focus outside the box background soft tissue hope …...journal club 23 milestone studies. 23 an...

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Soft tissue regeneration.Tackle soft tissue in daily practice. New strategies and therapeutic options.

BACKGROUND PAGE 30

Breakthrough solutions.Collagen products and customizeddevices. From bench to chairside there is something new going on.

OUTSIDE THE BOX PAGE 27

Hope from 3-D printing.Living tissues from 3-D bio-printers.A solution for overcoming the shortage of donor organs.

GEISTLICH BIOMATERIALS

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VOLUME 11, ISSUE 2, 2017

100 GEISTLICH NEWS 2-2017

LEADING REGENERATION.

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Issue 2 | 2017CONTENTS

EDITORIAL

4 Put to the acid test.FOCUS

5 Soft tissue management. 6 Soft tissue management with Geistlich Fibro-Gide®

Head of Academic Unit Daniel Thoma | Switzerland

9 Using a 3-D collagen matrix for a vestibuloplasty Dr. Christian Schmitt | Germany

13 How to create suffi cient volume and keratinized tissue Ass. Prof. Ignacio Sanz Martin, Prof. Mariano Sanz | Spain

16 A less invasive technique for greater successDr. Yoon Euy Hong | South Korea

19 Proper flap and suture techniques are key to successDr. Luca De Stavola | Italy

JOURNAL CLUB

23 Milestone studies. 23 An update on soft tissue management with collagen matrices

Dr. Nikolas Epp | Geistlich Pharma AG

OUTSIDE THE BOX

27 Hope from 3-D printing.GEISTLICH PHARMA AG | OSTEOLOGY FOUNDATION

30 Background. 31 New publication from Osteology Foundation

32 “It’s not only science. There is a lot of art involved.”

34 Two innovative solutions for soft tissue regeneration

36 A new treatment solution for major bone defects

INTERVIEW

38 A chat with Jung-Chul Park. 39 Publishing information


Put to the acid test.Editorial

“Drive slowly, we’re in a hurry.”That is how it is said a certain Winston Churchill, when late for an important meeting, once instructed his chauffeur. At Geistlich we understand the underlying meaning of this state-ment and are acting accordingly before launching the vol-ume-stable Geistlich Fibro-Gide® collagen matrix. Over a year ago this product was awarded the CE mark certifying its mar-ketability in Europe. Though a required confirmation, we at Geistlich consider the CE mark necessary but not sufficient to warrant a product launch. For this reason Fibro-Gide® is in a “pre-launch phase,” where it is undergoing the acid test of clin-ical experts before it is offered for general sale to all interest-ed dentists.At the same time we are preparing a wide range of training initiatives to carefully help prepare customers for the use of the product and to support their individual learning curves. Through our “blended learning” approach, customers can broaden and also strengthen their knowledge of the product’s attributes and learn clinical tips and tricks in traditionally for-matted, hands-on courses or e-based modules.We are proud to be able to take you along this new product path with us, and we wish you long-term success treating your patients.

Reto Falk Mirko ZinggDirector International Director InternationalMarketing Services Product Management

Change Signa-ture

This one is from Zingg

Falk in attach-ment

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SOFT TISSUE MANAGEMENT.Recession coverage, gain of keratinized tissue and augmentation of soft tissue volume. A clinical update from gold standards and new alternatives.

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and numerous articles have been pub-lished documenting their effectiveness, safety and long-term stability.6,7 Limita-tions and disadvantages of autologous tissue grafts include:

› The height, length and thickness of the donor tissue vary according to anatomic dimensions of the pala-tal vault,8

› Length and thickness are limited by anatomy, like a thick alveolar process, exostoses and the palatine nerves and blood vessels,9,10

› For several weeks following sur-gery, patients often complain about pain and numbness, especially at the donor site.11,12

In order to overcome these issues and reduce the morbidity due to graft har-vest, research activities have focused on the development of soft tissue graft sub-stitutes from various sources and for a number of clinical indications.13 For soft tissue volume augmentation a suitable biomaterial must provide volume sta-bility over time and favorable biological behavior that allows normal modeling and remodeling processes.

Development of Geistlich Fibro-Gide® Recently a 3-D stable, collagen matrix (Geistlich Fibro-Gide®) was developed. The biomaterial has been tested over

ten-years in numerous in vitro, preclin-i cal and clinical models that demon-strated:

› Favorable mechanical properties and biological attributes promot-ing the ingrowth of human fibro-blasts,14

› Favorable tissue integration and promotion of angiogenesis,15

› Non inferiority to the gold stan-dard autologous graft in terms of 2- and 3-D linear and volumetric gains.16,17

In terms of critical evidence, in a recent randomized controlled clinical trial Geistlich Fibro-Gide® was evaluated for mu cos al thickness augmentation around dental implants.4 (Fig. 1) Similar to previ-ous studies, Geistlich Fibro-Gide® pro-duced a volume increase non-inferior to autologous transplants and with rela-tive stability over a three-month period. Apart from these favorable mechanical and biological attributes, patient mor-bidity, of importance to both patients and clinicians, was reduced for Geistlich Fibro-Gide® compared with traditional connective tissue grafts.

Developing conceptPatients and clinicians have long await-ed a soft tissue substitute that not only delivers clinical performance but also addresses the major issues associated

A new volume stable soft tissue matrix enables soft tissue augmentation without using grafts from the palate. An overview of scientific data and new therapeutic options.

Soft tissue grafting procedures are in-creasingly performed for a number of indications in conjunction with dental implant therapy.1 Major clinical indica-tions include recession coverage, gain of keratinized tissue and augmentation of soft tissue volume.2-5 These periodontal plastic surgical procedures have been recommended to establish short and long-term favorable biological, func-tional and esthetic outcomes around teeth, as well as in pontic and dental im-plant sites. At dental implant sites, soft tissue volume is augmented most often to limit peri-implant marginal bone loss in the non-esthetic zone, to counteract volume loss following tooth extraction and to regenerate the buccal contour.

Current conceptCurrent concepts for augmenting soft tissue volume in a vertical and/or buc-cal direction are based on the use of au-tologous tissue that is harvested most often from the palatal area. These trans-plants have a long tradition in dentistry,

Head of Academic Unit Daniel Thoma, SwitzerlandClinic of Fixed and RemovableProsthodontics and Dental Material ScienceCenter for Dental MedicineUniversity of Zurich

Soft tissue management with Geistlich Fibro-Gide®

New therapeutic option

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| A Frontal view of esthetic area – mucosal gray show-through of implant in position 11. | B Probing in position 11 produces pus exudation. | C Radiograph showing misfit of implant-borne crown 11 and marginal bone loss. | D Implant-borne crown removed. Excess cement and failure of cementation visible. | E Occlusal view of implant site reveals a major buccal tissue deficit. | F–G A split-thickness pouch is prepared using a sharp blade and a microsurgical elevator. | H Geistlich Fibro-Gide® is shaped and prospectively positioned. | I Geistlich Fibro-Gide® is fixated on the palatal side of the implant with non-resorbable suture and placed in the buccal pouch. Blanched tissue area demonstrates augmentation. | J Occlusal view following surgical procedure. | K Buccal view following surgical procedure. | L Final view after insertion of new implant. No more show-through of implant 11. Peri-implant tissues are healthy and do not bleed upon probing. (Lab work: Dental Technician Andrea Patrizi).

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FIG. 1: SOFT TISSUE AUGMENTATION WITH GEISTLICH FIBRO-GIDE®

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with autologous transplants. Given the benefits of Geistlich Fibro-Gide® and based on current knowledge and experi-ence, clinicians will soon be able to offer a choice when an increase in mucosal thickness is desired. Having a choice will certainly increase the demand and broaden clinical indications, thereby improving therapies with dental im-plants and fixed-tooth-supported re-constructions.

Geistlich Fibro-Gide® is suitable for the following indications:

› Delayed implants with concomitant soft tissue augmentation (simulta-neous approach),

› Delayed soft tissue augmentation at implant sites in conjunction with or prior to abutment connection, and

› Soft tissue augmentation of pontic sites.

Clinical handling and benefits of Geistlich Fibro-Gide®

Considering current knowledge, learning curve and experience associated with any innovative biomaterial, Geistlich Fibro-Gide® is suitable for various indi-ca tions and offers favorable clinical handling. At the clinician’s discretion, Geistlich Fibro-Gide® can be cut and shaped to the appropriate size dry, wet

or even in an intermediate condition, by pre-wetting it and then letting it dry for 30–60 seconds. Once placed at the de -si red site, Geistlich Fibro-Gide® quickly soaks up blood, slightly increasing its volume by 20–30%. If needed, the ma-trix can be sutured using resorbable or non-resorbable sutures to fix it in the desired position.Preliminary feedback from patients re-ceiving treatment with Geistlich Fi-

bro-Gide® indicates only minimal pain. The majority of patients who had re-ceived an autologous connective tissue graft previously are enthused about and very satisfied with the matrix, primari-ly because no harvesting procedure is necessary and the clinical results fulfill the highest expectations. Apart from meeting patients’ demands, histologic data at three and four months post placement reveal a matrix body slightly degraded and yet fully integrat-ed with new blood vessels and connec-tive tissue. As a clinician and researcher I believe that Geistlich Fibro-Gide® is a break-through in soft tissue regeneration that expands our treatment options. We have been waiting for years for such a proved innovation, and, because I am confident about the clinical results and reassured by my patients, I am excited

“As a clinician and researcher I believe that Geistlich Fibro-Gide® is a breakthrough in oral soft tissue regeneration.”

to explore its use in expanded indica-tions.

References1 Thoma DS, et al.: J Clin Periodontol 2014; 41

Suppl 15: S77-91. 2 Lorenzo R, et al.: Clin Oral Implants Res 2012; 23:

316-24. 3 Basegmez C, et al.: Eur J Oral Implantol 2012; 5:

139-45.4 Thoma DS, et al.: J Clin Periodontol 2016; 43:

874-85. 5 Roccuzzo M, et al.: Clin Oral Implants Res 2014;

25: 641-46. 6 Bienz SP, et al.: Clin Oral Implants Res 2017a; 29.

[Epub ahead of print]7 Bienz SP, et al.: J Clin Periodontol 2017b; 44: 178-84. 8 Benninger B, et al.: J Oral Maxillofac Surg 2012;

70: 149-53. 9 Kim DH, et al.: Clin Anat 2014; 27: 578-84. 10 Yu SK, et al.: J Clin Periodontol 2014; 41: 908-13. 11 Zucchelli G, et al.: J Clin Periodontol 2010; 37:

728-38. 12 Griffin TJ, et al.: J Periodontol 2006; 77: 2070-79.13 Zuhr O, et al.: J Clin Periodontol 2014; 41 Suppl 15:

S123-42. 14 Mathes SH, et al.: Biotechnol Bioeng 2010; 107:

1033-43. 15 Thoma DS, et al.: Clin Oral Implants Res 2012; 23:

1333-39. 16 Thoma DS, et al.: J Clin Periodontol 2011; 38:

1063-70. 17 Thoma DS, et al.: J Clin Periodontol 2010; 37: 659-66.

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No painful graft harvest and very good color and texture match surrounding tissue. These are major advantages when perform-ing a vestibuloplasty with Geistlich Mucograft® 3-D collagen matrix. Now there is long-term data over five years.

In the last few years peri-implant soft tis-sue regeneration has acquired par ticular relevance in implantology. Liter ature is beginning to show the emergence of a tendency for an implant to be healthy, if there is a fixed, keratinized peri-implant mucosa of at least two mm in width.1 According to the current literature, the methods for widening the peri-implant keratinized mucosa are all associated with an apically positioned flap or a ves-tibuloplasty.2 A secondary granulation of the resultant wound surface is not ide al due to postoperative morbidity and wound contraction with a high tendency for muscular reattachment.2–4

Autologous grafts from the palateAutologous soft tissue grafts from the palate – such as free mucosal grafts (FMGs) or a connective tissue grafts (CTGs) – are the gold standards for cov-

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| A Clinical situation before treatment start. | B Necessity to remove tissue from the palate. | C Fixation of the FMG on the periosteum with maximum positional stability; this often requires the suture to be fixed with crossed sutures. | D Healing progress after 10 days. | E Healing progress after 3 months. | F Even after 5 years the soft tissue grafted from the palate can still be clinically distinguished from the surrounding soft tissue with respect to color and texture.

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FIG. 1: VESTIBULOPLASTY WITH AUTOLOGOUS GRAFTS

Dr. Christian Schmitt, GermanyClinic of Oral and Maxillofacial Surgery University Clinic Erlangen-NurembergErlangen

Using a 3-D collagen matrix for a vestibuloplasty

Keratinized tissue

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ering a wound surface. They reduce post-operative contraction and improve the regenerative result.2,3,5,6 Furthermore, autologous grafts show reproducible clinical results in terms of treatment, integration, shrinkage and long-term stability (Fig. 1). However, the following points are disadvantages of autologous tissue grafting:

1 Necessity for palatal harvest with additional surgical risks,2–4

2 Patients’ harvest site morbidity,63 Limited availability of the graft,3,44 Prolonged surgery time,2–4,6 and5 Poorly matched texture and color,

when using FMGs.4,6 (Fig. 1)

The Geistlich Mucograft® 3-D collagen matrix All these factors motivate the search for possible alternatives - chiefly absorbable collagen matrices. Their support for ep-ithelial proliferation has already been demonstrated and is partly based on in-filtration with fibroblasts and keratino-cytes and the formation of blood ves-sels.4,7 The porcine Geistlich Mucograft® 3-D collagen matrix has proven effective in open healing in numerous preclinical and clinical studies and is a good alter-native to autologous tissue (FMG and CTG).2,5,6,8 By using biomaterials as scaf-fold for ingrowth of soft tissue, there is no need to harvest autologous grafts.3,4

Geistlich Mucograft® 3-D collagen matrix consists of compact and porous collagen layers and was specially developed for oral soft tissue regeneration. The com-pact collagen layer ensures the stability of the collagen matrix. Upon insertion it should face outwards the oral cavity, where it shields against mechanical in-sults from the oral cavity and provides adequate suturing. When in direct contact with the wound bed, the porous matrix layer can biointe-grate by rapidly stabilizing the blood clot and enabling invasion of local growth factors from the graft bed for cell prolif-eration, vascularization and new tissue formation.6,7

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| A Clinical situation before treatment start | B Macroscopic view of the 3-D collagen matrix with compact and cancellous layer. | C Clinical situation immediately after inserting the collagen matrix. | D Clinical situation 10-days after surgery. | E After 3-months the freshly regenerated soft tissue has matured and exhibits keratinized morphology. The freshly regenerated soft tissue is comparable in texture and color to surrounding soft tissue. | F Clinically stable situation after 5-years. Reduction in the width of the keratinized mucosa in the course of healing (5-years). “Over-aug - mentation” equivalent to anticipated shrinkage is recommended in order to avoid recurrence.

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FIG. 2: VESTIBULOPLASTY WITH GEISTLICH MUCOGRAFT®

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FIG. 3: BIOLOGICAL MECHANISMS FOR THE FORMATION OF KERATINIZED AND

NON-KERATINIZED ORAL MUCOSA AFTER PLACEMENT OF GEISTLICH MUCOGRAFT®

Application and aftercareWhen using Geistlich Mucograft®, pa-tient selection criteria, patient compli-ance and surgical requirements should be followed, as they should for autolo-gous soft tissue transplants. After be-ing cut to the necessary shape and size, Geistlich Mucograft® 3-D collagen ma-trix is placed in a dry state on the reci pi-ent region on the periosteum. We rec-ommend the periosteum be prepared as cleanly as possible with an apical periostal fixation of the mucosal split flap to ensure an optimum immobile integration of the matrix. (Fig. 2) No

pre treatment of the collagen matrix is required. The collagen matrix should be fixed stably onto the periosteum with absorbable sutures, as gap-free as pos-sible to ensure maximum vasculariza-tion from the graft bed. As soon as it is

applied, the matrix is impregnated with blood from the graft bed with a conse-quent stabilization of the blood clot.3,4 (Fig. 2) After surgery the patient should be asked to treat the treatment site as gently as possible. Soft food should be

“Free mucosal grafts are contra indicated in the exposed esthetic zone.”

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Epithelium

Keratinized oral mucosaBasal cells

Residual Geistlich Mucograft®

Mucogingival junction

Non-keratinized oral mucosa

PeriosteumBone

Connective tissue signaling molecules for inducing the differentiation of basal cells towards non-keratinized oral mucosa

Connective tissue signaling molecules for inducing the differentiation of basal cells towards keratinized oral mucosa

Migration of cells signaling for kerati-nized oral mucosa into the matrix

Area where Geistlich Mucograft® has been placed

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recommended for 14 days, and patients should avoid any mechanical manip-ulation in the area of the graft, espe-cially during hygiene. Chemical plaque control can be achieved with antiseptic and antibacterial oral rinsing solutions for ten-days after surgery. If a further flap mobilization is planned in the re-gion, we recommend waiting for at least three months for the soft tissue to ma-ture. (Fig. 2)

Biological adaptation to the surrounding epitheliumHistological examinations of human tissue samples, which were taken three- to four-months after augmentation of the keratinized mucosa using free mu-cosal grafts or Geistlich Mucograft®, ex-hibit the characteristics of a multilayer keratinized squamous epithelium com-parable to native local gingiva.4,5 Immu-no-histological verification of the ex-pression patterns of the keratinization markers of the oral mucosa demonstrate the keratinization of the oral mucosa re-generated with Geistlich Mucograft®.4 When using autologous mucosa from the palate, directly after healing and also long-term over five-years, the regenerat-ed soft tissue in the target region shows no change in texture and color in com-parison to the original graft.3 (Fig. 1) This effect, which is detrimental to esthetics, can be explained by the biological deter-mination of the mucosa removed from the palate, which remains unchanged over time. This confirms the hypothesis that autologous mucosa from the palate is revascularized basally after grafting into the target region. Therefore, FMGs are contraindicated in the exposed es thet ic zone.3 When using CTGs or Geistlich Mucograft® 3-D collagen ma-trix, a clinical appearance comparable to the surrounding tissue manifests after

inte gration. The reason is that the bio-logical information from the epi theli um is absent, and an epithelial layer match-ing the target region forms after neo-ep-ithelialization of the graft.6 (Fig. 3)

Long-term stability of the graft-ed mucosaMeasurements of the shrinkage of the augmentation zone over time have re-vealed that a substantial shrinkage re-duces graft width and takes place from initial healing until three months after surgery.3,4,6 The regeneration result then stabilizes with only minimal chang-es.3 Shrinkage using autologous mu-cosa from the palate is approximately 33% after six months, and when using Geistlich Mucograft® there is no signif-icant difference at approximately 42%.3 As for operation time, the literature concurs that using collagen matrices in comparison to using autologous trans-plants from the palate shortens opera-tion time significantly by approximately 15–20 minutes.4,9 This, however, depends on the size of the region to be augment-ed and the number of grafts taken4 and is relative when small grafts are harvest-ed. Regardless, in large vestibuloplasties the quantity of available autologous tis-sue is limited, which again justifies the use of harvest graft alternatives. Long-term data over five years reveals comparatively stable regeneration suc-cess between autologous mucosa from the palate and Geistlich Mucograft® 3-D collagen matrix.3 Initial shrinkage af-ter six-months remains relatively un-changed for up to five-years. When us-ing free mucosa grafts from the palate, the total shrinkage of the augmentation zone after five years is 40.65%, and with the Geistlich Mucograft® 3-D collagen matrix, it is 52.89%, with no significant difference. After five years with free mu-

cosa grafts, the keratinized peri-implant soft tissue has a width of 8.4 ± 2.4 mm and 6.2 ± 1.2 mm with Geistlich Muco-graft®.3 Anticipated shrinkage should be planned in order to avoid unsatisfactory results and disease recurrence. We rec-ommend an “over-augmentation” equiv-alent to anticipated shrinkage. (Fig. 2)

References1 Brito C, et al.: Journal of Biomedical Materials

Research Part B, Applied Biomaterials 2014; 102: 643-50.

2 Thoma DS, et al.: J Clin Periodontol 2014; 41 Suppl 15: S77-91.

3 Schmitt CM, et al.: Clin Oral Implants Res 2015; 26(9): 1043-50.

4 Schmitt CM, et al.: Journal of periodontology 2013; 84: 914-23.

5 Nevins M, et al.: Int J Periodontics Restorative Dent 2011; 31: 367-73.

6 Sanz M, et al.: J Clin Periodontol 2009; 36: 868-76.7 Ghanaati S, et al.: Biomedical materials 2011; 6:

015010.8 Lee KH, et al.: Journal of periodontal & implant

science 2010; 40: 96-101.9 Lorenzo R, et al.: Clin Oral Implants Res 2012; 23:

316-24.

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In Periodontics, autogenous soft tissue grafts have been used broadly for a va-riety of indications, as root coverage of localized gingival recessions, tissue aug-mentation when there is insufficient keratinized tissue around teeth and vol-ume augmentation around edentulous sites. As the know-how of tissue man-agement around teeth has expanded, clinicians have opted to apply these prin-

ciples to implants.1 In current implant dentistry the focus has shifted from os-seointegration to the esthetics of implant restorations and how they integrate har-moniously with adjacent tissues.

Importance of soft tissue volume around dental implants The physiologic changes that occur after tooth extraction, which have been wide-

Suffi cient soft tissue vol-ume and keratinized tissue around implants are of importance for both the esthetics and function of implants. A clinical update on gold standards and alternatives.

How to create suffi cient volume and keratinized tissue

Soft tissue management around dental implants

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FIG. 1: SOFT TISSUE AUGMENTATION WITH AUTOGENOUS GRAFT

Ass. Prof. Ignacio Sanz MartinProf. Mariano Sanz, SpainComplutense University of MadridDepartment of Stomatology IIIMadrid

| A Site 25 presents with an implant supported restoration. Patient complains of grayish color of the mucosa and poor esthetics. Diagnosis reveals no signs of peri-implant pathology. | B Lateral image reveals signifi cant ridge deformity. | C Tunnel preparation is performed, and autogenous soft tissue from the tuberosity is grafted in the area. | D Autogenous graft is fi xed in the transition zone between implant shoulder and gingival margin. | E Final reconstruction of implant in position 25 and full coverage restoration in 26. | F Occlusal view 24-months after fi nal restoration. | G Lateral view revealing improved soft tissue contours.

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ly described in the literature, frequently create soft and hard tissue deficiencies that negatively influence the appearance of the prosthetic restoration and the peri-implant tissues.2 In the past, these clinical situations were treated primari-ly through bone regenerative techniques to regenerate ridge volume. However, more recently these bone regenerative interventions have been combined with soft tissue grafting to maximize volume gain and to restore the contours of the alveolar ridge.3 Moreover, it has been shown that tissue thickness is not only a key treatment goal for esthetics, since it significantly influences the translucen-cy and color of the peri-implant tissues, but also a goal for peri-implant muco-sa stability. Recent data have shown that thick tissues may be less prone to the initial bone loss that occurs with the establishment of the biologic width.4 For these reasons, soft tissue grafting around dental implants has become an important part of the routine interven-

tions employed in the treatment of es-thetically demanding situations.

Use of autogenous soft tissueWhen treating these clinical indications, autogenous connective tissue grafts have been shown to increase soft tis-sue contours and, therefore, to improve the harmony between restorations and adjacent tissues.5 For harvesting these autogenous grafts the most used donor sites are the anterior and posterior parts

of the palate, including the maxillary tuberosity. However, the origin of the graft may influence the thickness of the tissue grafted and, therefore, the selec-tion must be based on the amount of tis-sue augmentation needed.6 (Fig. 1)

Although there is no clear evidence that graft composition influences volume gain and stability, clinicians are inclined to harvest autogenous grafts with great-er proportions of lamina propria, since

| A Ridge deformity after implant placement at site 22 with simultaneous ridge augmentation. | B Soft tissue volume augmentation procedure. Geistlich Fibro-Gide® is applied over the buccal aspect. An island flap is performed in the palatal aspect to insure passive soft tissue closure. | C 4-months after soft tissue augmentation, occlusal image reveals improved soft tissue contours.

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FIG. 2: SOFT TISSUE AUGMENTATION WITH GEISTLICH FIBRO-GIDE®

“There is great interest to develop alternatives to soft tissue grafts that might achieve similar outcomes with reduced morbidity.”

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it is believed that this tissue, com-pared with glandular or fatty tissue, will be more stable and less prone to vol-ume change. Interestingly, graft thick-ness has been directly correlated with the amount of pain perceived by pa-tients.7 Autogenous grafts are obvious-ly associated with a greater number of post surgical complications, including bleeding and pain.For these reasons, there is great inter-est in the scientific community to devel-op and test soft tissue substitutes that might achieve similar outcomes with reduced morbidity. To date numerous graft substitutes have been reported in the literature. Allogeneic grafts have been used to in-crease the width of keratinized tissue with varying results and with significant tissue shrinkage.8 Collagen matrices have been used around teeth and implants and have proved to be effective in attaining a sta-ble band of keratinized tissue with sim-ilar outcomes compared to autogenous connective tissue grafts.9 For volume augmentation researchers are testing a new 3-D collagen matrix designed to serve as a possible substi-tute for autogenous grafts to increase the quantity of soft tissue around im-plants. A recent publication has shown promising results for this matrix when compared to autogenous connective tissue.10 (Fig. 2) For the surgical approach to soft tissue volume augmentation, bilaminar tech-niques are the most common in the available literature, either in the form of conventional flaps or tunnel prepa-rations. Conventional flaps allow for better access and graft fixation, while tunnel preparations have the advan-tage of not disturbing the interproximal tissue and, therefore, better preserving

papillae height. Regardless of the sur-gical technique, it is important that the soft tissue graft or substitute be fixed in the area most likely to create a ben-efit: the transition zone from the im-plant shoulder to the gingival margin.

Importance of keratinized mu-cosa around dental implants Besides the thickness of the peri-im-plant tissues, the width of keratinized tissue has received significant attention. Recent systematic reviews have point-ed out that there is insufficient evidence to associate peri-implant bone levels with the width of keratinized tissue11, al-though a reduced width of keratinized mucosa may be more prone to lingual plaque accumulation, bleeding on prob-ing and buccal soft tissue recession.12 Recently published longitudinal studies have indicated that patients with min-imal amounts of keratinized tissue are more prone to inflammation even with proper home and professional oral hy-giene.13 Moreover, inadequate kerati-nized tissue has been associated with brushing discomfort.14 Considering the available data, clini-cians should consider procedures aimed at preserving keratinized tissue. When there is significant displacement of the mucogingival junction after GBR proce-dures in order to facilitate access to oral hygiene in non-esthetic areas, kerati-nized tissue augmentation procedures should also be considered.

References1 Zuhr O, et al.: J Clin Periodontol 2014; 41 Suppl

15: S123-42. 2 Jung RE, et al.: Int J Periodontics Restorative Dent

2008; 28(4): 357-65. 3 Schneider D, et al.: Clin Oral Implants Res 2011;

22(1): 28-37. 4 Berglundh T, Lindhe J: J Clin Periodontol 1996;

23(10): 971-73. 5 Thoma DS, et al.: J Clin Periodontol 2014; 41

Suppl 15: S77-91. 6 Zucchelli G, et al.: Clin Oral Implants Res 2013;

24(9): 957-62. 7 Burkhardt R, et al.: J Clin Periodontol 2015; 42(3):

281-87. 8 Wei PC, et al.: J Periodontol, 2000; 71(8): 1297-305. 9 Sanz M, et al.: J Clin Periodontol 2009; 36(10):

868-76. 10 Thoma DS, et al.: J Clin Periodontol 2017; 44(2):

185-94. 11 Gobbato L, et al.: Int J Oral Maxillofac Implants

2013; 28(6): 1536-45. 12 Schrott AR, et al.: Clin Oral Implants Res 2009;

20(10): 1170-77. 13 Roccuzzo M, et al.: Clin Oral Implants Res 2016;

27(4): 491-96. 14 Souza AB, et al.: Clin Oral Implants Res 2016 ;

27(6): 650-55.

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increasing keratinization, with or with-out connective tissue grafts or graft sub-stitute biomaterials. The literature and the clinical community have supported the superior outcomes of CAF 1. The CAF includes vertical releasing incisions that allow predictable coronal advancement of the flap. However, the incisions delay post-surgical wound healing and tend to expose grafts. Therefore, many clinicians have considered alternative surgical techniques that avoid vertical incisions.The tunneling technique was first intro-duced by Zabalegui et al2 and can be used for periodontal plastic surgery in multi-ple adjacent defects. Advantages of tun-neling techniques include the absence of vertical releasing incisions, intact papil-la due to lack of papilla reflections and graft adaptability with increased blood supply2. All of these factors accelerate initial wound healing. However, tunnel-ing techniques require operator skill and experience and are rather time consum-ing. The tunneling technique can mini-mize trauma to the gingiva, and the least traumatic surgical techniques are bene-ficiall for patients and surgeons.

Clinical tips: flap technique › The coronally advanced flap is prefer-

red when dealing with thin mucosal tissue (thin biotype), since the pre pa -ration of a tunnel is likely to cause perforations or tearing of the gingiva. The coronally advanced flap is also

recommended when a greater amount of coronal advancement is planned and if the scalloped nature of the free gingiva is absent – flatly contoured gingival zenith, such as in the lower anterior region.

› The tunneling technique is ideal when working with a thick biotype,

Different techniques and biomaterials can be used for recession coverage. When is the coronally advanced flap beneficial, when a tunneling approach? Gingival recession takes place when the free gingiva migrates apical to the ce-mentoenamel junction with concurrent displacement of the biologic width com-plex, including connective tissue, root cementum and alveolar bone. This is called clinical attachment loss. It is cru-cial to understand that this phenomenon increases tooth mortality. The etiology of gingival recession is di-verse. However, if ideal periodontal flaps and grafts are selected, recession cover-age can be beneficial for patients, provid-ing satisfactory outcomes for recession coverage and gains in keratinized gingi-va. Techniques in which connective tis-sue grafts or tissue biomaterials are used with coronally advanced flaps or tunnel-ing procedures have been well-docu-mented and proven to be effective.1

Tunneling technique vs. coro-nally advanced flapIn periodontal plastic surgery, the coro-nally advanced flap (CAF) has been used most widely for recession coverage and

A less invasive technique for greater success

Recession coverage

| A Advanced Miller Class II defect on tooth 25. Base of defect extending to mucosa. | B Complete recession coverage and gain in keratinized gingiva with connective tissue graft taken from the palate. Clinical picture 18 months after treatment.

FIG. 1: RECESSION COVERAGE WITH

CONNECTIVE TISSUE GRAFT.

Dr. Yoon Euy Hong, South Korea Private Practice, Center for Oral Plastic Surgery

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highly scalloped free gingiva and suitable keratinized tissue. The tunneling technique should also be considered if esthetics are critical and a mild to moderate coronal ad-van cement is anticipated. One of the key factors for success is the profi-ciency of the periodontal surgeon.

Connective tissue graft vs. bio-materialConnective tissue grafts help create kera-tinized gingiva, based on a study of tissue specificity by Karring and co-workers.3 In this epithelial differentiation study, Kar-ring was able to demonstrate that free grafts harvested from the palate produced keratinized gingiva, whereas grafts trans-planted from the non-keratinized alveo-

lar mucosa produced alveolar mucosa.4 Advantages of connective tissue grafts include plasmatic circulation (capillary beds within the grafts) that help with high graft survival, outstanding color match after healing and dimensional stability. Disadvantages include patient morbidity, e.g. bleeding, delayed healing and pain, along with the secondary graft harverst sites. (Figs. 1, 2) Accordingly, clinicians have been interested in de-

veloping a graft substitute. Such bioma-terials not only avoid connective tissue graft harvest and associated morbidity but also provide unlimited supply with consistent quality. Working with such biomaterials, complete primary closure with a tension-free flap is recommend-ed. Ideal biomaterials should act as scaf-folding to promote ingrowth and regen-eration by host cells, while remaining dimensionally stable. (Fig. 3)

| A Pre-orthodontic situation. | B Coronally advanced flap with vertical releasing incisions were performed on tooth 6 and 11 root cementum removed. | C connective tissue graft is applied and immobilized. | D Complete primary wound closure with a tension-free flap. | E–F 24 Months after recession coverage the orthodontic treatment started. Soft tissue complex traveled with orthodontic tooth movement. | G Clinical results after 8 years. No re-entry interventions were performed.

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FIG. 2: COMPLEX ORTHODONTIC CASE INCLUDING RECESSION COVERAGE AND INCREASE IN KERATINIZATION PRE-OP

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“Ideal biomaterials should act as scaffold to promote ingrowth and regeneration by host cells.”


can all help with the minimally invasive approach in periodontal plastic surgery.

Clinical tips: minimum invasionThese are the key factors for a minimally invasive approach to periodontal plas-tic surgery:

› Limited flap reflections › Use of SM67 or SM69 blades

(Swann-Morton) › Use of 5–0 or 6–0 sutures › Introduction of microscopes or › loupes › Use of specified instruments, such

as tunneling instruments › Combination of tunneling techniques

and biomaterials.

References1 Chambrone L, Tatakis DN: J Periodontol 2015;

86(2 Suppl): S8-51. 2 Zabalegui I, et al.: Int J Periodontics Restorative

Dent. 1999; 19(2): 199-206.3 Karring T, et al.: J Periodontol. 1975; 46(10): 577-85. 4 Karring T, et al.: J Periodontal Res. 1975 Feb;

10(1): 1-11.5 Reiser GM, et al.: Int J Periodontics Restorative

Dent 1996; 16(2): 130-37.6 Tibbetts LS, Shanelec DA: Curr Opin Periodontol

1994: 187-93.7 Cortellini P, Tonetti MS: J Periodontol 2001;

72(4): 559-69.

| A Root exposure on teeth 23, 24, 25. | B The 3-D collagen matrix Geistlich Mucograft® used for recession coverage. | C Conservation of the thickness of Geistlich Mucograft® is the key for ingrowth and repopulation by host cells. | D Clinical results after 5 years with good oral hygiene.

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FIG. 3: COVERING MULTI RECESSIONS WITH GEISTLICH MUCOGRAFT®

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Clinical tips: biomaterial › When the connective tissue graft is

chosen as a graft material, its avail-ability must be determined prior to the intervention using bone sounding. Reiser5 emphasized the importance of the anatomy of the donor area and classified the vault dimension as shallow, medium or high.

› The collagen matrix Geistlich Muco-graft® should be handled, trimmed, positioned and sutured before the biomaterial becomes wet. Therefore, it is beneficial to finish any neces-sary preparation of the biomaterial extra-orally in order to minimize in-tra-oral working time. In this way the volumetric dimension is not com-promised. The periodontal flap should be reflected without tension. A tension-free flap is critical for pri-mary closure, and a passive flap will not compress the underlying Geistlich Mu co graft® collagen matrix.

Minimally invasive approachA meticulous periodontal surgeon is always investigating advances in peri-odontal plastic surgery. How can we improve surgical techniques in order to improve predictability and reduce com-plications? Can the surgical time be shortened or post-surgical wound heal-ing be accelerated? Minimally invasive surgery can be the answer. Shanelec and colleagues first introduced periodontal surgery using a microscope, which pro-vided clinical benefits over convention-al treatment.6 Cortellini and co-workers studied a minimally invasive surgical approach to periodontal surgery.7 Atrau-matic flaps, harvest graft substitute bio-materials, use of microscopes and loupes (without increasing surgery time due to unfamiliarity), teamwork, proper arma-mentarium, surgical skill and experience

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augmentation, such as Guided Bone Re-generation (GBR) or autogenous bone block graft.2–4

Reducing flap tensionIndependent from the bone augmenta-tion itself, primary wound healing ap-pears crucial for a positive outcome. Unfortunately, complications associat-ed with these procedures are not irrele-vant. Studies report complication rates of 45% with vertical GBR3 or 29.8% with vertical block grafts.4 Flap tension for primary wound closure of mucoperiostal flaps seems to the most important fac-tor.5 Minimal flap tension (lower than 5 gr) is associated with 100% prima-ry wound closure, while increasing the flap tension increases the incidence of

wound dehiscence. This means that soft tissue release is a crucial step in bone augmentation surgery. Clinically, three types of flaps can be released by perios-tal incisions and coronal advancement – these are the lingual and vestibular flaps in the mandible, and the vestibular flap in the maxilla.

Three types of released and advanced flapsThe mandibular lingual flap is released by interrupting the thin periosteum layer with an elevator or dissector. (Fig. 1) The use of a blade may be avoided or limit-ed to the mesial area of the mandible, where the periosteum is thicker.6 In the distal area the more superficial fibers of the mylohyoid muscle may be denuded

Major bone augmentations with either Guided Bone Regeneration or a bone block increase bone volume significantly. But with - out proper flap techniques, wound dehiscenses can jeopardize success.

Dental implant therapy is a well-docu-mented and well-supported procedure with high predictability,1 particularly if hard tissue is optimal. But in cases with insufficient bone volume, a bone aug-mentation procedure is required. Many techniques have proved to be effective for horizontal and vertical hard tissue

Proper flap and suture techniques are key to success

Major bone augmentations

Dr. Luca De Stavola, ItalyStudio Odontoiatrico Associato Rubano / Treviso

| A Full thickness lingual flap elevated. The periosteum is intact representing the inner face of the flap. Only in the apical and distal area (in the region of the 3rd molar) the superficial fibers of the mylohyoideus muscle could be visible. | B Release of the periosteum by the use of a non-cutting tool, such as an elevator or dissector. | C Lingual flap elongat-ed. If required, detaching the superficial fibers of the mylohyoideus muscle from the flap, a secondary coronal flap advancement could be obtained.

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simply by elevating a full thickness flap, since the mylohyoid line is in a more cranial position. In some cases, detach-ing muscle fibers from the internal face of the flap may increase the coronal ad-vancement of the flap.7

The mandibular vestibular flap is re-leased with a scalpel blade (15c). The tip of the blade should contact the superfi-cial inner face of the flap starting from the vertical releasing incision and mov-ing distally or mesially. (Fig. 2) The blade works with the cutting face upside down and the non cutting area facing the flap. Once the periosteum is interrupted, the flap can be elongated with an elevator or dissector, avoiding vascular damage. It is important to work where the flap reach-es the fornix, so as not to weaken the

flap itself. Consider the position of the mental foramina and the mental nerve, maintaining a safe distance of six mm from these anatomical structures.

The maxillary vestibular flap is re-leased in a manner similar to the man-dibular vestibular flap, except that usu-ally, once the periosteum is interrupted, the flap is elongated with a blade (in-stead of elevator or dissector) because the density of elastic muscle fibers in-hibits coronal advancement.

Avoiding the killer loop effectThe surgeon should keep in mind that a released and elongated flap does not necessarily result in a correctly released flap. When the flaps are not optimally re-leased, the suture lines, which are usu-ally composed of horizontal mattress

sutures and single sutures, may make the marginal part of the wound is chemic, which can result in necrosis. This “kill-er loop effect” of horizontal mattress sutures is amplified by increasing the residual flap tension at the end of the surgery. The application of a breaking force suture seems to reduce the mar-ginal flap tension prior to the horizontal mattress.8 Two suturing technique em-ploy a breaking force suture – one in the maxilla and one in the mandible.

The maxillary suture involves the entire thickness of the palatal flap and just the coronal periosteum layer of the vestibu-lar flap. The needle engages the palatal flap seven to ten mm apical to the flap margin, then moves to the vestibular side and engages the periosteum on the cor-onal margin of the releasing periosteum incision. It then moves palatally again through the entire palatal flap.After the suture is tied, the vestibular flap slips coronally. (Figs. 3, 4) Then mat-tress sutures and single sutures are ap-plied with no or minimal residual ten-sion.

The mandibular suture involves the inner part of the flaps. The needle en-gages the periosteum on the coronal margin on the lingual flap, then moves to the vestibular flap, engaging the cor-onal margin of the released periosteum in the same manner.After the suture is tied, both flaps move coronally and will usually come in con-tact with one another. Then mattress sutures and single sutures are applied with no or minimal tension. (Figs. 5, 6) The breaking force suture involves just the periosteal layers without creating any killer loop effect, while leaving the vascularity intact. This suture can re-

| A The mandibular vestibular flap is released with a scalpel blade. | B The tip of the blade contacts the superficial inner face of the flap starting from the vertical releasing incision and moves distally or mesially. | C The periosteum is interrupted. | D The flap is elongated with an elevator or dissector avoiding damage to flap vessels.

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FIGS. 3, 4: BREAKING FORCE SUTURE I: MAXILLARY SUTURE – ILLUSTRATIONS AND CLINICAL CASE

| 3A Initial situation for a maxillary suture with the vestibular flap already elongated. | 3B–4A–B The needle engages the palatal flap seven to ten mm apical to the flap margin, then moves to the vestibular side and engages the periosteum on the coronal margin. It moves then palatally again through the entire palatal flap. | 3C–4C Suture is tied and the vestibular flap slips coronally. | 3D-4D Mattress sutures and single sutures are applied with no or minimal residual tension.

4A 4B 4C

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duce the residual flap tension prior to wound closure by about 87%.8

An alternative: The tunnel approach Flap design can also be an opportunity to improve or simplify the primary wound closure and reduce the risk of dehis-cence. The tunnel approach proposed by Khoury is one of these opportunities.9 The technique avoids any crestal in-cision in the area of the graft. A single vertical incision is made at the distal aspect of the mesial tooth closest to

the defect. The flap is then elevated as a full thickness flap, tunneling around the defect. In this way there is optimal graft protection, and wound dehiscence is avoided by the continuity of the soft tissue over the graft. Visualization of the surgical field is obviously limited, and this must be taken into consideration. The anatomy of the defect must be an-alyzed preoperatively, and the bone de-fect should be quite smooth and regular without deep bone septa, which could interfere with the correct elevation of a full thickness flap.10 Nevertheless, many

publications report limited or no soft tissue complications.9–11

Soft tissue adheres more tena-ciously to bone than dentinConsidering flap stability as a factor in-fluencing flap tension, Werfully et al. (2002)12 demonstrated differences in flap adhesion to different substrates. Their study in dogs revealed that, at all healing times, the flap tensile strength at the flap-bone interface was at least twice that of the flap-dentin interface (after seven days: 5.08 N versus 1.82 N,

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respectively). This means that soft tis-sue is able to adhere more strongly and quickly to bone than to dentin. The dif-ference is the favorable relationship between the underlying coagulum of the flap with bone, whereas the coag-ulum-dentin interface is more tenu-ous. Extrapolating these findings to augmentation, a key factor for stress reduction of the flap margins in ear-ly healing could be the capacity of the coagulum and the overlying flap to ad-here to the graft material. It is reason-able to assume that the stability of the complex coagulum-flap interface is not optimal when a graft material is the in-

FIGS. 5, 6: BREAKING FORCE SUTURE II: MANDIBULAR SUTURE – ILLUSTRATIONS AND CLINICAL CASE

| 5A Initial situation for a mandibular suture with both the lingual and the vestibular flaps already elongated. | 5B–6A–B The needle engages the periosteum on the coronal margin of the releasing periosteum on the lingual flap, then moves to the vestibular flap, engaging the coronal margin of the released periosteum. | 5C–6C The suture is tied and both flaps move coronally coming in contact with each other. | 5D–6D Mattress sutures and single sutures are applied with no or minimal residual tension.

5A 5B 5C 5D

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terface (non-resorbable idrophobic PTFE membrane), which might ex-plain the high complication rate asso-ciated with augmentation procedures. But for overall flap stability, the suture line is the key to maintaining primary wound closure.

References1 Jung RE, et al.: Clin Oral Implants Res 2012;

23 Suppl 6: 2-21. 2 Donos N, et al.: J Clin Periodontol 2008; 35

(8 Suppl):173-202. 3 Rocchietta I, et al.: J Clin Periodontol 2008; 35

(8 Suppl): 203-15. 4 Jensen Storgard, Terheyden SS, et al.: Int J Oral

Maxillofac Implants 2009; 24 Suppl: 218-36.

5 Burkhardt R, Lang NP: Clin Oral Implants Res 2010; 21(1): 50-4.

6 Urban I, et al.: The International journal of peri-odontics & restorative dentistry 2017; 37: 347-53.

7 Ronda M, Stacchi C: Int J Periodontics Restorative Dent 2011; 31(5): 505-13.

8 De Stavola L, Tunkel J: Int J Oral Maxillofac Implants 2014; 29(4): 921-26.

9 Khoury F, Happe A: Quintessence Int 2000; 31 (7): 483-99.

10 De Stavola L, Tunkel J: Int J Periodontics Restor-ative Dent 2013; 33(5): 651-59.

11 Mazzocco C, et al.: Int J Periodontics Restorative Dent 2008; 28(1): 45-53.

12 Werfully S, et al.: J Periodontal Res 2002; 37: 366–74.

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MILESTONE STUDIES.An update on soft tissue management with collagen matrices

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INTRODUCTION Soft tissue management implant therapy is of growing impor-tance. Widening of keratinized tissue as well as recession coverage and volume augmentation around implants and un-der pontics are part of the therapy reper-toire in many dental surgery practices. Driven by patient quality of life, Geistlich has marketed two innovative collagen matrices that enable dentists to oper-ate without soft tissue graft harvests. While Geistlich Mucograft® has been developed primarily as an alternative to free gingival grafts to be left exposed during healing, the new collagen matrix Geistlich Fibro-Gide® behaves like a con-nective tissue graft. Both matrices have been extensively investigated in multi-ple studies and have been compared to gold-standard autologous grafts. Do they perform as well as the gold-standard?

Patients more satisfied with collagen matrixIn order to gain keratinized tissue – e.g., prior to implant place-ment – dentists frequently use a combination of apically po-sitioned flaps and free gingival grafts. However, as graft har-vesting from the palate is associated with pain and bleeding, an alternative approach might be beneficial. The American re-searchers Michael McGuire and Todd Scheyer compared the 3-D collagen matrix Geistlich Mucograft® with autogenous free gingival graft in vestibuloplasties around teeth. Their random-ized and controlled split-mouth study (30 patients with zones of insufficient keratinized tissue < 2 mm, with follow-up to six-months) achieved similar results for both treatment op-tions. More than two-thirds (70%) of patients preferred the appearance of sites where the collagen matrix was used – due to better texture and color matches to the adjacent gingival tis-sue – and there was less pain with Geistlich Mucograft®.

McGuire MK, Scheyer ET: J Periodontol 2014; 85(10): 1333-41.

Smart combination of tissue grafts and collagen matricesAfter major bone augmentation procedures, large free gingival grafts are frequently needed to restore a healthy width of kera-tinized tissue. A prospective case series study by Urban et al. from 2015 (20 patients, follow-up twelve-months) evaluat-ed a clever alternative to this approach: the combined use of a small free gingival “strip graft” and the porcine collagen matrix Geistlich Mucograft®. While the small autologous graft acts as a “cell donator” for new keratinized tissue, the collagen ma-trix extends the formation of new keratinized tissue to a larger area. Results: compared to baseline, at twelve months a signif-icant increase in keratinized tissue of 6.33±2.16 mm on average in all treated sites and low graft contraction (43%). Patients re-ported no post-operative complications. This study shows that biological understanding of the regeneration process leads to good results – in this case understanding the origin of the “biologic information” for newly formed keratinized tissue.

Urban IA, et al.: Int J Periodontics Restorative Dent 2015; 35(3): 345-53.

Dr. Nikolas Epp Post Marketing Clinical ScienceGeistlich Pharma AG

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The long-term proof

In German oral-maxillofacial surgeon Christian Schmitt’s study (14 patients, follow-up three-months), patients un-derwent augmentation of insufficient keratinized peri-implant mucosa with either Geistlich Mucograft® or a free gingival graft from the palate. During the 90-day study period, the two treat-ment alternatives showed similar clinical and histologic out-comes in terms of healing, overall shrinkage and increase in keratinized mucosa. But in the collagen matrix group, clinical color and texture were comparable to adjacent native muco-sa. Using Geistlich Mucograft® also shortened the surgery time compared with free gingival graft therapy. Similar results were achieved over the long-term as shown in the publication by Schmitt et al. in 2016 (48 patients, fol-low-up five years). Vestibuloplasty with Geistlich Mucograft® resulted in favorable esthetic appearance of soft tissue with similar texture and color to adjacent areas five years after aug-mentation. Free gingival grafts, by contrast, were still distin-guishable from the adjacent native gingiva.

Schmitt CM, et al.: J Periodontol 2013; 84(7): 914-23.

Schmitt CM, et al.: Clin Oral Implants Res 2016; 27(11): 125-33.

Use for vestibuloplasty in cancer patientsResection of oral cancer is often accompanied by anatomical deformities affecting teeth, bone and soft tissue. This, togeth-er with an impaired healing capacity,makes oral rehabilitation difficult. Can the collagen matrix Geistlich Mucograft® serve as an alternative to autolgous grafts for a vestibuloplasty in these patients? A clinical study by Lorenz et al. 2017 (six pa-tients, follow-up six months) revealed a complete epitheli-alization of the defect site after a mean healing period of three weeks without adverse reactions, transplant loss, severe pain, wound healing complications or persistent discomfort. The width of the attached peri-implant gingiva, starting from a baseline of less than 1 mm in each implant site, could be in-creased to a mean width of 4.4 mm immediately after vestib-uloplasty and 3.9 mm six-months after vestibuloplasty.

Lorenz J, et al.: Clin Oral Invest 2017; 21(4): 1103–11.

Geistlich Fibro-Gide® not inferior to connective tissue graftThe first two preclinical studies on the new 3-D collagen ma-trix Geistlich Fibro-Gide® were published in 2011 by Thoma et al. (six dogs, two test groups, one control group, follow-up three-months). The authors investigated effectiveness of Geistlich Fibro-Gide® for ridge width gain compared with gold standard connective tissue grafts and also controls with no tis-sue augmentation. After three-months there was a volume gain of 1.4 mm for both Geistlich Fibro-Gide® and connective tissue graft, and a loss of 0.3 mm for the control. Based on histomorphometric analyses in the second publication with the same study design, applica-tion of Geistlich Fibro-Gide® resulted in favorable tissue inte-gration toward both the covering flap and the underlying bone. This uneventful integration is special, because, according to the authors, in the past cross-linked collagen devices exhib-ited an increased rate of soft tissue complications when used as barrier membranes for Guided Bone Regeneration. The au-thors see the Geistlich Pharma AG research and collagen ex-pertise used to cross-link Geistlich Fibro-Gide® as a possible reason for this improved clinical performance.

Thoma DS, et al.: J Clin Periodontol 2010; 37(7): 659-66.


Less cross-linking, better stability

Cross-linking was also investigated in another pre-clinical study by Thoma et al. 2012 (14 mice, two collagen matrix prototypes, follow-up three and six weeks). The authors evaluated whether tissue integration, angiogenesis and matrix degradation in two different Geistlich Fibro-Gide® prototypes

“More than two-thirds of patients preferred the ap-pearance of sites where the collagen matrix was used.”McGuire MK, Scheyer ET 2014

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depended on the degree of chemical cross-linking. Two colla-gen matrices with high and low levels of chemical cross-link-ing were implanted in mice, approximately 10 mm above the hip socket, and analyzed at three and six-weeks. Both prototypes showed only minimal infl ammatory reactions and favorable integration into the surrounding tissues. How-ever, the authors reported that low chemical cross-linking en-hanced angiogenesis compared with high cross-linking. An-giogenesis is expected to have a signifi cant impact on healing outcome. In addition, volume stability of the low cross-linked collagen matrix was superior to the high cross-linked colla-gen matrix.In conclusion: less cross-linked collagen matrices might be more favorable for soft tissue augmentation in terms of blood vessel formation, matrix integration and volume stability. Ac-cordingly, the less cross-linked collagen matrix was later devel-oped into Geistlich Fibro-Gide®.

Thoma DS, et al.: Clin Oral Implants Res 2012; 23(12): 1333-39

Clinical study: Augmentation of soft tissue with matrix vs. graftThoma et al. 2016 demonstrated that Geistlich Fibro-Gide® and subepithelial connective tissue grafts lead to similar re-sults when used to augment soft tissue around implants. In a randomized clinical trial (20 patients, two test groups, fol-low-up three-months), patients with insuffi cient tissue vol-ume at single implants underwent soft tissue augmentation with Geistlich Fibro-Gide® or connective tissue graft.The results after three-months: median soft tissue thickness on the occlusal aspect increased by 1.8 mm for Geistlich Fibro- Gide® and 0.5 mm for connective tissue graft. Median soft tissue thickness on the buccal aspect increased by 1 mm for Geistlich Fibro-Gide® and 1.5 mm for connective tissue graft. Both, grafts and biomaterials, integrated well without any rejection reac-tions. Authors concluded that Geistlich Fibro-Gide® in soft tis-sue augmentation at single implants is as eff ective and well-tol-erated as the gold standard connective tissue graft.


Good soft tissue response

Another pre-clinical study by Ferrantino et al. 2016 (six dogs, test and control groups, follow-up 90-days) exam-ined the soft tissue response to the collagen matrix Geistlich Fibro-Gide® histologically at diff erent time points. The matrix did not alter the healing process compared to the sham-oper-ated sites. After four-days, the fi rst small blood vessels were seen at the margins of Geistlich Fibro-Gide®. The number of blood vessels and mesenchymal-like cells increased over time. After 90-days, the residual collagen matrix was fully integrat-ed in newly formed connective tissue.

Ferrantino DL, et al.: Int J Periodontics Restorative Dent. 2016; 36(6): 807-15.

Two matrices, two indications

The two collagen matrices Geistlich Fibro-Gide® and Geistlich Mucograft® were compared in a preclinical study by Thoma et al. published in 2015 (50 rats, four treatment modali-ties, follow-up two-months). Favorable soft tissue integra-tion was achieved with both collagen matrices. While the com-pact layer of Geistlich Mucograft® delayed angiogenesis and connective tissue formation in a submerged healing situation, the spongious cross-linked matrix Geistlich Fibro-Gide® fa-cilitated early vascularization and demonstrated matrix pres-ence over a long time span. This is in line with the intended use of the two collagen matrices. While Geistlich Mucograft® demonstrates its best clinical performance when used for the gain of keratinized tissue in open healing situations, Geistlich Fibro-Gide® provides volume stability and new connective tis-sue formation when used in submerged healing situations.

Thoma DS, et al.: Clin Oral Implants Res 2015; 26(3): 263-70.

“Geistlich Fibro-Gide® is as effective and well-tolerated as connective tissue graft.”Thoma DS, et al. 2016

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HOPE FROM 3-D PRINTING.Demand for human tissue is enormous. As a result, great hope is now being placed on computer-controlled “bio-printers”. In particular, considerable progress is being made with tissues that do not depend on capillaries and nerves.

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“The number of people desperately awaiting organ transplants by far exceeds the number of available donor organs”, says Dr. Anthony Atala, Director of the Wake Forest Institute for Regenerative Medicine in Winston Salem, North Caro-lina.1 “Every day 21 US citizens fall victim to there being no such organ available to them. To rectify this shortfall, many re-search teams are currently endeavoring to construct living tissue with 3-D print-ers.”

First bio-printer at the turn of the millenniumIn the mid 1980’s the US American Charles W. Hull developed a printer that enabled 3-D objects to be manufactured under the control of special “computer aided design” (CAD) software.2,3 At first the materials used were chiefly poly-mers, then, as of the beginning of the

90’s, nanocomposites, blended plastics and powdered metals. It was not long before medical researchers also turned their attention to this development: If a solid plaster or plastic ornament could be manufactured using a printer, should it not be possible to print a living organ? In 1999 scientists at the Wake Forest In-stitute used a 3-D printer for the first to manufacture a scaffold for a human bladder. They coated the modeled scaf-fold with cells from their patients. Oth-er groups followed by printing the first miniature kidneys in 2002 and the first blood vessels in 2010.

Like an inkjet printerThe operation of a bio-printer mirrors the operation of a normal 3-D printer. A computer controls extruders that con-struct desired structures from a polymer gel. Using a 3-D model, spray nozzles ex-

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trude a cellular suspension in the form of tiny droplets. The gel is usually based on an alginate composite. Every drop-let deposited contains several thousand cells capable of regeneration. These cells are collected in advance by biopsy from the organ to be replaced and then mul-tiplied in a liquid nutrient medium con-taining oxygen. Experiments have also been conducted with adult or induced pluripotent stem cells (e.g., from bone marrow). With appropriate growth fac-tors designated by the researchers and by defining both viscosity and tempera-ture of the matrix exactly, researchers encourage cells to organize themselves into functional tissue.

Research in full swingScientists throughout the world are currently working on methods for tis-sue-engineering human organs using 3-D printers. Most models, however, are still on the drawing board. In particular, building functional organs that rely on nutrient blood vessels and nerves is still a pipe dream in the view of researchers like Simon Hoerstrup, the Director of the Institute for Regenerative Medicine at the University of Zurich, where polymer scaffolds are subsequently coated with the patients’ own cells using a 3-D print-er.4 In children with serious congenital heart defects, Dr. Hoerstrup intends to implant living, i.e., growing, heart valves after birth. What he has already shown can work in animal experiments on lambs is soon to be studied in the clin-ic with human babies. The development of less complex tissues like heart valves, blood vessels and cartilage that do not

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need a direct supply of blood nutrient is already well ahead. For example, Swed-ish researchers recently made cartilage consisting of a new hydrogel biomaterial and human cells, which grew successful-ly in mouse skin.5

Meanwhile, a team of researchers at the University of California in San Di-ego (UCSD) was successful using a 3-D printer to manufacture a small, function-al system of blood vessels and implant it into live mice.6 And a new hydrogel made from alginate, polyvinyl alcohol and hy-droxyapatite was recently developed by scientists led by Stephanie T. Bendtsen at the Institute for Material Sciences, University of Connecticut. The alginate is designed to improve the properties of bones “printed” using 3-D printers.7 Fi-nally, victims of serious burns and an-imal testing for cosmetics and drugs could benefit from a bilayer human skin sourced from a 3-D printer. A bio-ink for the printer cartridges containing blood plasma, fibroblasts and keratinocytes was developed by Spanish scientists, and the resulting bilayer skin grew without difficulty when implanted in mice.8 New earsUsing an experimental technique at the end of last year, Chinese researchers created a new ear by an unusual means.9 The patient lost an ear that had been damaged irreparably in a car accident. Dr. Wang Jihua, Director of Plastic Sur-gery at the Kunming Medical Second Hospital, printed a model of an ear us-ing a 3-D printer and fashioned a new ear out of rib cartilage. This model was then

implanted under the skin of the patient’s arm, so it could continue to grow for sub-sequent transplant onto the patient’s head. Doctors are also currently using 3-D printing techniques in Edinburgh, Scotland to make a new ear for a nine-year old girl afflicted by a congenital ear muscle abnormality. Using a 3-D print-er, researchers created a mirror image of the normal ear out of plastic and used this template to model a new ear from rib cartilage. Initial surgery entailed the plastic ear being attached to the head be-neath the skin in order to create the site and structure for the new ear. As soon as the skin has adapted, a second operation will allow the replacement ear to be at-tached in the desired position.

Be it ears, heart valves, skin, bone, kid-neys or other tissues: 3-D technology could soon open up a new era in med-icine.

“The number of people desper-ately awaiting organ trans plants by far exceeds the number of available donor organs.”Dr. Anthony Atala | Wake Forest Institute for Regenerative Medicine

References1 www.huffingtonpost.com/2015/03/01/3d-print-

ed-organs-regenerative-medicine_n_6698606.html.

2 Hull CW, et al.: Apparatus for production of three-dimensional objects by stereolithography. US patent: 4, 575, 330. 1986.

3 Gu KB, et al.: Biomaterials Research 2016; 20:12 .4 Dijkman PE, et al.: Transfus Med Hemother 2016;

43(4): 282–290. 5 Möller T, et al.: Plastic and Reconstructive Surgery

2017; 5(2). 6 http://ucsdnews.ucsd.edu/feature/how_3d_print-

ing_could_one_day_save_lives.7 Bendtsen ST, et al.: Journal of Biomedical Materi-

al Science 2017; 105(5): 1457–1468.8 Cubo N, et al.: Biofabrication 2016; 9(1). 9 www.3d-grenzenlos.de/magazin/thema/bioprint-

ing/page/2/.

OUTSIDE THE BOX


BACKGROUND.GEISTLICH PHARMA AG | OSTEOLOGY FOUNDATION

31BACKGROUND

The 52-page book entitled “Oral Regeneration in a Nutshell” provides an overview of the basic principles, as well as the goals, indications and techniques of oral regeneration. Using illustrations and clinical pictures, the authors Prof. Christoph Hämmerle, Prof. Giulio Rasperini, PD Dr. Daniel Thoma and Dr. Nele Van Assche introduce the reader to the key aspects of periodontal regeneration, hard and soft tissue regeneration and alveolar ridge preservation.Further information about the book and how to obtain it is available online. In addition, the full content can be accessed on the Osteology Foundation’s online platform THE BOX.

www.oral-regeneration.org

Oral Regeneration in a Nutshell

New publication fromthe Osteology Foundation

In June 2017 the Osteology Foundation published a new book for dental students and dentists who have not had any previous experience on the field of oral regeneration.

Osteology Timetable 2017/18

National Osteology SymposiaOsteology Moscow, Russia 21–22 October 2017Osteology Zurich, Switzerland 12–13 January 2018Osteology Phoenix, USA 9–10 February 2018Osteology London, UK 20 April 2018Osteology Frankfurt, Germany 20–21 April 2018Osteology Turin, Italy 27–29 September 2018Osteology Paris, France 18–20 October 2018

Collaborative Education EventsOsteology Session

@ ÖGI Graz, Austria 10 Nov. 2017

@ FIPP Congress Santiago, Chile 17 Nov. 2017

@ DGI Congress Düsseldorf, Germany 30 Nov. – 2 Dec. 2017

@ KAOMI Seoul, South Korea 10 – 11 Mar. 2018

Further dates and information at www.osteology.org

Dr. Heike Fania | Osteology Foundation


Geistlich Fibro-Gide® is the latest product from Geistlich for regenerative dentistry. Why does Geistlich want to pro-vide a new therapeutic solution?Dr. T. Hart: We wanted to offer a product that regenerates soft tissue while also maintaining volume and providing excel-lent mechanical properties. Several of our key partners from universities and dental clinics highly appreciated the idea of a volume-stable collagen matrix that could be used for indi-cations such as soft tissue augmentation around implants or under pontics. Currently many of those treatments are per-formed with autologous tissue, which always involves graft harvesting and, therefore, donor-site morbidity.

What was the most difficult part developing Geistlich Fibro-Gide®? Dr. T. Hart: The most difficult part was combining the mechan-ical stability and handling of the matrix with cell biocompati-

bility and tissue regeneration. There is a fundamental trade-off between better mechanical properties and cellular recognition of the matrix. For example, by enhancing the mechanical sta-bility with chemical cross-linking, the regenerative proper-ties of the matrix are diminished. Cells read the hidden 3-D amino acid code that is written inside the collagen. Too much cross-linking destroys the code and makes the material biolog-ically invisible to cells. Under cross-linking, on the other hand, does not allow for mechanical stability of the matrix, and it will be resorbed too quickly by the body through enzymatic hydro-lysis. As you can imagine, much R&D time was spent trying to optimize all these conflicting factors. Keyword: Cross-linking. The use of cross-linking was in-tentionally avoided in Geistlich Bio-Gide® and Geistlich Mucograft® in favor of improved tissue compatibility. How has this changed with Geistlich Fibro-Gide®?

Geistlich invested heavily to develop its latest product, the 3-D collagen matrix Geistlich Fibro-Gide®. Dr. Terance Hart, Chief Scientific Officer, and Dr. Mark Spilker, Deputy Chief Scientific Officer, talk about innovation, research pathways and strategic collaborations.

“It is a very exciting time to be work-ing in R&D at Geistlich”, says Dr. Terance Hart. “In collaboration with our University partners around the world we are working to under-stand the evolutionary code that is hidden within collagen so that we can make regenerative products that really work.” And Dr. Mark Spilker adds: “It’s the discovery! The first time you solve an unsolved problem or meet an unmet clinical need is very satisfying. That’s the driver for the work.”

“It’s not only science. There is a lot of art involved.”

Development of Geistlich Fibro-Gide®Ph

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Thomas Phyffer, Verena Vermeulen | Geistlich Pharma AG

33BACKGROUND

Dr. M. Spilker : All collagen is naturally cross-linked; oth-erwise, we would be soup! Synthetic cross-linking has ad-vanced considerably in the past 20 years. For example, in the past cross-linking a collagen product with outdated aldehyde technology resulted in poor tissue compatibility. But Geistlich has now been able to develop a minimal cross-linking ap-proach that balances mechanical volume stability with cell compatibility and tissue integration. Geistlich uses a natural and “soft” form of cross-linking in the sense that the cross-linked collagen can be integrated and then turned over by the body’s enzymes.

How many prototypes are tested in a development like this, before the ideal product is found?Dr. T. Hart: For Geistlich Fibro-Gide®, Geistlich tested more than 1000 collagen matrix prototypes obtained under differ-ent preparation conditions and having different features. This is not so different from the Pharma industry where 1000 mol-ecules are typically made in the lab to produce one clinical candidate.

Geistlich has more than 160 years of expertise in collagen. How does this help today?Dr. M. Spilker: Collagen is a very complicated and vitally im-portant macro molecule. Much about collagen is scientifical-ly understood, but there is a great deal of collagen technology that rests in art, experience and expertise. Because of our her-itage, we have built up considerable collagen art and expertise at Geistlich. To quote Isaac Newton, “if we now see further, it is because we stand on the shoulders of giants”. It is this sum of experience of sourcing, purifying and handling of natural col-lagens, beginning at Geistlich with glue and gelatin, that has directly led to Geistlich Bio-Gide®, Geistlich Mucograft® and now Geistlich Fibro-Gide®.

To what extent could experience gained from the develop-ment of Geistlich Mucograft® be used in the development of Geistlich Fibro-Gide®?Dr. T. Hart: Geistlich Mucograft® was the first and very im-portant step into the field of soft tissue regeneration, for ex-ample, to gain keratinized tissue. We learned a lot about the trade-off between volume stability, cell behaviour and tis-sue compatibility, as well as the necessity of delivering not only a biomaterial but also effective protocols that work in clinical practice.

What was it in the development and testing of the product and prototype that ultimately drove the decision to focus all efforts on this product and get it to market?Dr. M. Spilker: When we received the histology showing the tissue integration and volume retention in the pre-clinical studies we knew we had something special. I am convinced that this is indeed a step forward in technology, and it has huge potential.

Is the research side of Geistlich Fibro-Gide® finished with the market launch?Dr. M. Spilker: Definitely not. We have entered the phase where clinical research is the highest priority. Geistlich is now embarking on the clinical evaluations of Geistlich Fibro-Gide® in larger patient populations and with various clinical applica-tions. Our key is to generate the clinical data that will directly benefit clinicians and their patients, for example, best practice cases, clinical guidelines and dos and don’ts. Although all of our products have been developed in close collaboration with key partners from universities and dental clinics, our large network of clinical partners contributes greatly during these pre-launch clinical phases.

The regulatory hurdles for new product approvals have grown in recent years. How does Geistlich Pharma deal with them?Dr. T. Hart: For us, this is good. It has always been one of our core strengths. Geistlich has always developed our products in a very careful way, because we must convince ourselves that our products are safe and perform effectively for both patient and clinician. So the increasing regulatory hurdles for new product approvals have validated Geistlich’s evidence-based approach to the development of medical devices for the ben-efit of patient and clinician.

“Geistlich has developed a mini-mal cross-linking approach that balances mechanical volume stability with cell compatibility.”Dr. Mark Spilker | Deputy Chief Scientific Officer Geistlich Pharma AG


References Geistlich Mucograft®

1 Lorenzo R, et al.: Clin Oral Implants Res 2012; 23(3): 316-24.2 Sanz M, et al.: J Clin Periodontol 2009; 36(10): 868-76.3 McGuire MK, Scheyer ET: J Periodontol 2014; 85(10): 1333-41.4 Nevins M, et al.: Int J Periodontics Restorative Dent 2011; 31(4): 367-73.5 Urban IA, et al.: Int J Periodontics Restorative Dent 2015; 35(3): 345-53.6 Schmitt CM, et al.: J Periodontol 2013; 84(7): 914-23.7 Schmitt CM, et al.: Clin Oral Implants Res 2016; 27(11): e125-e133.8 Herford AS, et al.: J Oral Maxillofac Surg 2010; 68(7): 1463-70.9 Jung RE, et al.: J Clin Periodontol 2013; 40(1): 90-98.

Two innovative solutions for soft tissue regeneration

Geistlich Mucograft® and Geistlich Fibro-Gide®

Available sizes> Rectangular matrix 15×20 mm > Rectangular matrix 20×30 mm > Geistlich Mucograft® Seal round matrix 8 mm

StudiesGeistlich Mucograft® was clinically evaluated for augmentation of keratinized mucosa > Around teeth³,⁴

> Around implants or fi xed prosthetic restorations¹,²

> Before implant placement⁵ > In vestibuloplasties with long-term

follow-up⁶,⁷

> As socket seal after ridge preservation⁹

… where it was left for open-healing. Geistlich Mucograft® is a predictable alternative to free gingival grafts.¹,²,⁴,⁶

Geistlich Mucograft® was also clinically evaluated for recessions > In single recessions with coronally advanced fl aps¹⁰-¹³> In multiple recession coverage with coronally advanced fl ap¹⁴–¹⁸... where it was used in a submerged situa-tion. Geistlich Mucograft® is a predictable alternative to connective tissue grafts.¹¹,¹⁴

Treatment optionCan be used in submerged or open healing applications for soft tissue augmentation> Gain of keratinized tissue¹–⁵ > Vestibuloplasty⁶–⁸> Socket Seal⁹> Recession Coverage¹⁰–¹⁸

CompositionReconstituted, native collagens type I and III. The compact structure is derived from native collagen, which permits suturing to the host mucosal margins and gives stability allowing open healing.The underlying porous structure, which is specifi cally reconstituted from collagen fi bers, allows tissue adherence favoring wound healing and sup-porting cell integration.

Susanne Schick, Dr. Giselle Richterich | Geistlich Pharma AG

10 McGuire MK, Scheyer ET: J Periodontol 2016; 87:221-227.11 Cardaropoli D, et al.: J Periodontol. 2012; 83(3):321-8.12 Camelo M, et al.: Int J Periodontics Restorative Dent. 2012; 32(2):167-73.13 Jepsen K, et al.: J Clin Periodontol. 2013; 40(1):82-9.14 Rotundo R, et al.: Int J Periodontics Restorative Dent. 2012 15 Cardaropoli D, et al.: Int J Periodontics Restorative Dent. 2014; 34:s97-s102.16 Schlee M, et al.: Int J Periodontics Restorative Dent. 2014; 34(6):817-23.17 Molnàr B, et al.: Quintessence Int. 2013; 44(1):17-24.18 Aroca S, et al.: J Clin Periodontol. 2013; 40(7):713-20.

Microscopic Structure of Geistlich Mucograft®

35BACKGROUND

References Geistlich Fibro-Gide®

1 Instructions for Use. Geistlich Fibro-Gide®. Geistlich Pharma AG, Wolhusen, Switzerland.

2 Thoma DS, et al.: Clin Oral Implants Res. 2015 Mar;26(3):263-70.3 Thoma DS, et al.: J Clin Periodontol. 2016 Oct;43(10):874-85. 4 Thoma DS, et al.: Clin Oral Impl Res. 2009; 20 (Suppl. 4): 146–65.5 Zeltner M, et al.: J Clin Periodontol. 2017 Apr;44(4):446-453.6 Buser D, et al.: Data on fi le. Unpublished clinical data. Geistlich Pharma AG,

Wolhusen, Switzerland.

In September 2017, Geistlich Pharma AG extended its soft tissue regeneration product portfolio. Geistlich’s collagen experts developed a second 3-D collagen matrix named Geistlich Fibro-Gide®. But what are the diff erences between Geistlich Fibro-Gide® and Geistlich Mucograft®?

Treatment optionCan be used in submerged applica-tions> Gain of soft tissue volume around implants and under pontics¹

StudiesClinical studies in the following indica-tions are showing positive results:> Soft tissue augmentation around

implants after staged Guided Bone Regeneration³,⁵

> Soft tissue augmentation around implants together with Guided Bone Regeneration⁶

Geistlich Fibro-Gide® is proving to be a valuable alternative to autologous connective tissue grafts.³–⁵Composition

Reconstituted & cross-linked colla-gens type I and III. The spongious network of Geistlich Fibro-Gide® (indicated for submerged healing) allows angiogenesis, connective tissue formation and good volume stability of the collagen network.²,³

Available sizes> Rectangular matrix 15×20×6 mm > Rectangular matrix 20×40×6 mm

Microscopic Structure of Geistlich Fibro-Gide®

Disclaimer: Geistlich Fibro-Gide® is not available in every Country. Please contact your local distributor for further information.


Geistlich is the exclusive marketing partner for the innovative Yxoss CBR® titanium scaffold – a customized 3-D printed scaffold for major bone augmentations with particulate bone graft.

Major ridge defi ciencies, especially vertical and combined de-fects, frequently require bone augmentation with a form-sta-ble reinforcement, such as a form-stable membrane, titanium mesh, bone shield, bone blocks or the bony walls themselves in techniques such as interpositional grafting or distraction osteogenesis. When increasing the bone more than 3.7 mm in combined defects, titanium meshes were also recommended in the last systematic review.1 The conventional titanium meshes are de-livered as fl at meshes which are then adapted to the defect intraoperatively. As all the other approaches these titanium meshes require a high level of surgical skills and their use is often time-consuming. Moreover, they are reported to be as-sociated with a high risk for soft tissue dehiscences.2 Howev-er, using a space-making, form-stable grid or membrane off ers several advantages, for example, the possibility of using partic-ulate graft material and thus, avoiding time-consuming adap-tation of block grafts to the defect morphology.

A customized 3-D printed solutionUnsatisfi ed with the disadvantages of the techniques avail-able for major bone augmentation, about ten years ago Dr. Markus Seiler, Germany, envisioned a customized treatment of patients with complex alveolar ridge defects. Combining the advantages of titanium, 3-D imaging, planning tools and 3-D printing, Dr. Seiler’s company ReOss, Ltd. engineered and de-veloped the 3-D printed, titanium-scaff old Yxoss CBR®. Today the 3-D printed Ti-grid Yxoss CBR® is being routinely used in his clinic and the innovation is now made available to the com-munity of oral surgeons.

A new product in the Geistlich portfolioYxoss CBR® off ers several advantages:

› Intuitive and customer-friendly online ordering system, › Customized shapes for optimized defect fi t, › Opportunity for reduced surgery time, › Smooth edges and surfaces to reduce the risk for soft tissue

healing issues, › Predefi ned breaking points for easy removal of the grid at

the time of re-entry.

To date Yxoss CBR® is being used in clinics and several public hospitals across Germany, with more advocates daily. It fi ts the trend in digitalized clinical workfl ow perfectly and the aim of treating patients as individually as possible, while reduc-ing morbidity and surgery time. In addition, Yxoss CBR® com-plements existing therapy solutions with Geistlich Bio-Oss® and Geistlich Bio-Gide®. That’s why Yxoss CBR® is now being exclusively marketed by Geistlich and offi cially introduced at the EAO in Madrid (2017).

References1 Troeltzsch M, et al.: J Craniomaxillofac Surg 2016; 44(10): 1618-1629. 2 Bormann KH, et al.: J Oral Maxillofac Surg 2011; 69(6): 1562-70.

A new treatment solution for major bone defects

Yxoss CBR®

Dr. David Märki, Dr. Luis Marcelo Calderero | Geistlich Pharma AG

37BACKGROUND

| A Situation showing the highly atrophied edentulous area. | B CBCT scan of the defect showing the complex 3-dimensional defect configuration with a vertical component | C Modelling of the defect and elaborate design of Yxoss CBR® | D As a test, Yxoss CBR® is placed at the defect site and shows the high accuracy of the fit to the morphology. | E Perforation of the corticalis to induce bleeding. | F Filling of Yxoss CBR® with a mixture of Geistlich Bio-Oss® and autologous bone and opimal fit to the remaining bone. | G Application of Geistlich Bio-Gide® to cover the defect site | H Primary wound closure with GoreTex suture. | I Three-dimensional implant planning. | J Re-entry 6 months after augmentation. Note the vital bone all the way up to the Yxoss CBR® scaffold without incorporation of Yxoss CBR® into the newly formed bone. | K Implant placement in prosthetically correct situation. | L Radio-graph after implant placement. | M Clinical situation after implant placement with final prosthetic restoration

FIG. 1: SURGICAL PROCEDURE Clinical case kindly provided by Dr. Keyvan Sagheb und Dr. Eik Schiegnitz, Department of Oral and Maxillofacial Surgery – Plastic Surgery University of Mainz

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You just gave a presentation about Ridge Preservation here at the ITI World Symposium in Basel. When did you start using this technique? Dr. Park: About five years ago. In the beginning I was skepti-cal: why should I preserve the ridge, if I could also wait and do implant placement with simultaneous GBR later on? But Ridge Preservation is a much less aggressive treatment com-pared to GBR and much more comfortable for patients. Also, recently I’ve come to believe that it is as much about soft tis-sue as hard tissue.

Under the label “Back to the Suture” you have an App and publish videos on YouTube. What’s your motivation?Dr. Park: In my opinion, 50 % of the success of a surgical treat-ment depends on the incision or flap design, the other 50% on the suturing. What you do in-between is much easier to learn. Many clinicians use the same suturing technique for everything, although there are better and more effective suturing techniques.

You use social media extensively for educational purposes… Dr. Park: Yes. I am very dedicated to dental education, and I am trying to find the best way to deliver knowledge to my students. Nowadays it’s mobile devices and social media. I can create tiny bits of knowledge they can digest easily. Once I get their atten-tion, it is easier to motivate them to learn more.

A chat with Jung-Chul Park.Interview

Interview by Verena Vermeulen

You work at the Dankook University in Cheonan. How many patients do you see in an average day?Dr. Park: Between 25 and 30. You can see immediately why I am happy that my Open Healing Ridge Preservation shortens my chair time (laughs).

So, your work load does not leave very much room for research. On which topic would you like to do more research if you had more time?Dr. Park: Dental stem cell research was one of my major inter-ests. Now I do more clinical trials than bench-test research. Klaus Lang gave me very good advice during the Osteology Research Academy. He said, “Don’t waste your precious time with many studies; instead, do one, very good randomized clinical trial.” That’s what I am focusing on now.

Is there any time for hobbies?Dr. Park (laughs): Like all Koreans I am an avid karaoke singer. And I like magic. I do lots of card and coin tricks for my kids. And somehow this also helps me with my lectures, because it’s all about surprise and misdirection and playing with the psychology of the audience. Everything is connected after all.

Dr. Jung-Chul Park was awarded a PhD at the Yonsei University Dental College, Seoul, Korea in 2012 for his study of stem cells acquired from inflamed periodontal ligament. Also, he received the Andre Schroeder award in 2013 during his ITI scholarship at Eastman Dental Institute, London, UK. He is now Assistant Professor at the Department of Periodontology, Dankook University Dental College, Cheonansi, Korea. He is also associate editor of the Journal of Periodontal and Implant Science, member of the Korean Dental Association and Academy of Periodontology, and author and co-author of several scientific publications and textbook chapters.

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39BACKGROUND

Issue 1 | 18

will be published in April 2018. FOCUS

Minimally invasive approaches in regenerative dentistry JOURNAL CLUB

Orthodontic treatments and biomaterials OUT OF THE BOX

Regeneration of the retina with gene therapy

Magazine for customers and friends of Geistlich BiomaterialsIssue 2/2017, Volume 11

Publisher©2017 Geistlich Pharma AG Business Unit Biomaterials Bahnhofstr. 406110 Wolhusen, Switzerland Tel. +41 41 492 55 55Fax +41 41 492 56 39 [email protected]

IMPRINT

EditorDr. Giulia Cerino, Verena Vermeulen

LayoutBüro Haeberli

Publication frequency2 × a year

Circulation25,000 copies in various languages worldwide

GEISTLICH NEWS content is created with the utmost care. The content created by third-parties, however, does not necessarily match the opinion of Geistlich Pharma AG. Geistlich Pharma AG, therefore, neither guarantees the correctness, completeness and topicality of the content provided by third parties nor liability for damages of a material or non-material nature incurred by using third-party information or using erroneous and incomplete third-party information unless there is proven culpable intent or gross negli- gence on the part of Geistlich Pharma AG.

Publisher©Geistlich Pharma AG Business Unit Biomaterials Bahnhofstr. 406110 Wolhusen, Switzerland Tel. +41 41 492 55 55Fax +41 41 492 56 39 www.geistlich-biomaterials.ch

More details via oursales partners:www.geistlich-pharma.com

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focus outside the box background soft tissue hope …...journal club 23 milestone studies. 23 an...

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