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Case report

Vertical augmentation with granulate graft

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Large vertical augmentations require a staged approach that may consist of several treatment steps to ensure optimal hard and soft tissue results, as ­presented in this complex case.

Prof. Massimo Simion | Italy, Dr. Stefano Pieroni | Italy

The patient was a 55-year old female, non-smoker in good systemic and periodontal health. Teeth 11, 21, 23, 24 had to be extracted due to extreme periodontal attachment loss. The extraction sockets were filled with Geistlich Bio-Oss® Collagen, and a free gingival graft was used to close the cavity and enhance clot formation. After 4 months, vertical bone augmentations were performed: two non-resorbable titanium-reinforced membranes protected grafts consisting of a 1:1 mixture of autogenous bone and Geistlich Bio-Oss®. The membranes were fixed by four bone fixation pins and sustained by a tenting screw, which was exposed over the portion corresponding to the vertical defect. Periosteal releasing incisions allowed the flap to be advanced coronally. The flap was sutured using horizontal mattress U-stitches to ensure proper flap apposition.

Six months later, machined implants were inserted, and a horizontal bone augmentation was performed using Geistlich Bio-Oss® and Geistlich Bio-Gide® to enhance the esthetic outcome.

After another four months, the soft-tissue thickness was augmented using a Geistlich Mucograft® collagen matrix. Two months later minimally invasive re-entry allowed the connection of the implant abutment and the beginning of prosthetic procedures.

Are there any special considerations?

Vertical bone augmentation by means of Guided Bone Regeneration (GBR) is a well-documented procedure that insures good long-term results.1–6 It allows a proper prosthetic rehabilitation with a crown length ideally proportioned to the adjacent teeth. However, the efficacy of this technique strictly depends on a standardized surgical protocol.

Ridge Preservation techniques may be performed to minimize soft tissue and bone contraction that generally follow tooth extraction.7 Eventually, a horizontal GBR in relation to implant positioning and a soft-tissue augmentation may be performed to increase tissue thickness, resulting in a better blood supply and very good long-term stability of the peri-implant tissues.

Prof. Massimo Simion

Prof. Massimo Simion | Italy

Full Professor, Department of Implantology
UOC Maxillofacial Surgery & Odontostomatology
Fondazione IRCCS Ospedale Policlinico, Milan

Dr. Stefano Pieroni

Dr. Stefano Pieroni | Italy

Department of Implantology
UOC Maxillofacial Surgery & Odontostomatology
Fondazione IRCCS Ospedale Policlinico, Milan

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