No clues exist in this situation; so in order to prevent excessive bone removal, a small hole is made in the cortical plate over the apex and filled with a small piece of gutta-percha or lead. Then, a parallel radiograph is taken and proper adjustment is made to make the osteotomy right over the apex of the root.
Enough bone has to be removed to be able to identify and expose the apex or the radicular surface of the defect, and create an adequate access for all microinstruments to the lesion. Osteotomy is an extremely important issue because, if it is done incorrectly, it can dramatically extend the time of treatment and complicate any single step of the procedure.
There are four gingival blood supply systems interconnected and running in an apical to coronal direction (Bone marrow intraseptal arteries perforate the bone cortex and become the supraperiosteal plexus. These vessels of 100-nanometer diameter penetrate the submucosa and, just below the basal layer of the epithelium, form the subepithelial plexus that extends, in the tooth area, along the sulcular epithelium joining the periodontal ligamental arteries.
There is a horizontal sulcular incision and only one vertical releasing incision (A triangular flap made with one vertical incision. This is a very practical flap for short roots, premolars and molars, preventing damage to important landmarks and allowing access for a bone graft donor area). Both extend at least one or two teeth away from the bone lesion.
The importance of the soft tissue management is crucial if a correct esthetic and functional result is to be achieved. At least two aspects are of equal importance in reaching this goal: the design and management of the flap and the suturing technique.
Anesthesia serves two purposes: to prevent pain during surgery, and to get presurgical hemostasis in the area.
Lidocaine (2%) with 1:50,000 epinephrine is the anesthetic of choice, because it causes activation of alpha receptors, that are in the majority in arteriolar muscles, submucosa and periodontium, causing vasoconstriction. Epinephrine is a safe drug1’2 and allergies to it are extremely rare. It is contraindicated only in severe cardiovascular disorders.
Optics quality. This is extremely important because it will determine the surgeon's eye fatigue and documentation quality. Also, the stereoscopic lens structure allows the viewing of objects in three dimensions with an excellent impression of depth.
Papilla Regeneration Technique:
In occlusal rehabilitation using implants as anchors for the reconstruction, the implant unit (the titanium fixture and the abutment) must be looked upon as a tooth root. The degree of bone resorption and other anatomical characteristics also have to be considered. Furthermore, it is important to keep in mind that implant components of approximately the same dimension are intended to serve as supports for teeth of different sizes.
Occlusion is important for the load distribution; the lesser resilience of the implant segments relative to the adjacent teeth may force the implants to take the major share. If cuspal contact is allowed, higher cusp inclination leads to higher relative magnitude of the transverse force component and the position of the lateral excursive contact determines the position of the force; the more lateral the contact, the greater the leverage.