Therapeutic Area: Extraction Socket Management

WEBINAR

BIOBRIEF

Alveolar Ridge Preservation with vallos® Mineralized Cortico-Cancellous Allograft

Hanae Saito, DDS, MS, CCRC
Andrew Tong, DDS

THE SITUATION

A 68 year old female patient was referred from her general dentist for persistent minor discomfort on #31, suspected endo-perio lesion. Upon the examination, deep probing depth and grade 1 mobility were noted. Radiographic interpretation indicating a large J shaped lesion and possible root fracture. Patient had missing #30 and #32 has been mesially drifted and left a restorative space more than > 13 mm mesio-distally.

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system/Non-smoker Light smokerImpaired immune system 
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
* The esthetic related risk factors are not needed for this case. Restorative space of more than 13 mm may be an additional risk factor.
watch video download pdf

THE APPROACH

A successful treatment outcome comes with proper selection of the technique and materials. In order to facilitate an implant supported restoration in the site with > 13mm mesio-distal space, a staged approach was selected, with alveolar ridge preservation (ARP) performed using an atraumatic extraction technique and vallos® mineralized cortico-cancellous bone allograft chosen as the material.

Preoperative radiograph of #31 with guarded prognosis due to potential root fracture and infection.
Atraumatic extraction was performed and intact furcation bone is noted.
vallos® mineralized cortico-cancellous bone allograft was placed.
A collagen plug was used to cover the bone allograft
Immediate post alveolar ridge preservation radiograph.
Healing at 2 weeks prior to implant placement.
Healing at 4 months prior to implant placement.
Implant was placed with 32 Ncm. Post implant placement radiograph.
6 months after the implant placement, the final restoration was delivered.

“Ensuring atraumatic extraction techniques, regardless of whether it’s in the anterior or posterior regions, is crucial for preserving the integrity of both hard and soft tissues. Equally important is the selection of biomaterials that not only offer structural support but also possess bone regeneration properties.”

— Dr. Hanae Saito

THE OUTCOME

The planned treatment of replacing a tooth with a dental implant in the regenerated alveolar ridge was achieved. By employing secondary intention healing following ARP and utilizing a lingual paracrestal incision, adequate keratinized tissue was preserved on the buccal side of the implant-supported restoration. 

6 months after the implant placement, the final restoration was delivered.

Removal of the infection and maintaining the ridge dimension for the implant supported restoration in the site with > 13 mm mesio-distal space were required.”

Dr. Hanae Saito

Hanae Saito, DDS, MS, CCRC

Hanae Saito, DDS, MS, CCRC serves as a clinical associate professor and oversees the Dual Perio-Pros program and predoctoral periodontal education within the Division of Periodontics, at the University of Maryland School of Dentistry. She is a Diplomate of the American Board of Periodontology. Dr. Saito obtained a Master of Science in Clinical Research and a certificate in Periodontics from New York University College of Dentistry. Additionally, she operates a faculty practice focused on periodontology and implant dentistry.

Andrew Tong, DDS

Andrew Tong, DDS earned his Bachelor of Science degree from the University of Maryland at College Park in 2015 before completing his Doctor of Dental Surgery (D.D.S) degree at the University of Maryland School of Dentistry in 2019. Following this, he undertook a General Practice Residency at the Newark Beth Israel Medical Center in New Jersey from 2019 to 2020. Dr Tong now practices general dentistry at Tong Dental Care in Gaithersburg, MD. Concurrently, he is pursuing a Master’s degree in Periodontics at the University of Maryland School of Dentistry.

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WEBINAR

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BIOBRIEF

Immediate Mandibular Molar Transition

Dr. Peter Hunt

THE SITUATION

The case here is typical enough, a failing mandibular molar with a vertical sub-osseous fracture. Traditionally, the replacement process can take three or more surgical exposures (extraction and regeneration), (implant placement), (second stage exposure) and more than a year of therapy.

THE RISK PROFILE

Low RiskMedium RiskHigh Risk
Patient’s healthIntact immune system
Non-smoker 		Light smokerImpaired immune system 
Patient’s esthetic requirementsLowMediumHigh
Height of smile lineLowMediumHigh
Gingival biotypeThick – “low scalloped”Medium – “medium scalloped”Thin – “high scalloped”
Shape of dental crownsRectangularTriangular
Infection at implant sightNoneChronicAcute
Bone height at adjacent tooth site≤ 5 mm from contact point5.5 – 6.5 mm from contact point≥ 7 mm from contact point
Restorative status of adjacent toothIntactRestored
Width of tooth gap1 tooth (≥ 7 mm)1 tooth (≤ 7 mm)2 teeth or more
Soft-tissue anatomyIntactCompromised
Bone anatomy of the alveolar ridgeNo defectHorizontal defectVertical defect
watch video download pdf

THE APPROACH

Immediate molar replacement requires atraumatic removal of the fractured tooth, careful socket debridement and development of a channel for an ideally positioned implant. The implant then needs to be placed down in the bone channel with the implant platform positioned just below the socket walls. It needs to be stable. Channel deficiency augmentation is achieved with Geistlich Bio-Oss Collagen® which is covered with a collagen matrix, Geistlich Mucograft® with the edges tucked under the gingival margins and sealed over with tissue glue.

Initial Situation: a failing mandibular molar with a vertical sub-osseous fracture.
A pre-operative radiograph and CBCT showing the cross-section of the involved tooth.
An implant site was developed by placing a pilot drill down the mesial root space, then uprighting it. This was continued up through the drill sequence. The mesial radicular septum is moved in the process.
A Camlog® 5.0 x 11 mm implant was placed with the platform set just down below the bone height of the socket walls.
After placing a 4.0 mm height cylindrical gingiva former in the implant, 250 mg of Geistlich Bio-Oss Collagen® was packed down in the socket around the implant.
Geistlich Mucograft® was adapted to the region then tucked down under the gingival margin.
The gingival margins were adapted and closed together with 4.0 teflon sutures (Cytoplast™, Osteogenics). The region was then covered with Glustich – PeriAcryl®90 Oral Tissue Adhesive.
After 3 months of healing, the top of the gingiva former is exposed and the situation is ready for Emergence Profile Development. This is quite standard.
4 months later following Emergence Profile Development.
An occlusal view of the final one-piece, screw-retained zirconia crown restoration based on a Camlog® Titanium Base Abutment.

“The patient desires an implant placement for a fractured mandibular molar, as fast as possible.”

– Dr. Peter Hunt

THE OUTCOME

This single stage replacement protocol has proven to be simple, safe and highly effective providing the socket is fully degranulated and the implant is stable and not loaded in the early healing stages. It works well when a gingiva former is immediately placed into the implant instead of a cover screw, Geistlich Bio-Oss Collagen® is packed around the implant to fill the residual socket, then covered with a Geistlich Mucograft® and sutured. There is no need for flap advancement to cover over the socket.

This procedure really just merges a socket regeneration procedure with implant placement. It’s a simple and effective procedure which has now become quite standard for us.”

Dr. Peter Hunt

Dr. Peter Hunt

After graduate training on an Annenberg Fellowship at the University of Pennsylvania, dr. hunt helped start up the University of the Western Cape dental School in Cape Town, South Africa. he returned to the University of Pennsylvania where in time he became Clinical Professor of Periodontics. later he helped start up Nova Southeastern‘s dental School where he was Professor of Restorative dentistry, Post Graduate director and director of Implantology. he has had a private practice in Philadelphia focusing on implant and rehabilitation dentistry since 1981.

WEBINAR

WEBINAR

WEBINAR

WEBINAR

CLINICAL CASE

1 – Extraction of tooth 21 due to a trauma with concomitant external resorptions. Care was taken in preserving the alveolar bone.
2 – Crestal view of the socket after tooth extraction. No flaps are raised around the affected area. A slight buccal bone defect was observed.
3 – The socket is gently curetted for removal of granulation tissue. Subsequently, the wound margins were de-epithelialized with a diamond in a counter piece with water cooling
4 – Filling of the extraction socket with Geistlich Bio-Oss® Collagen to the level of the palatal bone
5 – After measuring the alveole, Geistlich Mucograft® is punched (8 mm diameter
6 – The Geistlich Mucograft® punch is placed on top of Geistlich Bio-Oss® Collagen to seal the filled alveole.
7 – Suturing of the Geistlich Mucograft® with 6-0 single interrupted sutures.
8 – Nice healing of the soft tissues 1 week after extraction.
9 – Situation 7.5 months after extraction revealing nice soft tissue situation with a slight dip at the buccal aspect.

CLINICAL CASE

1 – Pre-operative situation, tooth #7 with periapical infection and horizontal fracture.
2 – CT Scan showing tooth #7 with significant bone loss.
3 – Occlusal view of the clinical situation prior to extraction of tooth #7.
4 – Extraction socket with Geistlich Bio-Oss Collagen® in place.
5 – Geistlich Mucograft® Seal is placed over the extraction socket and secured with single interrupted sutures.
6 – 3 months post-operative: soft tissue healing at the time of implant placement.
7 – Buccal view showing excellent soft tissue healing and keratinized tissue.
8 – 5 months post-operative.
9 – 2 years post-operative: final restoration in place.

CLINICAL CASE

Initial Situation: a failing mandibular molar with a vertical sub-osseous fracture.
A pre-operative radiograph and CBCT showing the cross-section of the involved tooth.
An implant site was developed by placing a pilot drill down the mesial root space, then uprighting it. This was continued up through the drill sequence. The mesial radicular septum is moved in the process.
A Camlog® 5.0 x 11 mm implant was placed with the platform set just down below the bone height of the socket walls.
After placing a 4.0 mm height cylindrical gingiva former in the implant, 250 mg of Geistlich Bio-Oss Collagen® was packed down in the socket around the implant.
Geistlich Mucograft® was adapted to the region then tucked down under the gingival margin.
The gingival margins were adapted and closed together with 4.0 teflon sutures (Cytoplast™, Osteogenics). The region was then covered with Glustich – PeriAcryl®90 Oral Tissue Adhesive.
4 months later following Emergence Profile Development.
An occlusal view of the final one-piece, screw-retained zirconia crown restoration based on a Camlog® Titanium Base Abutment.

CLINICAL CASE

1 – Initial Radiograph
2 – Pre-Operative assessment
3 – Tooth removal
4 – Mixture of Geistlich vallomix™
5 – Placement of Geistlich vallomix™
6 – Coverage with Geistlich Mucograft® Seal and sealed with sutures
7 – 2 weeks post-operative
8 – 4 weeks post-operative
9 – 6 weeks post-operative
10 – 6 months follow-up the digital implant planning was performed highlighting 3D adequate bone support.
11 – Initial presentation at the moment of implant placement.
12 – Full thickness flap elevation and initial osteotomy performed.
13 – Implant placed and cover screw positioned.
14 – Flap approximations using a PTFE suture after the implant was placed.
15 – Healing at 2 weeks after the implant placement.
16 – Overview of the radiographic sequence of the implant placement: A. The initial bone presentation. B. The guiding pin in position revealing the mesio-distal position. C. The final implant in place.

CLINICAL CASE

1 – Baseline frontal view: missing central incisor.
2 – Baseline occlusal view: The facial contour is flattened by physiological dimensional ridge alterations post-extraction.
3 – Full-thickness flap using one releasing incision in the distal aspect of the canine. Simultaneous contour augmentation using GBR was performed with autogenous bone chips to cover the exposed implant combined with a layer of Geistlich Bio-Oss®and Geistlich Bio-Gide®.
4 – Application of Geistlich Fibro-Gide® on top of the augmented area. A tension-free primary wound closure was obtained by a periosteal releasing incision.
5 – Suture removal 14 days post-surgery. Uneventful wound healing and an increase in soft-tissue volume.
6 – Frontal view 4 weeks post-surgery.
7 – 2 months follow-up combined with abutment connection.
8 – Occlusal view of final restoration 2 years post-surgery.
9 – Final restoration 2 years post-surgery shows pleasing esthetics.

CLINICAL CASE

1 – Baseline occlusal view: situation before removal of tooth #20.
2 – Tooth removal and extraction socket management with Gesitlich Bio-Oss® and Geistlich Bio-Gide®.
3 – Geistlich Fibro-Gide® was trimmed to the defect size, to augment the buccal and crestal soft-tissue area of the ridge.
4 – Geistlich Fibro-Gide® in place, augmenting buccal and crestal area of tooth #20 and buccal in the edentulous area tooth #21 to tooth #19.
5 – Immediate provisionalization of the implants.
6 – 3 weeks post-surgery: occlusal view of augmented area with created emergence profile.
7 – 3 weeks post-surgery: buccal view of augmented area with created emergence profile.
8 – Provisional reconstruction 6 weeks post-surgery.
9 – Final restoration 2.5 years post-surgery: soft-tissue thickness remains stable over time.

CLINICAL CASE

1 – Initial clinical situation, tooth #8 and #9 require extraction.
2 – Clinical view post extraction of tooth #8 and #9.
3 – Evaluation of the buccal soft-tissue thickness.
4 – Trimming of Geistlich Fibro-Gide® to fit in the gap between the buccal soft-tissue and the buccal bone wall.
5 – Geistlich Fibro-Gide® in place: an immediate volume increase of the buccal soft-tissues are visible.
6 – Mixing of autologous bone and Geistlich Bio-Oss® particles for placement in the gaps around the implants.
7 – Immediate implant placement with the bone mixture applied was performed.
8 – Provisional restoration at time of surgery (occlusal view).
9 – Provisional restoration at time of surgery (frontal view).