The loss of soft and hard tissue contour in the esthetic zone compromises both esthetics and function, and creates a myriad of cosmetic surgical and prosthetic challenges for the implant team.  This clinical presentation will introduce Digitally Guided Bone Augmentation (DGBA)TM, a state-of-the-art approach for the objective diagnosis, definition and surgical implementation of restoration-specific three-dimensional soft and hard tissue augmentations for optimal esthetic zone reconstruction.  

The DGBA concept of reverse-engineering soft and hard tissue augmentation for optimal implant placement and restoration is the 21st century manifestation of restorative driven implantology using cone beam CT and interactive CT software. Emphasis will be on recipient and harvest site assessment, surgical protocol utilizing mandibular block and tibial autografts in conjunction with connective tissue grafts, acellular dermis matrix, and related soft tissue procedures to avoid functional and esthetic pitfalls. Pre and post-grafting prosthetic workup, reverse engineering with interactive CT graft assessment and prosthetic driven implant planning, with stent driven implant placement will be featured. 

Learning Objectives:

1. Understand the concept of Digitally Guided Bone AugmentationTM and the sequence of its application
2. Understand the application of interactive CT imaging in the development of prosthetic driven soft and hard tissue grafting for specific implant placement in the esthetic zone
3. Describe the indications for and sequencing of hard and soft tissue grafting in the esthetic zone
4. Understand the role and surgical protocol of mandibular block autografts, tibial grafts, connective tissue grafts, acellular dermal matrix, and use of platelet rich plasma in the esthetic zone.

Soft tissue deficiencies may occur around implants in spite of careful treatment planning, resulting in both esthetic and functional problems.  This presentation will demonstrate soft tissue surgical techniques using both palatal connective tissue autografts and acellular dermal allografts for solving soft tissue problems including thin marginal tissue, mobile marginal tissue, loss of vestibular depth and implant exposure.

Learning Objectives:

1. Describe the special considerations for grafting around implants.
2. Describe the technique for use of AlloDerm around implants.
3. State the evidence for the equivalence of outcomes of autogenous and alloplastic grafting.
4. Describe the prevention and management of surgical complications associated with soft tissue grafting around implants.

All mature edentulous sites have lost original bone dimension and many have significant gingival deficiencies. With a goal to restore patients to natural contour, comfort, function, esthetics and health, implant treatment must be accompanied by bone and gingival enhancement. A 40 year observation of onlay grafted bone instability when compared to alveolar bone stability has led the speaker to maximize the avoidance of onlay bone grafts. The required bone enhancement is achieved by manipulation or repositioning (in conjunction with inter-positional grafts) of vascularised alveolar bone, to the positions needed, to support implants of natural diameters and in normal root locations. Implants are placed with no flap reflection, minimal bone removal and trans-mucosal. Maxillary gingival enhancement is usually accomplished during implant placement with palatal tissue manipulation. Mandibular tissue enhancement is done with grafting. The trans-mucosal placed implants are restored with natural emergence profiles and with no damage to the new biologic seals, which will have formed around the implants. Both plaque control and occlusal management are required for optimum long-term service.

Learning Objectives:

1. Limitations of onlay grafts
2. Importance of alveolar bone stability
3. Concept of bone compaction and expansion
4. Concept of vascularised osteotomies
5. Techniques of tissue enhancement
6. Importance of "Natures' Seal"
7. How to put a restorative dentist back in control in implantology
8. Importance of long term supervision of implant patient

"Sandwich bone augmentation" has recently been suggested as a predictable way to augment horizontal ridge deficiency.  This technique uses layers of bone grafts -Inner layer - human mineralized cancelllous bone for quick bone turnover, outer layer - human mineralized cortical bone or bovine hydroxyapatite for space creation and maintenance then covers with absorbable membrane for primary would closure and exclusion of unwanted epithelial cells. A detailed description of surgical technique and why these materials are used will be addressed and demonstrated.  Data from controlled human clinical cases pertaining to this newly developed bone augmentation technique will also be presented.   Furthermore, a flap design (mucogingival pouch) that can ensure tension free primary flap closure will also be presented.

Learning Objectives:

1. Know the concept of sandwich bone augmentation.
   
2. Learn how to perform sandwich bone augmentation and mucogingival pouch flap.
3. Familiarize to indications and contraindications associated with sandwich bone augmentation.