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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.
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BIOBRIEF
A 30-year-old male patient was referred to me with bilateral congenitally missing lateral incisors in the maxilla. The referring general dentist had previously made a resin-bonded bridge which was successful for a few years but had frequent debondings. Clinical examination revealed lack of ridge contour but the CBCT revealed existence of adequate width for placement of narrow-diameter implants with additional bone grafting and contour augmentation. The existing bone anatomy precluded placement of implants for screw-retained restorations without a pre-surgical lateral ridge augmentation procedure. The patient accepted a treatment plan for placement of two narrow-diameter implants and simultaneous bone grafting and contour augmentation followed by restoration with zirconia cement-retained crowns.
| 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 | Compromised | |
| 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 |
My treatment goals were to preserve the existing soft-tissue architecture, especially the interdental papilla, mesial and distal to the lateral incisors, improve the facial contour at the lateral incisor sites by bone grafting with a low substitution biomaterial, and harmonize esthetics and function with optimal implant-supported restorations.
“The patient had failed resin-bonded bridges with deficient contours for bilateral congenitally missing lateral incisors.”
Single-stage implant placement with bilateral papilla-sparing incision design and simultaneous contour augmentation using a mixture of Geistlich Bio-Oss® autologous bone chips and Geistlich Bio-Gide®.
The low substitution bone graft, combined with a rapidly vascularizing membrane, helped to achieve the biological integration of the biomaterial.”
Dr. Avinash Bidra
The use of Geistlich Bio-Gide® and Geistlich Bio-Oss® mixed with autologous bone can lead to a successful outcome in single-stage implant placement with simultaneous contour augmentation.”
Dr. Avinash Bidra
Dr. Bidra is a Board Certified Maxillofacial Prosthodontist and Director of the Prosthodontics Residency Program at UCONN School of Dental Medicine. He has extensive surgical experience and maintains a part-time private practice restricted to Implant Surgery and Prosthodontics in Meriden, CT. He has lectured at national and international meetings, as well as published extensively in international scientific journals. He has invented prosthetic components and is a co-inventor of a new implant design.
BIOBRIEF
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.
| 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 |
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.
“Guided tissue regeneration is indicated to correct the vertical bone loss around the #9-10 area and stabilize the periodontium.”
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.
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
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.
BIOBRIEF
An adult female patient presented with a long history of edentulism at site #9. Patient was interested in replacing her missing tooth with a dental implant, and was wearing a Nesbit appliance. The irritation from the ill-fitting Nesbit appliance resulted in irregular and friable soft-tissue at site #9.
Pre-operative CBCT demonstrated a hard-tissue concavity apical to the crest of the bone. The primary goal of therapy was to regain horizontal dimension of hard and soft-tissue to achieve prosthetically-driven placement of a dental implant to replace the patient‘s left central incisor.
| 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 |
The treatment goal was to regain the horizontal dimension of hard and soft-tissue through guided bone regeneration. In coordination with the restoring dentist, a diagnostic wax up was completed to determine the ideal tooth position and to regain mutually protected occlusion on the patient’s left side. The combination of Geistlich Bio-Oss® and autologous bone chips was used along with Geistlich Bio-Gide® to regenerate the horizontal dimension for prosthetically-driven implant placement.
“Patient with a long history of partial edentulism was seeking a long-term, predictable restorative option to replace her missing left central incisor.”
Adequate hard and soft-tissue architecture was restored with the use of Geistlich Bio-Oss® and Geistlich Bio-Gide® for predictable, prosthetically-driven implant placement. The combination of Geistlich Bio-Oss® and autologous bone chips provides the best chance for regeneration while maintaining the hard and soft-tissue contours.
Decortication allows for improved blood supply and nutrients to the bone graft.”
Dr. Justin Kang
This case demonstrates the importance of meticulous incision design, flap advancement, and suturing technique to ensure adequate blood supply and nutrients to the graft material and to maintain primary closure throughout the course of healing.”
Dr. Justin Kang
The combination of Geistlich Bio-Oss® and autologous bone chips provides the best chance for regeneration while maintaining the hard and soft-tissue contours.”
Dr. Justin Kang
Dr. Justin Kang received his Doctor of Dental Medicine degree from University of Pennsylvania School of Dental Medicine. He completed his residency and received his Masters of Science in Periodontics at Columbia University College of Dental Medicine. Dr. Kang is a Diplomate of the American Board of Periodontology and a member of numerous professional associations including the Academy of Osseointegration, American Dental Association and the New Jersey Dental Association.
BIOBRIEF
A 70-year-old female in good health presented with a fracture of tooth #19 which is the distal abutment for a four-unit bridge tooth #19-22, with pontics in the #20 and #21 positions. With the loss of the bridge, the patient desired a fixed prosthetic replacement. A bridge from tooth #22 to an implant placed at the #18 position was not deemed mechanically sound. She opted for implant placement at positions #19, #20 and #21 following lateral ridge augmentation with autogenous bone and Geistlich Bio-Oss® contained with a Geistlich Bio-Gide® membrane.
| 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 | Compromised | |
| 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 |
A subperiosteal flap with a mid-ridge incision was performed with anterior and posterior releasing incisions which were placed the distance of one tooth mesial and one tooth distal from the graft site. The posterior releasing incision allowed for exposure of the ramus for harvesting of the autologous bone. The grafted site was allowed to heal for a period of 8 months at which time the implants were placed. Abutment connection occurred 4 months following implant placement.
“A bone graft was required to augment the ridge, a CBCT scan was performed prior to surgery to determine bone volume and the amount of bone required to graft.”
Following 8 months of healing, the augmented site showed sufficient bone width that was assessed with a CT scan. After examination, it was determined that the bone width was adequate for implant placement in the desired position to allow an esthetically pleasing and functional outcome for the patient.
The use of Geistlich Bio-Oss® in combination with autogenous bone provides an excellent recipient site for the placement of dental implants and long-term maintenance of bone volume for implant survival.”
Dr. John M. Sisto
The Geistlich Micross is essential in harvesting bone from the lateral ramus in an efficient and stress-free manner.”
Dr. John M. Sisto
Dr. John M. Sisto received his Doctorate in Dental Surgery degree from Loyola University and completed his residency and certification in Oral and Maxilofacial Surgery at the Cook County Hospital in Chicago. Dr. Sisto was the Director of Residency Education at Cook County Hospital from 1985 to 2010 and started the residency program in oral and maxillofacial surgery in 1990. He held teaching positions at both Northwestern and University of Illinois Dental schools as a clinical assistant professor, and also at Northwestern Medical School. He was the Division Chief of Oral and Maxillofacial Surgery at Cook County Hospital and Chairman of Dentistry at Resurrection Medical Center. Dr. Sisto has published papers on dental implant surgery, trauma surgery, orthognathic surgery and maxillofacial infections. He has lectured both locally and nationally at various educational forums.
BIOBRIEF
The patient presented to the clinic with a discolored tooth #8, with mobility and a history of trauma. The tooth has a horizontal fracture in the apical third of the root and has recurrent infection after the root canal treatment. The patient feels discomfort and dislikes his esthetic appearance. He would like the fractured tooth #8 removed and replaced with a fixed solution.
| 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 |
To carefully extract tooth #8 and to replace it with an early-stage implant placed with simultaneous guided bone regeneration through the use of Geistlich Bio-Oss Collagen® trimmed in an “L-Shape” under the protection of a Geistlich Bio-Gide® membrane. To augment the peri-implant soft-tissue with the use of a connective tissue graft during implant healing time, increasing the overall volume of site #8. To provisionalize the implant for the development of a proper emergence profile. To deliver a definitive reconstruction which is functional and esthetic for the patient.
“A fractured anterior tooth needs to be replaced with an implant-supported reconstruction.”
The implant and its prosthetic reconstruction were successful because they provided the patient with a fixed solution with adequate function and esthetics. The implant shows stable marginal bone levels due to the proper implant placement together with the guided bone regeneration procedure. The peri-implant soft-tissue is healthy and stable with sufficient volume created by the soft-tissue augmentation. The definitive reconstruction meets the patient’s esthetic demands and is functional in occlusion.
By using Geistlich Bio-Oss Collagen® trimmed into an “L-Shape” covered with Geistlich Bio-Gide® a very stable horizontal and vertical bone volume around the implant is provided. This results in a stable hard and soft-tissue condition following healing. This is key for the long-term performance of an implant especially in the esthetic zone.”
Prof. Dr. Ronald Jung
Four months after implant placement a limited access “U”-flap was created and an implant impression was taken. The tissue was rolled to the buccal side and the abutment connection was performed.”
Prof. Dr. Ronald Jung
Primary stability of the augmented bone volume is the clinical challenge in guided bone regeneration after flap closure. In this case Geistlich Bio-Oss Collagen® has been used to augment on the buccal side of the implant.”
Prof. Dr. Ronald Jung
Prof. Dr. Jung is currently Head of the Division of Implantology, Clinic for Fixed and Removable Prosthodontics and Dental Material Science, Center of Dental Medicine at the University of Zürich. In 2006 he worked as Visiting Associate Professor at the Department of Periodontics at the University of Texas Heath Science center at San Antonio, USA (Chairman: Prof. D. Cochran). In 2008 he finalized his “Habilitation” (venia legendi) in dental medicine and was appointed associate professor at the University of Zürich. In 2011 he received his PhD degree from the University of Amsterdam, ACTA dental school, The Netherlands. He is an accomplished and internationally renowned lecturer and researcher, best known for his work in the field of hard- and soft-tissue management and his research on new technologies in implant dentistry.
BIOBRIEF
An adult female patient presented with an endodontic/prosthetic failure on the maxillary left lateral incisor. The patient‘s request was to have a definitive implant-supported single crown. The clinical situation revealed recession of the free gingival margin, while the CBCT evaluation showed the missing buccal bone plate, which contra-indicated an immediate implant placement. The treatment plan included a staged approach with a ridge augmentation procedure at the time of tooth extraction, in order to recreate the buccal bone plate and reduce the gingival recession. By moving the free gingival margin, keratinized tissue was gained through an open-healing approach.
| 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 treatment goals were to improve the soft-tissue levels and regenerate the buccal bone plate. After performing a flapless extraction procedure, a specifically designed resorbable bilayer collagen membrane, Geistlich Bio-Gide® Shape, was inserted into the socket with the long wing in contact with the buccal surface and the smooth, compact upper layer facing outward. The alveolus was then grafted with Geistlich Bio-Oss Collagen®. The three smaller wings of the membrane were folded on top of the graft material and sutured to the surrounding soft-tissue, allowing for open-healing.
“The patient had a failing crown with compromised soft tissue and requested a single crown rehabilitation with improved esthetics.”
This case demonstrates how it is possible to improve the clinical and esthetic situation that was presented at baseline. Despite missing the buccal bone plate and the recession of the free gingival margin, the ridge augmentation procedure performed with the combination of Geistlich Bio-Gide® Shape and Geistlich Bio-Oss Collagen® was able to create a positive volume of the ridge, allowing for a prosthetically guided implant placement.
Ridge augmentation combining the use of Geistlich Bio-Oss Collagen® and Geistlich Bio-Gide® Shape is a predictable minimally invasive regenerative procedure able to create sufficient ridge volume suitable for prosthetically driven implant placement.”
Dr. Daniele Cardaropoli
Prosthetically guided implant placement can be planned 4 months after the ridge augmentation procedure. The specifically designed Geistlich Bio-Gide® Shape was able to protect the Geistlich Bio-Oss Collagen®, not only in the coronal position but also aided in recreating the missing buccal bone.”
Dr. Daniele Cardaropoli
The use of the Cardaropoli Compactor instrument helped to carefully adapt Geistlich Bio-Gide® Shape onto the inner buccal surface of the alveolus and to properly compact Geistlich Bio-Oss Collagen® inside the socket.”
Dr. Daniele Cardaropoli
Periodontist – PRoED, Institute for Professional Education in Dentistry, Torino
Doctor of Dentistry and Certificate in Periodontology from the University of Torino, Italy.
Active member of the Italian Society of Periodontology, European Federation of Periodontology, Italian Academy of osseointegration and Academy of osseointegration. International member of the American Academy of Periodontology. Scientific Director of Institute for Professional Education in Dentistry (PRoED), Torino. Member of the Editorial Board of The International Journal of Periodontics and Restorative Dentistry. Private practice in Torino, Italy.
BIOBRIEF
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.
| 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 |
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.
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.
Patient satisfaction is my driver for excellence. That’s why I always apply the Prosthetically Guided Regeneration principle together with Geistlich Biomaterials: proven and predictable long-term patient success.”
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.
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.
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