This case is an excellent demonstration of the use of the minimally invasive access flap technique for treatment of (chronic) periodontitis in an esthetically critical zone. The access flap was used in conjunction with enamel matrix proteins for regenerative therapy.,

Overview: - Access and incision: Creation of a vestibular pedicled mucoperiosteal flap via a gingival margin incision while preserving the papilla - Removal of vestibular bone in the region of tooth 46 using a microsurgical instrument - Exposure of the neurovascular bundle - Removal of the foreign body - Re-adaptation of the mucoperiosteal flap - Wound closure with atraumatic suture material Contents: Female patient with an indication for microsurgical foreign body removal (removal of a fractured root canal instrument from a previous endodontic treatment of tooth 46) using a surgical microscope. The foreign body extends from the apex into the mandibular canal.

Procedure: Theoretical Part: - Adult male with a deep and broad intraosseous bone defect located on tooth #13 - The indication for modified papilla preservation in the scope of regenerative therapy was established based on the width of the diastema - Regenerative periodontal therapy with Emdogain and a Bio-Oss® cancellous bone graft - Emdogain is applied to the root surface to stimulate regeneration of periodontal structures - To prevent graft collapse and to minimize the risk of development of too large a recession in this esthetically important region, the defect was filled with Bio-Oss® cancellous bone material Practical Part: - The papilla preservation technique was performed using microsurgical instruments - The root surface area was conditioned with 24% EDTA for ca. 2 minutes - Emdogain was applied to the root surface - The defect was filled with the Emdogain/Bio-Oss® mixture - The wound was closed with two mattress sutures one horizontal mattress suture to secure the graft in place, and a second modified vertical mattress suture to tightly close the papilla - A 5-0 suture was used for the horizontal mattress suture, and a 6-0 monofilament was used for the vertical mattress suture - Postoperative care entailed rinsing the wound twice daily for 4 weeks with 0.2% chlorhexidine and ibuprofen analgesia on the first few days after surgery Contents: The patient's jaw displayed a generalized loss of clinical attachment and alveolar bone. His general history was unremarkable; the patient was a non-smoker. Microbiological tests showed large numbers of Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. The diagnosis was "generalized aggressive periodontitis". After four months of initial therapy consisting of antibiotic combination therapy (amoxicillin + metronidazole), intraoral radiographs showed a deep and wide intraosseous bone defect located mesial and palatal to tooth #13. To preserve this strategically important tooth we opted to perform regenerative therapy with Emdogain and Bio-Oss cancellous bone material. Ten months after regenerative periodontal therapy, the probing depth had decreased by 7 mm, and 5-6 mm of clinical attachment had been gained. At this time, the probing depth was 2-3 mm and intraoral radiographs showed near-complete filling of the osseous defect.

Procedure: - Introduction: History -Taking, Examination, Diagnosis, Etiology, Prognosis for Individual Teeth - Four - Phase Treatment Sequence - Modified Papilla Preservation Technique(MPPT) - Simplified Papilla Preservation Technique (SPPT) - Findings 6 months after Surgery Synopsis The Modified and Simplified Papilla Preservation Techniques for conservation of interproximal papillary tissue were designed to provide access to deep and narrow bony defects to enable regenerative periodontal treatment. The Modified Papilla Preservation Technique (MPPT) was designed to ensure tension-free primary closure via barrier membranes in patients with small interdental spaces. The Simplified Papilla Preservation Technique(SPPT) is used to gain access to narrow interdental spaces ( < 2mm) and to deep defects in the lateral tooth region. Apart from preserving primary wound closure in the interdental space, the two techniques also serve to keep the membrane from collapsing into the bony defect. Both MPPT and SPPT employ special suture techniques to ensure tension-free primary closure of the interdental space. This video clip also serves to demonstrate that the two techniques of interproximal tissue preservation can also be used for periodontal interventions without regenerative measures.

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.

Procedure: - Incisal edge restoration at Tooth 11 - Sketch prior to widening procedure in anterior teeth region - Placement and shaping of matrix band retainer used for tooth widening - Application of composite material and spreading with small Heidemann spatula to establish stable and broad approximal contact - Application of dentin and enamel composite - Shaping and completing; positioning of the lateral edge lines; shaping the interincisal triangle. - Creation of an invisible transition, composite/enamel, with scalpel #15 - Polishing Materials Adhesive: Optibond Fl (Kerr) Composite: Enamel HFO (Micerium) Dentin UD4, UD3,5 and UD3 Enamel GE2 Opalescence OBN Flowable Composite: Tetric Flow A4 (Vivadent) Temporary Composite for shaping of matrix band retainer SystepOnlay (Vivadent)