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 RiskMedium RiskHigh Risk
Patient’s healthIntact immune system
Non-smoker 
Light smokerImpaired immune system 
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
watch video download pdf

THE APPROACH

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

“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 RiskMedium RiskHigh Risk
Patient’s healthIntact immune system
Non-smoker 
Light smokerImpaired immune system 
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
watch video download pdf

THE APPROACH

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

A flap has been raised and reveals a significant facial and palatal defect at congenitally missing site #10.
Harvested ramal graft. Slightly over-sized to allow for mitering and harvest of particulate autograft with a bone trap on the suction.
Onlay graft now secured with two fixation screws (Stryker) with a lag screw technique. Geistlich Bio-Oss Collagen® has been placed on the palatal aspect of site #10
Combination of a fixated onlay graft with Geistlich Bio-Oss®/autograft particulate graft at the periphery and over the facial plate of the adjacent dentition
Geistlich Mucograft® matrix placed over facial augmentation of the adjacent dentition and ridge crest of the augmented site
Closure following ramal grafting and Geistlich Mucograft®matrix application
Implant placement with static guide and dental implant hand driver
Implant placement with slight subcrestal placement of the platform just prior to osteoplasty by the periodontist.

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

THE OUTCOME

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

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

Dr. Richard E. Bauer, III

Dr. Richard E. Bauer, III

Oral and Maxillofacial Surgeon – University of Pittsburgh

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

BIOBRIEF

Enhance Periodontal Phenotype with Geistlich Mucograft® for Soft Tissue Augmentation 

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

THE SITUATION

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

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system 
Non-smoker
Light smokerImpaired immune system 
Heavy smoker
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect

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

THE APPROACH

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

A mid-facial incision was made, with the intent to preserve the minimal keratinized tissue that was available, as well as vertical incisions along the line angles of the canines to reflect a partial thickness flap.
Platelet-rich fibrin clots were formed by centrifugation. The leukocyte-PRF (L-PRF) was extracted, and the L-PRF was used to hydrate Geistlich Mucograft®
Geistlich Mucograft® and PRF stabilized via glycolon sutures.
Clinical situation at three-week follow up.
Occlusal view at twelve-month follow up.
Frontal view at twelve-month follow up.

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

THE OUTCOME

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

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

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

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

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

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

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

BIOBRIEF

Clinical efficacy of Geistlich Mucograft® in regeneration of oral mucosa combined with the surgical treatment of peri-implantitis in implants with lack of keratinized tissue

Dr. Alberto Ortiz-Vigón
Dr. Erik Regidor Correa

THE SITUATION

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

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system 
Non-smoker
Light smokerImpaired immune system 
Heavy smoker
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
watch video download pdf

THE APPROACH

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

Pathological peri-implant pocket depth combined with bleeding on probing.
Partial thickness flap in order to create a periosteal bed free of any muscle attachment and apically positioned.
Implantoplasty of the exposed rough implant surface using burs and silicon carbide polishers.
Xenogeneic collagen matrix structure (Geistlich Mucograft®).
Future position of the xenogeneic collagen matrix facilitated by prosthodontic abutment.
Suture of xenogeneic collagen matrix around the abutment and over the recipient bed.
Buccal view of xenogeneic collagen matrix and apically positioned flap.
Occlusal view of xenogeneic collagen matrix and apically positioned flap.
Lateral view of xenogeneic collagen matrix and apically positioned flap.
Peri-implant tissue health and maintenance of keratinized tissue after one year of surgical treatment.
Periimplant tissue health and maintenance of keratinized tissue after 2 years

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

THE OUTCOME

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

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

Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

The use of soft-tissue substitutes may play an important role in patient perception and satisfaction without jeopardizing the final clinical outcome.

Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

Dr. Alberto Ortiz-Vigón

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

Dr. Erik Regidor Correa

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

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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.