Background information
Problem and method of resolution: soft tissue defect after extraction
Dr. Ronald Jung, Prof. Christoph Hämmerle:
«It is quite challenging to replace a single tooth with an implant in an esthetically-critical region.
To achieve optimal esthetic results, any bone or soft tissue defect is unacceptable.
Even though one has a maximum of bone contour available with immediate implantation, the primary wound closure is nevertheless encumbered by the soft tissue defect over the socket. With
early implantation, however, the implant is first inserted a few weeks after the extraction. It is
during this time that the spontaneous healing of the soft tissue wound occurs. The duration of the
healing time influences the degree of thickness formed by the mucosa in the center of the socket.
The biological processes that lead to bone resorption and to a partial or complete loss of bone
lamellae commence immediately after tooth extraction. This again exerts a negative influence on
the hard and soft tissue contour. It is our assessment that one usually cannot prevent the bone loss
that occurs after extraction using Geistlich Bio-Oss® Collagen and soft tissue grafts; nevertheless,
Geistlich Bio-Oss® Collagen does support the graft and the buccal soft tissue and this helps
counteract the loss of soft tissue contour over the resorbing bone lamella. For its part, the graft
closes and protects the fresh extraction wound and leaves a soft tissue arrangement of optimal
thickness and structure for the impending implantation.»
Fig 7 The graft is removed using a scalpel or a sharp
tissue elevator. Bleeding is stopped using compression with sterile gauze, and the wound is covered
with a tissue adhesive.
Fig 8 Using 6 – 8 single button sutures, the graft over
the Geistlich Bio-Oss® Collagen is carefully fixed to
the marginal gingiva of the extracted tooth. Followup treatment: Antibiotics for 4 days (Clamoxyl, 750 mg,
3x/day), analgesics (Ponstan 500 mg) as needed;
tooth cleaning: 2x daily 0.2 % chlorohexidine rinse
for 1 week. No tooth brushing or other mechanical
trauma in the operative area.
Fig 9 During suture removal after 7 – 10 days, one
sees an integrated graft, partially covered with fibri n.
Fig 10 After 7 – 10 days, unremarkable wound situation seen in the gum region.
Fig 11 Clinical situation after 6 weeks. The graft is,
biologically and color-wise, very well integrated and
shows a mature mucosa in the area where the implant will later be inserted. In spite of the lacking
buccal bone lamella, the crestal contour is well preserved.
Fig 12 During implantation after 6 weeks, as expected, no significant amount of bone regeneration has
occurred. Non-integrated Geistlich Bio-Oss® particles that were used to support the soft tissue are
removed. One sees an alveolar defect with a lacking
buccal bone lamella.
2. Aims of the therapy
> At the time of the implant insertion 6 weeks after extraction, there should be an optimal soft
tissue situation with respect to appearance and thickness.
> To promote healing, the blood coagulum should be stabilized.
> The buccal and crestal contours of the soft tissue should be supported and maintained after
extraction.
3. Methods
> Creating a soft tissue arrangement that is optimal in contour, thickness, structure and color over the
extraction sockets using a punched free gingival graft and Geistlich Bio-Oss® Collagen.
> Primary wound closure achieved with a punched, palatal graft.
> Stabilization of the blood coagulum and support of the buccal wall using Geistlich Bio-Oss® Collagen.
4. Surgical procedure
Fig 1 Status after front tooth trauma with a root fracture at 21 and periodontal bone loss interdentally
and buccally at 21.
Fig 2 Gentle extraction of tooth 21. Granulation tissue carefully debrided. Inspection and palpation of
the socket show a lacking buccal bone lamella.
Fig 3 De-epithelialization of the wound margin using
a coarse diamond drill.
Fig 13 After implant insertion in the prostheticallycorrect position, Geistlich Bio-Oss® is placed into
the buccal defect.
Fig 14 The Geistlich Bio-Oss® is covered with a
Geistlich Bio-Gide® membrane, and apically fixed
using 2 Resor-Pins®.
Fig 15 Thanks to the good mucosa quality and the
maintained contour, a relief incision is made in the
periost, and a tension-free wound closure is achieved,
without strongly changing the gingival architecture.
Fig 1 Selection of the punch with suitable diameter.
Fig 5 Application of an amount of Geistlich
Bio-Oss® Collagen that corresponds to the tooth
root.
Fig 6 Independent of whether the buccal bone wall is
present or not, Geistlich Bio-Oss® Collagen is applied
with light stuffing motions until it reaches the height
of the rim of the palatine bone.
Fig 16 After the implant healing phase, a minimallyinvasive abutment connection of implant 21 is made.
Fig 17 Status of the final prosthetic construction of
tooth 11 and of the zirconium oxide abutment at 21.
Fig 18 Prosthetic construction with 2 full ceramic
crowns.
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