Post surgical incision line failures is a common occurrence for various reasons. The damaged tissue from the incision is required to re-attach but the biological process of wound healing dictates in period of vulnerability to the site.  The tissue integrity is compromised because of surgical trauma. It may he further compromised if there is opposing tension within the flap.  Bacterial ingress and/or physical trauma at the incision region is always a threat. The latter ranges from food impaction, muscle pull, pressure from adjacent structures such as the tongue and even normal function such as deglutition or speech may interfere with the timely healing of the incision site. The act of suturing and the frequency of punctures to the tissue as part of the suture placement also compromises the blood supply and tissue integrity at the incision line. The act of releasing the periosteum compromises the blood supply of the overlying soft tissue and further increases the risk of incision line failure.  Finally, the suturing soft tissue flaps over non-vital graft material devoid of blood supply is never ideal for soft tissue healing. Therefore, surgical success may be greatly enhanced if incisions are avoided over any graft material. Remote incision and tunnel approach to bone grafting are two fundamentally game changing principles that bares examination.  The concepts are part of a larger philosophy of Natural Implant Restoration In Stable Alveolar Bone. ( NIRISAB )  that was developed since the 1970’s and first presented by Hilt Tatum. This article presents three clinical cases with ten year plus followup results of three bone grafting modalities: 1. Tunnel particulate graft,  2. Tunnel alloblock graft, 3. Tatum Vascularized Osteotomy.  All three modalities utilized the philosophy of NIRISAB.  Of particular emphasis in this article, is the surgical approach of tunnelling and lack of a crestal incision and a remotely placed access incision.

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