Therapy Concepts for Oral & Maxillofacial Surgery

1 LEADING REGENERATION

Geistlich a Company with Tradition

The history of the company Geistlich began in 1851 with the manufacturing of glues from bones. Later, bones and other animal tissues were processed to yield flower fertiliser and high-quality gelatine for foodstuffs. In the following years, the company expanded into the field of pharmaceuticals and established a second plant in Wolhusen near Lucerne. In 1983, a new business idea was stimulated by a report from Professor Philip Boyne on the successful reconstruction of crushed jaws with cattle bone. This led to the birth of Geistlich Bio-Oss: a highly purified anorganic bone material with a high similarity to human bone for effective bone regeneration. Thereafter, a manufacturing process to free the bone of organic constituents, while maintaining its natural microstructure and anorganic composition, was developed and patented. Already during the initial discovery and development phases there was close cooperation with various experts and leading clinics. This laid the foundation for todays sound scientific evidence base which presently consists of more than 600 publications. In 1996, another fundamental innovation from Geistlich changed the market of bone and tissue regeneration substantially through the introduction of Geistlich Bio-Gide: the first natural and fully resorbable collagen membrane now replacing the non-resorbable e-PTFE membrane in a majority of indications. The natural composition of this membrane, which is very similar to human collagen, proved to be a key parameter for its positive effect on bone and soft tissue healing processes. Nowadays, Geistlich Bio-Oss and Geistlich Bio-Gide have become a benchmark in dental bone regeneration, confirmed by more than 20 years of clinical experience and an ever increasing number of scientific publications. In addition, the range of applications are continuously being expanded within the dental, maxillofacial, and orthopaedic fields. With the brochure at hand we would like to offer you an overview on current treatment methods for complex cases of bone regeneration in the oral and maxillofacial areas.

Your Geistlich Biomaterials Team

Acknowledgments: Geistlich Biomaterials wishes to thank Dr. Z. Krol, Prof. Dr. Dr. R. Sader and Prof. Dr. Dr. H.F. Zeilhofer (Hightech Research Center of Cranio-Maxillofacial Surgery, University Hospital Basel) for kindly delivering the oblique view of the craniofacial CT, visualized by volume rendering method, which appears on the cover and in the outlook. We acknowledge all the authors of the Clinical Cases for their valuable contribution and efforts. Geistlich Biomaterials thanks Blackwell Publishing (Wiley InterScience), RC Libri, Quintessence Publishing, and Quintessenz Verlag for the copyright permissions.

Index
Scientific Background
06 06 07 08 Bone and Bone Substitutes Clinical Facts Quality of Life High Therapy Safety with a Membrane

Clinical Cases
10 12 12 13 14 15 16 17 18 19 19 20 21 22 23 24 25 26 27 28 29 30 30 31 32 33 34 35 Cawood Classification Cawood Class IV Dr. J.J. Aranda Dr. K.H. Bormann, Prof. Dr. Dr. N.C. Gellrich Prof. Dr. D. Buser, PD Dr. T. von Arx Prof. Dr. C. Hmmerle Dr. G. Iglhaut Prof. Dr. C. Maiorana Prof. Dr. I. Urban Cawood Class V Prof. Dr. M. Chiapasco Dr. P. Felice MD/DDS, Prof. L. Checchi MD/DDS, Prof. M. Marchetti MD/DDS Dr. U. Grunder Dr. M. Merli Prof. Dr. A.R. Paranque PD Dr. Dr. K.A. Schlegel Prof. Dr. Dr. R. Schmelzeisen, Prof. Dr. Dr. R. Gutwald, Dr. Dr. A. Stricker, Dr. M. Vogeler, Dr. S. Sauerbier Prof. Dr. M. Simion, Dr. I. Rocchietta Dr. M. Steigmann Dr. S. Stbinger, Prof. Dr. Dr. R. Sader Dr. T. Testori Cawood Class VI Dr. Dr. C. Glatzer, Dr. O. Schwerdtner Prof. Dr. Dr. T. Iizuka PD Dr. Dr. C. Jaquiry, Dr. N. Gabutti, Prof. Dr. Dr. H.F. Zeilhofer Univ.-Prof. Dr. C. Krenkel, Dr. Dr. S. Enzinger Prof. Dr. Dr. H. Terheyden Dr. A. Triaca, Dr. Dr. R. Minoretti, Dr. D. Kraus

Product Range
36 Geistlich Bio-Gide / Geistlich Bio-Oss

Outlook

Scientific Background
Bone and Bone Substitutes
Bone is made up of several types of tissues. The primary part being the mineralized tissue that is composed mostly of calcium hydroxylapatite and collagen I which gives it rigidity and a three-dimensional trabecular structure. Other types of tissue found in bones include marrow, endosteum and periosteum, nerves, blood vessels and cartilage. Additionally, bone tissue consists of living cells and various proteins embedded in the mineralised matrix that makes up the osseous tissue.1 Bone grafting procedures are often needed to replace missing bone at one site with material from another site. The bone material may stem from the patients own body (autograft), from human cadavers (allograft), from animal origin (xenograft), or from synthetic material. Allografts and xenografts are principally unprocessed bone substitute mostly obtained from bone banks. Geistlich Bio-Oss, different from all the above mentioned materials, is a highly purified xenogeneic bone substitute completely void of organic tissue and solely made up of the mineral component of bovine bone.

Clinical Facts
Volume Preservation: Presently, autogenous bone is irreplaceable in the treatment of large bony defects and is regarded as the gold standard for bone augmentations. However, it has been scientifically proven that autogenous bone grafts show a stronger resorption than a mixture of a slow resorbable bone substitute with autogenous bone. Schlegel and co-workers2 claim that the augmented bone volume is preserved in the sinus cavity filled with a mixture of Geistlich Bio-Oss, while the height of a purely autogenous bone graft diminishes markedly. Comparison of horizontal augmentation techniques shows lower resorption rates, if the autogenous block graft is covered with Geistlich Bio-Oss and Geistlich Bio-Gide (Fig. 1).36 Alternatively, using only these biomaterials for horizontal augmentations is an effective treatment and avoids completely the harvest of autogenous bone.7

Resorption (%)

Fig. 1: Resorption rate of the autogenous block graft in different augmentation techniques.
autog. block + autog. chips peripherically 3 autog. block + Geistlich Bio-Oss peripherically 4 autog. block + autog. chips peripherically + Geistlich Bio-Gide 5 autog. block + Geistlich Bio-Oss cover 3 autog. block + Geistlich Bio-Oss cover + Geistlich Bio-Gide 6

Garg AK. Knochen / Biologie, Gewinnung, Transplantation in der zahnrztlichen Implantologie. Berlin: Quintessenz 2006. Schlegel KA et al. Histologic findings in sinus augmentation with autogenous bone chips versus a bovine bone substitute. Int J Oral Maxillofac Implants 2003 Jan-Feb;18(1):53-8. 3 Maiorana C et al. Reduction of autogenous bone graft resorption by means of bio-oss coverage: a prospective study. Int J Periodontics Restorative Dent 2005;25(1):19-25. 4 Proussaefs P et al. The use of ramus autogenous block grafts for vertical alveolar ridge augmentation and implant placement: a pilot study. Int J Oral Maxillofac Implants 2002 Mar-Apr;17(2):238-48. 5 Proussaefs P. Clinical and histologic evaluation of the use of mandibular tori as donor site for mandibular block autografts: report of three cases. Int J Periodontics Restorative Dent 2006 Feb;26(1):43-51. 6 von Arx T & Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Implants Res 2006;17(4):359-66. 7 Hmmerle CHF et al. Ridge augmentation by applying bioresorbable membranes and deproteinized bovine bone mineral: a report of twelve consecutive cases. Clin Oral Implants Res 2008;19(1):19-25.
1 2

Implant survival rates: In the past years, several clinical studies and meta-analysis have evaluated the implant survival rate depending on the furnishing bony support in sinus lift procedures. The survival rate increases after augmentation with bone substitutes alone or in a mixture with autogenous particulate grafts, as compared to sites augmented with autogenous bone only (Fig. 2a,b).810 Generally it has been shown that the implant survival in augmented bone is similar to the survival rate in sites where an augmentation was not needed.8
100 95

Implant survival rate (%)

90 85 80 75 70 65
0

Fig. 2a: Implant survival rates in external sinus floor elevation differ with augmentation materials (5128 implants, follow-up 12102 months).9
81.0 synthetic (n=190) 88.0 iliac crest (n=1845) 92.0 autogenous (n=2904) 93.3 allogeneic (n=189) 95.6 xenogeneic* (n=443)

* Note: the 22 referenced studies with xenogeneic materials

were conducted with Geistlich Bio-Oss.

Implant survival rate (%)

. . .

autogenous bone

autogenous bone + bone substitute

bone substitute

Fig. 2b: The implant survival rate is significantly higher in augmentations with biomaterials compared to those with autogenous bone only.10

Therapeutic Flexibility: Autogenous bone resorption narrows the therapeutic time window for implant placement. The slow-resorbing matrix structure of Geistlich Bio-Oss increases the stability of the graft and prevents premature resorption of the newly formed bone.36 The augmented volume is preserved over a prolonged period and so extends the therapeutic window.

Quality of Life
Numerous clinical studies report from 18% up to 50% of patients with diminished sensitivity after bone harvesting from the chin.1113 Joshi et al.14 state 20% and 25% of donor site morbidity after bone harvesting from the ramus and the iliac crest, respectively. The addition of a bone substitute may render the access of a second surgical site unnecessary, which, in turn, increases the quality of life.

Wallace SS & Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003;8(1):328-43. 9 Aghaloo TL & Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants 2007;22Suppl:49-70. 10 Del Fabbro M et al. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodontics Restorative Dent 2004 Dec;24(6):565-77. 11 von Arx T et al. Neurosensory disturbances following bone harvesting in the symphysis: a prospective clinical study. Clin Oral Implants Res 2005;16(4):432-9. 12 Raghoebar GM et al. Morbidity of chin bone harvesting. Clin Oral Implants Res 2001 Oct;12(5):503-7. 13 Misch CE. Implant dentistry. Dent Today 2002 Nov;21(11):62. 14 Joshi A & Kostakis GC. An investigation of post-operative morbidity following iliac crest graft harvesting. Br Dent J 2004 Feb 14;196(3):167-71; discussion 155.
8

High Therapy Safety with a Membrane

The use of a membrane for the regeneration of bone and soft tissue is the essential component of the Guided Bone Regeneration (GBR) and Guided Tissue Regeneration (GTR) concept. The membrane performs several important functions and forms a basis for predictable clinical results. An optimal barrier function, stabilisation of the augmentate, and supportive properties for excellent wound healing are all crucial prerequisites for high therapy safety and an optimal outcome in the aesthetic zones. More bone: Recent animal experiments and clinical studies have analysed the new bone formation with and without the use of a membrane. Gielkens et al.15 conclude that bone formation is significantly higher in the presence of Geistlich Bio-Gide, than in its absence, a finding also reflected in the clinical trial results of Wallace and co-authors16. Higher bone density: Kim et al.17 show in the dog model that the combination of Geistlich Bio-Oss and Geistlich Bio-Gide leads to significantly higher bone density in GBR procedures than Geistlich Bio-Oss alone (compare Figure 3).

Bone density ()

. . .

Control Geistlich Bio-Oss Geistlich Bio-Oss and Geistlich Bio-Gide weeks weeks

Fig. 3: Bone density measured by dental CT postoperatively (100% is intact adjacent alveolar bone). The extraction socket sites were treated with (i) Geistlich Bio-Oss, (ii) Geistlich Bio-Oss and Geistlich Bio-Gide, or (iii) neither Geistlich Bio-Oss nor Geistlich Bio-Gide (control).17

Less Resorption: In horizontal augmentations, scientific evidence demonstrates that the autogenous block undergoes less resorption, when combining Geistlich Bio-Oss with Geistlich Bio-Gide compared to the same treatment without Geistlich Bio-Gide (von Arx 20066, Maiorana 20053). Enhanced Wound Healing: Vascularization is critically important in the early phases of successful wound healing. Therefore, the requirements proposed for an adequate barrier in GBR/GTR are, among others, tissue integration, nutrient transfer and biocompatibility.18,19 Clinical studies comparing different membranes conclude that the resorbable collagen membrane Geistlich Bio-Gide shows a lower incidence of wound dehiscencies.20,21 In case of a dehiscence the wound heals uneventfully.

Gielkens PF et al. Vivosorb, Bio-Gide, and Gore-Tex as barrier membranes in rat mandibular defects: an evaluation by microradiography and micro-CT. Clin Oral Implants Res 2008;19(5):516-21. 16 Wallace SS et al. Sinus augmentation utilizing anorganic bovine bone (Bio-Oss) with absorbable and nonabsorbable membranes placed over the lateral window: histomorphometric and clinical analyses. Int J Periodontics Restorative Dent 2005;25(6):551-9. 17 Kim M et al. Effect of bone mineral with or without collagen membrane in ridge dehiscence defects following premolar extraction. In Vivo 2008 Mar-Apr;22(2):231-6. 18 Lakey LA et al. Angiogenesis: Implications for tissue repair. In: Davies JE, ed. Bone Engineering. Toronto: Em Squared Incorporated 2000;137-142. 19 Hardwick R et al. Membrane design criteria for guided bone regeneration of the alveolar ridge. In: Buser D, et al. Guided bone regeneration in implant dentistry. Hong Kong: Quintessence 1994;101-136. 20 Tal H et al. Long-term bio-degradation of cross-linked and non-cross-linked collagen barriers in human guided bone regeneration. Clin Oral Implants Res 2008;19(3):295-302. 21 Zitzmann NU et al. Resorbable versus nonresorbable membranes in combination with Bio-Oss for guided bone regeneration. Int J Oral Maxillofac Implants 1997;12(6):844-52.
15

As seen from the below immunohistochemical evaluations in a rat model, Geistlich Bio-Gide shows a homogeneous angiogenesis pattern and transmembraneous vascularisation after two weeks (Fig. 4).22 Other collagen membranes tested do not vascularise until 4 to 8 weeks, some not even after 24 weeks.22,23
a b c

AT

EL

ML

IL

AT

EL

ML

IL

AT

EL

ML

IL

Fig. 4: Immunohistochemical stainings 2 weeks after implant. Complete transmembraneous vascularization with Geistlich BioGide(a). Angiogenesis merely reached the external layer of the respective membrane bodies of (b) Bio-Mend Extend and (c) TutoDent (original magnification 20x)22. AT: adjacent tissue; EL: external layer; ML: middle layer; IL: internal layer. Arrows indicate the formation of blood vessels in the respective layers.

Reliable Barrier Function and Biocompatibility: Alteration of natural collagen structures by cross-linking reduces the enzymatic degradation rate at the cost of decreased biocompatibility, as seen in Figure 5 (adapted from Rothamel 200524). The literature does not report a difference in bone formation in relation to the duration of the barrier function25. Due to the natural bilayer structure and its similarity to human collagen, Geistlich Bio-Gide leads to optimal bone formation as well as excellent wound healing. Native collagen is resorbed enzymatically through an irritation-free process and consequently shows significant less dehiscences than cross-linked collagen.20

Duration of Biodegradation

Biocompatibility, tissue integration, vascularization

Geistlich Bio-Gide

Cross-linked membranes
Fig. 5: Geistlich Bio-Gide offers the optimal barrier function while providing the highest level of biocompatibility (based on Rothamel 200524).

Non-resorbable membranes

Predictable Outcome: The use of a membrane to cover the lateral window in sinus lift has been correlated with a higher implant survival rate in a systematic review and meta-analysis.8 Thus, a more predictable outcome can be expected due to consistently better bone formation obtained using a membrane.

Schwarz F et al. Angiogenesis pattern of native and cross-linked collagen membranes: an immunohistochemical study in the rat. Clin Oral Implants Res 2006;17(4):403-9. 23 Schwarz F et al. Immunohistochemical characterization of guided bone regeneration at a dehiscence-type defect using different barrier membranes: an experimental study in dogs. Clin Oral Implants Res 2008 Apr;19(4):402-15. 24 Rothamel D et al. Biodegradation of differently cross-linked collagen membranes: an experimental study in the rat. Clin Oral Implants Res 2005 Jun;16(3):369-78. 25 Becker J. Interview: Is a long barrier function necessary?. Geistlich News 2007;2:28-29.
22

Clinical Cases
Cawood Classification
In 1988, Cawood and Howell26 established a classification of edentulous jaws that has been generally accepted over the years. Such a classification serves to simplify description of the residual ridge and thereby aid selection of the appropriate surgical and prosthodontic technique. Arising from their morphological studies of edentulous jaws, Cawood and Howell concluded that (i) basal bone does not change shape significantly (unless subjected to harmful local effects) and (ii) alveolar bone changes shape significantly following a predictable pattern. The most commonly observed changes in shape of the alveolar process are summarised for the mandible (Fig. 6 a,b) and for the maxilla (Figure 7a,b).

Anterior Mandible

Fig. 6a: Classification of anterior mandible. Basal bone and alveolar bone in blue and white, respectively.

Posterior Mandible

Fig. 6b: Classification of posterior mandible. Basal bone and alveolar bone in blue and white, respectively.

26

Cawood JI & Howell RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg 1988 Aug;17(4):232-6.

10

Anterior Maxilla

Fig. 7a: Classification of anterior maxilla. Basal bone and alveolar bone in blue and white, respectively.

Posterior Maxilla

Fig. 7b: Classification of posterior maxilla. Alveolar bone in blue.

Descriptive classifications of the alveolar bone changes derived from the composite diagrams: Class I dentate Class II immediately post-extraction Class III well-rounded ridge form, adequate in height and width Class IV knife-edge ridge form, adequate in height and inadequate in width Class V flat ridge form, inadequate in height and width Class VI depressed ridge form, with some basalar loss evident Although this classification was originally based on the observations of edentulous jaws, it can also be used to describe defects in partially edentulous jaws, taking into account that the transitions between classes are gradual. The clinical cases presented subsequently show different therapy concepts in partially or fully edentulous jaws for oral and maxillofacial defects belonging to Cawood Class IV, V, or VI.

11

Cawood Class IV

GBR with Block Grafting

(Dr. Juan Jos Aranda; Madrid)

Aim
> Horizontal ridge augmentation: a GBR procedure is performed with an autogenous bone block graft harvested from the chin area utilizing Geistlich Bio-Oss and Geistlich Bio-Gide. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone block (chin) > Geistlich Bio-Oss > Geistlich Bio-Gide (fixed with tacks)

Therapy Concept

1 CT-scan images of the recipient area.

2 Intrasurgical view of the recipient area. Note the severe horizontal ridge resorption.

3 Intrasurgical view of the donor site filled with Geistlich Bio-Oss. A single flap was elevated including receptor and donor areas.

4 Autogenous bone graft placed and fixed in its correct position at the recipient area.

5 Geistlich Bio-Oss covers the block in order to achieve a soft contour of the grafted area. This avoids potential complications during the healing process and the collapse of the membrane.

6 Two layers of Geistlich BioGide, fixed with tacks, cover the recipient area. This provides protection against a potential soft tissue fenestration and also from an eventual resorption of the grafts.

7 Re-entry surgery after 6 months, demonstrating optimal bone regeneration.

8 Panoramic X-ray after implant placement.

Conclusion
Within the available treatment modalities for the regeneration of posterior mandibular areas, autogenous bone block grafts from the mandibular symphysis remain as one of most popular procedures performed by the dental community as this surgical technique offers an easy access and enough graft material for adequate augmentation. The biomaterials, Geistlich Bio-Oss and Geistlich Bio-Gide may help the surgeon to obtain optimal regeneration results, avoiding potential soft and hard tissue complications during the healing process in both donor and receptor areas.

12

Cawood Class IV

Combining Cortical and Particulate Bone

(Dr. Kai-Hendrik Bormann, Prof. Dr. Dr. Nils-Claudius Gellrich; Hannover)

Aim
> Horizontal ridge augmentation: to achieve an excellent aesthetical outcome with an alveolar zygomatic buttress bone transplant in combination with autogenous bone chips covered with Geistlich Bio-Gide. Jaw Upper Jaw Lower Jaw Material Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

> Autogenous bone transplant and chips (alveolar zygomatic buttress) > Geistlich Bio-Gide

Therapy Concept

1 Bony defect in the anterior region.

2 A cortical bone transplant is gained from the alveolar zygomatic buttress region.

3 The bone graft is harvested without harming the Schneiderian membrane.

4 The thin cortical bone graft in place with transosseous screw fixation.

5 After filling the gap under the alveolar zygomatic buttess with autogenous bone chips, Geistlich Bio-Gide is placed over the augmented defect.

6 Soft tissue situation after 4 weeks.

7 Situation at re-opening before implant insertion, 12 weeks after augmentation.

8 Fixation screws are removed and the dental implant is inserted.

Conclusion
The combination of autogenous bone grafts harvested from the alveolar zygomatic buttress with autogenous bone chips is suited for reconstruction of bony alveolar crest defects in the anterior maxillary region. Bone harvesting was performed with the piezoelectric device (Mectron Medical Technology), which avoids trauma to the mucosal membrane of the maxillary sinus. Besides a minimal morbidity, the zygomatic buttress donor site supplies good quality bone with a natural convex shape ideally suited for the anterior alveolar process region. The combination of cortical bone (external layer) covering the autogenous bone chips (internal filling) provides an excellent basis for successful osseointegration of dental implants. This avoids the need for later secondary corrective soft tissue augmentation with fibrous tissue grafts to reconstitute the vestibular projection. Geistlich Bio-Gide protects the bone graft, favours wound healing, and adds additional safety to a predictable outcome.

13

Cawood Class IV

GBR with Block Grafting

(Prof. Dr. Daniel Buser, PD Dr. Thomas von Arx; Bern)*

Aim
> Horizontal ridge augmentation: using Geistlich Bio-Oss and Geistlich Bio-Gide to cover the autogenous bone block for minimizing resorption of the bone graft. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone block (retromolar area posterior to the augmentation) > Geistlich Bio-Oss > Geistlich Bio-Gide (double-layer technique)

Therapy Concept

1 Thin ridge situation in the posterior mandible.

2 The bone cortex is perforated with a small round bur to induce bleeding from the marrow cavity.

3 Bone graft from the retromolar area fixed with a titanium screw.

4 Coverage with Geistlich BioOss.

5 The collagen membrane, Geistlich Bio-Gide , is applied using the double-layer technique.

6 Primary wound closure is accomplished with single interrupted sutures.

7 Optimal bony support for implant placement after approx. 6 months.

8 Stable peri-implant bone level 18 months postoperatively.

Conclusion
The technique is appropriate for patients with severe horizontal bone atrophy and provides a successful ridge augmentation with high predictability. Covering the autogenous block graft with Geistlich Bio-Oss and Geistlich Bio-Gide significantly reduces autogenous bone block resorption. The resorbable membrane, Geistlich Bio-Gide, shows an easy handling and simplifies the surgical method. The stability of the membrane can be further improved using the double-layer technique.

von Arx T & Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Implants Res 2006;17(4):359-66.

14

Cawood Class IV

GBR with Biomaterials

(Prof. Dr. Christoph Hmmerle; Zurich)*

Aim
> Horizontal ridge augmentation: GBR using biomaterials as sole substitute for alveolar bone augmentation to avoid autogenous bone graft harvesting. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Geistlich Bio-Oss Spongiosa Block > Geistlich Bio-Oss > Geistlich Bio-Gide

Therapy Concept

1 Buccal view of the defect sites.

2 Augmentation with Geistlich Bio-Oss granules and Geistlich Bio-Oss Spongiosa Blocks.

3 The resorbable Geistlich BioGide membrane covering the right side of the augmented area.

4 The entire area covered with Geistlich Bio-Gide.

5 Suitable bone support for implant insertion 9-10 months postoperatively.

6 After placement of the implants, no remaining bone defects were present.

7 Occlusal view of the defect closure.

8 Final outcome after insertion of the fixed partial denture.

Conclusion
This method appears suitable for successful horizontal ridge augmentation, prior to implant placement, in the indications of single tooth gaps, multiple tooth gaps, and edentulous distal extension situations. The combination of Geistlich Bio-Oss and Geistlich Bio-Gide appears to be an effective treatment option for horizontal ridge augmentation and avoids harvesting of autogenous bone. The barrier function of the resorbable collagen membrane (Geistlich Bio-Gide) seems to be adequate for the desired bone regeneration in these indications.

Hmmerle CHF, Jung RE, Yaman D, Lang NP. Ridge augmentation by applying bioresorbable membranes and deproteinized bovine bone mineral: a report of twelve consecutive cases. Clin Oral Implants Res 2008;19(1):9-25.

15

Cawood Class IV

Crest Splitting
(Dr. Gerhard Iglhaut; Memmingen)

Aim
> Horizontal ridge augmentation: the crest splitting procedure in combination with Geistlich Bio-Oss and Geistlich Bio-Gide is used to increase ridge width. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone chips (retromolar) > Geistlich Bio-Oss > Geistlich Bio-Gide

Therapy Concept

1 Occlusal view of the ridge after flap elevation.

2 Longitudinal split of the alveolar crest.

3 Two implants are placed in the expanded crest.

4 The split around the implants is filled with a mixture of autogenous bone chips and Geistlich Bio-Oss.

5 The augmented ridge is covered with a Geistlich Bio-Gide membrane before closure of the soft tissue.

6 Lingual view of the final situation.

7 Occlusal view of the prosthetic outcome.

8 X-ray findings 6 months after implant placement.

Conclusion
The crest splitting technique allows the placement of implants in anatomic situations with insufficient ridge thickness, by moving the external cortical plate of the maxilla in a labial direction. This technique allows immediate implant placement, despite a large ridge augmentation. The gap resulting from the crest splitting is filled with autogenous particulate bone and Geistlich Bio-Oss (ratio 1:1), which allows a predictable bone volume preservation. Due to the good adhesion of Geistlich Bio-Gide to the defect, the particulate bone graft is kept in situ during the regeneration process.

16

Cawood Class IV

Block Contouring
(Prof. Dr. Carlo Maiorana; Milan)*

Aim
> Horizontal ridge augmentation: smoothing the surface of the autogenous bone block with Geistlich Bio-Oss to avoid soft tissue ingrowth and bone resorption. Jaw Upper Jaw Lower Jaw Material Dentition Partially Edentulous Fully Edentulous > Autogenous bone blocks (chin) > Geistlich Bio-Oss Region Anterior Posterior Augmentation Horizontal Vertical

Therapy Concept

1 Preoperative panoramic radiograph showing partially edentulous ridge at teeth 32, 31, 41.

2 Bone resorption and ridge width reduction can be seen in the edentulous area.

3 Bone harvesting from chin.

4 Onlay graft fixation and Geistlich Bio-Oss contouring and covering.

5 Soft tissue healing 6 months after surgery.

6 Occlusal view showing complete preservation of the graft volume after 6 months.

7 Dental implants in place.

8 Postoperative panoramic radiograph.

Conclusion
Optimal horizontal augmentation can be achieved in partially edentulous areas by contouring the autogenous bone block with Geistlich Bio-Oss. Geistlich Bio-Oss can be placed over grafted areas, taking advantage of its osteocondutive properties and compensating for the natural bone resorption that always occurs. Geistlich Bio-Oss provided a space-making effect that allowed better healing with osteogenic cell colonization and adequate volume of the grafted area. Further, it appeared to favour good blood supply and resulted in relatively dense bone within 6 months.

Maiorana C & Simion M. Advanced Techniques for Bone Regeneration with Bio-Oss and Bio-Gide. RC libri 2005;34-37.

17

Cawood Class IV

GBR with Particulate Grafting

(Prof. Dr. Istvan Urban; Budapest)

Aim
> Horizontal ridge augmentation: minimal invasive augmentation procedure to obtain sufficient bone with a mixture of autogenous bone and Geistlich Bio-Oss covered with a Geistlich Bio-Gide membrane. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone chips (oblique ridge of the retromolar area) > Geistlich Bio-Oss > Geistlich Bio-Gide (fixed with titanium pins)

Therapy Concept

1 Pre-clinical situation.

2 Knife-edge ridge in the posterior mandible.

3 Mixture of autogenous particulate bone and Geistlich Bio-Oss is placed onto the residual ridge.

4 The graft is further protected with Geistlich Bio-Gide.

5 Titanium pins are used to fix the collagen membrane.

6 Clinical situation after two weeks of healing.

7 Excellent incorporation of the graft at re-entry (7 months after first surgery). The ridge width is approximately 10 mm and therefore sufficient for implant placement.

8 Implant insertion.

Conclusion
The combination of particulate autogenous bone and Geistlich Bio-Oss allows a minimal invasive horizontal ridge augmentation. This procedure avoids harvesting of an autogenous bone block and its related morbidity of the donor site. The graft is further protected with Geistlich Bio-Gide. The barrier function of the bioresorbable collagen membrane gives the needed protection for optimal GBR and soft tissue healing. The fixation of the membrane is mandatory in this case, as it is vital to prevent micromovements of the graft.

18

Cawood Class V

Sinus Lift and Block Grafting

(Prof. Dr. Matteo Chiapasco; Milan)

Aim
> Vertical ridge augmentation: reduction of autogenous bone graft resorption by covering the augmented site with Geistlich Bio-Oss and Geistlich Bio-Gide. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone block and chips (left ramus) > Geistlich Bio-Oss > Geistlich Bio-Gide

Therapy Concept

1 Preoperative radiograph showing a partially edentulous maxilla on both sides with an associated vertical atrophy, more severe on the left side.

2 Sinus grafting with a mixture of Geistlich Bio-Oss and autogenous bone associated with vertical onlay grafting of the atrophic left maxilla.

3 Coverage and contouring of the graft and the autogenous bone in the lateral fenestration with Geistlich Bio-Oss.

4 The lateral window and the autogenous bone block are covered with Geistlich BioGide.

5 Radiographic control after surgery (sinus grafting with simultaneous implant placement on the right side has been performed during the same session).

6 Clinical situation after soft tissue closure.

7 Prosthetic rehabilitation outcome (right side).

8 Clinical situation after completion of prosthetic rehabilitation (left side).

Conclusion
Both edentulous upper jaw sites are vertically augmented with a sinuslift procedure. On the left site an autogenous block graft compensates additionally the severe vertical atrophy. To prevent bone resorption and to preserve the augmented volume, Geistlich Bio-Oss is used in the sinus lift in combination with autogenous bone and to cover the lateral window in the sinus lift. Furthermore, before soft tissue closure the collagen membrane, Geistlich Bio-Gide, is placed on the entire defect to protect it and to favour an optimal aesthetic outcome.

19

Cawood Class V

Interpositional Bone Grafting

(Dr. Pietro Felice* MD/DDS, Prof. Luigi Checchi MD/DDS, Prof. Claudio Marchetti MD/DDS; Bologna)
Aim
> Vertical ridge augmentation: gain of sufficient ridge height with a sandwich osteotomy filled with Geistlich Bio-Oss Spongiosa Block and covered with Geistlich Bio-Gide. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Osteosynthesis plates > Geistlich Bio-Oss Spongiosa Block > Geistlich Bio-Gide

Therapy Concept

1 Exposure of the alveolar ridge and buccal bone.

2 Horizontal and vertical osteotomies of the distracted segment.

3 The upward lift of the transported segment, obtaining a height dimension gain of 7 mm.

4 Geistlich Bio-Oss Spongiosa Block is trimmed to the adequate dimension and shape to be completely fitted in the recipient site.

5 The distracted segment and the biomaterial block are fixed with miniplates and miniscrews.

6 A resorbable bilayer collagen membrane (Geistlich Bio-Gide) is used to cover the graft material.

7 Intra-operative situation following implants insertion, 4 months after the reconstruction.

8 Periapical x-ray evaluation immediately after implant insertion.

Conclusion
The sandwich osteotomy procedure in the posterior mandible yields an optimal vertical gain, which allows adequate bone for implant placement, in patients with a minimum of 5 mm of bone above the mandibular canal. Filling the recipient site with Geistlich Bio-Oss Spongiosa Block avoids a second intervention for collection of autogenous bone. Thus, the use of an inorganic cancellous bone block simplifies the inlay surgery for both, dentist and patient. Geistlich Bio-Gide covers the distracted segment and the substitute bone graft and enhances wound healing without complications.

Felice P et al. Vertical ridge augmentation of the atrophic posterior mandible with interpositional block grafts: bone from the iliac crest versus bovine anorganic bone. Eur J Oral Implant 2008 Sept (in press).

20

Cawood Class V

Horizontal/Vertical Augmentation
(Dr. Ueli Grunder; Zurich-Zollikon)

Aim
> Horizontal and vertical ridge augmentation: adequate bone volume as a support for soft tissue to obtain an optimal aesthetic result. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone block (spina nasalis) > Geistlich Bio-Oss Collagen > Titanium-reinforced e-PTFE membrane > Geistlich Bio-Gide

Therapy Concept

1 The vertical bony defect is visible after flap elevation.

2 The autogenous bone graft is used for stabilising the height of the membrane.

3 The 3-dimensional volume is created by using Geistlich Bio-Oss Collagen, and covered by a titanium-reinforced e-PTFE membrane.

4 Geistlich Bio-Gide is placed over the non-resorbable ePTFE membrane for better wound healing.

5 The e-PTFE membrane is removed and the implant is inserted 8 months postoperatively.

6 Closure of the soft tissue after implant placement.

7 6 months after implant placement the soft tissue heals uneventfully and the vertical and horizontal ridge dimension is regained.

8 Optimal outcome in the aesthetic relevant zone.

Conclusion
This method is appropriate for augmentations in the anterior region to allow implant placement and to ensure a good aesthetic result. The autogenous bone graft is used for supporting the titanium-reinforced e-PTFE membrane, which defines the appropriate ridge height. The horizontal and vertical volume is created by using Geistlich Bio-Oss Collagen. The use of Geistlich Bio-Gide over the non-resorbable membrane favours the healing of the soft tissue and minimises the incidence of wound dehiscence.

21

Cawood Class V

Vertical Augmentation
(Dr. Mauro Merli; Rimini)

Aim
> Vertical ridge augmentation: graft stability is achieved using osteosynthesis microplates. GBR is performed with autogenous bone graft and a resorbable barrier membrane, Geistlich Bio-Gide. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous > Autogenous bone chips (ramus) > Osteosynthesis plates > Geistlich Bio-Gide Region Anterior Posterior Augmentation Horizontal Vertical

Material

Therapy Concept

1 Radiological findings showing the defect prior to the intervention.

2 Immediate implant insertion before vertical ridge augmentation.

3 Titanium osteosynthesis plates are opportunely bent and fixed with screws on the defect.

4 The resorbable barrier Geistlich Bio-Gide is placed over osteosynthesis plates filled with the particulate autogenous bone graft.

5 X-ray displaying the situation immediately after augmentation.

6 Tissues during the healing phase of the graft just before implant exposure.

7 Exposure of the regenerated area with the plates still in situ 9 months after implant insertion.

8 The implants are completely surrounded by bone.

Conclusion
This technique is relatively simple and can provide excellent GBR results in partially endentulous patients. The osteosynthesis plates can be rapidly shaped and customized to any possible situation providing a rigid scaffold to protect the bone graft. The resorbable Geistlich Bio-Gide is preferred over non-resorbable membranes in order to minimize postoperative complications.

22

Cawood Class V

Alveolar Reconstruction and Sinus Lift

(Prof. Dr. Armand R. Paranque; Paris)

Aim
> Horizontal and vertical ridge augmentation: alveolar crest reconstruction associated with maxillary sinus lift.

Jaw Upper Jaw Lower Jaw Material

Dentition Partially Edentulous Fully Edentulous

Region Anterior Posterior

Augmentation Horizontal Vertical

> Autogenous bone blocks and chips (ramus and chin) > Geistlich Bio-Oss

Therapy Concept

1 Computed Tomography before augmentation.

2 The drawing shows the strongly resorbed alveolar bone. Autogenous bone blocks in buccal and palatal sides create a 3 wall cavity, which is filled with a mixture of Geistlich Bio-Oss and autogenous bone chips (ratio 3:1).

3 CT showing the augmented defect.

4 3-dimentional CT showing the augmented defect from the left profile.

5 CT showing the situation 6 months after bony augmentation.

6 Geistlich Bio-Oss fills the sinus cavity and the gaps between the autogenous bone block grafts.

7 6 months post-bone grafting, implants are inserted.

8 X-ray findings after implant placement.

Conclusion
Maxillary sinus augmentation with Geistlich Bio-Oss, combined with autogenous bone block grafts is a possible method for creating adequate bone height and width before implant insertion. In cases of severe atrophy autogenous block grafts in the buccal and in the palatal sides create a 3-wall cavity for reconstruction of the alveolar crest. The created cavity can be easily filled with Geistlich Bio-Oss and autogenous bone chips. The Geistlich Bio-Oss material not only serves as a scaffold for blood clot formation, but also preserves the augmented volume due to its slow rate of conversion to autogenous bone (remodeling).

23

Cawood Class V

Sinus Lift and Bone Substitute Grafting

(PD Dr. Dr. Karl Andreas Schlegel; Erlangen)

Aim
> Horizontal and vertical ridge augmentation: Geistlich Bio-Oss used in sinus elevation and in horizontal augmentation, supported by a titanium mesh. Jaw Upper Jaw Lower Jaw Material Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

> Geistlich Bio-Oss (stabilised with a titanium mesh)

Therapy Concept

1 Preoperative panoramic radiograph.

2 Clinical situation in the right maxilla after implant placement.

3 The site augmentated with Geistlich Bio-Oss is stabilised with a titanium mesh.

4 Geistlich Bio-Oss fills the lateral fenestration of the sinus.

5 Situation in the left upper jaw after lateral window preparation.

6 Geistlich Bio-Oss fills the sinus cavity and covers the defect around the implants. A titanium mesh stabilises the retromolar augmentation.

7 Radiographic findings 6 months after augmentation.

8 Final outcome 8 months after surgery (right side).

Conclusion
The combination of sinus lift with horizontal and vertical augmentation using particulate bone substitute allows implant insertion in a one-stage procedure. Geistlich Bio-Oss is used to fill the sinus cavity and for augmentation of the ridge defect. The use of particulate bone substitute, which is stabilised with a titanium mesh, avoids completely the harvesting of autogenous bone and the risk of morbidity of the donor site.

24

Cawood Class V

Sinus Lift with Harvest BMAC

*FRCS (London)

TM

(Prof. Dr. Dr. Rainer Schmelzeisen*, Prof. Dr. Dr. Ralf Gutwald, Dr. Dr. Andris Stricker, Dr. Michael Vogeler, Dr. Sebastian Sauerbier; Freiburg)
Aim
> Vertical ridge augmentation: acceleration of the tissue regeneration process to obtain mature bone in a short period of time after augmentation. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Harvest BMACTM (Bone Marrow Aspirate Concentrate) > Geistlich Bio-Oss > Geistlich Bio-Gide

Therapy Concept

1 Panoramic X-ray of the initial situation.

2 Bone marrow (approx. 60 ml) is harvested with a needle from the pelvis (dorsal or ventral). The bone marrow aspirate is concentrated in a centrifuge to 37 ml in approx. 15 minutes.

3 Geistlich Bio-Oss is mixed with the bone marrow concentrate and with autologous thrombin.

4 The mixture is filled into the sinus floor defect through the lateral fenestration and into the extraction socket.

5 The lateral fenestration and augmentation sites are covered by a Geistlich Bio-Gide.

6 Implant placement at re-entry only 3 months after sinus lift.

7 Final situation with the prosthetic supply on both sites.

8 Panoramic X-ray after implant insertion.

Conclusion
The sinus model demonstrates that the combination of Harvest BMAC (Bone Marrow Aspirate Concentrate) with Geistlich Bio-Oss and Geistlich Bio-Gide accelerates the tissue regeneration. Histological analysis confirms the presence of mature bone with a high percentage of lamellar bone, already after 3 months. The concentrated bone marrow aspirate delivers growth factors and mononuclear cells (including mesenchymal stem cells) specifically targeted to the defect. This allows the immediate presence of the complex physiological system needed for tissue regeneration. Therefore, the addition of Harvest BMAC to Geistlich Bio-Oss may be a successful technique for a broad range of clinical indications. The Harvest BMAC in combination with Geistlich Bio-Oss and Geistlich Bio-Gide is currently being tested in a prospective multicenter study.

25

Cawood Class V

Vertical Augmentation
(Prof. Dr. Massimo Simion, Dr. Isabella Rocchietta; Milan)

Aim
> Vertical ridge augmentation: combination of a mixture of Geistlich Bio-Oss and autogenous bone chips (1:1) with a titanium-reinforced e-PTFE membrane for long-term successful GBR. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone chips (maxillary tuberosity) > Geistlich Bio-Oss > Titanium-reinforced e-PTFE membrane (fixed with screws)

Therapy Concept

1 Intraoral view of the defect in the posterior right mandible.

2 Two tenting screws are inserted to support the overlying membrane and the particulated graft.

3 Augmentation with Geistlich Bio-Oss and autogenous bone (1:1) and covering with a titanium reinforced e-PTFE membrane.

4 The e-PTFE membrane is shaped to adapt to the defect. The membrane is secured bucally by two fixation screws.

5 Primary wound closure.

6 Panoramic X-ray of the augmented sites.

7 After 6 months of uneventful healing, the screws and the membrane are removed.

8 Three titanium implants are placed.

Conclusion
Successful vertical ridge augmentation can be achieved in partially edentulous lower jaws by covering a mixture of particulate Geistlich Bio-Oss and autogenous bone chips with a titanium-reinforced e-PTFE membrane. Histologic observations confirm a positive osteoconductivity of Geistlich Bio-Oss in close contact with the newly formed bone.* Geistlich Bio-Oss undergoes very slow resorption and substitution with new bone (remodelling), which is expected to be advantageous for the long-term stability of regenerated bone.

Simion M et al. Vertical ridge augmentation by expanded-polytetrafluoroethylene membrane and a combination of intraoral autogenous bone graft and deproteinized anorganic bovine bone (Bio Oss). Clin Oral Implants Res 2007 Oct;18(5):620-9.

26

Cawood Class V

Horizontal/Vertical Augmentation
(Dr. Marius Steigmann; Neckargemnd)*

Aim
> Horizontal and vertical ridge augmentation: GBR in a ridge width of less than 5 mm using Geistlich Bio-Oss Spongiosa Block in order to avoid the need of autogenous bone harvesting. Jaw Upper Jaw Lower Jaw Material Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

> Geistlich Bio-Oss Spongiosa Block > Geistlich Bio-Gide

Therapy Concept

1 X-ray showing the defect prior to augmentation.

2 Initial situation with a visible dehiscence on the extracted site.

3 Vertical and horizontal defect is visible after flap elevation.

4 Geistlich Bio-Oss Spongiosa Block is placed after extraoral modelling of the graft. The graft is covered with Geistlich Bio-Gide.

a 5 After 6 months, block integration is visible without vertical resorption. 6 Buccal view showing the healthy condition of the keratinized gingiva. 7 Occlusal view showing the horizontal dimension.

8 Augmented site after 6 months: with (b) and without (a) implant. (c) The regenerated defect after 1 year showing minimum resorption.

Conclusion
Severe horizontal and vertical anterior ridge deficiency after single tooth extraction may be treated with Geistlich Bio-Oss Spongiosa Block. The substitute bone block provides sufficient augmentation for an optimal two-stage implant procedure and eliminates the need of autogenous bone donor site. The bovine bone material undergoes slow remodelling over time and becomes incorporated into the native bone, maintaining its volume over a long period of time. This ensures stability of the interproximal bone height of the augmentation site until the implants are functionally loaded and natural remodelling occurs.

Steigmann M. A bovine-bone mineral block for the treatment of severe ridge deficiencies in the anterior region: a clinical case report. Int J Oral Maxillofac Implants 2008 JanFeb;23(1):1238.

27

Cawood Class V

Palatal Sinus Elevation

(Dr. Stefan Stbinger, Prof. Dr. Dr. Robert Sader; Frankfurt)

Aim
> Vertical ridge augmentation: sinus lift to obtain adequate ridge height avoiding the release incision in the buccal side.

Jaw Upper Jaw Lower Jaw Material

Dentition Partially Edentulous Fully Edentulous > Geistlich Bio-Oss > Geistlich Bio-Gide

Region Anterior Posterior

Augmentation Horizontal Vertical

Therapy Concept

1 Preoperative panoramic radiograph for surgical planning.

2 Clinical situation in the left upper jaw showing the intended site for a palatal sinus elevation procedure.

3 Palatally located crestal and bevelled incision of the palatal mucosa with an oblique releasing incision in the premolar region for access to the palatal sinus wall.

4 Mucoperiosteal flap elevation and window osteotomy for later palatal sinus elevation (WOLPE). To reduce possible bleeding tendency from small vessels a gauze is temporarily fixed in the distal parts.

5 Dissection and elevation of the sinus membrane up to the buccal plate of the alveolar ridge.

6 Complete filling of the prepared sinus cavity with Geistlich Bio-Oss.

7 Covering of the augmented area with a Geistlich Bio-Gide membrane.

8 Primary wound closure was with resorbable tension-free single sutures.

Conclusion
The window osteotomy for later palatal sinus elevation (WOLPE) appears to be a predictable and safe surgical technique, which allows favourable hard and soft tissue management. As no releasing incisions are necessary in the buccal aspect there are no scarring, plastic deformations, or distortions in the muco-gingival margin. The use of Geistlich Bio-Oss and Geistlich Bio-Gide avoids the harvesting of autogenous bone and favors tissue regeneration. Postoperative swelling is minimal on the palatal aspect. Patients are able to wear their overdentures all but immediately after the surgical procedure. This technique may be an alternative to other sinus augmentation approaches, where enough transversal width of the posterior alveolar crest is available.

28

Cawood Class V

Sinus Lift Augmentation

(Dr. Tiziano Testori; Como)

Aim
> Vertical ridge augmentation: reconstructive surgery with a sinus lift augmentation with multiple septa.

Jaw Upper Jaw Lower Jaw Material

Dentition Partially Edentulous Fully Edentulous > Geistlich Bio-Oss > Geistlich Bio-Gide

Region Anterior Posterior

Augmentation Horizontal Vertical

Therapy Concept

1 Computed tomography showing the complexity of the sinus anatomy.

2 Orthopantomograph of the initial situation.

3 Antrostomy with membrane elevation displaying the multiple septa.

4 The Schneiderian membrane is protected with Geistlich Bio-Gide.

5 The antrum is filled with large particles of Geistlich Bio-Oss.

6 Geistlich Bio-Oss completely fills the antrum up to the vestibular cortical wall.

7 Placement of two Geistlich Bio-Gide membranes (double-layer technique) to cover the antrostomy.

8 Post-op orthopantomograph showing the sinus lift procedure.

Conclusion
Thanks to the CT diagnostic, the complexity of the sinus cavity can be revealed and an appropriate surgical procedure can be planned. In sinuses with multiple septa, careful attention should be payed in membrane elevation in order to preserve its integrity. The Schneiderian membrane can be successfully protected or repaired in case of perforation with Geistlich Bio-Gide. With Geistlich Bio-Oss, a predictable implant outcome can be achieved even without the use of autogenous bone.

29

Cawood Class VI

Le Fort I Osteotomy
(Dr. Dr. Corvin Glatzer, Dr. Oliver Schwerdtner; Berlin)

Aim
> Vertical ridge augmentation: oral functionality restored with the Le Fort I osteotomy.

Jaw Upper Jaw Lower Jaw

Dentition Partially Edentulous Fully Edentulous

Region Anterior Posterior

Augmentation Horizontal Vertical

Material

> Autogenous bone chips (harvested intraorally) > Osteosynthesis plates > Geistlich Bio-Gide

Therapy Concept

1 Preoperative situation: Typical Class III malocclusion.

2 Buccal view with an extremely atrophied alveolar ridge.

3 Le Fort I osteotomy and fixation with osteosynthesis plates.

4 Contouring with autologous bone chips.

5 The defect is covered with a resorbable collagen membrane (Geistlich Bio-Gide).

6 Situation 6 months after surgery.

7 Osteosynthesis plates are removed at the stage of reentry.

8 Successful Le Fort I osteotomy outcome leading to a pleasant profile.

Conclusion
Le Fort I osteotomies allow the repositioning of the maxilla in an aesthetic as well as a functional context. The resulting facial contours lead to a juvenilisation of the profile, which cannot be achieved by using maxilliary sinus grafting. The coverage of the autogenous bone graft by Geistlich Bio-Gide reduces the autogenous bone resorption, and ensures the bony bridging of the osteotomy gap.

30

Cawood Class VI

GBR with Block Grafting

(Prof. Dr. Dr. Tateyuki Iizuka; Bern)

Aim
> Horizontal and vertical ridge augmentation: reconstruction of extremely atrophied maxilla and mandible to restore oral function. Jaw Upper Jaw Lower Jaw Material Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

> Autogenous bone blocks and chips (calvaria) > Geistlich Bio-Gide

Therapy Concept

1 Pre-operative x-ray reveals strong resorption of the maxilla and the mandible (left side).

2 Situation after exposure of the maxillary alveolar ridge.

3 Autogenous bone block grafts are fixed and contoured with autogenous bone chips.

4 The maxillary graft is covered completely with several layers of Geistlich Bio-Gide.

5 Autogenous bone block in place (mandible).

6 Contouring of the mandibular graft with autogenous bone chips.

7 Resorbable collagen membranes (Geistlich Bio-Gide) are placed over the augmented site before suture.

8 Radiography, 3 months after surgery.

Conclusion
The autogenous bone graft allows full reconstruction of a severely atrophied alveolar ridge in both the upper and the lower jaw with recovery of oral function. The bone blocks are further contoured with autogenous bone chips to fill the remaining gaps and even out the labial alveolar ridge. Due to multiple layers of Geistlich Bio-Gide covering the defect, the bony augmentation is strongly stabilized, which enhances a proper GBR.

31

Cawood Class VI

Sinus Lift and Block Grafting

(PD Dr. Dr. Claude Jaquiry, Dr. Nicolas Gabutti, Prof. Dr. Dr. Hans-Florian Zeilhofer; Basel)
Aim
> Horizontal and vertical ridge augmentation: successful vertical and lateral ridge augmentation in a severe atrophy case.

Jaw Upper Jaw Lower Jaw

Dentition Partially Edentulous Fully Edentulous

Region Anterior Posterior

Augmentation Horizontal Vertical

Material

> Autogenous bone blocks and chips (iliac crest) > Geistlich Bio-Oss > Geistlich Bio-Gide

Therapy Concept

1 Partially edentulous maxilla showing severe atrophy of posterior ridge. Residual vertical bone ( 1 mm) does not allow simultaneous implant installation.

2 The bony window is removed (Piezo-Surgery) and the Schneiderian membrane is successfully elevated. A Geistlich Bio-Gide is placed to protect the mucosa and to facilitate introduction of autologous bone and biomaterial.

3 Autologous blocks harvested from the iliac crest are placed in multilayer technique. Gaps between the blocks are filled up using a 1:1 mixture of Geistlich Bio-Oss and cancellous bone.

4 The bony window is replaced and additional blocks for lateral augmentation are fixed by titanium screws.

5 The augmented area is covered by a Geistlich Bio-Gide membrane in order to prevent invasion of fibrous tissue.

6 CT-scan (sagittal section) of the right upper jaw 9 months after augmentation showing consolidated hard tissue within the newly created ridge.

7 The vertical dimension (> 10 mm) allows successful implant installation (4.2 mm diameter and 12 mm length).

8 Clinical view after fixed prosthetic rehabilitation.

Conclusion
This method is suitable and safe for bilateral sinus elevation and simultaneous lateral ridge augmentation in cases where large volumes of hard tissue (> 6 cc) are required. Bilateral sinus elevation by using biomaterial alone is possible under the conditions of: (i) undamaged Schneiderian membrane, and (ii) relatively low volume of hard tissue required ( 3 cc) for successful implant installation. In severe atrophy cases however, the combination of autologous bone harvested from the iliac crest and Geistlich Bio-Oss provides: (i) sufficient volume of regenerative material by simultaneous reduction in the need for autologous bone, (ii) sufficient stability by introducing a slow resorbable biomaterial, and (iii) sufficient amount of potentially osteogenic cells.

32

Cawood Class VI

Distraction
(Univ.-Prof. Dr. Christian Krenkel, Dr. Dr. Simon Enzinger; Salzburg)

Aim
> Vertical ridge augmentation: full reconstruction of the alveolar bone and recovery of oral functionality.

Jaw Upper Jaw Lower Jaw Material

Dentition Partially Edentulous Fully Edentulous > Endo-Distractor Krenkel

Region Anterior Posterior

Augmentation Horizontal Vertical

Therapy Concept

1a Clinical situation before surgery.

2a Augmented site after 14 weeks of distraction procedure.

3a Implant insertion and temporary bridge 4 months after first surgery.

4a Final prosthodontic rehabilitation with fixed bridge in the lower jaw 9 months after first surgery.

1b X-ray corresponding to picture 1a.

2b X-ray corresponding to picture 2a.

3b X-ray corresponding to picture 3a.

4b X-ray corresponding to picture 4a.

Conclusion
The endodistraction device, looking like a dental implant, is positioned in the centre of the bone and, when escalated, creates a distraction chamber, which fills up with callus formation and later original bone. Compared to conventional devices with plates, the main advantages are: no tilting tendency to the lingual side and no second operation for device removal. Using the endodistraction technique bone, gums, and the rehabilitation of the aesthetics of face and lips are gained within one operation.

33

Cawood Class VI

Le Fort I and Sandwich Osteotomies

(Prof. Dr. Dr. Hendrik Terheyden; Kassel)*

Aim
> Horizontal and vertical ridge augmentation: use of Geistlich Bio-Oss and Geistlich Bio-Gide for reconstruction of extremely atrophied ridges in edentulous patients. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Autogenous bone blocks and chips (iliac crest) > Geistlich Bio-Oss > Geistlich Bio-Gide

Therapy Concept

1 Preoperative radiologic findings showing strong bone resorption in mandible and maxilla.

2 The gap left after osteotomy was filled with iliac crest and Geistlich Bio-Oss (1:3).

3 The defect in the maxilla was covered with Geistlich BioGide.

4 Filling of the mandibular sandwich osteotomy with a mixture of particulate iliac crest and Geistlich Bio-Oss (1:3).

5 After 4 months implants were placed.

6 Situation in the maxilla after implant insertion.

7 Optimal outcome with fixed prosthetic supply.

8 Panoramic X-ray after implant placement.

Conclusion
Interpositional bone graft procedures (i.e., Le Fort I osteotomy in the maxilla and sandwich osteotomy in the mandible) provide several advantages to edentulous patients with moderate to severe bone loss after periodontitis: (i) sagittal and vertical movement of the ridges with compensation of the bone loss, (ii) conservation of the fixed gingival tissues on top of the ridge, (iii) less resorption than with onlay grafts, (iv) good wound healing of the bony defect. The good biological prerequisites for regeneration in the osteotomy gaps (interpositional grafting) allow clinical use of bone substitute materials such as Geistlich Bio-Oss.

Terheyden H et al. Interpositionsosteoplastik des zahnlosen Ober- und Unterkiefers Eine therapeutische Alternative bei Knochenverlust durch aggressive Parodontitis. Implantologie 2007;15(3):297-304.

34

Cawood Class VI

Distraction and Block Grafting

(Dr. Albino Triaca, Dr. Dr. Roger Minoretti; Zurich & Dr. Dan Kraus; Lugano)

Aim
> Vertical ridge augmentation: the distraction procedure and an iliac crest bone graft used for excellent outcome in the aesthetically relevant zone. Jaw Upper Jaw Lower Jaw Dentition Partially Edentulous Fully Edentulous Region Anterior Posterior Augmentation Horizontal Vertical

Material

> Distractor (MDO-C, Orthognathics) > Autogenous bone blocks and chips (iliac crest, stabilised with a titanium mesh) > Osteosynthesis screws

Therapy Concept

1 Preoperative clinical situation.

2 Raising the mucoperiosteal flap, after a vestibular incision, and performing the osteotomy.

3 Fixation of the crane distractor (MDO-C, Orthognathics) with screws.

4 Situation at the end of the distraction procedure (0.25 0.5 mm per day).

5 The distractor is removed at the end of the distraction retention period, which lasts 3 months.

6 Autogenous bone blocks and chips are use for further augmentation and fixed with screws and a titanium mesh.

7 After 8 months, the titanium mesh and screws are removed. Additionally the attached gingiva is broadened with a palatal soft tissue graft.

8 Situation after implant placement and healing.

Conclusion
One therapy concept for vertical ridge augmentation of a partially endentulous ridge in an aesthetically relevant region is the combination of distraction osteogenesis followed by an autogenous bone grafting. The pre-requisite for using distraction osteogenesis is a minimum of 6 to 7 mm of bone height above the vital structures. In the distraction phase, the two pieces of bone undergo gradual incremental separation and new bone fills in the defect. Due to the additional bone grafting after distraction, a good aesthetic outcome is ensured. Implant placement is carried out in a third stage.

35

Product Range Geistlich Bio-Gide and Geistlich Bio-Oss: your successful regeneration team

Less resorption!

Resorption (%)

Comparison of horizontal augmentation techniques shows lower resorption rates, if the autogenous block graft is covered with Geistlich Bio-Oss and Geistlich Bio-Gide.

autog. block + autog. chips peripherically 3

autog. block + Geistlich Bio-Oss peripherically 4

autog. block + autog. chips peripherically + Geistlich Bio-Gide 5

autog. block + Geistlich Bio-Oss cover 3

autog. block + Geistlich Bio-Oss cover + Geistlich Bio-Gide 6

Geistlich Bio-Gide

Perio-System Combi-Pack

Geistlich Bio-Oss

Geistlich Bio-Oss Collagen

36

Geistlich Bio-Gide

Geistlich Bio-Oss

Geistlich Bio-Gide resorbable, bilayer membrane 25 x 25 mm

Geistlich Bio-Oss spongiosa granules 0.251 mm; 0.25 g, 0.5 g, 2 g

Geistlich Bio-Gide resorbable, bilayer membrane 30 x 40 mm

Geistlich Bio-Oss spongiosa granules 12 mm; 0.5 g, 2 g

Geistlich Bio-Gide Perio resorbable, bilayer membrane 16 x 22 mm, sterile templates

Geistlich Bio-Oss Collagen spongiosa granules + 10% collagen 100 mg (approx. 0.20.3 cm3) 250 mg (approx. 0.50.6 cm3)

Perio-System Combi-Pack Geistlich Bio-Oss Collagen 100 mg + Geistlich Bio-Gide Perio 16 x 22 mm, sterile templates

Geistlich Bio-Oss Spongiosa Block 1 block 1 x 1 x 2 cm (approx. 2 cm3)

37

Outlook
Oral and maxillofacial surgery offers a plurality of therapy concepts for regeneration of soft and hard tissues. A broad variety of surgical approaches within the alveolar ridge augmentation therapies has been presented in this brochure. As a pioneer in bone and soft tissue regenerative processes, Geistlich Biomaterials is committed to scientific research in better solutions and new areas of regeneration. With this goal, Geistlich Biomaterials together with leading international surgeons conduct several clinical studies, focusing on a broad spectrum of oral and maxillofacial indications, namely: cranial defects, orbital floor, rhinoplasty, palatal and alveolar cleft, orthognathics, genioplasty. We are looking forward to presenting you our results and discussing with you new indications for using biomaterials in cranial and maxillofacial surgery.

Cranial Defects

Orbital Floor

Rhinoplasty

Palatal Cleft

Alveolar Cleft

Orthognathics

Genioplasty

38

Geistlich Pharma AG Business Unit Biomaterials Bahnhofstrasse 40 CH-6110 Wolhusen

phone +41 41 492 56 30 fax +41 41 492 56 39 biomaterials@geistlich.ch www.geistlich.com

31290.1/0808/e