Hard and Soft Tissue Grafting

Category: Surgery

Instructor(s): Filippo Fontana, Marco Ronda, Luca De Stavola, Andrea Chierico, Pietro Felice

Course structure: Lessons: 8 lessons | Duration: 8 h

Course overview

Who is the course for?

Attendance at this course is recommended for all professionals involved in implantology and bone regeneration as the authority and experience of the speakers guarantees a valid, complete and timely update on the best and latest techniques for everyone.
“Hard and Soft Tissue Grafting” is the how-to-do-it video course on the latest and most efficient bone regeneration techniques.

Each video lesson focuses on a specific aspect of bone regenerative surgery, with the aim of providing you with the tools to immediately make your surgical practice less invasive and more effective, faster, and predictable.

Given the great variety of regenerative techniques, the course includes stimulating debates between the speakers to allow you to explore the pros and cons of different approaches.

Enriched with clinical cases and ReLIVE surgeries, this course provides an all-encompassing learning experience covering horizontal bone regeneration for both simple and more challenging defects, vertical bone regeneration in the aesthetic area, the latest innovations in flap design, peri-implant soft tissue management, and analog vs digital approaches with their advantages and limitations.

Topics covered in the course:
-Biological principles underlying bone regeneration;
-Case selection and treatment planning;
-Resorbable vs non-resorbable membranes: how to choose?
-Management of bone defects;
-Khoury Technique with digitally-driven approach;
-Vertical bone regeneration in the aesthetic area;
-Different graft types: membranes vs autologous bone;
-Flap design for regenerative techniques.

At the end of the course, you will be able to:
-Understand which factors influence the regenerative capacity of a defect;
-Choose between different techniques, depending on your skills and learning curve and on the patient’s defect;
-Choose between GBR with non-resorbable membranes or the Khoury Technique;
-Achieve correct flap passivation and closure by first intention;
-Manage soft tissues during bone regeneration;
-Minimize the risk of intra and post-operative complications;
-Adopt both analog and digital approaches, knowing their pros and cons.

Curriculum

Video Lecture 1 - Horizontal augmentations using resorbable membranes

• In this first video lecture, Dr. Filippo Fontana provides an in-depth discussion on how to regenerate bone using resorbable membranes. The lesson, presented in a full “how to do it" mode, focuses on managing minor defects with a high occurrence rate in the daily practice of every professional. Participants will learn how, contrary to traditional belief, resorbable membranes, when accompanied by fixation systems, can also be used to manage poorly supportive defects, as they are less prone to complications compared to non-resorbable membranes. The lesson ends with a step-by-step discussion of two clinical cases, one in the mandible and one in the maxilla, with the aim of showing participants the correct surgical protocols and the ease with which optimal outcomes were achieved using resorbable membranes.
• In particular, this lesson covers the following topics:
• What is the scope of use for resorbable membranes?
• Types of defects: supportive, non-supportive, and poorly supportive
• Proper fixation systems for resorbable membranes
• Managing the resorbable membrane: cutting, modifying, shaping, fixation, and suture protocols
• How to stabilize the membrane to unlock great regenerative potential
• Suture techniques: internal horizontal mattress and single suture lines
• 6-month follow-up after surgery

Video Lecture 2 - Khoury Technique: how to regenerate alveolar bone?

• In this lesson, Dr. Luca De Stavola discusses the operative protocol of the Khoury Technique for bone regeneration using 100% autologous bone as graft material. Participants will understand how regeneration is linked to a biological process that must form the foundation of every clinician's decisionmaking algorithm. To this end, the first part of this lesson is dedicated to analyzing the biological rules for transitioning from a clot to a provisional matrix, woven bone, and finally, lamellar bone, with particular emphasis on the importance of vascular support, mechanical stability, and the presence of inductive factors. The second part of the video lecture includes a step-by-step commentary of each phase of the Khoury Technique’s operative protocol with a digitally driven approach, particularly focusing on the block luxation, incision, and flap release phases.
• In particular, this lesson covers the following topics:
• The decision-making algorithm guided by the patient's defect
• What factors most influence the regenerative potential? • The macro-architecture of the defect: particulate bone vs. compact bone
• Digital planning: Khoury Technique
• Block exposure and nerve trapped inside the luxated bone block: complication management

Video Lecture 3 - Vertical bone regeneration in the aesthetic zone: which technique to adopt - Part I

• The next two lessons represent the first opportunity for debate and comparison between two different philosophies on the important topic of vertical bone regeneration in the esthetic zone. In this first video lesson, Dr. Marco Ronda discusses how he adopts the GBR technique with non-resorbable membranes as the gold standard, while in the subsequent presentation, Dr. Luca De Stavola explains why his primary technique of choice is the Khoury Technique.
• Dr. Ronda demonstrates the management of a prosthetic restoration in the anterior zone that has become mobile and is no longer supported by the dental elements, due to a very severe vertical bone defect between teeth 21 and 14. Participants will appreciate the entire treatment process, from the clearance to the GBR, performed in two stages, to the removal of the non-resorbable membrane, implant placement, and connective tissue grafting, to implant activation following bone maturation, and finally to prosthetics and delivery of the final restoration. Dr. Ronda also highlights the importance of flap passivation for achieving primary intention closure.
• In particular, this lesson covers the following topics:
• Battle of concepts: GBR with non-resorbable membranes vs. Khoury Technique
• Management of a large vertical bone defect
• Timing of the surgical process
• Step-by-step commentary on each phase of the surgery

Video Lecture 4 - Vertical bone regeneration in the aesthetic zone: which technique to adopt? - Part II

• In this lesson, Dr. Luca De Stavola demonstrates how, unlike Dr. Ronda in the previous lesson, he uses the Khoury Technique as the gold standard for vertical bone regeneration of defects in the esthetic zone. At the end of the presentation, there is ample time for a debate between the two presenters. Participants will understand that the greatest strength of the Khoury Technique is the use of only autologous bone, which is more effective in supporting the regenerative potential of the defect. Dr. Luca De Stavola discusses the advantages of adopting a digitallydriven protocol for performing the Khoury Technique, such as the simplicity and increased safety in harvesting autologous bone.
• In particular, this lesson covers the following topics:
• How does the nature of the defect influence implant osseointegration?
• The biological rules for transitioning from provisional matrix to woven bone and then to primary bone
• How does the Khoury Technique provide greater vascular support to the defect?
• Battle of concepts: differences in the type of graft used by the two presenters

Video Lecture 5 - Flap design for regenerative techniques

• How should soft tissues be managed during bone regeneration? In this lesson, Dr. Luca De Stavola discusses the surgical phase of flap design, a key step for achieving primary intention closure. At the end of this video lecture, participants will learn the landmarks that allow for predictable and replicable outcomes, as well as how to minimize the risk of intra and post-operative complications such as flap dehiscence and bone defect exposure. By showcasing various clinical cases, Dr. De Stavola emphasizes how flap stability is influenced more by tension than by the thickness of the flap itself and discusses the necessity of performing tension-reducing sutures to relieve pressure on horizontal mattress sutures.
• In particular, this lesson covers the following topics:
• Flap tension: a key element in minimizing the risk of complications
• Calculating the optimal flap design
• Flap incision protocol: lower arch vs. upper arch
• Lingual flap extension vs vestibular flap extension
• The sequence of flap closure using tension-reducing sutures

Video Lecture 6 - Management of peri-implant soft tissues

• In this lesson, Dr. Andrea Chierico focuses on the management of soft tissues around teeth and implants when faced with bone volume loss. Three different clinical scenarios are presented: single tooth loss without attachment loss, single tooth loss with attachment loss, and the case of multiple adjacent missing teeth in the anterior sector. Participants will observe how, in the absence of attachment loss, the need is to preserve the situation by minimizing the surgical approach, while in the presence of attachment loss there is a necessity to regenerate hard tissues for the correct three-dimensional placement of implants. At the end of the lecture, there is time for a discussion on the rationale behind the decision to perform immediate loading or not when extracting elements in the esthetic zone.
• In particular, this lesson covers the following topics:
• Definition of the peri-implant phenotype
• Application of correct protocols to achieve the right thickness of soft and hard tissues
• How to create a perfect gingival outline at the end of treatment
• Management of the discrepancy between the bone crest and gingival contour
• Proper prosthetic management of bone volume loss

Video Lecture 7 - Analogue VS Digital: hard tissue regeneration - Part I

• This learning experience concludes with another "battle of concepts" between Dr. Filippo Fontana and Dr. Pietro Felice regarding the differences between analogue and digital approaches to hard tissue regeneration.
• In this first part, Dr. Fontana explains that the differences between these two approaches are logistical rather than conceptual, focusing on the stages of preliminary planning, membrane preparation and fixation, and graft placement. Participants will observe, for example, how membrane preparation in the analogue approach occurs intra-operatively, while in the digital approach it is done pre-operatively.
• In particular, this lesson covers the following topics:
• Differences between the analogue and digital approach
• Membrane preparation in the analogue vs. digital approach
• Membrane fixation in the analogue vs. digital approach
• Graft placement in the analogue vs. digital approach
• Hybrid approach combining analogue and digital methods

Video Lecture 8 - Analogue VS Digital: hard tissue regeneration - Part II

• This second part of the "battle of concepts" between the analogue and digital approaches begins with a presentation on the evolution of devices available for the digital approach to regenerative surgery. Dr. Felice demonstrates how the digital approach simplifies membrane fixation procedures, particularly on the lingual side in patients with severe atrophy. Finally, the characteristics of customized titanium mesh, occlusive or semi-occlusive custom grids, is shown to highlight the advantage of not needing to modify the membrane intra-operatively.
• In particular, this lesson covers the following topics:
• The biological principles of the membrane: biocompatibility, stability, ability to integrate with surrounding tissues, and ease of use
• The evolution of devices for the digital approach to regenerative surgery
• Battle of concepts: advantages and disadvantages of the analog and digital approaches