Root Coverage with the Tunnel Technique: 25 Years’ Experience

Soft tissue grafting has advanced over the past 75 years to become a refined surgical procedure with predictable root coverage, enhanced esthetics, and a more pleasant experience for the patient. Development of effective alternative graft materials has reduced the dependence on the palate for donor tissue and site preparation has become less invasive with the introduction of the tunnel technique.

Although the tunnel technique has become increasingly popular, there are misunderstandings about its use where there is thin mucosa, minimal keratinized tissue, aberrant frenal pull, or shallow vestibular form. This lecture will address these concerns with the tunnel technique.

Learning Objectives:

• Describe the evolution of soft tissue grafting techniques.
• Describe the modifications of tunnel technique in mandibular anterior sites with complications including aberrant frenal attachment, deep recession, shallow recession and shallow vestibule.
• Explain the lack of significance of keratinized tissue gain in bilaminar techniques.

Soft Tissue Grafting with the Tunnel Technique

This interactive limited attendance hands-on course presents detailed information for successful soft tissue grafting with the tunnel technique using current allografts and xenografts. The treatment concepts presented are based on clinical and biological research. Step-by-step illustration of the surgical technique along with hands-on exercises on custom models, provide in-depth knowledge and experience in the use of minimally invasive grafting to achieve predictable coverage of single and multiple recessions, increase in tissue thickness, and extension of the vestibule. An illustrated step-by-step procedural manual is included.

Please bring loupes for the hands-on workshop

The participants will learn:

• Microsurgical instrumentation for the tunnel technique
• Continuous sling suturing technique specifically designed for the tunnel technique
• Evidence-based selection of a grafting tissue

Complex Bone and Soft Tissue regeneration procedures in The Digital Era

In the last decade, the rehabilitation of edentulous patients presenting with relevant or severe bone defects with implant-supported restorations has become routine, although large defects reconstruction /regeneration is still challenging.

Different reconstructive procedures can be applied to regenerate/reconstruct severely atrophic edentulous ridges, such as GBR or autogenous bone block grafts, but, still, some procedures are complex and technique-sensitive.

The development of digital technologies, including customized CAD-CAM devices have played a significant role in simplifying planning and treatment of patients.

Moreover, the management not only of deficient bone, but also of peri-implant soft tissues, demonstrated to play a fundamental role in the medium to long-term outcome of implant-supported prostheses, both from a functional and an aesthetic point of view.

Aim of this lecture is to present the most recent developments of hard and soft tissue regenerative procedures according to the principle of PGR (prosthetically Guided Regeneration), underlying pros and cons of each technique.

LEARNING OBJECTIVES

• How to plan a case presenting with a large defect of the alveolar bone according to the PGR principle (Prosthetically Guided Regeneration)
• How to select the most appropriate technique for the regeneration/reconstruction of hard and soft tissues
• How to take advantage from digital technologies
• How to reduce morbidity and prevent complications following extensive reconstruction of hard and soft tissues

Protected Bone regeneration with Customized Titanium Meshes

LEARNING OBJECTIVES

• How to optimize pre-operative planning of a clinical case in need of reconstruction of an atrophic edentulous ridge with a customized Ti-Meshes
•  How to optimize the combination of autogenous bone chips with bovine bone mineral for guided bone regeneration 
• How to adapt the preformed Ti-Mesh to the defect and how to stabilize it with titanium screws
• How to release mucoperiosteal flaps to obtain a water-tight and tension-free suture (hands-on on animal model (pig);
• How to optimize timing of implant placement and prosthetic loading.

PROGRAM

This workshop offers a unique opportunity to practice both form an animal and plastic model all the surgical steps for optimizing a bone regenerative procedure with a CAD-CAM customized Titanium mesh

INTRODUCTION 

• The initial scenarios and the reconstruction alternatives
• How to plan a case presenting with atrophy of and edentulous alveolar ridge
• The rational of Customized titanium meshes

HANDS- ON ON ANIMAL MODEL – PIG MANDIBLE

• Incision lines and elevation of flaps for ideal approach to the atrophic area
• Bone harvesting with scrapers from the pig mandibular ramus
• Releasing incisions to obtain a tension-free suture after bone augmentation using an alloplastic material
• Suturing techniques

HANDS-ON ON PLASTIC MODELS

• Handling of a customized titanium mesh
• Mixing bone particles taken from the pig mandible with a xenograft
• Fixation of the customized mesh with screws
• Fixation of a resorbable membrane over the mesh 

Peri-implantitis: Challenges and solutions

Peri-implantitis occurs in around 1 in 5 patients restored with implant-supported prostheses. Peri-implantitis is a plaque associated pathologic condition characterised by clinical inflammation of the peri-implant soft tissues (bleeding/suppuration) and progressive bone loss. Peri-implantitis may progress rapidly and is challenging to treat.

In this presentation the key aspects of an accurate diagnosis, control of risk factors and effective treatment will be outlined following a step-wise anti-infective approach. Indications for the choice of surgical approach (resective or reconstructive) when required will be discussed based on implant-, site- and patient-related factors. Protocols to reconstruct peri-implantitis bony defects while minimising soft tissue recession will be outlined providing the evidence for treatment outcomes in the medium to long-term. Patient-reported outcomes following treatment will be discussed, providing an insight into management of patient expectations. The importance of prosthetic, hard and soft tissue management will be highlighted in order to achieve healthy peri-implant tissues, stability and a satisfied patient.

Learning objectives

• Understand the aetiology and diagnosis of peri-implant diseases
• Understand when to choose which treatment approach 
• Understand how best to prevent peri-implantitis and its recurrence

Interproximal Attachment Gain and Papillae

In today’s dentistry the aesthetic demand from the patients has become the main challenge in Periodontology. Besides the obvious functional results is now important to achieve aesthetic success, particularly in the anterior areas, where the expectations of the patients are higher. Understanding the biology of the periodontal wound healing, will lead to respect and protect the healing phase. The New Classification of Periodontal Disease is focused on the interdental Clinical Attachment level. The Aim of Classic Periodontal reconstructive surgical techniques is the regeneration of the infrabony defects or the root coverage in case of gingival recessions. Recently the evolution of the regenerative plastic surgery makes possible to treat simultaneously both. So, the develop of regenerative clinical and biological concepts, biomaterials and new surgical techniques during the last years, makes possible to answer to the patient’s demands and regenerate the interdental attachment of compromised teeth with predictable long-term results.

Interproximal Attachment Gain and Papillae

On the hands-on course would be shown and developed by the participants main periodontal surgical techniques. Paying attention simultaneously to the soft and hard tissues in the treatment of intrabony defect, will maximize the prognostic and aesthetic outcome in the treatment of periodontally compromised natural teeth. The hands on will be with exercise on the use of different techniques and biomaterials in different clinical scenario of missing papillae and interproximal attachment loss.

Vertical Ridge Augmentation: Tradition and new technologies

Localized vertical ridge augmentation with GBR has demonstrated to be a predictable technique in long term studies with more than 30 year follow-up. The use of titanium reinforced PTFE membranes associated with autologous particulated bone grafts and deproteinized bovine bone is the most documented method, however, it is technically sensitive and available only for experienced surgeons. The non-resorbable membrane must be manually trimmed, shaped to fit with the anatomical characteristics of the defect
and fixed with several tacs or screws. New devices are actually available to simplify the surgical technique, like customized semi-permeable titanium meshes that can be manufactured in advance from a tridimensional CBCT image and fixed with only a couple of mini-screws. The traditional and the new techniques will be presented and compared by
means of histological analysis. 

LEARNING OBJECTIVES
Describe the traditional GBR technique by means of e-PTFE membranes associated with autologous particulated bone grafts and deproteinized bovine bone. Consider what is possible to obtain with GBR techniques in advanced cases. Describe the new technique by means of semi-permeable customized titanium meshes associated with autologous particulated bone grafts and deproteinized bovine bone. Describe the histologic characteristics of the bone regenerated with the new titanium meshes technique.

Vertical Ridge Augmentation Surgical Technique

Localized vertical ridge augmentation with GBR has demonstrated to be a predictable technique in long term studies with more than 30 year follow-up. The use of titanium reinforced PTFE membranes associated with autologous particulated bone grafts and deproteinized bovine bone is the most documented method, however, it is technically sensitive and available only for experienced surgeons. The non-resorbable membrane must be manually trimmed, shaped to fit with the anatomical characteristics of the defect
and fixed with several tacs or screws. New devices are actually available to simplify the surgical technique, like customized semi-permeable titanium meshes that can be manufactured in advance from a tridimensional CBCT image and fixed with only a couple of mini-screws. The traditional and the new techniques will be presented and compared by
means of histological analysis. 

LEARNING OBJECTIVES
Describe the traditional GBR technique by means of e-PTFE membranes associated with autologous particulated bone grafts and deproteinized bovine bone. Consider what is possible to obtain with GBR techniques in advanced cases. Describe the new technique by means of semi-permeable customized titanium meshes associated with autologous particulated bone grafts and deproteinized bovine bone. Describe the histologic characteristics of the bone regenerated with the new titanium meshes technique.

Timelessness in Regeneration

New Perspectives on Vertical Augmentation using bone and soft tissue reconstruction

Vertical augmentation presents one of the greatest challenges in implant dentistry.
This is primarily due to the difficulty of the surgical procedure and its potential complications.
The reconstruction of the Extreme Vertical Deficiency of different regions will be one of the key topics of this presentation. The detailed surgical anatomy of the floor of the mouth,
the Modified Lingual Flap as well as the technique for protecting the mental and infraorbital nerves will be presented in details.
New research revealed details of the regenerated ridge that is essential for bone maintenance around implants. The utilization of this knowledge for long term success will be discussed as
well as the Sausage technique TM applied to extremely atrophic ridges.
Selection and use of different growth factors will be discussed in details such as the use of growth factors for simultaneous GBR and periodontal regeneration of denuded interproximal
roots. Research on the Lasagna technique using micro dose of BMP-2 will be also presented.
Peri and inter-implant papilla regeneration around implants using the Iceberg and Garage connective tissue graft techniques will be introduced during this presentation.
The reconstruction of the vestibule and mucogingival junction using the minimally invasive labial Strip Graft Technique will be presented with long-term clinical outcomes.
The CPR of the bone graft will be discussed with the goal of the successful management of complications.

Minimally Invasive Approach on Vertical and Horizontal Augmentation using the Sausage Technique ^TM

Vertical and horizontal augmentation presents one of the greatest challenges of bone regeneration in implant dentistry. This is primarily due to the difficulty of the surgical procedure and its potential complications.

These complications include postsurgical swelling, bruising, and potential neurosensory disturbances. Minimally invasive flap management that can minimize the chances of these complications will be revealed during this hands-on course. Graft harvesting, membrane fixation for vertical augmentation as well as for the Sausage Technique TM will be practiced.

A step by step approach how to protect the neurovascular bundles such as the mental nerve and to achieve a safe, tension free closure will be learned during this practical course.

Learning objectives:

• Understand the surgical anatomy of the floor of the mouth
• Learn the surgical principles of ridge augmentation surgery
• Learn the tension free closure of the flaps after vertical ridge augmentation
• Learn soft tissue reconstructions after ridge augmentation

The Reconstruction of the Peri-implant Papilla using Bone and Soft Tissue Reconstructive Techniques

The reconstruction of the peri implant papilla presents one of the greatest challenges in implant dentistry. Hopeless teeth are often characterized by interproximal clinical attachment loss at the adjacent dentition, which inevitably increases the complexity of implant therapy, especially in the esthetic zone. Without proper management of the hard and soft tissue components after the extraction of hopeless dentition, dental implants often have suboptimal esthetic outcomes. These outcomes can be related to the midfacial level of the peri-implant soft tissue margin alone, or also to the interproximal soft tissue. Implants with deficient papillae and black triangle are common findings. It should be noted that both clinicians’ and patients’ standards for dental implants have significantly increased in the last decade.  Even a small deficiency of a peri-implant papilla in the anterior region can be considered a compromised clinical outcome.

This workshop will focus on ridge augmentation using Guided bone regeneration in difficult clinical scenarios when patients presenting with a lack of the interproximal bony peak.

The utilization of biomaterials, membranes and growth factors such as ABBM, perforated d-PTFE in combination with collagen membranes and PDGF-BB for the  combination of vertical ridge augmentation and interproximal bone reconstruction will be discussed in details.  Subsequent soft tissue augmentation for papilla reconstruction using the Iceberg and Garage connective tissue graft techniques will be introduced. These techniques are also applied to enhance inter implant papilla height after vertical ridge augmentation. Long-term follow-up utilizing these techniques will be presented.

• To learn material selection for combined ridge and interproximal reconstructions
• To learn surgical technique for combined ridge and interproximal reconstructions
• To learn soft tissue reconstructive techniques for peri-implant papilla reconstruction.

Prevention and Management of Complication of Hard Tissue Reconstruction

Guided bone regeneration (GBR) or bone augmentation procedures, integral to routine implant therapy, involve both horizontal and vertical augmentation to facilitate optimal hard tissue reconstruction. Despite their commonality, complications associated with these procedures pose significant challenges for implantologists. This course delves into the essential aspects of preventing and effectively managing complications in these procedures. The presentation addresses the primary etiologies linked to hard tissue reconstruction complications and emphasizes strategies for their avoidance. Additionally, it explores key considerations for implant prosthesis design, crucial for ensuring long-term stability post-horizontal and vertical bone augmentation procedures.

Learning Objectives:

• Understand the primary etiologies associated with complications in hard tissue reconstruction during bone regeneration procedures.
• Acquire knowledge on effective strategies to prevent complications in horizontal and vertical bone augmentation.
• Learn practical approaches for managing complications when they arise during the course of implant therapy.
• Gain insights into the latest advancements and techniques in bone regeneration to optimize patient outcomes and enhance clinical expertise.

EP-DDS approach for Peri-implantitis infraosseous defects regeneration

Implant complications pose a significant challenge for many dentists who placed implants. This hands-on exercise is designed to equip participants with expertise in the innovative "EP-DDS submerged approach" for regenerating peri-implant infraosseous defects. This exercise will help participants to familiarize with "EP-DDS submerged approach" and its intricate techniques, offering valuable insights into addressing implant complications effectively.

Learning Objectives:

• Gain practical experience and confidence in determining how to treat different types of peri-implantitis lesion. 
• Master the EP-DDS protocol for regenerating peri-implant defects, gaining proficiency in a cutting-edge approach to enhance clinical outcomes.
• Familiarize yourself with specialized tools for disinfecting contaminated implant surfaces including implantoplasty, enhancing your ability to manage and resolve complications associated with implant placement.

Beyond the limits of soft tissue management in implant esthetic therapy

Soft tissue management around implants is becoming more and more critical e especially for the esthetic outcome. The possibility to maintain a good buccal soft tissue profile and papilla height is well established in the case of immediate implant placement when the anatomic condition at the tooth that has to extracted are ideal: intact papillae and interdental  bone picks, healthy buccal bone position and thickness and correct position of the gingival margin. What still has not been established is the possibility to improve the buccal and interproximal soft tissue profile in the presence of interdental papilla loss or loss of attachment at the level of the tooth adjacent to that that has to be extracted.

Even more is not well established the possibility to reconstruct peri-implant papilla in the presence of multiple edentulous sites with horizontal and vertical soft and hard tissue
defects

The possibility and limits of soft tissue management to solve these challenging clinical
situations will be shown during the lecture.

Beyond the limits of soft tissue management in implant esthetic therapy

Soft tissue management around implants is becoming more and more critical e especially for the esthetic outcome. The possibility to maintain a good buccal soft tissue profile and papilla height is well established in the case of immediate implant placement when the anatomic condition at the tooth that has to extracted are ideal: intact papillae and interdental  bone picks, healthy buccal bone position and thickness and correct position of the gingival margin. What still has not been established is the possibility to improve the buccal and interproximal soft tissue profile in the presence of interdental papilla loss or loss of attachment at the level of the tooth adjacent to that that has to be extracted.

Even more is not well established the possibility to reconstruct peri-implant papilla in the presence of multiple edentulous sites with horizontal and vertical soft and hard tissue
defects

The possibility and limits of soft tissue management to solve these challenging clinical
situations will be shown during the lecture.