peri-implant augmentation - geistlich biobrief...peri-implant augmentation indication sheet pir3...

Early implantation with simultaneous GBR for contour augmentation using the technique by Prof. Daniel Buser and Prof. Urs Belser, University of Berne, Switzerland

> Implantation 4 to 8 weeks following extraction > Implantation with simultaneous contour augmentation for a stable long-term

result

References

Contact> Prof. Daniel Buser, Oral Surgery and Stomatology Clinic, University of Berne, Freiburgstrasse 7, 3010 Berne, Switzerland.

Telephone: +41 (0)31 632 25 55, Fax: +41 (0)31 632 98 84, e-mail: [email protected].

Further Indication Sheets> For free copies, please go to: www.geistlich.com/indicationsheets.> If you would like to stop receiving Indication Sheets, please advise your local distributor.

RegionBone Situation

Soft Tissue SituationBone Augmentation Indicated

Implantation

n Aesthetic region n Non-aesthetic regionn No bony defect present n Crater-shaped defect in the facial bony walln Primary wound closure quite feasible n Primary wound closure difficultn Yes, immediately n Yes, on implantation n Non Yes, 4 – 8 weeks following the extraction n No

1. Indication Profile

Peri-implant AugmentationIndication Sheet PIR3

Fig. 22 The peri-apical X-ray shows the implant nor-mally integrated in the bone.

Fig. 23 Status following exposure: the mucosa has been punched and a longer titanium healing cap introduced.

Fig. 24 One week later, the soft tissues have healed well around the titanium cap. The prosthetic phase now commences and the soft tissues are condi-tioned using the temporary crown.

Fig. 19 The occlusal view clearly shows the tension-free primary closure with no evidence of ischaemia in the soft tissues. As is customary, 5-0 sutures are used in the region of the ridge.

Fig. 20 The clinical findings one week following the implantation operation show normal wound healing and the temporary partial prosthesis in situ.

Fig. 21 Clinical findings after 8 weeks. The sub-merged healing phase of the implant is complete and the implant can now be uncovered for the tem-porary restoration.

Fig. 27 X-ray findings 1 year following implantation. The dental X-ray shows the implant optimally inte-grated in the bone.

Fig. 28 Clinical findings at the 4-year follow-up. The aesthetic result is stable. Only a small difference is evident in the incisal edge, which suggests that the 29-year-old patient is still exhibiting residual growth in the alveolar process.

Fig. 29 X-ray findings at the 4-year follow-up. The peri-implant bony conditions are absolutely stable.

Fig. 25 Clinical findings after completion of the soft- tissue conditioning with the temporary crown. The peri-implant soft tissues now exhibit good aesthetic progress.

Fig. 26 Clinical findings at the 1-year follow-up after the definitive metal ceramic crown was placed. The aesthetic treatment result is excellent.

Suppliers> Implant: Straumann Standard Plus, Tissue Level SLA; Institute Straumann, Basle, Switzerland.

> Suture material: Polypropylene, monofilament, 5-0; Hu Friedy, Rotterdam, Holland.

> Medication: Antibiotic prophylaxis 2 hours before the surgical procedure. Up to 3 days post-operatively: amoxicillin, 1g, 2x daily, orally. Concurrent rinsing with chlorhexidine digluconate (0.1%) 3x daily.

> Biological materials: Geistlich Bio-Oss® 0.5 g (0.25 mm–1 mm), Geistlich Bio-Gide® 25 x 25 mm.

Fig. 30 The clinical findings at the 7-year follow-up exhibit an aesthetically attractive long-term result with intact papillae and no indication at all of soft- tissue recession. The convex soft-tissue contour in the region of the implant crown is noted. The incisal edge has not increased further.

Fig. 33 The aesthetic treatment result is excellent as seen in the clinical image with a distinct high smile line.

Fig. 31 The oro-facial DVT section shows a com-pletely intact facial wall approximately 2 mm in thickness. This is the result of a GBR contour augmentation using autogenous bone chips and Geistlich Bio-Oss®, covered by a Geistlich Bio-Gide® membrane and primary soft-tissue closure.

Fig. 32 The horizontal DVT section shows the completely intact facial bone structures in a 3-dimensionally correctly placed implant. The slightly palatal position of the implant here is important: this allows adequate space facially for the bony regeneration.

1 Araujo MG, Sukekava F, Wennstrom JL, Lindhe J (2005). Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol 32:645-52.2 Araujo MG, Sukekava F, Wennstrom JL, Lindhe J (2006). Tissue modeling following implant placement in fresh extraction sockets. Clin Oral Implants Res 17:615-24.3 Buser D, von Arx T (2000). Surgical procedures in partially edentulous patients with ITI implants. Clin Oral Implants Res 11 Suppl 1:83-100.4 Buser D, Martin W, Belser UC (2004). Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 19 Suppl:43-61.5 Buser D, Bornstein MM, Weber HP, Grutter L, Schmid B, Belser UC (2008a). Early Implant Placement With Simultaneous Guided Bone Regeneration Following Single-Tooth Extraction in the Esthetic Zone: A Cross-Sectional, Retrospective Study in 45 Subjects With a 2- to 4-Year Follow-Up. J Periodontol 79:1773-1781.6 Buser D, Chen ST, Weber HP, Belser UC (2008b). Early implant placement following single-tooth extraction in the esthetic zone: biologic rationale and surgical procedures. Int J Periodontics Restorative Dent 28:441-51.7 Buser D, Hart C, Bornstein M, Grütter L, Chappuis V, Belser UC (2009). Early implant placement with simultaneous GBR following single-tooth extraction in the esthetic zone: 12-month results of a prospective study with 20 consecutive patients. J Periodontol 80:152-162.8 Buser D, Wittneben J, Bornstein M, Grütter L, Chappuis V, Belser UC (2011). Stability of Early Contour Augmentation and Esthetic Outcomes of Implant Supported Single Crowns in the Esthetic Zone. 3-Year Results of a Prospective Study with Early Implant Placement Post Extraction. J Periodontol 82:342-349.9 Buser D, Chappuis V, Bornstein M, Wittneben J, Frei M, Belser UC (2013). Long-term Stability of Contour Augmentation with Early Implant Placement following Single Tooth Extraction in the Esthetic Zone: A prospective, cross-sectional Study in 41 Patients with a 5-9 year Follow-up. J Periodontol (e-pub).10 Chen ST, Darby IB, Adams GG, Reynolds EC (2005). A prospective clinical study of bone augmentation techniques at immediate implants. Clin Oral Implants Res 16:176-184.11 Chen ST, Buser D (2008). Implant placement in post-extraction sites: A literature update. In: Buser D, Wismeijer D, Belser U (eds). Implant placement in post-extraction

sites. Treatment options. ITI Treatment Guide, Vol. 3, Quintessence Publ.12 Dawson A, Chen S (eds) (2009) The SAC Classification in Implant Dentistry. Quintessence Publ.13 Evans CJD, Chen ST (2008). Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 19:73-80.14 Fickl S, Zuhr O, Wachtel H, Bolz W, Hürzeler M (2008). Tissue alterations after tooth extraction with and without surgical trauma: a volumetric study in the beagle dog. J Clin Periodontol 35:356-63.15 Hämmerle CH, Chen ST, Wilson TG, Jr. (2004). Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 19 Suppl1:26-28.16 Kan JYK, Rungcharassaeng K, Sclar A, Lozada JL (2007). Effects of the facial osseous defect morphology on gingival dynamics after immediate tooth replacement and guided bone regeneration: 1-year results. J Oral Maxillofac Surg 65:13-19.17 Martin WC, Morton D, Buser D (2006). Diagnostic factors for esthetic risk assessment. In: Buser D, Belser U, Wismeijer (eds). Implant Therapy in the Esthetic Zone: Single-

Tooth Replacements. ITI Treatment Guide, Vol. 1, Quintessence Publ., Pp. 11-20.18 Martin WC, Morton D, Buser D (2006). Diagnostic factors for esthetic risk assessment. In: ITI Treatment Guide Vol 1: Implant therapy in the esthetic zone - single-tooth replacements. D Buser, U Belser and D Wismeijer editors. Berlin: Quintessence Publishing Co, Ltd, pp. 11-20.19 Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld LD (1972). Alveolar crest reduction following full and partial thickness flaps. J Periodontol 43:141-4.

Prof. Daniel Buser and Prof. Urs Belser:

The objective of implant therapy is a successful treatment result from an aesthetic and functional point of view, with a high degree of predictability and low risk of aesthetic complications. The clinician has four treatment options available (Haemmerle et al. 2004, Chen and Buser 2008), including early implantation after 4 – 8 weeks of soft-tissue healing. While defining the therapy, an aesthetic risk analysis is essential to determine the patient’s individual risk profile (Martin et al. 2006). This comprises a total of 12 parameters, including 9 anatomical parameters. The present case history of a 25-year-old female patient indicates an overall moderate risk profile (see "Risk Profile" table).

In our view, immediate implantation on the day of extraction should only be selected under ideal clinical conditions, which is only very rarely the case in the anterior maxillary region. In addition, due to the complex degree of difficulty inherent in immediate implantation, only very experienced implant specialists should use this method (Dawson and Chen, 2009). In patients with high risk factors, the risk of aesthetic complications is considerably increased, whereby the recession of the facial mucosa is the most important consideration. Consequently, frequent occurrence of soft-tissue recession associated with immediate implant placement has been documented in a number of clinical studies (Chen et al. 2005; Lindeboom et al. 2006; Kan et al. 2007; Evans and Chen 2008).

Early implantation 4 – 8 weeks following extraction is a good alternative to immediate implantation because it shortens the treatment time and, at the same time, substantially reduces the risk of an undesirable aesthetic complication (Buser et al. 2008a; Buser et al. 2009 , Buser et al. 2011). Our understanding of the changes in the alveolar ridge following an extraction has improved considerably over the previous 5 years. Various animal studies have shown that after the extraction, the bundle bone, which coats the alveolus, is resorbed within 4 – 8 weeks as the blood supply from the periodontal membrane to the bundle bone is disrupted by the extraction (Araujo et al. 2005). This bone resorption is a biological phenomenon and cannot be prevented by the immediate placement of an implant (Araujo et al. 2006). The thin facial bony ridge in the anterior mandible consists mostly of bundle bone, for which reason generally a crater-shaped bony defect develops in the centre of the alveolus due to the bone resorption following an extraction. For a good aesthetic result, local bone augmentation in the sense of a bone contour augmentation is essential. The facial bony wall is deliberately over-augmented with the aid of the GBR technique to create good pre-conditions for a stable, aesthetic, long-term result.

From a surgical point of view, extraction preserving the tissues and without creating a flap is important in order to prevent the additional bony resorption at the surface of the alveolar ridge which would be caused by the removal of the periosteum (Wood et al. 1972; Fickl et al. 2008). After curettage of the alveolus, a collagen cone is generally applied, in order to stabilise the blood coagulum. Depending on the size of the alveolus, a healing phase of 4 – 8 weeks is required. Thereby, an intact covering of soft tissue is obtained, together with 3 – 6 mm of additional keratinised mucosa. Both of these are greatly advantageous for the subsequent implantation, in order to achieve a tension-free primary wound closure without massive coronal displacement of the mucogingival boundary. Routine mucosa transplantation to seal the alveolar access after the extraction is deliberately dispensed with, as this would create additional costs and increased morbidity at the donor site. In the healing phase following the extraction, the papillae and the facial contour of the alveolar ridge in the centre of the alveolus are flattened, which is caused, as has already been shown, by the resorption of the bundle bone.

Basic surgical principles, as have been established for some time for aesthetic implant sites, should be adhered to during the implant placement operation. (Buser and von Arx 2000; Buser et al. 2004). The most important factor is a prosthetic-orientated implantation, for which reason the implant must be inserted in the correct three-dimensional position. At the same time, the implant should be placed with its implant shoulder, in the mesio-distal, corono-apical and oro-facial orientation, in the so-called comfort zones. Early implantation following extraction, as a rule, results in a small to moderate bony defect, which is generally 2-walled and must be augmented simultaneously at the time of implantation in order to be able to achieve a long-term stable aesthetic result. The objective is a contour augmentation with the build-up of a facial bony wall around 3 mm thick to support the facial soft tissues. The long-term stability of the contour augmentation has been documented in a current clinical study (Buser et al. 2013).

Background Information

2. Treatment ObjectivesPrimary objective following the extraction: > Soft-tissue healing over 4 – 8 weeks, in order to achieve an intact soft-tissue coveringSecondary objectives during and after the implantation: > Implantation in the correct 3-dimensional position> Local contour augmentation in the facial region with autogenous bone chips, Geistlich Bio-Oss®

granules and Geistlich Bio-Gide®

> Primary wound closure with 6 – 8 week healing phase> Aesthetic restoration with screw-retained implant crown

Fig. 10 The crater-shaped bony defect in the centre of the former alveolus 11 can be easily seen after folding the mucoperiostial flap outwards.

Fig. 11 The intra-operative occlusal view clearly shows the excellent ridge breadth (> 6 mm) in the region of the single-tooth gap.

Fig. 12 Following the insertion of the screw-retained implant in a correct 3-dimensional position and the application of a 1.5 mm healing cap, the exposed implant surface can be easily seen in the region of the crater-shaped defect. This is clearly within the alveolar ridge.

Fig. 7 During the healing phase, as is usual, there is a slight shortening of the papillae as well as a flatten-ing in the centre of the alveolus on the facial side of the alveolar ridge, which is caused by the resorption of the bundle bone.

Fig. 8 The occlusal view shows that, within 4 – 8 weeks of soft tissue healing, no visible reduction can be seen in the breadth of the ridge in the approximal region of the tooth gap.

Fig. 9 The dental X-ray shows the residual defect in the region of the former alveolus.

Fig. 13 The occlusal view shows the correct oro-facial position of the implant and the 2-walled bony defect of the exposed implant surface. Reliable bone regeneration using the GBR technique is of benefit for this defect morphology.

Fig. 15 The bone volume is further optimised by local augmentation using Geistlich Bio-Oss® granules. The low substitution rate of Geistlich Bio-Oss® helps to maintain the volume of the alveolar ridge over time, a factor of great importance to the maintenance of the long-term aesthetic outcome.

Fig. 14 The exposed implant surface is covered with locally harvested chips of autogenous bone in order to promote bone re-formation in the region of the defect as quickly as possible. The use of autogenous bone chips facilitates a brief healing phase of around 8 weeks after implantation with simultaneous contour augmentation.

3. Surgical MethodThe surgical method for the early implantation has been described in detail, together with the biological considerations as to why this therapeutic concept can be recommended for day-to-day use in clinical practice (Buser et al. 2008b).

Fig. 1 Clinical findings in the initial examination of the 25-year-old female patient. The patient exhib-its a high smile line and reports an accident several years ago, which affected tooth 11.

Fig. 2 Tooth 11 exhibits a chronic infection with a fistula in the peri-apical region.

Fig. 3 The dental X-ray shows the rooted tooth 11. It was decided to extract the damaged tooth and to re-place it with an implant.

The 25-year-old Patient's Risk Profile

Aesthetic Risk Assessment Low Moderate High

Medical status Healthy Reduced immune system

Smoking habits Non-smokerLight smoker

(≤ 10 cigarettes per day)Heavy smoker

(> 10 cigarettes per day)

Patient's aesthetic expectations Low Moderate High

Smile line Low Medium High

Gingival biotype Thick biotype, low-scalloped Medium scalloped, medium thick Thin biotype, high scalloped

Tooth crown shape Rectangular Triangular

Alveolar infection status Infection-free Chronic infection Acute infection

Bone level of the adjacent teeth ≤ 5 mm to contact point 5.5 to 6.5 mm to contact point ≥ 7 mm to contact point

Restoration status of the adjacent teeth

Natural Restored

Gap breadth Single tooth gap (> 7 mm) Single tooth gap (< 7 mm) Multiple tooth gap

Soft tissue anatomy Intact soft tissue Soft tissue defect

Bone anatomyAlveolar ridge with no

bony defectHorizontal bony defect Vertical bony defect

Fig. 4 The dental extraction is performed without creating a flap. The alveolus is curetted thoroughly in order to remove the inflamed tissues.

Fig. 5 The extracted tooth shows signs of external root resorption with a large amount of granulation tissue.

Fig. 6 A temporary partial prosthesis is provided im-mediately after the extraction in order to close the gap aesthetically.

Fig. 17 A collagen membrane, used as a barrier, is applied in two layers in order to improve the stabili-ty. Geistlich Bio-Gide® not only acts as a temporary barrier, but also as a place-holder and stabiliser for the augmentation material applied.

Fig. 18 An important component of this concept is the tension-free primary wound closure. For this, it is necessary to make a relieving incision in the periosteum in order to be able to move the flap slightly coronally. The primary closure protects the biological materials applied from the bacteria in the oral cavity.

Fig. 16 The occlusal view shows the contour aug-mentation using Geistlich Bio-Oss®. The underlying bone chips are intended to promote the re-growth of the new bone into the Geistlich Bio-Oss® layer, which is important due to the low substitution rate of the biological material.

Natural Restored

result

References

Implantation

result

References

Implantation

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