This case report describes a ridge preservation procedure performed after extracting a maxillary incisor tooth with a history of trauma and infection. The socket was cleaned and a collagen membrane was placed over a labial perforation. The socket was then filled with Bio-Oss bone graft material and a Parasorb Sombrero membrane was adapted under the gingiva and over the bone to prevent epithelial downgrowth and allow natural bone formation in the socket. An implant was successfully placed 6 months later.

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.
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3. Fig. 1
Initial radiograph of the region showing the involved tooth with the periapical radiolucency.
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4. Fig. 2
Under local anaesthetic, the tooth was removed along with the apical granuloma.
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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.
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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.
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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.
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8. Fig. 6
The x-ray shows the Bio-Oss® in the socket and a nice level of marginal bone.
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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.
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10. Fig. 8
The x-ray at 3 weeks appears fine with no signs of marginal bone resorbtion.
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11. Fig. 9
After 3 months the mucosa are fully healed with good color and contour.
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12. Fig. 10
The x-ray at 3 months shows the bone and BioOss® to be stable. There is no marginal bone loss.
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13. Fig. 11
At 6 months the mucosa has healed very well.
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14. Fig. 12
A 3.8 x 13mm Camlog Screwline PromotePlus implant was placed at the bone level.
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15. Fig. 13
A 4 mm cylinder healing cap is placed. The site is closed with two interproximal resorbable sutures.
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16. Fig. 14
The postoperative x-ray. Placement of the implant is fine. There was excellent primary stability.
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17. Fig. 15
After 2 months the healing is good. There is some overgrowth of mucosa over the healing cap.
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18. Fig. 16
The x-ray shows excellent osseointegration. The percussion and torque tests are very satisfying.
The marginal bone level is well preserved.
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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.
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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!
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21. Fig. 19
The final crown in place. Notice the nice papillas and the fine texture of the mucosa.
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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.
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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.
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24. Tak
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