Socket Preservation - A Case Report

Keywords

Socket Preservation; Demineralized Freeze Dried Bone Allograft; Periocol Membrane.

Introduction

Each time a tooth is lost due to caries or any other cause; there are morphological and dimensional changes in the alveolar bone surrounding that region. These changes are observed both in the vertical and horizontal directions [1]. Bone remodelling takes place in the initial 3-6 months after the tooth is extracted [2]. This is a critical phase wherein maximum dimensional changes are expected. Therefore, preservation of the alveolar socket post extracting the tooth plays an important role in preventing the dimensional changes. This further impacts the placement of implant in that region without compromising the implant dimensions hence resulting in long-term success of the implant. If the socket is compressed after tooth extraction, there may be severe bone defects near the socket, which will hamper the further prosthetic rehabilitation of that area.

Case Report

A 23-year-old male patient reported to the department with a complaint of a fractured tooth in the lower right back region of the jaw. The patient was systemically healthy. He gave a history of root canal treatment in relation to the same tooth. On clinical examination it was found that there was insufficient crown height (FIG 1). The patient was advised a CBCT scan from another department to evaluate the cause of pain, which revealed a fracture line along with some periapical pathology in relation to tooth number 46 (FIG 2a,2b). The treatment plan comprising of an atraumatic tooth extraction by hemisectioning the tooth, followed by socket preservation with demineralized freeze dried bone allograft and PerioCol membrane, was discussed with the patient. An informed consent was obtained from the patient followed by scaling and root planing 2 weeks prior to the procedure. On the day of the procedure local anesthesia (2% lignocaine with 1:80,000 adrenaline) was administered to the patient. A full thickness mucoperiosteal flap was reflected beyond the mucogingival junction and the tooth was hemisectioned with the help of an airotor and a straight diamond bur (FIG 3). A radiograph was taken to evaluate whether or not the vertical groove of hemisection has reached the furcation of the tooth (FIG 4). Once the desired depth of hemisection was attained, Periotomes were used for extracting the tooth atraumatically while simultaneously preserving the inter-radicular bone. Curettage of the extraction socket was done using a spoon excavator and the socket was rinsed with sterile saline(FIG 5). PerioCol membrane was adapted around the socket after which demineralized freeze dried bone allograft (500-1000 micron particle size) was used to graft the socket upto an extent such that the membrane would not collapse into the socket (FIG 6). The flap was then coronally advanced and sutured using interrupted sutures to attain maximum closure (FIG 7). The entire procedure was performed under antibiotic coverage (Amoxicillin 500mg) post-operative medication comprising of Cap. Amox 500 TDS for 5 days , Metronidazole 400 mg TDS for 5 days and Ibuprofen 400 mg BID for 3 days were prescribed. Suture removal was done after 2 weeks. After 1 month the patient was recalled and evaluated for healing which was satisfactory. Patient was recalled after 3 months for clinical and CBCT scan to evaluate the bone fill. On CBCT evaluation it was seen that there was minimum amount of radiolucency at the grafted site (FIG 9a, 9b). Clinical examination of the surgical site showed complete soft tissue healing (FIG 8).

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Figure 1:

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Figure 1-9.

Discussion

Studies have quoted the use of guided bone regeneration techniques in socket preservations gives better results, especially when a membrane is used [3]. In this case a socket preservation was done along with raising a full thickness mucoperiosteal flap, there are certain known disadvantaged of raising a flap during socket preservation as there is difficulty in attaining primary closure along with increased tension in the flap and reduction of vestibular depth. To overcome these drawbacks newer techniques are used which are more conservative as a flap reflection is not required [4, 5]. The grafting material should be biocompatible, osteoconductive and osteoinductive [6]. Xenografts and alloplasts with or without a membrane have shown adequate results for socket preservation. Few studies have also used a combination of allografts; however, there are negligible differences in changes to alveolar ridge dimensions when comparing DFDBA to combination allografts [7]. DFDBA has been extensively used in periodontal treatment and has proven to be safe, and it induces the formation of new bone. DFDBA is both osteoconductive and osteoinductive in nature. Use of DFDBA has been used in several animal studies and has proven that it could stimulate the formation of new bone by osteoinduction. DFDBA also acts as a scaffold for osteoconduction [8]. Among all the available membranes, collagen membrane was preferred as it has a high biocompatibility and haemostatic activity that facilitates clot formation and stabilizes the wound. Collagen has a high chemotactic function for fibroblasts. This promotes cell migration, and primary wound coverage [9]. In this case the ridge dimensions were preserved because of the use of DFDBA and PerioCol membrane for a better outcome.

Conclusion

Socket preservation done with the help of guided bone regeneration technique can minimize bone resorption and aid in further placement of implants.