WEBINAR

BIOBRIEF

Selecting Biomaterials for Combined Complex Defects

Irina F. Dragan, DDS, DMD, MS, eMBA

THE SITUATION

The patient called the office complaining of sensitivity and swelling in the maxillary left quadrant. He was seen and prescribed an antibiotic. Tooth #12 was deemed hopeless, and the peri-apical and radicular lesion presented on the radiograph extended significantly on the mesial aspect, impacting the interproximal bone level for tooth #11. Patient presents with implant supported restorations distal to the affected area and was concerned about the infection spreading to that area as well. The area was treated successfully, and the patient was pleased with the outcome, allowing him to preserve the tooth, on the mesial aspect of the lesion and the implant distally.

THE RISK PROFILE

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

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THE APPROACH

The goals of the procedure were to eliminate infection, the source of pain, and reduce periodontal problems to the adjacent tooth and implant. Full thickness flap was reflected, #12 was removed and the socket was debrided and irrigated. A peri-radicular lesion was removed and submitted for histopathological exam.

Full thickness flap elevation exposing the complex clinical situation.

Alveolar socket after the tooth removal exposing the loss of bone on the distal of tooth #11, prior to the debridement of the granulation tissue and root preparation.

Adaptation on the buccal defect prior to placement of bone grafting with vallos® mineralized cortical cancellous mix granules (bottom) followed Geistlich Bio-Oss® (top).

Post adaptation with Geistlich Bio-Gide® for alveolar ridge preservation and guided tissue regeneration, followed by final suturing of the site using ePTFE material.

Radiographic overview of the clinical procedure: initial presentation with the bony defect impacting distal of #11 and #12 – mesial and inter-radicular, site after the tooth #12 was extracted, radiographic bone fill of the defect post-operative.

Post-operative healing of the site, 4 weeks after the procedure was completed.

“A localized infection can easily spread and impact adjacent teeth and implants. It is critical for clinicians to intervene as soon as possible to prevent further complications. Patient education and motivation is key to successfully treat these types of clinical situations encountered in a daily practice.”
— Dr. Irina Dragan

THE OUTCOME

The combined defect: #11 distal guided tissue regeneration and #12 alveolar ridge preservation for #12. This area was treated with vallos®, Geistlich Bio-Oss Collagen®, and Geistlich Bio-Gide®. The xenograft was placed in the apical portion of the socket and the allograft towards the coronal surface.

Healing of the site at 4 weeks post-operative.

Considering today’s advancements in regeneration we are able to successfully treat complex clinical scenarios that involve combined therapeutic applications, such as guided tissue regeneration and alveolar ridge preservation.”
Dr. Irina Dragan

Periotomes were able to support with an atraumatic extraction of tooth #12 and maintaining as much as possible the soft and hard tissue present in this compromised area.”
Dr. Irina Dragan

Irina F. Dragan, DDS, DMD, MS, eMBA

Periodontology and Implant Dentistry
Dr. Irina Dragan is board certified and an examiner for the American Board of Periodontology and Implant Dentistry. She is part-time faculty in postgraduate periodontics at Harvard School of Dental Medicine and an adjunct associate professor of periodontology at Tufts University School of Dental Medicine. She is a periodontist and clinical researcher at The Perio Studio, a practice limited to periodontology and implant dentistry in Boston, MA.

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BIOBRIEF

Mandibular Alveolar Ridge Split with Delayed Implant Placement

Gregory A. Santarelli, DDS

THE SITUATION

A healthy (ASA 1) non-smoker 63-year-old female presented to my office with Kennedy Class II partial edentulism in the mandibular right posterior quadrant for several years. She denied removable options and wanted dental implants to individually replace her missing teeth. The clinical and radiographic evaluation revealed atrophic mandibular bone height and width at site #’s 29, 30 & 31. The edentulous site required engineering prior to the placement of conventional dental implants and prosthetics.

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 goal is to provide adequate soft and hard tissue at edentulous site #’s 29, 30 & 31 in order to place dental implants and restore a stable balanced occlusion.

Alveolar ridge split with Geistlich Bio-Oss® graft in place (subsequently applied Geistlich Mucograft®).

6 months post grafting with Geistlich Bio-Oss® and Geistlich Mucograft®.

Implant osteotomies with adequate alveolar width.

Implants in tooth positions 29, 30 and 31.

“The hard and soft tissue of the edentulous posterior mandible were inadequate to rehabilitate with dental implants.”
— Dr. Gregory Santarelli

THE OUTCOME

The patient summarized this challenging case very well – “I never imagined I would have fixed teeth again.” Geistlich Bio-Oss® and Geistlich Mucograft® allowed for retention of the hard and soft tissue volume to achieve our final result and for maintenance of the final prosthesis.

Careful patient selection, treatment planning and operative efficiency were used to provide a previously non-functional segment with fixed stable dental implant prosthetics and a balanced occlusion.”
Dr. Gregory Santarelli

Precise osteotomies along with the use of Geistlich Bio-Oss® and Geistlich Mucograft® provide adequate bone volume for dental implants.”
Dr. Gregory Santarelli

Gregory A. Santarelli, DDS

Dr. Santarelli earned his DDS degree in 1998 from the University School of Dentistry, Milwaukee, WI, after graduating with his B.S. in Biology from Arizona State University (Tempe, AZ). In 1999, he completed his General Practice Residency at the University of Iowa Hospital and Clinics, and went on to an Oral & Maxillofacial Surgery Internship at the Medical College of Virginia (Richmond, VA) as well as an Oral & Maxillofacial Surgery Residency Program, Christiana Care Health System (Wilmington, DE).

After completing his formal training in 2004, Dr. Santarelli’s work experience includes the Bankor Hospital for Children, Cambodia (2003), Adjunct Clinical Professor, University of Marquette, School of Dentistry, Department of Oral Sugery, Marquette, WI (2005), and Oral Surgery Associates of Milwaukee, Milwaukee, WI (2004-2005). He now maintains a private practice in Kenosha, WI with his partner Dr. Deno Tiboris.

Dr. Santarelli performs numerous hard/soft tissue regeneration surgeries in preparation for dental implants and is actively involved in clinical research with The McGuire Institute (iMc).

BIOBRIEF

Odontogenic Keratocyst Management

Bassam Kinaia, DDS, MS, DICOI

THE SITUATION

A 60-year-old-heathy Caucasian female presented with the chief complaint: “I noticed a bump on my lower left teeth since last year.” An examination revealed a stable periodontium except for enlarged gingival tissue between #21-22 measuring 10x8x5mm, well-defined borders, depressible, non-painful, and vital teeth without displacement. The treatment plan included flap surgery, excisional biopsy, GTR #21-22 (Diff Dx: Lateral periodontal cyst (LPC), Odontogenic Keratocyst (OKC), Benign Fibro-Osseous lesion (BFOL).

Guided Tissue Regeneration (GTR) using Geistlich Bio-Oss® and vallos®f was performed and covered with a resorbable collagen membrane (Geistlich Bio-Gide®).

Primary closure was completed using non-resorbable sutures. Follow-up at 2, 4 weeks, 3, 6 months showed stable periodontium without re-occurrence. The pathology report indicated OKC and the area is monitored annually.

THE RISK PROFILE

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

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THE APPROACH

The treatment goal was to excise the lesion around #21-22 and stabilize the periodontium. Sulcular incisions #20-22 with vertical incision #22 MF were performed. Upon full thickness flap reflection, the lesion was removed (excisional biopsy). The defect extended #21M-#22D with complete facial bone loss. It was a wide 1-2 bony wall defect measuring 10x8x5mm. GTR procedure using Geistlich Bio-Oss® and vallos®f and Geistlich Bio-Gide® for the collagen membrane were employed. Primary closure was obtained using 6-0 prolene suture.

Initial clinical and radiographic presentation shows buccal soft tissue enlargement and bone loss #21-22 area.

Clinical facial view showing full thickness flap reflection with complete enucleation of cystic lesion (excisional biopsy).

Clinical view showing hydration of vallos®f and Geistlich Bio-Oss® as two separate grafts.

Clinical facial view showing placement of vallos®f internally for maximum osteogenic/osteoinductive potential and Geistlich Bio-Oss® externally for space maintenance.

Clinical facial view showing placement of Geistlich Bio-Gide® covering the defect and extending one tooth mesillay and distally.

Clinical facial view showing primary closure using 6-0 prolene sutures.

CBCT immediately post-surgery showing radiolucent allograft internally for osseoinduction and radiopaque xenograft externally for space maintenance.

After flap elevation at 4 months showing, the new buccal bone plate together with a completely filled alveolus.

Clinical facial views showing healing at 2 and 4 weeks with proper soft tissue healing.

6 months post-surgery radiographic presentation showing stable periodontium and proper bone fill #21-22 area.

Comparison of pre- and post-surgical CBCT views showing good bone formation.

Comparison of pre- and post-surgical clinical views showing stable periodontium.

“Excisional biopsy and guided tissue regeneration is indicated to treat the pathology (#21-22 area) and stabilize the periodontium.”
— Dr. Bassam Kinaia

THE OUTCOME

Complete excision of pathology and biopsy followed by GTR using vallos®f internally for maximum osteogenic/osteoinductive potential and Geistlich BioOss® externally for space maintenance showed excellent radiographic bone fill and stable periodontium.

Six-month post-surgical clinical view shows stable periodontium.

Guided tissue regeneration using vallos®f bone graft (allograft as an internal first layer), Geistlich Bio-Oss® (as an outside second layer), and collagen membrane showed predictable periodontal regeneration.
Dr. Bassam Kinaia

Bassam Kinaia, DDS, MS, DICOI

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

BIOBRIEF

The Buccal Pedicle Flap for Peri-Implant Soft Tissue Volume

Dr. Giorgio Tabanella

THE SITUATION

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

THE RISK PROFILE

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

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

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THE APPROACH

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

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

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

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

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

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

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

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

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

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

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

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

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

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

THE OUTCOME

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

Dr. Giorgio Tabanella

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

BIOBRIEF

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

Dr. Avinash Bidra

THE SITUATION

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

THE RISK PROFILE

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

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THE APPROACH

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

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

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

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

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

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

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

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

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

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

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

THE OUTCOME

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

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

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

Dr. Avinash Bidra

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

BIOBRIEF

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

Bassam Kinaia, DDS, MS, DICOI

THE SITUATION

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

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

THE RISK PROFILE

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

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THE APPROACH

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

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

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

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

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

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

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

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

Facial and occlusal clinical views showing healing at 6 weeks

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

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

THE OUTCOME

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

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

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

Bassam Kinaia, DDS, MS, DICOI

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

BIOBRIEF

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

Dr. John Kim

THE SITUATION

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

THE RISK PROFILE

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

Note: Very limited range of opening

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THE APPROACH

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

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

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

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

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

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

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

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

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

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

THE OUTCOME

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

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

Dr. John Kim

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

BIOBRIEF

Horizontal Ridge Augmentation in the Esthetic Zone

Dr. Justin Kang

THE SITUATION

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

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

THE RISK PROFILE

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

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

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THE APPROACH

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

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

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

Presence of horizontal tissue deficiency clearly visible following flap elevation.

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

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

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

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

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

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

THE OUTCOME

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

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

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

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

Dr. Justin Kang

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

BIOBRIEF

Lateral Ridge Augmentation in the Posterior Mandible

Dr. John M. Sisto

THE SITUATION

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

THE RISK PROFILE

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

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THE APPROACH

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

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

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

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

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

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

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

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

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

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

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

THE OUTCOME

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

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

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

Dr. John M. Sisto

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

BIOBRIEF

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.

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

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

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

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

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

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

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

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

4 months later following Emergence Profile Development.

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

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

THE OUTCOME

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

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

Dr. Peter Hunt

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

BIOBRIEF

Ramal Bone Graft for Congenitally Missing Maxillary Lateral Incisor

Dr. Richard E. Bauer, III

THE SITUATION

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

THE RISK PROFILE

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

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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

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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)

download pdf

THE APPROACH

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

Panoramic radiograph of initial situation showing the atrophic mandibular areas.

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

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

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

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

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

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

THE OUTCOME

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

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

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

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

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

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

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

WEBINAR

CLINICAL CASE

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

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

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

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

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

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

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

Clinical view showing primary closure using Vicryl™ sutures.

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

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

CLINICAL CASE

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

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

11 – Initial presentation at the moment of implant placement.

12 – Full thickness flap elevation and initial osteotomy performed.

13 – Implant placed and cover screw positioned.

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

15 – Healing at 2 weeks after the implant placement.

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

CLINICAL CASE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CLINICAL CHALLENGE:

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

AIM/APPROACH:

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

CLINICAL CASE

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

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

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

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

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

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

7 – Soft tissue situation after 6 months of healing.

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

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

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

CLINICAL CASE

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

2 – Clinical situation before opening the area.

3 – Incision for the creation of a poncho flap.

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

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

6 – Successive application of Geistlich Bio-Gide®.

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

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

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

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

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

CLINICAL CASE

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

2 – Fixation of the autologous block from the symphysis.

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

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

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

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

7 – Implant placement 3 months post augmentation.

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

CLINICAL CASE

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

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

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

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

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

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

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

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

9 – Postoperative panoramic radiograph after implant placement.

10 – Clinical situation 3 months post implant insertion.

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

12 – Final prosthetic reconstruction 16 months post regenerative surgery.

CLINICAL CASE

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

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

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

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

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

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

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

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

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

10 – Implant placement in the newly regenerated bone.

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

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

CLINICAL CASE

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.