Atraumatic extraction and clot preservation with PTFE: Thoughts?

If the socket is intact, free from pathosis and bone quality is good to provide good fixation, there is no reason why you cannot place the implant immediately. In the anterior esthetic zone, early placement (at 4-8 weeks), rather than immediate placement seems to be the better choice to provide more soft tissue volume and coverage. Esthetic failure of immediate placement is possible due to unpredictable bone healing. If you are doing an immediate or early placement, grafting an intact socket with or without a membrane is not necessary and may interfere with the normal healing process. Socket preservation with graft and membrane is only indicated if the walls are missing or horizontal defects of greater than 2 mm is present. Dr Fairbairn may disagree with the use of membrane but I find that healing under the membrane is more predictable, in my hands. In your case, the patient has thick biotype and your use of membrane/ graft is unnecessary and has complicated the treatment process. The membrane should be removed to allow normal healing.

Dr.Chan am I correctly understand you,what in uneventful exraction, when all plates are intact,Its optimal to use membrane only-PTFE(without graft) to predict optimal healing of socket and clot conservation on purpose of early (6 weeks) implant placement.. Thanks

In this case I did use membrane only...

The two most common ways to treat a case like this is immediate placement, as Dr. Chan stated, or immediate delayed placement, where you wait only for soft tissue closure approximately 3 to 4 weeks, and then place the implant. The literature supports immediate placement as one method that preserves the most bone. Proponents of the immediate delayed method like the fact that the implant heals fully submerged (covered) and they have more soft tissue to play with. I believe both are acceptable and choose on a case by case. In your case if you wanted to do the implant in 4 weeks, you did not need the membrane. Nice case. Thanks for sharing.

Dr.Carlos I just want understand is it correct to use membrane only for clot conservation without graft ??

Hi Dr Chan , you may have slightly misundertood what I have said ,as we know the use of a membrane to stablaize a particulate graft and prevent soft tissue ingrowth is critical . All the research ( Buser, Jung , Schenk etc ) backs this up and when using Bio-Oss the use of a double bio-Guide is advocated for this reason or you possibly would have merely some bovine HA in Fibrous tissue . When I say membrane free it is because the graft materials that I have used over the last 9 years have properties ( CaSo4 ) that make them both stable and soft tissue cell occlusive , hence the graft is its own membrane for the critical initial 3 to 4 week period . This is where a traditional membrane ( collagen ) may impede healing by excluding the critical Periosteal ( more than 85% of blood supply to the bone and our defect site ) blood supply hence reduce the healing of the site . We are currently doing some extensive research ( at an Eminent Eu university MFOS Dept )to show this . But all the work I have done shows this to be the case when restoring big buccal defects . I have extensive case research using Core samples , Osstell readings , Scans etc to help shows this ( over 1,000 cases mostly well documented ). We are merely helping the body to heal and hence the fewer foriegn materials we put in the better. As to the Carlos comment , I agree I place 90% of my implants at the 3 week delayed period to get some soft tissue closure and before the modelling of the residual bone. Again we always place the implant if it has been possible to attain primary stability , as the Implant is the "gold " Standard graft material as we will need it there to attach the crown , it stabalises the surrounding graft and upregulates the host response to regenerate bone ( semi-conductive ). So that is the way I would do it and load at 10 weeks even with a big defect , if you break a leg you do not put bovine bone in and tell the patient he needs to stay in traction for 6 months the body wants to Heal and the patients want teeth. Regards Peter

Hi David sorry ,just so often there is that small understanding , Yes materials are a mixture of CaSo4 and BTcP with a negative Zeta Potential ( Vital ) but can do cases with Bond Bone and whatever particultes you like . Oddly many years ago it was literally not done to place Implants at the same time as augmenting sinuses , but now it is routine and we do it with only 1mm of residual bone . Materials and techniques do advance hopefully for the benefit of both us and our patients. Kind Regards Peter

Two-implant insertion only does not give neither cosmetic nor functional benefits for the patient. The upper prosthesis is supposed to be removable.

Dr R. In response to your question: "Dr.Carlos I just want understand is it correct to use membrane only for clot conservation without graft ??" I did not say it is correct to use a membrane for clot conservation. The proper use of a membrane was clearly stated by Peter to be to stabilize a particulate graft and prevent soft tissue growth where you want the slower growing bone to grow. By using a membrane alone you do prevent the soft tissue ingrowth but depending on the amount of time you wait for implant placement, you may loose more bone than if you had placed a particulate graft in the socket. That is why I mentioned the delayed immediate placement which minimizes the bone loss. I hope this clarifies what I said.

You asked why the socket does not just fill with bone. The reason is because when a tooth is removed and not grafted the bone lining the extraction socket dies(blood clot or no blood clot). Dead bone never heals. It is either resorbed or expelled. So if you have thick buccal bone you will have trabecular bone between the socket wall and the buccal cortical plate. The trabecular bone is the source of osteoclasts that remove the dead socket wall and the osteoblasts that regenerate the lost bone. If the buccal bone is thin there is only cortical bone with no trabecular bone and therefore no osteoclasts or osteoblasts for repair and you will lose the entire buccal wall of the alveolus. I graft all sockets but never raise the gingiva to place a membrane because you are just causing more trauma, inflammation and therefore more resorption. I place a seal in the extraction socket orifice to isolate the socket graft which does not traumatize the buccal bone and compromise its blood supply. Excuse me for being picky but socket preservation is a misnomer. The socket is the hole in the bone and we are not trying to preserve it. Greg Steiner Steiner Laboratories

The research of Lindhe and others would suggest otherwise. It depends on the bone type first of all. If it is a thinner bone type then you will get more recession in the apical and lingual directions. Thicker bone types may not resorb as much, but they are rare. Count on resorption in most cases. Do immediate implants and graft the buccal (because you must place them in the lingual part of the socket). Graft with a mic of Encore and Bovine. A good provisional or healing cap can sometimes make the need for a membrane unnecessary if they cover the graft material and keep it from being exposed to the oral environment.

Greg, what is your "seal" material?

In the maxilla, immediate implant placement, if at all possible, is best in my hands. Otherwise, I graft in the maxilla and all extractions should be atraumatic, wether an implant is planned or not. In the mandible, if there is a solid tooth on either side of the extraction site, I can get by without a graft. We do this all the time in the case of the abscessed lower molars or premolars. My Breif experience leads me to believe, if you are using autogenous bone, you can't go wrong. Bv

Dr. B The material is very similar in chemical composition to normal synthetic membranes but it is constructed as a foam so it is thick and designed to sit in the socket orifice and not under the gingiva. We call it Socket Seal. Greg Steiner Steiner Laboratories

My question to you is, what are you planning at the posterior ? There is a significant transverse discrepancy ( lack of adequate width ) of the arch itself. Without seeing the opposing dentition, I am only speculating, but it seems as if you are going to need some increased bulk. I have not used this material, but I mentioned the use of an allograft a month ago, ala. Mike Block. He just came out with a published article in this journal of omfs. Get a copy from your freindly surgeon and take a look. I am going to use this technique soon. I hope you find this helpful. Bv

The material in Block's article is actually a xenograft. Bv

Greg Stainer Where can I find this material? Thanks