Self-Directed Learning (SDL), a process by which individuals take the initiative – with or without the assistance of others – in diagnosing their own learning needs and formulating learning goals, has been identified as an essential skill for clinicians. As dental clinicians, our busy patient schedules and time constraints prevent us from updating our knowledge with regular CE courses. SDL is therefore fundamental in meeting the challenges of today’s dental care environment, helping us to learn more and to learn better, as a “lifelong learning” process for acquiring both clinical skill and knowledge on our own. I would like to thank Straumann Thailand for organizing such an excellent campaign with the “Dental Implant Esthetic Competition”, the first ever regional dental implant competitive award for Thailand or Asia. It provided me with the opportunity to write up and evaluate my patient’s case report for the competition. Writing a case report is a good example of SDL since I have to organize the manuscripts systemically by reviewing the patient’s chart record, radiography and photos, and self-evaluation is part of the outcome. Not only was I updating my awareness of the literature and my knowledge in order to provide the optimal treatment plan, but processing the completed consent form correctly was an additional benefit for me when collecting the legal documentation prior to publication. SDL is an important expertise for all dental clinicians since its main purpose is to enhance individuals’ knowledge and clinical skill. Dental clinicians who pursue SDL are continually developing and, more importantly, constantly acquiring new knowledge and skills for the rest of their lives. As for me, the SDL clinician, I realize that the better I properly document my patient/case report and clinical photos, and the more new knowledge I acquire, the better clinician I become since I am able to learn from my mistakes and experiences and am willing to improve and learn more as a lifelong learning process. PRODUCT FEATURE Straumann® Bone Level Implant The Straumann® Bone Level Implant line was designed for a natural look and feel, providing flexibility and a balanced prosthetic portfolio for every indication. It enables for esthetically pleasing solutions, featuring important technical and biological concepts (Crossfit® connection, Consistent Emerging Profiles™, Bone Control Design™, Loxim™). It is available from Roxolid® and SLActive® and with the SLActive® or SLA® surfaces. By using the same surgical and prosthetic kit as the Straumann® Soft Tissue Level Implant line, the Bone Level Implant is the perfect addition to the Straumann® Dental Implant System, offering unmatched treatment flexibility and options. MORE? All the articles about the Straumann® Bone Level Implant at a glance. Click here PICTURE DOCUMENTATION Fig. 1 roongkit01 Fig. 2 roongkit02 Fig. 3 roongkit03 Fig. 4 roongkit04 Fig. 5 roongkit05 Fig. 6 roongkit06 Fig. 7 roongkit07 Fig. 8 roongkit08 Fig. 9 roongkit09 Fig. 10 roongkit10 Fig. 11 roongkit11 Fig. 12 roongkit12 Fig. 13 roongkit13 Fig. 14 roongkit14 Fig. 15 roongkit15 Fig. 16 roongkit16 Fig. 17 roongkit17 Fig. 18 roongkit18 Fig. 19 roongkit19 Fig. 20 roongkit20 Fig. 21 roongkit21 Fig. 22 roongkit22 Fig. 1 levine01 INITIAL SITUATION The following case report describes the management of replacing a maxillary lateral incisor with a hopeless prognosis with the Straumann® Bone Level Implant to achieve “a natural look and feel” for the patient. The replacement of a missing anterior tooth with an implant-supported prosthesis has become an accepted treatment modality. It counts as one of the greatest challenges in dentistry since it must meet functional requirements and satisfy patients’ high esthetic demands in this visible area. A 36-year old woman presented with the principal complaint that her front tooth was broken. The patient was aware that her tooth had a bad prognosis and desired a single-tooth implant replacement. She was very concerned about the final esthetic result and her expectations were extremely high (Figs. 1-3). TREATMENT PLANNING Tooth #12 had a complicated crown-root fracture at sub-gingival level. The existing coronal structure was attached with gingival tissue. Intra-oral examination showed the tooth was discolored with 2 degrees of mobility. Minimal discomfort was reported. The gingival tissue presented with very thin biotype. Radiographic and CT examination revealed the root fracture at the cervical third and deficient labial plate thickness. The diagnosis was “crown root fracture with pulp involvement” (Figs. 4, 5). Several options were discussed with the patient regarding management of the tooth. Risks and benefits were explained. The patient agreed that the treatment of choice was extraction of the tooth followed by a dental implant. Type II implant placement was planned since the condition of the labial plate and the tissue biotype were compromised, however the palatal bone was thick enough to place the implant in a 3D position without any need for ridge preservation at the time of tooth extraction. The patient was informed of the compromised esthetic result due to the thin labial plate thickness and gingival tissue biotype. SURGICAL PROCEDURE Prior to extraction of tooth #12, an acrylic partial denture was fabricated as a temporary prosthesis. Atraumatic tooth extraction was performed but the labial plate was still lost about 8 mm from the gingival margin. The immediate denture was then delivered. The extraction socket had been left for 8 weeks to achieve soft and hard tissue healing (Figs. 6, 7). A Straumann® Bone Level Implant NC (Narrow Neck CrossFit®, Ø 3.3 mm, L 12 mm) was submerged in the site of #12 with a bone graft followed by surgical guide and CT evaluation (Figs. 8, 9), and a soft tissue graft was then performed to achieve the proper thickness (Fig. 10). The acrylic partial denture was adjusted so there was no undue load on the implant during the healing period. The patient was told to maintain good oral hygiene. After a twelve-week healing period (Fig. 12), a second soft tissue graft was performed to achieve optimal soft tissue thickness again (Figs. 11-14). The second-stage surgery was then completed for healing abutment delivery 8 weeks later (Figs. 15, 16). PROSTHETIC PROCEDURE About 5 months after implant placement, the implant was seen to be well osseointegrated with a satisfactory soft tissue profile and was ready for the implant prosthesis. An impression was taken at fixture level for the temporary abutment and crown. They were then delivered to create an optimal soft tissue emergence profile around the implant (Figs. 17, 18). The dental implant fixture and abutment used in this patient are the original Straumann components for ensuring consistent quality through high-precision manufacturing. FINAL RESULT “SELF-DIRECTED LEARNING IS FUNDAMENTAL IN MEETING THE CHALLENGES OF TODAY’S DENTAL CARE ENVIRONMENT, HELPING US TO LEARN MORE AND TO LEARN BETTER, AS A ‘LIFELONG LEARNING’ PROCESS FOR ACQUIRING BOTH CLINICAL SKILLS AND KNOWLEDGE ON OUR OWN.” Six weeks later, the surrounding soft tissue had acquired an esthetic and natural profile. The customized impression coping was then fabricated and taken at implant fixture level for the final prosthesis (Fig. 19). The zirconia abutment had been carefully selected and prepared and the ceramic crown of the implant (IPS e.max) was then delivered (Figs. 20, 21). The patient was extremely happy with the final result at the three-week follow-up (Figs. 22, 23). ACKNOWLEDGEMENTS Bangkok Hospital Dental Center: Atraumatic tooth extraction by Dr. Jarinda Thaisangsa-Nga. Implant and soft tissue surgery by Assistant Prof. Pintippa Bunyaratavej. Prosthetic work by In-House Dental Lab (Thailand): Mr. Uthai Mhudvongse Ron Leehacharoenkul DDS, MS DDS (Mahidol University, Thailand). Certificate in Operative Dentistry and MS (UNC at Chapel Hill, USA). Certificate in Prosthodontics (University of Iowa, USA) The post Ron Leehacharoenkul: Esthetic tooth replacement (Straumann® Bone Level Implant) appeared first on STARGET COM.
A 29-year-old female patient presented at our clinic with the desire for an esthetic improvement of her teeth. Teeth 1.2 to 1.4 showed multiple Miller class I recessions with a particularly deep recession of >6mm at tooth 1.3 (Fig. 1). The patient was healthy with good oral hygiene. She raised concerns against the harvesting of a connective tissue graft from the palate; therefore, we decided to treat the recessions with botiss mucoderm®, an acellular dermal collagen matrix which is derived from the dermis of pigs through a multi-stage wet-chemical cleaning process. It can be applied instead of an autologous tissue graft in various situations, including the augmentation of attached gingiva and covering of gingival recessions. PICTURE DOCUMENTATION Fig. 1 kasaj1 Fig. 2 kasaj2 Fig. 3 kasaj3 Fig. 4 kasaj4 Fig. 5 kasaj5 Fig. 6 kasaj6 PROCEDURE The exposed tooth roots were prepared with an air scaler and then treated with 24 % EDTA for 2 minutes. The flap was performed according to Zucchelli with two angular incisions, avoiding the need for vertical incisions (Fig. 2). The anatomical papillae were de-epithelialized. The mucoderm® was rehydrated for 7 minutes in sterile saline solution to enable sufficient flexibility for the adaptation of the matrix to the tooth roots. The matrix was then fixed to the periosteum with cross sutures (Fig. 3). Subsequently, the flap was coronally repositioned and fixed with polypropylene 6-0 sutures (Premilene by B. Braun Melsungen AG). The surgically created papillae were sutured over the de-epithelialized anatomical papillae. Particular attention was paid to complete coverage of the collagen matrix (Fig. 4). Post-operative care included rinsing with 0.12 % CHX solution twice a day and 600 mg ibuprofen if needed. Furthermore, the patient was briefed to avoid tooth brushing in the affected region for 14 days. Sutures were removed 10 days post-operative. The healing time was uneventful. The control at 3 months post-op demonstrated almost complete coverage of the previously exposed tooth roots as well as clear thickening of the marginal gingiva (Fig. 5). In region 1.3 to 1.4, an area of dense connective tissue was visible with a cleft marking the area were the mucoderm® matrix was sutured. Eighteen months post-op, this irregularity has disappeared, without the need for gingival plastic surgery. The gingiva were homogenous and bright (Fig. 6). The patient was very satisfied with the esthetic result. DISCUSSION In the last two years, we have treated more than 50 patients with the mucoderm® membrane. Due to very good and predictable results, we prefer applying the matrix using either the tunnel technique or the Zucchelli approach. In any case, good flap mobilization is very important to allow for complete coverage of the matrix and a tension-free closure, both of which are essential for a successful and esthetic outcome. mucoderm® is an acellular matrix which needs to be revitalized. As revitalization from the underlying tooth roots is not possible, an ingrowth of vessels from the covering flap should be ensured. Insufficient mobilization with tensions on the flap could lead to early exposure of the matrix and hence its degradation. An interesting observation that we made in many cases was an improvement in the esthetic outcome progressing for several months after the surgical treatment. A kind of creeping substitution as well as the leveling of irregularities in the thickness of the gingiva without any plastic surgery intervention can be observed. Adrian Kasaj p_kasaj Adrian Kasaj Dr. med. dent/PhD Specialist in periodontology (European Dental Association). Associate Professor at the Department of Operative Dentistry and Periodontology, University of Mainz, Germany. Vice Chairman of the “Neue Arbeitsgruppe Parodontologie e.V” (NagP). Author and co-author of more than 80 scientific publications within the field of periodontology. Numerous national and international courses and lectures in the fields of regenerative periodontal therapy and plastic periodontal surgery. The post Adrian Kasaj: Treatment of multiple recessions with a modified coronally advanced flap (botiss mucoderm®) appeared first on STARGET COM.
Each situation and patient is individual – and so is the clinical user. Today, a multitude of different bonegrafting materials are available that offer attractive alternatives to patients’ autologous bone. In addition, there is widespread use of various membranes and other collagen-based materials that support bone and soft tissue regeneration. All of these materials demonstrate distinctive properties, based on their origin and the production process, that result in certain advantages or disadvantages, depending on the specific situation. Dr. Christiane Marinc, Head of Product Management at botiss medical. Each patient is individual and the same applies to the clinical users. Consequently, the treatment plan and applied materials should be chosen with regard to the individual indication, defect configuration, the preferences of the patient, as well as the experience and skills of the surgeon. Hence, the many expectations with respect to the “ideal” bone graft or the “ideal” membrane cannot be met by one single product. This is the reason why botiss offers a broad portfolio of different biomaterials – the botiss regeneration system – enabling the clinical user to achieve optimal and predictable results in every situation. (Click on the picture for a more detailed view) CERABONE® RELATED ARTICLES PREDICTABLE LONG-TERM VOLUME STABILITY WITHOUT THE RISK OF RECURRING RESORPTION Among bone graft materials, bovine bone has a very long tradition and well-documented use. The bovine bone graft cerabone® is produced from the femoral heads of cattle destined for the food industry. The unique high-temperature treatment during the production process lays the basis for its maximum safety, turning the bovine bone into a pure hydroxyapatite ceramic of such high crystallinity that it is insusceptible to complete degradation by the body’s own processes. The cerabone® particles become completely integrated into the newly formed bone matrix, offering the advantage of predictable long-term volume stability without the risk of recurring resorption. This feature is of importance in several indications, e.g. augmentations of the buccal wall in the anterior ridge where the bony support of the soft tissue is critical for a long-term aesthetic result. cerabone® is especially useful in maintaining the contours of the ridge when no implantation is planned, and hence no functional loading will take place after augmentation. MAXRESORB® RELATED ARTICLES SYNTHETIC BONE GRAFT SUBSTITUTE WITH CONTROLLED RESORPTION PROPERTIES While many doctors are successful and satisfied with the application of bovine products, others prefer fully synthetic bone-grafting materials. Synthetic materials provide solutions for patients that oppose the use of xenogenic materials, and are also favorable in cases where the patient’s own regenerative capacity allows complete resorption of the biomaterial. The purely synthetic bone graft maxresorb® is completely resorbed and replaced by the body’s own bone within about two years. Due to its biphasic composition of 60 % HA and 40 % beta-TCP, the material is gradually degraded, providing space for new bone formation while ensuring mechanical stability over a longer time period. By mixing maxresorb® particles with a nano-HA gel, an injectable and non-hardening bone paste is obtained; the maxresorb® inject. The large surface area of the nano-HA particles facilitate interaction with bone cells, thus promoting rapid regeneration. On the other hand high cellular interaction increases the particles susceptibility to degradation, thus the material is not suited for the regeneration of larger or non-contained defects. MAXGRAFT® RELATED ARTICLES EXCELLENT HANDLING IN TERMS OF SHAPING AND SCREWING If the focus is on an especially natural regeneration, fast and complete remodeling may be achieved with allogenic materials from human donors. Even complex, three-dimensional defect situations may be treated with allogenic bone blocks; this is made especially easy by using the sophisticated maxgraft® bonebuilder concept. The allogenic blocks and granules of the maxgraft® product line contain natural collagen that is preserved within the mineral phase of the bone during the production process. Collagen is a versatile protein that exerts chemotactic influence on osteoblasts and endothelial cells, thereby supporting the rapid incorporation and complete remodeling of the biomaterial. In addition, blocks of mineralized collagen offer excellent handling in terms of shaping and screwing, and have therefore become the current material of choice for block augmentation. The new maxgraft® solutions further demonstrate that botiss not only pursues established approaches, but also focuses on individual concepts and problem-oriented individual solutions. The maxgraft® bonebuilder technology is an important innovation in the field of block augmentation. Based on the three-dimensional radiological data of the defect/ridge, the allogenic bone transplant is designed and shaped into an individual construct. The exact fitting of the individualized bone block to the surface contours of the bone bed promotes optimized healing and improves the predictability of the augmentation. The shortened surgical time as compared to traditional block grafts (no intra-operative adaptation of the block) further adds to its advantages. MAXGRAFT® BONE RING RELATED ARTICLES SIMULTANEOUS AUGMENTATION AND IMPLANTATION IN A ONE-STAGE PROCEDURE The maxgraft® bone ring is a prefabricated allogenic bone ring that enables simultaneous augmentation and implantation in a one-stage procedure. The so-called bone ring technique can be applied for many indications and is of particular benefit for vertical augmentations and one-stage sinus lifts with minimal maxillary bone height (between 1-4 mm). JASON® MEMBRANE RELATED ARTICLES A NATURAL MULTILAYER STRUCTURE FOR APROLONGED BARRIER FUNCTION The botiss soft tissue portfolio also takes account of different treatment concepts. For instance, there is currently a general agreement that barrier membranes of collagen, which exhibit a long barrier function or support rapid vessel penetration, lead to especially successful GBR. Botiss has picked up on both ideas in its soft tissue product line. The Jason® membrane, which originates from porcine pericardium, offers a naturally long barrier function of 4 – 6 months due to its native multilayer structure. Accordingly, it guarantees an undisturbed bony regeneration, in particular for larger augmentative procedures. Due to its inherent architecture based on collagen type-1 and an increased content of collagen type-III, the Jason® membrane demonstrates excellent tear resistance and its low thickness supports excellent surface adaptation and aids in achieving tension-free wound closures. COLLPROTECT® MEMBRANE RELATED ARTICLES FOR MEDIUM BARRIER FUNCTION WITH EXCELLENT ANGIOGENIC FEATURES With the launch of the collprotect® membrane, botiss has extended its range of membranes to include a membrane with a medium barrier function of 2 – 3 months that displays excellent angiogenic features. The collprotect® membrane originates from porcine dermis. Its transmembraneous pore structure supports the rapid ingrowth of blood vessels into the defect area, while the dense collagen structure maintains a barrier against soft tissue ingrowth. It offers adequate protection for regeneration of most defetcs. JASON® FLEECE RELATED ARTICLES RESORBABLE COLLAGEN SPONGE FOR WOUND MANAGEMENT In situations that do not require a particular barrier function, the Jason® fleece offers a cost-effective alternative, e.g. for protection of the Schneiderian membrane or covering extraction sockets. Du to the inherent hemostatic effect of the natural collagen and the highly porous structure, Jason® fleece helps to stabilize the blood coagulum and supports wound healing. It might be applied to cover minor oral wounds or biopsy harvesting sites. Furthermore, Jason® fleece offers a cost-effective alternative in situation that do not require a particular barrier function, e.g. for protection of the Schneiderian membrane or to cover extraction sockets. COLLACONE® RELATED ARTICLES A CONE-SHAPED COLLAGEN FLEECE TO FIT IN THE EXTRACTION SOCKET Collacone® is a cone-shaped collagen fleece that was designed to fit in the extraction socket and specifically aimed at stabilization of the blood clot following tooth extraction. MUCODERM® RELATED ARTICLES A THREE DIMENSIONAL COLLAGEN MATRIX Another innovative product from the botiss portfolio is mucoderm®, which is made from porcine dermis, developed for soft tissue augmentation. The complex collagen structure serves as a scaffold for ingrowing vessels and soft tissue cells, and is gradually remodeled into the patient’s own tissue. The application of mucoderm® circumvents the need for harvesting autologous gingival or subepithelial transplants during recessions coverage, regeneration of soft tissue defects and augmentation of attached gingiva. Accordingly, post-operative pain and risk of complications may be reduced, while the patient’s acceptance of the surgical intervention may increase. INNOVATION AND EDUCATION In the future, we will continue to work on the development of new and innovative products and concepts. A composite material made of biphasic calcium phosphate and porcine collagen has been registered and the market entry is under preparation. Furthermore, allogenic plates of cortical bone will be available soon for application of the shell technique. A non-resorbable synthetic membrane made of dPTFE is currently going through the approval process. It is the broad product portfolio and the ongoing development of new innovative biomaterials that makes the botiss regeneration system stand out. The clinical users may select their own individual portfolios based on different aspects, knowing that in case of need there are always other prominent alternatives within the system they can rely on. Moreover, a broad product portfolio requires a complex system of ongoing education. botiss continuously recruits experts to give lectures and courses at different levels and to discuss their clinical and scientific results. botiss-academy.com THE BOTISS PORTFOLIO All articles related to the botiss biomaterials portfolio. Click here BROCHURE All about the Straumann® Biomaterials offering: “When one option is not enough”. Click here SUBSCRIBE Subscribe to our monthly STARGET newsletter to receive the latest news about implant dentistry. Click here The post The growing importance of biomaterials (botiss regeneration system) appeared first on STARGET COM.
The patient, a 45 year-old female in good general systemic health, had undergone some unsuccessful dental treatments, with failed restorations resulting in the loss of multiple maxillary teeth. Teeth 1.2 to 2.2 were extracted after failed endodontic treatments and periapical complications. The aim of the patient was to replace the removable partial prosthesis with a fixed implant supported restoration. PRODUCT INFORMATION BY THE MANUFACTURER The Jason® membrane is a native collagen membrane obtained from procine pericardium, developed and manufactured for dental tissue regeneration. The advantageous biomechanical and biologic properties of the natural pericardium are preserved during the production process. Straumann® BoneCeramic® is one of the best documented alloplastics in the market, offering a state-of-the-art scaffold with controlled resorption for vital bone regeneration without compromising on volume preserva-tion. It is an excellent choice for you and your patients in virtually any clinical situation. The Straumann® Bone Level Implant introduces confidence at bone level, providing great flexibility to deliver esthetically pleasing solution to patients. The cylindrical (parallel) outer contour allows for flexible, coronal-apical implant placement – making it the implant of choice for esthetic sites. PICTURE DOCUMENTATION Fig. 1 galante01 Fig. 2 galante02 Fig. 3 galante03 Fig. 4 galante04 Fig. 5 galante05 Fig. 6 galante06 Fig. 7 galante07 Fig. 8 galante08 Fig. 9 galante09 Fig. 10 galante10 Fig. 11 galante11 Fig. 12 galante12 Fig. 13 galante13 Fig. 14 galante14 Fig. 15 galante15 Fig. 16 galante16 Fig. 17 galante17 Fig. 18 galante18 Fig. 19 galante19 Fig. 20 galante20 Fig. 21 galante21 Fig. 22 galante22 TREATMENT PLANNING The clinical examination showed a significant horizontal deficiency of the anterior(Figs. 1, 2). Panorex Rx (Fig. 3). Study models mounted on a semi-adjustable articulator were taken and a diagnostic wax-up of the four incisors was made with a modeled gingiva (Fig. 4) to provide an idea of the amount of tissue to be regenerated. In the axial slices and the 3D reformatted CT images, the lack of bone in the horizontal and vertical dimensions could be evaluated precisely. A stepwise surgical approach was planned: in a first step, a GBR procedure would be performed. In a second step, two submerged implants should be inserted and, if necessary, an additional GBR procedure performed. In a third step, implants should be uncovered together with a soft tissue augmentation. The initiation of the prosthetic phase was planned 30 days after the implant activation surgery. SURGICAL PROCEDURE Under local infiltrative anesthesia, a full thickness horizontal incision was made at the keratinized tissue, on the buccal 2.5 mm apical to the most coronal aspect of the residual ridge, extending intrasulcular to the distal papilla of teeth 13 and 23. Two vertical releasing incisions were performed distally to 13 and 23. A full thickness flap was elevated to expose the alveolar ridge. At the inner aspect of the flap, a split thickness incision was made to allow a complete mobilization of the flap in order to achieve a tension-free closure of the flap by primary intention. Two mini osteosynthesis plates were placed at the projection of the crestal peak of bone, corresponding to the interdental papilla between 12/11 and 21/22 (Fig. 5). These mini plates were used as tent poles and support to avoid the collapse of the collagen membrane. Each mini plate was fixed with two self-tapping micro screws (Walter Lorenz, 1.2×4 mm). The mini plates were shaped to reproduce the ideal anatomic profile of the ridge, creating a space underneath for the biomaterial and preventing collapse of the overlaying membrane (Fig. 6). The space under the mini plates was filled with Straumann® BoneCeramic. After that, the augmentation site was covered with two pericardium membranes (Jason® membrane, 20×30) placed at each side and fixed mesially and distally with 2 mini titanium pins (Figs. 7, 8). A suture was performed with a nylon monofilament 5.0 (Ethicon). The first suture was at the vertical incisions distal of 13 and 23, replacing the papilla with a vertical mattress suture. Another three vertical mattress sutures were placed mesially of both teeth and at the midline. Two horizontal mattress sutures were performed at each side. Both vertical and horizontal mattress sutures cause eversion of the flaps to face connective tissue at each side of the wound. The closure was completed with an interrupted simple suture along the horizontal and vertical incisions (Fig. 9). The healing process was uneventful; sutures were removed three weeks post-op. Six months post-op, the clinical evaluation demonstrated a nice macroscopic contour of the regenerated area (Fig. 10). Images of paraxial slices and 3D reformatted CT (Fig. 11) showed very good integration of the biomaterial, adopting the shape predetermined by the mini plates. The second surgical approach consisted of a horizontal incision and two verticals, the same as in the first surgery. The full thickness flap elevation revealed homogeneous, well-vascularized hard tissue. The mini plates were partially covered by newly formed bone (Figs. 12, 13). Once the plates were retired, two Straumann® Bone Level, implants (4.1/14) were installed in region 12 and 21 with the help of a surgical stent (Figs. 14, 15). Biomaterial and a Jason® membrane were added in the midline with the intention of gaining extra volume for esthetic reasons.Wound closure was performed according to the first surgical intervention. Again, the healing was uneventful and sutures were removed three weeks post-op. Three months later, uncovering of the implants was performed with a soft tissue management to improve the peri-implant esthetics (Fig. 16). Healing screws were installed at implants. A ramp suture was made to promote coronal advance of the entire flap (Fig. 17). PROSTHETIC PROCEDURE Two weeks later, sutures were removed, and the temporary fixed screw-retained partial prosthesis was placed (Fig. 18). Teeth 13 and 23 were prepared for full crowns (Fig. 19). As the patient was under orthodontic treatment, it was decided to make a new resin fixed screw-retained prosthesis in order to have ideal conditions for the placement of the two implants to replace teeth 24/25, and to delay the definitive porcelain restorations once the case was completed (Fig. 20). FINAL RESULT The treatment planning of complex cases like this one, with a young patient and high esthetic expectations, is challenging. Although the total treatment time is longer, the results obtained by this stepwise approach allow the interdisciplinary team to interact in a more secure and precise way(Figs. 21, 22). FINDINGS A remarkable finding was the extent of the regenerated tissue, taking into consideration the extended three-dimensional horizontal and vertical defect. The other significant aspect is that only synthetic biomaterial was used with no need for autologous bone. The fact that the mini plates prevent a collapse of the membrane may be favorable for regeneration. In addition, the pericardium membrane provides a long-term barrier function, giving the biomaterial sufficient time to integrate. Further investigation should be made in the field to encourage this kind of method to be applied as a valid procedure in the treatment of three-dimensional defects. Prof. Dr. Jorge M. Galante Specialized in bucco-dento-maxillary prosthetics and implant surgery. Director at the Galante Institute, Mar del Plata, Argentina. Professor at the Dental School of the University of Buenos Aires, Argentina (F.O.U.B.A). Director of the Advanced Course on Complex Surgery in Implantology by the Argentinian Association of Odontology, A.O.A. at the University of Salvador (U.S.A.L.), Buenos Aires, Argentina. email@example.com BROCHURE All about the Straumann® Biomaterials offering: “When one option is not enough”. Click here SUBSCRIBE Subscribe to our monthly STARGET newsletter to receive the latest news about implant dentistry. Click here The post Jorge M. Galante: Predictable GBR procedures in sites with high esthetic compromise (botiss Jason® membrane/Straumann® BoneCeramic) appeared first on STARGET COM.