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SOCKET AND RIDGE PRESERVATION TECHNIQUE AT THE DAY OF
TOOTH EXTRACTION.
Dr Henning Bastian
Slotsgade 18, 2.
5000 Odense
Denmark
Dr Bastian graduated as a dentist in 1971 from the dental school
at Århus University, Denmark and specialized in Oral and
Maxillo-Facial Surgery in 1986 from Odense University Hospital.
Contact address: hlb@os.dk
SUMMARY:
This case presents a ridge preservation procedure on
extraction of a maxillary incisor using the “parasorb
sombrero membrane procedure”.
Dr Bastian was Head of the Department of Oral and Maxillofacial Surgery at Odense University
Hospital 1988-2010. He was Ass. Professor in Oral Medicine and Oral Pathology at Odense and
Århus University. Since 1977 he has been Forensic Odontologist at the Department for Forensic
Medicine, Odense University. He is Editor in Chief of the Danish internet site
www.tandogmund.dk-2000. Since 2009 he has been a Member of the Camlog Expert Panel and since
2010 in private pratice in Oral and Maxillofacial Surgery in Odense, Denmark.
21, March 2012,
INTRODUCTION:
A 44 year old woman was referred to the clinic because she had a grey front maxillary right
central incisor tooth with an apical infection. There was a history of trauma to the tooth in
childhood and of several episodes of periapical infection with acute exacerbations. She had
received an apicoectomy. At the initial visit the infection was chronic with no pus or swelling.
CURRENT SITUATION:
There was some pain on palpation in the sulcus above the root of the tooth. In the mucosa there
was a slight amalgam tattoo but this did not bother the patient. On a radiograph the root canal
was obliterated with calcifications, the apical region had been removed and there was a
retrograde amalgam filling. A periapical radiolucency remained.
Her general health was good. She was not taking any medications and she had no history of any
allergies.
She requested an implant born crown.
TREATMENT PLAN:
Removal of the tooth, degranulation of the infected region, regeneration of the site and
placement of a dental implant to secure an abutment and crown.
21, March 2012,
Fig. 1
Initial radiograph of the region showing the involved tooth with the periapical radiolucency.
21, March 2012,
Fig. 2
Under local anaesthetic, the tooth was removed along with the apical granuloma.
21, March 2012,
Fig. 3
The socket was cleaned out with sharp spoon excavators. There was a labial perforation in the
region of the apicoectomy. It was decided to proceed with a socket augmentation.
21, March 2012,
Fig. 4
The first stage was to raise the labial soft tissues around the perforation, then to place a resorbable
collagen membrane (Bio-Gide®) down between the perforation and the periosteum.
21, March 2012,
Fig. 5. The socket was filled 2/3rds full with Bio-Oss®. The attached gingiva around the socket was
lifted back 2.0 mm, a Parasorb Sombrero® membrane was placed down into the socket and
adapted around the bone margin, under the gingiva. 3.0 Vicryl cross sutures then closed the wound.
21, March 2012,
Fig. 6
The x-ray shows the Bio-Oss® in the socket and a nice level of marginal bone.
21, March 2012,
Fig. 7
After 3 weeks there is a little dehiscence in the mucosa and some of the membrane is seen, but
there are no signs of infection.
21, March 2012,
Fig. 8
The x-ray at 3 weeks appears fine with no signs of marginal bone resorbtion.
21, March 2012,
Fig. 9
After 3 months the mucosa are fully healed with good color and contour.
21, March 2012,
Fig. 10
The x-ray at 3 months shows the bone and BioOss® to be stable. There is no marginal bone loss.
21, March 2012,
Fig. 11
At 6 months the mucosa has healed very well.
21, March 2012,
Fig. 12
A 3.8 x 13mm Camlog Screwline PromotePlus implant was placed at the bone level.
21, March 2012,
Fig. 13
A 4 mm cylinder healing cap is placed. The site is closed with two interproximal resorbable sutures.
21, March 2012,
Fig. 14
The postoperative x-ray. Placement of the implant is fine. There was excellent primary stability.
21, March 2012,
Fig. 15
After 2 months the healing is good. There is some overgrowth of mucosa over the healing cap.
21, March 2012,
Fig. 16
The x-ray shows excellent osseointegration. The percussion and torque tests are very satisfying.
The marginal bone level is well preserved.
21, March 2012,
Fig. 17
The cylinder gingivaformer is exchanged for a wideneck. The mucosal blanching will quickly
disappear. This change will improve the final result and enhance the papilla.
21, March 2012,
Fig. 18
The x-ray is taken just after the crown has been cemented, 9 months since the start of the
treatment. The marginal bone appearance is still amazing!
21, March 2012,
Fig. 19
The final crown in place. Notice the nice papillas and the fine texture of the mucosa.
21, March 2012,
DISCUSSION
There are many approaches to handling a failing anterior tooth. Once it has been determined
that the tooth has to be lost then there are generally three main alternatives:
1. “Immediate” implant placement with simultaneous augmentation.
2. “Socket Regeneration”, to regain bone and and enable an implant to be placed later.
3. “Delayed” protocol where implants are placed after natural healing and ridge stabilization.
In this case the “Socket Regeneration” protocol was used. There are many different
approaches to this. As there was a labial perforation, it was considered necessary to raise a
labial “pouch” and to insert a collagen resorbable membrane between the periosteum and the
bone. Then the socket was filled 2/3rds full with BioOss® allograft bone material which has a
long history of stimulating natural bone formation, while at the same time helping resist
socket collapse.
Most operators would bring the bone graft to the crest of the socket, even over the top of it.
Yet in this case the Parasorb Sombrero®membrane was inserted down into the residual 1/3rd
of the socket, while the “rim” of the sombrero was bought out over the top of the bone, and
under the surrounding gingival structures. The gingival tissues are closed over the top of the
membrance with simple sutures. This is a very simple procedure. It ensures that epithelial
downgrowth is inhibited so that natural bone formation occurs in the socket.
21, March 2012,
CONCLUSION:
Successful replacement of a single maxillary incisor is demanding. In this situation, it was
decided to use a “Socket Regeneration” protocol to gain an intact ridge prior to placing an
implant. This was accomplished by using a conventional bone grafting procedure in the base
of the socket, up to and above the level of a labial perforation.
Above this a simple, innovative membrane-based procedure provided regeneration of the
remainder of the socket. The implant procedure and restoration could then proceed so that an
excellent result was obtained.
21, March 2012,
Tak
21, March 2012,

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Teknik til bevarelse af marginal knogle før implantatbehandling

  • 1. SOCKET AND RIDGE PRESERVATION TECHNIQUE AT THE DAY OF TOOTH EXTRACTION. Dr Henning Bastian Slotsgade 18, 2. 5000 Odense Denmark Dr Bastian graduated as a dentist in 1971 from the dental school at Århus University, Denmark and specialized in Oral and Maxillo-Facial Surgery in 1986 from Odense University Hospital. Contact address: hlb@os.dk SUMMARY: This case presents a ridge preservation procedure on extraction of a maxillary incisor using the “parasorb sombrero membrane procedure”. Dr Bastian was Head of the Department of Oral and Maxillofacial Surgery at Odense University Hospital 1988-2010. He was Ass. Professor in Oral Medicine and Oral Pathology at Odense and Århus University. Since 1977 he has been Forensic Odontologist at the Department for Forensic Medicine, Odense University. He is Editor in Chief of the Danish internet site www.tandogmund.dk-2000. Since 2009 he has been a Member of the Camlog Expert Panel and since 2010 in private pratice in Oral and Maxillofacial Surgery in Odense, Denmark. 21, March 2012,
  • 2. INTRODUCTION: A 44 year old woman was referred to the clinic because she had a grey front maxillary right central incisor tooth with an apical infection. There was a history of trauma to the tooth in childhood and of several episodes of periapical infection with acute exacerbations. She had received an apicoectomy. At the initial visit the infection was chronic with no pus or swelling. CURRENT SITUATION: There was some pain on palpation in the sulcus above the root of the tooth. In the mucosa there was a slight amalgam tattoo but this did not bother the patient. On a radiograph the root canal was obliterated with calcifications, the apical region had been removed and there was a retrograde amalgam filling. A periapical radiolucency remained. Her general health was good. She was not taking any medications and she had no history of any allergies. She requested an implant born crown. TREATMENT PLAN: Removal of the tooth, degranulation of the infected region, regeneration of the site and placement of a dental implant to secure an abutment and crown. 21, March 2012,
  • 3. Fig. 1 Initial radiograph of the region showing the involved tooth with the periapical radiolucency. 21, March 2012,
  • 4. Fig. 2 Under local anaesthetic, the tooth was removed along with the apical granuloma. 21, March 2012,
  • 5. Fig. 3 The socket was cleaned out with sharp spoon excavators. There was a labial perforation in the region of the apicoectomy. It was decided to proceed with a socket augmentation. 21, March 2012,
  • 6. Fig. 4 The first stage was to raise the labial soft tissues around the perforation, then to place a resorbable collagen membrane (Bio-Gide®) down between the perforation and the periosteum. 21, March 2012,
  • 7. Fig. 5. The socket was filled 2/3rds full with Bio-Oss®. The attached gingiva around the socket was lifted back 2.0 mm, a Parasorb Sombrero® membrane was placed down into the socket and adapted around the bone margin, under the gingiva. 3.0 Vicryl cross sutures then closed the wound. 21, March 2012,
  • 8. Fig. 6 The x-ray shows the Bio-Oss® in the socket and a nice level of marginal bone. 21, March 2012,
  • 9. Fig. 7 After 3 weeks there is a little dehiscence in the mucosa and some of the membrane is seen, but there are no signs of infection. 21, March 2012,
  • 10. Fig. 8 The x-ray at 3 weeks appears fine with no signs of marginal bone resorbtion. 21, March 2012,
  • 11. Fig. 9 After 3 months the mucosa are fully healed with good color and contour. 21, March 2012,
  • 12. Fig. 10 The x-ray at 3 months shows the bone and BioOss® to be stable. There is no marginal bone loss. 21, March 2012,
  • 13. Fig. 11 At 6 months the mucosa has healed very well. 21, March 2012,
  • 14. Fig. 12 A 3.8 x 13mm Camlog Screwline PromotePlus implant was placed at the bone level. 21, March 2012,
  • 15. Fig. 13 A 4 mm cylinder healing cap is placed. The site is closed with two interproximal resorbable sutures. 21, March 2012,
  • 16. Fig. 14 The postoperative x-ray. Placement of the implant is fine. There was excellent primary stability. 21, March 2012,
  • 17. Fig. 15 After 2 months the healing is good. There is some overgrowth of mucosa over the healing cap. 21, March 2012,
  • 18. Fig. 16 The x-ray shows excellent osseointegration. The percussion and torque tests are very satisfying. The marginal bone level is well preserved. 21, March 2012,
  • 19. Fig. 17 The cylinder gingivaformer is exchanged for a wideneck. The mucosal blanching will quickly disappear. This change will improve the final result and enhance the papilla. 21, March 2012,
  • 20. Fig. 18 The x-ray is taken just after the crown has been cemented, 9 months since the start of the treatment. The marginal bone appearance is still amazing! 21, March 2012,
  • 21. Fig. 19 The final crown in place. Notice the nice papillas and the fine texture of the mucosa. 21, March 2012,
  • 22. DISCUSSION There are many approaches to handling a failing anterior tooth. Once it has been determined that the tooth has to be lost then there are generally three main alternatives: 1. “Immediate” implant placement with simultaneous augmentation. 2. “Socket Regeneration”, to regain bone and and enable an implant to be placed later. 3. “Delayed” protocol where implants are placed after natural healing and ridge stabilization. In this case the “Socket Regeneration” protocol was used. There are many different approaches to this. As there was a labial perforation, it was considered necessary to raise a labial “pouch” and to insert a collagen resorbable membrane between the periosteum and the bone. Then the socket was filled 2/3rds full with BioOss® allograft bone material which has a long history of stimulating natural bone formation, while at the same time helping resist socket collapse. Most operators would bring the bone graft to the crest of the socket, even over the top of it. Yet in this case the Parasorb Sombrero®membrane was inserted down into the residual 1/3rd of the socket, while the “rim” of the sombrero was bought out over the top of the bone, and under the surrounding gingival structures. The gingival tissues are closed over the top of the membrance with simple sutures. This is a very simple procedure. It ensures that epithelial downgrowth is inhibited so that natural bone formation occurs in the socket. 21, March 2012,
  • 23. CONCLUSION: Successful replacement of a single maxillary incisor is demanding. In this situation, it was decided to use a “Socket Regeneration” protocol to gain an intact ridge prior to placing an implant. This was accomplished by using a conventional bone grafting procedure in the base of the socket, up to and above the level of a labial perforation. Above this a simple, innovative membrane-based procedure provided regeneration of the remainder of the socket. The implant procedure and restoration could then proceed so that an excellent result was obtained. 21, March 2012,