Socket Preservation _NIDM January 2011


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  • So the whole idea behind this is to prevent situations like this arising, we see these types of resorptive defects commonly and they can be avoided by utilising a few different procedures at the time of extraction to prevent the need for extensive grafting in the future, make doing aesthetic implant dentistry more achievable But also not just the procedures that are available to us now with the increasing advances in biomaterials, but also treatment strategies, and knowing at the time of extraction where this site is headed, be it for an immediate implant, for an implant in the near future, as a pontic site or also for a denture
  • bundle bone supported by the PDL less mineralised buccal wall is less than 0.5 in 50% and still less than 1mm in 80 %
  • 1 Week - initial connective tissue matrix, blood clot, 2 Week - large amounts of woven bone in lateral and apical areas of socket 4 Week - dominated by newly formed woven bone bundle bone of buccal crest has resorbed, with some replacement by woven bone position of buccal crest compared to palatal wall
  • 8 Week - socket entrance sealed by hard tissue ridge 12 Weeks -
  • Socket Preservation _NIDM January 2011

    1. 1. Extraction Socket Management January 2011 Dr Rory Nolan
    2. 2. Background Atraumatic Extraction technique Hands on 1: Atraumatic extraction technique Biomaterials “ Closed” Socket preservation Hands on 2: Socket preservation “ Open” Socket preservation and Ridge augmentation Hands on 3: Ridge augmentation Implant treatment options Summary and conclusions Today’s Plan
    3. 4. <ul><li>Implant therapy including bone regeneration is continuously improving... </li></ul><ul><li>Implant design </li></ul><ul><li>Biomaterials </li></ul><ul><ul><li>- Collagens </li></ul></ul><ul><ul><li>- Membranes </li></ul></ul><ul><ul><li>- Bone grafts </li></ul></ul><ul><li>Treatment strategies are continuously evolving </li></ul>
    4. 5. Socket preservation Ridge preservation Ridge augmentation Guided bone regeneration Site preparation Immediate implant placement Delayed implant placement Root submergence
    5. 6. Background Socket preservation after tooth extraction can maintain the alveolar ridge dimensions The whole idea of this is to perform a series of straightforward procedures at the time of extraction that will result in a better site for dental implants, pontics or dentures .....especially for implant therapy where this can allow for aesthetic implant therapy without the need for extensive grafting later on
    6. 7. Anatomy Buccal bone - bundle bone poor blood supply thin absent Gingival biotype - thick thin scalloped normal
    7. 8. Blood Supply <ul><li>Buccal plate of woven bone is supplied by: </li></ul><ul><li>PDL </li></ul><ul><li>Periosteum </li></ul><ul><li>Haversion canal system </li></ul>
    8. 9. Bone Resorption Extraction of teeth results in resorption of the alveolar process in both a vertical and horizontal direction Different rates of resorption around the mouth More loss of height and width buccally Complicates implant therapy for patients Aesthetic result may be compromised
    9. 10. Resorption following extraction 1 Week 2 Weeks 4 Weeks
    10. 11. Resorption following extraction 8 Weeks 12 Weeks
    11. 12. Does placement of an immediate implant prevent this bone loss? 4 weeks 12 weeks
    12. 13. Treatment Strategies Ultimate goal is to preserve as much of the alveolar ridge as possible and prevent resorption of the buccal plate in particular Biomaterials can help prevent this resorption 1. At extraction time - graft materials - graft materials + implant - implant - nothing 2. Wait 4 weeks or 12 weeks - graft materials + implant
    13. 14. Extraction Socket Treatment Options <ul><li>Atraumatic extraction technique </li></ul><ul><li>Nil </li></ul><ul><li>Collaplug </li></ul><ul><li>Closed socket preservation </li></ul><ul><li>Open ridge augmentation </li></ul><ul><li>Immediate implant placement </li></ul><ul><li>Delayed implant placement </li></ul><ul><li>Submerged root technique </li></ul>
    14. 15. “ Important to identify the probable and possible short, medium and long term treatment plan prior to treatment planning the extraction socket effectively”
    15. 16. Treatment Strategies XLA - 4-6 weeks - Implant placement XLA - 12 weeks - Implant placement XLA + Bone graft - 6-9 months - Implant placement Bone grafting materials need 6-9 months to allow for enough graft replacement and new bone formation - Depends on size of defect and presence of bony walls providing blood supply Collagen materials do not delay implant placement
    16. 17. Rule Book! <ul><li>In addition to the 2 main parameters </li></ul><ul><li>- Buccal plate </li></ul><ul><li>- Gingival BioType </li></ul><ul><li>Aesthetic risk </li></ul><ul><li>Smile line </li></ul><ul><li>Restorative status of neighbouring teeth </li></ul><ul><li>Smoker </li></ul><ul><li>Periodontal disease </li></ul><ul><li>Age </li></ul><ul><li>It is mainly the aesthetic risk of the case that will guide your treatment </li></ul>
    17. 18. Rule Book! Socket BioType Treatment Options Intact buccal plate Thin Closed/Delayed/Immediate Thick Immediate/Delayed/Closed Buccal dehiscence Thin Closed/Open/Delayed/Immediate Thick Closed/Immediate/Delayed/Open Missing buccal plate Thin Open Thick Open
    18. 19. Atraumatic Extraction Technique
    19. 20. Atraumatic Extraction Technique <ul><li>Preservation of alveolar bone, especially fragile buccal bundle bone </li></ul><ul><li>Pericision </li></ul><ul><li>Periotomes </li></ul><ul><li>Extraction forceps </li></ul><ul><li>Socket degranulation!!! </li></ul><ul><li>Socket inspection </li></ul>
    20. 21. 1. Pericision Size 15, 15c or 12 blade Separating supracrestal periodontal attachment apparatus Incision can extend into PDL
    21. 22. 2. Elevation Periotomes, other... Used mainly mesially and distally avoiding damage or fracture to buccal plate
    22. 23. 3. Forceps Delivery Root separation if required Appropriate extraction forceps Modify delivery technique Delivery of all roots......
    23. 24. 4. Socket Degranulation !! Often overlooked Remove all soft tissue remnants Bone files, spoon excavators, other Care of maxillary sinus and ID Canal
    24. 25. 5. Socket Inspection Bony dehiscence Bony fenestration No soft tissue remnants Buccal wall thickness
    25. 26. Hands on 1: Atraumatic extraction technique
    26. 27. Atraumatic Extraction Technique <ul><li>Pericision </li></ul><ul><li>Periotomes </li></ul><ul><li>Extraction forceps </li></ul><ul><li>Socket degranulation!!! </li></ul><ul><li>Socket inspection </li></ul>
    27. 28. Clinical scenarios
    28. 31. Biomaterials
    29. 32. Materials Collagen Membranes Bone grafts Sutures
    30. 33. Collagen <ul><li>Collagen plug </li></ul><ul><li>Collagen foam </li></ul><ul><li>Collagen tape </li></ul><ul><li>NuOss Collagen </li></ul>
    31. 34. Resorbable Haemostatic Extraction sockets Socket seal Simple use
    32. 35. Membranes Resorbable Non-resorbable - rarely used nowadays Resorbable - Collagen (bovine, porcine) - Cross linking - Resorption rates - Memory - Friabilty
    33. 36. Type 1 Bovine Collagen Cross linked Zero memory Hydrate 4-6 months resorption Similar to BioGide - Natural collagen - Resorbs quicker
    34. 37. Longer resorption times 6-8 months Elastic memory + rigidity Largely removes the need to use non-resorbable membranes - Gortex, EPTFE
    35. 38. Bone Grafts Autogenous - Your own bone Allograft - Other human bone Xenograft - Animal bone Alloplast - Synthetic bone substitute Donor site availability Resorption rates Moral issues
    36. 39. Bovine bone Porous mineralised bone matrix No organic component Very similar to BioOss Particle size 0.2-0.5 microns 1.0-2.0 microns Generally use the smaller size except for sinus grafting
    37. 40. Bio-Oss® Human Bone NuOss™
    38. 41. New Vital Bone (red) NuOss (tan)
    39. 43. Closed Socket Preservation
    40. 44. Collaplug Technique Allow stabilisation of blood clot Can also prevent a ridge with hard tissue defect from collapsing in the short term
    41. 45. “ Closed” Socket Preservation Intact socket walls Collagen seal technique Delays implant placement by 6-9 months
    42. 46. “ Closed” Socket Preservation Buccal dehiscence Ice-cream cone technique Delays implant placement by 6-9 months
    43. 47. “ Closed” Socket Preservation <ul><li>Socket degranulation </li></ul><ul><li>Socket inspection </li></ul><ul><li>Membrane preparation </li></ul><ul><li>depth of socket/defect </li></ul><ul><li>width of defect </li></ul><ul><li>width of socket </li></ul><ul><li>Socket haemorrhage </li></ul><ul><li>Membrane placement </li></ul><ul><li>Graft placement </li></ul><ul><li>Membrane tuck </li></ul><ul><li>Suture </li></ul>
    44. 48. Socket Preservation
    45. 49. Socket Preservation
    46. 50. Socket Preservation
    47. 51. Hands on 2: Closed socket preservation
    48. 52. Socket Preservation <ul><li>1. Buccal plate intact </li></ul><ul><li>Place graft material in socket to level of bony crest </li></ul><ul><li>Halve the CollaPlug, compress it and then place it over the socket entrance (alternative options here) </li></ul><ul><li>Suture, interupted, mattress or criss-cross(8) </li></ul><ul><li>2. Buccal dehiscence 1/2 root length </li></ul><ul><li>Trim membrane to ice-cream cone shape </li></ul><ul><li>Place membrane in socket </li></ul><ul><li>Place graft in socket </li></ul><ul><li>Tuck membrane into palatal mini-flap </li></ul><ul><li>Suture </li></ul>
    49. 53. Open Socket Preservation + Ridge Augmentation
    50. 54. “ Open” Socket Preservation Ridge Augmentation Extensive buccal wall defect Extensive infection
    51. 55. Ridge Augmentation
    52. 56. Ridge Augmentation
    53. 57. Ridge Augmentation
    54. 58. Ridge Augmentation
    55. 59. Ridge Perforation
    56. 60. Cortical Perforation
    57. 61. Periosteal Incision
    58. 62. Hands on 3: Open socket preservation + Ridge Augmentation
    59. 63. Ridge Augmentation <ul><li>Flap design </li></ul><ul><li>3 sided or 2 sided </li></ul><ul><li>Incision </li></ul><ul><li>sulcular </li></ul><ul><li>vertical, at least one tooth away from site </li></ul><ul><li>blood supply </li></ul><ul><li>Vital structures, mental nerve etc. </li></ul><ul><li>Flap elevation </li></ul><ul><li>Cortical perforation </li></ul><ul><li>Periosteal releasing incision (if needed) </li></ul><ul><li>Membrane trimming </li></ul><ul><li>Graft placement </li></ul><ul><li>Membrane placement </li></ul><ul><li>Suturing </li></ul>
    60. 64. Alternatives Implants, etc
    61. 65. Implant Timing Options Type 1: Immediate implant placement Type 2: Early delayed implant placement Type 3: Late delayed implant placement Type 4: Healed ridge
    62. 67. Delayed implant placement
    63. 68. Delayed implant placement
    64. 69. Delayed implant placement
    65. 70. Delayed implant placement
    66. 71. Root Submergence
    67. 72. Orthodontic Extrusion Consider extrusion of teeth with vertical bone defects Even teeth that are due for extraction Predictable method of vertical augmentation Aesthetic demand Sectional fixed appliance 3-6 months active treatment followed by 3 months retention
    68. 73. Considerations + Summary
    69. 74. Post-Op <ul><li>Hygiene - Chlorhex </li></ul><ul><ul><ul><li>- Toothbrush, cotton buds </li></ul></ul></ul><ul><li>Pain - usual analgesia advice as following XLA </li></ul><ul><ul><li>- additional pain relief if a flap was raised </li></ul></ul><ul><li>Bruising - normal response as after XLA </li></ul><ul><ul><ul><li>- Extensive flaps and periosteal incisions can result in facial bruising </li></ul></ul></ul><ul><li>Swelling - normal response as after XLA </li></ul><ul><ul><ul><li>- Extensive flaps and periosteal incisions can result in facial swelling </li></ul></ul></ul>
    70. 75. Post-Op Regimen Gauze pack + Ice pack Analgesia - Paracetamol 500mg x2 QDS - Ibuprofen 400mg TDS - Difene 50mg TDS - Tylex 30/500mg x2 QDS Antibiotics ?? - Augmentin 375mg BD - Metronidazole 200mg TDS Chlorhexidine 0.2% QDS Warm salty mouthrinse additionally as required Diet instructions Suture removal 7-14 days ....
    71. 77. Summary <ul><li>Consider likely future treatment prior to extraction </li></ul><ul><li>Maximise regenerative potential at each stage of treatment </li></ul><ul><li>If no treatment provided at time of extraction then implant placement should be done within 1-3 months </li></ul><ul><li>Bone grafting will delay treatment 6-9 months </li></ul><ul><li>Watch for high smile lines </li></ul><ul><li>Beware of thin biotypes!! </li></ul><ul><li>Beware of hidden underlying bony defects </li></ul><ul><li>Atraumatic extraction technique </li></ul><ul><li>Thorough socket degranulation </li></ul><ul><li>Flexibility of treatment options </li></ul><ul><li>Delay extraction where no acute infection/pain until treatment plan is finalised </li></ul>
    72. 78. Thank you for your time