BIOBRIEF

Alveolar Ridge Preservation with vallos® Mineralized Cortico-Cancellous Allograft

Hanae Saito, DDS, MS, CCRC

Andrew Tong, DDS

THE SITUATION

A 68 year old female patient was referred from her general dentist for persistent minor discomfort on #31, suspected endo-perio lesion. Upon the examination, deep probing depth and grade 1 mobility were noted. Radiographic interpretation indicating a large J shaped lesion and possible root fracture. Patient had missing #30 and #32 has been mesially drifted and left a restorative space more than > 13 mm mesio-distally.

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 esthetic related risk factors are not needed for this case. Restorative space of more than 13 mm may be an additional risk factor.

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THE APPROACH

A successful treatment outcome comes with proper selection of the technique and materials. In order to facilitate an implant supported restoration in the site with > 13mm mesio-distal space, a staged approach was selected, with alveolar ridge preservation (ARP) performed using an atraumatic extraction technique and vallos^®mineralized cortico-cancellous bone allograft chosen as the material.

Preoperative radiograph of #31 with guarded prognosis due to potential root fracture and infection.

Atraumatic extraction was performed and intact furcation bone is noted.

vallos® mineralized cortico-cancellous bone allograft was placed.

A collagen plug was used to cover the bone allograft

Immediate post alveolar ridge preservation radiograph.

Healing at 2 weeks prior to implant placement.

Healing at 4 months prior to implant placement.

Implant was placed with 32 Ncm. Post implant placement radiograph.

6 months after the implant placement, the final restoration was delivered.

“Ensuring atraumatic extraction techniques, regardless of whether it’s in the anterior or posterior regions, is crucial for preserving the integrity of both hard and soft tissues. Equally important is the selection of biomaterials that not only offer structural support but also possess bone regeneration properties.”
— Dr. Hanae Saito

THE OUTCOME

The planned treatment of replacing a tooth with a dental implant in the regenerated alveolar ridge was achieved. By employing secondary intention healing following ARP and utilizing a lingual paracrestal incision, adequate keratinized tissue was preserved on the buccal side of the implant-supported restoration.

Removal of the infection and maintaining the ridge dimension for the implant supported restoration in the site with > 13 mm mesio-distal space were required.”
Dr. Hanae Saito

Hanae Saito, DDS, MS, CCRC

Hanae Saito, DDS, MS, CCRC serves as a clinical associate professor and oversees the Dual Perio-Pros program and predoctoral periodontal education within the Division of Periodontics, at the University of Maryland School of Dentistry. She is a Diplomate of the American Board of Periodontology. Dr. Saito obtained a Master of Science in Clinical Research and a certificate in Periodontics from New York University College of Dentistry. Additionally, she operates a faculty practice focused on periodontology and implant dentistry.

Andrew Tong, DDS

Andrew Tong, DDS earned his Bachelor of Science degree from the University of Maryland at College Park in 2015 before completing his Doctor of Dental Surgery (D.D.S) degree at the University of Maryland School of Dentistry in 2019. Following this, he undertook a General Practice Residency at the Newark Beth Israel Medical Center in New Jersey from 2019 to 2020. Dr Tong now practices general dentistry at Tong Dental Care in Gaithersburg, MD. Concurrently, he is pursuing a Master’s degree in Periodontics at the University of Maryland School of Dentistry.

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 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

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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

Clinical Efficacy of Geistlich Mucograft® in Regeneration of Oral Mucosa Combined with the Surgical Treatment of Peri-implantitis in Implants with Lack of Keratinized Tissue

Dr. Alberto Ortiz-Vigón

Dr. Erik Regidor Correa

THE SITUATION

Adult patient, non-smoker and without relevant systemic history, attends to clinic referring peri-implant tissue inflammation, bleeding and brushing discomfort around her implant in the upper jaw. Clinically peri-implant pocket depth > 5 mm, bleeding and suppuration on probing were observed. Furthermore, the implant presented < 2 mm of keratinized mucosa and radiographic horizontal bone loss.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system Heavy smoker
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

Intrasulcular incision was made and a mucosal partial thickness flap was raised. The recipient site was prepared by sharp disection in order to create a periosteal bed free of any muscle attachment. Peri-implant granulation tissue was removed and implantoplasty was performed. Finally, Geistlich Mucograft® was used to support the gain of keratinized tissue. Thus, the collagen matrix was sutured with the resulting flap apically at the base of the newly created vestibulum.

Pathological peri-implant pocket depth combined with bleeding on probing.

Partial thickness flap in order to create a periosteal bed free of any muscle attachment and apically positioned.

Implantoplasty of the exposed rough implant surface using burs and silicon carbide polishers.

Xenogeneic collagen matrix structure (Geistlich Mucograft®).

Future position of the xenogeneic collagen matrix facilitated by prosthodontic abutment.

Suture of xenogeneic collagen matrix around the abutment and over the recipient bed.

Buccal view of xenogeneic collagen matrix and apically positioned flap.

Occlusal view of xenogeneic collagen matrix and apically positioned flap.

Lateral view of xenogeneic collagen matrix and apically positioned flap.

Peri-implant tissue health and maintenance of keratinized tissue after one year of surgical treatment.

Periimplant tissue health and maintenance of keratinized tissue after 2 years

Absence of > 2 mm of keratinized mucosa was associated with peri-implant soft-tissue inflammation, bleeding and discomfort on brushing.

THE OUTCOME

After two years follow-up, the successful outcome can be observed in terms of clinical peri-implant parameters, gain of keratinized mucosa without significant graft shrinkage and stability of vertical position of the mucosal margin.

The use of Geistlich Mucograft® xenogeneic collagen matrix for regeneration of oral mucosa, combined with the surgical respective approach to peri-implantitis provides an improvement in clinical parameters and increase of the peri-implant keratinized mucosa minimizing the risk of recession in the esthetic area.”
Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

The use of soft-tissue substitutes may play an important role in patient perception and satisfaction without jeopardizing the final clinical outcome.”
Dr. Erik Regidor Correa & Dr. Alberto Ortiz-Vigón

Dr. Alberto Ortiz-Vigón

DDS from the University of the Basque Country
MSc and PhD in bone regeneration from the University Complutense of Madrid (UCM)
Master in Periodontology and Implant dentistry from the EFP
Research fellowship at the University of Gothenburg
MBA from the Deusto Business School
Assistant professor and clinical researcher at UCM and ThinkingPerio Research
PerioCentrum Clinic in Bilbao
Co-founder of ARC Healthtech Innovation Holding
Socially engaged & NGO co-founder of Smile is a Foundation