TREATMENT CONCEPTS FORMINOR BONE
AUGMENTATION

1TABLE OF CONTENTS

3

Minor bone defects: key factors for successful treatment

5Long-term success with the dream-team

6–9

Clinical Cases Class 0
Prof. Ronald Jung
Dr. Benoit Brochery & Dr. Gary Finelle
Dr. Raffaele Cavalcanti
Dr. Paul Rosen

10–11

12–13

14

Clinical Cases Class I
PD Dr. Dr. Markus Schlee

15–20

Clinical Cases Class I
Dr. Ueli Grunder
Dr. Su Yu Cheng

Clinical Cases Class II
Dr. Teppei Tsukiyama
Prof. Ui-Won Jung
Dr. João Batista César Neto
Dr. Colin Campbell
Dr. Marlene Teo
Prof. Saso Ivanovski

21

Recommendend material combinations I References

Treatment Decisions in Minor Bone Augmentation

22

Product Range“The GBR technique with the combination of autologous
bone chips, Geistlich Bio-Oss® and Geistlich Bio-Gide®
offers predictable outcomes for contour augmentation.
It’s important that the products are both clinically and­scientifically well documented.”
Prof. Daniel Buser | Switzerland

2 – TREATMENT CONCEPTS MINOR BONE AUGMENTATION

Minor Bone Augmentation: Bone defects
around implants
Guided Bone Regeneration (GBR) is a well-documented and­successful method for bone augmentation. The term Minor Bone
Augmentation is used to describe GBR procedures around an
implant when a bony defect leaves part of the implant surface
exposed. Therefore Minor Bone Augmentation is defined as thetreatment of a bone defect around an implant and amongst others
includes dehiscences and apical fenestrations.1
In the present treatment concepts we focus on minor bone augmentations and differentiate them from major bone augmentation andridge preservation procedures. Major bone augmentation includes
staged approaches for implant placement. Ridge preservation may
be accomplished by grafting of the extraction socket with biomaterial in order to avoid ridge resorption after tooth extraction. (Tab. 1)

Theorie

MINOR BONE DEFECTS: KEY FACTORSFOR SUCCESSFUL TREATMENTl­ocal factors are influenced by the decision-making of the clinician. The first and most important local factor is the ratio between
the surface area of the exposed bone and the defect volume tobe regenerated. Whereas the bone regeneration depends on thenumber of bone walls available that can contribute to new boneformation, a simple rule summarizes: the more bone walls are available in a defect area, the better the healing potential in a given
defect site. One-wall defects are more demanding than two- or
three-wall defects.
The 3 most important criteria for implant placement with simultaneous GBR are: 2
1. CORRECT 3D-IMPLANT POSITION(Fig. 1–3) The implant must be placed in a correct three-dimensional position in order to obtain an optimal functional andesthetic outcome.2
2. PRIMARY STABILITY

Decision criteria for implant placementwith a simultaneous GBR
Besides general factors like smoking behavior, age, disease, etc.
­local factors play an important role for a successful GBR procedure.
General factors cannot be influenced by the clinician whereas

Primary implant stability has to be achieved for a predictableosseointegration.2
3. FAVORABLE MORPHOLOGY(Fig. 4–6) The peri-implant bone defect must have a f­ avorable
defect morphology to allow predictable bone regeneration of
the defect area and successful implant placement.2

TAB. 1: DIFFERENT THERAPEUTIC AREAS WITH VARIOUS TREATMENT SOLUTIONS:EXTRACTION SOCKETMANAGEMENTMINOR BONE
AUGMENTATION

MAJOR BONE
AUGMENTATION

Ridge Preservation procedures
irrespective of the prosthetic
restoration time point (implant/
bridge).

Implant placement c­ ombinedwith GBR

GBR prior to implant ­placement /GBR with form stable compontents / sinus elevation

See “Treatment Concepts for­Extraction Sockets”

See online version of the present“Treatment Concepts for Minor
Bone Augmentations”

See “Innovative Treatment Concepts in Oral and Maxillofacial
Surgery”

3Correct 3D implant position
The placement of implants in a correct three-dimensional position is one of the keys to an esthetic and functional treatment outcome:
1

3

2

1.0 mm
2.0 mm
1.5–2.0 mm
1.5 mm

1.5 mm

FIG.1 MESIODISTAL DIMENSION

Minimal distance to neighboring teeth or implants needs to berespected at implant placement to prevent vertical bone loss on adjacent teeth in the mesiodistal dimension. Correct implant positionin the comfort zone (blue zone fig. 1) avoiding the danger zone (redzone fig. 1), which is dependent on the nature of adjacent structures.3
FIG. 2 OROFACIAL DIMENSIONIn the orofacial dimension, the implant shoulder should be positioned in the comfort zone (blue zone fig. 2) which measuresabout 1.5–2.0 mm in width when measured from the ideal pointof emergence. The danger zones (red zone fig. 2) are located bothfacially and palatally from the comfort zone.3
FIG. 3 CORONOAPICAL DIMENSIONIn the coronoapical dimension, the comfort zone (blue zone fig. 3)
is a narrow band of about 1.0 mm and is dependent on implantsystems and manufacturers recommendations. In general, theimplant shoulder should be positioned approximately 2.0 mm
apical to the mid-facial gingival margin of the implant restoration.
Apical and coronal to this narrow band the danger zone (red zone
fig. 3) is positioned.3

Favorable defect morphology 1 and treatment with Geistlich biomaterials
Successful Minor Bone Augmentation with Geistlich Bio-Oss® and Geistlich Bio-Gide® can be expected if the following defect­ orphology is prevalent:m
4

5

FIG. 4 CONTOUR DEFICIT: CLASS 0

Implant is placed in a bony envelope, but a contour augmentation is necessary for an esthetic outcome. GBR procedure with
Geistlich Bio-Oss® and Geistlich Bio-Gide® is performed in thesesituations. (Picture by courtesy of Dr. Raffaele Cavalcanti)

6

and the intact bone walls. If necessary, combined GBR procedure
is performed with Geistlich Bio-Oss® and Geistlich Bio-Gide® toalso account for filling the gap as well as for contour augmentation. (Picture by courtesy of Dr. Su Yu Cheng)
FIG. 6 DEHISCENCE-TYPE DEFECT: CLASS II

FIG. 5 INTRA-ALVEOLAR DEFECT: CLASS I

Implant is placed and an intra-alveolar gap defect is visible. A
GBR procedure is performed with Geistlich Bio-Oss ® 17 andGeistlich Bio-Gide® to fill the gap between the implant surface

After implant placement a peri-implant defect is visible with ­deficientbone wall. The GBR procedure is performed with Geistlich Bio-Oss®
and Geistlich Bio-Gide® to fill the defect and adapt the contour
augmentation.3,9 (Picture by courtesy of Dr. Teppei Tsukiyama)“I have been practicing implant dentistry for more than 20 years. The
majority of that time I have exclusively used Geistlich products fortreatment involving bone regeneration. The results, year after year, areexceptionally ­predictable.” Jay Beagle | USA

4 – TREATMENT CONCEPTS MINOR BONE AUGMENTATION

Theorie

LONG-TERM SUCCESS WITH THE DREAM-TEAM
GBR with the dream-team: Geistlich Bio-Oss®
and Geistlich Bio-Gide® for outstanding andpredictable clinical outcomes›› Maintained facial bone wall in 95 % of the patients for up to
5–9 years follow-up.7–9

Implant placement and simultaneous GBR with Geistlich Bio-Oss®
and Geistlich Bio-Gide® perform as well as implant placement into
native bone with respect to implant survival, marginal bone heightand peri-implant soft tissue parameters (cross-sectional retrospective study).4 According to studies on simultaneous implantation
and GBR with Geistlich Bio-Oss® and Geistlich Bio-Gide® results
suggest:›› High predictability for successful esthetic outcomes and goodlong-term stability of the established facial bone wall.9›› Stable peri-implant soft tissue.8

IMPLANT SURVIVAL RATE AT UP TO 13 YEARS6›› Successful osseointegration of implants and high stability ofsimultaneous augmented peri-implant bone volume.5

94.6

Implants in intact bone›› Comparable implant survival rate after at least 5 years.4 The
implant survival rate remains comparable after 12–14 years.6

GBR with Geistlich Bio-Oss® and Geistlich Bio-Gide® 91.9
0

20

40

60

80

100

Implant survival rate (%)

Rel

ia

9 1.9 b l e%Im

sur v planival tr
1 2 – a f te r ate
14 y
ear 6
s

Milestones in GBR & Geistlich Biomaterials history go hand in hand
96% Implantsurvival rate with
Geistlich Bio-Oss® andGeistlich ­Bio-Gide®13

MILESTONES OF GEISTLICH BIOMATERIALS
1st clinical results with
Geistlich Bio-Oss®

1st resorbable collagen membrane
Geistlich Bio-Gide®
on the market18

Proven long-term­success with
Geistlich Bio-Oss® andGeistlich Bio-Gide® 5–8,13

1980s early

mid-to late1980

30 years ofGeistlich Bio-Oss®
20 years ofGeistlich Bio-Gide®

Geistlich Bio-Oss®
is the most-usedbone substituteworldwide in oral
and maxillofacial
surgery19

1986 1990

GBR as standard procedure
with ePTFE and­auto­genous
bone grafts2

1996

Introduction of
GBR utilizing
resorbable barrier
membranes2

1998

2004

LESS ­DEHISCENCES
with Geistlich Bio-Gide®
in comparison withePTFE11Hürzeler et al. published about the native
collagen membrane
Geistlich Bio-Gide® 10

2007

2016

MARKET
DEMANDTODAY12for successful osseointegration of dental
implants:››Sufficient alveolar
ridge bone height››Sufficient alveolar
crest width

Drawbacks of the utilization of ePTFE membranes in combination with bone grafts or bone
substitutes: Tissue dehiscences | Local infections | Compromised GBR treatment outcome2
MILESTONES OF GBR

5

CONTOUR AUGMENTATIONWITH L-SHAPE TECHNIQUE
Prof. Ronald Jung, PhD | Switzerland

CLINICAL CHALLENGE

AIM / APPROACH

For buccal, peri-implant defects in the esthetic region, Geistlich Combi-Kit
Collagen offers the possibility of building up volume and of imitating thenatural root prominence.

Geistlich Bio-Oss® Collagen is cut into an L-shape and is adapted to thedefect using Geistlich Bio-Gide® and resorbable pins. This supports the periimplant soft tissue and mimics the natural root contour at the implant site.

DEFECT
Class 0Class IREGIONClass II

TREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss® | Geistlich Bio-Oss® Collagen

Autogenous bone chips

posteriormandible

Geistlich Bio-Gide

Resorbable pins

®

1

2

3

4

5

6

7

8

CAPTION
1. Initial situation before extraction of teeth 11 and 21. A fistula apicallyof tooth 21 is visible.
2. After implant placement a small dehiscence defect was visible at the
buccal aspect of implant site 11 and a large buccal bone dehiscence
was present at the implant in region 21.
3. In order to cover the implant surfaces, a mixture of autogenous bone chips from the surrounding area was combined with
Geistlich ­Bio-Oss® particles.
4. Preparation of the Geistlich Bio-Oss® Collagen by cutting into an
L-shape. The cutting process is easier when it is wet.
5. Occlusal view displaying how nicely Geistlich Bio-Oss® CollagenL-shape was used for contour augmentation in regions 11 and 21.
Geistlich Bio-Oss® particles are used additionally to smooth thecontour.
6. The defect is covered with a Geistlich Bio-Gide® membrane, which
is tacked and stabilized with two resorbable pins made of polylactic
acid placed at the apical part of the collagen membrane.
7. After abutment connection with subsequent soft tissue conditioning using screw retained temporary crowns an excellent emergenceprofile was achieved 4 months after implant placement.
8. A very natural appearance was achieved with two all-ceramic screw
retained crowns 11 and 21. An optimal result for the ridge contour
8 years after crown insertion.

CONCLUSION
The 10% collagen component probably supports stabilization of the blood coagulum and keeps the Geistlich Bio-Oss® particles together.

6 – TREATMENT CONCEPTS MINOR BONE AUGMENTATIONCONTOUR AUGMENTATIONWITH RIDGE PRESERVATION

CLINICAL CHALLENGE

AIM / APPROACH

This case illustrates a proposition of implant protocol adapted to the initial
tissue conditions and to the esthetic and functional requirements of previous restorations. Tooth 21 presents a root fracture causing a total loss of
buccal cortical bone, while this tooth is the anterior abutment of a bridge
replacing 22 and relying on 23. The clinical challenge to be overcome is
the reconstruction of lost tissue and the choice of temporary restoration.

The loss of buccal cortical bone requires reconstruction by GBR. A 2-step
surgical approach is performed in order to optimize the reconstruction of
the missing bone and to keep a fixed temporary restoration, firstly toothsupported and then implant-supported, used to shape the morphology
of soft tissues.

DEFECT
Class 0REGIONClass IIanterior
posteriorClass ITREATMENT

ADDITIONAL MEANS
Connective Tissue Graft (CTG)

Geistlich Bio-Oss®

maxillamandible

Geistlich Bio-Gide

®

1

2

3

4

5

6

7

8

CAPTION
1. Buccal view of the bridge 21–23: the deep buccal probing on
tooth 21 indicates the presence of a root fracture and absence of
buccal cortical bone.
2. First stage: the surgery reveals a prominent horizontal bone defectafter extraction of 21. Placement of implant at 22.
3. Buccal view of guided bone reconstruction with Geistlich Bio-Oss®
and Geistlich Bio-Gide® of site 21 and of the buccal deficit of theimplant 22.

5. Re-entry at 8 months showing the good results of reconstruction atsite 21 and integration of implant 22.
6. Implant placement at 21, use of CTG for soft tissue augmentationand impression taking of implant 22 to change the temporary restoration.
7. 18-month follow-up: Situation with the final restorations.
8. Retroalveolar x-ray taken at 18-month follow-up

4. Occlusal view of Geistlich Bio-Gide® covering the bone reconstruction of site 21–22.

CONCLUSION
The esthetic objective of anterior implant restorations is made possible by obtaining a thick bony and soft tissue environment in the long term.
Case source: “Anterior maxillary implant rehabilitation: tissue management and protocol of temporization; Réalités Cliniques – HS, June 2016,
B. Brochery, G. Finelle”

7

Clinical Cases Class 0

Dr. Benoit Brochery & Dr. Gary Finelle | France

CONTOUR AUGMENTATION IN A
DEMANDING ESTHETIC SITUATION
Dr. Raffaele Cavalcanti | Italy

CLINICAL CHALLENGE

AIM / APPROACH

Replacement of a compromised upper lateral incisor (due to external root
resorption) in a young woman with high expectations in an estheticallydemanding area.

To achieve, after tooth extraction and residual major bone defect, regeneration of a sufficient amount of bone to place, after six months healing
period, a dental implant with simultaneous bone recontouring and soft
tissue graft, in order to optimize functional and esthetic result.

DEFECT
Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

1

2

3

5

6

7a

Connective Tissue Graft (CTG)

®

4

7b

8

CAPTION
1. Three-month follow-up situation after major bone augmentation
treatment with Geistlich Bio-Oss® and Geistlich Bio-Gide®.

5. Simultaneous soft tissue augmentation using a connective­tissue graft.

2. Six-month follow-up situation showing the regenerated ridge in theintraoperative view.

6. Immediate post-operative picture after suture placement.

3. The residual small bone defect after implant placement.
4. Contour augmentation using Geistlich Bio-Oss® in order to meet thehigh esthetic demand.

7a Clinical picture after second surgical stage and tissue conditioningby mean of screw-retained provisional crown.
7b Radiographic picture after 18-month
8. Final clinical picture. Follow-up shows a very nice situation.

CONCLUSION
The 18-month follow-up shows a remarkable tissue stability which is very important in an esthetic area.

8 – TREATMENT CONCEPTS MINOR BONE AUGMENTATIONRIDGE OVER-CONTOUR FOR­I MPROVED ANTERIOR ESTHETICS

CLINICAL CHALLENGE

AIM / APPROACH

A 49-year-old male with no contributory medical conditions presented
with maxillary incisors that had undergone endodontics during his teenage
years. Tooth 11 had mobility of ½ degree, no significant probing depths, butfailed endodontics while tooth 21 presented with a 6 mm mesial pocket.
Previous surgery to correct the apical lesion on tooth 11 and the infrabony
defect on tooth 21 had failed, leaving a gingival, black triangle deformity.

Extraction and degranulation revealed fairly intact labial bony walls but
a bony fenestration on tooth 11. Geistlich Bio-Oss® pen was mixed withsterile saline, and defects around the immediately placed dental implants
were overfilled. Geistlich Bio-Gide® was trimmed to cover the grafting area
but to be slightly relieved from the implant/ healing abutment. Interrupted
sutures (ePTFE) were used to coronally advance the labial gingiva from its
preexisting height. The implants were stable, and radiographs revealed
what appeared to be new interproximal and coronal bone.

DEFECT
Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

®

1

2

3

4

5

6

7

8

CAPTION
2. Degranulated extraction sockets

5. Geistlich Bio-Gide® placed to cover the graft but also relieved from
implant / healing abutment.

3. Immediate implants in place. Resonance frequency analysis (RFA)
was 69–70 for tooth 11 and 70–75 for tooth 21.

6. ePTFE interrupted suture used to pull gingiva labially from palate.
7. Good gingival healing and contouring around healing abutments

4. Geistlich Bio-Oss® Pen used to fill defects and over-contour
the ridge.

8. Final crowns with good gingival contouring after 6-months postoperative. The GBR procedure provided a bone foundation for good
soft tissue esthetics.

1. Preoperative view of maxillary incisors

CONCLUSION
A good example of how predominantly intact coronal extensions of extraction socket, buccal bony walls (despite bony dehiscences) provide an­opportunity for immediate implant placement, grafting and good soft tissue healing, using Geistlich Biomaterials. Prosthetic planning and soft tissue
contouring, on a solid graft foundation, can provide patients with a relatively quick solution, good function and improved anterior esthetics.

9

Clinical Cases Class 0

Dr. Paul Rosen | USA

CONTOUR AUGMENTATION WITHGEISTLICH BIO-OSS® COLLAGEN

25 yfoll ears
owup

Dr. Ueli Grunder | Switzerland

CLINICAL CHALLENGE

AIM / APPROACH

The upper premolar had to be removed due to an advanced periodontal
disease and severe bone loss around the infected tooth. The bone defectwas an intra-alveolar defect without dehiscence or fenestration.

An early implant placement approach – with a healing time of six weeks
before implant placement – was chosen. The bone augmentation with
Geistlich Bio-Oss® Collagen was conducted simultaneously with implant
placement. As this patient was treated in 1991, the case is one of the very
first clinical applications of Geistlich Bio-Oss® Collagen.

DEFECT
Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss Collagenposteriormandible

Geistlich Bio-Gide®

Collagen Fleece

®

1

2

3

4

5

6

7

8

CAPTION
1. Preoperative radiograph showing the severe bone defect around thetooth.

5. After augmentation with Geistlich Bio-Oss® Collagen the site wascovered with a collagen fleece.

2. Six weeks after tooth extraction an uneventful soft-tissue healing
in the post-operative phase is visible.

6. Final crown restoration after 6 months post-operative.

3. After flap preparation an implant was placed in a site with a severebone defect.

8. The clinical picture after 25 years follow-up presents a very nice andstable bone and soft tissue situation.

7. The radiograph after 25 years shows a stable bone situation.

4. In order to fill up the defect and provide volume stability Geistlich
Bio-Oss® Collagen was applied.

CONCLUSION
A premolar grafted with Geistlich Bio-Oss® Collagen during implant placement showed good long-term result after 25 years. Satisfactory hard and soft
tissue contour are present 25 years after implantation.

10 – TREATMENT CONCEPTS MINOR BONE AUGMENTATIONCONTOUR AUGMENTATION OF
AN INTRABONY DEFECT
Dr. Su Yu Cheng | China

AIM / APPROACH
The implant was placed immediately after extraction of tooth 11. To minimizebone resorption and volume loss, the space between the implant and thealveolar bone walls was filled with Geistlich Bio-Oss® and the area wascovered with Geistlich Bio-Gide® membrane.

DEFECT
Class 0REGIONClass IIClass ITREATMENT

Clinical Cases Class I

CLINICAL CHALLENGE
The maxillary central incisor had to be extracted and was replaced with an
implant immediately after tooth extraction. The clinical challenge in thissituation is to maintain the ridge volume – which is crucial not only froma functional, but also from an esthetic point of view.

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

None

®

1

2

3

4

5

6

7

8

CAPTION
1. Preoperative situation, upper right central incisor, showing the soft
tissue situation.
2. Status following implant placement. Probing at buccal alveolar wallis shown. Note the local bone defect between the implant and buccal
wall.
3. Use of Geistlich Bio-Oss® granules in the local bone defect. Boneanatomy was improved at the same time.
4. Covering of the Geistlich Bio-Oss® granules with a Geistlich Bio-Gide®
membrane in accordance with the GBR principle.

5. Occlusal view, the augmented site is protected by the membrane,­extending its margins to the native bone. Flaps are prepared toobtain primary closure of the regenerated site.
6. Clinical situation after 6 months before restoration.
7. At 12 months: lateral view of the restoration. An optimal ridge contour is achieved.
8. Frontal view, successful esthetic outcome in the upper right central
incisor site, status at the 12-month follow-up.

CONCLUSION
By using regenerative surgery, predictable esthetic outcomes were achieved for immediate implant placement in esthetic area.

11

TREATMENT DECISIONS IN
MINOR BONE AUGMENTATION

Bony defect around implant

Defect morphology1

Minor Bone Augmentation is defined as a GBR
at a bone defect around an implant, mainly dehiscences and apical fenestrations.

CLASS 0 DEFECT
Implant can be placed in a bonyenvelope, but to increase thecontour of the ridge a contour
augmentation is necessary. Sidewith a ridge contour deficit andsufficient bone volume for standard implant placement

CLASS I DEFECT
Intra-alveolar defect ­between
the implant surface and intactbone walls (gap-grafting)

YES

WHICH
CLASS OF­D EFECT
EXISTS?

CLASS II DEFECT
Peri-implant dehiscence, inwhich the volume stability of
the area to be augmented is provided by the adjacent bone walls.

IS AN ­
IMPLANTPLACEMENTTOGETHERWITH GBR­P OSSIBLE ?

PERI-IMPLANT FAILURE

YESNOWAS THE­I MPLANT­P LACED­P REVIOUSLY?

NO

12 –– TREATMENT
TREATMENTCONCEPTS
CONCEPTSMINOR
MINORBONE
BONEAUGMENTATIONAUGMENTATION

Peri-implant bone atrophy andsoft tissue recession in the esthetic area.

Extraction Socket Management
or Major Bone Augmentation(scan the QR-code on page 3)

Register now for THE BOX
https://box.osteology.org/

Clinical example

Online content: Treatment of Class 0
Defect with Geistlich Bio-Gide®
Compressed and Geistlich Bio-Oss®
as esthetic follow-up of a previous
Major Bone Augmentation Procedure.
(Dr. Luca De Stavola, Italy)

Recommended material

CONTOUR AUGMENTATION BUCCAL BONE
­Geistlich Bio-Oss® orGeistlich Bio-Oss® Collagen­Geistlich Bio-Gide® orGeistlich Bio-Gide® Compressed+

FILL-THE-GAP INTRA ALVEOLAR­Geistlich Bio-Oss® orGeistlich Bio-Oss® Collagen­Geistlich Bio-Gide® orGeistlich Bio-Gide® Compressed+

CONTOUR AUGMENTATION DEHISCENCE DEFECT / FENESTRATION DEFECT­Geistlich Bio-Oss® orGeistlich Bio-Oss® Collagen­Geistlich Bio-Gide® orGeistlich Bio-Gide® Compressed+

CONTOUR AUGMENTATION OF PERI-IMPLANT DEFECT AFTER PRIOR DECONTAMINATION OF THE IMPLANT SURFACE­Geistlich Bio-Oss® orGeistlich Bio-Oss® Collagen­Geistlich Bio-Gide® orGeistlich Bio-Gide® Compressed+

13

IMMEDIATE IMPLANT PLACEMENT­I NVOLVING THIN BUCCAL BONE LAMELLAClinical Cases Class I

PD Dr. Dr. Markus Schlee | Germany

CLINICAL CHALLENGE

AIM / APPROACH

The torn, perforated buccal bone lamella is very thin due to the horizontal
absorption distally and the angulation of the tooth occurring as a resultof the extraction.

Preserving the extraction socket and alveolar ridge volume in immediate implant placement and simultaneous bone augmentation with
­Geistlich Bio‑Oss®.

DEFECT
Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

None

®

1

2

3

4

5

6

7

8

CAPTION
1. Tooth needs to be extracted due to insufficient crown length.

4. Postoperative state following 2 weeks of healing.

2. The buccal bone wall is very thin due to the horizontal absorption
distally and the angulation of the tooth; it is apically perforated
and torn due to the extraction. The immediate implant in region 43
is aligned to the lingual bone wall.

5. X-ray of the implants in region 43, 44 and 46, 5 months post-­
operative.

3. Discongruences of shape between the socket and buccal bonelamella were augmented with Geistlich Bio-Oss®. The gingiva­former tabilizes the graft.

6. X-ray picture 6 years postoperative.
7. Clinical situation 6 years after treatment.
8. The occlusal view shows the preservation of the buccal contour
6 years postoperative.

CONCLUSION
Augmentation with Geistlich Bio-Oss® enabled the ridge volume and the esthetics to be preserved.

14 – TREATMENT CONCEPTS MINOR BONE AUGMENTATIONCONTOUR AUGMENTATION AND
DOUBLE LAYER TECHNIQUE
Dr. Teppei Tsukiyama | Japan

CLINICAL CHALLENGE

AIM / APPROACH

34 year old female complained about swollen gingiva and a loose tooth.
After the atraumatic removal of tooth 11, the buccal bone was alreadylost due to the acute infection. A horizontal alveolar ridge reduction wasobserved. Soft tissue healing was uneventful 4 weeks after extraction;
therefore, early implant placement together with guided bone regeneration was performed. The patients risk profile according to the ITI SAC
classification is Moderate-High, which requires delicate tissue handlingand meticulous restorative planning.

After correct 3D implant placement a decortication of the bone was performed. Geistlich Bio-Oss® granules were grafted over the exposed implantsurface and covered with Geistlich Bio-Gide® double-layer technique. A
periosteal incision was performed to release the tension of the flaps andachieve adequate primary closure of the flaps. After 4-months uneventfulhealing, an incision for implant exposure was performed to uncover the
implant. The patient was satisfied with the final restorations on teeth 11
and 21. The esthetic and functional result has been followed for 18 months.

Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

Connective Tissue Graft (CTG)

®

1

2

3

4

5

6

7

8

Clinical Cases Class II

DEFECTCAPTION
1. Preoperative frontal view. Extraction of tooth 11 due to the acute­apical periodontitis and vertical root facture. After 8 weeks of­uneventfully soft tissue healing a significant horizontal volume
reduction of the alveolar ridge is present.
2. Despite the ridge deficiency, it was possible to stabilize the implantin the apical bone. Implant fixture was placed on a correct 3D position based on the future restorative margin of tooth 11.
3. Geistlich Bio-Oss® was grafted over the implant to correct the horizontal bony defect.
4. Geistlich Bio-Gide® was placed using a double-layer technique to
exclude the soft tissue invagination and allow for bone formation.

5. Horizontal mattress suture and simple interrupted sutures were performed after releasing incision allowing tension free primary closure.
6. After a punch incision to uncover the implant, a pouch technique
was utilized to create the space for connective tissue insertion. A
healing abutment was placed into the fixture.
7. Tooth 21 was prepared for a ceramic veneer in order to match thesymmetry with tooth 11. A customized Impression was placed on
implant 11. Adequate amount of peri-implant tissue can be observed.
8. A natural esthetic outcome was achieved as shown after months­following the insertion of the final restorations. The horizontal defect was corrected with the use of Geistlich Bio-Oss® andGeistlich Bio-Gide®.

CONCLUSION
Treatment planning for implant replacement in the esthetic zone, requires a comprehensive understanding of biology, basic biomaterial concepts,
restorative concepts and delicate tissue management techniques. The surgical treatment phase has to be led by the final prosthetic desired results,
proper implant positioning and hard and soft tissue management to obtain proper long-term and ideal soft tissue environment surrounding the implant
restoration.

15

CONTOUR AUGMENTIONAFTER SOFT TISSUE PUNCH
Prof. Ui-Won Jung | South Korea

CLINICAL CHALLENGE

AIM / APPROACH

Restoration of anterior area is intimately concerned with esthetic aspect aswell as functional aspects. When incisors are extracted due to periodontal
or endodontic problems, the labial wall of the sockets frequently partiallyor completely resorb. This results in loss of bone tissue volume, also negatively affecting soft tissue contour. Moreover, following extraction, often
thin mucosa can be observed in the extraction site.

The soft tissue punch technique was used immediately following maxillary
incisor extraction. After 3 months, the implant was placed with the GBR
using a Geistlich Bio-Oss® and Geistlich Bio-Gide®.

DEFECT
Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

Soft Tissue Punch

®

1

2

3

4

5

6

7

8

CAPTION
1. Inflamed labial gingiva due to root fracture of the left maxillary
central incisor.
2. Soft tissue punch technique from palatal donor site (diameter 6 mm)

5. 6 month after implantation and GBR on the left maxillary central
incisor area. The right maxillary central incisor was extracted due
to trauma. The defect was augmented with Geistlich Bio-Oss®.

3. Implant placement 3 months after healing.

6. Placing Geistlich Bio-Gide® over Geistlich Bio-Oss®

4. Placing Geistlich Bio-Oss® on labial bone defect and covering
Geistlich Bio-Gide® over bone graft material

8. 3-year follow-up (facial view)

7. 1.5-year follow-up (occlusal view)

CONCLUSION
Successful and esthetic outcome has been obtained showing augmentation of edentulous ridge volume on the maxillary incisor area.

16 – TREATMENT CONCEPTS MINOR BONE AUGMENTATIONTREATMENT OF A FENESTRATION
DEFECT WITH GBR AND CT GRAFTREGISTER NOW FOR THE BOX
HTTPS://BOX.OSTEOLOGY.ORG
Movie to thepresent caseDr. João Batista César Neto, Dr. Roberto Zangirolami*, Dr. Ricardo Takiy Sekiguchi* | Brazil
Anotherexample of­treatment

CLINICAL CHALLENGE

AIM / APPROACH

Replacement of tooth 12 with predictable procedures, comfortable to thepatient and, achieving good esthetic results.

Implant placement simultaneously to GBR was adopted due to the possibility of placing an implant in a prosthetic driven position with primarystability.

Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

Connective Tissue Graft (CTG)

®

1

2

3

4

5

6

7

8

Clinical Cases Class II

DEFECTCAPTION
1. Preoperative buccal view of the intended treatment area. The
right lateral incisor is absent and a provisional restoration is­replacing it.
2. Implant site preparation: occlusal view of the perforation showing
a favorable prosthetic position.
3. Implant in place showing a fenestration with apical implant
threads exposed.
4. Geistlich Bio-Gide® trimmed according to the anatomy of bone
defect.

5. Note that the palatal bone was thin. Then, Geistlich Bio-Oss® wasplaced both on top of buccal exposed threads and on palatal region.
Geistlich Bio-Gide® was initially placed in palatal region and prepared to cover buccal defect.
6. Geistlich Bio-Gide® positioned on buccal defect to act as a barrier
and favor bone formation on the exposed threads.
7. Nine-months after implant placement: a connective tissue graft wasused to improve soft tissue volume.
8. Final restoration 21 months after implant placement associatedwith GBR.

CONCLUSION
A careful clinical and CBCT examination may identify situations in which the simultaneous approach is favorable. Such an approach may reduce thetreatment time and number of surgical procedures.
*In collaboration with Dr. Roberto Zangirolami (Restorative Dentistry) and Dr. Ricardo Takiy Sekiguchi (Crown Lengthening Procedure)

17

SINGLE IMPLANT
PLACEMENT WITH GBR
Dr. Colin Campbell | UK

CLINICAL CHALLENGE

AIM / APPROACH

Patient presented following extensive periodontal treatment within ourpractice. Periodontist seeking to replace tooth 11 with fixed restoration.The
patient was keen to retain as many teeth as possible and although prognosis
of tooth 12 was questionable, it was agreed to provide a single implant
replacement with GBR and attempt long term maintenance of tooth 21.

Type 2 implant placement tooth 11 with autogenous bone and Geistlich
Geistlich Bio-Oss® and Geistlich Bio-Gide® GBR procedure to provide stablemucosal result around implant restoration for the long term.

DEFECT
Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

Autogenous Bone Chips

®

1

2

3

4

5

6

7

8

CAPTION
1. Image of area to be treated immediately following local anaesthetic
administration. Note pre-existing recession of tooth 12 and earlyrecession of tooth 21.
2. Retraction of flap shows considerable bone loss associated withtooth 12 and early bone loss associated with tooth 21. Vertical andhorizontal defects associated with 11 implant site also clearly visible.
3. Additional picture with surgical guide in position demonstrating­correct vertical position of implant.

5. Geistlich Bio-Oss® granules applied over autogenous bone to act as
slow substituting filler to provide stability to graft volume.
6. Double layer Geistlich Bio-Gide® application to protect graft during
healing.
7. View immediately postoperatively following application of sutures.
8. Photograph of patient at 2-year follow-up with stable gingival­­position.

4. Implant placed with cover screw in position. Autogenous bone chips
applied which were harvested locally.

CONCLUSION
Even in an extremely difficult esthetic case including horizontal and vertical bone and tissue loss with associated recession (teeth 12 and 21), this­procedure allows a predictable outcome which is acceptable for the patient and gives good long term chances of success.

18 – TREATMENT CONCEPTS MINOR BONE AUGMENTATIONTREATMENT OF FENESTRATIONAND OF PERIAPICAL BONE DEFECT
Dr. Marlene Teo | Singapore

CLINICAL CHALLENGE

AIM / APPROACH

The CT scan showed barely sufficient bone to achieve an implant stability.
The patient was suggested a bridge spanning tooth 11 to tooth 22, but did
not like the idea of having three frontal teeth linked together. Furthermore,
there was a recurring abscess at tooth 11 due to an unresolved PA lesion.
Root canal treatment on tooth 11 was done 3 years prior to the consultation
at our clinic. Tooth 11 would not have served as a proper bridge abutment
without treating the recurrent periodical abscess.

This case required a multidisciplinary approach. Our endodontist suggested an apisectomy procedure instead of retreatment for tooth 11 as thecrown was intact and the root canal fill looked dense. Hence, we decided
to raise a flap to see if we could augment the bone at tooth 21 and place
an implant on the day of the apisectomy surgery. If the implant could bestabilized at the time of surgery, the implant could be used as a tenting
screw to support bone regeneration around the implant.

Class 0REGIONClass IIClass ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

Autogenous Bone Chips

®

1

2

3

4

5

6

7

8

Clinical Cases Class II

DEFECTCAPTION
1. Tooth 21 was extracted 2 months ago. Tooth 11 has recurrent­periapical infections.

4. The buccal defects in regions 11 and 21 were filled with
Geistlich ­Bio-Oss® particles.

2. An apisectomy was done and the root tip was retro-filled with­mineral trioxide aggregate (MTA).

5. The augmentation was covered with Geistlich Bio-Gide®.

3. The buccal view showing exposure of the implant threads withgood primary stability.

6. The site was sutured with non-resorbable sutures.
7. Follow-up picture 4 months postoperative.
8. Implant crown at region 21 and a crown at tooth 22 after 20-monthfollow-up situation.

CONCLUSION
Treatment successfully cleared off the recurrent infection at tooth 11 with an apisectomy procedure. Stable implant placement at tooth 21 in a thin
buccal piece of native bone. Regeneration of bone in both regions with good clinical results using Geistlich Bio-Oss® and Geistlich Bio-Gide®.

19

TREATMENT OF A
DEHISCENCE DEFECT
Prof. Saso Ivanovski | Australia

CLINICAL CHALLENGE

AIM / APPROACH

Patient presented with a fractured maxillary right central incisor which
had been restored with a post and core following endodontic treatment.
Following the extraction of the tooth, implant placement was planned after
a healing period of 8 weeks. A large buccal dehiscence was observed after
accessing the site for implant placement.

A large dehiscence defect was seen in the buccal wall. After implant placement, most of the threads were exposed due to the dehiscence defect.
Geistlich Bio-Oss® particles were used to cover the implant threads andaugment the site to the original contour of the buccal bone. The bone graft
was then covered with a Geistlich Bio-Gide® membrane and flap closure
was carried out with 4/0 non-resorbable sutures. A healing abutment wasused and a semi-submerged protocol was employed.

DEFECT
Class 0REGIONClass II

Clinical Cases Class II

Class ITREATMENT

ADDITIONAL MEANS

anterior

maxillaGeistlich Bio-Oss

posteriormandible

Geistlich Bio-Gide®

None

®

1

2

3

4

5

6

7

8

CAPTION
1. Frontal view of the right central incisor which had to be extracted
after fracture and previous endodontal treatment. Extraction socket
was left for spontaneous healing and implant placement was planned
8 weeks after extraction.
2. Occlusal view of the healed extraction socket 8 weeks after­extraction.
3. Occlusal view of a full mucoperiosteal flap raised with a verticalreleasing incision at the distal of the adjacent lateral incisor. A large
dehiscence defect was aparent in the buccal wall.

5. Frontal view of the crest using Geistlich Bio-Oss® to cover the
implant threads and augment the site to the original contour of the
buccal bone.
6. The bone graft was then covered with a Geistlich Bio-Gide®
­membrane.
7. Frontal view of the flap closure carried out with 4/0 non-resorbablesutures. A healing abutment was used and a semi-submerged­protocol was employed.
8. Postoperative, 1-year follow-up situation after implant p­ lacement.

4. Frontal view after implant placement according to the ­manufacturer’s
instructions. After placement, most of the implant threads were
exposed due to the dehiscence defect.
CONCLUSION
Successful rehabilitation of a large buccal dehiscence defect in the anterior maxilla was carried out with simultaneous guided bone regeneration using
Geistlich Bio-Oss® and Geistlich Bio-Gide®.

20 – TREATMENT CONCEPTS MINOR BONE AUGMENTATION

Theorie

RECOMMENDED M­ ATERIAL COMBINATIONSCLASS 0 DEFECT

CLASS I DEFECT

CLASS II DEFECT

PERI-IMPLANT FAILURE

BONE REPLACEMENT MATERIALSGEISTLICH BIO-OSS®
Granules 0.25–1 mm
0.25 g ~ 0.5 cm3
GEISTLICH BIO-OSS®
Granules 0.25–1 mm
0.5g ~ 1.0 cm3
GEISTLICH BIO-OSS® PEN
Granules 0.25–1 mm
0.25 g ~ 0.5 cm3
GEISTLICH BIO-OSS® PEN
Granules 0.25–1 mm
0.5 g ~ 1.0 cm3
GEISTLICH BIO-OSS® COLLAGEN
100 mg ~ 0.2–0.3 cm3

MEMBRANESGEISTLICH BIO-GIDE®
25 × 25 mm, 30 × 40 mm
GEISTLICH BIO-GIDE® COMPRESSED*
13 × 25 mm
GEISTLICH BIO-GIDE® COMPRESSED*
20 × 30 mm

COMBI
GEISTLICH COMBI-KIT COLLAGEN
Geistlich Bio-Oss® Collagen 100 mg+ Geistlich Bio-Gide® 16 × 22 mm*Product availability may vary from country to country

References
1

Benić GI & Hämmerle C. Periodontol 2000. 2014 Oct;66(1):13–40.

11

2

Buser D. 20 Years of Guided Bone Regeneration in Implant Dentistry. 2009.

12 Geistlich Regeneration Leaders’ Meeting 2016.

3

ITI Treatment Guide Vol. 1–6.

13 Aghaloo TL & Moy PK. Int J Oral Maxillofac Implants. 2007;22 Suppl:49–70.

4

Benić GI et al., Clin Oral Implants Res. 2009 May;20(5):507–13.

14 Garber DA & Belser UC. Compend Contin Educ Dent. 1995 Aug;16(8):796, 798–802, 804.

5

Buser D et al., J Periodontol. 2011 Mar;82(3):342–9.

15 Buser D et al., Int J Oral Maxillofac Implants. 2004;19 Suppl:43–61.

6

Jung RE et al., Clin Oral Implants Res. 2013 Oct;24(10):1065–73.

16 Grunder U et al., Int J Periodontics Restorative Dent. 2005 Apr;25(2):113–9.

7

Buser D et al., J Periodontol. 2013 Nov;84(11):1517–27.

17 Cardaropoli D et al., Int J Periodontics Restorative Dent. 2015 Mar–Apr;35(2):191–8.

8

Jensen SS et al., J Periodontol. 2014 Nov;85(11):1549–56.

9Buser D et al., J Dent Res. 2013 Dec;92(12 Suppl):176S–82S.

18 Geistlich Bio-Gide® is the first resorbable collagen membrane specifically for use in
guided tissue regeneration. Data on file, Geistlich Pharma AG (Wolhusen, Switzerland).

10 Hürzeler M et al., Deutsche Zahnärztliche Zeitschrift. 1996; 51.

Zitzmann NU et al., Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998 Jan;85(1):8–17.

19 Millennium Research Group, Dental Bone Graft Substitutes and Tissue Regeneration
2005, AP/US/EU.

21

Product Range

PRODUCT RANGEGEISTLICH BIO-OSS®
Small granules (0.25–1 mm) | Quantities: 0.25 g, 0.5 g, 1.0 g, 2.0 g (1 g ~ 2.05 cm3)
Large granules (1–2 mm) | Quantities: 0.5 g, 1.0 g, 2.0 g (1 g ~ 3.13 cm3)
The small Geistlich Bio-Oss® granules are recommended for smaller 1–2
socket defects and for contouring auto­genous block grafts. The large
Geistlich Bio-Oss® granules enable improved regeneration over large
distances and provide enough space for the in-growing bone.

GEISTLICH BIO-OSS® COLLAGEN
Geistlich Bio-Oss ® (small granules) + 10 % collagen (porcine)
Sizes: 100 mg (0.2–0.3 cm3), 250 mg (0.4–0.5 cm3), 500 mg (0.9–1.1 cm3)
Geistlich Bio-Oss® Collagen is indicated for use in periodontal defects
and extraction sockets. Through the addition of collagen, Geistlich­Bio-Oss® Collagen can be tailored to the morphology of the defect andis particularly easy to apply.

GEISTLICH BIO-OSS® PEN
Small granules (0.25–1 mm) | Quantities: 0.25 g ~ 0.5 cm3, 0.5 g ~ 1.0 cm3
Large granules (1–2 mm) | Quantity: 0.5 g ~ 1.5 cm3Geistlich Bio-Oss® granules are available in an applicator. It allows thebone substitute material to be applied more precisely to the surgicalsite. Geistlich Bio-Oss® Pen is available with either the small granules
or the large granules.

GEISTLICH BIO-GIDE®
Geistlich Bio-Gide® | Sizes: 25 × 25 mm, 30 × 40 mm
Geistlich Bio-Gide® protects the grafted area and supports soft tissue
healing with its bilayer structure – a rough side that faces the bone anda smooth side that faces the soft tissue. Geistlich Bio-Gide® is easy tohandle: it can be positioned easily, adheres well to the defect, and isresistant to tension and tearing.

GEISTLICH BIO-GIDE® COMPRESSED
Geistlich Bio-Gide® Compressed* | Sizes: 13 × 25 mm, 20 × 30 mm
Geistlich Bio-Gide® Compressed is the product twin to Geistlich­Bio-Gide®. It combines the proven biofunctionality of Geistlich Bio-Gide®
with a different feel. Its bilayer structure protects the graft and supports
wound healing. Geistlich Bio-Gide® Compressed is easy to handle andcan be positioned easily.

GEISTLICH COMBI-KIT COLLAGEN
Geistlich Bio-Oss® Collagen 100 mg+ Geistlich Bio-Gide® 16 × 22 mm
When used in combination, the system has optimized properties for
Ridge Preservation and minor bone augmentations according to the
GBR principle.

22 – TREATMENT CONCEPTS MINOR BONE AUGMENTATIONFROM A TO Z:
THE WHOLE ­P RODUCTKNOWLEDGEIS IN OUR HANDS

Geistlich Expertise
Geistlich has specialized in bone mineral purification processes andcollagen purification processes involving ­natural tissues for over
160 years. Manufacturing p­ rocesses and systems have been continually optimized to result in ­cutting-edge products in their field.
Today’s product line c­ omprises bone regeneration materials suchas Geistlich Bio-Oss® and many specialized ­collagen ­products
such as a membrane with a barrier function (Geistlich Bio-Gide®),a matrix with a scaffold function for soft tissue regeneration(Geistlich Mucograft®) and products designed for easy handling(Geistlich Bio-Oss® Collagen).

23

601601/1611/EN

MANUFACTURER© Geistlich Pharma AG
Business Unit Biomaterials
Bahnhofstrasse 40
CH-6110 Wolhusen
Tel. +41 41 4 92 55 55
Fax +41 41 4 92 56 39
www.geistlich-biomaterials.com