5 61

© Geistlich Pharma AGBusiness Unit BiomaterialsCH-6110 Wolhusenphone +41 41 492 56 30 fax +41 41 492 56 39www.geistlich-pharma.com

Extraction SocketsIndication Sheet E4

Clinical Procedure by Assoc. Prof. Dr. Dietmar Weng, Private Practice, Starnberg, Germany

> Ridge preservation following tooth extraction in an alveolus with buccal bone wall defect in preparation for later implantation

3154

3.1/

120

5/en

Area

Bone situation

Soft tissue situation

Implantation

n aesthetic region n non-aesthetic regionn single tooth gap n multiple tooth gap

n bone defect present n no bone defect present

n recession n no recession

n thick biotype n thin biotype

n primary wound closure possible n primary wound closure not possible

n sufficient keratinised mucosa n insufficient keratinised mucosa

n unremarkable

n at the same time as n following bone augmentation (1 step) bone augmentation (2 steps)

1. Indication profile

1 Weng D, Nagata MJH, Bell M, Bosco AF, Melo LGN, Richter EJ: Influence of microgap location and configuration on the periimplant bone morphology in submerged implants. An experimental study in dogs. Clin Oral Implants Res 19:1141-1147 (2008)

2 Araújo MG, Lindhe J: Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 32:212-218 (2005)3 Weng D, Stock V, Schliephake H: Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaining the tissues of the alveolar ridge? Eur J Oral Implantol 4 (Suppl):

p59-p66 (2011) (Proceedings of the 1st Consensus Conference of the German Association of Oral Implantology)

Literature references

Providers> Gelatin sponge: Gelastypt®, sanofi-aventis, Frankfurt, Germany

> Implant system: ANKYLOS® C/X, Dentsply Friadent GmbH, Mannheim, Germany

> Suture material: Seralene® 6-0, Serag-Wiessner KG, Naila, Germany

> Geistlich Bio-Oss® Collagen + Geistlich Bio-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland

Contact> Assoc. Prof. Dr. Dietmar Weng, Dentistry Practice Böhm & Weng, Maximilianstraße 17, 82319 Starnberg, Germany Phone: +49-8151-652525, fax: +49-8151-652511, e-mail: dw@max-17.de, website: www.max-17.de

More indication sheets> To have these posted to you free of charge, please contact: www.geistlich.com/indicationsheets> If you do not wish to collect any more indication sheets, please unsubscribe at your local distribution partner

2 3

Dr. Dietmar Weng:Directly after tooth extraction, alveolar sockets of single- and multirooted teeth present the den-tist working in implantology with several problems. In molar alveoli, the prosthetically correct implant position is in the region of the interradicular septa. However, the drilling procedures re-quired for creating the implant osteotomy are difficult in this region and frequently lead to loss of the septa. If this is the case, primary stability can only be achieved beyond the alveolar floor in the remaining millimetres above the inferior alveolar nerve or below the maxillary sinus floor. After implantation in the molar region, the question is furthermore, what to do with the remaining gap between implant and alveolar wall. Moreover, closed healing is possible only in the rarest of cases, unless one is willing to accept large flaps and extensive periostal slitting for primary closure of the alveolus. Instead, gingiva formers are in most cases screwed onto the implant for open healing, which in turn means that higher requirements with regard to primary stability must be met. In single-rooted alveoli, the implant osteotomy must be performed along the oblique plane of the oral alveolar wall in order to be able to position the implant slightly more oralwards. This is neces-sary due to the microgap activity of most implant systems1, and in order to create a fillable com-pensatory space between implant and vestibular alveolar wall to make up for the vertical compo-nent of post-extractional bundle bone loss along the thin vestibular alveolar wall2. The purpose of this vestibular “air bag” is to prevent hard and soft tissue recession later on.If these challenges to a three-dimensionally successful immediate implantation in prosthetically correct position are to be avoided, or if the residual alveoli are too defective or inflamed for im-mediate implantation, ridge preservation must be considered3. In defective alveoli (> 1.5 mm height loss in one or more alveolar walls and/or presence of apical fenestration, e.g. due to previous root tip resection), ridge preservation as in the case described here is performed. The procedure for intact alveoli is identical, except that no membrane is required because four walls are present.

Medication used: Clindamycin (2 x 600 mg for 7 days), ibuprofen (2 x 600 mg for 3 days), chlorhexidine digluconate 0.1% (twice daily for 4-6 weeks)

Background information

2. Treatment objectives > The aim of ridge preservation therapy is to completely transform the alveolar inner space still

present at extraction into a hard-tissue implant bed with minimal surgical intervention and without flap formation, and furthermore to regenerate the already missing alveolar portions by applying the GBR technique.

Fig. 1 Tooth 46 had been fitted with a full cast crown following endodontic treatment. Clinical examination revealed significantly increased mesio-buccal probing depths.

Fig. 2 A region with markedly decreased radi-opacity can be seen along the mesial root. After consulting with the endodontist, the tooth was assessed as not worth preserving due to suspected longitudinal fracture.

Fig 3 After removal of the crown and bucco-lingual separation, the two halves of the tooth were removed atraumatically from the alveolus.

Fig. 4 The longitudinal fracture of the mesial root was confirmed when the tooth was extracted.

Fig. 5 The mesio-buccal gingiva height as measured with a probe placed on the remaining alveolar wall was 10 mm, i.e. the vertical loss of alveolar wall was 7 mm.

Fig. 7 The alveolar space was filled up with Geistlich Bio-Oss® Collagen. Condensing of the material right into the apical root areas was not performed.

Fig. 8 The open part of the Geistlich Bio-Gide® membrane was inserted lingually between the periosteum and the alveolar wall.

Fig. 9 A gelatine sponge was placed on the Geistlich Bio-Gide® membrane and secured in position with a horizontal cross suture for initial crestal wound closure.

Fig. 10 Status at suture removal 6 days after ridge preservation treatment.

Fig. 11 Status 4 weeks after ridge preservation treat-ment.

Fig. 12 Status on the day of implantation 6 months after ridge preservation treatment.

Fig. 13 Ridge incision reveals a horizontally very well preserved ridge. The original mesio-buccal dehiscence defect has been regenerated.

Fig. 14 An Ankylos C/X implant measuring 4.5 x 9.5 mm was inserted. After insertion, a bone wall 1.5 mm thick was present on the buccal side of the implant.

Fig. 15 The flaps could be closed again tension-free with a two-row suture closure without periostal slitting.

Fig. 6 The periosteum was lifted off the buccal bone wall over a vertical stretch of 3-4 mm using a blunt micro-raspatory, and a Geistlich Bio-Gide® membrane was inserted into the space between the periost and the alveolar wall.

3. Surgical procedure

Fig. 19 A single-component sulcus former was screwed on after minimally invasive exposure.

Fig. 20 The single-tooth radiograph taken imme-diately after exposure shows the radiologically osseointegrated implant with more advanced ossification of the peri-implant hard tissue.

Fig. 21 Status of the soft tissue funnel 4 weeks after implant exposure on the day of fitting of the superstructure.

Fig. 16 The postoperative radiograph shows an adequate safety distance to the inferior alveolar nerve as well as the still ongoing ossification in the region of the former alveolar parts.

Fig. 17 Wound healing 1 week after implantation. Fig. 18 Status 4 months after implantation on the day of implant exposure.

Fig. 22 Individual CAD/CAM titanium post screwed onto the implant with 15 Ncm.

Fig. 23 VMK crown after being cemented onto the implant post.

Fig. 24 The buccal view reveals that the soft tissue boundary in the central buccal region is higher than before the tooth was extracted.

Fig. 25 Single-tooth radiograph after crown cemen-tation to check for excess cement.

4

2 3

Dr. Dietmar Weng:Directly after tooth extraction, alveolar sockets of single- and multirooted teeth present the den-tist working in implantology with several problems. In molar alveoli, the prosthetically correct implant position is in the region of the interradicular septa. However, the drilling procedures re-quired for creating the implant osteotomy are difficult in this region and frequently lead to loss of the septa. If this is the case, primary stability can only be achieved beyond the alveolar floor in the remaining millimetres above the inferior alveolar nerve or below the maxillary sinus floor. After implantation in the molar region, the question is furthermore, what to do with the remaining gap between implant and alveolar wall. Moreover, closed healing is possible only in the rarest of cases, unless one is willing to accept large flaps and extensive periostal slitting for primary closure of the alveolus. Instead, gingiva formers are in most cases screwed onto the implant for open healing, which in turn means that higher requirements with regard to primary stability must be met. In single-rooted alveoli, the implant osteotomy must be performed along the oblique plane of the oral alveolar wall in order to be able to position the implant slightly more oralwards. This is neces-sary due to the microgap activity of most implant systems1, and in order to create a fillable com-pensatory space between implant and vestibular alveolar wall to make up for the vertical compo-nent of post-extractional bundle bone loss along the thin vestibular alveolar wall2. The purpose of this vestibular “air bag” is to prevent hard and soft tissue recession later on.If these challenges to a three-dimensionally successful immediate implantation in prosthetically correct position are to be avoided, or if the residual alveoli are too defective or inflamed for im-mediate implantation, ridge preservation must be considered3. In defective alveoli (> 1.5 mm height loss in one or more alveolar walls and/or presence of apical fenestration, e.g. due to previous root tip resection), ridge preservation as in the case described here is performed. The procedure for intact alveoli is identical, except that no membrane is required because four walls are present.

Medication used: Clindamycin (2 x 600 mg for 7 days), ibuprofen (2 x 600 mg for 3 days), chlorhexidine digluconate 0.1% (twice daily for 4-6 weeks)

Background information

2. Treatment objectives > The aim of ridge preservation therapy is to completely transform the alveolar inner space still

present at extraction into a hard-tissue implant bed with minimal surgical intervention and without flap formation, and furthermore to regenerate the already missing alveolar portions by applying the GBR technique.

Fig. 1 Tooth 46 had been fitted with a full cast crown following endodontic treatment. Clinical examination revealed significantly increased mesio-buccal probing depths.

Fig. 2 A region with markedly decreased radi-opacity can be seen along the mesial root. After consulting with the endodontist, the tooth was assessed as not worth preserving due to suspected longitudinal fracture.

Fig 3 After removal of the crown and bucco-lingual separation, the two halves of the tooth were removed atraumatically from the alveolus.

Fig. 4 The longitudinal fracture of the mesial root was confirmed when the tooth was extracted.

Fig. 5 The mesio-buccal gingiva height as measured with a probe placed on the remaining alveolar wall was 10 mm, i.e. the vertical loss of alveolar wall was 7 mm.

Fig. 7 The alveolar space was filled up with Geistlich Bio-Oss® Collagen. Condensing of the material right into the apical root areas was not performed.

Fig. 8 The open part of the Geistlich Bio-Gide® membrane was inserted lingually between the periosteum and the alveolar wall.

Fig. 9 A gelatine sponge was placed on the Geistlich Bio-Gide® membrane and secured in position with a horizontal cross suture for initial crestal wound closure.

Fig. 10 Status at suture removal 6 days after ridge preservation treatment.

Fig. 11 Status 4 weeks after ridge preservation treat-ment.

Fig. 12 Status on the day of implantation 6 months after ridge preservation treatment.

Fig. 13 Ridge incision reveals a horizontally very well preserved ridge. The original mesio-buccal dehiscence defect has been regenerated.

Fig. 14 An Ankylos C/X implant measuring 4.5 x 9.5 mm was inserted. After insertion, a bone wall 1.5 mm thick was present on the buccal side of the implant.

Fig. 15 The flaps could be closed again tension-free with a two-row suture closure without periostal slitting.

Fig. 6 The periosteum was lifted off the buccal bone wall over a vertical stretch of 3-4 mm using a blunt micro-raspatory, and a Geistlich Bio-Gide® membrane was inserted into the space between the periost and the alveolar wall.

3. Surgical procedure

Fig. 19 A single-component sulcus former was screwed on after minimally invasive exposure.

Fig. 20 The single-tooth radiograph taken imme-diately after exposure shows the radiologically osseointegrated implant with more advanced ossification of the peri-implant hard tissue.

Fig. 21 Status of the soft tissue funnel 4 weeks after implant exposure on the day of fitting of the superstructure.

Fig. 16 The postoperative radiograph shows an adequate safety distance to the inferior alveolar nerve as well as the still ongoing ossification in the region of the former alveolar parts.

Fig. 17 Wound healing 1 week after implantation. Fig. 18 Status 4 months after implantation on the day of implant exposure.

Fig. 22 Individual CAD/CAM titanium post screwed onto the implant with 15 Ncm.

Fig. 23 VMK crown after being cemented onto the implant post.

Fig. 24 The buccal view reveals that the soft tissue boundary in the central buccal region is higher than before the tooth was extracted.

Fig. 25 Single-tooth radiograph after crown cemen-tation to check for excess cement.

4

2 3

Dr. Dietmar Weng:Directly after tooth extraction, alveolar sockets of single- and multirooted teeth present the den-tist working in implantology with several problems. In molar alveoli, the prosthetically correct implant position is in the region of the interradicular septa. However, the drilling procedures re-quired for creating the implant osteotomy are difficult in this region and frequently lead to loss of the septa. If this is the case, primary stability can only be achieved beyond the alveolar floor in the remaining millimetres above the inferior alveolar nerve or below the maxillary sinus floor. After implantation in the molar region, the question is furthermore, what to do with the remaining gap between implant and alveolar wall. Moreover, closed healing is possible only in the rarest of cases, unless one is willing to accept large flaps and extensive periostal slitting for primary closure of the alveolus. Instead, gingiva formers are in most cases screwed onto the implant for open healing, which in turn means that higher requirements with regard to primary stability must be met. In single-rooted alveoli, the implant osteotomy must be performed along the oblique plane of the oral alveolar wall in order to be able to position the implant slightly more oralwards. This is neces-sary due to the microgap activity of most implant systems1, and in order to create a fillable com-pensatory space between implant and vestibular alveolar wall to make up for the vertical compo-nent of post-extractional bundle bone loss along the thin vestibular alveolar wall2. The purpose of this vestibular “air bag” is to prevent hard and soft tissue recession later on.If these challenges to a three-dimensionally successful immediate implantation in prosthetically correct position are to be avoided, or if the residual alveoli are too defective or inflamed for im-mediate implantation, ridge preservation must be considered3. In defective alveoli (> 1.5 mm height loss in one or more alveolar walls and/or presence of apical fenestration, e.g. due to previous root tip resection), ridge preservation as in the case described here is performed. The procedure for intact alveoli is identical, except that no membrane is required because four walls are present.

Medication used: Clindamycin (2 x 600 mg for 7 days), ibuprofen (2 x 600 mg for 3 days), chlorhexidine digluconate 0.1% (twice daily for 4-6 weeks)

Background information

2. Treatment objectives > The aim of ridge preservation therapy is to completely transform the alveolar inner space still

present at extraction into a hard-tissue implant bed with minimal surgical intervention and without flap formation, and furthermore to regenerate the already missing alveolar portions by applying the GBR technique.

Fig. 1 Tooth 46 had been fitted with a full cast crown following endodontic treatment. Clinical examination revealed significantly increased mesio-buccal probing depths.

Fig. 2 A region with markedly decreased radi-opacity can be seen along the mesial root. After consulting with the endodontist, the tooth was assessed as not worth preserving due to suspected longitudinal fracture.

Fig 3 After removal of the crown and bucco-lingual separation, the two halves of the tooth were removed atraumatically from the alveolus.

Fig. 4 The longitudinal fracture of the mesial root was confirmed when the tooth was extracted.

Fig. 5 The mesio-buccal gingiva height as measured with a probe placed on the remaining alveolar wall was 10 mm, i.e. the vertical loss of alveolar wall was 7 mm.

Fig. 7 The alveolar space was filled up with Geistlich Bio-Oss® Collagen. Condensing of the material right into the apical root areas was not performed.

Fig. 8 The open part of the Geistlich Bio-Gide® membrane was inserted lingually between the periosteum and the alveolar wall.

Fig. 9 A gelatine sponge was placed on the Geistlich Bio-Gide® membrane and secured in position with a horizontal cross suture for initial crestal wound closure.

Fig. 10 Status at suture removal 6 days after ridge preservation treatment.

Fig. 11 Status 4 weeks after ridge preservation treat-ment.

Fig. 12 Status on the day of implantation 6 months after ridge preservation treatment.

Fig. 13 Ridge incision reveals a horizontally very well preserved ridge. The original mesio-buccal dehiscence defect has been regenerated.

Fig. 14 An Ankylos C/X implant measuring 4.5 x 9.5 mm was inserted. After insertion, a bone wall 1.5 mm thick was present on the buccal side of the implant.

Fig. 15 The flaps could be closed again tension-free with a two-row suture closure without periostal slitting.

Fig. 6 The periosteum was lifted off the buccal bone wall over a vertical stretch of 3-4 mm using a blunt micro-raspatory, and a Geistlich Bio-Gide® membrane was inserted into the space between the periost and the alveolar wall.

3. Surgical procedure

Fig. 19 A single-component sulcus former was screwed on after minimally invasive exposure.

Fig. 20 The single-tooth radiograph taken imme-diately after exposure shows the radiologically osseointegrated implant with more advanced ossification of the peri-implant hard tissue.

Fig. 21 Status of the soft tissue funnel 4 weeks after implant exposure on the day of fitting of the superstructure.

Fig. 16 The postoperative radiograph shows an adequate safety distance to the inferior alveolar nerve as well as the still ongoing ossification in the region of the former alveolar parts.

Fig. 17 Wound healing 1 week after implantation. Fig. 18 Status 4 months after implantation on the day of implant exposure.

Fig. 22 Individual CAD/CAM titanium post screwed onto the implant with 15 Ncm.

Fig. 23 VMK crown after being cemented onto the implant post.

Fig. 24 The buccal view reveals that the soft tissue boundary in the central buccal region is higher than before the tooth was extracted.

Fig. 25 Single-tooth radiograph after crown cemen-tation to check for excess cement.

4

5 61

© Geistlich Pharma AGBusiness Unit BiomaterialsCH-6110 Wolhusenphone +41 41 492 56 30 fax +41 41 492 56 39www.geistlich-pharma.com

Extraction SocketsIndication Sheet E4

Clinical Procedure by Assoc. Prof. Dr. Dietmar Weng, Private Practice, Starnberg, Germany

> Ridge preservation following tooth extraction in an alveolus with buccal bone wall defect in preparation for later implantation

3154

3.1/

120

5/en

Area

Bone situation

Soft tissue situation

Implantation

n aesthetic region n non-aesthetic regionn single tooth gap n multiple tooth gap

n bone defect present n no bone defect present

n recession n no recession

n thick biotype n thin biotype

n primary wound closure possible n primary wound closure not possible

n sufficient keratinised mucosa n insufficient keratinised mucosa

n unremarkable

n at the same time as n following bone augmentation (1 step) bone augmentation (2 steps)

1. Indication profile

1 Weng D, Nagata MJH, Bell M, Bosco AF, Melo LGN, Richter EJ: Influence of microgap location and configuration on the periimplant bone morphology in submerged implants. An experimental study in dogs. Clin Oral Implants Res 19:1141-1147 (2008)

2 Araújo MG, Lindhe J: Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 32:212-218 (2005)3 Weng D, Stock V, Schliephake H: Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaining the tissues of the alveolar ridge? Eur J Oral Implantol 4 (Suppl):

p59-p66 (2011) (Proceedings of the 1st Consensus Conference of the German Association of Oral Implantology)

Literature references

Providers> Gelatin sponge: Gelastypt®, sanofi-aventis, Frankfurt, Germany

> Implant system: ANKYLOS® C/X, Dentsply Friadent GmbH, Mannheim, Germany

> Suture material: Seralene® 6-0, Serag-Wiessner KG, Naila, Germany

> Geistlich Bio-Oss® Collagen + Geistlich Bio-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland

Contact> Assoc. Prof. Dr. Dietmar Weng, Dentistry Practice Böhm & Weng, Maximilianstraße 17, 82319 Starnberg, Germany Phone: +49-8151-652525, fax: +49-8151-652511, e-mail: dw@max-17.de, website: www.max-17.de

More indication sheets> To have these posted to you free of charge, please contact: www.geistlich.com/indicationsheets> If you do not wish to collect any more indication sheets, please unsubscribe at your local distribution partner

5 61

© Geistlich Pharma AGBusiness Unit BiomaterialsCH-6110 Wolhusenphone +41 41 492 56 30 fax +41 41 492 56 39www.geistlich-pharma.com

Extraction SocketsIndication Sheet E4

Clinical Procedure by Assoc. Prof. Dr. Dietmar Weng, Private Practice, Starnberg, Germany

> Ridge preservation following tooth extraction in an alveolus with buccal bone wall defect in preparation for later implantation

3154

3.1/

120

5/en

Area

Bone situation

Soft tissue situation

Implantation

n aesthetic region n non-aesthetic regionn single tooth gap n multiple tooth gap

n bone defect present n no bone defect present

n recession n no recession

n thick biotype n thin biotype

n primary wound closure possible n primary wound closure not possible

n sufficient keratinised mucosa n insufficient keratinised mucosa

n unremarkable

n at the same time as n following bone augmentation (1 step) bone augmentation (2 steps)

1. Indication profile

1 Weng D, Nagata MJH, Bell M, Bosco AF, Melo LGN, Richter EJ: Influence of microgap location and configuration on the periimplant bone morphology in submerged implants. An experimental study in dogs. Clin Oral Implants Res 19:1141-1147 (2008)

2 Araújo MG, Lindhe J: Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 32:212-218 (2005)3 Weng D, Stock V, Schliephake H: Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaining the tissues of the alveolar ridge? Eur J Oral Implantol 4 (Suppl):

p59-p66 (2011) (Proceedings of the 1st Consensus Conference of the German Association of Oral Implantology)

Literature references

Providers> Gelatin sponge: Gelastypt®, sanofi-aventis, Frankfurt, Germany

> Implant system: ANKYLOS® C/X, Dentsply Friadent GmbH, Mannheim, Germany

> Suture material: Seralene® 6-0, Serag-Wiessner KG, Naila, Germany

> Geistlich Bio-Oss® Collagen + Geistlich Bio-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland

Contact> Assoc. Prof. Dr. Dietmar Weng, Dentistry Practice Böhm & Weng, Maximilianstraße 17, 82319 Starnberg, Germany Phone: +49-8151-652525, fax: +49-8151-652511, e-mail: dw@max-17.de, website: www.max-17.de

More indication sheets> To have these posted to you free of charge, please contact: www.geistlich.com/indicationsheets> If you do not wish to collect any more indication sheets, please unsubscribe at your local distribution partner