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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 6  |  Issue : 4  |  Page : 265-270

Osteobiologics for predictable augmentation


1 Department of Periodontics, Krishnadevaraya College of Dental Sciences, Hunasamaranahalli, Bengaluru, Karnataka, India
2 Department of Periodontics, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication23-Nov-2015

Correspondence Address:
Himani Gupta
19 Dwarka Chs, Plot 31 Sector 9/A, Vashi, Navi Mumbai - 400 703, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-433X.170290

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  Abstract 

Placement of an implant in an edentulous area requires an adequate alveolar architecture that can be conserved by extraction socket preservation technique minimizing the necessity for future augmentation procedures. Use of osteobiologics such as deproteinized bovine bone, assures osteoblastic attachment, and differentiation in socket resulting in reliable bone formation. This article describes the technique utilizing xenograft with a membrane that gave successful regeneration of the deficient ridge's hard and soft tissues after 6 months posttherapy as determined clinically and radiographically. Socket preservation surgery utilizing deproteinized bovine bone with collagen membrane is an effective procedure for posterior socket preservation that aids in providing sound bone quality for successful implant placement.

Keywords: Bone, bovine bone, preservation, socket


How to cite this article:
Raghunatha K, Prabhuji ML, Gupta H, Simon C. Osteobiologics for predictable augmentation. SRM J Res Dent Sci 2015;6:265-70

How to cite this URL:
Raghunatha K, Prabhuji ML, Gupta H, Simon C. Osteobiologics for predictable augmentation. SRM J Res Dent Sci [serial online] 2015 [cited 2022 Jun 30];6:265-70. Available from: https://www.srmjrds.in/text.asp?2015/6/4/265/170290


  Introduction Top


The alveolar process develops in congruency with the progressing formation of teeth, and its topography is determined by their eruption axes. Anatomically and histologically, the extraction of a tooth begins a dynamic cascade of events that impoverish the vertical and horizontal dimensions of the alveolar bone, culminating in a final contour that is reduced in width by 25% and subsequently increasing to about 40% loss in 3 years. [1] The proclivity for resorption of bundle bone and its replacement by woven bone, especially on the buccal aspect, occur due to compromised nutritive support. Maximal loss of soft tissue occurs within the first months and stabilizes after 6 months. In addition, preexisting periodontal or endodontic disease or trauma from the extraction often destroy the labial bony plate and causes the immediate loss of width and height of bone, which may exceed 50% of the optimum volume. [2]

Rehabilitation with an osseointegrated implant that is prosthetically guided and esthetically maintainable with good soft tissue support is fast becoming the norm today, making it mandatory to preserve the dimensions of tooth socket after extraction. [2] Various technically exacting strategies have been implemented for ridge reconstruction that lean more toward the quality of the regenerated bone as a prerequisite for establishing an adequate implant site and less toward the preservation of the topography and the esthetic contours of the soft tissues of the ridge. Socket seal surgery, a simplified, minimally invasive regenerative approach, was introduced more than a decade ago as a tool for optimizing the preservation of the hard and soft tissue components of the alveolar ridge with greater predictability immediately following tooth extraction. [3] Techniques that conjointly fall in the category of socket seal procedures are: Connective Tissue Grafts - Langer and Calangar (1980), Socket Seal or Free Gingival Graft - Landsberg and Bicchacho (1994), Bio-Col or Resorbable Hemostatic Plug Technique - Sklar (1999), Guided Bone Regeneration Using Resorbable/Nonresorbable Membranes, Alloderm or Acellular Dermal Graft - Misch (1998), Prosthetic Pontic Socket Plug (a) Removable - Misch (1998), Kois and Kan (2001) and (b) Fixed - Kois (1998), Spear (1999), Sklar (1999), Modified Socket Seal Surgery with Composite Graft Approach - Misch and Misch (1999), Modified Bio-Col Technique - Fowler, Whickler (2004), Bone Cores with Rotated Palatal Flap - Peñarrocha M (2005), and Combination Epithelized-subepithelial Connective Tissue Graft - Stimmelmayr (2010). [4]

The prime objective and acme of osteobiologics lies in the promotion of osteoblast attachment and differentiation in the socket. Deproteinized bovine bone is the most researched grafting material and is widely used in dentistry because of its similarity to human bone. Bovine bone derivative undergoes a heat treatment and chemical extraction process by which the organic components are removed to avoid immunologic rejection after implantation; however, as the deproteinizing procedure eliminates the osteoinductive capacity, it acts solely as an osteoconductive scaffold that constitutes the natural architecture of cancellous bone. [5] Bio-Oss® (Geistlisch Pharmaceutical, Wolhusen, Switzerland) is a natural, nonantigenic, porous bone mineral matrix composed of deproteinized, sterilized bovine bone and is categorized as a calcium deficient carbonate apatite. The hydrophilic properties of Bio-Oss® ensure complete hydration of the biomaterial via the physical phenomenon of capillary action and effective blood clot stabilization. The surface supports the adsorption of proteins enabling efficient adhesion of osteoblasts, thus creating an environment for biological interaction leading to the reliable bone formation. [6]

This paper presents a case report of socket seal procedure carried out to preserve and augment the bone at the mandibular first molar site, for future implant placement, utilizing Bio-Oss® , and a collagen barrier membrane Healiguide® .


  Case report Top


The patient, aged 25 years, presented to the Department of Periodontics, Krishnadevaraya College of Dental Sciences, Banglore in November 2012 with the chief complaint of pain and inability to chew food associated with a mandibular left first molar (36). The patient was a nonsmoker and had good general health. Clinical examination revealed that the tooth was destroyed by caries and the remnants were the roots. Radiographic examination revealed bone present around both roots. The patient voiced his opinion regarding no additional intervention to save the tooth. Consequently, two main options were discussed: Replacing the tooth with an implant and replacing the tooth with a fixed prosthesis such as a bridge. The patient opted for an implant.

Clinical procedure

Initial therapy

Initial therapy consisted of detailed oral hygiene instructions. Full mouth scaling and root planning was performed using hand curettes and an ultrasonic device under local anesthesia. Trauma from occlusion was evaluated by examining the obvious presence of fremitus in centric occlusion or in working or balancing excursions. 6 to 8 week following Phase I therapy, a periodontal re-evaluation was performed to confirm the suitability of the site for this periodontal socket seal surgery.

Preoperative protocol

Following thorough cleansing of the teeth, the patient was instructed to use 0.2% chlorhexidine as a mouthrinse. Patients' vital signs were assessed, and intraoral periapical (IOPA) radiograph was done before commencing surgical treatment. To minimize vasoconstriction, a local anesthetic (lidocaine 2%), with minimal epinephrine concentration, that is, a maximum of 1:100,000, was administered in the extraction site [Figure 1] and [Figure 2].
Figure 1: Preoperative view of 36

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Figure 2: Radiographic view of 36

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Tooth removal

A sharp #15 surgical blade was used to sever the dentogingival and dentoalveolar connective tissue fibers around 36. To achieve a forceless extraction, a slow, gentle rotational pulling force was preferred until the periodontal ligament fibers were torn completely and to minimize the amount of mechanical pressure applied to the buccal bone. Thumb support against the labial aspect of the alveolus and a check on the state of the soft tissue walls of the fresh extraction socket to ensure intactness was done [Figure 3].
Figure 3: Atraumatic extraction of root pieces of 36

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Socket preparation

The fresh socket was debrided thoroughly of granulation tissue and residual periodontal ligament fibers followed by a thorough evaluation of the remaining bony housing. The socket bony walls were decorticated with a half round bur further in their apical part (except for the labial wall) to increase the participation of endosteal bone-forming cells in the wound. The epithelialized inner layer of the gingival walls at the socket orifice was removed gently by a sterile water - cooled high-speed coarse diamond bur to expose the vascularized lamina propria.

Bone grafting

An osteoconductive material Bio-Oss® was selected for socket seal. Condensation of the bone graft was not done because this action could block or inhibit vascularization and mesenchymal cell participation inside the healing socket. Except for the most coronal 2 mm, the bone material was used to fill the socket. This allowed appropriate space for the collagen membrane to be placed atop the bone graft [Figure 4].
Figure 4: Socket grafting with Bio-Oss™

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Socket sealing and suturing

The extraction socket graft was covered with a resorbable collagen membrane (Healiguide® ) to protect the bone graft from the intrusion of undesired tissue growth and oral debris [Figure 5]. Resorbable collagen membrane was inserted just below the free gingival margins without pouch or flap elevation. The membrane was intentionally exposed and secured using cross-mattress black braided silk sutures [Figure 6] and [Figure 7].
Figure 5: Placement of barrier membrane heali-guide™

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Figure 6: Coronal advancement of flap

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Figure 7: Wound sutured

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Postoperative treatment

Periodontal dressing was placed over the surgical area, postoperative IOPA radiograph was taken [Figure 8] and [Figure 9] and antibiotics (amoxicillin 500 mg every 8 h for 7 days) and oral analgesics (ibuprofen 400 mg, every 4 h as needed for pain) were prescribed. 0.2% chlorhexidine mouthwash was prescribed every 12 h for 2-week duration postsurgically. The patient was instructed not to use a toothbrush or mechanical cleansing at the surgical area. Only a soft diet is advised for the first 2 weeks of the healing process. Sutures were removed 7-14 days postsurgery and healing was found to be satisfactory, with no bone graft exposed to the oral cavity. The patient did not report any untoward consequences. The patient was assessed after 3 months and 6 months [Figure 10] and [Figure 11].
Figure 8: Placement of periodontal dressing

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Figure 9: Immediate post operative IOPA

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Figure 10: Post operative view after 6 months

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Figure 11: Post operative IOPA after 6 months

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  Discussion Top


The use of bone replacement grafts has been shown to enhance socket healing and to potentially modify the resorption process. Bio-Oss® has a compressive strength of 35 MPa and its porous nature (75-80% of the total volume) serves to greatly increase the surface area of the material (79.7 m 2 /g as evaluated by gas adsorption) providing a substratum for an increased angiogenesis and represents a scaffold for bone formation leading to more contact surface between new bone and the bone substitute. [5] Bio-Oss® becomes integrated with newly forming bone resulting in an increased level of bone mineral density within the grafted defect sites. [6] As in human cancellous bone mineral, Bio-Oss® exhibits a highly porous structure that facilitates vascular ingrowth and osteoblastic cell migration with an intact mesopore system that connects directly to the macropore system. Mesopores are large enough to allow entrance to cells and blood vessels throughout the grafted site. A complex network of regularly arranged interconnected micropores penetrates the entire grafted site allowing for complete wetting of the Bio-Oss® , boosting cell adhesion, cell differentiation, and cell proliferation. [7] The porosity of the Bio-Oss material is around 67%, while calcium and phosphate content are similar to hydroxyapatite (ca/P ratio = 1.58). Sollazzo et al. have reported the effect of Bio-Oss® on mesenchymal stem cells in the early differentiation stages indicated by the activation of bone-related markers RUNX1, FOSL1, and SPP1. [8] Lindhe et al. performed ridge preservation with the use of Bio-Oss® in 20 extraction sockets and concluded that placement of biomaterial retards healing, however, the grafted sites failed to undergo dimensional changes due to nonresorptiveness of Bio-Oss® particles. [9]

The resorbable barrier was used to cover the graft material. The collagen membrane has the ability to promote platelet aggregation, be chemotactic for fibroblast, and enhance wound stability, required for proper healing. It is biocompatible, exhibits multidirectional strength and tear resistance, easy to use, and possesses adequate cell occlusiveness to promote osteoblasts proliferation while excluding gingival cell invasion. The use of an occlusive membrane eliminates the problem of particle migration while simultaneously preventing epithelial and soft tissue migration into the socket. It also prevents external ridge resorption in the early healing period. Perelman-Karmon et al. histologically compared socket site preservation using bovine bone mineral with and without a bioresorbable collagen membrane and concluded that at the end of 9 months the amount of the osseous fraction increased with guided tissue regeneration membrane. [10]

The socket seal presented in this case resulted in an appreciable bone fill after 6 months. Deproteinized bovine bone is the most researched grafting material and is widely used in dentistry because of its similarity to human bone. Biocompatibility refers to the ability of a material to perform with an appropriate host response in a specific situation. Proteins in deproteinized bovine bone have been extracted to avoid immunologic rejection after implantation; however, as the deproteinizing procedure eliminates the osteoinductive capacity, deproteinized bovine bone act solely as an osteoconductive scaffold. [5] An increased surface area provides a substratum for an increased angiogenesis and represents a scaffold for bone formation. When Bio-Oss® is used, bone grows upward from the preexisting bone into the grafted area, maintaining the space, helping to prevent the unwanted early resorption, and not showing inflammatory reaction making it a biocompatible graft. [6] It has been reported that Bio-Oss® promotes osteogenesis and has a very low resorption rate. In some cases, it can be very disadvantageous to use a material that shows very little degradation such as Bio-Oss® . [5] Foreign body reaction to anorganic bovine bone has been reported as well. This technique offers the dual vantage of maintaining soft and hard tissue contours as well as an augmenting bone with the help of deproteinized bovine bone and collagen barrier membrane seal. However, histologic and radiographic analysis needs to be done to evaluate the effectiveness of this combination in the socket preservation procedure.


  Conclusion Top


The dimensions of a socket need to be conserved using socket preservation procedures at the time of tooth extraction so as to maintain the width and height of the remaining bone for future implant placement. Careful treatment planning with this technique aimed to preserve as much as possible of the patient's existing gingival and alveolar bone contours during extraction. Decortication of the bony walls ensured osteoinduction to facilitate native bone formation conducive to endosseous implant placement. Use of a resorbable collagen membrane served as a hemostyptic and eliminated the need for a second surgical approach that may cause soft tissue defects associated with the use of nonresorbable membranes. The uniqueness of this technique lies in the fact that it is simple to perform and provides maximum conservation of the hard and soft tissues, especially in a young patient that guarantees rehabilitation with an implant of suitable size. The technique used has not only tried to harness the maximum inductive potential of extraction socket but also the osteobiologics used namely Bio-Oss.

The use of deproteinized bovine bone proved to be beneficial in achieving successful socket preservation and forming bone of acceptable quantity and quality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Carlsson GE, Bergman B, Hedegård B. Changes in the contour of the maxillary alveolar process under immediate dentures. A longitudinal clinical and x-ray cephalometric study covering 5 years. Acta Odontol Scand 1967;25:45-75.  Back to cited text no. 1
    
2.
Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313-23.  Back to cited text no. 2
    
3.
Landsberg CJ, Bichacho N. A modified surgical/prosthetic approach for optimal single implant supported crown. Part I - The socket seal surgery. Pract Periodontics Aesthet Dent 1994;6:11-7.  Back to cited text no. 3
    
4.
Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res 2012;23 Suppl 5:22-38.  Back to cited text no. 4
    
5.
Hallman M, Thor A. Bone substitutes and growth factors as an alternative/complement to autogenous bone for grafting in implant dentistry. Periodontol 2000 2008;47:172-92.  Back to cited text no. 5
    
6.
Degidi M, Artese L, Rubini C, Perrotti V, Iezzi G, Piattelli A. Microvessel density and vascular endothelial growth factor expression in sinus augmentation using Bio-Oss. Oral Dis 2006;12:469-75.  Back to cited text no. 6
    
7.
Weibrich G, Trettin R, Gnoth SH, Götz H, Duschner H, Wagner W. Determining the size of the specific surface of bone substitutes with gas adsorption. Mund Kiefer Gesichtschir 2000;4:148-52.  Back to cited text no. 7
    
8.
Sollazzo V, Palmieri A, Scapoli L, Martinelli M, Girardi A, Alviano F, et al. Bio-Oss®acts on stem cells derived from peripheral blood. Oman Med J 2010;25:26-31.  Back to cited text no. 8
    
9.
Lindhe J, Cecchinato D, Donati M, Tomasi C, Liljenberg B. Ridge preservation with the use of deproteinized bovine bone mineral. Clin Oral Implants Res 2014;25:786-90.  Back to cited text no. 9
    
10.
Perelman-Karmon M, Kozlovsky A, Liloy R, Artzi Z. Socket site preservation using bovine bone mineral with and without a bioresorbable collagen membrane. Int J Periodontics Restorative Dent 2012;32:459-65.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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