Treatment Concepts for

Extraction Sockets

?
tudies
Scientific S
ses
Clinical Ca
02
 1 Summary
The healing of extraction sockets and the resorption pro
cesses that take place after tooth extraction have been inves
tigated thoroughly in recent years. The most recent scientific
studies have shown that:
> after tooth extraction the bundle bone resorbs,
and hence part of the buccal lamina1
> immediate implant placement cannot prevent
resorption of bundle bone2
> Geistlich Bio-Oss and Geistlich Bio-Oss Collagen can
compensate for buccal bone loss and preserve the
contour of the alveolar ridge3,4
Different treatment concepts
Many different treatment options are available for the ex
traction socket. When an individual patient risk profile has
been compiled, the most suitable type of treatment for
management of the extraction socket can usually be inferred
by coherently evaluating the various aesthetic risk parame
ters. Importantly, the scheduling of treatment must be com
patible with the type of treatment selected. This brochure
provides several examples for the treatment of extraction
sockets matching various common clinical presentations.
Long-term successful outcome with
Geistlich Bio-Oss
The use of a biofunctional material such as Geistlich Bio-Oss
is crucial to the long-term successful outcome of extraction
socket treatment. After tooth extraction, the slowly resorb
1
Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of clinical periodontology 2005; 32: 212-218.
2
Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. Journal of clinical periodontology
2005; 32: 645-652.
3
Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler M. Tissue alterations after tooth extraction with and without surgical trauma: a volumetric study in the beagle dog. Journal of clinical
periodontology 2008;35:356-363.
4
Ackermann KL. Extraction site management using a natural bone mineral containing collagen: rationale and retrospective case study. The International journal of periodontics & restorative
dentistry 2009; 29: 489-497.
ing bone matrix Geistlich Bio-Oss and Geistlich Bio-Oss
Collagen preserve volume over time and thus make a major
contribution towards the success of treatment when they
are used:
for Ridge Preservation, i.e. with intact buccal bone wall, or
in combination with Geistlich Bio-Gide when a buccal
bone defect is present, or
at a later point in time within the scope of guided bone
regeneration (GBR).
Driving new discoveries
Research in recent years has provided plenty of new informa
tion about the mechanisms underlying resorption processes in
the extraction socket and highlighted the most appropriate
case management, but some issues are still unresolved.
Geistlich Biomaterials has initiated further research investiga
tions to support the discovery process and deliver competent
replies to the open questions. In addition, Round Table Meet
ings on the topic of extraction sockets are conducted by
Geistlich Biomaterials in several countries worldwide with the
aim to facilitate the establishment of the most effective treat
ment concepts.
The concepts presented in this brochure have been deve
loped in collaboration with leading implant dentists and we
would like to take this opportunity to express our sincere
gratitude for the productive collaboration and the valuable
exchange of experiences.
03
 Table of contents

3 1 Summary
5 2 Introduction
6 3 Scientific data
9 4 Clinical data
11 5 Extraction socket treatment options
12 6 Benefits of regenerative measures for the outcome of treatment
12 7 The patients individual aesthetic risk profile
13 8 Geistlich extraction socket round table meetings
14 9 Cases
Immediate implant placement
14 Case 1: Immediate implant placement with Ridge
Preservation, Dr. Tiziano Testori (Milan, Italy)

Early implant placement

16 Case 2: Ridge Preservation for early implant placement,
PD Dr. Ronald E. Jung (Zurich, Switzerland)
18 Case 3: Ridge Preservation for early implant placement,
Dr. Adrin Guerrero / Dr. Julia Guerrero (Mlaga, Spain)

Delayed/late implant placement

20 Case 4: Ridge Preservation for delayed implant placement,
Dr. KarlLudwig Ackermann (Filderstadt, Germany)
22 Case 5: Ridge Preservation for delayed implant placement,
Dr. Ham ByungDo (Seoul, Korea)
24 Case 6: Ridge Preservation for late implant placement,
Dr. Dietmar Weng (Starnberg, Germany)
26 Case 7: Ridge Preservation and softtissue grafting with delayed implant
placement, Prof. Dr. Martin Lorenzoni / Dr. Marlene Stopper (Graz, Austria)

No implant placement
28 Case 8: Ridge Preservation for bridge restoration,
Dr. Pedro Pea (Madrid, Spain)
30 10 Product range

04
 2 Introduction

Although the first publications describing the healing processes that take place after tooth extraction date back to the
1960s1, the healing of extraction sockets and the resorption processes after tooth extraction are still today active areas of
investigation. Researchers are constantly providing us with new information about how management of the extraction so-
cket with various treatment concepts simplifies implantation and leads to a predictable positive outcome. Ridge Preservation
techniques using biomaterials have shown to be effective and are outlined below.

Treatment of extraction sockets

Irrespective of the time of treatment and the individual situa ment. Regenerative measures to preserve the ridge in extrac
tion in each patient, the products from Geistlich Biomaterials tion sockets are the following:
can make a major contribution towards the success of treat

Ridge Preservation with intact socket

Regenerative measures for extraction sockets without bone wall defects; Geistlich Biomaterials recommends the use of Geistlich BioOss Collagen.

Ridge Preservation with deficient socket

Regenerative measures for extraction sockets with bone wall defects; Geistlich Biomaterials recommends the use of Geistlich BioOss Collagen in combination
with Geistlich BioGide (Geistlich CombiKit Collagen).

1
Amler MH, Johnson PL, Salman I. Histological and histochemical investigation of human alveolar socket healing in undisturbed extraction wounds. Journal of the American Dental Association
1960; 61: 32-44.

05
 3 Scientific data

Animal-experimental and clinical studies have allowed investigators to decipher the basic biological processes taking place
in fresh extraction sockets. Already in 1960 Amler described in a publication the different phases of wound healing in ex-
traction sockets.1 However, only recent animal studies have demonstrated in detail the processes that take place after
tooth extraction and proposed solutions to prevent tissue loss.

Biological processes of alveolar healing
Alveolar healing in a dog model2 (Fig. 1a):
1) Stabilisation of blood coagulum
2) Formation of provisional matrix (after 7 days)
3) Woven bone (after 1430 days)
4) Lamellar bone (after 30180 days)
5) Resorption of lamellar bone and replacement by
bone marrow (after 60180 days)
Bundle bone plays a key role
The main reason for the changes of the alveolar dimensions
after tooth extraction is the loss of the bundle bone; a tooth-
related structure that is lost when the tooth is extracted.
The buccal bone wall of the socket is very thin3 ,11 and consists
largely of the bundle bone. Accordingly, the loss of the bundle
bone inevitably results in a reduction of the vertical and hori
zontal dimensions of the alveolar ridge.4
Bundle bone will be lost in any case
Irrespective of the procedure, the bundle bone and hence a
large part of the buccal lamina will always resorb after tooth
extraction (Fig. 1).4,5 It does not matter whether the socket re
mains untreated (Fig. 1a)4, immediate implant placement is
performed5 (Fig. 1b) or augmentative measures are taken
(Fig. 1c)6. On the buccal side of the extraction socket 2.2 mm
vertical bone resorption were measured.2,6 In such cases,
Geistlich Bio-Oss Collagen is able to compensate for the
resorbed hard tissue structures in the buccal aspect of the
socket.7, 8
Possible precautions to prevent tissue loss
Bone: Even though prevention of bundle bone resorption was
not possible in an animal model, filling of Geistlich Bio-Oss
Collagen led to regeneration in the socket which mostly com
pensated for the horizontal and vertical bone loss (Fig. 1c).7, 9
The hard and soft-tissue volume was thus preserved in the coro

06
 Contour changes in extraction socket (animal model)

a) spontaneous healing

Starting situaton Situation after

0 weeks 1 week 2 weeks 4 weeks 8 weeks 12 weeks

b) immediate implant placement

Starting situaton Situation after

0 weeks 12 weeks

c) augmentation with Geistlich Bio-Oss Collagen

Starting situaton Situation after

0 weeks 12 weeks

Fig. 1: Contour changes in extraction sockets up to 12 weeks after tooth extraction (dog model); a) spontaneous healing, b) immediate implant placement, and c)
augmentation with Geistlich Bio-Oss Collagen. CEJ=cemento-enamel junction; aJE=apical cells of junctional epithelium; LB=lingual bone; BB=buccal bone;
PM=provisional matrix; C=blood clot; WB=woven bone; BM=bone marrow; M=mucosa.

07
 Coronal bone volume in the extraction socket (animal model)
+ 1.7% (with Geistlich Bio-Oss Collagen)
100%
Benefit of Geistlich Bio-Oss Collagen
Coronal bone volume

30.1% (without Geistlich Bio-Oss Collagen)

0 2 4 6 8 10 12 weeks

Fig. 2: Development of coronal bone volume in extraction sockets7.

nal part of the socket up to the time of the check-up (6 months).9

Soft tissue: Geistlich Bio-Oss Collagen was able, in an animal
Landmarks for histometric measurements2,8,10
model, to support the soft tissue above the bone.8 Further LCs
more, in clinical cases it was shown that Ridge Preservation
can preserve soft-tissue volume, leading to an improved BCs
Coronal
treatment outcome.10
Middle

Main loss coronal Apical

In their studies, Araujo et al. divided the extraction sockets
into an apical portion, a middle portion and a coronal portion.
For the authors analysis it is the coronal third, which is cru
cial. If the extraction socket is filled with Geistlich Bio-Oss LC: Lingual crest
Collagen, one can expect to preserve coronal bone volume. Socket BC: Buccal crest
On the other hand, the volume of the coronal portion de
Fig. 3: Schematic drawing (buccolingual view) illustrating measurements made
creased by about 30% if no Geistlich Bio-Oss Collagen was to determine cross-sectional area of the apical, middle and coronal thirds of
used (Fig. 2 and 3). Geistlich Bio-Oss Collagen was thus able the socket.7
to substitute for coronal bone structure.7, 9

1
Amler MH, Johnson PL, Salman I. Histological and histochemical investigation of human alveolar socket healing in undisturbed extraction wounds. Journal of the American Dental Association
1960; 61: 32-44.
2
Cardaropoli G, Araujo M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An experimental study in dogs. Journal of clinical periodontology 2003;30:809-818.
3
Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D, Ferrus J, Lindhe J, et al. Analysis of the socket bone wall dimensions in the upper maxilla in relation to immediate implant placement.
Clinical oral implants research 2010; 21: 37-42.
4
Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of clinical periodontology 2005; 32: 212-218.
5
Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. Journal of clinical periodontology
2005; 32: 645-652.
6
Cardaropoli G, Araujo M, Hayacibara R, Sukekava F, Lindhe J. Healing of extraction sockets and surgically produced - augmented and non-augmented - defects in the alveolar ridge. An
experimental study in the dog. Journal of clinical periodontology 2005;32:435-440.
7
Araujo M, Linder E, Wennstrom J, Lindhe J. The influence of Bio-Oss Collagen on healing of an extraction socket: an experimental study in the dog. The International journal of periodontics &
restorative dentistry 2008; 28: 123-135.
8
Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler M. Tissue alterations after tooth extraction with and without surgical trauma: a volumetric study in the beagle dog. Journal of clinical
periodontology 2008;35:356-363.
9
Araujo M, Lindhe J. Ridge preservation with the use of Bio-Oss collagen: A 6-month study in the dog. Clinical oral implants research 2009; 20: 433-440.
10
Ackermann KL. Extraction site management using a natural bone mineral containing collagen: rationale and retrospective case study. The International journal of periodontics & restorative
dentistry 2009; 29: 489-497.
11
Januario, A. L., W. R. Duarte, et al. Dimension of the facial bone wall in the anterior maxilla: a cone-beam computed tomography study. Clin Oral Implants Res. 2011; 22(10):1168-71.

08
 4 Clinical data

The majority of research findings presented so far is based on preclinical data. It may be assumed that the basic biological
processes taking place in the extraction socket of human beings and animals are comparable. However, the time intervals
of the animal model cannot be applied to humans, but more and more clinical studies on the processes that take place after
tooth extraction are published and the amount of clinical data confirming the preclinical findings is growing.

Human histological analysis various stages of maturity, and histological micrographs de

with Geistlich Bio-Oss
In a histomorphometric analysis, Heberer et al. provides further
information about the healing processes in intact human
sockets.37
In principle, the biological processes taking place in the
patients socket are comparable to those described by Car
daropoli et al.2 The hard tissue in the socket passes through
monstrate that after 12 weeks the tissue is on its way to becom
ing bone. Figures 46 show histologies representing a range of
phases, from provisional matrix to mature lamellar bone. Ac
cording to Heberer et al., however, it is not possible in a hetero
geneous patient population to determine with absolute reliabi
lity what bone quality is to be expected at what time.36 The
variability in humans is greater than in dogs.3

WB
GBO GBO
GBO LB

PM

Fig. 4: High proportion of provisional matrix (PM).1 Fig. 5: Woven bone (WB) envelops Fig. 6: Formation of lamellar bone (LB) round
Geistlich Bio-Oss particles (GBO).1 Geistlich Bio-Oss (GBO).1

Volume loss
Clinical investigations have also demonstrated that the alveo
lar volume loss after tooth extraction is severe: it was ob
served that approximately 50% of the buccal ridge width27
and 24 mm of the alveolar ridge height are lost within the
first year after extraction. Two-thirds of resorption takes
place within the first three months.4
A thin buccal bone wall often leads to recessions around im
plants, and treating such recessions is very challenging.8
When extraction sockets are left to heal without Ridge Preser
vation, collapse of soft tissues will occur when the underlying
bony support is lost. Furthermore, a shift of the mucogingival
line and loss of the papilla over the defect have been
observed.9

Hard and soft-tissue recession Ridge Preservation

Implant placement, especially in the aesthetic area, is very
demanding because if no additional measures are taken after
tooth extraction, the socket will not refill with bone to the
original level of the alveolar crest. Buccal hard and soft-tissue
resorption is observed in most cases.5 In patients with a thin
periodontal biotype and especially with prominent roots
major horizontal and vertical volume loss of the alveolar ridge
must be expected.6 Thereby, the horizontal bone loss is larger
than the vertical.7,26
Clinical data indicate that Ridge Preservation can prevent
volume loss and lead to an optimised hard and soft- tissue
situation independently from the chosen time for implanta
tion.1,9-15,27,28 Also, when the treatment goal is to place a
bridge, Ridge Preservation can improve the aesthetic out
come by preserving the alveolar ridge volume and contour.16
Furthermore a Ridge Preservation procedure may increase
the possibility of inserting implant without the need for a
sinus augmentation procedure.38

09
 Immediate implantation: fill the gap
It has been proposed that immediate implant placement
should be performed to preserve hard and soft tissues. How
ever, changes in the level of hard and soft tissues have been
reported.17, 29,30 It was observed that the horizontal resorption
of the buccal bone dimension amounted to about 56%.18
Therefore, when immediate implant placement is performed
it may be beneficial to fill the gap between the implant and
the buccal bone wall with a slowly resorbing bone substitute,
such as Geistlich Bio-Oss, or autogenous bone to reduce
resorption as supported by clinical19,20,31 and preclinical32-34
data. This is especially important since about 90% of the buc
cal bone walls in the aesthetic region were shown to be thin
ner than 1 mm.21,35 In these cases augmentation is necessary,
which will lead to complete filling of the gap independently
from the thickness of the bony wall.22 Without filling the gap,
healing of the defect can be expected to be adequate only in
sockets with thicker bone walls.
When a buccal bone defect is present, immediate implant
placement may not be successful. In molar implants which
had horizontal defect dimensions of 4 mm, only 17% bone-to-
implant contact was observed.23
1
Al Chawaf B, et al. Bone formation in extraction sockets augmented with Bio-Oss Collagen after a healing
period of 6 to 12 weeks. Scientific poster, AO 23rd Annual Meeting 2008, Boston.
2
Cardaropoli G, Araujo M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An
experimental study in dogs. Journal of clinical periodontology 2003; 30: 809-818.
3
Trombelli L, Farina R, Marzola A, Bozzi L, Liljenberg B, Lindhe J. Modeling and remodeling of human
extraction sockets. Journal of clinical periodontology 2008; 35: 630-639.
4
Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following
single-tooth extraction: a clinical and radiographic 12-month prospective study. The International journal of
periodontics & restorative dentistry 2003; 23: 313-323.
5
Covani U, Bortolaia C, Barone A, Sbordone L. Bucco-lingual crestal bone changes after immediate and
delayed implant placement. Journal of periodontology 2004; 75: 1605-1612.
6
Nevins M, Camelo M, De Paoli S, Friedland B, Schenk RK, Parma-Benfenati S, et al. A study of the fate of the
buccal wall of extraction sockets of teeth with prominent roots. The International journal of periodontics &
restorative dentistry 2006; 26: 19-29.
7
Van der Weijden F, DellAcqua F, Slot DE. Alveolar bone dimensional changes of post-extraction sockets in
humans: a systematic review. Journal of clinical periodontology 2009; 36: 1048-1058.
8
Small PN, Tarnow DP: Gingival recession around implants: a 1-year-longitudinal prospective study. Int Journal
Oral Maxillofacial Implants 2000; 15: 527-532.
9
Stimmelmayr M, Stangl M, Gernet W, Edelhoff D, Gueth JF, Beuer F: Biology of socket healing and surgical
procedures for socket and ridge preservation. Deutsche Zahnrztliche Zeitschrift 2010; 65: 294-303.
10
Shakibaie-M B: Socket and Ridge Preservation. Dental Magazin 2009; 2: 24-33.
11
Weng D, Bhm S. Simplify your Augmentation - Was bei der Extraktion zu beachten ist, damit die
Implantation einfach wird. Implantologie 2006; 14: 355-363.
12
Ackermann KL. Extraction site management using a natural bone mineral containing collagen: rationale and
retrospective case study. The International journal of periodontics & restorative dentistry 2009; 29: 489-497.
13
Artzi Z. Coronal ridge augmentation in the absence of bilateral bony plates around a pathologically denuded
implant surface. The International journal of periodontics & restorative dentistry 2000; 20: 191-197.
14
Irinakis T, Tabesh M. Preserving the socket dimensions with bone grafting in single sites: an esthetic surgical
approach when planning delayed implant placement. The Journal of oral implantology 2007; 33: 156-163.
15
Jung RE, Siegenthaler DW, Hmmerle CH. Postextraction tissue management: a soft tissue punch technique.
The International journal of periodontics & restorative dentistry 2004; 24: 545-553.
16
Schlee M, Esposito M. Aesthetic and patient preference using a bone substitute to preserve extraction
sockets under pontics. A cross sectional survey. Eur J Esthet Dent 2009; 2: 209-217.
17
Kan JY, Rungcharassaeng K, et al. Facial gingival tissue stability following immediate placement and
provisionalization of maxillary anterior single implants: a 2- to 8-year follow-up. Int J Oral Maxillofac
Implants. 2011 Jan-Feb;26(1):179-87.
18
Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in
extraction sites. Journal of clinical periodontology 2004; 31: 820-828.
19
van Steenberghe D, Callens A, Geers L, Jacobs R. The clinical use of deproteinized bovine bone mineral on bone
regeneration in conjunction with immediate implant installation. Clinical oral implants research 2000; 11: 210-216.
20
Chen ST, Darby IB, Reynolds EC. A prospective clinical study of non-submerged immediate implants: clinical
outcomes and esthetic results. Clinical oral implants research 2007; 18: 552-562.
10
Flap or flapless?
The question, whether to prepare a flap or not, remains open.
Preclinical data have demonstrated that resorption might be
reduced when no flap is opened.24 However, clinical investiga
tions thus far could not confirm this, and no differences were
observed in regard to the amount of bone resorption.25
When immediate implant placement is performed it may be benefical to fill the
gap with Geistlich Bio-Oss.
21
Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D, Ferrus J, Lindhe J, et al. Analysis of the socket bone wall
dimensions in the upper maxilla in relation to immediate implant placement. Clinical oral implants research
2010;21:37-42.
22
Matarasso S, Salvi GE, Iorio Siciliano V, Cafiero C, Blasi A, Lang NP. Dimensional ridge alterations following
immediate implant placement in molar extraction sites: a six-month prospective cohort study with surgical
re-entry. Clinical oral implants research 2009;20:1092-1098.
23
Wilson, T. G., Jr., R. Schenk, et al. Implants placed in immediate extraction sites: a report of histologic and
histometric analyses of human biopsies. Int J Oral Maxillofac Implants 1998;13(3): 333-41.
24
Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler M. Tissue alterations after tooth extraction with and without
surgical trauma: a volumetric study in the beagle dog. Journal of clinical periodontology 2008;35:356-363.
25
Esposito M, et al. Interventions for replacing missing teeth: management of soft tissues for dental implants.
Cochrane Database Syst Rev. 2012 Feb 15;2:CD006697.
26
Tan, WL et al. (2011) A systematic review of post-extractional alveolar hard and soft tissue dimensional
changes in humans Clin Oral. Impl. Res. 2012; 23 (Suppl. 5) 1-21
27
Weng, D. Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaing
the tissues of the alveolar ridge? Eur J Oral Implant 2011; 4 (Suppl): S5-S10.
28
Hammerle, C. H., M. G. Araujo, et al. Evidence-based knowledge on the biology and treatment of extraction
sockets. Clin Oral Implants Res 2012; 23 Suppl 5: 80-2.
29
Caneva, M., D. Botticelli, et al. Alveolar process preservation at implants installed immediately into
extraction sockets using deproteinized bovine bone mineral - an experimental study in dogs. Clin Oral
Implants Res 2011; 00 1-8.
30
Vignoletti, F., N. Discepoli, et al. Bone modelling at fresh extraction sockets: immediate implant placement
versus spontaneous healing. An experimental study in the beagle dog.
J Clin Periodontol 2012; 39(1): 91-7.
31
Neves M et al. A novel approach to preserve the buccal wall in immediate implant cases - a Clinical Report J
Oral Implantol 2011; PMID: 21767202.
32
Araujo, M. G., E. Linder, et al. Bio-Oss Collagen in the buccal gap at immediate implants: a 6-month study in
the dog. Clin Oral Implants Res 2011; 22(1): 1-8.
33
Araujo, M. G. and J. Lindhe et al. Socket grafting with the use of autologous bone: an experimental study in
the dog. Clin Oral Implants Res 2011; 22(1): 9-13.
34
Santis, E. D., D. Botticelli, et al. Bone regeneration at implants placed into extraction sockets of maxillary
incisors in dogs. Clin Oral Implants Res 2011; 22(4): 430-7.
35
Januario, A. L., W. R. Duarte, et al. Dimension of the facial bone wall in the anterior maxilla: a cone-beam
computed tomography study. Clin Oral Implants Res. 2011; 22(10):1168-71.
36
Heberer S, Histomorphometric analysis of extraction sockets augmented with Bio-Oss Collagen after a
6-week healing period: A prospective study. Clin. Oral Impl. Res. 19, 2008; 12191225.
37
Heberer S et al. Osteogenic potential of mesenchymal cells embedded in the provisional matrix after a
6-week healing period in augmented and non-augmented extraction sockets: an immunohistochemical
prospective pilot study in humans. Clin Oral Implants Res. 2012;23:19-27.
38
Rasperini G et al. Socket grafting in the posterior maxilla reduces the need for sinus augmentation.
Int J Periodontics & Restorative Dentistry 2010;30:265-273.
 5 Extraction socket treatment options

The appropriate type of treatment for the management of extraction sockets is derived from a coherent evaluation of the
aesthetic risk factors (see section 6: The patients individual aesthetic risk profile). In addition to the time of implantation,
the attending dentist needs to make a decision regarding regenerative measures directly after tooth extraction. Various
procedures are recommended, such as Ridge Preservation for intact and deficient sockets in addition to the soft-tissue
punch technique.

What is the patients individual aesthetic risk profile and how does it influence the treatment concept?

Should I place an implant?

yes no

When should I place an implant? What are the consequences for my further treatment steps?

delayed*
immediately* early* (48 weeks) (1012 weeks)/
late* (>16 weeks)

Fill the gap Socket sealing or Ridge Preservation Ridge Preservation Ridge Preservation
spontaneous healing and socket sealing

GBR when implant

is placed If needed

*ITI Treatment Guide, Implant Therapy in the Esthetic Zone, Single-Tooth Replacements, 2007.

11
 6 Benefits of regenerative measures for
treatment outcome
Numerous reports from practice and laboratory findings indicate that the use of a slowly resorbing, biofunctional bone substitute
material can have a positive inuence both on the soft-tissue situation and on the hard tissue structure of intact sockets.

Practicerelevant advantages of
Ridge Preservation:
> In aesthetically challenging regions, an optimum outcome in
terms of pink and white aesthetics can be achieved. WITH WITHOUT
> Alveolar ridge dimensions are preserved also under conven
tional construction (bridge).1
Ridge Preservation
> The therapeutic time window for subsequent implantation is
can preserve
extended. the alveolar ridge
> The extent of any future invasive surgery can be reduced. dimensions.2,3

7 The patients individual aesthetic risk profile

The table below lists various diagnostic parameters which can be used for patient evaluation before treatment. This cata-
logue of criteria is used to compile the patients individual risk profile, which can point to opportunities for achieving an
aesthetically positive therapeutic outcome. In order to present the initial situation of the case studies below in a simple,
comparable manner, each patient situation is first evaluated on the basis of this risk profile.

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker Impaired immune system
Patients health
system (nonsmoker) (heavy smoker)
Patients aesthetic requirements Low Medium High
Height of the smile line Low Medium High
Thick Medium Thin
Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
5 mm from 5.56.5 mm from 7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Softtissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect
Fig. 5: Evaluation of aesthetic risk factors with extraction sockets; based on Buser D, Belser U, Wismeijer D, ITI Treatment Guide, Implant Therapy in the Esthetic
Zone, SingleTooth Replacements, 2007.

1
Schlee M, Esposito M. Aesthetic and patient preference using a bone substitute to preserve extraction sockets under pontics. A cross sectional survey. . Eur J Esthet Dent 2009; 2: 209-217.
2
ShakibaieM B: Socket and Ridge Preservation. Dental Magazin 2009; 2: 24-33.
3
ShakibaieM B: Socket and Ridge Preservation from the threedimensional prespective a clinical study. ZZI 2009;4:369-377

12
 8 Geistlich extraction socket round
table meetings
Round table meetings organised by Geistlich Biomaterials have taken place in several countries worldwide with the aim
of promoting discussion and evolving a consensus on the treatment concepts for extraction sockets. These round table
meetings also help to define where research still needs to be done.

Conclusions on the treatment of Open questions the topic of extraction

extraction sockets
Several points emerged from the round table meetings on
which an international consensus already exists. The majority
of the experts came to the following conclusions in several
countries, independently of one another:
> In the event of buccal bone defects and especially in the
anterior region, besides a volume filling material (e.g.
Geistlich BioOss or Geistlich BioOss Collagen), a mem
brane should also be used (e.g. Geistlich BioGide) for
Ridge Preservation.
> Ridge Preservation should be performed under a nonim
plant restoration (bridge) to maintain the volume of tissues.
> In the case of immediate implantation, the gap between
the implant and buccal wall should be treated with volume
stable filler (e.g. Geistlich BioOss).
> If Ridge Preservation is performed, there should be at least
a fourmonth wait before implantation.
> A dentist inexperienced in implantology is recommended
to perform Ridge Preservation immediately after dental ex
traction and to choose a later time for implantation.
sockets remains exciting
Besides many enriching discussions, numerous problems
solved and the consensus achieved, there remain some open
questions.
Sophisticated surgical techniques that are only partly relia
ble in everyones hands, reproducible results and problems
in determining the patients individual biotype these are
the difficulties frequently cited.
Likewise, different therapeutic procedures exist for early im
plantation (i.e. ITI type 2, 48 weeks after extraction). One
solution could be Ridge Preservation directly after extraction
(sometimes in conjunction with a softtissue punch), followed
by an additional small augmentation at the time of implanta
tion after 48 weeks. Another is characterised by early implan
tation with concomitant GBR, albeit without Ridge Preserva
tion. In any case, according to the ITI 2010, DGI 2010 and
Osteology 2011 consensus, for each implantation into an ex
traction socket, the need for regenerative therapy should be
considered. Bone augmentation is explicitly recommended to
optimise the functional and aesthetic results.1 Since there is,
however, insufficient evidence clearly defining the advantages
or disadvantages of immediate, immediatedelayed, or de
layed implantation2,3, which technique to choose remains a
matter of experience and depends on the practitioners con
cept.

Further round table

meetings planned
Extraction sockets remain a
topic in focus. Since
the Geistlich Biomaterials
round table meetings have
been considered a great
success, further national and
international round table
meetings on the topic of
extraction sockets will be
conducted.
1
Chen ST et al.: Konsensuserklrungen und klinische Empfehlungen zu chirurgischen
Verfahren. Implantologie (Sonderheft) 2010; 18 (3): S2-S28.
2
Esposito, M et al.: Zeitpunkt der Implantation nach Zahnextraktion: Sofort, verzgerte
Sofort oder Sptimplantation? Ein systematischer Cochrane Review. Eur J Oral Implantol
2010; 3 (3): 189-205
3
Hammerle, C. H., M. G. Araujo, et al. Evidencebased knowledge on the biology and
treatment of extraction sockets. Clin Oral Implants Res 2012; 23 Suppl 5: 80-2. 13
 Case 1 Immediate implant placement

9 Cases
Immediate implant placement with Ridge Preservation
Dr. Tiziano Testori (Milan, Italy)

Objectives
> Minimise surgical trauma with gentle (atraumatic) teeth extractions
> Immediate implant placement to reduce treatment time for patients
> Maintenance of mucosa and periodontal architecture with minimal flap elevation
> Maintenance of buccal and palatal bone volume after tooth extraction
> Over correct defects anticipating physiological resorption to obtain long-term best aesthetic results
> Use of low resorption rate biomaterials to obtain long-term best aesthetic results

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> Geistlich Bio-Oss spongiosa small granules (0.25 1 mm)

Material selection
> Geistlich Bio-Gide membrane, 25 x 25 mm

Conclusion
Immediate post extraction implants represent a valid
approach for optimising surgical procedures, timing and
management of the aesthetic issues after tooth extraction
in anterior area. It is important to pay attention during
diagnostic phase to carefully evaluate the patient risk profile.
In this way, nothing will be left behind causing unfavorable
results. Implants were thought to preserve bony buccal plates
from resorption. However, recent studies and our clinical
experience underline that buccal bone resorption takes
place despite placement of an implant immediately after
tooth removal, mainly because of vascular supply changes:
a permanent loss of periodontal ligament vessels and, if flap
elevated, a temporary periosteal vascular supply loss. These
changes affect the thin buccal bundle bone mostly. Bone
augmentation procedures are often required at the time of
implantation since the goal is to preserve the buccal plate and
reduce bone resorption over time. Long-term results depend on
biomaterial resorption rate: many studies showed that Geistlich
Bio-Oss has a low substitution rate during years and thats
why Geistlich Bio Oss represents our choice when clinical
goal is hard and soft-tissue stability over years. Furthermore, an
aesthetic score is needed to evaluate the outcome.

14
 Immediate implant placement Case 1

Case documentation

1 A hopeless first upper premolar.
2 Tooth socket after the atraumatic extraction.
3a Implant direction pin parallel to the root of the
adjacent premolar.
3b Buccal angulation to avoid apical fenestration
and to achieve a correct emergence profile of
the future crown.

4 Implant positioned with a 2 mm healing abut 5  Intra-external grafting (inside and outside of 6 Geistlich Bio-Gide membrane is placed over the
ment. the socket) with small Geistlich Bio-Oss parti healing abutment and left exposed to avoid any
cles. The particles are covered with a Geistlich secondary mucosal approximation.
Bio-Gide membrane.

7 H
 ealing of the peri-implant soft tissue after 3 8 Temporary prosthesis 4 months after implant 9 Temporary prosthesis 4 months after implant
months. placement, vestibular view. placement, occlusal view.

10 Definitive prosthesis 2 months after provisional, 11 Definitive prosthesis 2 months after provisional, 12 X-ray 6 months after final prosthesis restored
vestibular view. occlusal view. with the platform switching concept.

15
 Case 2 Early implant placement

Ridge Preservation for early implant placement

PD Dr. Ronald E. Jung (Zurich, Switzerland)

Objectives
> Optimum soft-tissue situation 6 weeks after extraction
> The buccal and crestal contours of the soft tissue should be supported and preserved after extraction

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> At the first step of alveolar management: soft-tissue punch from the palate with
Geistlich Bio-Oss Collagen, 100 mg
Material selection
> At the second step of alveolar management: Geistlich Bio-Oss spongiosa small
granules (0.251 mm) and Geistlich Bio-Gide membrane, 25 x 25 mm

Conclusion
In the case of early implant placement, the implant is
placed a few weeks after extraction. During that period the
soft tissue undergoes spontaneous healing. The thickness
of the mucosa forming at the centre of the socket varies
according to healing time. However, the biological processes
which lead to bone resorption and partial or complete loss of
the bone lamina commence directly after tooth extraction.
This, in turn, has a negative influence on hard and soft-tissue
contours. Although in my opinion it is not usually possible
to prevent bone loss after extraction with Geistlich Bio-Oss
Collagen and soft-tissue grafts, Geistlich Bio-Oss Collagen
supports the graft and buccal soft tissue so it counteracts
loss of soft-tissue contour above the resorbing bone lamina.
The graft for its part closes and protects the fresh extraction
wound and creates an optimum thickness and structure of
soft tissue available for ensuing implant placement.

16
 Early implant placement Case 2

Case documentation

1 Gentle extraction of tooth 21. Granulation tissue 2 De-epithelialization of the wound margin using 3 Application of an amount of Geistlich Bio-Oss
carefully debrided. Inspection and palpation of a coarse diamond drill. Collagen that corresponds to the tooth root.
the socket show a lacking buccal bone lamella.

4 Independent of whether the buccal bone wall is 5 The graft is removed using a scalpel or a sharp 6 Using 68 single button sutures, the graft over
present or not, Geistlich Bio-Oss Collagen is ap tissue elevator. Bleeding is stopped using com the Geistlich Bio-Oss Collagen is carefully fixed
plied with light stuffing motions until it reaches pression with sterile gauze, and the wound is to the marginal gingiva of the extracted tooth.
the height of the rim of the palatine bone. covered with a tissue adhesive. Follow-up treatment: antibiotics for 4 days.

7 During suture removal after 710 days, one sees 8 Clinical situation after 6 weeks. The graft is, bio 9 After implant insertion in the prosthetically
an integrated graft, partially covered with fibrin. logically and color-wise, very well integrated and correct position, Geistlich Bio-Oss is placed
shows a mature mucosa in the area where the into the buccal defect. The Geistlich Bio-Oss is
implant will later be inserted. covered with a Geistlich Bio-Gide membrane.

10 Thanks to the good mucosa quality and the main 11 After the implant healing phase (3 months), a 12 Prosthetic construction with 2 full ceramic
tained contour, a relief incision is made in the minimally invasive abutment connection of im crowns after 7 months of loading.
periosteum, and a tension-free wound closure is plant 21 is made.
achieved.

17
 Case 3 Early implant placement

Ridge Preservation for early implant placement

Dr. Adrin Guerrero / Dr. Julia Guerrero (Mlaga, Spain)

Objectives
> To reduce treatment time
> To avoid complex augmentation procedures in cases with severe resorption of the buccal bone crest
> To achieve an optimal soft-tissue healing before implant placement
> To create a favourable situation for early implant placement in the prosthetically position
> To increase buccal contour and reduce or avoid soft-tissue grafting
> To achieve optimal clinical results

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> At the first step of alveolar management: Geistlich Bio-Oss Collagen, 100 mg;
Geistlich Bio-Gide membrane, 25 x 25 mm
Material selection
> At the second step of alveolar management: Geistlich Bio-Oss spongiosa small
granules (0.251 mm) & Geistlich Bio-Gide membrane, 30 x 40 mm

Conclusion
We apply this treatment concept to aesthetically demanding
cases with compromised bony walls with the aim of avoiding
complex procedures. In this case the buccal bone wall was
completely resorbed due to the infection process. This fact
introduces a high risk for immediate implant installation.
The use of this slow-resorbable bone substitute embedded
into a collagen matrix provides some soft-tissue support
on the buccal aspect of the extraction socket and it may
serve, at least, to promote a mature provisional matrix for
early bone formation at 6 weeks after its application. Thus,
implant placement could be performed at an early stage
and in the ideal position. The buccal aspect of the implant
was surrounded by previously grafted Geistlich Bio-Oss
Collagen, that has been in place for 6 weeks. In addition,
as soft-tissue healing is completed at this stage, further
augmentation procedures can be applied and primary
intention healing can be obtained by tension-free soft-tissue
flaps. This simple 2-step procedure may reduce treatment
time and morbidity in these complex cases.

18

Case documentation
1 Tooth 21 cannot be preserved due to recurrent
endodontic problems. A re-endodontic treatment
and an unsuccessful apicectomy were previously
performed.
4 Application of Geistlich Bio-Gide on top of the
Geistlich Bio-Oss Collagen. The membrane is
fixed with an internal matrice cross suture and left
for open healing.
7 Application of Geistlich Bio-Oss granules.
10 Occlusal view on soft-tissue healing 4 weeks after
implant placement.
2A
 traumatic extraction of tooth 21. A severe resorp
tion of the buccal bone wall was confirmed. The
probe measures an 8 mm distance between the
gingival margin and the most coronal aspect of the
actual buccal bone crest.
5 Healing and clinical situation 6 weeks after tooth
extraction.
8 Application of Geistlich Bio-Gide membrane. The
implant was installed following a one-stage pro
cedure, exposing a healing abutment to the oral
cavity.
11 1 year follow-up on the definitive restoration.
Early implant placement Case 3
3 Application of Geistlich Bio-Oss Collagen, mois
tened with saline solution. All granulation tissue
was carefully debrided before the application of
the biomaterial.
6 Reopening after 6 weeks and early implant place
ment. Geistlich Bio-Oss Collagen is visible, but
well integrated in native bone. Geistlich Bio-Oss
Collagen is left in place. The coronal aspect of the
implant is exposed and further GBR is needed.
9 Healing, at suture removal, 10 days after implant
placement.
12 Radiological view before and 1 year after
implantation.
19
 Case 4 Delayed/late implant placement

Ridge Preservation for delayed implant placement

Dr. Karl-Ludwig Ackermann (Filderstadt, Germany)

Objectives
> Three-dimensional structure preservation
> Alveolar over-epithelialisation
>P
 redictability of final outcome

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> Geistlich Bio-Oss Collagen, 100 mg

Material selection
> Palatal connective tissue graft

Conclusion
3-D preservation of the alveolar hard and soft tissue is
the focus of attention in the Ridge Preservation technique.
The cause of losing the tooth or teeth and the quantity of
bone and soft-tissue structure remaining intact are of no
consequence. Based on an introduced substitute the
hard and soft tissue can regenerate in the healing phase.
Consequently, the tissue collapse defect, which always occurs
otherwise, is avoided and the basis of all further treatment
is improved. With regard to the treatment decision in favour
of Ridge Preservation, it does not matter whether further
treatment will be solely prosthetic, augmentative or implant
dentistry, or a combination.

20

Case documentation
1 A close-up shows the different heights of the mar
ginal gingiva, the marginal discoloration and sub
stantial train of scars in the vestibule.
4 Four months after alveolar filling with Geistlich
Bio-Oss Collagen volume preservation is clearly
evident. On the crestal side an intact mucoperi
ostal cover has formed above Geistlich Bio-Oss
Collagen on account of secondary epithelialisation.
7 The soft-tissue flap is a combination of mucosal and
mucoperiosteal flaps. The perforating muscle fi
bres are systematically excised and the periosteum
is exposed separately.
10 The connective tissue graft from the palate
should, whenever possible, take the form of a so-
called soft-tissue sandwich from labial between
the periosteum and the mucosa. Implants usu
ally settle in transgingivally without any stress.
Delayed/late implant placement
2 After gentle extraction the large-volume socket is
impressive. The labial bone lamina is missing.
5 Structural preservation is also in evidence from the
labial side. Papillary height and the shape of the
marginal gingiva labially and palatally are the
same as those of the corresponding structures on
the adjacent teeth.
8 After currettage of the alveolar segment and par
tial removal of the Geistlich Bio-Oss Collagen,
which has now fulfilled its placeholder function,
the labial and crestal bone is built up by the bone
block.
11 The gingiva can be conditioned accordingly with
temporary prosthetic solution. The labial soft
tissue can be fully contoured and the papillae can
be shaped in the interproximal regions by means
of skilful tissue pushing.
Case 4
3 Application of Geistlich Bio-Oss Collagen is very
easy on account of its material properties. Intra-al
veolar bleeding is stopped by the Geistlich Bio-Oss
Collagen. The 3-D structure soaks up intra-alveolar
blood like a sponge and ensures haemostasis.
6 The mineralised portion (55.9%) of the biopsy ap
pears below the yellow line and is alveolar bone.
Newly formed bone (36.3% in bright red) with in
tegrated Geistlich Bio-Oss (19.6% in green) is
seen in the upper part of the image .
9 After a few weeks, the three-dimensional large-
volume augmentation can also be seen at the soft-
tissue level. Changes in the height of the papillae
are barely visible but in the region of the marginal
gingiva they are distinct.
12 4 years follow up. Stable hard and soft-tissue con
ditions.
21
 Case 5 Delayed/late implant placement

Ridge Preservation for delayed implant placement

Dr. Ham Byung-Do (Seoul, Korea)

Objectives
> Reconstruct alveolar bone for the lower left second molar
> Augment severely reduced vertical bone loss from chronic periodontitis at the time of tooth extraction
> Investigate the clinical and histological result by using both Geistlich Bio-Oss Collagen and Geistlich Bio Gide
after tooth extraction

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
I ntact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> Geistlich Combi-Kit Collagen (Geistlich Bio-Oss Collagen, 100 mg +

Material selection Geistlich Bio-Gide membrane, 16 x 22 mm)
> Implantium 4.8w x 10 mm, Dentium, Korea

Conclusion
Most of clinicians have met an unsolved question whether
extraction socket heals spontaneously in a certain period
of time regardless of the socket environment, or not. In a
situation of severe loss of alveolar bone, augmentation
procedure may be necessary to make sure of delayed
implant placement. In this particular case, the initial defect
was completely filled with newly-formed hard tissue after 6
months and the primary stability of the implant was good.
Histomorphometric analysis revealed 45% of the hard tissue
area including bone substitutes material and 28% of the soft
tissue area. The restorative procedures were uneventful with
the screw-retained type of PFM restoration.

22
 Delayed/late implant placement Case 5

Case documentation

1 Radiological status prior to extraction. 2 S tarting situation. 3 Status following atraumatic extraction of tooth 17.

4 A flap is raised. 5 Filling of the extraction socket up to the level of 6 Insertion of the Geistlich Bio-Gide membrane
the crestal bone level using Geistlich Bio-Oss over the defect .
Collagen.

7 Closure of the extraction socket with a mattress 8 Situation 6 months post-op. 9 Newly formed hard tissue. Geistlich Bio-Oss Col
suture. Open healing. lagen is not obvious.

10 One stage protocol with healing abutment. 11 Provisional prosthesis. 12 Radiological view after implantation.

23
 Case 6 Delayed/late implant placement

Ridge Preservation for late implant placement

Dr. Dietmar Weng (Starnberg, Germany)

Objectives
> Healing of alveolar bone
> Preservation of the alveolar ridge in its original form
> Healed and closed soft tissue cover at the time of implant placement
> Avoidance of connective tissue invasion due to dehiscence
> Implant placement in prosthetically correct position without any additional augmentation

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> Geistlich Bio-Oss spongiosa small granules (0.251 mm)

Material selection > Geistlich Bio-Gide membrane, 25 x 25 mm
> Gelastypt resorbable gelatine sponge, Aventis Pharma, Frankfurt

Conclusion
The concept presented for the management of extraction
sockets which is not suitable for immediate implant
placement propagates filling with Geistlich Bio-Oss and
covering the dehiscence defect with Geistlich BioGide,
whereby the collagen membrane is introduced between
the periosteum and the bone in a low-risk, atraumatic
intervention.
After several months of healing the alveolar ridge has
resumed its original width and thus permits implantation
without any lateral augmentation. The use of slow-resorbable
bone substitute material ensures that the original volume of
the alveolar bone is preserved in the long-term. Performing
augmentation and implant placement at different times and
separating them physically reduces the wound healing risk,
facilitates soft-tissue management and simplifies surgical
requirements. Owing to the slow resorption of Geistlich
Bio-Oss the time window for further treatment steps is
extended.

24
 Delayed/late implant placement Case 6

Case documentation

1 S tarting situation shows tooth 16 before extrac 2 Situation after atraumatic extraction of tooth 16. 3 On the buccal side Geistlich Bio-Gide was placed
tion. On the buccal side the tooth was already exhibit between the periosteum and the bone surface
ing a recession of hard and soft tissue. after exposure without cutting. No incisions were
made.

4 The socket was filled with Geistlich Bio-Oss, 5 On the palatal side, the free end of the Geistlich 6 A gelatine sponge has been positioned over the
which restores the original contour of the alveolar Bio-Gide membrane was pushed between the Geistlich Bio-Gide membrane and fixed in place
ridge. periosteum and the bone surface. with cross suture.

7 A second gelatine sponge has been placed on the 8 Situation of the socket from figures 2 to 7 after ten 9 S ituation of the socket from figures 2 to 7 after
first cross suture and held in place with a second days. After disintegration of the covering layers iso three weeks. After disintegration of the covering
cross suture. lated particles of Geistlich Bio-Oss are visible. layers , again, some isolated particles of Geistlich
Bio-Oss are visible.

10 Situation 13 months after Ridge Preservation. 11 A

 flap is raised during implant placement: The 12 I mplant insertion in the region of 16. After Ridge
buccal contour is completely intact. Preservation it was possible to perform implant
placement without any complicated augmenta
tion, despite the original recession defect.

25
 Case 7 Delayed/late implant placement

Ridge Preservation and soft-tissue grafting

with delayed implant placement
Prof. Dr. Martin Lorenzoni / Dr. marlene Stopper (Graz, Austria)

Objectives
> Reduction of crestal bone loss
> Improved soft-tissue coverage
> Reduced scarring after extraction
> Augmentation of facial contours
> Preservation of healthy periimplant tissue
> Preservation of the papillae architecture

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> Geistlich Bio-Oss Collagen, 100 mg

Material selection > Geistlich Bio-Oss spongiosa small granules (0.251 mm)
> Geistlich Bio-Gide membrane, 25 x 25 mm

Conclusion
Ridge Preservation with Geistlich Bio-Oss is a viable
treatment concept to prevent crestal hard and soft-tissue
loss of extraction sites with remaining buccal bone plate. To
avoid a soft-tissue collapse into the socket and undesired
scarring, a free gingival graft harvested from the tuberosity, is
applied to seal the socket. The maintenance of hard and soft-
tissue contours facilitates implant placement. Additionally,
a subepithelial connective tissue graft at reentry increases
the facial tissue volume and stability and provides improved
aesthetic outcome.

26
 Delayed/late implant placement Case 7

Case documentation

1 External root resorption (trauma) tooth 11. 2R

 adiographic view. 3 Grafting with Geistlich Bio-Oss Collagen (Ridge
Preservation).

4 Adaption and fixation of subepithelial connective 5 S ocket sealing with free gingival graft (punch) se 6 Post-op. radiograph.
tissue graft (palate). cured with non-resorbable sutures 6.0.

7 Implant placement 4 months post-op. including 8 Soft-tissue graft (subepithelial connective tissue) 9 Acrylic screw-retained provisional immediately
GBR with Geistlich Bio-Oss and Geistlich Bio- 8 weeks post reentry. post-op.
Gide.

10 Soft-tissue healing 3 weeks post-op. 11 Clinical appearance 3 months after all-ceramic 12 Radiographic view of osseointegrated implant
crown incorporation (labwork by MT Rudi Hrdina). with customized zirconia abutment.

27
 Case 8 No implant placement

Ridge Preservation for bridge restoration

Dr. Pedro Pea (Madrid, Spain)

Objectives
> Maintenance of hard- and soft tissue
> Preservation of the papillae architecture
> Patients comfort with immediate extraction/immediate loading
> Shorter treatment time

The patient's risk profile

Aesthetic risk factors Low risk Medium risk High risk
Intact immune Light smoker I mpaired immune system
Patients health
system (non-smoker) (heavy smoker)
Patients aesthetic requirements Low Medium High

Height of the smile line Low Medium High

Thick Medium Thin

Gingival biotype
low scalloped medium scalloped high scalloped
Shape of dental crowns Rectangular Triangular
Infections at implantation site None Chronic Acute
 5 mm from
5.56.5 mm from  7 mm from
Bone height at adjacent tooth
contact point contact point contact point
Restorative status of adjacent tooth Intact Restored
Width of tooth gap 1 tooth ( 7 mm) 1 tooth ( 7 mm) 2 teeth or more
Soft-tissue anatomy Intact Defective
Bone anatomy of the alveolar ridge No defect Horizontal defect Vertical defect

> REPLANT, 4.3 x 13 mm ImplantDirect. California

Material selection > Straight Sthetic abutments, ImplantDirect California USA
> Geistlich Bio-Oss spongiosa small granules (0.251 mm)

Conclusion
Patients who suffer from a severe degree of bone loss in the
vertical dimension show an increased risk of dehiscence and
a collapse of the soft tissue into the socket. A combination
of immediate implant placement, flapless surgery and the
use of Geistlich Bio-Oss enable a provisional prosthesis
to be employed. Additionally, the gingival architecture and
entire tissue volume are maintained, facilitating the final
aesthetic restoration.

28
 No implant placement Case 8

Case documentation

1 Pre-op orthopantomograph of the clinical case. 2G

 eneral situation of the patient. Frontal view. 3 It is more challenging to achieve an aesthetically
Severe horizontal bone loss and mobilization of satisfying result if the teeth show a triangular
teeth in region 12, 11 , 21, 22. shape.

4 Frontal view of the orientation guide devices. An 5 Occlusal view of the orientation guide devices. It 6 Transgingival positioning of the implants. The
x-ray from this surgical step is recommended. is crucial to check the distance between the pins transfer device shown in the picture is a helpful
and the teeth. tool when a casting has to be taken.

7 Provisional bridge made of acryl, which is mounted 8 Mounting of the abutments and augmentation of 9 Occlusal view. Gingival volume preservation from
onto the abutments. the sockets 11 and 21 and the gaps in region 12 and region 12 to 22.
22 with Geistlich Bio-Oss granules.

10 Clinical situation right after application of the 11 Frontal view of the well healed tissue 5 months 12 Orthopantomograph, 5 months post-op.
provisional prosthetics. post-op. After 68 months the finals casts will be
taken and the case is finished.

29
 10 Product range*

Geistlich Bio-Oss
Small granules (0.25 1 mm)
Quantities: 0.25 g, 0.5 g, 2.0 g (1 g = 2.05 cm3)
The small Geistlich BioOss particles allow close contact
with the surrounding bone wall. They are recommended for
smaller 12 socket defects and for contouring autogenous
block grafts.

Geistlich Bio-Oss
Large granules (12 mm)
Quantities: 0.5 g, 2.0 g (1 g = 3.13 cm3)
The large Geistlich BioOss granules have more space bet
ween the particles than the small granules. Particularly in
large defects, this enables improved regeneration over large
distances and provides enough space for the ingrowing bone.

Geistlich Bio-Oss Pen

Small granules (0.25 1 mm)
Quantities: 0.25 g 0.5 cc, 0.5 g 1.0 cc
Large granules ((12 mm)
Quantities: 0.5 g 1.5 cc
Geistlich Bio Oss granules are available in an applicator. It
allows the bone substitute material to be applied faster and
more precisely to the surgical site. The Geistlich BioOss Pen
is available containing both the small granules and the large
granules.

Geistlich Bio-Oss Collagen

Geistlich BioOss (small granules) + 10% collagen (porcine)
Sizes: 100 mg (0.20.3 cm3), 250 mg (0.40.5 cm3),
500 mg (0.91.1 cm3)
Geistlich BioOss Collagen is indicated for use in periodon
tal defects and extraction sockets. Through the addition of
collagen, Geistlich BioOss Collagen can be tailored to the
morphology of the defect and is particularly easy to apply.

*
Product availability may vary from country to country

30
Geistlich Bio-Gide
Resorbable bilayer membrane
Sizes: 25 25 mm, 30 40 mm

Geistlich BioGide consists of porcine collagen and has a

bilayer structure a rough side that faces the regenerated
bone tissue and a smooth size that faces the soft tissue.
Geistlich BioGide is easy to handle: it can be positioned
easily, adheres well to the defect, and is resistant to tension
and tearing.

Geistlich Bio-Gide Perio

Resorbable bilayer membrane
Size: 16 22 mm with cutting pattern
Geistlich BioGide Perio has the same biological properties
as Geistlich BioGide but has a smoothened upper surface.
This slows the absorption of moisture. Particularly in perio
dontal indications, this offers the practitioner a longer time
window to enable exact positioning of the membrane, espe
cially in the interdental space.

Perio-System Combi-Pack
Geistlich BioOss Collagen 100 mg
+ Geistlich BioGide Perio 16 22 mm
When used in combination, the system has optimised prop
erties for periodontal regeneration.

Geistlich Combi-Kit Collagen

Geistlich BioOss Collagen 100 mg
+ Geistlich BioGide 16 22 mm
When used in combination, the system has optimised prop
erties for ridge preservation and minor augmentations ac
cording to the GBR principle.
 31465.1/1204/e

Subsidiary Great Britain, Ireland

Geistlich Biomaterials
Geistlich Sons Limited Manufacturer
1st Floor, Thorley House
Geistlich Pharma AG
Bailey Lane Business Unit Biomaterials
Manchester Airport Bahnhofstrasse 40
GB-Manchester M90 4AB CH-6110 Wolhusen
Phone +44 161 490 2038 Phone +41-41-4925 630
Fax +44 161 498 6988 Fax +41-41-4925 639
www.geistlich.co.uk www.geistlich-pharma.com

More details about our distribution partners:

www.geistlich-pharma.com/mycontact