Advanced Perio Excellence (APEX)

Contents

Lecture 1 - Introduction to Restorative Dilemmas & the Restorative Ladder

Course framing; aesthetic outcomes as the end goal; minimum intervention principle; root-to-coronal assessment framework applied to a failed-crown case; three case-based ortho decision examples.

Lecture 2 - Soft Tissue Assessment Provisionals & Road-Testing Outcomes

Diagnosing soft tissue before replacing crowns; extruded anteriors from cingulum design failure; roadtesting provisionals for phonetics, stops and tissue response; 1-year stable outcome.

Lecture 3 - Biological Width – Introduction, Anatomy & Clinical Importance

Four normal and four abnormal gingival classifications introduced; 3mm BW compartments (connective tissue + junctional epithelium + sulcus); clinical cases illustrating 3mm vs 2mm bone-to-margin; why invasion must be avoided.

Lecture 4 - Normal Crest, Safe Margin Placement & Biotype Responses to Violation

Normal crest present in 85% of patients; 0.5mm subgingival prep rule; thick biotype (inflammation, hyperplasia) vs thin biotype (recession, attachment loss).

Lecture 5 - Bone Sounding Technique & the Kois Classification

Bone sounding method with probe kept on tooth surface; Kois 1996 paper; normal crest (3mm), high crest (1–2mm) and low crest (4mm) defined; high crest danger signs including retraction cord sign

Lecture 6 - Low Crest: Stable vs Unstable Tissue, Thin Phenotype & Classification Recap

Stable low crest (long JE, probe not visible) vs unstable (sulcusdominant, probe visible through tissue); thin phenotype clinical signs; provisionals to convert unstable to stable; management recap for all four Kois types.

Lecture 7 - Altered Passive Eruption – Definition, Prevalence & the Sickle Probe

APE defined as excess gingiva covering enamel coronal to the CEJ; short clinical crowns; 12% prevalence, twice as common in females; sickle probe technique for CEJ detection introduced.

Lecture 8 - APE Classification: Types 1a, 1b, 2a & 2b

Type 1 (adequate KT) vs Type 2 (mucogingival line close to crown); subtype a (bone 3mm from CEJ) vs subtype b (bone at CEJ); treatment per type — gingivectomy, gingivectomy + bone removal, or APF.

Lecture 9 - APE Differential Diagnosis: Gummy Smile, Wear Small Teeth & Diagnostic Limits

Hyperactive lip vs APE vs incisal wear vs small teeth; 10.5mm central reference; sickle probe + perioprobe sequence; two contrasting gummy smile cases — one treatable, one untreatable.

Lecture 10 - APE in Practice: Crown Lengthening to Save an Unrestorable Tooth

Tooth referred for extraction; Type 1a APE confirmed; gingivectomy + provisional + 5-month maturation; 10-year stable outcome; restorative ladder principle reinforced.

Lecture 11 - Clinical Pitfall 1: Crown Replacement Without Bone Sounding

Crown replaced without diagnosis; assumed 85% normal crest; massive BW invasion confirmed 6 weeks post-fit; corrective flap and interproximal bone removal; BW variation occurs tooth-by-tooth in the same patient.

Lecture 12 - Clinical Pitfall 2 : Veneers Placed Without Checking Bone Level PostGingivectomy

Gingivectomy for symmetry followed immediately by veneer prep without bone sounding; bone found at CEJ; massive inflammation from BW invasion; corrective bone removal; 5- year result with minor rebound.

Lecture 13 - APE Surgery: CEJ Marking Gingivectomy Bone Removal & Osteoplasty in Detai

Gummy smile case with bone at CEJ; per-tooth bleeding-point marking; scalpel gingivectomy with papilla definition; raising the flap; osteotomy to 3mm; osteoplasty to contour bone shelf; suturing at CEJ; 6-month result.

Lecture 14 - APE Surgery Cases: Simple Gingivectomy Pre-Ortho Tissue Prep & Diagnosing Inflammation

Second gappy APE case (Type 1a, no bone removal needed); scalpel vs electrosurgery; improved bracket placement post-gingivectomy; third case — differentiating plaqueinduced from BW invasion using bone sounding.

Lecture 15 - Type 2 APE & the Apically Repositioned Flap: Preserving Keratinised Tissue

When insufficient KT band prevents gingivectomy; APF technique: splitthickness papillae to maintain blood supply; suturing at base of papilla (not tip) to gain 2.5mm crown length without cutting tissue.

Lecture 16 - APF Case Example: Bone Removal Papilla Base Suturing & Outcome

APF applied with bone removal; papillae split-thickness preserved; suture tied at papilla base; 2-week result; composite tips for residual wear; black triangle risk if papilla is inadvertently removed.

Lecture 17 - Gum Level Manipulation: Root Reduction Emergence Profile & Slow Orthodontic Principles

Lowering the gum line via root bulk reduction; emergence profile on implants to push or lower gingival margin; slow ortho allows BW to adapt; rapid intrusion/extrusion concept; root resorption warning with duration limits.

Lecture 18 - Crown + Ortho Sequencing: Why Anatomical Temporaries Must Come Before Orthodontics

Ortho on non-anatomical crowns creates false tooth positioning; rotated tooth found only after treatment; correct protocol: remove crowns, fit anatomical temps, then move; wedding-deadline case as cautionary lesson.

Lecture 19 - Complex Ortho-Restorative Case: Bridges Spacing Deep Bite & Bite Raising

Ill-fitting bridges + spacing + deep bite + gummy smile; anatomical temps first; slow anterior intrusion to close spaces; posterior extrusion to open bite; bite-raising appliance for severe deep bite; incisal wear counselling.

Lecture 20 - Advanced Case: Gummy Smile with Bruxism & Evaluating All Treatment Options

Natalie, 26, bruxism, parafunctional wear, mild Type 1a APE, hyperactive lip; gingivectomy insufficient; lip repositioning risks discussed (asymmetry in one third, 50% relapse); veneers contraindicated; rapid intrusion proposed.

Lecture 21 - Rapid Orthodontic Intrusion: Converting Type 1a to 1b Technique & 17-Year Follow-Up

Rapid intrusion to move CEJ to bone before BW can adapt; isolated intrusion jig for centrals (TADs modern equivalent); 3–5 months; then gingivectomy + bone removal; composite added; 17-year follow-up; lip musculature reduction with age noted.

Lecture 22 - Restored Teeth & No Overbite: When Rapid Intrusion Is Contraindicated

Four restored veneers, no overbite: intrusion would cause open bite and BW reaction from crown material pushed subgingivally; alternative — levelling + aligning + elective bone removal beyond 3mm; triangular crown profile trade-off; 10-year review.

Lecture 23 - Refusing Orthodontics: Aggressive Bone Removal to Reposition the Gum Line

Patient declines ortho; 4–5mm bone removed to raise gum line to upper lip level; provisionals for aesthetic and phonetic check; 5-year review; Emax shine-through on dark root identified as material complication.

Lecture 24 - Non-Vital Teeth: Dark Roots Material Selection Internal Bleaching & CTG Masking

Dark core shine-through with Emax vs zirconia opacity trade-off; walking bleach limitations (50% relapse at 5 years); inside/outside home bleaching protocol; CTG tunnel to thicken gum and mask root; recurring recession cycle management.

Lecture 25 - Root Coverage: Indications CAF vs Tunnelling & Trapezoidal Flap Design

Root coverage indications; CAF vs tunnelling meta-analysis — operator mastery is the key variable; mathematical flap advancement matching recession depth; composite removal; EDTA 24% and Emdogain protocol; split/full thickness sequence.

Lecture 26 - Root Coverage: Releasing the Flap, Muscle Separation & Coronal Advancement

Flap anatomy (periosteum, muscle, buccal mucosa); muscle must be separated from flap to prevent relapse and vestibule loss; coronal advancement; big-square papilla design for predictability; suturing; 6- year stable outcome.

Lecture 27 - No-Vertical-Cut Technique: Multiple Recession, Sling Sutures & Soft Tissue Grafts

Cuts converging to canine eliminate vertical scarring; 45° split-thickness blade angle; root cleaning mandatory for reattachment; sling sutures; CTG in enamel concavities to prevent collapse; full-arch approach; integration with simultaneous implant placement.

Lecture 28 - Soft Tissue Management Around Implants: Immediate Implant & CTG Protocol

Envelope flap with no vertical cuts; CTG sutured inside buccal flap for thick peri-implant tissue; immediate implant + bone graft + STG; provisional shaped to preserve CTG space; 7-year CT scan follow-up; why STG is always essential around implants; course conclusion.

Exam

APEX Exam

£350 or 3 monthly payments of £116.67

Dr Rob Oretti

Rob qualified at King's College, London in 1987 before beginning his career in an orthodontic practice in Colchester.

After four years, he moved to Newbury, Berkshire, where he spent the next 14 years working in a busy private practice.

During this time, he built a reputation for treating complex cases involving cosmetic, implant and orthodontic treatments.

Rob now spends his time between treating referred patients at Pentangle Dental Transformations and teaching. He is a postgraduate tutor for the Thames Valley Deanery, a mentor and faculty educator for the ADI (Association of Dental Implantology), a mentor and international speaker for the ITI (International Team of Implantologists), a Royal College of Surgeons examiner for the implant diploma (RCS Edin) and the Membership in Advanced General Dental Surgery (MAGDS RCS Edin), and was president of BAAD (British Academy of Aesthetic Dentistry) from 2018-2020.