Hands on Workshop

Soft tissue deficiencies around teeth and implants are often first noted, because they compromise esthetics. However, soft tissue deficiencies are also associated with progressive periodontal and peri-implant attachment loss. Periodontal plastic surgery has flourished as an approach to address periodontal soft tissue deficiencies that pose esthetic and functional concerns. One of the major objectives of periodontal plastic surgery is to treat gingival recession defects, through an array of classic and novel approaches. This presentation will review the risk factors that influence disease progression and predict therapeutic outcomes. The rationale, scientific evidence and material selection for various therapeutic approaches will be discussed. In particular, Vestibular Incision Subperiosteal Tunnel Access (VISTA) will be introduced as a predictable technique for periodontal and peri-implant soft tissue regeneration.
EDUCATIONAL OBJECTIVES

• Diagnosis: Classification of gingival/mucosal recession of teeth/implants and and relationship to outcome
• Risk Assessment: Patient and site characteristics and risk management

Material Selection:

• Autogenous tissue: Palate vs tuberosity; Epithelialized graft; connective tissue graft
• Allogenic grafts (acellular dermis); Xenograft: form-stable and native grafts
• Platelet Rich Fibrin (PRF)
• Pontic contour augmentation
• Vestibular Incision Subperiosteal Tunnel Access (VISTA) protocol

Simulated workshop and live surgery

• Treatment of gingival recession with VISTA
• Autogenous tissue harvesting: Palate, tuberosity
• PRF preparation & application

Regenerative therapies in preparation for implant installation are quite complex. The performance of a surgical technique, according to proper surgical principles is only one aspect of a diversified cascade. The multi-dimensionality of wound healing requires understanding of the following topics, which will be reviewed in this presentation and applied in the workshop:

• Clinical reality in relation to wound healing disorder and soft tissue regeneration
• Attenuation of atrophy for successful regeneration
• Guided Bone Regeneration: regeneration or augmentation?
• Guided Tissue Regeneration: barrier membrane or functional barrier membrane?
• Understanding of the cellular tissue’s response of biomaterials
• Negative impact of the tissue healing due to foreign body reactions
• Necessity of biologization of biomaterials for successful surgical-based regeneration
• Blood concentrates: Differences and indications
• Development of PRF research and the Low Speed Centrifugation Concept (LSCC)
• Blood sample collection for PRF production
• Clinical indications of PRF
• Complex three-dimensional augmentation with place holders for successful surgery: MODfix and titanium mesh
• Piezo-surgery for accurate surgical cutting of bone

Hands-on Simulated Exercises and live surgery:

• LSCC-PRF: Phlebotomy, PRF- production step by step together with participants
• Biologisation of collagen membranes and bone substitute materials
• Piezo surgery and MODfix for bone cutting tenting during GBR

Live surgery:

• Treatment of gingival recession with VISTA
• Autogenous soft tissue harvesting
• LSCC-PRF preparation & application

Theoretical background

• Is guided bone regeneration a safe therapy and what is known about long-term results?
• New innovative clinical approaches will be demonstrated to solve the problem of hard- and soft tissue volume stability
• Are there reliable off-the-shelf solutions that will bring us to the next level of soft tissue regeneration
• Do we need GBR procedures for small bony defects in the posterior areas?

Hands-on Simulated Exercises:

• L-shape technique: A new surgical technique for simultaneous GBR and Implant placement, using stabilized graft materials
• Handling of the GBR materials
• Stabilizing graft materials
• Handling and management of the soft tissues

Presentation synopsis:
Soft tissue defects around teeth and implant are common. These can be managed by treatment of gingival recession around teeth, as well as improvement of soft tissue quality (keratinized gingiva). A variety of techniques are available for soft tissue augmentation. However, the conventional techniques have a number of limitations including, exposure of graft material due to flap opening, scar formation at recipient sites due to surface incisions and relapse of recession due to muscle pull during healing. This presentation will discuss the various techniques and will introduce a novel, minimally invasive approach, referred to as “vestibular incision subperiosteal tunnel access” (VISTA), together with a method for stabilizing mucosal margins to achieve optimal coronal positioning. The rationale and technique of VISTA will be presented and illustrated with clinical cases.

Presentation objectives:

• Rationale and technique of VISTA for soft tissue augmentation around teeth and implants.
• Application of autogenous tissue, allograft, xenograft and growth factors for soft tissue augmentation.
• Video demonstration of the step-by-step VISTA procedure and suturing with bonded composite for soft tissue augmentation.

Hands-on Simulated Exercises:

• VISTA for soft tissue augmentation around teeth and implants.

This course is designed to make an immediate impact to the bottom line of your practice. The presenters will introduce you to marketing tools that will increase your patient traffic and excel your esthetic case acceptance. We will combine simple yet effective clinical photography techniques that will enhance the new patient experience and have patients wanting your recommendations. Finally, you will discover the ART (additive reductive template) protocol which enables conservative preparation and minimizes chair time while delivering biomimetic ultra-thin Lumineers. Your hands-on experience will include preparation of two 8 unit veneer cases using the minimally invasive techniques you just learned. We will also be making an esthetic 8 unit provisional temporary, using the diagnostic wax up and a clear silicone matrix, that is then converted into your patients provisional nightguard in less than 5 minutes! Lastly, we will explore color modification decisions and the materials available to ensure shade satisfaction with chairside changes.

Course Objectives:

• Understand strategic tooth recontouring through better lab communication for the placement of ultra-thin veneers
• Learn to tackle challenging alignment, asymmetrical arch forms and other complex cases with veneers
• Practice color modification techniques
• Understand how the business of esthetics brings in qualified patients

Hands-on Simulated Exercises:

• Preparation of two 8-unit veneers, using a minimally invasive technique
• Fabrication of esthetic 8-unit provisional
• Shade modification

Workshop:

ABSTRACT
Contemporary clinicians have focused on the osseointegration of their implants together with their survival rates. But when we evaluate implant placement, esthetics becomes crucial to the success of the final restoration. The pursuing of an optimal soft tissue integration, with perfect pink esthetics may represent an obligation, and this is related to the patients’ increasing demand of restorations that are as esthetic as they are functional. The preservation or the creation of an optimal soft tissue contour in order to reproduce the natural architecture of the gingival tissues is always a priority. During this workshop different surgical techniques will be showed, with the use of connective tissue graft as well as with the use of tridimensional collagen matrix, together with the description of a novel volume-stable cross-linked matrix, for soft tissue augmentation. Simultaneously, techniques used to increase the width of keratinized mucosa will be described, both with the use of FGG or substitute biomaterials. But a proper soft tissue management, following the principles of periodontal plastic surgery, is always mandatory.

Augmentation procedures are needed when the pre-existing bone height doesn’t allow for a correct space-related implant insertion, when a proper primary stability cannot be reached or when the prosthetic rehabilitation will provide an unfavorable crown/root ratio. Once hard tissue has been successfully augmented, an adequate soft tissue thickness becomes mandatory in order to create healthy and stable peri-implant tissues and to improve the final esthetic outcome.

Hands-on Simulated Exercises:

• Soft tissue augmentation around teeth and implants on porcine jaws
• Flap design and management
• Material selection: autogenous, allograft, xenograft
• Suture techniques