Oral Surgery Posts

Anterior partial edentulism: the Fence Technique
Mauro Merli

A new challenge in dentistry – Complex Oral Surgery in the Office
Roberto Barone Carlo Clauser Angelo Baleani

Maxillary sinus surgery: lateral approach. The state of the Art
Tiziano Testori

“Fence Technique”: an innovative reconstruction procedure
Mauro Merli

Localized Management of Sinus Floor
Giovanni Battista Bruschi

Oral surgery in childhood and adolescence
Roberto Barone Carlo Clauser Angelo Baleani

Surgical extraction of mandibular third molar: a rational and safe technique
Roberto Barone Carlo Clauser Angelo Baleani

The Membragel Straumann liquid membrane
Fabio Cozzolino

Mandibular full-arch restoration with Straumann implant-supported metal mesostructures and zirconia-based prosthesis: a case report
Roberto Sorrentino Fabio Cozzolino

Micro-surgical Endodontics. The State of the Art
Arnaldo Castellucci Matteo Papaleoni

Anterior partial edentulism: the Fence Technique

Anterior partial edentulism: the Fence Technique

A serious car accident caused severe damage, both systemically as well as to the oral cavity of a young 17 year old female (Fig. 1).
The loss of teeth, hard tissue and soft tissue in the fifth sextant resulted in a critical esthetic-functional deficit.

The patient’s request was to restore the compromised zone with a prosthetic rehabilitation that would be as similar as possible to the area prior to the trauma, avoiding solutions that foresee the presence of artificial gingiva .

The required vertical bone regeneration exemplifies one of the most complex procedures, mainly with regards to the correct management of the soft tissue compromised by the injury.

Following an accurate clinical-radiographic assessment of the skeletal maturity, a complex therapeutic strategy was undertaken (Figs. 2, 3).

A new challenge in dentistry – Complex Oral Surgery in the Office

A new challenge in dentistry – Complex Oral Surgery in the Office

Root canal therapy of a molar tooth was a sophisticated treatment 50 years ago: the extraction was the rule.

Endodontics of a molar tooth is still a sophisticated treatment today, but it has become a normal dental procedure in any dental office.

What has changed? Tools, techniques, mentality of the dentist and patient needs.

Dentists today are used to working in very narrow spaces.

Progress in some surgical disciplines, such as periodontology and implantology, has been extraordinary.

Oral surgery, however, was excluded: the tools and techniques for the extraction of wisdom teeth are the same as 50 years ago, even in the video clips we see today on the Internet.

The contrast is even more striking when we consider that dentists safely perform sinus lift procedures in their offices, while referring cases of cysts to hospitals. Yet, the elevation of the sinus membrane requires greater skill than the detachment of a cyst wall.

Maxillary sinus surgery: lateral approach. The state of the Art

Maxillary sinus surgery: lateral approach. The state of the Art


The physiological resorption of alveolar process in the corono-apical and vestibular-palatal direction following tooth loss often does not allow the positioning of implants in the posterior part of the upper jaw without an adequate bone reconstruction. The functional load exerted on the residual crest which transforms into compression force favors centripetal and cranio-caudal bone resorption (Cawood et al. 1988) with consequent reduction in size of the alveolar process associated with a progressive pneumatization of the maxillary sinus.

Among the pre-implant surgical procedures for bone reconstruction, the maxillary sinus surgery has been shown to have a high clinical predictability (Wallace et al. 2003,Del Fabbro et al. 2004-2008-2012-2013 a-b, Pjetursson et al. 2008, Testori et al. 2012). Historically in cases of bone atrophy where the residual bone is less than 4 mm, the lateral approach was utilized.

“Fence Technique”: an innovative reconstruction procedure

“Fence Technique”: an innovative reconstruction procedure

Edentulism was defined as a pathological condition by the World Health Organization in 1990. The discomfort and inconvenience that this condition can generate in terms of aesthetics, function, as well as psychologically, can be so debilitating as to consider edentulism a social handicap.

Due to the gradual increase in the average age of the population, today there are more and more people in their seventies who are enjoying overall good health and intrapersonal relationships. Their expectations have significantly increased as well, and as patients are no longer satisfied with traditional removable dentures; explicit requests are now frequently made for fixed prosthetic solutions with a high level of aesthetics and correct function.

One such example is this patient who came to our observation in 2009 complaining of severe discomfort from a functional and aesthetic perspective (Fig. 1). His dentures were worn and unstable, causing frequent lacerations and sores on the gingival tissues and oral mucosa. The patient reported that this condition was causing psychological problems and lowering his self-esteem, therefore his desire was to solve this complex situation , if possible, with a fixed prosthesis. The assessment of the patient’s systemic risk profile pointed out that his general health conditions were good and that he would classify as ASA class I (Owens et al. 1978).

The evaluation of local risk factors showed the presence of few dental elements (that were in fact compromised) and a particularly marked atrophy of both the upper and lower jaw. The severe bone deficit could have been related also to infrequent readjustment of the prosthesis.


Localized Management of Sinus Floor

Localized Management of Sinus Floor


The Localized Management of Sinus Floor is a surgical technique for transcrestal maxillary sinus floor elevation. Its aim is to create a surgical site for implants by displacing a portion of native residual below bone within the cavity of the maxillary sinus. This particular type of bone is usually found below the sinus floor and, through this technique, is displaced vertically in order to create a new implant alveolar portion. In the final configuration of the surgically created alveolus, the coronal portion of the crest must give primary implant stability. This will be completed by the coronal bone portion – pushed laterally and internally of the sinus cavity – from which, a sort of closed “tent” formed by the sinus membrane, will keep the cavity closed. The latter will be filled by blood produced by the alveolar walls.

Tissue repair of the peri-implant alveolus is totally entrusted to the physiological mechanism of bone repair on the site chosen for the implant osteotomy. 3-4-13-14

The goal is to change the height of available bone by creating an osteotomy tunnel starting from the crestal position and extending, initially transversally and medially, in a direction parallel to the palatine vault. This way, the osteotomy tunnel pushes the spongy bone against the floor of the maxillary sinus and avoids loss of the precious calcified structure.

The initially transverse direction (and not vertical, according to the normal prosthetic axis) is essential to:

1. Increase the height of native bone, interfacing the implant to improve primary stability;

2. Use the higher portion of the sinus floor which is normally found towards the medial side of the sinus cavity.

Preparation of the surgical field

According to the protocol, the preparation of the soft tissues is made with a partial thickness technique that has the objective to leave a thin layer of connective tissue which:

1. Ensures the integrity of the periosteum;

2. Allows to easily read the underlying bony anatomy.

The protection of the periosteum is critical, of course, to maintain the integrity of the blood supply15. Also the layer of connective tissue, and the interposed periosteum between tissue and bone, will be fundamental to promote the peri-implant tissue secondary intention healing. This is one of the main issues of the protocol.

This preparation enables to firmly anchor the keratinized tissue – using the sub-periosteal sutures – in an apical and vestibular position. This residual displaced tissue, previously covering the crest, has been displaced vestibularly14.

The flap preparation begins with a palatally beveled incision which slides along the bone plane, starting from the palatal angle of the crest, exactly where the palatal structure crosses the horizontal portion of the edentulous ridge. This has the aim of exposing the crest and displacing vestibularly the keratinized crestal residual tissue to the future implant emergency. This crestal tissue is the same one which has been previously moved from the palatal aspect of the surgical field. Fig. 01/05


Oral surgery in childhood and adolescence

Oral surgery in childhood and adolescence



Oral surgery in children is not always an easy surgery. It is often complicated by:

– specific age-related pathologies, not always easy to recognize

– complex anatomy associated with the mixed dentition

– reduced surgical access

– difficulties in obtaining the cooperation

– the need for coordinating surgery and orthodontics

There are opportunities for oral surgery typical age-related operations and other conditions that require a different approach when patients are children:

– extraction of infraoccluded primary teeth

– extraction of impacted supernumerary teeth

– treatment of cysts

– germectomies of mandibular wisdom teeth

Surgical extraction of mandibular third molar: a rational and safe technique

Surgical extraction of mandibular third molar: a rational and safe technique



The extraction of the mandibular third molar is the most frequent intervention in oral surgery and it is sometimes associated with less or more severe complications. Among these, the most dangerous is the damage to the inferior alveolar nerve.


1 panoramic x-ray impacted wisdom tooth

In the last decades, thanks to the improved expertise in identifying risky cases and the refinement of surgical techniques, the prevalence of complications has been progressively reduced.

The present paper describes a rational approach to the surgical extraction of the mandibular third molar, in order to limit surgical complications.

As to the method, several factors contribute to the clinical success, just like:

  • a correct pre-operative diagnosis;
  • a rational choice of surgical instruments;
  • a minimally invasive surgical technique.

The last two points are closely interdependent.

Pre-operative diagnosis


The diagnosis includes:

  • study of indications and contraindications for surgery;
  • risk and difficulty assessment;
  • intervention planning.

The orthopantomogram (OPG) is the golden standard for pre-operative diagnosis.

From the OPG it is possible to evaluate:

  • tooth position (angulation, depth, proximity to the neurovascular bundle);
  • presence of risk factors for mandibular alveolar nerve damage, according to the criteria of Rood & Shehab (1990);
  • diseases (caries, cysts etc.).

According to Rood & Shebab, the following risk indicators for damage of the mandibular alveolar nerve can be identified on OPG:

  • root radiolucency;
  • angled roots;
  • interruption of the radiopaque lines that mark the alveolar canal;
  • narrowing of the mandibular alveolar canal;
  • radiolucent and bifid roots;
  • narrowing of roots;
  • deviation of the mandibular alveolar canal.

Nowadays, since the OPG does not allow to establish the bucco-lingual position of roots and neurovascular bundle, in particular cases it is possible to recur to 3D imaging, particularly to Cone Beam technology.

Clinical indications for 3D imaging are:

  • signs of risk with complete overlapping of the roots to the alveolar canal;
  • alveolar canal crossing the roots near to the bifurcation.

From an operative point of view, one more indication for 3D imaging is the necessity to understand on which side of the tooth the alveolar canal passes, in order to plan properly the bone resection and odontotomy.

The Membragel Straumann liquid membrane

The Membragel Straumann liquid membrane



The Straumann® Membragel™ is a technologically advanced resorbable membrane that simplifies the clinical procedures of guided bone regeneration (GBR).
The application of the liquid membrane is very easy, fast and accurate. Once it solidifies, the Membragel stabilizes the bone graft material, acting as a barrier for 4-6 months before its resorption. Preclinical data showed that the Membragel is resorbed significantly more slowly than conventional collagen membranes, offering an excellent biocompatibility to surrounding tissues. Due to its gel consistency, it can be placed accurately onto the bone defect, over the graft material. In order to stabilize the liquid membrane, it is sufficient to extend it 1-2 mm beyond the margins of the bone defect.
The use of the Straumann® Membragel™ allows for the formation of as much regenerated bone tissue as it is achieved with conventional non resorbable ePTFE membranes.
The application of such a liquid membrane is indicated in the following guided bone regeneration procedures:

  • periimplant defects (dehiscences, fenestrations);
  • post-extractive sites;
  • horizontal bone defects.

Mandibular full-arch restoration with Straumann implant-supported metal mesostructures and zirconia-based prosthesis: a case report

Mandibular full-arch restoration with Straumann implant-supported metal mesostructures and zirconia-based prosthesis: a case report

A 63-year-old female patient presented with a severe chronic periodontitis at the mandibular arch. Only teeth 33 and 44 were present and had been used as abutments for a resin removable partial denture which did not satisfy the functional and estethic needs of the patient. Moreover, a metal-ceramic crown with a supragingival margin and a mesial metal connector was evidenced on tooth 33; the patient reported that the mandibular front teeth had been previously prepared for a metal-ceramic fixed dental prosthesis, in order to limit the discomfort due to the mobility of such teeth.At the maxillary arch, the patient wore a complete removable denture which was esthetically unsatisfactory but valid to accomplish oral functions.
edentulia mascellare

Micro-surgical Endodontics. The State of the Art

Micro-surgical Endodontics. The State of the Art


By Surgical Endodontics one refers to that branch of Dentistry that is concerned with the diagnosis and treatment of lesions of endodontic origin that do not respond to conventional endodontic therapy or that cannot be treated by conventional Endodontic therapy. The scope of Surgical Endodontics is to achieve the three dimensional cleaning, shaping and obturation of the apical portion of the root canal system which is not treatable via an access cavity, but only accessable via a surgical flap (Fig. 1 a,b,c,d).

Apicoectomy surgical endodontics


surgical endodontics


For this reason it is preferable to use the term Surgical Endodontics rather than Endodontic Surgery, in as much as the procedure should be planned and carried out as an endodontic procedure via surgical access and not a surgical procedure done for endodontic reasons.
Once a diagnosis of Endodontic failure has been made, it is necessary to understand what the cause of the failure was so that successively the possibility of correcting the failure by orthograde retreatment can be evaluated. Only in the case where this possibilità does not exist or better still after failure of the non-surgical therapy carried out to resolve the problem, only then is one authorized to intervene surgically. Apical Surgery in other words is not a substitute for incomplete debridement and poor endodontics (Fig. 2 a,b,c,d).