BIOBRIEF

Prosthetic-Surgical Approach to Regenerative Treatment for Peri-Implantitis

Andrea Ravidà, DDS, MS, PhD

Anu Viswanathan DDS, MDS

THE SITUATION

A 68-year-old male patient, who received an implant in tooth position #31 about 8 years prior, presented for an examination. He reports bleeding during brushing around the implant and some discomfort. Clinically, there was severe vertical bone loss, profuse bleeding on probing, and deep probing depths, but no pain. The condition was diagnosed as peri-implantitis according to the 2018 classification.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Infection at implant sight	None	Chronic	Acute
Restorative status of adjacent tooth	Intact		Restored
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Additional Risk Factors: The patient exhibited bleeding on probing and deep pocket depths. He also reported occasional marijuana use and was inconsistent with periodontal maintenance and oral hygiene visits.

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THE APPROACH

The treatment goals were to eliminate peri-implant infection, regenerate lost hard and soft tissues, and ensure long-term implant stability. A closed regenerative approach was utilized, including crown removal, thorough implant decontamination with Perioflow®, an airpolishing technology, application of the correct bone grafting materials (Geistlich Bio-Oss®, vallos® and GEM 21S®), enclosed healing, and fabrication of a new crown to facilitate hygiene.

Clinical presentation of tooth #31 showing radiographic evidence of bone loss, profuse bleeding on probing (BOP), deep probing depths, and suppuration, indicative of peri-implantitis with a Class I-infraosseous (c) circumferential-type defect, as described in the study by Monje et al. (2019) Clin Implant Relat Res, 21(4)635-643.

Crown removal by the prosthodontist, followed by placement of a healing abutment for non-surgical therapy using PerioFlow®. After therapy, a cover screw was placed, and the tissue was allowed to heal over the implant for eight weeks.

Surgical treatment initiated with a midcrestal incision and full-thickness flap elevation. Granulation tissue was removed using a surgical curette, revealing a deep infrabony defect.

Implant thoroughly decontaminated using Perioflow® with erythritol powder to ensure a clean surface for regeneration.

rhPDGF-BB was used to hydrate bone grafting materials (vallos® Demineralized Cortical Granules and Geistlich Bio-Oss®), which were first hydrated with sterile water before rhPDGF-BB was added. The materials were mixed in a 1:1 ratio and allowed to sit for 10 minutes before being applied to the deep infrabony defect to promote regeneration.

Collagen membrane stabilized with 5-0 chromic gut sutures using the lasso technique. Flap closed primarily with 5-0 PTFE horizontal mattress and single interrupted sutures for secure closure.

After 5 months of healing, significant bone gain is evident. Geistlich Bio-Oss® was placed on the buccal site to enhance thickness, covered with an amnion-chorion membrane. A healing abutment was placed at this stage.

Two-year follow-up shows disease resolution with shallow probing depths, no bleeding or suppuration, and complete bone gain. A new crown was fabricated with an increased final abutment height (>2mm), contributing to optimal maintenance and long-term stability based on evidence supporting its role in promoting long-term success. A second surgery may be necessary to gain additional tissue thickness or cover residual thread exposure to achieve the desired long-term results.

“The implant presented with significant bone loss, deep probing depths, and bleeding on probing, placing it at risk of failure and requiring intervention to preserve function and longevity.”
— Andrea Ravidà, DDS, MS, PhD

THE OUTCOME

At the two-year follow-up, clinical and radiographic assessments showed disease resolution, complete bone gain, and stable peri-implant tissues. Probing depths were within healthy ranges, and no bleeding on probing was observed, confirming the long-term success of the treatment.

Enclosed healing, meticulous implant decontamination, appropriate selection of bone grafting materials, and customized crown design, combined with patient compliance and regular maintenance, contributed to disease resolution and complete bone regeneration.”
Andrea Ravidà, DDS, MS, PhD

The air polishing device with erythritol powder ensured thorough implant decontamination, while the bone grafting materials combined with rhPDGF-BB provided essential biologic support for regeneration and improved peri-implantitis treatment outcomes.”
Andrea Ravidà, DDS, MS, PhD

Andrea Ravidà, DDS, MS, PhD

Dr. Andrea Ravidà is the Director of the Graduate Periodontics Program in the department of Periodontics at the University of Pittsburgh. He conducts clinical research focusing on peri-implantitis, periodontitis and short implants. He has published more than 70 peer-reviewed articles and conference abstracts/presentations related to periodontics and implant therapy. He is section editor of the International Journal of Oral Implantology and the Journal of Translational Medicine.

Anu Viswanathan DDS, MDS

Dr. Anu Viswanathan is a Diplomate of the American Board of Periodontology and Implant Dentistry. She earned her Doctor of Dental Surgery degree from the University of Colorado School of Dental Medicine in 2019. Dr. Viswanathan completed a Certificate in Periodontics and earned a Master of Dental Science at the University of Pittsburgh School of Dental Medicine. She also obtained a Certificate in IV Sedation. Dr. Viswanathan is currently in private practice in Shoreline, Connecticut.

BIOBRIEF

Mandibular Ridge Augmentation Using Customized Titanium Mesh

Shaun R. Young, DMD

THE SITUATION

A 60-year-old healthy male presented with a failing lower left bridge. Due to a long history of missing teeth, he had a significantly atrophic mandibular ridge. We decided to use a customized titanium mesh to achieve the necessary vertical and horizontal bone augmentation for dental implant rehabilitation.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

The goal of this procedure was to regenerate sufficient bone to place restoratively driven dental implants. Due to the horizontal and vertical ridge deficiency, we used a customized titanium mesh to predictably achieve this outcome.

Autogenous bone collected with SafeScraper Twist and Geistlich Bio-Oss® filled the Yxoss CBR® Protect and a Geistlich Bio-Gide® collagen membrane covered the mesh.

Pre-op mandibular ridge after the extraction of teeth #17 and #20. Note the significant horizontal ridge deficiency.

Yxoss CBR® Protect Customized Bone Regeneration Titanium Mesh in place, secured with two Stryker screws, 1.2 mm in diameter and 6 mm in length.

Note the excellent adaptation of the Yxoss CBR® Protect and that the edges are apical to the adjacent bony sockets.

Geistlich Bio-Gide® (resorbable collagen membrane) draped over the Yxoss CBR® Protect to separate osteoblasts from fibroblasts.

Implants restored with single-unit crowns.

Guide pins in place for implants #19, #20, and #21, with adequate ridge height and width.

Screw-retained final implant crowns with healthy keratinized tissue on the facial side.

“Success in these cases primarily depends on proper mesh design and careful handling of soft tissue to ensure zero-tension primary closure.”
— Shaun R. Young, DMD

THE OUTCOME

A left mandibular ridge deficiency was corrected using a Yxoss CBR® Protect Customized Bone Regeneration Titanium Mesh, designed from the patient’s CBCT scan.

Guided bone regeneration using Yxoss CBR® Protect to correct vertical and horizontal mandibular ridge deficiencies is a predictable procedure.”
Shaun R. Young, DMD

Shaun R. Young, DMD

Dr. Shaun Young, an Oral and Maxillofacial Surgeon based in Tampa, Florida, specializes in complex ridge augmentation, immediate implants, and All-on-X full arch rehabilitation. He earned his Doctor of Dental Medicine degree from the University of Florida and completed his OMFS residency at Emory University in Atlanta, Georgia, where he served as Administrative Chief Resident. Dr. Young brings his expertise to a full-scope group practice, serving Tampa, Clearwater, and New Port Richey, Florida.

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BIOBRIEF

Alveolar Ridge Preservation with vallos® Mineralized Cortico-Cancellous Allograft

Hanae Saito, DDS, MS, CCRC

Andrew Tong, DDS

THE SITUATION

A 68 year old female patient was referred from her general dentist for persistent minor discomfort on #31, suspected endo-perio lesion. Upon the examination, deep probing depth and grade 1 mobility were noted. Radiographic interpretation indicating a large J shaped lesion and possible root fracture. Patient had missing #30 and #32 has been mesially drifted and left a restorative space more than > 13 mm mesio-distally.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system/Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

* The esthetic related risk factors are not needed for this case. Restorative space of more than 13 mm may be an additional risk factor.

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THE APPROACH

A successful treatment outcome comes with proper selection of the technique and materials. In order to facilitate an implant supported restoration in the site with > 13mm mesio-distal space, a staged approach was selected, with alveolar ridge preservation (ARP) performed using an atraumatic extraction technique and vallos^®mineralized cortico-cancellous bone allograft chosen as the material.

Preoperative radiograph of #31 with guarded prognosis due to potential root fracture and infection.

Atraumatic extraction was performed and intact furcation bone is noted.

vallos® mineralized cortico-cancellous bone allograft was placed.

A collagen plug was used to cover the bone allograft

Immediate post alveolar ridge preservation radiograph.

Healing at 2 weeks prior to implant placement.

Healing at 4 months prior to implant placement.

Implant was placed with 32 Ncm. Post implant placement radiograph.

6 months after the implant placement, the final restoration was delivered.

“Ensuring atraumatic extraction techniques, regardless of whether it’s in the anterior or posterior regions, is crucial for preserving the integrity of both hard and soft tissues. Equally important is the selection of biomaterials that not only offer structural support but also possess bone regeneration properties.”
— Dr. Hanae Saito

THE OUTCOME

The planned treatment of replacing a tooth with a dental implant in the regenerated alveolar ridge was achieved. By employing secondary intention healing following ARP and utilizing a lingual paracrestal incision, adequate keratinized tissue was preserved on the buccal side of the implant-supported restoration.

Removal of the infection and maintaining the ridge dimension for the implant supported restoration in the site with > 13 mm mesio-distal space were required.”
Dr. Hanae Saito

Hanae Saito, DDS, MS, CCRC

Hanae Saito, DDS, MS, CCRC serves as a clinical associate professor and oversees the Dual Perio-Pros program and predoctoral periodontal education within the Division of Periodontics, at the University of Maryland School of Dentistry. She is a Diplomate of the American Board of Periodontology. Dr. Saito obtained a Master of Science in Clinical Research and a certificate in Periodontics from New York University College of Dentistry. Additionally, she operates a faculty practice focused on periodontology and implant dentistry.

Andrew Tong, DDS

Andrew Tong, DDS earned his Bachelor of Science degree from the University of Maryland at College Park in 2015 before completing his Doctor of Dental Surgery (D.D.S) degree at the University of Maryland School of Dentistry in 2019. Following this, he undertook a General Practice Residency at the Newark Beth Israel Medical Center in New Jersey from 2019 to 2020. Dr Tong now practices general dentistry at Tong Dental Care in Gaithersburg, MD. Concurrently, he is pursuing a Master’s degree in Periodontics at the University of Maryland School of Dentistry.

BIOBRIEF

The Buccal Pedicle Flap for Peri-Implant Soft Tissue Volume

Dr. Giorgio Tabanella

THE SITUATION

Patient presented with a fistula buccal on tooth #9 associated with a chronic peri-apical lesion and external root resorption. Also tooth #8 showed a chronic peri-apical lesion. Her chief complaint was the misalignment of her teeth. The clinical situation revealed the presence of bleeding upon probing and generalized moderate periodontal disease (Stage II, Grade I) as well as multiple endodontic failures.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: request for reducing the healing time, long-term maintenance

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THE APPROACH

The aim of the treatment is to eradicate periodontal disease and restore esthetics and function. Treatment planning: non-surgical and surgical periodontal treatment, orthodontic alignment, extraction of both central incisors, immediate implant placement and Guided Bone Regeneration with Geistlich Bio-Oss®, peri-implant soft tissue boosting with a buccal pedicle flap and full ceramic CAD-CAM restorations.

The clinical picture is showing a fistula buccal to #21 as well as leakage on old composite restorations. A thin biotype is evident.

The sagittal cuts are reporting chronic peri-apical lesions on both central incisors and a thin buccal plate with minor vertical bone loss but fenestration apical to #21.

The intrasurgical picture is showing the bony defect, the buccal fenestration and the thin buccal plate.

After allowing the tissue to heal for 4 months a first “Buccal Pedicle Flap” was performed during the uncovery of the dental implant. Simultaneously, Geistlich Fibro-Gide® was inserted into the envelope created by the flap design.

Geistlich Fibro-Gide® is reduced to a thickness of 4 mm at its borders so that it is easier to get adapted to the recipient site.

The Fibro-Gide® is trimmed so that its borders don’t approach the vertical incisions of the Buccal Pedicle Flap.

Polypropylene 6.0 sutures are used to compressed the Fibro-Gide® underneath the flap thus creating the “wrinkles” on the mucosa.

The wrinkles are visible also on the occlusal view. The mucogingival line is repositioned at its original level.

Four months after immediate implant placement and GBR in area #11 a second Buccal Pedicle Flap is performed to reduce the buccal concavity, boost the peri-implant mucosa and increase the thickness as well as the band of the keratinezed mucosa.

As in the previous surgery the Fibro-Gide® is inserted underneath the Buccal Pedicle Flap and stabilized with e-PTFE 6.0 sutures.

8 weeks post surgery, the occlusal view is showing a biomimetic countouring of the peri-implant mucosa.

The final esthetic result is emphasizing an excellent blending of “white” and “pink” esthetics.

“Orthodontic treatment must be postponed because of the presence of periodontal disease. A thin biotype and a high smile line needs to be taken into consideration.”

THE OUTCOME

The final outcome at 8 weeks is showing pink esthetics as well as biomimetics and function. The use of the buccal pedicle flap allowed the increased volume of the peri-implant mucosa with a minimally invasive approach. The combination of Geistlich Fibro-Gide® and a buccal pedicle flap had the main advantage of reducing the morbidity generally associated with CT harvesting.

Dr. Giorgio Tabanella

Dr. Tabanella is a Diplomate of the American Board of Periodontology, an Active Member of the Italian Academy of Esthetic Dentistry and author of the book “Retreatment of Failures in Dental Medicine”. He graduated from the University of Southern California, Los Angeles, USA where he obtained his Certificate in Periodontics as well as a Master of Science in Craniofacial Biology. He is Director of O.R.E.C. – Oral Reconstruction and Education Center (www.tabanellaorec.com), reviewer and author of original articles.

BIOBRIEF

Use of Geistlich Fibro-Gide® for Correction of Maxillary Anterior Soft Tissue Peri-implant Ridge Deficiencies

Dr. Israel Puterman

THE SITUATION

A 27-year-old female with congenitally missing maxillary lateral incisors was referred for implant placement. Following completion of orthodontics, a plan was developed to place dental implants at the #7 and #10 positions. Based on CBCT evaluation, alveolar ridge height and width was deemed sufficient for implant placement. Despite sufficient bone volume, facial ridge volume deficiencies were noted at both edentulous sites, requiring augmentation to allow for optimal esthetics.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

The goal of treatment was to replace missing maxillary lateral incisors with dental implants, while providing an esthetic result with predictable and minimally invasive techniques. Employing a surgical guide for implant placement, implants were placed in precise 3-dimentional positions. The use of xenograft biomaterials (Geistlich Fibro-Gide®) allowed for the augmentation of gingival biotype and elimination of the buccal ridge deficiencies while avoiding the harvesting of autogenous tissue.

Pre-surgical, occlusal view, demonstrating buccal ridge concavities at edentulous sites, #7 and #10.

Geistlich Fibro-Gide® collagen matrix is cut and shaped prior to placement into surgical sites.

Immediate post-surgical occlusal view following placement of implants and Geistlich Fibro-Gide® on facial aspects. Implant #7 was provisionalized immediately, however implant #10 did not achieve sufficient stability and a healing abutment was placed.

Immediate post-surgical facial view. One can note the buccal prominences being developed by the presence of Geistlich Fibro-Gide®.

2-month post-surgical view, following provisionalization of implant #10. Buccal convexities at the implant sites are still evident.

8 month view of implant sites at time of torque test, following maturation of gingival emergence. Of note is thick, convex buccal tissue free of any sign of inflammation.

Occlusal view following final restoration, (Dr. Paul Krainson). Natural-appearing buccal gingival convexities remain 1.5 years post-surgery.

Frontal view of final restoration of implants. The tissue health with stippling and root-like gingival prominences are noted.

“A buccal ridge deficiency with congenitally missing lateral incisors in a high-scallop, high-smile young female patient.”

THE OUTCOME

The presented case involves a female patient with congenitally missing maxillary lateral incisors and soft tissue ridge deficiencies. Implants were placed and a volume-stable collagen matrix Geistlich Fibro-Gide® was placed to provide labial soft tissue volume. The tissue emergence was then developed with the use of provisional restorations, one placed at the time of surgery, the other following implant integration. The implants were restored with gingival tissue transformed to mimic convex root emergence.

Correction of labial soft tissue ridge deficiencies at implant sites through use of a Geistlich Fibro-Gide® volume stable, collagen matrix.”
Dr. Israel Puterman

A volume-stable collagen matrix can be used to correct a labial soft tissue deficiency, eliminating the potential negative sequelae of an autogenous connective tissue graft.”
Dr. Israel Puterman

Various materials can be used to restore a soft tissue deficiency; use of a volume-stable collagen matrix provides numerous advantages when used in the proper indication.”
Dr. Israel Puterman

Dr. Israel Puterman

Dr. Puterman, originally from Montreal Canada, received his DMD from Boston University in 2002 and dual graduate certificates in Implant Dentistry and in Periodontics from Loma Linda University in 2008. He is a published author in various journals including the Journal of Prosthetic Dentistry and the Journal of Prosthodontics. He practices in the Washington, DC area.

BIOBRIEF

Successful Implant Placement and Horizontal Augmentation for Bilateral Congenitally Missing Maxillary Incisors

Dr. Avinash Bidra

THE SITUATION

A 30-year-old male patient was referred to me with bilateral congenitally missing lateral incisors in the maxilla. The referring general dentist had previously made a resin-bonded bridge which was successful for a few years but had frequent debondings. Clinical examination revealed lack of ridge contour but the CBCT revealed existence of adequate width for placement of narrow-diameter implants with additional bone grafting and contour augmentation. The existing bone anatomy precluded placement of implants for screw-retained restorations without a pre-surgical lateral ridge augmentation procedure. The patient accepted a treatment plan for placement of two narrow-diameter implants and simultaneous bone grafting and contour augmentation followed by restoration with zirconia cement-retained crowns.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Compromised
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

My treatment goals were to preserve the existing soft-tissue architecture, especially the interdental papilla, mesial and distal to the lateral incisors, improve the facial contour at the lateral incisor sites by bone grafting with a low substitution biomaterial, and harmonize esthetics and function with optimal implant-supported restorations.

Frontal view revealed adequate contours of soft-tissue especially in gingival height and presence of interdental papilla which needed to be preserved.

Bilateral papilla-sparing incisions were used to preserve the existing papilla and the osteotomies were prepared to allow implant trajectories for cement retained restorations.

An apical fenestration was noted in the osteotomies. After placement of a narrow diameter implant at patient’s right lateral incisor, the site was grafted with a mixture of autologous bone chips and Geistlich Bio-Oss®.

Geistlich Bio-Gide® is trimmed to match the trapezoidal flap design and placed over the graft material.

Healing Abutments 3.5 mm were placed at time of surgery for single-stage healing

After a 3-month healing period, the implants were osseointegrated and then screw-retained provisional crowns were fabricated over both implants. The soft-tissues showed an excellent response to the bone graft materials.

The soft tissues around the implants show excellent maturation and support especially in the interdental papilla region which was preserved during surgery.

Occlusal view shows adequate restoration of the facial contour around the implant restorations indicating excellent outcome from the contour augmentation procedure.

Frontal close-up view of the implant restorations shows pleasing dental and gingival esthetics.

“The patient had failed resin-bonded bridges with deficient contours for bilateral congenitally missing lateral incisors.”

THE OUTCOME

Single-stage implant placement with bilateral papilla-sparing incision design and simultaneous contour augmentation using a mixture of Geistlich Bio-Oss® autologous bone chips and Geistlich Bio-Gide®.

The low substitution bone graft, combined with a rapidly vascularizing membrane, helped to achieve the biological integration of the biomaterial.”
Dr. Avinash Bidra

The use of Geistlich Bio-Gide® and Geistlich Bio-Oss® mixed with autologous bone can lead to a successful outcome in single-stage implant placement with simultaneous contour augmentation.”
Dr. Avinash Bidra

Dr. Avinash Bidra

Dr. Bidra is a Board Certified Maxillofacial Prosthodontist and Director of the Prosthodontics Residency Program at UCONN School of Dental Medicine. He has extensive surgical experience and maintains a part-time private practice restricted to Implant Surgery and Prosthodontics in Meriden, CT. He has lectured at national and international meetings, as well as published extensively in international scientific journals. He has invented prosthetic components and is a co-inventor of a new implant design.

BIOBRIEF

Phenotype Conversion Using Geistlich Fibro-Gide® for Immediate Implants in the Esthetic Zone

Dr. Robert A. Levine

THE SITUATION

A healthy non-smoking 50-year-old female patient who desires a single tooth solution to replace a non-restorable tooth, #12. A root fracture at the level of the palatal post was diagnosed in a root canaled tooth. Maintaining esthetics of the adjacent teeth is important as they are also restored with single full coverage porcelain crowns. Lastly, treatment time reduction and a minimally invasive surgical technique are desired by the patient for reduced downtime and post-operative morbidity.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Patients Esthetic Expectations: Realistic
Facial Bone Wall Phenotype: High Risk (<1mm)
Esthetic Risk Profile (ERP) = Medium (summary of above)

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THE APPROACH

A minimally invasive surgical removal of tooth #12 with maintenance of the buccal plate and leaving a 3mm buccal gap. The implant will be placed one mm below the level of the intact buccal plate with an anatomically correct surgical guide template to provide for a screw-retained solution. The gap will be filled with Geistlich Bio-Oss Collagen® to maintain the bone buccal to the implant, and a palate free approach utilizing Geistlich Fibro-Gide® for soft tissue thickening to accomplish “phenotype conversion.” The long-term surgical goal is >2-3mm thickness of both hard and soft tissue buccal to the implant.

Pre-operative assessment demonstrates minimal zone and thickness of buccal keratinized gingiva, with a medium periodontal phenotype.

Pre-operative CBCT with virtually planned implant placement. A thin buccal plate (<1mm) is measured. Good apical bone is noted for the placement of a Straumann® 12mmx4.1mm bone level tapered implant.

Minimally invasive removal of #12 using only a buccal approach mini-flap showing an intact buccal plate with immediate placement of the implant (1 mm below the intact buccal wall) in a screw-retained position. A 3mm buccal gap is measured and a 1.5mm palatal gap.

Both the buccal and palatal gaps have been packed with Geistlich Bio-Oss Collagen® hydrated with Gem 21S. It’s my preference to squeeze Geistlich Fbro-Gide® between thumb and forefinger, prior to placement. A dry-carved piece of Geistlich Fibro-Gide® is in position thinned approximately 2mm with beveling laterally and coronally with a new #15 blade.

Geistlich Fibro-Gide® in place facial to the intact buccal wall under a full thickness buccal approach mini-flap. Immediate contour management was completed using an Anatotemp® for a maxillary bicuspid tooth.

Suturing completed using 4-0PTFE and 5 -0 polypropylene non-resorbable sutures. Anticipated short-term 25% post-operative swelling is discussed with the patient.

3 months post-operative appointment showing a well-developed subgingival transition zone created with immediate contour management. A reverse torque test was completed, and the case proceeded to completion.

9 month post-operative view with final screw-retained crown in place. Good interproximal papilla healing is noted with thickening of the buccal periodontal phenotype compared with Fig. #1. (Restorative Therapy: Drew Shulman DMD, MAGD; Philadelphia, PA)

“High esthetic demands were the primary concern with this case. They were addressed with the diagnostic tools of clinical photos, a site specific CBCT to evaluate the buccal wall status, and summing the findings with patient expectations gathered using the Esthetic Risk Assessment (knee-to-knee; eye-to-eye) which is used along with our consent agreement to treatment.”

THE OUTCOME

Minimally invasive surgery for buccal wall maintenance, virtually planning the buccal gap and implant width, using a xenograft in the buccal gap with phenotype conversion using a volume stable collagen matrix in conjuction with immediate contour management, allows for the best chance for papillae fill interproximally and maintenance of the mid-buccal gingival margin long-term.

Virtual planning the implant width for a screw-retained prosthesis based on an intact buccal wall after extraction to allow for a buccal gap of >2mm to be grafted are important keys for esthetic success.”
Dr. Robert A. Levine

The importance of the ‘one-two punch’ of ROUTINE phenotype-conversion using Geistlich Fibro-Gide® in conjunction with bone grafting the >2mm buccal gap with Geistlich Bio-Oss Collagen® provides excellent buccal convex tissue maintenance long-term.”
Dr. Robert A. Levine

Dr. Robert A. Levine

Robert A. Levine DDS is a board-certified periodontist at the Pennsylvania Center for Dental Implants and Periodontics in Philadelphia. He is a Fellow of the International Team for Dental Implantology (ITI), College of Physicians in Philadelphia, International Society of Periodontal Plastic Surgeons and the Academy of Osseointegration. He has post-graduate periodontology and implantology teaching appointments at Temple University in Philadelphia, UNC in Chapel Hill and UIC in Chicago and has over 80 scientific publications.

BIOBRIEF

Guided Tissue Regeneration in the Esthetic Zone of a 34-Year-Old Male

Bassam Kinaia, DDS, MS, DICOI

THE SITUATION

A 34-year-old healthy male presented with increased spacing between maxillary left central and lateral incisors. Clinical examination showed deep probing depths between #9-10 area. Cone-beam computed tomography (CBCT) showed vertical bone loss #9-10 wrapping around the palatal surfaces. Treatment recommendation included guided tissue regeneration (GTR) to stabilize the periodontium.

Area #9-10 was debrided and showed a wide 1-2 wall defect measuring ~7mm vertical bone loss. GTR procedure using Geistlich vallomix™ bone graft (allograft + xenograft) and a collagen membrane were employed and primary closure obtained. Healing at 2 and 4 weeks and 6 months showed proper bone fill with stable periodontium.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

Correct the vertical bone loss around #9-10 and save the dentition. Sulcular incisions with a paracrestal incision around #9-10 were performed. The area was debrided showing a wide 1-2 bony wall defect (measuring ~7mm vertical bone loss). Primary closure was obtained using 6-0 prolene sutures.

Initial clinical and radiographic presentation showing vertical bone loss #9-10 area

Initial CBCT presentation showing bone loss between #9-10 wrapping palatally

Occlusal clinical views showing sulcular incision with paracrestal incision #9-10

Facial and occlusal clinical views showing full thickness flap reflection with wide 1-2 bony wall defect measuring ~7mm vertical bone loss

Facial clinical views showing full thickness flap reflection and GTR procedure using Geistlich vallomix™ bone graft (allograft as an internal first layer and xenograft as an outside second layer) and collagen membrane

Facial and occlusal clinical views showing primary closure using 6-0 prolene sutures with immediate post-surgical bone addition

Facial and occlusal clinical views showing healing at 10 days with tissue granulating in

Facial and occlusal clinical views showing healing at 6 weeks

Pre-operative vs post-surgical clinical and radiographic views showing adequate bone fill and reduction in probing depths

“Guided tissue regeneration is indicated to correct the vertical bone loss around the #9-10 area and stabilize the periodontium.”

THE OUTCOME

The use of a minimally invasive surgical GTR approach showed excellent radiographic bone fill and reduction in probing depths from 8mm to 3mm at 6 months follow-up. Treatment outcome revealed stable periodontium and the patient was happy with the healthy stable teeth.

Guided tissue regeneration using Geistlich vallomix™ bone graft (allograft as an internal first layer and xenograft as an outside second layer) and collagen membrane showed predictable periodontal regeneration.”
Dr. Bassam Kinaia

Understanding the biology of Geistlich vallomix™ to layer the allograft first (internally for better osteogenic potential) and xenograft second (externally due to slower resorption rate) allowed better space maintenance and predictable regeneration.”
Dr. Bassam Kinaia

Bassam Kinaia, DDS, MS, DICOI

Dr. Kinaia is the Associate Director of the Graduate Periodontology Program at the University of Detroit Mercy (UDM). He is also the former Director of the Periodontology Program at UDM in Michigan and Boston University Institute for Dental Research and Education in Dubai. He is a Diplomate of the American Acade- my of Periodontology (AAP) and International Congress of Oral Implantology (ICOI). He received a certificate of Excellence from the AAP in recognition of teaching-research fellowship.

BIOBRIEF

Geistlich Mucograft® for the Treatment of Multiple Adjacent Recession Defects: A More “Palatable” Option

Dr. Daniel Gober

THE SITUATION

A 35-year-old male presented in my practice with a chief complaint of recession. Multiple buccal recession defects ranging 2-5 mm were noted by teeth #11-14 with a minimal amount of keratinized tissue on the buccal of #14. Bone levels were within normal limits with no loss of interproximal tissue observed. These recession defects are classified as Miller Class I recession defects. Typically, 100% root coverage is expected for recession defects of this type.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Bone defect(s)	Not present	Slight defect <2mm	Significant >3mm
Keratinized tissue	Adequate 5mm	Inadequate <5mm	Inadequate <3mm
Miller classification	Class I-II	Class III	Class IV

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THE APPROACH

My treatment goals included completing root coverage of the recession defects and augmentation of the width of attached keratinized tissue by tooth #14. My patient had similar recession defects on teeth #3-6 which were previously treated with an autogenous sub-epithelial connective tissue graft. Instead of autogenous tissue grafting, Geistlich Mucograft®, a xenogenic collagen matrix, was used in conjunction with a coronally advanced flap.

Pre-operative view of recession defects that ranges from 2-5 mm. There is minimal keratinized tissue on #14. Pocket depths are within limits with no loss of interproximal tissue.

A 15c blade is used to make sulcular incisions with scooping incisions at the level of the CEJ. A combination flap consisting of full-thickness coronally followed by a partial-thickness dissection apically is reflected.

The papillary tissue is de-epithelialized with a football diamond bur on a rotary hand piece. This exposes a vascular bed for the graft and intended coronal positioning of the flap.

Side-view of the recession defects. It is clearly visible how deep the recession defects are.

Geistlich Mucograft® is trimmed and positioned to extend beyond the root surfaces. A combination of simple interrupted sutures at its coronal edge and mattress sutures extending over the entire graft are used to adapt the graft to the recipient site.

The flap is then advanced and coronally positioned with horizontal mattress sutures to release tension and simple interrupted sutures to approximate the flap edges to the de-epithelialized papillas.

Follow-up after 1 week: note that the flap margins appear stable. Erythema and edema evident with maturation of the tissue beginning.

Follow-up after 3 months: maturation of the tissue evident with complete root coverage. An increase in the zone of keratinized tissue by #14 is also visible.

Follow-up after 1 year: stability of the graft is evident, complete coverage and a healthy and maintainable gingival situation have been achieved.

“The patient was unhappy with the post-operative morbidity he
experienced as a result of the previous connective tissue graft.”

THE OUTCOME

This case illustrates the successful use of Geistlich Mucograft®, a xenogenic collagen matrix, for the treatment of multiple adjacent recession defects. Complete root coverage and an increase in the zone of keratinized tissue was obtained and a dento-gingival complex that is amenable to long-term health and stability was achieved. My patient was spared from the inevitable morbidities associated with a sub-epithelial connective tissue graft from a palatal donor site.

Geistlich Mucograft® is a viable alternative to an autogenous tissue graft for the treatment of recession defects.”
Dr. Daniel Gober

Having a thorough knowledge of wound healing can make all of the difference. Every step of the procedure must be planned with the goal of maximizing vascularization of the graft matrix.”
Dr. Daniel Gober

Due to its ability to smoothly and meticulously guide small suture needles through soft-tissue, the castroviejo needle holder is my instrument of choice when suturing during periodontal plastic procedures.”
Dr. Daniel Gober

Dr. Daniel Gober

Dr. Daniel D. Gober received his DDS from SUNY Stony Brook School of Dental Medicine in 2010. He completed his residency in periodontics and implantology at Nova Southeastern University. Dr. Gober is board certified by the American Academy of Periodontology and is a Diplomate of the International Congress of Oral Implantology. He is also certified in the administration of IV sedation and specializes in soft-tissue procedures around both natural teeth and implants. He currently practices in Cedarhurst, NY at South Island Periodontics & Implantology, PLLC.

BIOBRIEF

Soft-Tissue Augmentation in the Esthetic Zone

Prof. Dr. Daniel S. Thoma

THE SITUATION

A young male patient was referred to the clinic with a missing central incisor, #9 following trauma. An implant was placed and the patient was referred for an implant-born reconstruction. The patient does not smoke and drinks occasionally. Upon a clinical examination, extensive horizontal and vertical contour deficiencies are present prior to abutment connection.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: The fractured tooth has a periapical lesion together with a severe bone defect around the horizontal fracture.

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THE APPROACH

The compromized situation with a horizontal and vertical hard and soft-tissue deficit required a soft-tissue volume grafting procedure. A buccal split-thickness flap was prepared and Geistlich Fibro-Gide® shaped and placed. Primary wound closure was obtained. Abutment connection was performed after 8 weeks and the emergence profile created with a provisional reconstruction. The final reconstruction was placed at 3 months.

A young male patient was referred to the clinic with a missing central incisor, #9 following trauma.

Preparation of a split-thickness flap (buccal pouch).

Due to releasing incisions within the periosteum, the tissues can be advanced more coronally.

The dimension and shape of Geistlich Fibro-Gide® with a maximal thickness (5mm) at the transition between the buccal and occlusal aspect.

Geistlich Fibro-Gide® inserted and immobilized with a horizontal cross-suture to the palatal flap.

A provisional reconstruction is inserted; blanching of the tissues can be observed.

Final emergence profile established with a provisional reconstruction.

8 weeks healing: Abutment connection is performed

The clinical situation at 1-year follow-up.

“The patient presented with severe horizontal and vertical hard and soft-tissue defects. I needed a solution that could increase the soft-tissue anatomy around the implant and prosthesis.”

THE OUTCOME

The outcome of the case was very pleasing having fulfilled the patient’s expectations in terms of esthetics and function. The tissues are healthy and volume was obtained through the grafting procedure to match the contour of the neighboring natural tooth.

Soft-tissue augmentation using Geistlich Fibro-Gide® results in a predictable volume gain and reduces surgery time, as well as patient discomfort.”
Dr. Daniel S. Thoma

Prof. Dr. Daniel S. Thoma

Prof. Dr. Daniel Thoma is the head of Reconstructive dentistry and Vice-chairman at the Clinic for Fixed and Removable Prosthodontics and Dental Material Sciences, University of Zurich, Switzerland. He graduated in 2000 at the University of Basel, Switzerland and was trained in implant dentistry and prosthodontics at the clinic for Fixed and Removable Prosthodontics and dental Material Sciences, University of Zurich, Switzerland.

BIOBRIEF

Horizontal Ridge Augmentation in the Posterior Mandible of a 90-Year-Old Female

Dr. John Kim

THE SITUATION

A 90-year-old female presented requesting dental implants be placed in the left mandibular posterior region. Her chief complaint was increased drooling and difficulty chewing on only one side. She lost her bridge one year prior to her visit and firmly stated that she did not want to wear a partial denture. The clinical exam and CBCT showed that there was a horizontal alveolar ridge deficiency that precluded the implants from being placed in a restoratively desirably position. Therefore, a horizontal ridge augmentation was done using multiple layers of Geistlich Bio-Gide® Compressed over a 1:1 ratio of autogenous bone and Geistlich Bio-Oss® xenograft.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: Very limited range of opening

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THE APPROACH

The treatment goal was to gain adequate horizontal bone dimension to allow for prosthetically-driven implant placement. Guided bone regeneration was performed in which autogenous bone was mixed with Geistlich Bio-Oss® xenograft in a 1:1 ratio. PRF was used to create “sticky bone” and was covered by multiple layers of Geistlich Bio-Gide® Compressed. The membrane was stabilized with periosteal biting stabilizing sutures. Tension-free primary closure was achieved and the grafted site was allowed to heal for 8 months prior to the implant surgery for #19 and #20.

Pre-operative situation showing the horizontal ridge deficiency (left). Buccal bone concavity evident after full thickness flap elevation (middle). There is insufficient bone to place implants in an ideal restorative position (right).

It is important to locate the mental foramen. Intramarrow penetrations were done to allow for improved blood supply to the bone graft.

The clinical cocktail used for guided bone regeneration: 1) 50/50 mixture of autogenous bone chips, collected with Geistlich SafeScraper TWIST, and Geistlich Bio-Oss®, and 2) Geistlich Bio-Gide® Compressed 20 x 30 mm and 13 x 25 mm.

“Sticky bone”, created by combining PRF with the bone graft, adapted well to the site of the defect. Periosteal biting sutures were used for stabilization of the multiple layers of Geistlich Bio-Gide® Compressed and underlying bone graft.

Geistlich Bio-Gide® Compressed was carefully trimmed to be mindful of the mental nerve.

Tension-free primary closure achieved with horizontal mattress sutures and simple interrupted sutures.

Re-entry and CBCT scan at 8 months showing a significant increase in horizonal bone dimension.

Sufficient regenerated bone to allow for implant therapy (left). Implants #19 and #20 placed. Vital bone from guided bone regeneration as evidenced by the bleeding bone (middle). Tension-free primary closure achieved using 5-0 glycolon sutures.

“A predictable ridge augmentation procedure was needed to help our 90-year-old patient avoid having nutritional deficiencies due to lack of proper chewing ability and also to improve her quality of life.”

THE OUTCOME

The horizontal ridge augmentation procedure resulted in adequate bone for implant therapy as evidenced by the CBCT scan and re-entry surgery. With a sufficient quantity of good quality regenerated bone, implants for #19 and #20 were placed using a surgical guide based on a diagnostic wax up. Our 90-year-old patient is very happy to be able to chew efficiently again.

Stabilizing Geistlich Bio-Gide® Compressed and the underlying particulate graft allows for predictable ridge augmentation across multiple edentulous sites.”
Dr. John Kim

Dr. John Kim

Dr. Kim, originally from Fairfax, VA, received his DMD from Harvard School of Dental Medicine. He completed his residency and received his M.S. in Periodontics at UNC School of Dentistry at Chapel Hill. Dr. Kim is a Diplomate of the American Board of Periodontology and actively speaks as an expert on guided bone regeneration, implant therapy, soft tissue grafting, and managing complications domestically and internationally. He is also an adjunct faculty at UNC Adams School of Dentistry.

BIOBRIEF

Horizontal Ridge Augmentation in the Esthetic Zone

Dr. Justin Kang

THE SITUATION

An adult female patient presented with a long history of edentulism at site #9. Patient was interested in replacing her missing tooth with a dental implant, and was wearing a Nesbit appliance. The irritation from the ill-fitting Nesbit appliance resulted in irregular and friable soft-tissue at site #9.

Pre-operative CBCT demonstrated a hard-tissue concavity apical to the crest of the bone. The primary goal of therapy was to regain horizontal dimension of hard and soft-tissue to achieve prosthetically-driven placement of a dental implant to replace the patient‘s left central incisor.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: Lack of mutually protected occlusion on the patient‘s left side due to wear from parafunctional habit.

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THE APPROACH

The treatment goal was to regain the horizontal dimension of hard and soft-tissue through guided bone regeneration. In coordination with the restoring dentist, a diagnostic wax up was completed to determine the ideal tooth position and to regain mutually protected occlusion on the patient’s left side. The combination of Geistlich Bio-Oss® and autologous bone chips was used along with Geistlich Bio-Gide® to regenerate the horizontal dimension for prosthetically-driven implant placement.

Baseline: compromised soft-tissue architecture at site #9 due to ill-fitting Nesbit appliance.

Sulcular and paracrestal incision for full thickness flap elevation with single vertical incision distal to the site.

Presence of horizontal tissue deficiency clearly visible following flap elevation.

Application of 50:50 mixture of Geistlich Bio-Oss® and autologous bone chips harvested using Geistlich SafeScraper Twist.

Geistlich Bio-Gide® stabilized using fixation pins and covering the graft material.

Tension-free primary closure achieved using 4-0 PTFE sutures.

Soft-tissue contour at 4-month healing. Fixed provisional in place for soft-tissue contouring.

Occlusal view demonstrating gain in horizontal dimension for prosthetically guided implant placement.

“Patient with a long history of partial edentulism was seeking a long-term, predictable restorative option to replace her missing left central incisor.”

THE OUTCOME

Adequate hard and soft-tissue architecture was restored with the use of Geistlich Bio-Oss® and Geistlich Bio-Gide® for predictable, prosthetically-driven implant placement. The combination of Geistlich Bio-Oss® and autologous bone chips provides the best chance for regeneration while maintaining the hard and soft-tissue contours.

Decortication allows for improved blood supply and nutrients to the bone graft.”
Dr. Justin Kang

This case demonstrates the importance of meticulous incision design, flap advancement, and suturing technique to ensure adequate blood supply and nutrients to the graft material and to maintain primary closure throughout the course of healing.”
Dr. Justin Kang

The combination of Geistlich Bio-Oss® and autologous bone chips provides the best chance for regeneration while maintaining the hard and soft-tissue contours.”
Dr. Justin Kang

Dr. Justin Kang

Dr. Justin Kang received his Doctor of Dental Medicine degree from University of Pennsylvania School of Dental Medicine. He completed his residency and received his Masters of Science in Periodontics at Columbia University College of Dental Medicine. Dr. Kang is a Diplomate of the American Board of Periodontology and a member of numerous professional associations including the Academy of Osseointegration, American Dental Association and the New Jersey Dental Association.

BIOBRIEF

Root Coverage for Multiple Adjacent Teeth in the Maxilla with Geistlich Fibro-Gide® 1.5-Year Follow-Up

Dr. Vinay Bhide

THE SITUATION

The patient is a healthy, 60-year-old female who presented to our clinic with a chief complaint of progressive gum recession which had led to compromised esthetics and sensitivity involving the maxillary left lateral incisor (#10), canine (#11), and first bicuspid (#12) teeth. The teeth in question had 3-4 mm of gingival recession on the buccal surface with a sufficient zone of keratinized gingiva. These teeth also had obvious cervical abrasion.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Classification of recession – RT1 i.e. intact interdental bone and soft tissues
Severity of recession – mild to moderate
Amount of keratinized gingiva – 2 mm or greater for all teeth involved

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THE APPROACH

Treatment goals for this case were to obtain complete root coverage, increase soft tissue thickness, and reduce/eliminate cervical sensitivity. A split-thickness envelope flap approach was used. Geistlich Fibro-Gide® was then trimmed, hydrated with saline, and placed over the exposed root surfaces. The flap was coronally advanced in a tension-free manner to completely cover the biomaterial and exposed root surfaces.

Pre-operative condition: Note that the gingival recession of 3-4 mm is evident as is the cervical root abrasions. The interdental papillae completely fills the embrasure space.

Incision design showing the sulcular incisions with horizontal incisions across the interdental regions ending with a remote oblique vertical releasing incision distal to the first bicuspid tooth.

The interdental papillae were de-epithelialized and Geistlich Fibro-Gide®was placed over the exposed roots extending onto the bone. Geistlich Fibro-Gide® was not secured with sutures.

Internal periosteal releasing incision was made to allow tension-free coronal advancement of the buccal flap to completely cover Geistlich Fibro-Gide®.The flap was secured with 5-0 Monocryl® sutures.

1-week post-operative visit: the healing looks good and sutures are intact. There was a small soft-tissue dehiscence at the buccal margin of the canine tooth.

Healing progressed well at 2 months post-operatively and the dehiscence defect seen at 1 week appears to be healing. Soft-tissue thickness is also evident at this stage.

At 6 months, 100% root coverage has been achieved. Note the increase in keratinized gingiva at the canine tooth where there was previously delayed healing. The patient is happy with the esthetic and functional outcome.

At 1 year, we can see root coverage has been sustained. Complete root coverage is not seen for the upper left bicuspid, not surprising given the tooth had an older restoration which was removed prior to grafting and the CEJ on the proximal surface is visible. Partial coverage was achieved however and is much more pleasing to the patient.

At 1.5 years, the tissue looks stable, healthy and esthetic. The patient is very happy with results thus far both from esthetic and functional standpoints. She is still free of sensitivity.

“The patient’s main priorities were to improve esthetics and reduce/eliminate root sensitivity. Soft tissue grafting was done with autologous connective tissue in other areas of her mouth many years ago and she was hesitant to undergo surgery again if it involved harvesting tissue from her palate due to the post-operative pain she experienced after these previous procedures.”

THE OUTCOME

This case nicely shows that the result following root coverage surgery to treat multiple adjacent teeth using a volume-stable collagen matrix is comparable to that seen with autologous connective tissue. At 1.5 years, there is continued stability of the treated site. The tissue appears healthy and firm. The patient‘s chief complaints of esthetics and sensitivity have been addressed and the patient is maintaining excellent oral hygiene and home care.

Multiple recessions on adjacent teeth in the maxilla can be treated successfully with a volume-stable collagen matrix and coronally-advanced flap.”
Dr. Vinay Bhide

The most important material for this case is the use of a volume-stable collagen matrix used in place of autologous connective tissue. Using this material has significantly decreased patient morbidity.”
Dr. Vinay Bhide

Dr. Vinay Bhide

Dr. Vinay Bhide is a board certified Periodontist with a special interest in periodontal plastics and reconstructive surgical procedures. Dr. Bhide did his dental and specialty training at the university of Toronto. In addition to private practice, Dr. Bhide is a clinical instructor in the Department of Periodontics at the university of Toronto. He is also a staff periodontist in the Center for Advanced Dental Care and Research at Mount Sinai Hospital, Toronto.

BIOBRIEF

Lateral Ridge Augmentation in the Posterior Mandible

Dr. John M. Sisto

THE SITUATION

A 70-year-old female in good health presented with a fracture of tooth #19 which is the distal abutment for a four-unit bridge tooth #19-22, with pontics in the #20 and #21 positions. With the loss of the bridge, the patient desired a fixed prosthetic replacement. A bridge from tooth #22 to an implant placed at the #18 position was not deemed mechanically sound. She opted for implant placement at positions #19, #20 and #21 following lateral ridge augmentation with autogenous bone and Geistlich Bio-Oss® contained with a Geistlich Bio-Gide® membrane.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Compromised
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

A subperiosteal flap with a mid-ridge incision was performed with anterior and posterior releasing incisions which were placed the distance of one tooth mesial and one tooth distal from the graft site. The posterior releasing incision allowed for exposure of the ramus for harvesting of the autologous bone. The grafted site was allowed to heal for a period of 8 months at which time the implants were placed. Abutment connection occurred 4 months following implant placement.

CT scan showing insufficient bone width for implant placement < 4mm.

Initial incisions on the midcrest of the ridge were performed for full-thickness flap preparation.

Four mucoperiosteal flaps were done with vertical releasing incisions and interosseous holes created to stimulate bone formation (RAP phenomenon).

Harvesting of the autologous cortical bone from the lateral surface of the ramus, utilizing the Geistlich Micross.

Geistlich Bio-Oss® granules mixed with harvested autologous bone chips.

Geistlich Bio-Oss® and autologous bone mixture was placed and covered with Geistlich Bio-Gide®. Pins and screws were utilized for fixation to provide primary stability.

Re-entry 8 months post-grafting: sufficient bone has been regenerated to place implants in the desired positions.

Follow-up at the time of implant uncovering and placement of the healing abutments, (4 months post- implant placement). All implants were successfully reverse torqued at 20ncm.

At re-entry eight months post-grafting, the width of the bone had increased significantly and measured 7.46mm at position #21.

“A bone graft was required to augment the ridge, a CBCT scan was performed prior to surgery to determine bone volume and the amount of bone required to graft.”

THE OUTCOME

Following 8 months of healing, the augmented site showed sufficient bone width that was assessed with a CT scan. After examination, it was determined that the bone width was adequate for implant placement in the desired position to allow an esthetically pleasing and functional outcome for the patient.

The use of Geistlich Bio-Oss® in combination with autogenous bone provides an excellent recipient site for the placement of dental implants and long-term maintenance of bone volume for implant survival.”
Dr. John M. Sisto

The Geistlich Micross is essential in harvesting bone from the lateral ramus in an efficient and stress-free manner.”
Dr. John M. Sisto

Dr. John M. Sisto

Dr. John M. Sisto received his Doctorate in Dental Surgery degree from Loyola University and completed his residency and certification in Oral and Maxilofacial Surgery at the Cook County Hospital in Chicago. Dr. Sisto was the Director of Residency Education at Cook County Hospital from 1985 to 2010 and started the residency program in oral and maxillofacial surgery in 1990. He held teaching positions at both Northwestern and University of Illinois Dental schools as a clinical assistant professor, and also at Northwestern Medical School. He was the Division Chief of Oral and Maxillofacial Surgery at Cook County Hospital and Chairman of Dentistry at Resurrection Medical Center. Dr. Sisto has published papers on dental implant surgery, trauma surgery, orthognathic surgery and maxillofacial infections. He has lectured both locally and nationally at various educational forums.

BIOBRIEF

Bone Augmentation L-Shape Technique with Early Implant Placement

Prof. Dr. Ronald E. Jung

THE SITUATION

The patient presented to the clinic with a discolored tooth #8, with mobility and a history of trauma. The tooth has a horizontal fracture in the apical third of the root and has recurrent infection after the root canal treatment. The patient feels discomfort and dislikes his esthetic appearance. He would like the fractured tooth #8 removed and replaced with a fixed solution.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: The fractured tooth has a periapical lesion together with a severe bone defect around the horizontal fracture.

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THE APPROACH

To carefully extract tooth #8 and to replace it with an early-stage implant placed with simultaneous guided bone regeneration through the use of Geistlich Bio-Oss Collagen® trimmed in an “L-Shape” under the protection of a Geistlich Bio-Gide® membrane. To augment the peri-implant soft-tissue with the use of a connective tissue graft during implant healing time, increasing the overall volume of site #8. To provisionalize the implant for the development of a proper emergence profile. To deliver a definitive reconstruction which is functional and esthetic for the patient.

The patient presented to the clinic with a discolored tooth #8, with mobility and a history of trauma. The tooth has a horizontal fracture in the apical third of the root and has recurrent infection after the root canal treatment.

The tooth has had root canal treatment, has a horizontal root fracture in the apical third and exhibits with a periapical lesion.

The tooth is carefully extracted and the socket is left to heal through unassisted healing.

After 6 weeks a full thickness flap is elevated with a distal releasing vertical incision. A bone level implant is placed according to the prosthetic plan through a surgical guide. Notice the buccal dehiscence.

Geistlich Bio-Oss Collagen® is trimmed to an “L-Shape” and is placed on the buccal-occlusal side of the implant. Additional Geistlich Bio-Oss® granules are placed around the remaining gaps.

To stabilize the grafted area the bone augmentation is covered with Geistlich Bio-Gide®, which is fixated apically with two resorbable pins.

The flap is sutured with horizontal mattress and single interrupted sutures and primary closure is achieved.

Four months after implant placement, a limited access “U”-flap was created and an implant impression was taken. The tissue was rolled to the buccal side and the abutment connection was performed.

The definitive layered zirconia crown was fabricated and placed. The clinical situation 5 months after implant placement, shows harmonious soft tissue and a well-integrated implant crown. The patient is satisfied with the esthetic result.

The periapical radiograph taken at the one-year follow-up shows stable marginal bone levels.

“A fractured anterior tooth needs to be replaced with an implant-supported reconstruction.”

THE OUTCOME

The implant and its prosthetic reconstruction were successful because they provided the patient with a fixed solution with adequate function and esthetics. The implant shows stable marginal bone levels due to the proper implant placement together with the guided bone regeneration procedure. The peri-implant soft-tissue is healthy and stable with sufficient volume created by the soft-tissue augmentation. The definitive reconstruction meets the patient’s esthetic demands and is functional in occlusion.

By using Geistlich Bio-Oss Collagen® trimmed into an “L-Shape” covered with Geistlich Bio-Gide® a very stable horizontal and vertical bone volume around the implant is provided. This results in a stable hard and soft-tissue condition following healing. This is key for the long-term performance of an implant especially in the esthetic zone.”
Prof. Dr. Ronald Jung

Four months after implant placement a limited access “U”-flap was created and an implant impression was taken. The tissue was rolled to the buccal side and the abutment connection was performed.”
Prof. Dr. Ronald Jung

Primary stability of the augmented bone volume is the clinical challenge in guided bone regeneration after flap closure. In this case Geistlich Bio-Oss Collagen® has been used to augment on the buccal side of the implant.”
Prof. Dr. Ronald Jung

Prof. Dr. Ronald E. Jung

Prof. Dr. Jung is currently Head of the Division of Implantology, Clinic for Fixed and Removable Prosthodontics and Dental Material Science, Center of Dental Medicine at the University of Zürich. In 2006 he worked as Visiting Associate Professor at the Department of Periodontics at the University of Texas Heath Science center at San Antonio, USA (Chairman: Prof. D. Cochran). In 2008 he finalized his “Habilitation” (venia legendi) in dental medicine and was appointed associate professor at the University of Zürich. In 2011 he received his PhD degree from the University of Amsterdam, ACTA dental school, The Netherlands. He is an accomplished and internationally renowned lecturer and researcher, best known for his work in the field of hard- and soft-tissue management and his research on new technologies in implant dentistry.

BIOBRIEF

Ridge Augmentation and Delayed Implant Placement on an Upper Lateral Incisor

Dr. Daniele Cardaropoli

THE SITUATION

An adult female patient presented with an endodontic/prosthetic failure on the maxillary left lateral incisor. The patient‘s request was to have a definitive implant-supported single crown. The clinical situation revealed recession of the free gingival margin, while the CBCT evaluation showed the missing buccal bone plate, which contra-indicated an immediate implant placement. The treatment plan included a staged approach with a ridge augmentation procedure at the time of tooth extraction, in order to recreate the buccal bone plate and reduce the gingival recession. By moving the free gingival margin, keratinized tissue was gained through an open-healing approach.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: The compromised soft-tissue created a high risk situation for esthetic failure and the need for a staged approach, in order to coronalize the free gingival margin.

download pdf

THE APPROACH

The treatment goals were to improve the soft-tissue levels and regenerate the buccal bone plate. After performing a flapless extraction procedure, a specifically designed resorbable bilayer collagen membrane, Geistlich Bio-Gide^® Shape, was inserted into the socket with the long wing in contact with the buccal surface and the smooth, compact upper layer facing outward. The alveolus was then grafted with Geistlich Bio-Oss Collagen^®. The three smaller wings of the membrane were folded on top of the graft material and sutured to the surrounding soft-tissue, allowing for open-healing.

Baseline: endodontic/prosthetic failure on the maxillary left lateral incisor.

The cone beam image shows the missing bony buccal plate.

Clinical situation following a minimally invasive, flapless extraction approach.

Geistlich Bio-Gide® Shape is inserted into the socket, with the long wing in contact with the buccal surface in order to recreate the cortical bone.

The socket is carefully grafted with Geistlich Bio-Oss Collagen®.

The three remaining wings of Geistlich Bio-Gide® Shape are folded over the bone graft and gently secured inside the gingival sulcus. The membrane is then sutured to the surrounding soft-tissue with six single-interrupted sutures.

Implant placement can be planned 4 months after the ridge augmentation procedure.

4 weeks post-operative view with an open-healing approach, showing a positive soft-tissue response.

After flap elevation at 4 months, the new buccal bone plate can be detected, together with a completely filled alveolus. An implant can now be easily inserted into a fully healed ridge.

Clinical image of the final ceramic crown. An esthetic improvement can be noted when compared with the baseline image. The free gingival margin has been shifted in a coronal direction.

“The patient had a failing crown with compromised soft tissue and requested a single crown rehabilitation with improved esthetics.”

THE OUTCOME

This case demonstrates how it is possible to improve the clinical and esthetic situation that was presented at baseline. Despite missing the buccal bone plate and the recession of the free gingival margin, the ridge augmentation procedure performed with the combination of Geistlich Bio-Gide^® Shape and Geistlich Bio-Oss Collagen^® was able to create a positive volume of the ridge, allowing for a prosthetically guided implant placement.

Clinical image of the final ceramic crown

Ridge augmentation combining the use of Geistlich Bio-Oss Collagen® and Geistlich Bio-Gide® Shape is a predictable minimally invasive regenerative procedure able to create sufficient ridge volume suitable for prosthetically driven implant placement.”
Dr. Daniele Cardaropoli

Prosthetically guided implant placement can be planned 4 months after the ridge augmentation procedure. The specifically designed Geistlich Bio-Gide® Shape was able to protect the Geistlich Bio-Oss Collagen®, not only in the coronal position but also aided in recreating the missing buccal bone.”
Dr. Daniele Cardaropoli

The use of the Cardaropoli Compactor instrument helped to carefully adapt Geistlich Bio-Gide® Shape onto the inner buccal surface of the alveolus and to properly compact Geistlich Bio-Oss Collagen® inside the socket.”
Dr. Daniele Cardaropoli

Dr. Daniele Cardaropoli

Periodontist – PRoED, Institute for Professional Education in Dentistry, Torino

Doctor of Dentistry and Certificate in Periodontology from the University of Torino, Italy.
Active member of the Italian Society of Periodontology, European Federation of Periodontology, Italian Academy of osseointegration and Academy of osseointegration. International member of the American Academy of Periodontology. Scientific Director of Institute for Professional Education in Dentistry (PRoED), Torino. Member of the Editorial Board of The International Journal of Periodontics and Restorative Dentistry. Private practice in Torino, Italy.

BIOBRIEF

Combined Horizontal and Vertical Regeneration Using a CAD-CAM Titanium Scaffold

Dr. Gian Maria Ragucci

Prof. Federico Hernández-Alfaro

THE SITUATION

A 54-year-old, systematically healthy male patient (*ASA) came to our attention presenting with partial edentulism in the lower jaw and requiring a fixed and esthetic rehabilitation, refusing any removable solution. The clinical and radiographic evaluation resulted in significant bone atrophy both in the vertical and horizontal components; which makes it impossible to place both conventional implants and short or narrow implants.

*American Society of Anesthesiologists Physical Status Classification System

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

download pdf

THE APPROACH

Solving the case was developed in two steps: first bone reconstruction to restore the ideal anatomy, second positioning of the prosthetically guided implants. An individualized regeneration technique was chosen using a CAD-CAM titanium scaffold (Yxoss CBR®) in conjunction with a mix of 60% autogenous bone and 40% Geistlich Bio-Oss®, covered by Geistlich Bio-Gide®. At 9 months, the titanium scaffold was easily removed and 3 prosthetically guided implants were placed, completely surrounded by bone. At 12 months, a free gingival graft was performed to re-establish the missing amount of keratinized mucosa. Finally, at 16 months, the final rehabilitation was carried out with a fixed prosthesis on implants.

Panoramic radiographic view of the defect

Horizontal and vertical augmentation step by step

Baseline situation (left) and 9-month follow-up (right)

Scaffold removal and implant placement step by step

Soft-tissue management with free gingival graft

Periapical radiographs of implants and prosthesis

“Combined horizontal and vertical bone augmentation utilizing a CAD CAM titanium scaffold can be achieved with less surgical time and less complications.”

THE OUTCOME

The final resolution of the case was very satisfactory. There were no complications during all the procedures performed. The Yxoss CBR® allowed for easier reconstructive surgery and a significant reduction in surgical times, thanks to the precise dimensions of the scaffold. This resulted in a favorable post- operative situation for the patient and complications were prevented.

Vertical bone reconstruction combining the use of Yxoss CBR®, Geistlich Bio-Oss® and Geistlich Bio-Gide® allows a predictable regenerative procedure that is able to create sufficient bone volume suitable for prosthetically guided implant placement.”
Dr. Gian Maria Ragucci

The use of CAD-CAM Titanium scaffold Yxoss CBR® allows an ideal bone regeneration and a faster and easier surgery.”
Dr. Gian Maria Ragucci

Dr. Gian Maria Ragucci

Universitat Internacional de Catalunya (UIC), Barcelona Dental degree at Universidad Europea de Madrid 2015
International Master in oral surgery at UIC, Barcelona 2018
PhD student at UIC, Barcelona 2018
EAO Certification program in implant dentistry 2018
EAO European prize in implant dentistry 2019

Prof. Federico Hernández-Alfaro

Full professor & Chairman, Department of Oral and Maxillofacial Surgery, UIC, Barcelona
Institute of Maxillofacial Surgery, Teknon Medical Center, Barcelona

BIOBRIEF

Immediate Mandibular Molar Transition

Dr. Peter Hunt

THE SITUATION

The case here is typical enough, a failing mandibular molar with a vertical sub-osseous fracture. Traditionally, the replacement process can take three or more surgical exposures (extraction and regeneration), (implant placement), (second stage exposure) and more than a year of therapy.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

download pdf

THE APPROACH

Immediate molar replacement requires atraumatic removal of the fractured tooth, careful socket debridement and development of a channel for an ideally positioned implant. The implant then needs to be placed down in the bone channel with the implant platform positioned just below the socket walls. It needs to be stable. Channel deficiency augmentation is achieved with Geistlich Bio-Oss Collagen® which is covered with a collagen matrix, Geistlich Mucograft® with the edges tucked under the gingival margins and sealed over with tissue glue.

Initial Situation: a failing mandibular molar with a vertical sub-osseous fracture.

A pre-operative radiograph and CBCT showing the cross-section of the involved tooth.

An implant site was developed by placing a pilot drill down the mesial root space, then uprighting it. This was continued up through the drill sequence. The mesial radicular septum is moved in the process.

A Camlog® 5.0 x 11 mm implant was placed with the platform set just down below the bone height of the socket walls.

After placing a 4.0 mm height cylindrical gingiva former in the implant, 250 mg of Geistlich Bio-Oss Collagen® was packed down in the socket around the implant.

Geistlich Mucograft® was adapted to the region then tucked down under the gingival margin.

The gingival margins were adapted and closed together with 4.0 teflon sutures (Cytoplast™, Osteogenics). The region was then covered with Glustich – PeriAcryl®90 Oral Tissue Adhesive.

After 3 months of healing, the top of the gingiva former is exposed and the situation is ready for Emergence Profile Development. This is quite standard.

4 months later following Emergence Profile Development.

An occlusal view of the final one-piece, screw-retained zirconia crown restoration based on a Camlog® Titanium Base Abutment.

“The patient desires an implant placement for a fractured mandibular molar, as fast as possible.”
– Dr. Peter Hunt

THE OUTCOME

This single stage replacement protocol has proven to be simple, safe and highly effective providing the socket is fully degranulated and the implant is stable and not loaded in the early healing stages. It works well when a gingiva former is immediately placed into the implant instead of a cover screw, Geistlich Bio-Oss Collagen® is packed around the implant to fill the residual socket, then covered with a Geistlich Mucograft® and sutured. There is no need for flap advancement to cover over the socket.

This procedure really just merges a socket regeneration procedure with implant placement. It’s a simple and effective procedure which has now become quite standard for us.”
Dr. Peter Hunt

Dr. Peter Hunt

After graduate training on an Annenberg Fellowship at the University of Pennsylvania, dr. hunt helped start up the University of the Western Cape dental School in Cape Town, South Africa. he returned to the University of Pennsylvania where in time he became Clinical Professor of Periodontics. later he helped start up Nova Southeastern‘s dental School where he was Professor of Restorative dentistry, Post Graduate director and director of Implantology. he has had a private practice in Philadelphia focusing on implant and rehabilitation dentistry since 1981.

BIOBRIEF

Ramal Bone Graft for Congenitally Missing Maxillary Lateral Incisor

Dr. Richard E. Bauer, III

THE SITUATION

An 18-year-old female presented with a congenitally missing tooth #10. The patient previously sought care by another provider and had undergone guided bone regeneration with allograft and subsequent implant placement with additional grafting at the time of implant placement. The implant ultimately failed and was removed prior to my initial consultation. An examination revealed maximal incisal opening, within normal limits, missing #10 with 6 mm ridge width. In addition there was a significant palpable cleft-like depression on the facial aspect of the ridge, adequate attached tissue but reduced vertical height in relation to adjacent dentition and attached tissue. Previous surgeries resulted in extensive fibrous tissue with scarring at site #10. Plan: A ramal bone graft is indicated at the congenitally missing site #10 with Geistlich Bio-Oss® and Geistlich Mucograft® matrix utilized for ridge augmentation prior to secondary implant placement.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

download pdf

THE APPROACH

The goals for this patient are to reconstruct the osseous foundation and provide a matrix for improvement with the overlying soft tissue. Specifically, a coordinated multidisciplinary plan was established with the restoring dentist, periodontist and oral surgeon. A plan for idealized anterior cosmetic prosthetic restoration was established. Sequencing of treatment was established. Surgical phase one included a ramal bone graft to site #10 and Essix type temporary prosthesis for immediate post-operative phase followed by a temporary Maryland bridge. Surgical phase two included implant placement and simultaneous crown lengthening and osteoplasty. This stage was done with immediate provisionalization.

A flap has been raised and reveals a significant facial and palatal defect at congenitally missing site #10.

Harvested ramal graft. Slightly over-sized to allow for mitering and harvest of particulate autograft with a bone trap on the suction.

Onlay graft now secured with two fixation screws (Stryker) with a lag screw technique. Geistlich Bio-Oss Collagen® has been placed on the palatal aspect of site #10

Combination of a fixated onlay graft with Geistlich Bio-Oss®/autograft particulate graft at the periphery and over the facial plate of the adjacent dentition

Geistlich Mucograft® matrix placed over facial augmentation of the adjacent dentition and ridge crest of the augmented site

Closure following ramal grafting and Geistlich Mucograft®matrix application

Implant placement with static guide and dental implant hand driver

Implant placement with slight subcrestal placement of the platform just prior to osteoplasty by the periodontist.

“This is a young patient with a congenitally missing incisor that has high esthetic concerns and has had multiple failed surgical attempts that is now presenting for definitive management.”

THE OUTCOME

This case was dependent upon adequate hard-tissue reconstruction combined with soft-tissue manipulation to eliminate scar tissue and provide esthetic recontouring. Obtaining an adequate autogenous graft combined with Geistlich Bio-Oss® at the periphery of the onlay graft is essential for anterior-posterior and vertical augmentation. Utilizing a Geistlich Mucograft® matrix at the ridge crest to help contain the particulate graft and improve the soft-tissue profile for subsequent immediate provisionalization and re-contouring of the surrounding soft tissue played a significant role in the esthetic success.

Immediate provisional in place two days after implant placement and osteoplasty. There has been significant gain in bony architecture and development of soft-tissue contours at a site that was extremely deficient of structure to begin with.”
Dr. Richard E. Bauer, III

Dr. Richard E. Bauer, III

Oral and Maxillofacial Surgeon – University of Pittsburgh

Richard E. Bauer, III, DMD, MD is a graduate of the University of Pittsburgh Schools of Dental Medicine and Medicine. Dr. Bauer completed his residency training in Oral and Maxillofacial Surgery at the University of Pittsburgh Medical Center. Dr. Bauer has served on multiple committees for the American Association of Oral and Maxillofacial Surgery (AAOMS). He is a full-time faculty member and Residency Program Director at the University of Pittsburgh in the department of Oral and Maxillofacial Surgery and his practice is focused on dental implants and corrective jaw surgery. He has been active in research with focus on bone regeneration and virtual applications for computer assisted planning and surgery.

BIOBRIEF

Prosthetically Guided Regeneration (PGR) in the Posterior Maxilla

Paolo Casentini, DDS

THE SITUATION

The 60-year-old female patient’s chief complaint was represented by unsatisfactory esthetics and function, related to loss of multiple maxillary teeth. Her request focused on improving esthetics and function by means of a fixed reconstruction.

The patient presented five residual anterior maxillary teeth (from 6 to 10) that could be maintained. After preliminary periodontal diagnosis and treatment, specific diagnostic steps for implant treatment demonstrated inadequate bone volume for implant placement.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

download pdf

THE APPROACH

Bi-lateral sinus lift with Geistlich Bio-Oss Pen® and horizontal bone augmentation with a 1:1 mix of autogenous bone and Geistlich Bio-Oss® were performed six months prior to implant placement, following a Prosthetically Guided Regenerative (PGR) approach. The augmented sites were protected with Geistlich Bio-Gide® stabilized with titanium pins. The template utilized for radiographic diagnosis and GBR was then used to guide the implants’ placement.

Baseline full-mouth intra-oral view: the residual maxillary teeth were preliminarily reconstructed with a composite mock-up. The horizontal atrophy of the posterior areas of the maxilla is clearly visible.

The cone beam, realized with a radio-opaque diagnostic template, shows inadequate bone volume for implant placement in all the analyzed sites.

The use of the diagnostic template during the augmentation procedure helps to highlight the presence of bone defects in relationship to the restorative plan and future position of implants.

Large Geistlich Bio-Oss® particles are directly applied inside the sinus with Geistlich Bio-Oss Pen®.

The Geistlich Bio-Gide®, fixed with titanium pins is used to protect and stabilize the augmented site. As the surgical template shows, the bone augmentation is based on the future restorative project following the principle of PGR.

The same surgical procedure is performed on the left posterior side of the maxilla.

Cone-beam 6 months after surgery and prior to implant placement. The relationship between the template used for diagnosis and the bone crest reveals adequate bone volume to place implants in the correct prosthetically driven position.

Implant placement was guided by the same template utilized for diagnosis and bone augmentation.

Final view of the prosthetic reconstruction demonstrates bio-mimetic integration of implant-supported prostheses and ceramic veneers bonded to residual natural teeth.

The panoramic radiograph shows adequate integration of the implants and absence of peri-implant bone resorption.

Using a diagnostic template during the GBR procedure helps to highlight the presence of bone defects in relationship to the restorative plan and future position of implants.

THE OUTCOME

After a healing period of six months, adequate bone volume was achieved for the placement of five implants. Geistlich Fibro-Gide® was also used to optimize soft tissue volume at the buccal aspect of implants.

Implants were early loaded with a temporary screw-retained fixed prostheses six weeks after placement. The final prosthetic reconstruction included ceramic veneers of the frontal residual teeth and zirconium-ceramic screw-retained fixed prostheses on implants.

Patient satisfaction is my driver for excellence. That’s why I always apply the Prosthetically Guided Regeneration principle together with Geistlich Biomaterials: proven and predictable long-term patient success.”
Paolo Casentini, DDS

Paolo Casentini, DDS

Graduated in Dentistry at the University of Milan, Fellow and Past Chairman of the Italian section of ITI, Active member Italian Academy of Osseointegration. Co-author of 10 textbooks including ITI Treatment Guide volume 4, translated in eight languages, and “Pink Esthetic and Soft Tissues in Implant Dentistry” translated in five languages. His field of interest is advanced implantology in complex and esthetically demanding cases. He has extensively lectured in more than 40 countries.

BIOBRIEF

Avoiding Post-Implant Placement and Long Term Crestal Bone Resorption by Thickening Vertical Soft Tissue

Tamir Wardany, D.D.S.

THE SITUATION

Our patient is a 60-year-old caucasian male that had just finished a large ridge augmentation in the area of #4 and #5. We used the sausage technique for the ridge augmentation and yielded excellent bone volume in this area. However, as we began the 2nd stage implant placement procedure, we noticed, as is frequently seen following a large ridge augmentation, very thin vertical soft tissue over the crest of the bone. We know that inadequate soft tissue thickness will lead to compromised vasculature and transfer of oxygen and nutrients to the bone which can absolutely lead to a loss of crestal bone surrounding the implants.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: Bone was augmented prior to this case report due to a severe horizontal defect.

download pdf

THE APPROACH

Our goal here is to create increased vertical soft tissue thickness over the crest of the implant site. Following implant placement and placement of the cover screws, we used Geistlich Fibro-Gide^® over the implants and then layed it over the crest and buccal aspect. Following the placement of Geistlich Fibro-Gide^®, we gently released the full thickness flap so that we can achieve tension-free primary closure over the site.

6 months following horizontal ridge augmentation, using Dr. Urban’s sausage technique, we re-entered the site for implant placement using a full thickness flap with no vertical incisions, to not disrupt collateral blood supply. There is excellent bone volume, but a very thin vertical soft tissue volume over the crest of the implant site.

Straumann implants are placed in sites #4 and #5 to a 25Ncm torque value with no issues and the cover screws were placed.

Geistlich Fibro-Gide® is placed crestally over the implants and draped to the buccal and slightly towards the lingual. Geistlich Fibro-Gide® was trimmed slightly to minimize the thickness of the material.

The flap was released so that we can achieve tension-free primary closure over the implant and the Geistlich Fibro-Gide® soft tissue augmentation site.

Following an 8 week healing period, we make a crestal incision and lay a conservative full-thickness flap to uncover the implants. We observe a 3-4 mm increase in verticle soft tissue thickness over the implant site.

We allow 3 weeks following the initial uncovering and can now see beautiful soft tissue architecture surrounding the implants.

Prior to the restorative process we see the pre-restorative radiograph with the healing abutments in place and we can also observe excellent crestal bone levels around the implants.

1 year follow-up. The restorative dentist opted to splint the crowns together. The patient did not want implants posterior to this area and he did not want any sinus augmentation as he had a history of sinus issues.

The use of Geistlich Fibro-Gide^® is a wonderful alternative to using a connective tissue graft to thicken vertical soft tissue, which will help minimize crestal bone loss around implants.

THE OUTCOME

The soft tissue that will now surround the implant site is thick and healthy due to the use of Geistlich Fibro-Gide^® at the time of implant placement. This is a simple technique and only requires a minimal amount of flap release to achieve tension-free primary closure over the site. The results are phenomenal and will be beneficial for the stability of the crestal bone surrounding the implants for years to come.

Thin vertical soft tissue over the implant site following ridge augmentation is one of the key factors which may lead to crestal bone loss around the implants that will be placed.
Tamir Wardany, D.D.S.

I find the Mini-Me Periosteal to be my most versatile instrument for all my hard and soft tissue cases. I always have this instrument out on my surgical tray.
Tamir Wardany, D.D.S.

Beginning with thin soft tissue, we were able to achieve very thick and healthy vertical soft tissue over the implants, which will improve blood flow to the bone and minimize crestal bone loss in future.
Tamir Wardany, D.D.S.

Tamir Wardany, D.D.S.

Dr. Wardany is a graduate of Meharry Medical College School of Dentistry in Nashville, TN. After completion of a dental implant fellowship through State University of New York Stonybrook, he continues to spend extensive time in Europe training under Dr. Istvan Urban in the field of advanced bone and soft tissue regeneration.

He is a Diplomate of the American Board of Implantology, and lectures extensively on the topic of bone regeneration. He maintains a referral based surgical implant practice in San Francisco and Sacramento, California.

BIOBRIEF

A Regenerative Approach to Peri-implantitis

Hector L. Sarmiento, D.M.D., MSc.

THE SITUATION

A 55-year-old man was referred to me by his general dentist. Upon initial clinical and radiographic findings, failing implant #9 showed signs of peri-implantitis that included BoP, Suppuration, 9+mm PD and radiographic bone loss affecting both the implant and the natural adjacent tooth. Patient stated that although his gums bleed, he does not have any pain. Gingival erythema was also found.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: Peri-implantitis on implant #9 migrating to the mesial portion of root #8

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THE APPROACH

The clinical goals were to eliminate the peri-implant infection, restore hard and soft-tissues and have long-term success. The technique utilized was a systematic regenerative approach to eliminate the underlying cause of the peri-implantitis infection and restore hard and soft-tissues to prior health.

Initial situation, patient presented with radiographic and clinically traditional signs of peri-implantitis, including bleeding on probing, suppuration, radiographic progressive bone loss and clinical pathologic probing depths.

Mechanical debridement was achieved using titanium scalers, an ultrasonic device with an implant protective cap and titanium brushes to remove all of the visible contaminants of the implant surface. Citric acid was then placed on shreds of a non-woven gauze and applied to the surface for approx. 1min. Copious irrigation was done using saline solution and the surface was ablated using the Er:YAG laser at 20pps/50mj.

After the surface was prepped and no signs of residual granulation tissue was noted, the defect was grafted with Geistlich Bio-Oss®. Attention was given towards not augmenting beyond the bony envelope.

A protective Geistlich Bio-Gide® membrane was placed over Geistlich Bio-Oss®.

Geistlich Fibro-Gide® was placed over Geistlich Bio-Gide® to enhance soft-tissue volume and quality. Geistlich Fibro-Gide® was trimmed and adapted to the defect site ensuring a tension free closure.

Geistlich Fibro-Gide® was place on the top of the bone graft to enhance soft-tissue thickness. Geistlich Fibro-Gide® is porous. We can observe the rapid penetration of blood through the matrix.

Closure with a tension-free flap was achieved by releasing incisions and secured using 4-0 chromic gut sutures.

1.5 year post-operative photo and radiograph show the healing of the soft-tissues with no signs of peri-implantitis and adequate tissue thickening. Radiographic bone levels have maintained stable over the course of the year.

Geistlich Fibro-Gide^® has the capacity to enhance the soft-tissue during a bone regenerative approach.

THE OUTCOME

My observation at the 1.5 year follow-up shows the elimination of peri-implantitis and complete peri-implant health was achieved showing a reduction in BOP, PD and most importantly soft tissue thickness stability. Radiographically, crestal bone shows no signs of progressive pathological loss and has maintained adequate volume.

Geistlich Fibro-Gide^® was utilized to enhance the soft-tissues during a regenerative peri-implantitis approach. In my opinion, healthy, thick soft-tissue is easier for a patient to maintain and creates a better environment for long-term survival.
Hector L. Sarmiento, D.M.D., MSc.

Hector L. Sarmiento, D.M.D., MSc.

Dr. Hector Sarmiento was awarded his D.M.D. degree by the University of Rochester. He is uniquely trained in both maxillofacial surgery and periodontics. He is a professor in the maxillofacial surgery department of trauma and reconstructive unit at the Regional Hospital in Mexico and is an Assistant Clinical Professor in periodontics at the University of Pennsylvania. Along with his periodontal degree, he also received his masters in oral biology from the University of Pennsylvania. Dr. Sarmiento is an international and national lecturer and has published numerous articles in peer reviewed journals and textbooks. His research focus includes infected dental implants such as peri-implantitis, sinus complications as well as bone biology. Dr. Sarmiento maintains his private practice in the upper east side of Manhattan in NYC.

BIOBRIEF

3D Bone Augmentation Using Customized Titanium Mesh in Conjunction with Autogenous Bone and Bovine Bone Material Granules

Matteo Chiapasco, D.D.S., M.D.

Grazia Tommasato, D.D.S., M.S.C.

THE SITUATION

A 75-year-old systemically healthy female came to our attention presenting with absent mandibular second bicuspids and molars and requiring a fixed rehabilitation supported by implants as she refused a removable solution. The clinical and radiographic evaluation showed a relevant vertical and horizontal bone atrophy of such an extent that short or narrow implants were not considered a reliable option. The patient smoked <10 cigarettes per day.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: Yxoss CBR® by ReOss® Screws 5mm – MCbio (G-fix system)

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THE APPROACH

The main goal was to obtain a horizontal and vertical reconstruction of the deficient alveolar bone in order to allow safe and prosthetically-guided implant placement. Reconstruction was obtained by means of a customized titanium mesh, Yxoss CBR^®, in combination with a mixture of autologous bone chips harvested from the mandibular ramus and bovine bone mineral, Geistlich Bio-Oss^®.

Panoramic radiograph of initial situation showing the atrophic mandibular areas.

The customized Ti-mesh is filled with the autologous bone chips mixed with Geistlich Bio-Oss® granules in a 50:50 ratio.

Intra-operative view at the end of the reconstruction showing the bone augmentation: the customized mesh was stabilized with 2 fixation screws.

A Geistlich Bio-Gide® membrane is used to cover the customized mesh in order to increase the barrier effect.

Intra-operative view after primary closure of the surgical wound.

Clinical control 3 months later showing favorable healing of the soft tissue and correction of the defect.

The 3-dimensional reproduction of the left edentulous area permits the production of a precise and customized Ti-mesh.

THE OUTCOME

Post-operative recovery of this patient was uneventful, no complications such as dehiscence or late exposure of the customized mesh, with complete correction of the initial defect. The Yxoss CBR^® allowed an easy and faster reconstruction thanks to the precision of the prefabricated mesh filled with autologous chips, Geistlich Bio-Oss^® and Geistlich Bio-Gide^®.

While it is important to be an expert in guided bone regeneration, this technique reduces the difficulties to less than one-half and is predictable, effective, and precise.
Matteo Chiapasco, D.D.S., M.D.

GBR combining the use of Geistlich Bio-Oss^®, autologous bone chips taken from the mandibular ramus associated with a customized Yxoss CBR^®, covered with a Geistlich Bio-Gide^®, is a predictable regenerative procedure allowing for the creation of an adequate volume suitable for a prosthetically-guided implant placement with optimization of the final restoration.
Matteo Chiapasco, D.D.S., M.D.

Matteo Chiapasco, D.D.S., M.D.

Graduated in Medicine and specialized in Maxillofacial Surgery at the University of Milan, Italy. Professor, Unit of Oral Surgery, University of Milan; Associate Professor, Loma Linda University, Los Angeles, California, USA.

Grazia Tommasato, D.D.S., M.S.C.

Graduated in Dentistry in 2013, specialized in Oral Surgery at the University of Milan magna cum laude. PhD student and a medical consultant of the Clinical Unit of Oral Surgery (“G. Vogel” Clinic, Milan).

BIOBRIEF

Enhance Periodontal Phenotype with Geistlich Mucograft® for Soft Tissue Augmentation

Allison Rascon, D.D.S., M.S.

THE SITUATION

A healthy, non-smoking, 37- year-old female presented for second stage surgery at implant sites #23 and #26. Limited keratinized tissue width and gingival thickness can be appreciated in the edentulous ridge, and the patient can be classified as having a thin periodontal phenotype. Additionally, the patient states she experiences sensitivity, and the tissue feels “tender” when brushing. The patient hopes to address her needs in a minimally invasive manner.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system Heavy smoker
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Note: The patient‘s keratinized tissue is inadequate (<2 mm) and the recession on the canines can be classified as RT 1 defects.

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THE APPROACH

The aim of treatment was to enhance the existing periodontal phenotype from that of one which is thin, with limited keratinized tissue, to one that is thick and maintains an adequate band of attached keratinized tissue. Geistlich Mucograft® was used in conjunction with a PRF membrane, in order to provide optimal wound healing, due to its chemotactic and angiogenic properties.

A mid-facial incision was made, with the intent to preserve the minimal keratinized tissue that was available, as well as vertical incisions along the line angles of the canines to reflect a partial thickness flap.

Platelet-rich fibrin clots were formed by centrifugation. The leukocyte-PRF (L-PRF) was extracted, and the L-PRF was used to hydrate Geistlich Mucograft®

Geistlich Mucograft® and PRF stabilized via glycolon sutures.

Clinical situation at three-week follow-up.

Occlusal view at twelve-month follow-up.

A viable option that allows for reduced patient morbidity, adequate functional necessity, and ideal esthetics.

THE OUTCOME

Dual application of platelet-rich fibrin (PRF) and a xenogenic collagen matrix, Geistlich Mucograft®, led to successful augmentation of the edentulous ridge. At one-year, the tissues appear healthy, and an increased keratinized tissue width and gingival thickness can be appreciated. By using this soft tissue alternative, the patient was able to avoid post-operative morbidity from a second surgical site, and the chief complaint was addressed.

Soft tissue procedures are technique sensitive and success requires appropriate graft size and thickness, recipient bed preparation, and adequate stabilization. Having a xenograft matrix provides control over having the necessary graft dimensions, without requiring a second surgical site, and it’s easy-handling properties ensure placement and stability are done in a predictable manner.”
Allison Rascon, D.D.S, M.S

With adequate recipient bed preparation, the ease of manipulation with the hydrated xenograft matrix allowed for intimate adaptation, and the overlaying PRF was easily compressed against Geistlich Mucograft^®. At twelve months follow up, stable soft tissue dimensions are observed with adequate thickness, as well as esthetically appropriate blend of the tissue color and texture.”
Allison Rascon, D.D.S, M.S

Allison Rascon, D.D.S., M.S.

Dr. Allison Rascon was born and raised in Miami, Florida. She received her Bachelor of Science in Biomedical and Health Sciences from the University of Central Florida. She received her DDS from New York University, where she graduated with honors in Periodontics and was inducted into the Omicron Kappa Upsilon National Dental Honor Society in 2020. She then went on to receive a Certificate in Periodontics and Master of Science in Oral Biology from the University of Pennsylvania. Currently, she is board-eligible by the American Academy of Periodontology. She is an active member of the AAP, AO, OF, and ADA. Aside from her active participation in organized dentistry, she is also passionate about her research in periodontal and peri-implant regeneration. Dr. Rascon was a recipient of the George J. Coslet Memorial Scholarship in 2021 and 2022. During her residency, she was awarded the Best Oral Clinical Presentation Award at the Academy of Osseointegration Annual Meeting in 2022 and was the recipient of the Northeastern Society of Periodontists Tannenbaum/ Schoor Resident School Competition Award for 2023. Currently, Dr. Rascon works in private practice in Manhattan, NY.

BIOBRIEF

Clinical Efficacy of Geistlich Mucograft® in Regeneration of Oral Mucosa Combined with the Surgical Treatment of Peri-implantitis in Implants with Lack of Keratinized Tissue

Dr. Alberto Ortiz-Vigón

Dr. Erik Regidor Correa

THE SITUATION

Adult patient, non-smoker and without relevant systemic history, attends to clinic referring peri-implant tissue inflammation, bleeding and brushing discomfort around her implant in the upper jaw. Clinically peri-implant pocket depth > 5 mm, bleeding and suppuration on probing were observed. Furthermore, the implant presented < 2 mm of keratinized mucosa and radiographic horizontal bone loss.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system Heavy smoker
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

Intrasulcular incision was made and a mucosal partial thickness flap was raised. The recipient site was prepared by sharp disection in order to create a periosteal bed free of any muscle attachment. Peri-implant granulation tissue was removed and implantoplasty was performed. Finally, Geistlich Mucograft® was used to support the gain of keratinized tissue. Thus, the collagen matrix was sutured with the resulting flap apically at the base of the newly created vestibulum.

Pathological peri-implant pocket depth combined with bleeding on probing.

Partial thickness flap in order to create a periosteal bed free of any muscle attachment and apically positioned.

Implantoplasty of the exposed rough implant surface using burs and silicon carbide polishers.

Xenogeneic collagen matrix structure (Geistlich Mucograft®).

Future position of the xenogeneic collagen matrix facilitated by prosthodontic abutment.

Suture of xenogeneic collagen matrix around the abutment and over the recipient bed.

Buccal view of xenogeneic collagen matrix and apically positioned flap.

Occlusal view of xenogeneic collagen matrix and apically positioned flap.

Lateral view of xenogeneic collagen matrix and apically positioned flap.

Peri-implant tissue health and maintenance of keratinized tissue after one year of surgical treatment.

Periimplant tissue health and maintenance of keratinized tissue after 2 years

Absence of > 2 mm of keratinized mucosa was associated with peri-implant soft-tissue inflammation, bleeding and discomfort on brushing.

THE OUTCOME

After two years follow-up, the successful outcome can be observed in terms of clinical peri-implant parameters, gain of keratinized mucosa without significant graft shrinkage and stability of vertical position of the mucosal margin.

The use of Geistlich Mucograft® xenogeneic collagen matrix for regeneration of oral mucosa, combined with the surgical respective approach to peri-implantitis provides an improvement in clinical parameters and increase of the peri-implant keratinized mucosa minimizing the risk of recession in the esthetic area.”
Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

The use of soft-tissue substitutes may play an important role in patient perception and satisfaction without jeopardizing the final clinical outcome.”
Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

Dr. Alberto Ortiz-Vigón

DDS from the University of the Basque Country
MSc and PhD in bone regeneration from the University Complutense of Madrid (UCM)
Master in Periodontology and Implant dentistry from the EFP
Research fellowship at the University of Gothenburg
MBA from the Deusto Business School
Assistant professor and clinical researcher at UCM and ThinkingPerio Research
PerioCentrum Clinic in Bilbao
Co-founder of ARC Healthtech Innovation Holding
Socially engaged & NGO co-founder of Smile is a Foundation

Dr. Erik Regidor Correa

DDS from the University of the Basque Country
MSc from the U. of the Basque Country
Master in Periodontology and Implant Dentistry U. of the Basque Country
PhD student in the U. of the Basque Country
Assistant professor and clinical researcher ThinkingPerio Research

WEBINAR

CLINICAL CASE

1 – Extraction of tooth 21 due to a trauma with concomitant external resorptions. Care was taken in preserving the alveolar bone.

2 – Crestal view of the socket after tooth extraction. No flaps are raised around the affected area. A slight buccal bone defect was observed.

3 – The socket is gently curetted for removal of granulation tissue. Subsequently, the wound margins were de-epithelialized with a diamond in a counter piece with water cooling

4 – Filling of the extraction socket with Geistlich Bio-Oss® Collagen to the level of the palatal bone

5 – After measuring the alveole, Geistlich Mucograft® is punched (8 mm diameter

6 – The Geistlich Mucograft® punch is placed on top of Geistlich Bio-Oss® Collagen to seal the filled alveole.

7 – Suturing of the Geistlich Mucograft® with 6-0 single interrupted sutures.

8 – Nice healing of the soft tissues 1 week after extraction.

9 – Situation 7.5 months after extraction revealing nice soft tissue situation with a slight dip at the buccal aspect.

CLINICAL CASE

1 – Pre-operative situation, tooth #7 with periapical infection and horizontal fracture.

2 – CT Scan showing tooth #7 with significant bone loss.

3 – Occlusal view of the clinical situation prior to extraction of tooth #7.

4 – Extraction socket with Geistlich Bio-Oss Collagen® in place.

5 – Geistlich Mucograft® Seal is placed over the extraction socket and secured with single interrupted sutures.

6 – 3 months post-operative: soft tissue healing at the time of implant placement.

7 – Buccal view showing excellent soft tissue healing and keratinized tissue.

9 – 2 years post-operative: final restoration in place.

CLINICAL CASE

1 – Pre-operative lateral smile showing the recession defect of tooth 5.

2 – Pre-operative image of recession defect (tooth 5).

3 – After elevation of split-full-split flap the interdental papillae are de-epithelialized.

4 – Geistlich Mucograft® is placed over the root and sutured to the papillae

5 – The flap is mobilized, coronally advanced and sutured completely covering the Geistlich Mucograft®.

6 – Healing of the surgical site 2 weeks after surgery.

7 – Surgical site 6 months after surgery.

9 – Lateral smile 1 year after surgery showing the optimal esthetic outcome.

CLINICAL CASE

1 – Before preparation of the flap the exposed root portion is cleaned with a scraper and is wiped with EDTA (or similar).

2 – After measuring the dimension of the recession defect using a periodontal probe, the incisions for raising the flap are cut.

3 – A split-full-split thickness flap is elevated and coronally mobilized.

4 – The area of the papillae is de-epithelialized to allow anchorage of the flap coronal to the cemento-enamel junction.

5 – Geistlich Mucograft®is applied dry to the defect and is fixed with 4 single sutures.

6 – The coronally advanced flap is sutured over Geistlich Mucograft®.

7 – Nice, uneventful healing 15 days post-operatively at suture removal.

8 – Soft tissue situation immediately after suture removal.

9 – Complete root coverage 7 months after surgery. Note the excellent color match.

CLINICAL CASE

1 – Pre-operative image showing the recession defect on tooth #6.

2 – After elevation of a partial thickness flap, the interdental papillae are de-epithelialized.

3 – Geistlich Mucograft® is placed over the defect and sutured to the papillae.

4 – The flap is coronally advanced and sutured completely covering the matrix.

5 – Follow-up after 1 week: healing of the surgical site.

8 – Follow-up after 6 months: note the natural appearance of the soft tissue achieved with Geistlich Mucograft®.

CLINICAL CASE

1 – Pre-operative picture of the area intended to treat. Note the thin biotype.

2 – Initial situation showing Miller Class I defects on region 4 (3 mm) and 5 (2 mm).

3 – A split-full-split thickness flap without releasing incisions is elevated.

4 – The anatomical papillae are de epithelialized.

5 – The collagen matrix Geistlich Mucograft® is placed under the flap.

6 – Immediate post-operative situation after suturing of the flap covering Geistlich Mucograft® completely

7 – Follow-up picture 2 weeks after surgery.

8 – Nice healing of the site 1.5 months post-operative.

9 – Pleasant esthetic outcome 7 months after surgery.

CLINICAL CASE

1 – This case shows a shallow vestibule and almost no keratinized tissue on the lower crestal part. The horizontal incision has to be made within the keratinized tissue (see depicted line).

2 – Ensure the incision is within the keratinized tissue: an apically fixed split flap is used here. Remove the muscles, scar fibers and ligaments before application of Geistlich Mucograft®.

3 – Measure the defect carefully with a periodontal probe and cut Geistlich Mucograft® in a dry state. In the case of a large vestibuloplasty, several pieces of Geistlich Mucograft® can be sutured side by side.

4 – Geistlich Mucograft® is sutured directly onto the periosteum with 5.0 resorbable sutures and left exposed for open healing (healed by secondary intention).

5 – 10 days post-operative: favorable healing where granulation tissue and new soft tissues have formed.

6 – 1 month post-operative: excellent wound healing with complete integration and epithelialization of Geistlich Mucograft® as well as keratinization of the crestal aspect could be observed.

7 – 3 months post-operative: excellent esthetic outcome with full integration and epithelialization of Geistlich Mucograft® to the surrounding tissue and keratinization of the crestal aspect.

8 – 1 year post-operative: the formed keratinized tissue fulfills its functionality and shows an esthetically pleasing result matching the structure and color of the surrounding tissues. The mean width of the peri-implant keratinized mucosa was 4.0 mm, and a low shrinkage was assessed at 38%.

9 – 5 years post-operative: the mucogingival appearance remains stable. The resulting keratinized tissue fulfills its functionality and shows an esthetically pleasing result.

CLINICAL CASE

1 – Pre-operative view. A small band of keratinized gingiva is present

2 – The band of keratinized gingiva is split and a split-thickness flap is elevated exposing connective tissue and periosteum.

3 – Geistlich Mucograft®is sutured to the recipient bed and left exposed.

4 – Follow-up after 1 week: the area appears to granulate underneath the fibrin clot.

5 – Follow-up after 4 weeks: excellent wound healing.

8 – Follow-up after 6 months: Lugol’s iodine staining indicates delineating keratinized tissue.

9 – Follow-up after 6 months: mucogingival appearance with 4 mm of keratinized tissue.

CLINICAL CASE

1 – Pre-operative radiograph showing the severe bone defect around the tooth.

2 – Six weeks after tooth extraction, uneventful soft-tissue healing in the post-operative phase is visible.

3 – After flap preparation, an implant was placed in a site with a severe bone defect.

4 – In order to fill up the defect and provide volume stability Geistlich Bio-Oss Collagen® was applied.

5 – After augmentation with Geistlich Bio-Oss Collagen®, the site was covered with a collagen fleece.

6 – Final crown restoration after 6 months post-operative.

7 – The radiograph after 25 years shows a stable bone situation.

8 – The clinical picture after 25 years follow-up presents a very nice and stable bone and soft-tissue situation.

CLINICAL CHALLENGE:

The upper premolar had to be removed due to advanced periodontal disease and severe bone loss around the infected tooth. The bone defect was an intra-alveolar defect without dehiscence or fenestration.

AIM/APPROACH:

An early implant placement approach with a healing time of six weeks before implant placement was chosen. The bone augmentation with Geistlich Bio-Oss Collagen^® was conducted simultaneously with implant placement. As this patient was treated in 1991, the case is one of the very first clinical applications of Geistlich Bio-Oss Collagen^®

CONCLUSION:

A premolar grafted with Geistlich Bio-Oss Collagen^® during implant placement showed good long-term result after 25 years. Satisfactory hard and soft-tissue contour are present 25 years after implantation.

CLINICAL CASE

1 – Pre-operative photograph showing the horizontal bone defect at sites #18 and #19

2 – Cone-Beam Computed Tomography (CBCT) showing the horizontal and vertical bone defects at sites #18 and #19

3 – Full-thickness flap reflection and buccal flap release to achieve tension-free primary closure

4 – Harvested autograft and vallos™ fibers hydrated with platelet-rich plasma and placed in the Yxoss CBR®mesh

5 – The titanium mesh was covered with a Geistlich Bio-Gide® Compressed membrane and platelet-rich fibrin (PRF) membranes

6 – week post-operative healing of surgical site shows increase in tissue width and no membrane exposure

CLINICAL SITUATION:

A 60-year-old female presented to the periodontics clinic at UTHSA for implant placement at sites #18 and #19. Upon clinical and radiographic examinations, the lower left edentulous ridge was diagnosed as a Siebert class III due to the presence of bucco-lingual and apico-coronal tissue defects. The treatment proposed included soft tissue grafting for increase of keratinized tissue followed by ridge augmentation using Yxoss CBR^®mesh and a mix of autograft, vallos^™ fibers, and platelet-rich plasma (PRP)

OUTCOME:

The vallos^™ fibers combined with autogenous bone and the PRP created a stable fibrin bone graft that could be easily molded and contained within the mesh. Hydration with PRP was progressive until the graft reached the desired consistency. Wound healing following ridge augmentation was uneventful. There were no signs of infection or membrane exposure at the site. Mesh removal and implant placement is planned at 6-months following ridge augmentation.

CLINICAL CASE

1 – Initial clinical presentation showing impacted #10 with anterior ridge deficiency.

2 – Initial radiographic presentation showing fractured/deficient alveolar bone and impacted #10.

3 – Facial and occlusal clinical views showing full thickness flap reflection with verticals #6 & #11 disto-facially.

4 – Facial and occlusal clinical views showing extraction #10 and ridge deficiency present.

Facial clinical view showing use of tacks to secure Geistlich Bio-Gide® membrane.

6 – Facial clinical view showing addition of Geistlich vallomix™ bone graft.

7 – Facial clinical view showing Geistlich vallomix™ bone graft added and secured with Geistlich Bio-Gide® membrane and tacks.

Clinical view showing primary closure using Vicryl™ sutures.

9 – Immediate post-surgical CT scan showing addition of proper bone volume.

10 – Clinical view showing appropriate healing at 2 and 4 weeks.

CLINICAL CASE

6 – Coverage with Geistlich Mucograft® Seal and sealed with sutures

10 – 6 months follow-up the digital implant planning was performed highlighting 3D adequate bone support.

11 – Initial presentation at the moment of implant placement.

12 – Full thickness flap elevation and initial osteotomy performed.

13 – Implant placed and cover screw positioned.

14 – Flap approximations using a PTFE suture after the implant was placed.

15 – Healing at 2 weeks after the implant placement.

16 – Overview of the radiographic sequence of the implant placement: A. The initial bone presentation. B. The guiding pin in position revealing the mesio-distal position. C. The final implant in place.

CLINICAL CASE

1 – The basis for planning implant therapy is clinical and radiological diagnosis with a CBCT scan.

2 – A precise 3-D planning model will be created based on CBCT data. Adaptations of the exact shape are possible, depending on the surgeon’s preference and feedback.

3 – The usual oral surgery and implantology hygiene provisions apply for the use of Yxoss CBR® intraoperatively. The same applies to patient medication.

4 – The opening incision should be designed in accordance with the extent, location and with respect to the anatomical structures of the region to be augmented.

5 – Subsequent steps are the preparation of a mucoperiosteal flap, debridement of scar tissue and the exposure of the defect. Sufficient blood supply of the flap is favored by a flap with a wide base.

6 – Autologous bone can be harvested from the usual intraoral donor sites and can be mixed with bone substitutes (e.g. Geistlich Bio-Oss®).

7 – The Yxoss CBR® is initially filled with autologous bone and bone substitute material (e.g. Geistlich Bio-Oss®).

8 – Yxoss CBR® is fixed on the existing residual bone with an osteosynthesis screw. The titanium screw can generally be introduced, depending on the intended position, through any opening of the titanium grid. The edges of Yxoss CBR® rest on the underlying bone tissue.

9 – A resorbable membrane (e.g. Geistlich Bio-Gide®) should be placed over the Yxoss CBR® to prevent ingrowth of soft-tissue and to support soft-tissue regeneration over the titanium frame.

10 – The wound should be closed completely whenever possible. The mucoperiosteal flap is positioned tightly but tension-free over Yxoss CBR® with single interrupted and deep mattress sutures. Pressure on the augmented crest has to be avoided. Dentures are not to be applied.

11 – Before reopening, clinical and radiological diagnosis are to be taken into consideration.

12 – Reopening of the augmented site approx. 4 to 6 months post surgery and depend on the defect geometry, at latest 9 months after initial surgery.

13 – After removing the fixation screws, Yxoss CBR® can be easily removed using preset breaking points

14 – Newly formed vital bone is regenerated up to the contour defined by the shape of the Yxoss CBR®.

15 – Insertion of implants into the augmented alveolar ridge according to the prosthetic position.

16 – Prosthetic restoration is carried out in accordance with the usual precautions.

17 – Follow-up and radiological evaluation should be performed according to the standardized recommendations of the respective dental societies.

18 – Clinical and radiological imaging of long-term outcome in this case at 5-year follow-up.

CLINICAL CHALLENGE:

The planning of the patient’s case takes local and general patient-specific risk factors into consideration according to the principles of backward planning for implant positioning.

AIM/APPROACH:

Highlights step-by-step the important procedures to regenerate the bone (horizontal and vertical) with the 3-D printing technology, Yxoss CBR^®.

CLINICAL CASE

1 – Baseline: multiple recession defect Miller Class I with keratinized tissue less than 3 mm on teeth #7 to #5.

2 – Coronally advanced flap preparation and elevation for sufficient release.

3 – Geistlich Fibro-Gide® is cut in half to 3 mm thickness.

4 – 3 mm Geistlich Fibro-Gide® is placed in the defect and absorbs blood immediately.

5 – Positioning of Geistlich Fibro-Gide® and fixation with single sutures (7-0 PGA sutures).

6 – Tension-free wound closure with sling sutures (6-0 PGA sutures).

7 – Suture removal 14 days post-surgery.

8 – Follow-up after 12 months: complete root coverage with Geistlich Fibro-Gide® is achieved.

9 – 2 year follow-up: complete root coverage with Geistlich Fibro-Gide®.

CLINICAL CASE

1 – Clinical presentation at baseline, with the patient exhibiting multiple gingival recessions associated with dental hypersensitivity.

2 – A coronally advanced flap was performed, with the interincisal papilla that was preserved.

3 – Xenogeneic cross-linked collagen matrix (Geistlich Fibro-Gide®).

4 – Application of the collagen matrix over the recipient site.

5 – Suturing of the collagen matrix to the de-epithelialized anatomical papillae using simple interrupted sutures (7/0 PGA).

6 – Stabilization of the two collagen matrices.

7 – The flap was coronally advanced and stabilized with sling sutures (7/0 polypropylene).

8 – Clinical outcomes at 6 months showing complete root coverage of the frontal teeth, and a significant reduction on the first premolars. The patient reported a substantial reduction of the preoperative dental hypersensitivity, together with high treatment satisfaction.

CLINICAL CASE

3 – 10 week post op healing. Root coverage achieved. Patient reports no problems and is pleased with the results. More follow ups to come.

2 – Sites at the day of the procedure after sutures placed. Tunnel between #23,24 and partial thickness flap raised between #23,22.

CLINICAL CASE

1 – Baseline: recession defect Miller Class I on tooth #11.

2 – Trapezoidal flap design: split-full-split flap elevation flap.

3 – Positioning of Geistlich Fibro-Gide® and fixation with single sutures (PGA 7.0 Sutures) at the base of the de-epithelialized anatomic papillae and in the apical mesial and distal angles.

4 – Tension-free wound closure with two sling sutures (PGA 6.0 Sutures).

5 – Suture removal 14 days post-surgery.

8 – Follow-up after 1 year: complete root coverage with Geistlich Fibro-Gide® is achieved.

9 – 3 year post-surgery: stable results with Geistlich Fibro-Gide®.

CLINICAL CASE

1 – Baseline frontal view: missing central incisor.

2 – Baseline occlusal view: The facial contour is flattened by physiological dimensional ridge alterations post-extraction.

3 – Full-thickness flap using one releasing incision in the distal aspect of the canine. Simultaneous contour augmentation using GBR was performed with autogenous bone chips to cover the exposed implant combined with a layer of Geistlich Bio-Oss®and Geistlich Bio-Gide®.

4 – Application of Geistlich Fibro-Gide® on top of the augmented area. A tension-free primary wound closure was obtained by a periosteal releasing incision.

5 – Suture removal 14 days post-surgery. Uneventful wound healing and an increase in soft-tissue volume.

7 – 2 months follow-up combined with abutment connection.

8 – Occlusal view of final restoration 2 years post-surgery.

9 – Final restoration 2 years post-surgery shows pleasing esthetics.

CLINICAL CASE

1 – Baseline before implant placement showing the soft-tissue deficiency.

2 – Implant surgery after implant placement showing the need for guided bone regeneration.

3 – Guided bone regeneration with Geistlich Bio-Oss® and Geistlich Bio-Gide®.

4 – Geistlich Fibro-Gide® was trimmed to the defect size and placed at full thickness (6 mm) on top of Geistlich Bio-Gide®.

5 – Wound closure (PTFE 5/0 sutures) by combining horizontal mattress sutures and single sutures in a double layer.

8 – Re-entry was performed 3 months post-surgery. Soft-tissue emergence profile at the time of final ceramic-crown delivery 4 months after implant placement.

9 – Clinical and radiographic situation 2 years after implant insertion.

CLINICAL CASE

1 – Baseline occlusal view: situation before removal of tooth #20.

2 – Tooth removal and extraction socket management with Gesitlich Bio-Oss® and Geistlich Bio-Gide®.

3 – Geistlich Fibro-Gide® was trimmed to the defect size, to augment the buccal and crestal soft-tissue area of the ridge.

4 – Geistlich Fibro-Gide® in place, augmenting buccal and crestal area of tooth #20 and buccal in the edentulous area tooth #21 to tooth #19.

5 – Immediate provisionalization of the implants.

6 – 3 weeks post-surgery: occlusal view of augmented area with created emergence profile.

7 – 3 weeks post-surgery: buccal view of augmented area with created emergence profile.

8 – Provisional reconstruction 6 weeks post-surgery.

9 – Final restoration 2.5 years post-surgery: soft-tissue thickness remains stable over time.

CLINICAL CASE

1 – Baseline buccal view: soft-tissue concavity at the dental implant site.

2 – Baseline occlusal view: volume deficiency on the buccal aspect.

3 – Adapting and trimming of Geistlich Fibro-Gide® to the defect size. Additional bevel cut performed for the area to be positioned close to the incision line.

4 – Position and fixation of Geistlich Fibro-Gide® to the buccal flap with horizontal mattress suture.

5 – Primary closure obtained by horizontal mattress and single interrupted sutures.

6 – 4 months follow-up: showing the healed soft-tissue after augmentation surgery.

7 – 4 months follow-up: provisional restoration. Notice volume recovery.

8 – Occlusal view before final restoration.

9 – 9 months follow-up: final restoration after soft-tissue augmentation surgery.

CLINICAL CASE

1 – Exposure of the alveolar ridge and buccal bone.

2 – Horizontal and vertical osteotomies of the distracted segment.

3 – The upward lift of the transported segment, achieving a height gain of 7 mm.

4 – Geistlich Bio-Oss® Block is trimmed in a dry state with a piezo surgical device to the required dimension and shaped to completely fit into the recipient site.

5 – The coronally shifted segment is fixed with miniplates and miniscrews and thus immobilizes also the biomaterial block.

6 – The coronally shifted segment is fixed with miniplates and miniscrews and thus immobilizes also the biomaterial block.

7 – Intra-operative situation following implants insertion 4 months after interpositional grafting.

8 – Periapical X-ray evaluation immediately after implant insertion.

CLINICAL CHALLENGE:

Insufficient alveolar ridge height for implant placement and proximity to the alveolar nerve
Autologous bone harvesting is associated with patient discomfort

AIM/APPROACH:

Interpositional grafting with Geistlich Bio-Oss^® Block for vertical augmentation
Alveolar ridge volume preservation and minimizing patient morbidity

CLINICAL CASE

1 – Preoperative radiograph depicting the severe bony atrophy in the posterior mandible.

2 – Fixation of the pre-formed osteosynthesis plate with miniscrews.

3 – Augmentation with autologous bone harvested from the angular region of the mandible and mixed with Geistlich Bio-Oss®.

4 – The grafted site including the osteosynthesis plate is covered with Geistlich Bio-Gide® and the tensile collagen membrane is pinned down. Thus, the augmented site is accurately covered and stabilized.

5 – In order to obtain primary wound closure, a double-layered suturing technique is used by combining a horizontal internal mattress and a coronal single stitch technique.

6 – Implants are inserted 6 months after augmentation and the healing abutments are connected to the implants.

7 – Lateral view of the final prosthetic restoration 6 months after implant placement.

8 – Intraoral radiograph 15 months after augmentation procedure showing a stable bony situation.

CLINICAL CHALLENGE:

Severely atrophied alveolar ridge with insufficient bone volume for implant placement
High complication rates and patient discomfort associated with large augmentations when using autologous bone grafts

AIM/APPROACH:

3-dimensional augmentation of alveolar ridge by the fence technique for implant placement
At the same time reducing complication rates and patient discomfort

CLINICAL CASE

1 – Occlusal view of the ridge after flap elevation.

2 – Longitudinal split of the alveolar crest by use of piezo-surgical instruments.

3 – Two implants are placed in the expanded crest.

4 – The split around the implants is filled with a mixture (1:1) of autologous bone chips from the retromolar area and Geistlich Bio-Oss®.

5 – The augmented ridge is covered with a Geistlich Bio-Gide® membrane before closure of the soft tissue.

7 – Occlusal view of the prosthetic outcome.

8 – X-ray findings 6 months after implant placement.

CLINICAL CHALLENGE:

Insufficient alveolar ridge width for implant placement
Autologous bone is subject to resorption and may lead to loss of volume

AIM/APPROACH:

Ridge Split procedure in combination with Geistlich Bio-Oss^® and Geistlich Bio-Gide^® for horizontal augmentation
Preservation of the alveolar ridge volume

CLINICAL CASE

1 – 3D reconstruction from CBCT images showing horizontal maxillary atrophy at the two-teeth gap.

2 – Intraoperative view of the atrophied anterior maxillary site. Tenting screws are placed to support the collagen membrane.

3 – Application of a mixture (1:1) of autologous bone chips from the retromolar area and Geistlich Bio-Oss®.

4 – Coverage with a double layer of collagen membrane Geistlich Bio-Gide®.

5 – Tension-free, primary wound closure by mattress and single interrupted sutures.

6 – Situation at re-opening after 6 months showing vital bone and reconstructed ridge contour.

7 – Guided implant placement in regenerated bone with stent (additional implant placement at position 22).

CLINICAL CHALLENGE:

Insufficient alveolar ridge width for implant placement
Donor site morbidity after autologous bone block harvesting and resorption of autologous bone

AIM/APPROACH:

Horizontal alveolar ridge augmentation with Geistlich Bio-Oss^® and Geistlich Bio-Gide^®
Minimizing autologous bone harvesting and resorption protection

CLINICAL CASE

1 – Patient with missing teeth 3, 4 and 5 in combination with horizontal and vertical atrophy. Situation incompatible with ideal and prosthetically guided implant insertion.

2 – Initial CBCT showing vertical and horizontal bone deficit.

3 – 3-D model obtained from CBCT with the corresponding Yxoss CBR® design.

4 – Final titanium scaffold ready for use.

5 – Exposure of the bone defect with full thickness flap.

6 – Fixation of Yxoss CBR® filled with a mix of autologous bone chips and Geistlich Bio-Oss® using two titanium screws.

7 – Coverage with a Geistlich Bio-Gide® membrane.

8 – Tension-free hermetic suture of the flap.

9 – After 8 months, the adequate rooting of the bone graft is assessed by CBCT and the insertion of the implants is planned in a prosthetically guided manner.

10 – 8 months after the GBR the scaffold is removed and two endosseous implants are inserted.

11 – Radiography with three elements supported by implants.

12 – Final prosthetic reconstruction 3 months after implant placement, without the need of a temporary interim solution.

CLINICAL CASE

1 – Initial clinical situation showing an extended horizontal and vertical bone gap at former positions of teeth 3 and 4 which were extracted 8 weeks earlier.

2 – CBCT showing a deficient vestibular contour and the corresponding bone defect. 3-D design of Yxoss CBR® derived from the patient’s anatomy.

3 – Surgical situation with horizontal and vertical bone defect.

4 – After testing the adaptation of Yxoss CBR® to the defect, it is filled with a graft consisting of 30% autologous particulate bone and 70% granules of Geistlich Bio-Oss®.

5 – Yxoss CBR® fixed with titanium screws.

6 – Adaptation of Geistlich Bio-Gide® over the structure. Complete, tension-free wound closure will follow.

7 – Sites at the day of the procedure after sutures placed. Tunnel between #23,24 and partial thickness flap raised between #23,22.

8 – Radiographic situation after 6 months of healing, before reopening.

9 – Insertion of two implants (Straumann® BLT). The resonance frequency measurement shows ISQ values of 70-75.

10 – Insertion of the healing abutments and adaptation of the flap.

11 – Soft tissue maturation 12 weeks after implant insertion.

12 – Clinical situation after prosthetic finalization, 18 months after surgery. X-ray shows stability of marginal bone levels.

CLINICAL CASE

1 – Large horizontal and vertical bone defect in region 5-12; deficit emerging from many years of wearing mucosa-supported dentures.

2 – 3-D design including 3-D model, grafting volume, Yxoss CBR® and implants.

3 – 3-D Design including 3-D model and Yxoss CBR®.

4 – Initial clinical situation before opening of the soft tissue.

5 – Presentation of bony situs with a full-thickness flap (ridge incision).

6 – Titanium scaffold filled with 100% Geistlich Bio-Oss® and placed onto bone defect. Fixation performed with 4 mini-screws in the buccal area.

7 – Soft tissue situation after 6 months of healing.

8 – Careful separation of Yxoss CBR® into two parts at predetermined breaking points (Easy Removal Design®). Pilot drill performed through built-in holes according to backward planning principle.

9 – 4 implants placed in positions 5, 7, 10 and 12 to support the prosthesis. Bleeding out of the bone shows a good vascularization.

10 – Panoramic X-ray 6 months after the augmentation. In the meantime, 4 additional implants have been placed in the lower jaw.

CLINICAL CASE

1 – Radiographic image showing the vertical bone deficit in the left mandible.

2 – Clinical situation before opening the area.

3 – Incision for the creation of a poncho flap.

4 – Starting in the retromolar area the incision is directed toward the distal region of tooth 23.

5 – Cortical bone is removed with the trephine, crushed and mixed with Geistlich Bio-Oss® (50:50).

6 – Successive application of Geistlich Bio-Gide®.

7 – Dehiscence after 1.5 months. The soft tissue was de-epithelialized and a free gingival graft was sutured to protect the exposition. Dehiscence may occur but usually heals spontaneously after appropriate cleaning.

8 – After 6 months, the ridge incision is applied to access the 3-D titanium scaffold.

9 – Buccal view of the regenerated bone. Even though there was dehiscence, the bone was regenerated satisfactorily.

10 – Four implants are inserted and the soft tissue is healed showing the contour provided by the good adaptation of the provisional prosthesis.

11 – Clinical situation after the final prosthesis and the soft tissue frenum removal.

CLINICAL CASE

1 – Clinical situation in the posterior maxilla depicting a large buccal defect in the edentulous area.

2 – Fixation of the autologous block from the symphysis.

3 – Contouring of the grafted site with Geistlich Bio-Oss®.

4 – The augmented area is covered with the collagen membrane Geistlich Bio-Gide®.

5 – Primary wound closure is accomplished with single interrupted sutures.

6 – Clinical aspect of the augmented ridge with no signs of block resorption.

7 – Implant placement 3 months post augmentation.

8 – Long-term follow-up showing stable peri-implant bone level 3 years after implant placement.

CLINICAL CASE

1 – The preoperative radiograph displays the vertical bone defect in the left mandible and thus, insufficient vertical bone volume to allow implant placement.

2 – Yxoss CBR® is planned based on the preoperative CBCT data.

3 – Opening the defect site using the ridge incision technique. The titanium scaffold fits the bone defect precisely during the augmentation procedure.

4 – The titanium scaffold is filled with 50% autologous bone and 50% Geistlich Bio-Oss®. Fixation is performed with one titanium screw in vestibulolingual direction.

5 – A collagen membrane (Geistlich Bio-Gide®) is used to provide an additional barrier for bone regeneration.

6 – Stable soft tissue situation after 6 months with no complications during the healing period. After reopening, bone is regenerated to the contour defined by the titanium scaffold.

7 – The bone is completely regenerated in the correct three-dimensional orientation. This is also visible in the respective CBCT. Implant placement is now possible.

8 – Two implants were placed with good primary stability. The vertical bone regeneration is also visible in the CBCT data.

9 – Postoperative panoramic radiograph after implant placement.

10 – Clinical situation 3 months post implant insertion.

11 – Final prosthetic reconstruction 6 months post implant insertion and 16 months post regenerative surgery.

12 – Final prosthetic reconstruction 16 months post regenerative surgery.

CLINICAL CASE

1 – Pre-operative assessment demonstrating significant bone loss, prior to vertical ridge augmentation.

2 – Labial view of the posterior mandibular defect site. Cortical bone was perforated to increase the blood supply.

3 – RPM™ was secured on the lingual side prior to applying a 1:1 mixture of autogenous bone and Geistlich Bio-Oss®.

4 – RPM™ was secured over the bone graft with titanium pins and screws.

5 – Geistlich Bio-Gide® is placed on top of RPM™ to prevent early soft tissue ingrowth while allowing for graft vascularization.

6 – Labial view of the soft tissue 9 months after the vertical bone augmentation.

7 – RPM™ exposed at 9 months, following flap elevation.

8 – Labial view of the regenerated surgical site at 9 months demonstrates well vascularized bone.

9 – Occlusal view of the regenerated surgical site at 9 months demonstrates well vascularized bone.

10 – Implant placement in the newly regenerated bone.

Geistlich Fibro-Gide® (15x20x6mm) was placed on top of two implants, to increase soft tissue thickness.

12 – Periapical x-ray 1 year post-operatively, demonstrates implant stability and mature bone formation following vertical bone augmentation and soft tissue thickening.

CLINICAL CASE

Geistlich Fibro-Gide® is trimmed in a dry state to 10 x 15 x 6mm. The corners were trimmed for better adaptation and the matrix was then hydrated in sterile saline solution.

CLINICAL CASE

1 – Baseline: recession defects on teeth #19 to #22 in the lower left quadrant. Exposed root surfaces of these teeth were thoroughly scaled and root planed before surgery.

2 – A full thickness muco-gingival tunnel was prepared through a minimally-invasive vestibular access incision apical to the teeth with gingival recessions.

3 – Geistlich Fibro-Gide® was cut into small pieces in a dry state using a scalpel.

4 – Insertion of Geistlich Fibro-Gide® into the subperiosteal tunnel.

5 – Geistlich Fibro-Gide® in situ: the gingival margin had been coronally advanced and stabilized after pieces of Geistlich Fibro-Gide® were placed.

6 – 1 week post-surgery: anchoring sutures were left in place for 1-2 weeks.

7 – 2 weeks post-surgery: anchoring sutures in place.

8 – 2 weeks post-surgery: removal of anchoring sutures.

9 – 7 months post-surgery: complete recession coverage.

CLINICAL CASE

1 – Baseline frontal view: missing central incisor. Implant visible through mucosa due to thin biotype.

2 – Baseline occlusal view: soft-tissue deficit in the buccal and occlusal area.

3 – Flap elevation on the buccal side using a full flap crestally and a split flap buccally.

4 – Adaption of Geistlich Fibro-Gide® to the defect size.

5 – Palatal island flap prepared to allow for tension-free wound closure. Geistlich Fibro-Gide® in situ, immobilized with a mattress suture.

6 – Tension-free wound closure using single interrupted sutures (Dafilon 5-0, Braun).

8 – 6 months follow-up: final crown in place.

9 – 2.5 year follow-up shows stable soft-tissue conditions.

CLINICAL CASE

1 – Pre-operative view of the atrophied ridge.

2 – Application of a 1:1 mixture of autologous bone and Geistlich Bio-Oss®.

3 – Geistlich Bio-Gide® is tightly fixed and pinned, thus immobilizing the particulate graft. The sausage-like augmentation allows extended horizontal augmentation.

4 – Primary wound closure is obtained with a combination of mattress and single-interrupted sutures.

5 – Sufficient amount of augmented bone for implant placement 8 months after augmentation. Implants are placed in a submerged procedure.

6 – Insufficient vestibular depth and keratinized tissue after alveolar ridge augmentation.

7 – Application of a keratinized strip towards the vestibulum and Geistlich Mucograft® over the augmented area where it is left exposed for healing.

8 – Situation before reopening for abutment connection after 3 months showing increased vestibular depth

CONCLUSIONS:

Geistlich Mucograft® with a keratinized tissue strip was utilized to increase vestibular depth and gain additional keratinized tissue.
Augmentation of severely atrophied alveolar ridge provided sufficient bone for implant placement 8 months following augmentation.