Therapeutic Area: Soft-Tissue Regeneration

BIOBRIEF

Avoiding Post-Implant Placement and Long Term Crestal Bone Resorption by Thickening Vertical Soft Tissue

Tamir Wardany, D.D.S.

THE SITUATION

Our patient is a 60 year old caucasian male that had just finished a large ridge augmentation in the area of #4 and #5. We used the sausage technique for the ridge augmentation and yielded excellent bone volume in this area. However, as we began the 2nd stage implant placement procedure, we noticed, as is frequently seen following a large ridge augmentation, very thin vertical soft tissue over the crest of the bone. We know that inadequate soft tissue thickness will lead to compromised vasculature and transfer of oxygen and nutrients to the bone which can absolutely lead to a loss of crestal bone surrounding the implants.

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: Bone was augmented prior to this case report due to a severe horizontal defect.
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THE APPROACH

Our goal here is to create increased vertical soft tissue thickness over the crest of the implant site. Following implant placement and placement of the cover screws, we used Geistlich Fibro-Gide® over the implants and then layed it over the crest and buccal aspect. Following the placement of Geistlich Fibro-Gide®, we gently released the full thickness flap so that we can achieve tension-free primary closure over the site.

6 months following horizontal ridge augmentation, using Dr. Urban’s sausage technique, we re-entered the site for implant placement using a full thickness flap with no vertical incisions, to not disrupt collateral blood supply. There is excellent bone volume, but a very thin vertical soft tissue volume over the crest of the implant site.
Straumann implants are placed in sites #4 and #5 to a 25Ncm torque value with no issues and the cover screws were placed.
Geistlich Fibro-Gide® is placed crestally over the implants and draped to the buccal and slightly towards the lingual. Geistlich Fibro-Gide® was trimmed slightly to minimize the thickness of the material.
The flap was released so that we can achieve tension-free primary closure over the implant and the Geistlich Fibro-Gide® soft tissue augmentation site.
Following an 8 week healing period, we make a crestal incision and lay a conservative full-thickness flap to uncover the implants. We observe a 3-4 mm increase in verticle soft tissue thickness over the implant site.
We allow 3 weeks following the initial uncovering and can now see beautiful soft tissue architecture surrounding the implants.
Prior to the restorative process we see the pre-restorative radiograph with the healing abutments in place and we can also observe excellent crestal bone levels around the implants.
1 year follow-up. The restorative dentist opted to splint the crowns together. The patient did not want implants posterior to this area and he did not want any sinus augmentation as he had a history of sinus issues.

The use of Geistlich Fibro-Gide® is a wonderful alternative to using a connective tissue graft to thicken vertical soft tissue, which will help minimize crestal bone loss around implants.

THE OUTCOME

The soft tissue that will now surround the implant site is thick and healthy due to the use of Geistlich Fibro-Gide® at the time of implant placement. This is a simple technique and only requires a minimal amount of flap release to achieve tension-free primary closure over the site. The results are phenomenal and will be beneficial for the stability of the crestal bone surrounding the implants for years to come.

1-year follow-up. The restorative dentist opted to splint the crowns together. The patient did not want implants posterior to this area, and he did not want any sinus augmentation as he had a history of sinus issues.

Thin vertical soft tissue over the implant site following ridge augmentation is one of the key factors which may lead to crestal bone loss around the implants that will be placed.

Tamir Wardany, D.D.S.

I find the Mini-Me Periosteal to be my most versatile instrument for all my hard and soft tissue cases. I always have this instrument out on my surgical tray.

Tamir Wardany, D.D.S.

Beginning with thin soft tissue, we were able to achieve very thick and healthy vertical soft tissue over the implants, which will improve blood flow to the bone and minimize crestal bone loss in future.

Tamir Wardany, D.D.S.

Tamir Wardany, D.D.S.

Dr. Wardany is a graduate of Meharry Medical College School of Dentistry in Nashville, TN. After completion of a dental implant fellowship through State University of New York Stonybrook, he continues to spend extensive time in Europe training under Dr. Istvan Urban in the field of advanced bone and soft tissue regeneration.

He is a Diplomate of the American Board of Implantology, and lectures extensively on the topic of bone regeneration. He maintains a referral based surgical implant practice in San Francisco and Sacramento, California.

BIOBRIEF

A Regenerative Approach to Peri-implantitis

Hector L. Sarmiento, D.M.D., MSc.

THE SITUATION

A 55-year-old man was referred to me by his general dentist. Upon initial clinical and radiographic findings, failing implant #9 showed signs of peri-implantitis that included BoP, Suppuration, 9+mm PD and radiographic bone loss affecting both the implant and the natural adjacent tooth. Patient stated that although his gums bleed, he does not have any pain. Gingival erythema was also found.

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: Peri-implantitis on implant #9 migrating to the mesial portion of root #8
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THE APPROACH

The clinical goals were to eliminate the peri-implant infection, restore hard and soft-tissues and have long-term success. The technique utilized was a systematic regenerative approach to eliminate the underlying cause of the peri-implantitis infection and restore hard and soft-tissues to prior health.

Initial situation, patient presented with radiographic and clinically traditional signs of peri-implantitis, including bleeding on probing, suppuration, radiographic progressive bone loss and clinical pathologic probing depths.
Mechanical debridement was achieved using titanium scalers, an ultrasonic device with an implant protective cap and titanium brushes to remove all of the visible contaminants of the implant surface. Citric acid was then placed on shreds of a non-woven gauze and applied to the surface for approx. 1min. Copious irrigation was done using saline solution and the surface was ablated using the Er:YAG laser at 20pps/50mj.
After the surface was prepped and no signs of residual granulation tissue was noted, the defect was grafted with Geistlich Bio-Oss®. Attention was given towards not augmenting beyond the bony envelope.
A protective Geistlich Bio-Gide® membrane was placed over Geistlich Bio-Oss®.
Geistlich Fibro-Gide® was placed over Geistlich Bio-Gide® to enhance soft-tissue volume and quality. Geistlich Fibro-Gide® was trimmed and adapted to the defect site ensuring a tension free closure.
Geistlich Fibro-Gide® was place on the top of the bone graft to enhance soft-tissue thickness. Geistlich Fibro-Gide® is porous. We can observe the rapid penetration of blood through the matrix.
Closure with a tension-free flap was achieved by releasing incisions and secured using 4-0 chromic gut sutures.
1.5 year post-operative photo and radiograph show the healing of the soft-tissues with no signs of peri-implantitis and adequate tissue thickening. Radiographic bone levels have maintained stable over the course of the year.

Geistlich Fibro-Gide® has the capacity to enhance the soft-tissue during a bone regenerative approach.

THE OUTCOME

My observation at the 1.5 year follow-up shows the elimination of peri-implantitis and complete peri-implant health was achieved showing a reduction in BOP, PD and most importantly soft tissue thickness stability. Radiographically, crestal bone shows no signs of progressive pathological loss and has maintained adequate volume.

Geistlich Fibro-Gide® was utilized to enhance the soft-tissues during a regenerative peri-implantitis approach. In my opinion, healthy, thick soft-tissue is easier for a patient to maintain and creates a better environment for long-term survival.

Hector L. Sarmiento, D.M.D., MSc.

Hector L. Sarmiento, D.M.D., MSc.

Dr. Hector Sarmiento was awarded his D.M.D. degree by the University of Rochester. He is uniquely trained in both maxillofacial surgery and periodontics. He is a professor in the maxillofacial surgery department of trauma and reconstructive unit at the Regional Hospital in Mexico and is an Assistant Clinical Professor in periodontics at the University of Pennsylvania. Along with his periodontal degree, he also received his masters in oral biology from the University of Pennsylvania. Dr. Sarmiento is an international and national lecturer and has published numerous articles in peer reviewed journals and textbooks. His research focus includes infected dental implants such as peri-implantitis, sinus complications as well as bone biology. Dr. Sarmiento maintains his private practice in the upper east side of Manhattan in NYC.

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)
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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®.

1. Panoramic radiograph of initial situation showing the atrophic mandibular areas.
2. The final Yxoss CBR® ready for use.
3. The customized Ti-mesh is filled with the autologous bone chips mixed with Geistlich Bio-Oss® granules in a 50:50 ratio.
4. Intra-operative view at the end of the reconstruction showing the bone augmentation: the customized mesh was stabilized with 2 fixation screws.
5. A Geistlich Bio-Gide® membrane is used to cover the customized mesh in order to increase the barrier effect.
6. Intra-operative view after primary closure of the surgical wound.
7. Panoramic radiograph after surgery.
8. 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).

BIOBRIEF

Enhance Periodontal Phenotype with Geistlich Mucograft® for Soft Tissue Augmentation 

Allison Rascon, D.D.S., M.S.

THE SITUATION

A healthy, non-smoking, 37- year-old female presented for second stage surgery at implant sites #23 and #26. Limited keratinized tissue width and gingival thickness can be appreciated in the edentulous ridge, and the patient can be classified as having a thin periodontal phenotype. Additionally, the patient states she experiences sensitivity, and the tissue feels “tender” when brushing. The patient hopes to address her needs in a minimally invasive manner. 

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system 
Non-smoker		Light smokerImpaired immune system 
Heavy smoker
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: The patient‘s keratinized tissue is inadequate (<2 mm) and the recession on the canines can be classified as RT 1 defects. 
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THE APPROACH

The aim of treatment was to enhance the existing periodontal phenotype from that of one which is thin, with limited keratinized tissue, to one that is thick and maintains an adequate band of attached keratinized tissue. Geistlich Mucograft® was used in conjunction with a PRF membrane, in order to provide optimal wound healing, due to its chemotactic and angiogenic properties. 

A mid-facial incision was made, with the intent to preserve the minimal keratinized tissue that was available, as well as vertical incisions along the line angles of the canines to reflect a partial thickness flap.
Platelet-rich fibrin clots were formed by centrifugation. The leukocyte-PRF (L-PRF) was extracted, and the L-PRF was used to hydrate Geistlich Mucograft®
Geistlich Mucograft® and PRF stabilized via glycolon sutures.
Clinical situation at three-week follow up.
Occlusal view at twelve-month follow up.
Frontal view at twelve-month follow up.

A viable option that allows for reduced patient morbidity, adequate functional necessity, and ideal esthetics.

THE OUTCOME

Dual application of platelet-rich fibrin (PRF) and a xenogenic collagen matrix, Geistlich Mucograft®, led to successful augmentation of the edentulous ridge. At one-year, the tissues appear healthy, and an increased keratinized tissue width and gingival thickness can be appreciated. By using this soft tissue alternative, the patient was able to avoid post-operative morbidity from a second surgical site, and the chief complaint was addressed. 

Soft tissue procedures are technique sensitive and success requires appropriate graft size and thickness, recipient bed preparation, and adequate stabilization. Having a xenograft matrix provides control over having the necessary graft dimensions, without requiring a second surgical site, and it’s easy-handling properties ensure placement and stability are done in a predictable manner. 

Allison Rascon, D.D.S, M.S

With adequate recipient bed preparation, the ease of manipulation with the hydrated xenograft matrix allowed for intimate adaptation, and the overlaying PRF was easily compressed against Geistlich Mucograft®. At twelve months follow up, stable soft tissue dimensions are observed with adequate thickness, as well as esthetically appropriate blend of the tissue color and texture.  

Allison Rascon, D.D.S, M.S

Allison Rascon, D.D.S., M.S.

Dr. Allison Rascon was born and raised in Miami, Florida. She received her Bachelor of Science in Biomedical and Health Sciences from the University of Central Florida. She received her DDS from New York University, where she graduated with honors in Periodontics and was inducted into the Omicron Kappa Upsilon National Dental Honor Society in 2020. She then went on to receive a Certificate in Periodontics and Master of Science in Oral Biology from the University of Pennsylvania. Currently, she is board-eligible by the American Academy of Periodontology. She is an active member of the AAP, AO, OF, and ADA. Aside from her active participation in organized dentistry, she is also passionate about her research in periodontal and peri-implant regeneration. Dr. Rascon was a recipient of the George J. Coslet Memorial Scholarship in 2021 and 2022. During her residency, she was awarded the Best Oral Clinical Presentation Award at the Academy of Osseointegration Annual Meeting in 2022 and was the recipient of the Northeastern Society of Periodontists Tannenbaum/ Schoor Resident School Competition Award for 2023. Currently, Dr. Rascon works in private practice in Manhattan, NY.

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CLINICAL CASE

1 – Extraction of tooth 21 due to a trauma with concomitant external resorptions. Care was taken in preserving the alveolar bone.
2 – Crestal view of the socket after tooth extraction. No flaps are raised around the affected area. A slight buccal bone defect was observed.
3 – The socket is gently curetted for removal of granulation tissue. Subsequently, the wound margins were de-epithelialized with a diamond in a counter piece with water cooling
4 – Filling of the extraction socket with Geistlich Bio-Oss® Collagen to the level of the palatal bone
5 – After measuring the alveole, Geistlich Mucograft® is punched (8 mm diameter
6 – The Geistlich Mucograft® punch is placed on top of Geistlich Bio-Oss® Collagen to seal the filled alveole.
7 – Suturing of the Geistlich Mucograft® with 6-0 single interrupted sutures.
8 – Nice healing of the soft tissues 1 week after extraction.
9 – Situation 7.5 months after extraction revealing nice soft tissue situation with a slight dip at the buccal aspect.

CLINICAL CASE

1 – Pre-operative situation, tooth #7 with periapical infection and horizontal fracture.
2 – CT Scan showing tooth #7 with significant bone loss.
3 – Occlusal view of the clinical situation prior to extraction of tooth #7.
4 – Extraction socket with Geistlich Bio-Oss Collagen® in place.
5 – Geistlich Mucograft® Seal is placed over the extraction socket and secured with single interrupted sutures.
6 – 3 months post-operative: soft tissue healing at the time of implant placement.
7 – Buccal view showing excellent soft tissue healing and keratinized tissue.
8 – 5 months post-operative.
9 – 2 years post-operative: final restoration in place.

CLINICAL CASE

Initial Situation: a failing mandibular molar with a vertical sub-osseous fracture.
A pre-operative radiograph and CBCT showing the cross-section of the involved tooth.
An implant site was developed by placing a pilot drill down the mesial root space, then uprighting it. This was continued up through the drill sequence. The mesial radicular septum is moved in the process.
A Camlog® 5.0 x 11 mm implant was placed with the platform set just down below the bone height of the socket walls.
After placing a 4.0 mm height cylindrical gingiva former in the implant, 250 mg of Geistlich Bio-Oss Collagen® was packed down in the socket around the implant.
Geistlich Mucograft® was adapted to the region then tucked down under the gingival margin.
The gingival margins were adapted and closed together with 4.0 teflon sutures (Cytoplast™, Osteogenics). The region was then covered with Glustich – PeriAcryl®90 Oral Tissue Adhesive.
4 months later following Emergence Profile Development.
An occlusal view of the final onepiece, screw-retained zirconia crown restoration based on a Camlog® Titanium Base Abutment.

CLINICAL CASE

1 – Pre-operative lateral smile showing the recession defect of tooth 5.
2 – Pre-operative image of recession defect (tooth 5).
3 – After elevation of split-full-split flap the interdental papillae are de-epithelialized.
4 – Geistlich Mucograft® is placed over the root and sutured to the papillae
5 – The flap is mobilized, coronally advanced and sutured completely covering the Geistlich Mucograft®.
6 – Healing of the surgical site 2 weeks after surgery.
7 – Surgical site 6 months after surgery.
8 – Outcome 1 year after treatment.
9 – Lateral smile 1 year after surgery showing the optimal esthetic outcome.

CLINICAL CASE

1 – Before preparation of the flap the exposed root portion is cleaned with a scraper and is wiped with EDTA (or similar).
2 – After measuring the dimension of the recession defect using a periodontal probe, the incisions for raising the flap are cut.
3 – A split-full-split thickness flap is elevated and coronally mobilized.
4 – The area of the papillae is de-epithelialized to allow anchorage of the flap coronal to the cemento-enamel junction.
5 – Geistlich Mucograft®is applied dry to the defect and is fixed with 4 single sutures.
6 – The coronally advanced flap is sutured over Geistlich Mucograft®.
7 – Nice, uneventful healing 15 days post-operatively at suture removal.
8 – Soft tissue situation immediately after suture removal.
9 – Complete root coverage 7 months after surgery. Note the excellent color match.

CLINICAL CASE

1 – Pre-operative image showing the recession defect on tooth #6.
2 – After elevation of a partial thickness flap, the interdental papillae are de-epithelialized.
3 – Geistlich Mucograft® is placed over the defect and sutured to the papillae.
4 – The flap is coronally advanced and sutured completely covering the matrix.
5 – Follow-up after 1 week: healing of the surgical site.
6 – Follow-up situation after 4 weeks.
7 – Follow-up after 3 months.
8 – Follow-up after 6 months: note the natural appearance of the soft tissue achieved with Geistlich Mucograft®.
9 – Follow-up after 1 year.

CLINICAL CASE

1 – Pre-operative picture of the area intended to treat. Note the thin biotype.
2 – Initial situation showing Miller Class I defects on region 4 (3 mm) and 5 (2 mm).
3 – A split-full-split thickness flap without releasing incisions is elevated.
4 – The anatomical papillae are de epithelialized.
5 – The collagen matrix Geistlich Mucograft® is placed under the flap.
6 – Immediate post-operative situation after suturing of the flap covering Geistlich Mucograft® completely
7 – Follow-up picture 2 weeks after surgery.
8 – Nice healing of the site 1.5 months post-operative.
9 – Pleasant esthetic outcome 7 months after surgery.

CLINICAL CASE

1 – Pre-operative view of recession defects that ranges from 2-5 mm. There is minimal keratinized tissue on #14. Pocket depths are within limits with no loss of interproximal tissue.
2 – A 15c blade is used to make sulcular incisions with scooping incisions at the level of the CEJ. A combination flap consisting of full-thickness coronally followed by a partial-thickness dissection apically is reflected.
3 – The papillary tissue is de-epithelialized with a football diamond bur on a rotary hand piece. This exposes a vascular bed for the graft and intended coronal positioning of the flap.
4 – Side-view of the recession defects. It is clearly visible how deep the recession defects are.
5 – Geistlich Mucograft® is trimmed and positioned to extend beyond the root surfaces. A combination of simple interrupted sutures at its coronal edge and mattress sutures extending over the entire graft are used to adapt the graft to the recipient site.
6 – The flap is then advanced and coronally positioned with horizontal mattress sutures to release tension and simple interrupted sutures to approximate the flap edges to the de-epithelialized papillas.
7 – Follow-up after 1 week: note that the flap margins appear stable. Erythema and edema evident with maturation of the tissue beginning.
8 – Follow-up after 3 months: maturation of the tissue evident with complete root coverage. An increase in the zone of keratinized tissue by #14 is also visible.
9 – Follow-up after 1 year: stability of the graft is evident, complete coverage and a healthy and maintainable gingival situation have been achieved.

CLINICAL CASE

1 – This case shows a shallow vestibule and almost no keratinized tissue on the lower crestal part. The horizontal incision has to be made within the keratinized tissue (see depicted line).
2 – Ensure the incision is within the keratinized tissue: an apically fixed split flap is used here. Remove the muscles, scar fibers and ligaments before application of Geistlich Mucograft®.
3 – Measure the defect carefully with a periodontal probe and cut Geistlich Mucograft® in a dry state. In the case of a large vestibuloplasty, several pieces of Geistlich Mucograft® can be sutured side by side.
4 – Geistlich Mucograft® is sutured directly onto the periosteum with 5.0 resorbable sutures and left exposed for open healing (healed by secondary intention).
5 – 10 days post-operative: favorable healing where granulation tissue and new soft tissues have formed.
6 – 1 month post-operative: excellent wound healing with complete integration and epithelialization of Geistlich Mucograft® as well as keratinization of the crestal aspect could be observed.
7 – 3 months post-operative: excellent esthetic outcome with full integration and epithelialization of Geistlich Mucograft® to the surrounding tissue and keratinization of the crestal aspect.
8 – 1 year post-operative: the formed keratinized tissue fulfills its functionality and shows an esthetically pleasing result matching the structure and color of the surrounding tissues. The mean width of the peri-implant keratinized mucosa was 4.0 mm, and a low shrinkage was assessed at 38%.
9 – 5 years post-operative: the mucogingival appearance remains stable. The resulting keratinized tissue fulfills its functionality and shows an esthetically pleasing result.

CLINICAL CASE

1 – Pre-operative view. A small band of keratinized gingiva is present
2 – The band of keratinized gingiva is split and a split-thickness flap is elevated exposing connective tissue and periosteum.
3 – Geistlich Mucograft®is sutured to the recipient bed and left exposed.
4 – Follow-up after 1 week: the area appears to granulate underneath the fibrin clot.
5 – Follow-up after 4 weeks: excellent wound healing.
6 – Follow-up situation after 2 months.
7 – Follow-up after 3 months.
8 – Follow-up after 6 months: Lugol’s iodine staining indicates delineating keratinized tissue.
9 – Follow-up after 6 months: mucogingival appearance with 4 mm of keratinized tissue.

CLINICAL CASE

1 – Baseline: multiple recession defect Miller Class I with keratinized tissue less than 3 mm on teeth #7 to #5.
2 – Coronally advanced flap preparation and elevation for sufficient release.
3 – Geistlich Fibro-Gide® is cut in half to 3 mm thickness.
4 – 3 mm Geistlich Fibro-Gide® is placed in the defect and absorbs blood immediately.
5 – Positioning of Geistlich Fibro-Gide® and fixation with single sutures (7-0 PGA sutures).
6 – Tension-free wound closure with sling sutures (6-0 PGA sutures).
7 – Suture removal 14 days post-surgery.
8 – Follow-up after 12 months: complete root coverage with Geistlich Fibro-Gide® is achieved.
9 – 2 year follow-up: complete root coverage with Geistlich Fibro-Gide®.

CLINICAL CASE

1 – Clinical presentation at baseline, with the patient exhibiting multiple gingival recessions associated with dental hypersensitivity.
2 – A coronally advanced flap was performed, with the interincisal papilla that was preserved.
3 – Xenogeneic cross-linked collagen matrix (Geistlich Fibro-Gide®).
4 – Application of the collagen matrix over the recipient site.
5 – Suturing of the collagen matrix to the de-epithelialized anatomical papillae using simple interrupted sutures (7/0 PGA).
6 – Stabilization of the two collagen matrices.
7 – The flap was coronally advanced and stabilized with sling sutures (7/0 polypropylene).
8 – Clinical outcomes at 6 months showing complete root coverage of the frontal teeth, and a significant reduction on the first premolars. The patient reported a substantial reduction of the preoperative dental hypersensitivity, together with high treatment satisfaction.

CLINICAL CASE

1 – Gingival recessions #23 and #22
3 – 10 week post op healing. Root coverage achieved. Patient reports no problems and is pleased with the results. More follow ups to come.
2 – Sites at the day of the procedure after sutures placed. Tunnel between #23,24 and partial thickness flap raised between #23,22.

CLINICAL CASE

1 – Baseline: recession defect Miller Class I on tooth #11.
2 – Trapezoidal flap design: split-full-split flap elevation flap.
3 – Positioning of Geistlich Fibro-Gide® and fixation with single sutures (PGA 7.0 Sutures) at the base of the de-epithelialized anatomic papillae and in the apical mesial and distal angles.
4 – Tension-free wound closure with two sling sutures (PGA 6.0 Sutures).
6 – Buccal view 3 months post-surgery.
5 – Suture removal 14 days post-surgery.
7 – Buccal view 6 months post-surgery.
8 – Follow-up after 1 year: complete root coverage with Geistlich Fibro-Gide® is achieved.
9 – 3 year post-surgery: stable results with Geistlich Fibro-Gide®.

CLINICAL CASE

1 – Baseline frontal view: missing central incisor.
2 – Baseline occlusal view: The facial contour is flattened by physiological dimensional ridge alterations post-extraction.
3 – Full-thickness flap using one releasing incision in the distal aspect of the canine. Simultaneous contour augmentation using GBR was performed with autogenous bone chips to cover the exposed implant combined with a layer of Geistlich Bio-Oss®and Geistlich Bio-Gide®.
4 – Application of Geistlich Fibro-Gide® on top of the augmented area. A tension-free primary wound closure was obtained by a periosteal releasing incision.
5 – Suture removal 14 days post-surgery. Uneventful wound healing and an increase in soft-tissue volume.
6 – Frontal view 4 weeks post-surgery.
7 – 2 months follow-up combined with abutment connection.
8 – Occlusal view of final restoration 2 years post-surgery.
9 – Final restoration 2 years post-surgery shows pleasing esthetics.

CLINICAL CASE

1 – Baseline before implant placement showing the soft-tissue deficiency.
2 – Implant surgery after implant placement showing the need for guided bone regeneration.
3 – Guided bone regeneration with Geistlich Bio-Oss® and Geistlich Bio-Gide®.
4 – Geistlich Fibro-Gide® was trimmed to the defect size and placed at full thickness (6 mm) on top of Geistlich Bio-Gide®.
5 – Wound closure (PTFE 5/0 sutures) by combining horizontal mattress sutures and single sutures in a double layer.
6 – 2 weeks follow-up post-surgery.
7 – 3 months follow-up post-surgery.
8 – Re-entry was performed 3 months post-surgery. Soft-tissue emergence profile at the time of final ceramic-crown delivery 4 months after implant placement.
9 – Clinical and radiographic situation 2 years after implant insertion.

CLINICAL CASE

1 – Baseline occlusal view: situation before removal of tooth #20.
2 – Tooth removal and extraction socket management with Gesitlich Bio-Oss® and Geistlich Bio-Gide®.
3 – Geistlich Fibro-Gide® was trimmed to the defect size, to augment the buccal and crestal soft-tissue area of the ridge.
4 – Geistlich Fibro-Gide® in place, augmenting buccal and crestal area of tooth #20 and buccal in the edentulous area tooth #21 to tooth #19.
5 – Immediate provisionalization of the implants.
6 – 3 weeks post-surgery: occlusal view of augmented area with created emergence profile.
7 – 3 weeks post-surgery: buccal view of augmented area with created emergence profile.
8 – Provisional reconstruction 6 weeks post-surgery.
9 – Final restoration 2.5 years post-surgery: soft-tissue thickness remains stable over time.

CLINICAL CASE

1 – Baseline buccal view: soft-tissue concavity at the dental implant site.
2 – Baseline occlusal view: volume deficiency on the buccal aspect.
3 – Adapting and trimming of Geistlich Fibro-Gide® to the defect size. Additional bevel cut performed for the area to be positioned close to the incision line.
4 – Position and fixation of Geistlich Fibro-Gide® to the buccal flap with horizontal mattress suture.
5 – Primary closure obtained by horizontal mattress and single interrupted sutures.
6 – 4 months follow-up: showing the healed soft-tissue after augmentation surgery.
7 – 4 months follow-up: provisional restoration. Notice volume recovery.
8 – Occlusal view before final restoration.
9 – 9 months follow-up: final restoration after soft-tissue augmentation surgery.

CLINICAL CASE

1 – Pre-operative condition: Note that the gingival recession of 3-4 mm is evident as is the cervical root abrasions. The interdental papillae completely fills the embrasure space.
2 – Incision design showing the sulcular incisions with horizontal incisions across the interdental regions ending with a remote oblique vertical releasing incision distal to the first bicuspid tooth.
3 – Geistlich Fibro-Gide® is trimmed in a dry state to 10 x 15 x 6mm. The corners were trimmed for better adaptation and the matrix was then hydrated in sterile saline solution.
4 – The interdental papillae were de-epithelialized and Geistlich Fibro-Gide®was placed over the exposed roots extending onto the bone. Geistlich Fibro-Gide® was not secured with sutures.
5 – Internal periosteal releasing incision was made to allow tension-free coronal advancement of the buccal flap to completely cover Geistlich Fibro-Gide®.The flap was secured with 5-0 Monocryl® sutures.
6 – 1 week post-operative visit: the healing looks good and sutures are intact. There was a small soft-tissue dehiscence at the buccal margin of the canine tooth.
7 – Healing progressed well at 2 months post-operatively and the dehiscence defect seen at 1 week appears to be healing. Soft-tissue thickness is also evident at this stage.
8 – At 6 months, 100% root coverage has been achieved. Note the increase in keratinized gingiva at the canine tooth where there was previously delayed healing. The patient is happy with the esthetic and functional outcome.

CLINICAL CASE

1 – Baseline: recession defects on teeth #19 to #22 in the lower left quadrant. Exposed root surfaces of these teeth were thoroughly scaled and root planed before surgery.
2 – A full thickness muco-gingival tunnel was prepared through a minimally-invasive vestibular access incision apical to the teeth with gingival recessions.
3 – Geistlich Fibro-Gide® was cut into small pieces in a dry state using a scalpel.
4 – Insertion of Geistlich Fibro-Gide® into the subperiosteal tunnel.
5 – Geistlich Fibro-Gide® in situ: the gingival margin had been coronally advanced and stabilized after pieces of Geistlich Fibro-Gide® were placed.
6 – 1 week post-surgery: anchoring sutures were left in place for 1-2 weeks.
7 – 2 weeks post-surgery: anchoring sutures in place.
8 – 2 weeks post-surgery: removal of anchoring sutures.
9 – 7 months post-surgery: complete recession coverage.

CLINICAL CASE

1 – Baseline frontal view: missing central incisor. Implant visible through mucosa due to thin biotype.
2 – Baseline occlusal view: soft-tissue deficit in the buccal and occlusal area.
3 – Flap elevation on the buccal side using a full flap crestally and a split flap buccally.
4 – Adaption of Geistlich Fibro-Gide® to the defect size.
5 – Palatal island flap prepared to allow for tension-free wound closure. Geistlich Fibro-Gide® in situ, immobilized with a mattress suture.
6 – Tension-free wound closure using single interrupted sutures (Dafilon 5-0, Braun).
7 – Abutment connection.
8 – 6 months follow-up: final crown in place.
9 – 2.5 year follow-up shows stable soft-tissue conditions.

CLINICAL CASE

1 – Baseline buccal view: immediate implant placement was performed 3 months prior to replacing tooth #8.
2 – Baseline occlusal view: soft-tissue deficiency on the buccal aspect.
3 – Placement of Geistlich Fibro-Gide® with minimal envelope flap and inserting a temporary crown.
4 – Stabilization of Geistlich Fibro-Gide® to the buccal mucosa using internal mattress sutures.
5 – 2-week follow-up at suture removal.
6 – 4 weeks post-surgery: uneventful wound healing and an increase in soft-tissue volume.
7 – Occlusal view 11 months post-surgery: there is a clear substantial increase in the soft-tissue thickness.
8 – Buccal view 11 months post-surgery: a substantial increase in soft-tissue thickness is evident.
9 – Buccal view 2 years post-surgery.

CLINICAL CASE

1 – Thin mucosal tissue over implant #7 creating an unesthetic appearance.
2 – Occlusal view of #7 reveals buccal soft-tissue defects.
3 – Augmentation of the soft-tissue on two implant sites, #7 and #10, using a conventional full thickness flap with vertical releasing incisions on site #7 and an envelope flap on site #10.
4 – Geistlich Fibro-Gide® is split into two 3mm thick matrices to be used in both sites, hydrated with sterile saline and trimmed to the defect dimensions.
5 – Geistlich Fibro-Gide® is secured to the periosteum apically and the interproximal papillae with 5-0 chromic gut sutures.
6 – Passive closure of the flap achieved with 6-0 vicryl sutures.
7 – 1 week post-surgery reveals uneventful healing with maintenance of tissue volume.
8 – Buccal view at 8 weeks reveals uneventful healing with maintenance of tissue volume.
9 – Occlusal view at 8 weeks post-surgery.

CLINICAL CASE

1 – Initial Clinical Situation, Occlusal/Buccal Shots of Missing teeth #12 and 13.
2 – Intra-Operative, Implant Placement of #12 and 13.
3 – Intra-Operative, Placement of Geistlich Fibro-Gide® in the Buccal Concavity of #12 and 13.
4 – Immediate Post-Operative Buccal Soft Tissue Thickness.
5 – Two Months Post-Operative Healing with Provisional Restorations.

CLINICAL CASE

Implant placement planned for site #3 and #5 with soft-tissue treatment utilizing a CTG and for sites #10, #12 and #13 with soft-tissue augmentation using Geistlich Fibro-Gide®
2 – Uncovering of site #10 shows a narrow ridge width and an insufficient amount of soft-tissue thickness.
3 – Tooth #10 was extracted and immediately replaced by an implant.
4 – Fill the gap procedure with Geistlich Bio-Oss Collagen® to achieve contour augmentation and preserve horizontal ridge dimensions.
5 – Geistlich Fibro-Gide® was trimmed to half of the thickness to fit the defect and placed into sites #10, 11, 12 and 13.
6 – The entire site was closed tension-free to facilitate uneventful wound healing.
7 – The 3 month follow-up shows uneventful soft-tissue healing and an increase of soft-tissue thickness at the desired sites.
8 – The 6 month follow-up with the final reconstruction shows that the soft-tissue thickness at the desired site is maintained over time. This contributes to an esthetic and pleasing outcome. (Restorative work by Dr. Chao-Chieh Yang, IUSD)
9 – The 2 month follow-up showing a comparison of the treated sites, one with CTG (left) and one with Geistlich Fibro-Gide® (right) in the same patient. Comparable results have been achieved with both treatments, but without the need for a donor site.

CLINICAL CASE

1 – Initial clinical situation, tooth #8 and #9 require extraction.
2 – Clinical view post extraction of tooth #8 and #9.
3 – Evaluation of the buccal soft-tissue thickness.
4 – Trimming of Geistlich Fibro-Gide® to fit in the gap between the buccal soft-tissue and the buccal bone wall.
5 – Geistlich Fibro-Gide® in place: an immediate volume increase of the buccal soft-tissues are visible.
6 – Mixing of autologous bone and Geistlich Bio-Oss® particles for placement in the gaps around the implants.
7 – Immediate implant placement with the bone mixture applied was performed.
8 – Provisional restoration at time of surgery (occlusal view).
9 – Provisional restoration at time of surgery (frontal view).