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Soft Tissue Articles
Surgical Veneer Grafting - Compensation for Natural Labial Plate Remodeling After Immediate Implant Placement

Surgical Veneer Grafting - Compensation for Natural Labial Plate Remodeling After Immediate Implant Placement
Contemporary implant therapy aims to provide highly esthetic and predictable treatment outcomes while decreasing treatment duration and complexity. The clinician must therefore be cognizant of circumstances with a predisposition toward esthetic outcomes and treatment plan accordingly. Preservation of the surrounding hard and soft tissues associated with an immediate postextraction socket implant to replace a nonrestorable tooth in the esthetic zone is one of the greatest challenges facing the dental team. A case report of a hopeless maxillary left central incisor in a patient with a thin periodontal phenotype illustrates this new surgical and prosthetic approach. Clinical, radiological, and esthetic parameters were recorded to evaluate primary treatment outcomes.

Author(s): Alessandro Agnini, DMD;Maurice Salama, DMD;Henry Salama, DMD;David Garber, DMD;Andrea Mastrorosa Agnini, DDS
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Antimicrobial Effect of a Single Dose of Amoxicillin on the Oral Microbiota

Antimicrobial Effect of a Single Dose of Amoxicillin on the Oral Microbiota
Amoxicillin is commonly used in oral surgery for antimicrobial prophylaxis against surgical-site infection and bacteremia because of its effect on oral streptococci. The aim of this study was to determine whether amoxicillin reaches the break-point concentrations in saliva and has any effect on the salivary microbiota, colonizing bacteria on mucosal membranes and on the gingival crevice after a single dose of amoxicillin. A single dose given as prophylaxis to prevent a surgical-site infection results in a significant reducing effect on the oral streptococcal microflora in the gingival crevice and may have an impact on bacteria spreading into tissues and the bacteria of streptococci.

Author(s): Cecilia Larsson Wexell, DDS, PhD; Henrik Ryberg, PhD; Wivi-Anne Sjöberg Andersson, DDS; Susanne Blomqvist, BSc; Pieter Colin, PhD; Jan Van Bocxlaer, PhD; Gunnar Dahlén, DDS PhD
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Developing Optimal Peri-Implant Papillae within the Esthetic Zone: Guided Soft Tissue Augmentation

Developing Optimal Peri-Implant Papillae within the Esthetic Zone: Guided Soft Tissue Augmentation
Osseointegrated dental implants have enjoyed long-term success in the rehabilitation of totally edentulous patients. Every aspect of traditional treatment planning protocols continues to be re-evaluated and updated to better incorporate the benefits of osseointegration into clinical practice. This is particularly evident as dentistry has committed to fully integrating this approach into the more varied and demanding environment of the partially edentulous patient. Along with the many benefits of added predictability and enhanced options, the ever-evolving role of osseointegrated implants in the treatment pf the partially edentulous jaw has also created new challenged. Unlike the fully edentulous individual who maintains the implant-restorative interface beyond the lip perimeter, many partially edentulous patients undergo the transition within the esthetic zone.

Author(s): Henry Salama, DMD;Maurice Salama, DMD;David Garber, DMD;Pinhas Adar, MDT, CDT
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The Socket-Shield Technique to Support the Buccofacial Tissues at Immediate Implant Placement

The Socket-Shield Technique to Support the Buccofacial Tissues at Immediate Implant Placement
Tooth loss and subsequent ridge collapse continue to burden restorative implant treatment. Careful management of the post-extraction tissues is needed to preserve the alveolar ridge. In-lieu of surgical augmentation to correct a ridge defect, the socket-shield technique offers a promising solution. As the root submergence technique retains the periodontal attachment and maintains the alveolar ridge for pontic site development, this case report demonstrates the hypothesis that retention of a prepared tooth root section as a socket-shield prevents the recession of tissues buccofacial to an immediately placed implant. The socket-shield technique is a highly promising addition to clinical implant dentistry and this case report is among the first to demonstrate the procedure in clinical practice with a 1-year follow up.

Author(s): Howard Gluckman, BDS, MChD;Maurice Salama, DMD;Jonathan Du Toit, BChD
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The Management of Recession Midfacial to Immediately Placed Implants in the Aesthetic Zone

The Management of Recession Midfacial to Immediately Placed Implants in the Aesthetic Zone
Immediate placement and loading protocols are the most technique sensitive and at the highest risk of complication, especially in the aesthetic zone. The peri-implant tissues undergo a resorption pattern that may see exposure of parts supporting the restoration, otherwise intended to be submerged, with extreme aesthetic compromise or even complete failure of treatment. The literature is not definitive in terms of any one treatment modality to recover such a complication. Grafting the exposure by a guided bone regeneration technique and an adjunct soft tissue augmentation could well restore an unaesthetic recession exposure. Recovery of midfacial recession by soft tissue augmentation alone may be successful, as is presented hereafter.

Author(s): Howard Gluckman, BDS, MChD;Jonathan Du Toit
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A Novel Approach to Root Coverage: The Pinhole Surgical Technique

A Novel Approach to Root Coverage: The Pinhole Surgical Technique
Free connective tissue graft techniques are currently considered the most predictable surgical method for root coverage. However, morbidity associated with secondary graft sites has generated interest in other methods. The purpose of this study was to investigate the feasability of a novel surgical approach to root coverage: the pinhole surgical technique (PST). The retrospective study examined the results of PST used for 43 consecutive patients on 121 recession sites, of which 85 were Class I or II and 36 were Class III. The documented results indicate that PST holds promise as a minimally invasive, predictable, effective, and time and cost-effective method for obtaining optimal patient-based outcomes.

Author(s): John C. Chao, DDS
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Enhancing Esthetics with a Fixed Prosthesis Utilizing an Innovative Pontic Design and Periodontal Plastic Surgery

Enhancing Esthetics with a Fixed Prosthesis Utilizing an Innovative Pontic Design and Periodontal Plastic Surgery
During the past two decades, significant advancements with the integration of periodontal plastic surgery into esthetic restorative dental procedures have received increased attention. While ovate pontics have traditionally been used as a restorative design following augmentation procedures to enhance esthetics, an alternate E-pontic design aims to predictably support and maintain the gingival architecture between a single missing anterior tooth adjacent to a natural tooth or an implant that is in harmony with the lip line and face. In addition, the E-pontic design promotes the gingival facial tissue to coronally migrate over the pontic, creating a gingival sulcus. This article describes an innovative new technique and a pontic design that predictably will develop, support, and maintain the gingival architecture to provide a long-term esthetic and functional outcome.

Author(s): Robert P. Korman, DDS, MAGD
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10 Tips About Aesthetic Implantology That Will Help You in Your Daily Practice

10 Tips About Aesthetic Implantology That Will Help You in Your Daily Practice
For these reasons there are some golden rules that every implantologist should manage in order to achieve predictable results on the aesthetic zone and in this article there will be described ten rules that everyone should consider:

Author(s): Dr. Francisco Teixera Barbosa
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Biologic Width Adjacent to Loaded Implant with Machined and Rough Collars in the Dog

Biologic Width Adjacent to Loaded Implant with Machined and Rough Collars in the Dog
Dental implant surface technology has evolved from a relatively smooth machined implant surface for osseointegration to more roughened osteoconductive surfaces. Recent studies suggest that peri-implant soft tissue inflammation with progressive bone loss (ie peri-implantitis) is becoming a prevalent condition. One possibility that could explain sucha a finding is that more bacterial plaque forms on the roughened implant and abutment surfaces, which may result in the peri-implant inflammation if the soft tissues. This study compared 36 tissue-level implants with a machined transmucosal collar to 36 implants with a relatively roughened transmucosal surface in the dog. The results demonstrated that the connective tissue contact was similar between the two implant types but that the junctional epithelium and biologic width dimensions were greater around the implants with the machined collars...

Author(s): David L. Cochran, DDS, PhD; Marcel Obrecht, SDIS; Klaus Weber, PhD, MDV, MS; Michel Dard, DDS, PhD; Dieter Bosshardt, PhD; Frank L. Higginbottom, DDS; Thomas G. Wilson Jr., DDS; Archie A. Jones, DDS
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Oral Soft Tissue Laser Ablative and Coagulative Efficiencies Spectra

Oral Soft Tissue Laser Ablative and Coagulative Efficiencies Spectra
The key to the success of soft tissue lasers is their ability to cut and coagulate the soft tissue at the same time. Present work is aimed to derive the wavelength-dependent differences in photo-thermal ablation and coagulation efficiencies for oral soft tissue pulsed dental Near-IR Diode, Mid-IR Erbium and IR CO2 lasers. Even though the soft tissue photothermal ablation has been extensively studied, there remains a discrepancy between (a) the widely proliferated notion about efficient Near-IR 800-1,100 nm laser ablation of the oral soft tissue, and (b) studies reporting the inefficient soft tissue Near-IR absorption/ablation. Indeed, the notions about “the key to the usefulness of the Nd:YAG is that this wavelength is highly absorbed in oral soft tissue”, and “all currently available dental laser instruments and their emission wavelengths have indications for use for incising, excising... oral soft tissue surgery”, contradict an observation illustrated here...

Author(s): Peter Vitruk, PhD
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The Management of Immediate Implant Placement to Optimize Aesthetic Outcome in the Anterior Maxilla

The Management of Immediate Implant Placement to Optimize Aesthetic Outcome in the Anterior Maxilla
Following tooth extraction the implant surgeon may select between various implant placement timing and loading protocols. Ideally these are to be determined prior to extraction, be it immediate, early, or late placement. Immediate implant placement even in the aesthetic zone is a literature supported treatment modality with success comparable to alternative placement protocols. Meticulous restorative treatment planning of a tooth destined for extraction is essential. Selecting the appropriate implant and techniques may preserve and ensure natural aesthetics. Utilizing the patient’s own tooth crown can better provisionalize the implant with a ‘walk out as you walk in’ result.

Author(s): Howard Gluckman, BDS, MChD;Jonathan Du Toit
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Soft Tissue Stability with Immediate Implants and Concave Abutments

Soft Tissue Stability with Immediate Implants and Concave Abutments
The aim on the present retrospective study was to observe the dimensional alterations of the peri-implant tissues after immediate implants and single tooth restorations with concave abutments performed on 28 patients, with a mean follow-up time on 20.4 months.

Author(s): Marco Redemagni, MD, DDS; Sergio Cremonesi, DDS; Guiliano Garlini, DDS; Carlo Maiorana, MD, DDS
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Changes in Soft Tissue Dimensions Following Three Different Techniques of Stage-Two Surgery: A Case Series Report

Changes in Soft Tissue Dimensions Following Three Different Techniques of Stage-Two Surgery: A Case Series Report
The aim of this case report is to compare the resilts of the increase in keratinized mucosa using three different techniques of stage-two surgery. Thirty-two patients with one to eight dental implants who received prosthetic rehabilitation of the maxilla were included. Patients were divided into three groups based on preoperative anatomical considerations. Stage-two surgery was performed using wither the apically repositioned flap, the roll flap, or an apically repositioned flap combined with a connective tissue graft.

Author(s): Jochen Tunkel, DMD; Luca de Stavola, DMD; Fouad Khoury, Prof Dr med dent
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Two Immediate Temporization Methods Exemplified: Flap vs. Punch Technique in Implant Surgery

Two Immediate Temporization Methods Exemplified: Flap vs. Punch Technique in Implant Surgery
Protocols and techniques for immediate tooth replacement in the esthetic zone have become more popular and predictable within the past decade. Two different clinical scenarios are presented where immediate temporization of implants placed into healed or augmented ridges is exemplified. The benefits of augmentation prior to implant placement and temporization are that flap elevation is not required; therefore, the blood supply to the labial plate is not compromised, thereby eliminating potential midfacial recession. In addition, the soft tissue subgingival shape of the temporary crown can be non-surgically sculpted at the time of implant placement since the patient is already anesthetized.

Author(s): Stephen J. Chu, DMD, MSD, CDT;Dennis P. Tarnow, DDS
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Acellular Dermal Matrix Grafts for Root Coverage Procedures: Review of Products and Introduction of a New Technique

Acellular Dermal Matrix Grafts for Root Coverage Procedures: Review of Products and Introduction of a New Technique
Gingival recession remains a significant problem in dental esthetics as well as periodontal health. Adequate zones of keratinized, attached tissue are vital for long-term periodontal health and maintenance. The correction of gingival recession is an important principle in cosmetic dental procedures that requires a harmonious gingival complex. Correction of deficient gingival tissues by either autogenous or allogenic tissue grafts has been well documented in the literature. This article will delineate differences among the various acellular dermal grafts as well as introduce a new technique that can enhance success.

Author(s): Paul S. Petrungaro, DDS;Jennifer T. Silc, DDS, MS
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Soft Tissue Cone-Beam Computed Tomography: A Novel Method for the Measurement of Gingival Tissue and the Dimensions of the Dentogingival Unit

Soft Tissue Cone-Beam Computed Tomography: A Novel Method for the Measurement of Gingival Tissue and the Dimensions of the Dentogingival Unit
The purpose of the present study was to develop a soft tissue cone-beam computed tomography (ST-CBCT) to improve soft tissue image quality and allow the determination of the dimensions and relationships of the structures of the dentogingival unit. Two separate CBCT scans were obtained from three patients with different periodontal biotypes. The first was a scan following standard methods; however, for the ST-CBCT the patients wore a plastic lip retractor and retracted their tongues toward the floor of their mouths.

Author(s): ALESSANDRO LOURENÇO JANUÁRIO, DDS, MS, PhD; MAURÍCIO BARRIVIERA, DDS, MS; WAGNER RODRIGUES DUARTE, DDS, PhD
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Esthetic Correction of Gingival Recession Using a Modified Tunnel Technique and an Acellular Dermal Connective Tissue Allograft

Esthetic Correction of Gingival Recession Using a Modified Tunnel Technique and an Acellular Dermal Connective Tissue Allograft
Esthetic correction of gingival recession is an important goal of periodontal therapy. This article describes a surgical technique that combines a modified tunnel technique and an acellular dermal connective tissue allograft. With the aid of vertical incisions, a tunnel is created under the buccal mucosa of the affected tooth. These incisions enable easy access for graft placement and create mobility for gingival coronal positioning. The use of an accelular dermal connective tissue allograft eliminates the need for a surgical palatal donor site. This minimizes post-surgical complications.

Author(s): Douglas H. Mahn, DDS
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Mucosal Coronally Positioned Flap for the Management of Excessive Gingival Display in the Presence of Hypermobility of the Upper Lip and Vertical Maxillary Excess: A Case Report

Mucosal Coronally Positioned Flap for the Management of Excessive Gingival Display in the Presence of Hypermobility of the Upper Lip and Vertical Maxillary Excess: A Case Report
Excessive gingival display is a frequent finding that can occur because of various intraoral or extraoral etiologies. This report describes the use of a mucosal coronally positioned flap for the management of a gummy smile associated with vertical maxillary excess and hypermobility of the upper lip. For patients desiring a less invasive alternative to orthognathic surgery, the mucosal coronally positioned flap is a viable alternative. We demonstrate short-term successful use of this technique for the management of excessive gingival display in the presence of slight vertical maxillary excess and hypermobility of the upper lip. Long-term follow-up studies are needed to determine stability of the results.

Author(s): Monish Bhola, DDS, MSD;Nomahn Humayun; Shilpa Kolhatkar; Jason Souiyas
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Influence of Thin Mucosal Tissues on Crestal Bone Stability Around Implants With Platform Switching: A 1-year Pilot Study

Influence of Thin Mucosal Tissues on Crestal Bone Stability Around Implants With Platform Switching: A 1-year Pilot Study
The aim of this pilot study was to determine what effect thin mucosal tissues can have on crestal bone stability around implants with platform switching. Within the limitations of this pilot study it can be concluded that implants with platform switching did not preserve crestal bone better in comparison with implants with traditional implant-abutment connection if, at the time of implant placement, thin mucosal tissues were present.

Author(s): Tomas Linkevicius, DDS, Dip Pros, PhD;Peteris Apse, Prof, DDS, Dip Pros, MSc (Toronto); Dr hab Med (Latvia); Simonas Grybauskas, DDS, MOS, RCSEd, PhD; Algirdas Puisys, DDS
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Soft Tissue Enhancement After Implant Placement

Soft Tissue Enhancement After Implant Placement
Soft tissue management is one of the key factors for successful implant restoration. Esthetics can be strongly influenced by the conditions of the peri-implant tissue. Substantial knowledge of tissue anatomy and biology is a fundamental prerequisite for surgical success. The present chapter introduces different techniques to improve the appearance of the soft tissue after implant placement. Cases of repositioned flaps, FGGs, and CTGs are presented along with biological considerations. It was our intention to present various indications and options to the clinician to achieve an increased amount of peri-implant KG or connective tissue thickness.

Author(s): Christian F.J. Stappert, DDS, MS, PhD, Priv-Doz;Davide Romeo, DDS, PhD
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Peri-implant Soft Tissue Conditioning with Provisional Restorations in the Esthetic Zone: The Dynamic Compression Technique

Peri-implant Soft Tissue Conditioning with Provisional Restorations in the Esthetic Zone: The Dynamic Compression Technique
An optimal esthetic implant restoration is a combination of a visually pleasing prosthesis and surrounding peri-implant soft tissue architecture. This article introduces a clinical method, the dynamic compression technique, of conditioning soft tissues around bone-level implants with provisional restorations in the esthetic zone. The technique has several goals: to establish an adequate emergence profile; to recreate a balanced mucosa course and level in harmony with the gingiva of the adjacent teeth, including papilla height/width, localization of the mucosal zenith and the tissue profile's triangular shape; as well as to establish an accurate proximal contact area with the adjacent tooth/implant crown.

Author(s): Julia-Gabriela Wittneben, DMD, MMSc; Daniel Buser, DMD; Urs C. Belser, DMD; Urs Bragger, DMD
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The Use of PerioDerm for Root Coverage and Correction of Insufficiently Attached Gingiva

The Use of PerioDerm for Root Coverage and Correction of Insufficiently Attached Gingiva
The objective of this article is to demonstrate the benefits of an acellular dermal matrix called PerioDerm™ Acellular Dermis in correcting recession and adding connective tissue during periodontal-restorative comprehensive treatment. 1,2 It has long been established that connective tissue is an integral factor in the protection of the underlying periodontal foundation. Connective tissue tends to be tenacious in makeup and have far less vascularization than mucosa. It prevents bacterial infiltration to the underlying supportive periodontal tissues, and in restorative applications, it adds stability to gingival areas during impression taking and cementation of restorations. Though the quality of tissue is critical, it is also important that the tissue is bound down to either tooth surface or bone to serve as a supportive mechanism for protection of the periodontium.

Author(s): Daniel J Melker, DDS
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Soft Tissue Waxup and Mock-Up as Key Factors in a Treatment Plan: Case Presentation

Soft Tissue Waxup and Mock-Up as Key Factors in a Treatment Plan: Case Presentation
Rehabilitation of edentulous spaces in esthetic areas is a challenge to the clinician due to the loss of soft tissues. In these clinical situations, it would be desirable to evaluate and predict the gingival architecture to recover in the oral rehabilitation. To fulfill this need, the diagnostic was should anticipate the final rehabilitation with the integration of hard and soft tissue.

Author(s): Pedro Couto Viana, DMD; Andre Correia, DMD, PhD; Manuel Neves, DMD; Zsolt Kovacs, CDT; Rudiger Neugbauer, CDT
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Maintaining Interimplant Crestal Bone Height Via a Combined Platform-Switched, Laser-Lok Implant/Abutment System: A Proof-of-Principle Canine Study

Maintaining Interimplant Crestal Bone Height Via a Combined Platform-Switched, Laser-Lok Implant/Abutment System: A Proof-of-Principle Canine Study
Interimplant papillae are critical for achieving esthetic implant-supported restorations in the maxillary esthetic zone. Stable papillary anatomy, however, depends upon a stable volume underlying crestal bone for support. Multiple studies have documented a critical interimplant distance of 3mm under which crestal bone resorption occurs. This preclinical proof-of-principle canine study examines a novel implant-abutment system design, combining platform switching with precisely configured laser-ablated abutment and implant microgrooves to maintain interimplant crestal bone at interimplant distances of 2 and 4 mm. Results of this initial preclinical study suggest that it is possible through precise implant/abutment design modifications to place adjacent implants at distance of 2 to 4 mm without inducing subpapillary crestal bone loss.

Author(s): Myron Nevins, DDS;Marc Nevins, DMD, MMSc; Luca Gobbato, DDS, MS; Hyo-Jung Lee, DDS, PhD; Chin-Wei Wang, DDS; David M. Kim, DDS, DMSc
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Maxillary Anterior Papilla Display During Smiling: A Clinical Study of the Interdental Smile Line

Maxillary Anterior Papilla Display During Smiling: A Clinical Study of the Interdental Smile Line
The purpose of this research was to quantify the presence or absence of interdental papillae during maximum smiling in a patient population aged 10 to 89 years. The visual display of interdental papillae during maximum smiling occurred 380 of the 420 patients examined in this study, equivalent to a 91% occurrence rate. Eighty seven percent of all patients categorized as having a low gingival smile line were found to display the interdental papillae upon smiling. Differences were noted for individual age groups according to the decade of life as well as a trend toward decreasing papillary display with increasing age. The importance of interdental papillae display during dynamic smiling should not be left undiagnosed since it is visible in over 91% of older patients and in 87% of patients with a low gingival smile line, representing a common and important esthetic element that needs to be assessed during smile analysis of the patient.

Author(s): Stephen J. Chu, DMD, MSD, CDT;Dennis P. Tarnow, DDS;Mark N. Hochman, DDS
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Labial Bone Thickness in Area of Anterior Maxillary Implants Associated with Crestal Labial Soft Tissue Thickness

Labial Bone Thickness in Area of Anterior Maxillary Implants Associated with Crestal Labial Soft Tissue Thickness
Soft tissue problems (ie, gingival recessions) are common in implantology and are often associated with thin soft tissue biotypes or buccally placed implants. Goaslind described 2 types of biotypes commonly found in the natural dentition: thick and thin. It has been suggested that thicker soft tissue biotypes are associated with less tissue recession, higher crestal bone levels, and better aesthetics. A thin tissue biotype has been shown to be more prone to tissue recession. Gingival recession is always associated with alveolar bone dehiscences. Furthermore, there is evidence that thick soft tissue may be protective against crestal bone loss (ie, tissue thickness of ,2.5 mm resulted in crestal bone loss of 1.45 mm vs. thicker tissues had 0.26 mm). This protective effect occurred, despite the supracrestal position of the implant-abutment interface.

Author(s): Bach Le, DDS, MD, FICD;Ali Borzabadi-Farahani, DDS, MScD, MOrth RCS
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Advantages of the Root Submergence Technique for Pontic Site Development in Esthetic Implant Therapy

Advantages of the Root Submergence Technique for Pontic Site Development in Esthetic Implant Therapy
This article suggests a strategy to provide a more predictable protocol for esthetic implant treatment for multiple- tooth defects using the root submergence technique (RST). The RST maintains the natural attachment apparatus of the tooth in the pontic site, which in turn allows for complete preservation of the alveolar bone frame and assists in the creation of an esthetic result in adjacent multipletooth- replacement cases.

Author(s): Maurice Salama, DMD;Henry Salama, DMD;Akiyoshi Funato, D.D.S.;Tomohiro Ishikawa, DDS;David Garber, DMD
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A Decision Tree for Soft Tissue Grafting

A Decision Tree for Soft Tissue Grafting
The decision tree proposed serves as a guide for clinicians to select the most appropriate and predictable soft tissue grafting procedure to minimize unnecessary mistakes while providing the ultimate desired treatment outcome.

Author(s): Hom-Lay Wang, DDS, MSD, PhD;Daylene Jack-Min Leong, BDS
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Subpapillary Continuous Sling Suturing Method for Soft Tissue Grafting with the Tunneling Technique

Subpapillary Continuous Sling Suturing Method for Soft Tissue Grafting with the Tunneling Technique
This paper describes a new suturing method, the subpapillary continuous sling suture, for use with soft tissue grafts in tunnel procedures to treat gingival recession.

Author(s): Edward P. Allen, DDS, PhD.
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Clinical Realities - Maximizing Aesthetics and Health Using a Closed-Flap ER: YSGG Laser Technique

Clinical Realities - Maximizing Aesthetics and Health Using a Closed-Flap ER: YSGG Laser Technique
Dental lasers have evolved considerably as an adjunct and alternative treatment to safely, conservatively, and reliably decrease bacterial levels and improve the hard and soft tissue contours. In selected cases, long-term aesthetic and functional parameters are satisfied with precise restorative planning and technique and by utilizing minimally invasive procedures. Furthermore, patients are provided with optimal results more comfortably and efficiently.

Author(s): Hugh Flax, DDS, PC
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Use of the Natural Tooth for Soft Tissue Development - A Case Series

Use of the Natural Tooth for Soft Tissue Development - A Case Series
esults from this study showed that all patients achieved a normal or Class 1 papilla appearance similar to the original appearance of the natural tooth.

Author(s): Marius Steigmann, DDS;Hom-Lay Wang, DDS, MSD, PhD;Jason Cooke, DDS
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Lip Repositioning for Reduction of Excessive Gingival Display: A Clinical Report

Lip Repositioning for Reduction of Excessive Gingival Display: A Clinical Report
This case report demonstrates the successful management of excessive gingival display with a lip-repositioning procedure.

Author(s): Ari Rosenblatt, DMD, DDS; Ziv Simon, DMD, MSc
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Healing of Gingival Recessions Using a Collagen Membrane with a Demineralized Xenograft

Healing of Gingival Recessions Using a Collagen Membrane with a Demineralized Xenograft
A Randomized Controlled Clinical Trial

Author(s): Daniele Cardaropoli, DDS
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Use of PRGF to Accelerate Bone and Soft Tissue Regeneration in Postextraction Sites

Use of PRGF to Accelerate Bone and Soft Tissue Regeneration in Postextraction Sites
Evealuation of regenerated bone density.

Author(s): Eduardo Anitua, MD, DDS, PhD;Gorka Orive, MD, DDS; Isabel Andia, PhD
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Use of the Natural Tooth for Soft Tissue Development: A Case Series

Use of the Natural Tooth for Soft Tissue Development: A Case Series
The achievement of optimal esthetics around anterior dental implants has been a major challenge for many clinicians. The key to an esthetically pleasing appearance lies in the clinician’s ability to properly manage the soft tissue profile around dental implants. Hence, the purpose of this case report is to describe a new technique that uses the patient’s own natural tooth for the provisional implant restoration to develop soft tissue architecture that is almost identical to the patient’s original immediately…

Author(s): Marius Steigmann, DDS;Hom-Lay Wang, DDS, MSD, PhD;Jason Cooke, DDS
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The Tunnel Technique in the Periodontal Plastic Treatment of Multiple Adjacent Gingival Recession Defects

The Tunnel Technique in the Periodontal Plastic Treatment of Multiple Adjacent Gingival Recession Defects
“Originally published in Inside Dentistry, 2008. Copyright 2008. AEGIS Communications. Reprinted with permission.”

Author(s): David Garber, DMD;Maurice Salama, DMD;Henry Salama, DMD
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Bipolar Electrosurgery: Gingival Modification in Passive Eruption

Bipolar Electrosurgery: Gingival Modification in Passive Eruption
Excessive gingival display can affect the total aesthetics of a smile, becoming its focus instead of its frame. This can be the result of passive eruption of the gingival complex as the teeth erupt. The condition of delayed or altered passive eruption exists when the gingival complex remains coronal to the cementoenamel junction (CEJ), with the attachment on the enamel instead of the cementum of the root, giving the appearance of short clinical crowns. Crown lengthening is critical to the success…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Gregori M. Kurtzman, DDS
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Connective Tissue & Bone Graft for Anterior Immediate Implant Placement

Connective Tissue & Bone Graft for Anterior Immediate Implant Placement
Immediate implant placement in a one-stage approach, with or without provisionalization, has proven to be advantageous in preserving gingival anatomy around dental implants. But placing implants immediately in the changing alveolar bone of an extraction socket can result in progressive recession of the gingival labial margin over the implant restoration. Thicker biotypes and bone of the labial periimplant tissue have been shown to promote long-term stable gingival margins. A surgically simple technique…

Author(s): Thomas J. Han, DDS
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Bipolar Soft Tissue Management & Functional Mock-Ups

Bipolar Soft Tissue Management & Functional Mock-Ups
Patients desiring a cosmetic smile improvement can present challenges to the dentist when treatment planning. An excessive display of gingiva due to a high lip line often complicates treatment planning and can compromise the final esthetic result when proper planning is not considered prior to finalizing the case. We often have to ask ourselves as we evaluate the patient, do we “lower the river” (increase tooth length incisally), “raise the bridge” (increase tooth length gingivally) or a combination…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Gregori M. Kurtzman, DDS
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Soft Tissue Management and Functional Mock-Ups

Soft Tissue Management and Functional Mock-Ups
Patients desiring a cosmetic smile improvement can present treatment planning challenges. An excessive display of gingiva resulting from a high lip line often complicates treatment planning and can compromise the final esthetic result. As we evaluate the patient, we often have to ask ourselves, do we “lower the river” (increase tooth length incisally), “raise the bridge” (increase tooth length gingivally) or use a combination of both approaches? This article addresses this issue using a methodological…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Gregori M. Kurtzman, DDS
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Predictable Gingival Correction of Passive Eruption

Predictable Gingival Correction of Passive Eruption
While the need to maintain a dry operative field has traditionally caused complications during various soft tissue surgical procedures, the use of bipolar electrosurgical techniques can eliminate the need to maintain a dry field, thus increasing the clinician’s ability to deliver predictable, long-term results. This case presentation describes how to determine the presence of passive eruption, treatment plan its correction, and surgically alter the gingiva to provide a more aesthetic smile. This…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Gregori Kurtzman, DDS
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Laser Assisted Crown Lengthening

Laser Assisted Crown Lengthening
Clinical scenarios where crown lengthening procedures are indicated within the esthetic zone require special consideration to achieve predictable restorative results. Whether they are performed for the purposes of exposing sound tooth structure, or to enhance the appearance of the definitive restorations, these procedures must be planned to satisfy biologic requirements, while simultaneously avoiding deleterious esthetic effects. The implementation of diagnostic criteria, along with evidence-based…

Author(s): Ernesto A. Lee, DMD
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Achieving Predictable Connective Tissue Root Coverage

Achieving Predictable Connective Tissue Root Coverage
Gingival recession creates esthetic issues. These issues may be corrected from a restorative perspective by the placement of composite resin or ceramic over the exposed root. But this approach often results in a gingival-incisal length that does not blend esthetically with the adjacent teeth. Often accompanying the gingival recession is a decrease in the band of attached gingiva. The wider the band of attached gingiva, the more stable the long-term result. Therefore, surgical correction of the recession…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Gregori M. Kurtzman, DDS, David Kurtzman, DDS, Peter C. Shatz, DDS
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Achieving Predictable Connective Tissue Root Coverage

Achieving Predictable Connective Tissue Root Coverage
Gingival recession creates esthetic issues. These issues may be corrected from a restomtive perspective by the placement of composite resin or ceramic over the exposed root. But this approach often results in a gingival-incisal length that does not blend esthetically with tire adjacent teeth. Often accompanying the gingival recession is a decrease in the band of attached gingiva. The wider the band of attached gingiva, the more stabIe the long-term result Therefore, surgical correction of the recession…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Gregori M. Kurtzman, DDS, David Kurtzman, DDS, Peter C. Shatz, DDS
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Achieving Predictable Connective Tissue Root Coverage

Achieving Predictable Connective Tissue Root Coverage
Gingival recession creates esthetic issues. These issues may be corrected from a restorative perspective by the placement of composite resin or ceramic over the exposed root. But this approach often results in a gingival-incisal length that does not blend esthetically with the adjacent teeth. Often accompanying the gingival recession is a decrease in the band of attached gingiva. The wider the band of attached gingiva, the more stable the long-term result. Therefore, surgical correction of the recession…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD
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Current Trends in Gingival Recession Coverage

Current Trends in Gingival Recession Coverage
The recession of the gingiva is increasingly becoming a more prominent condition in the oral health of many patients and should be treated at its earliest detection. The multifactorial etiology, decision modality, and current trends followed in the treatment of gingival recession are discussed in this presentation. The correction of Class I and II gingival recessions are presented as a means of minimizing surgical trauma and achieving predictable aesthetic results. Part II of this discussion will present alternative techniques in treating gingival recession.

Author(s): André P. Saadoun, DDS, MS
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Current Trends in Gingival Recession Coverage 2

Current Trends in Gingival Recession Coverage 2
The recession of the gingiva is increasingly becoming a prominent condition in the oral health of many patients and should be treated at its earliest detection. Part I of this discussion reviewed the multifactorial etiology and decision modality; a treatment option was demonstrated for gingival recession using the tunneling technique. This concluding part of the discussion highlights two clinical cases using alternative approaches. The correction of Class I and II gingival recessions are presented as a means of minimizing surgical trauma and achieving predictable aesthetic results.

Author(s): André P. Saadoun, DDS, MS
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A Review of Dental Suturing for Optimal Soft-Tissue Management

A Review of Dental Suturing for Optimal Soft-Tissue Management
Establishing nontension primary wound closure of various softtissue flaps is paramount for optimal postsurgical wound healing. Surgical procedures that require clinical flap manipulation such as those used with traditional periodontal therapy, periodontal plastic cosmetic surgery, hard- and soft-tissue regeneration, and the excision of pathologic tissue also require excellence in execution and thorough understanding of the various techniques of surgery, suturing, and the materials currently available to…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Gregori M. Kurtzman, DDS
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Aesthetic Crown Lengthening

Aesthetic Crown Lengthening
The rationale for crown lengthening procedures has progressively become more aesthetic-driven due to the increasing popularity of smile enhancement therapy. Although the biologic requirements are similar to the functionally oriented exposure of sound tooth structure, aesthetic expectations require an increased emphasis on the appropriate diagnosis of the hard and soft tissue relationships, as well as the definitive restorative parameters to be achieved. The development of a clinically relevant aesthetic blueprint and attendant surgical guide is of paramount importance for the achievement of successful outcomes.

Author(s): Ernesto A. Lee, DMD
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Soft Tissue Procedures Related to Dental Implant Surgery

Soft Tissue Procedures Related to Dental Implant Surgery
Clinicians often encounter an insufficient amount of keratinized soft tissue in the proposed implant site. When this occurs, the question arises: Should the necessary softtissue manipulation be performed before, during, or after placement of the implant? There are three answers or scenarios for this question, according to Lee Silverstein, DDS, associate professor at the Medical College of Georgia in Augusta.

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD
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Using an Acellular Dermal Matrix for Increasing Keratinized Tissue Around Dental Implants

Using an Acellular Dermal Matrix for Increasing Keratinized Tissue Around Dental Implants
In previously published articles, investigators concluded that gingival recession may affect up to 90% of the population. Gingival recession ranges from one to three millimeters and is predominantly noted on the buccal surfaces of molar, premolar, and lower incisor teeth. Although surgical grafting techniques have traditionally been used to restore these recession sites, an acellular allograft material has recently been developed for increasing the zone of keratinized tissue surrounding teeth and…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD
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Similarities Between an Acellular Alloderm and a Palatal Graft for Tissue Augmentation

Similarities Between an Acellular Alloderm and a Palatal Graft for Tissue Augmentation
Predictable tissue regeneration presents a considerable challenge in the surgical treatment of gingival tissue defects. Soft-tissue augmentation procedures to increase the existing or create a new zone of attached keratinized gingival tissue have classically been performed using the patient's own masticatory mucosa and, more recently, using an acellular dermal allograft as the donor material. This article presents a clinical case whereby an acellular dermal allograft was placed on the buccal surface…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Russell A. Gornstein, DDS, MD, Donald P. Callan, DDS, Baldev Singh, BDS, PhD
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Similarities Between an Acellular Dermal Allograft and a Palatal Graft for Tissue Augmentation

Similarities Between an Acellular Dermal Allograft and a Palatal Graft for Tissue Augmentation
Predictable tissue regeneration presents a considerable challenge in the surgical treatment of gingival tissue defects. Soft-tissue augmentation procedures to increase the existing or create a new zone of attached keratinized gingival tissue have classically been performed using the patient's own masticatory mucosa and, more recently, using an acellular dermal allograft as the donor material. This article presents a clinical case whereby an acellular dermal allograft was placed on the buccal surface…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Russell A. Gornstein, DDS, MS, Donald P. Callan, DDS, Baldev Singh, BDS, PhD
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Fundamentally Changing Soft Tissue Grafting

Fundamentally Changing Soft Tissue Grafting
Soft tissue augmentation procedures to increase the existing zone or create a new zone of keratinized tissue have been classically, and are routinely, performed using the patient's palate as the donor material. This article describes the simplistic use of a periodontal material that can be used for soft tissue augmentation procedures without using the patient's own palate to procure the donor tissue. This periodontal material is an acellular dermal allograft that has been used extensively in medicine.…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD
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The Aesthetic Smile: Diagnosis and Treatment

The Aesthetic Smile: Diagnosis and Treatment
Until recently, dentists' and the public's concept of dental aesthetics was necessarily limited to alterations of the teeth themselves. Dentists concerned themselves with changing the position, the shape and the color of the teeth -basically restoring missing units or enhancing those already present. For the most part the dentist was forced to accept the pre-existing relationship between the three components of the smile; the teeth, the gingival scaffold and the lips.

Author(s): Maurice Salama, DMD;David Garber, DMD
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Developing Optimal Peri-Implant Papillae within the Esthetic Zone: Guided Soft Tissue Augmentation

Developing Optimal Peri-Implant Papillae within the Esthetic Zone: Guided Soft Tissue Augmentation
Osseointegrated dental implants have enjoyed longterm success in the rehabilitation of totally edentulous patients. Every aspect of traditional treatment planning protocols continues to be re-evaluated and updated to better incorporate the benefits of osseointegration into clinical practice. This is particularly evident as dentistry has committed to fully integrating this approach into the more varied and demanding environment of the partially edentulous patient.

Author(s): David Garber, DMD;Maurice Salama, DMD;Henry Salama, DMD;Pinhas Adar, MDT, CDT
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Use of the Subepithelial Connective Tissue Graft to Improve Esthetics

Use of the Subepithelial Connective Tissue Graft to Improve Esthetics
The subepithelial connective tissue graft is a gingival grafting plastic surgery procedure that can be used to enhance the aesthetic and gingival contour of the periodontium around dental implants. This technique is described and illustrated to create a soft-tissue root prominence and mask the grey color penetrating the thin labial attached gingival tissues over dental implants.

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;Michael D. Lefkove, DDS
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A Modified Surgical/Prosthetic Approach for Optimal Single Implant Supported Crown

A Modified Surgical/Prosthetic Approach for Optimal Single Implant Supported Crown
Optimal implant placement can be achieved only if the ridge maintains its dimensions and the qllality of bone. To prevent the resorption of the ridge and to enhance the quality of regenerated bone, two main approaches have been suggested. Palt I of this article presents a modified regenerative technique - the "socket seal surgery"' (SSS). Part II will present a modified prosthetic technique - the "cervical contouring concept" (CCC) - and it will be published in the May, 1994, issue of PP&A. The…

Author(s): Nitzan Bichacho, DMD;Cobi J. Landsberg, DMD
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Bone Regeneration and Tissue Acceptance of Human Fascia Lata Grafts Adjacent to Dental Implants

Bone Regeneration and Tissue Acceptance of Human Fascia Lata Grafts Adjacent to Dental Implants
The biologic principle of guided tissue regeneration (GTR) has been studied extensively in hopes of regenerating alveolar bone. Various materials have been utilized as regenerative membranes; however, all materials have disadvantages, and the ideal membrane material is yet to be identified. In this case report, human freeze-dried fascia lata strips were used as a regenerative barrier membrane in conjunction with the placement of endosseous root implants and demineralized, freeze-dried bone allograft.…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD;James D. Kraft, BS, CPTC , Ronald Wand, DDS
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The Endentulous Ridge in Fixed Prosthodontics

The Endentulous Ridge in Fixed Prosthodontics
In those clinical situations in which missing teeth are replaced with fixed prosthodontics, the clinician is faced with the task of fabricating the pontics to fulfill the requirements of esthetics, form and function, and oral physiotherapy. The relationship of the "dummy tooth", or pontic to the underlying ridge is inordinately complex, since the esthetic requirements invariably conflict with those of function and hygiene. Although pontic designs have been discussed in some depth in the literature,…

Author(s): David Garber, DMD;Edwin Rosenberg, BDS, DMD
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Connective Tissue Graft Using Alloderm

Connective Tissue Graft Using Alloderm
Gingival recession is a clinical condition encountered in many dental practices during routine patient care. Fortunately, there are a variety of surgical procedures that the clinician can use to address gingival recession and return the patient to optimal health and aesthetics. As dental professionals gain a higher awareness of the available surgical materials and restorative techniques, the success and predictability of treatment for gingival recession on single and multiple adjacent teeth has…

Author(s): Lee H. Silverstein, DDS, MS, FACD, FICD
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Laser Assisted Gingival Tissue Procedures

Laser Assisted Gingival Tissue Procedures
Soft tissue lasers are increasing in popularity among clinicians in part due to their potential value in preprosthetic gingival procedures. The ability of soft tissue lasers to control moisture and facilitate hemostasis appears particularly promising for clinicians excising gingival tissues, performing esthetic crown lengthening, and using resective techniques for gingival troughing—and these applications will grow as practitioners become more familiar with such technologies. This presentation highlights…

Author(s): Ernesto A. Lee, DMD
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