, and several Booths
were fill’d as full with Serges, Du-Roys, Druggets, Shalloons,
Cantaloons, Devonshire Kersies, &c., from Exeter, Taunton, Bristol,
and other Parts West, and some from London also.
But all this is still out done, at least in show, by two Articles, which
are the peculiars of this Fair, and do not begin till the other part of
the Fair, that is to say for the Woolen Manufacture begins to draw to
a Close; these are Wooll, and the Hops, as for the Hops there is
scarce any Price fix’d for Hops in England, till they know how they
sell at Sturbridge Fair; the Quantity that appears in the Fair is indeed
prodigious, and they, as it were, possess a large Part of the Field on
which the Fair is kept, to themselves; they are brought directly from
Chelmsford in Essex, from Canterbury and Maidstone in Kent, and
from Farnham in Surrey, besides what are brought from London, the
growth of those, and other places.
Enquiring why this Fair should be thus, of all other Places in
England, the Center of that Trade; and so great a Quantity of so
Bulky a Commodity be carry’d thither so far: I was answer’d by one
thoroughly acquainted with that matter, thus: The Hops, said he, for
this part of England, grow principally in the two counties of Surrey
and Kent, with an exception only of the town of Chelmsford in Essex,
and there are very few planted anywhere else.
... I must not omit here also to mention, that the River Grant, or
Cam, which runs close by the N.W. side of the Fair in its way from
Cambridge to Ely, is Navigable, and that by this means, all heavy
Goods are brought even to the Fair-Field, by Water Carriage from
London, and other Parts, first to the Port of Lynn, and then in Barges
up the Ouse, from the Ouse into the Cam, and so, as I say to the
very Edge of the Fair.
In like manner great Quantities of heavy Goods, and the Hops
among the rest, are sent from the Fair to Lynn by Water, and
shipped there for the Humber, to Hull, York, &c., and for New Castle
upon Tyne, and by New Castle, even to Scotland itself. Now as there
is still no planting of Hops in the North, tho’ a great Consumption,
and the Consumption increasing Daily, this, says my Friend, is one
reason why at Sturbridge Fair there is so great a Demand for the
Hops: He added, that besides this, there were very few Hops, if any
worth naming, growing in all the Counties even on this side Trent,
which were above forty miles from London; these Counties
depending on Sturbridge Fair for their supply, so the Counties of
Suffolk, Norfolk, Cambridge, Huntingdon, Northampton, Lincoln,
Leicester, Rutland, and even to Stafford, Warwick, and
Worcestershire, bought most if not all their Hops at Sturbridge Fair.
These are the Reasons why so great a Quantity of Hops are seen
at this Fair, as that it is incredible, considering too, how remote from
this Fair the Growth of them is, as above.
 This is likewise a testimony of the prodigious Resort of the Trading
people of all Parts of England to this Fair; the Quantity of Hops that
have been sold at one of these Fairs is diversley reported, and some
affirm it to be so great, that I dare not copy after them; but without
doubt it is a surprising Account, especially in a cheap Year.
The next Article brought hither, is Wool, and this of several sorts,
but principally Fleece Wool, out of Lincolnshire, where the longest
Staple is found; the sheep of those Countries being of the largest
Breed.
The Buyers of this Wool, are chiefly indeed the Manufacturers of
Norfolk and Suffolk and Essex, and it is a prodigious Quantity they
buy.
Here I saw what I have not observ’d in any other county of
England, namely, a Pocket of Wool.
This seems to be first call’d so in Mockery, this Pocket being so
big, that it loads a whole Waggon, and reaches beyond the most
extream Parts of it, hanging over both before and behind, and these
ordinarily weigh a Ton or 25 Hundred weight of Wool, all in one Bag.
The Quantity of Wool only, which has been sold at this Place at
one Fair, has been said to amount to £50,000 or £60,000 in value,
some say a great deal more.
By these Articles a Stranger may make some guess at the
immense Trade carry’d on at this Place; what prodigious Quantities
of Goods are bought and sold here, and what a confluence of People
are seen here from all Parts of England.
I might go on here to speak of several other sorts of English
Manufactures, which are brought hither to be sold; as all sorts of
wrought Iron, and Brass-Ware from Birmingham; Edg’d Tools,
Knives, &c., from Sheffield; Glass-Wares and Stockings from
Nottingham, and Leicester; and an infinite Throng of other things of
smaller value, every Morning.
 To attend this Fair, and the prodigious conflux of People which
come to it, there are sometimes not less than fifty Hackney Coaches,
which come from London, and ply Night and Morning to carry the
People to and from Cambridge; for there the gross of the People
lodge; nay, which is still more strange, there are Wherries brought
from London on Waggons to plye upon the little River Cam, and to
row People up and down from the Town, and from the Fair as
Occasion presents.
It is not to be wondered at, if the Town of Cambridge cannot
Receive or Entertain the Numbers of People that come to this Fair;
not Cambridge only, but all the Towns round are full; nay, the very
Barns, and Stables are turn’d into Inns, and made as fit as they can
to Lodge the meaner Sort of People.
As for the People in the Fair, they all universally Eat Drink and
Sleep in their Booths and Tents; and the said Booths are so
intermingled with Taverns, Coffee-Houses, Drinking-Houses, Eating-
Houses, Cook-Shops, &c., and all in Tents too; and so many
Butchers, and Hagglers from all the Neighboring Counties come into
the Fair every Morning with Beef, Mutton, Fowls, Butter, Bread,
Cheese, Eggs, and such things; and go with them from Tent to Tent,
from Door to Door, that there’s no want of any Provisions of any
kind, either dres’d or undres’d.
In a Word, the Fair is like a well Fortify’d City, and there is the
least Disorder and Confusion (I believe) that can be seen anywhere,
with so great a Concourse of People.
Towards the latter End of the Fair, and when the great Hurry of
Wholesale Business begins to be over, the Gentry come in, from all
parts of the County round; and tho’ they come for their diversion;
yet ’tis not a little Money, they lay out; which generally falls to the
share of the Retailers, such as Toy-shops, Goldsmiths, Brasiers,
Ironmongers, Turners, Milleners, Mercers, &c., and some loose
Coins, they reserve for the Puppet Shows, Drolls, Rope-Dancers, and
such-like, of which there is no want, though not considerable like the
rest: The last Day of the Fair is the Horse-Fair, where the whole is
closed with both Horse and Foot-Races, to divert the meaner Sort of
People only, for nothing considerable is offered of that Kind: Thus
Ends the whole Fair, and in less than a week more, there is scarce
any sign left that there has been such a thing there....
I should have mention’d, that here is a Court of Justice always
open, and held every Day in a Shed built on purpose in the Fair; this
is for keeping the Peace, and deciding Controversies in matters
Deriving from the Business of the Fair: The Magistrates of the Town
of Cambridge are Judges in this Court, as being in their Jurisdiction,
or they are holding it by special Priviledge: Here they determine
Matters in a Summary way, as is practis’d in those we call Pye-
Powder Courts in other Places, or as a Court of Conscience; and they
have a final Authority without Appeal.
1729. This year was passed “An Order for the Registering and
Regulating the Prices of Hackney Coaches at Sturbridge Fair,” which
was quite a formidable document. I give one paragraph only: ... And
whereas in pursuance and by virtue of such immemorial prescription
usage and Charters the said mayor bailiffs and burgesses have from
time to time taken on themselves the regulation of Hackney Coaches
coming to the said fair; and did heretofore take a toll of 5s. from
each coach coming to the said fair, which of late years they have
omitted to receive in consideration of the great expenses of such
hackney coachmen coming to the said fair; and did order appoint
and establish the prices to be taken by all coachmen coming to the
said fair and there tendering themselves to carry passengers and
persons from the town of Cambridge to the said fair, and from the
said fair to the town of Cambridge, at the price or sum of 3d. ...
The price (after many more recitals) was fixed at 6d.
1733. There was a dispute between the University and the
Corporation as to the right to weigh hops in the fair, as indeed there
had been for several previous years. The matter was referred to the
Commissary of the University and the Recorder of the Town, who
decided in favour of the University. A paper on the subject was
drawn up and published by Thomas Johnson of Magdalen College,
one of the taxors.
1738. The University published a severe edict against schismatical
congregations at Stourbridge fair, and appointed Pro-proctors to see
it executed. These measures were occasioned by the fear that the
famous John Henley would erect an oratory in the fair. He had
applied to the Vice-chancellor for leave to hold an oratory there and
had been refused.
1741. A great gale this year blew down many of the booths at the
fair, and caused great inconvenience and some damage.
1747. On 29th June the Court of Common Pleas gave judgment in
an action of trespass brought by James Austin against King Whittred
for seizing his cheese, &c., at this fair in 1745; which trespass the
defendant justified by way of distress damage feasant made by him
as servant to the Corporation, the owners of the fair. The court held
the plea bad in substance, as every person had of common right a
liberty of carrying his goods to a public fair for sale.—“Willes
Reports,” 623.
1748. A company of players from the theatres in London
performed a pantomime called “Harlequin’s Frolics or Jack Spaniard
caught in a Trap,” in Hussey’s Great Theatrical Booth. There were
also some entertainments of singing and dancing. It was believed
these were permitted in honour of the approaching peace. But in the
following year there were also companies of players present.
—“Annals,” iv. p. 262, note.
1749. The Land Tax assessed on the fair this year amounted to
£112 7s. 10d.
Carter the Historian of Cambridge published an account of the fair
this year. I shall only quote from it such points as have not been
mentioned by De Foe and others. He refers to the name of the fair
being obviously derived from the rivulet called the Stour, which has a
bridge over it near the site of the fair.
 “During the fair Colchester oysters (natives) and white herrings,
just coming into season are in great request, at least by such as live
in the inland part of the kingdom.” ... “The fair is like a well
governed city.... If any dispute arise between buyer and seller &c.,
on calling out ‘Red-coat’ you have instantly one or more come
running to you; and if the dispute is not quickly decided, the
offender is carried to the said Court [of the fair] where the case is
determined in a summary way....”
1757. Postlethwayt in his “Dictionary of Trade and Commerce,” 2nd
edition, speaks of the fair as “beyond all comparison the greatest in
Britain, and perhaps in the world”—as it certainly was at this time.
1759. The Corporation ordered the collector of the tolls to provide
weights and scales for weighing hops and other goods at the fair,
and agreed to indemnify him against any suit in relation to the
weighing of such goods.
Peculiar custom of the Fair.—1762. At this fair about this date,
there was in practice the custom of “Initiation” or “Christening.” It
took place usually on the evening of the horse-fair day—perhaps
because there was a species of horse-play about the performance,
at the “Robin Hood” inn, famous in the annals of the fair. The
formula was as follows:—The freshman was introduced to the elder
members in the parlour of the inn, and two sponsors being
previously chosen for him, he was placed in an armchair, his head
uncovered, and his shoes off. Two vergers, holding staves and
lighted candles, assisted the officiator, who was robed in a Cantab’s
gown and cap, with a bell in one hand and a book in the other. He
commenced the ceremony by asking “Is this an Infidel?” Answer,
“Yes.” “What does he require?” Answer, “Instruction (or to be
instructed).” “Where are the sponsors? let them stand forward!” A
bowl of punch or a bottle of wine was placed on the table handy for
the officiator, who then chaunted the following doggrel:—

Over thy head I ring this bell,

Because thou art an infidel,
 And I know thee by thy smell—[7]
Chorus. With a hoccius proxius mandamus,
Let no vengeance light on him,
And so call upon him.
With several verses more of the same sort.
Then the officiator turned round and inquired “Who names this
child?” The sponsors replied “We do,” and then they called the
novitiate by some slang name, as “Nimble-heels,” “Stupid Stephen,”
“Tommy Simper,” or other ludicrous designation. The officiator then
drank and gave the novice a full bumper, continuing the chaunt:—

“Nimble-heels” henceforward shall be his name,

Which to confess let him not feel shame
Whether ’fore matter, miss, or dame—

And then the chorus as before. Then,—

This child first having paid his dues,

Is welcome then to put on his shoes,
And sing a song, or tell a merry tale—
As he may choose.

Chorus and conviviality ending up by a formal supper. If several

novices were offered together, one ceremony sufficed, with a few
necessary verbal alterations.
1771. In a letter of the Rev. Michael Tyson, dated Corpus Christi
College, Cambridge, Sept. 12th, this year, occurs the following
passage:—“There is an old and curious plan of Sturbridge Fair in the
mayor’s booth, taken when it was in its splendour, when its street
and square extended all over those fields by Barmwell. I mean to
make a copy of this, and to draw up an Historiola of the Fair; but
this is too local to be of any entertainment but to those connected
with Cambridge. Thank Heaven my Deanship ends on Michaelmas
day....”—Nichols’ “Literary Anecdotes,” viii. 569.
 1778. Violent storm during the fair; Bailey’s large music booth
blown down and many others injured.
1783. At the Quarter Sessions of Cambridge held July this year the
following order was made:
“Whereas some disputes have arisen, touching the Intercommon
of Stirbridge Fair Green, between the Commoners of Cambridge, and
those of Barnwell within the said Town, and a suit hath been
instituted in order to try the right of the said Common: It is this day
agreed and ordered, that the Costs of such suit on the part of the
said town of Cambridge, touching the said intercommon, be paid
and borne by the said town; and that the Town Clerk be desired to
prosecute the said suit, to assert the right of the inhabitants of the
said town to the said Common.”
It is recorded that some of the scenes at the fair about this date
were of a reprehensible character, and tradition especially points to a
booth raised by Charles Day, the character of one of whose patrons
is sketched with a free hand in “Nichols’ Literary Anecdotes,” viii. p.
540.
1786. There was published “The History and Antiquities of
Barnwell Abbey, and of Sturbridge Fair” (being a reprint of
“Bibliotheca Topographica Britannica,” No. xxxviii.), from which I
have drawn some of the preceding details.
1789. An interesting and amusing account of the fair as it
appeared in 1789—reign of George III.—is given in “Reminiscences
of Cambridge,” by Henry Gunning, formerly an Esquire Bedell, vol. i.,
pp. 149-158, second edition, London, 1855.
 CHAPTER XIII.
THE NINETEENTH CENTURY.
1802.
During the performance at the theatre in the fair, 27th Sept., a cry of
“fire” arose in different parts of the house, which was greatly
crowded. Although the manager and performers assured the
audience that the alarm was without foundation, and tried every
persuasion to obtain order, a general rush took place. Some threw
themselves over from the upper boxes into the pit; others were
trampled upon and bruised on the stairs. In the end three girls and a
boy were taken up dead, and many others were more or less
seriously injured. It was supposed the cry was got up for the
purposes of robbery; one hundred guineas reward was offered for
the offenders, but they escaped detection.
1827. In Hone’s “Year Book” is given a graphic account of this fair
as it had existed within the memory of the writer, whose “personal
recollections of more than sixty years ago,” are embodied therein;
from which I condense the following, as giving a view of its later, but
not last stage:
The first booths, on the north side of the road were occupied by
the customary shows of wild beasts and wild men, conjurors,
tumblers and rope-dancers. Mr. Baker’s company of “comedians” was
respectable; and Lewy Owen the clown, a young man of good
family, who had abandoned himself to this way of life, full of
eccentric wit and grimace, continually excited broad grins. The late
Mrs. Inchbald was a performer at this fair. There was a large
theatrical booth, occupied by a respectable company of comedians
from Norwich, under the management of Mr. Bailey, formerly a
merchant of London. He was a portly good-looking man, of
gentlemanly manners and address, the compiler of the Directory
bearing his name—a work of much merit, containing besides the
names of residents in the several towns, concise yet correct
topographical description of the places: the book has now become
very scarce. Other show booths, occupied by giants and dwarfs,
savage beasts and other savages, extended with stunning din along
this noisy line. In front of these were the fruit and gingerbread
stalls.... On the south side of the road opposite to these booths was
the cheese fair. Dealers from various parts took their stands there,
and many tons weight were disposed of. Such as were fit for the
London market were bought by the cheese factors from thence; and
cheese from Cheshire, Wilts, and Gloster by the gentry and farmers
and dealers from Suffolk, Norfolk, and adjoining counties; large
quantities of Cottenham and cream cheeses being brought by
farmers from those counties for sale. Opposite to the east end of the
cheese fair, on the north side of the road stands an ancient chapel or
oratory, no doubt erected for the devout dealers and others resorting
to this fair, and for such pious travellers as passed or repassed the
ferry to Chesterton [various references have been made to it; still
standing, 1882]. At and nigh to this spot were the wool-fair and the
hop-fair. Large stores of sack-cloths, waggon-tilts, and such like were
near the skin, leather sellers’ and glovers’ row, where the finer
articles of leather and leather gloves were sold. Little edifices of
general convenience were numerous.
At the end of the show-booths and facing the row began the
principal range of booths, called Garlick-row. This range of shops
was well constructed. Each booth consisted of two rooms; the back
room separated from the shop by a boarded partition served for a
bed chamber and other domestic purposes, from which a door
opened into a field. A range of booths was generally appropriated to
furniture sellers, ironmongers, silversmiths, jewellers, japanners and
fine cutlery dealers. Another range to silk-mercers, dealers in muslin,
toys and millinery. Yet another to dealers in Norwich and Yorkshire
manufactures, mercery, lace, hose, fine made shoes, boots, clogs
and patterns (sic). While dealers in fashionable wares from London,
as furs, fans, toys, &c. occupied a distinct group. A further group
was devoted to oilmen, dealers in pickles, and preserves, one of
whom—Mr. Green from Limehouse—kept a most important store
here. His returns were from £1,500 to £2,000 during the fair. The
father of the writer from whom I am quoting “kept the fair” for forty
years and upwards, “and usually brought home £1,000 or more for
goods sold and paid for, besides selling to half that amount on credit
to reputable dealers and farmers.” At the end of this row stood the
dealers in glass-ware, looking-glasses and small articles of
mahogany furniture. The Inn—the King’s Arms, I believe—was the
common resort of the horse-dealers. Here sat the Pied-poudre court,
having a pair of stocks and a whipping-post in front, and a strong
room underneath. Close adjoining northward was the oyster fair. The
oysters brought from Lynn were very large, about the size of a
horse’s hoof, and were opened with pincers; the more delicate from
Colchester and Whitstable were very small. In the meadow adjoining
were the coal fair, pottery fair and Staffordshire dealers. The greater
part of these articles were delivered from on board vessels which
drew up close to the bank of the river.
Opposite to the oyster fair was a close wherein the horse fair was
kept. The show of beautiful animals in that place was perhaps
unrivalled, unless in Yorkshire. The finest racers and hunters from
Yorkshire, the most brawny and muscular draught horses from
Suffolk, and from every other country famous for breeding horses
animated the scene. This horse fair drew together a great concourse
of gentry, farmers and dealers from all parts of the neighbouring
counties, and scores of valuable animals changed masters in the
space of a few hours. The horse fair was held on the first Friday
after the fair was proclaimed.
Higher up, and about fifty yards from the road was Ironmongers’
row, with booths occupied by manufactures from Sheffield,
Birmingham, Wolverhampton, and other parts; and dealers in
agricultural tools, nails, hatchets, saws, and such like implements.
About twenty yards nearer the road were woollen drapers; and
further on, and opposite to Garlick-row westward, were booths for
slop sellers, and dealers in haubergs, or waggoners’ frocks, jackets,
half-boots, and such like habiliments for robust ploughmen and farm
labourers. Then followed the hatters’ row, close to which was a very
respectable coffee-house and tavern, fitted up with neat tables
covered with green baize, having glazed sash-windows and a
boarded floor, kept by the proprietor of Dochrell’s coffee-house in
Cambridge, famed for excellent milk punch. There were also a
number of suttling booths where plain and substantial dinners were
served up in a neat comfortable style, well cooked and moderately
charged, “except on the horse fair and Michaelmas days, when an
extra sixpence was generally tackt to the tail of the goose.”
Shoemaker row was at the end of Garlick-row and consisted of ten
or twelve booths. The basket fair, Tunbridge ware fair, and broom
fair, were behind nearly at the top. In the basket fair were to be had
all kinds of hampers, baskets and basket work; hay rakes, scythe-
hafts, pitchfork and spade-handles, and other implements of
husbandry, waggon loads of which were piled up there. In the
Tunbridge ware section were malt, shovels, churns, cheese-presses
and other wooden ware.
The circuit of the fair at the period to which this account relates
was estimated at three miles. A list of many of the principal London
dealers who attended this fair is appended to this account. Vide
Hone’s “Year Book,” 1841 ed. col. 1539-48. A rough plan or chart of
the fair is there given.
1828. The formal opening of the fair is described in Wall-Gunning,
“The ceremonies observed in the senate-house of the University of
Cambridge.” Camb. pp. 129-31.
1842. The practice—the origin of which I have not been able to
trace—of the Proctors of the University giving entertainments at the
Midsummer and Sturbridge fairs was this year discontinued by a
Grace passed 2nd July.
1855. The University, for the last time, “called the fair” on 18th
Sept. this year. The following form was used on the occasion—very
much modified from that of 1548.
 Proclamation of the Fair, by the University.—Oyez! Oyez! Oyez! All
persons are desired to keep silence while Proclamation of this Fair is
being made.
His Royal Highness Prince Albert, Chancellor of this University
Doth in the name of our Sovereign Lady Queen Victoria strictly
charge and command:
That all persons who shall repair to this Fair or the precincts
thereof Do keep Her Majesty’s peace, and make no affrays or
outcries whereby any gathering together of people be made, nor
that they wear any weapons upon pain of imprisonment and loss of
their weapons and further correction as shall be thought fit by the
Officers of the said University.
That all unhonest women, all vagrant and unruly persons avoid
and withdraw themselves from this Fair and the precincts thereof
immediately after this proclamation, that Her Majesty’s Subjects may
be quieter, and good rule the better maintained upon pain of
imprisonment and further correction at the discretion of the Officers
of this University.
That all Bakers baking bread to sell at this Fair or the precincts of
the same Do bake and sell good and wholesome bread, and of such
goodness as the law doth require, upon pain of the Statute in that
behalf provided. [Bale (“Declaration of Bonner’s Articles,” fo. 21 b,
about 1550), mentions the Baker-Boyes crye, as he sat between his
Bread-Panners at the fair, “Buy and beare away; steal and runne
awaye,” &c.]
That all persons who sell Ale or Beer within this Fair or the
precincts of the same Do sell by no other measures than by Gallon,
Pottle, Quart, Pint, and half-pint, sized and sealed according to the
Standard of this University upon pain and penalty of the Statute in
that behalf provided, and that every such Victualler and seller of Ale
and Beer have a sign at his door upon pain of Three Shillings and
four pence.
 That all persons who sell by weights and measures any kinds of
Victuals, Wares, or Merchandize, that their weights and their
measures be sized and sealed, and be in all respects according to
the Standard of this University upon pain of the Statute in that
behalf provided.
That all Vintners do sell good and wholesome wines without
mixing or imposition, and that their wine Pots be sized and sealed
according to the Standard of this University upon pain of three
shillings and four pence for every offence.
That no persons in this Fair Do suffer, keep or maintain any
unlawful gaming in their houses or grounds, upon pain of the
Statute in that behalf provided.
That no person receive into his house or booth any person of ill
life and conversation or suspected of the same, upon pain of
imprisonment and further correction as shall be thought fit by the
Officers of this University.
That no person whatsoever sell or offer to put to sale any kind of
wares upon the Sunday upon pain of imprisonment and further
punishment by law provided: And that no person upon the said day,
especially in the time of service or sermon, receive any persons into
their houses or booths, and there suffer them to remain idle or
drinking upon such pain and penalty as shall be inflicted upon them
by the officers of this University.
If there be any that will sue for any wares, Debts, Injuries or
Trespasses, or think themselves wronged in any of the premises, let
them make complaint to the Chancellor’s Commissary of this
University who will hold and keep Court at the Great Tiled Booth on
— next, the — instant at — o’clock to the intent that Justice may be
administered according to the Charters and Privileges of this
University.
God save the Queen.
[Copied from the book of Formulæ in the University Registry.
 Alfred Rogers,
April 28, 1882.]
1882. The fair still lingers on. Its commercial greatness has long
since passed away—ebbed out of existence by slow degrees,
resulting from many social and other changes, rather than from any
one marked cause. But, as may be expected after six and a half
centuries (at least) of notable existence, it dies hard. Three of its
features still remain. The horse fair, always famous, was this year
greater than for some time past. The onion fair is still associated
with Garlick row, while hurdles, gates, and implements of wood are
still prominent. Thus traditions cling. In “Æsop Dress’d”—a rare
collection of fables by J. Mandeville (4to. 1704, p. 9; should be 33),
there appeared the following:

“An ass of stupid memory

Confes’d, that going to Stourbridge Fair,
His back most brok with wooden ware.”

The old associations are, however, rapidly crumbling away.

The fair is still proclaimed by the mayor at the old time of
commencing; but the fair is not now held until a fortnight later and
only lasts three days. There are points in the Proclamation worthy of
note.
Proclamation of Sturbridge Fair by the Mayor of Cambridge.—
Oyez! Oyez! Oyez! Mr. Mayor doth strictly charge and command all
manner of persons to keep silence whilst the Fair of Sturbridge is
publicly proclaimed. God save the Queen.
Oyez! Oyez! Oyez! Our most Gracious Sovereign Lady Victoria by
the Grace of God of the United Kingdom of Great Britain and Ireland
Queen Defender of the faith by Mr. Mayor of the Borough of
Cambridge Her Majesty’s Lieutenant of the said Borough one of Her
Majesty’s Justices of the Peace for the Borough and County of
Cambridge and chief Governor of this Fair Doth strictly charge and
command that all Merchants and other persons that be repaired or
shall or will repair to this Fair of Sturbridge beginning on the feast of
St. Bartholomew the Apostle (old style) and continuing until the
fourteenth day next after the feast of the exaltation of the Holy
Cross (old style) do keep Her Majesty’s Peace.
That all idle and evil disposed persons within this Fair depart the
same forthwith.
That no Merchant put to sale or offer to sell any wares or
merchandize but in the usual and accustomed places for their
several wares and merchandizes appointed.
That Victuallers Tiplers and other persons buy no goods or
merchandize of any wayfaring man or other person who shall bring
the same to their booths or houses to sell but only of such as shall
be known unto them to be of honest conversation whom they shall
be always able to have forthcoming upon demand.
That all Merchants and other persons within this fair cease from
shewing or selling any wares or merchandizes and from all labour
and travel on the Lord’s day.
And lastly Mr. Mayor giveth to understand that if any Merchant or
other person will sue or complain touching any cause or matter done
and committed within this Fair or the liberties thereof and here
determinable let him repair to the place accustomed and there
according to the law of the land the same cause or matter shall be
heard and determined. God save the Queen.
 CHAPTER XIV.
CONCLUSION.
While the presentation of the preceding details has been essential to
the plan of this work, I desire, by way of appropriate conclusion, to
estimate the influence of the fair upon the development of
commerce in England, and, in some degree, also in Europe. I find a
most comprehensive review of this character from the masterly pen
of Prof. James E. Thorold Rogers, M.A., in his great work, the
“History of Agriculture and Prices in England” (1866, vol. i. pp. 142-
4).
After pointing out that the port of Lynn, with the rivers Ouse, and
Cam, were the means by which water-carriage was made available
for goods—an important point; indeed it may be regarded as certain
that in the middle ages and later, no great fair could be held far
removed from water communication—he proceeds:
The concourse must have been a singular medley. Besides the
people who poured forth from the great towns—from London,
Norwich, Colchester, Oxford, places in the beginning of the
fourteenth century of great comparative importance, and who gave
their names, or, in case certain branches of commerce had been
planted in particular London streets, the names of such streets, to
the rows of booths in the three-weeks’ fair of Stourbridge—there
were, beyond doubt, the representatives of many nations collected
together to this great mart of medieval commerce. The Jew,
expelled from England, had given place to the Lombard exchanger.
The Venetian and Genoese merchant came with his precious stock of
Eastern produce, his Italian silks and velvets, his store of delicate
glass. The Flemish weaver was present with his linens of Liege and
Ghent. The Spaniard came with his stock of iron, the Norwegian with
his tar and pitch. The Gascon vine-grower was ready to trade in the
produce of his vineyard; and, more rarely, the richer growths of
Spain, and, still more rarely, the vintages of Greece were also
supplied. The Hanse towns sent furs and amber, and probably were
the channel by which the precious stones of the East were supplied
through the markets of Moscow and Novgorod. And perhaps by
some of those unknown courses, the history of which is lost, save by
the relics which have occasionally been discovered, the porcelain of
the farthest East might have been seen in some of the booths.
Blakeney, and Colchester, and Lynn, and perhaps Norwich, were
filled with foreign vessels, and busy with the transit of various
produce; and Eastern England grew rich under this confluence of
trade. How keen must have been the interest with which the franklin
and bailiff, the one trading on his own account, the other entrusted
with his master’s produce, witnessed the scene, talked of the
wonderful world about them, and discussed the politics of Europe!
To this great fair came, on the other hand, the woolpacks, which
then formed the riches of England and were the envy of outer
nations. The Cornish tin-mine sent its produce, stamped with the
sign of the rich earl who bought the throne of the German Empire,
or of the warlike prince who had won his spurs at Crecy, and
captured the French king at Poitiers. Thither came also salt from the
springs of Worcestershire, as well as that which had been gathered
under the summer sun from the salterns of the eastern coast. Here,
too, might be found lead from the mines in Derbyshire, and iron,
either raw or manufactured, from the Sussex forges. And besides
these, there were great stores of those kinds of agricultural produce
which, even under the imperfect cultivation of the time, were
gathered in greater security, and therefore in greater plenty, than in
any other part of the world, except Flanders.
To regulate the currency, to secure the country against the loss of
specie, and more harmlessly to prevent the importation of spurious
or debased coin, the officers of the king’s exchange examined into
the mercantile transactions of the foreign traders. To form a ready
remedy against fraud, the mayor sat at his court “of the dusty feet;”
a mixed multitude were engaged in sale or purchase; the nobles
securing such articles of luxury as were offered them, or which law
and custom assigned to their rank—their rich robes of peace, their
armour from Milan, their war horses from Spain. The franklin came
for materials for his farm, and furniture for his house; sometimes
even to buy rams in order to improve the breed of his flock. The
bailiffs of college and monastery were busy in the purchase of
clothing. And on holidays and Sundays, some canon, deputed from
the neighbouring priory, said mass and preached in the booth
assigned for religious worship.
This is certainly a not over-coloured picture of the past of this
once mighty fair. Mr. Cunningham, in his most excellent work, “The
Growth of English Industry and Commerce” (1882, Cambridge
University Press, p. 164), says:—“By far the greater part of the
commerce of this country was carried on at such fairs; and
Sturbridge Fair was one of the most important in the whole
kingdom, rivalling it was said the great fair of Nijni Novgorod, as a
gathering of world-wide fame.” And he adds by way of note:—“In
the eighteenth century it continued to be a most important mart for
all sorts of manufactured goods, as well as for horses, wool, and
hops.”
BARTHOLOMEW FAIR.
 CHAPTER XV.
ORIGIN.
This is I believe the only fair, or certainly the only one of any note,
ever held within the walls of the City of London. Southwark Fair
became vested in the Corporation in the fifteenth century. I do not
propose to write anything more than an outline history of
Bartholomew Fair. Mr. Morley’s most interesting “Memoir of
Bartholomew Fair” (1859) is available to those who desire more
minute details. But as an institution which existed for seven hundred
years, and more or less illustrates the social history of the
metropolis, and in some sort its trading customs, during a
considerable portion of that period, it cannot be passed over lightly. I
shall adopt a chronological mode of illustration as, on the whole,
best suited to the end in view.
Founding the Priory of Bartholomew, a.d. 1102.—In the reign of
Henry I., the Priory, Hospital and Church of St. Bartholomew, in
Smithfield, were founded by one Rahere, a minstrel of the king, and
“a pleasant witted gentleman.” It seems that Rahere was determined
to this pious work in a fit of sickness, during a pilgrimage he made
to Rome agreeably to the fashion of the times, when St.
Bartholomew appeared to him, and required him to undertake the
work and perform it in Smithfield. Before that time Smithfield, or the
greater part of it, was called “the Elms,” because it was covered with
elm trees. FitzStephen says the name of Smithfield is merely a
corruption of “Smooth field,” or plain, which harmonizes with the fact
that the ground was used at an early period for tilting matches or
tournaments, which were provided for the amusement of the
citizens, who then consisted of most of the noble families of the
land, and who daily took their active exercise here. These “jousts” or
entertainments were carried out with great splendour.
 This monk Rahere, the founder of the Priory, &c., has been termed
the king’s jester, or court fool. The Cotton MS. records in its quaint
language and spelling that Rahere “ofte hawnted the Kyng’s palice,
and amo’ge the noysefull presse of that tumultuous courte, enforsed
himself with jolite and carnal suavite: ther yn spectaclis, yn metys,
yn playes, and other courtely mokkys, and trifyllis intrudying, he lede
forth the besynesse of alle the day.” There always existed at the
court in these early times some one employed as story-teller and
companion in the king’s amusements; and it seems not to be
doubted that Rahere occupied this position—turning his
opportunities of patronage to good account (as others occupying a
like office have done) for the benefit of his fellow citizens. His
memory is still perpetuated by the Association of “Rahere Almoners,”
who meet at stated periods in the famed historical precincts of
Smithfield.
Rahere became the first Prior of the monastery he had thus
founded, and seems to have established a fair almost
simultaneously, as was indeed the custom of the age. There appears
to have existed here, even at this early period, a periodical gathering
known as the “King’s Market,” which Mr. Morley considers may have
been held amongst the trees, while the Priory was built upon the
marsh or smooth-field, around which the fair was held. The Prior is
said—either in consequence of his zeal for the monastery, or from
the old associations of his former profession—to have gone annually
into the fair, and exhibited his skill as a juggler: giving the largesses
he so received from the spectators to the treasury of the monastery.
—Frost, p. 9.
Rahere also became Lord of the Fair, and his representative
presided as judge in the Court of Piepowder attached to the fair. This
court was held within the Priory gates. This at all events was the
case down to 1445.
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