1. Extraction Socket Management January 2011 Dr Rory Nolan

2. Background Atraumatic Extraction technique Hands on 1: Atraumatic extraction technique Biomaterials “ Closed” Socket preservation Hands on 2: Socket preservation “ Open” Socket preservation and Ridge augmentation Hands on 3: Ridge augmentation Implant treatment options Summary and conclusions Today’s Plan

5. Socket preservation Ridge preservation Ridge augmentation Guided bone regeneration Site preparation Immediate implant placement Delayed implant placement Root submergence

6. Background Socket preservation after tooth extraction can maintain the alveolar ridge dimensions The whole idea of this is to perform a series of straightforward procedures at the time of extraction that will result in a better site for dental implants, pontics or dentures .....especially for implant therapy where this can allow for aesthetic implant therapy without the need for extensive grafting later on

7. Anatomy Buccal bone - bundle bone poor blood supply thin absent Gingival biotype - thick thin scalloped normal

9. Bone Resorption Extraction of teeth results in resorption of the alveolar process in both a vertical and horizontal direction Different rates of resorption around the mouth More loss of height and width buccally Complicates implant therapy for patients Aesthetic result may be compromised

10. Resorption following extraction 1 Week 2 Weeks 4 Weeks

11. Resorption following extraction 8 Weeks 12 Weeks

12. Does placement of an immediate implant prevent this bone loss? 4 weeks 12 weeks

13. Treatment Strategies Ultimate goal is to preserve as much of the alveolar ridge as possible and prevent resorption of the buccal plate in particular Biomaterials can help prevent this resorption 1. At extraction time - graft materials - graft materials + implant - implant - nothing 2. Wait 4 weeks or 12 weeks - graft materials + implant

15. “ Important to identify the probable and possible short, medium and long term treatment plan prior to treatment planning the extraction socket effectively”

16. Treatment Strategies XLA - 4-6 weeks - Implant placement XLA - 12 weeks - Implant placement XLA + Bone graft - 6-9 months - Implant placement Bone grafting materials need 6-9 months to allow for enough graft replacement and new bone formation - Depends on size of defect and presence of bony walls providing blood supply Collagen materials do not delay implant placement

18. Rule Book! Socket BioType Treatment Options Intact buccal plate Thin Closed/Delayed/Immediate Thick Immediate/Delayed/Closed Buccal dehiscence Thin Closed/Open/Delayed/Immediate Thick Closed/Immediate/Delayed/Open Missing buccal plate Thin Open Thick Open

19. Atraumatic Extraction Technique

21. 1. Pericision Size 15, 15c or 12 blade Separating supracrestal periodontal attachment apparatus Incision can extend into PDL

22. 2. Elevation Periotomes, other... Used mainly mesially and distally avoiding damage or fracture to buccal plate

23. 3. Forceps Delivery Root separation if required Appropriate extraction forceps Modify delivery technique Delivery of all roots......

24. 4. Socket Degranulation !! Often overlooked Remove all soft tissue remnants Bone files, spoon excavators, other Care of maxillary sinus and ID Canal

25. 5. Socket Inspection Bony dehiscence Bony fenestration No soft tissue remnants Buccal wall thickness

26. Hands on 1: Atraumatic extraction technique

28. Clinical scenarios

31. Biomaterials

32. Materials Collagen Membranes Bone grafts Sutures

34. Resorbable Haemostatic Extraction sockets Socket seal Simple use

35. Membranes Resorbable Non-resorbable - rarely used nowadays Resorbable - Collagen (bovine, porcine) - Cross linking - Resorption rates - Memory - Friabilty

36. Type 1 Bovine Collagen Cross linked Zero memory Hydrate 4-6 months resorption Similar to BioGide - Natural collagen - Resorbs quicker

37. Longer resorption times 6-8 months Elastic memory + rigidity Largely removes the need to use non-resorbable membranes - Gortex, EPTFE

38. Bone Grafts Autogenous - Your own bone Allograft - Other human bone Xenograft - Animal bone Alloplast - Synthetic bone substitute Donor site availability Resorption rates Moral issues

39. Bovine bone Porous mineralised bone matrix No organic component Very similar to BioOss Particle size 0.2-0.5 microns 1.0-2.0 microns Generally use the smaller size except for sinus grafting

40. Bio-Oss® Human Bone NuOss™

41. New Vital Bone (red) NuOss (tan)

43. Closed Socket Preservation

44. Collaplug Technique Allow stabilisation of blood clot Can also prevent a ridge with hard tissue defect from collapsing in the short term

45. “ Closed” Socket Preservation Intact socket walls Collagen seal technique Delays implant placement by 6-9 months

46. “ Closed” Socket Preservation Buccal dehiscence Ice-cream cone technique Delays implant placement by 6-9 months

48. Socket Preservation

49. Socket Preservation

50. Socket Preservation

51. Hands on 2: Closed socket preservation

53. Open Socket Preservation + Ridge Augmentation

54. “ Open” Socket Preservation Ridge Augmentation Extensive buccal wall defect Extensive infection

55. Ridge Augmentation

56. Ridge Augmentation

57. Ridge Augmentation

58. Ridge Augmentation

59. Ridge Perforation

60. Cortical Perforation

61. Periosteal Incision

62. Hands on 3: Open socket preservation + Ridge Augmentation

64. Alternatives Implants, etc

65. Implant Timing Options Type 1: Immediate implant placement Type 2: Early delayed implant placement Type 3: Late delayed implant placement Type 4: Healed ridge

67. Delayed implant placement

68. Delayed implant placement

69. Delayed implant placement

70. Delayed implant placement

71. Root Submergence

72. Orthodontic Extrusion Consider extrusion of teeth with vertical bone defects Even teeth that are due for extraction Predictable method of vertical augmentation Aesthetic demand Sectional fixed appliance 3-6 months active treatment followed by 3 months retention

73. Considerations + Summary

75. Post-Op Regimen Gauze pack + Ice pack Analgesia - Paracetamol 500mg x2 QDS - Ibuprofen 400mg TDS - Difene 50mg TDS - Tylex 30/500mg x2 QDS Antibiotics ?? - Augmentin 375mg BD - Metronidazole 200mg TDS Chlorhexidine 0.2% QDS Warm salty mouthrinse additionally as required Diet instructions Suture removal 7-14 days ....

78. Thank you for your time www.nidm.ie