Major Bone Augmentation
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Dr. Christopher Ho
Advanced Ridge Augmentation with 3-D Printed Titanium Scaffold
The Situation A 34-year-old female was referred for rehabilitation of her partially edentulous maxillary dentition; a situation which she has endured since her early teenage years. She has been wearing a removable partial denture ever since failure of her fixed dental bridgework. The patient was keen on an implant
solution to manage her situation, originally requesting an allon-four implant rehabilitation of her maxillary arch. She was medically healthy, a non-smoker, and taking oral contraceptive medication. Clinical examination revealed extensive horizontal and vertical ridge deficiencies with a knife-edge ridge.
The Risk Profile Low Risk
Medium Risk
High Risk
Patient’s health
I ntact immune system/ Non-smoker
Light smoker
I mpaired immune system/ Heavy smoker
Patient’s esthetic requirements
Low
Medium
High
Height of smile line
Low
Medium
High
Gingival biotype
Thick – “low scalloped”
Medium – “medium scalloped”
Thin – “high scalloped”
Shape of dental crowns
Rectangular
Infection at implant sight
None
Chronic
Acute
Bone height at adjacent tooth site
≤ 5 mm from contact point
5.5 - 6.5 mm from contact point
≥ 7 mm from contact point
Restorative status of adjacent tooth
Intact
Width of tooth gap
1 tooth (≥ 7 mm)
Soft-tissue anatomy
Intact
Bone anatomy of the alveolar ridge
No defect
Triangular
Restored 1 tooth (≤ 7 mm)
2 teeth or more Compromised
Horizontal defect
Dr. Christopher Ho BDS Hons (SYD), Grad Dip Clin Dent (Oral Implants) (SYD), M Clin Dent (Pros) (LON), D Clin Dent (Pros) (SYD) Dr. Christopher Ho is a Specialist Prosthodontist with a Bachelor of Dental Surgery with First Class Honours at the University of Sydney. He completed postgraduate studies in the Graduate Diploma in Clinical Dentistry in Oral Implants, Masters of Clinical Dentistry in Prosthodontics with Distinction from the University of London and Doctorate in Clinical Dentistry in Prosthodontics from University of Sydney. He is Editor of the Wiley textbook “Practical Procedures in Aesthetic Dentistry” and “Practical Procedures in Implant Dentistry.”
Vertical defect
® “Yxoss CBRhad “The patient enables a customised a failing crown reconstruction correwith compromised sponding precisely soft-tissue andto the desired bone volume and re quested a single crown contour, without the need rehabilitation with of harvesting shaping improved and esthetics.„ bone blocks.”
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The Approach
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The goal was to re-establish sufficient ridge volume for dental implant rehabilitation. Advanced postextraction ridge resorption necessitated both horizontal and vertical augmentation. Due to the large extent of the defect and need to ensure long-term volume stability, a slowly resorbing bovine bone augmentation material (Geistlich Bio-Oss®) was combined with autologous bone to establish the foundation for bone regeneration. The mixture was stabilised with an Yxoss CBR® titanium scaffold. A resorbable collagen barrier membrane (Geistlich Bio-Gide®) was draped over the scaffold to ensure separation of the osseous and soft tissues during the early healing phase. The underlying regenerating bone was well-supported and protected by Yxoss CBR® and Geistlich Bio-Gide®. The intaglio surface of the removable dental prosthesis was relieved such that minimal pressure would be applied to the healing soft tissues.
The Outcome 7
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The patient presented with an extensive bone defect making ridge reconstruction particularly challenging. Use of the volume-stabilising Geistlich Bio-Oss® shaped by the innovative Yxoss CBR® 3-D titanium scaffold enabled reconstruction of the ridge to the correct anatomical form. Despite a minor dehiscence of the flap during the healing phase, which sometimes occurs, the ridge augmentation was successfully achieved in a controlled and efficient manner.
| 1 Pre-operative frontal photograph of partially edentulous condition with horizontal and vertical defects. | 2 Pre-operative occlusal photograph of partially edentulous condition. Note the large horizontal deficiency in bone. | 3 3-D volume rendering of the partially edentulous site, with the through and through defect within the ridge contour and view of the thin nature of the ridge with the associated minimal radiopacity. | 4 Cross-sectional slices of CBCT displaying knife edge contour of alveolar ridge with minimal ridge dimensions. | 5 3-D modelling from DICOM files with the extensive deficiency of bone and with Yxoss CBR® titanium scaffold. | 6 Yxoss CBR® filled with a 50:50 mixture of autologous bone and bovine bone substitute (Geistlich Bio-Oss®). 1.2 mm fixation screws used to stabilize the scaffold. | 7 Note the extension of the flap to include one further tooth for vertical incision to allow flap elevation and tension-free closure. | 8 Porcine collagen membrane (Geistlich Bio-Gide®) applied to cover Yxoss CBR® to allow for guided bone regeneration. | 9 Implant placement with healing abutments. | 10 Placement of multi-unit abutments for fabrication of implant supported bridgework. | 11 Final zirconia/ titanium implant supported bridgework. | 12 Final broad smile.
Keys to Success More details about our distribution partners: www.geistlich-biomaterials.com Manufacturer Geistlich Pharma AG Bahnhofstrasse 40 6110 Wolhusen, Switzerland Phone +41 41 492 55 55 Fax +41 41 492 56 39 www.geistlich-biomaterials.com Affiliate Australia and New Zealand Geistlich Pharma Australia and New Zealand The Zenith – Tower A Level 19, Suite 19.01 821 Pacific Highway NSW 2067 Chatswood, Australia Phone +61 1800 776 326 Fax +61 1800 709 698 info@geistlich.com.au www.geistlich.com.au Affiliate Great Britain and Ireland Geistlich Sons Limited 1st Floor, Thorley House Bailey Lane Manchester Airport Manchester M90 4AB, Great Britain Phone +44 161 490 2038 Fax +44 161 498 6988 info@geistlich.co.uk www.geistlich.co.uk
Stabilization of 3-D titanium scaffold and membrane Flap design and tension-free closure Use of deproteinized bovine bone mineral with low substitution rate and autologous bone (50:50 ratio) Importance of keratinized tissue for soft tissue stability Relief of provisional prosthesis to reduce pressure on the underlying healing tissues
Complex ridge bone defects present with the challenge of not just creating the bony quantity required for placement of implants, but additional difficulty to rebuild the correct anatomical contour. The use of Yxoss CBR® titanium scaffold allowed the reconstruction of bone volume with a pre-planned augmentation that allows correct prosthetic outcomes. Due to the large bone defect the use of autologous bone combined with the volume stabilizing Geistlich Bio-Oss® allows for augmentation in a successful and predictable manner.
Affiliate North America
Distribution Canada HANSAmed Ltd. 2830 Argentia Road Unit 5–8 L5N 8G4 Mississauga, Canada Phone +1 800 363 2876 Fax +1 800 863 3213 orders@hansamed.net www.hansamed.net
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Geistlich Pharma North America, Inc. 902 Carnegie Center, Suite 360 Princeton, NJ 08540 Phone +1 855 799 5500 info@geistlich-na.com www.geistlich-na.com