Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 2-year results of an RCT using 3D digital measuring for volumetric comparison of gingival dimensions.

AIM: The aim of this randomized clinical trial was to compare clinical and volumetric outcomes of tunnel technique (TUN) with subepithelial connective tissue graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD) 2 years after gingival recession (GR) treatment. MATERIALS AND METHODS: Twenty-three patients contributed 45 Miller class I or II GR. At baseline and follow-up examinations, study models were collected. Their three-dimensional scans allowed precise computer-assisted measurement of recession depth (REC), complete root coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal (aTHK) marginal soft tissue thickness. Clinical examination delivered probing depths (PPD) and height of keratinized tissue. RESULTS: 24 months after surgery, digitally evaluated CRC was present in 60.0% of the TUN + CTG and 0.0% of the CAF + EMD-treated sites (p < .0001), meaning a certain relapse of the gingival margin ragarding both approaches. RC amounted to 94.0% (TUN + CTG) and 57.3% (CAF + EMD), respectively (p < .0001). REC reduction (RECred) was significantly higher for TUN + CTG (1.81 ± 0.56 mm) than for CAF + EMD (0.90 ± 0.45 mm) (p < .0001). pTHK and aTHK values were significantly greater in the TUN + CTG group (1.41 ± 0.35 mm and 1.11 ± 0.26 mm) than in the CAF + EMD group (0.78 ± 0.32 mm and 0.60 ± 0.26 mm) (p < .0001). Statistical analysis detected positive correlations between THK and both RC and RECred (p < .001). CONCLUSIONS: Two years post-operatively, CTG showed better clinical and volumetric outcomes than EMD. Increased THK values were associated with improved outcomes regarding RC and RECred.

Surgery without papilla incision: tunneling flap procedures in plastic periodontal and implant surgery.

Diverse clinical advancements, together with some relevant technical innovations, have led to an increase in popularity of tunneling flap procedures in plastic periodontal and implant surgery in the recent past. This trend is further promoted by the fact that these techniques have lately been introduced to a considerably expanded range of indications. While originally described for the treatment of gingival recession-type defects, tunneling flap procedures may now be applied successfully in a variety of clinical situations in which augmentation of the soft tissues is indicated in the esthetic zone. Potential clinical scenarios include surgical thickening of thin buccal gingiva or peri-implant mucosa, alveolar ridge/socket preservation and implant second-stage surgery, as well as soft-tissue ridge augmentation or pontic site development. In this way, tunneling flap procedures developed from a technique, originally merely intended for surgical root coverage, into a capacious surgical conception in plastic periodontal and implant surgery. The purpose of this article is to provide a comprehensive overview on tunneling flap procedures, to introduce the successive development of the approach along with underlying ideas on surgical wound healing and to present contemporary clinical scenarios in step-by-step photograph-illustrated sequences, which aim to provide clinicians with guidance to help them integrate tunneling flap procedures into their daily clinical routine.

Socket Shield Technique for immediate implant placement - clinical, radiographic and volumetric data after 5 years.

OBJECTIVES: Implant placement immediately after tooth extraction is often accompanied by resorption of surrounding tissues. A clinical technique was developed where the buccal portion of the root is retained to preserve the periodontal ligament and bundle bone. This technique is based on animal studies showing the potential to preserve the facial tissues utilizing this approach. The purpose of this study was to gain more insight regarding the safety of the technique with regard to biological and implant-related long-term complications and to observe the clinical appearance of the peri-implant tissues. Another objective was to evaluate volumetric changes of the affected facial contours in long-term and the esthetic outcomes. MATERIAL AND METHODS: This study is a retrospective case series of 10 consecutive patients with implant replacement between the maxillary first premolars. Impressions were made prior to extraction (t1) and 5 years post-implant placement (t2). 3D-surface scans of the casts were digitally superimposed for quantitative evaluation of alterations of the facial peri-implant tissue contours and soft tissue recessions. Additionally, clinical data were collected (PPD, BOP, peri-apical radiographs and photographs). RESULTS: All implants healed without adverse events. Peri-implant probing revealed healthy conditions. The comparison of radiographic images showed physiologic bone remodeling at the implant shoulders. Mean tissue loss on the facial side in oro-facial direction was -0.21 ± 0.18 mm. Average recession at implants was -0.33 ± 0.23 mm and at neighboring teeth -0.38 ± 0.27 mm. Mean loss of the marginal bone level at the implant shoulder amounted to 0.33 ± 0.43 mm at the mesial and 0.17 ± 0.36 mm at the distal aspect of the implants. A mean pink esthetic score of 12 was recorded. CONCLUSION: Volumetric analysis showed a low degree of contour changes from extraction and implant placement to the follow-ups. Mucosal recession at the implant restoration was comparable to that of the neighboring teeth. Within the limitations of this descriptive study, the socket shield technique offers reduced invasiveness at the time of surgery and high esthetic outcomes with effective preservation of facial tissue contours. This technique should not be used in routine clinical practice until a higher level evidence in the form of prospective clinical trials is available.

The socket-shield technique: first histological, clinical, and volumetrical observations after separation of the buccal tooth segment ­ a pilot study.

BACKGROUND: The "socket-shield technique" has shown its potential in preserving buccal tissues. However, front teeth often have to be extracted due to vertical fractures in buccolingual direction. It has not yet been investigated if the socket-shield technique can only be used with intact roots or also works with a modified shield design referring to vertical fracture lines. PURPOSE: The aim of this study was to assess histologically, clinically, and volumetrically the effect of separating the remaining buccal root segment in two pieces before immediate implant placement. MATERIAL AND METHODS: Three beagle dogs were selected in the study. The third and fourth premolars on both sides of the upper jaw were hemisected and the clinical crown of the distal root was removed. Then, the implant bed preparation was performed into the distal root so that a buccal segment of healthy tooth structure remained. This segment was then separated in a vertical direction into two pieces and implants placed lingual to it. After 4 months of healing, the specimens were processed for histological diagnosis. In a clinical case, the same technique was applied and impressions taken for volumetric evaluation by digital superimposition. RESULTS: The tooth segments showed healthy periodontal ligament on the buccal side. New bone was visible between implant surface and shield as well as inside the vertical drill line. No osteoclastic remodeling of the coronal part of the buccal plate was observed. The clinical volumetric analysis showed a mean loss of 0.88 mm in labial direction with a maximum of 1.67 mm and a minimum of 0.15 mm. CONCLUSION: The applied modification seems not to interfere with implant osseointegration and may still preserve the buccal plate. It may offer a feasible treatment option for vertically fractured teeth.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivative for root coverage: a RCT using 3D digital measuring methods. Part II. Volumetric studies on healing dynamics and gingival dimensions.

AIM: The aim of this randomized clinical trial (RCT) was to compare the clinical performance of the tunnel technique with subepithelial connective tissue graft (TUN) versus a coronally advanced flap with enamel matrix derivative (CAF) in the treatment of gingival recession defects. The use of innovative 3D digital measuring methods allowed to study healing dynamics at connective tissue (CT)-grafted sites and to evaluate the influence of the thickness of the root covering soft tissues on the outcome of surgical root coverage. MATERIAL & METHODS: Twenty-four patients contributed a total of 47 Miller class I or II recessions for scientific evaluation. Precise study models collected at baseline and follow-up examinations were optically scanned and virtually superimposed for digital evaluation of clinical outcome measures including mean marginal soft tissue thickness (THK). Healing dynamics were measured in a defined region of interest at CT-grafted sites where volume differences between time points were calculated. RESULTS: At 12 months, recession reduction as well as mean root coverage were significantly better at CT-grafted sites treated in the TUN group (1.94 mm and 98.4% respectively) compared to the non-augmented sites of the CAF group (1.17 mm and 71.8% respectively) and statistical analysis revealed a positive correlation of THK (1.63 mm TUN versus 0.91 mm CAF, p < 0.0001) to both these variables. Soft tissue healing following surgical root coverage with CT-grafting was mainly accomplished after 6 months, with around two-thirds of the augmented volume being maintained after 12 months. CONCLUSIONS: The TUN resulted in thicker gingiva and better clinical outcomes compared to CAF. Increased gingival thickness was associated with better surgical outcomes in terms of recession reduction and root coverage.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivative for root coverage: a RCT using 3D digital measuring methods. Part I. Clinical and patient-centred outcomes.

AIM: The aim of this randomized clinical trial (RCT) was to introduce 3D digital measuring methods for evaluating the outcomes after surgical root coverage (RC) and to assess the clinical performance of the tunnel technique with subepithelial connective tissue graft (TUN) versus the coronally advanced flap (CAF) with enamel matrix derivative in the treatment of shallow localized gingival recession defects. MATERIAL AND METHODS: Twenty-four patients contributed a total of 47 Miller class I or II recessions for scientific evaluation. Clinical outcomes were evaluated at 6 and 12 months. Precise study models gained at baseline and follow-up examinations were optically scanned and virtually superimposed for digital evaluation of clinical outcome measures including percentage of RC and complete root coverage (CRC). Patient-centred outcomes were evaluated with questionnaires. Final aesthetic outcomes were assessed using the root coverage esthetic score (RES). RESULTS: At 12 months, RC was 98.4% for TUN-treated and 71.8% for CAF-treated defects (p = 0.0004). CRC was observed in 78.6% (TUN) and 21.4% (CAF) of the cases (p = 0.0070). Results for patient-centred outcomes were equivalent for both groups but evaluation of the final aesthetic outcomes using the RES revealed a significant difference (9.06 versus 6.92, p = 0.0034) in favour of TUN. CONCLUSIONS: TUN resulted in significantly better clinical outcomes compared with CAF. The new measuring method provided high accuracy and unforeseen precision in the evaluation of treatment outcomes after surgical RC.

Pre-extractive interradicular implant bed preparation: case presentations of a novel approach to immediate implant placement at multirooted molar sites.

Immediate implant placement at multirooted molar sites involves a series of site-specific anatomical challenges, including implant bed preparation in the presence of interradicular bone septa. The aim of this article is to present and discuss a novel approach that gives improved guidance during implant bed preparation for immediate implants at multirooted extraction sites in both the mandible and maxilla. Following decoronation of the concerned teeth, osteotomies were performed directly through the teeth's initially retained root complexes. After completion of the drilling protocol, the remaining root aspects were extracted, and treatment was continued in the usual manner. With the osteotomy drills stabilized and guided by the retained root aspects, this approach allows for precise positioning and angulation of the implant bed preparation, thus enabling ideal implant positioning during immediate implant placement at multirooted extraction sites.

The socket-shield technique: a proof-of-principle report.

AIM: Clinical studies have suggested that retaining roots of hopeless teeth may avoid tissue alterations after tooth extraction. Therefore, the objective of this proof-of-principle experiment was to histologically assess a partial root retention (socket-shield technique) in combination with immediate implant placement. MATERIAL AND METHODS: In one beagle dog, the third and fourth mandibular pre-molar were hemisected and the buccal fragment of the distal root was retained approximately 1 mm coronal to the buccal bone plate. Following application of enamel matrix derivate, a titanium implant was placed lingual to that tooth fragment either with or without contact to the buccal tooth fragment and a healing abutment was connected. Four months after implant placement, histological evaluation, and backscatter scanning electron microscopy were performed. RESULTS: All four implants were osseointegrated without any histologic inflammatory reaction and the tooth fragment was devoid of any resorptional processes. On the buccal side, the tooth fragment was attached to the buccal bone plate by a physiologic periodontal ligament. On the lingual side of the fragment, newly formed cementum could be detected. In the areas where the implant was placed into the fragment, newly formed cementum was demonstrated directly on the implant surface. CONCLUSIONS: Retaining the buccal aspect of the root during implant placement does not appear to interfere with osseointegration and may be beneficial in preserving the buccal bone plate.

A modified suture technique for plastic periodontal and implant surgery--the double-crossed suture.

To enable uneventful and accelerated healing processes to occur, common techniques in plastic periodontal and implant surgery focus on stable postoperative flap positions. Flap stability is, in particular, positively influenced by an adequate suturing technique, which therefore represents one important factor with regard to the predictability of successful treatment outcomes. The following article illustrates the use of a modified suturing technique, which aims to improve wound adaptation and soft tissue stabilization after surgical treatment with tunneling flap preparation techniques. Anchored at the incisal contact points of the affected teeth, the suture is crossed through the buccal as well as through the palatal aspect. In this manner, the suture maintains the surgically established coronal displacement of the buccal flap and provides a stable and intimate contact to the underlying tissues.