In this module, Dr. Thomas G. Wilson, Jr., presents a variety of post-operative complications, discusses their prevention as well as treatment. Dr. Wilson’s lessons covers the spectrum from the initial consultation through long-term follow up.

Objectives: Ridge-splitting techniques are used in resorbed ridges. They are difficult to perform and highly technique sensitive. In this case report we present a mini­invasive protocol for a safe and reproducible single-implant rehabilitation in resorbed anterior sites. The rationale for our technique is increasing crest thickness with a controlled bone expansion and achieving optimal aesthetic with a safe and simple protocol. Methods: An 18-year-old patient had a traumatic avulsion of the right central incisor due to maxillofacial trauma. Surgical debridement of the contaminated alveolus and socket preservation using deproteinised bovine bone were performed. An epithelial connective graft was sutured to size to cover the bone graft and promote healing by first intention. A Maryland bridge was used for interim restoration during the healing period, using a woven polyethylene fibre, the lost tooth and a flowable composite to define an ovatic pontic profile (BeautifilTM/®). After 4 months the site was healed. The proximal papillae were maintained and moderate resorption in the buccolingual direction was clinically evident. A mini-invasive partial thickness flap was performed to access the bone crest, with an insertion axis determined using a pilot drill. A series of four ( 1.80mm, 2.15mm, 2.50mm, 3.30mm) hand-screwable bone expanders (BTLockTM/® expanders kit) were inserted to increase peri-implant bone density and crest thickness. Bleeding was induced by scratching site walls with the 2.50-mm expander, and a 3.75-mm wide implant was inserted. A connective graft was inserted to reproduce the iugum alveolare and to improve soft tissue aesthetics. The flap was sutured around a composite custom healing cup, reproducing the transmucous tooth morphology and the Maryland was affixed to the adjacent teeth. After 6 months the implant was functionalised with a provisional screwed restoration. Results: Clinical evaluation of soft tissue healing was positive after 4 months from socket preservation. The combination of bone expansion and connective graft was successful in restoring the buccolingual dimension and achieving a natural aesthetic. The use of bone expanders reduced patient discomfort because no cooling system is needed, and improved implant primary stability through their compacting action on peri-implant bone. An adequate pink aesthetic was achieved by using a continuous tissue-conditioning action of interim restorations with an ovatic pontic profile of the Mariland bridge and a tooth-like custom composite healing cap, and surfaces with properties that minimise plaque adhesion (Surface Pre-Reacted GlassTM/®). Proximal papillae were adequately represented during all treatment phases. Conclusions: Bone condensers should be the object of future studies as their use provides a predictable solution for cases that often come to the attention of general dentists but are difficult to treat (even for experienced surgeons). Because they do not need cooling, they are useful in patients with a pronounced gag reflex. They can be used in the posterior maxillary region to increase bone density around implant sites. In this report, they were used in combination with routine periodontal and prosthodontic procedures to treat a mild transversal crest resorption in a highly aesthetic area.

Procedure Case description: -Class II furcation defect at teeth 46 and 47 and gingival recessions at teeth 43 and 44 - Root planing using PerioSet - Incision technique - Cleaning furcation defect at tooth 46 - Pref Gel application, rinsing and Emdogain application - Insertion of Bio-Oss into the furcation space with an amalgam plugger after hydration - Condensation of the bone replacement material and application of an absorbable membrane (Bio-Gide) - Atraumatic suture closure using 6/0 Seralene Contents: This video demonstration shows the simultaneous treatment of recessions at teeth 43 and 44 and of class II furcation defects at teeth 46 and 47. After a brief case description, root planning is done using PerioSet. Next, an incision is made and the furcation defects are very carefully cleaned using hand instruments and ultrasonic scalers (Soniflex). The cleaned root surfaces and furcation defects are conditioned with Pref Gel (Straumann) for two minutes. The objective of conditioning is to remove the smear layer, to open the dentine tubules, and to enable surface demineralization. Moreover, this measure serves to optimize the contact between Emdogain and the root surface. After two minutes, the EDTA suspension is removed using physiological saline solution or water spray. Immediately afterwards, Emdogain is applied to the blood and saliva-free root surface. This procedure was also used to treat the furcation defect at tooth 47. Regenerative treatment of tooth 46 was performed since that tooth had a very extensive furcation defect. The defect was filled with Bio-Oss, which was applied using an amalgam plugger. Absorbable Bio-Gide was used for coverage of the furcation entrance. Finally, the wound was closed using loop sutures and single interrupted sutures.