Horizontal bone and soft tissue augmentation in the posterior mandible

Major Bone Augmentation

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Dr. Ilkka Pallonen, DDS

Horizontal bone and soft tissue augmentation in the posterior mandible.

The Situation left mandible posterior site and wanted to have a fixed solution also at the right side. The patient was informed about the lack of horizontal bone volume and accepted to undergo through a GBR procedure before implant placement.

A healthy 75-years-old woman lost her dental bridge on area ­44–47, due to fracture of tooth 44. Patient’s dental hygiene was excellent and she was very motivated to return to chew normally. The patient had previous implant treatment at the

The Risk Profile Low Risk

Medium Risk

High Risk

Patient’s health

I ntact immune system/ Non-smoker

Light smoker

I mpaired 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

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

Width of tooth gap

1 tooth (≥ 7 mm)

Soft-tissue anatomy

Intact

Bone anatomy of the alveolar ridge

No defect

Triangular

Restored 1 tooth (≤ 7 mm)

2 teeth or more Compromised

Horizontal defect

Dr. Ilkka Pallonen, DDS Maxillofacial Surgeon DDS in Tampere University Finland.

Maxillofacial specialty training in central Finland (Jyväskylä & Tampere) 2011–2018.

Consultant Maxillofacial surgeon, in charge of implant therapy, bone and soft tissue regeneration in Tampere University Hospital.

President of Implantology division of Finnish dental association Apollonia.

Tampere Oral Hammaslääkärit Sumeliuksenkatu, private practice.

Helsinki Terveystalo Kamppi, private practice.

Vertical defect

“Patient had high expectations for treatment outcome.

There was a need to reconstruct bone volume horizontally. ­Deficiency of keratinized tissue needed to be taken care of during treatment.”

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The Approach

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In order to be able to provide an implant ­supported bridge, we needed to reconstruct the bone with the horizontal sausage technique ­approach ­described by Dr. Istvan Urban. ­After bone grafting and ­implant placement, a free ­gingival graft was used to increase the thickness of the keratinized tissue. A wide keratinized ­tissue zone key to ensure long-term success of the ­implant treatment.

The Outcome 6

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Prior to implant placement, a Geistlich B ­ io-Gide® membrane was used to stabilize the graft, which consisted of a 50/50% mix of a­ utologous bone and Geistlich Bio-Oss®. Implantation was ­pleasant due to good volume of r­egenerated bone. ­Keratinized gingiva was widened with a palatal free gingival graft two months after ­implant placement.

The patient was satisfied with the outcome.

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1 Patient loses dental bridge on region 44–46, due to fracture of tooth nr.

44. | 2 Operative situation 3 months after tooth 44 extraction. Safety-flap, from tooth 42 to ramus. Clinically 2 mm horizontal width at the top of ridge.

Oblique-form ridge and implants would have to be lowered 6–7mm, to have a good bone coverage. | 3 Horizontal bone regeneration using a mix of 50% autologous bone from ramus and 50% of small granules of Geistlich Bio-Oss®. | 4 A 30×40 mm Geistlich Bio-Gide® fitted to the site and fixed with titanium pins to stabilize the graft underneath. | 5 Double layer ­closure with PTFE 3-0 and Novafil 6-0 sutures. | 6 After six months of healing there was 8–9mm of horizontal bone width at the whole area. We noticed the need to reduce bone height of 2 mm, to have enough room for future prosthetic ­restorations | 7 4,2 mm diameter wide implants placed on sites 44 and 46. | 8 After healing, only 2mm of keratinized gingiva was left. Soft tissue ­augmentation with a free gingival graft was performed. | 9 Second stage surgery to reveal implants, 4 months after implant placement. ­Lingually moved keratinized tissue around implants. Closure with Caprosyn 5-0 ­sutures. | 10 Radiological status 1-year after loading. There was excellent bone coverage on every aspect of both implants. | 11 Occlusal view of the clinical status 1-year after loading. | 12 Lateral view of the clinical status 1-year after loading.

Keys to Success More details about our distribution partners: www.geistlich-biomaterials.com Manufacturer Geistlich Pharma AG Business Unit Biomaterials Bahnhofstrasse 40 6110 Wolhusen, Switzerland Phone +41 41 492 55 55 Fax +41 41 492 56 39 www.geistlich-biomaterials.com Affiliate Australia and New Zealand Geistlich Pharma Australia Pty Ltd. The Zenith – Tower A Level 21, Suite 21.01 821 Pacific Highway NSW 2067 Chatswood, Australia Phone +61 1800 776 326 Fax +61 1800 709 698 info@geistlich.com.au www.geistlich.com.au

Patient motivation and oral hygiene improvement.

Soft tissue handling.

Hard tissue augmentation prior to implant placement.

The use of a native collagen membrane.

Prosthetic driven implant planning.

Bone augmentations need stability. Due to long ­resorption time of Geistlich Bio-Oss® and protectiveness of Geistlich Bio-Gide® stability and healing are more ­predictably achieved. With these materials from Geistlich we can treat difficult cases less invasive and more ­predictably.

Testimonial of Dr. Ilkka Pallonen

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