Product: Yxoss CBR®

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 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

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
Final restoration
Periapical radiographs of implants and prosthesis
Final restoration at 16 months

“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.

Final restoration at 16 months

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

Dr. Matteo Chiapasco
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 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
Note: Yxoss CBR® by ReOss® Screws 5mm – MCbio (G-fix system)
watch video 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 final Yxoss CBR® ready for use.
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.
Panoramic radiograph after surgery.
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.
Dr. Matteo Chiapasco

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

WEBINAR

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®.

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.
12 – Radiographic situation.

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.