BIOBRIEF

Vertical Bone Augmentation with Bone Plate Technique and Soft Tissue Phenotype Modification

Muhammad Saleh, BDS, MSD, PhD

THE SITUATION

A patient presented with a vertical bone defect in the maxillary anterior region and expressed high esthetic demands while explicitly wishing to avoid autogenous grafting. This required a regenerative strategy that could reliably achieve vertical augmentation, maintain space, and deliver a stable peri-implant soft tissue phenotype—all without harvesting autogenous blocks or connective tissue.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s esthetic requirements	Low	Medium	High
Height of the smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth	≤ 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 (#8 has been 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

Vertical ridge augmentation was performed using allogenic cortical plates fixed with microscrews to create a stable, space-maintaining box, which was densely packed with vallos^® mineralized cortico-cancellous granules hydrated with the rhPDGF-BB component of GEM 21S^®. Five months later, the implants were placed, and the peri-implant soft tissue phenotype was enhanced using Geistlich Mucograft^® and Geistlich Fibro-Gide^® to improve soft-tissue height and thickness.

Preoperative view showing the anterior maxillary defect with loss of #6 and #7; #5 and #8 are planned to be extracted because of severe mobility and advanced bone loss.

Full-thickness mucoperiosteal flap elevation revealing a vertically and horizontally deficient ridge in the #5–8 region, prepared for augmentation.

Adaptation and fixation of two allogenic cortical bone plates to the native ridge using micro screws to create a “box” configuration for vertical bone augmentation. The box between and around the plates is packed with vallos® mineralized cortico-cancellous granules mixed with rhPDGF-BB component of GEM 21S®, completing the three-dimensional reconstruction of the defect.

Immediate closure with PTFE sutures providing tension-free primary closure over the augmented site.

Re-entry after healing demonstrating well integrated cortical plates and a vertically augmented ridge suitable for implant placement.

Occlusal view showing well integrated particulate bone at relatively early stage.

Placement of two implants into the regenerat ed ridge, with a regular diameter implant anteriorly and a wide diameter implant posteriorly.

Geistlich Mucograft® is layed on top of the implants before flap closure to improve the tissue phenotype.

Occlusal view after the second stage for implant uncovery with Geistlich Fibro-Gide® left between the flap intentionally slightly exposed. Due to volume stability of Geistlich Fibro-Gide®, it aids in maintaining tissue verticality during healing.

Occlusal view after 2 weeks of the second stage showing excellent healing of Geistlich Fibro-Gide® with secondary intention with traces of keratinzed tissue forming between wound edges. Both healing abutments were replaced with bigger sizes to aid with tissue contouring before final restoration.

“The patient had high esthetic demands and specifically wanted to avoid autogenous grafting. Remarkably, this case was completed with 0% autogenous tissue, demonstrating that outcomes traditionally thought to require autogenous grafts can be achieved otherwise.”
— Dr. Muhammad Saleh

THE OUTCOME

Vertical ridge augmentation of the maxillary anterior was achieved using allogenic cortical bone plates fixed with microscrews to create a box configuration, filled with vallos^® mineralized cortico-cancellous granules mixed with rhPDGF-BB component of GEM21S^®. At implant placement, soft tissue phenotype was enhanced using Geistlich Mucograft^® and Geistlich Fibro-Gide^®.

Rigid fixation of cortical plates creating a stable, space-maintaining box with tension-free soft tissue closure are the most critical factors for predictable vertical ridge augmentation.”
Muhammad Saleh, BDS, MSD, PhD

Muhammad Saleh, BDS, MSD, PhD

Dr. Muhammad H. Saleh, Diplomate of the American Board of Periodontology, is a full-time faculty member at the University of Michigan and an internationally recognized lecturer in periodontology and implant dentistry. He has published over 140 peer-reviewed articles and reviews for leading Q1 journals. His numerous honors include the 2021 AAPF Schoor Award, 2022 Ramfjord Symposium Award, 2022 AAP Institute Award, 2024 AAPF LEAD and Nevins Awards, and the 2025 Roy H. Roberts Award.

BIOBRIEF

Vertical and Horizontal Maxillary Ridge Reconstruction with Advanced Grafting

Nikolaos Soldatos, DDS, PhD, MSD

THE SITUATION

A 26-year-old edentulous female presented for implant-supported maxillary rehabilitation. She was systemically healthy and classified as ASA I. Clinical and radiographic evaluation revealed a Seibert Class III maxillary ridge defect with combined horizontal and vertical deficiencies. The patient exhibited a medium smile line and reported a highly active lifestyle with regular physical activity, indicating the need for a stable, durable, and esthetically driven implant rehabilitation capable of meeting long-term functional demands.

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 the smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

Horizontal and vertical ridge augmentation was performed using a full-thickness maxillary flap with two distal vertical releasing incisions. Extensive buccal periosteal release and cortical perforations were carried out. A composite graft of large-particle vallos^®allograft (demineralized cortical granules) and large-particle Geistlich Bio-Oss^® xenograft, combined with rhPDGF-BB, a component of GEM 21S^®, was placed and stabilized under a high-density PTFE membrane, which was secured with four horizontal mattress and multiple simple interrupted 4-0 PTFE sutures.

Pre‑operative occlusal photograph of the maxillary arch showing a pronounced Seibert Class III ridge deformity, with simultaneous horizontal and vertical soft and hard tissue loss in the edentulous area.

Intraoperative view following reflection of full‑thickness flaps, revealing a pronounced combined horizontal and vertical ridge deficiency.

Upper left view showing the mixture of large-particle vallos® allograft, demineralized cortical granules, and large-particle Geistlich Bio-Oss® xenograft, combined with rhPDGF-BB, a component of GEM 21S®.

Upper right view showing the mixture of large-particle vallos® allograft, demineralized cortical granules, and large-particle Geistlich Bio-Oss® xenograft, combined with rhPDGF-BB, a component of GEM21S®.

Closure of the maxilla was achieved using a PTFE barrier membrane and 4‑0 PTFE sutures. Horizontal mattress sutures were placed to provide initial tension relief and flap stabilization, while simple interrupted sutures were used for precise approximation of the wound margins.

Six‑month postoperative CBCT images with virtual implant planning reveal sites #5, 7, 10, and 12, exhibiting 5–7 mm of horizontal ridge augmentation and 3–4 mm of vertical ridge augmentation.

Intraoperative view demonstrating vertical and horizontal ridge augmentation at 7 months following the initial augmentation procedure.

A 4.3 × 8 mm tapered implant with crestal sinus elevation was placed at site #5, and a 4.3 × 10 mm tapered implant was placed at site #7.

(Left) A 4.3 × 10 mm implant was inserted at the site. (Right) Placement of a 4.3 × 10 mm implant in conjunction with a crestal sinus elevation.

“The patient’s young age and
excellent systemic health are favorable prognostic factors, but achieving optimal outcomes requires meticulous surgical execution, careful soft tissue management, and strict adherence to post-operative instructions to minimize complications and ensure long-term success.”
— Nikolaos Soldatos, DDS, PhD, MSD

THE OUTCOME

Horizontal (5–7 mm) and vertical (3–4 mm) ridge augmentation were successfully obtained, with stablewound management achieved through precise suturing techniques. The osteoinductive properties of the large vallos^®, demineralized granules combined with rhPDGF-BB, a component of GEM21S^® promoted high-quality bone regeneration, whereas the large Geistlich Bio‑Oss^®, xenograft particles contributed to volume preservation by moderating resorption. As a result, four 4.3 mm implants were placed with high primary stability, each exceeding 35 N·cm of insertion torque, providing a strong foundation for a predictable esthetic and functional restoration.

The combination of rhPDGF-BB, a component of GEM 21S®, promotes enhanced bone regeneration by stimulating cellular proliferation and osteogenesis. When supplemented with Geistlich Bio-Oss®, which maintains graft volume through slow resorption kinetics, this approach provides predictable ridge augmentation. Together, these graft components support stable, high‑quality bone formation and foster optimal conditions for long‑term implant integration.”
Nikolaos Soldatos, DDS, PhD, MSD

Nikolaos Soldatos, DDS, PhD, MSD

Dr. Soldatos is a tenure-track Associate Professor and Clinical Director of the Postgraduate Advanced Program in Periodontics at Oregon Health & Science University. He is a Board-Certified Periodontist and Implant Surgeon, he holds a DDS, PhD, and MSD, and has completed advanced periodontal and implant training in both the U.S. and Europe. Dr. Soldatos’ research focuses on translational implant biology and bone regeneration. He is also a Fellow of the Academy of Osseointegration.

CLINICAL CASE

Bone graft placement, saturated with rhPDGF-BB

After six months, healing was complete, resulting in a 10×10×6.5 mm bone fill. Tooth #7, which was part of the combined defect, was fully regenerated.

The adjacent ridge defect was also restored, enabling the placement of a standard-sized implant without the need for additional grafting.

THE OUTCOME

At 6 months, healing was complete with a bone fill of 10x10x6.5 mm. Tooth #7, affected by the combined defect, was fully regenerated. The adjacent ridge defect was also restored, enabling the placement of a regular-sized implant without the need for additional grafting.

Disclaimer: These results are not guaranteed; individual outcomes may vary depending on patient circumstances. This information is for informational purposes only and may not reflect Geistlich’s official position, opinion, or recommendation. Treatment decisions are made at the physician’s discretion, based on the unique needs of each patient.

GEM 21S® has not been approved by FDA for use in ridge augmentation in the US and the safety and effectiveness of GEM 21S® for this use has not been established by FDA.

CLINICAL CASE

Flap reflection showing defect on the mesial and distal of central incisor (#25)

Flap reflection showing 6mm deep infrabony one wall defect on tooth #25

Regenerative treatment: Allograft + rhPDGF-BB

Amnion/chorion membrane used to cover the graft

Polypropylene 6-0 used for suture placement

At 7 months, pocket depth reduced to 3 mm, with 90% bone fill and 3mm attachment gain. Patient had no mobility due to splinting and good compliance.

THE APPROACH

Considering the patient’s age, condition, and good compliance, a regenerative approach was chosen to preserve all teeth. Due to the extent and severity of the defect, a bone graft, biologics, and a membrane were utilized. The goal was to restore lost attachment and stabilize the teeth through splinted therapy.

THE OUTCOME

At the 7-month follow-up, probing depths decreased from 7 mm (MB, DB) to 3 mm, with radiographic bone fill indicating a 90% success. Attachment gain of 3 mm was achieved, improving from 7 mm to 4 mm. The patient reported satisfactory outcomes, and splinting effectively maintained tooth stability with no mobility.

CLINICAL CASE

Flap reflection showing the defect tooth #30

Defect dimensions from the lingual aspect

Defect filled and graft is extended beyond margins, 1-2mm on the buccal aspect

Suturing with 5/0 polypropylene sutures. Primary closure is attained.

Radiograph 1-year post-op showing almost complete bone fill

THE APPROACH

Following flap elevation and thorough defect debridement, a xenograft bone substitute mixed with PDGF (GEM 21S®) was used to fill the defect. The graft was left uncovered without a membrane.

THE OUTCOME

The 1-year follow-up radiograph demonstrated near-complete bone fill in a previously deep defect. Clinically, shallow probing depths and healthy tissue were also observed at the 1-year follow-up.

CLINICAL CASE

Geistlich Bio-Gide® covering bone graft and soaked in rhPDGF-BB

Suturing with 5/0 nylon sutures. Primary closure attained.

THE APPROACH

The crown was biologically shaped, and the root surface was detoxified using Ellman burs. Following flap elevation and thorough defect debridement, an allograft mixed with GEM 21S® was used to fill the defect. The graft was then covered with Geistlich Bio-Gide®.

THE OUTCOME

At the 10-month follow-up, radiographs revealed evidence of bone fill, and clinically, the interdental tissue showed signs of maturation. At the 9-year follow-up, clinical photos demonstrated long-term stability, with maintained bone levels, minimal interproximal recession, and lack of facial recession. Radiographic analysis further confirmed the sustained stability of the bone.

BIOBRIEF

Prosthetic-Surgical Approach to Regenerative Treatment for Peri-Implantitis

Andrea Ravidà, DDS, MS, PhD

Anu Viswanathan DDS, MDS

THE SITUATION

A 68-year-old male patient, who received an implant in tooth position #31 about 8 years prior, presented for an examination. He reports bleeding during brushing around the implant and some discomfort. Clinically, there was severe vertical bone loss, profuse bleeding on probing, and deep probing depths, but no pain. The condition was diagnosed as peri-implantitis according to the 2018 classification.

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”
Infection at implant sight	None	Chronic	Acute
Restorative status of adjacent tooth	Intact		Restored
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

Additional Risk Factors: The patient exhibited bleeding on probing and deep pocket depths. He also reported occasional marijuana use and was inconsistent with periodontal maintenance and oral hygiene visits.

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THE APPROACH

The treatment goals were to eliminate peri-implant infection, regenerate lost hard and soft tissues, and ensure long-term implant stability. A closed regenerative approach was utilized, including crown removal, thorough implant decontamination with Perioflow®, an airpolishing technology, application of the correct bone grafting materials (Geistlich Bio-Oss®, vallos® and GEM 21S®), enclosed healing, and fabrication of a new crown to facilitate hygiene.

Clinical presentation of tooth #31 showing radiographic evidence of bone loss, profuse bleeding on probing (BOP), deep probing depths, and suppuration, indicative of peri-implantitis with a Class I-infraosseous (c) circumferential-type defect, as described in the study by Monje et al. (2019) Clin Implant Relat Res, 21(4)635-643.

Crown removal by the prosthodontist, followed by placement of a healing abutment for non-surgical therapy using PerioFlow®. After therapy, a cover screw was placed, and the tissue was allowed to heal over the implant for eight weeks.

Surgical treatment initiated with a midcrestal incision and full-thickness flap elevation. Granulation tissue was removed using a surgical curette, revealing a deep infrabony defect.

Implant thoroughly decontaminated using Perioflow® with erythritol powder to ensure a clean surface for regeneration.

rhPDGF-BB was used to hydrate bone grafting materials (vallos® Demineralized Cortical Granules and Geistlich Bio-Oss®), which were first hydrated with sterile water before rhPDGF-BB was added. The materials were mixed in a 1:1 ratio and allowed to sit for 10 minutes before being applied to the deep infrabony defect to promote regeneration.

Flap closed primarily with 5-0 PTFE horizontal mattress and single interrupted suture for secure closure.

Collagen membrane stabilized with 5-0 chromic gut sutures using the lasso technique.

After 5 months of healing, significant bone gain is evident. Geistlich Bio-Oss® was placed on the buccal site to enhance thickness, covered with an amnion-chorion membrane. A healing abutment was placed at this stage.

Two-year follow-up shows disease resolution with shallow probing depths, no bleeding or suppuration, and complete bone gain. A new crown was fabricated with an increased final abutment height (>2mm), contributing to optimal maintenance and long-term stability based on evidence supporting its role in promoting long-term success. A second surgery may be necessary to gain additional tissue thickness or cover residual thread exposure to achieve the desired long-term results.

“The implant presented with significant bone loss, deep probing depths, and bleeding on probing, placing it at risk of failure and requiring intervention to preserve function and longevity.”
— Andrea Ravidà, DDS, MS, PhD

THE OUTCOME

At the two-year follow-up, clinical and radiographic assessments showed disease resolution, complete bone gain, and stable peri-implant tissues. Probing depths were within healthy ranges, and no bleeding on probing was observed, confirming the long-term success of the treatment.

Enclosed healing, meticulous implant decontamination, appropriate selection of bone grafting materials, and customized crown design, combined with patient compliance and regular maintenance, contributed to disease resolution and complete bone regeneration.”
Andrea Ravidà, DDS, MS, PhD

The air polishing device with erythritol powder ensured thorough implant decontamination, while the bone grafting materials combined with rhPDGF-BB provided essential biologic support for regeneration and improved peri-implantitis treatment outcomes.”
Andrea Ravidà, DDS, MS, PhD

Andrea Ravidà, DDS, MS, PhD

Dr. Andrea Ravidà is the Director of the Graduate Periodontics Program in the department of Periodontics at the University of Pittsburgh. He conducts clinical research focusing on peri-implantitis, periodontitis and short implants. He has published more than 70 peer-reviewed articles and conference abstracts/presentations related to periodontics and implant therapy. He is section editor of the International Journal of Oral Implantology and the Journal of Translational Medicine.

Anu Viswanathan DDS, MDS

Dr. Anu Viswanathan is a Diplomate of the American Board of Periodontology and Implant Dentistry. She earned her Doctor of Dental Surgery degree from the University of Colorado School of Dental Medicine in 2019. Dr. Viswanathan completed a Certificate in Periodontics and earned a Master of Dental Science at the University of Pittsburgh School of Dental Medicine. She also obtained a Certificate in IV Sedation. Dr. Viswanathan is currently in private practice in Shoreline, Connecticut.

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