From Bern out into the world

The first Osteology-EFP Virtual Live Surgery Day on 17 June 2021 was a huge success! Broadcasted live from Bern, over 1000 attendees from more than 80 countries attended the event organised jointly by the Osteology Foundation and the European Federation of Periodontology (EFP). The event consisted of two sessions, one on recession coverage, the other on peri-implantitis treatment.

After the welcome and the introduction by the two presidents, William Giannobile for the Osteology Foundation and Lior Shapira for the EFP, the first session started with the Key Note Lecture by Martina Stefanini. She talked about “recession coverage in the mandible: possibilities and limits”.

Session one: Recession coverage in the mandible

Recession coverage treatment in the mandibular area is often complex due to the unfavourable anatomical condition, Stefanini explained. It is influenced by several factors, e.g. tooth position, vestibulum depth and tissue phenotype. The classic old-fashioned techniques used for recession coverage are the free gingival graft (FGG), modified two-step approach and the laterally and coronally moved flap. The Vertically Coronally Advanced Flap (VCAF) and the Laterally Closed Tunnel (LCT) are two new procedures that can obtain complete root coverage, increased vestibular depth, soft tissue depth, decreased morbidity of the harvest area, and esthetics. Stefanini said that compared to the traditional techniques, the CAF Difficulty Score across different parameters is high for the VCAF, but the surgical technique itself is more difficult.

Martina Stefanini on stage

After Stefanini’s lecture, the moderator of the first session, Mariano Sanz, introduced the patient of the first live surgery of the day. Anton Sculean performed the surgery on a thin phenotype patient with an RT2 (Miller’s class III) recession in the lower right central incisor 41. The patient was in general good health with a history of orthodontic treatment. The treatment in this patient aimed to improve oral hygiene, alleviate the pain and esthetic improvement. The technique used to treat this recession was the LCT or the Modified Coronally Advanced Tunnel (MCAT) in conjunction with a palatal subepithelial connective tissue graft. The LCT has advantages in a thin phenotype with limited or no attached gingiva. Tension-free mobilisation of soft tissue can be obtained without any incision on the papilla or the flap to optimise wound stability

Anton Sculean in the OR

The LCT procedure started with mechanical debridement of the root followed by an intrasulcular incision in the depth of the recession to enable the tunnel. Following this, detachment of the periosteum and frenulum was performed. Once the desirable flexibility of the tunnel was achieved, a 1 mm connective tissue graft (CTG) was harvested from the lateral part of the palate, stabilised over the recession area and closed with mattress sutures. Sutures enhance keratinisation. Therefore, Sculean’s recommendation was to keep them in place for three weeks. Postoperative painkillers, a dose of dexamethasone and chlorhexidine mouthwash was recommended. 

Lots of questions arrived from the audience during the surgery and were addressed live and in the panel discussion following the surgery. Whilst Sculean was finishing the surgery, the panel discussion started with Martina Stefanini, Andreas Stavropoulos, and Giovanni Salvi. One of the topics that were discussed was that verticality is restored with both VCAF and the LCT. Stefanini said that it is immediate in VCAF, whereas in LCT, the verticality is restored after some time. Stavropoulos pointed out that compared to the maxilla, the mandible has a shallow vestibule and shorter alveolar ridge, which leads to a less stabilised wound. Hence, the techniques need to be adapted accordingly.

When Sculean joined the panel, he mentioned that in addition to the LCT, the VISTA (vestibular incision subperiosteal tunnel access) technique is a smart technique for recession coverage and better than the Pinhole technique, for which not many scientific publications are currently available. Sculean further highlighted the fact that 80% of young patients can develop recession post orthodontic treatment because the activation of the retainers during orthodontic treatment pushes the teeth both labially and lingually. His recommendation was a CBCT to check if enough bone is present both labially and lingually as part of the pre-treatment planning phase.

The panel of the first session

Session two: peri-implantitis in focus

The second session, moderated by Giovanni Salvi, started with a lecture by Frank Schwarz on surgical techniques for peri-implantitis treatment. He explained that the selection of the approach depends on the category of the defect. He recommended a non-reconstructive approach for implants with a machined surface, a reconstructive approach for class 1 defects with four walls present, and a combined approach for the more challenging cases, which are unfortunately the most common in clinical praxis. These challenging cases are class 1 with three walls and class 2 and 3 defects. He explained that the combined approach consists of open flap debridement, implantoplasty, and the application of a bone filler material. Regarding decontamination protocols, Schwarz said that there is no scientific evidence that favours any decontamination protocol. Therefore, he recommends keeping it simple. The most significant influence factor for a successful treatment is the implant surface. Furthermore, he also explained the importance of concomitant soft tissue volume grafting with a scaffold (CTG or collagen matrix) to compensate for the insufficient thickness of the mucosa and to overcome soft tissue recession post-operatively. 

Frank Schwarz on Stage

Salvi then introduced the patient of the second live surgery performed by Andreas Stavropoulos: a systemically and periodontally healthy 34-year old female patient with congenitally missing teeth 12 and 22 replaced by implants. Due to peri-implantitis on implant regio 12, the cemented crown was removed one month ago and replaced with a temporary bridge to allow mucosa healing. A mesial defect with an infrabony component was visible in the radiograph. Buccal bone dehiscence was present. After opening the flap, the surface was cleaned with an air-polishing device and implantoplasty was performed on the buccal side of the implant. The soft tissue situation was fragile in the central position over the implant and very difficult to manage. After implantoplasty, he harvested autologous bone chips locally to fill the defect and covered it with a collagen membrane cut in shape to cover the defect. He perforated it over the implant to allow transmucosal healing. 

Mariano Sanz, Anton Sculean, and Frank Schwarz joined Giovanni Salvi for the panel discussion after the live surgery. Andreas Stavropoulos joined as well after he had finished the surgery. One of the topics that were discussed was whether implants should be placed at all in high-risk patients because of a periodontitis history. Sculean said yes and that also in those patients, predictable results can be achieved. However, he advised that an implant should never be placed in a periodontally compromised patient before systemic periodontal therapy has been completed, and only if the amount of bone and soft tissues are sufficient for implant placement and prosthetic planning. It requires a comprehensive treatment approach. The panel also discussed the influence of implant surfaces on peri-implantitis progression. Schwarz emphasised that he sees that some implant surfaces are more susceptible than others. He would also advise using single one-piece implants. 

Sculean explained when asked which factors minimise peri-implantitis that prosthetics play an essential role to allow cleaning; furthermore, the position of the implant, sufficient bone around the implant, and the amount of attached mucosa and the thickness of the mucosa. Moreover, the number of implants is important: They should be placed only in strategically important positions, and they should be not too close to the teeth. Otherwise, the chance that the papilla will melt away will be high.

After Stavropoulos joined the panel, the topic of the decontamination procedure was discussed again. He confirmed that there is no evidence that one decontamination is better than others. Therefore, one should use a simple method and what is at hand. Sanz added that every method decontaminates the implant, even if it is just saline. The surface is more relevant for recolonization. He advised to also focus on the surface that is going to stay outside the bone. The elimination of the rough surface is as important as the decontamination during the surgery, he said.

The panel of the second session

Thank you very much to all the speakers, the attendees and the EFP to make this exceptional event happen. If you missed the event, you can still register here and watch the recordings until 31 October 2021. We will publish more follow-up reports in the coming weeks.