Preserve Bone at Extraction Site: What are the Best Approaches?

This question is bound to get many different solutions as it is a broad one but it depends on the presence of the buccal plate , whether there is acute infective issues and patient risk factors etc. But I think essentially youare asking about socket grafting and here again there will be many views . I used to never graft sockets using the theory that a clot and the body is best . But a number of years ago saw the work on socket grafting at the Uni of Zurich and have since been a convert and show some great cases of the value of this procedure. As for material I only use synthetic and here Easygraft ( Degradable solutions ) is ideal as the pol-lactide coated particles are held together by a bacterio-static bio-linker making the graft stable and thus you do not need closure for even up to 3 weeks. The graft material will not be lost and the soft tissue will granulate over the site. ( oddly just this minute taken some sutures out after a week and there is still no closure and the graft is intact.) Just an idea and if there is substatial granulation material in the socket I currette out but leave attached at one site then gaft the socket and place the granulation tissue back over the grafted site to improve healing of the soft tissues. Benefits of grafting are retention of bone width , prevention of food entering the socket , reduced soft tissue ingrowth into the socket and we have noticed reduced post-op pain. Then palce the implant at 3 to 4 months dependant on patient physiology. Peter

You can use DentoGen, which is calcium sulfate based bone graft. Since it has barrier properties as well, you do not even need a barrier on top of it. Only place a suture to hold it in place.

Dear Dr. S thanks for your reply. DO you use dentogen as a sole grafting material. As being calcium sulfate hemihydrate some reviews says it resorbs fairly quickly and can lead to some volume loss. what your clinical experience as I havnt used it. Regards

I starting socket preservation about 5 years ago, and do it routinely now for "STRATEGIC" locations. Obviously areas where an implant is to be placed in the near future or areas where an ovate pontic is desirable; if a bridge is being planned. The product depends on whether an implant is chosen over a bridge and how soon an implant is planned. I use Bio-Oss collagen[OSTEOHEALTH-Bovine bone with collagen coating] with Bio-Gide membrane [OSTEOHEALTH-porcine collagen membrane] and passive suturing, if an implant is planned in next 3-4 months. Post-op healing is beautiful and buccal bone stays nice and high and wide too. Is expensive though. For an ovate pontic design and where a good buccal bone volume is desired, an inexpensive synthetic product like Osteograf LD/300 from Dentsply should work fine. Usually a membrane is not required and results are good. Although will take upto an year for the body to replace it with natural bone though. I think MIS Implants came out with something new last month. So many out there, same basic principles though. One note: I don't augment where active granulation tissue is present or bone is too infected. Here, chances of graft resorption/loss are high.

Dr. B If I can place an immediate implant and I know I will get the same bone and tissue health as a delayed implant then I place the implant immediately. As a result I am currently only placing immediate implants in bicuspid and single rooted teeth. Whether I place an implant in the extraction socket or not in both instances I graft with Socket Graft and cover with Socket Seal. If it is in the esthetic zone I will place an immediate implant with abutment and graft the defects with Socket Graft before I cement the temporary. Because Socket Graft is quickly resorbed and stimulates osteogenesis delayed implants are placed 2 months after extraction. As for full disclosure I own the company that makes Socket Graft. If you are interested in more information Google Socket Graft. Greg Steiner Steiner laboratories

The use of regenerative materials in socket preservation, or where a defect is present, socket grafting, largely depend on the risk factors presenting. These might include site location (aesthetic zone), soft tissue biotype, presence of bone defect, treatment plan time scales, implant or bridge etc. A barrier membrane would be indicated only where a bone defects was present (principle of GBR). If the extraction is artraumatic and no defect then a membrane should not be needed. The choice of regenerative materials would lie with patient preference (consent ie animal, human synthetic), surgeon preference (same + experience), resorption profile (time) and application ease (ie a setting material stays in site). If an implant is planned according to the immediate delayed principle (>3 months) then fully resorbing material such as bTCP, (Easygraft, Cerasorb etc) or bTCP in combination with Calcium Sulphate (Fortoss VITAL,) is appropriate. Where a bridge is planned then a non resorbable material such as HA (ie, Bio-Oss) may be more appropriate. A fully resorbing regenerative material could again be indicated at the time of placement where a "gap" above c1.5mm exists assuming the implant is placed more palatal than the original tooth root

the best way is to put allograft particles(puros or FDBA)TO FILL2/3 of the alveolus height and collaplug in the 1/3 and X suture and implant after 5 months.

I agree that this question will receive different answers based on individual preferences of the surgeon. if the extraction site has no defects and the labial plate is intact then applying a bone substitute material should be straight forward. personally i use RTR from septodent which is B-TCP material that resorbs within six months. The material is supplied in a plastic syringe which makes it very easy to deliver the material directly to the socket. i usually cover the graft with collaplug from zimmer dental which is an absorbable collagen wound dressing. If the labial plate is defective i use socket repair membrane also from zimmer dental. i place this inside the socket and then pack the bone against the membrane.The membrane is pre shaped so it is easily applied to socket. other membranes that i have used is the cytoplast PTFE membrane from oraltronics. this membrane is non resorbable but has the advantage that it can be left exposed in the oral cavity so it is ideal for cases when primary tension free closure is not possible.

Dear Dr. Peter Fairbiarn, many thanks for valuable info. I just wanted to know what form easygraft comes in like putty, granules and does it stabilize without even a collagen plug. if you are unable to achieve closure do you do criscross sutures. thanks Behzad

Dear Dr. Peter Fairbiarn also do you use easygraft crystal or classic thanks

Hi Dr B I prefer the Classic when placing an Implant into it, as there is no HA component thus all the graft material will bio-absorb returning the site to host bone only , thus what you see radiographically is bone. There are 2 particle sizes 150 and 400 but generally in the molar sites where socket grafting is most utilized we us ethe 400 . The particles are held together as the BTcp is coated with a Poly-lactide and when the Bio-linker is mixed in ( "2 syringe system)it becomes sticky when exposed to blood or saliva. You then pack the material with a plugger into the socket and compact it with a damp gauze (Saline). In a minute the material will be every hard to the touch and you can suture possible with cross suturing but closure will not be possible and is NOT important. Often when the patient comes back for the suture removal a week later the site will still be open again do not worry it will granulate over and the material will not be lost. I usually place at 4 months and load 4 months later. Crystal has HA and thus is best for sites where you may be not placing an implant but is a pontic arae for a bridge . Regards Peter

Peter is correct. I myself mix Osteogen with PRP when I can. If not Osteogen w/ saline is ok, but it has to be a thick mix. The keys to success are: undisturbed graft material, more walls the better for the defect, supply of marrow blood and cover with a resorbable membrane. Do not place a nonresorbable graft material in any site where you want to place an implant. The non resorbables are great fillers and space maintainers. Always follow the KISS principles.

Dear peter fairbairn many thanks for taking time out and such useful information thanks ben

Dear peter fairbairn another quick question did you ever used easygraft for GBR? if so does it require membrane? many thanks Ben

Hi Dr B , yes you can but always start on smaller defects to begin with I have shown many cases around the world and have not used a membrane for about 7 years ( Over 800 sucessful cases )as it impedes the blood supply to the graft site . But there technique sensitivities and as it is not cell occlusive although hard and stable for 3 weeeks until the poly-lactide breaks down, thus I coat it with CaSo4 to improve initial cell occlusion. Regards Peter

Another technique that has not been discussed is the use of l-prf plugs to fill the extraction socket. L-prf will promote quick epithelialization of the extraction site, and turn over into bone. The procedure is simple, inexpensive, can be done in place of a bone graft and collagen membrane and will become more widely used as we learn more about its benefits.

The main problem is that if u use a quickly resorbable material such as collagen or calcium sulfate, u will get major resorption if u do not place an implant at about 3 months later. On the other hand if u use a slowly resorbable material such as BioOss and u enter at 5 or 6 months you will get no initial implant stability and u probably won't get osseointegration. You will have to enter at about 8-9 months to be sure. Plus u need to use some barrier material and that skyrockets the cost. I have been recently using an innovative material, Novabone putty that shows great potential in maintaining the sockets size after 5-6 months and i always seem to get excellent implant primary stability even for immediate loading after waiting for about 5 months. Plus due to its unique putty consistency there is no need for any barrier material since it doesnt not undergo water mediated solution. Hope i helped.Gd luck

Dear Dr B, To preserve bone in the socket and cause it to grow back healthily, you can try screwing in a mini-implant into the socket immediately after extraction. In the aesthetic zone, you can composite on a temporary crown or leave it be in a non-aesthetic zone. And Wolff's Law of Bone Maintenance/Transformation will take over. Very often, you will find "bone climbing up the implant", tsk!, and the socket bone will be not only be preserved but the alveolar bone height will be also maintained... and...... healthy cortical bone forms around its neck. You are kidding!?! I am not totally sure myself because none of my patients has let me open a flap and check around the minis to date. But the before/after xrays seem to display the same phenomenon over and over again. Check them out.

please disregard the previous message... typos Thoughts on GBR post ext…..my most sincere opioion; constuctive, as this is my thinking for this forum...provideing that you receive this bottle 1. dont let the pt push you, you only want the best for your pt 2. wait if you can, this might piss a lot of dds off, but it will make your life a lot better. 3. Bio-oss (I do not and do not have any financial interests in Swiss). It has probabily the most literature support and works best in my hand). Do Bio-oss 4. When I first started ” I know I sound like your grandfather” I would wait 4 mos, but use your judgement, the larger the defect, the longer you wait. Else you will be drilling into a pile of bone powder at the time of your implant surgery. 6mos is beautiful for most moderate size GBR 5. Try Bio-oss collagen out, and post your thoughs to let us know. I know because we have try it many times, let me know how it feels when you curettage the previous GBR site prior to implant….. a little soft, granulation tissue like…. I like Bio-oss and Bio-gide but have little hessitance regarding …. 6. Not a big fan of immediated ext and placement of implant for posterior teeth. A lot of literature support for this idea, but all we are asking for is a good night of sleep. Bone remodelling may not be as simple as we think due to pt individualization. Play safe may not be a bad idea…. explain to the pt, we are sure they will understand.