Indication Sheet PIR-1 Periimplant Regeneration Fenestration Treatment concept of Dr. Jean-Pierre Gardella (surgeon) and Dr. Christian Richelme (prosthodontist), Marseille, France > Filling of a peri-implant defect, combining an autogenous bone graft with Geistlich Bio-Oss to correct substantial tissue loss > Extraction of a mandibular incisor also valid technique for a maxillary incisor > For early implantation 1. Indication profile (see Figure 1a and 1b) Region Bone quality Soft tissue Indication for bone filling n aesthetic region n one missing tooth n absence of bone lesion n bone augmentation indicated n absence of recession n inflammation n without complications n soft-tissue augmentation indicated n yes, at the time of implant insertion n no n non-aesthetic region n several missing teeth n bone lesion(s) n recession n infection n thin n lack of keratinised gingiva 1
. Surgical procedure Background information Dr. Jean-Pierre Gardella and Dr. Christian Richelme: Substantial tissue loss usually necessitates grafting prior to implant placement. However, the anatomy of the defect determines whether primary implant stabilisation is possible1,5. If this is possible, it can be performed simultaneously with an autogenous bone graft. This reconstruction can be optimised by combining the osteoinductive potential of autogenous bone with the osteoconductive capacity of Geistlich Bio-Oss as well as its low resorption speed. This technique can also shorten the treatment time because grafting and implant placement are performed during the surgical operating phase. In order to manage this type of situation and improve the biotype of the future implant site, primary closure of the extraction site is performed with the aid of an epithelial connective tissue graft. Concept: > Rapid treatment to halt the progression of bone resorption caused by the infectious process. > Primary closure of the extraction site with an epithelial connective tissue graft8. ombining Geistlich Bio-Oss with autogenous bone makes it possible: to combine osteoinduction of the autogenous bone and osteoconduction of Geistlich Bio-Oss 7,9. to reduce the volume of autogenous bone harvested, which allows for a less invasive surgical technique and more comfortable postoperative course for the patient. se of a Geistlich Bio-Gide bilayer membrane in double layer technique. Surgical technique: > Atraumatic extraction technique. losure of the extraction site with an epithelial connective tissue graft which allows: soft-tissue healing within a short time, while recreating aesthetic crestal morphology, and re-operation for implant placement before alveolar bone resorption reaches its peak. > Assessment of the site two months postoperatively (the expanded operation window for treatment is obtained by using Geistlich Bio-Oss or Geistlich Bio-Oss Collagen). > Obtaining of adequate primary stability by adaptation of the drilling sequence. > Performing an autogenous bone graft with core bone harvested by trepan (symphyseal region). > Placement of Geistlich Bio-Oss above the graft and onto the outer surface of the vestibular cortex. The Geistlich Bio-Gide membrane is placed over the site in a double layer. > A fter months, the second surgical phase is started with a minimal incision. > P lacement of the temporary prosthesis after 6 months of healing. sual prosthesis at 9 months. Limitations and open questions: As a result of post-extraction resorption, we sometimes have to perform grafting prior to implant placement. Despite this compensation, remodelling continues for 18 months following extraction and occasionally leads to mucosal collapse, which can compromise the aesthetic outcome. To make up for this, in eminently aesthetic situations, an excess of soft tissue must be available, which is why over-correction of the defect at the bony and mucosal level is necessary6. Fig. 1a Tooth 1 is compromised for obvious endodontic reasons. This tooth has already undergone retrograde surgery and apicectomy. Fig. 1b See Figure 1a. Fig. a After extraction, in order to solve the problem of primary closure of the site, an epithelial connective tissue graft was raised from the tuberosity and grafted to the extraction site. Fig. 11b See Figure 11a. Fig. 1a Clinical view of the second phase of surgery. Fig. 1b See Figure 1a. Fig. b See Figure a. Fig. Clinical view of healing after 10 days. Fig. a Clinical view of healing after months. Fig. 1 Postoperative radiograph of the nd surgical phase. Bone regeneration with very good results and observed. Fig. 1a Clinical view of the temporary prosthesis and after it has been unscrewed. Fig. 1b See Figure 1a. Fig. b See Figure a. Fig. 5 Clinical view of the defect, the two vestibular and lingual cortices are swollen. The probe passes through the drill hole. Fig. 6 Implant placement. Fig. 15 Radiograph of the temporary prosthesis in place. Fig. 16 Clinical view of the final prosthesis 8 months after extraction. Fig. 17 Radiograph of the final prosthesis in place. Fig. 7 Filling the defect with autogenous bone cores. Fig. 8 Placement of Geistlich Bio-Oss to maintain volume and protect the autogenous graft against resorption. Fig. 9 Postoperative radiograph of the first surgical phase. Fig. 18a Clinical view of the mucosa after unscrewing of the prosthesis one year post- extraction (note the extent of soft and hard-tissue reconstruction). Fig. 18b See Figure 18a. Fig. 10a Geistlich Bio-Gide arranged in a double layer. Fig. 10b See Figure 10a. Fig. 11a Closure of the site by first intention.. Aims of the therapy > T o optimise and speed up soft tissue healing in order to allow peri-implant reconstruction. > Early implantation combined with an autogenous bone graft, combining Geistlich Bio-Oss and Geistlich Bio-Gide 7. > To restore natural tissue architecture.
. Surgical procedure Background information Dr. Jean-Pierre Gardella and Dr. Christian Richelme: Substantial tissue loss usually necessitates grafting prior to implant placement. However, the anatomy of the defect determines whether primary implant stabilisation is possible1,5. If this is possible, it can be performed simultaneously with an autogenous bone graft. This reconstruction can be optimised by combining the osteoinductive potential of autogenous bone with the osteoconductive capacity of Geistlich Bio-Oss as well as its low resorption speed. This technique can also shorten the treatment time because grafting and implant placement are performed during the surgical operating phase. In order to manage this type of situation and improve the biotype of the future implant site, primary closure of the extraction site is performed with the aid of an epithelial connective tissue graft. Concept: > Rapid treatment to halt the progression of bone resorption caused by the infectious process. > Primary closure of the extraction site with an epithelial connective tissue graft8. ombining Geistlich Bio-Oss with autogenous bone makes it possible: to combine osteoinduction of the autogenous bone and osteoconduction of Geistlich Bio-Oss 7,9. to reduce the volume of autogenous bone harvested, which allows for a less invasive surgical technique and more comfortable postoperative course for the patient. se of a Geistlich Bio-Gide bilayer membrane in double layer technique. Surgical technique: > Atraumatic extraction technique. losure of the extraction site with an epithelial connective tissue graft which allows: soft-tissue healing within a short time, while recreating aesthetic crestal morphology, and re-operation for implant placement before alveolar bone resorption reaches its peak. > Assessment of the site two months postoperatively (the expanded operation window for treatment is obtained by using Geistlich Bio-Oss or Geistlich Bio-Oss Collagen). > Obtaining of adequate primary stability by adaptation of the drilling sequence. > Performing an autogenous bone graft with core bone harvested by trepan (symphyseal region). > Placement of Geistlich Bio-Oss above the graft and onto the outer surface of the vestibular cortex. The Geistlich Bio-Gide membrane is placed over the site in a double layer. > A fter months, the second surgical phase is started with a minimal incision. > P lacement of the temporary prosthesis after 6 months of healing. sual prosthesis at 9 months. Limitations and open questions: As a result of post-extraction resorption, we sometimes have to perform grafting prior to implant placement. Despite this compensation, remodelling continues for 18 months following extraction and occasionally leads to mucosal collapse, which can compromise the aesthetic outcome. To make up for this, in eminently aesthetic situations, an excess of soft tissue must be available, which is why over-correction of the defect at the bony and mucosal level is necessary6. Fig. 1a Tooth 1 is compromised for obvious endodontic reasons. This tooth has already undergone retrograde surgery and apicectomy. Fig. 1b See Figure 1a. Fig. a After extraction, in order to solve the problem of primary closure of the site, an epithelial connective tissue graft was raised from the tuberosity and grafted to the extraction site. Fig. 11b See Figure 11a. Fig. 1a Clinical view of the second phase of surgery. Fig. 1b See Figure 1a. Fig. b See Figure a. Fig. Clinical view of healing after 10 days. Fig. a Clinical view of healing after months. Fig. 1 Postoperative radiograph of the nd surgical phase. Bone regeneration with very good results and observed. Fig. 1a Clinical view of the temporary prosthesis and after it has been unscrewed. Fig. 1b See Figure 1a. Fig. b See Figure a. Fig. 5 Clinical view of the defect, the two vestibular and lingual cortices are swollen. The probe passes through the drill hole. Fig. 6 Implant placement. Fig. 15 Radiograph of the temporary prosthesis in place. Fig. 16 Clinical view of the final prosthesis 8 months after extraction. Fig. 17 Radiograph of the final prosthesis in place. Fig. 7 Filling the defect with autogenous bone cores. Fig. 8 Placement of Geistlich Bio-Oss to maintain volume and protect the autogenous graft against resorption. Fig. 9 Postoperative radiograph of the first surgical phase. Fig. 18a Clinical view of the mucosa after unscrewing of the prosthesis one year post- extraction (note the extent of soft and hard-tissue reconstruction). Fig. 18b See Figure 18a. Fig. 10a Geistlich Bio-Gide arranged in a double layer. Fig. 10b See Figure 10a. Fig. 11a Closure of the site by first intention.. Aims of the therapy > T o optimise and speed up soft tissue healing in order to allow peri-implant reconstruction. > Early implantation combined with an autogenous bone graft, combining Geistlich Bio-Oss and Geistlich Bio-Gide 7. > To restore natural tissue architecture.
. Surgical procedure Background information Dr. Jean-Pierre Gardella and Dr. Christian Richelme: Substantial tissue loss usually necessitates grafting prior to implant placement. However, the anatomy of the defect determines whether primary implant stabilisation is possible1,5. If this is possible, it can be performed simultaneously with an autogenous bone graft. This reconstruction can be optimised by combining the osteoinductive potential of autogenous bone with the osteoconductive capacity of Geistlich Bio-Oss as well as its low resorption speed. This technique can also shorten the treatment time because grafting and implant placement are performed during the surgical operating phase. In order to manage this type of situation and improve the biotype of the future implant site, primary closure of the extraction site is performed with the aid of an epithelial connective tissue graft. Concept: > Rapid treatment to halt the progression of bone resorption caused by the infectious process. > Primary closure of the extraction site with an epithelial connective tissue graft8. ombining Geistlich Bio-Oss with autogenous bone makes it possible: to combine osteoinduction of the autogenous bone and osteoconduction of Geistlich Bio-Oss 7,9. to reduce the volume of autogenous bone harvested, which allows for a less invasive surgical technique and more comfortable postoperative course for the patient. se of a Geistlich Bio-Gide bilayer membrane in double layer technique. Surgical technique: > Atraumatic extraction technique. losure of the extraction site with an epithelial connective tissue graft which allows: soft-tissue healing within a short time, while recreating aesthetic crestal morphology, and re-operation for implant placement before alveolar bone resorption reaches its peak. > Assessment of the site two months postoperatively (the expanded operation window for treatment is obtained by using Geistlich Bio-Oss or Geistlich Bio-Oss Collagen). > Obtaining of adequate primary stability by adaptation of the drilling sequence. > Performing an autogenous bone graft with core bone harvested by trepan (symphyseal region). > Placement of Geistlich Bio-Oss above the graft and onto the outer surface of the vestibular cortex. The Geistlich Bio-Gide membrane is placed over the site in a double layer. > A fter months, the second surgical phase is started with a minimal incision. > P lacement of the temporary prosthesis after 6 months of healing. sual prosthesis at 9 months. Limitations and open questions: As a result of post-extraction resorption, we sometimes have to perform grafting prior to implant placement. Despite this compensation, remodelling continues for 18 months following extraction and occasionally leads to mucosal collapse, which can compromise the aesthetic outcome. To make up for this, in eminently aesthetic situations, an excess of soft tissue must be available, which is why over-correction of the defect at the bony and mucosal level is necessary6. Fig. 1a Tooth 1 is compromised for obvious endodontic reasons. This tooth has already undergone retrograde surgery and apicectomy. Fig. 1b See Figure 1a. Fig. a After extraction, in order to solve the problem of primary closure of the site, an epithelial connective tissue graft was raised from the tuberosity and grafted to the extraction site. Fig. 11b See Figure 11a. Fig. 1a Clinical view of the second phase of surgery. Fig. 1b See Figure 1a. Fig. b See Figure a. Fig. Clinical view of healing after 10 days. Fig. a Clinical view of healing after months. Fig. 1 Postoperative radiograph of the nd surgical phase. Bone regeneration with very good results and observed. Fig. 1a Clinical view of the temporary prosthesis and after it has been unscrewed. Fig. 1b See Figure 1a. Fig. b See Figure a. Fig. 5 Clinical view of the defect, the two vestibular and lingual cortices are swollen. The probe passes through the drill hole. Fig. 6 Implant placement. Fig. 15 Radiograph of the temporary prosthesis in place. Fig. 16 Clinical view of the final prosthesis 8 months after extraction. Fig. 17 Radiograph of the final prosthesis in place. Fig. 7 Filling the defect with autogenous bone cores. Fig. 8 Placement of Geistlich Bio-Oss to maintain volume and protect the autogenous graft against resorption. Fig. 9 Postoperative radiograph of the first surgical phase. Fig. 18a Clinical view of the mucosa after unscrewing of the prosthesis one year post- extraction (note the extent of soft and hard-tissue reconstruction). Fig. 18b See Figure 18a. Fig. 10a Geistlich Bio-Gide arranged in a double layer. Fig. 10b See Figure 10a. Fig. 11a Closure of the site by first intention.. Aims of the therapy > T o optimise and speed up soft tissue healing in order to allow peri-implant reconstruction. > Early implantation combined with an autogenous bone graft, combining Geistlich Bio-Oss and Geistlich Bio-Gide 7. > To restore natural tissue architecture.
Pre- and postoperative situation Pre-operative clinical view. Clinical view, 9 months after extraction. Excellent soft-tissue integration and splendid laboratory work. Literature references 1 Antoun H, Sitbon JM, Missika P, Martinez H; A prospective randomized study comparing two techniques of bone augmentation: onlay graft alone or associated with a membrane; Clin. Oral Impl. Res. 001; 1:6 69. Cardaropoli G, Hayacibara R, sukekava F, Araujo M, Lindhe J.; Healing of extraction sockets and surgically produced-augmented and non augmented defects in the alveolar ridge. An experimental study in the dog; J Clin Periodontol. 005; :5-0. Funato A; Salama MA; Ishikawa T; Garber DA; Salama H.; Timing, Positioning, and Sequential Staging in Esthetic Implant Therapy: A Four-Dimensional Perspective; International Journal of Periodontics and Restorative Dentistry 007; 7:1-. Gardella JP, Chelli S.; Atraumatic extraction technique; In Press. 5 Gardella JP, Renouard F.; Guided bone regeneration, autegenous bone graft: limits ans indications; Journal de parodontol & implantol orale 1999; 18:17-1. 6 Grunder U, Gracis S, Capelli.: Influence of the -D bone-to-implant relationship on esthetics; Int J Periodontics Restorative Dent. 005;5:11-119. 7 Hämmerle CH, Chen ST, Wilson TG Jr.; Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets; Int J Oral Maxillofac Implants. 00; 19 Suppl: 6-8. Review. 8 Jung RE, Siegenthaler DW, Hammerle CH; Postextraction tissue management: a soft tissue punch technique; Int J Periodontics Restorative Dent. 00 Dec; (6):55-5. 9 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 patients; Clin Oral Implants Res. 006 Aug; 17():59-66. Contact > Dr. Jean-Pierre Gardella, 11 avenue du Prado, 1008 Marseille, France telephone: + (0) 91 79 0 90, fax: + (0) 91 79 9 9, e-mail: jpgardella@gardellaclinic.com Suppliers > Implant: Speedy NP Nobel Biocare > Suture material: /0 Surgilon, 6/0 Monosof Syneture > Medication: Amoxicillin 1 g/day, Ibuprofen 00 mg times/day, for 8 days Further Indication Sheets > For free delivery please contact: www.geistlich.com/indicationsheets > If you no longer wish to collect Indication Sheets, please unsubscribe with your local distribution partner 5
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