Clinical Techniques in Periodontics

With Laura Minsk, DMD

Extraction-Site Ridge Preservation

hysiological healing after tooth extraction involves a significant amount of bone and soft-tissue remodeling, which often results in considerable anatomical, functional, and esthetic deformities. These defects can create difficulties in, or even impede, the fabrication of conventional or implant-supported prostheses (Figure 1). Radiographic evaluations of alveolar ridge dimensions have indicated a loss of height and width of the alveolar ridge when bone levels are compared at the time of tooth extraction and then 12 months later.1 The extent and pattern of the resorption is variable, with a progressive loss of ridge contour that results from physiological bone remodeling. Postextraction bone loss is accelerated in the first 6 months, with as much as 40% of alveolar height and 60% of width lost.2 Patients with thin and scalloped periodontium (thin gingival and labial plate) are more susceptible to remodeling and could experience greater vertical and horizontal ridge deficiencies. Larger deficiencies also may be seen when the walls of the socket are missing or mechanically compromised. In the normal sequence of healing after tooth extraction, the socket consists of cortical bone covered by torn periodontal ligaments with a rim of oral epithelium remaining at the
Laura Minsk, DMD
Assistant Professor of Periodontics University of Pennsylvania School of Dental Medicine Philadelphia, Pennsylvania Diplomate American Board of Periodontology Private Practice Limited to Periodontics and Implant Dentistry Media, Pennsylvania

coronal portion. The socket fills with blood, which coagulates to seal the socket from the oral environment. Fibroplasia begins in the first week, with the ingrowth of fibroblasts and capillaries. The epithelium migrates down the socket wall until either reaching a level at which it contacts epithelium from the other side of the socket or it finds a bed of granulation tissue (tissue filled with numerous capillaries and fibroblasts), over which it can continue to migrate.3

uided bone regeneration (GBR) changes the pattern of bone loss after tooth extraction, thereby predictably enhancing alveolar ridge bone quality for dental implant procedures and esthetic restorative dentistry.

Blockage of the epithelial migration into bone defects leads to enhanced regeneration of bone. This is the result of selective cell repopulation of the wound by osteoprogenitor cells and by local concentration of biological growth factors.4 This process, known as guided bone regeneration (GBR), changes the pattern of bone loss after tooth extraction, thereby predictably enhancing alveolar ridge bone quality for dental implant procedures and esthetic restorative dentistry.2,5 GBR involves the use of a cell occlusive membrane to prevent soft-tissue migration into the healing socket and of a bone augmentation material to act as a scaffold for new bone formation. Membrane The role of the barrier is to protect the blood clot, keep the space for new bone formaVol. 26, No. 4

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Figure 2Failing tooth treatment planned for extraction.

Figure 1Anatomical, functional, and esthetic deformity resulting from bone and soft-tissue remodeling after tooth extraction. This patient requires several reconstructive surgical procedures to improve function and esthetics. Figure 3Extraction socket after thorough debridement. Note that a full-thickness gingival flap was reflected with divergent vertical incisions. The interdental papillae were preserved as much as possible. Figure 4Bio-Ossa bovine bone graft particles placed in extraction socket.

Figure 5Bio-Gidea resorbable membrane adapted to fit over the bone graft.

Figure 6Periosteal releasing incisions were made and the gingival flap was coronally advanced to achieve tension-free primary closure.

tion in the socket, and prevent epithelial and connective tissue cells from the gingiva to migrate into the defective area.6,7 If extraction sockets are treated with membranes, they result in significantly greater dimensions of the alveolar ridge compared with sites not treated with a membrane.5 Membranes used for GBR are either nonresorbale (requiring removal) or bioabsorbable. The first membranes used for GBR were nonresorbable expanded polytetrafluoroethylene (ePTFE). They are considered the gold standard with which other barrier membranes are compared. However, the major disadvantage of ePTFE membranes is that they have the potential for exposure in the course of healing and subsequent colonization by oral bacteria. In addition, they necessitate a second surgical procedure for their removal.2
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Bioabsorbable membranes (synthetic polymers, as well as natural biological materials such as collagen and calcium sulfate) have successfully eliminated these problems.2 To be effective and achieve maximum regenerative results, these membranes must remain in place for at least 6 to 8 weeks. Bone Bone graft material is used to maintain the space under the membrane that is necessary for new bone formation. Many graft materials are available, with various biological properties. Most bone graft materials are considered osteoconductive because of their ability to act as a scaffold for new bone formation.8 In some cases, bone grafts are considered to be osteoinductive because they contain growth factors that promote new bone formation. Autogenous bone grafts also may be osteogenic, incorporatVol. 26, No. 4

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Figure 7Implant placed 6 months after tooth extraction.

Figure 8Restored implant. Note the harmony of the ridge and soft-tissue contours.

Figure 9Function and esthetics were restored after implant placement and restoration.

ing vital cells with osteogenic capacity in the bone matrix.9 Technique One of the most important steps in preventing ridge deformities is to avoid tissue loss at the time of tooth removal. Failing teeth should be extracted as soon as possible to avoid additional bone loss, and the appropriate surgical techniques ensure the best possible outcome (Figure 2).

ne of the most important steps in preventing ridge deformities is to avoid tissue loss at the time of tooth removal.

After administering a local anesthetic, start with a sulcular, circular incision around the tooth. Vertical incisions are made on the labial and palatal (or lingual) aspects close to the tooth to be extracted. Care must be taken to preserve the papilla of the adjacent teeth. The incisions should extend apically beyond the mucogingival junction at an angle, providing a wide base and thus maximizing the blood supply to the flap. Full-thickness flaps are reflected on both surfaces to expose the tooth to be extracted.
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The tooth should be extracted with minimal trauma to the remaining bone. Careful luxation and prudent use of burs to section ankylosed or curved roots will help prevent bone loss. After the tooth is extracted, the socket is curetted to remove soft tissue and to expose the alveolar bone lining. Intramarrow penetration (Figure 3) may be done to promote intrasocket bleeding. The bone graft material is moistened with sterile saline or autogenous blood coagulum and delivered to the extraction site. The graft should be packed gently and with care to avoid overpacking, which could hinder revascularization of the site (Figure 4). The membrane is then trimmed and placed over the extraction socket to cover at least 3 mm of the surrounding alveolar ridge. It should fit passively over the existing bone (Figure 5). Periosteal releasing incisions can be made to allow for more movement and tension-free approximation of the gingival flaps over the extraction site. The flaps are sutured in place first with an inverted mattress suture to revert the flaps and ensure good contact between the bleeding surfaces of the flaps, and then with interrupted sutures between the inverted mattress sutures. Finally, interrupted sutures are used to close the vertical releasing incisions. Gentle pressure is then applied to the surgical area with sterile gauze to obtain initial flap adaptation and clot stabilization (Figure 6). Antibiotics and antimicrobial mouthrinses are prescribed postoperatively, with oral analgesics administered as needed. Discussion The only absolute contraindication to GBR is active infection with the presence of purulent
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drainage, swelling, or pain. Suspected infection should be resolved before any regenerative procedures. Membrane exposure is a frequently seen complication after GBR procedures. These flap-management and suturing principles help lessen the risk of membrane exposure but do not eradicate it. Exposed membranes may be maintained infection free with antimicrobial mouthrinses and frequent oral hygiene but have to be removed as soon as possible if infected. Extraction-site ridge preservation gives rise to a new standard of care after tooth extraction. Instead of only eradicating disease, we also are able to restore alveolar form and function. Therefore, we help preserve the maximum height and width of hard and soft tissues. GBR after tooth extraction can help prevent a significant amount of jawbone atrophy that commonly follows tooth loss, and, consequently, we can help create an environment that is more suitable for pontic placement, for a saddle area of a removable partial denture, or for future implant placement (Figures 7 to 9).

References
1. Johnson K. A study of the dimensional changes occurring in the maxilla following tooth extraction. Aust Dent J. 1969;14:241-244. 2. Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol. 1998;69:1044-1049. 3. Hupp JR. Principles of surgery. In: Peterson LJ, Ellis E III, Hupp JR, Tucker NR, eds. Contemporary Oral and Maxillofacial Surgery. St Louis: CV Mosby; 1988:13-26. 4. Caton JG, DeFuria EL, Polson AM, Nyman S. Periodontal regeneration via selective cell repopulation. J Periodontol. 1987;58:546-552. 5. Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol. 1997;68:563-570. 6. Gottlow J. Periodontal regeneration. In: Lang NP, Karring T, eds. Proceedings of the 1st European Workshop on Periodontology. London, United Kingdom: Quintessence; 1994:172-192. 7. Wikesjo UM, Crigger M, Nilveus R, Selvig KA. Early healing events at the dentin-connective tissue interface. Light and transmission electron microscopy observations. J Periodontol. 1991;62:5-14. 8. Schenk RK, Buser D, Hardwick WR, Dahlin C. Healing pattern of bone regeneration in membrane-protected defects: a histologic study in the canine mandible. Int J Oral Maxillofac Implants. 1994;9:13-29. 9. Cushing M. Autogenous red marrow grafts: their potential for induction of osteogenesis. J Periodontol. 1969;40:492-497.

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