Dental Tribune Middle East & Africa Edition

rounding tissues (Figure 5,6,7). It was demonstrated that following tooth extraction the buccal bone plate will un- dergo some modifications due to bone re- modeling1 . In order to reduce the bone loss, several surgical techniques have been pro- posed. Nowadays it is still possible to min- imize osseous deformities problems by car- rying out the ridge preservation techniques in extraction sockets and using bone fillers materials with barrier membranes13 . Today the advanced wide range of bone grafting materials and collagen membranes guides us into taking in charge many compro- mised cases. It was noted that the resorption of bone ridge is faster during the first six months following extraction5 , therefore a conser- vative approach remains necessary. Many measures should be taken into consider- ation when conducting the socket preser- vation surgery such as: reducing the ex- traction trauma and limiting the flap eleva- tion6 . It was found histologically that bone formation occurs over the surface of the im- planted osteoconductive graft fillers7 . This article goes through the technical basis for socket preservation procedure and ex- poses its importance as an available treat- ment in order to prevent ridge atrophy and optimize esthetics in the anterior maxillary area. Clinical Case: A 49 -year-old female with a noncontribu- tory medical history, presented to our clin- ic with a mobile tooth 21 and an apical re- sorption, the chief complaint was pressure in the upper anterior left area of the cen- tral incisor. Clinical examination showed tooth 21 mobile with gray coloration. Peri- apical radiograph examination revealed an apical resorption with an imcomplete end- odontic treatment (Figure 8). The tooth was deemed hopeless and referred for extrac- tion with socket preservation for future dental implant placement. After tooth was carefully removed with forceps technique (Figure 9), the extraction site was grafted with an osteoconductive bone graft (Figure 10, 11). A resorbable col- lagen membrane was placed on the buccal aspect of the extraction socket and sutured to the palatal flap to attempt a primary clo- sure, with an exposed membrane left at the occlusal aspect of the extraction socket. A Temporary bridge was placed to guide the healing process and conserve the es- thetic in the anterior region (Figure 12). Af- ter six months surgical re-entry during im- plant placement showed a good bony heal- ing, that allowed the placement of a regu- lar platform implant within the bony enve- lope (Figure 13), and achieved a good pri- mary stability that allowed the placement of single piece, direct-to-fixture provision- al screw-retained restoration on site 21 in order to guide the healing process (Figure 14,15,16). A period of three months elapsed to permit osseointegration, afterwards the patient present for final impression (Figure 17,18), it was noted that the long axis of the im- plant correlated to the central fossa of the expected final restoration (Figure 19). The final restoration showed an ideal esthetic restoration with healthy surrounding soft tissues. Discussion: The failure to preserving the anatomy of hard and soft tissues will result in esthetic failures and compromises the final results. Araujo mentioned in a paper published in 2009, the use of xenograft in socket pres- ervation techniques will delay the socket healing but will help at the same time to conserving the anatomy2 . Xenografts are considered the most used bone fillers in the socket preservation procedures due to their osteoconductive matrix framework which enhances the growth of new bone around it, as their name suggests2 . Following tooth extraction the buccal plate formed especial- ly by bundle bone will experience more re- sorption than lingual and palatal ones3,10 , and is considered the first to be absorbed4 . Loss of vertical ridge height will also occur less than the horizontal one, reducing the Socket preservation in the daily practice: A clinical case report Figure 1: Preoperative situation, note the unaligned incisive edge of tooth 21 with the grey cervical lining. Figure 2: Clinical view showing a complete horizontal fracture of the crown of tooth 21. Figure 3: After conservative extraction of tooth 21, collagen membrane is placed inside the bony envelope. Note the intact socket bone walls. Figure 4: Xenograft (Bio os®) is placed inside the socket and covered by a collagen membrane sutured to the palatal flap and intentionally left exposed so as not to create a mucosal defect from flap advancement. Figure 5: A temporary Maryland bridge is prepared in order to guide the healing of soft tissues and enhance the esthetics in anterior maxillary region. Figure 6: Temporary Maryland Bridge in place to guide the healing process of socket 21. Figure 7: Three weeks postoperatively by Dr. Rabih Abi Nader & Dr. Carine Tabarani S oft tissue contour depends on the underlying bone anatomy, follow- ing tooth extraction, sockets under- goes a remodeling process that in- fluences the implant rehabilitation treat- ment of the edentulous areas. Socket preservation procedure following tooth extraction will reduce the need for any further ridge augmentation technique prior to implant placement and will con- serve the existing bone. The aim is to pre- serve the original bone dimensional con- tours by limiting the normal post extrac- tion resorptive process8. The overall goal of this article is to provide the dental professional with valid tools in order to help them make a conscious de- cision considering the indications of this therapy and dependent on each clinical case. Keywords: Extraction, socket preservation, implant, resorption process. 1- Private practice Oral Surgery, Implantolo- gy, Oral Medicine, Dubai Sky Clinic, Dubai, U.A.E. 2- Senior lecturer, Oral Surgery department, Saint- Joseph University Faculty of Dental Medicine, Beirut, Lebanon. Private practice Oral Surgery, Implantology, Oral Medicine, French Dental Center, Abu Dhabi, U.A.E. Nowadays the outcome of implant surgery is measured by the long-term esthetic and functional success and not by the survival rate. A correlation exists between the hard and soft tissues in order to assure esthet- ic outcomes in implant surgery. Significant changes in bone volume and morphology following tooth extraction, can make im- plant rehabilitation very difficult, as the time from extraction to implant placement increases. Bone substitute in alveolar ridge preser- vation and prevention of additional bone grafting is highly supported and has a wide range of advantages. The socket preserva- tion technique allows the placement of im- plants in sites that was considered compro- mised in the past. Following the conserva- tive extraction (Figure 1,2), a bone filler is placed in the empty socket with a cross or non-cross linked membrane (Figure 3) and closed partially(Figure 4) or totally by a flap adding stitches, note that a provisional preparation is sometimes mandatory in or- der to guide the healing process of the sur- Centre for Advanced Professional Practices (CAPP)is an ADA CERP Recognized Provid- er. ADA CERP is a service of the American Dental Assotiation to assist dental profession- als in identifying quality providers of continue dental education. ADA CERO does not approve or endors individuals courses or instructors, nor does it imply accseptance of credit hoiurs by boards of dentistry. 2 Hours Fig. 1 Fig. 3 Fig. 5 Fig. 6 Fig. 7 Fig. 4 Fig. 2 12 MEDIA CME – IMpLANT TRIBUNE Dental tribune Middle East & Africa Edition | March-April 2013