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Therapeutic Area: Major Bone Augmentation
WEBINAR
BIOBRIEF
Mandibular Alveolar Ridge Split with Delayed Implant Placement
THE SITUATION
A healthy (ASA 1) non-smoker 63-year-old female presented to my office with Kennedy Class II partial edentulism in the mandibular right posterior quadrant for several years. She denied removable options and wanted dental implants to individually replace her missing teeth. The clinical and radiographic evaluation revealed atrophic mandibular bone height and width at site #’s 29, 30 & 31. The edentulous site required engineering prior to the placement of conventional dental implants and prosthetics.
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 |
download pdfTHE APPROACH
The goal is to provide adequate soft and hard tissue at edentulous site #’s 29, 30 & 31 in order to place dental implants and restore a stable balanced occlusion.
“The hard and soft tissue of the edentulous posterior mandible were inadequate to rehabilitate with dental implants.”
— Dr. Gregory Santarelli
THE OUTCOME
The patient summarized this challenging case very well – “I never imagined I would have fixed teeth again.” Geistlich Bio-Oss® and Geistlich Mucograft® allowed for retention of the hard and soft tissue volume to achieve our final result and for maintenance of the final prosthesis.
Gregory A. Santarelli, DDS
Dr. Santarelli earned his DDS degree in 1998 from the University School of Dentistry, Milwaukee, WI, after graduating with his B.S. in Biology from Arizona State University (Tempe, AZ). In 1999, he completed his General Practice Residency at the University of Iowa Hospital and Clinics, and went on to an Oral & Maxillofacial Surgery Internship at the Medical College of Virginia (Richmond, VA) as well as an Oral & Maxillofacial Surgery Residency Program, Christiana Care Health System (Wilmington, DE).
After completing his formal training in 2004, Dr. Santarelli’s work experience includes the Bankor Hospital for Children, Cambodia (2003), Adjunct Clinical Professor, University of Marquette, School of Dentistry, Department of Oral Sugery, Marquette, WI (2005), and Oral Surgery Associates of Milwaukee, Milwaukee, WI (2004-2005). He now maintains a private practice in Kenosha, WI with his partner Dr. Deno Tiboris.
Dr. Santarelli performs numerous hard/soft tissue regeneration surgeries in preparation for dental implants and is actively involved in clinical research with The McGuire Institute (iMc).
BIOBRIEF
Horizontal Ridge Augmentation in the Posterior Mandible of a 90-Year-Old Female
THE SITUATION
A 90-year-old female presented requesting dental implants be placed in the left mandibular posterior region. Her chief complaint was increased drooling and difficulty chewing on only one side. She lost her bridge one year prior to her visit and firmly stated that she did not want to wear a partial denture. The clinical exam and CBCT showed that there was a horizontal alveolar ridge deficiency that precluded the implants from being placed in a restoratively desirably position. Therefore, a horizontal ridge augmentation was done using multiple layers of Geistlich Bio-Gide® Compressed over a 1:1 ratio of autogenous bone and Geistlich Bio-Oss® xenograft.
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 |
watch videoTHE APPROACH
The treatment goal was to gain adequate horizontal bone dimension to allow for prosthetically-driven implant placement. Guided bone regeneration was performed in which autogenous bone was mixed with Geistlich Bio-Oss® xenograft in a 1:1 ratio. PRF was used to create “sticky bone” and was covered by multiple layers of Geistlich Bio-Gide® Compressed. The membrane was stabilized with periosteal biting stabilizing sutures. Tension-free primary closure was achieved and the grafted site was allowed to heal for 8 months prior to the implant surgery for #19 and #20.
“A predictable ridge augmentation procedure was needed to help our 90-year-old patient avoid having nutritional deficiencies due to lack of proper chewing ability and also to improve her quality of life.”
THE OUTCOME
The horizontal ridge augmentation procedure resulted in adequate bone for implant therapy as evidenced by the CBCT scan and re-entry surgery. With a sufficient quantity of good quality regenerated bone, implants for #19 and #20 were placed using a surgical guide based on a diagnostic wax up. Our 90-year-old patient is very happy to be able to chew efficiently again.
Dr. John Kim
Dr. Kim, originally from Fairfax, VA, received his DMD from Harvard School of Dental Medicine. He completed his residency and received his M.S. in Periodontics at UNC School of Dentistry at Chapel Hill. Dr. Kim is a Diplomate of the American Board of Periodontology and actively speaks as an expert on guided bone regeneration, implant therapy, soft tissue grafting, and managing complications domestically and internationally. He is also an adjunct faculty at UNC Adams School of Dentistry.
BIOBRIEF
Combined Horizontal and Vertical Regeneration Using a CAD-CAM Titanium Scaffold
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 |
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.
“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.
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
Immediate Mandibular Molar Transition
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 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 |
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.
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
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 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 |
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.
“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.
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
Prosthetically Guided Regeneration (PGR) in the Posterior Maxilla
THE SITUATION
The 60-year-old female patient’s chief complaint was represented by unsatisfactory esthetics and function, related to loss of multiple maxillary teeth. Her request focused on improving esthetics and function by means of a fixed reconstruction.
The patient presented five residual anterior maxillary teeth (from 6 to 10) that could be maintained. After preliminary periodontal diagnosis and treatment, specific diagnostic steps for implant treatment demonstrated inadequate bone volume for implant placement.
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 |
THE APPROACH
Bi-lateral sinus lift with Geistlich Bio-Oss Pen® and horizontal bone augmentation with a 1:1 mix of autogenous bone and Geistlich Bio-Oss® were performed six months prior to implant placement, following a Prosthetically Guided Regenerative (PGR) approach. The augmented sites were protected with Geistlich Bio-Gide® stabilized with titanium pins. The template utilized for radiographic diagnosis and GBR was then used to guide the implants’ placement.
Using a diagnostic template during the GBR procedure helps to highlight the presence of bone defects in relationship to the restorative plan and future position of implants.
THE OUTCOME
After a healing period of six months, adequate bone volume was achieved for the placement of five implants. Geistlich Fibro-Gide® was also used to optimize soft tissue volume at the buccal aspect of implants.
Implants were early loaded with a temporary screw-retained fixed prostheses six weeks after placement. The final prosthetic reconstruction included ceramic veneers of the frontal residual teeth and zirconium-ceramic screw-retained fixed prostheses on implants.
Paolo Casentini, DDS
Graduated in Dentistry at the University of Milan, Fellow and Past Chairman of the Italian section of ITI, Active member Italian Academy of Osseointegration. Co-author of 10 textbooks including ITI Treatment Guide volume 4, translated in eight languages, and “Pink Esthetic and Soft Tissues in Implant Dentistry” translated in five languages. His field of interest is advanced implantology in complex and esthetically demanding cases. He has extensively lectured in more than 40 countries.
WEBINAR
WEBINAR
WEBINAR
WEBINAR
CLINICAL CASE
CLINICAL CASE
CLINICAL CHALLENGE:
The upper premolar had to be removed due to advanced periodontal disease and severe bone loss around the infected tooth. The bone defect was an intra-alveolar defect without dehiscence or fenestration.
AIM/APPROACH:
An early implant placement approach with a healing time of six weeks before implant placement was chosen. The bone augmentation with Geistlich Bio-Oss Collagen® was conducted simultaneously with implant placement. As this patient was treated in 1991, the case is one of the very first clinical applications of Geistlich Bio-Oss Collagen®
CONCLUSION:
A premolar grafted with Geistlich Bio-Oss Collagen® during implant placement showed good long-term result after 25 years. Satisfactory hard and soft-tissue contour are present 25 years after implantation.
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
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
CLINICAL CASE
CLINICAL CHALLENGE:
- Insufficient alveolar ridge height for implant placement and proximity to the alveolar nerve
- Autologous bone harvesting is associated with patient discomfort
AIM/APPROACH:
- Interpositional grafting with Geistlich Bio-Oss® Block for vertical augmentation
- Alveolar ridge volume preservation and minimizing patient morbidity
CLINICAL CASE
CLINICAL CHALLENGE:
- Severely atrophied alveolar ridge with insufficient bone volume for implant placement
- High complication rates and patient discomfort associated with large augmentations when using autologous bone grafts
AIM/APPROACH:
- 3-dimensional augmentation of alveolar ridge by the fence technique for implant placement
- At the same time reducing complication rates and patient discomfort
CLINICAL CASE
CLINICAL CHALLENGE:
- Insufficient alveolar ridge width for implant placement
- Autologous bone is subject to resorption and may lead to loss of volume
AIM/APPROACH:
- Ridge Split procedure in combination with Geistlich Bio-Oss® and Geistlich Bio-Gide® for horizontal augmentation
- Preservation of the alveolar ridge volume
CLINICAL CASE
CLINICAL CHALLENGE:
- Insufficient alveolar ridge width for implant placement
- Donor site morbidity after autologous bone block harvesting and resorption of autologous bone
AIM/APPROACH:
- Horizontal alveolar ridge augmentation with Geistlich Bio-Oss® and Geistlich Bio-Gide®
- Minimizing autologous bone harvesting and resorption protection
CLINICAL CASE
CLINICAL CASE
CLINICAL CASE
CLINICAL CASE
CLINICAL CASE
CLINICAL CASE
CLINICAL CASE
CLINICAL CASE
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.
