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.

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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

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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

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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.

“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

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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

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.

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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^®.

1. Panoramic radiograph of initial situation showing the atrophic mandibular areas.

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

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

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

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

8. 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

Ridge Augmentation and Delayed Implant Placement on an Upper Lateral Incisor

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

Dr. Daniele Cardaropoli

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

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

Dr. Gian Maria Ragucci

Prof. Federico Hernández-Alfaro

Immediate Mandibular Molar Transition

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

Dr. Peter Hunt

Ramal Bone Graft for Congenitally Missing Maxillary Lateral Incisor

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

Dr. Richard E. Bauer, III

Prosthetically Guided Regeneration (PGR) in the Posterior Maxilla

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

Paolo Casentini, DDS

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

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

Tamir Wardany, D.D.S.

A Regenerative Approach to Peri-implantitis

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

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

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

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

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

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

Enhance Periodontal Phenotype with Geistlich Mucograft® for Soft Tissue Augmentation

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

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

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

THE SITUATION

THE RISK PROFILE

THE APPROACH

THE OUTCOME

Dr. Alberto Ortiz-Vigón

Dr. Erik Regidor Correa

CLINICAL CASE