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

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.

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

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.

4 months later following Emergence Profile Development.

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

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.