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IMPLANT YES OR IMPLANT NO?
Ridge preservation compensates for the buccal bone resorption that occurs when a tooth and associated tooth-bound structures are lost. It aids implant placement and can reduce the need for later bone augmentation. When no implant is scheduled a graft that is resilient to remodelling is recommended to help protect against atrophy. The following sections discuss when to place a biomaterial, what type and why and how the timing of a dental implant restoration can influence the optimal choice.
To prevent bone atrophy the socket should be filled with a slow or non-resorbing porous graft material. Such grafts provide long-term volume preservation of the newly regenerated bone due to the incorporation of particles that are resilient to dissolution or cellular degradation.
Granule and Membrane
If Kometabio processing is available then the tooth can be recycled with its enamel to provide the regenerative and long-term volume preservation needed.
If tooth recycling is not available then granules of xenograft, mineralised allograft or synthetic are available containing hydroxyapatite to provide the non-resorbing element. Powerbone Biphasic (BCP) is ideal as it contains a resorbing Beta TCP fraction fused with a non-resorbing hydroxyapatite (HA) element.
A dental membrane is advised to support and retain the mobile granules. However, the typical collagen membrane will dissolve quickly when exposed and requires a more complex flap procedure to cover it. If using primary closure then Powerbone synthetic membrane or Bionnovation Titanium foil are more resilient and can be tucked inside the soft tissue on either side of the socket. Unlike collagen, Powerbone resorbable synthetic membrane is resilient to salivary proteins. Bionnovation titanium foil is bio-electrically neutral for low biofilm retention and can be removed easily without trauma.
Open healing
More recently advancements in bone graft forms have seen the emergence of self-retentive grafts designed for placement inside three or four-walled sites like a socket. Examples of this are Powerbone Dental Putty, Powerbone Socket Cone Graft and Biphasic Socket Cone Graft (all discussed below).
When self-retentive grafts are used healing will be achieved by secondary intention. Placement of an Ora-Aid film dressing on top will help tissue healing and protect the site from the oral environment. Ora-Aid is a self-sealing film dressing. To ensure protection for the period required we recommended retention by placing a cross suture over but not through the Ora-Aid.
Socket Cone Format – the most convenient option
Biphasic (BCP) is available as an easy-to-place socket-shaped cone graft that is compressible, absorbs blood and does not require a membrane for stabilisation. Simply cover the site with Ora Aid self-adhesive dressing and a cross suture.
Removal of degranulation tissue prior to graft placement will speed up the regenerative process. A Degranulatrion Kit is an effective and inexpensive re-usable tool designed specifically for this purpose.
Implant when?
The key question to determine the graft choice is the timing of dental implant placement.
This could be immediately after extraction, delayed by a few weeks to allow soft tissue healing or as part of a two-stage delayed placement at 4 to 6 months.
Extraction and an Immediate Implant
Extraction includes the loss of tooth-bound structures including bundle bone meaning replacement with an implant does not prevent post-extraction ridge atrophy.
Mind the gap – For these reasons, the implant is placed more buccally than the line of the tooth and new bone is regenerated in the resulting gap so as to bulk out the buccal ridge.
Fully resorbing graft material is recommended to regenerate maximum high-quality new none in contact with the implant surface. A form-stable fully resorbing graft material such as Powerbone Dental Putty is ideal for this application because it can be forced into the space and is sufficiently stable not to require a membrane. Low trauma simple closure is achieved with a sling-type suture around the implant healing cap or tissue former. New bone will be regenerated in 10 -14 weeks and remodelled as loading forces are applied through the implant and adjacent structures.
Removal of degranulation tissue prior to implant and graft placement is important to allow unchallenged bone healing.
Decortication will allow progenitor cells easy access to facilitate early angiogenesis and improve the physical connection between the graft and recipient site. Bionnovation decortication drills are effective, inexpensive reusable tools designed for this purpose.
Extraction and an Immediate Delayed Implant
Delaying implant placement for 3 to 4 weeks allows time for surrounding soft tissue healing which can contribute to a more pleasing aesthetic outcome.
Removal of degranulation tissue prior to graft placement will speed up the regenerative process and allow for inspection of the bony surface to determine if the socket walls are intact.
1. Intact socket walls – no bone defect.
In such cases, a Dense Parasorb Socket Cone can be placed to help the clot and support soft tissue healing. Closure is by secondary intention without additional flaps. Cover the site with Ora Aid self-adhesive dressing and retain this in place with a simple cross suture over the top but not through the Ora-Aid.
Without bone graft – It is important to note that Parasorb and less dense haemostatic sponges do not contain a bone graft.
2. Non-intact socket bone defect – simultaneous implant and graft placement.
Requires a regenerative procedure with a bone graft. A fully resorbing material is recommended to regenerate maximum high-quality new none in contact with the implant surface. A form-stable fully resorbing graft material such as Powerbone Dental Putty is ideal for this application because it can be forced into the space and is sufficiently stable not to require a membrane. Tissue apposition is assisted by a simple cross suture on top of a self-sealing Ora Aid dressing. New bone will be regenerated in 10-14 weeks and remodelled as loading forces are applied through the implant and adjacent structures.
3. Non-intact socket bone defect – delayed implant placement.
Requires a regenerative procedure with a bone graft. A fully resorbing material is recommended to regenerate maximum high-quality new none in contact with the implant surface.
Powerbone Socket Cone Graft is ideal for this indication as it contains the highly effective silicate substituted beta TCP used in Powerbone Dental Putty in a compressible socket cone shape that is easy to apply. Cover the site with Ora Aid self-sealing dressing and retain with a simple cross suture over but not through the Ora-Aid.
Implant placement is typically at 12 to 14 weeks. A more buccal insertion is recommended. Powerbone Dental Putty 0.3cc can be used to inject graft into any remaining bone voids.
Implant Loading
Measuring ISQ (implant stability coefficient) removes doubt about loading an implant in the above indications. PenguinRFA is an easy-to-use tool for this. An ISQ of 70 or highlights an implant with sufficient stability for restorative loading.
READ MORE OR PURCHASE THE PRODUCTS HIGHLIGHTED ABOVE
Powerbone Resorbing Synthetic Membrane
Ora Aid Self adhesive dressing
This blog is taken from a Post Extraction Guidebook available upon request from Regen Store at Restore-Surgical.
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