BIOBRIEF

Lateral and Vertical Bone Regeneration with Simultaneous Soft Tissue Augmentation

Arnd Lohmann, MSc

THE SITUATION

After extraction of the periodontally damaged tooth #20 the preoperative Cone-Beam Computed Tomography (CBCT) imaging shows reduced vertical bone volume in the area of tooth #s 18 – 20. A lateral and vertical bone regeneration was necessary.

The goal of treatment was a late implant placement after bone regeneration and creation of stable periimplant soft tissue for long-term implant preservation.

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
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
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

Additional Risk Factors: Roots were divergent, and intra-radicular bone (septal bone) was excellent, with more than 5 mm of remaining apical bone to achieve optimal primary stability.

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THE APPROACH

A customized bone regeneration procedure utilizing Yxoss CBR®. Followed by coverage of the graft with Geistlich Bio-Gide® for the purpose of Guided Bone Regeneration (GBR). Soft tissue thickening using Geistlich Fibro-Gide®. Delayed implantation into the augmented tissue. A vestibuloplasty with Geistlich Mucograft® for the regeneration of keratinized mucosa.

Baseline situation and planning: vertical bone deficit of 5.29mm in section 18-20.

Central incision in the keratinized mucosa and perforated cortical bone

Yxoss CBR® filled with a 50:50 mix of autologous bone and Geistlich Bio-Oss®. Coverage of the titanium scaffold with Geistlich Bio-Gide®

Geistlich Fibro-Gide® is tailored to the defect and a tension-free suture is done.

4 months after augmentation shows the bone situation after removal of the titanium scaffold and insertion of implants. Autologous bone chips are applied on top of the implants. Occlusal view of the mucosa level after implantation and wound closure.

6 weeks after implantation and 5 1/2 months after augmentation. The mucosa is prepared apically; the preparation reaches the periosteum apically. The recipient site is fully surrounded by keratinized mucosa. Geistlich Mucograft® is sutured into the area.

6 months after regeneration shows about 5mm of vertical bone regeneration. Panoram ic X-Ray after implant placement shows clearly recognizable mucosa shadows.

One year after augmentation shows the dental prosthesis inserted occlusally.

“Using the Geistlich Fibro-Gide® matrix enabled concurrent augmentation of hard
and soft tissues without any postoperative complications. At the same time, the soft
tissue thickening facilitated floor of the mouth surgery and vestibuloplasty.”
— Arnd Lohmann, MSc

THE OUTCOME

Treatment resulted in approximately 5 mm of vertical bone regeneration. The potential occurrence of a dehiscence associated with a wound opening and exposure of Yxoss CBR® was able to be prevented with Geistlich Fibro-Gide®.

On one hand, the quality of the peri-implant soft tissue was improved by the
soft tissue thickening with Geistlich Fibro‑Gide® and, on the other, by increasing the width of keratinized mucosa with Geistlich Mucograft®. The treatment method chosen resulted in a reduced invasiveness and morbidity by avoiding a donor site for sourcing a transplant.

Implant therapy should restore the natural anatomical structures as closely as possible in order to avoid subsequent peri-implant problems.”
Arnd Lohmann, MSc

Arnd Lohmann, MSc

Dr. Arnd Lohmann is a recognized specialist in implantology and periodontology. He earned his dental license in Hamburg in 2002, completed his doctorate in 2003, and has been a partner at a private practice in Bremen since then.

With a Master of Science in Implantology (2007), he specializes in dental implantology and bone augmentation. He is an active speaker at national and international congresses, leads the Bremen study group of the German Society of Oral Implantology (DGOI), and is a member of DGOI, DGZI, and DGI. His practice is equipped with state-of-the-art technology, ensuring high-quality patient care.

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

Dr. Erik Regidor Correa

DDS from the University of the Basque Country
MSc from the U. of the Basque Country
Master in Periodontology and Implant Dentistry U. of the Basque Country
PhD student in the U. of the Basque Country
Assistant professor and clinical researcher ThinkingPerio Research

CLINICAL CASE

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.

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.

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.

Side-view of the recession defects. It is clearly visible how deep the recession defects are.

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.

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.

Follow-up after 1 week: note that the flap margins appear stable. Erythema and edema evident with maturation of the tissue beginning.

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.

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.

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

6 – Coverage with Geistlich Mucograft® Seal and sealed with sutures

10 – 6 months follow-up the digital implant planning was performed highlighting 3D adequate bone support.

11 – Initial presentation at the moment of implant placement.

12 – Full thickness flap elevation and initial osteotomy performed.

13 – Implant placed and cover screw positioned.

14 – Flap approximations using a PTFE suture after the implant was placed.

15 – Healing at 2 weeks after the implant placement.

16 – Overview of the radiographic sequence of the implant placement: A. The initial bone presentation. B. The guiding pin in position revealing the mesio-distal position. C. The final implant in place.

18 - Final restoration, occlusal view — 18 – Final restoration, occlusal view

CLINICAL CASE

1 – Pre-operative view of the atrophied ridge.

2 – Application of a 1:1 mixture of autologous bone and Geistlich Bio-Oss®.

3 – Geistlich Bio-Gide® is tightly fixed and pinned, thus immobilizing the particulate graft. The sausage-like augmentation allows extended horizontal augmentation.

4 – Primary wound closure is obtained with a combination of mattress and single-interrupted sutures.

5 – Sufficient amount of augmented bone for implant placement 8 months after augmentation. Implants are placed in a submerged procedure.

6 – Insufficient vestibular depth and keratinized tissue after alveolar ridge augmentation.

7 – Application of a keratinized strip towards the vestibulum and Geistlich Mucograft® over the augmented area where it is left exposed for healing.

8 – Situation before reopening for abutment connection after 3 months showing increased vestibular depth

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.