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

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

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).

WEBINAR

CLINICAL CASE

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.

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.

5 – 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.

8 – 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

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 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 – 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 – 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

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.