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Tooth Extraction—An Opportunity for Site Preservation

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Tooth Extraction—An Opportunity for Site Preservation IMPLANT DENTISTRY Tooth Extraction—An Opportunity for Site Preservation or a patient, the loss of a tooth flat basilar bone.9-11 induces not only emotional Alveolar bone survives only in the Ftrauma but also physical presence of dentition. The existence deformity. Removal spurs bone of intact teeth in a partially edentu- resorption, which increases over lous ridge defies or at least delays the time. As the soft-tissue drape follows sort of severe loss reported above Michael Sonick, DMD the osseous contour, such remodel- because the bone remains to support Director of Sonick Seminars ing may result in a depressed mucos- them; this is the concept fundamental Private Practice 8 Periodontics and Implant Dentistry al profile, especially if a thin biotype to the use of overdentures. Despite Fairfield, Connecticut exists. This becomes a possible visu- adjacent teeth, some level of resorp- Phone: 203.254.2006 al concern. Immediately after extrac- tion occurs after the removal of 1 Email: [email protected] Web site: www.sonickdmd.com tion, the socket walls undergo inter- tooth, depending on a host of factors. nal and external turnover, resulting These influencing variables include: Board Member Contemporary Esthetics in crestal bone loss as well as hori- • Anatomy. A thicker, wider ridge zontal reduction. Buccolingual loss tends to resorb less, possibly overall exceeds that in the vertical because of higher vascularity. As it direction, though both occur. Several is typically thinner, the buccal wall investigations report horizontal and diminishes more than the lingual vertical deficits of 3.0 mm to 6.0 mm 2 to 4 months after tooth removal. and 1.0 mm to 2.0 mm, respectively, It experiences 56% horizontal re- per site after an initial healing period sorption compared to 30% vertical of 4 months.1-5 and is in a position roughly 2.0 mm Debby Hwang, DMD The newly edentulated jaw apical to its lingual counter- 12,13 Private Practice exhibits 10 times more resorption in part. A naturally thin wall Fairfield, Connecticut the first year than in those subse- encloses fewer vessels and marrow 203.254.2006 quent, with 4 times greater mandibu- spaces for regeneration and may Email: [email protected] 6 Web site: www.sonickdmd.com lar reduction than maxillary. Up to be easily broken (see Trauma). 25% horizontal and 4.0 mm vertical • Trauma. Fracture of the alveolus loss occurs within the first year.7,8 In sustained before or during extrac- 3 years, ridge volume diminishes by tion will lead to greater osseous 40% to 60%.8 After 25 years, the resorption. Iatrogenic buccal plate mandible loses nearly 8.0 mm of height damage from surgery may occur without teeth. A ridge with long-term and hinders ideal healing. Re- edentulism may be comprised of just moval of an ankylosed tooth often 38 CONTEMPORARY ESTHETICS | FEBRUARY 2007 necessitates extensive preparation not have restoration performed? Steps for Socket Preservation around it, again generating fur- Regardless of the prosthetic plan for 1. Flap design—Perform a sulcular ther bone loss. the newly edentulous area, it is better incision circumferentially around • Pathology. Any infective process, to have more bone present than less. the tooth with scalpel to sever soft- including periodontitis and peri- A patient with no immediate plans tissue fibers (Figures 3B and 6B). odontal or endodontic abscesses, for any type of tooth replacement in Try not to raise a flap unless the destroys bone. Patients with the site may change his or her plans buccal plate is not intact or surgical severe chronic periodontitis as time passes. For those who seek extraction is necessary. First, probe demonstrate little initial bone rehabilitation with removable partial to determine the existence of labial around the extracted tooth and dentures, a bulkier ridge improves bone (Figure 6C). If a flap must be adjacent teeth, thus complicating force distribution as well as mechani- raised, perform an envelope flap repair and restoration. In addi- cal support and retention. A wider (no verticals) by extending the sul- tion, cysts, tumors, or congenital pontic site eases restorability and cular incision to the mesial or distal disorders may instigate loss. esthetics for conventional fixed par- of the adjacent teeth. Vertical inci- • Genetic predisposition. It is probable tial denture fabrication. Last, a site sions may compromise the blood that genetics affect the healing planned for implant replacement supply, but if one is anticipated, sequence but it is unknown how requires a ridge with enough verti- place it in the manner demonstrat- exactly or to what extent. Some cal and horizontal proportions for ed (Figure 6D). patients naturally possess less stability and proper mucosal con- 2. Atraumatic removal of tooth— osteoclastic activity than others. tour. The absolute minimum Remember that atraumatic equals • Medical status and drugs. Me- amount of bone surrounding an removal of no bone from the tabolic diseases, especially if implant on the buccal or lingual is extraction site. Section any multi- poorly controlled, alter tissue 1.0 mm, but in the anterior zone, at rooted tooth with a long carbide turnover. Diabetes, for instance, least 2.0 mm of facial bone must bur to separate the roots. Use a disturbs collagen turnover and occur to resist recession.22 periotome to sever the periodontal bone formation.14 Habits such as If retaining as much bone as ligament (PDL) fibers from the smoking similarly interrupt wound possible is preferable, how do we tooth. Insert the device into the healing.15,16 Smoking increases the combat the natural resorption that PDL space at the line angles and risk for localized alveolitis postex- occurs postextraction? That is, how palatally, parallel to the root, apply traction as well.17,18 One class of do we maintain the bone already apical force incrementally. The bone-sparing drugs, IV bisphos- present? Termed “ridge preserva- periotome should advance further phonates, may be associated with tion” or “socket preservation,” this apically with time. If more mobili- the development of osteonecrosis, procedure of site maintenance usu- ty is required, elevate the root gen- especially after dental procedures. ally involves the major steps listed tly with a small straight or Molt Current guidelines suggest that below. The general goal is to pre- elevator. If a root remains recalci- patients on these medications vent resorption and not necessarily trant to multiple applications of cannot undergo elective dental to augment the ridge, though this these methods or if ankylosis is sus- procedures.19-21 may be a desired secondary goal. pected, use of a long, thin diamond Preservation upholds enough bone bur is suggested. Apply a bur to the Extraction Socket Remodeling to facilitate an uncomplicated Stage PDL space around the tooth. Extraction socket remodeling 1 surgery (Figures 1 and 2). Most Remove loosened roots with an is complex. But why does bone studies on this subject attempt elevator or forceps. resorption matter from a clinical preservation, not enhancement at 3. Degranulation—Remove soft tissue standpoint? Is preservation of a site the time of extraction, and this will and debris with curettes and necessary if the patient elects to be the focus of this article as well. Neumeyer bur application. This CONTEMPORARY ESTHETICS | FEBRUARY 2007 39 IMPLANT DENTISTRY bur will remove soft tissue but bony crest or further coronally if made, primary closure may occur leave hard structures intact. Irrigate desired (Figures 3D and 4A). by creating a split-thickness dissec- with saline or 0.12% chlorhexidine 5. Membrane application—If the buccal tion at the thick, apical aspect of solution. wall is thin or not intact, contain the flap (periosteal release). The 4. Bone grafting—If the socket does not the bone graft with a membrane of tissue may be advanced over the bleed, decorticate it apically with a choice placed on the buccal wall socket. If this is the goal, make sure small round bur to induce bleed- (Figure 7A). Make sure it is at least there is no tension of the flap. ing. Be careful not to fenestrate the 1.0 mm away from the necks of the Perform further periosteal release buccal or lingual wall or penetrate adjacent teeth, though it may con- as necessary. If no vertical incisions surrounding structures (eg, teeth, tact the roots. If desired, the buccal were made, place a collagen plug sinus, etc). Place graft material of wall may be built up 1.0 mm to 2.0 on top of the socket to cover the choice into the socket. Condense mm horizontally with more bone bone graft. The plug may be flat- gently with a cotton tip applicator graft material under the membrane. tened to enhance surface area or instrument handle. Fill up to the 6. Closure—If vertical incisions were (Figures 4B and 4C). The plug Each figure contains four panels. Starting from the top left and proceeding clockwise, these are designated from A to D. Figure 1— A: A parulis at the apex of tooth Figure 2—A: Maxillary teeth. B: Ridge Figure 3—A: Tooth No. 7. B: Sulcular incision No. 9, which exhibits endodontic failure. B: preservation performed with FDBA and performed. C: Atraumatic removal of tooth Socket preservation performed with freeze- collagen plugs contained with 4-0 expanded and degranulation. D: Placement of FDBA dried bone allograft (FDBA) and a collagen polytetrafluoroethylene (ePTFE) sutures. C: to the crest of the socket. plug contained with 4-0 chromic gut. C: Six- Uncomplicated implantation 4 months postex- week healing. D: Implant placement without traction. D: Healing abutments placed for one- need for further grafting. stage surgery. Figure 4—A: Occlusal view of FDBA in sock- Figure 5—A: Horizontal mattress suture Figure 6—A: Hopeless tooth No.
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