The way dentistry is performed has changed dramatically. New techniques, new materials, and new views dictate new concepts and handling. The importance of bone grafting materials is growing rapidly because these materials can play a crucial role in improving the outcome in aesthetics and function of dental implants and prostheses. Also, the treatment of bony defects caused by surgery, trauma, dental disease, and extractions is enhanced dramatically by the use of these materials. Extraction, or exodontia, is probably the most common daily procedure in most general dentistry practices.
Extraction of teeth produces a 40% to 60% alveolar bone loss over a period of 2 to 3 years in every segment of the population.1 The jawbone is different from any other bone in the body in that it recedes once its function is eliminated. Because its function is to hold teeth, removal of teeth begins the recession process.2 Not only does the bone reduce in height, but also in width. If you remove a tooth, a likely result is a “saucerization” effect that will encompass about 20% of the bone holding the adjacent teeth. Thus, you’ll see a reduction in the inciso-apical portion of the alveolar ridge. General aging, facial lines, shifting of teeth, and unaesthetic dental restorations because of irregular bone loss after extraction are among the conditions accelerated by this loss of alveolar bone.
The introduction of synthetic bone for hard-tissue replacement has opened many new opportunities to the general dentist. The aesthetic and functional advantages of ridge preservation are impressive. Once practitioners see the result of ridge preservation, it is hard not to become committed to the concept. This article discusses the use of Bioplant HTR (Kerr) for postextraction socket grafting.
CASE STUDY
A woman in her mid-40s presented with severe pain from tooth No. 11 (Figure 1). Upon clinical examination, cervical caries was present (Figure 2).
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| Figure 1. Preoperative full-face photo. | Figure 2. Retracted view of tooth No. 11 that will require extraction. |
Radiographically, the tooth exhibited severe periodontal problems resulting in deep periodontal pocketing. All risks, benefits, and alternatives were reviewed with the patient. The patient desired to have a mouth free from infection. Currently, she had no prosthetic device for her multiple missing teeth. She had limited funds, but wanted something that would replace her missing teeth, make her look younger, and look aesthetic. Since she would still have teeth Nos. 8, 9, 10, and 13 remaining after the extraction of No. 11, these teeth would be utilized for her partial denture. A Valplast partial would be utilized, since the patient desired a prosthesis that would not show metal clasps.
After administering local anesthetic, a small, thin instrument was used to sever the periodontal fibers around the tooth. This would aid in the preservation of soft tissue and result in an atraumatic removal of the tooth (Figure 3). Once the tooth was extracted, the socket was inspected for debris or pathology, since these would interfere with osseous growth in the socket. The socket was debrided of all soft tissue, and bleeding was stimulated from the osseous base (Figure 4). This bleeding contains all the components to form new bone in this site. This could be done with a rotary instrument or a curette.
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| Figure 3. Extracted tooth No. 11. | Figure 4. Extraction site immediately after extraction. |
The customized tip on the Bioplant HTR syringe was easily inserted into the socket to draw blood into it (Figure 5). This blood is used to wet the Bioplant HTR (Figure 6). Osseous bleeding is crucial to bone regeneration. Once the material is wet, it will stick together, allowing it to stay where it is placed (Figure 7). The tissue around the site may be sutured closed to help confine the material during the initial healing phase. An alternative approach that was used in this particular case was to place a strip of Biofoil (Kerr) over the socket and adapt it to the gingival walls (Figure 8). By this time, the bleeding from the socket had already stopped.
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| Figure 5. Blood being drawn to wet Bioplant material. | Figure 6. Tip removed and ready for delivery. | |
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| Figure 7. Bioplant material placed in socket void. | Figure 8. Biofoil placed over grafted socket. | |
When the patient returned a week later, impressions were taken using Virtual monophase impression material (Ivoclar Vivadent) for partial denture fabrication. The laboratory was instructed to fabricate a Valplast partial. After a wax, try in of the prosthesis, the partial was sent back to the lab for final fabrication. Shortly after, the partial was delivered and tried in for fit and function. The aesthetics of the partial blended in very well with the surrounding dentition, and the patient was very pleased (Figures 9 and 10).
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| Figure 9. Retracted view of restored area. | Figure 10. Postoperative full-face photo. |
CONCLUSION
Postextraction ridge preservation and bone maintenance are important components of any successful practice. Use of extraction socket grafting reaps many benefits for the provider and the patient. Hemostasis, minimal postoperative infection, and establishing the groundwork for future treatment procedures are some of the advantages of this procedure. Aesthetics and proper function can best be accomplished when the foundation is present for the final replacement of teeth. Together with increases in practice revenue, this protocol is a win-win situation for everyone involved.
References
1. Ashman A. Ridge preservation: important buzzwords in dentistry. Gen Dent. 2000;48:304-312.
2. Gross J. Using HTR and Biofoil in ridge preservation immediately after extraction. Contemp Esthet. Feb 2001;5:78-92.
Additional Reading
Ashman A, Bruins P. Prevention of alveolar bone loss postextraction with HTR grafting material. Oral Surg Oral Med Oral Pathol. 1985;60:146-153.
Christensen GJ, Christensen RP. Product use survey: surgery. CRA Newsletter. 1995:19(10):4.
Preserving the alveolar ridge. AAOMS Surgical Update. 2001;16(1):1-8.
Dr. Nazarian is a graduate of the University of Detroit-Mercy School of Dentistry. Upon graduation, he completed an AEGD residency in San Diego, Calif, with the United States Navy. Currently, he maintains a private practice in Troy, Mich, with an emphasis on comprehensive and restorative care. He is a recipient of the Excellence in Dentistry Award and Scholarship. His articles have been featured in many of today’s dental publications. Dr. Nazarian also serves as a clinical consultant for the Dental Advisor, testing new products on the market. He is a member of the Academy of General Dentistry and the American Academy of Cosmetic Dentistry. He can be reached at (248) 457-0500 or at ara20002@comcast.net.
