The socket of a tooth is often not fully surrounded by bone and every damaged socket presents with a unique set of challenges. Different types of damage require different decisions to be made to regenerate the lost bone and support an implant for a lifetime.
Socket grafting is becoming one of the most complex bone grafting procedures dentists perform and the more knowledge we acquire, the higher the success rates for our implants. The following case presented several challenges that required on-the-spot decisions to achieve long term success of the bone graft and implant.
Grafting Severely Damaged Sockets
7/21/2017
This patient presented with significant dental disease throughout his mouth that required the dentist to prioritize treatment. Both bicuspids presented with significant disease. The first bicuspid (#21) presents with an acute lesion but because the second bicuspid supported a functioning bridge, the patient wanted this maintained while other disease was treated. The first bicuspid was scheduled for extraction, grafting, and a dental implant.
7/21/2017
Atraumatic extraction of the first bicuspid was performed with sectioning the root and collapsing the root sections inside the socket. The root of the first bicuspid had been moved distally by the chronic infection and the distal wall of the socket was missing. In addition, the buccal wall was completely missing except for a small bony ridge at the crest.
07/21/2017
After sectioning the root, it is separated with a small elevator and the sections of the root are collapsed into the socket.
7/21/2017
The root fragments are removed without force.
7/21/2017
This granulation tissue exerted hydraulic force on the mesial root of the bicuspid and pushed the root of the first bicuspid into the second bicuspid destroying the distal wall of the socket.
7/21/2017
This shows how an atraumatic extraction allowed maintenance of the thin buccal strand of bone and the missing mesial wall of the socket.
Using Socket Graft Plus
When a portion of the socket wall is damaged, the graft material must be able to maintain shape until converted into bone. The crest and the area of the missing buccal wall need to resist pressure for weeks until bone cells can migrate into the bone graft and convert it into bone. The only current material able to maintain shape when walls are missing are granules. The granules are designed so they are not resorbed by any other cell than osteoclasts.
Because osteoclasts only exist in bone, the granules stay in the site until the area is converted into bone and then the resorption of the granules begins. Since Socket Graft Plus is composed of 50% βTCP granules and 50% Socket Graft, the bone cells grow throughout the putty and convert it into bone before the granules are resorbed.
7/21/2017
While frozen, the Socket Graft Plus petals are placed into the socket and begin to thaw immediately. In a severely infected socket, bleeding is inevitable during gentle graft condensation, as shown in this photo.
7/21/2017
Use the tip of a moist cotton roll to absorb the blood and set the graft material simultaneously as you continue to gently condense the graft material in the socket.
7/21/2017
After drying, continue condensing Socket Graft Plus into the socket.
7/21/2017
After using the moist cotton roll, the graft material and blood flow is controlled as shown in this photo. With the buccal wall missing, it is necessary to apply finger pressure on the mucosa to contain the graft material when gently condensing the graft material. Applying excessive force to reshape the graft material after packing can damage the mucosa. The graft should slightly overfill the extracted socket upon completion.
7/21/2017
A non-resorbable membrane is used to cover the graft site. In this case, since the majority of the buccal wall was missing, the membrane is cut to be long enough to reach the buccal apex of the bony defect.
7/21/2017
The membrane is in place and sutured. The buccal flap was dissected to allow for placement of the membrane over the graft in the buccal apex region. Suturing too tight will move the buccal keratinized gingiva to the lingual, resulting with no keratinized gingiva on the buccal of the future implant.
7/21/2017
After suturing, Oral Bond is applied. Oral Bond adhesive will both secure the membrane in place and bond the sutures, keeping them in place. In addition, the exposed membrane is permeable to oral fluids which have been found to compromise crestal bone growth. Superior bone growth has been found when the membrane is sealed with an adhesive.
7/21/2017
This post-operative radiograph shows the graft in place. There appears to be endo-cement on the mesial root of the second bicuspid.
8/2/2017
Two weeks after extraction and grafting, the sutures have been lost but the membrane and tissues are still secured by Oral Bond. The site is covered with bacteria. However, because the membrane has been sealed with adhesive, no toxins from the bacteria are able to enter the graft.
8/2/2017
At 2 weeks, the graft is consolidating; the apical portion of the graft material is being converted into bone but the crestal graft material is not yet mineralized. Also, note the radiolucency on the mesial of the second bicuspid. There appears to be residual foreign material on the mesial of this tooth that is inhibiting bone formation. However, bone is forming around this area so the lesion will be monitored and the bridge maintained until other lesions in the patient’s mouth are treated.
8/17/2017
4 weeks Post-Op
8/17/2017
The membrane is removed at 4 weeks, showing good ridge maintenance and healthy connective tissue.
8/17/2017
At 4 weeks, mineralization is continuing toward the crest and is within a few millimeters of the crest. In this radiograph, the radiolucency mesial to the second bicuspid appears to be reduced.
8/31/2017
At 6 weeks, the graft is nearing complete mineralization except for the last few millimeters at the crest. The patient is scheduled for implant placement 3 months after extraction and grafting.
10/20/2017
3 months after extraction and grafting, a broad ridge is maintained with slight loss of buccal and lingual width.
10/20/2017
3 months, radiograph of grafted site.
10/20/2017
After reflecting the flap, the ridge appears to be fully regenerated. It appears that much of the loss of ridge width was due to shrinkage of the gingiva caused by placement of the membrane.
10/20/2017
As expected, the small bridge of bone at the crest was resorbed. The boundaries of the old bone and the regenerated new bone are indicated by the arrows.
10/20/2017
Implant placement at 3 months.
In cases of severe bone loss like this case, we advise waiting 4 months to ensure adequate mineralization for implant placement.
Socket Graft Plus is our best performing bone graft material when repairing severe bone loss and for ridge augmentation. A dentist new to bone grafting is advised to use Socket Graft Plus for all grafting situations.
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American Society for Bone and Mineral Research (ASBMR)
Tissue Engineering and Regenerative Medicine International Society (TERMIS)