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.

WEBINAR

BIOBRIEF

Mandibular Alveolar Ridge Split with Delayed Implant Placement

Gregory A. Santarelli, DDS

THE SITUATION

A healthy (ASA 1) non-smoker 63-year-old female presented to my office with Kennedy Class II partial edentulism in the mandibular right posterior quadrant for several years. She denied removable options and wanted dental implants to individually replace her missing teeth. The clinical and radiographic evaluation revealed atrophic mandibular bone height and width at site #’s 29, 30 & 31. The edentulous site required engineering prior to the placement of conventional dental implants and prosthetics.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system/Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

The goal is to provide adequate soft and hard tissue at edentulous site #’s 29, 30 & 31 in order to place dental implants and restore a stable balanced occlusion.

Alveolar ridge split with Geistlich Bio-Oss® graft in place (subsequently applied Geistlich Mucograft®).

6 months post grafting with Geistlich Bio-Oss® and Geistlich Mucograft®.

Implant osteotomies with adequate alveolar width.

Implants in tooth positions 29, 30 and 31.

“The hard and soft tissue of the edentulous posterior mandible were inadequate to rehabilitate with dental implants.”
— Dr. Gregory Santarelli

THE OUTCOME

The patient summarized this challenging case very well – “I never imagined I would have fixed teeth again.” Geistlich Bio-Oss® and Geistlich Mucograft® allowed for retention of the hard and soft tissue volume to achieve our final result and for maintenance of the final prosthesis.

Careful patient selection, treatment planning and operative efficiency were used to provide a previously non-functional segment with fixed stable dental implant prosthetics and a balanced occlusion.”
Dr. Gregory Santarelli

Precise osteotomies along with the use of Geistlich Bio-Oss® and Geistlich Mucograft® provide adequate bone volume for dental implants.”
Dr. Gregory Santarelli

Gregory A. Santarelli, DDS

Dr. Santarelli earned his DDS degree in 1998 from the University School of Dentistry, Milwaukee, WI, after graduating with his B.S. in Biology from Arizona State University (Tempe, AZ). In 1999, he completed his General Practice Residency at the University of Iowa Hospital and Clinics, and went on to an Oral & Maxillofacial Surgery Internship at the Medical College of Virginia (Richmond, VA) as well as an Oral & Maxillofacial Surgery Residency Program, Christiana Care Health System (Wilmington, DE).

After completing his formal training in 2004, Dr. Santarelli’s work experience includes the Bankor Hospital for Children, Cambodia (2003), Adjunct Clinical Professor, University of Marquette, School of Dentistry, Department of Oral Sugery, Marquette, WI (2005), and Oral Surgery Associates of Milwaukee, Milwaukee, WI (2004-2005). He now maintains a private practice in Kenosha, WI with his partner Dr. Deno Tiboris.

Dr. Santarelli performs numerous hard/soft tissue regeneration surgeries in preparation for dental implants and is actively involved in clinical research with The McGuire Institute (iMc).

BIOBRIEF

The Buccal Pedicle Flap for Peri-Implant Soft Tissue Volume

Dr. Giorgio Tabanella

THE SITUATION

Patient presented with a fistula buccal on tooth #9 associated with a chronic peri-apical lesion and external root resorption. Also tooth #8 showed a chronic peri-apical lesion. Her chief complaint was the misalignment of her teeth. The clinical situation revealed the presence of bleeding upon probing and generalized moderate periodontal disease (Stage II, Grade I) as well as multiple endodontic failures.

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

Note: request for reducing the healing time, long-term maintenance

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THE APPROACH

The aim of the treatment is to eradicate periodontal disease and restore esthetics and function. Treatment planning: non-surgical and surgical periodontal treatment, orthodontic alignment, extraction of both central incisors, immediate implant placement and Guided Bone Regeneration with Geistlich Bio-Oss®, peri-implant soft tissue boosting with a buccal pedicle flap and full ceramic CAD-CAM restorations.

The clinical picture is showing a fistula buccal to #21 as well as leakage on old composite restorations. A thin biotype is evident.

The sagittal cuts are reporting chronic peri-apical lesions on both central incisors and a thin buccal plate with minor vertical bone loss but fenestration apical to #21.

The intrasurgical picture is showing the bony defect, the buccal fenestration and the thin buccal plate.

After allowing the tissue to heal for 4 months a first “Buccal Pedicle Flap” was performed during the uncovery of the dental implant. Simultaneously, Geistlich Fibro-Gide® was inserted into the envelope created by the flap design.

Geistlich Fibro-Gide® is reduced to a thickness of 4 mm at its borders so that it is easier to get adapted to the recipient site.

The Fibro-Gide® is trimmed so that its borders don’t approach the vertical incisions of the Buccal Pedicle Flap.

Polypropylene 6.0 sutures are used to compressed the Fibro-Gide® underneath the flap thus creating the “wrinkles” on the mucosa.

The wrinkles are visible also on the occlusal view. The mucogingival line is repositioned at its original level.

Four months after immediate implant placement and GBR in area #11 a second Buccal Pedicle Flap is performed to reduce the buccal concavity, boost the peri-implant mucosa and increase the thickness as well as the band of the keratinezed mucosa.

As in the previous surgery the Fibro-Gide® is inserted underneath the Buccal Pedicle Flap and stabilized with e-PTFE 6.0 sutures.

8 weeks post surgery, the occlusal view is showing a biomimetic countouring of the peri-implant mucosa.

The final esthetic result is emphasizing an excellent blending of “white” and “pink” esthetics.

“Orthodontic treatment must be postponed because of the presence of periodontal disease. A thin biotype and a high smile line needs to be taken into consideration.”

THE OUTCOME

The final outcome at 8 weeks is showing pink esthetics as well as biomimetics and function. The use of the buccal pedicle flap allowed the increased volume of the peri-implant mucosa with a minimally invasive approach. The combination of Geistlich Fibro-Gide® and a buccal pedicle flap had the main advantage of reducing the morbidity generally associated with CT harvesting.

Dr. Giorgio Tabanella

Dr. Tabanella is a Diplomate of the American Board of Periodontology, an Active Member of the Italian Academy of Esthetic Dentistry and author of the book “Retreatment of Failures in Dental Medicine”. He graduated from the University of Southern California, Los Angeles, USA where he obtained his Certificate in Periodontics as well as a Master of Science in Craniofacial Biology. He is Director of O.R.E.C. – Oral Reconstruction and Education Center (www.tabanellaorec.com), reviewer and author of original articles.

BIOBRIEF

Use of Geistlich Fibro-Gide® for Correction of Maxillary Anterior Soft Tissue Peri-implant Ridge Deficiencies

Dr. Israel Puterman

THE SITUATION

A 27-year-old female with congenitally missing maxillary lateral incisors was referred for implant placement. Following completion of orthodontics, a plan was developed to place dental implants at the #7 and #10 positions. Based on CBCT evaluation, alveolar ridge height and width was deemed sufficient for implant placement. Despite sufficient bone volume, facial ridge volume deficiencies were noted at both edentulous sites, requiring augmentation to allow for optimal esthetics.

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 goal of treatment was to replace missing maxillary lateral incisors with dental implants, while providing an esthetic result with predictable and minimally invasive techniques. Employing a surgical guide for implant placement, implants were placed in precise 3-dimentional positions. The use of xenograft biomaterials (Geistlich Fibro-Gide®) allowed for the augmentation of gingival biotype and elimination of the buccal ridge deficiencies while avoiding the harvesting of autogenous tissue.

Pre-surgical, occlusal view, demonstrating buccal ridge concavities at edentulous sites, #7 and #10.

Geistlich Fibro-Gide® collagen matrix is cut and shaped prior to placement into surgical sites.

Immediate post-surgical occlusal view following placement of implants and Geistlich Fibro-Gide® on facial aspects. Implant #7 was provisionalized immediately, however implant #10 did not achieve sufficient stability and a healing abutment was placed.

Immediate post-surgical facial view. One can note the buccal prominences being developed by the presence of Geistlich Fibro-Gide®.

2-month post-surgical view, following provisionalization of implant #10. Buccal convexities at the implant sites are still evident.

8 month view of implant sites at time of torque test, following maturation of gingival emergence. Of note is thick, convex buccal tissue free of any sign of inflammation.

Occlusal view following final restoration, (Dr. Paul Krainson). Natural-appearing buccal gingival convexities remain 1.5 years post-surgery.

Frontal view of final restoration of implants. The tissue health with stippling and root-like gingival prominences are noted.

“A buccal ridge deficiency with congenitally missing lateral incisors in a high-scallop, high-smile young female patient.”

THE OUTCOME

The presented case involves a female patient with congenitally missing maxillary lateral incisors and soft tissue ridge deficiencies. Implants were placed and a volume-stable collagen matrix Geistlich Fibro-Gide® was placed to provide labial soft tissue volume. The tissue emergence was then developed with the use of provisional restorations, one placed at the time of surgery, the other following implant integration. The implants were restored with gingival tissue transformed to mimic convex root emergence.

Correction of labial soft tissue ridge deficiencies at implant sites through use of a Geistlich Fibro-Gide® volume stable, collagen matrix.”
Dr. Israel Puterman

A volume-stable collagen matrix can be used to correct a labial soft tissue deficiency, eliminating the potential negative sequelae of an autogenous connective tissue graft.”
Dr. Israel Puterman

Various materials can be used to restore a soft tissue deficiency; use of a volume-stable collagen matrix provides numerous advantages when used in the proper indication.”
Dr. Israel Puterman

Dr. Israel Puterman

Dr. Puterman, originally from Montreal Canada, received his DMD from Boston University in 2002 and dual graduate certificates in Implant Dentistry and in Periodontics from Loma Linda University in 2008. He is a published author in various journals including the Journal of Prosthetic Dentistry and the Journal of Prosthodontics. He practices in the Washington, DC area.

BIOBRIEF

Phenotype Conversion Using Geistlich Fibro-Gide® for Immediate Implants in the Esthetic Zone

Dr. Robert A. Levine

THE SITUATION

A healthy non-smoking 50-year-old female patient who desires a single tooth solution to replace a non-restorable tooth, #12. A root fracture at the level of the palatal post was diagnosed in a root canaled tooth. Maintaining esthetics of the adjacent teeth is important as they are also restored with single full coverage porcelain crowns. Lastly, treatment time reduction and a minimally invasive surgical technique are desired by the patient for reduced downtime and post-operative morbidity.

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

Patients Esthetic Expectations: Realistic
Facial Bone Wall Phenotype: High Risk (<1mm)
Esthetic Risk Profile (ERP) = Medium (summary of above)

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THE APPROACH

A minimally invasive surgical removal of tooth #12 with maintenance of the buccal plate and leaving a 3mm buccal gap. The implant will be placed one mm below the level of the intact buccal plate with an anatomically correct surgical guide template to provide for a screw-retained solution. The gap will be filled with Geistlich Bio-Oss Collagen® to maintain the bone buccal to the implant, and a palate free approach utilizing Geistlich Fibro-Gide® for soft tissue thickening to accomplish “phenotype conversion.” The long-term surgical goal is >2-3mm thickness of both hard and soft tissue buccal to the implant.

Pre-operative assessment demonstrates minimal zone and thickness of buccal keratinized gingiva, with a medium periodontal phenotype.

Pre-operative CBCT with virtually planned implant placement. A thin buccal plate (<1mm) is measured. Good apical bone is noted for the placement of a Straumann® 12mmx4.1mm bone level tapered implant.

Minimally invasive removal of #12 using only a buccal approach mini-flap showing an intact buccal plate with immediate placement of the implant (1 mm below the intact buccal wall) in a screw-retained position. A 3mm buccal gap is measured and a 1.5mm palatal gap.

Both the buccal and palatal gaps have been packed with Geistlich Bio-Oss Collagen® hydrated with Gem 21S. It’s my preference to squeeze Geistlich Fbro-Gide® between thumb and forefinger, prior to placement. A dry-carved piece of Geistlich Fibro-Gide® is in position thinned approximately 2mm with beveling laterally and coronally with a new #15 blade.

Geistlich Fibro-Gide® in place facial to the intact buccal wall under a full thickness buccal approach mini-flap. Immediate contour management was completed using an Anatotemp® for a maxillary bicuspid tooth.

Suturing completed using 4-0PTFE and 5 -0 polypropylene non-resorbable sutures. Anticipated short-term 25% post-operative swelling is discussed with the patient.

3 months post-operative appointment showing a well-developed subgingival transition zone created with immediate contour management. A reverse torque test was completed, and the case proceeded to completion.

9 month post-operative view with final screw-retained crown in place. Good interproximal papilla healing is noted with thickening of the buccal periodontal phenotype compared with Fig. #1. (Restorative Therapy: Drew Shulman DMD, MAGD; Philadelphia, PA)

“High esthetic demands were the primary concern with this case. They were addressed with the diagnostic tools of clinical photos, a site specific CBCT to evaluate the buccal wall status, and summing the findings with patient expectations gathered using the Esthetic Risk Assessment (knee-to-knee; eye-to-eye) which is used along with our consent agreement to treatment.”

THE OUTCOME

Minimally invasive surgery for buccal wall maintenance, virtually planning the buccal gap and implant width, using a xenograft in the buccal gap with phenotype conversion using a volume stable collagen matrix in conjuction with immediate contour management, allows for the best chance for papillae fill interproximally and maintenance of the mid-buccal gingival margin long-term.

Virtual planning the implant width for a screw-retained prosthesis based on an intact buccal wall after extraction to allow for a buccal gap of >2mm to be grafted are important keys for esthetic success.”
Dr. Robert A. Levine

The importance of the ‘one-two punch’ of ROUTINE phenotype-conversion using Geistlich Fibro-Gide® in conjunction with bone grafting the >2mm buccal gap with Geistlich Bio-Oss Collagen® provides excellent buccal convex tissue maintenance long-term.”
Dr. Robert A. Levine

Dr. Robert A. Levine

Robert A. Levine DDS is a board-certified periodontist at the Pennsylvania Center for Dental Implants and Periodontics in Philadelphia. He is a Fellow of the International Team for Dental Implantology (ITI), College of Physicians in Philadelphia, International Society of Periodontal Plastic Surgeons and the Academy of Osseointegration. He has post-graduate periodontology and implantology teaching appointments at Temple University in Philadelphia, UNC in Chapel Hill and UIC in Chicago and has over 80 scientific publications.

BIOBRIEF

Geistlich Mucograft® for the Treatment of Multiple Adjacent Recession Defects: A More “Palatable” Option

Dr. Daniel Gober

THE SITUATION

A 35-year-old male presented in my practice with a chief complaint of recession. Multiple buccal recession defects ranging 2-5 mm were noted by teeth #11-14 with a minimal amount of keratinized tissue on the buccal of #14. Bone levels were within normal limits with no loss of interproximal tissue observed. These recession defects are classified as Miller Class I recession defects. Typically, 100% root coverage is expected for recession defects of this type.

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”
Bone defect(s)	Not present	Slight defect <2mm	Significant >3mm
Keratinized tissue	Adequate 5mm	Inadequate <5mm	Inadequate <3mm
Miller classification	Class I-II	Class III	Class IV

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THE APPROACH

My treatment goals included completing root coverage of the recession defects and augmentation of the width of attached keratinized tissue by tooth #14. My patient had similar recession defects on teeth #3-6 which were previously treated with an autogenous sub-epithelial connective tissue graft. Instead of autogenous tissue grafting, Geistlich Mucograft®, a xenogenic collagen matrix, was used in conjunction with a coronally advanced flap.

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.

“The patient was unhappy with the post-operative morbidity he
experienced as a result of the previous connective tissue graft.”

THE OUTCOME

This case illustrates the successful use of Geistlich Mucograft®, a xenogenic collagen matrix, for the treatment of multiple adjacent recession defects. Complete root coverage and an increase in the zone of keratinized tissue was obtained and a dento-gingival complex that is amenable to long-term health and stability was achieved. My patient was spared from the inevitable morbidities associated with a sub-epithelial connective tissue graft from a palatal donor site.

Geistlich Mucograft® is a viable alternative to an autogenous tissue graft for the treatment of recession defects.”
Dr. Daniel Gober

Having a thorough knowledge of wound healing can make all of the difference. Every step of the procedure must be planned with the goal of maximizing vascularization of the graft matrix.”
Dr. Daniel Gober

Due to its ability to smoothly and meticulously guide small suture needles through soft-tissue, the castroviejo needle holder is my instrument of choice when suturing during periodontal plastic procedures.”
Dr. Daniel Gober

Dr. Daniel Gober

Dr. Daniel D. Gober received his DDS from SUNY Stony Brook School of Dental Medicine in 2010. He completed his residency in periodontics and implantology at Nova Southeastern University. Dr. Gober is board certified by the American Academy of Periodontology and is a Diplomate of the International Congress of Oral Implantology. He is also certified in the administration of IV sedation and specializes in soft-tissue procedures around both natural teeth and implants. He currently practices in Cedarhurst, NY at South Island Periodontics & Implantology, PLLC.

BIOBRIEF

Soft-Tissue Augmentation in the Esthetic Zone

Prof. Dr. Daniel S. Thoma

THE SITUATION

A young male patient was referred to the clinic with a missing central incisor, #9 following trauma. An implant was placed and the patient was referred for an implant-born reconstruction. The patient does not smoke and drinks occasionally. Upon a clinical examination, extensive horizontal and vertical contour deficiencies are present prior to abutment connection.

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

Note: The fractured tooth has a periapical lesion together with a severe bone defect around the horizontal fracture.

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THE APPROACH

The compromized situation with a horizontal and vertical hard and soft-tissue deficit required a soft-tissue volume grafting procedure. A buccal split-thickness flap was prepared and Geistlich Fibro-Gide® shaped and placed. Primary wound closure was obtained. Abutment connection was performed after 8 weeks and the emergence profile created with a provisional reconstruction. The final reconstruction was placed at 3 months.

A young male patient was referred to the clinic with a missing central incisor, #9 following trauma.

Preparation of a split-thickness flap (buccal pouch).

Due to releasing incisions within the periosteum, the tissues can be advanced more coronally.

The dimension and shape of Geistlich Fibro-Gide® with a maximal thickness (5mm) at the transition between the buccal and occlusal aspect.

Geistlich Fibro-Gide® inserted and immobilized with a horizontal cross-suture to the palatal flap.

A provisional reconstruction is inserted; blanching of the tissues can be observed.

Final emergence profile established with a provisional reconstruction.

8 weeks healing: Abutment connection is performed

The clinical situation at 1-year follow-up.

“The patient presented with severe horizontal and vertical hard and soft-tissue defects. I needed a solution that could increase the soft-tissue anatomy around the implant and prosthesis.”

THE OUTCOME

The outcome of the case was very pleasing having fulfilled the patient’s expectations in terms of esthetics and function. The tissues are healthy and volume was obtained through the grafting procedure to match the contour of the neighboring natural tooth.

Soft-tissue augmentation using Geistlich Fibro-Gide® results in a predictable volume gain and reduces surgery time, as well as patient discomfort.”
Dr. Daniel S. Thoma

Prof. Dr. Daniel S. Thoma

Prof. Dr. Daniel Thoma is the head of Reconstructive dentistry and Vice-chairman at the Clinic for Fixed and Removable Prosthodontics and Dental Material Sciences, University of Zurich, Switzerland. He graduated in 2000 at the University of Basel, Switzerland and was trained in implant dentistry and prosthodontics at the clinic for Fixed and Removable Prosthodontics and dental Material Sciences, University of Zurich, Switzerland.

BIOBRIEF

Root Coverage for Multiple Adjacent Teeth in the Maxilla with Geistlich Fibro-Gide® 1.5-Year Follow-Up

Dr. Vinay Bhide

THE SITUATION

The patient is a healthy, 60-year-old female who presented to our clinic with a chief complaint of progressive gum recession which had led to compromised esthetics and sensitivity involving the maxillary left lateral incisor (#10), canine (#11), and first bicuspid (#12) teeth. The teeth in question had 3-4 mm of gingival recession on the buccal surface with a sufficient zone of keratinized gingiva. These teeth also had obvious cervical abrasion.

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

Classification of recession – RT1 i.e. intact interdental bone and soft tissues
Severity of recession – mild to moderate
Amount of keratinized gingiva – 2 mm or greater for all teeth involved

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THE APPROACH

Treatment goals for this case were to obtain complete root coverage, increase soft tissue thickness, and reduce/eliminate cervical sensitivity. A split-thickness envelope flap approach was used. Geistlich Fibro-Gide® was then trimmed, hydrated with saline, and placed over the exposed root surfaces. The flap was coronally advanced in a tension-free manner to completely cover the biomaterial and exposed root surfaces.

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.

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.

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.

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.

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.

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.

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.

At 1 year, we can see root coverage has been sustained. Complete root coverage is not seen for the upper left bicuspid, not surprising given the tooth had an older restoration which was removed prior to grafting and the CEJ on the proximal surface is visible. Partial coverage was achieved however and is much more pleasing to the patient.

At 1.5 years, the tissue looks stable, healthy and esthetic. The patient is very happy with results thus far both from esthetic and functional standpoints. She is still free of sensitivity.

“The patient’s main priorities were to improve esthetics and reduce/eliminate root sensitivity. Soft tissue grafting was done with autologous connective tissue in other areas of her mouth many years ago and she was hesitant to undergo surgery again if it involved harvesting tissue from her palate due to the post-operative pain she experienced after these previous procedures.”

THE OUTCOME

This case nicely shows that the result following root coverage surgery to treat multiple adjacent teeth using a volume-stable collagen matrix is comparable to that seen with autologous connective tissue. At 1.5 years, there is continued stability of the treated site. The tissue appears healthy and firm. The patient‘s chief complaints of esthetics and sensitivity have been addressed and the patient is maintaining excellent oral hygiene and home care.

Multiple recessions on adjacent teeth in the maxilla can be treated successfully with a volume-stable collagen matrix and coronally-advanced flap.”
Dr. Vinay Bhide

The most important material for this case is the use of a volume-stable collagen matrix used in place of autologous connective tissue. Using this material has significantly decreased patient morbidity.”
Dr. Vinay Bhide

Dr. Vinay Bhide

Dr. Vinay Bhide is a board certified Periodontist with a special interest in periodontal plastics and reconstructive surgical procedures. Dr. Bhide did his dental and specialty training at the university of Toronto. In addition to private practice, Dr. Bhide is a clinical instructor in the Department of Periodontics at the university of Toronto. He is also a staff periodontist in the Center for Advanced Dental Care and Research at Mount Sinai Hospital, Toronto.

BIOBRIEF

Immediate Mandibular Molar Transition

Dr. Peter Hunt

THE SITUATION

The case here is typical enough, a failing mandibular molar with a vertical sub-osseous fracture. Traditionally, the replacement process can take three or more surgical exposures (extraction and regeneration), (implant placement), (second stage exposure) and more than a year of therapy.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

Immediate molar replacement requires atraumatic removal of the fractured tooth, careful socket debridement and development of a channel for an ideally positioned implant. The implant then needs to be placed down in the bone channel with the implant platform positioned just below the socket walls. It needs to be stable. Channel deficiency augmentation is achieved with Geistlich Bio-Oss Collagen® which is covered with a collagen matrix, Geistlich Mucograft® with the edges tucked under the gingival margins and sealed over with tissue glue.

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.

After 3 months of healing, the top of the gingiva former is exposed and the situation is ready for Emergence Profile Development. This is quite standard.

4 months later following Emergence Profile Development.

An occlusal view of the final one-piece, screw-retained zirconia crown restoration based on a Camlog® Titanium Base Abutment.

“The patient desires an implant placement for a fractured mandibular molar, as fast as possible.”
– Dr. Peter Hunt

THE OUTCOME

This single stage replacement protocol has proven to be simple, safe and highly effective providing the socket is fully degranulated and the implant is stable and not loaded in the early healing stages. It works well when a gingiva former is immediately placed into the implant instead of a cover screw, Geistlich Bio-Oss Collagen® is packed around the implant to fill the residual socket, then covered with a Geistlich Mucograft® and sutured. There is no need for flap advancement to cover over the socket.

This procedure really just merges a socket regeneration procedure with implant placement. It’s a simple and effective procedure which has now become quite standard for us.”
Dr. Peter Hunt

Dr. Peter Hunt

After graduate training on an Annenberg Fellowship at the University of Pennsylvania, dr. hunt helped start up the University of the Western Cape dental School in Cape Town, South Africa. he returned to the University of Pennsylvania where in time he became Clinical Professor of Periodontics. later he helped start up Nova Southeastern‘s dental School where he was Professor of Restorative dentistry, Post Graduate director and director of Implantology. he has had a private practice in Philadelphia focusing on implant and rehabilitation dentistry since 1981.

BIOBRIEF

Ramal Bone Graft for Congenitally Missing Maxillary Lateral Incisor

Dr. Richard E. Bauer, III

THE SITUATION

An 18-year-old female presented with a congenitally missing tooth #10. The patient previously sought care by another provider and had undergone guided bone regeneration with allograft and subsequent implant placement with additional grafting at the time of implant placement. The implant ultimately failed and was removed prior to my initial consultation. An examination revealed maximal incisal opening, within normal limits, missing #10 with 6 mm ridge width. In addition there was a significant palpable cleft-like depression on the facial aspect of the ridge, adequate attached tissue but reduced vertical height in relation to adjacent dentition and attached tissue. Previous surgeries resulted in extensive fibrous tissue with scarring at site #10. Plan: A ramal bone graft is indicated at the congenitally missing site #10 with Geistlich Bio-Oss® and Geistlich Mucograft® matrix utilized for ridge augmentation prior to secondary implant placement.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

The goals for this patient are to reconstruct the osseous foundation and provide a matrix for improvement with the overlying soft tissue. Specifically, a coordinated multidisciplinary plan was established with the restoring dentist, periodontist and oral surgeon. A plan for idealized anterior cosmetic prosthetic restoration was established. Sequencing of treatment was established. Surgical phase one included a ramal bone graft to site #10 and Essix type temporary prosthesis for immediate post-operative phase followed by a temporary Maryland bridge. Surgical phase two included implant placement and simultaneous crown lengthening and osteoplasty. This stage was done with immediate provisionalization.

A flap has been raised and reveals a significant facial and palatal defect at congenitally missing site #10.

Harvested ramal graft. Slightly over-sized to allow for mitering and harvest of particulate autograft with a bone trap on the suction.

Onlay graft now secured with two fixation screws (Stryker) with a lag screw technique. Geistlich Bio-Oss Collagen® has been placed on the palatal aspect of site #10

Combination of a fixated onlay graft with Geistlich Bio-Oss®/autograft particulate graft at the periphery and over the facial plate of the adjacent dentition

Geistlich Mucograft® matrix placed over facial augmentation of the adjacent dentition and ridge crest of the augmented site

Closure following ramal grafting and Geistlich Mucograft®matrix application

Implant placement with static guide and dental implant hand driver

Implant placement with slight subcrestal placement of the platform just prior to osteoplasty by the periodontist.

“This is a young patient with a congenitally missing incisor that has high esthetic concerns and has had multiple failed surgical attempts that is now presenting for definitive management.”

THE OUTCOME

This case was dependent upon adequate hard-tissue reconstruction combined with soft-tissue manipulation to eliminate scar tissue and provide esthetic recontouring. Obtaining an adequate autogenous graft combined with Geistlich Bio-Oss® at the periphery of the onlay graft is essential for anterior-posterior and vertical augmentation. Utilizing a Geistlich Mucograft® matrix at the ridge crest to help contain the particulate graft and improve the soft-tissue profile for subsequent immediate provisionalization and re-contouring of the surrounding soft tissue played a significant role in the esthetic success.

Immediate provisional in place two days after implant placement and osteoplasty. There has been significant gain in bony architecture and development of soft-tissue contours at a site that was extremely deficient of structure to begin with.”
Dr. Richard E. Bauer, III

Dr. Richard E. Bauer, III

Oral and Maxillofacial Surgeon – University of Pittsburgh

Richard E. Bauer, III, DMD, MD is a graduate of the University of Pittsburgh Schools of Dental Medicine and Medicine. Dr. Bauer completed his residency training in Oral and Maxillofacial Surgery at the University of Pittsburgh Medical Center. Dr. Bauer has served on multiple committees for the American Association of Oral and Maxillofacial Surgery (AAOMS). He is a full-time faculty member and Residency Program Director at the University of Pittsburgh in the department of Oral and Maxillofacial Surgery and his practice is focused on dental implants and corrective jaw surgery. He has been active in research with focus on bone regeneration and virtual applications for computer assisted planning and surgery.

BIOBRIEF

Prosthetically Guided Regeneration (PGR) in the Posterior Maxilla

Paolo Casentini, DDS

THE SITUATION

The 60-year-old female patient’s chief complaint was represented by unsatisfactory esthetics and function, related to loss of multiple maxillary teeth. Her request focused on improving esthetics and function by means of a fixed reconstruction.

The patient presented five residual anterior maxillary teeth (from 6 to 10) that could be maintained. After preliminary periodontal diagnosis and treatment, specific diagnostic steps for implant treatment demonstrated inadequate bone volume for implant placement.

THE RISK PROFILE

	Low Risk	Medium Risk	High Risk
Patient’s health	Intact immune system Non-smoker	Light smoker	Impaired immune system
Patient’s esthetic requirements	Low	Medium	High
Height of smile line	Low	Medium	High
Gingival biotype	Thick – “low scalloped”	Medium – “medium scalloped”	Thin – “high scalloped”
Shape of dental crowns	Rectangular		Triangular
Infection at implant sight	None	Chronic	Acute
Bone height at adjacent tooth site	≤ 5 mm from contact point	5.5 – 6.5 mm from contact point	≥ 7 mm from contact point
Restorative status of adjacent tooth	Intact		Restored
Width of tooth gap	1 tooth (≥ 7 mm)	1 tooth (≤ 7 mm)	2 teeth or more
Soft-tissue anatomy	Intact		Compromised
Bone anatomy of the alveolar ridge	No defect	Horizontal defect	Vertical defect

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THE APPROACH

Bi-lateral sinus lift with Geistlich Bio-Oss Pen® and horizontal bone augmentation with a 1:1 mix of autogenous bone and Geistlich Bio-Oss® were performed six months prior to implant placement, following a Prosthetically Guided Regenerative (PGR) approach. The augmented sites were protected with Geistlich Bio-Gide® stabilized with titanium pins. The template utilized for radiographic diagnosis and GBR was then used to guide the implants’ placement.

Baseline full-mouth intra-oral view: the residual maxillary teeth were preliminarily reconstructed with a composite mock-up. The horizontal atrophy of the posterior areas of the maxilla is clearly visible.

The cone beam, realized with a radio-opaque diagnostic template, shows inadequate bone volume for implant placement in all the analyzed sites.

The use of the diagnostic template during the augmentation procedure helps to highlight the presence of bone defects in relationship to the restorative plan and future position of implants.

Large Geistlich Bio-Oss® particles are directly applied inside the sinus with Geistlich Bio-Oss Pen®.

The Geistlich Bio-Gide®, fixed with titanium pins is used to protect and stabilize the augmented site. As the surgical template shows, the bone augmentation is based on the future restorative project following the principle of PGR.

The same surgical procedure is performed on the left posterior side of the maxilla.

Cone-beam 6 months after surgery and prior to implant placement. The relationship between the template used for diagnosis and the bone crest reveals adequate bone volume to place implants in the correct prosthetically driven position.

Implant placement was guided by the same template utilized for diagnosis and bone augmentation.

Final view of the prosthetic reconstruction demonstrates bio-mimetic integration of implant-supported prostheses and ceramic veneers bonded to residual natural teeth.

The panoramic radiograph shows adequate integration of the implants and absence of peri-implant bone resorption.

Using a diagnostic template during the GBR procedure helps to highlight the presence of bone defects in relationship to the restorative plan and future position of implants.

THE OUTCOME

After a healing period of six months, adequate bone volume was achieved for the placement of five implants. Geistlich Fibro-Gide® was also used to optimize soft tissue volume at the buccal aspect of implants.

Implants were early loaded with a temporary screw-retained fixed prostheses six weeks after placement. The final prosthetic reconstruction included ceramic veneers of the frontal residual teeth and zirconium-ceramic screw-retained fixed prostheses on implants.

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

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.

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 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

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.

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 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

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.

WEBINAR

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

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 – 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.

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 assessment demonstrating significant bone loss, prior to vertical ridge augmentation.

2 – Labial view of the posterior mandibular defect site. Cortical bone was perforated to increase the blood supply.

3 – RPM™ was secured on the lingual side prior to applying a 1:1 mixture of autogenous bone and Geistlich Bio-Oss®.

4 – RPM™ was secured over the bone graft with titanium pins and screws.

5 – Geistlich Bio-Gide® is placed on top of RPM™ to prevent early soft tissue ingrowth while allowing for graft vascularization.

6 – Labial view of the soft tissue 9 months after the vertical bone augmentation.

7 – RPM™ exposed at 9 months, following flap elevation.

8 – Labial view of the regenerated surgical site at 9 months demonstrates well vascularized bone.

9 – Occlusal view of the regenerated surgical site at 9 months demonstrates well vascularized bone.

10 – Implant placement in the newly regenerated bone.

Geistlich Fibro-Gide® (15x20x6mm) was placed on top of two implants, to increase soft tissue thickness.

12 – Periapical x-ray 1 year post-operatively, demonstrates implant stability and mature bone formation following vertical bone augmentation and soft tissue thickening.

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).

8 – 6 months follow-up: final crown in place.

9 – 2.5 year follow-up shows stable soft-tissue conditions.

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.