BIOBRIEF

Lateral and Vertical Bone Regeneration with Simultaneous Soft Tissue Augmentation

Arnd Lohmann, MSc

THE SITUATION

After extraction of the periodontally damaged tooth #20 the preoperative Cone-Beam Computed Tomography (CBCT) imaging shows reduced vertical bone volume in the area of tooth #s 18 – 20. A lateral and vertical bone regeneration was necessary.

The goal of treatment was a late implant placement after bone regeneration and creation of stable periimplant soft tissue for long-term implant preservation.

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
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
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

Additional Risk Factors: Roots were divergent, and intra-radicular bone (septal bone) was excellent, with more than 5 mm of remaining apical bone to achieve optimal primary stability.

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THE APPROACH

A customized bone regeneration procedure utilizing Yxoss CBR®. Followed by coverage of the graft with Geistlich Bio-Gide® for the purpose of Guided Bone Regeneration (GBR). Soft tissue thickening using Geistlich Fibro-Gide®. Delayed implantation into the augmented tissue. A vestibuloplasty with Geistlich Mucograft® for the regeneration of keratinized mucosa.

Baseline situation and planning: vertical bone deficit of 5.29mm in section 18-20.

Central incision in the keratinized mucosa and perforated cortical bone

Yxoss CBR® filled with a 50:50 mix of autologous bone and Geistlich Bio-Oss®. Coverage of the titanium scaffold with Geistlich Bio-Gide®

Geistlich Fibro-Gide® is tailored to the defect and a tension-free suture is done.

4 months after augmentation shows the bone situation after removal of the titanium scaffold and insertion of implants. Autologous bone chips are applied on top of the implants. Occlusal view of the mucosa level after implantation and wound closure.

6 weeks after implantation and 5 1/2 months after augmentation. The mucosa is prepared apically; the preparation reaches the periosteum apically. The recipient site is fully surrounded by keratinized mucosa. Geistlich Mucograft® is sutured into the area.

6 months after regeneration shows about 5mm of vertical bone regeneration. Panoram ic X-Ray after implant placement shows clearly recognizable mucosa shadows.

One year after augmentation shows the dental prosthesis inserted occlusally.

“Using the Geistlich Fibro-Gide® matrix enabled concurrent augmentation of hard
and soft tissues without any postoperative complications. At the same time, the soft
tissue thickening facilitated floor of the mouth surgery and vestibuloplasty.”
— Arnd Lohmann, MSc

THE OUTCOME

Treatment resulted in approximately 5 mm of vertical bone regeneration. The potential occurrence of a dehiscence associated with a wound opening and exposure of Yxoss CBR® was able to be prevented with Geistlich Fibro-Gide®.

On one hand, the quality of the peri-implant soft tissue was improved by the
soft tissue thickening with Geistlich Fibro‑Gide® and, on the other, by increasing the width of keratinized mucosa with Geistlich Mucograft®. The treatment method chosen resulted in a reduced invasiveness and morbidity by avoiding a donor site for sourcing a transplant.

Implant therapy should restore the natural anatomical structures as closely as possible in order to avoid subsequent peri-implant problems.”
Arnd Lohmann, MSc

Arnd Lohmann, MSc

Dr. Arnd Lohmann is a recognized specialist in implantology and periodontology. He earned his dental license in Hamburg in 2002, completed his doctorate in 2003, and has been a partner at a private practice in Bremen since then.

With a Master of Science in Implantology (2007), he specializes in dental implantology and bone augmentation. He is an active speaker at national and international congresses, leads the Bremen study group of the German Society of Oral Implantology (DGOI), and is a member of DGOI, DGZI, and DGI. His practice is equipped with state-of-the-art technology, ensuring high-quality patient care.

BIOBRIEF

Mandibular Ridge Augmentation Using Customized Titanium Mesh

Shaun R. Young, DMD

THE SITUATION

A 60-year-old healthy male presented with a failing lower left bridge. Due to a long history of missing teeth, he had a significantly atrophic mandibular ridge. We decided to use a customized titanium mesh to achieve the necessary vertical and horizontal bone augmentation for dental implant rehabilitation.

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
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

The goal of this procedure was to regenerate sufficient bone to place restoratively driven dental implants. Due to the horizontal and vertical ridge deficiency, we used a customized titanium mesh to predictably achieve this outcome.

Autogenous bone collected with SafeScraper Twist and Geistlich Bio-Oss® filled the Yxoss CBR® Protect and a Geistlich Bio-Gide® collagen membrane covered the mesh.

Pre-op mandibular ridge after the extraction of teeth #17 and #20. Note the significant horizontal ridge deficiency.

Yxoss CBR® Protect Customized Bone Regeneration Titanium Mesh in place, secured with two Stryker screws, 1.2 mm in diameter and 6 mm in length.

Note the excellent adaptation of the Yxoss CBR® Protect and that the edges are apical to the adjacent bony sockets.

Geistlich Bio-Gide® (resorbable collagen membrane) draped over the Yxoss CBR® Protect to separate osteoblasts from fibroblasts.

Implants restored with single-unit crowns.

Guide pins in place for implants #19, #20, and #21, with adequate ridge height and width.

Screw-retained final implant crowns with healthy keratinized tissue on the facial side.

“Success in these cases primarily depends on proper mesh design and careful handling of soft tissue to ensure zero-tension primary closure.”
— Shaun R. Young, DMD

THE OUTCOME

A left mandibular ridge deficiency was corrected using a Yxoss CBR® Protect Customized Bone Regeneration Titanium Mesh, designed from the patient’s CBCT scan.

Guided bone regeneration using Yxoss CBR® Protect to correct vertical and horizontal mandibular ridge deficiencies is a predictable procedure.”
Shaun R. Young, DMD

Shaun R. Young, DMD

Dr. Shaun Young, an Oral and Maxillofacial Surgeon based in Tampa, Florida, specializes in complex ridge augmentation, immediate implants, and All-on-X full arch rehabilitation. He earned his Doctor of Dental Medicine degree from the University of Florida and completed his OMFS residency at Emory University in Atlanta, Georgia, where he served as Administrative Chief Resident. Dr. Young brings his expertise to a full-scope group practice, serving Tampa, Clearwater, and New Port Richey, Florida.

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

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)

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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 – Pre-operative photograph showing the horizontal bone defect at sites #18 and #19

2 – Cone-Beam Computed Tomography (CBCT) showing the horizontal and vertical bone defects at sites #18 and #19

3 – Full-thickness flap reflection and buccal flap release to achieve tension-free primary closure

4 – Harvested autograft and vallos™ fibers hydrated with platelet-rich plasma and placed in the Yxoss CBR®mesh

5 – The titanium mesh was covered with a Geistlich Bio-Gide® Compressed membrane and platelet-rich fibrin (PRF) membranes

6 – week post-operative healing of surgical site shows increase in tissue width and no membrane exposure

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

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^®.