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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 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

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.

Initial presentation – buccal view.
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

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 RiskMedium RiskHigh Risk
Patient’s healthIntact immune system 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 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

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 RiskMedium RiskHigh Risk
Patient’s healthIntact immune system 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

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.

6 months follow-up

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.

WEBINAR

CLINICAL CASE

CLINICAL SITUATION:

A 60-year-old female presented to the periodontics clinic at UTHSA for implant placement at sites #18 and #19. Upon clinical and radiographic examinations, the lower left edentulous ridge was diagnosed as a Siebert class III due to the presence of bucco-lingual and apico-coronal tissue defects. The treatment proposed included soft tissue grafting for increase of keratinized tissue followed by ridge augmentation using Yxoss CBR®mesh and a mix of autograft, vallos fibers, and platelet-rich plasma (PRP)

OUTCOME:

The vallos fibers combined with autogenous bone and the PRP created a stable fibrin bone graft that could be easily molded and contained within the mesh. Hydration with PRP was progressive until the graft reached the desired consistency. Wound healing following ridge augmentation was uneventful. There were no signs of infection or membrane exposure at the site. Mesh removal and implant placement is planned at 6-months following ridge augmentation.

CLINICAL CASE

CLINICAL CASE