Contents: - Exploration - Incision and Flap Mobilization - Palatal Flap Preservation with Interdental Tissue Preservation - Detoxification and Concrement Removal at 11 - Harvesting of Autogenous Bone Chips from the Spina Nasalis - Conditioning of the Root Surface with EDTA-Gel - Application of Emdogain and Filling of the Bone Defect - Wound Closure Synopsis After Finishing the Initial Treatment for Aggressive Periodontitis, Regenerative Treatment of a Tunnel-Shaped Pocket at Tooth 11 was attempted. Rotation and Crowding of the Buccally Inclined Tooth represented a favorable Etiological Factor. The patient did not wish to receive Orthodontic Treatment to eliminate this Causal Factor after Completion of Primary Treatment. Treatment was therefore limited to the Surgical Regeneration Attempt. The Interdental Space was larger than 3 mm and the Bone Pocket was a mostly Three-Walled Structure, so the Chances of Success were considered to be good. Exploration was first performed to identify the Course of the Defect Margins. Exact knowledge of the Bone Anatomy in all three Planes is essential to successful Incision Planning. A Tunnel-Shaped Defect delimited by Bone in the Region of Tooth 11 with good chances of Periodontal Regeneration was found. A major Challenge of this Procedure is the need to keep the Defect completely covered with Soft Tissue throughout the Healing Process. Cortellini's Papilla Preservation Technique was used for this Purpose. After Incision and Flap Mobilization, it became evident that the Defect only had two Walls in the Coronal Region and that Bone was lacking in the Buccal Region. According to the current Data on Periodontal Regeneration, the Attachment Gain achieved using an Enamel Matrix Protein (Emdogain®) alone can be just as good as that achieved using Emdogain and Bone Graft Material combined. Still, we elected to use a Combination Technique in the Present Case because it provides better Papillary Support. The Graft Material consisted of Autogenous Bone Chips from the Spina Nasalis, which can easily be harvested by Means of the Piezo Technique After gentle Detoxification, the Root Surface was treated with Emdogain. The Defect was then filled with Autogenous Bone Chips and closed by Microsurgical Suture Techniques. Six months after Surgery, Partial Regeneration of the Papilla can be seen.

Objectives: The objective was to simplify the regenerative procedure using a minimally invasive technique. Ridge preservation at the time of the patient’s tooth avulsion was not possible because of acute infection. Surgery was performed using biomaterials during the early post-extractive healing process. The "early build-up technique", as used in healthy patients, was chosen to reduce comorbidity risks in a single high-risk patient.
Methods: A 69-year-old woman had been treated with oral alendronate 70 mg weekly since 2001 because of a vertebral fracture caused by osteoporosis. She had experienced in anamnesis breast neoplasm in 2000 (and recurrence in 2015) and myocardial infarction for which she had a triple bypass in 2007 and angioplasty in 2014. The patient attended the clinic for chronic periodontitis and the tooth 4.7 was extracted because of recurrent periodontal abscesses. Before the extraction, cone beam computed tomography (CBCT) allowed evaluation of cortical wall thickness around the mobile mesial inclined 4.7 from the most significant eight cross sections (CS), and 16-mm mesiodistal bone assessment. The edentulous area 4.6 was partially included in the evaluation. Photographs were taken and periodontal probing performed 2 months after extraction of 4.7. The surgical protocol involved flapless avulsion of the tooth in October 2011 and the flap procedure 2 months later (December 2011). The early alveolar build-up was performed using bovine-derived xenograft and collagen matrix. The surgical design was restricted to keratinised gingiva 4.6–4.7. The intra-alveolar connective tissue of the thick vestibular flap was preserved and rotated on the second layer of the matrix to protect the wound. The exposed surface of the matrix resembled geometrically a post-extract alveolus and flap suture was performed without periosteal-releasing incisions to guide soft tissue proliferation (GGP; guided gingival proliferation).
Results: No complications were reported after surgery. The exposed matrix surface was part of the GGP procedure. As in healthy patients, the exposed biomaterial surface was sealed after 4 weeks. The gain in keratinised gingiva was 2mm. The hard tissue outcome was detected by 16-mm mesiodistal CBCT changes before the extraction and after surgery. Before the extraction, the bone crest width in the distal area 4.7 was 6 mm in two cross-sections and 8–9 mm in three mesial cross sections (area missing 4.6). Near the roots in 4.7 in three central cross-sections, there was only 1 mm of lingual cortical wall with fenestration defects (1 CS) and vestibular bone was largely absent (>50%). The alveolar cavity was partially retentive. After lateral ridge regeneration the bone crest width was 10–12 mm in seven cross-sections, with the greatest linear horizontal bone gain (of 10 mm) in four central cross-sections. The lingual osseous fenestration was healed. Overall the lingual bone plate height in distal area 4.7 was decreased by 1–2 mm (three distal cross-sections), with no differences in central and mesial areas (five sections). The vestibular cortical wall height was 2–5 mm greater in the central and distal area 4.7 (six cross-sections), with no differences in the mesial area (two cross-sections). The vertical distance between bone crest and alveolar nerve level was 8–9 mm in all cross sections, without residual defect area. After 4 years of follow-up the 4.7 site is in a stable condition according to ortopantomography and photographs.
Conclusions: In healthy patients, this surgical augmentation of horizontal alveolar bone and keratinised gingiva is problem-free, and was shown to be the case also in this high-risk patient, in whom implant surgery is contraindicated because of comorbid conditions and uncontrolled periodontitis. In healthy patients, implant insertion is possible 6–12 months after bone augmentation. The choice of the GGP protocol for this alendronate-treated patient was associated with fewer risks than surgery with primary intention healing of the wound. Further clinical trials should be conducted on the GGP protocol, and may show that covering bone substitutes with collagen matrix exposed during the early post-extractive wound healing process is a surgical step instead of a complication of the GBR procedure.