rounding tissues (Figure 5,6,7).

It was demonstrated that following tooth extraction the buccal bone plate will un-dergo some modifications due to bone re-modeling1. In order to reduce the bone loss, several surgical techniques have been pro-posed. Nowadays it is still possible to min-imize osseous deformities problems by car-rying out the ridge preservation techniques in extraction sockets and using bone fillers materials with barrier membranes13. Today the advanced wide range of bone grafting materials and collagen membranes guides us into taking in charge many compro-mised cases.

It was noted that the resorption of bone ridge is faster during the first six months following extraction5, therefore a conser-vative approach remains necessary. Many measures should be taken into consider-ation when conducting the socket preser-vation surgery such as: reducing the ex-traction trauma and limiting the flap eleva-tion6. It was found histologically that bone formation occurs over the surface of the im-planted osteoconductive graft fillers7.

This article goes through the technical basis for socket preservation procedure and ex-poses its importance as an available treat-ment in order to prevent ridge atrophy and optimize esthetics in the anterior maxillary area.

Clinical Case:A 49 -year-old female with a noncontribu-tory medical history, presented to our clin-ic with a mobile tooth 21 and an apical re-sorption, the chief complaint was pressure in the upper anterior left area of the cen-tral incisor. Clinical examination showed tooth 21 mobile with gray coloration. Peri-apical radiograph examination revealed an apical resorption with an imcomplete end-odontic treatment (Figure 8). The tooth was deemed hopeless and referred for extrac-tion with socket preservation for future dental implant placement.

After tooth was carefully removed with forceps technique (Figure 9), the extraction site was grafted with an osteoconductive bone graft (Figure 10, 11). A resorbable col-lagen membrane was placed on the buccal aspect of the extraction socket and sutured to the palatal flap to attempt a primary clo-sure, with an exposed membrane left at the occlusal aspect of the extraction socket.

A Temporary bridge was placed to guide the healing process and conserve the es-thetic in the anterior region (Figure 12). Af-ter six months surgical re-entry during im-plant placement showed a good bony heal-ing, that allowed the placement of a regu-lar platform implant within the bony enve-lope (Figure 13), and achieved a good pri-mary stability that allowed the placement of single piece, direct-to-fixture provision-

al screw-retained restoration on site 21 in order to guide the healing process (Figure 14,15,16).

A period of three months elapsed to permit osseointegration, afterwards the patient present for final impression (Figure 17,18), it was noted that the long axis of the im-plant correlated to the central fossa of the expected final restoration (Figure 19). The final restoration showed an ideal esthetic restoration with healthy surrounding soft tissues.

Discussion:The failure to preserving the anatomy of hard and soft tissues will result in esthetic failures and compromises the final results. Araujo mentioned in a paper published in 2009, the use of xenograft in socket pres-ervation techniques will delay the socket healing but will help at the same time to conserving the anatomy2. Xenografts are considered the most used bone fillers in the socket preservation procedures due to their osteoconductive matrix framework which enhances the growth of new bone around it, as their name suggests2. Following tooth extraction the buccal plate formed especial-ly by bundle bone will experience more re-sorption than lingual and palatal ones3,10, and is considered the first to be absorbed4.

Loss of vertical ridge height will also occur less than the horizontal one, reducing the

Socket preservation in the daily practice: A clinical case report

Figure 1: Preoperative situation, note the unaligned incisive edge of tooth 21 with the grey cervical lining. Figure 2: Clinical view showing a complete horizontal fracture of the crown of tooth 21. Figure 3: After conservative extraction of tooth 21, collagen membrane is placed inside the bony envelope. Note the intact socket bone walls. Figure 4: Xenograft (Bio os®) is placed inside the socket and covered by a collagen membrane sutured to the palatal flap and intentionally left exposed so as not to create a mucosal defect from flap advancement.

Figure 5: A temporary Maryland bridge is prepared in order to guide the healing of soft tissues and enhance the esthetics in anterior maxillary region. Figure 6: Temporary Maryland Bridge in place to guide the healing process of socket 21. Figure 7: Three weeks postoperatively

by Dr. Rabih Abi Nader & Dr. Carine Tabarani

Soft tissue contour depends on the underlying bone anatomy, follow-ing tooth extraction, sockets under-goes a remodeling process that in-

fluences the implant rehabilitation treat-ment of the edentulous areas.Socket preservation procedure following tooth extraction will reduce the need for any further ridge augmentation technique prior to implant placement and will con-serve the existing bone. The aim is to pre-serve the original bone dimensional con-tours by limiting the normal post extrac-tion resorptive process8.The overall goal of this article is to provide the dental professional with valid tools in order to help them make a conscious de-cision considering the indications of this therapy and dependent on each clinical case.

Keywords: Extraction, socket preservation, implant, resorption process. 1- Private practice Oral Surgery, Implantolo-gy, Oral Medicine, Dubai Sky Clinic, Dubai, U.A.E.

2- Senior lecturer, Oral Surgery department, Saint- Joseph University Faculty of Dental Medicine, Beirut, Lebanon. Private practice Oral Surgery, Implantology, Oral Medicine, French Dental Center, Abu Dhabi, U.A.E.

Nowadays the outcome of implant surgery is measured by the long-term esthetic and functional success and not by the survival rate. A correlation exists between the hard and soft tissues in order to assure esthet-ic outcomes in implant surgery. Significant changes in bone volume and morphology following tooth extraction, can make im-plant rehabilitation very difficult, as the time from extraction to implant placement increases.Bone substitute in alveolar ridge preser-vation and prevention of additional bone grafting is highly supported and has a wide range of advantages. The socket preserva-tion technique allows the placement of im-plants in sites that was considered compro-mised in the past. Following the conserva-tive extraction (Figure 1,2), a bone filler is placed in the empty socket with a cross or non-cross linked membrane (Figure 3) and closed partially(Figure 4) or totally by a flap adding stitches, note that a provisional preparation is sometimes mandatory in or-der to guide the healing process of the sur-

Centre for Advanced Professional Practices (CAPP)is an ADA CERP Recognized Provid-er. ADA CERP is a service of the American Dental Assotiation to assist dental profession-als in identifying quality providers of continue dental education. ADA CERO does not approve or endors individuals courses or instructors, nor does it imply accseptance of credit hoiurs by boards of dentistry.

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12 MEDIA CME – IMpLANT TRIBUNE Dental tribune Middle East & Africa Edition | March-April 2013

buccal bone aspect of the bony ridge19. The rate of residual ridge resorption is related to the time extended since the tooth was re-moved11.

Many factors such as trauma can cause loss of alveolar bone, since many extractions are done with no regard for maintaining the al-veolar bone volume12. With time bone re-sorption will evolve up to 2 mm in verti-cal and 4 mm in horizontal directions the first year following the extraction18. An ar-ticle published by Araujo in 2006, showed that implants placed directly after extrac-tion will not preserve the dimension of the ridge, which results in marginal bone loss21.

It is demonstrated that flap elevation will disturb the thin cellular layer of cells in periosteum which causes more resorption than conservative flapless technique6, this is why it is recommended in socket preser-vation surgeries in order to enhance heal-ing and lower or stabilize bone resorp-tion. On the other hand bone fillers may in-terfere with the earliest stages of alveolar bone healing and it may need several years to be absorbed8, still it can lack resorption9.

It was found that implants placed into grafted sockets expressed a clinical perfor-mance similar to implants placed into non-grafted sites in terms of survival and mar-ginal bone loss. On the other hand, graft-ed sites made the placement of larger im-plants easier and did not required augmen-tation procedures compared to naturally healed sites17.

Another article published by Araujo in

2009, demonstrated that the placement of a biomaterial in an extraction socket will en-hance bone modeling and compensate the marginal ridge contraction20.

As shown in the clinical case, the socket preservation technique led to an esthetic success for several reasons, the absence of gray hue in the free gingiva with the pres-ervation of the interproximal bone between tooth 11 and implant 21. Note the dimen-sion of the preserved bone lead us to place a narrow neck implant in ideal position, the resulting occlusal forces did not cause any overload and conserved an excellent prog-nosis. It was noted that ridge resorption in the mandible is more than the maxilla14. To-day many have investigated that BIC (Bone implant contact) of the natural compared to regenerated bone. Trisi and coll. found that BIC in rough surfaced implants is enhanced with time up to 72%15. Valentini published an article showing that the BIC at the sites grafted with bovine bone fillers is greater than in the nongrafted sites16.

The aim of this article is to focus on the healing patterns of bone after socket pres-ervation techniques with focusing the light on the rationale for preservation of the di-mensions of the extraction sockets.

Conclusion:Loss of teeth due to caries or traumas, of-ten result in hard and soft tissue collapse, therefore the preservation of bone vol-ume is of major importance in order to in-sure the proper implant and esthetic reha-

bilitations. In order to insure the success of implant therapies, a sufficient volume of healthy bone at recipient site at the time of implant placement is mandatory.Today the commonly used method for ridge preservation procedure is a bone graft ma-terial placed in the extraction socket and covered by a cross or non-cross linked membrane followed by complete or par-tial flap closure. The decision to use socket preservation technique should be made on a case-by-case basis. Surgeons should fa-miliarize with the wide array of techniques and materials used in order to optimize and preserve the anatomy of bone and soft tissues. The following article offers infor-mations that can help clinicians to imple-ment the socket preservation technique in their daily practice. In conclusion the sock-et preservation technique seems to show important results concerning bone volume conservation and favorable architecture of the alveolar ridge in order to obtain ideal functional and esthetic prosthesis after im-plant rehabilitations12.

References:1- Cardaropoli G., Araujo M. Dynamic of bone tis-sue formation in tooth exraction sites. An exper-imental study in dogs. J Clin Periodontal. 2003; 30(9): 809-18.2- Araujo M., Linder E. Effect of a xenograft on ear-ly bone formation in extraction sockets: an experi-mental study in dog. Clin Oral Implants Res. 2009; 20(1): 1-6.3- G.Huynh-Ba. Analysis of the socket bone wall di-mensions in the upper maxilla in relation to imme-diate implant placement. Clin Oral Implants Re-

Figure 8: Periapical radiograph showing the resorbed apex of tooth 21. Figure 9: Clinical view after extraction of tooth 21, note the resorbed apex.Figure 10: Intraoral view of the socket of tooth 21 after been filled with porous bovine bone minerals. Figure 11: Periapical radiograph showing the xenograft in place in socket of tooth 21. Figure 12: Temporary crowns prepared in order to guide the healing of the surrounding tissues. Figure 13: Implant in place six months after the healing, the figure shows successful preservation of the ridge and placement of a regular-platform implant. Figure 14: Temporary crowns placed on tooth 11 and a single piece, direct-to-fixture provisional screw-retained restoration on site 21 to guide the healing process.

search 2010; 21(1): 37-42.4- P.J.Boyne. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med. Oral Pathol 1966; 21(6): 805-813.5- J.Pietrokovski and M. Massler. Alveolar ridge re-sorption following tooth extraction. The journal of Prosthetic Dentistry 1967; 17(1): 21-27.6- S.Fickl, O. Zuhr. Tissue alterations after tooth ex-traction with or without surgical trauma: a volu-metric study in the beagle dog. J.of Clin Periodon-tology 2008; 35(4): 356-363.7- Z.Artzi, H.Tal.Porous bovine bone mineral in healing of human extraction sockets: Histochemi-cal observations at 9 months. J. of Periodontology 2001; 72(2): 152-159.8-M.Araujo, E.Linder. The influence of Bio-Oss col-lagen on healing of an extraction socket: an ex-perimental study in dog. Int. J. of Periodontics and Res. Dentistry 2008; 28(2): 123-135.9-A.Mordenfeld, M.Hallman. Histological and his-tomorphometrical analyses of biopsies harvested 11 years after maxillary sinus floor augmentation with deproteinized bovine and autogenous bone. Clin Oral Implants Research 2010; 21(9): 961-970.10-Carlsson GE. Morphological changes of the mandible after extraction and wearing of den-tures. A longitudinal, clinical, and x-ray cephalo-metric study covering 5 years. Odontol Revy 1967; 18(1): 27-54.11-Ulm C, Solar P. Reduction of the compact and cancellous bone substances of the edentulous mandible caused by resorption. Oral Surg Oral Med Oral Pathol 1992; 74(2): 131-6.12-Marcus SE. Tooth retention and tooth loss in the permanent dentition of adults: United states, 1988-1991. J Dent Res 1996; 75: 684-95.13-Zubillaga G. Changes in alveolar bone height and width following post-extraction ridge aug-mentation using a fixed bioabsorbable membrane and demineralized freeze-dried bone osteoinduc-tive graft. J Periodontol 2003; 74(7): 965-75.14-Tallegren A. Changes in adult face height due to aging, wear and loss of teeth and prosthetic treatment. Acta Odontol Scand 1957; 15(24): 73-122.15-Trisi P. Bone-implant contact on machined and dual acid-etched surfaces after 2 months of healing in the human maxilla. J Periodontol 2003; 74(7): 945-56.16-Valentini P. Histological evaluation of Bio-Oss in a 2-stage sinus floor elevation and implanta-tion procedure. A human case report. Clin Oral Im-plants Res 1998; 9(1): 59-64.17- Barone A, Orlando B. A randomized clinical trial to evaluate and compare implants placed in augmented versus non-augmented extrac-tion sockets: 3-year results. J Periodontol. 2012; 83(7):836-46.18-Rothamel, Quintessence 2010; 61(11): 1379-89.19-Lekovic V. Preservation of alveolar bone in ex-traction sockets using bioabsorbable membranes. J Periodontol 1998; 69: 1044-9.20-Araujo MG., Lindhe J. Ridge alterations follow-ing tooth extraction with and without flap eleva-tion: an experimental study in the dog. Clin Oral Implants Res 2009; 20(6): 545-9.21-Araujo MG., Wennstrom JL. Modeling of the buccal and lingual bone walls in fresh extraction sites following implant installation. Clin Oral Im-plants Res 2006; 17: 600-614.

Figure 15: Clinical view showing the healthy soft tissue surrounding the temporary crowns. Figure 16: Ideal biotype of the surrounding soft tissue ready for impres-sion. Figure 17, 18: Impression on the head of the implant simulating the surrounding soft tissues. Figure 19: Clinical presentation of the final esthetic result with the healthy surrounding soft tissues. The clinical crowns conserved the gingival architecture and met the patient’s esthetic demands.

MEDIA CME Self-Instruction Program

How to earn CME Credits? Contact CAPP: events@cappmea.com; +971 43616174

Rabih Abi Nader, DDS, MSc Oral Surg. and Im-plantology, Dipl. Patho.Oral.rader680@hotmail.com

Carine Tabarani, DDS, MSc Oral Surg. and Im-plantology, Dipl. Patho.Oral.ctabarani@hotmail.com

Contact Information

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13MEDIA CME – IMpLANT TRIBUNEDental tribune Middle East & Africa Edition | March-April 2013